Introduction to Community Pharmacy Practice and Responding to Symptoms (Lecture 1) PDF

Introduction to Community Pharmacy Practice and Responding to Symptoms Majeed Al-Shaeer Lecture 1  Background 1- Community pharmacists are the most accessible healthcare professional, where no appointment is needed to council a pharmacist and the p...

Introduction to Community Pharmacy Practice and Responding to Symptoms Majeed Al-Shaeer Lecture 1  Background 1- Community pharmacists are the most accessible healthcare professional, where no appointment is needed to council a pharmacist and the patient can receive a free advice anywhere without long waiting times at clinics or at other health facilities. 2-Medications include Over-The-Counter medications (OTC) as well as prescription only medications (POM). Nonprescription (or OTC) products are a group of pharmaceuticals considered to be sufficiently safe for use without the intervention of a physician.  Background Note: in UK, They refer to prescribed medicines as prescription-only medicines (POMs), while medicines provided by a pharmacy without a prescription but under the supervision of pharmacists are under the “P” classification. In addition, medicines sold without a pharmacist’s supervision (e.g. Paracetamol and ibuprofen) classified as General Sale List (GSL) so they can be sold anywhere, such as supermarkets). 3-Because over-the-counter medications are used so frequently. It is important to know the differences between prescription and over- the-counter medications. Differences between prescription and over-the-counter medications  Background 4-For pharmacists to safely and effectively manage minor ailments requires considerable knowledge (about the diseases and their clinical signs and symptoms) and skill (mainly communication skills).  The switch of prescription -only –medicine (POM) to OTC status The availability of drugs over the counter varies from country to country. Generally drugs will be accorded OTC status if they fulfill various criteria: 1-The condition for which they are used can be reliably self-diagnosed. 2-Where there is no evidence of irreversible or serious adverse reactions. 3-Where their use does not require medical supervision or monitoring by a doctor. OTC Approval processes in the UK (MHRA: Medicines and Healthcare products Regulatory Agency) History of switching from POM to OTC  Note when certain drug being OTC, not means that it is OTC in all strengths, in all dosage forms, for all indications, for all ages, in all countries, and in the same maximum dose or duration as when it is use by Rx ( as POM)  Note the process of switching may occur in reverse way (i.e. from OTC to POM). The UK has had two recent reclassifications return to POM (domperidone and oral diclofenac) due to cardiac risks.  The following table (highlights some future candidates that are potential POM to OTC switches in UK)  Note Trials in UK to switch some oral antibiotics to OTC (Trimethoprim and Nitrofurantoin to treat uncomplicated cystitis in women) were ultimately withdrawn in 2010 due to concerns over increasing antibiotic resistance. Responding to symptoms in Community pharmacy Responding to symptoms is a major activity for the community pharmacist. Many customers visit the community pharmacies each day with various symptoms for which they are seeking advice. This requires a greater focus from the pharmacists on illness management, rather than on product selling.  Pharmacists will consider 1 of 3 recommendations during each encounter involving symptom presentation: (1) Provide assurance that drug therapy is unnecessary. (2) Suggest treatment with non-drug measures, OTCs, or both. (3) Refer the patient to appropriate medical personnel.  Referral As a general rule, the following indicate a higher risk of a serious condition and should make the pharmacist consider referring the patient to the doctor: 1-Long duration of symptoms. 2-Recurring or worsening problems. 3-Severe symptoms. 4-Failed medication (one or more appropriate medicines used already, without improvement). 5-Suspected adverse drug reactions (to prescription or OTC medicine). 6-Danger symptoms (Blood in the sputum, vomit, urine or faeces would be examples of such symptoms, as would unexplained weight loss).  Getting information from the patient: The following steps highlight the key considerations you should think about when someone asks for your advice (as a pharmacist) about a particular symptom or condition they have. 1-Picking up on non-verbal cues: Assessment of the patient begins the moment the patient enters the pharmacy and this 'first impression' can be very helpful in giving you clues to their state of health. For example, does the patient look well or poorly? For people who appear in discomfort or look visibly poorly, this might influence your decision to treat or refer.  2-Questioning: Arriving at a diagnosis is a complex process. In medicine it is based on three kinds of information: patient history; physical examination; and the results of investigations. Currently, physical examination and using diagnostic tests are rarely used in community pharmacy practice. Pharmacists rely almost exclusively on questioning patients when deciding whether to offer treatment or perhaps refer the patient for further evaluation. Studies have shown that an accurate patient history (gained from asking questions alone) is a powerful diagnostic tool. The ability to ask good questions to gain the appropriate information is therefore critical.  Acronyms Acronyms have been developed to help pharmacists remember which questions should be asked. WHAM is the best known and simplest acronym to remember and has been advocated by many as a useful tool in gaining information from patients.  