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A CPPE interactive PDF learning programmeCENTRE FOR PHARMACY
POSTGRADUATE EDUCATION
CLICK TO ENTERUpdated July 2016
High-riskmedicinesand MURs
n e x tb a c k
Thank you for downloading this CPPE interactive learning programme. We hope that you will find it a fun and informative way to help you learn about high-risk medicines and medicines use reviews (MURs).
Welcome to High-risk medicines and MURs
The Centre for Pharmacy Postgraduate Education (CPPE) offers a wide range of learning opportunities in a variety of formats for pharmacy professionals from all sectors of practice. We are funded by Health Education England to offer continuing professional development for all pharmacists and pharmacy technicians providing NHS services in England. For further information about our learning portfolio, visit: www.cppe.ac.uk
Learning with CPPE
This document uses interactive features that may not be supported if you are using it on a mobile device. For best results, please use on your PC or laptop, using anup-to-date version of Adobe Reader.
CONTENTS
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This programme contains the following sections:
Click on a title to go directly to that section.
How to use this learning programme
About High-risk medicines and MURs
Learning objectives
What are high-risk medicines?
High-risk medicines and MURs
Introduction to the activities
Introductory quiz
Reflective questions and targeted MUR resources
High-risk medicines – targeted MUR scenarios
Test your knowledge quiz
Next steps
References
Programme credits
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55
10
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2
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How to use this learning programme
This programme uses an interactive PDF format. You
can navigate your way through by using the arrows in
the bottom right corner of each page. Where directed,
you can also navigate to sections by clicking on text or
images. Hovering over bold and coloured text will reveal
additional information. The programme uses quizzes,
reflective questions, scenarios and web links to help you
explore this topic. You will need to be connected to the
internet to access the web links.
In some of the activities, there will be space for you
to type answers to the questions. You can save your
answers by saving this document to your computer. You
can also view our suggested answers – these are hidden
behind the Reveal answer text.
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We would recommend that you keep notes as you go along
as these could be ideal to generate CPD records.
If you are using a printed version of this programme, you will
not be able to view our suggested answers. To see these,
either open this document on your computer or download
the separate answers document from the CPPE website.
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The aim of this programme is to support pharmacy teams
in improving their knowledge of high-risk medicines and for
pharmacy professionals to identify how they can minimise
adverse events and improve patient understanding. We will
explore signs and symptoms, monitoring, education and advice
in relation to a range of high-risk medicines.
This programme features a range of activities which include
quizzes, reflective questions and scenarios relevant to targeted
MURs for high-risk medicines to support your personal
development and practice. It is also linked to a set of quick
practice guides on targeted MURs from the Wales Centre for
Pharmacy Professional Education (WCPPE).
About High-riskmedicines and MURs
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By the end of this learning programme, you should be able to:
define the term ‘high-risk medicines’ and update your knowledge
of them
determine what education and advice patients taking high-risk
medicines need
describe the signs and symptoms that would prompt a referral
identify actions to minimise risk to patients in your pharmacy
consider your professional judgement in the programme’s targeted
MUR scenarios relating to high-risk medicines and identify areas for
self-development.
Learning objectives
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The Patient Safety First campaign defines high-risk medicines as
‘medicines that are most likely to cause significant harm to the patient,
even when used as intended’.1
In your answer, you may have included a list of medicines that you
consider to be high risk. We will be looking at a number of high-risk
medicines in this programme, including the four groups of medicines
identified for high-risk medicines targeted MURs. A list of the drugs and
drug groups we will be looking at can be viewed in the word clouds on
pages 14 and 15. The Northern Ireland Centre for Pharmacy Learning
and Development determine that high-risk medicines are so called
because they may have:
• a narrow therapeutic range; therefore there is little difference
between sub-therapeutic, therapeutic and toxic doses
• serious side-effects when administered incorrectly or a dose is
calculated incorrectly.2
The United States Institute for Safe Medication Practices reports that
although the incident rates for groups of high-risk medicines may not be
necessarily higher than other medicines, when incidents do occur the
impact on the patient can be significant.1
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What are high-risk medicines?How do you define high-risk medicines? Type your answer below.
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The medicines listed for high-risk targeted MURs are those that are
listed in the following sections of the British National Formulary
(BNF):
• 2.2 Diuretics
• 2.8.1 and 2.8.2 Anticoagulants
• 2.9 Antiplatelets
• 10.1.1 Non-steroidal anti-inflammatory drugs (NSAIDs)
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An MUR involves reviewing the patient’s use of their medication,
ensuring they understand how their medicines should be used and
why they have been prescribed, identifying any problems and then,
where necessary, providing feedback to the prescriber. This supports
the principles of the NHS Constitution by working across boundaries,
providing value for money and meeting standards of excellence and
professionalism.
National target groups have been agreed in order to guide the selection
of patients to whom the service will be offered. One of the national
target groups is patients taking high-risk medicines. In June 2011, a
national reference group, including representatives from organisations
such as the Pharmaceutical Services Negotiating Committee (PSNC) and
NHS Employers, agreed that the following principles should determine
the list of high-risk medicines:
• the medicines should be associated with preventable harm, for
example, avoidable hospital admissions
• medicines should be selected where harm can be caused to the
patient by omission, overuse or incorrect use and where the
benefits of not taking the medicine are foregone
• the type of harm caused by the medicines could be prevented
by an MUR and the pharmacist will have the skills, knowledge and
information to deliver it.
High-risk medicines and MURsWhich groups of medicines are identified for high-risk
medicines targeted MURs? Type your answer below.
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PSNC provides a number of useful resources including a
list of suggested questions that have been developed to
help shape the discussion you have with patients during
the MUR consultation.
The CPPE guide Targeting your MURs more effectively
is designed to help you explore ways of targeting those
patients who will benefit most from MURs. Click on the
image opposite to access it (you will need to click on
login to log in first, then click on the PDF icon), or visit
www.cppe.ac.uk to read more about our series of guides.
