Chapter 44 Communication skills – role of the pharmacist in giving advice and information
It has always been the custom for pharmacists to give information and advice on the use of medicines. As long ago as 1986, the Nuffield Report recognized that there were ‘some categories of individuals who certainly will need advice, help and encouragement in the handling of their medicines’ and that ‘anyone … who has to rely on a continuous drug regime, should be a candidate for additional support and help from pharmacies’. These statements highlight the importance placed on the role of the pharmacist in the provision of advice to patients/customers in the Nuffield Report.
Since the Nuffield Report there have been developments in medicines research, production and packaging of medicines, together with changes in society’s attitudes towards patient/professional relationships, which have led to advice and information giving becoming an even greater part of the role of the pharmacist.
As a brief explanation of these developments, medicines research has led to the production of new powerful, effective drugs formulated in many specialized dosage forms, such as modified-release formulations, aerosols, patches, nail lacquers, etc. which utilize different absorption routes (e.g. percutaneous, nasal and vaginal) as well as more conventional routes (see Ch. 21). Additionally many medicines are packaged in specialized containers, for example aerosols for rectal use, self-administration parenteral products, metered dose nasal sprays, and often with complicated dosage methods or regimens, e.g. pipettes, times of administration, treatment with multiple drug therapy, such as for tuberculosis. Patients prescribed or purchasing these newer dosage formulations will almost certainly require some information from pharmacists on their method of use and the dosage regimen.
All modern medicines have some side-effects. Some of these side-effects will be relatively insignificant, some inconvenient, while others may be serious and in extreme cases threaten the life of the patient. Clearly it is essential that patients are provided with the knowledge of these side-effects and what to do if they occur. In addition, many medicines interact with other drugs (both over the counter (OTC) and prescribed medicines) and/or with food and drink. Thus, if patients/consumers are to get the best out of their medicines, then they need to know how to correctly use/administer these medicines in as safe a manner as possible, with knowledge about side-effects, interactions, etc. Pharmacists are in an excellent position to provide such advice to patients/consumers. It has been suggested that the advent of providing all medicines in original packs should release time for the pharmacist and thus enable pharmacists to spend more time on patient advice.
Against this background of technological and pharmaceutical advances in the delivery of medicines, attitudes within society have also changed. In recent years there has been a rapid rise in the consumer movement, with consumers questioning and demanding from producers better products, safer products, ecologically friendly products, etc. as well as more information on the products. For example, CFC-free aerosols, including pharmaceutical aerosols, were developed in response to fears of damage to the ozone layer (see Ch. 37). The challenge to the world of global warming due to carbon dioxide emissions will certainly affect the production and packaging of pharmaceuticals.
Alongside and in response to these challenges by consumers, there has been the development of legislation giving consumers more rights and hence more power. Medicines have not been isolated from this consumerism movement and patients and purchasers of medicines have become more demanding in their quest for knowledge about the medicines that they consume. Such patients have also become more questioning about their illness, its treatment and the need for specific medicines, their dosage regimens, alternative medicines, alternative formulations, etc. The introduction of the Internet has produced for consumers a readily available and extensive source of information about medicines, although the quality of some of the information on some websites may be dubious and the ability of the general public to understand the information questionable. However, there are some well recognized factually correct websites (see Ch. 23 for more detail). All the above has led to patients acting as consumers and becoming empowered and much more autonomous, resulting in them wanting more choice in the selection of their medicines/dosage regimens and questioning the justification for the prescribing and use of medicines.
Within the healthcare professions, there has been a move towards the accommodation of the consumer movement and a commitment to patient autonomy and the need for valid patient consent and choice. This has led to the acceptance that the patient has the right to be involved in decisions about their health care. However, in order to make an informed decision the patient needs the information surrounding the issues to make that decision. One of the first documents to accept that patients have the right to choose and the right to be involved in decision making about their medicines was published in 1997. ‘From compliance to concordance’ (see Ch. 46) outlined the move towards developing patient/professional relationships which represent a negotiation between the patient and the professional and allow the patient to take an active part in decision making about their medicines.
