a hub for emergency medicine supplies
• Opioid patches – back to basics
• Naming of medicines • Focus on deprescribing • Ashtons
training
seminars and online presentations
2
FEATURE
Reflections on COVID-19 6-7
News just in – August 2020: Restrictions on over-the-counter sale
of stimulant laxatives 14 Ordering 2% lidocaine in Lutrol gel
14
Contents A welcome from the Editor 3
Focus on deprescribing 4-5
Disposal of Ashtons cool boxes and coolant gel packs 8
Flu vaccine uptake – winter 2020/21 8
Ashtons training seminars and online presentations 9
Life support, first aid and mandatory training – update 9
Using the hospice as a hub for emergency medicine supplies
10-11
Opioid patches – back to basics 12-13
Naming of medicines, part one – introduction 15
Hay fever treatments 16
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HOSPITAL PHARMACY SERVICES
FOR YOUR INFORMATION: We provide two newsletters
A welcome from the Editor
3
The past few months have been like no other. When we first heard
about COVID-19, it was difficult to imagine the devastating effects
it would have on health services and our economy. Even in the UK,
with all its advanced healthcare, the pandemic has brought the
system close to breaking point. We saw such dedication amid extreme
suffering. Yet, there was also immense frustration in how it was
managed – and the effects it had on those working directly with
patients. Hospices seem to have been overlooked in their need for
the same level of PPE and testing as other, more acute settings. We
heard how managers spent many hours on the phone trying to get what
they needed while patients were arriving without a known COVID
status. This edition of the newsletter includes reflections on
these common experiences from our hospice colleagues. Thankfully,
most have found a way forward – strengthened by your determination
and passion for carrying on the work you do in your unique
way.
We were able to continue our service throughout and are immensely
thankful to all our Ashtons teams for keeping the supplies and
professional services going to support our customers. We know that
some establishments felt unable to invite us in to visit; still, we
are now back at all sites but one. It’s almost business as usual –
with the added precautions we
are now getting used to. We ensured a good enough supply of the
medicines we believed to be crucial to hospices, and this will
continue with careful attention from our purchasing
department.
It has certainly been an interesting time to be a pharmacist as
several great initiatives have developed. We were approved to relax
some regulatory processes if it meant patients could get their
medicines more promptly. It feels like this ‘honeymoon’ period is
now over, but it has enabled some innovative solutions to be
planned – you will find an article included describing one of these
medicines access projects which we hope to see in action
soon.
It has been a privilege to work alongside our hospice colleagues
during these challenging times, and we look forward to continuing
our work with you, whatever lies ahead as the winter
approaches.
With good wishes and kind regards,
Margaret Gibbs, Editor and Lead Palliative Care Pharmacist 07387
418 530
[email protected]
4
One of the audits collected on our Ashtons Live View system is the
number of prescription items for each patient. This information
enables us to provide you with comparative data and percentages for
our clinical interventions. It is not unusual to count more than
twenty items for one patient on a hospice drug chart, although many
of these items will be on the PRN pages. We pay great attention to
detail with the patient’s response to their medicines, but what are
the prompts for reducing the number of items? It can take
considerable time to administer medicines when a patient is weak
and finding large amounts to swallow challenging. It may be
observed but not always reported by the nurses and proposed as an
opportunity to rationalise. The patient may ask ‘do I really have
to take all these?’ or refuse their medicines selectively or
entirely. Making prescribing decisions may sometimes be quite
simple – the patient is reported as being constipated, so we write
up one or two laxatives. Their pain is showing
neuropathic characteristics, so we add in a tricyclic or
gabapentinoid and within a few moments, they are being asked to
take maybe six additional doses. Should we be looking at which
items on a drug chart we can safely remove as carefully and
regularly as those we might add? We know that many commonly used
medicines have similar side effect profiles, and that additive
sedation and anticholinergic effects can add to symptoms and
increase the risk of falls. The positive effects need to outweigh
the potential negatives, and we should review drug regimens for
such risks.
The term ‘polypharmacy’ has become a rather pejorative term and
although it is now acknowledged that it is difficult to avoid in
symptom control towards the end of life, we still need to consider
it.
Appropriate polypharmacy
Prescribing for a person for complex conditions or for multiple
conditions in circumstances where medicine use has been optimised
and where the
medicines are prescribed according to best evidence.
Problematic polypharmacy Problematic polypharmacy occurs when
multiple medicines are prescribed inappropriately or where the
intended benefits from the medicines are not realised.
