ce | October 2017 | www.ukclinicalpharmacy.org October 2017 “The UKCPA promotes expert pracƟce in medicines management for the benefit of paƟents, the public and members by establishing standards, workforce development and advancing innovaƟon in all health care seƫngs. The UKCPA encourages Excellence, Leadership and Partnership” In PracƟce In this issue: PresƟgious awards for UKCPA members (page 3) Clinical and core skills training by expert pracƟƟoners (page 4) An insight into pharmacist prescribing acƟvity in criƟcal care (page 9) Epilepsy in pregnancy: the risks and how to reduce them (page 11) EssenƟal informaƟon on new products and guidelines in respiratory medicine (page 13) Developing a pharmacy‐led anaemia management service in pre‐operaƟve assessment clinics (page 14) Image credit: jm1366 1 1 105620 UKCPA in practice 1 Front 2017/09/20 12:15:46
Transcript
UKCPA | In Prac ce | October 2017 |
www.ukclinicalpharmacy.org October 2017
“The UKCPA promotes expert prac ce in medicines management for the benefit of pa ents, the public and members by establishing standards, workforce development and advancing innova on in all health care se ngs.
The UKCPA encourages Excellence, Leadership and Partnership”
In Prac ce
In this issue:
Pres gious awards for UKCPA members (page 3)
Clinical and core skills training by expert prac oners (page 4)
An insight into pharmacist prescribing ac vity in cri cal care (page 9)
Epilepsy in pregnancy: the risks and how to reduce them (page 11)
Essen al informa on on new products and guidelines in respiratory medicine (page 13)
Developing a pharmacy‐led anaemia
management service in pre‐opera ve
assessment clinics (page 14)
Imag
e cr
edit
: jm
13
66
1
110
5620
UK
CP
A in
pra
ctic
e
1
Fro
nt
2017
/09/
20 1
2:15
:46
UKCPA | In Prac ce | October 2017 | 2
Thank you!
To all corporate members and sponsors for their support
Ague ant Ltd
AOP Orphan
Astellas Pharma Ltd
Baxter Healthcare Ltd
B. Braun Medical
Biogen Limited
Boehringer Ingelheim
Bowmed
hameln pharmaceu cals
Horizon Strategic Partners Ltd
Napp
Orion Pharma (UK) Ltd
Pfizer Ltd
Servier Laboratories Ltd
Sintek Ltd
Takeda UK Ltd
Vifor Pharma
For links to our corporate members’
websites, please visit
www.ukclinicalpharmacy.org/about/
supporters
inside this issue 02 Our supporters 02 Contact us 03 News 04 Learning events 07 Sharing exper se 07 Care of the Elderly 08 Community 09 Cri cal Care 10 Gastroenterology & Hepatology 11 Neurosciences 12 Pharmacy Infec on Network 13 Respiratory 14 Surgery & Theatres 15 Women’s Health
Key officers Ann Page, Chair: [email protected] Mark Tomlin, Treasurer: [email protected] UKCPA Suite 1.2F Lyn House 39 The Parade Oadby Leicester LE2 5BB www.twi er.com/UKCPAChair www.twi er.com/UKCPA www.facebook.com/UK.Clinical.Pharmacy.Associa on
Tel: 0116 2714894
www.ukclinicalpharmacy.org
Have you logged into our new website yet?
Please contact us if you need help with se ng up your password and ge ng started. Don’t miss out!
2
210
5620
UK
CP
A in
pra
ctic
e
1
Bac
k
2017
/09/
20 1
2:15
:46
UKCPA | In Prac ce | October 2017 | 3
Dr Gillian Hawksworth was presented with the Royal Pharmaceu cal Society Life me Achievement Award at the recent RPS Conference in September. Ash Soni, president of the Royal Pharmaceu cal Society, described Hawksworth as a “passionate and
reless advocate for the profession for decades”. Gillian is a Trustee for UKCPA and is certainly one of our most fervent supporters. A former President of the Royal Pharmaceu cal Society, Gillian was a community pharmacy prac oner for many years, and was most recently Senior Lecturer at the
University of Huddersfield. She is currently Chair of the RPS Panel of Fellows and a visi ng fellow at the University of Huddersfield. At the awards ceremony, Ash Soni told conference delegates that he wasn’t sure that “any other member of the Royal Pharmaceu cal Society could demonstrate a commitment and involvement that is anywhere near that shown by Gill’s CV. The profession is reaping the rewards of Gill’s hard work now, with the growing recogni on of the role of pharmacists”.
Pres gious awards for UKCPA members
news
Professor Ian Bates has been given the Charter Award for 2017 by the Royal Pharmaceu cal Society in recogni on of his outstanding service and contribu on to pharmacy. The Charter Award is made by the RPS and is awarded annually by the Society on the recommenda on of its President and approval by the Assembly. Amongst his many roles, he is Professor of Pharmacy Educa on at University College London, Professor of Integrated Care Educa on at the Whi ngton Health NHS Trust and Expert Advisor on Educa on for the Royal Pharmaceu cal Society. He is also a Trustee for UKCPA. Professor Bates is well known and respected for his interna onal work, chiefly as the Director for Educa on Development for the
Interna onal Pharmaceu cal Federa on (FIP) and Coordinator for the interna onal UNESCO UNITWIN network for Global Pharmacy Educa on, a transna onal network spanning universi es and countries worldwide. His work focusses on workforce and educa on development research and evalua on for both na onal and global perspec ves and associated policy forma on, and he provides advice on workplace educa on and workforce development for many domes c and interna onal ins tu ons and agencies. His work has resulted in the publica on of strategies for transforming the global pharmacy workforce.
We are delighted and proud to hear that two of our long standing UKCPA members have been presented with the most pres gious na onal pharmacy awards this year.
