Medicines Information
Enquiry answering guidelines
These guidelines draw together current UKMi guidance and resources and provide a guide to answering
enquiries categorised by type. They can be easily adapted to include local resources.
The document can be used for training or as a helpful reminder for more experienced medicines information.
For all enquiries you need to know:
1. The enquirer.
2. Contact details.
3. Urgency of enquiry.
4. Purpose of enquiry e.g. patient specific, project.
5. What sources already been used (NB. Try to assess enquirer’s experience of searching more
complicated resources as you may feel you need to do extra research).
Each monograph is divided into the following sections:
1. Background information – pointers to information that may be required.
2. Resources.
a. First-line resources, including:
i. In-house past enquiries. Use your judgement to decide if an enquiry is too old to be
relevant. For suggested keywords to search for, see the end of each monograph.
ii. UKMi Medicines Q&As Look for these early in your search; a relevant Q&A can save
you a lot of work.
b. Local resources e.g. contact details of experts, relevant departments, and policies.
3. Answering the enquiry – useful pointers to factors that should be considered.
4. Keyword suggestions for future enquiry retrieval.
Essential resource list
These guidelines should be used in conjunction with the UKMi Essential Resources list. This lists resources
for purchase and resources with free access for NHS Medicines Information Services and is accessed via:
www.ukmi.nhs.uk/activities/clinicalGovernance/default.asp?pageRef=4
Risk Management
No single source is totally comprehensive or completely up-to-date in all respects. Information about risks
associated with some resources used by UKMi can be accessed via:
www.ukmi.nhs.uk/filestore/ukmiacg/Risk-CommonInformationSources2.doc
Administration of medicines ...................... 2
Ophthalmology .......................................... 35
Adverse Drug Reactions ............................ 4
Paediatrics ................................................. 38
Drugs in breastfeeding ............................... 7
Palliative care ............................................ 41
Compatibility of intravenous drugs ......... 10
Pharmaceutical.......................................... 45
Compatibility of subcutaneous drugs ..... 12
Pharmacokinetics ..................................... 49
Complementary medicine ........................ 14
Poisoning or overdose ............................. 52
Contraception (hormonal) ........................ 17
Pregnancy.................................................. 53
Cytotoxic medicines ................................. 21
Drug use in psychiatry.............................. 55
Dental......................................................... 22
Renal impairment ...................................... 57
Drug use in hepatic impairment ............... 24
Medicines in sport ..................................... 61
Pharmaceutical identification .................. 27
Substance misuse..................................... 63
Immunisation ............................................ 29
Travel medicine ......................................... 66
Interactions ............................................... 31
Wound care ............................................... 71
New products ............................................ 33
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Publication date: January 2013
Revision date: January 2015
Administration of medicines
Background information
These guidelines are for situations where patients are unable to tolerate oral medicines and other options
need to be considered e.g. swallowing difficulties, patients who are nil-by-mouth (NBM) etc.

Have any other medicines or routes of administration been considered?

Are there any restrictions on the choice of administration route? For example, patients with diarrhoea
may not be able to use rectal preparations. Patients with burns, eczema, excess hair or very sensitive
skin conditions may not be able to use transdermal preparations. Patients with low muscle mass will not
be able to have intramuscular injections. Patients with increased bleeding risk will not be able to have
subcutaneous or intramuscular injections.

What other routes are available? For example, does the patient have a venflon inserted; do they have an
enteral feeding tube in situ? Is a subcutaneous pump being used?
Nil-by-mouth (NBM) prior to surgery:

What medicines and doses is the patient taking?

How long is the patient likely to be NBM?

Have any other formulations been considered?

What medicines and doses does the patient need? Can any be suspended temporarily?
Ocular administration:

If the question is about order or administration of eye drops - what are the names and doses of the
medicines?

If the question is about number of bottles of eye drops to dispense – who long will the patient be using
the eye drops for? Are the drops to go into one or both eyes? What is the dosage frequency?
Nebulised administration:

What medicines are to be nebulised?

What are the doses and frequency of administration?

What type of nebuliser is being used?
Swallowing difficulties:

What medicines and doses is the patient taking?

Is their swallowing expected to improve? If so when is this likely?

Have any other methods of administration been considered or tried? E.g. transdermal patches.

Is the patient able to swallow thin liquids or are thickened fluids or sip feeds being used?
Enteral feeding tube administration:

What type of feeding tube does the patient have e.g. Nasogastric, percutaneous endoscopic
gastrostomy or jejunostomy?

What feeding regime is being used? Which feed is being given? Consider interactions between
medicines and enteral feeds.

Have any other methods of administration been considered or tried? E.g. transdermal, rectal.

What medicines and doses is the patient taking?
For enquiries that relate to administration of medicines to children, please refer to the ‘Paediatrics’
monograph.
For enquiries that relate to parenteral administration refer to Compatibility of Intravenous Drugs’ and
‘Compatibility of Subcutaneous Drugs’ monographs.
-2-
Resources
Source
Notes
First-line resources
In-house past enquiries.
Relevant Medicines Q&As
via www.nelm.nhs.uk or
www.evidence.nhs.uk
British National
Formulary,
www.medicinescomplete.
com/mc/bnf/current/
See chapter 15.1 ‘surgery and long term medication’.
Electronic Medicines
Compendium,
www.medicines.org.uk/em
c
The Summary of Product Characteristics has details of administration of
nebuliser solution and information about combining solutions in the nebuliser
chamber.
Moorfields Eye Hospital
NHS Foundation Trust
Pharmacists Handbook.
2006.
Contains clinical guidelines and dosing information. Lists the preparations
available from Moorfields Eye Hospital. Provides a table for determining the
number of bottles of eye drops to be dispensed according to the dose
prescribed.
Hand book of Drug
Administration via Enteral
Feeding Tubes. White R
and Bradnam V.
Also available via MedicinesComplete
The NEWT Guidelines.
Smyth J. North East
Wales NHS Trust.
Useful for advice about patients with swallowing difficulties and those with
feeding tubes.
The Summary of Product Characteristics for a tablet and capsule preparation
may state if it can be crushed or opened.
Additional resources (tailor to local use/availability)
Rosemont
Pharmaceuticals website,
www.rosemontpharma.co
m
Rosemont are specialists in oral liquid medicines for people who have
swallowing difficulties (dysphagia). The website lists the liquid formulations they
make.
www.swallowingdifficulties
.com
This website has been produced by Dr David Wright at the University of East
Anglia. It is funded by Rosemont Pharmaceuticals. The website contains
information for patients with swallowing difficulties, guidelines for healthcare
professional and a list of liquid and non-oral alternatives.
Local resources
Answering the enquiry

Have any other methods of administration been considered or tried? E.g. transdermal, rectal.

The BNF and SPCs are a good place to start for most straightforward administration questions.

Crushing tablets or opening capsules renders them unlicensed. Consider if there is a licensed liquid or
dispersible formulation available.

Consider any potential interactions between medicines being administered via a feeding tube and
feeds.

Is there an alternative drug that can be used or administered more easily?
Keywords: drug name, TUBE FEEDING, DRUG ADMINISTRATION, SURGERY.
-3-
Adverse Drug Reactions
Background information
Retrospective enquiries (i.e. suspected ADR has already occurred)

Establish patient details, including age, sex etc.

What is the indication for the drug and any relevant medical history (e.g. renal function)?

What is the current and previous medical history if relevant, including risk factors for the ADR?

Is there a history of adverse drug reactions or allergies?

List current drug therapy, including OTC, alternative therapies and drugs of abuse whenever possible,
plus any medication taken within the last 3 months.

What is the timing of the reaction in relation to start or dose increase of the suspected drug?

Obtain a full description of the signs and symptoms of the reaction; clarify reactions such as 'rash',
'abnormal liver function tests (LFTs)', 'aching all over'.

Has the suspected drug been stopped?

How has the patient been managed so far?

Has rechallenge, deliberate or inadvertent, been undertaken?

Did the suspected ADR resolve when the suspect drug was stopped?

What are the results of any relevant biochemical tests e.g. renal function tests, liver function tests, full
blood count, biopsies, relevant ultrasound or screening tests.

Does the enquirer want to know which drug, A or B, is more likely to have caused side effect X?

Is the enquirer involved in a legal case? Always be aware that this may be the scenario (often
enquirers do not mention this).

Has the manufacturer been informed or a yellow card completed?
Prospective enquiries

Does the enquirer think that the patient may be at particular risk of an ADR e.g. a patient with a history
of an ADR to the same class of drugs? If so, what were the signs and symptoms of the suspected
previous reaction? N.B. caution may be required when using other drugs with similar ADR profiles.

Does the enquirer just want general information e.g. for informing a patient of possible side effects?

Does the enquirer want to know more information about a specific side effect e.g. because the patient
has asked?

Does the enquirer want to assess the risk/benefit comparison between two drugs e.g. which is safer,
drug A or drug B (often in relation to a specific side-effect)?

Some enquiries will involve a mixture of the two e.g. if a patient has a reaction which is subsequently
thought to be an ADR then it could be anticipated that the enquirer will want suggestions for
alternatives.
Resources
Source
Notes
First-line resources
In-house past enquiries.
Relevant Medicines Q&As via
www.nelm.nhs.uk or
www.evidence.nhs.uk
-4-
Electronic Medicines
Compendium
www.medicines.org.uk/emc/
For new drugs, adverse reaction information in the SPC comes from
clinical trials, data are limited and uncommon idiosyncratic reactions are
unlikely to be included. The SPCs for more established drugs include
adverse reactions identified by postmarketing surveillance studies and
spontaneous reporting schemes.
BNF
www.medicinescomplete.com/m
c/bnf/current/
Clinically relevant adverse effects are listed, generally in order of
frequency and arranged broadly by body systems.
AHFS Drug Information via
www.medicinescomplete.com
Monographs often contain extensive information on ADRs.
Martindale via
www.medicinescomplete.com
The Adverse Effect section summaries common ADRs and often
provides more detailed and referenced information on effects seen in
specific body systems.
Meyler's Side Effects of Drugs,
Dukes and Aronson.
Presented as individual drug monographs in alphabetical order with
general class monographs complemented by specific drug monographs.
Also contains information on non-drugs e.g. toxins, foods.
Additional resources (tailor to local use/availability)
Adverse Drug Reactions, Lee A.
Describes ADRs by organ class, lists commonly implicated drugs and
gives tips on management of suspected ADRs. N.B. most recent edition
is 2006.
Davies's Textbook of Adverse
Drug Reactions, Davies et al.
Chapters are arranged by system and adverse effect. NB. Now relatively
out of date (1998).
EMA – European database of
suspected adverse drug reaction
reports
http://www.adrreports.eu/
Launched in 2012 this database provides public access to reports
submitted electronically to EudraVigilance. EudraVigilance collects
reports of suspected ADRs from European medicines regulatory
authorities and pharmaceutical companies. Currently it only includes
medicines licensed through the EU centralised procedure.
MHRA Drug Analysis Prints
(DAP) via MHRA
Complete listings of the suspected ADRs reported to the MHRA through
the Yellow Card Scheme by healthcare professionals and patients are
provided in Drug Analysis Prints (DAPs). When sending DAP data to an
enquirer it is important to enclose a sheet explaining how to interpret this
(download from the MHRA website).
MHRA Drug Analysis Prints
Micromedex
www.micromedexsolutions.com
Classifies ADRs simply as common or serious by organ system often
with incidence as a percentage and in the detailed monograph provides
referenced information from case reports and studies.
Reactions weekly
http://link.springer.com/
Provides up-to-the minute summaries of the world's adverse drug
reaction news and comprehensive coverage of published adverse drug
reaction case reports through monitoring of all Medline- and Embaseindexed journals.
Bibliographic databases e.g.
Medline, Embase
Suggested terms: the reaction with the subheading ‘chemically induced’
(Medline) or ‘side effect’ (Embase) and/or the drug name with the
subheading ‘adverse effects’ (Medline) or ‘adverse drug reaction’
(Embase).
Drug Safety Update via MHRA
website at Drug Safety Update
A regular monthly electronic bulletin providing information and clinical
advice from the MHRA and the Commission on Human Medicines
Manufacturers’ Medical
Information departments.
Companies are legally obliged to follow up telephone enquiries about
ADRS (by sending an adverse event reporting form).
Natural Medicines
Comprehensive Database
www.naturaldatabase.com
Includes adverse effects of herbal medicines.
Local resources
-5-
Answering the enquiry

For retrospective enquiries use the information you have obtained from the 'background information'
questions and try to assess causality using the following criteria:
o
The nature of the reaction - certain disorders are commonly drug-induced e.g rashes,
constipation, gastrointestinal haemorrhage.
o
Previous SPC or literature reports describing the reaction.
o
The timing of the reaction can vary but most ADRs appear shortly after a drug is started or the
dose is increased.
o
Outcome on drug withdrawal, if resolution occurs this is a positive dechallenge.
o
Rechallenge outcome, although positive rechallenge strongly suggests drug cause deliberate
rechallenge is rarely justifiable and should not be suggested.
o
Risk factors, some patients have an increased susceptibility to ADRs (e.g. children, elderly,
multiple disease states, atopic patients).
o
Laboratory and diagnostic tests should indicate if there is a non-drug cause, ADRs are often a
diagnosis of exclusion.

When interpreting ADR data for the enquirer, be clear about the limitations of the Yellow Card data.
Warn that although there may be X number of reports we do not know the Y number of people who
have received the drug, therefore you cannot extrapolate to predict ADR incidence.

If there is a strong suspicion that an ADR has been identified complete a Yellow Card or offer to
help your enquirer complete a card. Report via MiDatabank or via the MHRA’s online Yellow
Card http://yellowcard.mhra.gov.uk/
Keywords: The drug name, disease term for the adverse effect.
-6-
Drugs in breastfeeding
Background information

Is the mother already breastfeeding?

Is the mother already taking the medicine in question?

Identify the drug, indication, dose and frequency, route of administration and intended duration of
treatment.

Has the mother taken the drug during pregnancy? If so, identify whether it is appropriate to switch to
an alternative if necessary. Note exposure during pregnancy does not confer safety during
breastfeeding.

How old is the infant, and was he/she premature or full-term?

Is the infant fed exclusively with breast milk? (Exposure is less in infants who are being weaned or
who have a mixture of breast milk and formula milk.)

Is the infant well? Is there anything to suggest that the infant may be at increased risk of drug harm,
e.g. impaired kidney or liver function? Has the infant been prescribed any medicines?

Is maternal drug therapy necessary? Has an alternative been considered or tried?
Resources
Source
Notes
First-line resources
In-house past enquiries.
Relevant Medicines Q&As via
www.nelm.nhs.uk or
www.evidence.nhs.uk
LactMed
http://toxnet.nlm.nih.gov/cgibin/sis/htmlgen?LACT
This database is part of TOXNET, the US equivalent of Toxbase and is
freely available. To search for a drug monograph type the drug or brand
name in the box and click on ‘search’; then select the monograph you
want from the list of hits.
Monographs are referenced. The date of last revision is at the bottom.
Medications and Mothers’ Milk.
Hale, T.
Standard US reference text on the safety of medicines during
breastfeeding. The preface includes key points about breastfeeding and
medicines, and highlights the benefits of breastfeeding.
Individual drug monographs are in alphabetical order and there is an
index at the back. Appendices provide information on chemotherapy
agents, radiopharmaceuticals, contraceptives and cold/flu remedies.
Note that brand names may differ in the UK.
Also available electronically (subscription required)
UKMi Drugs in Lactation website
www.ukmicentral.nhs.uk
This website is maintained by the UKMi Drugs in Lactation Advisory
Service. It has been completely updated and is due for partial re-launch
in Spring 2013. It is a useful quick reference source, provides
information on suitable alternatives where appropriate, and evidence
links.
Note. The site is still being populated with drugs with a target
overall completion date of the end of 2013. This will replace the old
ukmicentral website.
-7-
Additional resources (tailor to local use/availability)
Drugs during Pregnancy and
Lactation. Schaefer et al.
Chapter 3 includes general information about medicines use during
breastfeeding.
Chapter 4 provides information for individual agents and drug classes.
Use the index to find the drug you want. Each monograph has a boxed
‘recommendation’ at the end.
Note: last published (2nd edition) in 2007 so use with caution.
BNF for Children
www.medicinescomplete.com/m
c/bnfc/current/
If information is lacking from other sources, BNFC can be consulted to
see if the drug can be used in neonates or infants. The dose advised
can be compared to the theoretical dose the infant will receive via the
breast milk.
Information on drug safety in breastfeeding is included in drug
monographs. However, this is too brief to be of real value (note—the
same information is held in BNF monographs)
UKMi Drugs in Lactation
Advisory Service.
UKMi Trent (0116 258 6491) and West Midlands (telephone 0121 424
7298) jointly provide support directly to local MI centres for complex
enquiries or advice in high risk situations such as prematurity, low birth
weight and multiple medications.
Ensure you have adequate background information, and have checked
sources available to you before contacting the specialist service.
Drugs in Pregnancy and
Lactation. Briggs GG et al.
Standard US reference text on the safety of medicines in pregnancy and
breastfeeding. Each drug monograph has a section on breastfeeding at
the end. Individual drug monographs are in alphabetical order. However,
note that breastfeeding is not the main focus.
Electronic Medicines
Compendium
www.medicines.org.uk/emc
SPC section 4.6 (pregnancy and lactation) clarifies the licensed status of
medicines use during lactation. NB: Statements in SPCs are sometimes
more cautious than current evidence requires and should not be used as
the only source of information.
Maudsley Prescribing
Guidelines. Taylor D et al.
Chapter 7 contains a section on the choice of psychotropic medicines in
lactation.
Psychotropic Drug Directory.
Bazire S.
Chapter 3 contains a section on the choice of psychotropic medicines in
lactation.
Prescribing in Pregnancy. Rubin
D.
Chapter 14 of this UK reference has information on the safety of drugs in
breastfeeding.
Note: last published (4th edition) in 2007 so use with caution.
The Breastfeeding Network
www.breastfeedingnetwork.org.
uk/
This organisation is a registered charity providing independent advice
and support to breastfeeding women and others. Some of the
information is unreliable and is not recommended for use by health
professionals. However, as patients may be using these leaflets, it can
be helpful to know what they advise. The website has a section on drugs
in breastmilk (click on the link, the tabs towards the top of the screen).
There are two types of document available:
Drug information factsheets. These have the date produced on the
bottom but are not always referenced.
Medication FAQs (pdf document)
Bibliographic databases e.g.
Medline, Embase.
Suggested terms: BREAST FEEDING, BREAST MILK, LACTATION,
MILK-HUMAN (NB: Nursing is a US term for breastfeeding). For
recommended search strategies see:
www.ukmi.nhs.uk/activities/specialistServices/default.asp?pageRef=2
Local resources
-8-
Answering the enquiry
The following principles should be followed when prescribing for breastfeeding mothers:

It is seldom required that a breastfeeding mother stop breastfeeding in order to take a medication.

The benefits of breastfeeding must be recognized; a recommendation to stop breastfeeding must not
be made lightly.

The benefit and risk to both mother and infant must be considered.

Neonates and premature infants are at greater risk from exposure to drugs via breast milk, because
of immature excretory functions and the consequent risk of drug accumulation.

Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms.

Avoid unnecessary drug use and limit use of over-the-counter (OTC) products.

Avoid use of drugs known to cause serious toxicity in adults or children.

