Case 18- medication Flashcards
Pill burden
The effort required to manage the multiple medications a patient may have
Consequence of living with mutliple long term conditions
Can result in emotional or psychological problems or issues with managing treatment
Compulsion
If a medication is recommended by a healthcare practitioner the patient legally has to take it. Normally for infective diseases.
Compliance
According with the treatment plan. Should take medication because it’s the right thing to do, not because of legal duty. Stigmatism if not complying with treatment
Concordance
Agreement between the prescriber and the patient, the patient takes the medication because they think it will help them. Creates the principle of therapeutic citizenship where the person has a responsibility to take medication but also has the right to refuse treatment if they don’t agree with it. Moral economy- patient are encouraged to take medication and seen as bad patients if they refuse.
Adherence
Refers to whether the patient takes the medication. The doctor has no power over the patient and all the power sits with the patient and what they want to do. Tries to remove the moral context, more of an objective measurement
Therapeutic citizenship
Gives the patient responsibility for their own health
Difference between Compliance, Concordance and Adherence
- Compliance- do as I say
- Concordance- do you agree to do as I say?
- Adherence- are you sticking to it?
Is non-adherence the patients problem?
Non-adherence is not the patients problem but is a limitation in the delivery of healthcare, often because the patient does not agree with the prescription or they are not provided with adequate support.
Medication adherence definition
The extent to which patients take medications as prescribed by their healthcare provider. The patient has a choice, patients and providers mutually establish treatment goals and the medical regimen
Medical adherence equation
(Number of doses taken / Number of prescribed doses) x 100
Benefits of good adherence
Increases the effectiveness of treatment and improves patient safety. Also reduces healthcare costs. Better adherence is associated with 20% less hospital visits per year
Five dimensional model of adherence
Adherence is affected by:
1) Social and economic factors
2) Therapy related factors
3) Patient related factors
4) Condition related factors
5) Health system factors.
Therapy factors affecting adherence
- Complexity of the medication regime
- Ability to perform techniques required (inhaled, injections)
- Duration
- Frequent changes to medication regime
- Lack of immediate benefit from treatment
- Stigma of using certain medication
The Social and economic related factors of adherence
- Language proficiency
- Lack of family/social support
- Unstable living conditions
- Demanding schedule
- Access to health care
- Medication cost
- Side effects
- Cultural beliefs
- Discrimination
Patient related factors of adherence
- Physical factors- visual/hearing, cognitive impairment, impaired mobility, swallowing problems
- Psychological/behavioural factors- knowledge about disease, Perceived risk, Stress, Anxiety, Anger, Alcohol and substance use
Condition related factors of adherence
- Chronic condition
- Lack of symptoms
- Severity of symptoms
- Depression- not motivated to take medication
- Psychotic disorders
- Learning difficulties
- Physical / Cognitive disabilities
Health system factors related to adherence
- Patient provider relationship
- Communication skills of the provider
- Disparity of health beliefs between patient and provider
- Lack of capacity for patient education or follow up
- Long wait times
- Lack of continuity in care
- Patient information given at appropriate level
Perceptions and Practicalities model
- Unintentional- capacity and recourses, Practical barrier, Patient wants to take it but cant
- Intentional- motivation and beliefs, Perceptual barriers, Patient doesn’t want to take it but could
- Necessity concerns framework- if concerns outweigh necessity to use medication, then its intentional non-adherence. If necessity outweigh concerns about using medication, then its unintentional non-adherence
Individuals consequences of non-adherence (micro-social)
A reported 80% adherence is required for therapeutic effects. Otherwise can cause negative clinical outcomes like increased hospitalisation, increased morbidity, social impact and economic consequences
Global consequences of non-adherence (Macro-social)
The total cost of treatment increases. Hospital admissions and emergency care are consistently and disproportionately high. Broader socio-economic impact.
How to improve adherence
- Explain the underpinning necessity to use the medication- How will it work? Why does it need to be used regularly? Consequences of non-adherence?
- Ensure adequate access to medication- Is it about cost? Mobility?
- Consider cognitive and physical impairment- Polypharmacy confusion? Swallowing difficulties? Changes to packaging?
BNF, BNFC, NPF
- BNF- British National Formulary
- BNFC- the BNF for children
- NPF- the nurse prescribers formular
BNF initial pages
Prescribing information. Contains general guidance on prescribing, prescription writing, prescribing in special circumstances i.e. pregnancy etc.
BNF chapters 1-16 systems
The systems involved are GI, CVS, resp, nervous, infection, endocrine, GU, immune/malignancy, blood/nutrition, MSK, eye, ENT, skin, vaccines, anaesthesia and poisoning.
BNF- Drug monographs, Appendices and Index
Contains drug monographs- all information that relates to a single drug is contained within its drug monograph.
Appendices- interactions, borderline substances, cautionary labels, wound management, NPF.
Index- you can look medications up in alphabetic order
Yellow cards
- Used by healthcare practitioners to report safety concerns about medication. All have to do this.
- Helps monitor the safety of all healthcare products
Advanced life support algorithm
Emergency algorithm used in cardiac arrest
BNF- Emergeny medications, conversions and abbreviations
Emergency medications- covers common emergency situation in the community i.e. asthma, MI, hypoglycaemia. Laminated section easy to find.
Conversions- issues when converting units
Abbreviations- back page. Common latin dose abbreviations i.e. OB, BD, QDS and common medical abbreviations.
