Health & Medicine

The Role of the Pharmacy in Adherence Support

1. The Expanding Role of Pharmacists<br />Supporting Sustainable Adherence to HIV Prevention, Care & Treatment<br />ICAP Technical Workshop<br…
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  • 1. The Expanding Role of Pharmacists<br />Supporting Sustainable Adherence to HIV Prevention, Care & Treatment<br />ICAP Technical Workshop<br />October 19-22, 2009Kigali, Rwanda<br />Angela G Giovanniello, Pharm.D.<br />Aby Leonard, Cote d’Ivoire<br />GideonChelule, Kenya<br />KidwellMatshotyana, South Africa<br />
  • 2. Background<br />Suboptimal treatment exposure result in the failure of available regimens<br />Adherence is key to achieving successful treatment <br />Requires everyone to play a part <br />Regimens are complex and have little pharmacologic “forgiveness”<br />
  • 3. Pharmacist Role<br />The care of the HIV-infected individual presents special challenges that warrant the need for a pharmacists intervention<br />Large number of drug interactions <br />Prescribed/ Herbal / Food<br />The need for poly-pharmacy for effective treatment <br />Medication pick-up ultimately last stop in the clinic<br />Provide time to recap or address any unmet issues<br />Disclosure issues <br />Barriers to family support or help<br />Incorporate family health to strengthen the family unit<br />Part of the multidisciplinary team<br />Referring when needed to counselors, clinicians, and lab personnel<br />
  • 4. Potential Role of an HIV Pharmacist<br />Traditional Role<br />Dispensing<br />Inventory<br />Stock Management<br />Predictions<br />Tracking <br />Adherence<br />HIV Pharmacist<br />Approp. Drug Selection<br />Potency <br />Lack of interaction<br />Compatible with patient<br />Pre-therapy Counseling<br />Show & Tell<br />Drug/food restrictions<br />Side Effects<br />Adherence<br />Follow-up<br />Adherence<br />Tolerance/Toxicity<br />
  • 5. Opportunity for Intervention<br />Frequent patient interactions (monthly medication pick-up )<br />Allowing for engagement <br />Side effect/ toxicity identification <br />Quickly detect any adherence problems<br />Verify appropriate dosing and administration schedules<br />
  • 6. Case 1<br />AK is a 39 yo female <br />Started on HAART 2 months ago coming for her first medication refill <br />She has missed her medical follow-up appointment <br />Prompt a discussion about the timing of her medication pick-up<br />AK reveals she has a lot of diarrhea on the days she takes her medication and can not take her medications on the days she has to be out of the house.<br />
  • 7. Adherence Measures<br />3 day recall<br />In the past 3 days how many doses have you missed?<br />7 day recall<br />When was the last dose you missed?<br />What would make your regimen easier?<br />Pill count<br />Refill dates <br />
  • 8. Adherence Tools<br />
  • 9. Adherence Tools<br />Pillboxes<br />Alarms<br />Cellphones<br />Blister packaging<br />Peers – social supports<br />MEMS caps<br />
  • 10. Barriers to Adherence<br />Lack of education <br />Adherence goals <br />most pt do not know that &gt; 95% is the goal <br />If missing more then 1 day per month under 95%<br />Resistance <br />Evaluate barriers to adherence<br />Create a rapport – include family when possible<br />Depression <br />Side Effects/ Drug toxicity <br />Active substance abuse <br />Literacy<br />
  • 11. Case 2<br />EH is a 16 yo pregnant female coming to the clinic for prenatal care <br />Started on HAART consisting of NVP/3TC/d4T <br />Experiencing continued vomiting over the past 2 days due to the pregnancy and has been unable to continue the prescribed treatment<br />Based on the pharmacokinetic properties of her medications can she just stop all her medications? <br />
  • 12. NNRTI PK Problems<br />Prolonged half-life with a greater risk of developing regimen crippling mutations <br />Possible utility of continuing NRTI’s of the regimen to prevent this occurrence <br />Recommendations vary from 7 to 14 days of continued NRTI treatment after the discontinuation of the NNRTI<br />Others have recommended swapping NNRTI’s to LPV/r for 1 month then discontinuation of all agents<br />
  • 13. Case 3<br />MM a patient doing well on a regimen <br />AZT/3TC/NVP * 6 months <br />Diagnosed with TB and placed on<br />Isoniazid/Rifampin/Pyrazinamide/Ethambutol <br />Comes to the pharmacy for the additional treatment <br />What discussion occurs?<br />
  • 14. Key Drug-Drug Interactions<br />Rifampicin – potent CYP isoenzyme inducer<br />Alters drug concentrations of most ARV’s significantly<br />Changes to alternate ARV’s possible option<br />NVP  EFV <br />
  • 15. Case 4<br />ZR a 1 yo male comes for a monthly medication <br />d4T/3TC/NVP<br />The baby is healthy and developing well<br />Tolerating all medications<br />No present issues with adherence to liquids<br />Doses have remained the same for the past 3 months <br />Is this alarming?<br />
  • 16. Patient<br />Provider<br />Change in Dynamic<br />Patient<br />Provider<br />RPH<br />
  • 17. Key Points <br />Small steps incorporate 2 steps to each prescription.<br />Check refill dates <br />Check log and see if dates make sense<br />Ask simple questions about tolerability of ARV’s<br />Have you been having any problems that have made taking your medications difficult?<br />Any nausea/vomiting?<br />Any rash developments?<br />CNS SE of efavirenz? <br />
  • 18.