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This programme contains two e-challenge type quizzes, ten reflective question sections on high-risk medicines / medicine groups and
four high-risk medicines targeted MUR scenarios, all of which can be used to support your personal development and professional
practice. The activities will give you an opportunity to explore high-risk medicines and identify how to minimise their risk to patients.
Hover your cursor over the headings below to reveal more information about each type of activity.
Introduction to the activities
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Introductory quiz
A reduction in avoidable medicines-related hospital
admissions is linked to the government’s Quality, Innovation,
Productivity and Prevention (QIPP) programme. Pharmacy’s
contribution to the monitoring of patients taking high-risk
medicines can help to reduce hospital admissions.
Before you move on, why not test your existing knowledge
about high-risk medicines and their impact on patient safety.
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To refresh your knowledge of high-risk medicines, their uses,
appropriate doses, side-effects and interactions, the BNF
is a good starting point. Here you will find key information
relating to these groups of medicines.
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The programme is linked to a set of quick practice guides on
targeted MURs produced by WCPPE. This section is divided into
two parts, which we will describe on the next two pages.
We have included in this programme:
• drugs that have a narrow therapeutic index or risk causing
significant harm even when used as intended
• medicines where harm can be caused to the patient by
omission, overuse or incorrect use and where the benefits of
not taking the medicine are foregone.
Reflective questions andtargeted MUR resources
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Part 1 includes high-risk medicines / medicine categories that are identified for high-risk medicines targeted
MURs. You can click on a title in the word cloud below to go directly to that activity – you will be able to return
to this menu by clicking on Click to return to Part 1 menu at the end of each question set.
NSAIDs
antiplateletsthiazides
warfarin
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Part 2 of this section includes other high-risk medicines / medicine categories highlighted in the WCPPE
guides. You can click on the titles in the word cloud below to go directly to that activity – you will be able to
return to this menu by clicking on Click to return to Part 2 menu at the end of each question set.
Antihypertensives
lithiumcorticosteroids*
insulin andantidiabetic drugsmethotrexate
theophylline preparations
*oral and inhaled
Your answer may include the following:
• checking with the patient why the NSAID has been prescribed -
generally NSAIDs should be used for the shortest time and at
the lowest dose needed to control symptoms
• NSAIDs can increase blood pressure. For patients taking
etoricoxib, blood pressure should be checked within two weeks
of starting therapy and periodically thereafter
• signposting the patient with chronic pain to self-help leaflets and
websites
• counselling the patient to take their NSAIDs with or after food
• it might be appropriate to encourage patients to think about
appropriate ways to remain active, within any limitations
imposed by their concurrent medical condition. Consider
discussing weight loss (if body mass index is above 25 kg/m2)
if this is the factor that is worsening their underlying condition
• advising the patient not to take any over-the-counter (OTC)
aspirin/ibuprofen or other OTC NSAIDs with their medication
• advising the patient that, regardless of whether they are
co-prescribed a proton-pump inhibitor (PPI) or not, they should
report any gastrointestinal symptoms to the prescriber.
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NSAIDs are one of the groups of medicines in the target group for
high-risk medicines MURs. NICE guidance requires all patients
prescribed NSAIDs for osteoarthritis or rheumatoid arthritis or patients
over 45 who are prescribed NSAIDs for lower back pain to be
co-prescribed gastro-protection (eg, a proton-pump inhibitor).3, 4, 5
Education and advice – what advice could you give to a patient
who is taking NSAIDs?
Part 1 NSAIDs
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Your answer may include:
• black or ‘coffee ground’ stools, or vomit, suggesting gastrointestinal bleeding
• iron deficiency anaemia, suggesting chronic gastrointestinal bleeding (eg,
fatigue, dizziness, pale skin, shortness of breath)
• pregnancy and breastfeeding
• swollen ankles or feet
• unexplained, persistent recent-onset dyspepsia.
Other considerations:
• Does the NSAID used seem appropriate, considering their cardiovascular and
gastrointestinal risk?
• If gastro-protection is not co-prescribed, consider referral for review/
gastrointestinal assessment, particularly in cases of long-term use, age over
65, past gastrointestinal history, co-prescribing of other medicines such as
selective serotonin re-uptake inhibitors (SSRIs), aspirin, etc.
• If the patient is elderly, has ischaemic heart disease or has risk factors for
cardiovascular disease, consideration for monitoring blood pressure and renal
function should be given.6, 7
• The MRHA has advised that diclofenac is contraindicated in patients
with established ischaemic heart disease, peripheral arterial disease,
cerebrovascular disease and congestive heart failure (New York Heart
Association [NYHA] classification II–IV). Patients with these conditions should
be switched to an alternative treatment at their next routine appointment.
• An EU review also found that the cardiovascular risk of high dose ibuprofen
(greater than 2400 mg/day) is similar to that of diclofenac. Doses of
ibuprofen greater than or equal to 2400 mg/day should be avoided in
patients with established ischaemic heart disease, peripheral heart disease,
history of stroke, heart failure or uncontrolled hypertension. In patients with
significant risk factors for cardiovascular events, the benefits and risks of
treatment with high-dose ibuprofen should be carefully considered.
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Monitoring – what signs or symptoms would prompt the need for a referral?
Medicines and Healthcare products Regulatory Agency, Drug Safety Update:
High-dose ibuprofen (greater than or equal to 2400mg/day): small increase in
cardiovascular risk [internet] 2015.
Available from: www.gov.uk/drug-safety-update/high-dose-ibuprofen-2400mg-day-
small-increase-in-cardiovascular-risk
When identifying actions to improve your practice, you may want
to consider:
• engagement with GP practices – which patients would they
want referred (for example, those on a long-term NSAID with no
gastro-protection)
• national and local guidance – which NSAIDs are recommended
locally
• patient identification and prioritisation
• staff training
• standard operating procedures.
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Improving your practice – what do you need to do to ensure the risks are
minimised for this patient group in your pharmacy?
