1. Medicines Information
Useful sources
Basic enquiry answering
October 2017
W:\WMIC SHARED FILES\Training\All Wales Pre-reg sessions\Introductory session (September)\Intro to MI 2016

2. Session aims Increase awareness of what questions to ask an enquirer
Have practical experience using some resources which will be useful throughout the pre-registration year
Increase awareness of the Medicines Information (MI) services UK
Wales
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3. GPhC Registration Assessment Framework
10.2
Skills required in practice
10.2.1
Implementing health policy
Future pharmacists outcome
Indicative assessment topics
Medium
Access and critically evaluate evidence to support the safe, rational and cost-effective use of medicines
Principles of obtaining and applying evidence for use in current practice
Interpreting and applying information to improve patient care
Access and critically evaluate evidence to support the safe, rational and cost-effective use of medicines
All pre-reg need to develop these skills as they form part of the registration assessment framework. Essential clinical skills for all pharmacists irrespective of sector.
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4. Source of enquiries GP/hospital doctor Nurses – community/hospital
Pharmacy colleagues
Other healthcare professionals
Patient
Carer
Own knowledge/CPD
All pharmacists, whether working in community, hospital, on wards, in dispensary, will be asked questions about medicines from a variety of sources. Vital that we have the skills to obtain relevant background details of the enquiry to be able to understand the context and give an answer appropriate to the situation.
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5. Query #1 A GP rings and asks you: “Are steroids safe in pregnancy?”
What additional information may be required in order for you to answer the query (or for you to refer the query to MI for answering)?
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6. Query #1 Who is calling? Patient specific or general?
Name, designation, contact details etc.
Patient specific or general?
Prospective or retrospective?
At the end of the call, negotiate when you will provide an answer.

7. Query #1 Retrospective: Which steroid did she take?
What dose? Route? Indication?
At what stage of pregnancy was steroid taken?
try & get exact dates if possible
Taking anything else?
Purpose of call?
for reassurance or because something abnormal has been detected on a scan?

8. Query #1 Prospective: Stage of pregnancy (weeks)
What is being treated?
Severity of condition?
Which steroid? Dose? Frequency? Route?
What has been tried already?
Is pregnancy currently ‘healthy & normal’?
Any co-morbidities?
Any other drug therapy being taken?

9. Query #2 A nurse calls you and asks:
“Is fluoxetine safe to use in a breastfeeding mother who is depressed?”
What additional information may be required in order for you to answer the query (or for you to refer the query to MI for answering)?

10. Query #2 Who is calling? Patient specific or general?
Name, designation, contact details etc.
Patient specific or general?
Prospective or retrospective?
At the end of the call, negotiate when you will provide an answer.

11. Query #2
Prospective
Was baby born at term & is baby healthy & of normal weight for its age?
Has mum been treated for depression before e.g. while pregnant? If so with what & did it work?
Proposed dose of fluoxetine to be used?
Co-morbidities for mum?
Other drug therapy for either mum or baby?
Is prescriber open to suggestions of possible safer alternatives (if found)?

12. Query #2 Retrospective: Establish why nurse is ringing?
e.g. for reassurance, or is the baby showing signs or symptoms thought to be due to fluoxetine?
If so, further details as appropriate...
Was baby born at term & is baby healthy & of normal weight for its age?
Dose of fluoxetine used?
Co-morbidities for mum?
Other drug therapy for either mum or baby?

13. Query #3 A GP calls you and asks:
“Is their an interaction between clarithromycin and citalopram?”

14. Query #3 Who is calling? Patient specific or general?
Name, designation, contact details etc.
Patient specific or general?
Prospective or retrospective?
At the end of the call, negotiate when you will provide an answer.

15. Query #3
Prospective:
Is citalopram a ‘long-term’ therapy & clarithromycin being prescribed ‘new’?
Proposed doses, duration etc.
What infection is being treated? (Why clarithromycin?)
Other drug therapy being taken?

16. Query #3 Retrospective: Establish why is GP ringing?
e.g. following a query to the GP from a community pharmacist, or because a patient is exhibiting a new symptom etc.?

17. Enquiry for you... Patient on the Medical Admissions Unit
admitted with GI bleed
Consultant suggests may be due to citalopram
Junior Dr wants more information on this AE
What further information do you need?
Enquirer name, how to contact them
Patient details
What is the indication, dose?
When was it started?
Are they on any other medication?
Any other relevant medical history?
When do they need an answer by?
We document all of this on a database called MiDatabank – those of you who have a rotation through MI will have a chance to see this. Towards the end of the session I will give you copies of an enquiry that has been done on Midatabank so you can see how we would record it.
We will come back to this enquiry later in the session once we’ve looked at some resources.
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18. Further background information
Enquirer name & how to contact them?
Patient details?
(We know the query is retrospective)
What was the indication & the dose of citalopram?
When was it started/has the dose recently been increased?
Co-morbidities/risk factors?
Taking any other medication?
When is the answer needed?