Drugs licensed for use in infants do not generally pose a hazard to full-term, healthy infants.

Choose a regimen and route of administration which presents the minimum amount of drug to the
infant.

Be more cautious about recommending long-acting preparations, since these are more likely to
cause adverse effects.

Multiple drug regimens may pose an increased risk especially when adverse effects such as
drowsiness are additive.

Avoid new drugs if a therapeutically equivalent alternative with more safety data is available.
Keywords
BREAST FEEDING, LACTATION, MILK-HUMAN, drug name, and disease name (if appropriate).
-9-
Compatibility of intravenous drugs
Background information

How many intravenous lines are available, what type of lines are they (central or peripheral), how
many lumens does each line have? Can other lines be inserted if necessary?

What is the patient receiving through the lines at the moment? Ask about blood products, TPN, etc. as
well as drugs. For current drugs:
o
Check dose and administration schedule - are they being given continuously, or by short
infusion or as a bolus? If continuous infusion, can they be given intermittently?
o
What diluents and concentrations are being used?
o
Are filters being used? If yes, where are they placed and what size are they, e.g. 0.2 micron?
o
Can any drugs be discontinued?

Which drugs are to be added and why? Which brand(s) will you be using?

How will the drugs be mixed, e.g. in the same bag, the same intravenous line (Y site), same syringe or
the same venflon?

Is there a choice of drugs that could be used?

Are there any limitations on choice, e.g. fluid and electrolyte restrictions, renal or hepatic dysfunction?

Can the patient tolerate administration by another route, e.g. nasogastric tube, oral, rectal,
intramuscular, subcutaneous, topical?
N.B. If the enquiry concerns the compatibility of drugs in a syringe driver for subcutaneous administration
please refer to the ‘Compatibility of subcutaneous drugs’ monograph.
Resources
Source
Notes
First-line resources
In-house past enquiries.
Relevant Medicines Q&As via
www.nelm.nhs.uk or
www.evidence.nhs.uk
BNF
www.medicinescomplete.com/m
c/bnf/current/
Contains information about compatible/incompatible diluents.
BNF-C
www.medicinescomplete.com/m
c/bnfc/current/
Electronic Medicines
Compendium
www.medicines.org.uk/emc
SPCs may contain information about compatibility of commonly used
admixtures.
The Injectable Medicines Guide
www.injguide.nhs.uk
Regularly updated monographs and other useful resources.
Handbook on Injectable Drugs.
Lawrence A Trissel.
www.medicinescomplete.com
N.B. This is a US resource, but it does include UK drug monographs
(see section at the back in the paper version).
*Free to contributing trusts in England and Scotland, and all trusts in
Wales & N. Ireland.
Additional resources (tailor to local use/availability)
UCL Hospitals Injectable Drug
Administration Guide
www.uclhguide.com
Paper version also available.
- 10 -
Source
Notes
Pharmaceutical manufacturer.
They may have unpublished data, although many generics
manufacturers have little or no information.
Micromedex
www.micromedexsolutions.com
Contains information about compatibility of intravenous admixtures if
known.
Injectable Drugs Guide. Gray et
al. www.medicinescomplete.com
A-Z listing of injectable drugs in monograph format. Each monograph
covers pre-treatment checks, dosing regimens, preparation and
administration, compatibility and stability information, monitoring
requirements during treatment, side effects, interactions and
pharmacokinetic information.
Pediatric Injectable Drugs.
AHFS.
www.medicinescomplete.com
US resource listing injectable drug monographs specific to use in
children. Also available in paper format and known as the Teddy Bear
Book.
AHFS Drug Information via
www.medicinescomplete.com
Information in the stability section of individual monographs.
NEXIS National Extravasation
Information Service
www.extravasation.org.uk
Has information on recognising and treating extravasation and a
database of drugs, their pH and known reactions following extravasation.
Website is not currently updated but still a useful resource.
The first search page only searches for information on cytotoxic drugs.
To search for information on non-cytotoxic drugs, click the link provided.
A national extravasation protocol for cancer chemotherapy is currently in
development.
Stabilis www.infostab.fr/
French drug stability and compatibility database containing >400
monographs. Free access. Click arrow next to French flag to view in
English language.
Bibliographic databases e.g.
Medline, Embase.
Suggested terms: ADMINISTRATION-INTRAVENOUS and DRUG
INCOMPATIBILITIES
Local resources
Trust IV Nurse or HOPT (Home
and Outpatient Parenteral
Therapy) team
Answering the enquiry
When checking compatibilities, consider alternative ways of solving the problem, e.g. by using other routes
of drug administration. You must consider problems associated with other routes and whether they would be
appropriate for that particular patient.
When answering this type of enquiry consider:

Are all drugs essential?

What are the possible mechanisms of interactions/incompatibility – chemistry i.e. pH, adsorption?

Is it possible to administer drugs by an alternative route?

Could another line be inserted?

Is there more than one option available, i.e. could a different drug be used to avoid a compatibility
problem?

Could the timing of administration be altered to avoid the need for mixing?
Keywords: drug names, ADMINISTRATION-INTRAVENOUS, DRUG INCOMPATIBILITIES
- 11 -
Compatibility of subcutaneous drugs
Background information

Which other medicines is the patient receiving, what are they for and by what routes are they being
given?

Which drugs need to be mixed, what are they for and what is the dose?

What is the diluent to be used and the concentration required or the preferred total volume?

Over what time period is the infusion to be given?

What other routes of administration are available, e.g. intravenous lines?

Establish how the patient is fed – an enteral feed tube offers a potential alternative administration
route.
N.B. If the enquiry concerns the compatibility of drugs for intravenous administration please refer to the
‘Compatibility of intravenous drugs’ monograph. See also ‘Palliative Care’ monograph.
Resources
Source
Notes
First-line resources
In-house past enquiries.
Relevant Medicines Q&As via
www.nelm.nhs.uk or
www.evidence.nhs.uk
BNF
www.medicinescomplete.com/m
c/bnf/current/
Section on prescribing in palliative care includes information about drug
administration via syringe drivers.
The Syringe Driver.
Dickman, Schneider and Varga.
Contains comprehensive information about two or more admixtures of
commonly used combinations.
Palliative Care Formulary.
Twycross et al.
Available in paper and online versions. Syringe driver compatibility
charts are at the back of the paper book.
Palliative Drugs
www.palliativedrugs.com
Companion website to PCF. Syringe driver compatibility tables are freely
available at www.palliativedrugs.com/syringe-driver-databaseintroduction.html
The text of PCF is only available to subscribers to the website.
Palliative Care Matters website
www.pallcare.info
Website for healthcare professionals working in palliative care. Includes
a syringe driver compatibility database
www.pallcare.info/mod.php?mod=sdrivers&menu=14
Handbook on Injectable Drugs.
Trissel LA.
www.medicinescomplete.com
N.B. This is a US resource, but it does include UK drug monographs
(see section at the back in the paper version).
Additional resources (tailor to local use/availability)
Electronic Medicines
Compendium
www.medicines.org.uk
However, very few injectable drugs are licensed for subcutaneous
injection or infusion.
Scottish Palliative Care
Guidelines
www.palliativecareguidelines.sc
ot.nhs.uk
Currently these are NHS Lothian guidelines. However, a national
steering group has been established to develop palliative care guidelines
for Scotland. These will be available from 2014 with a format based on
the guidelines on this website.
Subcutaneous medication section is available with compatibility charts
www.palliativecareguidelines.scot.nhs.uk/subcutaneous_medication/
- 12 -
Source
Notes
Symptom Relief in Palliative
Care. Dean, Harris, Regnard
and Hockley.
Freely available via NHS Evidence. Click on the menu button ‘NHS
Athens Resources’ then ‘E-books’. Log in with your Athens password.
Type ‘symptom relief’ in the search box. Click on ‘Read Book’. The
chapter on ‘Problems with syringe pump infusions’ (within Drug
Information) contains useful trouble shooting advice. Paper version also
available.
Oxford Handbook of Palliative
Care. Watson M et al.
Freely available via NHS Evidence. Click on the menu button ‘NHS
Athens Resources’ then ‘E-books’. Log in with your Athens password.
Type ‘oxford palliative’ in the search box. Click on ‘Read Book’. Chapter
4 contains general information on the principles of drug use in palliative
care, including syringe drivers. Paper version also available.
Oxford Textbook of Palliative
Medicine. Hanks G et al.
Freely available via NHS Evidence. Click on the menu button ‘NHS
Athens Resources’ then ‘E-books’. Log in with your Athens password.
Type ‘oxford palliative’ in the search box. Click on ‘Read Book’. Useful
general information in Chapters 8 and 10. Paper version also available.
Bibliographic databases e.g.
Medline, Embase.
Suggested terms: SUBCUTANEOUS-DRUG-ADMINISTRATION,
INJECTIONS-SUBCUTANEOUS, ADMINISTRATIONSUBCUTANEOUS
Local resources
Trust Palliative Care Team
Answering the enquiry

There is a Macmillan nurse attached to every GP practice. For enquiries about managing a specific
patient in primary care (other than straightforward medicines information queries), advise the enquirer
to contact this nurse.

Mixing two or more licensed drugs for administration via a syringe driver, where one is not a vehicle for
administering the other, falls within the definition of manufacture and results in a new, unlicensed
product. The person undertaking this preparation, unless an exemption applies (as with doctors and
dentists), must hold a manufacturer’s licence. Legislation was changed following a public consultation
– Regulation 20 of the Human Medicines Regulations 2012 exempts nurse and pharmacist
independent prescribers, and supplementary prescribers, from these restrictions. It allows these
prescribers to mix medicines themselves or direct others to mix. Directions must be in writing.

Some drugs are too irritant to be given subcutaneously, e.g. prochlorperazine, diazepam and
chlorpromazine.

Some drugs should never be mixed e.g. phenobarbital. Many palliative care units will always give
dexamethasone in a separate syringe driver.

Use of more than one syringe driver may be an option if there are compatibility problems and
alternative routes are unsuitable.

Use of a larger total volume will improve the stability of many drug combinations and may be an option
for some patients.

Confirm maximum volume of the syringe driver. There may be limitations on concentrations that mean
more than one daily syringe driver change is needed. Check whether this is going to be practical.
Keywords: Drug names, ADMINISTRATION-SUBCUTANEOUS, DRUG INCOMPATIBILITIES
- 13 -
Complementary medicine
Background information

Is the patient already taking the alternative or complementary medicine or do they want to start taking
it?

Identify the alternative medicine, indication, route, strength, dose and frequency, formulation,
manufacturer and source if possible. If applicable, how long has it been taken for? Are they taking the
product as a short course, cyclically or long-term?

Has the patient self-diagnosed the condition that they are seeking to treat? If they have, perhaps they
should consider speaking to a healthcare professional first.

Does the patient take any conventional medication? Is there any history of ADRs or allergies?

Check current and past medical history.

Are they pregnant or breast feeding?

Where did the patient hear about this or who recommended starting it?

If information about the product was accessed online, which website?
Resources
Source
Notes
First-line resources
In-house past enquiries.
Relevant Medicines Q&As via
www.nelm.nhs.uk or
www.evidence.nhs.uk
Natural Medicines
Comprehensive Database
www.naturaldatabase.com
This is the preferred source.
Herbal Medicines via
www.medicinescomplete.com
Target audience is pharmacists.
Additional resources (tailor to local use/availability)
Meyler's Side Effects of Drugs.
Aronson JK.
General class monograph on herbal medicines complemented by
specific drug monographs.
Homeopathic Pharmacy. Kayne
S.
Dietary Supplements. Mason P.
via
www.medicinescomplete.com
The Desktop Guide to
Complementary and Alternative
Medicine. Ernst E.
Martindale via
www.medicinescomplete.com
See chapter on Miscellaneous Drugs and Other Substances and
individual monographs.
Drugs During Pregnancy and
Lactation. Schaefer et al.
See chapter 2.19 – Herbs during pregnancy.
Stockley’s Drug Interactions via
www.medicinescomplete.com
Index term – herbal medicines but also see individual drugs.
- 14 -
Source
Notes
Stockley's Herbal Medicines
Interactions via
www.medicinescomplete.com
Safety of Herbal Medicines
Herbal safety advice : MHRA
Latest safety advice from the MHRA. Go to A-Z index>H>Herbal
medicines: safety warnings and messages. All manufactured herbal
medicines are required to have either a traditional herbal registration
(THR) or a Marketing Authorisation (MA). Products therefore need to
meet specific standards of safety and quality. However, this only applies
where products come within the definition of a medicinal product. Many
herbal products will continue to be available as food supplements.
Public assessment reports on products with a THR product registration
can be accessed via:
http://www.mhra.gov.uk/Howweregulate/Medicines/Herbalmedicinesregu
lation/RegisteredTraditionalHerbalMedicines/Informationonproductsregis
teredundertheTHRschemethisschemecanbefoundinthepublicassessment
reportsforherbalmedicines/index.htm
The National Centre for
Complementary and Alternative
Medicine http://nccam.nih.gov
Access to clinical trials, fact sheets, safety alerts.
Herbmed
Access to published data on a variety of herbal preparations.
www.herbmed.org
Memorial Sloan-Kettering
Cancer Centre (USA)
www.mskcc.org/cancercare/integrative-medicine
Evidence-based information about herbs, botanicals, supplements, and
more. Monographs on herbal preparations include information relating to
cancer treatments.
Focus on Alternative and
Complementary Therapies
(FACT)
http://journals.medicinescomplet
e.com/journals/fact/current
A journal that reviews and critically comments on new research in
complementary medicine published worldwide.
Idis Herbalinks
www.uiowa.edu/~idis/herbalinks
A website that provides critical appraisal of herbal websites.
Quackwatch
www.quackwatch.org
www.homeowatch.org
Useful for checking out dubious complementary medicine claims. An
associated site Homeowatch looks at homeopathic medicines.
Cochrane database via
www3.interscience.wiley.com
Contains numerous systematic reviews of complementary therapies.
Chinese Medicines Advisory
Service
http://www.chimas.org/Enquiries
.aspx
Chinese Medicines Advisory Service (ChiMAS) run by Guys and St
Thomas’ NHS hospital trust. ChiMAS provides advice on the safe use of
Chinese and other traditional medicines, responding to all levels of
enquiry from health professionals. Health professionals, including
pharmacists, can contact ChiMAS for information on safety, potential
interactions, adverse health effects or general background on the use of
Chinese or Traditional medicine. ChiMAS can be contacted by fax, email
or telephone.
Traditional Chinese Medicine
Basics
tcmbasics.com/materiamedica.h
tm
Useful for finding the Latin name for the various ingredients, which can
then be used to search the standard alternative medicine databases.
Bibliographic databases e.g.
Medline, Embase.
Suggested terms: drug name, HERBAL MEDICINE, HERBALISM,
MEDICINE-HERBAL, DRUGS-CHINESE-HERBAL, HERBALPREPARATIONS, DIETARY SUPPLEMENTS, DIETSUPPLEMENTATION
- 15 -
Source
Notes
Manufacturers.
Individual manufacturers may be able to provide information. Several
have websites www.pottersherbals.co.uk,
www.nelsonshomoeopathy.co.uk, www.hollandandbarrett.com.
Local resources
Answering the enquiry

Ensure that the enquirer is aware of the lack of quality, reliable information in the literature regarding
complementary medicines. There is also an abundance of misleading information which is usually
what patients have access to! This is particularly true of internet based resources. When assessing
the quality of a website it is useful to ask yourself the following questions:
o
Is the information up-to-date?
o
Who has written the information?
o
Who ‘owns’ the website? Could there be a conflict of interest?
o
Are claims supported by reliable evidence?
o
Is any information provided about risks associated with treatments?

Overall there is limited information available regarding interactions between complementary/alternative
medicines and conventional medicines. Occasionally herbal products may be contaminated with other
active substances. As with conventional drug interactions, herb-drug interactions may be
pharmacodynamic or pharmacokinetic.

It is often difficult to assess whether a complementary medicine will interact with a conventional
medicine. In this situation it may be prudent to advise against using them together. In most cases this
is not because there is evidence of an interaction but because there is a lack of evidence to assess
risk. Individuals using a complementary medicine should be advised to be consistent with the brand,
dose and frequency of administration of the product being used.

Enquirers often ask about the likelihood of an interaction between prescribed and complementary
medicines. Some herbal products may compromise the efficacy of conventional medicines and there
are particular concerns for those individuals receiving drugs with a narrow therapeutic window such as
warfarin, phenytoin and digoxin. Ideally where there is limited safety data for a particular herbal
preparation it would be prudent to avoid their use in patients receiving these types of medicines or in
those whose therapy is deemed critical e.g. chemotherapy.

Pregnancy – there is very limited information on the use of alternative or complementary medicines in
pregnancy and should only be recommended after careful consideration of the risks and benefits.
Some preparations will be contraindicated in pregnancy – always consult a specialist source.
Keywords: Preparation name if possible, if not form of alternative medicine e.g. HERBAL MEDICINE,
DIETARY SUPPLEMENTS, AROMATHERAPY, HOMEOPATHIC MEDICINES, MEDICINE-CHINESE
TRADITIONAL.
- 16 -
Contraception (hormonal)
Background information
Hormonal contraception

Type of hormonal contraceptive: combined oral contraceptive (COC), progesterone only pill (POP),
patch, depot injection, implant, intrauterine system (IUS), vaginal ring?

Contraceptive pill: Name, type of pill (POP / COC)?

21 or 28 day pill?

Patch, injection, implant: Name of preparation?

Already taking or planned to take?

Other medical conditions?

Other medicines, including complementary and OTC?

Are they breast feeding?

Smoking status (relevant if the choice of agent is being discussed)?

Age of patient (relevant if choice of agent is being discussed)?
Missed contraceptive pills

Name of pill, type of pill (POP/COC/standard strength/low strength oestrogen) and number of days in
the pack (21 or 28 days)? N.B. Qlaira is a new COC with different missed dose advice – refer to the
Summary of Product Characteristics.

What time does she usually take her pill?

How many pills have been missed?

Was previous pack taken correctly?

Where in the cycle were they missed

How many pills are left in the pack?

COC: were the previous 7 pills taken correctly / any previous episodes of missed pills?

POP: were the previous 2 pills taken correctly / any previous episodes of missed pills?

COC : sexual intercourse, without any form of contraception, during the preceding 7 days?

POP: any sexual intercourse since the POP was missed (ie after 3hrs/12hrs)?

Diarrhoea and vomiting – when / how long for /severity?

Other medical conditions .e.g. IBD?

Other medicines, including complementary and OTC?
Delayed or detached patch

Patch: Name of patch (Evra)?

When does she usually change the patch (day and time)?

Which patch has been delayed or detached?

Delay in applying a new patch: how long?
- 17 -

Detached patch: how long?

Have all other patches been used correctly?

Sexual intercourse, without any form of contraception, during the preceding 7 days?

Other medical conditions?

Other medicines, including complementary and OTC?
Delayed injection or implant rods

Name of injection (Depo-Provera, Noristerat) or implant (Implanon - now replaced by Nexplanon).

How long is the delay in administration?

Sexual intercourse since replacement was due?

Weight/BMI (implant runs out earlier)

Other medical conditions?

Other medicines, including complementary and OTC?
Dislodged or delayed inter-uterine progesterone only system (Mirena coil)

When did the coil dislodge?

How long since the replacement was due?

