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Pharmaceutical care of people with chronic obstructive pulmonary disease
page 2 Contentsofpack 3 Introduction 8 Pre-readingpaper 17 TeachingPlan 18 PharmaceuticalCareNeedsAssessmentTool 19 Aidememoire 22 Lecture:COPD
Course information
� pharmaceutical care of people with chronic obstructive pulmonary disease
Contents of Pack
Your pack contains:
• PharmaceuticalcareofpeoplewithCOPD–Courseinformation
• PharmaceuticalcareofpeoplewithCOPD–Courseactivities
• DVDpresentation-16:9PALformat. ThisDVDwillplayinalmostanyDVDplayer,and
anyPCorMacwithDVDplayingsoftware
ThispackwasbroughttogetherwiththehelpofDrAnneBoyter(SeniorLecturer,UniversityofStrathclyde).AlsospecialthankstotheWestofScotlandPharmacistsRespiratoryNetworkandinparticularMargaretMacDonald(NHSGreaterGlasgow&Clyde)whoreviewedthepack.
Whileeveryprecautionhasbeentakeninthepreparationofthesematerials,neitherNESnorexternalcontributorsshallhaveanyliabilitytoanypersonorentitywithrespecttoliability,lossordamagecausedorallegedtobecauseddirectlyorindirectlybytheinformationtherein.
Acknowledgements
Disclaimer
course information �
Introduction
COPDisamajorbutunder-recognisedcauseofdeathanddisability.Globally,itisthefourthleadingcauseofdeathand,unlikeothermajorcausesofdeath,suchascardiovasculardisease,mortalityhasbeenrisingoverthepast40years.ConsultationswithgeneralpractitionersbypatientswithCOPDaresimilarinnumbertoasthmabutmorepatientswithCOPDwillbeadmittedtohospitalandtheywillstayinhospitalforonaverage7–10days.ThemortalityrateofCOPDisatleast14timesthatofasthma.
ThiscorecoursewillofferScottishpharmaciststheuniqueopportunitytobetrainedinaconsistentmanner.ItwillexplorehowpharmacistscancontributetothecareoftheirpatientswithCOPD,byapplyingtheprinciplesofpharmaceuticalcare.Thiswillbeinvaluabletrainingforcommunitypharmaciststohelppreparethemforthefuture.
ToupdatepharmacistsonthecurrentmanagementofCOPDandexplorewaystoimplementpharmaceuticalcareforthispatientgroupaspartofnormalworkingpractice.
Attheendofthesessionparticipantswillbeableto:
• definethecurrentstrategiesforthemanagementofpatientswithstableCOPDandexacerbationsofdisease
• identifypharmaceuticalcareissues,respondtosymptomsinpatientscenariosandidentifyappropriatemanagementsolutions
• explorehowtoimplementtheprinciplesofapharmaceuticalcareneedsassessmenttoolinpractice
JonesPW(2001)‘Healthstatusmanagementinchronicobstructivepulmonarydisease’,Thorax,56,880–887.
Pharmaceutical care of people with COPD
Objectives
Aim
Pre-course Reading
� pharmaceutical care of people with chronic obstructive pulmonary disease
Chronicobstructivepulmonarydisease(COPD)isdefinedintheNICE/BTSguidelines1as“airflowobstructionthatisusuallyprogressive,notreversible,anddoesnotchangemarkedlyoverseveralmonths.”Itispredominantlycausedbysmoking.
COPDisthefifthlargestcauseofdeathindevelopedcountriesandmortalityismorethantentimesthatduetoasthma.Preventionisthemainlong-termstrategyfordealingwithCOPDandtheachievementofsmokingcessationisthemajorgoal.InestablishedCOPD,diseaseprogressioncanbedelayedbydrugtreatmentbutcannotbereversed.
EstimationofCOPDprevalenceisdifficultduetounderdiagnosisbutitaccountsforabout10%ofallacutehospitalmedicaladmissions.TheincidenceofCOPDinwomencontinuestorisebutithasreachedaplateauinmen.ItisestimatedthateachGPwillhaveabout200patientswithCOPDontheirlist;eachpatientwillvisittheirGP6or7timesayearandcostsabout£1600.