Medicine rationalisation and deprescribing are now relevant in all
areas of therapeutics. NICE guidance suggests regimes for specific
diagnoses, but this does not take into account that some people
will have several co-morbidities and have multiple drugs prescribed
as a result. NICE has now collated resources to guide us in the
rationalisation of medicines, acknowledging the potential problems
with multi- morbidity and polypharmacy1. The new resource directs
to documents including those from the Royal Pharmaceutical Society
and the UK national health bodies with titles such as ‘Getting
medicines right’. These are generally similar and useful for GPs
caring for people with chronic
Focus on deprescribingFocus on deprescribing
5
conditions. Tools such as the Beers Criteria2 have been developed
to provide very detailed options on the various categories of
medicines however, there is a simpler and more appropriate tool for
people approaching the end of life. The STOPPFrail tool3 was
developed in Sunderland and validated by a study in Ireland4 as an
adaptation of the STOPP (Screening Tool of Older Persons
Prescriptions), specifically for frail adults with a limited life
expectancy. To apply this, the patient must fulfil all these
criteria:
• End stage irreversible pathology. • Poor one-year survival
prognosis. • Severe functional impairment or
severe cognitive impairment or both. • Symptom control is the
priority
rather than prevention of disease progression.
The first consideration in the STOPPFrail Tool focuses on
discontinuing any drug the patient persistently fails to take or
tolerate despite adequate explanation and consideration of
alternative formulations. The second consideration is – any drug
without clear clinical indication. It is concerning that some
prescriptions may be on repeat cycles and not reviewed periodically
in primary care. There is also understandable reluctance for
stopping medicines which have been prescribed by other specialists
and the guidance in these tools helps with these decisions.
Of course, there are some conditions where it is essential to
continue with the medicines until the last days of life, so we need
to refer to specific guidance for Parkinson’s disease and diabetes,
for example.
Suggestions start by looking at the drug chart for ‘refusals’ and
discussing with the patient why they do not want to take the
medicine – perhaps these items can be safely crossed off. Then look
at additive side effects and consider whether any causing side
effects such as drowsiness or dry mouth could be removed. Discuss
the pros and cons of stopping or continuing with the patient.
Look at those medicines which are preventative and consider the
benefits of continuing them (see box), but at all times consider
the risks and benefits for each individual patient.
In any prescribing decision it is important to involve the person
who is taking the medicine and this is equally pertinent when it
comes to stopping. When a patient
has been told they must take a medicine ‘for life’, stopping it can
feel dangerous and may also reinforce the fact that they are coming
towards the end of their life. However, in practice, many people
are relieved to reduce their tablet burden, so it is, as with
everything in palliative care, tailored to the patient. One helpful
strategy is to suggest a trial of stopping the drug and see what
the effects are. If stopping makes a symptom worse, the medicine
can be re-started.
If you would like to look at this in more detail, we can now offer
training sessions to hospice staff on these topics:
• Polypharmacy and deprescribing towards the end of life.
• Management of Parkinson’s disease towards the end of life.
• Management of diabetes towards the end of life.
References 1. NICE Key therapeutic topic www.
nice.org.uk/advice/ktt18 2. Beers Criteria https://bit.ly/3b2a0Ts
3. BMJ Support Palliat Care2017
Jun;7(2):113-121. doi: 10.1136/ bmjspcare-2015-000941. Epub 2016
Jan 5
4. Age and Ageing 2017; 46: 600– 607 doi: 10.1093/ageing/afx005
Published electronically 24 January 2017
Margaret Gibbs, Lead Palliative Care Pharmacist
Drugs to consider stopping towards the end of life
• Vitamin / mineral supplements • Statins – evidence shows
they
still protect for one year after stopping
• Review anti-hypertensives – may be able to reduce dose or
stop
• Aspirin low-dose • Some inhalers – especially
where patients are too weak to use them effectively
• Gastro-protection – maybe steroids have been stopped?
• Oral hypoglycaemics – if the person is no longer eating
• Oral anti-oestrogens/anti- androgens
Reflections on COVID-19Reflections on COVID-19
Looking back on my emails, I see that my first COVID-related
message came in on 3rd March. At first, it was impossible to judge
the impact the virus was going to have on our healthcare system and
hospices. The shocking lack of their inclusion in the two essential
components – PPE and testing – soon became
apparent. Many of our senior hospice colleagues have described how
they had to ‘fight’ for what was needed – on top of caring for very
sick patients who may or may not have the virus and staff having to
isolate for the statutory period.
A number of excellent documents and initiatives were produced
rapidly and we were pleased to be able to direct our customers to
the resources created by a joint group of experts from the Royal
College of General Practitioners and the Association of Palliative
Medicine:
https://elearning.rcgp.org.uk/mod/ page/view.php?id=10537
This comprehensive document is still available to provide
healthcare professionals with clear guidance on symptom control,
end of life care and supporting families. Palliative care was very
much in the news and we know that many of our colleagues working in
Trust hospitals were providing care to patients as well as
support to colleagues on every level.
Clinicians reported that the usual drugs we use for symptom control
were effective for the breathlessness and agitation which seemed
the most prevalent issues for COVID patients. Although there were
views that higher doses should not be avoided in emergencies from
the USA,1 Clinicians at Guy’s and St Thomas’ hospitals, who
recorded their data from 101 patients they cared for, agreed that
agitation was a common symptom observed and it was managed with
similar doses to those usually used. Breathlessness continued to be
a problem throughout the disease but cough less so towards the end.