Sexual intercourse during the preceding 7 days?
Vaginal ring (NuvaRing)

Delay in inserting new ring: how long?

Delay in removing the ring: how long?

Ring accidentally expelled: for how long and in which week?

Ring removed deliberately (for sex) but not replaced in time: for how and in which week?

Sexual intercourse, without any form of contraception, during the preceding 7 days?
Emergency contraception

What is the reason for needing it e.g. if missed pill may need to give advice on when to restart the pill
again and additional precautions required.

How long is it since unprotected intercourse occurred?

Other medical conditions and medicines, including complementary and OTC?

Age of patient?

Is the woman likely to be pregnant or are they breast feeding?

Has any other from of emergency contraceptive been used in the current cycle?
For enquiries regarding drug interactions, adverse effects, pregnancy or breast feeding associated with
contraception, refer to the relevant monographs.
- 18 -
Resources
Source
Notes
First-line resources
In-house past enquiries.
Relevant Medicines Q&As via
www.nelm.nhs.uk or
www.evidence.nhs.uk
BNF
www.medicinescomplete.com/m
c/bnf/current/
Electronic Medicines
Compendium
www.medicines.org.uk/emc
SPCs and PILs should contain up-dated missed COC pill advice
(FSRH/MHRA May 2011) .
Contraception: Your Questions
Answered. Guillebaud J &
MacGregor A.
Comprehensive resource covering all forms of contraceptives including
injectables, implants, IUDs, patches and EHC.
The Pill. Guillebaud J
Written for the public. N.B. contains old missed pill advice
Family Planning Association.
www.fpa.org.uk
Website aimed at the general public, good for contact details of local
clinics and good basic information about contraception.
Helpline (England):
Click Help & Advice> contraception
0845 1228690
Helpline staffed by nurse advisors
Mon-Fri 9:00-17:00.
IPPF (International Planned
Parenthood Federation)
Directory of Hormonal
Contraceptives
http://contraceptive.ippf.org/
Can be used to identify foreign contraceptive pills
Additional resources (tailor to local use/availability)
Faculty of Sexual and
Reproductive Healthcare(FSRH)
www.ffprhc.org.uk
Prodigy guidance: Contraceptive
guidance
http://www.prodigy.clarity.co.uk/
clinical_topics/by_clinical_specia
lty/womens_health#-325500
The website of the Royal College of Obstetricians and Gynaecologists.
Click Publications
Guidelines including choice of a contraceptive agent at different ages, in
breast feeding, inflammatory bowel disease, interactions, missed pills
and using pills outside their product licence, EHC, new product reviews.
Covers risk and benefits of methods available, including failure rates and
factors that influence choice.
NB: This will change to Clinical
Knowledge Summaries
guidance in early 2013.
World Health Organization
www.who.int/reproductivehealth/
Click Publications>Family Planning>
NICE guidance: Long acting
reversible contraception
www.nice.org.uk
Includes information on effective and appropriate use of LARC and
provides advice and information.
- 19 -
Source
Notes
Netdoctor www.netdoctor.co.uk
Useful resource for members of the public written by healthcare
professionals
Bibliographic databases e.g.
Medline, Embase.
Suggested terms: CONTRACEPTION, CONTRACEPTIONPOSTCOITAL, EMERGENCY CONTRACEPTION, CONTRACEPTIONBARRIER, plus drug name.
Local resources
Answering the enquiry

When answering an enquiry regarding missed pills make your answer as clear and practical as
possible, i.e. if they are to use additional contraceptive measures state for how long, what they do
when they finish the packet of pills, when they restart their pill after EHC etc.

Choice of therapy, ensure patient preference and concomitant risk factors have been considered.
Keywords: CONTRACEPTIVES-ORAL or CONTRACEPTIVES POSTCOITAL or use CONTRACEPTION
if neither of these terms are applicable. Also use individual estrogen or progestogen if appropriate.
- 20 -
Cytotoxic medicines
Background information

Most hospitals will have a specialist oncology pharmacist and will have chemotherapy protocols to
follow. These experts will be better placed to answer enquiries about cytotoxic medicines and regimes
for the treatment of patients with cancer.

For any enquiries about treatment regimes, refer to local policy.

For enquiries about manufacturing of cytotoxic medicines, the aseptic manufacturing unit in the hospital
should be contacted.
Resources
Source
Notes
First-line resources
In-house past enquiries.
Relevant Medicines Q&As
via www.nelm.nhs.uk or
www.evidence.nhs.uk
BNF
www.medicinescomplete.c
om/mc/bnf/current/
Chapter 8 contains general information about cytotoxic drugs.
Electronic Medicines
Compendium
www.medicines.org.uk/emc
The Summary of Product Characteristics contains information about the
administration of cytotoxic medicines and lists warnings, precautions and
adverse effects.
Cytotoxics Handbook.
Allwood, M et al.
Most manufacturing units hold this resource. Essential for MI centres
answering a significant number of cytotoxic-related enquiries.
Additional resources (tailor to local use/availability)
Specialist Centre for
Oncology is The Royal
Marsden NHS Foundation
Trust. Tel: 0208 661 3456
(medicines information).
Can assist with specialist advice on drug use in cancer patients. Phone
them only after a thorough search. Make sure you have all the relevant
background information.
Local cancer network.
Use Google to search for contact details of the cancer network in your
area.
NICE guidance - Cancer
http://guidance.nice.org.uk/
Topic/Cancer
Local resources
Answering the enquiry

Unless you are familiar with the chemotherapy regimens used for the treatment of cancer it would be
safer not to attempt to answer the enquiry. Liaise with the specialist oncology team and oncology
pharmacist.
Keywords: CYTOTOXINS, drug name.
- 21 -
Dental
Background information
Dentists often ask about adverse effects and possible drug interactions, these should be answered in the
same way as all other ADR or interactions question.
For antibiotic treatment choice enquiries:

What is the indication for the antibiotic?

Any allergies and details of the reaction?

Has the patient recently had any antibiotics? If so, which, what was the dose, duration and indication?
Dental prescribing enquiries:

Is the dentist treating an NHS or private patient?

What is the indication for the prescription?
Resources
Source
Notes
First-line resources
In-house past enquiries.
Relevant Medicines Q&As via
www.nelm.nhs.uk or
www.evidence.nhs.uk
BNF
www.medicinescomplete.com/m
c/bnf/current/
At the front of the BNF ‘Guidance on Prescribing’ includes ‘Prescribing in
dental practice’. The BNF online provides links to dentally relevant
sections in the body of the BNF and specific sections on:
 Medical emergencies in dental practice
 Medical problems in dental practice
Advice on prescribing for oral bacterial infections, or for prophylaxis can
be found at the beginning of section 5.
Within the monographs of the drugs that dentists can prescribe is the
statement ‘Dental prescribing on NHS’. The ‘Dental Practitioners’
Formulary’ (the list of dental preparations approved by the Secretaries of
State as prescribable by a dentist on an NHS prescription) can be found
between Appendix 9 and the Index of manufacturers.
Electronic Medicines
Compendium
www.medicines.org.uk/emc
Additional resources (tailor to local use/availability)
UKMi specialist centre - North
West Medicines Information
Centre 0151 794 8206
See Specialist services>Drugs in Dentistry page for details of
background information required before contacting the centre.
Antimicrobial Prescribing for
General Dental Practitioners
(2012, Faculty of General Dental
Practitioners (UK)).
When to use and appropriate doses for antibiotics, antifungals and
antivirals in adults and children for dental conditions.
Churchill's Pocketbook of
Clinical Dentistry.
Good for understanding dental procedures and terminology.
Oxford Handbook of Clinical
Dentistry.
Good for understanding dental procedures and terminology.
- 22 -
Source
Notes
Medical Problems in Dentistry,
Scully and Cawson.
Useful for dental management issues, relevant to a large number of
medical conditions.
Pharmacology and Dental
Therapeutics, Seymour et al.
Oral Microbiology, Marsh and
Martin.
Local Anaesthesia in Dentistry,
Robinson et al.
Good for local and systemic adverse effects of local anaesthetics.
Drug Dictionary for Dentistry,
Meechan and Seymour.
Useful for oral adverse effects and interactions.
ADA Guide to Dental
Therapeutics.
American text.
Guidance for the management
of natural rubber latex allergy in
dental patients and dental
healthcare workers (Faculty of
General Dental Practitioners
UK).
British Dental Association
www.bda.org
Useful 'Fact Files' e.g. filling materials safety, latex allergy, dental care
during pregnancy, bisphosphonates and 'Advice Sheets' e.g. Prescribing
in general practice. Access to documents on the website is restricted to
registered dental health professionals. For access to relevant documents
contact the Information Centre on 020 7563 4545 or email:
Infocentre@bda.org
General Dental Council
www.gdc-uk.org
The statutory body which regulates the dental profession in the UK.
Online access to the dental register.
Septodont
One of the biggest manufacturers of dental materials. The website
contains SPCs (on request) and safety data sheets.
www.septodont.co.uk
Dentsply
Has the SPCs for Dentsply local anaesthetics.
www.dentsply.co.uk
Bibliographic databases e.g.
Medline, Embase
Suggested terms: see range of keywords below.
Local resources
Answering the enquiry

Dentists see patients who may be taking a lot of medicines due to medical conditions and usually have
no other resource than the BNF.

All dental procedures undertaken in primary care can be classed as minor surgical procedures (even if
the dentist thinks they are major for them!). This has implications when considering choice of
prophylaxis, analgesia, management of patients on corticosteroids etc. Use the analogy: insertion of
joint prosthesis (major) vs. two or more tooth extractions (minor).
Keywords: Use the drug name where appropriate. Other useful keywords include;
DENTISTRY-OPERATIVE = dental procedures e.g. extractions (TOOTH EXTRACTION) ROOT CANAL
THERAPY, DENTAL MATERIALS = impression materials, filling materials, cements, toothpastes, DENTAL
CARIES, DENTIFRICES = toothpastes, CARTRIDGES-DENTAL, DENTAL ALLOYS = mercury amalgam
fillings, TOOTH DISEASES, TOOTH EXTRACTION, PERIODONTAL DISEASES including GINGIVITIS,
PERIODONTITIS, MOUTH DISEASES including TOOTH DISEASES, TASTE DISORDERS, GLOSSITIS,
XEROSTOMIA = dry mouth, ANAESTHESIA-DENTAL, ANAESTHESIA-LOCAL, ANAESTHETICS-LOCAL,
and PROPHYLAXIS, for endocarditis enquiries.
- 23 -
Drug use in hepatic impairment
Background information

Clinical condition of the patient, age, sex, presumed diagnosis and previous medical history if
relevant?

Type of liver disease and cause (e.g. acute, chronic, cirrhosis etc).

Results of any immunological/virological screens (e.g. hepatitis) and other diagnostic tests (e.g.
biopsies).

Symptoms (e.g. ascites, jaundice, varices, encephalopathy), extent and severity.

Liver function tests (bilirubin, alkaline phosphatase, ALT, AST, GGT) - most recent ones if possible.
Are they stable or changing?

What are the most recent albumin levels?

What is the most recent INR/prothrombin time for clotting?

What is the current medication including doses and any changes/short courses in last 2-3 months (e.g.
antibiotics)?

Ask about renal function. Multi-organ failure often co-exists but enquirers often forget to
mention this.

Is it suspected that the hepatic impairment is drug induced? Include questions about duration and
dose of suspected drug, timescales, type of liver injury, how patient has been managed, what other
drugs are being taken or were taken recently, and could there be another cause?
If the hepatic impairment is suspected to be drug-related refer to the monograph ‘Adverse drug
reactions'.

If requesting advice on dosage or suitability of a drug in hepatic dysfunction, what is the indication for
the drug and have alternatives been considered? What agent would normally be used if the patient did
not have liver dysfunction?
The following Medicines Q&As give further guidance on approach to liver related enquiries:

http://www.nelm.nhs.uk/en/NeLM-Area/Evidence/Medicines-Q--A/What-pharmacokinetic-andpharmacodynamic-factors-need-to-be-considered-when-prescribing-drugs-for-patients-with-liverdisease/?

http://www.nelm.nhs.uk/en/NeLM-Area/Evidence/Medicines-Q--A/Why-is-the-adverse-effect-profileof-a-drug-relevant-when-prescribing-for-patients-with-liver-disease/?
Resources
Source
Notes
First-line resources
In-house past enquiries.
Try keywords such as LIVER FUNCTION-IMPAIRED or LIVER
DISEASES
Relevant Medicines Q&As via
www.nelm.nhs.uk or
www.evidence.nhs.uk
BNF
www.medicinescomplete.com/m
c/bnf/current/
Use this as an initial source but remember minimal information is
included and it is inadequate as a sole reference source. NB. The
absence of information does not imply safety.
BNF-C
www.medicinescomplete.com/m
c/bnfc/current/
- 24 -
Source
Notes
Electronic Medicines
Compendium
www.medicines.org.uk/emc
SPCs may give advice on the need to reduce doses in hepatic
impairment. The ‘pharmacokinetics’ and ‘undesirable effects’ sections
may also be useful.
Martindale via
www.medicinescomplete.com
AHFS Drug Information via
www.medicinescomplete.com
Meyler’s Side Effects of Drugs.
Dukes and Aronson.
For information on drug-induced hepatic injury.
Drugs and the Liver. A guide to
drug handling in liver
dysfunction. North-Lewis P.
Covers background information on liver function, the principles of drug
use in liver disease and includes a section of worked examples of
commonly asked questions. Includes an ‘aide memoire’ section for
collecting background data.
UKMi workbook - Drugs in Liver
Disease
www.ukmi.nhs.uk/filestore/secur
e/training/workbook/pdfs_2011/2
011-WorkbookTutorial_9.pdf
Bibliographic databases e.g.
Medline, Embase.
If no information can be found in standard resources on the use of a
specific drug in a specific type of liver disease, consider conducting a
literature search for relevant papers. This should be done before using
pharmacokinetic/pharmacodynamic data to predict drug handling from
first principles.
Suggested terms: LIVER DISEASES, BILIARY TRACT DISEASES,
LIVER-TOXICITY, HEPATITIS-TOXIC, CHOLESTASIS, HEPATITIS,
LIVER FUNCTION-IMPAIRED, (NB: take care if using “LIVER
DISEASES” - may not include some cholestatic conditions)
Additional resources (tailor to local use/availability)
Micromedex
www.micromedexsolutions.com
Monographs have a 'dosage in hepatic insufficiency' section with links to
more general drug consults e.g. Antidepressant use in chronic liver
failure. Also useful for pharmacokinetic and adverse effect data.
Pharmacology textbooks.
Generally have a brief description of causes and background to liver
disease.
Therapeutic Drugs. Dollery
Although this resource is very old (2nd edition 1999) the monographs
have information about drug use in high-risk groups and is useful for
basic pharmacokinetic data for older drugs.
Goodman & Gilman’s
Pharmacological Basis of
Therapeutics.
Has information about drug metabolism and hepatic effects.
Applied Therapeutics: The
Clinical Use of Drugs. Koda
Kimble.
There is a section listing drugs reported to cause clinically significant
hepatotoxicity and the likely mechanism.
Handbook of Clinical Drug Data.
Knoben & Anderson.
Includes a table on drug-induced hepatotoxicity.
Pharmaceutical manufacturers
May have information about any reduction of doses which may be
necessary in hepatic impairment. May have relevant pharmacokinetic
details if working from first principles.
Specialist UKMi centre
www.ukmi.nhs.uk/activities/specialistServices/default.asp?pageRef=3
Please note there is no longer a specialist MI centre for referral of liver
enquiries. For a practical approach to management of patients with
hepatic disease contact your nearest liver unit.
- 25 -
Local resources
Answering the enquiry

The following factors should be considered when deciding an optimum drug treatment for a patient
with liver disease:
o
Type, extent and severity of liver disease
o
Pharmacokinetics and pharmacodynamics of the drug
o
Adverse reactions of the drug
o
Patient specific factors e.g. age, comorbidities, severity of the condition being treated,
concomitant medications

In patients with hepatic dysfunction, avoid hepatotoxic drugs where possible. Patients with existing
hepatic disease are not more prone to hepatotoxicity (unless it is dose-related), but they have
diminished reserve hepatic function and may suffer disproportionately if hepatotoxicity does occur.
Drug hepatotoxicity on top of existing liver disease will also confuse the diagnostic picture. Even
clinically insignificant and/or transient changes in LFTs may confuse the diagnostic picture.

For drugs metabolised by the liver, be alert to signs of drug side effects, know what they are and
monitor for them. Monitor drug levels where appropriate.

Non-systemic treatments should be chosen where possible. Renally excreted drugs are also preferred
as long as renal function is normal. Monitor for any changes in renal function.

Drugs that increase the risk of bleeding should be avoided or used with extreme caution, depending
on the severity of liver disease.

Drugs that are highly dependent on the liver for deactivation or clearance are likely to need dose
reduction in moderate to severe liver disease.

Avoid sedating drugs in patients at risk of developing encephalopathy. Many of these drugs have long
half-lives and are metabolised by the liver so their duration and intensity of action may be prolonged.
The brain also becomes more sensitive to sedating effects in liver disease. A sedative drug may
precipitate or mask encephalopathy.

The doses of highly protein-bound drugs may need reducing in patients with low albumin levels due to
chronic liver disease.

Drug prescribing should be kept to a minimum – use the smallest effective doses at the greatest
interval, and titrate according to clinical response.
Keywords: Include drug names and LIVER FUNCTION-IMPAIRED or LIVER DISEASES
- 26 -
Pharmaceutical identification
1.
Tablet or capsule identification
Background information

Describe the form, markings, colour, shape, size and weight.

What is the likely therapeutic indication?

What is the likely country of origin?

Is the preparation thought to be prescription/ herbal / illicit?
Resources
Source
Notes
First-line resources
Electronic Medicines
Compendium
www.medicines.org.uk/emc
SPCs describe products in the ‘Pharmaceutical form’ section and you
can search the whole database by clicking on ‘search by section’,
selecting relevant section and entering letters, numbers etc. This will not
help with generic products unless they are branded generics.
Pharmaceutical manufacturer.
If logo or marking suggests a particular company.
Tic Tac.
Free for Regional Medicines Information Centres. Some A&E units also
have access to this. If a particular logo is difficult to describe suggest the
enquirer faxes a drawing. For products with few distinguishing features,
an accurate weight and measurement of dimensions might help.
Local resources
Answering the enquiry

If there is a range of hits, highlight the fact that the only definitive way of identifying the preparation is
to analyse it.

Many of these enquiries involve a third party which may raise ethical questions. Refer to guidance on
answering third-party enquiries: http://www.ukmi.nhs.uk/filestore/misc/L&E_ThirdParty2002.pdf

From the age of 14, girls may be prescribed oral contraceptives without parental knowledge.

If an enquirer is concerned that their child is taking illicit drugs, you can refer them to
www.talktofrank.co.uk or 0800 776600. There is a parent section on the website which gives advice on
how to broach the subject with their children, as well as information about drugs.

General guidance on ‘street’ drugs:
o
Tablets may be embossed.
o
Any emboss is typically a picture or symbol, rather than words or numbers.
o
Often the tablet is crude with a texture like “extra strong mints”.
o
Tablets are unlikely to be smooth and pure white.
o
They are never in strip packs.
o
Street drugs are never coated.
2.
Foreign drug identification
Background information

What is the trade / generic / chemical name including spelling?

