Oxford Handbook of Clinical Pharmacy PDF

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 i OXFORD MEDICAL PUBLICATIONS Oxford Handbook of Clinical Pharmacy ii Published and forthcoming Oxford Handbooks Oxford Handbook for the Foundation Oxford Handbook of General Programme 4e Practice 4e Oxford Handbook of Acute Oxford Handbook of Genetics Medicine 3e Oxford Handbook of Genitourinary ...

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OXFORD MEDICAL PUBLICATIONS

Oxford Handbook of

Clinical Pharmacy

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Published and forthcoming Oxford Handbooks Oxford Handbook for the Foundation Programme 4e Oxford Handbook of Acute Medicine 3e Oxford Handbook of Anaesthesia 4e Oxford Handbook of Applied Dental Sciences Oxford Handbook of Cardiology 2e Oxford Handbook of Clinical and Healthcare Research Oxford Handbook of Clinical and Laboratory Investigation 3e Oxford Handbook of Clinical Dentistry 6e Oxford Handbook of Clinical Diagnosis 3e Oxford Handbook of Clinical Examination and Practical Skills 2e Oxford Handbook of Clinical Haematology 4e Oxford Handbook of Clinical Immunology and Allergy 3e Oxford Handbook of Clinical Medicine – Mini Edition 9e Oxford Handbook of Clinical Medicine 9e Oxford Handbook of Clinical Pathology Oxford Handbook of Clinical Pharmacy 3e Oxford Handbook of Clinical Rehabilitation 2e Oxford Handbook of Clinical Specialties 9e Oxford Handbook of Clinical Surgery 4e Oxford Handbook of Complementary Medicine Oxford Handbook of Critical Care 3e Oxford Handbook of Dental Patient Care Oxford Handbook of Dialysis 4e Oxford Handbook of Emergency Medicine 4e Oxford Handbook of Endocrinology and Diabetes 3e Oxford Handbook of ENT and Head and Neck Surgery 2e Oxford Handbook of Epidemiology for Clinicians Oxford Handbook of Expedition and Wilderness Medicine 2e Oxford Handbook of Forensic Medicine Oxford Handbook of Gastroenterology & Hepatology 2e

Oxford Handbook of General Practice 4e Oxford Handbook of Genetics Oxford Handbook of Genitourinary Medicine, HIV and AIDS 2e Oxford Handbook of Geriatric Medicine 2e Oxford Handbook of Infectious Diseases and Microbiology Oxford Handbook of Key Clinical Evidence Oxford Handbook of Medical Dermatology 2e Oxford Handbook of Medical Imaging Oxford Handbook of Medical Sciences 2e Oxford Handbook of Medical Statistics Oxford Handbook of Neonatology Oxford Handbook of Nephrology and Hypertension 2e Oxford Handbook of Neurology 2e Oxford Handbook of Nutrition and Dietetics 2e Oxford Handbook of Obstetrics and Gynaecology 3e Oxford Handbook of Occupational Health 2e Oxford Handbook of Oncology 3e Oxford Handbook of Operative Surgery 3e Oxford Handbook of Ophthalmology 3e Oxford Handbook of Oral and Maxillofacial Surgery Oxford Handbook of Orthopaedics and Trauma Oxford Handbook of Paediatrics 2e Oxford Handbook of Pain Management Oxford Handbook of Palliative Care 2e Oxford Handbook of Practical Drug Therapy 2e Oxford Handbook of Pre-Hospital Care Oxford Handbook of Psychiatry 3e Oxford Handbook of Public Health Practice 3e Oxford Handbook of Reproductive Medicine & Family Planning 2e Oxford Handbook of Respiratory Medicine 3e Oxford Handbook of Rheumatology 3e Oxford Handbook of Sport and Exercise Medicine 2e Handbook of Surgical Consent Oxford Handbook of Tropical Medicine 4e Oxford Handbook of Urology 3e

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Oxford Handbook of

Clinical Pharmacy Third Edition Edited by

Philip Wiffen Editor in Chief, European Journal of Hospital Pharmacy; Visiting Professor, Dept of Pharmacy and Pharmacology, University of Bath, UK

Marc Mitchell Divisional Lead Pharmacist, Oxford University Hospitals NHS Foundation Trust, UK

Melanie Snelling Lead HIV/Infectious Diseases Pharmacist, Oxford University Hospitals NHS Foundation Trust, UK

Nicola Stoner Cancer Consultant Pharmacist, Oxford Cancer and Haematology Centre and Oxford Cancer Research Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, UK; Visiting Professor, School of Chemistry, Food and Pharmacy, University of Reading, UK

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1 Great Clarendon Street, Oxford, OX2 6DP, United Kingdom Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries © Oxford University Press 2017 The moral rights of the authors have been asserted First Edition published in 2007 Second Edition published in 2012 Third Edition published in 2017 Impression: 1 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by licence or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this work in any other form and you must impose this same condition on any acquirer Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America British Library Cataloguing in Publication Data Data available Library of Congress Control Number: 2016945512 ISBN 978–0–19–873582–3 Printed and bound in China by C&C Offset Printing Co., Ltd. Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breast-feeding Links to third party websites are provided by Oxford in good faith and for information only. Oxford disclaims any responsibility for the materials contained in any third party website referenced in this work.

