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

Éirinn

PRESCRIBING SC1
Planning Management, Data Interpretation and Communication
Prescribing:

• Planning Management

• Data interpretation

• Communicating information about medications

LEARNING OUTCOMES

Students should be able to :

• Locate information in the BNF to help with prescribing
• Choose the best management options for the most common acute and
chronic conditions
• Identify abnormalities in data/investigations and identify the most likely
underlying causes and suitable action
• Identify essential information that should be communicated to patients
before commencing a medication
• Identify vulnerable patient groups that need special attention when
communicating drug information
BNF ON-LINE ACCESS
PLANNING MANAGEMENT

Do I have:

• The Right Drug

• The Right Diagnosis
• The Right Patient
• The Right Dose
• The Right Time

All are involved in planning management when prescribing

PLANNING MANAGEMENT

• Knowledge of the management of Acute and Chronic medical conditions is

necessary for safe prescribing.
• Planning management of a condition requires various steps:
 Step 1: ABC
 Step 2: History and thorough physical exam
 Step 3: Review any available investigations
 Step 4: Medication review and Allergy Review
 Step 5: Action
ACUTE MEDICAL CONDITIONS: PLANNING
MANAGEMENT IN PRESCRIBING
Examples
• Cardiac Emergencies: STEMI/NSTEMI, unstable angina, tachycardia's
(a.fib/v.tachy/SVT), bradycardias, acute heart failure, cardiac arrest
• Respiratory Emergencies: Anaphylaxis, Acute Asthma/COPD exacerbation,
type 1 and 2 respiratory failure, PE, Pneumonia
• Gastroenterology Emergencies: Acute GI bleed
• Neurological Emergencies: Stroke, meningitis, epilepsy
• Metabolic Emergencies: HONK/DKA, electrolyte abnormalities
(K/Na/Ca),Addisonian crisis, myxoedema coma, thyrotoxicosis
• Acute Kidney Failure
• Acute poisoning
• Infections: Cellulitis, sepsis (Resp/Urosepsis/Infective endocarditis)
CHRONIC MEDICAL CONDITIONS:
PLANNING MANAGEMENT IN
PRESCRIBING
Examples
• Cardiac: CCF, Arrhythmias (ex:a.fib), stable angina, hypertension
• Respiratory: COPD, stable Asthma, CF, bronchiectasis
• Endocrine: Diabetes (type 1 and type 2), Conns, Cushing’s
• Neurological: Parkinson's, Stroke, epilepsy, dementia
• Gastroenterology: Inflammatory bowel disease (Crohns/ulcerative colitis),
Peptic ulcer, H.Pylori
• Rheumatological: Osteoporosis, rheumatoid arthritis, gout
ACUTE CONDITIONS

• Should always begin with assessing ABC and act on this if needed;
i.e.: prescribe oxygen, IV fluids etc
• When deciding what to prescribe always ensure that you are confident with
your diagnosis- If in doubt ask a senior colleague.
• Prior to prescribing ensure no major allergies and ensure you have
confirmed that it is the correct patient
CASE 1

• Examples;
A 77 year old male presents with crushing chest pain, he is diaphoretic and
looks very unwell. You immediately perform an ECG which reveals ST-elevation
in the inferior leads. His BP is 100/80, pulse rate 90, temperature 36.8 and
oxygen saturations 95%. What is your management plan:
• ABC
• Primary PCI- revascularisation is priority, but while awaiting transfer to
Cath lab, the following medications should be considered:
• Oxygen: Prescribe nasal prongs or mask therapy (1-4 L via nasal prongs, up
to 15L by mask): In oxygen section of kardex
• Aspirin 300mg OD PO: In Stat section of kardex (anti-platelet)
• Morphine 5-10mg IV (may need to give with an anti-emetic ): In Stat section
of Kardex (for chest pain)
• GTN spray: In stat section or PRN section of Kardex 9, GTN to vasodilate to
improve perfusion)
• Transfer CCU
• Beta-blocker- Needs to be prescribed regularly after the initial acute
treatment plan.
MANAGEMENT: - 1