74% of those that were admitted to palliative care for symptom
control died2. Other doctors in the South of England, who were also
recording data, observed that patients fell into two main
categories: some deteriorated and died with a shorter than average
dying phase for hospital deaths – 39 hours rather than 72 hours –
while others had the more
FEATURE:FEATURE:
“Masks, aprons, and gloves create such a barrier to how we
communicate, and you were unable to apply the specific ways you are
used to caring, with close contact and gentle touch.”
7
usual trajectory. They observed the latter group were older and
frailer. They also noted that 72% of the patients in the study died
with a syringe pump in place compared to the usual number of around
half that3. Their report concludes that there should be no delay in
starting an infusion where indicated in COVID and that the need to
prepare family members for negative outcomes is more pertinent than
usual. Hopefully, this learning will be disseminated and increase
confidence in caring for dying people with the virus.
By early April we started to become aware that some end of life
injections were being supplied preferentially to NHS Trusts and the
Nightingale hospitals. Ashtons had created a list of essential
medicines early on and our excellent team ensured they obtained
good stocks of the likely medicines which would be required.
Hospices were prepared to admit additional patients for end of life
care and some found their numbers increased. Conversations with
hospice colleagues over April, May and June made it clear that some
people decided that visiting restrictions in hospitals and hospices
led them to want to stay in their own homes, so after an initial
increase, the actual occupied bed numbers were not as high as may
have been expected.
You explained that many patients were admitted without having been
tested so you needed to treat them as ‘possibly’ COVID-positive,
with all the ramifications of PPE and staff management. Some of you
have talked about the difficulties you encountered in your
interactions with patients and families. Masks, aprons and gloves
create such a barrier to how we communicate and you were unable to
apply the specific ways you are used to caring with close contact
and gentle touch.
This sounded the most difficult challenge for your teams and it was
expressed very clearly in a moving video produced by Princess Alice
Hospice (https://www. youtube.com/watch?v=5prToYDTdns) which was
shown on BBC Newsnight. Mercadante and colleagues reported on their
own experiences in Italy and showed that although virtual contact
with patients was of some comfort, unsurprisingly nothing
substitutes for human touch4.
With more patients remaining at home over this period, we worked
with some of the hospice community team leads and their CCGs to
ensure rapid access to symptom control medicines. It was clear in
the community too, that deterioration and death were occurring more
rapidly with COVID and some of the existing ‘Out of Hours’ pharmacy
schemes were not as responsive as they needed to be. The SW London
CCG provided emergency packs of injectable and oral drugs which
were stored in various settings and could be accessed at all hours.
Although the use of these packs was low, it was a very responsive
and innovative way to support those caring for people in the
community. We hope that shining a spotlight on emergency end of
life care drugs out of hours may help mould any future plans and we
continue to support some hospices in their aims to become hubs for
‘just in time’ supplies of small quantities of medicines when other
systems cannot meet the patients’ urgent needs.
Another welcome initiative has been the ability to re-purpose
medicines which have been supplied to a patient but not required.
We had heard from the CQC last year that they would not be against
hospices taking into stock items dispensed on a TTO from the
supplying pharmacy which subsequently could not
be used due to the patient not being well enough for discharge. We
had prepared a Standard Operating Procedure for this practice but
once COVID arrived, we decided to broaden the scope of this and
advise hospices to quarantine and potentially re-use other complete
packs of medicines which would otherwise be wasted. The NHS
subsequently produced more conservative guidance on this practice
but we hope that this may continue to be our practice and that we
can make use of unwanted TTOs, while carefully documenting the
practice and using our pharmacists to assist with the governance
processes.
This has been a summer none of us will forget. Some of us have lost
family members, friends and colleagues. All of us know people whose
lives have been affected and we, as Ashtons, were pleased to know
that we were able to support you in the unique role you have in
caring for those at the end of their lives.
1. https://www.jpsmjournal.com/
article/S0885-3924(20)30389-4/pdf
Ashtons have commenced supplying all fridge lines in the
environmentally friendly fridge boxes in place of the polystyrene
boxes previously used. The replacement fridge boxes are
manufactured from wood pulp, together with the insulation inserts,
and are therefore biodegradable and, being a paper-based product,
fully recyclable.
The coolant packs, which are used to keep the fridge box between
2°C and 8°C, are made from a low-density polyethylene (LDPE 4)
pouch. The contents of the coolant pack consist of an aqueous
(water- based) gel.
Ashtons will not be reusing these packs so they can be locally
disposed. The contents of the pouch are benign, given the dilution
of the polymer used to make the gel, are not harmful to humans and
can be poured away through the normal domestic waste drainage
system via a sink or sluice. The empty LDPE pouch film can then be
disposed as
general waste in locations where it is not possible to recycle
it.