The NHS Plan 2000 in the UK outlined the need for pharmacists to become more involved in helping patients to get the best from their medicines. The aim was for pharmacists to give extra help to patients who have difficulty in using their medicines correctly. The NHS Plan accepts that many patients are receiving less than optimum care because they find their medicines difficult to take or hard to remember when to take, because they do not have anyone to talk to about their medicines, or because they have complicated medication regimens. In 2005, medicine use reviews (MURs) were established as part of the NHS contract for community pharmacists. These are short, face-to-face confidential interviews involving a pharmacist and a patient together reviewing the patient’s current medicines. The aim is to help patients find out more about their medicines and to pick up any problems that they are having with the medicines. The pharmacist may advise on finding easier ways to take medicines, different formulations, or the correct method to take the medicine and can sort out any problems, or the problem can be referred to the prescriber. Thus the outcomes may be improved effectiveness of medicines and less unnecessary waste because the patient is more informed about their medicines and has received help from the pharmacist in how to take or use them.
Additionally the NHS Plan aims to ‘Give patients the confidence that they are getting good advice when they consult a pharmacist’. In other words, the NHS Plan is advocating a greater role for pharmacists in counselling and advice giving to patients. Furthermore, the NHS Plan emphasizes the need for medicines management services, the aims of which are to prevent, detect and address medicines-related problems to achieve optimum use of medicines. Pharmacists are already providing many of the elements of medicines management informally. However, medicines management implies a coordination and formalization of these elements. The element of relevance to this chapter is the ‘provision of support on medicines taking, which includes the identification of an individual’s pharmaceutical needs, provision of an opportunity for patients to discuss their medicines and the development of patient–professional partnerships to provide improvements in medicine taking’. Such support could in part be provided in the form of advice giving by pharmacists, when handing out prescription medicines or selling OTC medicines. Other opportunities for such advice giving exist on hospital discharge of patients, during medication reviews and with residential and nursing home staff and residents.
National service frameworks (NSFs) (see also Ch. 48) have been introduced in recent years to define standards for the treatment, health and social services necessary to ensure high-quality care of individuals with specific diseases or conditions, e.g. diabetes, mental health problems, or groups of individuals with special needs, e.g. older people. The use of medicines is a fundamental component of NSF standards. The emphasis is placed on achieving a greater partnership in medicine taking between patients and healthcare professionals, improving choice and addressing information needs. For example, the NSF for older people sets out its aims as ensuring that older people:
Both these aims encompass the need for pharmacists to advise older people (and their carers) about their medicines. Underlying all the above government documents is an acceptance that individuals need help with using their medicines.
Recently it has been acknowledged that some individuals with chronic conditions are very capable and competent in using their medicines to manage their condition(s). Such individuals have been termed ‘expert patients’. At the same time there is an increasing awareness of the importance of self-care and active patient involvement in making decisions about preventing and treating minor and major conditions/illness. Successful self-management programmes for chronic conditions such as arthritis have been developed and have been facilitated by lay individuals with patient experience of the condition. The identification of such ‘expert patients’ could lead to more user-led self-management programmes. It has been suggested that expert patients could help to ‘educate’ professionals about the self-management of illness. Healthcare professionals could pass on this ‘education’ to other patients with chronic conditions via advice giving techniques. However, the self-care of minor ailments will probably require a different approach. Pharmacists will need to facilitate the development of self-care and support the development of competencies by individuals to enable them to use appropriate medicines correctly and effectively. In other words, advice giving skills will be required by pharmacists to help in the empowerment of patients, so that they will be capable of making informed decisions about self-treatment with medicines for minor ailments.
Patients and customers have a right to be involved in the decisions about their treatment and their use and choice of medicines. Thus pharmacists require effective communication skills to be able to identify the individual needs of a patient/customer and to determine the type and amount of advice and level of explanation appropriate to provide at that particular time.
The professional standards and guidance which expand the Royal Pharmaceutical Society of Great Britain (RPSGB) Code of Ethics for Pharmacists and Pharmacy Technicians emphasize that when OTC and prescribed products are supplied, then sufficient advice to ensure the safe and effective use of the medicine should be provided. In the case of complementary therapies and medicines, pharmacists and technicians must assist patients in making informed decisions by providing them with necessary and relevant information.
In the UK, the Veterinary Medicines Regulations 2007 make it a legal requirement that any person supplying any veterinary medicine (apart from OTC animal medicines) must:
These conditions seem forward-looking and perhaps one day will apply to human medicines.