  • 19. ICAP Country Examples: Pharmacy Support for Adherence<br /><ul><li>Cote d’Ivoire – Role of Pharmacy in Patient Education
  • 20. Kenya – Integrated Appointment and Adherence Assessment
  • 21. South Africa – Development of VAS and Task Shifting</li></li></ul><li>Cote d’Ivoire Traditional Overview Role of Pharmacy<br />Ensure the availability of drugs and laboratory reagents (firstly)<br />Ensure drugs management and dispensing.<br />Ensure adherence to treatment through advices and treatment explanation<br />Ensure the pharmacological monitoring of the treatments introduced (Ensure the prescription conformity)<br />Implement pharmacy database<br />Pharmacovigilance<br />
  • 22. Cote d’IvoirePharmacy and Peer Educator Collaboration<br />Peer Educatoris the continuation of the pharmacist in the community<br />Pharmacistreinforce and deepen the Peer Educatorknowledge on ART treatment.<br /><ul><li>Pharmacist and PE share information on patients (diary, dispensingregister, etc.)</li></ul>Pharmacistencourages patients to see the PE aftereach ART dispensingto reinforceadherence<br />Strengthen communication betweenPharmacist, data officer and PE <br /><ul><li>Share information to allowverification of appointments, lost to follow up, deathsand other information</li></li></ul><li>Cote d’IvoirePharmacy and Support Group Linkages <br />Pharmacistinforms and remindspatients of the available support group<br />Pharmacistshouldleadsome sessions on adherenceat the support group on site <br />Discussion of the benefit of adherence to treatment, pharmacovigilance, and provideadvicewhichcan help withadherence.<br />
  • 23. Kenya<br /><ul><li>Pill count done at pharmacy
  • 24. An integrated diary able to book appointment and record pill count was developed.
  • 25. A formulae was integrated into the diary
  • 26. Integrated Diary was then stationed at the pharmacy</li></ul>Developing Integrated Appointment and Adherence Assessment System<br />
  • 27. Kenya<br /><ul><li>Task shifting to peer educators stationed at pharmacy was done
  • 28. Adherence assessment (including pill count) integrated in APS training curriculum
  • 29. Patients asked to return pill balances at every visit
  • 30. Patients collect their repeat medication on scheduled dates of appointment (28 day cycle pick-up)
  • 31. Adherence is then assessed</li></ul>Implementing Integrated Appointment and Adherence Assessment System<br />
  • 32. Diary<br />
  • 33. South Africa<br /><ul><li>Overview Role of Pharmacy in South Africa Care and Treatment
  • 34. Aim of pharmacy support is to provide a comprehensive pharmaceutical service at all ICAP supported sites
  • 35. Quality of care is at the centre
  • 36. Monitoring treatment outcomes through pharmacovigilance and adherence monitoring systems
  • 37. Monitor & support drug availability – all essential drugs in the program (anti-TB/ARV/OI)
  • 38. Compliance with minimum standards of pharmacy practice – legal requirement </li></li></ul><li>South Africa<br /><ul><li>Development and Use of VAS…
  • 39. Various methods used in assessing adherence : pill counts, appointment schedule, patient interviews / checklists,
  • 40. Pill boxes, alarm clocks, treatment diaries, treatment buddy
  • 41. There is no one effective system in monitoring and assessing adherence
  • 42. Adult Patient Adherence Record and Monitoring Form
  • 43. Owned by the National DOH
  • 44. Consists of: Pill Identification test, medication pick-up dates, Pill counts, Visual Analogue Scale, patient self reporting
  • 45. A comprehensive system to improve adherence
  • 46. Time consuming on the user but very effective in developing a stepped-up adherence plan</li></li></ul><li>South Africa<br /><ul><li>Opportunities for Task Shifting to PEs….
  • 47. PE tend to understand local languages
  • 48. They interact with the patients in the community and in the local HIV support group (PLHIV support group)
  • 49. Clinicians do not have enough time
  • 50. The large number of patients at each sites
  • 51. Some clinics have 3 PE and 1 PN, no pharmacy personnel,
  • 52. PE can do pill counts, VAS, Pill identification
  • 53. Clinicians – Patient self-reporting & interviewing then developing a plan to improve adherence. </li>
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