reflections on - ashtons hospital pharmacy
TRANSCRIPT
a hub for emergency medicine supplies
• Opioid patches – back to basics
• Naming of medicines • Focus on deprescribing • Ashtons training
seminars and online presentations
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FEATURE
Reflections on COVID-19 6-7
News just in – August 2020: Restrictions on over-the-counter sale of stimulant laxatives 14 Ordering 2% lidocaine in Lutrol gel 14
Contents A welcome from the Editor 3
Focus on deprescribing 4-5
Disposal of Ashtons cool boxes and coolant gel packs 8
Flu vaccine uptake – winter 2020/21 8
Ashtons training seminars and online presentations 9
Life support, first aid and mandatory training – update 9
Using the hospice as a hub for emergency medicine supplies 10-11
Opioid patches – back to basics 12-13
Naming of medicines, part one – introduction 15
Hay fever treatments 16
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HOSPITAL PHARMACY SERVICES
FOR YOUR INFORMATION: We provide two newsletters
A welcome from the Editor
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The past few months have been like no other. When we first heard about COVID-19, it was difficult to imagine the devastating effects it would have on health services and our economy. Even in the UK, with all its advanced healthcare, the pandemic has brought the system close to breaking point. We saw such dedication amid extreme suffering. Yet, there was also immense frustration in how it was managed – and the effects it had on those working directly with patients. Hospices seem to have been overlooked in their need for the same level of PPE and testing as other, more acute settings. We heard how managers spent many hours on the phone trying to get what they needed while patients were arriving without a known COVID status. This edition of the newsletter includes reflections on these common experiences from our hospice colleagues. Thankfully, most have found a way forward – strengthened by your determination and passion for carrying on the work you do in your unique way.
We were able to continue our service throughout and are immensely thankful to all our Ashtons teams for keeping the supplies and professional services going to support our customers. We know that some establishments felt unable to invite us in to visit; still, we are now back at all sites but one. It’s almost business as usual – with the added precautions we
are now getting used to. We ensured a good enough supply of the medicines we believed to be crucial to hospices, and this will continue with careful attention from our purchasing department.
It has certainly been an interesting time to be a pharmacist as several great initiatives have developed. We were approved to relax some regulatory processes if it meant patients could get their medicines more promptly. It feels like this ‘honeymoon’ period is now over, but it has enabled some innovative solutions to be planned – you will find an article included describing one of these medicines access projects which we hope to see in action soon.
It has been a privilege to work alongside our hospice colleagues during these challenging times, and we look forward to continuing our work with you, whatever lies ahead as the winter approaches.
With good wishes and kind regards,
Margaret Gibbs, Editor and Lead Palliative Care Pharmacist 07387 418 530 [email protected]
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One of the audits collected on our Ashtons Live View system is the number of prescription items for each patient. This information enables us to provide you with comparative data and percentages for our clinical interventions. It is not unusual to count more than twenty items for one patient on a hospice drug chart, although many of these items will be on the PRN pages. We pay great attention to detail with the patient’s response to their medicines, but what are the prompts for reducing the number of items? It can take considerable time to administer medicines when a patient is weak and finding large amounts to swallow challenging. It may be observed but not always reported by the nurses and proposed as an opportunity to rationalise. The patient may ask ‘do I really have to take all these?’ or refuse their medicines selectively or entirely. Making prescribing decisions may sometimes be quite simple – the patient is reported as being constipated, so we write up one or two laxatives. Their pain is showing
neuropathic characteristics, so we add in a tricyclic or gabapentinoid and within a few moments, they are being asked to take maybe six additional doses. Should we be looking at which items on a drug chart we can safely remove as carefully and regularly as those we might add? We know that many commonly used medicines have similar side effect profiles, and that additive sedation and anticholinergic effects can add to symptoms and increase the risk of falls. The positive effects need to outweigh the potential negatives, and we should review drug regimens for such risks.
The term ‘polypharmacy’ has become a rather pejorative term and although it is now acknowledged that it is difficult to avoid in symptom control towards the end of life, we still need to consider it.
Appropriate polypharmacy
Prescribing for a person for complex conditions or for multiple conditions in circumstances where medicine use has been optimised and where the
medicines are prescribed according to best evidence.
Problematic polypharmacy Problematic polypharmacy occurs when multiple medicines are prescribed inappropriately or where the intended benefits from the medicines are not realised.
Medicine rationalisation and deprescribing are now relevant in all areas of therapeutics. NICE guidance suggests regimes for specific diagnoses, but this does not take into account that some people will have several co-morbidities and have multiple drugs prescribed as a result. NICE has now collated resources to guide us in the rationalisation of medicines, acknowledging the potential problems with multi- morbidity and polypharmacy1. The new resource directs to documents including those from the Royal Pharmaceutical Society and the UK national health bodies with titles such as ‘Getting medicines right’. These are generally similar and useful for GPs caring for people with chronic
Focus on deprescribingFocus on deprescribing
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conditions. Tools such as the Beers Criteria2 have been developed to provide very detailed options on the various categories of medicines however, there is a simpler and more appropriate tool for people approaching the end of life. The STOPPFrail tool3 was developed in Sunderland and validated by a study in Ireland4 as an adaptation of the STOPP (Screening Tool of Older Persons Prescriptions), specifically for frail adults with a limited life expectancy. To apply this, the patient must fulfil all these criteria:
• End stage irreversible pathology. • Poor one-year survival prognosis. • Severe functional impairment or
severe cognitive impairment or both. • Symptom control is the priority
rather than prevention of disease progression.
The first consideration in the STOPPFrail Tool focuses on discontinuing any drug the patient persistently fails to take or tolerate despite adequate explanation and consideration of alternative formulations. The second consideration is – any drug without clear clinical indication. It is concerning that some prescriptions may be on repeat cycles and not reviewed periodically in primary care. There is also understandable reluctance for stopping medicines which have been prescribed by other specialists and the guidance in these tools helps with these decisions.
Of course, there are some conditions where it is essential to continue with the medicines until the last days of life, so we need to refer to specific guidance for Parkinson’s disease and diabetes, for example.
Suggestions start by looking at the drug chart for ‘refusals’ and discussing with the patient why they do not want to take the medicine – perhaps these items can be safely crossed off. Then look at additive side effects and consider whether any causing side effects such as drowsiness or dry mouth could be removed. Discuss the pros and cons of stopping or continuing with the patient.
Look at those medicines which are preventative and consider the benefits of continuing them (see box), but at all times consider the risks and benefits for each individual patient.
In any prescribing decision it is important to involve the person who is taking the medicine and this is equally pertinent when it comes to stopping. When a patient
has been told they must take a medicine ‘for life’, stopping it can feel dangerous and may also reinforce the fact that they are coming towards the end of their life. However, in practice, many people are relieved to reduce their tablet burden, so it is, as with everything in palliative care, tailored to the patient. One helpful strategy is to suggest a trial of stopping the drug and see what the effects are. If stopping makes a symptom worse, the medicine can be re-started.
If you would like to look at this in more detail, we can now offer training sessions to hospice staff on these topics:
• Polypharmacy and deprescribing towards the end of life.
• Management of Parkinson’s disease towards the end of life.
• Management of diabetes towards the end of life.
References 1. NICE Key therapeutic topic www.
nice.org.uk/advice/ktt18 2. Beers Criteria https://bit.ly/3b2a0Ts 3. BMJ Support Palliat Care2017
Jun;7(2):113-121. doi: 10.1136/ bmjspcare-2015-000941. Epub 2016 Jan 5
4. Age and Ageing 2017; 46: 600– 607 doi: 10.1093/ageing/afx005 Published electronically 24 January 2017
Margaret Gibbs, Lead Palliative Care Pharmacist
Drugs to consider stopping towards the end of life
• Vitamin / mineral supplements • Statins – evidence shows they
still protect for one year after stopping
• Review anti-hypertensives – may be able to reduce dose or stop
• Aspirin low-dose • Some inhalers – especially
where patients are too weak to use them effectively
• Gastro-protection – maybe steroids have been stopped?
• Oral hypoglycaemics – if the person is no longer eating
• Oral anti-oestrogens/anti- androgens
Reflections on COVID-19Reflections on COVID-19
Looking back on my emails, I see that my first COVID-related message came in on 3rd March. At first, it was impossible to judge the impact the virus was going to have on our healthcare system and hospices. The shocking lack of their inclusion in the two essential components – PPE and testing – soon became
apparent. Many of our senior hospice colleagues have described how they had to ‘fight’ for what was needed – on top of caring for very sick patients who may or may not have the virus and staff having to isolate for the statutory period.
A number of excellent documents and initiatives were produced rapidly and we were pleased to be able to direct our customers to the resources created by a joint group of experts from the Royal College of General Practitioners and the Association of Palliative Medicine:
https://elearning.rcgp.org.uk/mod/ page/view.php?id=10537
This comprehensive document is still available to provide healthcare professionals with clear guidance on symptom control, end of life care and supporting families. Palliative care was very much in the news and we know that many of our colleagues working in Trust hospitals were providing care to patients as well as
support to colleagues on every level.