Don’t forget to save your answers Click to return to Part 1 menu
More information can be found in the Non-steroidal anti-inflammatory drugs section
of the BNF and WCPPE has produced a quick practice guide for targeted MURs for
NSAIDs.
The Medicines and Healthcare products Regulatory Agency (MHRA) has released a
drug safety update on diclofenac.
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Oral antiplateletsAntiplatelet drugs are one of the groups of medicines in the target group
for high-risk medicines MURs. See the Antiplatelet drugs section of the
BNF for a full list of these drugs.
Education and advice – what advice could you give to a patient who is
taking oral antiplatelets?
Your answer may include:
• advising the patient to discard dipyridamole modified-release
capsules six weeks after opening
• counselling the patient on reducing alcohol intake and stopping
smoking
• ensuring tablets are taken with or after food (aspirin and
dipyridamole: slow release; immediate release should be taken
30 to 60 minutes before food)
• checking that the patient knows whether they are taking
clopidogrel for a year or longer term depending on stent or
stroke
• giving lifestyle advice.
When identifying actions to improve your practice, you may want
to consider:
• engagement with GP practices – discuss with GPs what
feedback they would like and what is urgent or routine
• national and local guidance
• patient identification and prioritisation
• staff training (CPPE offers a learning programme on new
medicine service consultations for patients newly prescribed
anticoagulants and antiplatelets)
• standard operating procedures.
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Monitoring – what signs or symptoms would prompt the need for a referral?
Improving your practice – what do you need to do to ensure the risks are
minimised for this patient group in your pharmacy?
Don’t forget to save your answers Click to return to Part 1 menu
Your answer may include:
• chronic gastrointestinal bleeding (severe abdominal pain,
vomiting blood, tarry black or blood mixed with stools, feeling
out of breath and dizziness)
• heaviness in the centre of chest
• severe itching or rash
• unusual bruising or bleeding
• pregnancy or breastfeeding.
More information can be found in the Antiplatelet drugs section of the BNF. Also,
WCPPE has produced a quick practice guide on targeted MURs for oral antiplatelets.
Your answer may include:
• checking the reason for warfarin and length of treatment (eg,
calf-vein thrombosis for six weeks, or three months for VTE with
transient risk factor)
• advising the patient that warfarin is taken at the same time of
day, once a day with a full glass of water. If a dose is missed
they should not double the dose the next day
• checking the patient has an oral anticoagulant pack with their
record booklet and alert card and ensuring that they have a
system for recording international normalised ratio (INR) and doses
• counselling the patient on informing their INR clinic of any
changes to medication
• checking that the patient has had their INR monitored every
three months (this may be more frequent if INR is not stable)
• giving lifestyle advice.
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WarfarinAnticoagulants are one of the groups of medicines in the target group for
high-risk medicines MURs. In addition to warfarin, anticoagulants you may
see frequently are low molecular weight heparins, dabigatran, apixaban
and rivaroxaban.
Education and advice – what advice could you give to a patient who is
taking warfarin?
When identifying actions to improve your practice, you may want
to consider:
• engagement with GP practices – discuss with GPs what
feedback they would like and what is urgent or routine
• national and local guidance
• patient identification and prioritisation
• staff training
• standard operating procedures.
Your answer may include:
• signs of bleeding
• signs of thrombosis (pain, swelling, tenderness usually in calf,
redness of skin)
• rash, skin necrosis
• headaches/confusion
• pregnancy.
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Monitoring – what signs or symptoms would prompt the need for a referral?
Improving your practice – what do you need to do to ensure the risks are
minimised for this patient group in your pharmacy?
More information can be found in the warfarin sodium section of the BNF. There is also
an National Patient Safety Agency (NPSA) safety alert for safer anticoagulant therapy.
WCPPE has produced a quick practice guide on targeted MURs for warfarin and CPPE
has a focal point programme on anticoagulation.
Don’t forget to save your answers Click to return to Part 1 menu
Your answer may include:
• checking that the patient has their blood pressure monitored at
least every 12 months
• advising the patient to sit up and stand slowly first thing in the
morning and to drink adequate fluid
• counselling the patient on the reason for taking a diuretic
and advising them on the best time to take medication to avoid
interference with their daily routine
• counselling the patient on healthy eating, reducing salt intake,
exercise and weight loss (if body mass index is above 25 kg/m2).
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DiureticsDiuretics are one of the groups of medicines in the target group for high-risk
medicines MURs.
Education and advice – what advice could you give to a patient who is
taking diuretics?
When identifying actions to improve your practice, you may want
to consider:
• engagement with GP practices – discuss with GPs what
feedback they would like and what is urgent or routine
• national and local guidance
• patient identification and prioritisation
• staff training
• standard operating procedures.
Your answer may include:
• heaviness in the centre of chest
• fatigue
• water retention
• depression
• extreme tiredness, thirst or excessive urination
• irregular heartbeat, muscle weakness, nausea
• gout.
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Monitoring – what signs or symptoms would prompt the need for a referral?
Improving your practice – what do you need to do to ensure the risks are
minimised for this patient group in your pharmacy?
More information can be found in the diuretics section of the BNF and the National
Institute for Health and Clinical Excellence (NICE) clinical guideline CG127. WCPPE has
produced a quick practice guide on targeted MURs for thiazides and related diuretics.
Don’t forget to save your answers Click to return to Part 1 menu
Your answer may include:
• checking the patient has their blood pressure monitored at least
every 12 months
• checking the patient has their renal function checked at least
every 12 months
• at the start of treatment with a new medicine, following a
dose increase, or if dizziness occurs, advising the patient to take
medication regularly with adequate amounts of fluid and to get
up slowly first thing in the morning
• counselling patients on avoiding OTC preparations that have a
high sodium content, such as soluble tablets
• counselling patient on reducing alcohol and salt intake, stopping
smoking, healthy eating, exercise and weight loss (if body mass
index is above 25 kg/m2).
