Download Respiratory Pharmacy & the Ward Pharmacist experience

Respiratory Pharmacy & the
Ward Pharmacist experience
by
Abdol Malek bin Abd Aziz, MSc
Clinical Pharmacy Conference , Port
Dickson, 9-11 Jan 2003
Respiratory pharmacy
• Emphasis on pharmaceutical care of
respiratory patients
plus
• Other conditions that the patient is
concurrently suffering
Respiratory Pharmacy
Covers:
•Asthma
•COPD
•Idiopathic interstitial lung
disease
•Pleural disorders
•Pneumonia
•Drug-induced pulmonary disease
NHMS 1996 - Findings
•
•
•
•
High percentage (62.4%) not on inhalers
Mild asthmatics: 65.3%
Moderate : 52.1%
Severe : 23.7%
Compliance / adherence
• Generally non-compliance rate ~ 50% (out
patients)
• 56% in Melaka (1999)*
• Leads to hospital admission
• 51.7% in Hospital Melaka **
• 13.3% were asthmatics (6/45 patients)
• Non-compliance to inhaled medications: 50%
(McGann & Elizabeth. Am J Nursing 1999)
•
•
Aziz AMA, Ibrahim MIM. Med J Malaysia 1999.
** Aziz AMA, Senthil N, Jenny W. J Pharm Sci. 2003 (in press)
Some avenues to patient care…
• Patients with allergic rhinitis often
experience symptoms of asthma (Linneburg.
Allergy 2002,57)
• Allergic rhinitis preceded or developed at
the same time as allergic asthma
• Tx of allergic rhinitis reduced asthmatic
symptoms or reduce risk of asthma
Inhaler technique
• “good” rating ranged from 5-86% using MDIs
• Technique improved after proper training*
• 37.5% of pharmacy staff & 45.4% (15/33)
outpatients having good technique€
€Inhaler technique survey among pharmacy staff and patients at the specialists
clinic pharmacy, Hospital Melaka. Abstract of the Konferens R&D Farmasi,
Kota Bharu 2002.
* Cochrane MG, Bala MV, Downs KE et al. Inhaled corticosteroids for asthma
therapy: patient compliance, devices , and inhalation technique. Chest
2000;117(2):542-550
Lung deposition of medication
• Terbutaline:
MDI – 8%, DPI – 22%*
• Effect of spacer device:
Lung deposition increase from 9 to 21%
Oropharynx deposition reduced from 81 to 17%#
* Borgstrom L, Derom E, Stahl E, et al. The inhalation device influences lung
deposition and bronchodilating effect of terbutaline. Am J Respir Care Med
1996;153:1636-1640.
#Newman SP, Millar AB, Lennard-Jones TR et al. improvement of pressurised
aerosol deposition with Nebuhaler spacer device. Thorax 1984;39:936-941.
Bronchial asthma
• Defn: Reversible airways obstruction ,
airway inflammation, airways
hyperreactivity to a variety of stimuli
• Incidence: 3-6% in Australia, 4.2% in
Malaysia* , 2-5% in Africa
• Symptoms: Wheezing, dyspnoea, chest
tightness, cough
* National Health and Morbidity
Survey Vol. 11, Public Health
Asthma in children
Children:
• Dry powder inhalers has greater systemic
effects than MDIs§
• Pharmacists: recommend MDI with
spacer device for children.
§ Kereem
E . Ann Allergy Asthma International 2002;89.
Pharmacist’s roles
•
•
•
•
•
•
•
As educator and support person
Counsel on role of each medication
Difference between preventer – reliever
Emphasise safety of inhaled c’steroids
Discuss adverse effects – ways to minimise
Check and correct proper use of inhalers
Encourage use of spacers and peak fl. meters
Pharmacist’s roles
• Check compliance – 56% noncompliance
rate1
• Check usage of medications for other
illnesses, OTC products, GP’s drugs, etc
• Dispels myths about asthma and inhaler
use
• Encourage asthma action plan
AMA Aziz, MIM Ibrahim.
