Clinical Pharmacy Conference , Port Clinical Pharmacy Conference , Port Dickson, 9-11 Jan 2003Dickson, 9-11 Jan 2003

Respiratory Pharmacy & the Respiratory Pharmacy & the Ward Pharmacist experienceWard Pharmacist experience

by by

Abdol Malek bin Abd Aziz, Abdol Malek bin Abd Aziz, MScMSc

Respiratory pharmacy

• Emphasis on pharmaceutical care of respiratory patients

plus

• Other conditions that the patient is concurrently suffering

Respiratory Pharmacy

Covers:

•Asthma•COPD•Idiopathic interstitial lung disease•Pleural disorders•Pneumonia•Drug-induced pulmonary disease

NHMS 1996 - Findings

• High percentage (62.4%) not on inhalers

• Mild asthmatics: 65.3%

• Moderate : 52.1%

• Severe : 23.7%

Compliance / adherence

• Generally non-compliance rate ~ 50% (out patients)

• 56% in Melaka (1999)*• Leads to hospital admission• 51.7% in Hospital Melaka **• 13.3% were asthmatics (6/45 patients)• Non-compliance to inhaled medications: 50%

(McGann & Elizabeth. Am J Nursing 1999)

• Aziz AMA, Ibrahim MIM. Med J Malaysia 1999.• ** Aziz AMA, Senthil N, Jenny W. J Pharm Sci. 2003 (in press)

Some avenues to patient care…

• Patients with allergic rhinitis often experience symptoms of asthma (Linneburg.

Allergy 2002,57)

• Allergic rhinitis preceded or developed at the same time as allergic asthma

• Tx of allergic rhinitis reduced asthmatic symptoms or reduce risk of asthma

Inhaler technique

• “good” rating ranged from 5-86% using MDIs• Technique improved after proper training*• 37.5% of pharmacy staff & 45.4% (15/33)

outpatients having good technique€

€Inhaler technique survey among pharmacy staff and patients at the specialists clinic pharmacy, Hospital Melaka. Abstract of the Konferens R&D Farmasi, Kota Bharu 2002.

* Cochrane MG, Bala MV, Downs KE et al. Inhaled corticosteroids for asthma therapy: patient compliance, devices , and inhalation technique. Chest 2000;117(2):542-550

Lung deposition of medication

• Terbutaline: MDI – 8%, DPI – 22%*• Effect of spacer device:Lung deposition increase from 9 to 21%Oropharynx deposition reduced from 81 to 17%#

* Borgstrom L, Derom E, Stahl E, et al. The inhalation device influences lung deposition and bronchodilating effect of terbutaline. Am J Respir Care Med 1996;153:1636-1640.

#Newman SP, Millar AB, Lennard-Jones TR et al. improvement of pressurised aerosol deposition with Nebuhaler spacer device. Thorax 1984;39:936-941.

* National Health and Morbidity Survey Vol. 11, Public Health Institute. 1996

Bronchial asthma

• Defn: Reversible airways obstruction , airway inflammation, airways

hyperreactivity to a variety of stimuli

• Incidence: 3-6% in Australia, 4.2% in Malaysia* , 2-5% in Africa

• Symptoms: Wheezing, dyspnoea, chest tightness, cough

Asthma in children

Children:• Dry powder inhalers has greater systemic

effects than MDIs§

• Pharmacists: recommend MDI with spacer device for children.

§ Kereem E . Ann Allergy Asthma International 2002;89.

Pharmacist’s roles

• As educator and support person• Counsel on role of each medication• Difference between preventer – reliever• Emphasise safety of inhaled c’steroids• Discuss adverse effects – ways to minimise• Check and correct proper use of inhalers• Encourage use of spacers and peak fl. meters

AMA Aziz, MIM Ibrahim. Medication noncompliance - a thriving problem. Med J Malaysia 1999;54:192-5.