• Acute
• Oxygen + dual anti-platelet
– (e.g. aspirin, ticagrelor)
• GTN + morphine
• Assess need for invasive versus conservative approach
MANAGEMENT: 2

• Invasive approach planned

• Oxygen + dual anti-platelet
– (e.g.aspirin, ticagrelor)
• GTN + morphine
• PCI
• Anti-coagulation:
– Unfractionated Heparin or LMWH
» E.g. Enoxaprin 1mg/Kg sub-cut every 12 hours
CASE 2

• A 88 year old man presents with acute shortness of breath. On review he

reports he is unable to lie flat for the last 2 weeks and has noticed lower
limb oedema. CXR shows gross pulmonary infiltrates. Vitals; BP
100/77mmHg, PR: 100, temperature 37.1 degrees Celsius, Oxygen
saturations 88%. ABG shows type 1 Respiratory failure. ECG: NAD.
Medications: Aspirin 75mg.
• What is your management plan/prescribing options:
• ABC: He is hypoxic and short of breath: He needs oxygen. Prescription
should be in the Oxygen section

• Treatment for his pulmonary oedema: at least 40 mg of IV Frusemide :

Written in Stat section or Regular section with a review date

• Need to monitor ins and outs/don’t lie flat/daily weights/salt restriction etc
MANAGEMENT PULMONARY OEDEMA FOR CCF 1.
ACUTE

• Initial Management
– Airway Assessment
– Continuous pulse oximetry
– Assess for hypo/hypertension
– Sit patient up
– Give 60-100% oxygen if no COPD
– Cardiac monitoring and treat any unstable arrhythmia
– Furosemide 40-120 mg intravenously (repeat if required)
– Urinary catheter in most cases to monitor urine
output/fluid balance
– Vasodilator therapy could be considered if no
contraindication: Morphine 2.5 – 5 mg iv (watch ABG);
GTN spray
MANAGEMENT (ACUTE)

• Investigate (as per previous)

– Repeat ABG

• May need GTN IV infusion if blood pressure allows

• If not responding may need transfer to intensive unit for Respiratory

support CPAP/BIPAP/intubation etc.
CASE 3

• A 17 year old boy presents with wheezing and facial swelling after eating a
chicken curry in his friends house. He has a known allergy to peanuts and
had forgotten to bring his EpiPen with. On arrival he looks very unwell, his
BP is 80/60mHg, pulse rate 122 and oxygen saturations 90%. He has a
diffuse wheeze on auscultation and facial and lip swelling.
• What are you planning to prescribe?
• ABC-Assess airway and ensure it is secure
• Oxygen: 100% (non-rebreather): Written in oxygen section
• Adrenaline 500 micrograms of 1:1000 IM: Written in stat section
• Chlorphenamine 10mg IV (antihistamine): Written in stat section
• Hydrocortisone 200mg IV: Written in stat section
• IV Fluid- 500ml bolus IV Normal Saline 0.9%: Written in fluids section
MANAGEMENT
BASIC CONCEPTS:
1. Airway
2. Breathing
3. Circulation
CHRONIC CONDITION

• Need to follow national and international guidelines or local hospital policies

• Most chronic conditions have recommended treatment options outlined by
numerous bodies: Ex;NICE, AHA/ASA (American Heart/Stroke Association),
European guidelines etc, Irish Heart Foundation.
PRESCRIBING IN CHRONIC CONDITIONS

• Most prescribing in chronic conditions needs regular review either by the GP

or in specialist OPD.
• Drug requirements may change as the chronic disease progresses. Ex:
Addition of extra inhalers in COPD, addition of additional anti-Parkinson's
medication in Parkinson's.
• Organ function may need to be monitored in chronic diseases as some
medications can affect organs in the long-term: Ex: Statins: monitor LFTs,
Diuretics; monitor renal function, amiodarone: monitor lungs function,
thyroid and liver etc.
• Drug dosage may need to be reviewed in the long term: Ex: may need to be
reduced if eGFR reduces or body weight decreases (ex: NOACs need to be
reduced if eGFR reduces) or may need to be increased if disease not
adequately controlled (Ex;anti-hypertensive therapy may need to be
optimised if BP poorly controlled)
CASE 1

