For many community pharmacists, supplementary prescribing must seem something that is unlikely to affect them in the foreseeable future, and the obstacles can seem insurmountable. Using a couple of case studies from my own clinics, I hope to show that the hurdles are not as high as you might think and, in many ways, there are positive advantages to prescribing in a pharmacy.

My funding for chronic disease work comes primarily from GPs who saw the benefits of employing a pharmacist under the new GMS contract. There were 11 conditions that attracted payments, although this has recently been increased. My work concentrates on diabetes, coronary heart disease/heart failure, hypertension, chronic obstructive pulmonary disease/asthma, diabetes and a small number of epilepsy patients.

The first patient, 65-year-old Mr A, was booked in for a complete asthma review. This requires a spirometer, which nearly all practices have; it is simply funded out of the ‘profits’ from the contract. Respiratory Education UK1 can provide training. Mr A gave a past history of very heavy smoking, over 40 a day for about 50 years, up to 2002 when he stopped because of the onset of angina. He recently presented to his GP with increased shortness of breath and a lower respiratory infection for which he received antibiotics. As he had a reduced peak flow, a clear wheeze and many of the symptoms of asthma, the GP recorded a diagnosis of asthma, which led to him seeing me some two months later.

Having taken his medical history, I followed with a pharmaceutical history. He was currently on glyceryl trinitrate spray, salbutamol inhaler 100mcg/puff, beclometasone inhaler 250mcg/puff, bisoprolol 5mg, aspirin 75mg and simvastatin 20mg. Spirometry revealed a forced expiratory volume 67 per cent of predicted, forced vital capacity of 1.91 litres and an FEV1/FVC ratio of 68 per cent. There was no reversibility to salbutamol given through a spacer device. Although the value of reversibility in a patient already on high dose steroid inhalers is limited, it has some value if a bronchodilator has not been used within six hours before the test.

Without reference to his notes and having taken a full history and undertaken spirometry, it was clear that the earlier diagnosis was incorrect. The GP, within the severe time limitations of his surgery, had seen typical asthma symptoms and had, not unreasonably, diagnosed asthma and passed the patient to me for review. The original diagnosis should have been acute exacerbation of chronic obstructive pulmonary disease (COPD). I was able to discern this from the previous very heavy smoking, lack of reversibility to salbutamol and history of slowly progressive, non-variable breathlessness that caused him to present to his GP only when an infection significantly worsened his symptoms.

Although I could not prescribe in this case, as my clinical management plan was for asthma not COPD, the required changes to medication were simply of dosage. The patient was advised to continue beclometasone; it has established evidence to support use in COPD to reduce severity of acute phases2. The salbutamol needed to be used more regularly and I had to arrange a prescription for ipratropium. With a change not only of diagnosis but also in medication, Mr A was booked in for follow-up review in two months.

The misdiagnosis of COPD is fairly common and, while it is a popular misconception that pharmacists cannot diagnose, this is not necessarily the case. Probably the worst scenario is a rushed diagnosis by a busy GP when presented with an acute exacerbation, be it COPD or asthma. Both should be diagnosed after taking a careful history and spirometry. This can easily be achieved in a community setting with appropriate training and equipment.

Although lack of access to notes is cited as a major obstacle to prescribing in community pharmacy, the supplementary prescribing course teaches how to take a medical history. This is similar to the regular training pharmacists receive in taking a pharmaceutical history.

No need for records?

The second patient, Mr B, was new to the practice and his case clearly demonstrates the fallacy that access to medical records
is necessary to review a patient, make a diagnosis and start on a course of therapy. It often takes a month or more for a new patient’s notes to reach the practice and Mr B was found to have a blood pressure of 170/105 during his new patient check with the practice nurse. Where there are concerns over medication or blood pressure in a new patient, it is routine for the practice to book the patient in to see me.

Mr B described a past stroke, a subarachnoid haemorrhage in 1995, for which he was prescribed tablets for high blood pressure and cholesterol lowering. Over the years and, as no one at his past surgery reviewed him, he had stopped taking them. The issues here are that, with a past history of stroke, he should be treated for his raised blood pressure and he should be on a statin regardless of his absolute cholesterol level. The Heart Protection Study3 demonstrated a 30 per cent reduction in stroke, regardless of starting cholesterol levels, for patients on simvastatin 40mg.

Mr B no longer smoked, but his body mass index was 29 and he could have benefited from dietary and exercise advice. His blood pressure was above the target for patients with history of stroke and my intention, in the absence of medical notes and past pathology reports, was to treat him as a newly diagnosed hypertensive and start from scratch. The absence of notes does not hinder the treatment in any way but demands a more detailed taking of past medical history and care to check with the patient about any drug sensitivities.

He was booked in for an ECG. This is important to determine if there is left ventricular hypertrophy, which will affect the choice of drugs and which would be an indication to send him for an echocardiogram. I also booked him in for blood tests, to include urea and electrolytes, fasting glucose and lipids and, as he was a new patient and I had no past records, a full blood count.

If this review were undertaken in a community pharmacy, then there would be a number of options available for an ECG. As with the spirometer, it is a piece of equipment that could be purchased and the training is relatively simple. Pathology services could be accessed in the community by sending the patient to a “walk-in centre” or by arrangement with the local GP surgery.

At the second appointment Mr B’s blood pressure was still raised at 164/90 and his blood results confirmed a fasting total cholesterol of 5.6mmol/L but little else of note. His ECG was normal, with a resting pulse of 70 beats/min. At the last visit my independent prescriber, who had seen the patient, agreed with my initial treatment plan and agreed a clinical management plan for stroke that would enable me to prescribe the appropriate medication. I started the patient on amlodipine for his blood pressure and gave a second prescription for simvastatin 40mg to be started a week later. Unless it is imperative for more than one drug to be given immediately, I always start one drug at a time so that any side-effects in the first few days can be more readily attributed. The patient was booked for follow-up review in one month’s time.

I hope that I have shown, with both these patients, that treatment is possible in a community setting. In fact, there are distinct advantages to the patient, often in terms of access. Both patients needed multiple appointments and it is rare in chronic disease work that a patient can be seen just once to start medication. In the second case study, if I had started an ACE inhibitor, then multiple appointments might have been required to titrate the dose correctly.

It is essential that community pharmacy is not overlooked as a potential readily accessible source for the management of the vast numbers of patients with chronic diseases, simply because they are deemed not to have access to medical records.

The first step was the introduction of the medications use review contract. This first step now needs to be expanded and developed together with appropriate training in the skills I hope I have demonstrated in the above case studies.

References

1. Respiratory Education UK (www.respiratoryetc.com ).
2. NICE. Chronic obstructive pulmonary disease: Management of COPD in adults in primary and secondary care. Clinical Guideline 12, February 2004.
3. Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo controlled trial. The Lancet 2002; 360: 1631–1639.