W–Who is the patient and What are the symptoms? H–How long have the symptoms been present? A–Action taken? (Any action taken by the patient should be established, including the use of any medication to treat the symptoms). M – Medication being taken? There are four obvious reasons for this:  A medicine may be causing the symptoms A medicine may indicate a disease state the patients have. The patient may already be taking a medicine the pharmacist is about to recommend and which is not providing relief. Medications that are recommended may interact with existing treatment Some patients do not yet understand why the pharmacist needs to ask questions before recommending treatment.  3-Outcomes from the consultation: The final step in prescribing for minor ailments is telling the patient what course of action you feel is most appropriate. This could be referral to another healthcare professional, giving advice or supplying a product.  A-Treatment and advice: For many therapeutic groups there is a wide variety of products available, often in various combinations. The pharmacist should take into account the efficacy, potential side-effects interactions, cautions and contraindications. When selecting a product, the patient's needs should be borne in mind. Factors such as prior use, formulation and dosage regimens should be considered. For example, antacids are available in both tablets and liquid form. Liquids tend to have a quicker onset of action than tablets but can be inconvenient for a patient to carry around with them or take to work.  Non-drug treatment should also be offered where appropriate. For example, advice on increasing dietary fibre and fluids is an essential part of the management of conditions such as constipation and haemorrhoids.  B-Timescales: One of the key things is telling the patient what action to take if the symptoms do not improve. Here, a defined treatment timescale should be used (this is the length of time for which the problem might be treated before the patient sees the doctor). The timescales given to each condition can vary.(The patient should seek medical attention if the cough does not improve in 7-10 days. While adult patient with diarrhea seek medical attention if the diarrhea does not improve in 2 days).  Children and the elderly These two patient groups have the highest usage of medicines per person compared with anyone else. Care is needed in assessing the severity of their symptoms as both groups can suffer from complications. For example, the risk of dehydration is greater in children with fever or the elderly with diarrhoea. Children should be offered sugar-free formulations to minimize dental decay and elderly people often have difficulty in swallowing solid dose formulations. It is also likely that th majority of elderly patients will be taking other medications for chronic disease and the possibility of OTC-POM interactions should be considered.  Pregnancy The potential for OTC medicines to cause teratogenetic effects is real. The safest option is to avoid taking medication during pregnancy, especially in the first trimester. Many OTC medicines are not licensed for use in pregnancy and breastfeeding because the manufacturer has no safety data or it is a restriction on their availability OTC.  examples of some OTC Medicines to be avoided during pregnancy  Interactions of OTC medicines with other drugs: Medicines that are available for sale to the public are relatively safe. However, there are some important drug-drug interactions to be aware of when recommending OTC medicines. These are listed in Table  Evidence-based medicine (EBM) and over-the-counter (OTC) drugs 1- Evidence-based medicine (EBM) emphasizes the use of evidence from well designed and conducted research in healthcare decision- making. 2-Although evidence-based medicine (EBM) is widely used for prescribed drugs, it is not currently utilized for OTC medicines in community pharmacies.  3-With regard to efficacy, pharmacists should be aware that many OTC medicines have little or no evidence base. Therefore, products with proven efficacy should constitute first-line treatment. Community pharmacists should stop selling over-the-counter (OTC) medicines that have little evidence of efficacy if they want to ensure the best treatment for patients. 4-The OTC products sold in pharmacies can be split into three categories. A-The products for which scientific evidence is lacking like: ,‫ا لالصقة ا لسحزية‬ ‫س ىار ابنس ينا‬ B-The second category is OTC medicines with a basis in science but which lack clear evidence of effectiveness. One example is the use of cough medicines (drug combinations can be illogical such as an expectorant with a cough suppressant).  Systematic reviews of cough medicines show a lack of effectiveness. Although products in the second category may often be requested by the public, certainly, the lack of evidence of effectiveness must be communicated clearly to patients. Cyproheptadine?  Cyproheptadine has been widely used as an appetite stimulant, but in the long-term appears to have little value in producing weight gain and such use is no longer generally recommended. There has been concern that cyproheptadine was being promoted and used inappropriately as an appetite stimulant in some developing countries. C-In the third group are OTC medicines for which there is clear evidence of effectiveness, and which can be sold with confidence. Many of these have been used for many years and have data to support their use, such as antifungal creams, painkillers, triptans, and chloramphenicol eye drops.  Current situation in Iraq In many countries including Iraq (which contain more than 6000 community pharmacy) it was found that in many cases the Iraqi pharmacist was not asking enough or appropriate questions and therefore had insufficient information to advice optimally the patient about their symptoms. It was also found that the pharmacists do not employ a safe and structured approach when responding to patients’ symptoms and they fail to differentiate between a symptom that might suggest a more serious pathology or one which can be easily managed with an OTC product. Thank you for your attention