Claudine Hughes

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• Claudine Hughes
• Chief Pharmacist, NMIC

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• 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

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Who can prescribe?

• Doctors
• Dentists
• Vets
• Future Nurses, Pharmacists??

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Influencing Factors

• Clinical status of the patient
• Considerations of cost and value for money
• Pressure from Pceutical Industry
• New drug development
• Patient preference
• Local formulary or prescribing policies

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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?

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Questions to ask before prescribing a drug?

• Who should not receive it?
• Where did I hear about it?
• What is its place in therapy?
• Does this drug provide good value for money?

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• Legal Issues
• S1A and S1B
• Generic Prescribing

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Information Support

• BNF
• Prescribers Guide
• www.medicines.ie

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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

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Consequences of Poor Prescribing

• Medication Errors
• Adverse Drug Effects

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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

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Adverse Drug Reactions

• May occur due to lack of consideration for
  drug-drug interactions
• Failure to dose adjust in patients with impaired
  organ function

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Herbal Medicines

• ................. Not all that is natural is
• harmless

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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

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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

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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

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Problems Associated with Use of Herbal Medicines

• Potential for drug interactions
• Lack of knowledge re interactions, ADRs

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Ask me no questions Ill tell you no lies(why
patients may not volunteer information)

• Lack of awareness of the potential for adverse
  effects/interactions
• Dont consider product to be a medicine
• Fear of censure
• Belief that the doctor/pharmacist doesnt know
  about alternative medicines

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Sources of Information

• Textbooks
• Product Information from manufacturers
• Published articles, studies, case reports
• Regulatory authorities

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St. Johns 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

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St. Johns 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

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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

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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

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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