Transcript Document

Role Preparation for NHS Direct Health
Information Advisors
Handling Medicines Calls
Day 2
Name
Centre Medicines Information Service
Learning Outcomes
1. Have an overview of NHS Direct policies and roles of
staff for Medicines Calls.
2. Have a baseline knowledge about medicines.
3. Have an overview of Community Pharmacy services
and emergency supply of medicines.
4. Be able to handle medicines calls safely and
effectively.
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Learning Outcomes
4. Be able to handle medicines calls safely and
effectively.

Know what background information is needed to clarify the
question and minimise the risks when advising the caller.

Be able to navigate the key medicines information sources.

Be able to interpret information about medicines and turn it
into appropriate advice.

Know when and how to refer medicines calls to UKMI.

Be able to use the NHS Direct Medicines Algorithm.
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Morning Timetable
9.30
Introduction & Re-cap
Adverse effects
Drug interactions
Workshop 4: Adverse effects & drug interactions
11.00
Tea break
Medicines in pregnancy
Medicines when breast feeding
Workshop 5: Meds in pregnancy & breastfeeding
1.00
Lunch
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Afternoon Timetable
1.45
Herbal medicines
Workshop 6: Herbal Medicines
3.00
Tea break
Where are the risks?
What next?
4.00
Close
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Adverse Effects
Unwanted effect that a drug has on a person
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Account for 2-6% of hospital admissions
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Type A
Type B
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Changes in health
e.g. digoxin / renal function, warfarin / heart failure
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Cross-sensitivity
e.g. amoxicillin / cefadroxil
predicted by mode of action
unpredictable
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Recent Drug Alerts / Scares
Rimonabant
Risk of suicide and depression
Co-proxamol
High risk of death in overdose
Rofecoxib
Withdrawn,  risk MI and stroke
HRT
Avoid longterm,  risk breast cancer
Kava-Kava
Withdrawn, hepatotoxicity
Cerivastatin
Withdrawn, rhabdomyolysis
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Incidence of Adverse Effects
Very common
10%
Common
1%
Risk of dying from cancer if
smoke 20 a day for 30 years
Uncommon
0.1%
Risk of being injured on the
stairs in next 12 months
Rare
0.01%
Risk of dying in an accident at
home in next 12 months
Very rare
up to
0.01%
Risk of being killed by
lightening
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Yellow Card Reporting Scheme
Both healthcare professionals and patients can report adverse effects
NEWER MEDICINES
& VACCINES ()
All ADRs even if
ESTABLISHED MEDICINES
& VACCINES
All serious ADRs

Not certain that the
medicine has caused it
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Fatal, life threatening or
disabling
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Reaction well known

Prolonged hospital stay
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Other drugs at same time
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Even if well known
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Drug Interactions

One drug modifies the
effect(s) of a second drug.

More likely if taking
several medicines.

Many types of interaction.

May or may not be
clinically significant.
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
When is a drug interaction
clinically significant?
Increase
toxicity
Reduce
efficacy
Warfarin
Amiodarone
Increased risk of bleeding
Simvastatin
Erythromycin
Increased risk of myopathy
Ciclosporin
Phenytoin
More ciclosporin needed
Thyroxine
Rifampicin
More thyroxine needed
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Drug interactions at the receptor
Salbutamol opens the
bronchioles
Atenolol closes the
bronchioles
Nerve ending
Nerve ending
Receptor stimulated
Receptor blocked
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Medicines that speed up the
metabolism of other medicines
Metabolic
Enhancers
Smoking
Alcohol
Carbamazepine
Phenytoin
Rifampicin
Blood level of
the other medicine
will go down
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Medicines that slow down the
metabolism of other medicines
Metabolic
Inhibitors
Cimetidine
Ciprofloxacin
Erythromycin
Metronidazole
Blood level of
the other medicine
will go up
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Narrow Therapeutic Range Drugs
CARBAMAZEPINE
CICLOSPORIN
DIGOXIN
LITHIUM
PHENYTOIN
THEOPHYLLINE
WARFARIN
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Workshop 5: Adverse Effects &
Drug Interactions
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Tea Break
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Morning Timetable
9.30
Introduction & Re-cap
Adverse effects
Drug interactions
Workshop 4: Adverse effects & drug interactions
11.00
Tea break
Medicines in pregnancy
Medicines when breast feeding
Workshop 5: Meds in pregnancy & breastfeeding
1.00
Lunch
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Medicines during pregnancy

Increased public awareness and concern since the
thalidomide tragedy.
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1 in 40 babies have a major birth defect of which 1%
due to exposure to medicines in-utero.