Pharmacist’s roles

• Check compliance – 56% noncompliance rate1

• Check usage of medications for other illnesses, OTC products, GP’s drugs, etc

• Dispels myths about asthma and inhaler use

• Encourage asthma action plan

Objective

• To have an influence on prescribing and related clinical practice

How to start?

• Ward pharmacy

• then

• Respiratory pharmacy

Ward pharmacy

• Back to basics

• Supplies, inventory, pricing,

• Dosage, category of drug in MOH list

• List A, std item

• Synergistic activity with in-patient pharmacist/satellite pharmacist

At the ward…

• Familiarise with the ward- acquaint with ward staff ie. sister & nurses

• Ward procedures• Own reading on common drugs used

• develop confidence

Ward rounds

• Consultant’s rounds: already have a high level of interest in optimising drug therapy

• Vigilant on ADR and side effects

Preparation before rounds

• Very, very important

• May take an hour or more initially

Objective:

‡ to anticipate areas where information is likely to be requested

‡ To identify topics for discussion

• Becoming prepared

provides…

Confidence

Clerking

• Same as any other pt• Biodata, diagnosis, investigations, lab results, x-

rays, etc, • Document using card or form • Monitor, • Identify drug-related problems or issues• Plan for solution - check-up- talk to Dr or specialist, nurse

Things to do…

• Estimate creatinine clearance ClCr if the serum creatinine is >150µmol/l in adults less than 70 yrs using Cockcroft and Gault equation

• Abnormal levels of urea or albumin may alter the disposition of some drugs

Patient parameters

• Pt. with liver disease – elevated liver function tests

• Severe cardiac failure may affect both renal and hepatic clearance of drugs may necessitate dose individualisation

• Calculate predicted blood levels if therapeutic monitoring of a drug is required

Attending ward rounds

• Be PUNCTUAL

• Degree of involvement and pharmacist’s role depend on the leading physician

• Doctors may undertake management or teaching role or both

• They may not ask for pharmacist’s comments

A successful attendance in ward rounds

• Adequate preparation• Being tactful, yet

assertive• prioritise

• Regular attendance• Present info on a

problem concisely• Provide adequate

follow up

Pharmacist’s comments

• Unlikely to be a personal insult and no offence should be taken

• The advice may be used on a similar pt in future• Occasionally it may be used by the consultant

against his junior staff – communicate with the houseman to avoid unnecessary embarrassment

• Follow up on pts where comments have been accepted ie. supplies and instructions on usage

Specialisation

• Collins English Dictionary and Thesaurus:defines special as ‘distinguished’ or ‘set apart from’

• Specialisation ~ characteristics that distinguish a clinical pharmacist from other pharmacists

• Obtained thru’ further education and training

Nursing profession development

• Shift in promotion ladder *

• Dual career pathway

• management sister – matron☞• Clinical nurse advanced practice nurse ☞

(same ranking as sister/tutor)

• Similar to UK and Canada situation*Nafsiah Shamsudin. Specialisation of the clinical nurse in the

Malaysian setting. Sept. 2000.

Specialisation

• Extra qualifications preferable

• Sometimes not necessary

• MSc, MPharm

• PhD

• Experience, confidence, way of thinking, networking, research-oriented, etc

Specific situations

• Asthma

• Counselling

• Pharmacoherapy issues ie. Drug of choice: β-2 agonists (short-acting, long-acting, corticosteroids (inhaled , oral),

• Drug forms: inhalers, oral tablets, nebs

Other roles

• Conformance to guidelines: MTS, GINA• Research: eg.

drug use

clinical trials on outcomes of pharmacist-treated pt vs non-pharmacist pts, counselled vs non-counselled

Inhaler technique – relate to outcomes• Asthma clinic – check peak flow, compliance to

tx, appointments for counselling, etc

What others have achieved…

• Pediatric asthma management programme Covenant Health System, Texas, US ±

• Found many asthma pts admitted for various reasons ie. Lack of medication, non-compliance, improper inhaler technique

• Remedy: face-to-face counselling. Pharmacists counselled pts and families

• Complete pt information leaflets given, videotapes

• Spent 30-60 mins per pt± Razia M, Gordon H. Am J Health-Syst Pharm 2002;59. p. 1829.

results

• 69 pt counselled: 106 vs 51 ER visits or admissions pre and post counselling (↓52%)

• Cost avoidance: USD126,500/=

→ Counselling beneficial and reduces admission rates.