3
310
5620
UK
CP
A in
pra
ctic
e
2
Fro
nt
2017
/09/
20 1
2:15
:46
UKCPA | In Prac ce | October 2017 | 4
Clinical Pharmacy Training Day 23 November 2017: Leeds UKCPA Conference 24 & 25 November 2017: Leeds Star ng out in cri cal care 8 December 2017: Manchester Founda on course 19 & 20 January 2018: Leeds Respiratory medicines op misa on (Joint event with Journal of Medicines Op misa on) 1 February 2018: Birmingham Managing pain: Make it ma er 7 February 2018: London
Gastroenterology and infec on 9 February 2018: Birmingham Star ng out in cri cal care 9 March 2018: London Diabetes medicines op misa on (Joint event with Journal of Medicines Op misa on) 15 May 2018: Manchester Star ng out in cri cal care 15 June 2018: Newcastle Women’s health 22 June 2018: London Infec on masterclass 21 September 2018: Birmingham
Visit www.ukclinicalpharmacy.org/educa on/events to find out how our learning events can benefit you
learning events Learn and connect:
Educa onal events to support your prac ce
“The speakers were superb and inspira onal, delivering
content at exactly the right level for me
to understand and learn more.”
4
410
5620
UK
CP
A in
pra
ctic
e
2
Bac
k
2017
/09/
20 1
2:15
:46
UKCPA | In Prac ce | October 2017 | 5
Baguiasri Mandane a ended the UKCPA Clinical Pharmacy Training Day last year as a junior pharmacist:
“A range of different ac vi es kept the training very lively and interes ng, from lectures, to case‐based scenarios, open debates and interac ve discussions around the various clinical topics. The teaching sessions generated great opportuni es for interac on between delegates and facilitators. The training really enabled us to gain a deeper insight into pharmacy prac ce and further developed our skills of cri cally ques oning the current prac ce and comparing it to more recent evidence‐based prac ce. Overall, the experts delivering the sessions really helped to unravel the different clinical topics in much greater depth in a relaxed and friendly learning environment. Con nuous development is key to every clinician’s growth; as a result of this ongoing acquisi on of knowledge, skills,
confidence and competence the clinician is able to provide be er care to all his or her pa ents. The UKCPA Clinical Pharmacy Training Day precisely helped with this, and as a result strongly empowered the next genera on of clinical pharmacy leaders to provide up‐to‐date, evidence‐based, safe and quality driven excellent care to all pa ents. In an era where healthcare professionals are very much expected to engage in self‐directed learning, the UKCPA Clinical Pharmacy Training Day really helped to guide delegates in their lifelong professional development journey. “
Clinical Pharmacy Training Day
Something for everyone
The Clinical Pharmacy Training Day has been specifically designed to give you an opportunity to a end educa onal sessions which are most appropriate for your specific prac ce.
Each session is run by expert clinical pharmacists so you can be assured that you will receive the best informa on and support.
You’ll be able to move between sessions in order to get the most out of the topical issues on offer across a number of therapeu c areas.
The day will be fantas c for: Pharmacists working in primary care Pharmacists working in community Pharmacists working in secondary care Pharmacy technicians Healthcare professionals involved in medicines
management
Whether you are new in your career, or prac cing at advanced level as a generalist or specialist, you’ll find sessions at the UKCPA Clinical Pharmacy Training Day that will support you in your prac ce. Sessions include updates in the following areas:
Asthma and COPD
Falls and fractures
Eczema
Cancer and co‐morbidi es
De‐prescribing
An coagula on
Liver disease
Medicines in pregnancy and breas eeding
Heart failure
Post opera ve surgery
Urinary tract infec ons
Stroke
Mul ple Sclerosis
Atrial fibrilla on
Diabetes and insulin
learning events
23 November 2017 at The Queen’s Hotel, Leeds
Book now at: ukclinicalpharmacy.org/events/clinical‐pharmacy‐training‐day Call us on: 0116 2714894
WORKSESSIONS A choice of 18 workshops delivered by experts
Management skills Iden fying and priori sing medica on safety issues: Yogini Jani
How to effec vely measure medica on safety: Gillian Cavell
Managing risks with medicines in e‐prescribing: Caroline Anderson & Emma Ritchie
Hierarchical vs network leadership: Richard Ca ell
Effec ve leadership Informed consent: whose problem is it anyway? Ewan Maule
Clinical priori sa on: Doing more with less: David Gibson & Jan Forlow
Different perspec ves on change: Chris Green
Sharing exper se Speed coaching: Developing yourself and others: Aamer Safdar
Delivering mul disciplinary team training and educa on: Hayley Wickens
Ten ways to be a safe and effec ve prescriber: Wasim Baqir, Ewan Maule & Roisin O’Hare
Strengthening research skills Developing your cri cal appraisal skills: Deborah Layton
How to present your research and audit at conferences: Tejal Vaghela
How to develop a mul tude of skills through conduc ng research: Richard Keers
Wri ng a research grant applica on: Rachel Joynes, Ivana Knyght & Helena Rosado
Building effec ve rela onships Introduc on to asser veness: Marian Wood
How to think crea vely to improve pa ent care: Clive Jolliffe
Improving discharge medica on prescrip ons: Raliat Onatade
Making the most of the whole pharmacy workforce: Joela Mathews & Jo Smith
KEYNOTE TALKS To inform and inspire
GPhC Revalida on Consulta on: results and update
Presented by Osama Ammar, Head of Con nuing Fitness to Prac se, General Pharmaceu cal Council Are you wondering what you will need to do to stay on the GPhC register? We can offer you the opportunity to hear directly from the GPhC about the new revalida on processes, and for you to have your ques ons answered.
What can different genera ons learn from each other?