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Preface to the third edition When we embarked on the first edition almost 10 years ago we did not envisage the enthusiasm that has developed for the Oxford Handbook of Clinical Pharmacy. We are very happy to launch the third edition. This edition has some 25 or so new topics and most of the existing topics have been revised or reworked in some way. We have widened the number of authors to bring new skills and knowledge into this edition. Clinical pharmacy has undergone rapid development during the lifetime of this little book. In the UK, a hospital pharmacy without clinical services now seems strange but the battle to establish clinical pharmacy is still not won in parts of Europe, particularly in Eastern Europe. The last 10 years have also seen rapid development around the appointment and role of consultant pharmacists, who are making major contributions in improving patient outcomes and raising the research agenda within pharmacy. We have sections in this edition on annotating medicine charts and writing in patients’ notes. We suspect the life of these topics is limited as we progress rapidly into electronic patient records. Finally, we are encouraged to see the concept of evidence-based practice permeating the whole of hospital pharmacy activities. We would remind you that this handbook was never perceived as a formulary but sits alongside such texts to provide evidence and hopefully wisdom for clinical pharmacists. PW MM MS NS

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Acknowledgements We are grateful to the following people who provided comments and help: Jen Weston, Janice Craig, David Hutchings, Rhiannon Thomas, Eunice Morley, Emma Pullan, Sarah Cripps, Charlotte Harris, Jo Coleman, Vicky Price, Yovana Sooriakumaran, and Hannah Hunter.

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Contents Contributors ix Symbols and abbreviations x 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

Adherence  Adverse drug reactions and drug interactions  Anaphylaxis  Clinical pharmacy skills  Clinical trials  Controlled drugs  Evidence-based medicine  Herbal medicines  Medical gases  Patient management issues  Patient-specific issues  Pharmaceutical calculations  Medicines management  Research  Therapy-related issues: gastrointestinal  Therapy-related issues: cardiovascular system  Therapy-related issues: respiratory system  Therapy-related issues: central nervous system  Therapy-related issues: infections  Therapy-related issues: endocrine  Therapy-related issues: obstetrics and gynaecology  Therapy-related issues: malignant diseases and immunosuppression 

1 17 27 33 105 117 123 143 157 171 203 229 239 291 299 321 373 397 447 483 505 517

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CONTENTS

23 24 25 26 27

Therapy-related issues: nutrition and blood  Therapy-related issues: musculoskeletal  Therapy-related issues: skin  Therapy-related issues: palliative care  Therapy-related issues: miscellaneous  Appendix: Supplementary data

Index 701

553 597 613 629 643 679

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Contributors Judith Bailey Oxford University Hospitals NHS Foundation Trust, Oxford, UK

Olivia Moswela Oxford University Hospitals NHS Foundation Trust, Oxford, UK

Nina Barnett Pharmacy, London Northwest Healthcare NHS Trust & NHS Specialist Pharmacy Service, UK

Bernard Naughton Formerly Oxford University Hospitals, NHS Foundation Trust, Oxford, UK

Rachel Brown Oxford Health NHS Foundation Trust, Oxford, UK

Sarah Poole Oxford University Hospitals NHS Foundation Trust, Oxford, UK

Fearn Davies Oxford University Hospitals NHS Foundation Trust, Oxford, UK

Jas Sagoo Medicines Management Lead, Oxfordshire Clinical Commissioning Group, UK

Louise Dunsmure Oxford University Hospitals NHS Foundation Trust, Oxford, UK

Aarti Shah Formerly Oxford University Hospitals, NHS Foundation Trust, Oxford, UK

Clare Faulkner Oxford University Hospitals NHS Foundation Trust, Oxford, UK

Laura Smith Oxford University Hospitals NHS Foundation Trust, Oxford, UK

Janet Hemingway Oxford University Hospitals NHS Foundation Trust, Oxford, UK

Amy Tse Oxford University Hospitals NHS Foundation Trust, Oxford, UK

Gwen Klepping Oxford University Hospitals NHS Foundation Trust, Oxford, UK

Laura Watson Formerly Oxford University Hospitals, NHS Foundation Trust, Oxford, UK