Almost all medicines cross the placenta and have the
potential to cause harm.
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Up to 50% pregnancies are unplanned.
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Medicines can not always be avoided.
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Teratogen
Any agent which given in pregnancy causes or
contributes to either malformation,
abnormal
physiological function or mental development of the
foetus or child after birth.
Carbimazole
Foetal goitre
Diethylstilboestrol
Cancer of vagina and cervix
Isotretinoin
Cranio-facial, CVS & CNS defects
NSAIDs
Closure of ductus arteriosis
Warfarin
Foetal warfarin syndrome
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Timing Of Exposure
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1st Trimester (weeks 1- 12)
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2nd Trimester (4th – 6th month)
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Up to 2 weeks, “all or nothing” effect
Weeks 3-8, major organ systems being formed
Cerebellum & urogential system still forming
Growth and functional development
3rd Trimester (6th – 9th month)

Specific effects e.g. NSAIDs (pulmonary
hypertension) B-blockers (hypoglycaemia)
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Identification Of Teratogens

Many possible causes for a birth defect (genetic,
physiological, nutrition, medicines, pollutants).
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Extremely difficult to determine whether or not a
particular agent is a teratogen.

Clinical trials of medicines in pregnant women is
usually unethical.

Difficult to extrapolate findings in animal studies to a
human pregnancy.
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
General Advice

Consider non-drug treatments.

Avoid all medicines in the 1st trimester if possible.

Assess benefit/risk ratio for both mother & infant.

Avoid new medicines as usually more experience
with well-established ones.

Use the lowest effective dose for as short a time as
possible.
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Essential questions to ask
Confirm no new or worsening symptoms
THE PERSON





Age?
Disease states?
Allergies?
Pregnant: no. of weeks,
going well, medicine taken
already?
Breastfeeding: baby age,
term/pre-term, well/unwell,
medicine taken already?
THE MEDICINE




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Name, dose, frequency?
Who is it for?
What prescribed for?
Why asking?
Other medicines? Name,
dose, frequency?
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Advice on infant feeding

Breast milk is the best form of nutrition for infants.

Exclusive breastfeeding for the first 6 months.

Breastfeeding (and/or formula milk) with appropriate
solid food after 6 months, ideally for up to 1 year.

Mothers unable (or choose not) to breastfeed should
be helped to optimise infant feeding.
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
How much of the medicine
reaches the baby?
Depends on:

Plasma concentration of medicine in the
mother.

Characteristics of the medicine.

Amount of milk taken by baby per feed
(approx 150mL/kg).
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
General advice

Avoid unnecessary use of medicines.

Assess risk / benefit for mother and baby.

Higher risk for premature babies.

Check if medicine licensed for babies.
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Avoid long-acting and black-triangle medicines.
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Try to time feed to avoids plasma peaks.
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Monitor baby for adverse effects.
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Essential questions to ask
Confirm no new or worsening symptoms
THE PERSON





Age?
Disease states?
Allergies?
Pregnant: no. of weeks,
going well, medicine taken
already?
Breastfeeding: baby age,
term/pre-term, well/unwell,
medicine taken already?
THE MEDICINE





Name, dose, frequency?
Who is it for?
What prescribed for?
Why asking?
Other medicines? Name,
dose, frequency?
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Workshop 6: Medicines during
pregnancy & when Breastfeeding
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Lunch Break
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Afternoon Timetable
1.45
Herbal medicines
Workshop 6: Herbal Medicines
3.00
Tea break
Where are the risks?
What next?
4.00
Close
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Homeopathic medicines
Do not interact with
conventional medicines

More dilute means
greater potency.

Potency expressed in ‘c’
- 6c means diluted
1:100 for 6 times.