What to include when writing a prescription
- BLOCK CAPITALS
- Black ink
- Full name of medication- (must not be abbreviated)
- Dose- (with no unnecessary decimal points. Eg. 0.1g is better written as 100mg)
- Frequency - OD/BD/TDS/QDS
- Times circled or ticked
- Clear units - g/mg
- Date prescription is written
- Indication
- Route - PO/IV/TOP/PR
- End date if needed
- Signature + name + GMC number
- Boxes after 7 day duration clearly crossed off + signed
Why is it important to adhere to prescription writing guidance
- Reduce risk of prescription errors
- Reduce risk of wrong medication/dose/route/ frequency being given
- Allows other healthcare professionals to see patients medication- contributes to safe handover
- Allows for prescriptions to be tracked if something does go wrong
Different types of prescription
Prescriptions can be hand written- there is an example of handwritten paper inpatient medication chart or Kardex.
Prescriptions can be electronic- this an example of a hospital electronic prescribing system.
Converting from kg -> g -> mg -> micrograms
- 1kg= 1000g
- 1g= 1000mg
- 1mg=1000micrograms
How to convert between ml to L
To convert from mL to L you divide by 1000, to convert from L to mL you multiply by 1000.
The 4 main expressions of concentration
- Quantity per volume- grams/litre
- Percentage concentrations- i.e. 0.9% NaCl IV fluid
- Parts- 1 in 1000
- Ratios- 1:1000, 1 gram of medicine is dissolved in 1000ml of fluid
Difference between Quantity per volume and Percentage concentration
Quantity per volume- The amount or weight of a drug in a volume of solution. Eg. 9g/l solution of sodium chloride means 9g of sodium chloride are dissolved in 1 litre of solution.
Percentage concentration- the number of parts of a medication in 100 parts of the dosage form
The 3 different percentage concentrations commonly used
- % W/V= percentage weight in volume. 0.9% w/v NaCl in water means that 0.9g of sodium chloride is dissolved in 100mL water
- % W/W= percentage weight in weight. 1% w/w hydrocortisone ointment means that 1g hydrocortisone is contained in 100g of the ointment
- % V/V= percentage volume in volume. 50% v/v liquid paraffin means 50mL of liquid paraffin is contained within 100mL of the final emulsion
Abbreviations frequency
OD- once a day BD- twice a day TDS- three times a day QDS- four times a day OM- in the morning ON- at night PRN- as required STAT- immediately
Abbreviations- route
Orally- PO Sublingually- SL Subcutaneously- SC Intravenously- IV Intramuscularly- IM By rectum- PR By vagina- PR Topically- TOP Inhaled- INH Nubulised- NEB Nasally- intranasal
Adverse drug reaction
Unwanted effects of drugs occurring under normal conditions of use. Can cause prevention of treatment, alterations in the dosage regimen or withdrawal of the product
Unwanted effects due to dose dependent interactions
- Pharmacodynamic adverse effects- one of the drug effects is reduced or enhanced i.e. propranolol reduces the effect of salbutamol
- Pharmacokinetic adverse effects- changes in ADME (absorption, distribution, metabolism and excretion) alters the drug effect. NSAIDs reduce the action of diuretics by reducing renal blood flow.
ABCDE classification
- A: Augmented – dose related
- B: Bizarre – non-dose related
- C: Chronic – dose and time related
- D: Delayed – time-related
- E: End of use – withdrawal
- F: Failure – unexpected failure
ABCDE- augmented response
Features- common, predictable, low mortality
Management- reduce dose or withold, consider effect of concomitant therapy
ABCDE- bizarre response
Features- uncommon, not related to the pharmacological effect of the drug, high mortality
Management- withhold and avoid in future
ABCDE- chronic (dose related)
Features- uncommon, related to cumulative dose
Management- reduce dose or withhold, withdrawal may have to be prolonged
ABCDE- Delayed (time related)
Features- uncommon, usually dose related, occurs some time after the drug has been takes
ABCDE- End of use (Withdrawal)
Features- uncommon, occurs soon after withdrawal of the drug
Management- reintroduce and withdraw slowly
ABCDE- failure (unexpected failure)
Features- common, dose-related, can be caused by drug interactions
Management- increase dosage, consider effects of concomitant therapy
DOTS
Classification system based on dose related, Timing and patient susceptibility
DOTS- dose
Divides adverse drug reactions into reactions that occur at:
- supratherapeutic doses (toxic effects)
- standard therapeutic doses (collateral effects)
- subtherapeutic doses in susceptible patients (hyper-susceptibility reactions).
DOTS- time and susceptibility
Time- time dependent or time independent
Susceptibility- age, gender, disease states, pregnancy, ethnicity and polypharmacy
ADR- morbidity and mortality
- 5% acute medical emergencies due to ADRs
- 10-20% hospital inpatients experience an ADR
Patients which are more prone to adverse drug effects
- Elderly patients – polypharmacy
- Pregnancy
- Pre-existing disease – liver and kidney
- Children
Poly-pharmacy increases risk due to drug-drug interactions (DDI)
ADRs may be due to
- Exaggerated dose dependent effects- insulin causing hypoglycaemia
- Unexpected effects not predicted from the drugs known pharmacological and toxicological profiles- amoxicillin causing maculopapular rash
Why do drugs have both beneficial and adverse effects
No drugs are 100% specific for only one receptor subtype
Therapeutic index
TD50/ED50
Dose of a drug that causes a toxic response in 50% of the population / Dose of a drug that is therapeutically effective in 50% of the population. The higher the TI the better.