Presented by Nicholas Butler, Educa on Supervisor, General prac ce pharmacist training pathway, CPPE, and Baguiasri Mandane, Junior Resident Pharmacist, University Hospitals of Leicester NHS Trust Do the older genera on struggle with technology? Will the younger genera on have to work harder to keep their jobs? The older genera on have decades of life and work experience. What have they learnt, what are their words of wisdom, what do they wish they had done differently? And what advice can the younger genera on give to those older than them, to help them navigate a very different world?
learning events
24 & 25 November 2017 at The Queen’s Hotel, Leeds
Book now at: ukclinicalpharmacy.org/events/ukcpa‐conference
A paper recently published in the European Journal of Hospital Pharmacy has concluded that ward‐based hospital pharmacists may improve the appropriateness of medica ons, seamless care and drug safety for geriatric inpa ents whilst being cost effec ve. The authors at the University Hospital of Munich in Germany reviewed research from over twenty research studies conducted in seven European countries on pharmaceu cal interven ons in geriatric inpa ents. They wanted to inves gate the available evidence on the effect of pharmaceu cal interven ons on geriatric pa ents, their medica ons and healthcare costs in clinical se ngs across Europe. The review demonstrated that pharmaceu cal care leads to more appropriate medica on use and might reduce outcomes like drug‐related re‐admissions. Intensified pharmaceu cal care showed addi onal effects, even in countries with established pharmaceu cal care in hospitals. Reference: Kiesel E, Hopf Y. Hospital pharmacists working with geriatric pa ents in Europe: a systema c literature review. Eur J Hosp Pharm h p://ejhp.bmj.com/content/early/2017/08/02/ejhpharm‐2017‐001239
Researchers at Johns Hopkins University School of Medicine in the USA have found that people with mild cogni ve impairment show a loss of serotonin transporters compared to a healthy control group. Whilst the degenera on of the serotonin system as a part of aging and in Alzheimer’s Disease is well known, there is li le evidence for its demise in mild cogni ve impairment. In this study, 28 adults with mild cogni ve impairment and 28 healthy, cogni vely normal matched control adults underwent a number of brain imaging procedures. The results showed that serotonin transporter levels in pa ents with mild cogni ve impairment were 10‐19 percent lower in the cor cal regions and the raphe nuclei and 10‐38 percent lower in the striatum and the thalamus, compared with the control group.
The researchers note that the loss of serotonin transporters in mild cogni ve impairment may have “a significant impact on brain func on and behaviour” given their widespread distribu on in the brain and previous evidence iden fying serotonin degenera on in Alzheimer’s Disease. They conclude that serotonergic agents could be poten ally used to prevent cogni ve decline and the emergence of neuropsychiatric symptoms in pa ents with mild cogni ve impairment. However, they admit that further inves ga on is needed to establish whether serotonin degenera on is a causa ve factor or a downstream effect of Alzheimer’s Disease. Reference: Smith GS et al. Molecular imaging of serotonin degenera on in mild cogni ve impairment. Neurobiol Dis. 2017;105:33‐41.
Derek Taylor, Chair of the Care of the Elderly Group, reviews recent research in this area of prac ce.
Care of the Elderly Group news
Image credit: stockdevil
7
710
5620
UK
CP
A in
pra
ctic
e
4
Fro
nt
2017
/09/
20 1
2:15
:46
UKCPA | In Prac ce | October 2017 | 8
sharing exper se
The important point about cancer awareness and cancer screening is the need to detect cancer earlier so that more lives can be saved. Cancer is the second biggest killer in England. The UK’s five year survival rates are lower than the average across Europe, so improving early cancer diagnosis is a key priority. Screening does not reduce the risk of developing cancer, nor does it defini vely diagnose cancer, but it looks for the presence or absence of a disorder in an otherwise healthy person. Community pharmacists have an important role in both raising cancer awareness and referral for cancer screening, and it is important to understand the differences between these two elements. LPCs have already developed or are planning cancer awareness or screening referral services and CPPE have a suppor ng workshop and distance learning programme. Cancer awareness involves an understanding of the risk factors and symptoms for each cancer type so that, as a pharmacist, you can signpost or refer pa ents who may be at risk or who may have symptoms as early as possible. This might be through rou ne conversa ons with customers, via a public health campaign, or as part of a local or na onal ini a ve, such as the Lung Cancer Awareness campaigns held in November each year. Cancer screening focuses on local or na onal screening services to which pa ents or customers can be referred by a healthcare professional, or to which they can self‐refer. There are currently three NHS cancer screening programmes which look at breast,
bowel and cervical cancer. In addi on, there is an ‘informed choice’ programme for prostate cancer. Local screening services might include a mobile screening unit or it could be a service commissioned locally for healthcare professionals such as pharmacists to refer customers to. Ask yourself how confident you are in helping pa ents to iden fy symptoms of specific cancers. Good communica on skills are vital for ini al conversa ons around such sensi ve topics and when speaking to people to iden fy barriers that they may have or to help them spot symptoms of cancer and encouraging them to visit their GP.
Cancer Research UK states that as many people now survive cancer as die from it and 4 in 10 cancers can be prevented with lifestyle changes. But worrying sta s cs such as a projected 80,000 addi onal new cases of cancer by 2030 and 15,400 new cases of melanoma skin cancer in 2014 make it a key area of development for targeted public health campaigns and Healthy Living Pharmacies which may have different priori es depending on
loca on. The range of topics to cover may be breast cancer, colorectal (bowel) cancer, lung cancer, female cancers (ovarian and cervical), skin cancer, oesophageal and stomach cancer, or bladder and kidney (renal) cancer. It is important for community pharmacists to be able to iden fy and engage people who may benefit from a public health campaign which helps to reduce the risk of cancer, and to know where to locate useful resources to support it. Explaining the benefits of earlier detec on of cancers is also important, through recognising common signs and symptoms of seven key cancer types and signpos ng customers to resources and organisa ons designed to support the early detec on, diagnosis and examina on of these key cancer types. With this in mind community pharmacists should be aware of the follow‐up and referral procedures to local primary and secondary care specialists, and to na onal NHS screening programmes as part of the primary healthcare team. Look out for what is happening in your area to help you achieve this.
