Download CPS News June 2014 - Consultant Pharmacy Services

Consultant Pharmacy Services
CPS News
2014 Issue 2
June 2014
Changes to Residential Medication Management Reviews
The Pharmacy Guild of Australia and the Australian Government have placed limitations on the frequency with
which Residential Medication Management Reviews (RMMRs) can be conducted by pharmacists. These include a
change to the frequency of RMMRs to once every 2 years, unless there is a clear “clinical need” for an RMMR.
There have been no changes to the rules for Medication Reviews (RMMRs) that form the basis for GP claims.
The end result of the changes is that residents can be reviewed once soon after admission and all subsequent
reviews will be limited to those patients who require an additional review because of an established “clinical
need”. There are many potential reasons for an additional review and these include:
• discharge from hospital after an unplanned admission in the previous four weeks;
• significant change to medication regimen in the past three months;
• change in medical condition or abilities (including falls, cognition, physical function);
• prescription of a medicine with a narrow therapeutic index or requiring therapeutic monitoring (for example:
antipsychotics, opioids, warfarin, insulin, antiparkinsonian agents, amiodarone, digoxin, thyroxine);
• presentation of symptoms suggestive of an adverse drug reaction;
• sub-therapeutic response to therapy; or
• suspected non-compliance or problems with managing medication related devices.
Consultant Pharmacy Services will continue to provide RMMR services to the residents of your facility. We are
seeking the assistance of staff at the facility to notify us of newly admitted residents and also to identify residents
that may have developed a “clinical need” for a review.
CPS will request referrals from GPs for residents soon after admission and on a regular basis thereafter. Staff at
the facility can also request a review be undertaken. Contact the patient’s GP or CPS if you have a resident that
you wish to have reviewed.
On Call Medication Advice
CPS provides an on-call service for facilities that it services. This allows senior
nursing staff to contact one of four accredited pharmacists to investigate and
then provide recommendations to resolve any specific medication-related clinical issues.
Simply email the office ([email protected]) or call
and one of the pharmacists will get back to you within
24 hours. We can help with information about adverse
effects, advice for GPs, or other medication-related issues.
This Issue:
 Changes to RMMR program
 On Call Medication Advice
 To Crush or not to Crush
 Digoxin and Pulse–
What’s the Story?
 Upcoming Educational
Events
CPS News
Crushing of Oral Solid Dose Forms
Crushing of medication is a common practice
that is required when patients begin to have
problems with swallowing (or resistance) to medication.
While you CAN crush just about anything, knowing which forms SHOULD be crushed is very useful. CPS recommends that each facility has a copy
of the Don’t Rush to Crush” handbook that is published by the Society of hospital Pharmacists of
Australia.
Crushing tablets or opening capsules will alter the
rate of absorption and release of the ingredients,
and this may result in an altered clinical effect of
the medication.
When administering tablets and
capsules to patients who have
difficulty swallowing or an enteral
feeding tube, healthcare professionals need answer to these
questions:
 can I crush it?
There are often alternatives to oral dose forms for
many medications, but one critical question that
needs to be asked when a patient is receiving
crushed medication is “ Is the medication still
necessary?”
A critical
question that
needs to be
asked when a
patient is
receiving
crushed
medication is
“ Is the
medication
still
necessary?”
If a patient needs to move onto a crushed medication, it is an ideal time to review the ongoing need
for the existing medication regimen.
 can I dissolve it?
 can I open the capsule?
 is there a liquid formulation?
 can I give the injection orally?
Answers to these and other questions for over 500 medicines
available in Australia. Chapters
on the principles of crushing and
what this can do to the pharmacokinetics of a medication.
$120 per copy
Further details available at:
http://www.shpa.org.au/
Publications/Do-not-Rush-toCrush
Algorithm for swallowing difficulties and the selection of medication
Page 2
2014 Issue 2
Digoxin and Pulse– What’s the Story?
Do you need to withhold digoxin when the pulse is less
than 60 beats per minute?
There are a number of factors to consider before
attempting to answer this question.
The basis of the practice has always been that when the
pulse is low, this is an indicator of possible digoxin toxicity and the digoxin should be withheld. However the
pharmacokinetics of digoxin and the nature of digoxin
toxicity is highly variable, particularly in elderly patients
and those with renal or cardiac disease. In addition, how
the pulse is taken and the reason for the use of digoxin
are both important to consider.
Bradycardia and Digoxin
Bradycardia (heart rate <60bpm) is poorly correlated
with digoxin toxicity. In many cases toxicity with digoxin
manifests firstly with gastrointestinal (nausea, vomiting,
diarrhea) and central nervous system (confusion, agitation, visual changes) signs before cardiac changes occur.
When the cardiac changes do occur, they can be variable
and include tachycardia and arrhythmias as well as bradycardia. Bradycardia is more common if other agents
that affect heart rate are present in the patient’s regimen (these include diltiazem, verapamil, amiodarone
and the beta blockers).
Half Life of Digoxin
The literature value for the half life of digoxin in patients
with normal renal function is 36-48 hours. In patients
with severe renal dysfunction, this can be as long as 5
days. Most residents in aged care institutions have a half
life somewhere between these two points. The long half
life means that changes in doses take a considerable
amount of time to show up in the “steady state” blood
level (at least 3 half lives, probably more like 5 half lives).
Thus withholding a single dose of digoxin would take at
least 4-5 days to impact on the blood level.
Apical vs Radial Pulse
The routine practice of taking the pulse at the radial artery can result in an incorrect interpretation of the true
heart rate, especially in the presence of any arrhythmias
such as atrial fibrillation. If two heartbeats occur very
close together, the first may not result in a sufficient
“pulse” of blood to be felt at the radial artery. Apical
(taken with a stethoscope by listening to the heart)
heart rate is often 20-50% higher than the radial pulse
in patients with atrial fibrillation. Thus on many occa-