19. So, the enquiry really is...
Mrs EW is an 83-year old lady who has been admitted to hospital with a GI bleed. The consultant has suggested her citalopram 40mg daily may be a possible cause (she has taken this for 2 months & takes no other regular medication) & has no risk factors for a GI bleed. No relevant PMH..
The junior doctor (Dr Jones) is not familiar with this adverse effect of citalopram and requests additional information on this as a possible cause of the GI bleed.

20. Where to look for information
You are going to need to look things up – none of us can know everything!
Will need it for your own practice as well as for when people approach you with questions.
Going to look at some useful resources now which will help you
- Some are free access while others require a subscription by your organisation – this may be limited to use within your MI centre.
Give out workbooks.
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21. eMC Access via www.medicines.org.uk/emc SPCs and PILs
Only for products registered with the ABPI (members supply ~90% of UK medicines)
Free access – no login required
Useful links, e.g. X-PIL
X-PIL = large print and screen reader versions of PILs
Show an example SPC, e.g. Citalopram – highlight the sections
Into groups to do questions.
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22. BNF / BNFc Access via www.medicinescomplete.com/mc
Apps also available to download
Same content and layout as books
Monthly updates
Show BNF contents page and an example monograph e.g. Citalopram – illustrate how similar to book.
Password and username not required for BNF and BNFc if logging in from an NHS Wales PC.
Community - Can log in via a personal Athens account or own subscription from a non-NHS Wales computer.
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23. Medicines Complete Access via www.medicinescomplete.com/mc
Subscription required
AHFS
Stockley’s Drug Interactions
Stockley’s Herbal Medicines Interactions
Handbook of Drug Administration via enteral feeding tubes
Trissel’s Handbook on Injectable Drugs
Herbal Medicines
Dietary Supplements
Username and password as per your organisation – those in community – check if you have access to any of these.
We will log you in for exercises today, but cannot give you this password to take away.
Please log out before closing down the window.
Brief description of what the sources are.
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24. MicroMedex Access via NHS Wales elibrary http://www.wales.nhs.uk/ehl
Basic access with NHS Athens password
Detailed drug monographs (including some complementary medicines)
Quick Answers/In-depth Answers
Martindale
Drug Interaction Checker
Trissel IV compatibility
Reprotox / TERIS / Shepard’s (MI only access)
Community pharmacists are allowed access – need to register for athens account, need to state which health board area you are working in
Internet / intranet accessible
Again, we will log you in for exercises today, but cannot give you this password to take away.
Please log out before closing down the window.
Show an example DrugDex monograph, e.g. Citalopram
Martindale monograph, e.g. Citalopram
Show how to access Drug interaction checker / IV compatability
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25. SPS website Medicines Use & Safety, Procurement,
Quality Assurance, Technical Services & UKMi
Access via
Fridge stability database
Drugs in lactation database
UKMi Q&As
Medicines compliance aid database
Medicines Q&As are produced by UKMi pharmacists in response to a demand to make available high quality, evidence-based, and quality controlled answers to common or unusual enquiries made to medicines information services. They usually answer an enquiry fully to save time and duplication.
Demonstrate:
Q&As list – e.g. Citalopram and GI bleed
Fridge database – e.g. Caspofungin
UKDILAS – e.g. Codeine
MCA database
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26. NICE Evidence Search https://www.evidence.nhs.uk/
Evidence on treatments, medicines and safety
Can search the latest key medicines and prescribing information in one place
Enter a term into the search bar
Use filters to narrow down search results
Register for updates
Demonstrate e.g. Citalopram bleed
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27. Review our enquiry So remember our patient with the GI bleed?
Give out enquiry handout
Once we’ve looked at all of these resources, and recorded them on MiDatabank – this is what our enquiry looks like.
So, do you think we need to report this adverse effect?
If so, how would we do that? Has anyone come across the Yellow Card Scheme?
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28. Yellow Card Scheme Run by the MHRA and Commission on Human Medicines
Introduced in 1964 after thalidomide tragedy
Spontaneous reports of suspected ADRs
Acts as an early warning system to identify ADRs and risk factors
Over 780,000 confidential reports received in UK
The Yellow Card Scheme is run by the MHRA and Commission on Human Medicines and collects, collates and investigates reports of Suspected ADRs
The thalidomide tragedy of the late 50’s and early 60’s highlighted the urgent need for routine monitoring of the safety of medicines by a central body independent of the pharmaceutical industry. This disaster prompted the establishment of The Yellow Card Scheme which was introduced in 1964.
It was the worlds first spontaneous reporting scheme for the reporting suspected adverse drug reactions and is the cornerstone of post marketing drug safety surveillance in the UK. The scheme is referred to as spontaneous as it voluntary and relies on observation and interpretation by health professionals in normal clinical practice. However this now includes reports from patients.
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29. Why report ADRs? Important role in patient safety
Allows continual safety monitoring of drugs
old and new
New drugs – lack of experience on ADRs
exposure in ~1500 people only for short duration
unlikely to detect frequency <1/500 or long latency
lack of experience in special patient groups
elderly, children, pregnancy, >1 disease / drug
Detect rare adverse effects
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30. What to report? Report all suspected ADRs for:
new drugs (marked ▼) – even if not serious
The black triangle  indicates a medicine is being intensively monitored.
It is assigned to :-
new drugs
new combinations of drugs
novel routes or delivery systems for drugs
significant new indications for drugs