Further resources
Cancer Research UK www.cancerresearchuk.org
CPPE learning resources www.cppe.ac.uk
Cancer screening programmes www.gov.uk/topic/popula on‐screening‐programmes
Gillian Hawksworth, Chair of the Community Group, discusses the importance of being knowledgeable of cancer awareness and screening resources and services.
Community Group news
“Good
communica on skills
are vital for ini al
conversa ons
around such
sensi ve topics”
8
810
5620
UK
CP
A in
pra
ctic
e
4
Bac
k
2017
/09/
20 1
2:15
:46
UKCPA | In Prac ce | October 2017 | 9
sharing exper se
Baseline pharmacist prescribing ac vity in cri cal care units published Cri cal care pharmacists in Sheffield have published baseline pharmacist prescribing ac vity in their general cri cal care units in the European Journal of Hospital Pharmacy. In a retrospec ve evalua on of e‐prescribing undertaken over a one month period, they analysed pharmacist prescribing ac vity including rate, indica on, therapeu c class and error rate. With 60 percent pharmacist prescriber coverage of units during the evalua on period, pharmacists accounted for just over 10 percent (576/5374) of medicines prescribed in 65 percent (126/193) of pa ents. The majority (59 percent) of pharmacist prescrip ons were for new medicines. Infec ons, CNS and nutri on/blood were the top three BNF therapeu c categories, accoun ng for just over 60 percent of all pharmacist prescrip ons. The cri cal care pharmacist prescribing error rate was 0.18 percent (1/550). These results provide some insight into the extent, wide ranging scope and safety of pharmacist prescribing in general cri cal care pa ents at a single centre. They also provide some early indica on of where pharmacist prescribing adds value in our specialty as we develop our understanding na onally of the importance of
advanced level prac ce underpinning medica on reviews that lead to pharmacist medicines op misa on and then prescribing opportuni es. Reference: Cross V, Parker J, Law Min M‐C, Bourne R. Pharmacist prescribing in cri cal care: an evalua on of the introduc on of pharmacist prescribing in a single large UK teaching hospital. Eur J Hosp Pharm. doi:10.1136/ejhpharm‐2017‐001267
How do pharmacists develop into advanced level prac oners? Ruth Seneviratne and colleagues have recently published a report on learning from cri cal care pharmacists on how to develop advanced level prac ce. They found that support was required by pharmacists and that this support should involve developing face‐to‐face access to expert cri cal care pharmacists within a na onal training programme. The importance of mentorship and peer review programmes were also emphasised, as was a local ethos to support advanced level prac ce which chief pharmacists needed to underpin. The results from this study give us some direc on in the educa onal strategy required to provide the
advanced‐level pharmacist workforce needed na onally to meet GPICS recommenda ons. Reference: Seneviratne R, Bradbury H, Bourne R. How do pharmacists develop into advanced level prac oners? Learning from the experiences of cri cal care pharmacists. Pharmacy 2017, 5(3), 38; doi:10.3390/pharmacy5030038
Ruth Forrest, Commi ee member of the Cri cal Care Group, highlights recent research in the area.
Cri cal Care Group news
Exci ng opportunity to network and develop na onal projects in cri cal care The Cri cal Care Group commi ee are looking for new members to join our Expert Group. The Expert Group has been in existence for more than a decade and works as an extension of the commi ee, suppor ng na onal projects and the development and promo on of cri cal care pharmacy. The group meets annually with regular contact via email and teleconference. If you are a consultant pharmacist working in cri cal care, or have been formally assessed at ASII or Fellow level (or equivalent) in cri cal care, or have previously been on the Expert group, commi ee or taught on cri cal care masterclasses, and you are interested in joining the team, please contact Greg Barton on [email protected] with a copy of your CV for considera on. We look forward to hearing from you!
Congratula ons to Alison O’Prey and David Drennan from the Queen
Elizabeth Hospital in Glasgow who have won the Sco sh Intensive Care Society Audit Group/NRS Research Award for their project on the valida on of a pharmacokine c equa on for individualised phosphate replacement in cri cally ill pa ents. The project results were included in the last edi on of In Prac ce.
9
910
5620
UK
CP
A in
pra
ctic
e
5
Fro
nt
2017
/09/
20 1
2:15
:46
UKCPA | In Prac ce | October 2017 | 10
New NICE guidance for ustekinumab Ustekinumab has been recently approved by NICE for Crohn’s disease Ustekinumab is an an ‐interleukin 12 & 23. An ‐Interleukins (an ‐IL) are monoclonal an body that neutralize IL 12/23 by targe ng the p40 shared subunit which has been shown to be effec ve in coli s. This prevents IL‐12/23 cytokine binding with IL‐12Rß1 receptor, thereby reducing immune cell ac va on. Ustekinumab is a fully humanized IgG1κ monoclonal an body that binds to p40 shared unit of unbound IL‐12 and Il‐23.The IM‐UNITI18 trial showed effec veness in CD. It is administered as a loading infusion of approx. 6mg/kg and followed by 90mg injec ons subcutaneously 8 weeks later and a er this 90 mg every 12 weeks. The dosing interval can be reduced to 8 weekly depending on symptom control. The safety profile is favourable, with nasophyrnagi s and headaches as the most common side effects, and infec on rates were similar to the placebo group. As a new
drug it will have to find its place in therapy over the next few years, most likely as a second line treatment for an ‐TNF failures. The pa ent should be reviewed at weeks 6‐8 a er the ini al infusion to assess for adequate response prior to the subsequent sub cutaneous injec ons. NHS England commissioning for orphan drugs in hepatology The new drug for PBC, Obe cholic acid has been approved by NICE. NHS England has restricted its use to certain centres (similar to the Hepa s C treatment opera onal delivery hubs) because only a very small cohort of pa ents will need it. This may cause access problems for pa ents who do not live near a designated centre as all dispensing must be done centrally and VAT free. Trien ne for the treatment of Wilsons Disease is now commissioned centrally via NHSE through an interim arrangement for all exis ng pa ents. New pa ents require an IFR for to secure funding.