What is the reference source of the drug name e.g. from packaging, dispensing label or from memory?

Is the country of origin known?
- 27 -

Is the manufacturer known?

Describe the form, markings, colour, shape, size and weight.

What is the dose, strength and likely indication?
Resources
Source
Notes
First-line resources
Martindale via
www.medicinescomplete.com
Internet search.
www.google.co.uk
Additional resources (tailor to local use/availability)
Tic Tac.
Free to Regional Medicines Information Centres. Can select option to
search American products only: Select ‘product’ tab then ‘American
drugs’.
Micromedex
www.micromedexsolutions.com
On ‘Drugs’ tab there is a drug identification option.
Royal Pharmaceutical Society
database via:
www.rpharms.com/bestpractice/identification-of-foreignmedicines.asp
RPS Support has collated a list of websites to help identify foreign
medicines from a number of countries. They also hold a collection of
foreign medicine literature that complements the catalogue of websites.
(available only to members)
Can also be contacted by phone
on 0845 257 2570.
MIMS via www.mims.co.uk
Click on ‘MIMS’ then type name in the ‘MIMS search’ box. Lists all of the
products featured in the MIMS reference book and gives detailed
descriptions of each product including tablet appearance.
AHFS Drug Information via
www.medicinescomplete.com
For US products.
Bibliographic databases e.g.
Medline, Embase, Pharmline
(via the medicines management
section of NeLM)
Suggested terms: known spelling of drug name or use truncation/wild
cards if partial name known.
Local resources
Answering the enquiry


3.
Bear in mind that the drug/brand name may be spelt incorrectly.
If you cannot identify the product from the available information, advise enquirer to check details or
contact original prescriber.
Investigational drugs
Refer to ‘New Products’ monograph.
- 28 -
Immunisation
Background information

Establish the situation the question relates to. Is it a general question about the UK immunisation
schedule or is the question regarding the management of a specific patient?

Does the question relate to routine childhood immunisation, vaccination for high-risk groups or travel
vaccination? For travel medicine, see the Travel Medicine enquiry answering guideline.

For questions relating to a specific patient establish age, vaccination history including dates, medical
and medication history and allergy status (including food allergies). If an allergy is reported, did this
involve anaphylaxis? Has the patient suffered adverse reactions to vaccinations in the past? Is the
patient pregnant or breastfeeding (see also the Drugs in Pregnancy and Drugs in Lactation enquiry
answering guidelines)?

To answer questions about the safety of vaccines given in error, establish exactly what vaccine(s) has
been given, including brand name if possible, and when.
For travel related immunisation enquiries see the ‘Travel Medicine’ monograph
Resources
Source
Notes
First-line resources
In-house past enquiries.
Relevant Medicines Q&As via
www.nelm.nhs.uk or
www.evidence.nhs.uk
British National Formulary via
www.medicinescomplete.com/m
c/bnf/current/
Chapter 14 provides information on vaccines and immunisation. Note
that the vaccine schedules in the BNF may be out of date.
BNF for Children via
www.medicinescomplete.com/m
c/bnfc/current/
Chapter 14 provides information on vaccines and immunisation. Note
that the vaccine schedules in BNFC may be out of date.
Department of Health
Immunisation website
www.immunisation.nhs.uk
Latest news is listed in the centre of the screen with links to relevant
documents such as Chief Medical Officer (CMO) letters and copies of
Vaccine Update, a monthly publication for staff involved in vaccination.
There are links to other sources of information (some of which are
described below):
“Green Book”
NB: Click on the green square that looks like the green book.
Immunisation against Infectious
Disease –otherwise known as
The Green book. (Click on
‘Green Book’.)
Comprehensive resource published by the Department of Health,
providing information about diseases and vaccines, including advice on
cautions and contraindications.
“Vaccine update”
http://immunisation.dh.gov.uk/ca
tegory/updates/
NB: Click on the blue square under the green book.
“Key vaccine information”
http://immunisation.dh.gov.uk/ca
tegory/key-vaccine-info/
Monographs on individual vaccines written in a straightforward Q&A
format. However, the date of production is not included and some links
in the documents are out of date.
Note: Always check that you are looking at the most up to date version
of the chapter you want. Be careful not to use chapter update patches or
old chapters.
Monthly publication for health professionals regarding vaccine supply.
Editions are listed in date order with the most recent at the top.
- 29 -
Source
Notes
Patient Group Directions
Example PGDs for the administration of vaccines (and other products)
are available from the PGD community area in NeLM.
www.nelm.nhs.uk/en/Communiti
es/NeLM/PGDs/
Health Protection Agency
www.hpa.org.uk
This website includes information on the incidence of cases of infectious
diseases and links to UK guidelines. From the home page, click on
‘Topics A-Z’ at the top of the screen and then select the vaccine or
disease you are interested in.
Additional resources (tailor to local use/availability)
Sanofi Pasteur MSD
www.spmsd.co.uk
This website provides useful information about diseases and vaccines.
Click on ‘healthcare professionals’ then choose ‘Product information’ or
‘Disease information’ in the list on the left side of the screen.
Health professionals can also access the company’s Vaccine
Information Service (VIS). Click on the link from the homepage. It
provides comprehensive information about vaccines and immunisation
schedules. Free registration is required.
Electronic Medicines
Compendium
www.medicines.org.uk/emc
For product information about individual vaccines. NB: Dosage
schedules may differ from those recommended nationally.
Medical information, vaccine
manufacturers.
Vaccine manufacturers may be able to answer questions relating to use
of their vaccines. For information outside of the SPC ask for ‘data on
file’.
World Health Organization
(WHO) www.who.int
This website includes information on international aspects of vaccines
and immunisation including the development of new vaccines and the
supply of vaccines throughout the world. From the home page, click on
‘health topics’ then ‘vaccines’ or ‘immunization’.
Bibliographic databases e.g.
Medline, Embase.
Suggested terms: IMMUNISATION, IMMUNISATION PROGRAMMES,
IMMUNISATION SCHEDULE, VACCINES, name of vaccine,
VACCINATION, MASS-IMMUNISATION.
Local resources
Answering the enquiry

NB: Always ensure you are using up-to-date resources as changes to vaccines schedules and catchup programmes may not be included in current editions of printed resources.

Reassure callers that having an extra dose of a vaccine is not usually a cause for concern. Many
preparations are formulated with multiple vaccines and it is inevitable that some patients will receive
doses of vaccines they do not require. The most likely adverse effect in this situation is irritation at the
site of injection.

Be aware of the difference between live and inactivated vaccines. When two live vaccines (e.g. yellow
fever, polio) are required, they should either be given simultaneously at different sites or with a gap of
at least four weeks.

Consider the risk/benefit of vaccination. In cases of unknown vaccination history, it is often considered
safer to give a vaccine than to assume prior vaccination.
Keywords: IMMUNISATION, name of vaccine, name of disease
- 30 -
Interactions
Background information

Establish patient details, including age, sex etc.

Consider whether the interaction is drug-drug, drug-food, drug-test or drug-disease.

Which drugs are being taken by the patient already? How long have they been taken and what are the
indications?

Has the enquirer read about the interaction? If so, where?

If the patient is already taking both drugs, have any problems been identified or investigated? Ask for
details of any suspected interaction (e.g. symptoms, lack of effect, timescales of starting drugs, any
action already taken).

If there is an interaction, is there any reason why alternatives can’t be used?

What is the patient’s liver and renal function?

Is the patient taking any other medicines, including complementary, OTC and illicit medicines?

If any ongoing or future monitoring is required, who would do this?
Resources
Source
Notes
First-line resources
In-house past enquiries.
Relevant Medicines Q&As via
www.nelm.nhs.uk or
www.evidence.nhs.uk
BNF
www.medicinescomplete.com/m
c/bnf/current/
Appendix 1 in the paper BNF, a ‘black dot’ implies a clinically significant
interaction. In the electronic BNF, type the drug names or classes in the
search box, on the results page click the ‘interactions‘ tab. Clinically
significant interactions are shaded in pink. Consider significance for your
patient even if the BNF doesn’t rate the significance highly.
AHFS Drug Information via
www.medicinescomplete.com
Each drug monograph includes referenced information on interactions
Electronic Medicines
Compendium
Section 4.5 of an SPC specifically relates to interactions but also check
contraindications and precautions and special warnings. Interactions
listed can be theoretical; manufacturer may clarify.
www.medicines.org.uk/emc
Stockley’s Drug Interactions via
www.medicinescomplete.com
Search by putting both potentially interacting drugs in the search box. If
you get no hits try using a broader term – these can be found in the grey
box on the right of the screen.
Stockley's Herbal Medicines
Interactions
www.medicinescomplete.com
Searchable in the same way as Stockley’s Drug Interactions. Each
included herbal medicine has monograph including uses,
pharmacokinetics and an interactions overview.
Natural Medicines
Comprehensive Database
www.naturaldatabase.com
For complementary drug-drug, drug-food, and drug-disease interactions.
Possible interactions are listed in each monograph. The interaction
checker can be used to check specific combinations.
Micromedex
www.micromedexsolutions.com
Interactions are described using the following headings: Interaction
effect, summary, severity, onset, substantiation, clinical management,
probable mechanism, literature reports.
Additional resources (tailor to local use/availability)
- 31 -
Source
Notes
Meyler’s Side Effects of Drugs,
Dukes and Aronson.
Bibliographic databases e.g.
Medline, Embase
Suggested terms: DRUG INTERACTION, FOOD-DRUGINTERACTIONS, HERB-DRUG-INTERACTIONS
Cytochrome p450 website:
http://medicine.iupui.edu/flockha
rt/
Indiana university website.
Antiviral drugs: www.hivdruginteractions.org/
University of Liverpool resource freely available to healthcare workers,
patients and researchers offering comprehensive evidence-based tables
of drug interactions between the HIV drugs or key interactions between
Protease Inhibitors, NNRTIs, NRTIs, or Entry/Integrase Inhibitors and
other drugs that may be prescribed to the HIV+ patient.
Hepatitis antiviral medicines
www.hep-druginteractions.org/
University of Liverpool resource offering a comprehensive drug-drug
interaction resource for antiviral drugs used for hepatitis and other
medicines which is freely available to healthcare workers, patients and
researchers.
Drugs that Prolong the QT
Interval and/or Induce Torsades
de Pointes (TdP)
www.azcert.org
A list of drugs that prolong QT interval and/or induce TdP drugs are
categorised into those that:
 are considered to carry a risk of TdP.
 prolong QT interval and/or have been associated with TdP, but at
this time lack substantial evidence for causing TdP.
 carry a risk of TdP and/or QT prolongation under certain conditions,
such as patients with congenital long QT syndrome, drug overdose
or co-administration of interacting drugs.
A table containing drugs listed in columns under specific cytochrome
P450 isoforms. Drugs are included if there is published evidence that
they are metabolised, at least in part, via the specific CYP isoform.
Local resources
Answering the enquiry

If the enquiry is prospective, reference to BNF, eMC and Stockley may be all that is required. Note that
that SPC warnings are often extrapolated from other drugs in the same class and an assessment
should be made as to how relevant this is to the individual drug.

If there is likely to be little experience with the two drugs used together e.g. new drug or rarely used,
review interactions with drugs from the same class and consider the pharmacology and
pharmacokinetics.

Consider whether an interaction is likely, on what basis and the limitations of information (e.g. if new
drug/not widely used/ previous experience with combination unlikely).

Can the two drugs be given together with appropriate monitoring? If so what should be monitored and
who should monitor?

Could a safer alternative be used?

Could a different route of administration overcome the problem?
Keywords: DRUG INTERACTIONS and drug names
- 32 -
New products
Background information

Has the product been launched in the UK?

If pre-launch in UK does the enquirer know whether it is available in another country?

Where has the enquirer heard about this product?

Ask for exact spelling, any known manufacturer, strength, dosage form and indication.

If you are asked to identify a specific clinical trial, gather as much data as possible about the trial i.e.
drug name, manufacturer, results, disease area, any acronym, authors’ names, date of publication etc.

What is the enquirer going to use the information for? If the enquirer is considering using the new
drug supply issues may be relevant.
Resources
Source
Notes
First-line resources
In-house past enquiries.
Pre- launch information
UKMI: New Drugs Online via
www.nelm.nhs.uk or
www.ukmi.nhs.uk
This contains monographs on developmental status of several hundred
drugs from PII onwards. Also contains links to more in-depth
independent evaluated information on individual drugs. Registration is
required for full access. Abbreviated monographs are accessible via
NHS Evidence. Put drug name and ‘NDO’ into search box to limit hits
just to NDO monographs (easier to do this via Google).
UKMI: Prescribing Outlook via
www.nelm.nhs.uk
Login required. Advanced information on drugs with market launches
planned in the next 12-18 months. Confidential to the NHS, produced for
those with budget setting, prescribing planning and medicines
management responsibilities.
Brief information on: generic name, trade name, company, indication,
NICE status, links to in-depth independent assessments, current status,
estimated UK launch, pharmacology, efficacy, safety, target population,
NHS service and financial implications.
NeLM news via
www.nelm.nhs.uk
News section highlights information on new drugs in press releases.
AHFS Drug Information via
Medicines Complete
www.medicinescomplete.com
Try these resources if product is already launched abroad especially in
US.
There is also a section on NeLM (password protected) where reviews
produced for Individual Funding Requests (IFRs) are published.
Micromedex
www.micromedexsolutions.com
Internet search e.g. Google.
Use for reviews published in other countries if already launched
elsewhere in the world.
Regional MI centre
Your regional MI centre may have access to other new drug/horizon
scanning databases.
Recently launched drugs
New medicines profiles via
www.nelm.nhs.uk
Reviews produced within 3 months of launch on UK market. Contain
information on comparative costs, place in therapy and risk management
issues. Search NeLM by drug name to locate.
London (Cancer) New Drugs
Group publications via
www.nelm.nhs.uk
Very detailed in-depth reviews of drugs pre and post launch. Search
NeLM by drug name to locate.
- 33 -
Additional resources (tailor to local use/availability)
Scottish Medicines Consortium
www.scottishmedicines.org.uk
Post launch appraisals used to provide advice to NHS Boards and their
Area Drug and Therapeutics Committees across Scotland about the
status of all newly licensed medicines, all new formulations of existing
medicines and any major new indications for established products
(licensed from January 2002).
All Wales Medicines Strategy
Group
www.wales.nhs.uk/awmsg
The All Wales Medicines Strategy Group (AWMSG) provides advice on
strategic medicines management and prescribing in Wales.
ADIS R&D database
Commercial database with up to date information on all aspects of drugs
in development and licence extensions. Contact your regional MI centre
for details.
Formulary Monograph Service
www.formularymonographs.com
In-depth reviews of products launched in US.
Midlands Therapeutics Review
and Advisory Committee
(MTRAC)
www.keele.ac.uk/pharmacy/mtra
c/
Post launch information to provide advice to general practitioners for
primary care prescribing.
Northern & Yorkshire Regional
MI centre www.nyrdtc.nhs.uk
Post launch information to provide advice to general practitioners for
primary care prescribing. Also available via NeLM.
EU licensing authority
(European Medicines Agency)
www.ema.europa.eu
European public assessment reports (EPARs) are published here.
These are summaries of the decisions of the EMA. It contains the SPC
and data used to support the application in the EU. However, they can
take time to be published and are only available for certain products.
US licensing authority: FDA
www.fda.gov
For products launched in US.
National Horizon Scanning
Centre www.hsc.nihr.ac.uk
Pre-launch reviews produced on drugs that are generally at PII to PIII
stage. This organisation is involved in advising on NICE appraisal topics.
Pharmaceutical manufacturer.
Companies can respond to individual requests for information on drugs
in development. However, depending on how far away from launch it is,
you are unlikely to obtain much more information than that found in the
above resources. Only use if there is little information elsewhere.
Bibliographic databases e.g.
Medline, Embase
Suggested terms: NEW PRODUCTS, DRUGS-INVESTIGATIONAL
Local resources
Answering the enquiry

Depends on level of information required from superficial availability information to in-depth reviews.

If only pre-launch reviews are available following product launch, use with caution as the information
they contain is likely to have been superseded, especially information relating to financial planning.
Keywords: NEW PRODUCT, drug name.
- 34 -
Ophthalmology
Background information

What eye drops or eye ointments is the patient using? Are there any other medicines being taken for
treatment of the ocular condition?

What eye condition or infection is being treated?

Does the patient have any known sensitivities to excipients in eye drops. This is useful to know when
recommending a product to treat a patient.

Establish whether the enquiry is concerning lids, conjunctiva or cornea.
Glaucoma

If the enquiry is about a patient with glaucoma and whether the medication is safe to use in a patient with
glaucoma, establish what type they have and whether the angles are open or narrow:
o
chronic open-angle glaucoma – this is the most common type of glaucoma and develops
very slowly.
o
primary angle-closure glaucoma – this is rare and can occur slowly (chronic) or may develop
rapidly (acute) with a sudden, painful build-up of pressure in the eye.

If the angles are open there is very little risk of angle closure – but patients must be able to identify the
signs of acute angle closure.

Narrow angle – these patients have usually had some type of intervention to allow the eye to drain.
Patients with narrow angles are at risk of acute angle closure.
Infections

Treatment is generally with antimicrobials in an eye drop or eye ointment formulation.

In the case of blepharitis topical or oral antimicrobials can be given.

When recommending treatment for an ocular infection it would be advisable to consult local antimicrobial
guidelines.
Dry eye

Establish if mild, moderate or severe.

What time of day are symptoms worse?

What drops have already been tried – did they work?

Does the patient wear contact lenses?

What is the age of patient?
Blepharitis

What treatments have already been tried?

How long has the patient been using therapy – sometimes therapy needs to be continued for months.

Explain the importance of lid hygiene.
Contact Lenses
If asked whether eye drops containing preservatives can be used with contact lenses consider:

Does the patient wear contact lenses and which type? This will help determine whether the patient
requires a preservative free eye drop.
- 35 -

If using hard/rigid lens – eye drops containing preservatives can be used.

Gas permeable lenses – establish the type of material, but in most cases eye drops containing
preservatives can be used. If unsure, seek advice from contact lens practitioner.