• A 66 year old male presents to the rheumatology clinic complaining of

recent flares in his rheumatoid arthritis. He has become stiffer in all joints
but especially his hands and feet. He finds it difficult to open his buttons on
his shirt. On examination his hand exam reveals swollen fingers and they
are tender and hot to touch. He is currently on methotrexate 7.5mg weekly
along with folic acid 5mg. He has been commenced on a course of reducing
steroids by his GP and takes regular ibuprofen 400mg TDS. All bloods and
vitals are normal bar a raised ESR and CRP. What is the most appropriate
action to optimise management of his Rheumatoid Arthritis:
A. Add in opioid analgesia
B. Convert to IV steroids
C. Increase ibuprofen to 1g TDS
D. Increase methotrexate to 15mg weekly
E. Stop methotrexate and commence colchicine
• Ans: D
Methotrexate should be increased to 15mg
Disease modifying anti-rheumatic drugs (DMARDS)
Analgesics such as NSAIDs and steroids will help with pain and reduce
inflammation but will not reduce the long-term damaging effects of RA
Opioids are not a suitable long-term treatment option
CASE 2

A 65 year old male with a 40 pack year smoking history presents to your out
patient department as he has been referred from his general practitioner to the
respiratory service for suspicion of chronic obstructive pulmonary disease. The
patient reports increased shortness of breath on exertion and occasional
wheeze. He has a cough that is often productive and has recently had 2 lower
respiratory tract infections. His pulmonary function tests (PFTS) reveal an
obstructive picture and his FEV1 is 55%. His general practitioner started him on
a short-acting beta agonist PRN however further treatment is warranted.
What prescription would be suitable in this man to treat his COPD?
Many resource tools available : BNF and Guidelines
DATA INTERPRETATION

• Data can give us clues to the underlying cause of illness

• Abnormal data results may be a result of the disease/illness or it may be
due to a medication/treatment.
• Very important to try and differentiate between them.
• Many investigative tests can help with your diagnosis.
• Data should always be used in conjunction with the clinical history and
examination.
• Appropriate testing should be ordered for the suspected condition, avoid
wasting resources by ordering unnecessary tests.
INTERPRETATION OF DATA

Blood Investigations:
FBC:
• ↑WCC/Neutrophils: Infection or drugs ex: steroids
• ↓Neutrophils: Infection or drugs ex: chemotherapy or clozapine,
carbimazole, anticonvulsants (ex: carbamazepine), sulfasalazine, antibiotics
(penicillin's)
• ↓ Platelets: Infection/haematological
abnormalities(MDS,myeloma/ITP/DIC/HUS) or drugs ex: Heparin
• ↓Hb: Bleeding/haematological abnormalities or underlying side effect of
medication (bleeding) ex: Aspirin, Clopidogel, NOACs, Warfarin
U&E

• ↓Na: Fluid loss/SIADH/fluid overload secondary to organ failure: CCF,renal,

liver failure, thyroid dysfunction, psychogenic polydipsia, Addison's or drugs:
Diuretics(any type), antidepressants (ex:SSRI), antipsychotics
(ex:risperidone),anticonvulsants (ex:carbamazepine)
• ↓K: Inadequate intake, diarrhoea/vomiting(GI loss), renal tubular acidosis,
endocrine disorder: Cushing's/Conns or drugs: Ex: Loop diuretics and
thiazide diuretics, salbutamol, laxatives, high-dose steroids
• ↑K: Renal failure, Endocrine disorders such as Addison's disease, DKA or a
drug-related cause: ex: Potassium-sparing diuretics(spironolactone), ACE-
inhibitors, beta-blockers, NSAIDs

