Helping to fill in the patient knowledge gaps

A pharmacist can be a valuable and reliable resource for reinforcing and monitoring often-complex medication regimens, writes Tim Perry

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For many years pharmacists have worked away, often in the background and sometimes invisibly,^{1 k}keeping patients on the right medication at the prescribed dose.

General practitioners sometimes deliver a lot of information during a consultation and patients are often very good at remembering most of that information.²

Sometimes, though, we know the message does not get through. To help facilitate team work, increase communication between healthcare professionals³ and improve health literacy of our shared patients, here are five examples of patient knowledge gaps commonly seen in pharmacy.

TREATMENT PRECAUTIONS

Doxycycline makes the skin more sensitive to sunlight.⁸ Pharmacists will probably point this out, especially if a patient is taking it for an extended period for malaria prophylaxis. Patients do not always take this news well, especially if the malaria area they are visiting happens to be hot and sunny most of the time.

If the pharmacist advises that alcohol may reduce doxycycline levels, patients sometimes see their dream tropical holiday being dramatically downgraded. Sensible advice about avoiding excessive sunshine is more easily accepted by the pre-warned patient.

TREATMENT FREQUENCY 

To eradicate scabies, permethrin should be used twice,  approximately one week apart.⁴ While the evidence to show the benefit of the second application is not strong,⁵ it is the recommended practice in Australia and your patient’s pharmacist will offer that advice. Unfortunately, if the patient has not been warned by their doctor, the patient may view this advice sceptically.

Pharmacists are happy to explain how to apply the cream – after an evening shower from neck down, wash off next day et cetera. They are also happy to give advice about how to manage the itch that will still probably be present after initial treatment, but the need for a repeat treatment in seven days is more readily accepted if the patient has already heard that advice from their GP.

TREATMENT DURATION

Morphine injections in palliative care may be prescribed at intervals from one to four hours, so a box of five ampoules may not last one day.⁶ Clindamycin for various reasons may be prescribed at doses of 450mg every eight hours, but the usual PBS supply is 150mg, 24 capsules,⁷ or less than three days’ supply.

Not providing an adequate quantity of medication for the patient may increase the risk of treatment failure, decrease patient comfort and increase costs to the patient. Arranging for an authority prescription for increased quantity will help avoid these challenges.

ALLERGIES

Clarifying “allergies” with patients is another worthwhile conversation that may ease patient angst about anaphylaxis. Patients often say they are allergic to “sulfur”, but do not always know whether they mean “sulfite” or “sulfonamide”. Sometimes they might see “sulfate” as part of a drug name and panic unnecessarily.⁹ 

Antibiotic allergies are associated with increased hospital admissions and may lead to inappropriate prescribing.¹⁰ Clarifying and easing your patient’s concern over their “sulfur” allergy would make life a little easier for all health professionals involved in the patient’s care.

CLARIFYING TREATMENT

Warfarin may be a waning star with the advent of newer direct acting oral anticoagulants, but it still holds an important place in our armamentarium.

Two major challenges with this drug are dietary advice and dose changes.

Pharmacists are more than happy to counsel patients about diet with warfarin knowing that a “consistent intake of green, leafy vegetables”¹¹ is much preferred to avoiding greens altogether, as some patients have interpreted the information.

Was the dose change half a tablet or half a milligram? Was the “2.5” that was mentioned referring to the INR or the new dose? Questions like these can be avoided with written advice, such as using the Warfarin booklet, including the new dose in milligrams and date the dose should be changed.

Patients using dose administration aids (DAAs) may delay changing dose because they have a supply of DAAs already.

CONCLUSION

Finally, it is worth remembering that your patient probably visits their pharmacy at least twice as often as they visit their GP.^12,13 Their pharmacist may know more about your shared patient’s adherence to medication, use of supplementary products and pain medicines than the patient remembers to tell you.

The pharmacist is a valuable resource and reliable method of reinforcing and monitoring the often-complex medication regimens patients have to manage.

They are an integral component of the healthcare system and should play a more visible role in the healthcare team.¹⁴

Tim Perry (B.Pharm, MPS, AACPA, Prac.Dip.Ac, Grad.Dip.Clin.Epid) is a general practice pharmacist and a member of  the Blacktown Medical Practitioners’ Association and the Hills Doctors’ Association

References

1. Taylor, R. (2017). The Invisible Pharmacist. Port Macquarie. Retrieved from https://mm2017shpa.com/wp-content/uploads/2017/11/Poster-46_Taylor.pdf.

2. Tarn, D. M., & Flocke, S. A. (2011). New prescriptions: how well do patients remember important information? Family Medicine, 43(4), 254–9. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21499998

3. Paola, S. (2016). Pharmacists welcomed in general practice | AJP. Retrieved November 24, 2017, from https://ajp.com.au/news/pharmacists-welcomed-general-practice/

4. AMH 2017. (n.d.). Permethrin – Australian Medicines Handbook. Retrieved November 24, 2017, from https://amhonline.amh.net.au/chapters/chap-08/scabicides-pediculicides/permethrin?menu=hints

5. Currie, B. J., & McCarthy, J. S. (2010). Permethrin and Ivermectin for Scabies. New England Journal of Medicine, 362(8), 717–725. http://doi.org/10.1056/NEJMct0910329

6. Pharmaceutical Benefits Scheme (PBS) |. (2017). Retrieved November 26, 2017, from http://www.pbs.gov.au/medicine/item/2622B-5195K

7. Pharmaceutical Benefits Scheme (PBS) |. (2017). Retrieved November 26, 2017, from http://www.pbs.gov.au/medicine/item/10862Q-10863R-10864T

8. AusDi. (n.d.). Tetracyclines (Systemic) – AusDI. Retrieved November 26, 2017, from https://ausdi.hcn.com.au/productMonograph.hcn?file=0569

9. Trubiano, J. A., Stone, C. A., Grayson, M. L., Urbancic, K., Slavin, M. A., Thursky, K. A., & Phillips, E. J. (2017). The 3 Cs of Antibiotic Allergy-Classification, Cross-Reactivity, and Collaboration. The Journal of Allergy and Clinical Immunology. In Practice, 5(6), 1532–1542. http://doi.org/10.1016/j.jaip.2017.06.017

10. ASCIA 2014. (2014). Sulfite sensitivity – Australasian Society of Clinical Immunology and Allergy (ASCIA). Retrieved November 26, 2017, from https://www.allergy.org.au/patients/product-allergy/sulfite-allergy?highlight=WyJzdWxmYXRlIiwiYW5kIiwic3VsZmF0ZSBhbmQiXQ==

11. Chalmers, L., Peterson, G., & Bereznicki, L. (2015). Warfarin: Important Information for patients. /www.aspenpharma.com.au/patRes/WarfarinInformationBooklet.pdf

12. The Pharmacy Guild of Australia We are community pharmacy Serving Australians: A system of community pharmacy. (2016). Retrieved from https://www.guild.org.au/__data/assets/pdf_file/0020/5942/serving-australians-a-system-of-community-pharmacy.pdf

13. Anne-marie Boxall. (2014). FactCheck: does the average Australian go to the doctor 11 times a year? Retrieved November 27, 2017, from http://theconversation.com/factcheck-does-the-average-australian-go-to-the-doctor-11-times-a-year-26242

14. Cohen, H. (2009). The Invisible Pharmacist. Retrieved November 28, 2017,  from https://www.uspharmacist.com/article/the-invisible-pharmacist