The British National Formulary (BNF) uses the term ‘counselling’ rather than advice as a heading in individual monographs to detail the type of advice to be given to a patient. Such advice is above that required on the label of a dispensed product and usually involves unusual/complicated methods or times of administration or the potential interaction with foods. For example, bulk-forming laxatives have the counselling statement ‘Preparations that swell in contact with liquid should always be carefully swallowed with water and should not be taken immediately before going to bed’.
While the term counselling is widely used in pharmaceutical literature, the definition of the term is less readily available. The British Association for Counselling (BAC) describes counselling as ‘giving clients the opportunity to explore, discover and clarify ways of living more resourcefully and towards greater well-being’. This definition encompasses some aspects of patient counselling, but patient counselling is more about giving information and guidance on medicines to patients and allowing the patient to make informed decisions but with the interests of the patient uppermost. Another description of patient counselling is ‘the sympathetic interaction between pharmacists and patients, which may go beyond conveyance of straightforward information about the medicine and how and when to use it’.
It is generally accepted that some patients have difficulty taking/using their medication and complying with the dosage regimens. Evidence comes from compliance and wastage studies.
It has been estimated that up to 50% of older people do not take their medicines as intended. The scope of this problem can be seen if the facts are considered. It is estimated that 80% of over-75-year-olds in the UK take at least one prescribed medicine and 36% take four or more medicines. Additionally, 50% of patients (not necessarily older people) with hypertension failed to take their medicines correctly and 1 in 10 deaths were attributable to stroke. It has been suggested that advice by pharmacists could lead to better compliance and hence less therapeutic failure and possible death.
The cost of unused medicines returned by patients to pharmacies has been estimated to be in excess of £100 million each year. Many of these unused and hence wasted medicines are because patients do not understand why their medicine(s) has been prescribed or how to take/use them. Hence the introduction of MURs to address these needs (see earlier in the chapter).
Although many medicines are supplied with a patient information leaflet, many patients do not always understand the contents and require further explanation from the pharmacist. Other patients may be scared by the information in the leaflet on, for example, side-effects. Pharmacists are in an ideal situation to provide additional information and advice and/or reassurance when prescription medicines are handed out and when OTC medicines are sold.
There is a lack of evidence that the provision of information alone is sufficient to enable patients to correctly take medicines or to change their existing behaviours and attitudes. Counselling, as the definition from the BAC states, enables clients to explore their beliefs and develop plans for behaviour change. Pharmacists in their patient-advising roles may adapt and make use of the problem-solving model of counselling developed by Egan (1990).
Thus the aims, in addition to the provision of advice, could be to:
The pharmacist is often the last healthcare professional whom a patient sees before starting drug therapy. It is at this stage that the pharmacist should identify the information and advice needs of the patient. Pharmacists should take a prominent and proactive role, especially since often some patients do not expect it. The opportunities for giving information and advice to patients are many, but the main opportunity is at the end of the dispensing process or the sale of a medicine.
In community pharmacy, information and advice giving should be an integral part of the dispensing of a prescription. No patient should receive a dispensed medicine without the pharmacist making an assessment of the needs of the patient. The availability of prescription medication records and the information contained within will underpin the extent and type of information and advice provided to an individual patient. Some pharmaceutical companies have developed computer-aided systems associated with their products which offer guidelines to pharmacists, when dispensing that product, to assist with information and advice giving. Such computerized systems provide an audit trail and can verify when advising took place.
Another opportunity in community pharmacy for giving advice and information is the provision of prescription only medicines via patient group directions (PGD). All PGDs require that the patient be given advice during the initial assessment of the appropriateness of the medicine for the patient and immediately on supply of the medicine.
The sale of medicines from a community pharmacy is another opportunity. The sale of medicines can be the result of a) a direct request for a named medicine by a customer and b) a request for advice on the treatment of a symptom or minor ailment by a patient. The amount and content of the information and advice given to a patient will vary with the type of initial request, the medicine sold and the patient.
The introduction of self-care programmes for patients with chronic disease or presenting with minor ailments will involve the community pharmacist becoming actively engaged and using their advising skills with patients.
Community pharmacists may provide diagnostic testing and health screening services to the public. In such situations the service specifications to the Code of Ethics requires pharmacists to provide patients with ‘any necessary counselling and available information’.
