Patient Group Direction for the Supply of Nicotine Replacement Therapy, (NRT) (Smoking Cessation Service for Pharmacies in Kent)
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1 Patient Group Direction for the Supply of Nicotine Replacement Therapy, (NRT) (Smoking Cessation Service for Pharmacies in Kent) Written by: Marion Walton, Pharmacist Advanced, Adult Services Date: February 2013 Reviewed by: Sarah Martin, Smoking and Wellbeing Project Manager, Stop Smoking Service Marion Walton, Pharmacist Advanced, Adult Services Date: January 2015 Ratified by: Kent Community Health NHS Trust (KCHT) Medicines Management Governance Group Signed by: Pharmacist: Doctor: Clinical Governance: Sarah Leaver, Head of Medicines Management Dr Peter Maskell, Medical Director Karen Proctor, Head of Nursing and Quality / DIPC Date: March 2015 Review Date: March 2018 If you have any comments to make about this Patient Group Direction please contact Sarah Leaver, Head of Medicines Management, Chair of Professional Advisory Group Tel: sarah.leaver@kentcht.nhs.uk 1 of 7
2 YOU MUST BE AUTHORISED BY NAME, UNDER THE CURRENT VERSION OF THIS PGD BEFORE YOU ATTEMPT TO WORK ACCORDING TO IT Clinical Condition Indication Current smoker wishing to make an attempt to quit who is supported via a trained specialist Stop Smoking Advisor recognised by Kent Community Health NHS Trust Inclusion criteria Adults and children living in Kent (aged 12 years and over) who are referred to the pharmacist and are in possession of a service appointment card signed by their adviser as part of Kent Community Health NHS Stop Smoking service. Children (aged years) should be accompanied by a parent or guardian however in extreme cases; supplies can be made under the Fraser guidelines. A valid Disclosure and Barring (DBS) certificate must be held to treat this age group. In circumstances where a DBS is not in place, the client must be referred to the NHS Stop Smoking Service Client must have set a quit date & attend support sessions Pregnant and breast feeding women (weekly supplies) Vapours and E-Cigarette users, who have set a Quit Date Exclusion criteria Smokers not sufficiently motivated to quit Previous significant reaction to NRT or any ingredients contained in the products Children under 12 years of age Clients already taking bupropion or varenicline Clients where bupropion or varenicline might be more appropriate Cautions/Need for further advice Clients who have had a recent cardiovascular events e.g. myocardial infarction, stroke, unstable angina (within the last two weeks) please consider the risk / benefit ratio with these clients Clients with a history of cerebrovascular accidents including transient ischaemic attacks Clients with severe cardiovascular disease including severe arrhythmia Pregnancy (avoid 24 hour patches and liquorice flavour gum) The various manufacturers of NRT products list a range of drugs that may theoretically be affected by smoking cessation - irrespective of the clinical significance of these effects. These include: Drugs which are metabolised by the liver and may require dose reduction after smoking cessation: e.g. paracetamol, caffeine, imipramine, oxazepam, pentazocine, propranolol, theophylline, warfarin, oestrogens, lidocaine, chlorpromazine Drugs which may require dose reduction due to other mechanisms, e.g. insulin, beta blockers Drugs which may theoretically require an increase in dose after smoking cessation, due to a decrease in circulating catecholamines, e.g. isoprenaline, phenylephrine Clozapine/olanzapine clients who stop smoking may require adjustments or reductions to dosages of this medication. The prescribing GP should be informed that the client is stopping smoking before NRT is supplied. The client s level should be monitored for increased response and adverse effects 2 of 7
3 Cautions/Need for further Advice (continued) Caution for patches only - clients with previously diagnosed chronic generalised skin disease such as psoriasis, chronic dermatitis and urticaria Action if patient declines or is excluded Explain reasons for need of treatment Discuss and refer to doctor 3 of 7
4 Drug Details Name, form & strength of medicine 24 hour Nicotine patch - 21mg, 14mg & 7mg 16 hour Nicotine patch - 25mg, 15mg & 10mg Nicotine gum - 2mg, 4mg Nicotine lozenges - 2mg, 4mg Nicotine small lozenges - 1.5mg, 2mg, 4mg Nicotine inhalator - 15mg cartridge Nicotine mouth spray (1mg/spray) Nicotine strips (oral film) - 2.5mg See Appendix A for full product details Route/Method Dosage Topical / oral / sublingual In accordance with current smoking habit, an appropriate dosage of an appropriate NRT product will be supplied. For typical dosage regimes of NRT products, please see Appendix A In special cases e.g. smokers who are Pregnant or breast feeding Have established cardiovascular disease Diabetic Under 18 years of age On identified medications (eg: insulin, anticoagulants, theophylline, clozapine and olanzapine) reference will be made on the Pharmacist Checklist (Appendix B) and these clients will be seen by the pharmacist for weekly supplies Frequency Duration of treatment Maximum or minimum treatment period Quantity to supply/administer For weekly supply guidance please refer to formulary, Appendix C1 Please refer to formulary (Appendix C1) according to identified product Total of 7 weeks (if supply required for both primary and secondary products) Total of 10 weeks (if supplied primary product only) See below Maximum provision of product under PGD Primary product to be supplied for a maximum of 7 weeks Secondary product to be supplied for a maximum of 3 weeks If further NRT is required the client must purchase products 4 of 7
