Date post: | 15-Jan-2015 |
Category: |
Health & Medicine |
Upload: | icapclinical |
View: | 1,923 times |
Download: | 0 times |
THE EXPANDING ROLE OF PHARMACISTS
Supporting Sustainable Adherence to HIV Prevention, Care & TreatmentICAP Technical WorkshopOctober 19-22, 2009Kigali, Rwanda
Angela G Giovanniello, Pharm.D.
Aby Leonard, Cote d’Ivoire
Gideon Chelule, Kenya
Kidwell Matshotyana, South Africa
Background
Suboptimal treatment exposure result in the failure of available regimens
Adherence is key to achieving successful treatment Requires everyone to play a part
Regimens are complex and have little pharmacologic “forgiveness”
Pharmacist Role The care of the HIV-infected individual presents
special challenges that warrant the need for a pharmacists intervention
Large number of drug interactions Prescribed/ Herbal / Food
The need for poly-pharmacy for effective treatment Medication pick-up ultimately last stop in the clinic Provide time to recap or address any unmet issues
Disclosure issues Barriers to family support or help Incorporate family health to strengthen the family unit
Part of the multidisciplinary team Referring when needed to counselors, clinicians, and
lab personnel
Potential Role of an HIV Pharmacist
Traditional Role
Dispensing
InventoryStock Management
PredictionsTracking
Approp. Drug Selection
Potency Lack of interaction
Compatible with patient
Pre-therapy Counseling
Show & TellDrug/food restrictions
Side Effects Adherence
Follow-up
AdherenceTolerance/Toxicity
HIV Pharmacist
Adherence
Opportunity for Intervention
Frequent patient interactions (monthly medication pick-up ) Allowing for engagement Side effect/ toxicity identification Quickly detect any adherence problems Verify appropriate dosing and
administration schedules
Case 1
AK is a 39 yo female Started on HAART 2 months ago coming for her
first medication refill She has missed her medical follow-up
appointment Prompt a discussion about the timing of her
medication pick-up AK reveals she has a lot of diarrhea on the days she
takes her medication and can not take her medications on the days she has to be out of the house.
Adherence Measures
3 day recall In the past 3 days how many doses have
you missed? 7 day recall
When was the last dose you missed? What would make your regimen easier?
Pill count Refill dates
Adherence Tools
Case 2
EH is a 16 yo pregnant female coming to the clinic for prenatal care Started on HAART consisting of
NVP/3TC/d4T Experiencing continued vomiting over
the past 2 days due to the pregnancy and has been unable to continue the prescribed treatment
Based on the pharmacokinetic properties of her medications can she just stop all her medications?
NNRTI PK Problems
Prolonged half-life with a greater risk of developing regimen crippling mutations
Possible utility of continuing NRTI’s of the regimen to prevent this occurrence
Recommendations vary from 7 to 14 days of continued NRTI treatment after the discontinuation of the NNRTI Others have recommended swapping NNRTI’s
to LPV/r for 1 month then discontinuation of all agents
Case 3
MM a patient doing well on a regimen AZT/3TC/NVP * 6 months
Diagnosed with TB and placed on Isoniazid/Rifampin/Pyrazinamide/
Ethambutol Comes to the pharmacy for the
additional treatment What discussion occurs?
Key Drug-Drug Interactions
Rifampicin – potent CYP isoenzyme inducer Alters drug concentrations of most ARV’s
significantly Changes to alternate ARV’s possible option
NVP EFV
Case 4
ZR a 1 yo male comes for a monthly medication d4T/3TC/NVP
The baby is healthy and developing well
Tolerating all medications No present issues with adherence to
liquids Doses have remained the same for the
past 3 months Is this alarming?
Change in Dynamic
Provider
Patient
RPH
Patient Provider
Key Points
Small steps incorporate 2 steps to each prescription.
Check refill dates Check log and see if dates make sense
Ask simple questions about tolerability of ARV’s Have you been having any problems that have
made taking your medications difficult? Any nausea/vomiting? Any rash developments? CNS SE of efavirenz?