Thus the opportunities for community pharmacists to become involved in patient advice are wide ranging. Other possible areas include:
In some of the above areas it may be necessary to give information and advice to the carer as well as the patient. But remember it is important to maintain patient confidentiality.
Similarly there are many opportunities for hospital pharmacists to counsel patients. Hospital pharmacists, unlike their community counterparts, have the advantage of access to a considerable amount of information about the patient. This information can include details of disease state, current therapy and home circumstances, all of which can be useful in providing information and advice. Patients in hospital often have their medication changed during their stay and so should be made fully aware of any alterations on discharge. Outpatients and inpatients at discharge receiving dispensed medicines will require the same sort of advice and counselling as patients receiving dispensed medicines from community pharmacies. Inpatients may require advice on their medicines during admission and with needs assessment.
Both community and hospital pharmacists may be involved in providing medication to patients in long-term residential homes or prisons. In such situations it may be necessary to give information and advice to both the patient and/or their carers.
Information and advice giving, wherever it occurs, should take place in a thoughtful, structured way. The pharmacist must possess not only a sound knowledge of the drugs and appliances being dispensed or sold, but also excellent communication skills. Pharmacists should be able to provide information and advice in a non-paternalistic way that allows the patient to ask questions in order to understand the information so that they can make decisions about their own treatment and care. Pharmacists must have the ability to explain information clearly and unambiguously and in language the recipient can understand. They must know the right questions and how to ask them and, most importantly, they must know how to listen. For information and advice giving to be successful, it must be a two-way process. Rapport is built up between the pharmacist and the patient and a much more meaningful dialogue can take place.
The Cambridge–Calgary model discussed in Chapter 13 details how to provide explanations to patients. It is important to provide the correct amount and type of information:
The overall communication skills needed for giving advice and information have been discussed in detail in Chapter 13.
Not every patient will require information and advice but it is important that pharmacists can correctly identify those who do. In deciding who to counsel, it is important to consider both the patient and the medication.
The medication can be prescribed or bought. If prescribed, the prescription may contain one or several items. A multiple-item prescription may present more problems to the patient in terms of different drugs, different dosage forms and regimens, etc. and so patients presenting such a prescription may require more counselling than patients presenting single-item prescriptions. Additionally, the individual medicine on any prescription, because of its characteristics, e.g. complex dosage regimen, special delivery methods, novel packaging, etc., may require explanation to ensure the patient has a clear understanding of how to use it.
Other reasons for considering counselling will be if the drug has:
Box 44.1 Some drugs and the type of side-effects that can occur
Some drugs cause side-effects which can be minimized by good management
| Drug | Side-effect | Precaution |
| Chlorpromazine | Photosensitivity | Use sunscreen |
| NSAIDs | GI disturbances | Take with food |
| Tamoxifen | Nausea | Take at bedtime |
| Bisphosphonates | Oesophageal reactions | Stand or sit upright for 30 minutes after taking the tablet |
Some drugs have side-effects which require the patient to be warned for their benefit
| Drug | Side-effect |
| CNS drugs | Drowsiness |
| Co-beneldopa | Colours urine |
Some drugs have side-effects that need monitoring
| Drug | Side-effect |
| Penicillamine | Blood and urine tests |
| Chloroquine | Ocular tests |
Some drugs have side-effects that require immediate reporting to the prescriber
| Drug | Side-effect |
| Gold therapy | Sore throat, breathlessness, rashes |
| Aminosalicylates | Bleeding, bruising |
CNS, central nervous system; GI, gastrointestinal; NSAID, non-steroidal anti-inflammatory drug.
It is part of the pharmacist’s role to decide which patients require information and advice. The level and type of information given and how it is given will depend on a variety of factors:
If information and advice giving is approached in a structured manner, then time will be used efficiently and there will be a greater likelihood of success. The following stages have been adapted from the guidelines on Counselling and Advice on Medicines and Appliances in Community Pharmacy Practice produced in 1996 by the Scottish Office Clinical Research and Audit Group:
The need for information and advice based on a consideration of the characteristics of the patient and the drug has been discussed earlier. In addition the pharmacist will need to consider the content of the prescription.
This is where a patient medication record (PMR) can be very useful (see Ch. 15). If the PMR cannot provide the answer and the patient is unknown, it is important to find out this information.
