PA30327 lectures Flashcards
Define Supplementary prescribing
- A voluntary prescribing partnership between an independent prescriber and a supplementary prescriber
- To implement an agreed patient-specific clinical management plan with the patient’s agreement
Describe who is involved in Supplementary Prescribing
Indepent prescriber
- doctor or dentist
Supplementary prescriber
- registered nurse, midwife, pharmacist, optometrist or allied healthcare professional
Independent and supplementary prescriber share, have access to, consult and use the same patient record
What is included in Clinical Management Plan (CMP)?
- Name of patient
- Illness or conditions
- date on which plan is to take effect
- reference to class or description of medicinal product
- restriction/limitation as to strength or dose of meds
- relevant warnings
- arrangement for notification of
: suspected or known ADR
What are the disadvantages of Supplementary prescribing?
- Very time consuming
- Very prescriptive
- Only really suitable for stepwise management of chronic conditions
Define ‘Independent Prescribing’
- prescribing by a practitioner responsible and accountable for the assessment of patients with undiagnosed or diagnosed conditions and for decisions about clinical management required including prescribing
What should a Treatment Plan include?
- Process of differential diagnosis
- Assessment of severity of staging
- Diagnostic tests
- Stages of treatment
- Medicines intended to be prescribed and evidence for this
- How you will check for patients safety associated with this decision
- How response to treatment will be monitored
- Referral indicators and associated process
what is a Compentency framework?
- There are 10 competencies split into 2 domains
- The Consultation
- Assess the patient
- Consider the options
- Reach a shared decision
- Prescribe
- Provide information
- Monitor and review - Prescribing Governance
- Prescribe safely
- Prescribe professionally
- Improve prescribing practice
- Prescribe as part of a team
What are the examples of Legal frameworks?
Criminal law
- prove that a crime has been committed
Civil law
- prove duty of care owed to a patient has been breached (tort)
Professional body
- competence to remain registered (GPhC has statutory powers)
Employer
- vicarious liability
Describe Human Rights Act (1998)
- is relevant to health care providers since it regulates the relationship between individuals and public authorities
- when a practitioner is making a decision about healthcare provision, it should be focused on patients’ wishes and interests
What are the 5 underlying principles of ethical decision making?
- Beneficence
- to do good
- HCP should balance the benefits of treatment against risks and costs in a manner which benefits the patient - Nonmaleficence
- to do no harm
- HCP should not harm the patient and, as all treatment has some associated harm, the harm should not be disproportional to benefits of traetment - Respect for autonomy
- self converning or independent
- HCP should respect patient’s ability to make a reasoned and informed choice by respecting the decision-making capabilites of an autonomous individual - Justice
- being fair
- HCP should note all patients in similar situation should be treated in similar manner, and that benefits, risks and costs should be distributed fairly - Respect for the patient
What factors might cause you to make a prescribing error?
- slips of action
- lapses of memory
- rule-based mistakes
- knowledge-based mistakes
- routine
- situational
- exceptional
What are the skills required for a pharmacist?
- consultation skills
- patience
- empathy
- shared decision making
- evidence based medicine
- creative thinking
- precision
Why is Calgary-Cambridge Guide so good?
- actively determines and explores patient’s ideas, concerns and expections
- accepts legitimacy of patient views
- shares thinking with patient to encourage patient involvement
- gives information in chunks
- check patient understanding of information
- involves patient by making suggestions, not directives
- encourages patient to contribute their ideas, suggestions, preferences and beliefs
- offers choices
- negotiates a mutually acceptable plan
- next steps, safety netting, summarsing
Why is effective communication important?
More effective gathering of ALL/RIGHT information
- revealing a hidden agenda that patient may be reluctant to share easily
- informing a more reliable/accurate/correct diagnosis
Establishing TRUST between you and the patient
- More likely to get the information you need
- More efficient consultation
- More likely to achieve a CONCORDANT outcome
More effective PROVISION of information
- patient has understanding of condition / risks and benefits of treatment / treatment
How do we become effective communicators when talking to patients/clients?
- body language
- open Qs
- probing questions
- closed Qs as needed
- identifies patient agenda/concerns
- active listening
- looking for verbal and non-verbal cues
- rapport
- management of environment
- confident structure
What are the barriers to effective communication?
Poor questioning technique
- chain Qs
- closed Qs
- Leading/negative Qs
Listening
- not actively listening
- stepping on silences
Not identifying patient agenda/concerns
- poor identification of CUES/CLUES
Distractions
- conscious of trying to get it right
- environment
- other cognitive pressure
Describe therapeutic empathy
- ability to identify an individual’s unique situation, to communicate that understanding back to the individual and to act on that understanding in a helpful way
Define ‘Differential diagnosis’ and ‘Provisional diagnosis’
Differential diagnosis
- list of possible medical causes behind the presenting symptoms or physical findings
Provisional diagnosis
- most likely diagnosis based on symptoms, findings and information gathering but not a fully committed diagnosis
What information do you need to get when taking full medical history?