TreatmentforCOPDisoutlinedintheNICE/BTSguidelinewhichwillbecoveredinthelecture.Bothpharmacologicalandnon-pharmacologicalmethodsneedtobeemployedinthemultidisciplinarycareofthesepatientsastherapyisaimedatthemanagementofsymptomsratherthanareversalofthediseaseprocess.Therehavebeenadvancesindiseasemanagementoverrecentyears,particularlyintheuseoflong-actinganticholinergicssuchastiotropiumandtheuseofinhaledcombinationpreparationsoflong-actingbetaagonistsandcorticosteroids.
ThefivequestionswhichhavebeenshowntobeeffectiveinmonitoringCOPDmanagementare:
1 Hasyourtreatmentmadeadifferencetoyou?2 Isyourbreathingeasierinanyway?3 Canyoudosomethingsnowthatyoucouldn’tdobefore,ordo
thesamethingsbutfaster?4 Canyoudothesamethingsasbeforebutarenowlessbreathless
whenyoudothem?5 Hasyoursleepimproved?
ThesequestionshavebeensuggestedasameansofassessingthebenefitofanewtherapyinpatientswithCOPDandformpartof
General
Implementing the needs assessment
course information �
theNeedsAssessmenttoolforpeoplewithCOPD.WhilethereareanumberoftoolssuchastheChronicRespiratoryQuestionnaire(CRQ),theStGeorge’sRespiratoryQuestionnaire(SGRQ)andtheBreathingProblemQuestionnaire(BPQ)thesetendtobelengthyandcumbersometoadministerandmaynotbeindicativeofanindividual’sresponsetotherapy.Thesetoolsare,however,importantinthefieldofclinicalresearch.
Thefivequestionsabovecanbeusedtoassessifanewlyintroducedtherapyhasmadeadifferencetoanindividualpatientbasedonthepatient’sexampleswhenansweringthequestions.
SimilarlytheMRCdyspnoeascore(below)canbeusedtoevaluatethepatientsstatus.
MRC Dyspnoea Scale
TheMRCdyspnoeascaleisaquestionnairethatconsistsoffivestatementsaboutperceivedbreathlessness.
Grade1 Ionlygetbreathlesswithstrenuousexercise.Grade2 Igetshortofbreathwhenhurryingonthelevelorupa slighthill.Grade3 Iwalkslowerthanpeopleofthesameageonthelevel becauseofbreathlessnessorhavetostopforbreath whenwalkingatmyownpaceonthelevel.Grade4 Istopforbreathafterwalking100yardsorafterafew minutesonthelevel.Grade5 Iamtoobreathlesstoleavethehouse.
� pharmaceutical care of people with chronic obstructive pulmonary disease
ChronicObstructivePulmonaryDisease(2004)‘Nationalclinicalguidelineonmanagementofchronicobstructivepulmonarydiseaseinadultsinprimaryandsecondarycare’,Thorax,59(suppl1)1–232
Thisdocumentislengthybutdoescontainausefulsummaryoftheguideline.ThesummaryandtheguidelinecanbeobtainedviatheThoraxwebsitehttp://thorax.bmj.com/content/vol59/suppl_1/
ABCofCOPD–availablefromBMJpublications£17.99butalsoavailableasaseriesofarticlesintheBMJ.