31. What to report?
Report all serious suspected adverse drug reactions to established drugs (adults and children)
Fatal
Life-threatening
Disabling or incapacitating
Result in or prolong hospitalisation
Congenital abnormalities
Medically significant

32. Completing a Yellow Card
Online
simple and fast
drop-down menus
can register to save time in the future
can be saved part way through
App for use via tablets or smartphones
Paper
available in BNF, MIMs, ABPI
available from YCC Wales
download from MHRA website
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33. Examples of ADRs identified by Yellow Card Scheme
Domperidone – risk of cardiac SEs
use now restricted to N&V indication
limited duration
Mirabegron – risk of severe hypertension
Strontium ranelate – risk of cardiac SEs
C/I in those with cardiac problems
use restricted to severe osteoporosis, last resort
Risk of switching between branded and generic anti-epileptics
Mirabegron -
Patient presented with a shortness of breath and raised blood pressure (160/80).
Medically Significant Details: Long-term implications of raised blood pressure.
Follow up: Shortness of breath and raised blood pressure resolved after stopping mirabegron.
Treatment provided - mirabegron stopped.
Submitted by Welsh GP
Four other similar examples
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34. Our enquiry
Should a yellow card be completed regarding our patient with the GI bleed?
Yes!!
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35. Applying theory to practice
Complete a yellow card and submit to MHRA OR
Document a basic enquiry (e.g. adverse effects/drug interactions/drug dosing in renal impairment)
Bring a copy of the yellow card/enquiry to next WCPPE MI session and be prepared to discuss it

36. Medicines Information Service
A service that
supports the safe, effective and efficient use of medicines by the provision of evidence-based information and advice on their therapeutic use
UKMi
Local centres
Regional centres
Specialist centres
Virtual national network
The UKMi service is provided by a network of: * 180 local medicines information centres based in the pharmacy departments of most hospital trusts
* 15 regional centres (1 of which is a national centre = Wales)
Provide an enquiry answering service on all aspects of drug therapy.
Local role :
Largely based in hospitals
support healthcare professionals in their area with any medicines-related enquiry
some take enquiries directly from patients who are under the care of a specialist in their organisation
formulary and drugs & therapeutics / prescribing committee work
producing guidelines and patient group directions
Regional centres:
support the local centres
strategic support for Health Boards (or English equivalents)
some are specialist centres, eg.
Cardiff = porphyria and tertiary service for complementary medicines enquiries
Trent and West Midlands = UKDILAS
Newcastle = UKTIS
Bristol = drugs in renal failure
National network
Reduction in duplication of effort
NICE Evidence
Horizon scanning
Fridge database
UKDILAS
Stabillity in compliance aids database
Info on supply issues
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37. UKMi Wales
Where the MI centres are in Wales – worth working out which your local centre is and finding out their phone number for future reference.
Ysbyty Gwynedd
Glan Clwyd
Wrexham
Withybush
Powys
Morriston
Princess of Wales (POW)
Royal Glamorgan
WMIC at UHW
Royal Gwent
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38. Who uses MI services in Wales?
Total enquiries taken in 2016 = 4,585
Enquirer
Percentage
Consultant 12
Senior Hospital Dr (SpR/ST) 4
Junior Hospital Dr 6 GP 10
Hospital Pharmacy staff 28
Community Pharmacy staff 5
Hospital Nurse 14
Member of public
Data collated from all centres across Wales
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39. What do they ask? Total enquiries taken in 2016 = 4,585 Category
Percentage
Administration / dose 26
Adverse effects 13
Availability / supply 9
Choice of therapy
Interactions
Pregnancy 7
Breastfeeding 3
Identifications 1
... so how do we handle the questions they ask us?
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40. Thank you for listening
MI Centre
Contact number
Ysbyty Gwynedd, Bangor
Glan Clwyd, Rhyl
ext.6216
Wrexham Maelor
Withybush, Haverfordwest
Powys Local Health Board
Morriston, Swansea
Princess of Wales, Bridgend
Royal Glamorgan, Llantrisant
WMIC, Cardiff
Royal Gwent, Newport
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41. Reflective learning In your own time, consider the following points:
What have I learnt today?
What do I need clarification on?
How am I going to go about clarifying that?
Consider these points in your own time to help make the most out of your learning.
Clarification may be contacting tutor / local MI centre / me / reading / pre-reg rotation etc etc
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