- previous surgery or hospital admission
- medical condition
- allergies
- family history
- medications
- social history
What are RED FLAG symptoms for Cardiovascular system?
- SOB
- Exercise tolerance
- Orthopnoea
- Paroxysmal nocturnal dyspnoea (PND)
- Chest pain/Angina
- Palpitations
- Diziness/blackouts
- ankle swelling
- calf/leg pain
- tiredness
What are RED FLAG symptoms for Respiratory?
- SOB
- Exercise tolerance
- Wheeze
- Chest pain
- Cough
- Phlegm
- Haemoptysis
- Stridor
- Hoarse voice
What are RED FLAG symptoms for GI?
- Weight loss or gain
- Appetite
- Indigestion/heartburn
- Dysphagia
- N & V
- Hematemesis
- Abdominal pain
- Jaundice
- Swellings
- Change in bowel habit
- Description of stool
What are RED FLAG symptom for CNS?
- Headaches
- Fits/faints/loss of consciousness
- Dizziness
- Vision-acuity
- Hearing
- Weakness
- Numbness/tingling
- Loss of memory/personality change
- Anxiety/Depression
Describe the following pain assessment tool
SOCRATES
S - Site O - Onset C - Character R - Radiation A - Associations T - Time course E - Exacerbation/relieving S - Severity
Why is taking accurate medical history important?
- Helps build the therapeutic relationship
- Determines how the illness may have affected the patient and their family
- Explores the patients ideas, concern and expectations
- Eliminates serious problems
- Determines more accurately what is wrong with the patient
- Finds a solution
When is Decision Aids used?
- Sometimes it can be difficult for patients to make a decision
- Patients sometimes need clear, concise and unbiased information in an easy to read formate to help them reach a decision
for example, smiley faces
What are definitions for the following terms?
- Decision Making
- Reasoning
- Judgement
Decision making
- cognitive process resulting in the selection of a belief or course of action.
- The act of choosing between two or more courses of action
Reasoning
- process of forming conclusions
Judgement
- ability to make considered decisions or come to sensible conclusions
What are the 9 GPhC Standards for Pharmacy professionals?
- Provide person-centred care
- work in partnership with others
- communicate effectively
- maintain, develop and use their professional knowledge and skills
- use professional judgement
- behave in a professional manner
- respect and maintain the person’s confidentiality and privacy
- speak up when they have concerns or when thngs go wrong
- demonstrate leadership
What is Berwick Report?
- place quality of patient care, especially patient safety, above all other aims
- engage, empower, and hear patients and carers at all times
Describe Selective and Creative clinical decision making
Selective
- options already exist and we use a structured process
- decision involves selecting from a choice
- a cognitive process
Creative
- allowed to think more freely
- need to generate solutions from the information gained
- can induce emotion and bias
- can be more risky
What are the common stated reasons for wrong diagnosis?
- too much hurry
- not listening enough to patient’s story
- too much attention to one finding
- didnt reassess the situation when things didnt fit
- overly influenced by similar case
Reasons for wrong decisions?
- made in haste
- made without consultation
- over-analysed
- based on past experiences rather than new situations
- based on other people’s decisions
Describe the Wingfield’s 4 stage approach to decision making
- gather relevant facts
- priorities and ascribe values
- generate options
- choose an option
Describe O’Neill’s 6 stage approach to decision making
- gather all relevant information
- identify and clarify the ethical problem
- analyse the problem by considering the various ethical theories and approaches
- explore the range of options or possible solutions
- make a decision
- implement and then reflect on decision
What are the core skills of clinical decision making?
- pattern recognition
- critical thinking
- communication skills
- evidence based medicine
- team work
- sharing
- reflection
Define ‘Leadership’
the art of motivating a group of people to act towards achieving a common goal.
What are the benefits of leadership in Pharmacy?
Individual level
- encourages self-reflection, identifies areas for further development, aids career progression
Local level
- enhances the effectiveness of a team, builds multi-disciplinary team working and improves the services/process being delivered
National level
- drives change and improvement across healthcare and organisations, ensures the profession takes a consistent approach to leadership development that is alinged with other HCP and strengthens the profession’s reputation and standing
What is Monitoring regarding prescribing?
- periodic measurement that guides the management of a chronic or recurrent condition
- establishing benefit for patients is important
- Monitoring can refer to blood monitoring, condition monitoring or patient monitoring which can be used to ensure patient safety
Why is monitoring required?
