PIP public is safe. I advice patients on the

PIP REFLECTIVE
PRESCRIBING CASE STUDY

Introduction

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These
reflective case studies have been authored as part of the requirement for the
completion of the pharmacist Independent Prescribing course at The Sheffield
Hallam University. All the cases reviewed in this portfolio were real cases
that were encountered while working at the local surgery with the designated
medical professional (DMP).I work as a pharmacist in the community setting. The
cores of my responsibilities at the pharmacy include ensuring that medication
dispensed to the general public is safe. I advice patients on the use their
medication and also warn of potential interactions. In addition to reviewing
patient’s medication on a regular basis and offering support when they are
initiated on new medication, I also liaise with doctors, consultants, other
pharmacists and prescribers when the need arises. This on most occasions is to
double check on medication alterations especially
when patients make the transition from hospital back to primary care.

On successful completion of the
pharmacist independent prescribing course, I will hopefully be splitting my
work time between the community pharmacy and running cardiovascular clinics at
a doctor’s surgery, helping to support patient diagnosis,
medicine optimisation and encouraging patient self care. This will hopefully free up more time for the GPs to
focus on more complex cases. The result of this would easily be improved
patient safety and possibly reduced waiting times and improved scarification
for patients who use the service.

In recent
years a number of countries have extended prescribing rights to pharmacists,
using quite a variety of formats. Pharmacists in the United States, Canada,
Australia and New Zealand are able to undertake forms of prescribing ranging
from collaborative prescribing with doctors, to prescribing from a limited
formulary (Emmerton et al 2005). In the United
Kingdom (UK), changes to medicines legislation in 2003 initially allowed
pharmacists to practice as supplementary prescribers using a condition-specific
treatment plan agreed with the independent prescriber (doctor) and patient.
Prescribing rights for UK pharmacists were extended in 2006, allowing qualified
pharmacists to independently prescribe medication for any condition they deemed
within their own competency, following some additional training (Pharmacists
were allowed to prescribed unlicensed medicines in 2009 and the rights to
prescribe controlled drugs followed 
three years later in 2012 (Baqir et al 2012). According to The Department of
health, Pharmacist
independent prescribers are able to prescribe any controlled drug listed in
schedules 2-5 for any medical condition within their competence, except
diamorphine, cocaine and dipipanone for the treatment of addiction.Pharmacist
independent prescribers are however able to prescribe other controlled drugs
for the treatment of addiction.

In order to
provide some form of structure to the consultations I had to carry out, I
explored a few consultation models. One of the doctors I worked with favoured
following a model proposed by Roger Neighbour and so I experimented with this
for over a few consultations. I soon discovered I preferred something which had
more structure. I studied and used the Calgary-Cambridge for the rest of the
consultations and realised that it saved me a bit of time during consultation.
With most of the other consultation models I used, the consultation sessions
were about 25 minutes long. However with the Calgary-Cambridge model, I was
able to effectively and safely conduct a good consultation in 20 minutes at the
surgery. I did realise that most consultations at the surgery were expected to
last 10 minutes. Some lasted a bit longer than 10 minutes depending on the
complexity of the case presented. I had concerns that if patients had to be
seen within very short time limits, it might possibly negatively affect a
general practitioner’s ability to make certain crucial diagnosis such as that
of cancers early(Lyratzopoulos G,2012)

 I critically analysed two
cases. The first was a 62 year old woman diagnosed with hypertension and the
second was 23 year old young woman suffering depression.To comply with The
Department of Health’s Code of Practice on Protecting the Confidentiality of
Service User Information issued in January 2009, the identities of the patients
in the cases will be protected with pseudonyms.