Ashtons are continually looking to improve quality and provide
innovative solutions and the introduction of these recyclable
fridge boxes has been well received.
Disposal of Ashtons cool boxes and Disposal of Ashtons cool boxes
and coolant gel packscoolant gel packs
Due to the impact of the COVID-19 pandemic, there will be a
national drive to increase the uptake of flu vaccinations, to
reduce pressure on the NHS. Healthcare staff and people with
certain health risk factors are the current focus for flu
vaccination and this list may be expanded to include other people
at risk. Ashtons have placed advance orders of the flu vaccine with
suppliers for the 2020/21 winter season, but will endeavour to
obtain further quantities if there is a demand.
For more information, please visit:
https://www.england.nhs.uk/wp-content/uploads/2020/05/
national-flu-immunisation-programme-2020-2021.pdf
Online presentations available The pandemic has made it difficult
for hospices to arrange training and there has been less demand for
Ashtons pharmacists to present seminars at sites. Consequently,
Ashtons is now able to make seminar presentations available via
online platforms such as Zoom or Microsoft Teams, meaning that all
available staff with online access can participate in the training,
without having to meet up in a room together.
NEW training seminars available: Management of diabetes towards the
end of life This seminar provides an overview of diabetes and the
oral and injectable treatments available. It guides
participants
through the management of diabetes towards the end of life, based
mainly on the highly regarded British Diabetic Association
guidelines.
Management of Parkinson’s disease towards the end of life This
seminar begins with the causes, symptoms and drugs used in
Parkinson’s
disease. It goes on to describe the end stages of the disease and
the specific considerations, including drug choices for symptom
management, towards the end of life.
Please contact your visiting pharmacist to arrange seminar
training, whether onsite or via webinar.
Ashtons training seminars and online Ashtons training seminars and
online presentations presentations
Life support, first aid and mandatory training – update
The concerns presented by COVID-19, and the need to prevent its
spread within hospices and hospitals, has forced many customers to
put critical face-to-face life support and mandatory training on
hold. The balancing act now is keeping up with statutory and
mandatory requirements while simultaneously adhering to social
distancing, restrictions on the gathering of groups and keeping
everyone safe.
While the HSE did allow extension times on the expiry of first aid
certificates, the first aid training industry in England is
confident that enough courses will now be available for all
required requalification training to take place. The HSE has
therefore agreed a final deadline for requalification of 30th
September 2020.
The HSE still strongly recommends that the practical elements of
actual First Aid At Work, Emergency First Aid At Work and
requalification courses are
delivered face to face, so that student competency can be properly
assessed.
In line with this, while Basic Life Support (BLS) courses can be
found online, we strongly recommend that hospices start returning
to face-to-face BLS and AILS (Adult Immediate Life Support).
The First Aid Training College and Ashtons have a concise COVID-19
training policy in place and we are confident that we can offer you
safe and effective training. Our training mannequins have always
been hygienically maintained and the advantage of each student
having their own face mask for the session has always been a safety
precaution for us. Mannequins will also be cleaned between each
user and we are encouraging the use of face masks and sitting at
least one metre apart in the classroom sessions.
If you would like to find out more about our first aid and life
support training,
please get in contact. We are currently taking bookings from
September through to December 2020 but have a couple of days left
in August.
The First Aid Training College is now also able to offer you a full
suite of 23 mandatory and statutory training courses. This a
relatively affordable but very effective way of training your
workforce and we have successfully rolled this out with a few
customers now.
The First Aid Training College and Ashtons – Your partner in
quality training, preparing you to make a difference.
Adrian Munday, Managing Director at The First Aid Training
College
10
For many years the NHS has struggled to fulfil the NHS Out of Hours
(OOH) standards that stated ‘patients should be able to access the
medicines they need at the time and place of the OOH consultation’.
The Drug Tariff, which determines the list of products which can be
prescribed on FP10 and their re-imbursement costs, still includes a
rather dated ‘Out of Hours national formulary’ which categorises a
wide range of medications for emergencies which include palliative
care.
When this formulary was introduced, in about 2008, various
solutions were proposed and many OOH medical services started to
investigate whether they could be the place to keep a stock of the
medicines required. Palliative care pharmacists worked with some of
these services to help with logistics of ordering, storing and
transporting Controlled Drugs in a service – made additionally
challenging in a service which was not staffed 24 hours each day.
Unfortunately, regulatory changes meant that in order to do this,
OOH services would require a Controlled Drugs licence so most
decided against holding stocks in a comprehensive way.