- increase in patient safety and reduction in avoidable hospital admissions
- improvement of adherence
- better selection of treatments based on individual response
- better titration of treatment
- patients’ learning about non-treatment factors that alter condition’s control
Monitoring must be balanced against the downsides of monitoring such as…
- inconvenience and costs
- the impact of false positive and false negative results which that can lead to inappropriate or delayed actions
What are the key biochemistry tests (for monitoring) for a generalist pharmacist?
Blood tests monitoring
- FBC
- U&Es, in elderies calculate CrCl
- Creatinine and urea
- Lipids
- TFTs (Thyroid function test)
- LFTs (Liver function test)
- Creatinine kinase
- HbA1c
- ACR
What are the physical examinations that pharmacist independent prescriber is expected to be competent at?
- Manual/electronic blood pressure
- Pulse
- Respiratory examination
- Blood glucose
- Urinalysis
- BMI
- Peak flow
- Temperature
What is monitoring requirements for Ramipril (ACEi)
BNF
- For all ACEi, renal function and electrolytes should be checked before starting (or increasing dose) and monitored during treatment
SPC
- Renal function should be assessed before and during treatment and dose adjusted especially in initial weeks of treatment
- Hyperkalaemia
- Hyponatremia
- Neutropenia
- Cough
What is Frailty?
- a state associated with low energy, slow walking speed, poor strength
- Common (30% of those over 80yrs old)
- Progressive (5-15 yrs)
- Episodic deteriorations
- Preventable components
- Potential to impact on QoL
- Expensive
What are the examples of Assessment Tools for identifying Frailty?
- Gait speed <0.8m/s
- Timed-up-and-go test <12s
- Grip strength
- PRISMA 7 questionnaire
- Clinical frailty scale
- Edmonton frail scale
- Clinical frailty scale
- Reported Edmonton frail scale
- ISAR tool
Describe PRISMA 7 Questions
- seven-item, self- completion questiionaire
- Are you more than 85yrs old?
- Male?
- In general do you have any health problems that require you to limit your activities?
- Do you need someone to help you on a regular basis?
- In general do you have any health problems that require you to stay at home?
- In case of need, can you count on someone close to you?
- Do you regularly use a stick, walker or wheelchair to get about?
READ (STATISTICS)
about frailty
For severe frailty average practice list per GP
- 7% of population over 65 yrs are likely to be severely frail
- In average practice this is about 27 patients per GP
Is frailty amenalbe to prevention and treatment? if so how?
Yes
- healthy ageing reduces risk of fdeveloping frailty
- Good nutrition
- Not too much alcohol
- Staying physically active
- Remaining engaged in local community / avoiding loneliness
- Patients can be signposted to NHS England and Age UK publications
Define Multi-morbidity and Co-morbidities
Multi-morbidity
- multiple long-term conditions
Co-morbidities
- when two disorders or illness occur in the same person, simultaneously or sequentially, they are described as comorbid.
- Comorbidity also implies interactions between illness that affect the course and prognosis of both
What is Multi-morbidity?
Presence of two or more long term health conditions, which can include
- physical and mental health pathologies
- ongoing conditions such as learning disability
- symptom complexes such as frailty or chronic pain
- sensory impairment such as sight or hearing loss
- alcohol and substance misuse
How is Multi-morbidities managed?
- Care for people with multi-morbidity is complicated because different conditions and their treatments often interact in complex ways
- Despite this, the delivery of care for people with multiple long term conditions is still often built around the individual conditions, rather than person as a whole
- Offer care that is tailored to the person’s personal goals and priorities and seeks to address the complexities surrounding the person’s multiple conditions and treatments
What are the tests needed prior to starting treatment of ACEi and ARB?
- U&E and eGFR
- in patinets with CKD, measure serum potassium and eGFR
What are the monitoring required until patient is stabilised on ACEi and ARB?
Heart failure
- measure serum urea, creatinine and electrolytes 1-2 weeks after initiation
CKD
- measure serum urea, creatinine and electrolytes 1-2 weeks after initiation
What are the Ongoing Monitorings needed for ACEi and ARB?
Heart failure
- measure serum urea, creatinine and electrolytes every 3 months
Post-MI
- measure renal function, electrolytes and BP at least annually
What is Malnutrition?
- state of nutrition in which a deficiency or excess (or imbalance) of energy, protein and other nutrients causes measurable adverse effects on tissue/body form (body shpae, size and composition) and function and clinical outcome
What is Cachexia?
- a multifactorial syndrome characterised by an ongoing loss of skeletal muscle mass (with or without loss of fat mass) that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment
What is Sarcopenia?