Soft/hydrophilic lens – eye drops containing preservatives cannot be used.
Use of eye drops in renal or liver impairment, pregnancy or breastfeeding

Significant problems are very uncommon as only a very small amount of topical medication reaches the
blood stream. Moorfields consider even 10% systemic absorption from eye drops to be an extreme over
estimation.
Duration of action of eye drops

Establish colour of eyes and skin. Many topical ocular preparations are bound to melanin and have a
longer duration in patients with dark skin and dark irises.
Resources
Source
Notes
First-line resources
In-house past enquiries.
Relevant Medicines Q&As via
www.nelm.nhs.uk or
www.evidence.nhs.uk
BNF
www.medicinescomplete.com/m
c/bnf/current/
The introduction to section 11 contains useful information
about administration of drugs into the eye and choice of agent
dependent on the infection being treated.
BNFC
www.medicinescomplete.com/m
c/bnfc/current/
Electronic Medicines
Compendium
www.medicines.org.uk/emc
Check relevant SPCs.
Moorfields Eye Hospital –
Pharmacists Handbook
Essential resource for answering ophthalmology related
questions.
Useful if the question is about excipients contained in eye
drops.
Includes a useful table to determine the number of eye drop
bottles to be dispensed according to the dose prescribed.
Martindale via
www.medicinescomplete.com
Useful for information on uses and doses.
Additional resources (tailor to local use/availability)
Prodigy Guidance
http://www.prodigy.clarity.co.uk/
home
NB: This will change to Clinical
Knowledge Summaries
guidance in early 2013
NICE www.nice.org.uk
Useful and practical sections on treatment of eye diseases
such as glaucoma, blepharitis and conjunctivitis:
www.prodigy.clarity.co.uk/clinical_topics/by_clinical_specialty/e
yes#-325198
Several relevant guidelines including Diagnosis and
management of chronic open angle glaucoma and ocular
hypertension
- 36 -
Source
Notes
The Royal College of
Ophthalmologists
A full range of Clinical Guidelines for the management of
ocular conditions are included.
www.rcophth.ac.uk/page.asp?se
ction=451&sectionTitle=Clinical+
Guidelines
There is also a section that contains useful information leaflets
for patients:
www.rcophth.ac.uk/page.asp?section=365&sectionTitle=Inform
ation+Booklets
Ophthalmic Pharmacists
Group. www.rpharms.com/clinic
al-and-pharmacy-practice/ukophthalmic-pharmacygroup.asp.
Membership is free to hospital pharmacists and technicians,
specialising/ interested in ophthalmology in the UK.
Bibliographic databases e.g.
Medline, Embase.
Suggested terms: Drug name, eye condition e.g GLAUCOMA,
EYE DROPS.
The group also holds an active discussion forum which can be
joined here:
https://groups.google.com/forum/?fromgroups#%21forum/ukophthalmic-pharmacists-group
Local resources
Answering the enquiry
Keywords: Drug name, eye condition, EYE, EYE DISEASES, OPHTHALMIC SOLUTIONS, EYE DROPS.
- 37 -
Paediatrics
Background information
These points are in addition to those required for enquiries related to other categories e.g. ADR,
compatibility, etc.

Establish patient details, including age and sex.

What is the weight (Kg) of the child? Confirm any discrepancy between age and weight.

If weight is not known, try to find out whether the child is considered under or overweight for their age.
For some drugs (e.g. cytotoxic agents) a more accurate dose is obtained by calculation of body
surface area, therefore you will need height as well as weight measurements.

If the patient is a young infant (less than 3 months old), were they premature? If so, what is their
gestational age?

What is the intended route of administration? If the route is oral, is the child able to swallow tablets?

Are there any problems that may affect drug or formulation choice e.g. renal failure, cystic fibrosis,
fluid requirements?
Resources
Source
Notes
First-line resources
In-house past enquiries.
Relevant Medicines Q&As via
www.nelm.nhs.uk or
www.evidence.nhs.uk
BNF for Children
www.medicinescomplete.com/mc/
bnfc/current/
Electronic Medicines
Compendium
www.medicines.org.uk/emc
Medicines for Children
www.medicinesforchildren.org.uk/
Extensive range of patient information leaflets about medicines for
children to view or print. Also leaflets and videos about how to give
medicines to children and information on missed doses. Written in plain
English and contains practical advice.
Produced by the Royal College of Paediatrics and Child Health
(RCPCH), Neonatal and Paediatric Pharmacists Group (NPPG), and
national child health charity, WellChild.
Paediatric Formulary.
Guy’s, St. Thomas’ & Lewisham
Hospitals.
Neonatal Formulary:
Northern Neonatal Network.
A companion website to the book at www.neonatalformulary.com
provides free updates and additional information for readers (the text of
the book itself is not available online).
Additional resources (tailor to local use/availability)
Nearest paediatric hospital
pharmacy department.
Contact the hospital caring for the child or your nearest paediatric
specialist centre, and take advice from their clinical pharmacists. The
UKMi Specialist Paediatric MI Service at the Royal Liverpool Children’s
NHS Trust (Alder Hey) (DIAL - Drug Information Advice Line) is no
longer unavailable.
Pharmaceutical manufacturer
May have unpublished data.
- 38 -
Source
Notes
Neonatal and Paediatric
Pharmacists Group
www.nppg.org.uk
Contains links to useful documents, relevant guidelines and advice, but
membership of NPPG is required for access to the full website.
Great Ormond Street Hospital
www.gosh.nhs.uk/medicalconditions/medicines-information/
Useful medicines information leaflets. Other sections of the website
describe procedures and treatments and list GOSH clinical guidelines.
Martindale via
www.medicinescomplete.com
Can sometimes be helpful.
Micromedex
www.micromedexsolutions.com
Monographs have a ‘Pediatric dosage’ section.
NHS Evidence
www.evidence.nhs.uk
NHS Evidence used to maintain a Child Health Specialist Collection
listing links to useful child health resources. This is no longer available,
although NHS Evidence suggests the resources are still accessible –
use the search box (and include the search term child) or browse the
topics pages (note: the only child or paediatric topics are fever and
immunisation).
There is an extensive collection of specialist paediatric e-books (log in
with your Athens password).
Pediatric & Neonatal Dosage
Handbook. Taketomo, Hodding
and Kraus.
Contains 960 drug monographs. Comprehensive guide to use and
dosing of medicines in children and neonates. Available in two editions
– with and without an International Trade Names Index. Over 100
monographs list an extemporaneous formulation.
Nelson Textbook of Pediatrics.
Berhman, Kleigman and Jenson.
Comprehensive US general paediatric reference text, providing a good
source of background information on disease states, clinical
manifestations, diagnosis and treatment, in addition to information on
complications and prognosis.
Evidence-based Pediatrics and
Child Health. Moyer, Williams and
Elliot.
Covers all major childhood conditions. Includes advice on management
and how best to practice evidence based medicine with reviews of all
the available evidence in a specific area.
Forfar and Arneil’s Textbook of
Pediatrics. McIntosh, Helms,
Smyth and Logan.
Evidence based reference book providing a good source of
background information on disease states.
Manual of Childhood Infections:
The Blue Book. Sharland, Cant,
Shingadia and Davies.
Contains two sections: Clinical Syndromes and Specific Infections.
Includes background information, investigations and management
advice, plus references.
Medicines for Children 2003.
RCPCH.
Superseded by BNF for Children and no longer in print. However it
contains some useful information not readily available elsewhere.
Bibliographic databases e.g.
Medline, Embase.
Suggested terms: CHILD (explode term), restrict search to documents
relating to specific age ranges, INFANT-NEWBORN, INFANTPREMATURE, NEONATAL DISEASES.
Local resources
Answering the enquiry

Consider whether recommendations are within the drug’s licensed indications or whether you are
advising off-label use. Prescribing unlicensed medicines, or medicines outside the terms of their
licence (off-label), alters the prescriber’s professional responsibility and liability. The prescriber and
pharmacist should have sufficient information to support using the medicine. Be aware that the
manufacturer’s patient information leaflet may not be relevant to the child and the parents should be
warned of this and appropriately reassured.
- 39 -

When calculating a dose on a mg/kg basis never exceed the maximum recommended dose (usually
the adult dose). If the child is obese consider calculating using ideal body weight.

When assessing the appropriate dose (making reference to available paediatric dosage formularies)
take account of the available formulations and their suitability.

If doses require calculation based on surface area, use recognised reference tables (see back pages
of BNF for Children) or a recognised formula to calculate the surface area.

With smaller doses used in paediatrics it is much easier to make ten fold errors in calculations. Be
especially vigilant with decimal points or avoid using them (and quote appropriate units in full), e.g.
100 micrograms NOT 0.1mg. Do not use trailing zeros, e.g. 5mg NOT 5.0mg.

If you are unsure of your calculations, ask someone to check them. It is good practice to do this where
calculations are complicated.

Always quote the dose to be given rather than the volume of liquid to avoid potential for errors, as
multiple strengths of medicines (and manufactured specials) are common in paediatric practice.

Consider timing of administration to avoid giving during school time if possible. Consider the hours the
child will be awake to avoid interrupting sleep to give medicines. Opt for once or twice daily dosing
where appropriate.

Consider formulation and appropriateness for the child’s age. As a general rule, liquid formulations are
preferable for children aged less than 5 years. Choose sugar-free formulations where available. If a
sugar containing preparation has to be used, provide advice on teeth cleaning after administration to
reduce the risk of dental caries.

The availability of a formulation in an apparently suitable form does not ensure its suitability for use in
children. Consider excipients, e.g. alcohol, sorbitol. For premature or low birth weight infants with very
low total fluid requirements, concentrated preparations may be more appropriate than dilute ones.

Consider how the dose will be given:
o
Will an oral syringe be necessary or is it better to provide a formulation where the dose is
contained in 5mL? Round the dose up or down if it makes administration easier (and safer) if
the medicine has a wide therapeutic range.
o
If the parents are considering mixing the medicine with a drink to mask the taste check the
potential for drug-drink interaction and advise that they should mix with a small volume of drink.
The whole drink must be consumed to ensure the intended dose is given.
o
Avoid mixing the dose in a baby’s feeding bottle.
o
If no suitable liquid formulation is available, consider crushing tablets or opening capsules and
mixing with a small amount of soft food, again ensuring the whole dose is consumed. Always
consider potential for drug-food or drug-drink interaction. Remember this renders the product
unlicensed.
o
Avoid intramuscular injections where possible. The exception to this may be for one off doses
where there is no other suitable formulation, e.g. vaccines.

If you are considering recommending an extemporaneous preparation, consider how supply will be
continued in the longer term. The local community pharmacist may require details of special-order
manufacturers to obtain the product; these can be very expensive.
Keywords: CHILD, INFANT, INFANT-NEWBORN INFANT-PREMATURE NEONATAL DISEASES,
PAEDIATRICS and relevant drug names.
- 40 -
Palliative care
Background information

Is a palliative care team, hospice or MacMillan nurse involved in the patient’s care? For enquiries
about managing a specific patient (other than straightforward queries), tell the enquirer to contact
them.

If the enquirer asks about compatibility of drugs in a syringe driver, check drugs, doses, diluents and
volume.

If the enquirer asks about symptom control, establish indication and what drug or non-drug options
they have tried already.

If the patient is unable to tolerate oral administration, can other routes be used?

Check concomitant medication and concurrent disease including renal and liver function.

If the enquiry is related to conversion between different opioids, what is the total daily (24 hour) dose,
including PRN doses, currently being taken? Is the patient’s pain well controlled?
N.B. If the enquiry concerns the subcutaneous administration of medicines via a syringe driver please also
refer to the ‘Compatibility of subcutaneous drugs’ monograph.
Resources
Source
Notes
First-line resources
In-house past enquiries.
Relevant Medicines Q&As via
www.nelm.nhs.uk or
www.evidence.nhs.uk
BNF
www.medicinescomplete.com/m
c/bnf/current/
The Palliative care section has been re-organised and includes new
tables for opioid conversions. The 'pain management with opioids'
section provides guidance on specific routes for pain management. The
'Equivalent doses of opioid analgesics' table has been expanded to
include more drugs and routes; also included is a buprenorphine table
and a fentanyl patch conversion table.
Electronic Medicines
Compendium
www.medicines.org.uk/emc
Palliative Care Matters website
www.pallcare.info
Website for healthcare professionals working in palliative care. Includes
a syringe driver compatibility database
www.pallcare.info/mod.php?mod=sdrivers&menu=14
Palliative Adult Network
Guidelines (PANG).
www.book.pallcare.info
Website aiming to offer up-to-date, evidence based information and
guidance on professional aspects of palliative care. Developed by a
collaboration of UK Cancer networks, and the Welsh Palliative Care
Implementation Group. Includes:
- an interactive opioid dose converter
http://book.pallcare.info/index.php?op=plugin&src=opiconv
- syringe driver compatibility database
http://book.pallcare.info/index.php?op=plugin&src=sdrivers
Palliative Care Formulary (PCF).
Twycross et al.
Available in paper and online versions.
Palliative Drugs
www.palliativedrugs.com
Companion website to PCF. Syringe driver compatibility tables are freely
available at www.palliativedrugs.com/syringe-driver-databaseintroduction.html
The text of PCF is only available to subscribers to the website.
- 41 -
Source
Notes
NICE www.nice.org.uk
Several relevant guidelines including Opioids in palliative care and
Clinical guidance on supportive and palliative care
Additional resources (tailor to local use/availability)
UK Cancer Networks
http://ncat.nhs.uk/cancernetworks
Find your local cancer network – lots of useful information about cancer
and palliative care is available on their websites. Note: some sites may
ask you to register.
Prodigy Guidance – Palliative
Care
http://www.prodigy.clarity.co.uk/
clinical_topics/by_clinical_specia
lty/palliative_care
Very useful and practical sections on palliative care.
NB: This will change to Clinical
Knowledge Summaries
guidance in early 2013
Scottish Palliative Care
Guidelines
www.palliativecareguidelines.sc
ot.nhs.uk
Currently these are NHS Lothian guidelines. However, a national
steering group has been established to develop palliative care guidelines
for Scotland. These will be available from 2014 with a format based on
the guidelines on this website.
A paediatric section is available with useful links
www.palliativecareguidelines.scot.nhs.uk/paediatric_palliative_care/
Liverpool Care Pathway
Multi-professional document which provides an evidence-based
framework for end-of-life care.
Symptom Relief in Palliative
Care. Dean, Harris, Regnard
and Hockley.
Evidence-based, comprehensive and practical resource.
Oxford Handbook of Palliative
Care. Watson M et al.
Covers all aspects of palliative care in a concise and succinct format.
Oxford Textbook of Palliative
Medicine. Hanks G et al.
Comprehensively covers treatment of symptoms, focussing on pain.
Supportive and Palliative Care in
Cancer: An Introduction.
Regnard and Kindlen.
Basic introduction to the symptoms, diagnosis and treatment of cancer,
and to key aspects of palliative and supportive care.
Handbook of Palliative Care.
Faull, DeCastecker, Nicholson
and Black.
Combines clinical practice and theory relevant to hospital, hospice, or
community settings. Provides guidance from UK and North American
clinicians and up-to-date overviews of medicine management and
complementary medicine.
Freely available via NHS Evidence. Click on the menu button ‘NHS
Athens Resources’ then ‘E-books’. Log in with your Athens password.
Type ‘symptom relief’ in the search box. Click on ‘Read Book’. Paper
version also available.
Freely available via NHS Evidence. Click on the menu button ‘NHS
Athens Resources’ then ‘E-books’. Log in with your Athens password.
Type ‘oxford palliative’ in the search box. Click on ‘Read Book’. Paper
version also available.
Freely available via NHS Evidence. Click on the menu button ‘NHS
Athens Resources’ then ‘E-books’. Log in with your Athens password.
Type ‘oxford palliative’ in the search box. Click on ‘Read Book’. Paper
version also available.
Freely available via NHS Evidence. Click on the menu button ‘NHS
Athens Resources’ then ‘E-books’. Log in with your Athens password.
Type ‘supportive’ in the search box. Click on ‘Read Book’. Paper version
also available.
Freely available via NHS Evidence. Click on the menu button ‘NHS
Athens Resources’ then ‘E-books’. Log in with your Athens password.
Type ‘palliative care’ in the search box. Click on ‘Read Book’. Paper
version also available.
- 42 -
Source
Notes
The Syringe Driver.
Dickman, Schneider and Varga.
Contains comprehensive information about two or more admixtures of
commonly used combinations.
Drugs in Palliative Care.
Dickman.
Begins with an overview of pharmacology and prescribing advice.
Contains over 100 monographs of palliative care drugs, in an easy to
use A-Z format.
Oxford Textbook of Palliative
Care for Children. Liben.
Discusses management of symptoms, social issues such as accessing
appropriate education, emotional issues such as communication
techniques, and spiritual issues such as feelings of guilt and isolation.
A guide to symptom relief in
advanced disease. Regnard and
Tempest.
The ‘Getting started’ chapter covers discussing problems with patients.
Symptom management in
advanced cancer. Twycross,
Wilcock and Stark Toller.
Offers practical information and advice on advanced symptoms.
Macmillan Cancer Support
www.macmillan.org.uk
Macmillan has merged with the CancerBACUP charity. The website
offers an information service for patients about cancer and its treatments
(‘Cancer information’ section). Within this section is an area for health
and social care professionals containing free information resources. Also
links to sites listing current UK and European cancer research trials.
Marie Curie Cancer Care
www.mariecurie.org.uk
Website provides information for people with cancer and other
conditions, including information sheets on managing symptoms (in the
‘Patients, carers and families’ section). The healthcare professional
section has a professional development section with links to training
resources.
NHS Evidence
www.evidence.nhs.uk
NHS Evidence used to maintain a Supportive and Palliative Care
Specialist Collection providing access to the best available evidence in
all aspects of supportive and palliative care. This is no longer available,
although NHS Evidence suggests the resources are still accessible –
use the search box (and include the search term palliative or cancer) or
browse the topics pages.
There is an extensive collection of palliative care e-books (log in with
your Athens password).
Bibliographic databases e.g.
Medline, Embase.
Suggested terms: PALLIATIVE TREATMENT, PALLIATIVE-CARE.
Local resources
Trust Palliative Care team
Answering the enquiry

Many uses of medicines within palliative care are off-label, but are based on current clinical practice.

A patient’s condition can change rapidly so it is imperative that their response to drug therapy is
monitored and assessed frequently.

Always make one change at a time; then reassess to judge whether the change is helpful.

Equivalent doses between opioids are approximate and can differ greatly between resources so
patients must always be monitored carefully and regularly if transferred to another opioid. Check
several resources when deciding on an equivalent dose.

Calculation errors involving opioid dose conversions are commonly reported to the UKMi IRMIS
database. The UKMi Clinical Governance Working Group strongly recommends:

Have all calculations checked by an independent person.

Do not be pressured into answering enquiries requiring calculations within an unrealistic
timescale.
- 43 -

If no independent person is available to check a calculation, and delaying the answer would be
detrimental to patient care, inform the enquirer that the calculation hasn’t been second checked,
document this in the answer field, and obtain a retrospective second check at the earliest
possible moment.
Keywords: PALLIATIVE TREATMENT, drug names.
- 44 -
Pharmaceutical
Background information
For enquiries about pharmaceutical excipients:

What is the reason for asking about excipients? Does the patient have a known problem, or is one
suspected?

What is the nature of any known or suspected reactions to excipients?

For patients experiencing intolerance to a product, how long has the patient been taking the medicine
that might be the source of the problem?

Is the patient taking other medicines? It may be possible to rule out suspected problems with excipients
if the patient has no problems already taking medicines that contain these excipients. For enquiries
about lactose or sodium content, an assessment of the total quantity provided by all of the patient’s
medicines can indicate the likelihood of a significant problem occurring.
For enquiries about latex allergy:

Obtain a full description of what happens when the patient is exposed to latex.

Which products do they intend to use, including the brand name if possible, and why?
For enquiries about products of animal origin or suitability for patients with religious beliefs:

Establish clearly which substances the patient objects to and the reason why. For example, the enquirer
may ask for a gelatin-free product – gelatin usually comes from animals and so is unsuitable for
vegetarians; gelatin in a non-edible form (e.g. tasteless capsule shell) is suitable for Jewish patients if no
alternative is easily available; all gelatin in medicinal products is deemed suitable for Muslim patients.

What is the drug to be prescribed and why?

Which other medicines is the patient taking?
For enquiries about stability of refrigerated products at room temperature, if frozen or in compliance aids:

For products that have been stored at temperatures outside the manufacturer’s recommended limits,
what was the highest (or lowest) temperature, how long were the products exposed to this temperature,
what are the brand names of the products and where are they stored now?