Katie McDonald Oxford University Hospitals NHS Foundation Trust, Oxford, UK

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Symbols and abbreviations i d > < ♂ ♀ ° 5-HT A&E A&W AAA ABC abdo ABPI ACE ACV ADR AF AFB ALP ALT APPT ARB ASCO AS AST AUC AV BDP BiPAP BMI BMR BNF BP BPH BSA

increased decreased greater than less than male female degrees 5-hydroxytryptamine (serotonin) accident and emergency alive and well abdominal aortic aneurysm airway, breathing, and circulation abdominal Association of the British Pharmaceutical Industry angiotensin-converting enzyme assist-control ventilation adverse drug reaction atrial fibrillation acid-fast bacilli alkaline phosphatase alanine aminotransferase activated partial thrombin time angiotensin receptor blocker American Society of Clinical Oncology ankylosing spondylitis aspartate aminotransferase area under the plasma concentration curve arteriovenous beclometasone dipropionate bi-level positive airway pressure body mass index basal metabolic rate British National Formulary blood pressure benign prostatic hyperplasia body surface area

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SYMBOLS AND ABBREVIATIONS

CAD CAPD CAVD CAVH CD CHF CMV CNS C/O CO2 COC COPD COSHH COX CPAP CrCl CRP CSF CTC CVC CVP CVS CVVHDF CXR CYP450 Da DDx, ZZ DHx DIC DM DOE DTI DUE DVT Dx, Z E/C EBM ECF ECG eGFR

coronary artery disease continuous ambulatory peritoneal dialysis continuous arteriovenous haemodialysis continuous arteriovenous haemofiltration controlled drug congestive heart failure continuous mandatory ventilation central nervous system complaining of carbon dioxide combined oral contraceptive chronic obstructive pulmonary disease Control of Substances Hazardous to Health cyclooxygenase continuous positive airway pressure creatinine clearance C-reactive protein cerebrospinal fluid common toxicity criteria central venous catheter central venous pressure cardiovascular system continuous venovenous haemodiafiltration chest X-ray cytochrome P450 dalton differential diagnosis drug history disseminated intravascular coagulation diabetes mellitus disease-orientated evidence direct thrombin inhibitor drug-use evaluation deep vein thrombosis diagnosis enteric-coated evidence-based medicine extracellular fluid electrocardiogram estimated glomerular filtration rate

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SYMBOLS AND ABBREVIATIONS

ESBL ESR EU FBC FH G6PD GABA GCP GFR GI GIT GMP GOR GORD GP GSL GTN HbA1c HCP HD HDF HDL HF HIT HIV HPA HPC HR HRS HRT IA ICF ICS IM IMP IMV INR IO IPS ITU

extended-spectrum B-lactamases erythrocyte sedimentation rate European Union full blood count family history glucose-6-phosphate dehydrogenase gamma-aminobutyric acid good clinical practice glomerular filtration rate gastrointestinal gastrointestinal tract good manufacturing practice glucose oxidation rate gastro-oesophageal reflux disease general practitioner general sales list glyceryl trinitrate glycosylated haemoglobin healthcare professional haemodialysis haemodiafiltration high-density lipid haemofiltration heparin-induced thrombocytopenia human immunodeficiency virus Health Protection Agency history of presenting complaint heart rate hepatorenal syndrome hormone replacement therapy intra-articular intracellular fluid inhaled corticosteroid intramuscular(ly) investigational medicinal product intermittent mandatory ventilation international normalized ratio intra-osseous Institute of Purchasing Supply intensive therapy unit

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SYMBOLS AND ABBREVIATIONS

IV Ix JVP K+ KCCT LABA LFT LMWH LTOT M/R MAOI MARS MCH MCHC MCV MDA MDI MDS MHRA MI MIC MOAI MRSA MSSA NBM ng NG NGT NHS NICE NNH NNRTI NNT NPSA NSAID NSF NSTEMI NYHA O/E O2

intravenous(ly) investigations jugular venous pressure potassium kaolin cephalin clotting time long-acting beta-2-agonist liver function test low-molecular-weight heparin long-term oxygen therapy modified-release monoamine oxidase inhibitor molecular absorbent recirculating system mean corpuscular haemoglobin mean corpuscular haemoglobin concentration mean cell volume Medical Devices Agency metered-dose inhaler monitored dose system Medicines and Healthcare products Regulatory Agency myocardial infarction minimum inhibitory concentration monoamine oxidase inhibitor meticillin-resistant Staphylococcus aureus meticillin-susceptible Staphylococcus aureus nil by mouth nanogram nasogastric nasogastric tube National Health Service National Institute for Health and Care Excellence number needed to harm non-nucleoside reverse transcriptase inhibitor number needed to treat National Patient Safety Agency non-steroidal anti-inflammatory drug National Service Framework non-ST-segment elevation myocardial infarction New York Heart Association on examination oxygen