- age-related reduction in skeletal muscle mass in the elderly which is a natural part of aging process
- primary Sarcopenia has no specific etiologic cause that can be identified
- secondary Sarcopenia is where the natural process is aggravated by an extrinsic factor, such as lack of physical activity, malnutrition, chronic inflammation and comorbidity.
- diagnosed by looking at muscle mass, muscle strength and physical performance
Who is at risk of malnutrition?
- Older people over the age of 65, particularly if they are living in a care home or nursing home or have been admitted to hospital
- Individuals with complex health needs
: e.g learning difficulties, mental health disorders - People with long-term conditions, such as diabetes, kidney disease, chronic lung disease
- People with chronic progressive conditions
: e.g dementia or cancer - People who abuse drugs or alcohols
What is prevalence of Malnutrition in... - Home - Sheltered housing - Hospital - Care homes ?
Home
- BMI <20kg/m2 = 5%
- BMI <18.5kg/m2 = 1.8%
- Elderly 14%
Sheltered Housing
- 10-14% of tenants
Hospital
- 25-34% of admissions
Care homes
- 30-42% of
What are the causes of Malnutrition?
- Physiological
- Psychological
- Social
- Increased nutritional needs
- Nutrient losses
Physiological
- swallowing problem
- taste changes
- poor dentition
- dry mouth
- pain
- constipation
- medicine side effects
- impaired GI function
- hunger / thirst
- impaired
Psychological
- low mood / depression
- dementia
- loss of interest in food
- poor appetite
Social
- Living / eating
- alone
- little money
- bereavement
- difficulty shopping or cooking
- reliance on others
Increased nutritional needs due to
- infection
- inflammation
- pyrexia (raised body temp)
- healing wounds
- involuntary movements
- increased physical activity
Nutrient losses
- malabsorption
- diarrhoea
- vomiting
- wound exudates
What are the consequences of malnutrition?
- Physiological
- Psychological
- Outcomes
Physiological
- reduced fat and muscle
- poor wound healing
- reduced mobility, weakness, fatigue
- increased risk of infection
- weak cough
- poor absorption of nutrients
- more side effects from medicines
Psychological
- Low mood / depression
- confusion
- appetite further reduced
Outcomes
- more falls and pressure ulcers
- more hospital admissions
- more GP visits
- require more prescriptions
- longer length of stay
- reduced quality of life
- increased mortality
What is the Cost of Malnutrition in UK and statistics regarding gp visit and hospital stay
3 million adults in UK malnourished costing 19 billion pound
3rd highest potential to deliver cost savings to NHS
Greater use of healthcare and costs associated with malnutrition mean
- 65% more GP visits
- 82% more hospital admissions
- 30% longer hospital stay
How do we measure disease related malnutrition?
- BMI of less than 18.5kg/m2
- Unintentional weight loss greater than 10% within the last 3-6 months
- BMI of less than 20kg/m2 and unintentional weight loss greater than 5% within last 3-6 months
- Eaten little or nothing for more than 5 days and/or are likely to eat little or nothing for next 5 days or longer
- Have a poor absorptive capacity, and/or have high nutrient losses and/or have increased nutritional needs from causes such as catabolism
What are the 5 steps of treating malnutrition?
- Managing factors affecting food intake
- Set treatment aims
- Food first
- Oral nutritional supplements
- Review + Monitor
Explain the following step of Treating malnutrition
- 1. Manage factors affecting food intake
- If concerns regarding swallow, has patient been referred to Speech & Language therapy?
- If difficulty using cutlery, has patient been referred to Occupational Therapy?
- If patient is constipated, have laxatives been prescribed?
- Are there medications causing problems that potentially could be stopped/rationalised e.g iron causing constipation
- If patient has nausea & vomiting, is something being prescribed for this?
- Does the patient struggle to buy/cook food? Do they need more support or meals from Wilshire Farm Foods?
Explain the following step of Treating malnutrition
- 2. Set Treatment Aims
- Avoiding further weight loss
- Achieving a BMI of 18.5 or 20kg/m2
- Would healing
- Regaining lost weight
Explain the following step of Treating malnutrition
- 3. Food First
- Improving an individuals nutritional intake with nourishing foods and drinks
Some ideas to help improve their nutritional intake include
- older ppl need a more nutrient dense range of foods
- nourishing meal, snack or drink every 2-3 hrs
- appetiser (fresh air, light exercise)
- full fat or high energy food options
- fortify food and drinks
- allow favourite foods at anytime of day
- make the most of times when appetite is better
What are the advantages of Oral Nutritional supplements?
- significantly reduce mortality
- significantly reduce complications
- significantly improve weight
- functional benefits
- better energy and protein intakes in supplemented patients in all trials
- acceptable to patients
When is Orarl Nutritional Supplements (ONS) given?