Many areas have OOH systems
where a select few community pharmacies hold an agreed stock of end
of life care medicines. In most of these areas, there is an
arrangement for the pharmacist to be available to attend at any
time in the OOH period to meet the healthcare professional or
family member and dispense the medicines required. This is a
valuable service which has prevented many hospital admissions but
there are occasions where it is still not sufficiently responsive
to meet the needs of the patient. In a few cases, the medicines
could be delivered but not all and it is never right to take a
family member away from the patient to obtain medicines – they
should be able to stay with them.
‘Just in case medicines’ started as a project nearly 20 years ago
in Bedfordshire and Hertfordshire. It was set up by two palliative
care pharmacists with support from other healthcare professionals
including Ros Taylor, now medical director for Michael Sobell
House. In an article1 they were able to show that provision of a
selection of the essential end of life care injections in prepared
packs over a 6 month period made it possible for 16 patients in the
area to stay at home
to die rather than be transferred to hospital. The Gold Standards
Framework encourages pre-emptive prescribing of ‘just in case’
medicines and people discharged from hospital or hospice will
usually be supplied with injectable medicines for use when they can
no longer take their oral medicines. This practice has become
widespread and has reduced the requirement for emergency medicines
so the schemes in place have not been on everyone’s radar. It is a
very positive practice with one downside, which is that these
injections are not always needed so at times they are wasted but on
balance, it is preferable to have the assurance they are in
place.
People dying with or from COVID-19 have been reported as
experiencing rapid deterioration, so prompt access to injectable
medicines has never been more urgent. Although we seem to be in a
quieter period now, we need to be prepared for winter and a
possible second surge. The pharmacy systems have not worked as well
in practice when the need for medicines is less easy to anticipate
yet more urgent. One of the hospices we work with has come up with
a potential solution, based on practice in at least one other
hospice.
Using the hospice as a hub for Using the hospice as a hub for
emergency medicine suppliesemergency medicine supplies
11
BENEFITS OF MEMBERSHIP The Association for Palliative Medicine of
Great Britain and Ireland (APM) is the largest body representing
doctors practicing or interested in Palliative Medicine. It is
widely acknowledged that in palliative and end of life care,
perhaps more than most specialties, excellent patient care is best
achieved through a multi- disciplinary team working together
providing high quality holistic care provision and support for
patients and their loved ones. In recognition of this the APM has
recently voted to open up membership to non- doctors including
pharmacists, nurses and allied health professionals. With the new
Associate Non-Doctor membership, individuals who join will have
access to the ever-growing community of professionals, resources
and benefits including:
• Networks and Special Interest Forums • APM bi-Monthly e-Bulletin
• Membership of the European Association for
Palliative Care (EAPC) • Palliative Medicine journal** • BMJ
Supportive and Palliative Care journal** • Palliative Care
Formulary (PCF)** • Quarterly paper copies of the BMJ SPC Journal**
• Study days and other meetings • APM awards
**Included with ‘Associate Non-Doctor Membership with
Journals’
Association for Palliative Medicine - membership now open to
non-doctors
ADVERTISEMENT FEATUREADVERTISEMENT FEATURE
11
We have been working with colleagues in Hillingdon CCG and Central
and West London NHS Trusts to build a procedure which allows
Michael Sobell Hospice to act as a hub for the supply of medicines
when other systems are not appropriate due to rapid deterioration.
We have commissioned one of the licenced pre-packing units to
prepare some small packs of injectables and a couple of oral
medicines. With the support of the CCG, Michael Sobell House will
keep a small stock and in extreme circumstances, the nurse or on
call GP will be able to call the hospice doctor on call and
arrange a prescription and pick-up of the medicines required in as
timely a way as possible.
We know some other hospices are interested in this possibility and
we look forward to seeing how it goes in the Hillingdon area. Once
it’s been tried and tested, we would love to support other hospices
in sharing this good practice. Although this scheme has been
created during the COVID period, like other initiatives, we hope to
be able to continue this afterwards. Please feel free to contact me
for more information (details on page 3).
References 1. https://www.
pharmaceutical-journal. com/pj-online-articles-how-
a-just-in-case-approach- can-improve-out-of-hours-
palliative-care/20015045. article?firstPass=false
12
The two opioids available for delivery via a transdermal patch in
the UK are fentanyl and buprenorphine. Fentanyl products are
licensed for severe and chronic pain that requires long-term
opioids or that does not respond to non-opioids. Buprenorphine is
available in two sets of products – the stronger patches have a
similar license to fentanyl while the lower strengths are indicated
for non-malignant pain when an opioid is necessary (they are used
for cancer pain in some cases, where patients only require low
opioid doses).
Patches are only suitable for stable pain as they take up to 24
hours to reach steady state, so they should only be used for people
whose pain is not rapidly increasing.
All fentanyl patches are effective for 72 hours once applied. The
stronger buprenorphine patches remain effective for 96 hours (apart
from one brand) but the weaker ones only need to be replaced once a
week and this can be confusing for prescribers who are unfamiliar
with these medicines.
We should advise patients to find the best way to remind themselves
of the day they must change their patch – some might want to mark
it on a calendar while others prefer to set a reminder on their
smart phone.
