W32 High Risk Drugs

Question 1

Adverse Drug Reactions (ADRs) example:

Answer 1

• An example of an ADR could be patients who experience stomach bleeds due to the use of Non-Steroidal Anti-inflammatory Drugs
  (NSAIDs) such as ibuprofen or aspirin.
• Patient’s health and wellbeing
• Significant costs of care
• Costs of potential litigation.

Question 2

What are some common problems from high risk drugs?

Answer 2

• Stomach problems such as bleeding, constipation and diarrhoea
• Heart complications and symptoms such as:
  -Shortness of breath or trouble breathing
  -New or worsening chest pain
  -New or worse pain in legs when walking
• Breathing problems (respiratory symptoms)
• Poor control of blood sugars (glycaemic control)

Question 3

Which drugs cause preventable admissions to hospital?

Answer 3

Antiplatelets
Diuretics
NSAIDs
Anticoagulants
Opiod analgesics
B-Blockers
Positive inotropes (e.g. digoxin)
Corticosteroids
Antidepressants
Nitrates
Inhaled corticosteroids
Potassium channel activators (e.g. nicorandil)
Anti-asthmatics

Question 4

Why do high-risk drugs cause hospital admission?

Answer 4

• Incorrect selection of drug, dose, frequency or route
• Inadequate medication monitoring
• “High risk” prescribing
  -contraindications
  -cautions
  -allergy
• Inadequate medication review
• Badly designed repeat prescribing systems
• Carer and patient not understanding how to take the medicine regularly and correctly
• Poor communication across organisations e.g. Community (GP and wider healthcare teams, pharmacy and care home), hospitals and social care

Question 5

Which patients have a higher risk of adverse effects from high-risk drugs? (7)

Answer 5

• Elderly people
• Patients with multiple diseases and conditions (co-morbidities)
• Patients taking several drugs
• Patients with impaired kidney (renal) function
• Patients with impaired memory or understanding (cognition –sometimes these are patients with dementia or learning difficulties)
• Patients with acute medical problems
• Patients who may be in a muddle with their prescribed medicines (with poor adherence)

Question 6

NSAIDs
Monitoring:
Warning Signs?
Actions required?
Interactions?

Answer 6

• Blood pressure (especially after dose changes), renal function, liver function, haemoglobin in those with risk factors for GI bleeding
• Black stools or ‘coffee ground’ vomit
• Iron deficiency anaemia
• Progressive unintentional weight loss or difficulty swallowing
• Pregnancy and breastfeeding
• Swollen ankles or feet
• Unexplained, persistent recent-onset dyspepsia
• Worsening of asthma
• Consider GI and CVS risk
• Lowest effective dose and for shortest period of time
• Consider gastroprotection (e.g. a proton pump inhibitor)
• Taken with or just after food
• Interactions leading to possible increased risk of convulsions, enhanced anticoagulant effects, increased risk of bleeding, increased risk of nephrotoxicity
• Possible enhanced effects of sulfonylureas
• May reduce excretion of lithium or methotrexate
• Increased side effects with concomitant use of other NSAIDs, aspirin
• NSAIDs antagonise hypotensive effect of some CVS drugs

Question 7

Corticosteroids:
Monitoring?
Warning signs?
Action required?
Interactions?

Answer 7

Monitoring:
* Blood pressure, blood lipids, serum potassium, body weight and height (in children and adolescents), bone mineral density, blood glucose, eye exam (for intraocular pressure, cataracts), signs of adrenal suppression

Actions Required:
* Advise patient to report immediately to a doctor if any warning signs occur
* Steroid treatment card
* Single morning dose
* Rinse mouth after using inhaled corticosteroids
* Avoid chicken pox and measles

Warning Signs:
* Paradoxical bronchospasm
* Symptoms of uncontrolled
* Frequent courses of antibiotics and/or oral corticosteroids
* Adrenal suppression
* Immunosuppression
* Psychiatric reactions
Interactions
* Metabolism of corticosteroids accelerated by carbamazepine,
phenobarbital, phenytoin and rifamycins
* Induce or enhance anticoagulant effect of coumarins
* High dose corticosteroid can impair immune response to vaccines
* Can mask the GI effects of NSAIDs
* Hypokalaemia when given with loop or thiazide diuretics
* Effects on antihypertensive and oral hypoglycaemic drug

Question 8

Methotrexate:
Monitoring?
Warning signs?
Action required?
Interactions?

