RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn

Complex Prescribing
2018-2019

Dr Judith Strawbridge (School of Pharmacy RCSI)

Enter subtitle here (24pt, Arial Regular)
Dr Emma Barry (Department of General Practice RCSI)
Enter date: 25.06.13
Dr Sumi Dunne (Department of General Practice RCSI)
Dr Mark Murphy (Department of General Practice RCSI)
Dr Karen Kyne (Department of General Practice RCSI)
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DOSAGE
WRITING A PRESCRIPTION
 Dr A. B. Kashan
123 High Street
Dublin 2
Tel: 01 4022482
22/02/17
Charlie Flanagan
456 Main Street, Beaumont
DOB: 05/09/2018

Rx
Amoxicillin 250mg three times daily for 1 week
(give 5mls of a 250mg/5ml solution three times daily). Two bottles.

A Kashan MD (MCN 12345)

 RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn

Children
 ABSORPTION
• Oral
– Can be variable Ph higher at birth (6-8) {achlorhydria}
• Increased absorption of acid-labile meds
– Reduced peristalsis & slow gastric emptying; Slower & unpredictable
absorption
• After a few months, the rate and extent of absorption of most drugs is
similar to that in adults
• IM route – AVOID (except vaccines)
• Reduced absorption of IM injections
• Painful & unpredictable
• Percutaneous
• Immature skin little barrier to systemic drug absorption
• Large SA relative to body weight
• Rectal
• Can be useful for infants
 METABOLISM AND EXCRETION

• Metabolism
• Hepatic metabolic systems poorly developed until 1 year old
• Increases to adult levels in first 3 years
• Significant for drugs metabolised through specific enzyme process
• Neonates are unable to form glucuronides
• Care with morphine, paracetamol
• Excretion
– GFR at birth depends on the gestational age
– Increases rapidly, reaching adult levels (proportionate to size) by 3
months
– Clearance of renally excreted medicines prolonged in infants especially
pre-terms
– Extended dose intervals required
FACTORS TO CONSIDER WHEN PRESCRIBING
FOR CHILDREN

• Variations in size & pharmacokinetics

• Compliance and concordance

– Education of patient, child and carers/ counselling
– Persuading the child to take the medicine
– Administration of medicines in schools or day care
– Choice of formulation (Ease of administration, Frequency, School
hours, liquid or tablet?)

• Formulation of medicines
– Licensed
– Suitable for administration
– Excipients

• Calculations
CONSENT TO MEDICAL TREATMENT FOR CHILDREN

16 and over
• Persons aged 16 and over can consent to medical, surgical and dental
treatments.
• Law relating to persons aged 16 and 17 refusing treatment is uncertain
(may need legal advice)

Under 16
• Persons aged below 16 (15 and under), usually require their parents or
legal guardians to consent to the treatment.
• If a person aged below 16 does not want to involve a parent or
guardian, you need to act a) in the patient’s best interests and b) taking
into account a specific list of recommendations (see Medical
Council, Guide to Professional Conduct for Ethics for Registered
Medical Practitioners 8th edition (2016): Section 16). Therefore < 16s
can consent if deemed to fully understand the treatment and its
consequences, as long as you are acting in the patient’s best interests.

• Look up Gillick Competency (The Fraser Guidelines) 1982 (UK).

 DOSE CALCULATIONS

Children’s doses usually calculated on an individual basis:

• Body surface area

• Most accurate, used for chemotherapy

• Dose per weight

• Most common

• Age band recommendations

• Popular for drugs with a wide therapeutic index e.g. antibiotics

• Most common cause of error is to miscalculate

• In particular the 10 fold overdose due to missing a decimal point

 RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn

Pregnancy

18
MEDICATION USE IN PREGNANCY

• Estimated that 26-99% of pregnant women used either prescribed or

• OTC medicines

• Up to 50% of pregnancies are unplanned

• Many take medicines before they know they are pregnant

• Medicines classified by FDA ( new system PLLR being introduced)

– A : Possibility of foetal harm remote e.g. folic acid
– B : Controlled studies fail to demonstrate risk e.g. amoxicillin
– C : Risk/benefit e.g.tramadol
– D : Positive evidence of risk but benefits may make use
unavoidable e.g. paroxetine
– X : Risk which outweighs benefit e.g. warfarin

• -8% of women use a category D/X medication during pregnancy

TIMING OF EXPOSURE AND RISK
• Important determinant of risk
• Important to determine no. of weeks post-conception
• Organogenesis in the 1st 12 weeks after conception
• 3 stages:
Pre-embryonic period 0-17 days
• “all or nothing effect”

Embryonic period (18 days – 8 weeks)

• fetus most vulnerable to toxins affecting organogenesis

Fetal period (week 9 – birth)

• some systems e.g. CNS & genitals, remain vulnerable; IUGR; functional defects

• Exposure close to term

– Neonatal effects or withdrawal effects
• Delayed effects are also possible causing effects years after exposure
in utero e.g. diethylstilbestrol - across generations
• Besides timing of exposure, other risk factors are important:
– Dose
– Polypharmacy - teratogens can act synergistically
– Genetic factors - genetic variation in drug metabolism
 PRINCIPLES OF PRESCRIBING IN PREGNANCY