Positive points • Convenient method of delivery. • Enables people
to think a bit less
about their medication and live their life.
• They can be applied on various parts of the body, the site should
be rotated to minimise the risk of irritation after repeated
applications to one spot.
• Useful for people who may have problems remembering to take
medicines.
• Useful for people: with cognitive impairment who struggle with
oral medicines or have nausea and vomiting or e.g. oral
cancers.
• Appropriate for people with renal insufficiency.
• The wide variation in strengths available makes it possible to
tailor the dose appropriately.
Cautions • Once applied, patches take several
hours to reach therapeutic levels so other analgesia should be
available.
• If the dose selected is too high for the patient and they become
toxic, drowsy, even unrousable, just taking the patch off won’t be
enough to assure their safety as it takes up to 24 hours for levels
to decrease. If the patient has become sufficiently
drowsy to require opioid reversal, ensure expert advice is
sought.
• Patches can be especially dangerous in this respect for
initiation in frail elderly patients on their own at home – they
must be monitored.
• If a patient is being switched from oral opioids to a patch the
prescriber should use the guide on the SPC or the local guidelines
for this. The fentanyl patches cover a wide range of possible doses
so the lower doses should be used initially, e.g. fentanyl 25mcg
patch is equivalent to between 90 and 134mg total daily morphine,
which makes it challenging to safely convert.
• Heat increases absorption – avoid hot showers/baths and caution
in extreme hot weather, like we have experienced recently. We need
to alert patients and carers about this without alarming them –
remind them to be aware of promptly reporting toxic effects.
• People should be given PRN opioids alongside the patch – this can
be morphine if they are not being used because of renal
insufficiency. Check in conversion tables to make sure the PRN dose
is commensurate.
• Fentanyl immediate release products, e.g. Abstral, are not
intended for use for PRN support in the same way as we use morphine
and oxycodone in
Opioid patches – back to basicsOpioid patches – back to
basics
one sixth of the daily dose. • GPs can sometimes be a bit
more
relaxed about prescribing patches. Remember that fentanyl is
between 100 and 150 times as potent as morphine so it must be
treated with respect.
• All but one brand of patches are now ‘matrix’ patches, where the
product is embedded in a plastic film or textile. Occasionally it
used to be recommended to cut patches, but now with a range of
strengths available, this should not be necessary. It is off
licence but not dangerous, however there are still a few products
which are ‘gel-filled’ patches (the older formulation) which must
never be cut.
• Some people have problems with
patches that won’t stick because of sweating or oily skin - try a
different brand.
• Some people have an allergic reaction to the patch, but this is
invariably due to the adhesive and not the drug – try a different
brand. (One unlicensed and imaginative way to reduce irritation is
to spray the area with a steroid using an inhaler e.g.
beclometasone).
Ensure people read the instructions – when applying a patch, hold
it down for 20 seconds to improve adhesion.
They can be disposed of in general waste – on removal, fold the
patch in on itself. Patches still contain a lot of fentanyl/
buprenorphine once removed so still should be disposed of
carefully.
Product selection There are many products available, although each
product with the same strength is therapeutically equivalent. We
advise you order using the trade name and aim to keep to one brand
if possible – to make stock-keeping simpler and provide a familiar
product to your patients. Although wards must order complete packs
for stock, pharmacies will supply the quantity specified to
complete an individual prescription.
As with many medicines, prices change periodically and although
there are not huge differences between the brands, it can make a
difference to your drugs budget when you use quantities. Ashtons
pharmacists can provide guidance on the most cost-effective choices
when we visit and attend medicines management meetings.
The table on this page shows the main products available but only
includes those where there is a Summary of Product Characteristics
available on the Electronic Medicines Compendium. Note one of the
buprenorphine patches needs changing every 72 hours which makes it
slightly less convenient for patients and as more are required,
slightly more expensive. All but one of these products is a matrix
patch where the drug is evenly distributed across the surface. One
remains a ‘reservoir’ patch where the active ingredient is in a gel
released via a membrane. Cutting patches is inadvisable at any time
but on no account must a reservoir patch be cut.