• Patients taking a combination of spironalactone and an ACE
Inhibitor or angiotensin receptor blocker (such as ramipril
or losartan) should only be taking this combination if it is
essential. This is because there is a high risk of having high
blood potassium levels with this combination. Patients taking
this combination should have their blood potassium levels and
kidney function checked regularly. You should check that they
are having these tests.
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In this section we look at antihypertensives other than thiazides and
their related diuretics.
Education and advice – what advice could you give to a patient
who is taking antihypertensives?
Part 2 Antihypertensives
Medicines and Healthcare products Regulatory Agency, Drug Safety Update:
Spironolactone and renin-angiotensin system drugs in heart failure: risk of
potentially fatal hyperkalaemia [internet] 2016.
Available from: www.gov.uk/drug-safety-update/spironolactone-and-renin-
angiotensin-system-drugs-in-heart-failure-risk-of-potentially-fatal-hyperkalaemia
When identifying actions to improve your practice, you may want
to consider:
• engagement with GP practices – discuss with GPs what
feedback they would like and what is urgent or routine
• national and local guidance
• patient identification and prioritisation
• patient compliance
• patient’s risk of falls
• staff training
• standard operating procedures.
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Monitoring – what signs or symptoms would prompt the need for a referral?
Improving your practice – what do you need to do to ensure the risks are
minimised for this patient group in your pharmacy?
More information can be found in the cardiovascular system section of the BNF and
NICE’s clinical guideline CG127. WCPPE has produced a quick practice guide for
targeted MURs for antihypertensives. NB in England, patients over 65 and those with
hypertension and cardiac complications qualify for an annual influenza vaccination.
Those with hypertension alone would not qualify.
Don’t forget to save your answers Click to return to Part 2 menu
Your answer may include:
• dizzy spells or falls
• heaviness in the centre of chest
• fatigue
• water retention
• depression
• extreme tiredness, thirst or excessive urination
• any other side-effect that is limiting compliance.
Your answer may include:
• checking the patient is taking oral steroids in the morning as a
single dose and has a steroid warning card
• counselling the patient on avoiding excessive alcohol intake and
stopping smoking
• checking that asthmatic patients are only using a long-acting
beta2 agonist in combination with a regular inhaled corticosteroid
• counselling the patient on inhaler technique - if soreness or dry
mouth remains problematic despite good inhaler technique a
spacer device could be considered
• asking the patient how long they have been taking oral steroids
• giving lifestyle advice
• ensuring that patients rinse their mouth or clean their teeth after
using inhaler corticosteroids
• advise the patient to use inhaled steroid regularly and to use as a
preventer - remind them it is different to a reliever.
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CorticosteroidsCorticosteroids are one of the groups of medicines in the target group for
respiratory MURs.
Education and advice – what advice could you give to a patient who is
taking oral or inhaled corticosteroids?
When identifying actions to improve your practice, you may want
to consider:
• engagement with GP practices – discuss with GPs what
feedback they would like and what is urgent or routine; set up
a meeting with the local asthma nurse
• national and local guidance
• patient identification and prioritisation
• staff training
• standard operating procedures
• obtaining placebo inhalers to check technique
• obtaining a device (eg, In-Check®) for checking that patients
are inhaling at the appropriate rate for their inhaler device as
part of a check of their inhaler technique.
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Monitoring – what signs or symptoms would prompt the need for a referral?
Improving your practice – what do you need to do to ensure the risks are
minimised for this patient group in your pharmacy?
More information can be found in the corticosteroids section of the BNF and NICE’s clinical
guideline CG101. For side-effects, refer to BNF Airways disease, use of corticosteroids.
WCPPE has produced a quick practice guide on targeted MURs for respiratory disease and
inhaler manufacturers sometimes provide clips on YouTube on how to use their inhalers,
that you might want to signpost patients to eg, www.youtube.com/watch?v=rH5fPcslZY0 and
technique videos available on the CPPE website.
Don’t forget to save your answers Click to return to Part 2 menu
Your answer may include:
• paradoxical bronchospasm (a constriction of the airways after
treatment with a sympathomimetic bronchodilator)
• symptoms of uncontrolled asthma (cough, wheeze, tight chest)
• frequent courses of antibiotics and/or oral corticosteroids
• nausea, vomiting, weight loss, fatigue, headache, muscular
weakness
• if the patient has not had their asthma or COPD reviewed in the
last year refer for a review.8
Your answer may include:
• checking the patient has attended their annual diabetic review
and ask for their latest HbA1c result
• advising the patient to take medication regularly and alert them
to the warning signs of hypoglycaemia
• counselling the patient on reducing alcohol intake and on healthy
eating, exercise and weight loss (if body mass index is above
25 kg/m2)
• checking that patients on insulin therapy have an insulin passport
and that they have notified the Driver and Vehicle Licensing
Agency of their condition
• ensuring that patients are aware of safe disposal of needles and
sharps and never reuse sharps
• give advice on storage of insulin and on travelling with insulin.
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Insulin and antidiabetic drugsEducation and advice – what advice could you give to a patient who is
taking insulin or antidiabetic drugs?
When identifying actions to improve your practice, you may want
to consider:
• engagement with GP practices – discuss with GPs what
feedback they would like and what is urgent or routine
• national and local guidance
• patient identification and prioritisation
• staff training
• standard operating procedures.
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Monitoring – what signs or symptoms would prompt the need for a referral?
Improving your practice – what do you need to do to ensure the risks are
minimised for this patient group in your pharmacy?
More information can be found in the drugs used in diabetes section of the BNF and NICE
guideline NG28. There is also a NPSA safety alert for safer administration of insulin. WCPPE has
produced a quick practice guide on targeted MURs for diabetes and CPPE has an e-learning
programme on the evidence-based management of diabetes (created by the Northern Ireland
Centre for Pharmacy Learning and Development) and a focal point programme on type 2
diabetes.