5 Side effects Side effects are usually transient but may include the following, some of which are a consequence of stopping smoking: nausea, dizziness, headaches, cold and flu-like symptoms, palpitations, dyspepsia and other gastrointestinal disturbances, hiccups, insomnia, vivid dreams, myalgia, chest pain, blood pressure changes, anxiety and irritability, somnolence and impaired concentration, dysmenorrhoea Product-specific side effects are detailed in the individual Summary of Product Characteristics (SPC) and reference made in Appendix A Additional facilities and supplies Variety of products available Product information leaflet Access to current BNF via Access to Summary of Product Characteristics via NICE guidance document on use of NRT PGD checklist completed Advice to client/carer The client must have set a quit date before starting NRT The risk/benefit from continuing smoking vs. using product with support should be explained The product should not be used if the client is still smoking A second product may be supplied for a maximum of three weeks at any stage of the intervention. A second prescription fee does apply, subject to the usual exemption categories If a client wishes to change to a different NRT product during the treatment period, they will incur an additional prescription charge, subject to the usual exemption categories Advise client of possible side effects of product Advise on withdrawal symptoms, e.g. weight gain, (how to manage this), the effects of smoking whilst using NRT particularly in vulnerable groups, (e.g. pregnant women, clients with cardiovascular disease) A client can access services if they wish to use an E-Cigarette in their quit attempt but these products are not available through the PGD and will need to be self-funded by the client. Give Product Information leaflet on specific product Give client (if appropriate) self-help leaflets NHS Helpline numbers for Kent Community Health NHS Stop Smoking Service , or text QUIT to National Numbers: General advice: (7am-11pm) Pregnancy advice: (12pm-9pm address: kcht.sss@nhs.net Web address: Follow-up information and advise on further supplies of NRT Follow up With GP/Stop Smoking Adviser if needed 5 of 7
6 Staff Characteristics Qualifications Specialist Competencies or Qualifications Continuing Training & Education Pharmacist holding current registration with General Pharmaceutical Council (GPhC) Has undertaken appropriate training and is approved as a supplier of NRT for Kent Community Health NHS Trust by the Stop Smoking Service (Training updates to be accessed every two years) via Has undertaken appropriate training for working under PGDs for the supply and administration of medicines The pharmacist is accountable for this work as defined in the current GPhC Standards of Conduct, Ethics & Performance and in agreement in place between KCHT and the supplying pharmacy Has read the current Fraser Guidelines if supplying to 12 to 16 year olds The practitioner should be aware of any change to the recommendations for the medicine listed. It is the responsibility of the individual to keep up-to-date with continued professional development and to work within the limitations of individual scope of practice Referral Arrangements and Audit Trail Referral arrangements As per local arrangements Records/audit trail Client s name, address, date of birth, NHS number and consent Contact details of GP Name and strength and quantity of NRT supplied Date of supply Advice given to client (including side effects) Signature/name of pharmacist who supplied the medication. Occasionally a third party may collect the prescription - but this should be minimised and not be a regular occurrence Signature of client (or client s representative) who received the medication References/Resources and BNF accessed online via (Feb 2015) Comments PGD for NRT (written by Sarah Martin and James Buckland, 2011) NICE guidance PH 26 (June 2010) Quitting smoking in pregnancy and following childbirth NICE guidance 10 Smoking cessation services (June 2008) NHS Local Stop Smoking Services: Service and Delivery Guidance NICE guidance Tobacco-harm reduction approaches to smoking (Jun13) The pharmacist will inform the Stop Smoking Service if they leave a pharmacy, and/or start work at another pharmacy in the Kent area. 5 of 7
7 This patient group direction must be agreed to and signed by all health care professionals involved in its use. The NHS Trust should hold the original signed copy. The PGD must be easily accessible in the clinical setting. Organisation Kent Community Health NHS Trust Authorisation Clinical Governance Lead Name: Karen Proctor Position: Head of Nursing and Quality / DIPC Signature: Date: 19 March 2015 Lead Pharmacist Name: Sarah Leaver Position: Head of Medicines Management Signature: Date: 11 March 2015 Lead Doctor Name: Dr Peter Maskell Position: Medical Director Signature: Date: 18 March 2015 Patient Group Direction Peer Reviewed by Name Position Date Susan Piddock Core team Manager, Smoking Cessation Service January 2015 Sarah Martin Project Officer, Smoking Cessation Service January 2015 Raymond Farmer Operations and Secondary Care Manager January 2015 Smoking Cessation Service Marion Walton Pharmacist Advanced, Adult Services February 2015 Elaine Anderson Matron Folkestone MIU February 2015 Emma Young Head of Podiatry Services February 2015 Emlata Ramdut Specialist Pharmacist, Adult Services February 2015 Kate Day GUM Lead nurse February of 7
8 Individual Authorisation PGDs DO NOT REMOVE INHERENT PROFESSIONAL OBLIGATIONS OR ACCOUNTABILITY. It is the responsibility of each professional to practice only within the bounds of their own competence and in accordance with their own Code of Professional Conduct. Note to Authorising Managers: authorised pharmacists should be provided with an individual copy of the clinical content of the PGD and a photocopy of the document showing their authorisation. This Patient Group Direction is to be read, agreed to and signed by all authorised pharmacists it applies to. One copy should be given to each authorised pharmacist with the original signed copy being kept by the nominated authorising manager with responsibility for PGDs within the practice. Reimbursement of products supplied under PGD Invoices must be received by the Stop Smoking Service no later than 6 weeks after last contact with the client. Failure to do so will result in non-payment of claims. I confirm that I have read and understood the content of this patient group direction and that I am competent to work under it within my professional code of conduct. Please sign and return this page to the Stop Smoking Service via to kcht.ssspharmacy@nhs.net Name of Professional Signature Signature of Authorising Manager with responsibility for PGDs Date 7 of 7
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