It is the pharmacist’s responsibility to make sure that the patient knows what instructions such as ‘when necessary’ or ‘as directed’ mean. An open question should be used here, e.g. ‘Tell me how you take this medicine’. If the patient does not know, then the necessary information can be provided. In some cases patients may be taking the medication incorrectly. The pharmacist is then in a position to rectify any misconceptions. Checking on imprecise dosage instructions can also pre-empt possible errors, as in Example 44.1.
Example 44.1
A prescription for 60 nitrazepam tablets 5 mg was received. The instructions read ‘m.d.u.’.
The prescription was dispensed as written and handed over to the patient without any dialogue taking place. Approximately 2 hours later the patient returned saying that the tablets had a different name and appearance from the ones dispensed previously. On checking with the prescriber, the pharmacist found out that an error in entering the drug details into the surgery computer had occurred. The patient should have been prescribed Nutrizym 10 capsules. The dose to be taken was ‘Two capsules with every meal and one with intervening snacks’. If the pharmacist had asked the patient how he was taking his medication, she would have realized something was wrong. The normal dose for nitrazepam is ‘two tablets at bedtime’. Fortunately in this instance no harm was done to the patient, but it illustrates very clearly the importance of the pharmacist’s involvement.
In some instances, with a little thought, the pharmacist can simplify matters. Example 44.2 is an illustration.
Example 44.2
A prescription for colestipol granules, 1 o.d, penicillin tablets 250 mg, 2 q.i.d. and captopril tablets, 25 mg b.d. is received.
Because colestipol interferes with the absorption of drugs, it must be given either 1 hour before or 4–6 hours after other drugs. A considerable amount of organization is needed to get this regimen right. Trying to fit even a single dose of colestipol around the other drug therapy could cause the patient considerable problems.
Although all individuals should be considered for information and advice, there will be some for whom little or none is required. For example a customer who asks for an OTC by name and has used it successfully on several previous occasions or an ‘expert patient’ receiving a dispensed medicine may require minimal information and advice. Giving information and advice is time-consuming and so pharmacists should concentrate their time and efforts on those patients requiring it. This entails assessing the needs of the patient and prioritizing so that efforts are directed at the most needy patients. In addition the pharmacist may have to be selective in what advice is given to a patient. The average number of facts which can be retained at any one time by most individuals is three. Example 44.3 illustrates this point.
Example 44.3
A prescription for metronidazole tablets is received.
Metronidazole tablets have five additional cautionary labels which should be added to the instructions. These are:
‘Avoid alcoholic drink’. This is because, when combined with alcohol, a disulfiram-like reaction occurs and the patient may suffer nausea and vomiting. Patients who are not aware of this interaction may think, incorrectly, that the drug does not agree with them and stop taking it.
‘Take at regular intervals. Complete the prescribed course unless otherwise directed’. Because of the antimicrobial effect of metronidazole, blood levels must be maintained and therapy must be continued for a minimum time period to prevent bacterial resistance developing.
‘Take with or after food’. Metronidazole can cause GI irritation and the presence of food in the stomach will reduce the likelihood of this.
‘To be swallowed whole, not chewed’. Metronidazole tablets are film coated which gives a degree of protection to the GI tract. If the preparation is chewed the coating will be destroyed, the drug will come into contact with the stomach lining and GI irritation will occur.
The film coating on the tablets may become sticky and if not taken with a reasonable draught of water can stick in the oesophagus. The drug will be released and could cause irritation to this least protected area of the GI tract.
Information/advice on cautionary labels should always include the reason why the precaution should be taken. Obviously, in this instance, to go into a detailed explanation for each caution could take a considerable amount of time. The large amount of information required might confuse the patient and the whole process becomes self-defeating. In instances like this the most important points should be selected for emphasis. Any other points may have to be left for another time. If only two points could be selected for this prescription, they would differ for different patients. In a patient who never drinks alcohol but is known to have a sensitive GI tract, the alcohol warning is less important than the warning about food intake and swallowing whole.
It cannot be assumed that because the information and advice has been given, that the patient understands or is able to adhere to that advice. It is therefore important that, before embarking on any information advice giving process, the pharmacist has an idea how the success of the process can be measured.
This assessment could consist of checking that the patient can read the label, use an inhaler device or open a container with a child-resistant cap. Checking on understanding may require follow-up, such as an enquiry the next time the patient visits the pharmacy, to ensure that no problems have occurred and the response to the therapy is as expected.
