SCRIPT: drug history Flashcards
Medicines reconciliation
a) purpose
b) sources
c) vs. med review
a) Ensures that medicines prescribed for your patient on admission to hospital correspond to those the patient was taking before admission
b) Two or more information sources*. Including:
- Patient’s own account (preferably)
- SCR (patients can opt out and some GP surgeries not included)
- GP records - referral letter, repeat prescription requests
- Clinic letters
- Discharge summaries
- Medical notes and electronic prescribing records
- Carers, community pharmacist
- Nursing homes - will have medication administration chart - request a copy (particularly helpful for dosing of insulin and warfarin in problematic patients)
- Document any discrepancies in the notes
c) Medication review: a structured, critical examination of a patient’s medicines
Effective drug history
- mnemonic: DRUGS
- Current drugs prescribed - adherence, side effects
- Previous drug exposure (eg. long-term NSAID use, recent courses of antibiotics/steroids, etc.)
- Allergies and sensitivities (drug and non-drug)
- Current or previous drug-related adverse effects
- OTC remedies (eg. St John’s Wort)
- Recreational drugs
DRUGS:
- Doctor - drugs prescribed by doctor/HCP
- Recreational
- User - obtained OTC
- Gynae - contraception
- Sensitivities and allergies
70 year old woman admitted with acute onset SOB and ankle swelling. You decide she is in heart failure.
Her drug history includes levothyroxine 150 micrograms. This was omitted on the TTO one month ago.
a) Explain why she is probably in heart failure
b) How would you manage this?
a) Thyroxine was probably omitted for a time during/just after her recent admission one month ago
- It was then restarted at a high dose*, which can precipitate a high-output acute heart failure
- When starting/ restarting levothyroxine, this should be done at a low dose and titrated up
- This is also the case for other drugs (eg. clozapine, warfarin, methadone) where you are unsure of patient compliance - starting at too high a dose if they have not been taking their meds can be catastrophic
- ACE inhibitors should always be started at low dose and titrated up
b) - Speak to endocrinology
Drug-related causes for hospital admission
a) Give some broad categories
b) Common culprit drug classes
a) - Adverse drug reactions - side effects, toxicity
- Omission/non-adherence causing disease worsening
- Treatment failure (eg. wrong drug, wrong dose, wrong diagnosis)
b) Antiplatelets, NSAIDs, anticoagulants, diuretics
How might a patient ‘accidentally’ overdose/ overuse drugs like paracetamol or NSAIDs
Multiple preparations:
- eg. paracetamol QDS + Lemsip QDS + co-codamol QDS
Lack capacity
Misunderstanding over doses
Low body weight
- need reduced paracetamol dose (if below 50kg, should be given 15 mg/kg rather than 1 g every 4 - 6 hours. E.g. 40 kg - only need 600 mg every 4 - 6h)
Drugs commonly forgotten in a drug history
- Borderline substances (e.g. vitamins, food supplements)
- Contraceptives (oral, injection, intra-uterine)
- Eye/ear drops
- Herbal medicines and homeopathic therapies
- Non-tablet drugs: inhalers, sprays, injections, topical
- Recreational drugs
Problems obtaining a complete drug history
Patient
- Unable to provide a history - confused, unconscious, does not know, dementia, communication issues (deaf, speech issues, no English)
- Uncooperative
Information sources:
- The GP surgery is closed
- The patient is from abroad
- The patient has no carer
- SCR not available
- No drug card
37 year old lady admitted with exacerbation of asthma. Her inhalers are with her. What should you confirm?
- Is inhaler in date?
- Technique - ask your patient to show you how she takes the inhaler.
- Adherence - “how often do you use this inhaler?”
- Get asthma nurse to do review
Monitored Dosage Systems (MDS).
a) What are they?
b) Can patients fill them?
c) What drugs are not found in an MDS?
d) Can MDS be used as a sole source in medicines reconciliation?
e) What database can be used for visual identification of tablets (if not clear in MDS)?
a) They divide a patient’s ORAL medication into days of the week and/or times of day. Compliance aid
b) - Some are filled by the pharmacy - prescribed drugs only
- Some are filled by patient - may include OTC remedies also (check with patient)
c) - When required medication (e.g. analgesics).
- Cytotoxic agents (e.g. thalidomide).
- Once weekly doses (e.g. risedronate, methotrexate).