sharing exper se
Anja St Clair Jones, Chair of the Gastroenterology & Hepatology Group Commi ee, reports
Gastroenterology & Hepatology Group news
Hepa s C (HCV) The new round of Hepa s C treatment tenders have been agreed and started in September 2017. If you work with a Hepa s C Opera onal Delivery Network, ensure that you are using the treatments that are approved for funding by liaising with your Hub pharmacy. The Bri sh Viral Hepa s Group pharmacy network can also assist with queries around the delivery of Hepa s C treatments (see www.basl.org.uk) Hepa s B (HBV) Tenofovir is now available as a generic which is part of the Medicines Op misa on CQUIN. Given the interna onal shortage of HBV vaccine, Public Health England have provided the following guidelines to help with priori sa on of pa ents and dosing schedules. (see www.gov.uk/government/publica ons/hepa s‐b‐vaccine‐recommenda ons‐during‐supply‐constraints)
Masterclass highlights In July the Gastroenterology & Hepatology Group delivered a masterclass for both generalist and specialist prac oners looking a er gastroenterology pa ents. Here are some highlights of the day:
Presenters from across the speciality discussed current topics and shared advice on how to look a er gastroenterology pa ents on the ward and in clinic.
Sarah Cripps provided an excellent overview of liver pa ents on the ward and ran a workshop on alcoholic liver disease. Generalists and specialist prac oners discussed how to manage a pa ent
ward and picked up knowledge on how to improve their daily prac ce.
Dr Sumita Verma provided an in depth talk about drug induced liver injury and encouraged us to use the LiverTox database, a comprehensive resource of idiosyncra c drug induced hepatotoxicity (www.livertox.nih.gov)
Dominic Moore provided an excellent talk on how to go about changing therapies and used the infliximab biosimilar switch as a prac cal example.
Archna Parmar introduced the concept of Therapeu c Drug Monitoring in IBD and presented
the innova ve work her team is doing in Brighton with pharmacist led outpa ent and infusion clinics.
Sarah Black from Succint Medical Communica ons provided very helpful advice on wri ng skills and Dr Rachel Joynes from the RPS encouraged us all to undertake research and set up a research program for pharmacists in gastroenterology.
The UKCPA Gastroenterology & Hepatology Group would like to set up a research subgroup to support prac oners in research. If you are interested in joining this group, led by Mikin Patel from Imperial College London, please contact us at anja.st.clair‐[email protected]
10
1010
5620
UK
CP
A in
pra
ctic
e
5
Bac
k
2017
/09/
20 1
2:15
:46
UKCPA | In Prac ce | October 2017 | 11
sharing exper se
In the UK about 2500 babies per year are born to women with epilepsy (0.3‐0.5 percent of all births). During pregnancy approximately one fi h of women experience a deteriora on of seizure control and one fi h improve. Babies born to women with epilepsy have a greater risk of major congenital malforma on than the general popula on (2.8 percent compared with 1‐2 percent), and in those taking an ‐epilep c drugs (AEDs) the risk is doubled (4‐9 percent). Epilepsy can present as generalized (for example, tonic‐clonic, absences) or focal seizures. In two thirds of people with epilepsy, seizures can be effec vely controlled using one or two drugs. The remaining third may never achieve seizure‐freedom and are designated drug‐resistant, or refractory. Whilst focal or absence seizures are unlikely to pose addi onal risks, a tonic‐clonic seizure during pregnancy poses poten al health risks, for the woman and for the baby. The risks to the baby include impaired foetal development, hypoxia, lac c acidosis, bradycardia, intracranial haemorrhage, and poor cogni ve performance in childhood. Abdominal trauma can result in ruptured foetal membranes with the a endant risks of infec on or premature labour. Status epilep cus may trigger intra‐uterine death. Effects of seizures on maternal health include injury from accidents or falls, and death from drowning or Sudden Unexpected Death in Epilepsy (SUDEP). The cause of SUDEP is unknown but is thought to result from altera ons in cardiac or respiratory func on induced by a tonic‐clonic seizure during sleep. To reduce these risks it is recommended that people
with epilepsy take showers rather than baths, and avoid swimming or sleeping alone. Ideally women should be referred to a neurologist a year before pregnancy because major congenital malforma ons occur during the first trimester, o en before a woman is aware she is pregnant. This allows
me to re‐assess the diagnosis, discuss the risks and harms of treatment, and op mize the AED regimen. Any changes to AEDs should be made prior to concep on. All AEDs are likely to be teratogenic, but exposure to valproate poses the greatest risk in terms of neural tube defects and neurodevelopment disability, as highlighted by a recent MHRA alert. It should be avoided unless there are no effec ve alterna ves. Women taking it should be informed of the risks. As pregnancy progresses some drugs such as lamotrigine, phenytoin, phenobarbital and topiramate, may need gradual dose increases to counteract the increased volume of distribu on and metabolism. As always, to avoid destabilizing seizure control, it is important to ensure that pa ents taking phenytoin, primidone, phenobarbital and carbamazepine are maintained on their same brand. To a lesser extent this also applies to those treated with valproate, lamotrigine, perampanel, topiramate, oxcarbazepine,
eslicarbazepine or zonisamide. Ul mately, the safest policy, for both mother and baby, is for the mother to take medica on and be seizure‐free. Further guidance:
Royal College of Obstetricians and Gynaecologists. Epilepsy in Pregnancy Green‐top Guideline No. 68, June 2016
MHRA resources for pa ents and health care professionals on valproate are available at: www.gov.uk/government/publica ons/toolkit‐on‐the‐risks‐of‐valproate‐medicines‐in‐female‐pa ents
Neurosciences Group news Ann Dougan, Specialist Pharmacist in Neurosciences & Surgery at Bart’s Health NHS Trust and speaker at the recent UKCPA Neurosciences Masterclass, summarises issues surrounding epilepsy in pregnancy.