The appearance of the pharmacy is an important factor. The environment should have a professional appearance and it should be apparent that information and advice are offered as a professional service. The service can be advertised in practice leaflets and within the pharmacy. Trying to give patients advice about their medication in a busy pharmacy can be difficult. Most pharmacies have a room or a special area set aside. This is essential for conducting MURs. Constant interruptions and customers milling around nearby are a major distraction and are barriers to good communication.
Time, or rather the lack of it, is a major barrier to good information and advice giving. Patients should be given an indication of why you wish to speak to them and you should always check that they have the time to listen. A patient who is worried about missing a bus or concerned about the car-parking fee is unlikely to give their undivided attention.
How the pharmacist appears is also of importance. An organized, calm person is more likely to inspire confidence in the patient than a pharmacist who appears distracted, harassed and unsure of him- or herself.
Over the last decade or so, through the National Pharmaceutical Association’s ‘Ask Your Pharmacist’ campaign, the public has been made more aware of the pharmacist’s role in the provision of healthcare advice. It is important that patients are made aware that pharmacies are sources of information about drug therapy and that information is available. If patients expect to be given information about their drug therapy then they will become more receptive to it.
If the patient is unknown to the pharmacist, it is important at the beginning of the conversation to try to gauge not just the amount of information that is needed but also the patient’s level of comprehension. The type of language used is very important, particularly guarding against being patronizing by oversimplification. However, the use of medical terminology must be considered carefully.
The information/advice giving process must not be a monologue by the pharmacist, giving a long list of information points. There should be ample opportunity for the patient to ask questions. The pharmacist should introduce aids to comprehension if this is felt necessary, e.g. an explanatory leaflet or diagram, a placebo device.
Having given the information, it is then of major importance to check if the process has been successful. What does the patient understand? Can he use his device? Does he have any problems? The ideal, where possible, is to assess compliance/concordance through follow-up.
During the information and advice giving process the pharmacist should be checking if the patient is understanding the information imparted. Watching the patient’s body language and maintaining eye contact can give useful clues as to whether the message is being understood and whether compliance/concordance is likely.
Patient information leaflets, warning cards and placebo devices are all useful aids when giving advice to patients. Most products are now provided with information leaflets. These should be used where appropriate and important points highlighted. Placebo devices can be used to demonstrate a particular technique and also to check a patient’s ability to use a device. The National Pharmacy Association is a useful source of information leaflets and warning cards. Leaflets on how to use ear drops, eye drops, eye ointment, pessaries, suppositories, a nebulizer, malaria tablets and head louse lotions are available. These, along with warning cards for anticoagulant therapy, lithium, monoamine oxidase inhibitors and steroids should be available in all pharmacies, hospitals and any other areas where counselling patients on drug therapy takes place. Whether commercially produced or prepared by individual pharmacists, ensure that the quality of any information leaflet is of the highest standard and is comprehensible to the patient.
In the following examples, details of a prescription and some biographical details of the patient are given. Various information and advice points are identified and information which could be given to the patient detailed. These examples illustrate the wide variety of issues which have to be dealt with by pharmacists. They are not intended to be comprehensive, as different situations and different patients will produce a variety of problems and issues.
Example 44.4
Mrs Oak, a lady of about 70 years, presents a prescription for diclofenac sodium 25 mg tablets. She has lived alone since the death of her husband, 2 years ago. When she is signing the back of her prescription she has difficulty holding the pen and complains that her hands and fingers are rather sore and stiff and hopes that the prescription will help. This is the first time she has had these tablets.
Mrs Oak has never been prescribed the tablets before, therefore basic information about the drug name and dose timings needs to be given.
NSAIDs can cause GI irritation if not taken with or after food. The warning label which indicates this will need to be reinforced.
Mrs Oak appears to have problems with her hands. Will she be able to open a bottle with a child-resistant cap (CRC)? She lives alone so does not have anyone to help her.
She has not been to the doctor previously for a prescription for her hands but has she been buying anything OTC to try to alleviate the pain? Many of the OTC products available for relief of arthritic pain contain diclofenac or other NSAIDs.
Mrs Oak will need to be advised to swallow the tablets whole and not to chew them. Will she be able to swallow them whole? Other formulations of diclofenac are available and may need to be considered for this patient.