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SYMBOLS AND ABBREVIATIONS

ortho PA PABA Paco2 Pao2 PC PCC PCI PE PEEP PEG PGD PICC PMCPA pMDI PMH PMR PMS PNS PO POD POEM POM PONV POP PPI ppm PR PRN PSV PT PUD QP R&D RA RBC Resp SABA SBOT

bones and joints psoriatic arthritis para-amino benzoic acid partial pressure of carbon dioxide in arterial blood partial pressure of oxygen in arterial blood presenting complaint prothrombin complex concentrate percutaneous coronary intervention pulmonary embolism positive end-expiratory pressure percutaneous endoscopic gastroscopy patient group direction peripherally inserted central catheter Prescription Medicines Code of Practice Authority pressurized metered-dose inhaler past medical history prescription medication records pre-menstrual syndrome peripheral nervous system per os (by mouth) patient’s own drug patient-orientated evidence that matters prescription-only medicine postoperative nausea and vomiting progestogen-only pill proton pump inhibitor parts per million per rectum (by the rectum) pro re nata (as required) pressure support ventilation prothrombin time peptic ulcer disease qualified person research and development rheumatoid arthritis red blood cell respiratory system short-acting beta-2-agonist short-burst oxygen therapy

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SYMBOLS AND ABBREVIATIONS

SC S/R SH SIMV SOB SPC SR SSRI stat STEMI T3 T4 Tmax TB TBC TBG TDM TENS TG TIA TNF t-PA TPN TPO TRH TSH TTO U&Es UFH UKMI UV v/v v/w VAC VAS VAT VF VRE VRSA

subcutaneous/ly systems review social history synchronous intermittent mandatory ventilation short of breath summary of product characteristics sinus rhythm selective serotonin re-uptake inhibitor at once ST-segment elevation myocardial infarction tri-iodothyronine thyroxine time to maximum drug concentration tuberculosis to be confirmed/awaiting confirmation thyroid-binding globulin therapeutic drug monitoring transcutaneous electronic nerve stimulation triglyceride transient ischaemic attack tumour necrosis factor tissue plasminogen activator total parenteral nutrition thyroid peroxidase thyrotropin-releasing hormone thyroid-stimulating hormone to take out urea and electrolytes unfractionated heparin UK Medicines Information ultraviolet volume in volume volume in weight vacuum-assisted closure visual analogue scale value added tax ventricular fibrillation vancomycin resistant enterococci vancomycin resistant MRSA

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SYMBOLS AND ABBREVIATIONS

VT VTE VV WCC w/v w/w WHO

ventricular tachycardia venous thromboembolism venovenous white cell count weight in volume weight in weight World Health Organization

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Chapter 1

Adherence Introduction to adherence 2 Assessing adherence 5 Adherence support 6 Adherence consultations 8 Writing patient information leaflets 11 Health coaching to support adherence 14

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CHApter 1

Adherence

Introduction to adherence What is adherence? It is estimated that 30–50% of prescribed medicines for long-term conditions are not taken as recommended. this represents a cost both in physical (ill health) and economic terms. ‘Compliance’ is defined as the extent to which the patient’s behaviour matches the prescriber’s recommendations. It implies that the patient will simply follow the recommendations of the doctor (or other healthcare professional) with little, if any, discussion or negotiation. ‘Concordance’ is a two-way exchange between the healthcare professional and the patient whereby the prescriber and the patient agree therapeutic decisions that incorporate their respective views. the patient participates in both the consultation and the decision-making process, and the patient’s preferences and beliefs are taken into account. ‘Adherence’ is somewhere between compliance and concordance. It is the extent to which the patient’s actions meet the prescriber’s recommendations or expectations. Ideally, the healthcare professional should accept that the patient’s beliefs, preferences, and prior knowledge influence medicine-taking and should attempt to address this. However, adherence interventions are often made after the prescription is written and the patient might not have had much influence on the choice of drug. Consequently, pharmacists and other healthcare professionals may have a bigger role in facilitating adherence than doctors. Adherence support is often a key activity for specialist pharmacists but it can (and should) be carried out to some extent by pharmacists in their everyday practice.

Why is adherence important? Non˗adherence usually limits the benefits of medicines, ...