Image credit: adamr
11
1110
5620
UK
CP
A in
pra
ctic
e
6
Fro
nt
2017
/09/
20 1
2:15
:46
UKCPA | In Prac ce | October 2017 | 12
sharing exper se
FIS Conference 2017 The Federa on of Infec on Socie es (FIS) Conference is in Birmingham this year from 30 November un l 2 December. We will be delivering a workshop on An microbial stewardship quality indicators for hospital and primary care, which will feature the following speakers:
Impact of NHS England quality indicators on an microbial resistance: Alan Johnson, Public Health England
Quality indicators and outcomes in the devolved na ons ‐ Wales: Nicholas Reid, All Wales Consultant An microbial Pharmacist, Public Health Wales
Quality indicators and outcomes in the devolved na ons ‐ Scotland: Jacqueline Sneddon, Project Lead SAPG, Healthcare Improvement Scotland
Quality indicators and outcomes in the devolved na ons ‐ Northern Ireland: Cairine Gormley, Chair of the Northern Ireland An microbial Pharmacist Network and Lead An microbial Pharmacist, Altnagelvin Hospital
The closing date for abstracts for oral presenta ons is the 30 September 2017 and the deadline for abstracts considered for poster presenta on is the 4 November 2017. ECCMID 2018 The next European Congress of Clinical Microbiology and Infec ous Diseases (ECCMID) is in April 2018 in Madrid. There was a great PIN representa on at this year’s mee ng and it is always a great conference. The abstract deadline is 30 November 2017 so write those posters and ask your trust to fund you!
Providing exper se to NICE The UKCPA Pharmacy Infec on Network has responded to NICE on two recent guideline consulta ons: acute sore throat, and sinusi s. The main points made were on the choice of penicillin over amoxicillin. While penicillin is preferred, amoxicillin is generally be er tolerated and less awkward to dispense. Issues over the dose and dura on of an bio cs as well as the use of the FeverPAIN score were also raised. We look forward to the guidance when it comes out later this year.
Jonathan Urch, Commi ee member of the Pharmacy Infec on Network, reports on the group’s ac vi es and prepara ons for campaigns and conferences.
Pharmacy Infec on Network news
@UKCPAPIN
If you are on social media (and if not, why not?!) follow WAAW/EAAD and AMR related ac vi es via #An bio cGuardian and #UKCPAPINJC. UKCPA Twi er Journal club Find out about recent An microbial Stewardship research and publica ons by searching for #UKCPAPINJC (you do not need a Twi er account). If you read a relevant ar cle share it with others by pos ng it via twi er and adding #UKCPAPINJC to your tweet.
An bio c Resistance Campaigns Public Health England (PHE) are launching a na onal campaign in October to support the government’s efforts to reduce inappropriate prescrip ons for an bio cs by raising awareness of the issue of an bio c resistance and reducing demand from the public. Resources will be available through the An bio c Guardian website and the PHE An bio c resistance page.
These resources can also be used for European An bio c Awareness Day (EAAD) and World An bio c Awareness Week (WAAW) ac vi es. As EAAD falls on a Saturday this year, it is proposed that key ac vi es for EAAD and An bio c Guardian take place on 15th and 16th November 2017.
www.an bio cguardian.com
h p:// nyurl.com/y83byvqv
12
1210
5620
UK
CP
A in
pra
ctic
e
6
Bac
k
2017
/09/
20 1
2:15
:46
UKCPA | In Prac ce | October 2017 | 13
sharing exper se
Launch of first triple therapy inhaler licensed for COPD This summer has seen the launch of the first triple therapy inhaler licensed for COPD: Trimbow® MDI (beclometasone/formoterol/glycopyrronium 87/5/9 micrograms). Other triple therapy inhalers are expected to be launched over the next few months and offer benefits to pa ents by simplifying inhaler regimens and to the NHS through reduced drug expenditure. Pharmacists should be aware of their place in therapy: the licence for these inhalers is as a step up in treatment in people with moderate to severe COPD uncontrolled by an ICS and a LABA. However, due to concerns about over‐prescribing of inhaled cor costeroids in people with COPD (such as pneumonia risk, uncertain benefit in non‐exacerbators), it is likely that they may be more suitable as a step up from LABA/LAMA, which reflects an off‐licence treatment approach.
Roflumilast for trea ng chronic obstruc ve pulmonary disease: NICE Technology Appraisal [461] Despite receiving a marke ng authorisa on in 2010, roflumilast has not been available to prescribe on the NHS due to lack of data on its place in therapy. Now recommended as add‐on therapy for trea ng severe COPD (post‐bronchodilator FEV1 <50%) in adults with chronic bronchi s with at least two or more exacerba ons in the previous 12 months despite triple inhaled therapy, this represents a new treatment op on. Pharmacists should be aware of the NICE recommenda ons and pa ent educa onal risk minimisa on materials. The recommenda ons are based largely on the pivotal 12‐month placebo‐controlled REACT study that demonstrated a small reduc on in moderate‐severe exacerba on rate when roflumilast is added to ICS/LABA or triple therapy (ICS/LABA + LAMA; 70 percent of the study popula on). NICE s pulate that roflumilast should only be prescribed by specialists a er considera on of poten al benefits and risks. Treatment should be avoided in people with severe immunological diseases or immuno‐suppressive therapies, severe acute infec ons, cancers, conges ve heart failure (NYHA grades 3 and 4) and mild hepa c impairment. All pa ents should be issued with a pa ent card advising about these cau ons, to report side effects of sleeplessness, psychiatric disorders and to weigh themselves every two weeks due to weight loss of around 2kg in studies.