All the
consultations for the cases being analysed were based on the Calgary Cambridge model.
I commenced both sessions by establishing initial rapport and established the
purpose for their visit on the day. I proceeded to gathering information by
exploring the patients’ problems and actively determining their ideas, concerns
and expectation with encouragement to express their feelings. I continued to
provide structure and build on the established relationship further. I offered
explanation and made plan for the consultation. I made sure the patients shared
in the decision making process. I closed the sessions with foward planning, safety
nets, explaining possible unexpected outcomes, what to do if the agreed plans
were not working, when and how to seek help.( Kurtz SM 1998)

Regular references will be made to the different
stages of National Prescribing Centre’s prescribing pyramid to demonstrate how
each stage has been considered for each of the patient in the cases being
analysed (NPC 1999)

 

CASE 1

Mrs Anne
Costello (not real name) is a 62 year old woman, of white ethnicity who at the
prompt of her GP, made an appointment at the surgery for a routine blood
pressure check. Her blood pressure was last measured during the annual flu
vaccine campaign at the surgery and it showed an elevated blood pressure of
176/94mmHg

 

Presenting
complaint

 

Hypertension

 

 

Current
medications

Pantoprazole
40mg once daily

Candersartan
32mg once daily                                       

 

 

Allergies

No known allergies

 

History
of presenting complaint

Hypertension
which causes her to be worried a bit sometimes as she knows there is no cure.

 

Past
medical history

Essential hypertension
diagnosed December 2017

Acid reflux
diagnosed 2012

 

 

Smoking

Non
smoking

 

Alcohol

Rarely,
consumes only one unit a month when she goes out with her husband.

 

Social
history

Mrs
Costello is married with two grown children. She has recently retired.

 

Family
medical history

Both
parents of Mrs Costello were hypertensive. They both died of stroke at ages 61
and 62.

 

Family
history

Mrs
Costello is the youngest of three children. She has a brother who is 68 and a
sister who is 66.

 

Examination

Measured
BP was 170/110mmHg

Regular
pulse of 78 beats per minute

HbA1c was highlighted
as being 46.1mmol/mol.

 

Mrs
Costello’s blood pressure was measured manually with a recently serviced and
validated sphygmomanometer and stethoscope while following the strict
guidelines of The National Institute for Care and Excellence (NICE) and The
British and Irish Hypertension Society (BIHS) (NICE CG127, 2011).The
appropriate cuff size was used and the patient was seated in a chair with a
back rest, feet on the floor for about 10 minutes, relaxed and not speaking. No
alcohol or caffeinated drinks were consumed within 24 hours of the BP
measurement.

Mrs Costello
was on an antihypertensive. Despite this, her blood pressure continued to
remain elevated. Even though she did not smoke and hardly drank, she did say
that her diet had been quite poor but had recently improved. She previously
weighed 85kg and had lost about 2kg of weight over the past 5 months as a
result. I checked a record of how often she had ordered repeat medication for
the prescribed candesartan and it was evident that she ordered her medication
each month for the past 11 months. On questioning, the patient confirmed that
she had never missed a dose of her antihypertensive. She did say however that
there were times when she might have taken them at different times of the day.
This response led me to conclude that it was highly unlikely that non-adherence
to medication was the cause of Mrs Costello’s uncontrolled hypertension.
According to the prescribing pyramid, at this point, I needed to consider a
strategy to achieve the outcome of a well controlled blood pressure and to
reduce any risk of cardiovascular events. The options we discussed were the
offer to assess her for cardiovascular risk and a recommendation for a referral
for the assessment of target organ damage and the possible addition of another
antihypertensive to her current medication.Mrs Costello agreed to this strategy
so blood samples were requested to measure levels of her plasma glucose,
electrolytes, creatinine, estimated glomerular filtration rate, serum total
cholesterol and HDL cholesterol. Another request for examination of her fundi
for the presence of hypertensive retinopathy was made as well as an arrangement
for a 12-lead electrocardiograph to be performed. (NICE
CG127, 2011).There is evidence to suggest that diet and exercise could reduce
cardiovascular risk. According to Villegas et al “It is now evident from a
health policy perspective that interventions at a population level addressing
diet, exercise and smoking, will have profound effects on blood pressure and
lipid levels in the population and ultimately on the incidence of cardiovascular
disease” This formed the basis of a discussion between the patient and I had about
maintaining the healthy lifestyle aspects she had adopted and on a gradual basis,
incorporate new healthy habits.