1 DevereauxG(2006)‘ABCofchronicobstructivepulmonarydisease.Definition,epidemiologyandriskfactors’BMJ,332:1142–1144
2 MacNeeW(2006)‘ABCofchronicobstructivepulmonarydisease.Pathology,pathogenesis,andpathophysiology’BMJ,332:1202-1204
3 CurrieGP,LeggeJS(2006)‘ABCofchronicobstructivepulmonarydisease.Diagnosis’BMJ,332:1261–1263
4 SrivastavaP,CurrieGP,BrittonJ(2006)‘ABCofchronicobstructivepulmonarydisease.Smokingcessation’BMJ,332:1324–1326
5 CurrieGP,DouglasJG(2006)‘ABCofchronicobstructivepulmonarydisease.Non-pharmacologicalmanagement’BMJ,332:1379–1381
6 CurrieGP,LipworthBJ(2006)‘ABCofchronicobstructivepulmonarydisease.Pharmacologicalmanagement–inhaledtreatment’BMJ,332:1439–1441
7 CurrieGP,LeeDKC,LipworthBJ(2006)‘ABCofchronicobstructivepulmonarydisease.Pharmacologicalmanagement–oraltreatment’BMJ,332:1497–1499
8 CurrieGP,DouglasJG(2006)‘ABCofchronicobstructivepulmonarydisease.Oxygenandinhalers’BMJ,333:34–36
9 CurrieGP,WedzichaJA(2006)‘ABCofchronicobstructivepulmonarydisease.Acuteexacerbations’BMJ,333:87–89
10 ChristieG,CurrieGP,PlantP(2006)ABCofchronicobstructivepulmonarydisease.Ventilatorysupport.BMJ,333:138–140
11 FreemanD,PriceD(2006)‘ABCofchronicobstructivepulmonarydisease.Primarycareandpalliativecare’BMJ,333:188–190
12 BarnesPJ(2006)‘ABCofchronicobstructivepulmonarydisease.Futuretreatments’BMJ,333:246–248
13 McIvorA,LittleP(2007)‘10-minuteconsultation.Chronicobstructivepulmonarydisease’BMJ,334:798
Other Useful Reading
course information �
1 ChronicObstructivePulmonaryDisease(2004)‘Nationalclinicalguidelineonmanagementofchronicobstructivepulmonarydiseaseinadultsinprimaryandsecondarycare’,Thorax,59(suppl1)1–232
BritishLungFoundation–http://www.lunguk.org/ChestHeartandStrokeScotland–http://www.chss.org.uk/BritishThoracicSociety–http://www.brit-thoracic.org.uk/GlobalInitiativeforChronicObstructiveLungDisease–http://www.goldcopd.com/EducationforHealthhasarespiratorycoursethatcanprogresstodegreelevel.Formoredetailscheckhttp://www.educationforhealth.org.uk
References
Useful contacts
� pharmaceutical care of people with chronic obstructive pulmonary disease
JonesPW.Healthstatusmanagementinchronicobstructivepulmonarydisease.Thorax2001;56:880–887
course information 1�
10mins Introductiontotheevening
50mins Lecture
10mins Comfortbreak
80mins Workshop
Splitthegroupintosmallergroupsofabout7or8
Thereare4casesbutinthetimeitisprobablyonlypossibletocoverthreeofthese.Thethreecasestobecoveredshouldbechoseninconsultationwiththelocaltutors.Ifspirometersareavailablethendiscussionofcase1shouldincludeallowingparticipantstomeasuretheirownlungfunction.
Eachofthegroupsshouldbeencouragedtocoverallthecases;thisshouldtakeabout15to20minutesforeachcaseandthenabout10to20minutesforgeneralfeedbacktocoverthemaindiscussionpointsforeachcase.
COPD teaching plan
Pharmaceutical Care Needs Assessment Chronic Obstructive Pulmonary Disease
Name Doctor’s name
Date of birth or CHI no. Date
Can you tell me what medical condition(s) you have?
dose frequency no ordered monthlyWhat is/are the name(s) of the medication you take for your condition(s) and how do you take it/them?
yes no
Do you ever forget or choose not to take your medication?If yes, how often – weekly/monthly?
Do you know what to do if you have missed a dose of your medication?
What, if any, side-effects do you experience from your medication?
yes no Do you feel that your medication is controlling your symptoms or have you noticed any changes since you started taking your medication? Do you know the trigger signs?
Do you have a regular check/blood test/review? Can you tell me when that was, and the outcome?
Would you like any information/advice on anything about your condition/medication/health promotion areas?
Do you smoke? If yes how many cigarettes and for how long?
Specific COPD questions yes noHas your treatment made a difference to you?Is your breathing easier in any way?Can you do some things now that you couldn’t do before or do the same things but faster?Can you do the same things as before but are now less breathless when you do them?Has your sleep improved?Please give me an example
Issue or action
Understanding Compliance Other Effectiveness Health/self help Safety Referral
Note any follow up action required and any outcome
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course information 1�
Aide memoire - chronic obstructive pulmonary disease
1. Can you tell me what medical condition(s) you have? Thishelpstoclarifytheirunderstandingoftheircondition(s).Length
ofdiagnosiscanbeimportant.Peopleareprovidedwithlotsofsupportandinformationatinitialdiagnosis–theamountofinformationandsupportreceivedatdiagnosiswillvary,alsotheymayormaynotbeattendingappropriateclinics.Overtimepeoplecanforgetkeyinformationorthemessagesmaychangeovertime.