There are a variety of issues here which will need to be checked.
It is important to ensure that Mrs Oak can open the container and that she will have no difficulty swallowing the tablets.
It is vitally important to alert Mrs Oak to the fact that the tablets may irritate her stomach and how she can avoid this.
To avoid any duplication of drug therapy it is very important to find out if Mrs Oak is taking any OTC medicines, what they are, and make sure they are not going to cause any problems.
Mrs Oak should be told that the tablets are not simply painkillers, to be taken infrequently. NSAIDs should give pain relief within 1 week and successful anti-inflammatory action should be seen within 3 weeks. To achieve these benefits, the drug must be taken at regular intervals. This should be explained to Mrs Oak.
There is obviously a considerable amount of information which needs to be given to Mrs Oak. However, none of it is too complex so it should be possible to deal with all of it.
A simple demonstration with a CRC will identify if she needs a container with a plain cap fitted. Showing her the tablets will also provide a clue as to whether she will be able to swallow them. Patients with swallowing difficulties can rarely conceal a look of horror when presented with tablets they know they cannot cope with. If swallowing is identified as a problem, she can be reassured that alternative therapy is available in liquid or granular form. It may then be necessary to contact the prescriber to alert him to this.
Any potential OTC problems can be dealt with by simple questioning.
It is preferable to give the patient all the drug details, if possible. However, if it is felt this will be counterproductive, dosing in relation to food is one that should have high priority.
Mrs Oak should be invited to let you know how she is getting on with her tablets and to contact you if she has any queries.
Example 44.5
You receive the following prescription:
The patient, Mr Yee, is a patient of long standing. He has been on the steroid inhaler for several months and was also prescribed terbutaline as a metered-dose inhaler. He seemed to be well controlled and did not need to use his bronchodilator very frequently. He tells you that recently he has had one or two frightening wheezing attacks where his ability to inhale was severely impaired. For that reason, the doctor has given him a new type of inhaler.
Mr Yee has not had the Turbohaler® before. The different method of use will need to be explained. Because of the lack of propellant, some patients are not aware they have inhaled the drug when using this device.
He will need to be told that the Turbohaler® is the same drug as his terbutaline metered-dose inhaler and that he must not use them both.
The maximum dose of one puff four times daily will need to be reinforced, as this is different from the metered-dose inhaler dose.
During the counselling session it is probably worth checking Mr Yee’s inhaler technique. The deterioration in his condition may be caused by insufficient steroid being inhaled. This could lead to ineffective prophylaxis.
Although asthmatic patients are normally on long-term treatment, it is dangerous to assume that they have good inhaler technique or are knowledgeable about their drug therapy. There should be regular checking of how devices are used and how frequently they are inhaled. Further information on this is found in Chapter 37.
Example 44.6
The following prescription is received:
You notice from your PMR that, other than the atenolol tablets, which had previously been prescribed as the proprietary brand Tenormin®, the other two items are new to the patient. A considerable number of issues need to be dealt with here.
An explanation needs to be given that, although the appearance and name have changed, atenolol and Tenormin® are the same drug. If the patient has any left at home, they should be finished and the generic then started. Unfortunately, cases are reported of patients who end up taking double doses of drugs owing to a generic being prescribed in place of the branded preparation.
Information about shelf life and storage of the eye drops should be given, i.e. the eye drops must be discarded 4 weeks after being opened and should preferably be stored in a fridge.
Compliance with eye drops should be checked and the need for a compliance aid ascertained.
The trimethoprim is for the treatment of a urinary tract infection. Advice on the duration of the therapy must be given. An indication of when an improvement in the condition can be expected should be given. If no decrease in the severity of the symptoms is seen within 48 hours, it is possible that the organism is resistant to the antibiotic and alternative therapy may be needed. Basic advice on maintaining fluid intake should be given as an adjunct to drug therapy.
Develop the habit of thinking about medicines from the patient’s point of view. What do patients need to know? What are their concerns about taking the medicine? What can be done to help patients resolve their concerns? Identifying information and advice giving points from the information at your disposal is fundamental to good pharmacy practice. It is important to remember, however, that asking questions and listening carefully to the information provided by patients is critical to the success of the process. Approximately 16% of hospital admissions are directly due to adverse drug reactions. How many of these could have been avoided if the patient had received appropriate information and advice from the pharmacist?