Clinicians reported that the usual drugs we use for symptom control were effective for the breathlessness and agitation which seemed the most prevalent issues for COVID patients. Although there were views that higher doses should not be avoided in emergencies from the USA,1 Clinicians at Guy’s and St Thomas’ hospitals, who recorded their data from 101 patients they cared for, agreed that agitation was a common symptom observed and it was managed with similar doses to those usually used. Breathlessness continued to be a problem throughout the disease but cough less so towards the end. 74% of those that were admitted to palliative care for symptom control died2. Other doctors in the South of England, who were also recording data, observed that patients fell into two main categories: some deteriorated and died with a shorter than average dying phase for hospital deaths – 39 hours rather than 72 hours – while others had the more
FEATURE:FEATURE:
“Masks, aprons, and gloves create such a barrier to how we communicate, and you were unable to apply the specific ways you are used to caring, with close contact and gentle touch.”
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usual trajectory. They observed the latter group were older and frailer. They also noted that 72% of the patients in the study died with a syringe pump in place compared to the usual number of around half that3. Their report concludes that there should be no delay in starting an infusion where indicated in COVID and that the need to prepare family members for negative outcomes is more pertinent than usual. Hopefully, this learning will be disseminated and increase confidence in caring for dying people with the virus.
By early April we started to become aware that some end of life injections were being supplied preferentially to NHS Trusts and the Nightingale hospitals. Ashtons had created a list of essential medicines early on and our excellent team ensured they obtained good stocks of the likely medicines which would be required. Hospices were prepared to admit additional patients for end of life care and some found their numbers increased. Conversations with hospice colleagues over April, May and June made it clear that some people decided that visiting restrictions in hospitals and hospices led them to want to stay in their own homes, so after an initial increase, the actual occupied bed numbers were not as high as may have been expected.
You explained that many patients were admitted without having been tested so you needed to treat them as ‘possibly’ COVID-positive, with all the ramifications of PPE and staff management. Some of you have talked about the difficulties you encountered in your interactions with patients and families. Masks, aprons and gloves create such a barrier to how we communicate and you were unable to apply the specific ways you are used to caring with close contact and gentle touch.
This sounded the most difficult challenge for your teams and it was expressed very clearly in a moving video produced by Princess Alice Hospice (https://www. youtube.com/watch?v=5prToYDTdns) which was shown on BBC Newsnight. Mercadante and colleagues reported on their own experiences in Italy and showed that although virtual contact with patients was of some comfort, unsurprisingly nothing substitutes for human touch4.
With more patients remaining at home over this period, we worked with some of the hospice community team leads and their CCGs to ensure rapid access to symptom control medicines. It was clear in the community too, that deterioration and death were occurring more rapidly with COVID and some of the existing ‘Out of Hours’ pharmacy schemes were not as responsive as they needed to be. The SW London CCG provided emergency packs of injectable and oral drugs which were stored in various settings and could be accessed at all hours. Although the use of these packs was low, it was a very responsive and innovative way to support those caring for people in the community. We hope that shining a spotlight on emergency end of life care drugs out of hours may help mould any future plans and we continue to support some hospices in their aims to become hubs for ‘just in time’ supplies of small quantities of medicines when other systems cannot meet the patients’ urgent needs.
Another welcome initiative has been the ability to re-purpose medicines which have been supplied to a patient but not required. We had heard from the CQC last year that they would not be against hospices taking into stock items dispensed on a TTO from the supplying pharmacy which subsequently could not
be used due to the patient not being well enough for discharge. We had prepared a Standard Operating Procedure for this practice but once COVID arrived, we decided to broaden the scope of this and advise hospices to quarantine and potentially re-use other complete packs of medicines which would otherwise be wasted. The NHS subsequently produced more conservative guidance on this practice but we hope that this may continue to be our practice and that we can make use of unwanted TTOs, while carefully documenting the practice and using our pharmacists to assist with the governance processes.
This has been a summer none of us will forget. Some of us have lost family members, friends and colleagues. All of us know people whose lives have been affected and we, as Ashtons, were pleased to know that we were able to support you in the unique role you have in caring for those at the end of their lives.
1. https://www.jpsmjournal.com/ article/S0885-3924(20)30389-4/pdf
Ashtons have commenced supplying all fridge lines in the environmentally friendly fridge boxes in place of the polystyrene boxes previously used. The replacement fridge boxes are manufactured from wood pulp, together with the insulation inserts, and are therefore biodegradable and, being a paper-based product, fully recyclable.
The coolant packs, which are used to keep the fridge box between 2°C and 8°C, are made from a low-density polyethylene (LDPE 4) pouch. The contents of the coolant pack consist of an aqueous (water- based) gel.
Ashtons will not be reusing these packs so they can be locally disposed. The contents of the pouch are benign, given the dilution of the polymer used to make the gel, are not harmful to humans and can be poured away through the normal domestic waste drainage system via a sink or sluice. The empty LDPE pouch film can then be disposed as
general waste in locations where it is not possible to recycle it.
Ashtons are continually looking to improve quality and provide innovative solutions and the introduction of these recyclable fridge boxes has been well received.
Disposal of Ashtons cool boxes and Disposal of Ashtons cool boxes and coolant gel packscoolant gel packs
Due to the impact of the COVID-19 pandemic, there will be a national drive to increase the uptake of flu vaccinations, to reduce pressure on the NHS. Healthcare staff and people with certain health risk factors are the current focus for flu vaccination and this list may be expanded to include other people at risk. Ashtons have placed advance orders of the flu vaccine with suppliers for the 2020/21 winter season, but will endeavour to obtain further quantities if there is a demand.
For more information, please visit: https://www.england.nhs.uk/wp-content/uploads/2020/05/ national-flu-immunisation-programme-2020-2021.pdf
Online presentations available The pandemic has made it difficult for hospices to arrange training and there has been less demand for Ashtons pharmacists to present seminars at sites. Consequently, Ashtons is now able to make seminar presentations available via online platforms such as Zoom or Microsoft Teams, meaning that all available staff with online access can participate in the training, without having to meet up in a room together.
NEW training seminars available: Management of diabetes towards the end of life This seminar provides an overview of diabetes and the oral and injectable treatments available. It guides participants
through the management of diabetes towards the end of life, based mainly on the highly regarded British Diabetic Association guidelines.
Management of Parkinson’s disease towards the end of life This seminar begins with the causes, symptoms and drugs used in Parkinson’s
disease. It goes on to describe the end stages of the disease and the specific considerations, including drug choices for symptom management, towards the end of life.
Please contact your visiting pharmacist to arrange seminar training, whether onsite or via webinar.
Ashtons training seminars and online Ashtons training seminars and online presentations presentations
Life support, first aid and mandatory training – update
The concerns presented by COVID-19, and the need to prevent its spread within hospices and hospitals, has forced many customers to put critical face-to-face life support and mandatory training on hold. The balancing act now is keeping up with statutory and mandatory requirements while simultaneously adhering to social distancing, restrictions on the gathering of groups and keeping everyone safe.
While the HSE did allow extension times on the expiry of first aid certificates, the first aid training industry in England is confident that enough courses will now be available for all required requalification training to take place. The HSE has therefore agreed a final deadline for requalification of 30th September 2020.
The HSE still strongly recommends that the practical elements of actual First Aid At Work, Emergency First Aid At Work and requalification courses are
delivered face to face, so that student competency can be properly assessed.
In line with this, while Basic Life Support (BLS) courses can be found online, we strongly recommend that hospices start returning to face-to-face BLS and AILS (Adult Immediate Life Support).
The First Aid Training College and Ashtons have a concise COVID-19 training policy in place and we are confident that we can offer you safe and effective training. Our training mannequins have always been hygienically maintained and the advantage of each student having their own face mask for the session has always been a safety precaution for us. Mannequins will also be cleaned between each user and we are encouraging the use of face masks and sitting at least one metre apart in the classroom sessions.
If you would like to find out more about our first aid and life support training,
please get in contact. We are currently taking bookings from September through to December 2020 but have a couple of days left in August.
The First Aid Training College is now also able to offer you a full suite of 23 mandatory and statutory training courses. This a relatively affordable but very effective way of training your workforce and we have successfully rolled this out with a few customers now.
The First Aid Training College and Ashtons – Your partner in quality training, preparing you to make a difference.
Adrian Munday, Managing Director at The First Aid Training College
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For many years the NHS has struggled to fulfil the NHS Out of Hours (OOH) standards that stated ‘patients should be able to access the medicines they need at the time and place of the OOH consultation’. The Drug Tariff, which determines the list of products which can be prescribed on FP10 and their re-imbursement costs, still includes a rather dated ‘Out of Hours national formulary’ which categorises a wide range of medications for emergencies which include palliative care.
When this formulary was introduced, in about 2008, various solutions were proposed and many OOH medical services started to investigate whether they could be the place to keep a stock of the medicines required. Palliative care pharmacists worked with some of these services to help with logistics of ordering, storing and transporting Controlled Drugs in a service – made additionally challenging in a service which was not staffed 24 hours each day. Unfortunately, regulatory changes meant that in order to do this, OOH services would require a Controlled Drugs licence so most decided against holding stocks in a comprehensive way.
