Prescribing in Primary Care

Question 1

Give 4 examples of independent prescribers

Answer 1

• Nurse
• Pharmacist
• Optometrist
• Physiotherapist
• Podiatrist

They can only prescribe medications within their competence and their scope of practice.

Question 2

What is the form colour of the prescriptions issued by GPs?

Answer 2

Green

Question 3

What is the code of the prescriptions issued by GPs?

Answer 3

All prescription forms originating in England begin with the code FP10.

Question 4

What does FP10 HNC indicate?

Answer 4

The suffix (HNC) indicates the prescriber - HNC for hospital

Question 5

What does a blue prescription form indicate?

Answer 5

Prescribers managing substance abuse patients

Question 6

What does a lilac prescription form indicate?

Answer 6

Community/independent nurse prescribers and AHP prescribers

Question 7

What does a yellow prescription form indicate?

Answer 7

Dentists

Question 8

How does 0.25 milligrams be written on a prescription? Why?

Answer 8

25 micrograms - helps to avoid confusion and miscalculation

Question 9

Describe how a prescription is sent using the Electronic Prescription Service (EPS)

Answer 9

• The prescription is generated by the GP and stored in the prescribing system
• The prescription is digitally “signed” by the Doctor
• The prescription is then sent directly to the Pharmacy electronically

Question 10

If the patient does not have a nominated pharmacy, what can they be issued with?

Answer 10

A prescription token - can be taken to any pharmacy

Question 11

What are ‘off license’ indications for drugs?

Answer 11

When drugs may be used successfully for other purposes, not stated in the list of indications, but accepted in current medical practice.

Question 12

Who takes responsibility in the context of off license prescriptions?

Answer 12

the individual prescriber must take personal responsibility for the use of a drug in a particular situation

Question 13

Example of ‘off licence’ use of lansoprazole (PPI):

Answer 13

Widely and successfully used by Paediatricians for reflux in children, but the manufacturer has no indication for its use in children

Question 14

Example of ‘off licence’ use of Domperidone (an antiemetic):

Answer 14

used by Obstetricians and Midwifes to enhance Breast Feeding, because it promotes Prolactin production, but the manufacturer has no indication for this use

Question 15

Example of ‘off licence’ use of paroxetine (SSRI):

Answer 15

used by some psychosexual counsellors as a treatment for Premature Ejaculation, because one of the side effects of SSRIs is to reduce sexual performance, but it’s use in this area is not indicated by the manufacturer

Question 16

Give some additional considerations when prescribing for the elderly

Answer 16

• Polypharmacy - greater risk of drug interactions
• Physiological changes - reduced renal & hepatic function
• Changes in pharmacodynamics - reduced absorption of drugs
• Patient factors e.g. confusion, poor vision, manual dexterity problems (think about container!)

Question 17

How can a reduced renal and hepatic function in the elderly affected prescribing?

Answer 17

Reduced renal and hepatic function can lead to reduce excretion of medications and possible accumulation & toxicity

Question 18

What is the drug reaction shown in this picture? Cause?

Answer 18

Typical macular rash that occurs in people allergic to broad-spectrum penicillins e.g. Amoxicillin

Question 19

What is this drug reaction? Why does it occur?

Answer 19

This is staining of the teeth (and bones) from tetracyclines → medication binds to calcium

Question 20

Who is staining of the teeth and bones by tetracyclines most common in?

Answer 20

Children

Question 21

What should you advise patients NOT to take tetracyclines with?

Answer 21

With milk or calcium products → affects absorption of medication

Question 22

What is this drug reaction?

Answer 22

This is hypopigmentation following a steroid injection (for De Quervains tendonitis)

This reaction may occur with any steroid (but this picture shows tracking of the hypopigmentation along the lymphatic drainage → indicates Trimacinolone)

Question 23

What are green drugs?

Answer 23

drugs which can be initiated and re-prescribed in Primary Care

Question 24

What are amber drugs?

Answer 24

require monitoring

Question 25

Where must amber drugs be initiated?