- considered for resisdents with a MUST score of 2 or more (high risk) if weight has decreased after one month of FOOD first advice
- ASK GP to prescribe, try 2 weeks and check acceptability
What are the Advisory Committee on Borderline substances (ACBS) approved categories for prescribing nutritional supplements?
- Short Bowel syndrome
- Dysphagia
- Interactable malabsorption
- Pre-operative preparation of undernourished patients
- Inflammatory bowel disease
- Total gastrectomy
- Bowel fistulae
- Disease related malnutrition
Explain the following step of Treating malnutrition
- 5. Review & Monitor
- has a weight been recorded on initiation & repeated a minimum of 3 monthly?
- Is there an ACBS indication documented?
- Do they have a MUST score, if so what is it?
- Has food first advice been given?
- Has an aim of treatment been set?
- Which supplements are being prescribed?
Summary - Nutrition READ
Malnutrition in vulnerable and elderly frail population groups is widespread.
Recognition and treatment of malnutrition in these particular groups is paramount to overcoming the negative impact on individuals health and prognosis as well as its burden on the health service.
A step-wise approach to its treatment i.e using MUST score system, adopting food first where risk of malnutrition is identified, and only then prescribing ONS is key to clinical and cost-effective treatment
What are the outcomes of Medicines Optimisation?
Outcome focused approach to safe and effective use of medicines that takes into account the patient’s values, perception and experience of taking their medicine.
- Improved quality of life
- Making a positive contribution
- Improved health and emotional well being
- Personal dignity
- Control and choice
- Economic well being
- Freedom from discrimination
What is a Clinical medication review?
- process where a health professional reviews the patient, the illness and the drug treatment during a consultation
- It involves evaluating the therapeutic efficacy of each drug, unmet therapeutic need and the progress of the conditions being treated
- Other issues, such as compliance, actual and potential adverse effects, interactions and the patient’s understanding of the condition and its treatment are considered where appropriate
- The outcome of a clinical review is a decision about the continuation of the treatment
What are the 4 commonly accepted levels of medication review?
Level 0
- Ad hoc
- unstructured, opportunistic review)
Level 1
- Prescription review
- technical review of a list of patient’s medicines
Level 2
- Treatment review
- review of medicines with full patient notes
Level 3
- Full review with notes
- prescription history and patient present
What are the considerations when reviewing patients’ medicines?
- SWAN
S: Safety
W: Working well
A: Appropriate
N: National guidance
Describe renal function in elderly patients
Clinical systems often only report eGFR or creatinine as a measure of renal function
In elderly patients this is often not an accurate indicator of renal function and many drugs may need dosages reduced or even therapy stopped
- eGFR assumes stable creatinine
- eGFR assumes normal body weight
- Reduced muscle mass in the elderly can result in reduced creatinine levels
In general in the elderly (over 75rs) we should use Cockcroft Gault to calculate renal function although debate exists about using IBW or current weight
eGFR can often significantly overestimate renal function in frail elderly patients
Give examples of high-risk medicines
- Antiplatelets 16%
- Diuretics 16%
- NSAIDS 11%
- Anticoag 8%
Describe how to identify patients at increased risk of ADRs
Be alert for
- older people
- Several medicines that can cause the same adverse effect
- drug-drug or drug-disease interactions
- laboratory data
Be proactive, prepare to ask the patient about specific symptoms
- drowsiness
- dizziness
- falls
- anticholingergic symptoms
- bleeding
What is Modified Anticholinergic Risk Scale (mARS)?
- Prescribers should exercise caution when considering anticholinergic in older people as they are more likely to experience adverse effects
- aims to assign one to three ‘points’ to medicines with anticholinergic effects; the higher the number, the stronger the anticholinergic effects
Falls and Falls-related injuries are a common problem for older people. Thirty percent of people older than 65 and fifty percent of people older than 80 fall at least once a year
What are the reasons that older people are risk of falls?
- Impaired balance or gait
- Mobility problems including arthritis and motor disorders such as Parkinson’s disease
- Muscle weakness
- Visual impairment
- Impaired cognition
- Home hazards (unsuitable footwear, rugs, pets)
- Postural hypotension
- Taking four or more medicines
- Infection
How can medicines cause falls?
- Sedation
- Confusion
- Hypoglycaemia
- Vestibular damage
- Orthostatic hypotension
- Hyponatraemia
- Dehydration
- Hypothermia
- Visual impairment
- Impaired postural stability
- Drug-induced Parkinsonism
Name some ‘Explicit, criterion-based’ tools and ‘Implicit, judgement-based apporach’ and their pros and cons
Explicit, criterion-based tools - Beers criteria - STOPP/START - STOPPfrail Pros = can be applied with little/no clinical judgement, low cost Cons = Don't address burden of co-morbidities or patient preference, need to be updated regularly
Implicit, judgement-based tools - NOTEARS - MAI Pros = focus on the patient, address entire medication regimen Cons = time consuming, less reliable
Why is polypharmacy increasing?