Many areas have OOH systems
where a select few community pharmacies hold an agreed stock of end of life care medicines. In most of these areas, there is an arrangement for the pharmacist to be available to attend at any time in the OOH period to meet the healthcare professional or family member and dispense the medicines required. This is a valuable service which has prevented many hospital admissions but there are occasions where it is still not sufficiently responsive to meet the needs of the patient. In a few cases, the medicines could be delivered but not all and it is never right to take a family member away from the patient to obtain medicines – they should be able to stay with them.
‘Just in case medicines’ started as a project nearly 20 years ago in Bedfordshire and Hertfordshire. It was set up by two palliative care pharmacists with support from other healthcare professionals including Ros Taylor, now medical director for Michael Sobell House. In an article1 they were able to show that provision of a selection of the essential end of life care injections in prepared packs over a 6 month period made it possible for 16 patients in the area to stay at home
to die rather than be transferred to hospital. The Gold Standards Framework encourages pre-emptive prescribing of ‘just in case’ medicines and people discharged from hospital or hospice will usually be supplied with injectable medicines for use when they can no longer take their oral medicines. This practice has become widespread and has reduced the requirement for emergency medicines so the schemes in place have not been on everyone’s radar. It is a very positive practice with one downside, which is that these injections are not always needed so at times they are wasted but on balance, it is preferable to have the assurance they are in place.
People dying with or from COVID-19 have been reported as experiencing rapid deterioration, so prompt access to injectable medicines has never been more urgent. Although we seem to be in a quieter period now, we need to be prepared for winter and a possible second surge. The pharmacy systems have not worked as well in practice when the need for medicines is less easy to anticipate yet more urgent. One of the hospices we work with has come up with a potential solution, based on practice in at least one other hospice.
Using the hospice as a hub for Using the hospice as a hub for emergency medicine suppliesemergency medicine supplies
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BENEFITS OF MEMBERSHIP The Association for Palliative Medicine of Great Britain and Ireland (APM) is the largest body representing doctors practicing or interested in Palliative Medicine. It is widely acknowledged that in palliative and end of life care, perhaps more than most specialties, excellent patient care is best achieved through a multi- disciplinary team working together providing high quality holistic care provision and support for patients and their loved ones. In recognition of this the APM has recently voted to open up membership to non- doctors including pharmacists, nurses and allied health professionals. With the new Associate Non-Doctor membership, individuals who join will have access to the ever-growing community of professionals, resources and benefits including:
• Networks and Special Interest Forums • APM bi-Monthly e-Bulletin • Membership of the European Association for
Palliative Care (EAPC) • Palliative Medicine journal** • BMJ Supportive and Palliative Care journal** • Palliative Care Formulary (PCF)** • Quarterly paper copies of the BMJ SPC Journal** • Study days and other meetings • APM awards
**Included with ‘Associate Non-Doctor Membership with Journals’
Association for Palliative Medicine - membership now open to non-doctors
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We have been working with colleagues in Hillingdon CCG and Central and West London NHS Trusts to build a procedure which allows Michael Sobell Hospice to act as a hub for the supply of medicines when other systems are not appropriate due to rapid deterioration. We have commissioned one of the licenced pre-packing units to prepare some small packs of injectables and a couple of oral medicines. With the support of the CCG, Michael Sobell House will keep a small stock and in extreme circumstances, the nurse or on call GP will be able to call the hospice doctor on call and
arrange a prescription and pick-up of the medicines required in as timely a way as possible.
We know some other hospices are interested in this possibility and we look forward to seeing how it goes in the Hillingdon area. Once it’s been tried and tested, we would love to support other hospices in sharing this good practice. Although this scheme has been created during the COVID period, like other initiatives, we hope to be able to continue this afterwards. Please feel free to contact me for more information (details on page 3).
References 1. https://www.
pharmaceutical-journal. com/pj-online-articles-how- a-just-in-case-approach- can-improve-out-of-hours- palliative-care/20015045. article?firstPass=false
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The two opioids available for delivery via a transdermal patch in the UK are fentanyl and buprenorphine. Fentanyl products are licensed for severe and chronic pain that requires long-term opioids or that does not respond to non-opioids. Buprenorphine is available in two sets of products – the stronger patches have a similar license to fentanyl while the lower strengths are indicated for non-malignant pain when an opioid is necessary (they are used for cancer pain in some cases, where patients only require low opioid doses).
Patches are only suitable for stable pain as they take up to 24 hours to reach steady state, so they should only be used for people whose pain is not rapidly increasing.
All fentanyl patches are effective for 72 hours once applied. The stronger buprenorphine patches remain effective for 96 hours (apart from one brand) but the weaker ones only need to be replaced once a week and this can be confusing for prescribers who are unfamiliar with these medicines.
We should advise patients to find the best way to remind themselves of the day they must change their patch – some might want to mark it on a calendar while others prefer to set a reminder on their smart phone.
Positive points • Convenient method of delivery. • Enables people to think a bit less
about their medication and live their life.
• They can be applied on various parts of the body, the site should be rotated to minimise the risk of irritation after repeated applications to one spot.
• Useful for people who may have problems remembering to take medicines.
• Useful for people: with cognitive impairment who struggle with oral medicines or have nausea and vomiting or e.g. oral cancers.
• Appropriate for people with renal insufficiency.
• The wide variation in strengths available makes it possible to tailor the dose appropriately.
Cautions • Once applied, patches take several
hours to reach therapeutic levels so other analgesia should be available.
• If the dose selected is too high for the patient and they become toxic, drowsy, even unrousable, just taking the patch off won’t be enough to assure their safety as it takes up to 24 hours for levels to decrease. If the patient has become sufficiently
drowsy to require opioid reversal, ensure expert advice is sought.
• Patches can be especially dangerous in this respect for initiation in frail elderly patients on their own at home – they must be monitored.
• If a patient is being switched from oral opioids to a patch the prescriber should use the guide on the SPC or the local guidelines for this. The fentanyl patches cover a wide range of possible doses so the lower doses should be used initially, e.g. fentanyl 25mcg patch is equivalent to between 90 and 134mg total daily morphine, which makes it challenging to safely convert.
• Heat increases absorption – avoid hot showers/baths and caution in extreme hot weather, like we have experienced recently. We need to alert patients and carers about this without alarming them – remind them to be aware of promptly reporting toxic effects.
• People should be given PRN opioids alongside the patch – this can be morphine if they are not being used because of renal insufficiency. Check in conversion tables to make sure the PRN dose is commensurate.
• Fentanyl immediate release products, e.g. Abstral, are not intended for use for PRN support in the same way as we use morphine and oxycodone in
Opioid patches – back to basicsOpioid patches – back to basics
one sixth of the daily dose. • GPs can sometimes be a bit more
relaxed about prescribing patches. Remember that fentanyl is between 100 and 150 times as potent as morphine so it must be treated with respect.
• All but one brand of patches are now ‘matrix’ patches, where the product is embedded in a plastic film or textile. Occasionally it used to be recommended to cut patches, but now with a range of strengths available, this should not be necessary. It is off licence but not dangerous, however there are still a few products which are ‘gel-filled’ patches (the older formulation) which must never be cut.
• Some people have problems with
patches that won’t stick because of sweating or oily skin - try a different brand.
• Some people have an allergic reaction to the patch, but this is invariably due to the adhesive and not the drug – try a different brand. (One unlicensed and imaginative way to reduce irritation is to spray the area with a steroid using an inhaler e.g. beclometasone).
Ensure people read the instructions – when applying a patch, hold it down for 20 seconds to improve adhesion.
They can be disposed of in general waste – on removal, fold the patch in on itself. Patches still contain a lot of fentanyl/ buprenorphine once removed so still should be disposed of carefully.
Product selection There are many products available, although each product with the same strength is therapeutically equivalent. We advise you order using the trade name and aim to keep to one brand if possible – to make stock-keeping simpler and provide a familiar product to your patients. Although wards must order complete packs for stock, pharmacies will supply the quantity specified to complete an individual prescription.
As with many medicines, prices change periodically and although there are not huge differences between the brands, it can make a difference to your drugs budget when you use quantities. Ashtons pharmacists can provide guidance on the most cost-effective choices when we visit and attend medicines management meetings.
The table on this page shows the main products available but only includes those where there is a Summary of Product Characteristics available on the Electronic Medicines Compendium. Note one of the buprenorphine patches needs changing every 72 hours which makes it slightly less convenient for patients and as more are required, slightly more expensive. All but one of these products is a matrix patch where the drug is evenly distributed across the surface. One remains a ‘reservoir’ patch where the active ingredient is in a gel released via a membrane. Cutting patches is inadvisable at any time but on no account must a reservoir patch be cut.
