Best practice prescribing and dispensing guidelines for HIV
prescribers and pharmacists.
Background:
To a large extent effective supply management in HIV can be achieved through
appropriate prescribing and dispensing of antiretrovirals in clinic. Pitfalls usually
centre on oversupply at a time when a patient needs to switch or stop treatment. This
guideline describes some broad principles in prescribing and dispensing that are
considered best practice and should lead to more cost-effective management of the
HIV treatments.
Prescribing considerations:
While pharmacy often discuss the length of prescription with prescribers, this may be
avoided by asking patients one or two questions:
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How much medicine supply do you have at home?
How much medicine supply do you need until you see the doctor again? (it is
usual to ensure the patient has a 4 week buffer supply in case they cannot
attend the planned appointment – especially those on Home Delivery)
Most clinics ask patients to be responsible for ensuring that they book their
appointments at a time before they would run out of medication or have requested
enough medicines until their next appointment. This can limit the number of patients
who tend to contact the clinic on an ad-hoc basis for a short prescription to follow-up
or for repeat prescriptions.
Consideration should be given to instalment dispensing if more than 4 months is
prescribed at once for stable patients, as a maximum of 4 months supply is now
recommended by the London HIV Consortium (Dec 2010).
Situations where you should not prescribe a 3 or 4 month supply:
(In most of these situations a one month supply may be more appropriate until
pending results are available.)
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A patient is starting a drug or combination for the first time
A patient with a detectable HIV viral load on treatment with likely emergent
resistance
You have just ordered a HIV genotype resistance or phenotype test
You have ordered a drug level (TDM) on an antiretroviral
The patient is experiencing intolerable side-effects
There is evidence of worsening hepatic or renal function that may require a change in
dose or combination
Pregnancy if the mother is not requiring continued treatment for her own health
Patient has missed an appointment and requests a supply to last until next
appointment
Dispensing considerations:
On receipt of a prescription, or when the patient is seen in pharmacy clinic or
pharmacy, it is best practice to:
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Check how much treatment the patient has at home
Check a patient’s drug history (GP prescribed medication OTC, herbal, recreational
drugs)
Clarify formulations as appropriate if not stated on the prescription (e.g. liquid or
tablets) and provide ongoing support for patients with swallowing difficulties to
manage the use of more costly liquid preparations effectively.
Remind patients of the importance of always checking how much medicine they have
left at home and bring in a record of this to show their doctor at the next appointment
On screening a prescription, it may be appropriate to discuss with the prescriber the
length of the prescription in relation to any of the points raised under “prescribing
considerations”. Having access to clinical databases, pharmacy records and medical
notes can support management of supply length. Familiarity with patients and their
care plans is encouraged in this Specialty.
At the point of dispensing:
Records of prior dispensing can reveal how much a patient should have at home.
Starting and switching therapy:
Always supply one month (if you don’t want to split packs), or two weeks initially at
start of therapy as toxicity/intolerance commonly appears within the first month of
treatment. A to-follow or instalment prescription may be a good way of managing
these patients if the original prescription is written for more than one month.
Original Pack Dispensing:
Dispense original packs as this saves time although be aware of packs that do not
have 30 days:
In these cases, pharmacy records will help you decide how much you need to supply.
Adjustments may need to be made to quantities prescribed to allow the management
of these drugs. Electronic prescribing systems allow easier recording of changes to
prescription however paper-based prescribing requires feedback to prescribers on
changes to ensure prescribing records are maintained.
Returns of medication to pharmacy
The Royal Pharmaceutical Society of Great Britain has been approached about the
position of drugs that are returned by patients from their home or where those
medicines have left the hospital. There is no situation where drugs that have been in
the possession of patients outside of the hospital can be re-used for other patients.
For this reason, this guideline aims to minimise the incidence of drug wastage
although it is recognised that there will always be situations where wastage is
unavoidable where delayed intolerance or toxicity to a treatment emerges or indeed
resistance.
Medicines dispensed for inpatients that have not left the hospital may usually be
returned to stock if it is “in date” and if correct storage can be accounted for. Each
hospital Trust may have their own policy on how these medicines are dealt with and
this should be followed.
21st December 2010