Don’t forget to save your answers Click to return to Part 2 menu
You answer may include:
• recurring episodes of hypoglycaemia (sweating, palpitations,
confusion, drowsiness)
• signs of diabetic ketoacidosis (nausea, vomiting, drowsiness)
• any symptoms of liver toxicity, heart failure or pancreatitis
(jaundice, abdominal pain, vomiting, fluid in abdomen, fatigue,
breathlessness, swollen ankles)
• ulceration of foot tissue
• if the patient has been testing blood glucose levels and tells you
that they are often high or erratic.
Your answer may include:
• counselling the patient on the signs of toxicity, side-effects
and maintaining a constant and adequate salt and water intake
(especially if they have an infection or during spells of hot
weather or in a hot environment)
• checking the patient has regular blood, kidney and thyroid tests,
knows the importance of staying on the same brand of lithium
and has a lithium booklet and alert card
• advising the patient on OTC interactions and to avoid alcohol
• counselling the patient on the risks of driving if they feel sleepy
and the importance of not stopping taking lithium suddenly
unless advised by a doctor.
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LithiumEducation and advice – what advice could you give to a patient who is
taking lithium?
When identifying actions to improve your practice, you may want
to consider:
• engagement with GP practices – discuss with GPs what
feedback they would like and what is urgent or routine;
ensure lithium is prescribed by brand name
• national and local guidance patient identification and
prioritisation
• staff training
• standard operating procedures.
Your answer may include:
• sickness and diarrhoea
• blurred vision, coarse tremor, drowsiness, unsteadiness,
confusion
• increased thirst or passing a lot of urine
• pregnancy and breastfeeding.
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Monitoring – what signs or symptoms would prompt the need for a referral?
Improving your practice – what do you need to do to ensure the risks are
minimised for this patient group in your pharmacy?
More information can be found about lithium in the antimanic drugs section of the BNF
and NICE’s clinical guideline CG185. There is also an NPSA safety alert for safer lithium
therapy and Patient.co.uk provides information on toxicity for patients. WCPPE has produced
a quick practice guide on targeted MURs for lithium.
Don’t forget to save your answers Click to return to Part 2 menu
Your answer may include:
• advising patients to have full blood count and renal and liver
function tests before starting treatment, which should be
repeated every one to two weeks until therapy stabilises and
monitored every two to three months thereafter
• counselling the patient that methotrexate tablets are taken once
a week, on the same day
• counselling the patient on the importance of effective
contraception during treatment
• advising the patient to avoid OTC preparations containing
NSAIDs/aspirin
• advising the patient that the beneficial effect from methotrexate
may not occur for up to 12 weeks and may take as long as six
months for full effect.
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MethotrexateEducation and advice – what advice could you give to a patient who is
taking methotrexate?
When identifying actions to improve your practice, you may want
to consider:
• engagement with GP practices – discuss with GPs what
feedback they would like and what is urgent or routine
• national and local guidance patient identification and
prioritisation
• staff training
• standard operating procedures.
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Monitoring – what signs or symptoms would prompt the need for a referral?
Improving your practice – what do you need to do to ensure the risks
are minimised for this patient group in your pharmacy?
More information can be found about methotrexate in the drugs that suppress the
rheumatic disease process section of the BNF and NICE’s clinical guideline CG79. There
is also an NPSA safety alert for safer methotrexate therapy. WCPPE has produced a quick
practice guide on targeted MURs for methotrexate and CPPE has a focal point programme
available on rheumatoid arthritis.
Don’t forget to save your answers Click to return to Part 2 menu
Your answer may include:
• severe sickness or diarrhoea
• severe itching or rash
• signs of liver or pulmonary toxicity
• pregnancy and breastfeeding
• close contact with someone with chickenpox or shingles
if the patient has never had these infections.
Your answer may include:
• checking whether the patient has a self-management plan and
their asthma/COPD is well controlled
• counselling the patient on potential interactions with theophylline
and the need to check with a pharmacist or doctor before
taking any new medication (including OTC, prescribed or herbal
medicines)
• checking that the patient has had an annual influenza vaccination
• giving lifestyle advice
• educate patients that it is that important they stick to the same
brand of theophylline.
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Theophylline preparationsTheophylline preparations are one of the groups of medicines in the target
group for respiratory MURs.
Education and advice – what advice could you give to a patient who is
taking theophylline preparations?
When identifying actions to improve your practice, you may want
to consider:
• engagement with GP practices – discuss with GPs what
feedback they would like and what is urgent or routine; set up
a meeting with the local asthma nurse
• national and local guidance
• patient identification and prioritisation
• staff training
• standard operating procedures.
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Monitoring– what signs or symptoms would prompt the need for a referral?
Improving your practice- what do you need to do to ensure the risks are
minimised for this patient group in your pharmacy?
More information can be found in the theophylline section of the BNF and NICE’s clinical
guideline CG101. WCPPE has produced a quick practice guide on targeted MURs for
respiratory disease.
Don’t forget to save your answers Click to return to Part 2 menu
Your answer may include:
• symptoms of uncontrolled asthma (cough, wheeze, tight chest)
• theophylline toxicity (vomiting, agitation, pupil dilation,
hypokalaemia)
• frequent courses of antibiotics and/or oral corticosteroids
• nausea, vomiting, weight loss, fatigue, headache, muscular
weakness
• check that the patient is receiving serum drug level monitoring.
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An MUR gives you the opportunity to check the patient’s knowledge of their
medicines, as well as the appropriateness and safety of those medicines.
Before you start, you may want to look at the MUR suggested questions
produced by PSNC and NHS Employers.
Note down why you think this set of questions can help you to provide an
effective MUR for patients.
High-risk medicines – targeted MUR scenarios
You may have identified that the majority of them are open
questions to get the patient talking, bringing out any issues
which are important to them. You can use the questions to help
shape your discussion.