Product name and strengths available Strength = micrograms
delivered per hour
Pack size
Duration of action
Buprenorphine matrix patches (lower strength) Bunov 5mcg, 10mcg,
20mcg 4 7 days Butec 5mcg, 10mcg, 15mcg, 20mcg 4 7 days BuTrans
5mcg, 10mcg, 15mcg, 20mcg 4 7 days Panitaz 5mcg, 10mcg, 20mcg 4 7
days Reletrans 5mcg, 10mcg, 15mcg, 20mcg 4 7 days Sevodyne 5mcg,
10mcg, 20mcg 4 7 days Buprenorphine matrix Patches (higher
strength) Bupeaze 35mcg, 52.5mcg, 70mcg 4 96 hours Buplast 35mcg,
52.5mcg, 70mcg 4 96 hours Carlosafine 35mcg, 52.5mcg, 70mcg 4 96
hours Hapoctasin 35mcg, 52.5mcg, 70mcg 4 72 hours
Relevtec 35mcg, 52.5mcg, 70mcg 4 96 hours Transtec 35mcg, 52.5mcg,
70mcg 4 96 hours Fentanyl matrix patches Durogesic DTrans 12mcg,
25mcg, 50mcg, 75mcg, 100mcg 5 72 hours FENCINO 12mcg, 25mcg, 50mcg,
75mcg, 100mcg 5 72 hours Matrifen 12mcg, 25mcg, 50mcg, 75mcg,
100mcg 5 72 hours Mezolar Matrix 12mcg, 25mcg, 37.5mcg 50mcg,
75mcg, 100mcg 5 72 hours Opiodur 12mcg, 25mcg, 50mcg, 75mcg, 100mcg
5 72 hours Yemex 12mcg, 25mcg, 50mcg, 75mcg, 100mcg 5 72 hours
Fentanyl reservoir patches – must never be cut Fentalis Reservoir
25mcg, 50mcg, 75mcg, 100mcg 5 72 hours
Examples of opioid patches available (brands in italics are those
most regularly used).
Two new hospices join Ashtons We are delighted to announce that
since April we’ve begun working with Springhill Hospice in
Rochdale, Lancashire. We’ll soon also be working with St Leonard’s
Hospice, Yorkshire. We’re looking forward to a long and successful
partnership with both of these hospices.
Margaret Gibbs, Lead Palliative Care Pharmacist
13
14
Restrictions on over-the-counter sale of stimulant laxatives
The MHRA has decided that stimulant laxatives can be
inappropriately used by people wanting to lose weight – especially
those who may have an eating disorder. In future, products such as
Senna and Bisacodyl will sold in small pack sizes only and to
people over 18.
Ordering 2% lidocaine in Lutrol gel
Guy’s and St Thomas’ manufacturing unit has now ceased supply of
this product and it is now distributed by Oxford Health – the NHS
specials and wholesale supplier. The price has increased
considerably, so please speak to your visiting pharmacist before
ordering to ensure you only order the essential quantity. Once
ordered it cannot be returned as it is a special order. We will
update our information sheet for this product accordingly.
1. Why is erythromycin used for constipation? Motilin is a
naturally occurring hormone secreted by the small intestine. It
increases gastro-intestinal motility and peristalsis and
accelerates gastric emptying. It functions mainly between meals and
in doing so prepares the gut for the next meal. Erythromycin
happens to be a motilin agonist – working in the same way as the
hormone – so can be used when metoclopramide or other prokinetics
are unsuitable. It is effective in about half of cases, and
concerns about the development of bacterial resistance have been
shown to be largely unfounded. Only small doses are required, 50 to
100mg QDS to start and up to 250mg QDS if necessary. For the small
doses it is necessary to use the suspension.
2. Are other hospices reporting losses with oxycodone liquid 5mg in
5ml?
Short answer – yes! The formulation of the 5mg in 5ml liquid in
existing brands is very syrupy and so it sticks to the bottle, oral
syringes and measuring vessels. We accept that each time a dose of
liquid is removed if using a syringe, a small volume will be lost
and when multiple doses taken from a bottle, the loss increases. We
recommend using a bung in all bottles of regularly used liquids as
this minimises the loss. Weekly measuring of Controlled Drug
liquids is common practice and ‘regular’ checks of stock balances
should involve measuring liquids but this will incur further loss.
There is a general acceptance that a 5% loss of liquid balance
since the last check should not need to be reported as an incident
but if more than this is unaccounted for, additional checks may
need to be made.
3. Is melatonin effective as a sleeping aid? Melatonin is a
naturally occurring hormone secreted when our pineal gland
senses darkness. It is considered less effective than conventional
hypnotics, but sleep disturbance is difficult to manage with any of
the current medicines in palliative care. Melatonin is reported as
causing less ‘hangover’ sedation and may be considered suitable for
those who cannot tolerate ‘z’ drugs and those who are at more risk
of falls due to sedation. There is no firm evidence for its
efficacy in palliative care but given its lack of side effects and
the existence of a licensed medicinal form in the UK, it is worth
considering.
Do you have a query about medicines or procedures in your hospice?
Email us at
[email protected] – it could appear in our
next issue!
Recent queries from hospices Questions on medicines, procedures and
practice from hospice staff
News just in –News just in – August 2020August 2020
15
Medical suppliesMedical supplies
In his poem The Naming of Cats, T.S. Eliot asserts that cats have
three names:
The Naming of Cats is a difficult matter, It isn’t just one of your
holiday games; You may think at first I’m as mad as a hatter When I
tell you, a cat must have THREE DIFFERENT NAMES. The Naming of
Cats, T.S. Eliot.