For products to be stored in compliance aids, how long will the product be stored in this way and which
type of aid is being used?
For enquiries about extemporaneous preparation:

Establish clearly what product has been prescribed including all ingredients, strengths and vehicles.
What condition is it being used to treat? What else has been tried? If no information is available on the
stability of the requested product, it may be possible to substitute the requested product with one that
has been made previously or one that is from an approved list. Is there a licensed alternative available?

If the patient is a hospital inpatient, consider what arrangements need to be made to continue the supply
of the product after the patient is discharged. Will a special-order manufacturer be able to supply the
product? Can the community pharmacist easily obtain supplies?
N.B. If the enquiry concerns the advisability of crushing tablets, opening capsules, mixing medicines with
food or drink, please refer to the ‘Administration of medicines’ monograph. See also the ‘Interactions’
monograph. If the enquiry concerns the advisability of mixing injectable products in syringes or fluid bags,
please refer to the ‘Compatibility of Intravenous Drugs’ and ‘Compatibility of Subcutaneous Drugs’
monographs.
- 45 -
Resources
Source
Notes
First-line resources
In-house past enquiries.
Relevant Medicines Q&As via
www.nelm.nhs.uk or
www.evidence.nhs.uk
Includes numerous documents on gluten, lactose and sodium content of
medicines. Also information on E-numbers, excipients in toothpastes and
latex in dental local anaesthetics. The Medicines Q&A on stability of
products in compliance aids (Pinderfields Guide) is no longer available (but
a UKMi database of drug stability in compliance aids is in development).
BNF
www.medicinescomplete.com/
mc/bnf/current/
The presence of selected excipients is noted. See General guidance
section for details.
BNF-C
www.medicinescomplete.com/
mc/bnfc/current/
Electronic Medicines
Compendium
www.medicines.org.uk/emc
All excipients need to be declared on the labeling and in the SPC/PIL of
injectable, topical or eye preparations. Excipients known to have a
recognised action or effect must be declared on the labeling and in the
SPC/PIL of all other medicinal products. See EMA Guideline.
Use Advanced search – ‘Search by section’ can be used to find SmPCs that
contain, or do not contain, an excipient.
MIMS www.mims.co.uk
Useful tables comparing sensitising excipients in eye preparations,
emollients and topical steroids.
Martindale
www.medicinescomplete.com
Drugs of porcine origin and
clinical alternatives. Medicines
Partnership 2004.
www.mcb.org.uk/uploads/PBE
nglish.pdf
Guidance booklet on drugs of porcine origin. Explains religious and cultural
aspects of porcine derived products. Also includes a section on issues for
Jewish patients and explains requirement for all medicines that are
swallowed to include kosher ingredients.
Religious leaders’ approval for
consumption of gelatin in
medicinal products by Muslims
www.immunize.org/concerns/p
orcine.pdf
Guidance from the World Health Organisation & the Islamic Organisation for
Medical Sciences stating ‘The gelatin formed as a result of the
transformation of the bones, skin & tendons of a judicially impure animal is
pure and it is judicially permissible to eat it’.
UKMI Latex Database
No longer available.
UKMI Fridge Database.
www.ukmi.nhs.uk/secure/fridg
e/index.asp
Provides stability information for medicines, intended for storage in the
fridge, inadvertently stored outside recommended storage temperatures
(requires UKMi log in).
Additional resources (tailor to local use/availability)
Manufacturers’ Medical
Information departments.
Handbook of Pharmaceutical
Excipients. Rowe, Sheskey
and Quinn.
www.medicinescomplete.com
Comprehensive guide to the uses, properties and safety of pharmaceutical
excipients.
Handbook of extemporaneous
preparation. Jackson and
Lowey.
Comprehensive and easy-to-follow guide to good practice in
extemporaneous compounding.
Aulton’s Pharmaceutics.
General reference textbook. Explains how pharmaceutical excipients are
manufactured and used in medicines.
- 46 -
PJ Online www.pjonline.com
Article published in the Pharmaceutical Journal lists medicines and their
stability in compliance aids (Church C and Smith J. How stable are
medicines moved from original packs into compliance aids? Pharm J 2006;
276: 75-81 www.pjonline.com/libres/pdf/articles/pj_20060121_stable.pdf).
Medicines and Healthcare
products Regulatory Agency
Staff at the MHRA Information Centre can search the licensing database
(Sentinel) to identify products that do not contain specific excipients. Email
info@mhra.gsi.gov.uk – enquiries are answered within 20 working days.
The Injectable Medicines
Guide www.injguide.nhs.uk
Monographs updated in the future will include information on latex content.
Website also has links to other locally produced documents listing latex
status (see Documents and Links Library).
*Free to contributing trusts in England and Scotland, and all trusts in Wales
& N. Ireland.
Bibliographic databases e.g.
Medline, Embase.
Suggested terms: name of the excipient (as in the thesaurus provided e.g.
MeSH or EMTREE).
Food Additives and Ingredients
Association www.faia.org.uk/
Includes information on E numbers, including a full list of E numbers, a
description of the main additive categories and an explanation of why
additives are needed.
Coeliac UK
www.coeliac.org.uk
Includes a section for healthcare professionals with advice on what gluten is
and how to achieve a gluten-free diet, links to coeliac disease management
guidelines and a list of prescribable gluten-free foods.
Drug Tariff
www.ppa.org.uk/ppa/edt_intro.
htm
Only available on-line. Part VIIIB is the Specials Drug Tariff, a list of high
cost, high volume specials and their agreed NHS prices.
List of preferred unlicensed
dermatological preparations
(specials). British Association
of Dermatologists.
www.bad.org.uk/Portals/_Bad/
Specials/BAD%20Specials%2
0Booklet.pdf
A list of unlicensed dermatological preparations recommended for
manufacture and supply in NHS hospitals (includes drug, vehicles and
strength).
Special-order manufacturers.
A list of special-order manufacturers is at the back of the BNF and BNF for
Children.
Association of Pharmaceutical
Specials Manufacturers
http://apsmuk.com/default.aspx
Includes a list of specials manufacturers who are members of APSM and a
link to their websites. Includes information about specials and links to
relevant guidance in the health professionals section.
Pro-file Database www.profile.nhs.uk
Produced by Guy’s and St Thomas’ Hospital NHS Trust. Useful for sourcing
unlicensed ‘special’ medicinal products. Registration required.
Trissel’s Stability of
Compounded Formulations.
>500 monographs providing stability information on drugs in compounded
oral, enteral, topical, ophthalmic and other preparations. US resource.
Local resources
Note: NPA Information Leaflets ’Sugar Content of Medicines’ and ’Diluent Directory’ are no longer freely
available. Subscription to NPA required.
Answering the enquiry

The individual product’s Summaries of Product Characteristics should always be checked as
formulations may change and the quantities of excipients used may vary by manufacturer, product,
formulation and strength.

It is our duty as a health professional to abide by the wishes of a patient, regardless of the reason why a
person objects to products of a certain animal origin. Therefore, for example, if a Muslim patient refuses
products containing gelatin, even after you have made them aware of the advice of the World Health
- 47 -
Organisation and the Islamic Organisation for Medical Sciences, it is our responsibility to help them to
find a suitable alternative product, if possible.

Approximately a third of ‘Specials’ produced within the NHS are for Dermatology; clinicians are
encouraged to prescribe from the list of preferred specials prepared by the British Association of
Dermatologists. The aim of the list is to ensure quality, safety and availability of extemporaneously
manufactured products.

The MHRA recommends that an unlicensed medicine should only be used when a patient has special
requirements that cannot be met by use of a licensed medicine.
Keywords: Name of the excipient (e.g. LACTOSE, GLUTEN, ALCOHOL, SODIUM CHLORIDE), or
LATEX or ROOM TEMPERATURE/FREEZING or COMPLIANCE AIDS and relevant drug names.
- 48 -
Pharmacokinetics
Background information

What is the drug, dose, frequency, indication, route and duration of therapy?

What is the patient’s age, gender and weight?

What is their renal and hepatic function? (for background information required and relevant
calculations please see the enquiry answering guidelines ‘Drug use in hepatic impairment’ and ‘Renal
impairment’).

Does the patient have any other disease states or conditions e.g. hypothyroidism, hyperthyroidism,
hypoalbuminaemia?

Is there concurrent medication?

Have any previous drug levels been taken? If so, check the exact time they were taken in relation to
drug administration and confirm the units of measurement.
Pharmacokinetic definitions and calculations
Bioavailability (F): the fraction of the dose that reaches the systemic circulation as intact drug.
Bioavailability =
Bioavailability factor (F) x dose
Volume of distribution (Vd): a hypothetical volume that relates the concentration of drug in the plasma to the
total amount of drug in the body.
Vd (L) =
Total amount of drug in the body (mg)
Plasma drug concentration (mg/L)
Clearance (Cl): the volume of blood cleared of drug per unit time and the units are normally litres per hour or
ml per minute.
Cl =
F x (Dose/Dose interval)
Average steady state plasma drug concentration (Css)
Loading dose: the dose required to rapidly achieve the desired plasma drug concentration (C)
Loading dose =
Vd x C
F
Maintenance dose: the regular dose required to maintain the desired plasma drug concentration.
Maintenance dose =
Cl x Css x dose interval
F
Steady-state: the equilibrium achieved after multiple dosing when the rate of drug administration equals the
rate of drug elimination. At steady-state the amount of drug in the body, and the plasma concentration, are
constant.
Half-life: is the time taken for the amount of drug in the body (or the plasma concentration) to fall by half.
Half-life is used to determine both the time to reach steady-state conditions with chronic dosing and the time
for elimination. As a rule of thumb it takes approximately 3 to 5 half-lives to achieve steady-state conditions
or for a drug to be completely eliminated from the plasma.
Half-life is proportional to Vd and inversely proportional to clearance:
Half-life (hrs) =
0.693 x Volume of distribution (L)
Clearance (L/hr)
- 49 -
Resources
Source
Notes
First-line resources
In-house past enquiries.
Relevant Medicines Q&As via
www.nelm.nhs.uk or
www.evidence.nhs.uk
BNF
www.medicinescomplete.com/m
c/bnf/current/
BNF-C
www.medicinescomplete.com/m
c/bnfc/current/
Provides details of recognised therapeutic ranges for drugs that require
monitoring e.g. digoxin, phenytoin, theophylline, gentamicin.
Electronic Medicines
Compendium
Section 5.2 ‘Pharmacokinetic properties’ provides pharmacokinetic
information including absorption, distribution, metabolism, elimination
and half-life. An indication of the recognised therapeutic range is usually
given within section 4.2 ‘Posology and method of administration’.
www.medicines.org.uk/emc
Basic Clinical Pharmacokinetics.
Winter ME.
(Access also available online
http://thepoint.lww.com/Winter5e
– registration required).
Easy to understand explanations of the basic principles of
pharmacokinetics in the clinical setting. Part One explains basic
principles; Part Two illustrates, with worked examples, the clinical
application of pharmacokinetics.
Bibliographic databases e.g.
Medline, Embase
Terms include PHARMACOKINETICS, ABSORPTION, INTESTINAL
ABSORPTION, BIOLOGICAL TRANSPORT, TISSUE DISTRIBUTION,
BIOTRANSFORMATION, DRUG ABSORPTION, DRUG
ACCUMULATION, DRUG ACTIVATION, DRUG ADSORPTION, DRUG
BIOAVAILABILITY, DRUG CLEARANCE, DRUG DIFFUSION, DRUG
DISPOSITION, DRUG DISTRIBUTION, DRUG ELIMINATION, DRUG
EXCRETION, DRUG HALF LIFE, DRUG PENETRATION, MAXIMUM
PLASMA CONCENTRATION, PLASMACONCENTRATION-TIME
CURVE, TIME TO MAXIMUM PLASMA CONCENTRATION, DRUG
METABOLISM, DRUG RELEASE.
Additional resources (tailor to local use/availability)
Micromedex
www.micromedexsolutions.com
Pharmacokinetic section provides therapeutic drug levels, absorption,
distribution, metabolism and excretion.
Goodman and Gilman’s Manual
of Pharmacology and
Therapeutics.
Chapter One provides a general overview of pharmacokinetics.
Avery's Drug Treatment.
Chapter One provides an overview of the basic concepts of
pharmacokinetics and Chapter Five addresses therapeutic drug
monitoring and target concentration intervention.
Pharmacokinetics Made Easy,
Birkett DJ.
An easy to understand explanation of pharmacokinetics with a practical
approach.
Applied Clinical
Pharmacokinetics. Bauer LA.
A comprehensive and detailed text on pharmacokinetics including
practical guidance on dosage optimisation in patients with hepatic, renal
and cardiac disease.
Clinical Pharmacokinetics,
Dhillon S and Kostrzewski A.
A practical guide to use of pharmacokinetic principles in clinical practice.
Questions and answers bridge the gap between pharmacokinetic
concepts and their practical application to patients.
Clinical Pharmacy and
Therapeutics, Walker R and
Whittlesea C.
Chapter Three provides a practical overview of pharmacokinetics and
how it is applied for commonly used drugs with a narrow therapeutic
range. Four case studies provide the opportunity to put theory into
practice.
- 50 -
Local resources
Trust formularies and/or clinical
chemistry labs and/or
therapeutic drug level monitoring
services.
Trusts will have local policies and procedures for measuring and
interpretation of drug levels.
Answering the enquiry

Always have calculations checked.

Pharmacokinetic parameters in elderly and paediatric patients may not be the same as in adult
patients and may alter drug response.

For highly protein bound drugs consider checking albumin levels.

If therapeutic drug level monitoring (TDM) is recommended ensure that levels are not taken before
steady state is reached.
Keywords: PHARMACOKINETICS, ABSORPTION, BIOLOGICAL AVAILABILITY, CLEARANCE-DRUG,
VOLUME OF DISTRIBUTION, EXCRETION, EXCRETION-DRUG, HALF LIFE, METABOLISM,
METABOLISM-DRUG, METABOLITES-ACTIVE, FIRST-PASS PHENOMENON.
- 51 -
Poisoning or overdose
Background information
A quick response may be required if an overdose has been taken. Be aware that referral to the National
Poisons Information Service (NPIS, telephone 0844 892 0111) may be required. Urgent medical attention
may be necessary.

How old is the person who took it? Do they have any underlying health conditions? Is the person
pregnant or breast feeding? What weight is the patient?

What is the name of the medicine or substance? What is the brand name and the ingredients?

How much has been taken?

How long ago was it taken?

Is the medicine or substance something the person takes regularly? If so, what is their regular dose?

What are the circumstances of the exposure? Was this an accidental or deliberate overdose? Was it
an administration error?

Was this a single overdose or have repeated overdoses been taken? If repeated overdoses, refer the
caller (if a healthcare professional) to NPIS.

Has more than one medicine or substance been taken? If so, consider referring the caller (if a
healthcare professional) to NPIS. This may not always be necessary e.g. a single additional dose of a
medicine a patient takes regularly may not be cause for concern.

Does the person have any symptoms? Has any action been taken? If the person has life-threatening
symptoms (e.g. is unconscious or having difficulty breathing) urge the caller to call an ambulance.
Resources
Source
Notes
First-line resources
Toxbase www.toxbase.org
Information from NPIS on the symptoms and management of
poisoning by medicines, plants, household chemicals and other
substances. Use the search box at the top of the home page or
click on the poisons A-Z index for an alphabetical list of products
and drugs. For a list of chemicals click on ‘Chemicals’, select
‘Household Chemicals’. This includes: cosmetics, hair products,
household cleaners, miscellaneous, pharmaceuticals, standard
formulation index, toiletries.
Electronic Medicines Compendium
www.medicines.org.uk/emc
SPC section 4.9 overdose may provide information on the
symptoms and management of toxicity.
SPC section 5.2 provides information on pharmacokinetics
Additional resources (tailor to local use/availability)
Martindale
www.medicinescomplete.com
Monographs provide information on pharmacokinetics including
elimination half-life.
Micromedex
Monographs provide information on pharmacokinetics including
elimination half-life.
www.micromedexsolutions.com
Answering the enquiry


If you are unable to answer the question using resources available, or are concerned that the person
requires specialist medical attention, refer the caller (if a healthcare professional) to NPIS.
Document all poisoning enquiries even those you refer directly to NPIS.
Keywords: POISONING, drug name or substance name
- 52 -
Pregnancy
Background information

Is the patient already pregnant?

Is the patient already taking the medicine in question?

If pregnant, how many weeks pregnant is the woman?

Has the woman had any previous pregnancies? Does she have a history of miscarriage or
malformations? Did she take medicines during previous pregnancies?

Establish dose, frequency, indication, route of medicine taken / intended to be taken.

Establish the current situation. Is the medicine still being taken or has it been stopped?

Is the woman taking any other medicines?

Is drug therapy necessary? Have other therapies/medicines been tried?

Have any investigations been performed?

If referring to the UK Teratology Information Service (UKTIS) for further information, ensure you have
GP or Consultant contact details and a patient identifier that will distinguish the patient if follow up is
required.
Resources
Source
Notes
First-line resources
In-house past enquiries.
Relevant Medicines Q&As via
www.nelm.nhs.uk or
www.evidence.nhs.uk
British National Formulary
www.medicinescomplete.com/m
c/bnf/current/
Information on drug safety in pregnancy is included in drug monographs.
(There is no longer a separate appendix.) Pregnancy advice is based on
manufacturer’s information therefore will be more cautious.
BNF for Children
www.medicinescomplete.com/m
c/bnfc/current/
Information on drug safety in pregnancy is included in drug monographs.
Electronic Medicines
Compendium
www.medicines.org.uk/emc
SPC section 4.6 (pregnancy and lactation) clarifies the licensed status of
medicines use during pregnancy. NB: Statements in SPCs are
sometimes more cautious than current evidence requires and it is worth
checking other sources.
Toxbase www.toxbase.org
Monographs from UKTIS are available on this website. Click on
‘exposures in pregnancy’.
Monographs are listed alphabetically by drug name. Toward the bottom
of the screen are monographs on managing various conditions during
pregnancy. The date of revision is on each monograph. If a monograph
is old, contact UKTIS for further information.
Drugs in Pregnancy and
Lactation. Briggs et al.
Drug monographs are listed in alphabetical order and provide in-depth
data.
- 53 -
Source
Notes
Drugs during Pregnancy and
Lactation. Schaefer.
Chapter 1 provides a useful overview of the risks of drug use in
pregnancy. Chapter 2 contains information on drugs in pregnancy by
therapeutic class. Each monograph has a boxed ‘recommendation’ at
the end that may suggest suitable alternatives. Note: this book is now
comparatively outdated (do not use in isolation, at least two resources
should be used for all pregnancy enquiries).
Additional resources (tailor to local use/availability)
UK Teratology Information
Service (UKTIS), UKMi
specialist centre for drugs in
pregnancy.
UKTIS (Telephone 0844 892 0909) provides information to medicines
information centres on safety of medicines in pregnancy. Before
contacting UKTIS ensure you have checked all available resources and
have obtained all the background information.
Prescribing in Pregnancy. Rubin
D.
Chapter 1 of this UK reference includes a table showing the time and
stages of embryo and foetal development. Chapter 2 discusses
management of common, minor and self-limiting conditions. Other
chapters cover management of chronic conditions and drug abuse
during pregnancy.
Handbook of Obstetric Medicine.
Nelson-Piercy C.
Early chapters cover the management different disease areas during
pregnancy. Later chapters consider the differential diagnosis of medical
problems in pregnancy.
Maudsley Prescribing
Guidelines. Taylor D et al.
Chapter 7 contains a section on the choice of medicines for psychiatric
conditions in pregnancy.
Psychotropic Drug Directory.
Bazire S.
Chapter 3 contains a section on the choice of medicines for psychiatric
conditions in pregnancy.
Bibliographic databases e.g.
Medline, Embase.
Suggested terms: PREGNANCY, PREGNANCY-COMPLICATIONS,
ABNORMALITIES-DRUG INDUCED, CONGENITAL
MALFORMATIONS plus individual drug name
Local resources
Answering the enquiry

Consider benefits and risks of medication to both the expectant mother and developing baby.