• Only when necessary

• Consider gestational period
• Discourage use of inappropriate medications/substances
• Encourage compliance with necessary medications
• Use lowest effective dose for the shortest time
• Avoid polypharmacy if possible
• Use older, more established drugs
 RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn

Lactation

22
 PRINCIPLES OF PRESCRIBING FOR
BREAST-FEEDING MOTHERS

• Almost all drugs are excreted into milk

• Some are toxic and are completely contraindicated (amiodarone, cytotoxics etc.)
• Drugs licensed for use in infants are generally less of a concern
• Older drugs have more information
• Herbal medicines also have risks and typically there is less information about these

• Pre-term infants and “small for dates” infants are more vulnerable

• A regimen and route should be chosen to minimise infant exposure when

drug use is necessary
– Use monotherapy where possible
– Use more established drugs that have information that they are safe in breast-feeding
– Avoid drugs with long half-lives
– Avoid long-acting formulations
– Use lowest dose possible
– Feed before a dose is due where possible
– Dose before a baby’s longest sleep period if possible
 RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn

The Elderly
 PRESCRIPTIONS & THE ELDERLY

• Older people (>65) receive 45% of all prescribed medicines

• 78% of all prescribed medicines are issued by repeat prescription

• 22 items/ year are dispensed per older person

• Older people are 3 times more likely to be admitted to hospital with an

adverse drug reaction

(Hudson S & Boyter A, Pharmaceutical Care of the Elderly, Pharm J Vol 259 Oct 25, 1997; 686)
 DRUG HANDLING & AGEING
• Pharmacokinetics
– Absorption
• Delay rate of absorption but not usually extent
– Distribution
• Reduced lean body mass
• Reduced total body water by up to 15%
• Increased total body fat
• Lower serum albumin by up to 25%
• Increased free concentration of protein bound drugs such as warfarin
– Metabolism
• Reduced
– Renal excretion
• Reduced glomerular filtration rate. Declines by 1% per year from age 40]
• Assume some degree of renal impairment and calculate creatinine clearance (CrCl)
Typical CrCl for 70 year old = 70ml/min
• Pharmacodynamics
– Molecular & cellular changes alter the response to drugs in the elderly
– Not very much data
– Ethical considerations re trial design
• Reduction in homeostatic reserve
• Age-related changes in specific receptors & target sites
 ADVERSE DRUG REACTIONS:
THE PRESCRIBING CASCADE

Initial treatment Adverse effect Subsequent treatment

NSAID Rise in BP BP lowering drug

Thiazide diuretic Hyperuricaemia Treatment for gout

Metoclopramide Parkinsonian symptoms Levodopa

 PRINCIPLES OF PRESCRIBING
FOR THE ELDERLY

• Avoid unnecessary drug therapy

Is it really necessary? Is there an alternative non-drug option?
e.g. Hypnotics
• Review the effect of treatment on quality of life
e.g. hip replacement vs NSAIDs
• Treat the cause versus the symptom
• Take a full drug and allergy history
• Co-morbidities
• Choosing the drug
e.g. Which drug for treating hypertension in elderly male with prostatic
hypertrophy?
• Dose titration
Start low, go slow
• Medication review regularly
– SEE eModule on Medication review and information on Potentially Inappropriate
Prescribing
 MEDICATION REVIEWS

• You will have to complete a Medication Review on your clinical attachment. See
the eModule on Moodle.

• This is summatively assessed and represents 5%

• Component of ePortfolio
• Could also be in Clinical Data paper

• Common errors with the Medication Review

• Remember to do Medicaton Review WITH a patient.
• Patient must be on 5 medications.
• Think about compliance, PiP, PPOs, the burden of polypharmacy.
• There is more to MONITORING than just measuring a laboratory value.
• Think about symptoms (benefit/ side effect), signs, laboratory and drug
monitoring, drug-disease interactions and drug-drug interactions. See the
eModule and Med RV example.
• HINT: Almost all medications will require some degree of monitoring!
 PRESCRIBING IN THE ELDERLY CASE
(POLYPHARMACY)
Mrs ED (a frail 78 year old) presents with her carer at your general practice to
get her repeat prescription. She has a history of congestive heart failure and
rheumatoid arthritis. Her drug history is as follows:

• Diclofenac 50mg tds po

• Aspirin e/c 75mg od po
• Furosemide 40mg bd po
• Prednisolone 5mg mane po
• Digoxin 125micrograms od po

• What side-effects of her medication may present a problem for Mrs ED?

• What monitoring is needed?

• Is there a PPI?

