Medicines Management Optimisation Achieving your 5 a day post-mi Medication WORKSHOP

Transcription

1 Medicines Management Optimisation Achieving your 5 a day post-mi Medication WORKSHOP

2 What is Medicines Optimisation? the safe and effective use of medicines to enable the best possible outcomes NICE ng

3 What do BACPR S&CC say? Cardioprotective Medication Current use of cardioprotective medication should be assessed (inc adherence) with the aim of ensuring uptitration of medication during the programme so that evidence-based dosages are achieved. Patients beliefs about medication should also be assessed as this affects adherence to drug regimens Key drugs: antiplatelets, lipid-lowering, betablockers, ACE-I/AIIRA, calcium channel blockers, anticoagulants, diuretics

4 What do CC for HBC&E say? Recognise opportunities and barriers to implementing interventions Agree goals for the intervention Implement behaviour change in a manner consistent with its underlying philosophy Make and review action plans based on identified goals Carry out health behaviour problem solving End the intervention in a planned manner and to plan for long term maintenance of the new health behaviours

5 What about non-medical prescribing? Aims: Medicine access patient choice increased more efficient and quicker Improve access to advice & services; Good use of appropriately skilled & placed healthcare workforce Includes allowing doctors to make best use of their expertise Contribute to an integrated seamless healthcare system; Increase capacity to meet the increased demand for the provision of new and existing NHS services; Improve patient care without compromising patient safety

6 Medicines Optimisation achieving 5-a-day as part of cardiac rehabilitation 0. General post-mi 1. Single / dual antiplatelet therapy 2. ACE-I / AIIRA 3. Statin 4. Betablocker 5. GTN 5. PPI

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8 0. General post-mi medication

9 0. General post-mi medication Reduced morbidity & mortality Reduce progression of disease (CHD. ACS. HF) Keenness to follow instructions High contact with CR for modifications, answers, info Address misconceptions Fit with lifestyle Instil ownership History & Examination Usual effects & s.effects of medications vs those of post-mi Effective system for your team & area Negotiation, communication, listening, pt-centred skills Guidelines Newness forgetting medication, lack of fit Wellness need not felt Side-effects of medication vs s.effects of post-mi Ownership. Whose job is it? Time for assessment, review, up-titration, follow-up Access to notes System safe, effective, individualised, aspirational CR play its part in the bigger picture: pt. relative. GP. PN. Cardiologist. Pharmacist. Daily News. Others Role of self Education & information opportunities

10 1. Anti-platelet: single / dual

11 1. Anti-platelet: single / dual Reduce platelet aggregation DAPT for time-limited period Bruising Bleeding Upper GI symptoms BD forgetfulness Misunderstanding of need for both synergistic effect Past gastric ulceration/issue, bleeding hx, age, anaemia. AF Surgery Anticoagulant Abdominal tenderness Aspirin: with or without water; with food Communicate length of therapy Doors and windows - DAPT Guidelines?

12 2. ACE-I / AIIRB

13 2. ACE-I / AIIRB Prevent HF. Reduced morbidity & mortality Re-introduction post revascularisation Up-titration. Down-titration Monitoring Sx, U&E, BP Symptomatic low BP Cough Angioedema. Renal failure. Bilateral RAS Ownership over titrations Past intolerance cough, angioedema, bilateral RAS Renal function Diuretics. Potassium supplementation Hypertension. HF U&E 7 days post up-titration Guidelines? Planned what to do if; monitoring; holidays Shared care GP, PN, Cardiologist, CR team nonprescribers, PATIENT Communication

14 3. Statin

15 3. Statin Reduce mortality and morbidity Improve the numbers lower LDL & cholesterol (when to test?) Reduce vascular inflammation, stabilise plaque Up-titrate. Down-titrate. Switch Past intolerance really? Alcohol excess Liver function test Familial hyperlipidaemia. Simon Broom criteria Lipid levels Guidelines? Simvastatin circadian rhythm forgetfulness Myopathy vs new exercise effect Keeping up with the latest news My cholesterol is normal Establishing on suitable, effective drug & dose Cost? Monitoring muscular aches CK after 2 day exercise-free symptomic only With exercise (HDL), weight loss, healthy eating Familial hypercholesterolaema nurse

16 4. Betablocker

17 4. Betablocker Up to 1 year post MI Reduce symptoms in HF Improve survival Up-titration. Down-titration. De-prescribing Timing Wheeze. Tiredness. Cold peripheries. ED. Mood Bradycardia. Heart block. Asthma 5 day dip post up-titration Reduced hypoglycaemia warning Chest conditions. Intolerance. Pulmonary oedema. Unstable HF Hypertension. Angina Guidelines? Planned what to do if; monitoring; holidays Shared care GP, PN, Cardiologist, CR team nonprescribers, PATIENT Communication

18 5. Nitrolingual spray

19 5. Nitrolingual spray Peripheral vasodilatation Increase confidence Reduce fear Reduce unnecessary re-admission Prophylaxis when pattern established Join with what to do if advice Past use. Associations of past use at MI ED & use of PDE5 inhibitors Trial in your clinic? Guidelines? Headaches. Hypotension Dyspepsia vs angina vs MSK vs anxiety Fear of use inevitable admission fear Embarrassment. Family concern Taste associated with effectiveness PDE5 inhibitors Avoid scare-induction Panic! I ve forgotten my spray Review if new or increased need for spray

20 5. PPI

21 5. PPI Prophylaxis in view if DAPT plus Reduce unnecessary re-admissions with CP Encourage best time of day empty stomach Appropriate referral for review Up-titration. Down-titration. De-prescribing Weight loss. Healthy eating. Alcohol & nicotine reduction or cessation Past tolerance and intolerance Chest and abdo exam & palpation Anaemia Guidelines? Gastric upset try another Not all fit with Clopidogrel Head and Shoulders effect Systemic effect of Aspirin & DAPT Start as in-pt CR review & alter or refer GP Information

22 Considerations for achieving 5 a day My role in medication optimisation As non-medical prescriber in CR As non-prescriber in CR Systems in place or not in place How I fit into the bigger team with patient, family, community pharmacist, GP, practice nurse, cardiologist; working together How can I and my team alter my / our / the system so it fits? A good start Improving my/our role with one medication Use resources team, guidelines made easy, web, forums, associations Audit results & share to improve care; NMC revalidation

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24 go forth & optimise Any questions or comments?