Action Noteanswerandofferpatientgeneralinformationonconditions.
2. What is/are the name(s) of the medication you take for your condition(s) and how do you take it/them?
Checkwithprescriptionorpatientmedicationrecords.Confirmthatthepatientistakingthemedicationasinstructedontheprescriptionwithanyappropriatecounsellinginstructions,e.g.swallowedwhole.
Action Notehowpersontakesmedicationandofferappropriateadvice.
3. Do you ever forget or choose not to take your medication? If yes, how often – weekly/monthly?
Clarifywhichdrugsaremissed,whenandwhy.Action Offerappropriateverbaladvicedependingonresponse.
4. Do you know what to do if you have missed a dose of your medication?
Documentresponse.Action Offerappropriateverbaladvicedependingonresponse.
5. What, if any, side effects do you think you are experiencing from your medication?
Adverseeffectsarecommon;mostaredose-relatedandpredictable.Idiosyncraticadverseeffectsarepotentiallydangerousandusuallyoccurinthefirstweeksoftreatment.Somepeopleerroneouslylinkmedicationtoadverseeffectsandthiscanaffecttheiradherencetotheirregimen.Itispossibletomanagesomeadverseeffects.
Action Noteanyadverseeffectsandconfirmthattheyareasaresultoftheir medicationandreassurepatientaccordingly.
Pharmaceutical Care Needs Assessment Chronic Obstructive Pulmonary Disease
�0 pharmaceutical care of people with chronic obstructive pulmonary disease
6. Do you feel that your medication is controlling your symptoms or have you noticed any changes since you started taking your medication? Do you know the trigger signs?
Documentresponse.Considerandofferappropriateadvice. Action Offerappropriateverbaladvicedependingonresponse.
7. Do you have a regular check/blood test/review? Can you tell me when that was, and the outcome? Documentresponse.Considerandofferappropriateadvice.Action Offerappropriateverbaladvicedependingonresponse.
8. Would you like any information on anything about your condition/ medication/health promotion areas? Thishelpstoidentifyanyself-helporhealthissues.Action Offeradviceandsupportonhowthepersoncanmanagetheir lifestylemoreeffectivelyorsignpostthemtootherorganisations. Offergeneralhealthyeatingadviceasappropriate.
9. Do you smoke? How many cigarettes do you smoke and how long have you smoked Smokingexacerbatesrespiratoryconditionsbycausingdamageto theairwaysandincreasingtheriskofanattack.Allpatientsshould beencouragedtostopsmoking.Identifywhatstagetheyareatinthe “cycleofchange”model.InpatientssuspectedofhavingCOPD,it isimportanttohaveasmokinghistoryasthismayhelptoconfirmthe diagnosis. Action Offerappropriatesupportorrefertolocalsupportagencydepending onlocalarrangements.
Thefollowingquestionsrelatetothequalityoflifeimprovementsthat canbeseenifthepatientisrespondingtotreatment.Patientswith COPDwillnoticeimprovementsintheirqualityofliferather thanchangesinlungfunctionwhichmaybesubtleornotrecorded. Whenaskingpatientsaboutthechangesthatfollow,ensurethatthey giveanexampleofhowthechangehasaffectedthem.Action Ifthechangeisthoughttobesignificantthenthepatientshould continueonthetherapy.Ifachangeintherapyhasnotleadtoa significantchangeintheseparametersthenthepatientshouldbe discussedwiththeirGP.
10. Has your treatment made a difference?
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11. Is your breathing easier in any way?
12. Can you do some things now that couldn’t do at all before or do the same things but faster?
13. Can you do the same things as before but are now less breathless when you do them?
14. Has your sleep improved?
Thisaidememoireisforguidanceandpharmacistsshouldusetheir professionaljudgementatalltimes.