COPD

C.O.P.D.-X Plan• C = ConfirmConfirm diagnosis, severity,

complications• O = OptimiseOptimise patient function

(impairment, disability and handicap)• P = PreventPrevent deterioration• D = DevelopDevelop self-monitoring and

self-management care plan• X = guide for managing

exacerbations

C….confirm...C….confirm...

• Exclude asthma, cardiac disease etc

• Assess severity

• Assess reversible components

• Identify complications and co-existing conditions– history, examination, spirometry, xray

chest, FBE

O….optimise….O….optimise….

– Smoking cessation– Optimise drugs

• safe and effective - don’t over-prescribe

– Treat complications– Optimise psychosocialpsychosocial issues– Optimise nutrition (consider dietician)– Encourage exercise (consider physio gym)– Pulmonary rehabilitationPulmonary rehabilitation– Lung reduction surgery or transplantation

P….prevent….P….prevent….

– Smoking cessation (help and monitor)• AAAAA

– Occupation and other dusts– Stop unhelpful drugs– Prevent infections

• influenza vaccination (?Pneumococcal)• relevant antibiotics for purulent sputum and

fever

– Pulmonary RehabilitationPulmonary Rehabilitation– Transplantation

P….prevent….P….prevent….

– Check for complications & concurrent conditions

• osteoporosis, depression, cor pulmonale, OSA/hypoventilation

– Consider oxygen if hypoxaemic – Regular review

• lung function

D….discuss, develop….D….discuss, develop….

• Educate patient and carers

• Pulmonary Rehabilitation and Pulmonary Rehabilitation and Patient Support GroupsPatient Support Groups

• Assess self-management capacity

• Develop a collaborative care plan– monitor to identify exacerbations early– how to self-initiate treatment– what to do in an emergency

X… Exacerbations

• Inhaled bronchodilators and systemic glucocortocoids are effective treatments for acute exacerbations (Evidence A)

• Patients with clinical signs of infection(change in sputum colour and/or fever, leucocytosis) benefit from antibiotics (Evidence A)

Asthma Action Plan

• Designed for pts with asthma to:^ recognise deterioration and^ respond appropriately• Action Plan will prevent ^ delay of initiation of preventer dose

increases^ prolonged exacerbation^ adverse effects on pts life

Peak Flow Monitoring

• Peak Expiratory Flow (PEF) – the greatest flow velocity which can be generated during a forced expiration starting with fully inflated lungs

• Simple, quantitative, reproducible measure of airway obstruction

• Meters are cheap, lightweight and portable• Repeated measures highly reproducible with

each individual patient, if the same meter is used

Peak Flow Monitoring

• Actual number not important, but the trend is• Measures response to bronchodilator therapy –

increase by 20% post treatment (provided the baseline reading > 300ml/min adults)

• Measures early deterioration before pt. feels the change in his disease

{diabetics monitor blood sugar, asthmatics measure lung function…}

Pulmonary Rehabilitation Program

• Established in the Repatriation General Hospital, Adelaide since many yrs ago

• A structured program using weekly lectures spanning over 3 months

• 2 hrs session (1 hr lecture each person ) @1.30pm

• Coordinated by the Resp. Rehab. Clinic • Pharmacist • Talked about “Medications and Airways

Disease”

PRP team

• Respiratory physician (Chairman), • Technical officer, Respiratory Function Unit• Clinical Nurse Consultant, Respiratory Rehab

Clinic• Clinical Pharmacist• Physiotherapist• Rehabilitation Counsellor• Dietician• Occupational therapist