- Population is ageing and the prevalence of chronic disease increasing
- Already, many patients have several long term codnitions
- If each one of these is treated according to national guidelines, patients may end up taking a complicated cocktail of drugs
What is Prescribing cascade?
- process whereby the side effects of drugs are misdiagnosed as symptoms of another problem resulting in further prescriptions and further side effects and unanticipated drug interactions
How could you avoid prescribing cascade?
- largely preventable by carefully considering whether any new medical condition might be the result of an existing drug treatment
- prescription of a new drug specifically to treat an adverse drug effect should be considered the choice of last resort in the care of older patients
Define ‘Deprescribing’
- process of withdrawal of an inappropriate medication, supervised by a health care professional with the goal of managing polypharmacy and improving outcomes
What are the barriers to de-prescribing?
- Patients and prescribers underestimate the risks of polypharmacy
- Patients and prescribers fear of what will happen if a medicine is discontinued
- Uncertainty… lots of advice regarding starting, very little on stopping medicines
- Incentives to over prescribe
- Complex and time consuming
- Few available resources and even less are validated
- Consideration of the law ‘Montgomery compliant’ consultation
What are the strategise for influencing prescribing decisions?
- Good consultation skills
- Justify benefits to change and risks of current practice
- Audit
- Prescribing data
- National and local guidance
- Education and training
- Policy and protocols
- Significant Event learning
What is a formulary?
- local formulary is the output of processes to support the managed introduction, utilisation or withdrawal of healthcare treatments within a local healthcare system, service or organisation
What is NICE Technology appraisals guidance?
- It assess the clinical and cost effectiveness of health technologies, and helps to ensure that all NHS patients have equitable access to the most clinically- and cost-effective treatments that are viable
What is Cardiovascular Risk? (QRisk)
- chance of someone developing cardiovascular disease (MI, stroke, TIA, Angina) at some point in the next 10 years if nothing about their current lifestyle changes
What are the modifiable and non-modifiable risk factors for CVD?
Modifiable
- High blood pressure
- Abnormal blood lipids
- Physical inactivity
- Obesity
- Unhealthy diet
- Diabetes
- Stress
- Alcohol use
- Mental ill health
- Low socioeconomic status
- Smoking
Non-modifiable
- Age
- Sex
- Gender
- Ethnicity
- Certain co-morbidities: AF, RA
Describe classification of hypertension
Stage 1
- Clinical BP greater than or equal to 140/90mmHg
(ABPM or HBPM >135/85mmHg)
Stage 2
- Clinical BP greater than or equal to 160/100mmHg
(ABPM or HBPM >150/95 mmHg)
Severe
- Clinical systolic BP greater than or equal to 180mmHg or clinic diastolic greater than or equal to 110mmHg
What are the BP targets for those under treatments?
140/90mmHg in ppl aged under 80 (150/90mmHg in ppl aged 80 or over)
- for those with ‘white coat effect’, aim 135/85mmHg in ppl aged under 80 (145/85mmHg in ppl aged 80 or over)
Patients with other co-morbidities such as diabetes and renal diseases will have lower targets:
Type 1 diabetic
- 135/85mmHg
Type 1 diabetic with
nephopathy
- 130/80mmHg
T2DM
- 140/80mmHg
T2DM + kidney, eye or CV damage
- 130/80mmHg
CKD
- 140/90mmHg
CKD + ACR >70mg/mmol
- 130/80mmHg
What are the common pharmacological treatments of hypertension?
- Diuretics
- Beta blockers
- Calcium channel blockers
- ACE inhibitors/ARB
- Alpha 1 antagonists
How does Diuretics lower blood pressure? (in patient friendly way)
- by helping your body get rid of excess water and salt through the kidney, allowing heart to pump better
How does Beta blockers
lower blood pressure? (in patient friendly way)
- by blocking the effects of adrenaline hormone, leading to your heart beating more slowly and with less force therefore reducing blood pressure
How does Beta blockers
lower blood pressure? (in patient friendly way)
- by preventing calcium entering heart cells and blood vessels wall which result in relaxing and widening of blood vessels hence lower BP
How does ACE inhibitors/ARB
lower blood pressure? (in patient friendly way)
- by blocking enzymes that narrows blood vessels which makes blood vessels relax and widen, reducing BP
How does ACE inhibitors/ARB
lower blood pressure? (in patient friendly way)
- by reducing vascular resistance, lowering BP
What is the drug monitoring required for ACEi and ARB?
