1. Claudine Hughes Chief Pharmacist, NMIC

2. Medicines should be prescribed only when they are necessary, and in all cases the benefit of administering the medicine should be considered in relation to the risk involved Important to discuss the treatment options carefully with the patient to ensure that the patients is content to take the medicine as prescribed

3. Who can prescribe? Doctors Dentists Vets Future – Nurses, Pharmacists??

4. Influencing Factors Clinical status of the patient Considerations of cost and value for money Pressure from P’ceutical Industry New drug development Patient preference Local formulary or prescribing policies

5. Questions to ask before prescribing a drug? What is it? What is the drug used for? How effective is this drug? How safe is this drug?

6. Questions to ask before prescribing a drug? Who should not receive it? Where did I hear about it? What is it’s place in therapy? Does this drug provide good value for money?

7. Legal Issues S1A and S1B Generic Prescribing

8. Information Support BNF Prescriber’s Guide www.medicines.ie

9. Clinical Pharmacy Comprehensive clinical pharmacy service in SJH Daily ward visits by Clinical Pharmacists Prescription review includes: assessment of legibility, dose & frequency, route of administration, drug-drug interactions Source of information Audit review

12. Consequences of Poor Prescribing Medication Errors Adverse Drug Effects

13. Medication Errors “To err is human”, IOM 1999 – 25% treatment errors related to medication Prescribing is an important area in terms of error occurrence Types include: Wrong drug, dose, inadequate consideration of patient factors

14. AminophyllineAmitriptyline CarbamazepineCarbimazole ChlorpromazineChlorpropamide Daonil  Danol  Losec  Lasix  Ritonavir Retrovir  Inderal  Ipral  Trental  Tegretol  Epilim  Epanutin 

15. Adverse Drug Reactions May occur due to lack of consideration for drug-drug interactions Failure to dose adjust in patient’s with impaired organ function

16. Herbal Medicines.................Not all that is natural is harmless

17. Why do people use herbal medicines? Used in developing countries where cost of drugs is prohibitive, poor accessibility to drugs in rural areas, shortage of physicians Perception that natural = safe “More” ADRs reported with conventional medicines than herbal preparations

18. Why do people use herbal medicines? Provide a sense of control, a mental comfort from taking action e.g. cancer, AIDS Cultural & religious beliefs Use differs by ethnic group, income, age & educational level

19. Problems Associated with Use of Herbal Medicines Lack of QC & standardisation Adulteration with other plants, pharmaceutical drugs or heavy metals Inappropriate use / misleading claims Type A & B ADRs

20. Problems Associated with Use of Herbal Medicines Potential for drug interactions Lack of knowledge re: interactions, ADRs

21. Ask me no questions – I’ll tell you no lies (why patients may not volunteer information) Lack of awareness of the potential for adverse effects/interactions Don’t consider product to be a medicine Fear of censure Belief that the doctor/pharmacist doesn’t know about alternative medicines

22. Sources of Information Textbooks Product Information from manufacturers Published articles, studies, case reports Regulatory authorities

23. St. John’s Wort Safety of concurrent administration of SJW with prescription or OTC medications has not been established Inducer of Cytochrome P450 Documented interactions with a number of prescription drugs

24. St. John’s Wort With SSRIs, triptans - symptoms characteristic of serotonin syndrome Theophylline (CYP1A2), cyclosporin (CYP3A4) and warfarin (CYP2C9) - reports of a reduction in the serum concs With COC - reports of breakthrough bleeding - reduced efficacy? Advice published by the IMB and CSM

25. Ginkgo Biloba ADRs - generally infrequent & transient GI upset, headaches, dizziness Contact with whole ginkgo plant associated with severe allergic reactions May prolong bleeding time - caution in patients taking anticoagulant/antiplatelet medication

26. Echinacea ADRs - Relatively free of toxicity either topically or orally Mild allergic reactions reported Serious allergic reactions reported in patients with a Hx of asthma, atopy, allergic reactions Drug Interactions - Antagonises immunosuppressants Increased bleeding time

27. In conclusion… Interest in and information on alternative therapies is increasing Lack of regulation – things are not always what they seem… Information on use of these therapies must be specifically elicited from patients