Medication noncompliance - a
Objective
• To have an influence on
prescribing and related clinical
practice
How to start?
• Ward pharmacy
• then
• Respiratory pharmacy
Ward pharmacy
•
•
•
•
Back to basics
Supplies, inventory, pricing,
Dosage, category of drug in MOH list
List A, std item
• Synergistic activity with in-patient
pharmacist/satellite pharmacist
At the ward…
• Familiarise with the ward- acquaint with
ward staff ie. sister & nurses
• Ward procedures
• Own reading on common drugs used
• develop confidence
Ward rounds
• Consultant’s rounds: already
have a high level of interest in
optimising drug therapy
• Vigilant on ADR and side
effects
Preparation before rounds
• Very, very important
• May take an hour or more initially
Objective:
‡ to anticipate areas where information is
likely to be requested
‡ To identify topics for discussion
• Becoming prepared
provides…
Confidence
Clerking
• Same as any other pt
• Biodata, diagnosis, investigations, lab results, xrays, etc,
• Document using card or form
• Monitor,
• Identify drug-related problems or issues
• Plan for solution
- check-up
- talk to Dr or specialist, nurse
Things to do…
• Estimate creatinine clearance ClCr if the
serum creatinine is >150µmol/l in adults
less than 70 yrs using Cockcroft and Gault
equation
• Abnormal levels of urea or albumin may
alter the disposition of some drugs
Patient parameters
• Pt. with liver disease – elevated liver
function tests
• Severe cardiac failure may affect both
renal and hepatic clearance of drugs
may necessitate dose individualisation
• Calculate predicted blood levels if
therapeutic monitoring of a drug is
required
Attending ward rounds
• Be PUNCTUAL
• Degree of involvement and pharmacist’s
role depend on the leading physician
• Doctors may undertake management or
teaching role or both
• They may not ask for pharmacist’s
comments
A successful attendance in ward
rounds
• Adequate preparation
• Being tactful, yet
assertive
• prioritise
• Regular attendance
• Present info on a
problem concisely
• Provide adequate
follow up
Pharmacist’s comments
• Unlikely to be a personal insult and no offence
should be taken
• The advice may be used on a similar pt in future
• Occasionally it may be used by the consultant
against his junior staff – communicate with the
houseman to avoid unnecessary
embarrassment
• Follow up on pts where comments have been
accepted ie. supplies and instructions on usage
Specialisation
• Collins English Dictionary and Thesaurus:
defines special as ‘distinguished’ or ‘set
apart from’
• Specialisation ~ characteristics that
distinguish a clinical pharmacist from other
pharmacists
• Obtained thru’ further education and
training
Nursing profession development
•
•
•
•
Shift in promotion ladder *
Dual career pathway
management ☞sister – matron
Clinical nurse ☞ advanced practice nurse
(same ranking as sister/tutor)
• Similar to UK and Canada situation
*Nafsiah Shamsudin. Specialisation of the clinical nurse in the
Malaysian setting. Sept. 2000.
Specialisation
•
•
•
•
Extra qualifications preferable
Sometimes not necessary
MSc, MPharm
PhD
• Experience, confidence, way of thinking,
networking, research-oriented, etc
Specific situations
• Asthma
• Counselling
• Pharmacoherapy issues ie. Drug of
choice: β-2 agonists (short-acting, longacting, corticosteroids (inhaled , oral),
• Drug forms: inhalers, oral tablets, nebs
Other roles
• Conformance to guidelines: MTS, GINA
• Research: eg.
drug use
clinical trials on outcomes of pharmacist-treated
pt vs non-pharmacist pts, counselled vs noncounselled
Inhaler technique – relate to outcomes
• Asthma clinic – check peak flow, compliance to
tx, appointments for counselling, etc
What others have achieved…
• Pediatric asthma management programme
Covenant Health System, Texas, US ±
• Found many asthma pts admitted for various
reasons ie. Lack of medication, non-compliance,
improper inhaler technique
• Remedy: face-to-face counselling. Pharmacists
counselled pts and families
• Complete pt information leaflets given,
videotapes
• Spent 30-60 mins per pt
± Razia M, Gordon H. Am J Health-Syst Pharm 2002;59. p. 1829.
results
• 69 pt counselled: 106 vs 51 ER visits or
admissions pre and post counselling
(↓52%)
• Cost avoidance: USD126,500/=
→ Counselling beneficial and reduces
admission rates.
