1. Role Preparation for NHS Direct Health Information Advisors Handling Medicines Calls Day 2 Name Centre Medicines Information Service

2. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Learning Outcomes 1.Have an overview of NHS Direct policies and roles of staff for Medicines Calls. 2.Have a baseline knowledge about medicines. 3.Have an overview of Community Pharmacy services and emergency supply of medicines. 4.Be able to handle medicines calls safely and effectively.

3. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Learning Outcomes 4.Be able to handle medicines calls safely and effectively. Know what background information is needed to clarify the question and minimise the risks when advising the caller. Be able to navigate the key medicines information sources. Be able to interpret information about medicines and turn it into appropriate advice. Know when and how to refer medicines calls to UKMI. Be able to use the NHS Direct Medicines Algorithm.

4. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Morning Timetable 9.30Introduction & Re-cap Adverse effects Drug interactions Workshop 4: Adverse effects & drug interactions 11.00Tea break Medicines in pregnancy Medicines when breast feeding Workshop 5: Meds in pregnancy & breastfeeding 1.00Lunch

5. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Afternoon Timetable 1.45Herbal medicines Workshop 6: Herbal Medicines 3.00Tea break Where are the risks? What next? 4.00Close

6. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Adverse Effects Account for 2-6% of hospital admissions Type A predicted by mode of action Type B unpredictable Changes in health e.g. digoxin / renal function, warfarin / heart failure Cross-sensitivity e.g. amoxicillin / cefadroxil Unwanted effect that a drug has on a person

7. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Recent Drug Alerts / Scares RimonabantRisk of suicide and depression Co-proxamolHigh risk of death in overdose Rofecoxib Withdrawn,  risk MI and stroke HRT Avoid longterm,  risk breast cancer Kava-KavaWithdrawn, hepatotoxicity CerivastatinWithdrawn, rhabdomyolysis

8. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Incidence of Adverse Effects Very common Common Uncommon Rare Very rare 10% 1% Risk of dying from cancer if smoke 20 a day for 30 years 0.1% Risk of being injured on the stairs in next 12 months 0.01% Risk of dying in an accident at home in next 12 months up to 0.01% Risk of being killed by lightening

9. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Yellow Card Reporting Scheme NEWER MEDICINES & VACCINES (  ) All ADRs even if Not certain that the medicine has caused it Reaction well known Other drugs at same time ESTABLISHED MEDICINES & VACCINES All serious ADRs Fatal, life threatening or disabling Prolonged hospital stay Even if well known Both healthcare professionals and patients can report adverse effects

10. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Drug Interactions One drug modifies the effect(s) of a second drug. More likely if taking several medicines. Many types of interaction. May or may not be clinically significant.

11. Role Preparation For NHS Direct HIAs: Handling Medicines Calls When is a drug interaction clinically significant? Increase toxicity Warfarin Amiodarone Increased risk of bleeding Simvastatin Erythromycin Increased risk of myopathy Reduce efficacy Ciclosporin Phenytoin More ciclosporin needed Thyroxine Rifampicin More thyroxine needed

12. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Drug interactions at the receptor Nerve ending Atenolol closes the bronchioles Salbutamol opens the bronchioles Receptor stimulated Receptor blocked Nerve ending

13. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Medicines that speed up the metabolism of other medicines Blood level of the other medicine will go down Metabolic Enhancers Smoking Alcohol Carbamazepine Phenytoin Rifampicin

14. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Medicines that slow down the metabolism of other medicines Metabolic Inhibitors Cimetidine Ciprofloxacin Erythromycin Metronidazole Blood level of the other medicine will go up

15. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Narrow Therapeutic Range Drugs CARBAMAZEPINE CICLOSPORIN DIGOXIN LITHIUM PHENYTOIN THEOPHYLLINE WARFARIN

16. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Workshop 5: Adverse Effects & Drug Interactions

17. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Tea Break

18. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Morning Timetable 9.30Introduction & Re-cap Adverse effects Drug interactions Workshop 4: Adverse effects & drug interactions 11.00Tea break Medicines in pregnancy Medicines when breast feeding Workshop 5: Meds in pregnancy & breastfeeding 1.00Lunch

19. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Medicines during pregnancy Increased public awareness and concern since the thalidomide tragedy. 1 in 40 babies have a major birth defect of which 1% due to exposure to medicines in-utero. Almost all medicines cross the placenta and have the potential to cause harm. Up to 50% pregnancies are unplanned. Medicines can not always be avoided.

20. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Teratogen Any agent which given in pregnancy causes or contributes to either malformation, abnormal physiological function or mental development of the foetus or child after birth. CarbimazoleFoetal goitre DiethylstilboestrolCancer of vagina and cervix IsotretinoinCranio-facial, CVS & CNS defects NSAIDsClosure of ductus arteriosis WarfarinFoetal warfarin syndrome

21. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Timing Of Exposure 1st Trimester (weeks 1- 12) Up to 2 weeks, “all or nothing” effect Weeks 3-8, major organ systems being formed 2nd Trimester (4th – 6th month) Cerebellum & urogential system still forming Growth and functional development 3rd Trimester (6th – 9th month) Specific effects e.g. NSAIDs (pulmonary hypertension) B-blockers (hypoglycaemia)

22. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Identification Of Teratogens Many possible causes for a birth defect (genetic, physiological, nutrition, medicines, pollutants). Extremely difficult to determine whether or not a particular agent is a teratogen. Clinical trials of medicines in pregnant women is usually unethical. Difficult to extrapolate findings in animal studies to a human pregnancy.

23. Role Preparation For NHS Direct HIAs: Handling Medicines Calls General Advice Consider non-drug treatments. Avoid all medicines in the 1 st trimester if possible. Assess benefit/risk ratio for both mother & infant. Avoid new medicines as usually more experience with well-established ones. Use the lowest effective dose for as short a time as possible.

24. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Essential questions to ask Name, dose, frequency? Who is it for? What prescribed for? Why asking? Other medicines? Name, dose, frequency? Age? Disease states? Allergies? Pregnant: no. of weeks, going well, medicine taken already? Breastfeeding: baby age, term/pre-term, well/unwell, medicine taken already? Confirm no new or worsening symptoms THE PERSONTHE MEDICINE

25. Role Preparation For NHS Direct HIAs: Handling Medicines Calls

26. Advice on infant feeding Breast milk is the best form of nutrition for infants. Exclusive breastfeeding for the first 6 months. Breastfeeding (and/or formula milk) with appropriate solid food after 6 months, ideally for up to 1 year. Mothers unable (or choose not) to breastfeed should be helped to optimise infant feeding.

27. Role Preparation For NHS Direct HIAs: Handling Medicines Calls How much of the medicine reaches the baby? Depends on: Plasma concentration of medicine in the mother. Characteristics of the medicine. Amount of milk taken by baby per feed (approx 150mL/kg).

28. Role Preparation For NHS Direct HIAs: Handling Medicines Calls General advice Avoid unnecessary use of medicines. Assess risk / benefit for mother and baby. Higher risk for premature babies. Check if medicine licensed for babies. Avoid long-acting and black-triangle medicines. Try to time feed to avoids plasma peaks. Monitor baby for adverse effects.

29. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Essential questions to ask Name, dose, frequency? Who is it for? What prescribed for? Why asking? Other medicines? Name, dose, frequency? Age? Disease states? Allergies? Pregnant: no. of weeks, going well, medicine taken already? Breastfeeding: baby age, term/pre-term, well/unwell, medicine taken already? Confirm no new or worsening symptoms THE PERSONTHE MEDICINE

30. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Workshop 6: Medicines during pregnancy & when Breastfeeding

31. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Lunch Break

32. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Afternoon Timetable 1.45Herbal medicines Workshop 6: Herbal Medicines 3.00Tea break Where are the risks? What next? 4.00Close

33. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Homeopathic medicines More dilute means greater potency. Potency expressed in ‘c’ - 6c means diluted 1:100 for 6 times. Inactivated by strong flavours, light and radiation. Do not interact with conventional medicines

34. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Plants as medicines 40 % of all pharmaceuticals in industrialised countries are plant based e.g. Digoxin, Taxols, Vincristine. 2% of prescriptions in USA are for medicines with natural ingredients. Over 80% of the world rely on plant based remedies.

35. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Herbal Medicine Philosophy is to treat the individual rather than the diagnosed disease. Whole plant extracts. Often non-standardised and so active ingredients may vary Where grown (sunshine, rainfall, temperature, soil). Storage conditions. Combine herbs.

36. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Public belief? CONVENTIONAL MEDICINES Artificial and toxic Versus HERBAL MEDICINES Natural & Safe

37. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Herbal medicines 3 types of product: (under review) Licensed herbal medicine. Herbal medicine exempt from licensing. Food supplement. May interact with conventional medicines

38. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Efficacy Evidence variable – very few systematic reviews or meta analyses. Herbs contain a variety of ingredients Which ones are active? Are they synergistic? Problems with standardisation between preparations. Hampered by safety and quality issues.

39. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Risks Delay conventional medical advice Inherent toxicity Kava kava (over 70 cases liver damage) Ginseng (teratogenic in rats) Ephedra (deaths in USA) Aristolochia / Mu tong (kidney failure, cancer) Mistaken identity Digitalis for plantain (1997 arrhythmias) Japanese for Chinese Star Anise (2001 fits) Aristolochia for Stephania (1993 renal failure)

40. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Risks Adulteration Contamination: bacteria, pesticides, heavy metals. Contamination: prescription medicines Glibenclamide (Xiaoke Wan in New Zealand) Fenfluramine (Qian Er in UK) Sildenafil (Hua Fo) Steroids (Yibishu ointment in UK) Drug interactions St John’s Wort (warfarin, COCs, digoxin, phenytoin, zidovudine and others) Cranberry (warfarin)

41. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Workshop 7: Herbal Medicines

42. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Afternoon Timetable 1.45Herbal medicines Workshop 6: Herbal Medicines 3.00Tea break Where are the risks? What next? 4.00Close

43. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Where are the risks when handling a Medicines Call? Clarify the question Plan search strategy & research problem Evaluate the information Tailor the answer/advice Refer to MI Record all stages

44. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Where are the risks when handling medicines calls? Missed symptoms. Misunderstanding what the caller said. Incomplete background information. Omitting relevant information sources. Searching / interpretation of information sources. Caller doesn’t understand the answer. Working outside your level of competency.

45. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Learning Outcomes 1.Have an overview of NHS Direct policies and roles of staff for Medicines Calls. 2.Have a baseline knowledge about medicines. 3.Have an overview of Community Pharmacy services and emergency supply of medicines. 4.Be able to handle medicines calls safely and effectively.

46. Role Preparation For NHS Direct HIAs: Handling Medicines Calls Learning Outcomes 4.Be able to handle medicines calls safely and effectively. Know what background information is needed to clarify the question and minimise the risks when advising the caller. Be able to navigate the key medicines information sources. Be able to interpret information about medicines and turn it into appropriate advice. Know when and how to refer medicines calls to UKMI. Be able to use the NHS Direct Medicines Algorithm.

47. Role Preparation For NHS Direct HIAs: Handling Medicines Calls What next? TRAINING Medicines Call Algorithm Hormonal contraception ASSESSMENT 3 mock scenarios assessed by UKMI before taking live calls 3 live calls assessed by NHSD and 2 of these by UKMI before independent practice

48. Role Preparation For NHS Direct HIAs: Handling Medicines Calls The Medicines Call Review Tool Add on to HIA Call review tool if call about medicines. 6 sections based on the key steps involved when handling a medicines call. Each section has a checklist of points to be addressed. Sections of Review Tool Screening Analysis & Critical Thinking Information Sources Referral to UKMI Answer Documentation Traffic Light Scoring Green: All points addressed Amber: Minor points missed Red: Major points or several minor points missed