Product name and strengths available Strength = micrograms delivered per hour
Pack size
Duration of action
Buprenorphine matrix patches (lower strength) Bunov 5mcg, 10mcg, 20mcg 4 7 days Butec 5mcg, 10mcg, 15mcg, 20mcg 4 7 days BuTrans 5mcg, 10mcg, 15mcg, 20mcg 4 7 days Panitaz 5mcg, 10mcg, 20mcg 4 7 days Reletrans 5mcg, 10mcg, 15mcg, 20mcg 4 7 days Sevodyne 5mcg, 10mcg, 20mcg 4 7 days Buprenorphine matrix Patches (higher strength) Bupeaze 35mcg, 52.5mcg, 70mcg 4 96 hours Buplast 35mcg, 52.5mcg, 70mcg 4 96 hours Carlosafine 35mcg, 52.5mcg, 70mcg 4 96 hours Hapoctasin 35mcg, 52.5mcg, 70mcg 4 72 hours
Relevtec 35mcg, 52.5mcg, 70mcg 4 96 hours Transtec 35mcg, 52.5mcg, 70mcg 4 96 hours Fentanyl matrix patches Durogesic DTrans 12mcg, 25mcg, 50mcg, 75mcg, 100mcg 5 72 hours FENCINO 12mcg, 25mcg, 50mcg, 75mcg, 100mcg 5 72 hours Matrifen 12mcg, 25mcg, 50mcg, 75mcg, 100mcg 5 72 hours Mezolar Matrix 12mcg, 25mcg, 37.5mcg 50mcg, 75mcg, 100mcg 5 72 hours Opiodur 12mcg, 25mcg, 50mcg, 75mcg, 100mcg 5 72 hours Yemex 12mcg, 25mcg, 50mcg, 75mcg, 100mcg 5 72 hours Fentanyl reservoir patches – must never be cut Fentalis Reservoir 25mcg, 50mcg, 75mcg, 100mcg 5 72 hours
Examples of opioid patches available (brands in italics are those most regularly used).
Two new hospices join Ashtons We are delighted to announce that since April we’ve begun working with Springhill Hospice in Rochdale, Lancashire. We’ll soon also be working with St Leonard’s Hospice, Yorkshire. We’re looking forward to a long and successful partnership with both of these hospices.
Margaret Gibbs, Lead Palliative Care Pharmacist
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Restrictions on over-the-counter sale of stimulant laxatives
The MHRA has decided that stimulant laxatives can be inappropriately used by people wanting to lose weight – especially those who may have an eating disorder. In future, products such as Senna and Bisacodyl will sold in small pack sizes only and to people over 18.
Ordering 2% lidocaine in Lutrol gel
Guy’s and St Thomas’ manufacturing unit has now ceased supply of this product and it is now distributed by Oxford Health – the NHS specials and wholesale supplier. The price has increased considerably, so please speak to your visiting pharmacist before ordering to ensure you only order the essential quantity. Once ordered it cannot be returned as it is a special order. We will update our information sheet for this product accordingly.
1. Why is erythromycin used for constipation? Motilin is a naturally occurring hormone secreted by the small intestine. It increases gastro-intestinal motility and peristalsis and accelerates gastric emptying. It functions mainly between meals and in doing so prepares the gut for the next meal. Erythromycin happens to be a motilin agonist – working in the same way as the hormone – so can be used when metoclopramide or other prokinetics are unsuitable. It is effective in about half of cases, and concerns about the development of bacterial resistance have been shown to be largely unfounded. Only small doses are required, 50 to 100mg QDS to start and up to 250mg QDS if necessary. For the small doses it is necessary to use the suspension.
2. Are other hospices reporting losses with oxycodone liquid 5mg in 5ml?
Short answer – yes! The formulation of the 5mg in 5ml liquid in existing brands is very syrupy and so it sticks to the bottle, oral syringes and measuring vessels. We accept that each time a dose of liquid is removed if using a syringe, a small volume will be lost and when multiple doses taken from a bottle, the loss increases. We recommend using a bung in all bottles of regularly used liquids as this minimises the loss. Weekly measuring of Controlled Drug liquids is common practice and ‘regular’ checks of stock balances should involve measuring liquids but this will incur further loss. There is a general acceptance that a 5% loss of liquid balance since the last check should not need to be reported as an incident but if more than this is unaccounted for, additional checks may need to be made.
3. Is melatonin effective as a sleeping aid? Melatonin is a naturally occurring hormone secreted when our pineal gland
senses darkness. It is considered less effective than conventional hypnotics, but sleep disturbance is difficult to manage with any of the current medicines in palliative care. Melatonin is reported as causing less ‘hangover’ sedation and may be considered suitable for those who cannot tolerate ‘z’ drugs and those who are at more risk of falls due to sedation. There is no firm evidence for its efficacy in palliative care but given its lack of side effects and the existence of a licensed medicinal form in the UK, it is worth considering.
Do you have a query about medicines or procedures in your hospice? Email us at [email protected] – it could appear in our next issue!
Recent queries from hospices Questions on medicines, procedures and practice from hospice staff
News just in –News just in – August 2020August 2020
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Medical suppliesMedical supplies
In his poem The Naming of Cats, T.S. Eliot asserts that cats have three names:
The Naming of Cats is a difficult matter, It isn’t just one of your holiday games; You may think at first I’m as mad as a hatter When I tell you, a cat must have THREE DIFFERENT NAMES. The Naming of Cats, T.S. Eliot.
Likewise, medicines can go by a few different names.
All drugs have a scientific name based on its organic chemistry. And even though morphine can be written simply as C17H19NO3, to also accurately describe its structure it needs to go by (4R,4aR,7S,7aR,12bS)-3- Methyl-2,3,4,4a,7,7a-hexahydro-1H-4,12- methanobenzofuro[3,2-e]isoquinoline-7,9- diol which by any standards is a bit of a mouthful.
For this reason, drugs are given a shorter ‘generic’ name. Drugs of a similar class share the same stem, so for example a benzodiazepine will have the ending -azepam (clonazepam, diazepam, lorazepam).
The manufacturer also comes up with a name that they use to market the drug, its brand name. These have to follow the same
rules for brand names for any product as well as meet regulators’ requirements that they are not easily confused with existing drugs.
I will discuss the rules for generic and brand names in a future edition. However, in the early days of medicines the rules around naming medicines used to allow more scope for the imagination.
One of the first drugs to be discovered was morphine in 1804 by Friedrich Sertürner. In typical style for the time, he tested the drug by taking it himself and promptly nearly became the first person to have a fatal overdose as well. Since it had a tendency to make people sleepy it was named after the Greek god of dreams, Morpheus (keeping up a family tradition as his father, Hypnos, has a whole class of drugs – the hypnotics – named after him). When a more potent version was discovered, Bayer named it after the fact that it could make you feel heroic – Heroin®.
However, it quickly became apparent that Heroin® also had some… non-heroic qualities (as Harry Hill put it, “It’s very moreish”). This, and also the fact that German companies like Bayer lost their trademarks after World War I, led to it becoming known by a more prosaic name:
since it is the diacetyl- version of morphine, it became diamorphine.
Barbiturates were also discovered in this period – the name apparently derives from celebrating the discovery at the feast of St Barbara – which Bayer marketed under the name Veronal®, supposedly after what one of the discoverers thought the most peaceful place on earth: Verona, Italy. As with morphine, it quickly became obvious that Veronal® had properties not entirely reflected by the brand name – it was both addictive and could be fatal in overdose.
As newer drugs came out manufacturers started to use less emotive names to describe their drugs; the age of the evocative name was over. Even a drug like promethazine, which suggests the titan Prometheus, is actually just a shortening of propyl dimethylamine phenothiazine.
Matthew Roberts, Senior Clinical Pharmacist and Supervisor
Naming of medicines, part one – introduction
CONTACT US Tel: 0345 222 3550 Email: [email protected] Address: 4 Dyke Road Mews, 74-76 Dyke Road, Brighton, BN1 3JD
ASHTONS PHARMACY NEWS PALLIATIVE CARE EDITION Editor: Margaret Gibbs, Lead Palliative Care Pharmacist Editorial team: Chris Burrell, Head of Marketing Shannen Stevens, Graphic Designer & Sub-editor
SUBSCRIBE Simply go to this link: http://eepurl.com/do9dtD or email us at [email protected] to get your free quarterly subscription. Previous issues are also available free of charge as an electronic PDF.
It’s summer and hay fever season is in full swing. Hay fever (allergic rhinitis) is an allergic reaction to pollen and symptoms include sneezing and coughing; a runny or blocked nose; itchy, red or watery eyes; an itchy throat, mouth, nose and ears; pain around your temples and forehead; headache; earache and feeling tired. People with asthma can experience additional symptoms.
The NHS suggests that the best way to prevent hay fever symptoms is to stay indoors whenever possible when the count is high. They also advise taking a shower and changing your clothes after being outdoors to remove the pollen on your body and wearing wraparound sunglasses to protect your eyes. If symptoms are still experienced, the most common treatment is to use oral antihistamines to try and control the allergic reaction, or corticosteroids to deal with the inflammation.
Ashtons can provide a full range of allergy treatments: https://bit.ly/30N2Lu8
From 31 March 2020 NHS and partner organisations are required to use modern communication methods instead of faxes, such as secure email, in order to comply with their information governance requirements and in a bid to improve patient safety and cyber security.
How do we swap to using secure email? 1. Form a project team 2. Review the number of existing NHS email accounts
currently within the business 3. Select shared emails for professionals where necessary
and agree a management process with staff 4. Remove fax numbers from stationery and media
Advantages • Fast, modern and efficient • Clearer communication (cannot be sent upside down!) • Reduction in wasted staff time spent faxing • Reduction in missing requests thanks to secure data
transfer and audit trail • Improved data security • Reduced running costs
Ashtons have set up a secure NHS email that can be used to scan and send orders – please refer to your Pharmacy Information Folder for advice on placing orders.