• AKI (raised urea and creatinine) : Pre/post or intrinsic kidney failure. Ex:
hypovolemia, obstruction, interstitial nephritis, GN, renal artery stenosis etc
or is this medication related: Many medications can cause renal impairment
or exacerbate pre-existing renal failure. Medications to watch for: NSAIDS,
ACE-I, aminoglycosides, diuretics
LFTs (Deranged LFTs↑)
Medical causes: Pre-hepatic (raised bilirubin: haemolysis), Hepatic (NASH,
Hepatitis, Cirrhosis, Malignancy, metabolic)
Or
Drug related ex: Statins, methotrexate, paracetamol, antibiotics
TFTs (↑↓)
Medical: Hypothyroid/hyperthyroid/tumour
Or
Drug Related: ex: Lithium, amiodarone, carbimazole, eltoxin
Radiological Investigations
• CXR: Need to identify abnormalities linked with common conditions:
- Pulmonary infiltrate: ?pneumonia
- Interstitial Oedema: ?CCF
- Cardiomegaly: ?Heart failure
- Fluid: ?Pleural effusion
- Tracheal deviation or collapse lung? Pneumothorax/obstructing tumour
- Fibrotic changes:? Pulmonary fibrosis (may be drug related)
By identifying changes on CXR will help you to decide on the appropriate
management and prescription.
Drugs can also cause certain lung changes which can be seen on CXR: Ex
Fibrosis ex: amiodarone, methotrexate, chemotherapy agents
ABG (Please refer to ABG clinical competencies lecture material
SC1)

Check for type 1 versus type 2 respiratory failure and metabolic

acidosis/alkalosis, will guide your management and prescription decisions.
Type 1 : ?Pneumonia, PE, CCF, Asthma
Type 2 : COPD Exaccerbation, chest wall deformities, Type 1 progressing to
Type 2 Resp failure, but also drugs: sedation/reduced breathing effort ex:
Opioids, Overdose of sedative medication
ECG(Please refer to Intermediate cycle ECG and cardiology
lectures)

-Bradycardia : heart block or Drug related ex: beta-blocker, donepezil, digoxin

-tachycardia: sinus tachy (Ex:infection)/ arrhythmias OR drug related:
Ex:salbutamol
-Wide QRS: Bundle-branch blocks, hyperkalaemia, ventricular tachycardia
OR drug related: antiarrhythmics (amiodarone, Sotalol), Antibiotics (ex:
Clarithromycin, Ciproflxacin,Levoflaxacin, ketoconazole), antidepressants
(ex:amitryptilline, sertraline, venlafaxine), antipsychotics
(ex:haloperidol,quetiapine)
CASE 1

• A 50 year old male presents to the hospital complaining of muscle aches on

his legs and shoulders. He reports that they have developed over the last 3
months and are constant in nature. His background medical history
includes:
-IHD(x2 coronary stents) inserted 4 months ago
-Hypercholesterolaemia: diagnosed 4 months ago
-Hypertension
• His recent bloods show:
ESR and CRP are normal
Physical Exam: NAD
He drinks 12 units of alcohol per week and works as a lorry driver. He has a
sedentary lifestyle.
Medications include: aspirin, clopidogrel, amlodipine, atorvastatin, bisoprolol

What is the most likely cause for this mans underlying blood abnormalities:

A. Polymyalgia rheumatica
B. Peripheral vascular disease
C. Acute decompensated liver disease secondary to alcohol
D. Side effect of statin therapy
E. Side effect of amlodipine
Ans: Statin therapy is the most likely cause

What should make you come to this conclusion?:

Polymyalgia Rheumatica: Infammatory markers normal so unlikely
PVD: Pain not limited to calves on walking, nature of pain not typical and pain
also in shoulders so unlikely.
Liver Failure secondary to alcohol: Patient not a very heavy drinker (12 units
per week) and AST:ALT ratio would go against diagnosis
Statin therapy: Symptoms correlate to when patient was diagnosed with
hypercholesterolaemia and likely when he was started on medication, CK
raised and pain typical of statin induced myopathy. LFT derangement also likely
to be cause by statin therapy
Amlodipine: Not typical to cause this pain, tends to cause lower limb oedema
CASE 2