Reslizumab for trea ng eosinophilic asthma: NICE Final Appraisal Determina on In July NICE proposed recommending reslizumab as an add‐on therapy for the treatment of severe eosinophilic asthma inadequately controlled in adults despite high‐dose ICS plus another drug, where blood eosinophil count has been recorded as exceeding 400 cells/microlitre, and with three or more asthma exacerba ons in the past year. Reslizumab is the second an ‐interleukin‐5 monoclonal an body licensed for severe eosinophilic asthma, a er mepolizumab, and there are prac cal differences between these two drugs that pharmacists should be aware of. Firstly the cut‐off for blood eosinophil count is higher for reslizumab (400 vs. 300 cells/microlitre), but there is no
me period that this applies to (in contrast to mepolizumab which mandates a count of 300 cells/microlitre within the past 12 months). Secondly, pa ents require to have experienced fewer exacerba ons to be eligible for reslizumab (3 vs. 4), although they may be eligible for mepolizumab if they are currently taking oral cor costeroids. Finally, mepolizumab may be simpler to administer to pa ents as a fixed dose monthly subcutaneous injec on, whilst reslizumab is licensed as a weight‐based monthly intravenous infusion. As there are no compara ve trials between reslizumab and mepolizumab, these prac cal differences are likely to dictate treatment choice for adults with severe uncontrolled eosinophilic asthma.
Respiratory Group news Toby Caps ck, Chair of the Respiratory Group commi ee, highlights what you need to know about new products and guidelines.
New products and guidelines: Essen al informa on you need to know
Further reading REACT study: Mar nez et al. Effect of roflumilast on exacerba ons in pa ents with severe chronic obstruc ve pulmonary disease uncontrolled by combina on therapy (REACT): a mul centre randomised controlled trial. Lancet 2015;385:857‐66. Roflumilast risk materials: www.medicines.org.uk/emc/medicine/23416.
13
1310
5620
UK
CP
A in
pra
ctic
e
7
Fro
nt
2017
/09/
20 1
2:15
:46
UKCPA | In Prac ce | October 2017 | 14
sharing exper se
Prescribing pharmacists at Betsi Cadwaladr University Health Board West have integrated within our pre‐opera ve assessment clinics (POAC) since 2012. Ini ally our main prescribing remit involved an coagula on and bridging management, an ‐platelet management and prophylac c an bio cs, but in 2015 an audit iden fied anaemia to be one of the main causes of delays in pa ent pathway through POAC. Tradi onally POAC pa ents who were iden fied with iron deficient anaemia were referred to primary care for treatment and op misa on prior to elec ve surgery. Pre‐opera ve iden fica on and op misa on is recommended by the Department of Health, Na onal Blood Transfusion Commi ee and the NHS Enhanced Recovery Partnership.(1) In November 2015 NICE stated that iron treatment was not consistently prescribed and that increasing iron prescribing pre‐opera vely should show a reduc on in blood transfusion. (2) A working group compromising of anaesthe sts, nurses and pharmacists collabora ng with a consultant haematologist, gastroenterologist and renal physicians, resulted in the service introduc on in 2016. Following ini al mee ngs a guideline was wri en. The anaemia evalua on and the decision to treat or refer for advice by others (such as renal physicians) is conducted by the pharmacist. If iron deficiency is iden fied the treatment choice compromises oral iron or IV iron. The IV iron is reserved for severe iron deficiency and pa ents whose surgery is within four weeks of POAC appointment. The IV Iron is
administered by POAC nurses, and administra on and observa on documenta ons were developed to aid this process. GPs are informed of our ac on via le ers. Within the assessment period 25 pa ents were treated with fernject® 1g, 24 pa ents were treated with ferrous fumarate 210mg three mes a day, and two pa ents were referred for specialist renal advice. Eight of the 51 pa ents received red blood transfusion in the peri‐opera ve period. The average me available between POAC and day of surgery in pa ents who received red blood transfusion was 35 days. Five of these eight pa ents received IV iron while three were prescribed oral iron replacement therapy. The impact of the anaemia service in POAC showed an average raise in HB of 12g/L prior to surgery. The fernject® cluster showed a mean raise in HB of 11g/L with an mean me of 27 days between iron treatment and pre‐opera ve Hb. The oral iron cluster had a mean raise of 14g/L in HB over a mean 70 days.
The main limita on to the service is the difficulty in managing pa ents who have less than 10 days for POAC appointment to surgery. POAC pharmacists within our anaemia service hope to work with surgeons to iden fy anaemic pa ents listed for surgery earlier within the pathway. We hope that future projects for POAC pharmacists will involve chronic disease op misa on (such as hypertension, diabetes, frail elderly) with the aim of avoiding delays in referral to treatment me and over burdening GPs with referral for op misa on when they are already under pressure in primary care.
Elena Roberts, Commi ee member of Surgery & Theatres Group, reports on introducing a pharmacy‐led
anaemia management service within the pre‐opera ve assessment in North Wales.
Surgery & Theatres Group news
Further reading 1. Kotzé, A et al. Bri sh commi ee for
standards in Haematology Guidelines on the iden fica on and Management of pre‐opera ve anaemia. Bri sh Journal of Haematology 2015: 171, 332‐331
2. Na onal Ins tute for Health and Care Excellence (NICE). Cos ng statement: Blood transfusion. 2015.
The objec ves of the service were to:
Reduce the likelihood of receiving transfusion post opera ve, reducing post opera ve morbidity, mortality and cost
Reduce demand on donors and conserving blood supplies for those who need it most
Reduce referral to treatment mes by minimising the delay of procedures for pa ents iden fied with iron deficient anaemia
Introduce parity for pa ent anaemia management prior to surgery, promo ng consistency in treatment of pre‐opera ve anaemia
Reduce amount of referrals to primary care, thus reducing the workload of already over stretched GPs.