Answer 8

Full blood count, renal function, liver function - local protocols for frequency of monitoring may vary.

• Gastro-intestinal toxicity
• Liver toxicity
• Blood disorders – bone marrow
• Pulmonary toxicity - pneumonitis
• Pregnancy and breast feeding
• Tablets are to be taken once a week, on the same day each week,
• Take folic acid as prescribed
• Methotrexate treatment booklet
• Effective contraception during treatment
• Avoid OTC preparations containing NSAIDs/aspirin
• Annual flu vaccine
• Increased plasma concentration and risk of hepatotoxicity with acitretin (avoid)
• Excretion reduced by NSAIDs and penicillins therefore increased risk of toxicity.
• Increased risk of toxicity when given with co-trimoxazole or trimethoprim

Question 9

Opioid Analgesics
1. What should be monitored?
2. What Instructions should you give? (Actions Required?)
3. What are the Warning Signs?
4. What are its main interactions? (2)

Answer 9

Monitoring:
Renal function, liver function

Actions Required:
* Opioids have a serious risk of addiction, especially with long-term use
* Take as directed.
* Do not increase the dose or take an extra dose
* Do not take any other medicines that contain opioids
* Consider pregnancy & breastfeeding
* Do not stop taking it suddenly
* Withdrawal side effects

Warning Signs:
* Craving for the medicine
* Taking more than prescribed, even if it is causing bad effects
* Feeling that you need to take additional medicines containing opioids
* Taking opioid medicines for reasons other than pain relief
* Experiencing withdrawal side effects when you stop taking the medicine suddenly
* Respiratory depression

Interactions:
* Alcohol causes rapid release of Morphine from extended-release preparations.
* Drugs causing constipation, concurrent use might increase the risk of developing intestinal obstruction.

Question 10

Antidepressants:

Answer 10

Monitoring
Validated depression questionnaire to monitor response to treatment,
such as PHQ-9.
Actions Required
* Providing advice on sources of information and support, including
activities to improve sense of wellbeing.
* Titrate up to the recognised minimum effective dose
* Consider switching if no response
Warning Signs
* Tricyclic antidepressants and MAOIs have the highest toxicity in
overdose.
* Decline in mental state or cognitive function
Interactions
* Possible drug interactions associated with tricyclic antidepressants (TCAs)
* SSRIs interact with OTC ibuprofen

Question 11

What should the Prescriber check for before prescribing High-risk drugs?

Answer 11

• Must assess potential harms and benefits
• Consider whether the medicines is appropriate for the patient.
• Co-morbidities
• Allergies
• Potential adverse effects
• Interactions
• OTC preparations?
• Non-drug interventions?
• Involve patients and carers in prescribing decisions
• Inform them of potential adverse effects
• Explain clearly directions for use of medicines.
• Use appropriate formulations
  -E.g., if the patient has difficulty swallowing, consider liquid /dispersible formulations

Question 12

Prescribing tips for high risk drugs:

Answer 12

• Review medication regularly
• Medicines which appear to have no benefit or have unacceptable side effects should be discontinued (deprescribing)
• Undertake blood tests to ensure the body is operating appropriately and/or the drug is working properly
• Liver function tests (LFT) to check the health of the liver.
• Urea and electrolytes (U&E) to check the kidneys are working.
• Blood tests to check if the drug is working properly (e.g. INR for warfarin).
• Ensure effective communication across organisations e.g. community (GP and wider
  healthcare teams, pharmacy and care home), hospitals and social care
• Review process for actioning medication changes.