Information governance update: faxes
• Opioid patches – back to basics
• Naming of medicines • Focus on deprescribing • Ashtons training
seminars and online presentations
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FEATURE
Reflections on COVID-19 6-7
News just in – August 2020: Restrictions on over-the-counter sale of stimulant laxatives 14 Ordering 2% lidocaine in Lutrol gel 14
Contents A welcome from the Editor 3
Focus on deprescribing 4-5
Disposal of Ashtons cool boxes and coolant gel packs 8
Flu vaccine uptake – winter 2020/21 8
Ashtons training seminars and online presentations 9
Life support, first aid and mandatory training – update 9
Using the hospice as a hub for emergency medicine supplies 10-11
Opioid patches – back to basics 12-13
Naming of medicines, part one – introduction 15
Hay fever treatments 16
SUBSCRIBE NOW Simply go to this link: http://eepurl.com/do9dtD
or email us at: [email protected]
HOSPITAL PHARMACY SERVICES
FOR YOUR INFORMATION: We provide two newsletters
A welcome from the Editor
3
The past few months have been like no other. When we first heard about COVID-19, it was difficult to imagine the devastating effects it would have on health services and our economy. Even in the UK, with all its advanced healthcare, the pandemic has brought the system close to breaking point. We saw such dedication amid extreme suffering. Yet, there was also immense frustration in how it was managed – and the effects it had on those working directly with patients. Hospices seem to have been overlooked in their need for the same level of PPE and testing as other, more acute settings. We heard how managers spent many hours on the phone trying to get what they needed while patients were arriving without a known COVID status. This edition of the newsletter includes reflections on these common experiences from our hospice colleagues. Thankfully, most have found a way forward – strengthened by your determination and passion for carrying on the work you do in your unique way.
We were able to continue our service throughout and are immensely thankful to all our Ashtons teams for keeping the supplies and professional services going to support our customers. We know that some establishments felt unable to invite us in to visit; still, we are now back at all sites but one. It’s almost business as usual – with the added precautions we
are now getting used to. We ensured a good enough supply of the medicines we believed to be crucial to hospices, and this will continue with careful attention from our purchasing department.
It has certainly been an interesting time to be a pharmacist as several great initiatives have developed. We were approved to relax some regulatory processes if it meant patients could get their medicines more promptly. It feels like this ‘honeymoon’ period is now over, but it has enabled some innovative solutions to be planned – you will find an article included describing one of these medicines access projects which we hope to see in action soon.
It has been a privilege to work alongside our hospice colleagues during these challenging times, and we look forward to continuing our work with you, whatever lies ahead as the winter approaches.
With good wishes and kind regards,
Margaret Gibbs, Editor and Lead Palliative Care Pharmacist 07387 418 530 [email protected]
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One of the audits collected on our Ashtons Live View system is the number of prescription items for each patient. This information enables us to provide you with comparative data and percentages for our clinical interventions. It is not unusual to count more than twenty items for one patient on a hospice drug chart, although many of these items will be on the PRN pages. We pay great attention to detail with the patient’s response to their medicines, but what are the prompts for reducing the number of items? It can take considerable time to administer medicines when a patient is weak and finding large amounts to swallow challenging. It may be observed but not always reported by the nurses and proposed as an opportunity to rationalise. The patient may ask ‘do I really have to take all these?’ or refuse their medicines selectively or entirely. Making prescribing decisions may sometimes be quite simple – the patient is reported as being constipated, so we write up one or two laxatives. Their pain is showing
neuropathic characteristics, so we add in a tricyclic or gabapentinoid and within a few moments, they are being asked to take maybe six additional doses. Should we be looking at which items on a drug chart we can safely remove as carefully and regularly as those we might add? We know that many commonly used medicines have similar side effect profiles, and that additive sedation and anticholinergic effects can add to symptoms and increase the risk of falls. The positive effects need to outweigh the potential negatives, and we should review drug regimens for such risks.
The term ‘polypharmacy’ has become a rather pejorative term and although it is now acknowledged that it is difficult to avoid in symptom control towards the end of life, we still need to consider it.
Appropriate polypharmacy
Prescribing for a person for complex conditions or for multiple conditions in circumstances where medicine use has been optimised and where the
medicines are prescribed according to best evidence.
Problematic polypharmacy Problematic polypharmacy occurs when multiple medicines are prescribed inappropriately or where the intended benefits from the medicines are not realised.
Medicine rationalisation and deprescribing are now relevant in all areas of therapeutics. NICE guidance suggests regimes for specific diagnoses, but this does not take into account that some people will have several co-morbidities and have multiple drugs prescribed as a result. NICE has now collated resources to guide us in the rationalisation of medicines, acknowledging the potential problems with multi- morbidity and polypharmacy1. The new resource directs to documents including those from the Royal Pharmaceutical Society and the UK national health bodies with titles such as ‘Getting medicines right’. These are generally similar and useful for GPs caring for people with chronic
Focus on deprescribingFocus on deprescribing
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conditions. Tools such as the Beers Criteria2 have been developed to provide very detailed options on the various categories of medicines however, there is a simpler and more appropriate tool for people approaching the end of life. The STOPPFrail tool3 was developed in Sunderland and validated by a study in Ireland4 as an adaptation of the STOPP (Screening Tool of Older Persons Prescriptions), specifically for frail adults with a limited life expectancy. To apply this, the patient must fulfil all these criteria:
• End stage irreversible pathology. • Poor one-year survival prognosis. • Severe functional impairment or
severe cognitive impairment or both. • Symptom control is the priority
rather than prevention of disease progression.
The first consideration in the STOPPFrail Tool focuses on discontinuing any drug the patient persistently fails to take or tolerate despite adequate explanation and consideration of alternative formulations. The second consideration is – any drug without clear clinical indication. It is concerning that some prescriptions may be on repeat cycles and not reviewed periodically in primary care. There is also understandable reluctance for stopping medicines which have been prescribed by other specialists and the guidance in these tools helps with these decisions.
Of course, there are some conditions where it is essential to continue with the medicines until the last days of life, so we need to refer to specific guidance for Parkinson’s disease and diabetes, for example.
Suggestions start by looking at the drug chart for ‘refusals’ and discussing with the patient why they do not want to take the medicine – perhaps these items can be safely crossed off. Then look at additive side effects and consider whether any causing side effects such as drowsiness or dry mouth could be removed. Discuss the pros and cons of stopping or continuing with the patient.
Look at those medicines which are preventative and consider the benefits of continuing them (see box), but at all times consider the risks and benefits for each individual patient.
In any prescribing decision it is important to involve the person who is taking the medicine and this is equally pertinent when it comes to stopping. When a patient
has been told they must take a medicine ‘for life’, stopping it can feel dangerous and may also reinforce the fact that they are coming towards the end of their life. However, in practice, many people are relieved to reduce their tablet burden, so it is, as with everything in palliative care, tailored to the patient. One helpful strategy is to suggest a trial of stopping the drug and see what the effects are. If stopping makes a symptom worse, the medicine can be re-started.
If you would like to look at this in more detail, we can now offer training sessions to hospice staff on these topics:
• Polypharmacy and deprescribing towards the end of life.
• Management of Parkinson’s disease towards the end of life.
• Management of diabetes towards the end of life.
References 1. NICE Key therapeutic topic www.
nice.org.uk/advice/ktt18 2. Beers Criteria https://bit.ly/3b2a0Ts 3. BMJ Support Palliat Care2017
Jun;7(2):113-121. doi: 10.1136/ bmjspcare-2015-000941. Epub 2016 Jan 5
4. Age and Ageing 2017; 46: 600– 607 doi: 10.1093/ageing/afx005 Published electronically 24 January 2017
Margaret Gibbs, Lead Palliative Care Pharmacist
Drugs to consider stopping towards the end of life
• Vitamin / mineral supplements • Statins – evidence shows they
still protect for one year after stopping
• Review anti-hypertensives – may be able to reduce dose or stop
• Aspirin low-dose • Some inhalers – especially
where patients are too weak to use them effectively
• Gastro-protection – maybe steroids have been stopped?
• Oral hypoglycaemics – if the person is no longer eating
• Oral anti-oestrogens/anti- androgens
Reflections on COVID-19Reflections on COVID-19
Looking back on my emails, I see that my first COVID-related message came in on 3rd March. At first, it was impossible to judge the impact the virus was going to have on our healthcare system and hospices. The shocking lack of their inclusion in the two essential components – PPE and testing – soon became
apparent. Many of our senior hospice colleagues have described how they had to ‘fight’ for what was needed – on top of caring for very sick patients who may or may not have the virus and staff having to isolate for the statutory period.
A number of excellent documents and initiatives were produced rapidly and we were pleased to be able to direct our customers to the resources created by a joint group of experts from the Royal College of General Practitioners and the Association of Palliative Medicine:
https://elearning.rcgp.org.uk/mod/ page/view.php?id=10537
This comprehensive document is still available to provide healthcare professionals with clear guidance on symptom control, end of life care and supporting families. Palliative care was very much in the news and we know that many of our colleagues working in Trust hospitals were providing care to patients as well as
support to colleagues on every level.
