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Some 800 pharmacists attended the 36th European Symposium on Clinical Pharmacy, held in Istanbul on 25–27 October 2007. The theme was sharing experience of community and hospital settings.
Laurence A Goldberg
FRPharmS
Editorial Consultant
HPE
Pharmacist participation in morning ward rounds where decisions were being made enabled them to build relationships with doctors and nurses and helped to establish clinical pharmacy services in Norway, Kirsten Viktil (Diakonhjemmet Hospital Pharmacy Oslo and Oslo University) told the audience. Another factor in their success was the appointment of four quarter-time equivalent positions instead of one full-time position, which made them much more visible, she added.
Currently in Norway, hospital pharmacies are owned by the government rather than the hospital, and healthcare institutions pay for the clinical pharmacy services. The main elements of the service are:
● Identification and prevention of drug-related problems in individual patients.
● Patient counselling about medicines.
● Provision of medicines-related advice to physicians and other healthcare professionals.
● Contributing to systems for the optimal use of medicines, eg administration guidelines and patient information leaflets.
A single prescription document is used and this eliminates transcription errors, explained Dr Viktil. Clinical pharmacists receive written referrals which are signed when the actions are complete. This form of communication is helpful because most clinical pharmacists work part-time. Some pharmacists have been granted permission to record their actions in electronic medical records, although only a few hospitals have these so far. In Norway, the law defines who may write in the medical record and what should be written, Dr Viktil pointed out.
There are still many challenges and barriers to overcome. “Take the opportunities – they are out there. Look for opportunities to optimise drug therapy”, she recommended.
Clinical pharmacy research
Both observational and intervention studies are needed in clinical pharmacy, according to Marcel Bouvy (SIR Institute for Pharmacy Practice and Policy, Leiden, and Division of Pharmacoepidemiology and Pharmacotherapy, Utrecht University, Netherlands).
Dr Bouvy suggested that clinical pharmacy research could be described under the four domains of Hippocrates: diagnosis, aetiology, prognosis and therapy. The general questions that fit under these headings are, respectively: “What is it?”, “Where does it come from?”, “How bad is it?” and “What can I do?”
Although diagnosis is not normally a pharmacist’s responsibility, pharmacists are increasingly undertaking diagnostic tasks such as diabetes screening and, in the UK, chlamydia testing in community pharmacies.
Two examples of studies that fall under the heading of “aetiology” are a study in the UK that showed that 6.5% of hospital admissions were due to adverse drug reactions, and the hospital admissions related to medication (HARM) study, published in the Netherlands in 2007. In both cases, drugs commonly involved were aspirin, diuretics, warfarin and non-steriodal anti-inflammatory drugs.
A study that examined re-prescribing of medicines after they had caused adverse reactions in elderly patients could be classified under the heading of “prognosis”. The results showed that 22% of medicines responsible for “serious adverse reactions” were prescribed again for the same patients within six months. Studies of adherence to long-term therapies also fell under this heading.
There are many studies concerned with therapy – most commonly the type that show that intervention by a pharmacist improves patient outcomes compared with “usual care”. Meta-analyses of some of these studies had now confirmed these findings, Dr Bouvy said.
Clinical pharmacy research is needed in several domains and the local situation should determine the starting point. In the UK, pharmacists should be involved in intervention studies because observational studies have already shown where the problems are, Dr Bouvy suggested. In other countries observational studies might be the best starting point to find out where the problems are. “We have to show that clinical pharmacy really improves patient outcomes,” he concluded.
Oncology care model
A study in Edinburgh, Scotland, has shown that about 50% of pharmaceutical care issues identified in patients receiving chemotherapy need to be followed up in the community. Julie Fisher (senior oncology pharmacist, Edinburgh Cancer Centre, Western General Hospital) described how a referral form had been developed which contained a list of the pharmaceutical care issues (PCIs) and suggested actions for the community pharmacist.
Increasing numbers of cancer patients are now receiving treatment at day-case chemotherapy clinics. New chemotherapy regimens, wider use of oral treatment and intravenous treatment delivered using ambulatory pumps have made this possible. There is still the opportunity for miscommunication, Ms Fisher said. On several occasions three-day courses of dexamethasone for chemotherapy-induced nausea and vomiting have been mistakenly continued by the patients’ general practitioners (GPs) – resulting in inappropriate steroid treatment for several weeks. The therapeutic plan should be communicated to both the GP and the community pharmacist so that they can participate in monitoring for adverse events. A prospective survey in 90 day-case patients receiving chemotherapy showed that the most common PCIs related to supportive therapy (eg for nausea and vomiting), corticosteroid use and warfarin treatment.
Warfarin therapy in this group of patients requires special attention. Patients who have central intravenous lines in position for intravenous chemotherapy are usually prescribed warfarin 1 mg daily for thromboprophylaxis. These patients do not routinely require monitoring of clotting status unless they are prescribed other medicines that can interact with the warfarin. Ms Fisher pointed out that there is a significant drug interaction between warfarin and capecitabine, which prolongs clotting time. In such cases regular monitoring of clotting status is required. Community pharmacists should check that patients taking this combination have regular monitoring of their clotting status performed, she added.