Answer 25

In 2ary care BUT have a Shared Care arrangement, such that they can be monitored and re-prescribed in Primary Care, e.g. Methotrexate for Rheumatoid Arthritis

Question 26

Is methotrexate green, amber or red?

Answer 26

Amber

Question 27

What are red drugs?

Answer 27

may only be prescribed in Secondary Care, e.g. cytotoxic agents, biologics and most cancer chemotherapy.

Question 28

Are biologics green, amber or red drugs?

Answer 28

Red

Question 29

Average cost of prescriptions dispensed in community per year?

Answer 29

£8/9 billion

Question 30

What % of prescriptions are dispensed free of charge?

Answer 30

Around 90%

Question 31

In England, how much do we pay for a prescription?

Answer 31

In England we pay **£9.00** per item on prescription, or prepaid for 3 months **£29.00**, 12 months **£104.00**

Question 32

What patient **age groups** do NOT pay for prescriptions

Answer 32

* \<16 * 16, 17 or 18 BUT in full time education * 60 or over y/o

Question 33

Give some other patient populations who do NOT have to pay for prescriptions

Answer 33

* Pregnancy or within 12 months of giving birth * Certain medication conditions → need to apply for a Medical Exemption Certificate * Low income * All contraceptives (not HRT unless \>60) * Some State Benefits

Question 34

What details are included in the **top section** of a FP10 prescription form?

Answer 34

* Patient age (in years and months if \<5 y/o) * Patient DOB * Patient name * Patient address

Question 35

What details are included in the **middle section** of a FP10 prescription form?

Answer 35

* **DRUG**: name, strength (e.g. 40mg) and formulation (e.g. tablets) * **DOSING**: patient-friendly dose in numbers (e.g. 1 tablet) followed by frequency in words (e.g. four times a day) * **QUANTITY**: quantity to be dispensed (e.g. 28 tablets) Example: Paracetamol 500mg tablets Take one to two tablets as required every four to six hours Maximum eight tablets in 24 hours Supply 28 tablets

Question 36

What details are included in the **bottom section** of a FP10 prescription form?

Answer 36

* Signature * GMC number * Date of signing prescription * Prescriber’s name and address (usually pre-printed)

Question 37

How should milligrams vs micrograms be written?

Answer 37

Milligrams → mg Micrograms → WRITE OUT **micrograms**

Question 38

How should gram be written?

Answer 38

g

Question 39

How should millilitres be writen?

Answer 39

mL

Question 40

How should litres be written?

Answer 40

L

Question 41

What should you do with any unused space in the prescription box?

Answer 41

Cross out any unused space

Question 42

What colour pen must you write in?

Answer 42

Black (must be inedible)

Question 43

With controlled drug prescriptions (e.g. diamorphine), how must these be written?

Answer 43

**_Strength_** must be spelled out in words as well as numeric e.g. 30mg (thirty mg) **_Dose_** must be spelled out in words as well as numeric e.g. 60mg (sixty mg) by subcutaneous infusion over 24 hours **_Quantity_** must be spelled out in words as well as numeric e.g. 6 (six) ampoules

Question 44

Give prescription example for Beclomethasone 100 migrograms inhaler

Answer 44

DRUG: Beclomethasone 100micrograms/puff inhaler DOSE: Two puffs twice a day QUANTITY: 1 inhaler * Write the **inhaler and puff content** in the _drug_ box * Write how many **puffs** in the _dose_ box

Question 45

What are PRN prescriptions?

Answer 45

The PRN prescription stands for 'pro re nata,' which means that **the administration of medication is not scheduled**. Instead, the prescription is _taken as needed_ e.g. Tramadol, Paracetamol

Question 46

For PRN prescriptions, what must be included?

Answer 46

Minimum dose interval e.g. as required every 4 to 6 hours Maximum total daily amount e.g. maximum eight tablets in 24 hours

Question 47

Use generic drug names (not brand names), except for which drugs?

Answer 47

* Inhalers * Insulin * Psychiatric drugs * Epilepsy drugs * Narrow therapeutic range ranges: * Gentamycin * Warfarin * Lithium * Digoxin * Theophylline * Methotrexate * Insulin * Ciclosporin * Carbamazepine