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Here are four short scenarios to support your personal development and practice. The scenarios
cover the groups of medicines that are identified for high-risk medicines targeted MURs. Click
on the medicine categories below to access each of the scenarios – you will be able to return to
this menu by clicking on Click to return to scenarios menu at the end of each question set.
antiplateletsdiureticsanticoagulantsNSAIDs
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Peter Scahill is 58 and was recently prescribed amiodarone when
he was admitted to hospital. Since he was discharged he has been
taking the dose all in one go. His INR is usually in range and he has
a check due next week.
Currently, Peter is on the following medicines:
• warfarin 3 mg: as directed by the INR clinic
• amiodarone 200 mg: one tablet each day
• digoxin 125 micrograms: one tablet each day.
Anticoagulants
Learning pointsOne of the main types of preventable harm associated with anticoagulant
therapy is omitted doses. View the patient’s oral anticoagulation therapy
book to check that regular monitoring is taking place and the INR is
within the recommended range. Record this information in the patient
medication record (PMR).
Checklist
Have you advised the patient about:
• interactions with medicines (for more details on increased toxicity for
amiodarone/digoxin, look up these medicines in the list in appendix 1
of the BNF)
• side-effects
• missed doses or difficulty taking medicines
• warning signs for over-anticoagulation (eg, bleeding/bruising) and when
necessary contact the patient’s GP
• food and vitamins that can affect INR
• regular INR monitoring?
Red flags that need referral
• Signs of bleeding or thrombosis (eg, bleeding gums, nose bleeds).
• Rash, purpura (a purplish discoloration of the skin produced by small
bleeding vessels near the surface), bruising, nose bleeds, purple toes,
skin necrosis.
• Diarrhoea and vomiting.
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1. What are the key points you could include in an MUR for this patient?
2. What could you include in the action plan?
Other considerations
• Check that the liver and thyroid function monitoring is being done
at intervals.
• Amiodarone can increase the blood levels of digoxin – has the
dose of digoxin been reduced to take account of this (see BNF
section – cardiac glycosides)? For safety, blood tests may be
required.
Minimising risks
• Do you have a standard operating procedure for assessing the
clinical appropriateness of prescriptions and is this effective for
ensuring that any issues are identified?
• Are the dispensary staff aware of the criteria for undertaking an
MUR? NB It is acceptable to do an MUR for a patient on one
regular item if this item is in the high-risk target group.
• Are the medicines counter assistants using WWHAM (Who is the
patient, What are the symptoms, How long have the symptoms
been present, Action taken, Medication being taken) questions
when talking to patients?
• Is staff training needed to recognise high-risk medicines
prescriptions?
• Are all interventions recorded on the PMR?
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3. What actions or development do you need to take to ensure risks are
minimised for this patient group in your pharmacy?
To refresh your knowledge on anticoagulants, view WCPPE’s quick practice guide on
targeted MURs for anticoagulants. NB in England, patients over 65 and those with
hypertension and cardiac complications qualify for an annual influenza vaccination. Those
with hypertension alone would not qualify. You can find out more about interactions in
appendix 1 of the BNF and more about cardiac glycoside.
Don’t forget to save your answers Click to return to scenarios menu
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Nina Garcia is 72 and has diabetes. She has recently been
prescribed fluoxetine for depression.
Her current medicines include:
• aspirin dispersible 75 mg: one tablet each morning
• dipyridamole 200 mg modified release: one capsule twice
a day
• fluoxetine 20 mg: one capsule each morning
• gliclazide 80 mg: one tablet each morning
• metformin 500 mg: one tablet three times a day
• simvastatin 40 mg: one tablet a day.
Antiplatelets
Learning pointsThe main type of preventable harm associated with antiplatelet
therapy is the increased risk of haemorrhagic complications,
particularly gastrointestinal bleeding,9 and they account for around
16 percent of medicines-related hospital admissions.10
Checklist
Have you advised the patient about:
• taking simvastatin at night time and avoiding grapefruit juice
• the side-effects of dipyridamole, including gastrointestinal effects,
headache, hypotension or dizziness
• missed doses or difficulty taking medicines
• taking aspirin with or after food
• annual renal and liver function tests
• taking metformin and gliclazide regularly to control blood glucose
levels
• why they are taking antiplatelet medication (from the combination
of aspirin and dipyridamole you may suspect that this could be
due to a transient ischaemic attack)?
Red flags that need referral
• Chronic gastrointestinal bleeding, persistent vomiting.
• Heaviness in the centre of chest, fatigue, water retention or dizziness.
• Whilst most patients do not suffer muscle side-effects, the patient
should report any unexplained muscle pain or weakness to their GP.
• Bruising or nose bleeds.
• Severe itching or rash.
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1. What are the key points you could include in an MUR for this patient?
2. What could you include in the action plan?
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Other considerations
• Fluoxetine in conjunction with aspirin increases the risk of gastric
bleeding.
• Fluoxetine can take several weeks to have a therapeutic effect.
Minimising risks
• Do you have a standard operating procedure for assessing the
clinical appropriateness of prescriptions and is this effective for
ensuring that any issues are identified?
• Are the dispensary staff aware of the criteria for undertaking an
MUR? NB It is acceptable to do an MUR for a patient on one
regular item if this item is in the high-risk target group.
• Are the medicines counter assistants using WWHAM questions
when talking to patients?
• Is staff training needed to recognise high-risk medicines
prescriptions?
• Are all interventions recorded on the PMR?
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3. What actions or development do you need to take to ensure risks are
minimised for this patient group in your pharmacy?
To refresh your knowledge on antiplatelets, view WCPPE’s quick practice guide on
targeted MURs for oral antiplatelets. You can find out more about interactions in
appendix 1 of the BNF.
Don’t forget to save your answers Click to return to scenarios menu
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Masood Ashmel is 69 and has not been taking his medication regularly
as it makes him feel tired in the day. He is struggling to lose weight and
has been taking some vitamin supplements to give him more energy.