ICAP Country Examples: Pharmacy Support for Adherence
Cote d’Ivoire – Role of Pharmacy in Patient Education
Kenya – Integrated Appointment and Adherence Assessment
South Africa – Development of VAS and Task Shifting
Cote d’Ivoire Traditional Overview Role of Pharmacy
1.Ensure the availability of drugs and laboratory
reagents (firstly)
2.Ensure drugs management and dispensing.
3.Ensure adherence to treatment through
advices and treatment explanation
4.Ensure the pharmacological monitoring of the
treatments introduced (Ensure the
prescription conformity)
5.Implement pharmacy database
6.Pharmacovigilance
Cote d’IvoirePharmacy and Peer Educator Collaboration
1. Peer Educator is the continuation of the pharmacist in
the community
2. Pharmacist reinforce and deepen the Peer Educator
knowledge on ART treatment.
• Pharmacist and PE share information on patients
(diary, dispensing register, etc.)
3. Pharmacist encourages patients to see the PE after
each ART dispensing to reinforce adherence
4. Strengthen communication between Pharmacist, data
officer and PE
• Share information to allow verification of
appointments, lost to follow up, deaths and other
information
Cote d’IvoirePharmacy and Support Group Linkages
1. Pharmacist informs and reminds patients
of the available support group
2. Pharmacist should lead some sessions
on adherence at the support group on site
3. Discussion of the benefit of adherence to
treatment, pharmacovigilance, and
provide advice which can help with
adherence.
Kenya
Pill count done at pharmacy An integrated diary able to book
appointment and record pill count was developed.
A formulae was integrated into the diary
Integrated Diary was then stationed at the pharmacyDeveloping Integrated Appointment and Adherence Assessment
System
Kenya
Task shifting to peer educators stationed at pharmacy was done
Adherence assessment (including pill count) integrated in APS training curriculum
Patients asked to return pill balances at every visit
Patients collect their repeat medication on scheduled dates of appointment (28 day cycle pick-up)
Adherence is then assessedImplementing Integrated Appointment and Adherence Assessment
System
DiarySCHEDULED VISITS: ART
Ser.no.Attended
(√) Unique ID Name Sex (M/F)
A=
Pills prescribed
B=
PillsDispensed
C=
Pills Returned
% Adherence
=
(B-C) * 100 A
1 □
2 □
UNSCHEDULED VISITS: ART
Ser.no. Attended
(√) Unique ID NameSex (M/F)
A=
Pills Should have taken
B=
PillsDispensed
C=
Pills Returned
% Adherence
=
(B-C) * 100 A
1 □
2 □
South Africa Overview Role of Pharmacy in South Africa Care
and Treatment Aim of pharmacy support is to provide a
comprehensive pharmaceutical service at all ICAP supported sites
Quality of care is at the centre Monitoring treatment outcomes through
pharmacovigilance and adherence monitoring systems
Monitor & support drug availability – all essential drugs in the program (anti-TB/ARV/OI)
Compliance with minimum standards of pharmacy practice – legal requirement
South Africa Development and Use of VAS… Various methods used in assessing adherence :
pill counts, appointment schedule, patient interviews / checklists, Pill boxes, alarm clocks, treatment diaries,
treatment buddy There is no one effective system in monitoring
and assessing adherence Adult Patient Adherence Record and Monitoring
Form Owned by the National DOH Consists of: Pill Identification test, medication
pick-up dates, Pill counts, Visual Analogue Scale, patient self reporting
A comprehensive system to improve adherence
Time consuming on the user but very effective in developing a stepped-up adherence plan
South Africa Opportunities for Task Shifting to PEs….
PE tend to understand local languages They interact with the patients in the
community and in the local HIV support group (PLHIV support group)
Clinicians do not have enough time The large number of patients at each sites Some clinics have 3 PE and 1 PN, no
pharmacy personnel, PE can do pill counts, VAS, Pill identification Clinicians – Patient self-reporting & interviewing
then developing a plan to improve adherence.