Medicines optimisation is all about supporting patients so that they get the best possible outcomes from their medicines. It is about talking and engaging with individuals to understand their beliefs and concerns about their medicines and what they would like their medication to achieve. It is also about ensuring that the medicine chosen is clinically appropriate, safe and effective and will help patients to achieve their goals, and about supporting patients to continue to use their medicines in a way that fits with their lifestyle.
To make medicines optimisation meaningful we need to engage with patients and involve them in decisions about their treatment. This may mean stopping medicines or providing non-medical treatment advice as well as starting medicines (PJ 2014;292:48).
The medicines optimisation briefings we have produced are for pharmacists working in all sectors of healthcare. We believe that, as experts in medicines and their use, pharmacy professionals are well placed to support patients to get the most from their medicines.
Medicines for cardiovascular disease
The briefing distributed with this week’s issue of The Journal focuses on medicines that are used for cardiovascular disease. This is the second in a series of briefings that complement and build on each other. The content is not intended to be exhaustive; the aim is to improve your approach to and understanding of patients who have cardiovascular disease. (Pharmacists should be aware that patients may have more than one condition and may be on a variety of different medicines.)
There are many things to think about when talking to patients about medicines for cardiovascular disease. Pharmacists should discuss when the patient wants to start taking the medicine and make sure the patient knows when the medication will be reviewed and by whom. Patients should also be made aware of what the effects of the medicine will be and how long it will take for effects to appear.
Pharmacists should check if the medicine is for short-term or long-term treatment. If it is for a long-term condition, pharmacists should discuss lifestyle changes and how the patient will manage the condition. Pharmacists should also check how medicines-taking is going to fit into the patient’s daily life and whether he or she needs reminders.
Tips
Tips for pharmacists to support patients with cardiovascular disease include:
Starting medication
- Explain to patients that the medication is for the long term and that although they may not have physical symptoms they need to take their medicine(s) regularly in order to prevent their condition from worsening and achieve long-term benefits.
- Talk to patients about their personal goals. What outcome do they expect from their medicines? How do they measure this?
- Provide guidance on recognising and responding to symptom deterioration and self-management strategies.
- Encourage annual flu vaccination for at-risk patients.
- Signpost to patient support groups such as the British Heart Foundation, Heart UK or the British Hypertension Society.
Side effects
- Let patients know what side effects may occur, how long they are expected to last and what they can do to minimise them.
- Explain to patients that they may feel “rough” at the start of treatment but that this will improve if they take the medicine regularly. Support them through this, emphasise long-term benefits and check that doses are being started low and increased slowly. Who is monitoring this and when?
- Advise patients to let you know if side effects last longer or are worse than they expected.
- Talk to patients about whether their medicines fit in with their daily routine, for example, diuretics will mean patients will need to visit the toilet more frequently and some cholesterol-lowering medicines are best taken at night. If this interferes with their routine encourage patients to talk to you about it rather than just stop taking their medicines.
- Reassure patients that there are alternative medicines available if they do not get on with the ones they have been given.
- Keep stocks of leaflets about cardiovascular drugs to reinforce the information you have provided verbally.
- Provide advice about over-the-counter medicines such as ibuprofen, which can cause salt and water retention and worsen renal function; ibuprofen may not be the best choice of analgesic. Is your whole pharmacy team aware of this and ready to give the best advice?
Smoking
- Ask patients if they smoke; stopping smoking is the most effective change patients with cardiovascular disease can make to improve their health.
- Offer patients smoking cessation advice when they are ready for it and signpost them to support groups.
- Have “Quit kits” ready for when they are needed.
Weight, exercise, diet and alcohol
- Give simple healthy dietary advice such as that eating five portions of fruit and vegetables a day, reducing salt and alcohol intake and eating more oily fish can improve cardiovascular outcomes.
- Advise patients to avoid salt substitutes that are high in potassium.
- Evaluate body mass index, waist circumference and cardiovascular risk, and provide advice. Patients with a BMI of greater than 29 have a three times greater risk of coronary heart disease because obesity increases blood pressure and cholesterol.
- Advise patients that regular exercise has positive effects on blood pressure, lipid profile and obesity.
- Talk to patients about their exercise routine. Work with them to find out what changes are most achievable and encourage them to work on those first. Small steps are more likely to result in permanent changes.
- Be aware of local initiatives and projects for patients with cardiovascular disease, such as healthy walks or exercise prescriptions. Do you know how patients can access these and who is eligible?
Opportunities
- Speak to your commissioners about introducing an alcohol brief advice service, stop-smoking service or health checks. Blood pressure, cholesterol, BMI and waist circumference can be monitored as part of primary prevention of coronary events and assessing individual risk.
Heidi Wright, practice and policy lead for England at the Royal Pharmaceutical Society, Anne Cole, Matthew Shaw, deputy director at the Centre for Pharmacy Postgraduate Education
