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Australian Journal of Pharmacy : April 2005
counselling casebook pharmacy ed quently used, particularly in older persons with underlying vas- cular disease and poor perfusion, CCF or chronic renal failure as well as arthritis. However, it exposes them to significant risk. NSAIDs and concurrent use of diuretics is associated with a two-fold increase in the risk of hospitalisation compared with diuretics alone. ACEIs, NSAIDs and diuretics individually or in combination are implicated in more than 50 per cent of cases of iatrogenic acute renal failure. This effect is described as the triple whammy: three simulta- Gastrointestinal tract Table One: Risk factors for taking NSAIDs2,6,12 Renal complications complications Age>65 years Age>65 years Co-morbid medical conditions History of peptic ulcer disease History of upper-gastrointestinal haemorrhage History of GORD Taking two NSAIDs Taking other medications with GI risk Table Two: Residential medication management review (adapted from 15) GP to determine the clinical need for a medication management review This step is not necessary for new residents as they are entitled to an RMMR on admission. GP to explain RMMR to resident/representative and obtain consent GP to initiate the RMMR and collaborate with reviewing pharmacist regarding the pharmacist’s component of the review The initial discussion with the reviewing pharmacist should cover: • a communication protocol; • exceptions to a post-review discussion*; and • clinical information relevant to the pharmacist’s component of RMMR. GP to engage in post-review discussion* with the reviewing pharmacist The post-review discussion should cover: • the findings of the pharmacist’s review; • medication management strategies; • means to ensure the strategies are implemented and reviewed; and • any issues for implementation and normal follow-up. GP then arranges consultation with the resident (or carer) to discuss the outcomes of the review and proposed medication management strategy and to gain the resident’s agreement to the plan Finalisation and preparation of a written Medication Management Plan Offering a copy of the plan to the resident, providing a copy for the resident’s records and for the nursing staff of the aged care home, and discussing the plan with aged care nursing staff. *A post-review discussion is not mandatory where: • no changes are recommended from the pharmacist’s review; • changes recommended by the pharmacist’s review are minor; and • outcomes of the pharmacist’s review considered in an Enhanced Primary Care (EPC case conference) 280 ? THE AUSTRALIAN JOURNAL OF PHARMACY VOL.86 APRIL 2005 Reduced creatine clearance Hypertension Congestive cardiac failure Use of ACE inhibitors Use of A11 receptor antagonists Use of diuretics neous deleterious blows with compounded effect.12 summarises risk factors for taking NSAIDs. Table One Glucosamine sulfate and chondroitin sulfate are derivatives of glycosaminoglycans found in articular cartilage. Two well-controlled studies have shown reduction of pain in patients with mild to moderate OA of the knee.13,14 Glucosamine should be used at a dose of 1,500mg per day and for at least three months to determine effectiveness. Opioids: The combination of codeine with paracetamol pro- vides additional analgesia but adverse effects such as nausea, vomiting, and constipation, plus tolerance and dependence make this not a favoured long-term option for OA. Tramadol, a cen- trally acting synthetic opioid which inhibits the reuptake of sero- tonin and noradrenaline is also used, but has a number of adverse effects, contraindications and drug interactions.6 Intra-articular hylans. Injections of hyaluronan (Synvisc) offer a small reduction in pain and may be useful for people awaiting joint surgery.2,6 Intra-articular corticosteroids provide little additional pain relief for OA of the knee. Common side effects include flushing, worsening hypoglycaemia and post-injection flare.2,6 Topical therapies such as NSAIDs, capsaicin and rubefa- cients may be added to paracetamol and may avoid the needs for an oral NSAID. There is some systemic absorption of topical NSAIDs but less frequent adverse effects.6 Surgery may be considered if patients are medically fit and can participate in the post-operative rehabilitation programs. With the increasing ageing population the number of residents in aged care homes suffering pain from OA is increasing. Risk factors for the use of NSAIDs are high for these residents. Improved management may often involve secondary prevention and a team approach. Medication reviews offer this opportunity. Residential medication management reviews (RMMRs) A new Medicare Benefits Schedule (MBS) item for general prac- titioners for collaborative medication management reviews for permanent residents of aged care homes was announced on 1 November 2004.15 The new item, Item 903, provides a Medicare rebate of $88.20 for a GP to work in collaboration with a pharmacist to review the medication management needs of a resident. RMMRs have been shown to optimise therapeutic effec- tiveness and management of the resident’s medication regimen and minimise possible adverse effects through collaboration between health professionals, the resident and their carers.16,17 In addition, the formation of Medication Advisory Committees (MAC) has emerged as a key strategy to implement quality use of medicines in aged care homes (ACH) using a collaborative approach.18 Previously accredited pharmacists, who had a contract with an aged care home, were initiating annual medication management reviews for all residents. These were either placed with the med- ication charts, or in a doctor’s book and/or forwarded to the Details of the role of MACs may be found in the Aus- tralian Pharmaceutical Advisory Council publication Guidelines for medication management in residential aged care facilities (www.health. gov.au).19