• Is there a PPO?
EXAMPLES OF POSSIBLE SIDE EFFECTS
OF HER MEDICATION:
Diclofenac- Deterioration in Renal Function, GI
disturbance.
Aspirin- Risk of GI problems, Bleeding.
Furosemide- Falls risk, Hypokalaemia, Hypotension.
Prednisolone- GI effects (especially in combination with
aspirin and Diclofenac).
Digoxin- Risk of digoxin toxicity if patient is hypokalaemic.
MONITORING THAT WOULD BE REQUIRED:

• Bloods- In particular U&E, Digoxin level

• Blood pressure
• Consider the need to do a DEXA scan
 RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn

Opiate Replacement Therapy

 OPIATE REPLACEMENT THERAPY
Opiate replacement therapy (ORT) or opiate substitution therapy is a procedure of
replacing an illegal opioid (e.g. heroin) with a longer acting, less euphoric opioid.
ORT can:
a) Introduce a stable lifestyle (less withdrawal and cravings)
b) Help a person reduce and come off opiates in the future.
• Examples include methadone and buprenorphine, but there are many others
internationally
• Methadone is given in Ireland
• All patients must be registered on the Central Treatment List before being
prescribed methadone.
• This is a confidential list, accessible to only doctors and pharmacists.
• Each registered patient is assigned a doctor and a pharmacist.
• Every person participating in a methadone treatment programme with a "Drug
Treatment Card" (DTC) which is valid for one year.
• Methadone may only be prescribed on a special prescription form.
• Prescriber specifies if the doses should be supervised by the pharmacist
everyday, some days, or not at all.
• There are exceptions for inpatients and methadone prescribed for other
indications e.g. Palliative care.
 RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn

Palliative Care
 RECALL PRESCRIBING REQUIREMENTS
FOR CONTROLLED DRUGS (CDS)

• Prescriptions for controlled drugs must:

– Be in ink
– Name and type of practitioner
– (Dr, Dentist, Vet, Registered Nurse - 2007 Amendment regulations)
– Signed by the practitioner
– Dated by the practitioner
– Medical Council Number (Dr)
– Address and telephone number of the practitioner

• It must specify in the prescriber’s handwriting:

 The name and address of the patient
 The dose to be taken
 The form in the case of products
 The strength (when appropriate) and
 In both words and figures, either the total quantity of the drug or the number of
dosage units to be supplied
 Dr A. B. Kashan

123 High Street

Dublin 2

Tel 4022482

22/09/2018
Joe Barnes
456 Main Street, Beaumont

Rx
Morphine Sulphate tablets 10mg ONE twice a day
Mitte 14 (fourteen) tablets

A Kashan MD (MCN 12345)

 PRESCRIBING SCENARIO : PRESCRIBING
A CONTROLLED DRUG – CASE

Georgina O Connell has terminal ovarian cancer, She takes long acting 40mg as morphine sulphate tablets twice daily.

She is at home and you are taking advice from her palliative care consultant.

Her address is 42 The Square Irishtown.

She phones to tell you that her pain is poorly controlled. On discussion with her consultant it is suggested that her long

acting morphine sulphate be increased to an oral dose of 60mg twice daily for a week. She also has bone pain for which

her consultant has recommended a non-steroidal anti-inflammatory to be taken regularly.

Please write the prescription, including an appropriate dose of morphine for this lady for break
through pain?

Long acting Morphine sulphate:

Morphine Sulphate C/R - Controlled release
Morphine Sulphate M/R - Modified release
Morphine Sulphate P/R - Prolonged release
 PRESCRIBING SCENARIO:
PRESCRIBING A CONTROLLED DRUG

• ? Prophylactic laxatives

• ? Prophylactic antiemetics

• ? Adjuvant NSAIDs

• ? Breakthrough pain
 CALCULATING MORPHINE
BREAKTHROUGH DOSE

• Morphine sulphate tablets are long acting, sustained-release for smooth onset and
duration of action.

• To counteract breakthrough pain you will need to prescribe a shorter-acting acute

onset formulation also.

• Normally given 6 hourly as required or “prn”

• The dose for the short-acting morphine is calculated at 1/10th to 1/6th of total daily
dose of long-acting morphine

• e.g if total dose 120mg then the breakthrough dose 12-20mg 6hrly as required (prn)
 Dr D Spencer
Health Centre Anytown
Tel: 01 2345678
Georgina O’Connell
42, The Square
Irishtown

Date: 22/09/2018

MORPHINE SULPHATE C/R Tablets 60mg

Take ONE PO bd x 1/52
≡ 14 fourteen tablets

MORPHINE SULPHATE (short acting) Tablets 20mg

Take ONE PO 6 hourly prn x 1/52
≡ 28 twenty-eight tablets

Ibuprofen 400mg tds PO

Mitte 120 tabs

Lansoprazole 30mg nocte

Mitte 30 tabs

Senna tablets, 2 nocte

Mitte 60 tablets

DR D SPENCER (MCN 12345)

 SUMMARY – REVIEW OF
LEARNING OUTCOMES

• You should be able to:

 Recall the principles of safe prescribing (see eModule on Moodle).

 Recall principles of the Medication Review (see eModule on Moodle).

 Facilitate use of a formulary on-line (BNF/BNFc).

 Demonstrate safe prescribing for vulnerable patient populations in primary care.

 Children
 Pregnant women
 Lactating mothers
 Elderly people
 Methadone users
 People requiring palliative care
 REFERENCES

• Medicines Complete – series of relevant core texts available as e-books

from the RCSI Library
• BNF
• BNFc
• Antibioticprescribing.ie
• Stockley’s drug interactions