A 77 year old male presents to the clinic complaining of worsening shortness of

breath with has been progressive in nature over the last year. He has a
background history of rheumatoid arthritis, atrial fibrillation, cataracts and
hypertension. His current medications include:
-Rivaroxaban 20mg OD
-Methotrexate 20mg Weekly
-Folic Acid 5mg Weekly
-Ramipril 5mg OD
-Paracetamol PRN
-Hydrochlorothiazide 25mg OD
He is an ex-smoker with a 5 pack year history. He works as an accountant and
keeps to pets.
CXR SHOWS

ABG
PH: 7.40 (7.35 - 7.45)
PO2: 8.0 (11–13 kPa )
PCO2: 6.0 (4.67 - 6.4 kPa)
HCO3: 25 (22 - 26 mmol/L)
• What is the most likely cause for his underlying respiratory condition?
A. Community acquired pneumonia
B. COPD
C. Pleural effusion secondary to congestive cardiac failure
D. Drug related pulmonary fibrosis
E. Asbestosis
• ANS: Drug related pulmonary fibrosis:
Methotrexate is the most likely cause. It can cause pulmonary fibrosis.
COMMUNICATION IN PRESCRIBING

• Adequate information should always be conveyed to patients when

prescribing medications
• Prior studies show poor knowledge of patients about their medications and
side-effect profile- this can lead to poor compliance
- 35% patients knew side-effects of medications1
- 30-50% of patients do not take their medication for chronic conditions
as prescribed4(WHO)
WHAT TO COMMUNICATE?

• Doctors and pharmacists should communicate with patients :

-Indication for the drug
-How to take the medication
-Potential serious side-effects
-Interactions (food/drink or drug interactions)
-Contraindications
-Alternative options if available
-Need for monitoring if applicable
-Caution with certain drugs in pregnancy should be conveyed to females
• Ensure the patient has no sensory impairment that can affect
communication. If hearing impairment ensure hearing aids/written
communication given. If sight is poor may have difficulty with medications
(ex: identifying them/reading side effects/directions etc) hence good oral
communication very important and blister packs or supervised
administration may be required.
• Translators if language barriers
• If cognitive deficits may need family member or carer involved in medication
communication
CASE 1

A 70 year Caucasian female presents to your out patient department with newly
diagnosed hypertension. Results from a 24-hour ABPM shows an average
daytime BP of 169/95 mmHg (normal range <135/85mmHg) and night-time
average of 164/89 mmHg(normal range <120/70mHg). Her background medical
history includes osteoporosis and depression. Her medications include
escitalopram 5mg,calcichew D3 forte BD and alendronate weekly. You decide
to commence blood pressure medications

What recommendation would you make?

What would you communicate to the patient?
What side effects would you warn her about?
PLAN……

• 1st step: Need to select appropriate treatment option. Follow NICE

guidelines (over 55 years of age and caucasian: Calcium-channel blocker)
• 2nd Step: Need to communicate to patient: Indication why you are starting it
(ex: to control your blood pressure to reduce your risk or cardiovascular,
stroke and kidney disease)
• 3rd step: Need to tell her how to take it: Oral tablet taken once daily
• 4th Step: Communicate significant/common side effects;
Dizziness/lightheaded (if BP goes too low), lower limb oedema, nausea/GI
upset
• 5th Step: Discuss that there are alternative therapies should this not work or
should she not tolerate medication (other options: ACE-I, thiazide diuretics
etc)
• 6th Step: Advise that you will need to see her back to monitor her BP to
ensure the medication is working in a few weeks/months time
• 7Th Step: Address any concerns or questions she may have
REFERENCES

1.Hays, Ron D., et al. "Physician Communication When Prescribing New

Medications.") Archives of Internal Medicine 166, no. 17 (2006): 1855-62
2.Pass the PSA: Author: William Brown, Kevin Loudon, James Fisher, Laura
Marsland. Publisher: Churchill Livingstone Elsevier 2014.
3. Rubio, J.S., et al., Measurement of patients' knowledge of their medication in
community pharmacies in Portugal. Cien Saude Colet, 2015. 20(1): p. 219-28.
4. Sabaté E, editor. , ed. Adherence to Long-Term Therapies: Evidence for
Action. Geneva, Switzerland: World Health Organization; 2003.