Consider the implications of unmanaged acute and chronic conditions on the expectant mother’s and
developing baby’s health.

Consider the period of gestation and, if possible, avoid all drugs during the first trimester.

Where appropriate, use the lowest effective dose for as short a period as possible.

Older drugs are often preferred to newer drugs as there is more information about their safety.

Avoid polypharmacy where possible.

Remember to consider maternal contraindications and precautions.

Reassure the patient/enquirer if the drug has already been taken and if there is no indication from the
literature that the drug poses significant harm.

Detailed scans during pregnancy may be appropriate if a medicine has been taken.

Remember there is a background risk of major congenital malformations of 2-3% in the population and
10-20% for miscarriage.
Keywords: PREGNANCY plus drug name and disease name (if appropriate)
- 54 -
Drug use in psychiatry
Background information

If patient specific, establish patient details, including age, sex etc.

Establish current and previous medical history, drug history (including OTC and illicit drugs).

Is the enquiry about a drug interaction or an adverse drug reaction? If so see guidelines specific to
these types of enquiry.
Resources
Source
Notes
First-line resources
In-house past enquiries.
Relevant Medicines Q&As via
www.nelm.nhs.uk or
www.evidence.nhs.uk
BNF
www.medicinescomplete.com/mc/
bnf/current/
Martindale via
www.medicinescomplete.com
Useful for information on uses, doses and interactions.
Electronic Medicines
Compendium
www.medicines.org.uk/emc
Check relevant SPCs
Psychotropic Drug Directory,
Bazire S.
Maudsley Prescribing Guidelines,
Taylor D et al.
Additional resources (tailor to local use/availability)
NICE Guidance – Mental Health
and behavioural conditions,
http://guidance.nice.org.uk/Topic/
MentalHealthBehavioural
Prodigy Guidance
http://www.prodigy.clarity.co.uk/ho
me
NB: This will change to Clinical
Knowledge Summaries guidance
in early 2013
Useful and practical sections on mental health conditions including
bipolar disorder, depression, obsessive-compulsive disorder,
schizophrenia and benzodiazepine and z-drug withdrawal:
http://www.prodigy.clarity.co.uk/clinical_topics/by_clinical_specialty/ment
al_health#-325205
Department of Health – Mental
health section, www.dh.gov.uk
From the A-Z list at the bottom of the home page click on ‘Mental health’.
The College of Mental Health
Pharmacy (CMHP)
www.cmhp.org.uk
Includes; clinical guidelines and miscellaneous documents from UK
trusts.
The Royal College of
Psychiatrists www.rcpsych.ac.uk
Includes useful fact sheets about mental health conditions and treatment
options.
NHS Evidence
www.evidence.nhs.uk
Browse the A-Z topics list to select the area of psychiatry or mental
health condition being treated.
There is an extensive collection of drugs in psychiatry e-books (log in
with your Athens password).
- 55 -
Source
Notes
Oxford Handbook of Psychiatry
Provides practical advice on all aspects of general adult psychiatry and
other psychiatric sub-specialties.
PsychINFO via
www.evidence.nhs.uk
Database of abstracts that covers psychological practice and research
(e.g. drug and behavioural therapy, treatment of disease, drug addiction,
developmental and educational psychology).
Choice and Medication
www.choiceandmedication.org.uk
This website offers information about medicines used in the mental
health setting to help people make informed decisions. Choice and
Medication is commercially available on subscription to NHS trusts,
specialist interest pharmacy groups, community pharmacies,
independent healthcare providers and charitable mental health
organisations.
The Ashton Manual
www.benzo.org.uk/manual/conten
ts.htm
Contains useful information about benzodiazepine withdrawal and
equivalent doses.
Psychiatrynet.eu
Contains tables for:
http://wiki.psychiatrienet.nl/index.p
hp/Main_Page.

Switching between antidepressants

Switching between antipsychotics

Benzodiazepine conversion calculator
NB. Inaccuracies in some tables have been identified. The authors have
subsequently corrected these. This resource should only be used in
conjunction with other resources and, ideally, be discussed with a
mental health specialist.
The British Association of
Psychopharmacology
www.bap.org.uk/docsbycategory.
php?docCatID=2
The British Association of Psychopharmacology Consensus Guideline
documents may be downloaded from this site. These are evidence
based guidelines for the treatment of several mental health conditions.
Bibliographic databases e.g.
Medline, Embase,
Suggested terms: ANTIDEPRESSIVE AGENTS, TRICYCLIC,
SEROTONIN UPTAKE INHIBITORS, ANTIPSYCHOTIC AGENTS
NEUROLEPTIC AGENT, SEROTONIN REUPTAKE INHIBITOR,
TRICYCLIC ANTIDEPRESSIVE AGENT.
Local resources
Answering the enquiry


Document thoroughly.
Be aware that psychotropic medication cannot be stopped abruptly due to risk of discontinuation
reactions.
Keywords: Include drug names and disease states
- 56 -
Renal impairment
Background information

Diagnosis and previous medical history if relevant.

Establish patient details, including age, sex, ethnic origin, height, weight etc.

U&Es and serum creatinine, eGFR - most recent if possible. Are they stable or changing? Is the renal
impairment acute or chronic?

Calculate the patient’s estimated creatinine clearance (CrCl). Use ideal body weight if obese*. See
notes below.

Current medication - include all drugs (prescription and OTC) currently taken by the patient including
doses.

Is the renal impairment suspected to be drug-induced? Which drug(s) are suspected?**

Is the patient receiving renal replacement therapy (RRT), if so how often and what type?
o Haemodialysis (HD)
o Haemodiafiltration (HDF)
o Peritoneal Dialysis (PD) [automated peritoneal dialysis (APD) and continuous ambulatory peritoneal
dialysis (CAPD)]
o Continuous arteriovenous haemofiltration (CAVHF)/continuous venovenous haemofiltration(CVVHF)
o Continuous arteriovenous haemodialysis (CAVHD)/continuous venovenous haemodialysis(CVVHD)
o Continuous arteriovenous haemodiafiltration (CAVHDF)/continuous venovenous haemodiafiltration
(CVVHDF)

If requesting advice on dosage or suitability of a drug in renal impairment, what is the indication for the
drug and have alternatives been considered? What agent would normally be used if the patient did not
have renal impairment?
*Measurement of renal function
Accurate measurement of renal function is essential in patients with renal impairment so that drug dosages
can be adjusted accordingly. The estimation of glomerular filtration rate (eGFR) provided by the Modification
of Diet in Renal Disease trial (MDRD) is now the routine method of estimating renal function within the NHS.
It is calculated differently to the traditional Cockcroft and Gault (C&G) estimation of creatinine clearance
(CrCl). The vast majority of published data on drug dose adjustment for patients with renal impairment have
been based on estimations of CrCl using C&G.MDRD has not yet been validated for drug dose calculations.
MDRD generally underestimates GFR whilst C&G overestimates it. Also, with MDRD being normalised for a
surface area of 1.73m 2, there is a concern that patients could be incorrectly dosed by switching to MDRD
unless it is adjusted for body surface area; GFR Absolute = eGFR × (individual’s body surface area/1.73).
Adjustment for body surface area is particularly important for patients in whom the eGFR falls on or near the
boundary between moderate and severe renal impairment, or for patients at extremes of body weight.
Estimates of eGFR or CrCl are only valid with stable serum creatinine (over a period of several days or
more). The BNF advises that in practice, for most drugs and for most patients (over 18 years) of average
build and height, eGFR (MDRD ‘formula’) can be used to determine dosage adjustments in place of CrCl.
 For potentially toxic drugs with a small safety margin CrCl (calculated from the Cockcroft and Gault
formula) should be used to adjust drug dosages in addition to plasma-drug concentration and clinical
response.
 In patients at both extremes of weight (BMI of less than 18.5 kg/m2 or greater than 30 kg/m2) the
absolute glomerular filtration rate or creatinine clearance (calculated from the Cockcroft and Gault
formula) should be used to adjust drug dosages.
 The MDRD equation should not be used for children.
In adults eGFR will be calculated by the laboratory using the 4-variable MDRD equation. The four variables
are serum creatinine concentration, age, sex, ethnic origin (for African-Caribbean people only, eGFR
multiplied by 1.212). The eGFR will be reported as mL/min/1.73 m2. When eGFR exceeds 89 mL/min/1.73
m2 values will usually be reported as > 90 mL/min/1.73 m2.
3
- 57 -
The Cockroft and Gault equation. N.B. If obese use ideal body weight.
CrCl (male) = 1.23 x (140 - age in years) x weight in kg
serum creatinine (micromol/l)
CrCl (female) = 1.04 x (140 - age in years) x weight in kg
serum creatinine (micromol/l)
** If
the renal failure is suspected to be drug related please refer to the monograph on ‘Adverse drug
reactions’
Information required by the specialist drugs in renal disease centre (Bristol) See:
http://www.ukmi.nhs.uk/activities/specialistServices/default.asp?pageRef=5
Before contacting the specialist centre please have the following information for patient specific enquiries:

Age and weight of patient.

Degree of renal impairment– CrCl or recent serum creatinine levels.

Is renal function stable or deteriorating?

Which, if any, renal replacement therapy is being used? To avoid confusion, state the name of the
renal replacement therapy in full e.g. continuous veno-venous haemofiltration rather than CVVH.

Is the patient currently taking the drug in question, and if so what dose?

Any other medication?

Any other medical problems?

For antibiotic dose enquiries, ask about the target organism or infection being treated; some antibiotics
have variable doses depending on the susceptibility of the bacteria being targeted
Resources
Source
Notes
First-line resources
In-house past enquiries.
Try keywords such as KIDNEY FAILURE, KIDNEY FAILURE-ACUTE,
KIDNEY FAILURE-CHRONIC, KIDNEY FUNCTION-IMPAIRED,
KIDNEY DISEASES.
Relevant Medicines Q&As via
www.nelm.nhs.uk or
www.evidence.nhs.uk
Medicines Q&As on drug dosing in renal impairment and renal
replacement therapies are available via NeLM
BNF
www.medicinescomplete.com/m
c/bnf/current/
Where care is needed when prescribing in renal impairment, this is
indicated under the relevant drug in the BNF. Use this as an initial
source but it is inadequate as a sole reference source.
BNF-C
www.medicinescomplete.com/m
c/bnfc/current/
Electronic Medicines
Compendium
www.medicines.org.uk/emc
SPCs should always be checked as they may give advice on the need to
reduce doses and a suitable regimen in renal impairment. This is
particularly important for new drugs, as the SPC is usually very detailed
and there are often no additional published data.
The Renal Drug Handbook.
Currie C. et al.
Drug monographs suggest doses in renal impairment and in patients
undergoing renal replacement therapies (UK book). Doses reflect
specialist practice and may differ from the licensed dose.
- 58 -
Source
Notes
Introduction to Renal
Therapeutics. Ashley C &
Morlidge C.
This discusses diseases affecting the kidney and their management
rather than providing dosing guidance. Useful for background
information and general principles of dose adjustment in renal
impairment and renal replacement therapies
Drug Prescribing in Renal
Failure: Dosing Guidelines for
Adults. Aronoff GR et al.
Information on doses of drugs separated into different clinical areas (US
book). Note latest edition (5th ) divided into ‘adult’ and ‘paediatric’ tables
Dialysis of Drugs 2012 Renal
Pharmacy Consultants, LLC via
CKD Insights
Dialysis of Drugs is an American text produced by an expert in
nephrology pharmacy. It is updated annually and provides information
on the dialysability of drugs in patients receiving hemodialysis and
peritoneal dialysis. Contains general information about what factors
determine whether a drug is removed during haemodialysis and
peritoneal dialysis, plus information on individual drugs.
http://renalpharmacyconsultants.
com/sitebuildercontent/sitebuilde
rfiles/2012dialysisofdrugsbooklet
.pdf
eGFR calculator. The Renal
Association
www.renal.org/eGFR/
Online calculator for eGFR. Has link to UK eCKD guide plus other useful
background information.
http://www.dh.gov.uk/en/Publicat
ionsandstatistics/Publications/Pu
blicationsPolicyAndGuidance/D
H_4133024
Department of Health guidance on eGFR.
Martindale via
www.medicinescomplete.com
AHFS Drug Information via
www.medicinescomplete.com
Meyler’s Side Effects of Drugs.
Dukes and Aronson (or other
side effects books).
For information on drug-induced renal impairment.
Additional resources (tailor to local use/availability)
Specialist Centre for Drugs in
Renal Disease. South & West
(Bristol) Medicines Information
Service. Tel: 0117 342 2867.
Can assist with specialist advice on drug dose adjustment in renal failure
and renal replacement therapies. Phone them only after checking
standard texts/resources :(including BNF, SPC, Renal Drug Handbook
and NeLM for Q&As).Make sure you have all the relevant background
information if the enquiry is patient specific (see background information
above). Advice on adverse effects of drugs on the kidney or drugs in
renal transplantation is not provided.
Micromedex
www.micromedexsolutions.com
Monographs have a ‘dosage in renal failure’ section.
Bibliographic databases e.g.
Medline, Embase.
Suggested terms: KIDNEY FAILURE, ACUTE KIDNEY FAILURE and
CHRONIC KIDNEY FAILURE, KIDNEY INJURY(Embase); ACUTE
KIDNEY INJURY, RENAL INSUFFICIENCY, RENAL
INSUFFICIENCY,CHRONIC (Medline)
Pharmaceutical manufacturers.
Manufacturers may have information about any necessary reduction of
doses in renal impairment.
Therapeutic Drugs, Dollery.
Although this resource is very old (2nd edition 1999) the monographs
have information about drug use in high-risk groups and is useful for
basic pharmacokinetic data for older drugs.
www.kidneycare.nhs.uk
Website that aims to support healthcare professionals and
commissioners to improve every aspect of kidney care for patients.
Contains links to guidelines, patient support materials etc.
http://www.renal.org/home.aspx
Renal association home page
- 59 -
Local resources
Answering the enquiry
Patients not on renal replacement therapies (RRT):

There are two approaches to altering drug maintenance doses in patients with renal impairment:
o Give the standard dose at extended intervals
o Give a reduced dose at standard intervals

For most drugs loading doses or single doses will be the same as for those with normal renal function.

When choosing a drug for patients with renal impairment:
o Only use drugs where there is a definite indication for prescribing
o Choose a drug that has minimal or no nephrotoxicity
o Use recommended dosage regimens for renal impairment
o Use plasma concentration measurements to adjust dose if possible and clinically relevant
o Monitor for evidence of clinical efficacy and toxicity
Patients on renal replacement therapies (RRT) – for more in-depth guidance see Medicines Q&A What
factors need to be considered when dosing patients on renal replacement therapies? :

There are a number of factors that need to be considered when dosing patients on RRT. Consider the
drug, the patient and the type of RRT.

Confirm if the patient has acute, acute on chronic or chronic renal failure and their CrCl or GFR/eGFR.
Haemofiltration could be used to correct acid-base balance in people with normal renal function or
much less severe renal impairment.

Dose adjustment for RRT is only necessary for drugs that require dose adjustment in the presence of
renal failure. No RRT is as effective as the normal kidney – so doses used will never be larger than
those recommended in normal renal function.

Alteration of drug dosage is only necessary if renal clearance exceeds 25% of total body clearance.

Drugs which are cleared by the kidneys are usually dialysed, and vice versa, although there are some
anomalies.

Advice on drug dosage in continuous RRT (CRRT) from the literature should be applied cautiously to
individual patients. These studies varied in design and calculated drug clearance by various methods.
If possible, ascertain the flow/flux rates used in the CRRT in question. Older available data on drug
removal may be from studies that used low flow/flux rates, compared to current practice, and hence
may need interpretation.

In patients on HD, dose after the dialysis session otherwise a proportion of the drug may be removed
during the HD session and its duration of action reduced. For CRRT and CAPD, since these are
continuous processes, there is no need to schedule doses around RRT sessions.

For toxic drugs, and for drugs with a narrow therapeutic index, drug monitoring with measurement of
plasma concentrations, where available, and monitoring of the patient for therapeutic response and
adverse effects, is essential.

Information from specialist sources may provide dosing information outside the product licence.

The omission of a drug from reference sources does not imply that the drug is safe for use in patients
with impaired renal function.

You should consider other therapeutic options that don’t require adjustment in renal failure e.g. drugs
that are primarily metabolised by the liver.
Keywords: KIDNEY, KIDNEY FUNCTION-IMPAIRED, KIDNEY FAILURE, drug name
- 60 -
Medicines in sport
Background information

Is this a prospective or retrospective enquiry i.e. is the drug already being taken?

What is the classification of the product involved e.g. prescribed medication, supplement?

Does the enquiry relate to a specific sport or competition?
Resources
Source
Notes
First-line resources
In-house past enquiries.
Relevant Medicines Q&As via
www.nelm.nhs.uk or
www.evidence.nhs.uk
BNF
www.medicinescomplete.com/m
c/bnf/current/
See under ‘Drugs and sport’.
UK Anti-Doping
www.ukad.org.uk
UK Anti-Doping is the national body responsible for the implementation
and management of the UK’s anti-doping policy and is responsible for
ensuring sports bodies in the UK comply with the World Anti-Doping
Code.
Click on ‘Resources’ then ‘Prohibited list’ to access the current
prohibited list and the UK Anti-Doping advice card. Click on ‘Support
Personnel’ to find the Therapeutic Use Exemption (TUE) form and
advice on supplements and links to further information.
The World Anti-Doping Agency
(WADA)
www.wada-ama.org/en
WADA is an international independent agency. It monitors the World
Anti-doping Code. The website contains a list of banned substances and
information on therapeutic use exemptions (TUE) – see the ‘Quick Links’
section
Drugs of abuse. Wills, S.
Pharmaceutical Press.
Contains a chapter on performance enhancing drugs.
Martindale
Drug monographs note if drugs are restricted in sports, but should not be
relied on as a single source. This information is usually at the beginning
of a monograph, after the medicine’s chemical structure.
Additional resources (tailor to local use/availability)
Drugs in sport. Mottram, DR.
Routledge
A 5th edition (2010) of this book is available; however some MI centres
may still hold an older edition. This should not be used as a single
source.
UK Sport www.uksport.gov.uk
Includes rules, guidelines and information. Click on ‘Explore UK Sport’ in
the bottom right corner to bring up an A-Z list of site contents
Relevant sport governing body
website.
Use Google to search for these. Examples are the Lawn Tennis
Association and the Football Association. They may be websensed.
Internet search engine
www.google.co.uk
Can be helpful in identifying claims made for products and supplements
Natural Medicines
Comprehensive Database,
www.naturaldatabase.com
Might be useful for contents of herbal products or supplements.
Bibliographic databases e.g.
Medline, Embase.
Suggested terms: SPORT, SPORTS MEDICINE, DOPING IN SPORT.
- 61 -
Local resources
Answering the enquiry

Athletes are personally responsible should a prohibited drug be detected in their body.