Clinicians reported that the usual drugs we use for symptom control were effective for the breathlessness and agitation which seemed the most prevalent issues for COVID patients. Although there were views that higher doses should not be avoided in emergencies from the USA,1 Clinicians at Guy’s and St Thomas’ hospitals, who recorded their data from 101 patients they cared for, agreed that agitation was a common symptom observed and it was managed with similar doses to those usually used. Breathlessness continued to be a problem throughout the disease but cough less so towards the end. 74% of those that were admitted to palliative care for symptom control died2. Other doctors in the South of England, who were also recording data, observed that patients fell into two main categories: some deteriorated and died with a shorter than average dying phase for hospital deaths – 39 hours rather than 72 hours – while others had the more
FEATURE:FEATURE:
“Masks, aprons, and gloves create such a barrier to how we communicate, and you were unable to apply the specific ways you are used to caring, with close contact and gentle touch.”
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usual trajectory. They observed the latter group were older and frailer. They also noted that 72% of the patients in the study died with a syringe pump in place compared to the usual number of around half that3. Their report concludes that there should be no delay in starting an infusion where indicated in COVID and that the need to prepare family members for negative outcomes is more pertinent than usual. Hopefully, this learning will be disseminated and increase confidence in caring for dying people with the virus.
By early April we started to become aware that some end of life injections were being supplied preferentially to NHS Trusts and the Nightingale hospitals. Ashtons had created a list of essential medicines early on and our excellent team ensured they obtained good stocks of the likely medicines which would be required. Hospices were prepared to admit additional patients for end of life care and some found their numbers increased. Conversations with hospice colleagues over April, May and June made it clear that some people decided that visiting restrictions in hospitals and hospices led them to want to stay in their own homes, so after an initial increase, the actual occupied bed numbers were not as high as may have been expected.
You explained that many patients were admitted without having been tested so you needed to treat them as ‘possibly’ COVID-positive, with all the ramifications of PPE and staff management. Some of you have talked about the difficulties you encountered in your interactions with patients and families. Masks, aprons and gloves create such a barrier to how we communicate and you were unable to apply the specific ways you are used to caring with close contact and gentle touch.
This sounded the most difficult challenge for your teams and it was expressed very clearly in a moving video produced by Princess Alice Hospice (https://www. youtube.com/watch?v=5prToYDTdns) which was shown on BBC Newsnight. Mercadante and colleagues reported on their own experiences in Italy and showed that although virtual contact with patients was of some comfort, unsurprisingly nothing substitutes for human touch4.
With more patients remaining at home over this period, we worked with some of the hospice community team leads and their CCGs to ensure rapid access to symptom control medicines. It was clear in the community too, that deterioration and death were occurring more rapidly with COVID and some of the existing ‘Out of Hours’ pharmacy schemes were not as responsive as they needed to be. The SW London CCG provided emergency packs of injectable and oral drugs which were stored in various settings and could be accessed at all hours. Although the use of these packs was low, it was a very responsive and innovative way to support those caring for people in the community. We hope that shining a spotlight on emergency end of life care drugs out of hours may help mould any future plans and we continue to support some hospices in their aims to become hubs for ‘just in time’ supplies of small quantities of medicines when other systems cannot meet the patients’ urgent needs.
Another welcome initiative has been the ability to re-purpose medicines which have been supplied to a patient but not required. We had heard from the CQC last year that they would not be against hospices taking into stock items dispensed on a TTO from the supplying pharmacy which subsequently could not
be used due to the patient not being well enough for discharge. We had prepared a Standard Operating Procedure for this practice but once COVID arrived, we decided to broaden the scope of this and advise hospices to quarantine and potentially re-use other complete packs of medicines which would otherwise be wasted. The NHS subsequently produced more conservative guidance on this practice but we hope that this may continue to be our practice and that we can make use of unwanted TTOs, while carefully documenting the practice and using our pharmacists to assist with the governance processes.
This has been a summer none of us will forget. Some of us have lost family members, friends and colleagues. All of us know people whose lives have been affected and we, as Ashtons, were pleased to know that we were able to support you in the unique role you have in caring for those at the end of their lives.
1. https://www.jpsmjournal.com/ article/S0885-3924(20)30389-4/pdf
Ashtons have commenced supplying all fridge lines in the environmentally friendly fridge boxes in place of the polystyrene boxes previously used. The replacement fridge boxes are manufactured from wood pulp, together with the insulation inserts, and are therefore biodegradable and, being a paper-based product, fully recyclable.
The coolant packs, which are used to keep the fridge box between 2°C and 8°C, are made from a low-density polyethylene (LDPE 4) pouch. The contents of the coolant pack consist of an aqueous (water- based) gel.
Ashtons will not be reusing these packs so they can be locally disposed. The contents of the pouch are benign, given the dilution of the polymer used to make the gel, are not harmful to humans and can be poured away through the normal domestic waste drainage system via a sink or sluice. The empty LDPE pouch film can then be disposed as
general waste in locations where it is not possible to recycle it.
Ashtons are continually looking to improve quality and provide innovative solutions and the introduction of these recyclable fridge boxes has been well received.
Disposal of Ashtons cool boxes and Disposal of Ashtons cool boxes and coolant gel packscoolant gel packs
Due to the impact of the COVID-19 pandemic, there will be a national drive to increase the uptake of flu vaccinations, to reduce pressure on the NHS. Healthcare staff and people with certain health risk factors are the current focus for flu vaccination and this list may be expanded to include other people at risk. Ashtons have placed advance orders of the flu vaccine with suppliers for the 2020/21 winter season, but will endeavour to obtain further quantities if there is a demand.
For more information, please visit: https://www.england.nhs.uk/wp-content/uploads/2020/05/ national-flu-immunisation-programme-2020-2021.pdf
Online presentations available The pandemic has made it difficult for hospices to arrange training and there has been less demand for Ashtons pharmacists to present seminars at sites. Consequently, Ashtons is now able to make seminar presentations available via online platforms such as Zoom or Microsoft Teams, meaning that all available staff with online access can participate in the training, without having to meet up in a room together.
NEW training seminars available: Management of diabetes towards the end of life This seminar provides an overview of diabetes and the oral and injectable treatments available. It guides participants
through the management of diabetes towards the end of life, based mainly on the highly regarded British Diabetic Association guidelines.
Management of Parkinson’s disease towards the end of life This seminar begins with the causes, symptoms and drugs used in Parkinson’s
disease. It goes on to describe the end stages of the disease and the specific considerations, including drug choices for symptom management, towards the end of life.
Please contact your visiting pharmacist to arrange seminar training, whether onsite or via webinar.
Ashtons training seminars and online Ashtons training seminars and online presentations presentations
Life support, first aid and mandatory training – update
The concerns presented by COVID-19, and the need to prevent its spread within hospices and hospitals, has forced many customers to put critical face-to-face life support and mandatory training on hold. The balancing act now is keeping up with statutory and mandatory requirements while simultaneously adhering to social distancing, restrictions on the gathering of groups and keeping everyone safe.
While the HSE did allow extension times on the expiry of first aid certificates, the first aid training industry in England is confident that enough courses will now be available for all required requalification training to take place. The HSE has therefore agreed a final deadline for requalification of 30th September 2020.
The HSE still strongly recommends that the practical elements of actual First Aid At Work, Emergency First Aid At Work and requalification courses are
delivered face to face, so that student competency can be properly assessed.
In line with this, while Basic Life Support (BLS) courses can be found online, we strongly recommend that hospices start returning to face-to-face BLS and AILS (Adult Immediate Life Support).
The First Aid Training College and Ashtons have a concise COVID-19 training policy in place and we are confident that we can offer you safe and effective training. Our training mannequins have always been hygienically maintained and the advantage of each student having their own face mask for the session has always been a safety precaution for us. Mannequins will also be cleaned between each user and we are encouraging the use of face masks and sitting at least one metre apart in the classroom sessions.
If you would like to find out more about our first aid and life support training,
please get in contact. We are currently taking bookings from September through to December 2020 but have a couple of days left in August.
The First Aid Training College is now also able to offer you a full suite of 23 mandatory and statutory training courses. This a relatively affordable but very effective way of training your workforce and we have successfully rolled this out with a few customers now.
The First Aid Training College and Ashtons – Your partner in quality training, preparing you to make a difference.
Adrian Munday, Managing Director at The First Aid Training College
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For many years the NHS has struggled to fulfil the NHS Out of Hours (OOH) standards that stated ‘patients should be able to access the medicines they need at the time and place of the OOH consultation’. The Drug Tariff, which determines the list of products which can be prescribed on FP10 and their re-imbursement costs, still includes a rather dated ‘Out of Hours national formulary’ which categorises a wide range of medications for emergencies which include palliative care.
When this formulary was introduced, in about 2008, various solutions were proposed and many OOH medical services started to investigate whether they could be the place to keep a stock of the medicines required. Palliative care pharmacists worked with some of these services to help with logistics of ordering, storing and transporting Controlled Drugs in a service – made additionally challenging in a service which was not staffed 24 hours each day. Unfortunately, regulatory changes meant that in order to do this, OOH services would require a Controlled Drugs licence so most decided against holding stocks in a comprehensive way.
Many areas have OOH systems
where a select few community pharmacies hold an agreed stock of end of life care medicines. In most of these areas, there is an arrangement for the pharmacist to be available to attend at any time in the OOH period to meet the healthcare professional or family member and dispense the medicines required. This is a valuable service which has prevented many hospital admissions but there are occasions where it is still not sufficiently responsive to meet the needs of the patient. In a few cases, the medicines could be delivered but not all and it is never right to take a family member away from the patient to obtain medicines – they should be able to stay with them.