Inactivated by strong
flavours, light and
radiation.
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Plants as medicines

40% of all pharmaceuticals in industrialised countries
are plant based
e.g. Digoxin, Taxols, Vincristine.

2% of prescriptions in USA are for medicines with
natural ingredients.

Over 80% of the world rely on plant based remedies.
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Herbal Medicine

Philosophy is to treat the individual rather than the
diagnosed disease.

Whole plant extracts.
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Often non-standardised and so active ingredients
may vary


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Where grown (sunshine, rainfall, temperature, soil).
Storage conditions.
Combine herbs.
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Public belief?
CONVENTIONAL MEDICINES
Artificial and toxic
Versus
HERBAL MEDICINES
Natural & Safe
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Herbal medicines
May interact with
conventional medicines
3 types of product:
(under review)

Licensed herbal
medicine.
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Herbal medicine
exempt from licensing.
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Food supplement.
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Efficacy
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Evidence variable – very few systematic
reviews or meta analyses.
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Herbs contain a variety of ingredients
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
Which ones are active?
Are they synergistic?

Problems with standardisation between
preparations.

Hampered by safety and quality issues.
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Risks

Delay conventional medical advice

Inherent toxicity
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Kava kava (over 70 cases liver damage)
Ginseng (teratogenic in rats)
Ephedra (deaths in USA)
Aristolochia / Mu tong (kidney failure, cancer)
Mistaken identity


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Digitalis for plantain (1997 arrhythmias)
Japanese for Chinese Star Anise (2001 fits)
Aristolochia for Stephania (1993 renal failure)
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Risks

Adulteration

Contamination: bacteria, pesticides, heavy metals.
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Contamination: prescription medicines
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Glibenclamide (Xiaoke Wan in New Zealand)
Fenfluramine (Qian Er in UK)
Sildenafil (Hua Fo)
Steroids (Yibishu ointment in UK)
Drug interactions


St John’s Wort (warfarin, COCs, digoxin, phenytoin, zidovudine and
others)
Cranberry (warfarin)
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Workshop 7: Herbal Medicines
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Afternoon Timetable
1.45
Herbal medicines
Workshop 6: Herbal Medicines
3.00
Tea break
Where are the risks?
What next?
4.00
Close
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Where are the risks when
handling a Medicines Call?
Clarify the question
Record
all
stages
Plan search strategy
& research problem
Evaluate the information
Tailor the answer/advice
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Refer
to MI
Where are the risks when
handling medicines calls?

Missed symptoms.

Misunderstanding what the caller said.

Incomplete background information.

Omitting relevant information sources.

Searching / interpretation of information sources.

Caller doesn’t understand the answer.

Working outside your level of competency.
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Learning Outcomes
1. Have an overview of NHS Direct policies and roles of
staff for Medicines Calls.
2. Have a baseline knowledge about medicines.
3. Have an overview of Community Pharmacy services
and emergency supply of medicines.
4. Be able to handle medicines calls safely and
effectively.
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
Learning Outcomes
4. Be able to handle medicines calls safely and
effectively.

Know what background information is needed to clarify the
question and minimise the risks when advising the caller.

Be able to navigate the key medicines information sources.

Be able to interpret information about medicines and turn it
into appropriate advice.

Know when and how to refer medicines calls to UKMI.

Be able to use the NHS Direct Medicines Algorithm.
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
What next?
TRAINING

Medicines Call
Algorithm

Hormonal contraception
ASSESSMENT

3 mock scenarios
assessed by UKMI
before taking live calls

3 live calls assessed by
NHSD and 2 of these
by UKMI before
independent practice
Role Preparation For NHS Direct HIAs: Handling Medicines Calls
The Medicines Call Review Tool

Add on to HIA Call review
tool if call about medicines.

6 sections based on the key
steps involved when
handling a medicines call.

Each section has a checklist
of points to be addressed.
Sections of Review Tool
Screening
Analysis & Critical Thinking
Information Sources
Referral to UKMI
Answer
Documentation
Traffic Light Scoring
Green: All points addressed
Amber: Minor points missed
Red: Major points or several minor
points missed
Role Preparation For NHS Direct HIAs: Handling Medicines Calls