1. OPTIMISING MEDICINES USE GRAHAM DAVIES Professor of Clinical Pharmacy & Therapeutics Institute of Pharmaceutical Science King’s College London

2. Learning outcomes 1.Describe the problems commonly associated with the use of medicines 2.Explore the common causes of adverse drug reactions 3.Describe how pharmacists can contribute to optimising medicines use

3. Typical patient journey PatientExperiences Symptoms or routine health check Diagnosis Seek health care Intervention (referral, procedure or medicine)

4. Medicines: the most common intervention NHS Budget: 1999/2000£40 billion 2011-12£105 billion Drug Expenditure 15% of budget

5. Medicines in perspective Explosion of anti-infective agents to target range of infections e.g. range of antibiotics; HIV Positive impact of low dose aspirin on mortality following a heart attack (1980s) The significant benefit of ACE Inhibitors to treat heart failure (1987) Impact of statins to control blood cholesterol (1990s) Expansion in the range of chemotherapy agents

6. Evidence based treatment

7. “ One of the greatest hazards is the use of potent drugs is their inherent toxicity…… …..the dangers of the drug appear to be greater now then ever before.” David Barr MD; Hazards of modern diagnosis and therapy – the price we pay. Frank Billings Memorial Lecture. J Am Med Assoc 1955;159 (15): 1452-1456

9. Problems caused by medicines

10. Adverse drug reactions causing hospital admission 1.6.5% of all admissions due to an ADR 2.Elderly patients 3-4 times more likely to be admitted with ADR 3.4% of hospital bed capacity 4.0.15% fatality 5.Drug-interactions responsible for 1 in 6 ADRs 6.72% were preventable 7.Cost to NHS £466 million/year Pirmohamed, M., et al. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18 820 patients. BMJ, 2004. 329(7456): 15-9.

11. Adverse drug reactions and the elderly Tangiisuran et al Drugs in Aging 2012

12. Which medicines cause harm? Safety in Doses. National Patient Safety Agency 2009

13. Non-adherence to medicines 1 World Health Organization Report 2003. 2 Horne et al. Concordance, adherence and compliance in medicine taking. NIHR SDO 2006. 3 NICE. Medicines concordance & adherence: involving adults and carers in decisions about prescribed medicines 2008/9 Recent reports: Estimated that between 30 - 50% medicines prescribed for long term illnesses are not taken as directed. Cost associated with wastage – not only the medicine but the time of healthcare staff.

14. Sources of medication problems - multifactorial Prescribing - selecting the wrong or inappropriate drug, often at the wrong dose for the patient, Co-prescribing – interacting medicines, complementary therapy or alcohol Lack of patient education - information relating to: –What do they understand about their disease? –Do they understand the benefits of therapy? –What concerns do they have about their prescribed medicines?

15. ROLE OF PHARMACISTS IN MANAGING MEDICINES

16. Pharmacists – optimising medicines use

17. Identifying medication problems Knowledge of patient – is there anything about this patient that concerns me? Knowledge of medicine – is there anything about this medicine that concerns me?

18. Patient factors Patient Characteristics –Age, ethnicity, gender –Height, weight, BMI –Pregnancy & breast feeding Co-morbidities (for example) –Asthma and hypertension –Arthritis and peptic ulcer disease –Allergy status and infection –Pain and renal disease Function and cognitive factors –Mobility, balance, sight, swallowing –Memory, comprehension Social and environmental factors –Lifestyle, home environment and family support –Support services available Patient’s perception of drug therapy

19. Medicine factors Toxicity Factors –Drug interactions, complementary medicines, –Allergy status, contraindications, –Adverse reaction profile –Therapeutic index of medicine Drug factors –Renal and hepatic function Evidence of efficacy supporting medicine Response to current and previous drug therapy –Did the treatment work? –Did the patient experience any problems?

20. The care process Establishing a therapeutic relationship - a continuous process PATIENT ASSESSME NT CARE PLAN EVALUATIO N

21. Use a range of information to: Identify actual and potential drug related problems Resolve actual drug related problems Prevent potential drug related problems

22. Summary Medicines are beneficial but can also cause harm Society needs a gatekeeper who manages medicines for society - seen as the drug expert - the pharmacist Pharmacists must adopt a patient focused approach to identifying and resolving medication related issues Understanding the aims and process which underpin the process of identifying medication - related problems is essential to delivering safe and effective care

23. OPTIMISING MEDICINES USE GRAHAM DAVIES Professor of Clinical Pharmacy & Therapeutics Institute of Pharmaceutical Science King’s College London