A referral form was designed and tested in 20 patients and their nominated community pharmacists. The results showed that of the 52 PCIs listed on the forms, about half were followed up by the community pharmacists. Lack of time was the reason for not following up more.
Kidney disease
Kidney Disease Improving Global Outcomes (KDIGO) was established in 2003 as an independently incorporated non-profit foundation governed by an international board. Mustafa Arıcı (consultant nephrologist, Ankara University Hospital, Turkey) explained that the mission of KDIGO is to “improve the care and outcomes of kidney disease patients worldwide by promoting coordination, collaboration, and integration of initiatives to develop and implement clinical practice guidelines”. The organisation has representatives from 24 countries and five continents.
KDIGO is currently developing three global clinical practice guidelines. They will address hepatitis C, chronic kidney disease (CKD) mineral and bone disorder and care of the kidney transplant recipient. The organisation also sponsors “controversies conferences” which are designed to tackle specific questions. Each conference follows a general framework – identification of what is known, formulation of recommendations based on this and identification of gaps in knowledge.
KDIGO has refined the definitions for chronic kidney disease and this has important implications for drug dosing, according to Vincent Launay-Vacher (nephrology clinical pharmacist, Pitié-Salpêtrière Hospital, Paris, France).
There are a number of methods for measuring renal function, but all have drawbacks. Creatinine clearance or glomerular filtration rate (GFR) are the best measures for routine use. These can be estimated using the Cockcroft-Gault or abbreviated Modification of Diet in Renal Disease (aMDRD) equations. Mild, moderate and severe decreases in GFR are defined as GFRs of 60–89 ml/min, 30–59 ml/min and 15–29 ml/min respectively. A GFR of less than 15 ml/min is indicative of kidney failure. This classification differs from the previously accepted scheme, Dr Launay-Vacher noted.
Clinical pharmacists have a critical role to play in raising awareness of the new definitions and in ensuring that drug doses are adjusted accordingly. More than 80% of antibiotics and 55% of antineoplastic agents require dose adjustment in renal insufficiency, he said.
Cardiovascular disease and renal disease are closely linked and factors that worsen the one inevitably worsen the other, Corinne Isnard-Bagnis (consultant nephrologist, Pitié-Salpêtrière Hospital) told the audience. One immediate implication of this is that studies with cardiovascular outcomes should include patients with CKD. Until now such patients have been excluded from clinical trials.
Infectious disease is the second most common cause of death among CKD patients and this is particularly relevant to people with chronic infectious diseases. For example, 5–10% of patients with HIV have CKD and the prognosis for this group is poor. One study had shown that 57% of doses of antiretroviral (ARV) therapy prescribed for human immunodeficiency virus (HIV) patients undergoing dialysis were incorrect. “Even nephrologists do not always know how to adjust doses of ARVs”, said Professor Isnard-Bagnis.
The KDIGO clinical guidelines recommend that patients with HIV and other chronic infectious diseases such as viral hepatitis (HCV and HBV), tuberculosis and malaria should be screened for CKD at the time of diagnosis, but this is not done routinely at present. Dialysis patients should also be vaccinated for influenza, hepatitis B and pneumococcus.
CKD is almost certainly a risk factor for mortality in all types of cancer and a recent study has shown that nearly 60% of cancer patients have some degree of renal insufficiency. Cancer patients should be routinely screened for CKD at first presentation and then again when treatments are started or changed. In addition, kidney-sparing oncological treatments should be used whenever possible and patients with CKD should be included in clinical trials for cancer treatments.
Professor Isnard-Bagnis concluded that CKD was common and harmful and greater awareness of the condition is needed among both healthcare professionals and the general public.
Nephrology outpatient care
Clinical pharmacists can contribute to the management of both CKD and the many associated conditions, according to Thierry Romanet (senior nephrology clinical pharmacist, Grenoble Teaching Hospital, France). He described how clinical pharmacy services for nephrology outpatients had grown over the past 10 years at his hospital.
The services embrace clinical trials, pharmaceutical care of transplant patients and pharmacist-led anaemia management. The anaemia service in particular has seen a number of developments over the past few years. The overall aim is to ensure that clinical practice guidelines are followed and that treatment is correctly monitored. The service operates on two mornings each week at the same time as the nephrology consultants’ clinic sessions. The nephrologists refer outpatients with stage 2–4 CKD (corresponding to mild, moderate or severe renal insufficiency) who are to start treatment with an erythropoiesis-stimulating agent (ESA). The pharmacist is responsible for ESA dose adjustment, prescribing of iron and vitamins, ordering of appropriate laboratory tests and blood pressure monitoring. Three or four consultations (at monthly intervals) are required to achieve the target haemoglobin levels and a total of 22 patients have been managed in this way to date. In future, this system could be the model for a broader service dealing with all the pharmaceutical care needs of CKD patients, Dr Romanet concluded. ■