‘Just in case medicines’ started as a project nearly 20 years ago in Bedfordshire and Hertfordshire. It was set up by two palliative care pharmacists with support from other healthcare professionals including Ros Taylor, now medical director for Michael Sobell House. In an article1 they were able to show that provision of a selection of the essential end of life care injections in prepared packs over a 6 month period made it possible for 16 patients in the area to stay at home
to die rather than be transferred to hospital. The Gold Standards Framework encourages pre-emptive prescribing of ‘just in case’ medicines and people discharged from hospital or hospice will usually be supplied with injectable medicines for use when they can no longer take their oral medicines. This practice has become widespread and has reduced the requirement for emergency medicines so the schemes in place have not been on everyone’s radar. It is a very positive practice with one downside, which is that these injections are not always needed so at times they are wasted but on balance, it is preferable to have the assurance they are in place.
People dying with or from COVID-19 have been reported as experiencing rapid deterioration, so prompt access to injectable medicines has never been more urgent. Although we seem to be in a quieter period now, we need to be prepared for winter and a possible second surge. The pharmacy systems have not worked as well in practice when the need for medicines is less easy to anticipate yet more urgent. One of the hospices we work with has come up with a potential solution, based on practice in at least one other hospice.
Using the hospice as a hub for Using the hospice as a hub for emergency medicine suppliesemergency medicine supplies
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BENEFITS OF MEMBERSHIP The Association for Palliative Medicine of Great Britain and Ireland (APM) is the largest body representing doctors practicing or interested in Palliative Medicine. It is widely acknowledged that in palliative and end of life care, perhaps more than most specialties, excellent patient care is best achieved through a multi- disciplinary team working together providing high quality holistic care provision and support for patients and their loved ones. In recognition of this the APM has recently voted to open up membership to non- doctors including pharmacists, nurses and allied health professionals. With the new Associate Non-Doctor membership, individuals who join will have access to the ever-growing community of professionals, resources and benefits including:
• Networks and Special Interest Forums • APM bi-Monthly e-Bulletin • Membership of the European Association for
Palliative Care (EAPC) • Palliative Medicine journal** • BMJ Supportive and Palliative Care journal** • Palliative Care Formulary (PCF)** • Quarterly paper copies of the BMJ SPC Journal** • Study days and other meetings • APM awards
**Included with ‘Associate Non-Doctor Membership with Journals’
Association for Palliative Medicine - membership now open to non-doctors
ADVERTISEMENT FEATUREADVERTISEMENT FEATURE
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We have been working with colleagues in Hillingdon CCG and Central and West London NHS Trusts to build a procedure which allows Michael Sobell Hospice to act as a hub for the supply of medicines when other systems are not appropriate due to rapid deterioration. We have commissioned one of the licenced pre-packing units to prepare some small packs of injectables and a couple of oral medicines. With the support of the CCG, Michael Sobell House will keep a small stock and in extreme circumstances, the nurse or on call GP will be able to call the hospice doctor on call and
arrange a prescription and pick-up of the medicines required in as timely a way as possible.
We know some other hospices are interested in this possibility and we look forward to seeing how it goes in the Hillingdon area. Once it’s been tried and tested, we would love to support other hospices in sharing this good practice. Although this scheme has been created during the COVID period, like other initiatives, we hope to be able to continue this afterwards. Please feel free to contact me for more information (details on page 3).
References 1. https://www.
pharmaceutical-journal. com/pj-online-articles-how- a-just-in-case-approach- can-improve-out-of-hours- palliative-care/20015045. article?firstPass=false
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The two opioids available for delivery via a transdermal patch in the UK are fentanyl and buprenorphine. Fentanyl products are licensed for severe and chronic pain that requires long-term opioids or that does not respond to non-opioids. Buprenorphine is available in two sets of products – the stronger patches have a similar license to fentanyl while the lower strengths are indicated for non-malignant pain when an opioid is necessary (they are used for cancer pain in some cases, where patients only require low opioid doses).
Patches are only suitable for stable pain as they take up to 24 hours to reach steady state, so they should only be used for people whose pain is not rapidly increasing.
All fentanyl patches are effective for 72 hours once applied. The stronger buprenorphine patches remain effective for 96 hours (apart from one brand) but the weaker ones only need to be replaced once a week and this can be confusing for prescribers who are unfamiliar with these medicines.
We should advise patients to find the best way to remind themselves of the day they must change their patch – some might want to mark it on a calendar while others prefer to set a reminder on their smart phone.
Positive points • Convenient method of delivery. • Enables people to think a bit less
about their medication and live their life.
• They can be applied on various parts of the body, the site should be rotated to minimise the risk of irritation after repeated applications to one spot.
• Useful for people who may have problems remembering to take medicines.
• Useful for people: with cognitive impairment who struggle with oral medicines or have nausea and vomiting or e.g. oral cancers.
• Appropriate for people with renal insufficiency.
• The wide variation in strengths available makes it possible to tailor the dose appropriately.
Cautions • Once applied, patches take several
hours to reach therapeutic levels so other analgesia should be available.
• If the dose selected is too high for the patient and they become toxic, drowsy, even unrousable, just taking the patch off won’t be enough to assure their safety as it takes up to 24 hours for levels to decrease. If the patient has become sufficiently
drowsy to require opioid reversal, ensure expert advice is sought.
• Patches can be especially dangerous in this respect for initiation in frail elderly patients on their own at home – they must be monitored.
• If a patient is being switched from oral opioids to a patch the prescriber should use the guide on the SPC or the local guidelines for this. The fentanyl patches cover a wide range of possible doses so the lower doses should be used initially, e.g. fentanyl 25mcg patch is equivalent to between 90 and 134mg total daily morphine, which makes it challenging to safely convert.
• Heat increases absorption – avoid hot showers/baths and caution in extreme hot weather, like we have experienced recently. We need to alert patients and carers about this without alarming them – remind them to be aware of promptly reporting toxic effects.
• People should be given PRN opioids alongside the patch – this can be morphine if they are not being used because of renal insufficiency. Check in conversion tables to make sure the PRN dose is commensurate.
• Fentanyl immediate release products, e.g. Abstral, are not intended for use for PRN support in the same way as we use morphine and oxycodone in
Opioid patches – back to basicsOpioid patches – back to basics
one sixth of the daily dose. • GPs can sometimes be a bit more
relaxed about prescribing patches. Remember that fentanyl is between 100 and 150 times as potent as morphine so it must be treated with respect.
• All but one brand of patches are now ‘matrix’ patches, where the product is embedded in a plastic film or textile. Occasionally it used to be recommended to cut patches, but now with a range of strengths available, this should not be necessary. It is off licence but not dangerous, however there are still a few products which are ‘gel-filled’ patches (the older formulation) which must never be cut.
• Some people have problems with
patches that won’t stick because of sweating or oily skin - try a different brand.
• Some people have an allergic reaction to the patch, but this is invariably due to the adhesive and not the drug – try a different brand. (One unlicensed and imaginative way to reduce irritation is to spray the area with a steroid using an inhaler e.g. beclometasone).
Ensure people read the instructions – when applying a patch, hold it down for 20 seconds to improve adhesion.
They can be disposed of in general waste – on removal, fold the patch in on itself. Patches still contain a lot of fentanyl/ buprenorphine once removed so still should be disposed of carefully.
Product selection There are many products available, although each product with the same strength is therapeutically equivalent. We advise you order using the trade name and aim to keep to one brand if possible – to make stock-keeping simpler and provide a familiar product to your patients. Although wards must order complete packs for stock, pharmacies will supply the quantity specified to complete an individual prescription.
As with many medicines, prices change periodically and although there are not huge differences between the brands, it can make a difference to your drugs budget when you use quantities. Ashtons pharmacists can provide guidance on the most cost-effective choices when we visit and attend medicines management meetings.
The table on this page shows the main products available but only includes those where there is a Summary of Product Characteristics available on the Electronic Medicines Compendium. Note one of the buprenorphine patches needs changing every 72 hours which makes it slightly less convenient for patients and as more are required, slightly more expensive. All but one of these products is a matrix patch where the drug is evenly distributed across the surface. One remains a ‘reservoir’ patch where the active ingredient is in a gel released via a membrane. Cutting patches is inadvisable at any time but on no account must a reservoir patch be cut.
