APPENDIX B
CHECKLIST FOR PHARMACISTS SUPPLYING
NICOTINE REPLACEMENT THERAPY UNDER A PGD – TO BE USED AT INITIAL
CONSULTATION
Client name:
Pharmacy details
Patient ref no
Pharmacists Name:
Adviser
Today’s date
Pharmacy Stamp
1. CRITERIA FOR INCLUSION
Is the client over 12 years old?
□YES □NO
Has the client set their Quit Date?
□YES □NO
If you answer no to either of these questions, then the client will not be able to be
supplied NRT through this PGD
2. CRITERIA FOR WEEKLY CONSULTATION
Is the client between 12 and 16 years of age?
□YES □NO
If yes, is the client accompanied by a parent/guardian?
□YES □NO
If no, have the Fraser guidelines been applied?
□YES □NO
Is the client pregnant or breastfeeding?
□YES □NO
Does the client suffer from or have suffered any of the following? (please tick)
□CHD
□ Stroke
□ Angina
□Diabetes
Check if the client is taking any of the following medicines and advise accordingly:-
Appendix Bv4 Pharmacy check list (Feb 2015)
Drug name
(BNF category)
Warfarin
(2.8.2)
Theophylline
(3.1.3)
Nature of interaction with
smoking
Clinical
relevance
Advise to patient
Warfarin is partly metabolised
via CYP1A2 however an
interaction with smoking is not
clinically relevant in most
patients
Moderate
Advise patient that smoking
cessation may cause a slight
increase in INR and they should
monitor their INR more closely –
Clients need to ensure they do
not miss their routine blood
testing and to tell their GP that
they are stopping smoking
Theophylline is metabolised
principally via CYP1A2.
Smokers need higher doses
of theophylline than nonsmokers due to theophylline’s
shortened half-life and
increased elimination. Some
reports suggest smokers may
need twice the dose of nonsmokers.
High
Advise patients to have a blood
test when they stop smoking as
their plasma theophylline
concentrations may change and
their dose may require reducing
by about one quarter to one third
one week after withdrawal.
However, it may take several
weeks for enzyme induction to
dissipate. Advise patients to have
their theophylline concentration
checked periodically.
Advise the patient to seek help if
they develop signs of theophylline
toxicity such as palpitations or
nausea.
Chlorpromazine Chlorpromazine is
(4.2.1)
Clozapine
(4.2.1)
Moderate
Advise patient to be alert for
increased adverse effects of
chlorpromazine (e.g. dizziness,
sedation, extra-pyramidal
symptoms) when they stop
smoking. Advise patient to see
GP if this occurs to review/reduce
dose
High
Advise patients that smoking
cessation may alter their
response to clozapine and they
may need additional blood
monitoring – they need to
ensure they do not miss their
blood testing.
metabolised principally via
CYP1A2. Smokers have lower
serum levels of
chlorpromazine compared
with non-smokers.
Clozapine is metabolised
principally via CYP1A2 and
clearance is increased in
smokers. Serum clozapine
levels are reduced in smokers
compared with non-smokers;
smokers may need higher
doses.
Date and prescriber details to
be documented.
Advise patient that their blood
should be monitored before they
stop smoking and one or two
weeks after having stopped. Their
dose may need reducing
Appendix Bv4 Pharmacy check list (Feb 2015)
Drug name
(BNF category)
Olanzapine
(4.2.1)
Nature of interaction with
smoking
Clinical
relevance
Olanzapine is metabolised
principally via CYP1A2 and
clearance is increased in
smokers. Serum olanzapine
levels are reduced in smokers
compared with non-smokers;
smokers may need higher
doses.
High
Advise to patient
Advise patients that smoking
cessation may alter their
response to olanzapine and
they may need additional blood
monitoring – they need to
ensure they do not miss their
blood testing.
Date and prescriber details to
be documented.
Advise patient that if they
experience increased adverse
effects of olanzapine (e.g.
dizziness, sedation, hypotension),
they should see their GP for dose
reduction
Methadone
(4.10)
Insulin
(6.1.1)
Methadone is metabolised via
isoenzymes including
CYP1A2.
Moderate
Advise patient to be alert for signs
of opioid toxicity and request their
GP to review /reduce the
methadone dose accordingly.
Smoking is associated with
poor glycaemic control in
patients with diabetes.
Smokers may require higher
doses of insulin but the
mechanism of any interaction
is unclear.
Moderate
If a patient with insulin-dependent
diabetes stops smoking, their
dose of insulin may need to be
reduced. Advise the patient to be
alert for signs of hypoglycaemia
and to test their blood glucose
more frequently.
(based on UKMi, August 2012)
The following criteria have been considered in grading the clinical relevance of interactions:
High:
Documented interaction with clinically important effects in a number of patients and/or
Drugs metabolised principally by CYP1A2 and with a narrow therapeutic range.
Moderate: Documented pharmacokinetic interaction with no or minor clinical effects, or isolated
reports of clinically important effects and/or
Drugs metabolised partly by CYP1A2 and with a narrow therapeutic range and/or
Drugs metabolised principally by CYP1A2 and with a wide therapeutic range.
If you have ticked yes to any of the boxes in section 2 or the client is taking any of the
medication listed above, please ensure you see the client weekly.
3. CRITERIA FOR REFERRAL TO THE GP
Is the client taking clozapine or olanzapine?
□YES □NO
Is the client taking varenicline or bupropion?
□YES □NO
If the answer is yes to the above then you must ensure that the client has been
referred to the GP and that they have agreed the use of NRT. You may need to check
this with the clients Stop Smoking Adviser.
Appendix Bv4 Pharmacy check list (Feb 2015)
4. CRITERIA FOR NRT PROVISION
Method and use of NRT product discussed?
□YES □NO
Possible side effects discussed?
□YES □NO
Please ensure the following is completed:
Stop Smoking Adviser
Name: ……………………………………………..
Location: …………………………………………………..
GP Details
Name and Surgery address:
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………
Quit Date:………………………………………
FOR PHARMACIST TO SIGN
I have taken account of all the information given to me by the client as recorded above and
have provided a risk versus benefits assessment as necessary.
Signature:
__________________________________________________________________
FOR CLIENT TO SIGN
I, _________________________ (Please print), state that the information that I have provided
above is correct to the best of my knowledge. I have discussed and understood the risks and
the benefits of taking NRT as an aid to stopping smoking.
I agree to only use the NRT product as I have been advised by the Pharmacist.
Signature:
__________________________________________________________________
Please note that the pharmacist will be making the supply under PGD and therefore will take
ultimate responsibility for the supply of any medicines. Records of supplies made should be
kept as required by local agreement.
Appendix Bv4 Pharmacy check list (Feb 2015)