His current medicines include:
• amlodipine 5 mg: one tablet each day
• atenolol 25 mg: one tablet each day
• bendroflumethiazide 2.5 mg: one tablet each morning
• ramipril 10 mg: one tablet each day
• simvastatin 20 mg: one tablet each evening.
Diuretics
Learning pointsThe main type of preventable harm associated with diuretic therapy is hospital admission due to non-adherence. A study has found that many admissions associated with diuretics were due to falls relating to hypotension and electrolyte disturbances.11
ChecklistHave you advised the patient about:• interactions with medicines, eg, avoiding grapefruit products (for
more details on drug interactions for diuretics and beta-blockers, look up these groups in the list in appendix 1 of the BNF)
• side-effects• missed doses and difficulty taking medicines• fluid and salt intake• foods and vitamins• taking simvastatin at night time?
Red flags that need referral• Heaviness in the centre of the chest, fatigue or water retention.• Feeling generally out of sorts, irregular heart beat and muscle weakness. • Intermittent dull, cramping pain in legs that disappear at rest.• Symptoms of depression or confusion.• Problematic dizziness could increase the risk of falls.• Unexplained muscle pain or weakness.• Thiazide diuretics (eg, bendroflumethiazide) can cause impaired
glucose tolerance. Furosemide and spironolactone are not known to do this.
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1. What are the key points you could include in an MUR for this patient?
2. What could you include in the action plan?
Other considerations
• Amlodipine and atenolol can cause fatigue and spironolactone
may cause drowsiness or there may be another cause for this.
Refer Masood back to his GP
• The weight that the patient is struggling to shift could be fluid
weight in his ankles due to a side-effect of amlodipine and/or his
heart condition.
Minimising risks
• Do you have a standard operating procedure for assessing the
clinical appropriateness of prescriptions and is this effective for
ensuring that any issues are identified?
• Are the dispensary staff aware of the criteria for undertaking an
MUR? NB It is acceptable to do an MUR for a patient on one
regular item if this item is in the high-risk target group.
• Are the medicines counter assistants using WWHAM questions
when talking to patients?
• Is staff training needed to recognise high-risk medicines
prescriptions?
• Are all interventions recorded on the PMR?
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3. What actions or development do you need to take to ensure risks are
minimised for this patient group in your pharmacy?
To refresh your knowledge on diuretics, view WCPPE’s quick practice guide on targeted
MURs for patients taking thiazides and related diuretics. You can find out more about
interactions in appendix 1 of the BNF.
Don’t forget to save your answers Click to return to scenarios menu
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Mary Warren is 72 and has osteoarthritis. She has come to the pharmacy
today to collect her prescription for naproxen and asks for some
Gaviscon® tablets.
On the PMR it says that Mary is on the following medicines:
• naproxen 250 mg: one tablet twice a day
• lansoprazole 30 mg: one capsule daily.
She agrees to have an MUR. During this, she mentions that she
sometimes takes ibuprofen, which she buys from the supermarket when
the pain of her arthritis gets bad. When you question her, Mary also tells
you that she often forgets to take the lansoprazole.
NSAIDs
Learning pointsNSAIDs account for around 11 percent of medicines-related hospital
admissions.10 Studies have shown that in patients with the co-
prescription of proton pump inhibitors for gastro-protection, up to one-
third do not adhere to the gastro-protection therapy.11 Non-adherence
increases the risk of gastrointestinal bleeding. The Medicines and
Healthcare products Regulatory Agency has advised that patients
who are prescribed NSAIDs should be considered to be at increased
cardiovascular risk.12 Traditional NSAIDs may be associated with an
increased cardiovascular risk. Diclofenac (150 mg a day) appears to be
associated with a similar excess risk to that of coxibs, whereas low-
dose ibuprofen (1200 mg per day or less) or naproxen (1000 mg per
day or less) appear to be associated with a lower risk.13
NICE guidance requires all patients prescribed NSAIDs for osteoarthritis
or rheumatoid arthritis and patients over 45 who are prescribed
NSAIDs for lower back pain to be co-prescribed gastro-protection (eg, a
proton pump inhibitor).3, 4, 5
Checklist
Have you advised the patient about:
• interactions with medicines (for more details on drug interactions
for NSAIDs and analgesics, look up these groups’ side-effects in
the list in appendix 1 of the BNF)
• concomitant OTC NSAIDs
• taking with or after food
• increased cardiovascular risk
• co-prescription of medicines for gastro-protection
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1. What are the key points you could include in an MUR for this patient?
2. What could you include in the action plan?
Red flags that need referral
• Unexplained fatigue or weakness, chest pain, palpitations,
shortness of breath.
• patients taking NSAIDs who are over 65 years old, taking aspirin,
anticoagulants, SSRIs, venlafaxine, duloxetine or corticosteroids if
not taking or adhering to medicines for gastro-protection
• Patients over 55 years with unexplained, persistent recent-onset
dyspepsia.
• Pregnancy.
• Patients prescribed more than one NSAID.
• Increased risk of thrombotic events with diclofenac compared to
naproxen (up to 1 g daily) or ibuprofen (up to 1.2 g daily).
Other considerations
• Does the NSAID used seem appropriate, considering their
cardiovascular and gastrointestinal risk?
• Have you discussed with your local GPs about which patients they
would wish to be referred back (eg, those on long-term NSAIDs
with no gastro-protection or on long-term diclofenac)?
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3. What actions or development do you need to take to ensure risks are
minimised for this patient group in your pharmacy?
Minimising risks
• Do you have a standard operating procedure for assessing the
clinical appropriateness of prescriptions and is this effective for
ensuring that any issues are identified?
• Are the dispensary staff aware of the criteria for undertaking an
MUR? NB It is acceptable to do an MUR for a patient on one
regular item if this item is in the high-risk target group.
• Are the medicines counter assistants using WWHAM questions
when talking to patients and do they understand the
consequences of taking OTC NSAID with prescribed medication?
• Is staff training needed to recognise high-risk medicines
prescriptions?
