OPTIMISING MEDICINES USEGRAHAM DAVIESProfessor of Clinical Pharmacy & TherapeuticsInstitute of Pharmaceutical ScienceKing’s College London

Learning outcomes

1. Describe the problems commonly associated with the use of medicines

2. Explore the common causes of adverse drug reactions

3. Describe how pharmacists can contribute to optimising medicines use

Typical patient journeyPatient Experiences Symptoms or routine health check

Diagnosis Seek health care

Intervention (referral, procedure or medicine)

Medicines: the most common intervention

NHS Budget:

• 1999/2000 £40 billion

• 2011-12 £105 billion

• Drug Expenditure 15% of budget

Medicines in perspective

• Explosion of anti-infective agents to target range of infections e.g. range of antibiotics; HIV

• Positive impact of low dose aspirin on mortality following a heart attack (1980s)

• The significant benefit of ACE Inhibitors to treat heart failure (1987)

• Impact of statins to control blood cholesterol (1990s)

• Expansion in the range of chemotherapy agents

Evidence based treatment

“One of the greatest hazards is the use of potent drugs is theirinherent toxicity……

…..the dangers of the drug appear to be greater now then ever before.”

David Barr MD; Hazards of modern diagnosis and therapy – the price we pay. Frank Billings Memorial

Lecture.

J Am Med Assoc 1955;159 (15): 1452-1456

Problems caused by medicines

Adverse drug reactions causing hospital admission1. 6.5% of all admissions due to an ADR2. Elderly patients 3-4 times more likely to be

admitted with ADR 3. 4% of hospital bed capacity4. 0.15% fatality5. Drug-interactions responsible for 1 in 6 ADRs6. 72% were preventable7. Cost to NHS £466 million/year

Pirmohamed, M., et al. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18 820 patients. BMJ, 2004. 329(7456): 15-9.

Adverse drug reactions and the elderly

Tangiisuran et al Drugs in Aging 2012

Which medicines cause harm?

Safety in Doses. National Patient Safety Agency 2009

Non-adherence to medicines

1World Health Organization Report 2003. 2 Horne et al. Concordance, adherence and compliance in medicine taking. NIHR SDO 2006. 3 NICE. Medicines concordance & adherence: involving adults and carers in decisions about prescribed medicines 2008/9

Recent reports:• Estimated that between

30 -50% medicines prescribed for long term illnesses are not taken as directed.

• Cost associated with wastage – not only the medicine but the time of healthcare staff.

Sources of medication problems - multifactorial• Prescribing - selecting the wrong or inappropriate

drug, often at the wrong dose for the patient,• Co-prescribing – interacting medicines,

complementary therapy or alcohol• Lack of patient education - information relating

to:– What do they understand about their disease?– Do they understand the benefits of therapy?– What concerns do they have about their

prescribed medicines?

ROLE OF PHARMACISTS IN MANAGING MEDICINES

Pharmacists – optimising medicines use

Identifying medication problems

• Knowledge of patient – is there anything about this patient that concerns me?

• Knowledge of medicine – is there anything about this medicine that concerns me?

Patient factors

• Patient Characteristics– Age, ethnicity, gender– Height, weight, BMI– Pregnancy & breast feeding

• Co-morbidities (for example)– Asthma and hypertension– Arthritis and peptic ulcer

disease– Allergy status and infection– Pain and renal disease

• Function and cognitive factors– Mobility, balance, sight,

swallowing– Memory, comprehension

• Social and environmental factors– Lifestyle, home environment

and family support– Support services available

• Patient’s perception of drug therapy

Medicine factors

• Toxicity Factors– Drug interactions,

complementary medicines,– Allergy status,

contraindications, – Adverse reaction profile– Therapeutic index of medicine

• Drug factors– Renal and hepatic function

• Evidence of efficacy supporting medicine

• Response to current and previous drug therapy– Did the treatment work?– Did the patient experience

any problems?

The care process

Establishing a therapeutic relationship - a continuous process

PATIENT ASSESSME

NTCARE PLAN EVALUATIO

N

Use a range of information to:

• Identify actual and potential drug related problems

• Resolve actual drug related problems

• Prevent potential drug related problems

Summary• Medicines are beneficial but can also cause harm

• Society needs a gatekeeper who manages medicines for society - seen as the drug expert - the pharmacist

• Pharmacists must adopt a patient focused approach to identifying and resolving medication related issues

• Understanding the aims and process which underpin the process of identifying medication - related problems is essential to delivering safe and effective care

OPTIMISING MEDICINES USEGRAHAM DAVIESProfessor of Clinical Pharmacy & TherapeuticsInstitute of Pharmaceutical ScienceKing’s College London