Likewise, medicines can go by a few different names.
All drugs have a scientific name based on its organic chemistry.
And even though morphine can be written simply as C17H19NO3, to
also accurately describe its structure it needs to go by
(4R,4aR,7S,7aR,12bS)-3- Methyl-2,3,4,4a,7,7a-hexahydro-1H-4,12-
methanobenzofuro[3,2-e]isoquinoline-7,9- diol which by any
standards is a bit of a mouthful.
For this reason, drugs are given a shorter ‘generic’ name. Drugs of
a similar class share the same stem, so for example a
benzodiazepine will have the ending -azepam (clonazepam, diazepam,
lorazepam).
The manufacturer also comes up with a name that they use to market
the drug, its brand name. These have to follow the same
rules for brand names for any product as well as meet regulators’
requirements that they are not easily confused with existing
drugs.
I will discuss the rules for generic and brand names in a future
edition. However, in the early days of medicines the rules around
naming medicines used to allow more scope for the
imagination.
One of the first drugs to be discovered was morphine in 1804 by
Friedrich Sertürner. In typical style for the time, he tested the
drug by taking it himself and promptly nearly became the first
person to have a fatal overdose as well. Since it had a tendency to
make people sleepy it was named after the Greek god of dreams,
Morpheus (keeping up a family tradition as his father, Hypnos, has
a whole class of drugs – the hypnotics – named after him). When a
more potent version was discovered, Bayer named it after the fact
that it could make you feel heroic – Heroin®.
However, it quickly became apparent that Heroin® also had some…
non-heroic qualities (as Harry Hill put it, “It’s very moreish”).
This, and also the fact that German companies like Bayer lost their
trademarks after World War I, led to it becoming known by a more
prosaic name:
since it is the diacetyl- version of morphine, it became
diamorphine.
Barbiturates were also discovered in this period – the name
apparently derives from celebrating the discovery at the feast of
St Barbara – which Bayer marketed under the name Veronal®,
supposedly after what one of the discoverers thought the most
peaceful place on earth: Verona, Italy. As with morphine, it
quickly became obvious that Veronal® had properties not entirely
reflected by the brand name – it was both addictive and could be
fatal in overdose.
As newer drugs came out manufacturers started to use less emotive
names to describe their drugs; the age of the evocative name was
over. Even a drug like promethazine, which suggests the titan
Prometheus, is actually just a shortening of propyl dimethylamine
phenothiazine.
Matthew Roberts, Senior Clinical Pharmacist and Supervisor
Naming of medicines, part one – introduction
CONTACT US Tel: 0345 222 3550 Email:
[email protected]
Address: 4 Dyke Road Mews, 74-76 Dyke Road, Brighton, BN1 3JD
ASHTONS PHARMACY NEWS PALLIATIVE CARE EDITION Editor: Margaret
Gibbs, Lead Palliative Care Pharmacist Editorial team: Chris
Burrell, Head of Marketing Shannen Stevens, Graphic Designer &
Sub-editor
SUBSCRIBE Simply go to this link: http://eepurl.com/do9dtD or email
us at
[email protected] to get your free quarterly
subscription. Previous issues are also available free of charge as
an electronic PDF.
It’s summer and hay fever season is in full swing. Hay fever
(allergic rhinitis) is an allergic reaction to pollen and symptoms
include sneezing and coughing; a runny or blocked nose; itchy, red
or watery eyes; an itchy throat, mouth, nose and ears; pain around
your temples and forehead; headache; earache and feeling tired.
People with asthma can experience additional symptoms.
The NHS suggests that the best way to prevent hay fever symptoms is
to stay indoors whenever possible when the count is high. They also
advise taking a shower and changing your clothes after being
outdoors to remove the pollen on your body and wearing wraparound
sunglasses to protect your eyes. If symptoms are still experienced,
the most common treatment is to use oral antihistamines to try and
control the allergic reaction, or corticosteroids to deal with the
inflammation.
Ashtons can provide a full range of allergy treatments:
https://bit.ly/30N2Lu8
From 31 March 2020 NHS and partner organisations are required to
use modern communication methods instead of faxes, such as secure
email, in order to comply with their information governance
requirements and in a bid to improve patient safety and cyber
security.
How do we swap to using secure email? 1. Form a project team 2.
Review the number of existing NHS email accounts
currently within the business 3. Select shared emails for
professionals where necessary
and agree a management process with staff 4. Remove fax numbers
from stationery and media
Advantages • Fast, modern and efficient • Clearer communication
(cannot be sent upside down!) • Reduction in wasted staff time
spent faxing • Reduction in missing requests thanks to secure
data
transfer and audit trail • Improved data security • Reduced running
costs
Ashtons have set up a secure NHS email that can be used to scan and
send orders – please refer to your Pharmacy Information Folder for
advice on placing orders.
Information governance update: faxes