Bradycardia (heart rate <60bpm) is poorly
correlated with digoxin toxicity.
 Patients with heart failure presenting with
bradycardia (<60bpm) who are
asymptomatic can be safely given digoxin.
 If symptomatic bradycardia is present, or
the patient displays signs and symptoms
of digoxin toxicity, the prescriber should
be contacted.
sions when the radial pulse is less than 60 beats per
minute, the actual heart rate is well above 60 beats
per minute.
Patients with bradycardia should be assessed for other clinical signs and symptoms. It is unlikely that a patient will be symptomatic of bradycardia if their apical
pulse is >50bpm. Patients presenting with hypotension, syncope, chest pain, and shortness of breath
along with bradycardia should be assessed by their
doctor.
Heart Failure vs Atrial Fibrillation
Digoxin is a cardiac glycoside that is indicated in the
treatment of heart failure and atrial fibrillation (and
some other supraventricular arrhythmias). At low levels, digoxin has neurohumoral effects such as changes
in the vascular tone and slowing of the heart rate. At
higher levels, there is an inotropic effect and the force
of contraction of the heart is increased. In both heart
failure and atrial fibrillation, the main benefit of digoxin is from the neurohumoral effects and therefore
high levels are no longer targeted. In the past, serum
level of 1.3-2.6nmol/L were considered appropriate,
more recently levels of 0.5-0.8nmol/L are considered
appropriate for both heart failure and atrial fibrilla-
Page 3
tion. In both these indications, the aim is to slow the
heart rate.
Gastrointestinal (most likely)
CPS does not recommend routine monitoring of pulse
for patients taking digoxin. However, patients with
symptoms consistent with digoxin toxicity should be assessed.
Nausea , Vomiting , Anorexia
Neurological
Weakness , Fatigue (most likely) , Confusion,
Visual disturbance (Blurred vision, flashing
The following information is relevant to assessing the
likelihood of any toxicity:
lights or halo’s ,Green-yellow colour

Observations ( Blood pressure, Heart rate , Alterations in food intake, Neurological status)
Cardiac
Signs of toxicity (Gastrointestinal ,Visual , Neurological )
arrhythmias, First, second or third degree

disturbances)
Clinical signs of toxicity may be present regardless of
blood levels and patients with gastrointestinal or other
typical signs should have the dose reduced or the ongoing need for the agent reviewed.
Supra ventricular arrhythmias , Ventricular
heart block, Sinus Bradycardia ,
Tachyarrhythmias (more common in patients
with heart disease)
Symptoms of Digoxin Toxicity
Upcoming CPS Medication Education Events
As well as the ongoing online education modules that are available, CPS is providing a number of face-to-face sessions over the
nest 3 months. Full details of upcoming events are available at the CPS website (www.cpsedu.com.au) or by contacting CPS
directly.
24th June: Pain and its Management in the Elderly (pathophysiology of pain, chronic and neuropathic pain, non-opioids and their
use, opioids and their use , Devonport, 08:00-13:30 (4.5 CPD points), cost $90 for CPS members
28th July: Management of Parkinson’s Disease, Launceston, 16:00-18:00 (2 CPD points), cost $10 for CPS members
17th August: Medications in Aged Care Seminar (How drugs work, Diabetes, Drugs and falls, Osteoporosis, Dementia, Medications and wounds, Parkinson’s Disease), Melbourne, 07:30-17:00 (7 CPD points), cost $180
26th and 27th August: Medication Endorsement Update (Day 1: Common symptoms in the elderly and when to refer. Day 2: Assisting with medication), Hobart, 09:00-17:00 (both days), cost $160
1st September: Thyroid disorders and their Management, Devonport, 16:00-18:00 (2 CPD points), cost $10 for CPS members
22nd September: Medications in Aged Care Seminar (Drugs and Effects on Cognition and Confusion, Drugs and Falls, Anxiety
and Depression in the Elderly, Other Psychiatric problems in the Elderly, Gastrointestinal Symptoms in the Elderly, Musculoskeletal Problems in the Elderly), Hobart, 08:00-17:30 (7 CPD points), cost $165 for CPS members
29th September: Psychiatric Disorders in the Elderly (Depression, Anxiety, Psychosis, Bipolar Affective Disorder, Behavioural and
Psychological Symptoms of Dementia), Launceston, 08:00-13:30 (4.5 CPD points), cost $90 for CPS members
CPS is the leading provider of medication review and related
services in Tasmania and currently provides services to almost
50 facilities in Tasmania and Western Australia.
Our team of specialist pharmacists provides consistently high
quality, relevant services to residents in aged care facilities
and in the wider community.