A risk factor
may be defined as a characteristic of an individual that is associated with an
increased risk of the development of a specific disease such as cardiovascular disease,
hypertension, increased cholesterol level and smoking as risk factors for
cardiovascular disease (CVD) are now firmly established. Multiple randomized
controlled trials have proven that treatment of elevated serum cholesterol and
blood pressure reduces mortality, and observational studies indicate that those
who do not smoke or stop smoking are at greatly reduced risk. (Leong T et al 2008) .The patient in question was not
a smoker however there are several other cardiovascular risk factors such as
her family history, her uncontrolled blood pressure, her diet, her HbA1c which places
her in the pre-diabetic range and her weight. Regardless of these risk factors,
I could not arbitrary suggest a prescription for medication  to reduce her CVD risk without objectively
measuring her cardiovascular risk. There is the need to have an accurate and
reliable tool to help identify patients at high risk of having a cardiovascular
event. Numerous multivariable risk scores have been developed to estimate a
patient’s 10 year risk of cardiovascular disease based on certain key known
risk factors (Hlatky MA et
al,2009).The two most widely used ones in the UK are the QRISK2 and the NICE
version of the Framingham equation. A recent prospective open cohort study
which sort to indepentley and externally validate the QRISK cardiovascular
disease score, revealed that QRISK2 offered improved prediction of a patient’s
10-year risk of cardiovascular disease over the NICE version of the Framingham
equation. Discrimination and calibration statistics were better with QRISK2.
QRISK2 explained 33% of the variation in men and 40% for women, compared with
29% and 34% respectively for the NICE Framingham and 32% and 38% respectively
for QRISK1. The incidence rate of cardiovascular events (per 1000 person years)
among men in the high risk group was 27.8 (95% CI 27.4 to 28.2) with QRISK2,
21.9 (21.6 to 22.2) with NICE Framingham, and 24.8 (22.8 to 26.9) with QRISK1.
Similarly, the incidence rate of cardiovascular events (per 1000 person years)
among women in the high risk group was 24.3 (23.8 to 24.9) with QRISK2, 20.6
(20.1 to 21.0) with NICE Framingham, and 21.8 (18.9 to 24.6) with QRISK1.(Gary S Collins et al,2010)  with these results, I chose the QRISK2 over
the alternative to calculate Mrs Costello’s CVD risk. Mrs Costello’s calculated
score was 13.6% the strategy as far as Mrs Costello was concerned was reducing
her blood pressure within the acceptable limits and reducing her CVD risk.

The third
step in the afore mentioned prescribing pyramid required that I made a choice
of medication to help achieve the expected outcome. In this case, the choice
was for a suitable antihypertensive and a statin for the primary prevention of
a cardiovascular event. In choosing an antihypertensive I evaluated my choice
to make sure that it was effective and backed by evidence, that is was appropriate
and safe for the patient in question as well as being cost effective. (NPC,
1999).Having considered all the facts regarding this patient and her current
health condition; I used the NICE guidelines and local CCG guidelines to select
an appropriate antihypertensive. The Patient was already on candesartan 32mg
yet her blood pressure remained elevated. According to NICE CG127, since Mrs
Costello is over 55 “Offer step 1 antihypertensive treatment with a
calcium-channel blocker (CCB) to people aged over 55 years and to black
people of African or Caribbean family origin of any age” based on this I chose
a calcium channel blocker as an addition to the candesartan 32mg.

The calcium
channel blocker of choice was Amlodipine because there was enough evidence to
support the fact that is safe, clinically effective and had a relatively low
acquisition cost. Amlodipine blocks voltage-gated L-type calcium channels by
binding to their ? 1-subunit and preventing the influx of calcium
ions after depolarisation of the cell membrane. In contrast to the
non-dihydropyridines it has a predilection for channels in smooth muscle, and
most clinical benefit is derived from its vasodilating effects on the coronary
and peripheral vasculature.Its relative lack of effect on the myocardial
calcium channels conferring inotropic stability. It has a long half-life
(around 40 hours) and can therefore be given once daily. Apart from the fact
that amlodipine is what NICE recommends for patients like Mrs Costello, there
is also evidence to suggest that it could potentially have a positive effect on
lipid profile of Mrs Costello. (Williamson et
al,2008) 