• Are all interventions recorded on the PMR?
To refresh your knowledge on NSAIDs, view WCPPE’s quick practice guide on targeted
MURs on NSAIDs. You can find out more about interactions in appendix 1 of the BNF.
The MHRA has released a drug safety update on diclofenac.
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3. What actions or development do you need to take to ensure risks are
minimised for this patient group in your pharmacy? (continued)
Don’t forget to save your answers Click to return to scenarios menu
You may have identified:
• patient satisfaction feedback/survey
• prevention of a potential hospital admission
• patient visits GP for reassessment.
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For the four scenarios you have just completed, how would you know that
your MUR consultation has had a positive outcome for the patient?
You may have identified:
• reduced adverse drug reactions
• better patient understanding of treatment
• safer prescribing
• discussion of referral criteria for specific polypharmacy issues.
How might the patient outcomes for each of the four scenarios be of
benefit to the GP?
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Now that you have worked through the reflective questions and targeted
MUR scenarios, why not test your knowledge of the high-risk medicines we
have looked at in this programme.
Add some notes below if you find out something you did not know before
or if you want to look up some additional information about the group of
medicines in the BNF, Clinical Knowledge Summaries or NICE guidance.
Test your knowledge quiz
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We hope that you found WCPPE’s quick practice guides for targeted MURs
to be useful resources.
You may also want to update your knowledge on other high-risk medicines
you see in your day-to day practice, for example, amiodarone, digoxin,
phenytoin or carbamazepine. Make some notes below to consider when
counselling the patient and to improve your practice with regard to any
additional medicines you identify.
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Now that you have completed this programme what’s next?
You might like to:
• revisit the learning objectives. Are you confident that you have
achieved these?
• return to the activities: quizzes, reflective questions and scenarios. You
might like to go back over the activities and discuss the answers with
your colleagues
• complete the online assessment for this programme, which you can
access from the e-assessment portfolio or via your record on the my
CPPE page (you will need to log in).
• complete a CPD entry
• email CPPE with any feedback you might have on your learning
experience.
We hope that you have enjoyed your learning.
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Next steps
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References1. Patient Safety First. The ‘How to Guide’ for Reducing Harm from High Risk Medicines. London: DH; 2008.
2. The Northern Ireland Centre for Pharmacy Learning and Development. Medicines Governance – Improving Patient Safety. Belfast: Queen’s University Belfast; 2007.
3. National Institute for Health and Clinical Excellence. Clinical guideline 88: Low back pain – early management of persistent non-specific low back pain. 2009.
4. National Institute for Health and Care Excellence. Clinical guideline 177: Osteoarthritis – care and management in adults. 2014.
5. National Institute for Health and Clinical Excellence. Clinical guideline 79: Rheumatoid arthritis – the management of rheumatoid arthritis in adults. 2009. 6. National Institute for Health and Clinical Excellence. Clinical knowledge summaries: NSAIDS - prescribing issues - monitoring.
7. Clinical Pharmacist. Pharmacists reminded to look out for risky combination of NSAIDs and blood pressure drugs. The Pharmaceutical Journal 2013;290: 5.
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8. NHS England, the British Medical Association and NHS Employers. 2013/14 general medical services (GMS) contract quality and outcomes framework (QOF): guidance for GMS contract 2013/14. Leeds: NHS Employers; 2013.
9. Northern and Yorkshire Regional Drug and Therapeutics Centre. Safer medication use No. 7: Oral antiplatelet drugs.Newcastle upon Tyne: NHS; 2010.
10. Howard RL et al. Which drugs cause preventable admissions to hospital? A systematic review. British Journal of Clinical Pharmacology 2007;63(2): 136-147.
11. Goldstein JL et al. Impact of adherence to concomitant gastroprotective therapy on nonsteroidal-related gastroduodenal ulcer complications. Clinical Gastroenterology and Hepatology 2006;4(11): 1337-1345.
12. Medicines and Healthcare products Regulatory Agency. Non-steroidal anti-inflammatory drugs: cardiovascular risk. Drug Safety Update 2009;2(7): 3.
13. National Prescribing Centre. Implementing key therapeutic topics: 1 – NSAIDs; antibiotics; and inhaled corticosteroids in asthma. MeRec Bulletin 2012;22(3).
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Programme creditsCPPE programme manager Mandy Jackson, joint head of communications
ReviewersMike Field, regional pharmacy tutor, CPPE; Sally Greensmith, regional pharmacy tutor, CPPE; Esnat Magola, community pharmacist and teacher practitioner, University of Manchester.
Carina Livingstone, associate director, East and South East Specialist Pharmacy Services (reviewer of NSAIDs-related content).
Piloted byEmma Anderson, community pharmacist, Manor Pharmacy, Ilkeston; Anne Cole, senior clinical pharmacist, Somerset Partnership NHS Foundation Trust; Andrew Downing, community pharmacist, Somerset; Alison Marshall, medicines information pharmacist, Frimley Park Hospital NHS Foundation Trust; Rob Mitchell, pharmacy manager, SF Wain and Sons Ltd, Tameside; Steve Costello, chairman, Dorset Local Pharmaceutical Committee.
CPPE editorNeil Condron, editor
DisclaimerWe have developed this learning programme to support your practice in this topic area. We recommend that you use it in combination with other established reference sources. If you are using it significantly after the date of initial publication, then you should refer to current published evidence. CPPE does not accept responsibility for any errors or omissions.
External websitesCPPE is not responsible for the content of any non-CPPE websites mentioned in this programme or for the accuracy of any information to be found there.
ProductionGemini West, 25 Hockeys Lane, Fishponds, Bristol, BS16 3HHT: 0117 965 5252. www.gemini-west.co.uk
Published in December 2013 (originally published in February 2013) by the Centre for Pharmacy Postgraduate Education, Manchester Pharmacy School, The University of Manchester, Oxford Road, Manchester M13 9PT.www.cppe.ac.uk
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