Product name and strengths available Strength = micrograms delivered per hour
Pack size
Duration of action
Buprenorphine matrix patches (lower strength) Bunov 5mcg, 10mcg, 20mcg 4 7 days Butec 5mcg, 10mcg, 15mcg, 20mcg 4 7 days BuTrans 5mcg, 10mcg, 15mcg, 20mcg 4 7 days Panitaz 5mcg, 10mcg, 20mcg 4 7 days Reletrans 5mcg, 10mcg, 15mcg, 20mcg 4 7 days Sevodyne 5mcg, 10mcg, 20mcg 4 7 days Buprenorphine matrix Patches (higher strength) Bupeaze 35mcg, 52.5mcg, 70mcg 4 96 hours Buplast 35mcg, 52.5mcg, 70mcg 4 96 hours Carlosafine 35mcg, 52.5mcg, 70mcg 4 96 hours Hapoctasin 35mcg, 52.5mcg, 70mcg 4 72 hours
Relevtec 35mcg, 52.5mcg, 70mcg 4 96 hours Transtec 35mcg, 52.5mcg, 70mcg 4 96 hours Fentanyl matrix patches Durogesic DTrans 12mcg, 25mcg, 50mcg, 75mcg, 100mcg 5 72 hours FENCINO 12mcg, 25mcg, 50mcg, 75mcg, 100mcg 5 72 hours Matrifen 12mcg, 25mcg, 50mcg, 75mcg, 100mcg 5 72 hours Mezolar Matrix 12mcg, 25mcg, 37.5mcg 50mcg, 75mcg, 100mcg 5 72 hours Opiodur 12mcg, 25mcg, 50mcg, 75mcg, 100mcg 5 72 hours Yemex 12mcg, 25mcg, 50mcg, 75mcg, 100mcg 5 72 hours Fentanyl reservoir patches – must never be cut Fentalis Reservoir 25mcg, 50mcg, 75mcg, 100mcg 5 72 hours
Examples of opioid patches available (brands in italics are those most regularly used).
Two new hospices join Ashtons We are delighted to announce that since April we’ve begun working with Springhill Hospice in Rochdale, Lancashire. We’ll soon also be working with St Leonard’s Hospice, Yorkshire. We’re looking forward to a long and successful partnership with both of these hospices.
Margaret Gibbs, Lead Palliative Care Pharmacist
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Restrictions on over-the-counter sale of stimulant laxatives
The MHRA has decided that stimulant laxatives can be inappropriately used by people wanting to lose weight – especially those who may have an eating disorder. In future, products such as Senna and Bisacodyl will sold in small pack sizes only and to people over 18.
Ordering 2% lidocaine in Lutrol gel
Guy’s and St Thomas’ manufacturing unit has now ceased supply of this product and it is now distributed by Oxford Health – the NHS specials and wholesale supplier. The price has increased considerably, so please speak to your visiting pharmacist before ordering to ensure you only order the essential quantity. Once ordered it cannot be returned as it is a special order. We will update our information sheet for this product accordingly.
1. Why is erythromycin used for constipation? Motilin is a naturally occurring hormone secreted by the small intestine. It increases gastro-intestinal motility and peristalsis and accelerates gastric emptying. It functions mainly between meals and in doing so prepares the gut for the next meal. Erythromycin happens to be a motilin agonist – working in the same way as the hormone – so can be used when metoclopramide or other prokinetics are unsuitable. It is effective in about half of cases, and concerns about the development of bacterial resistance have been shown to be largely unfounded. Only small doses are required, 50 to 100mg QDS to start and up to 250mg QDS if necessary. For the small doses it is necessary to use the suspension.
2. Are other hospices reporting losses with oxycodone liquid 5mg in 5ml?
Short answer – yes! The formulation of the 5mg in 5ml liquid in existing brands is very syrupy and so it sticks to the bottle, oral syringes and measuring vessels. We accept that each time a dose of liquid is removed if using a syringe, a small volume will be lost and when multiple doses taken from a bottle, the loss increases. We recommend using a bung in all bottles of regularly used liquids as this minimises the loss. Weekly measuring of Controlled Drug liquids is common practice and ‘regular’ checks of stock balances should involve measuring liquids but this will incur further loss. There is a general acceptance that a 5% loss of liquid balance since the last check should not need to be reported as an incident but if more than this is unaccounted for, additional checks may need to be made.
3. Is melatonin effective as a sleeping aid? Melatonin is a naturally occurring hormone secreted when our pineal gland
senses darkness. It is considered less effective than conventional hypnotics, but sleep disturbance is difficult to manage with any of the current medicines in palliative care. Melatonin is reported as causing less ‘hangover’ sedation and may be considered suitable for those who cannot tolerate ‘z’ drugs and those who are at more risk of falls due to sedation. There is no firm evidence for its efficacy in palliative care but given its lack of side effects and the existence of a licensed medicinal form in the UK, it is worth considering.
Do you have a query about medicines or procedures in your hospice? Email us at [email protected] – it could appear in our next issue!
Recent queries from hospices Questions on medicines, procedures and practice from hospice staff
News just in –News just in – August 2020August 2020
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Medical suppliesMedical supplies
In his poem The Naming of Cats, T.S. Eliot asserts that cats have three names:
The Naming of Cats is a difficult matter, It isn’t just one of your holiday games; You may think at first I’m as mad as a hatter When I tell you, a cat must have THREE DIFFERENT NAMES. The Naming of Cats, T.S. Eliot.
Likewise, medicines can go by a few different names.
All drugs have a scientific name based on its organic chemistry. And even though morphine can be written simply as C17H19NO3, to also accurately describe its structure it needs to go by (4R,4aR,7S,7aR,12bS)-3- Methyl-2,3,4,4a,7,7a-hexahydro-1H-4,12- methanobenzofuro[3,2-e]isoquinoline-7,9- diol which by any standards is a bit of a mouthful.
For this reason, drugs are given a shorter ‘generic’ name. Drugs of a similar class share the same stem, so for example a benzodiazepine will have the ending -azepam (clonazepam, diazepam, lorazepam).
The manufacturer also comes up with a name that they use to market the drug, its brand name. These have to follow the same
rules for brand names for any product as well as meet regulators’ requirements that they are not easily confused with existing drugs.
I will discuss the rules for generic and brand names in a future edition. However, in the early days of medicines the rules around naming medicines used to allow more scope for the imagination.
One of the first drugs to be discovered was morphine in 1804 by Friedrich Sertürner. In typical style for the time, he tested the drug by taking it himself and promptly nearly became the first person to have a fatal overdose as well. Since it had a tendency to make people sleepy it was named after the Greek god of dreams, Morpheus (keeping up a family tradition as his father, Hypnos, has a whole class of drugs – the hypnotics – named after him). When a more potent version was discovered, Bayer named it after the fact that it could make you feel heroic – Heroin®.
However, it quickly became apparent that Heroin® also had some… non-heroic qualities (as Harry Hill put it, “It’s very moreish”). This, and also the fact that German companies like Bayer lost their trademarks after World War I, led to it becoming known by a more prosaic name:
since it is the diacetyl- version of morphine, it became diamorphine.
Barbiturates were also discovered in this period – the name apparently derives from celebrating the discovery at the feast of St Barbara – which Bayer marketed under the name Veronal®, supposedly after what one of the discoverers thought the most peaceful place on earth: Verona, Italy. As with morphine, it quickly became obvious that Veronal® had properties not entirely reflected by the brand name – it was both addictive and could be fatal in overdose.
As newer drugs came out manufacturers started to use less emotive names to describe their drugs; the age of the evocative name was over. Even a drug like promethazine, which suggests the titan Prometheus, is actually just a shortening of propyl dimethylamine phenothiazine.
Matthew Roberts, Senior Clinical Pharmacist and Supervisor
Naming of medicines, part one – introduction
CONTACT US Tel: 0345 222 3550 Email: [email protected] Address: 4 Dyke Road Mews, 74-76 Dyke Road, Brighton, BN1 3JD
ASHTONS PHARMACY NEWS PALLIATIVE CARE EDITION Editor: Margaret Gibbs, Lead Palliative Care Pharmacist Editorial team: Chris Burrell, Head of Marketing Shannen Stevens, Graphic Designer & Sub-editor
SUBSCRIBE Simply go to this link: http://eepurl.com/do9dtD or email us at [email protected] to get your free quarterly subscription. Previous issues are also available free of charge as an electronic PDF.
It’s summer and hay fever season is in full swing. Hay fever (allergic rhinitis) is an allergic reaction to pollen and symptoms include sneezing and coughing; a runny or blocked nose; itchy, red or watery eyes; an itchy throat, mouth, nose and ears; pain around your temples and forehead; headache; earache and feeling tired. People with asthma can experience additional symptoms.
The NHS suggests that the best way to prevent hay fever symptoms is to stay indoors whenever possible when the count is high. They also advise taking a shower and changing your clothes after being outdoors to remove the pollen on your body and wearing wraparound sunglasses to protect your eyes. If symptoms are still experienced, the most common treatment is to use oral antihistamines to try and control the allergic reaction, or corticosteroids to deal with the inflammation.
Ashtons can provide a full range of allergy treatments: https://bit.ly/30N2Lu8
From 31 March 2020 NHS and partner organisations are required to use modern communication methods instead of faxes, such as secure email, in order to comply with their information governance requirements and in a bid to improve patient safety and cyber security.
How do we swap to using secure email? 1. Form a project team 2. Review the number of existing NHS email accounts
currently within the business 3. Select shared emails for professionals where necessary
and agree a management process with staff 4. Remove fax numbers from stationery and media
Advantages • Fast, modern and efficient • Clearer communication (cannot be sent upside down!) • Reduction in wasted staff time spent faxing • Reduction in missing requests thanks to secure data
transfer and audit trail • Improved data security • Reduced running costs
Ashtons have set up a secure NHS email that can be used to scan and send orders – please refer to your Pharmacy Information Folder for advice on placing orders.
Information governance update: faxes