Image credit: jm1366
14
1410
5620
UK
CP
A in
pra
ctic
e
7
Bac
k
2017
/09/
20 1
2:15
:46
UKCPA | In Prac ce | October 2017 | 15
sharing exper se
Masterclass success The first UKCPA Women’s Health Group Masterclass was held in London in June. The event had a good turnout of pharmacists from all over the UK and Ireland and covered aspects of epilepsy and infec on during pregnancy and the peripartum period. The day focused on the management of an ‐epilep c drugs during pregnancy, the obstetric risks to women, and the risks to the foetus and newborn resul ng from exposure to an ‐epilep c drugs. It also covered the management of maternal and neonatal sepsis, the management and pharmacological treatment of HIV posi ve women during pregnancy and the peripartum period, and the risks to the foetus and newborn from exposure to an ‐retrovirals. MHRA Valproate Alert The MHRA released an alert in April 2017 regarding the risk of valproate in
pregnancy to the unborn baby. The alert calls for all organisa ons to undertake a systema c iden fica on of girls and women who are taking valproate and to use the toolkit provided to support them in making informed choices regarding their management. Further informa on can be found here: h ps://improvement.nhs.uk/uploads/documents/Pa ent_Safety_Alert_‐_Resources_to_support_safe_use_of_valproate.pdf Contribu ng to the professional curriculum Following on from the first mee ng of the new commi ee, one of the group’s priori es over the next year is to work with the Royal Pharmaceu cal Society (RPS) to contribute to the Knowledge Interface Tool (KIT). The KIT is a database of knowledge,
skills and behaviours required to prac ce and advance. It is essen ally your pharmacy professional curriculum. It is hosted by the RPS, contributed by the RPS Affiliated Partners, and quality assured and validated by the RPS Faculty Curricula Panel. It is a constantly evolving resource, with changes in prac ce requiring updates in the curriculum. The Women’s Health Group standards and accredita on team aim to help the development of a structured and consistent approach to knowledge that will support pharmacy staff, across all sectors of prac ce, when dealing with women’s health queries. Work has already begun engaging with local, na onal and interna onal colleagues to start the process of contribu ng knowledge, skills and behaviours rela ng to pharmacy prac ce in women’s health.
Women’s Health Group news Chris na Nurmahi, Commi ee member of the Women’s Health Group commi ee, provides an update.
Commi ee refreshed The UKCPA Women’s Health Group was established in 2014 with a core group of individuals led by Elaine Smith as Chair. Three years on, with interest from new members, we decided to review and refresh our commi ee structure. We would like to say a big thank you to Elaine Smith (outgoing Chair) and Jane Bass (outgoing Secretary/Vice Chair) for ge ng the work of the UKCPA Women’s Health Group off the ground. Thank you also to Nicola Hill for her contribu ons over the past few years, and a big welcome to all the new commi ee members. We look forward to moving forward with the group and expanding our membership to further afield. Further informa on about us and our ac vi es can be found on our home page: www.ukclinicalpharmacy.org/groups/womens‐health/
UKCPA Women’s Health Group Commi ee: Chair: Jane Bass
Secretary/Vice Chair: Heather Calvert
Educa on leads: Chris na Nurmahi, Nicky Moya
Standards & Accredita on leads: Kat Hall, Nu an Tanna
If you are interested in being involved with the work of the Women’s Health Group in any way, or have any sugges ons regarding educa onal events or any other ideas, please contact Jane Bass (Jane.bass@gs .nhs.uk) or Heather Calvert ([email protected])
15
1510
5620
UK
CP
A in
pra
ctic
e
8
Fro
nt
2017
/09/
20 1
2:15
:46
UKCPA | In Prac ce | October 2017 | 16
www.ukclinicalpharmacy.org
UK licensed products: Adepend® (naltrexone) Esmolol hydrochloride* Naloxone* Naltrexone*
Tardiben®(tetrabenzine) Tetrabenzine* …Watch this space, more in pipeline for 2018 and beyond!
Company profile
HaematologyOncology Pulmonology
GastroenterologyNeurology
Cardiology
Psychiatry
Haematology
OncologyPulmonology
Gastroenterology
Neurology
Cardiology
Psychiatry
AOP Orphan Pharmaceutical AG UK office, Colmore Plaza, 20 Colmore Circus Queensway, Birmingham B4 6AT, UK.Medical Information +44 (0)121 262 4119.
(*supplied as generic)
Who is AOP Orphan?AOP Orphan is a European Pioneer in the area of Orphan Diseases; the company researches, develops, produces and markets innovative solutions for rare diseases worldwide. With over 20 years of experience in the field, AOP Orphan’s strategic goal is to deliver new treatment options for rare diseases by recognising early on new trends and challenges.
Where is AOP Orphan based?The company was established in Austria in 1996 and has its headquarters in Vienna. Privately owned and led by natural scientists, AOP Orphan is involved in supplying individualised therapies for patients with rare diseases. Today, AOP Orphan is active on the international stage, with an export ratio of around 70%.
What is the current research focus of AOP?A key priority is haematology, specifically myeloproliferative disorders, where the mutated haematopoietic stem cells form too many blood cells:
• Essential thrombocytopenia (ET): Since 2001, AOP Orphan has provided patients with ET, across various countries, with anagrelide. AOP Orphan has developed an improved formulation, which was submitted for approval in 2016.
• Polycythemia vera (PV): In clinical trials, encouraging results have been shown for ropeginterferon alfa-2b, which is currently under review by regulatory authorities.
UK activities:AOP is committed to giving patients in the UK access to medicines, that improve their quality of life.