 There has been interest in the potential role
of amlodipine as an anti-atherogenic agent with in vitro studies
suggesting biological effects such as lipid anti-oxidant activity, inhibition
of smooth muscle cell proliferation and protection of the cell from
cytokine-induced damage by molecules such as TNF?, all of which may be
independent of calcium channel modulation(Williamson et
al,2008)  The Anglo-Scandinavian
Cardiac Outcomes Trial (ASCOT) demonstrated superiority of an amlodipine based
antihypertensive regimen compared with an atenolol based one. In total, 19 257
participants with hypertension and at least three other cardiovascular risk
factors were randomised to receive either amlodipine (5/10 mg) ± perindopril
(4/8mg) or atenolol (50/100mg) ± bendroflumethiazide (1.25/2.5mg), titrated
with further therapy as required to achieve a blood pressure target of
<140/90mmHg. The trial was terminated early after 5.5 years' median follow-up with significantly fewer cardiovascular events or procedures, stroke or all-cause mortality in the group receiving the amlodipine based regimen (hazard ratios 0.84, 0.77 and 0.89 respectively). The superiority of the amlodipine based regimen can partly be explained by greater efficacy in lowering blood pressure (there was a 2.7mmHg systolic blood pressure difference between the groups throughout the trial), but favourable effects on other metabolic parameters, such as HDL-cholesterol, triglyceride and glucose values, may contribute.( Dahlöf B et al 2005).I recommended that Mrs Costello be prescribed amlodipine 5mg and monitored for side effects. The next step in the prescribing pyramid required that I negotiated a contract with Mrs Costello. This step wholly encapsulates the concept of concordance and empowers patients to be in charge or at the very least take active part in decisions about their care (NPC, 1999). This approach endorses the Department of Health's (2011) 'No decision about me without me' principle. Mrs Costello did mention that she did not particularly like taking tablets and that she would rather start on one tablet if she needed to and perhaps another one a few months down the line if needed. I had to prioritise the management of her blood over the reduction of her QRISK with the addition of a satin to her current drug regime. We agreed on the health outcome of reducing her blood pressure to the acceptable level of below 140/90mmHg and came up with a strategy to encourage concordance. Mrs Costello would place her medication in a safe place by her bedside so that she would remember to take her medication the first thing every morning. During this part of the consultaion, I ensured that I took into consideration any personal beliefs she had about her condition and medication in general. In my discussion with the patient, I did my best to present the information about the new medication and the purpose of her taking it in a way that was simple and straight to the point without any fancy medical jargons. I gave her some printouts on amlodipine after our discussion. This was to make sure that she clearly understood what needed to be achieved so she could make informed decisions about her care (Cheesman, 2006).Mrs Costello also had useful advice on some non-pharmacological interventions such as exercise and healthy eating and how these could help lower her currently elevated blood pressure. I planned a review with Mrs Costello. She went away and returned for a review three weeks later. When I saw her in consultation, she looked well. She has lost about 1kg of weight and her blood pressure was 137/88 mmHg. During the review I had the opportunity to explore whether Mrs Costello has been concordant with the mutually agreed management strategy for lowering her blood pressure. There are many reasons patients are poorly compliant with medicines I did my best to determine whether the patient had unintentionally missed her medication (forgot), or consciously decided not to take the prescribed course (Shepherd 2011) On direct questioning, she mentioned that she had no side effects of any sort from the amlodipine.She had stuck to our mutually agreed strategy and taken her medication without missing a day. In the absence of any side effects and with evidence of a clinically significant reduction in blood pressure. I recommended that a repeat prescription of amlodipine 5mg be made out to Mrs Costello with arrangements made for a half yearly review of her blood pressure. I kept accurate and comprehensive of the consultations with Mrs Costello on the surgery's clinical system, EMIS.I made sure that the records I kept were factual and could be used by other members of the healthcare team to provide care for the patient if needed. I have done quite a bit of reflections after seeing Mrs Costello. Prior to learning about consultations and using aids such as the prescribing pyramid, I wrongly assumed that because health professional were trained in certain fields and had specialist knowledge, they just had to tell patients what was good for them and by virtue of their knowledge and experience, patients were just expected to comply with what the doctor, nurse, pharmacist or health professional said. On reflection,i have come to the realisation that regardless of how knowledgeable or skilled a healthcare professional is, patients need to be the centre of decisions involving their care and must actively take part.When patients are allowed to freely do this,as in the case of Mrs Costello,they buy into whatever treatment strategies and plan that are made and do their best to make it work.   