- Baseline creatinine and electrolytes and eGFR
- Creatinine and electrolytes within 10 days and then 3 months of commencing or changing the dose and then annually
- If creatinine rises by >20% or eGFR falls by >15% stop ACEi/ARB, monitor and refer
- If potassium is >5.0mmol/L stop ACEi or ARB, monitor and refer
What is the drug monitoring required for diuretics?
- Baseline U&Es/urinalysis and eGFR
- U&E after one month or dose change
- U&E annually once stable
- Urinalysis annually
What is the drug monitoring required for Beta-blockers?
- Pulse (keep above 55)
What are the factors affecting Diabetes control?
- Food
- Alcohol
- Exercise
- Travel
- Medication
- Illness
- Complications and Co-morbidities
- Menstruation and menopause
- Stress
What is NHS Health Check Programme?
- Government initiative to reduce CVD through early identification of those at risk
- Excludes those alrdy with CVD
- Target 40-74 yrs olds in England every 5 years
- Lifestyle advice tailored to individual should be given at every assessment
Define hypertension
- Primary and Secondary
Primary or essential
- 95% of cases
- not a disease but arbitrarily selected BP above which benefits outweigh risk of treatment
- Secondary
- <5% of cases
- secondary to another cause
What are the signs and symptoms of hypertension?
- Usually asymptomatic except in malignant hypertension
- Some patients may experience dizziness, headache, breathlessness, blurred vision, nausea, nose bleeds, drowsiness, irregular heartbeats
When to add pharmacological intervention in different stages of Hypertension?
Stage 1 hypertension
- under 80 plus target organ damage +/or established CV disease +/or renal disease +/or diabetes +/or CV risk <20%
Stage 2 hypertension
- of any age
Severe hypertension
- treat immediately
Why do we treat patiens with diabetes more aggressively when managing BP?
People with type 2 diabetes are at high risk of
- CVD, Diabetes eye damage, renal disease
Improving blood pressure (BP) control reduces these adverse outcomes. it can also be used to lower the risk of
- Stroke, MI, Blindness, Renal failure
What are the treatment targets in Hypertension alone?
- 140/90mmHg in ppl aged under 80
- 150/90mmHg in ppl aged 80 or over
For those with ‘white coat effect’
- 135/85mmHg in ppl aged undr 80
- 145/85mmHg in ppl aged 80 or over
What are the topics to talk about in Hypertension Consultation?
Current medications
- patient’s experiences?
- ADRs?
Pulse
- irregular?
BP
CV Risk
- QRisk
Urine
- +ve glucose, +ve protein
Lifestyle advice
- motivational interviewing
What are the lifestyle changes known to reduce BP?
Lower risk alcohol itnake
- <14 units per week
Reduce weight if obese
- target BMI of 20-25
Reduce salt intake
Regular physical exercise >30mins 3 x week
Be realistic about what patient can achieve
Be encouraging
What are the first-line BP management drugs in the following population group?
- General population
- Ppl of African or Caribbean family origin
- Women who may become pregnant
General population
- Once daily, generic ACEi
Ppl of African or Caribbean family origin
- One daily, generic ACEi plus either a diuretic or a generic CCB
Women who may become pregnant
- Generic CCB
If the person’s BP is not reduced to individually agreed target with first-line therapy, add:
- CCB or diuretic
- other drug if target is not reached with dual therapy
If still not managed, add:
- Alpha blocker
- Beta-blocker
- Potassium-sparing diuretic
What are the side effects of ACEi?
- First dose hypotension especially in those who are volume depleted i.e elderly on high dose diuretics
- advice to start when not rushing out of the house - Persistent dry cough
- not in first few weeks but a year later due to build up of bradykinin
- switch to low cost ARB - Renal impairment
- monitor U&Es within 14 days of dose increase - Hyperkalaemia
- monitor U&Es especially those also taking potassium sparing diuretic
Why is ACEi and ARB not recommended to be used together?
- Greater renal risks and increased risk of hyperkalaemia
What are the side effects of CCB?
- headaches, abdominal pain, flushing, impotence, ankle oedema
Describe CCB’s use in hypertension
1st line in those >55ysr and in those of black African or Caribbean family origin of any age
In hypertension, CCB are favoured over diuretics as they demonstrated greater cost effectiveness except in patients >80yrs & combination of ACEi + CCB more effective than ACEi plus diuretic
Those that depress cardiac function are contraindicated for those with evidence of high risk of heart failure
Describe Diuretic’s use in hypertension
Ineffective if eGFR <30
U&E and urinalysis should be done at initation, after 1 month and thereafter annually
- NICE recommends indapamide 1.5mg MR or 2.5mg standard release or chlortalidone 25mg
What are the side effects of Diuretics?