COPD
C.O.P.D.-X Plan
• C = Confirm diagnosis, severity,
complications
• O = Optimise patient function
(impairment, disability and
handicap)
• P = Prevent deterioration
• D = Develop self-monitoring and
self-management care plan
• X = guide for managing
exacerbations
C….confirm...
• Exclude asthma, cardiac disease
etc
• Assess severity
• Assess reversible components
• Identify complications and coexisting conditions
– history, examination, spirometry, xray
chest, FBE
O….optimise….
– Smoking cessation
– Optimise drugs
• safe and effective - don’t over-prescribe
– Treat complications
– Optimise psychosocial issues
– Optimise nutrition (consider dietician)
– Encourage exercise (consider physio gym)
– Pulmonary rehabilitation
– Lung reduction surgery or transplantation
P….prevent….
– Smoking cessation (help and monitor)
• AAAAA
– Occupation and other dusts
– Stop unhelpful drugs
– Prevent infections
• influenza vaccination (?Pneumococcal)
• relevant antibiotics for purulent sputum and
fever
– Pulmonary Rehabilitation
– Transplantation
P….prevent….
– Check for complications & concurrent
conditions
• osteoporosis, depression, cor pulmonale,
OSA/hypoventilation
– Consider oxygen if hypoxaemic
– Regular review
• lung function
D….discuss, develop….
• Educate patient and carers
• Pulmonary Rehabilitation and
Patient Support Groups
• Assess self-management capacity
• Develop a collaborative care plan
– monitor to identify exacerbations early
– how to self-initiate treatment
– what to do in an emergency
X… Exacerbations
• Inhaled bronchodilators and systemic
glucocortocoids are effective treatments
for acute exacerbations (Evidence A)
• Patients with clinical signs of
infection(change in sputum colour and/or
fever, leucocytosis) benefit from antibiotics
(Evidence A)
Asthma Action Plan
• Designed for pts with asthma to:
^ recognise deterioration and
^ respond appropriately
• Action Plan will prevent
^ delay of initiation of preventer dose
increases
^ prolonged exacerbation
^ adverse effects on pts life
Peak Flow Monitoring
• Peak Expiratory Flow (PEF) – the greatest flow
velocity which can be generated during a forced
expiration starting with fully inflated lungs
• Simple, quantitative, reproducible measure of
airway obstruction
• Meters are cheap, lightweight and portable
• Repeated measures highly reproducible with
each individual patient, if the same meter is used
Peak Flow Monitoring
• Actual number not important, but the trend is
• Measures response to bronchodilator therapy –
increase by 20% post treatment (provided the
baseline reading > 300ml/min adults)
• Measures early deterioration before pt. feels the
change in his disease
{diabetics monitor blood sugar,
asthmatics measure lung function…}
Pulmonary Rehabilitation
Program
• Established in the Repatriation General
Hospital, Adelaide since many yrs ago
• A structured program using weekly lectures
spanning over 3 months
• 2 hrs session (1 hr lecture each person )
@1.30pm
• Coordinated by the Resp. Rehab. Clinic
• Pharmacist
• Talked about “Medications and Airways
Disease”
PRP team
• Respiratory physician (Chairman),
• Technical officer, Respiratory Function Unit
• Clinical Nurse Consultant, Respiratory Rehab
Clinic
• Clinical Pharmacist
• Physiotherapist
• Rehabilitation Counsellor
• Dietician
• Occupational therapist