- Variable doses (e.g. warfarin).
- Dispersible or effervescent formulations (e.g. aspirin).
- Buccal or sublingual formulation
- Orodispersable tablets (eg. some aspirin tabs)
- Chewable tabs (eg. Calci-chew)
d) No, due to reasons above
e) TICTAC - primarily tablets and capsules
Serotonin syndrome.
a) drug causes
b) presentation
c) management
a) Lots of drugs can cause serotonin syndrome (more likely if in combination)
- SSRIs - sertraline, citalopram, fluoxetine
- SNRIs - duloxetine
- SSNRIs - venlafaxine
- TCAs - amitryptilline, imipramine, clomipramine
- MAOIs - selegiline, phenelzine
- Atypical antipsychotics (2nd generation)
- Tramadol (other opiates less commonly)
b) Oh MAN, I’ve got serotonin syndrome:
- Mental state altered - agitated, anxious, confused
- Autonomic hyperactivity - tachy, HTN, hyperthermia, mydriasis, sweating, vomiting, diarrhoea
- Neuromuscular abnormalities - rigidity, clonus, hyper-reflexia, tremor
c) - IV fluids
- Monitor vital signs
- Cardiac monitoring
- Benzos for agitation and raised HR/BP
Warfarin.
a) You will need to know what information?
b) Source of info
c) If dose cannot be ascertained, do what?
d) Different warfarin tablet strengths
a) Warfarin - you will need to know…
- Indication
- Dose
- Target INR, current INR, previous INRs
- Adherence + side effects / adverse events
- Start / end date
b) - Anticoagulant clinic
- Yellow Oral Anticoagulant Book
- The medical notes
- Relatives/carers
- The community pharmacist
c) If anticoagulation is required, prescribe a LMWH until the warfarin dose can be deduced
d) - 500 micrograms (white)
- 1 mg (brown)
- 3 mg (blue)
- 5 mg (pink)
Insulin.
a) What you need to know
b) Sources
c) If insulin type/ dose cannot be ascertained, do what?
a) - Insulin name(s)
- Insulin device(s)
- Insulin frequency
- Diabetes control (i.e. previous HbA1c, previous admissions for hypo/DKA/HHS)
- Compliance
b) - Insulin passport (NPSA)
- Medical notes
- Clinical nurse specialist
- Relatives or carers
- Community pharmacist
c) - Type 1 diabetes/unstable Type 2 diabetes mellitus: start a sliding-scale with soluble insulin
- Stable Type 2 diabetes mellitus: may tolerate omission of insulin, with appropriate blood glucose monitoring until the insulin dose is confirmed
Drugs that are given less frequently than daily.
a) Examples
b) Issues
a) - Patches - eg. fentanyl
- Bisphosphonates (e.g. risedronate) may be taken daily, weekly, monthly or ?yearly basis.
- B12 injections - is given every 2 or 3 months for maintenance therapy, depending on the indication.
- Injectable antipsychotics - weekly and monthly dosing. Contact the psychiatric liaison nurse
- Methotrexate - once weekly usually. Confirm usual day, consult rheumatologist if necessary
- Biologics - injectables/ infusions every few weeks
- Goserelin (GnRH analogue) - monthly or 3 monthly depending on the preparation.
- Implants (e.g. parenteral progestogen-only contraceptives usually administered every 3 months)
b) - Changing usual day can confuse patient when they are discharged - communicate any changes clearly
- Confirm next dose by thorough investigation and liaise with patient
- Double dosing is usually more risky than a slight delay in giving these drugs - consult specialists where possible
Medication review.
a) NO TEARS structure for review
b) Possible actions to take
a) - Need and indication
- Open questions
- Tests and monitoring
- Evidence and guidelines
- Adverse events
- Risk reduction or prevention
- Simplification and switches
b) Do you need to STOP the drug? Do you need to REDUCE the dose? Do you need to INCREASE the dose? Do you need to SWITCH the drug? Do you need to PAUSE the prescription? Do you need to REPORT THE DRUG for an adverse reaction? Do you need to initiate a NEW treatment?
Drugs that interactive with contraceptives
P450 inducers:
- Carbamazepine, phenytoin, phenobarbital, topiramate
- rifabutin and rifampicin
- eslicarbazepine acetate, nevirapine, oxcarbazepine
- primidone
- ritonavir
- St John’s Wort
- griseofulvin