CASE 2 Amy Gray, a 27 year old Caucasian female with no past medical history presented at the doctor's surgery visibly upset with thoughts of harming herself. Miss Gray had recently split from her husband of 8 years. There was an ongoing legal tussle for the custody of their two year old son. The Patient was thought to be suffering from depression. To confirm this, a full assessment was carried out. The patient presented with low mood and reported random thoughts of suicide. From her history of presenting complaint, she had been depressed for about 7 weeks when her husband left, she had not slept well for about 2 months, and she mentioned she only got an average of two hours of sleep each night. She wakes up early each morning with recurring painful and unpleasant thoughts which she could not get out of her mind. She had lost a lot of weight and was visibly emaciated. She had lost interest in food. She had no appetite at all she mentioned she had lost interest in the one thing she loved the most, playing the piano. She was unable to concentrate long enough to read which she had always done before bedtime. Miss Gray's past medical history indicated that she had been diagnosed with depression 6 years ago when her mother died. For her drug history, she was not on any current medication though she did say she took the odd two paracetamol 500mg tablet when she needed it every now and then. She had no known allergies, did not smoke bur drank a glass of red wine most nights after her evening meal. Miss Gray's family history told us she had two brothers who were in excellent health. Both parents died a few years prior in a motor accident. Her family medical history had nothing of of concern. Social history indicated that Miss Gray worked as a dental nurse, recently split from her husband and had a toddler son aged 2. Her premorbid personality revealed that she was a very quiet young lady with few friends and enjoyed her own company majority of the time. Miss Gray underwent a mini mental state examination (MMSE) to determine if she was depressed. The Mini-Mental State Examination (MMSE) is one of the most widely used screening tools for cognitive dysfunction (Folstein et al,1975).On examination, Miss gray was found to appear dishevelled and unkempt but co-orperative.Behaviour wise, her eyes were constantly cast down during the consultation. Her speech was quiet and she was noticeably hesitant when she spoke. Her thought were that of failure as a wife and a mother. She had strong suicidal thoughts and a couple of times she mentioned she nearly acted on those thoughts. Her mood was quite low and subjectively scored a poor 4/10.Objectively she appeared depressed. She perceived no hallucinations, she had insight but her cognitive state indicated poor concentration. She also fidgeted a lot with her fingers and her hair during the consultation. Physical examination revealed a temperature of 36.1oC, oxygen saturation of 96% on air, heart rate was 70, blood pressure was 135/80mmHg and respiration rate 26. The patient's full blood count, Urea and electrolytes requested two weeks ago were all within normal range. Based on all the above and using recommendations from NICE guidelines GC90 (NICE, 2009) the patient was diagnosed with moderate to severe depression.   Depression is a brain disorder in which the chemicals used by nerve cells to communicate to each other are out of balance. Susceptibility to the disease seems to depend on a combination of genetic, psychological and environmental factors. The condition is quite complex, following numerous patterns with variations in symptoms, severity and persistence from one person to the next. The criteria used to diagnose clinical depression are based on distinct symptoms appearing in combination. These symptoms include: difficulty sleeping, feeling fatigued during the day, agitation, irritability, anger over minor things, loss of motivation, a sense of hopelessness, indifference and pessimism, problems with concentration and memory, social withdrawal, sexual dysfunction and thoughts of suicide. It is sometimes accompanied by other mental disorders such as anxiety, phobias or obsessive compulsion. Like many diseases, depression is often episodic in nature with periodic flare-ups. Some people may experience only one bout of clinical depression, while others suffer several serious depressions throughout their lives (CHM,2002).