- usually mild
- GI side effects
- Altered plasma lipid conc
- Electrolyte disturbance
- Hyperglycaemia
- Hyperuricaemia
Describe Beta blocker’s use in hypertension
No longer recommended before step 4
Many patients with longstanding hypertension are stabilised on these
What are the side effects of Betablockers?
- fatigue and lethargy
- bronchospasm
- cold extremities
Caution in diabetics and asthmatics
What are the targets and monitoring of managing CVD with statin?
- Measure liver transaminase enzymes within 3 months of starting treatment and at 12 months, but not agian unless clinically indicated
- Measure total cholesterol, HDL cholesterol and non-HDL cholesterol in all ppl who have been started on high intensity statin treatment at 3 months of treatment and aim for >40% reduction in non-HDL
- Do not stop statins because of increase in blood glucose level or HbA1c
What are the common side effects of statins?
- inflammation of nasal passages, pain in throat, nose bleed
- allergic reactions
- headache
- nausea, constipation, wind, indigestion, diarrhoea
What is the indication of Aspirin?
- Anti-platelet
- Not licensed or recommended in primary prevention (including diabetics) of CVD
- Recommended for secondary prevention
What is the treatment aim of Epilepsy?
- around 70% of ppl with epilepsy have the potential to be seizure free with anti-epileptic medication but not all will be
- aim to improve quality of life and potential isolation
- Lifestyle can have a good effect on incidence of seizures
What are the commonly used drugs in epilepsy?
Lamotrigine
- broader therapeutic profile, no enzyme induction
Carbamazepine
- enzyme inducer and auto inducer with long term use
Levetiracetam
- mood changes ‘levetiracetam rage’
Sodium Valproate
- strict controls in child bearing women, hepatitis
Symptoms and characteristics of COPD?
- Easily fatigued
- Frequent respiratory infections
- Use of accessory muscles to breathe
- orthopneic
- wheezing
- chronic cough
- bronchitis
What is Empirical therapy? What are its pros and cons?
- clinical diagnosis of likely infection without microbiological information
- Treatment of suspected infection with best guess antibiotics
- best guess based on knowledge of likely causative organisms
- usually formalised into empirical treatment guidelines for hospitals and primary care
Pros
- provides reproducible guide to practice
- should be effective in majority of cases
Cons
- Its only a guess, may not cover rarer causes of infection
- causative organism might be resistant
- tends to be broader spectrum: more risk of side effects and nosocomaial infections
What is MC&S guided therapy? What are its pros and cons?
Stepwise provision of information
- Culture positive (something is growing)
- Identification (we know what it is)
- Sensitives (we know what to treat it with)
Pros
- we know what is causing the infection
- we know about resistance
- treatment should be more success
- targeted antibiotic therapy, narrower spectrum
Cons
- we might be wrong
: could be contaminant or colonisation
- there might be mixed cause, all organisms might not have grown
What patient factors affect coice of therapy?
- Weight
- Age
- Renal function
- Liver function test
- Allergy status
- Suitable routes of administration
- Other co-pathologies
- Interacting drugs
IV reserved in general for severe infections or where patient unable to tolerate/absorb oral formulations
What are the considerations before switching from IV antibiotics to oral antibiotics?
- Temp <37.5 deg for 24 hrs
- Condition improving or stabilising
- signs and symptoms of infection improving
- decreasisng ESR/CRP/WBC
- no ongoing or potential absorption problems
- oral formulation or suitable oral alternative available
Why do GP staff prescribe antibiotics?
- Relief of symptoms
- Worry about complications/more serious illness
- Patient pressure
Why is urine dipstick not carried out in suspected UTIs in Elderlies?
For those over 65 with suspected UTI, PHE says
- do not perform urine dipstick, up to half of older adults will have bacteria present in the bladder/urine and positive dipstick without infection. This is not harmful and does not require treatment with antibitibiotics
What is treatment plan and why is it used?
- document that ensures the prescriber has safely completed the stages of differential diagnostic process and the appropriate selection of medicine or other treatment option
- guide to enable safe and effective prescribing of medicines in relation to patient care in a specific area
- It means when a prescribing decision is made there should be an anticipated outcome, a clear pathway for how to manage any adverse effects or non response to treatment and expected duration of treatment
What is Palliative care?
- active total care of patients and their families by a multi-professional team when the patient’s disease is no longer responsive to curative treatment
To palliate is…
- to alleviate the symptoms of a disease or disorder
What do dying people want?
- Symptoms well controlled
- Family issues resolved
- To have a bit of warning in order to put affairs in order
- Spiritually at peace
- A chance of review life and feel that it has been meaningful
- Main thing is to maintain some control over what is happening