Note that national legal controls vary.
Keywords: SPORT plus individual drug names.
- 62 -
Substance misuse
Background information
Illicit drug use:

Is drug use suspected or confirmed?

What drug or substance is involved? If slang names are used clarify what the drug name is.

Does use of the drug relate to a single exposure, short-term use, or a persistent habit?

How frequently has the patient used this drug? How long certain drugs stay in the body is influenced
by how often the patient is using it.

How is the subject taking the drug (e.g. injection, oral)? The form of the drug and knowing how a
patient is taking it may make a difference to your answer.

Is the subject taking other illicit drugs? Also ask about other substances (e.g. tobacco, alcohol,
prescribed drugs).

How confident are you that the amount of drug taken and the frequency of use is correct? Users may
lie about the quantities consumed and the purity of street drugs also varies widely.

Why are you being asked for the information? These enquiries can raise ethical/legal issues due to the
nature of the drugs involved. It is essential all background details are obtained to help assess if you
can answer the enquiry and what information you can give.

Has a drug test been performed or ordered? What were the results or when are they expected?

Are the Community Drug and Alcohol Team (CDAT), or similar involved in the management of this
patient?

Ask about other medicines or medical conditions.
Many enquiries concern identification, side effects, interactions or use in pregnancy. Refer to appropriate
enquiry answering guideline.
Drug withdrawal:

Has the drug/substance been withdrawn or is withdrawal being considered?

What is the reason for withdrawal? If for urgent medical reasons, withdrawal may need to be
immediate, with the actual withdrawal effects assuming secondary importance.

Does the patient agree with the decision to withdraw the drug? Without the patient’s co-operation,
attempts at withdrawal are not likely to succeed.

Has withdrawal been attempted before? How was it done? What happened?

Is withdrawal the only option? Have other options been considered (e.g. maintenance therapy)?

Are there objective signs of withdrawal, or only symptoms the patient claims to have?
Resources
Source
Notes
First-line resources
In-house past enquiries.
Maudsley Prescribing
guidelines, Taylor D et al.
Contains a chapter on the practical management of substance misuse
and some interactions with medicines prescribed in psychiatry.
Drugs of Abuse, Wills S.
Pharmaceutical Press.
A comprehensive source of information on drugs of abuse including
prescription drugs, OTC preps, alcohol, caffeine, nicotine and plants.
Includes information on uses, side effects, interactions, use in
concomitant disease states and useful websites.
- 63 -
Source
Notes
Department of Health (England)
and the devolved
administrations (2007). Drug
Misuse and Dependence: UK
Guidelines on Clinical
Management – “The Orange
Guide”.
http://www.nta.nhs.uk/areas/Clinical_guidance/clinical_guidelines/docs/cl
inical_guidelines_2007.pdf
Psychotropic Drug Directory,
Bazire S.
Contains sections on alcohol and benzodiazepine withdrawal.
Produced by the National Treatment Agency for Substance Misuse, on
behalf of the Department of Health. Contains practical advice on drug
withdrawal, drug testing and other health considerations. Focuses on
opioids; some information on amphetamines and benzodiazepines.
Relevant Medicines Q&As via
www.nelm.nhs.uk or
www.evidence.nhs.uk
Additional resources (tailor to local use/availability)
Prodigy guidance – Opioid
dependence
http://prodigy.clarity.co.uk/opioid
_dependence
Covers the management of opioid dependence in adults. The guideline
provides information on substitution therapy with methadone, naltrexone
and buprenorphine.
NB: This will change to Clinical
Knowledge Summaries
guidance in early 2013
Prodigy guidance Benzodiazepine and z-drug
withdrawal
Covers the assessment of a person who is being prescribed long-term
benzodiazepines or z-drugs, and offers advice on managing withdrawal of
treatment.
http://prodigy.clarity.co.uk/benzo
diazepine_and_z_drug_withdra
wal
NB: This will change to Clinical
Knowledge Summaries
guidance in early 2013
NICE guidance - Drug misuse:
opioid detoxification CG52, July
2007
http://guidance.nice.org.uk/CG52
This guideline makes recommendations for the treatment of people who
are undergoing detoxification for opioid dependence arising from the
misuse of illicit drugs.
Talk to Frank,
www.talktofrank.com
Department of Health backed site, which is aimed at concerned parents
and young people, answering their questions about drug misuse.
Provides contact details if they need to speak to someone.
Drugscope,
www.drugscope.org.uk
Drugscope is a UK independent organisation with expertise on drug use.
The website includes brief information about the law, uses and risks
associated with drugs, including plants and prescription medication.
From the homepage click on ‘Drug information’ then ‘DrugSearch’ to
bring up an A to Z list of drugs and substances.
National Institute on Drug
Abuse,
http://www.nida.nih.gov/NIDAHo
me.html
US website which contains evidence based fact sheets and resources
for healthcare professionals about drugs of abuse.
Bibliographic databases e.g.
Medline, Embase.
Suggested terms: DRUG ABUSE, SUBSTANCE ABUSE, SUBSTANCEABUSE-INTRAVENOUS, SUBSTANCE-RELATED-DISORDERS,
INTRAVENOUS DRUG ABUSE, MULTIPLE DRUG ABUSE.
Local resources
Answering the enquiry

It is important to consider the ethical/legal implications surrounding these types of enquiry. If you are in
doubt as to what information you should give the enquirer discuss with MI colleagues.
- 64 -

Remember with some of these agents there is limited information available so be aware when giving
advice particularly in patients with concomitant medical problems or those on other medication.
Keywords: DRUG ABUSE or SUBSTANCE ABUSE and where possible the name of the drug involved.
- 65 -
Travel medicine
There are four sections to this document:
Malaria prophylaxis and travel vaccinations
Travel-related DVT
Taking medicines abroad
Other travel-related medicines enquiries
Malaria prophylaxis and travel vaccinations
Background information

What country/countries are to be visited?

What is the departure date?

How long will the visit be for?

Where exactly are they travelling within the country and what type of accommodation will they be
staying in? (e.g. tourist areas, safari, backpacking)

Have they had malaria prophylaxis before and if so what? Did they have any problems with the
prophylaxis?

Have they had any vaccinations before, if so when, and did they have any problems?

What medication, if any, is the traveller taking?

What is the traveller's past and current medical history? Does it include:
o
Immunosuppression
o
Psoriasis
o
Epilepsy
o
Depressive or psychiatric illness
o
Renal or hepatic impairment
o
Splenectomy
o
Porphyria
o
G6PD deficiency
o
Sickle cell or thalassaemia

Is the traveller pregnant or breast-feeding?

Will any children be travelling, and if so what age and weight will they be at the time of travel?
Resources
Source
Notes
First-line resources
In-house past enquiries.
Relevant Medicines Q&As via
www.nelm.nhs.uk or
www.evidence.nhs.uk
Travax database,
www.travax.nhs.uk
This is a Scottish NHS website for healthcare professionals. Click on
‘malaria’ or select the destination you require.
Additional resources (tailor to local use/availability)
Fit for Travel,
www.fitfortravel.nhs.uk
This is the Travax sister-site and can be accessed by members of the
public and healthcare professionals. Click on ‘A to Z site index’ to bring
up a list of countries and topics.
- 66 -
Source
Notes
Health Protection Agency,
www.hpa.org.uk
Contains guidelines for malaria prevention in travellers from the United
Kingdom. Select M in the Topics A-Z at the top of the screen, then select
Malaria. Click on ‘guidelines’ for the current UK guidelines. They include
a chapter on ‘special categories’ that includes information on multi-trip
travel, cruises, emigration and information on variety of patient groups.
There is also a useful ‘Frequently asked questions’ chapter on malaria
prevention.
eMIMS www.mims.co.uk
Includes ‘travel tables’ of malaria prophylaxis and travel vaccination
requirements by country. Click ‘travel’ at the top of the page.
National Travel Health Network
and Centre (NaTHNaC) website,
www.nathnac.org
This website has information about yellow fever vaccination centres and
other travel information. You do not need to log in. If you cannot find
what you want on the website, healthcare professionals may telephone
the NaTHNaC helpline on 0845 602 6712 (9.00 to 12.00 and 14.00 to
16.30 hours Monday to Friday).
Sanofi Pasteur MSD online
vaccine information service
(VIS), www.spmsd.co.uk
Registration is required to access the VIS section of the site.
World Health Organisation,
www.who.int/ith/en/
WHO guidance on International travel and health.
Bibliographic databases e.g.
Medline, Embase.
Suggested terms: TRAVEL, ANTIMALARIALS, MALARIA, vaccine
name, EMPORIATRICS.
Local resources
Answering the enquiry

When formulating an answer consider if there is more than one option available.

The Health Protection Agency and MHRA has issued a warning against reliance on herbal or
homeopathic medicines for the prevention of malaria.

Try to give as much advice as possible. No prophylaxis regimen is 100% effective, so include general
advice regarding protection against mosquito bites – use of mosquito nets, insecticides, insect
repellents, wearing long-sleeved clothing after sunset etc.

Preferred malaria prophylaxis regimens should always be recommended unless there are medical
reasons why this is not possible. Alternative regimens may not give optimal prophylaxis.

During pregnancy, travel to malarious areas should be avoided wherever possible. If travel is
unavoidable, effective malaria prophylaxis should be used, as the risk of malaria to both the mother
and foetus is greater than the risk from antimalarial drugs at recommended doses. Vaccines may be
administered where the risk of exposure outweighs the risk of vaccination.

Breast-feeding infants will still require malaria prophylaxis, as the amounts of antimalarial drugs
excreted in breast milk are too variable to give reliable protection to the infant. Most vaccines can be
administered to breast-feeding women; however immunity is not passed to the infant via breast milk.

When advising on children’s dosages, calculate the dose by weight rather than by age wherever
possible.
Keywords: MALARIA, PROPHYLAXIS, VACCINE and VACCINATIONS, TRAVEL, name of country,
name of drugs recommended
Travel-related DVT
Background information

What type of travel is the patient undertaking and how long will it take?

What is the traveller’s past and current medical history? Does it include:
o
History of DVT or PE
- 67 -
o
o
o
o
History of stroke
Thrombophilia
Family history of clotting conditions
Cancer or treatment for cancer

Has the traveller undergone major surgery or had a hip or knee replacement within 3 months before
travel?

Is the traveller pregnant?

What medication, if any, is the traveller taking? Does it include warfarin or aspirin, HRT or hormonal
contraception?
Resources
Source
Notes
First-line resources
In-house past enquiries.
Relevant Medicines Q&As via
www.nelm.nhs.uk or
www.evidence.nhs.uk
Travax, www.travax.nhs.uk
Log in, click on ‘Health Information’ then ‘General health advice’ then
‘Deep vein thrombosis’.
British Committee for Standards
in Haematology guidelines on
travel-related venous
thrombosis.
www.bcshguidelines.com
Click on ‘view guidelines’ then ‘haemostasis and thrombosis’ then
‘Guidelines on travel-related venous thrombosis’.
Additional resources (tailor to local use/availability)
National Travel Health Network
and Centre (NaTHNaC) website,
www.nathnac.org
Click on ‘health information’ then ‘travel related DVT’ for a health
information monograph
Fit for Travel,
www.fitfortravel.nhs.uk
Click on ‘A to Z site index’ then ‘Air travel’.
Bibliographic databases e.g.
Medline, Embase.
Suggested terms: DEEP VEIN THROMBOSIS, FLYING, THROMBOSIS,
THROMBOSIS-PREVENTION.
Local resources
Answering the enquiry

Patients at high risk of DVT (as per the guidelines above) should discuss their need for prophylaxis
with their GP or haematologist.

Flight socks are not prescribable on the NHS but may be purchased from pharmacies.
Keywords: DEEP VEIN THROMBOSIS, FLYING, TRAVEL.
Taking medicines abroad
Background information

What medication is being taken abroad? Does it include controlled drugs? What quantity of medicines
are they planning to take?

Are the medicines prescription only or over-the-counter?

What countries are being visited?
- 68 -

How long will the patient be out of the UK for (for questions about prescription length or continued
supply)?
Resources
Source
Notes
First-line resources
In-house past enquiries.
Relevant Medicines Q&As via
www.nelm.nhs.uk or
www.evidence.nhs.uk
National Travel Health Network
and Centre (NaTHNaC) website,
www.nathnac.org
Click on ‘health information’ then ‘medicines – transportation by
travellers’ for a health information monograph.
Home Office Drugs Licensing
and Compliance Unit.
Details the requirements for travelling abroad with controlled drugs and
the relevant paper work and licenses required:
www.homeoffice.gov.uk/drugs/licensing/personal
Additional resources (tailor to local use/availability)
Embassy, Consulate or High
Commission for the country
being visited.
Check the specific entry requirements for the country being visited by
contacting the relevant Embassy, Consulate or High Commission.
Where possible, obtain a letter from them before you travel. Use
www.google.co.uk or the Home Office website above to find contact
details.
Travel Doctor,
www.traveldoctor.co.uk
This website is maintained by a pharmacist in Wales. It provides
information about medicines that may be required for travel to exotic
locations first-aid kits etc.
UK legislation: NHS patients
may be removed from GP list if
abroad for over 3 months.
www.legislation.gov.uk/uksi/1992/635/regulation/19/made (See
paragraphs 19(4) and 19(5)).
Local resources
Answering the enquiry

The legal status of medicines in other countries might differ from the UK.

For patients travelling with controlled drugs, check entry requirements with the relevant Embassy,
Consulate or High Commission. Where possible, the traveller should obtain a letter from them before
travelling.

GPs are not responsible for prescribing medicines for conditions which may arise during travelling, e.g.
antibiotics, oral rehydration

Travellers who leave the UK for more than three months can be removed from GP lists. Three months
is the generally accepted maximum length for a prescription for patients travelling abroad.
Keywords: TRAVEL, FIRST AID, CONTROLLED DRUGS, LEGISLATION
Other travel- related medicines enquiries
Resources
Source
Notes
First-line resources
In-house past enquiries.
Relevant Medicines Q&As via
www.nelm.nhs.uk or
- 69 -
Source
Notes
www.evidence.nhs.uk
Travax, www.travax.nhs.uk
This is a Scottish NHS website for healthcare professionals. Click on
‘advice sheets for travellers’ or select your destination.
Fit for Travel,
www.fitfortravel.nhs.uk
This is the Travax sister-site and can be accessed by members of the
public and healthcare professionals. Click on ‘A to Z site index’ to bring
up a list of countries and topics.
National Travel Health Network
and Centre (NaTHNaC) website,
www.nathnac.org
This website has information about yellow fever vaccination centers and
other travel information. You do not need to log in. If you cannot find
what you want on the website, healthcare professionals may telephone
the NaTHNaC helpline on 0845 602 6712 (9.00 to 12.00 and 14.00 to
16.30 hours Monday to Friday).
Additional resources (tailor to local use/availability)
Health Information for Overseas
Travel (2010) – The ‘Yellow
Book’.
www.nathnac.org/yellow_book/Y
Bmainpage.htm
This includes sections on risk assessment and risk management and
guidance for travellers with special health needs. This publication is
designed to complement information found on the NaTHNaC website.
World Health Organisation,
www.who.int/ith/en
WHO guidance on International travel and health.
NHS Choices
www.nhs.uk/Healthcareabroad/
Pages/Healthcareabroad.aspx
Includes health information for travellers, those emigrating and those
traveling abroad and also information about the European Health
Insurance Card (EHIC) which has replaced form E111. From the NHS
Choices homepage, click on ‘Health A to Z’ then ‘travel health’.
Health Protection Agency,
www.hpa.org.uk
Provides information on travel-related infections. Click on ‘T’ in the ‘A to
Z index’ at the top of the screen then select ‘Travel Health’.
Local resources
Answering the enquiry

See above for information about answering questions about malaria prophylaxis, travel vaccinations,
travel-related DVT or travelling abroad with medicines.
Keywords: TRAVEL, name of country
- 70 -
Wound care
Background information
Wound healing is complex and affected by patient and wound related factors. Holistic assessment should
take account of medical history as well as factors that may delay healing that include mobility, nutrition and
personal circumstances. Most organisations will have a tissue viability nurse who will be better placed to
advise on choice of dressings in individual circumstances. For many specialist wounds e.g. burns it is
unlikely you will be asked to advise on anything other than product availability. However, in the absence of
specialist healthcare professionals, the following will give you some pointers where to start. In order to
advise on choice of wound management product it is better if you see the patient and their wound and
consider the following:

What type of wound is it e.g. surgical, pressure sore, burns, extravasation?

What colour is the wound?

How long has the patient had the wound? This may give an impression of complexity of the wound.

What stage is the wound at i.e. does it need debridement or is it at the granulating stage?

What products have been tried already and what problems have there been?

Concomitant medication (may delay wound healing)?

Are there special factors that need to be addressed e.g. high amount of exudate, malodorous?

Could it be infected, if so, have swabs been taken?

Any known allergies especially to wound management products?
Resources
Source
Notes
First-line resources
In-house past enquiries.
Relevant Medicines
Q&As via
www.nelm.nhs.uk or
www.evidence.nhs.uk
World wide wounds.
Surgical Materials
Testing Laboratory
(SMTL) and the Medical
Education Partnership
www.worldwidewounds.
com.
The aim of this site is to be the premier online resource for peer-reviewed wound
management information. It contains details of published studies as well as review
articles on particular subjects including maggot therapy, infected wounds,
dressings and bandages. Individual product datacards are also available that list
indications, contra-indications, method of use, frequency of change, warnings,
presentation and availability (drug tariff).
Dressings.org Surgical
Materials Testing
Laboratory
www.dressings.org
Links to same information as above but information is specific to individual
dressings rather than containing information on the wide subject of wounds.
NHS Injectable
Medicines guide
www.medusa.wales.nhs.
uk
For extravasation guidance.
Use the quick search facility and you will also be able to access FAQs.
Additional resources (tailor to local use/availability)
NPC
A range of support tools is available via the NPC legacy site including PowerPoint
presentations (Wounds and dressings, Pressure ulcers, Leg ulcers)
Ten Guiding Principles for improving the systems and processes for the supply
and prescribing of wound dressings April 2012
- 71 -
MeReC bulletin via
www.npc.co.uk
Evidence-based prescribing of advanced wound dressings for chronic wounds in
primary care Volume 21 Number 01 July 2010
This covers the following and provides useful links to other resources:
What does the evidence say?
What clinical guidelines are there?
What clinical evidence is required for marketing approval?
What are the costs of wound dressings?
What does this mean for dressing choice?
What about antimicrobial dressings?
Do you have a local wound care formulary?
Prodigy Guidance
http://www.prodigy.clarit
y.co.uk/home
Focus search using specific wound type e.g. diabetic foot ulcer, venous ulcer etc.
NB: This will change to
Clinical Knowledge
Summaries guidance in
early 2013
Wound care information
network.
www.medicaledu.com
A US website that is an educational tool describing aetiology, staging of wounds,
choice of products, etc. It has lots of pictures! Lists the range of products by
dressing category e.g. antimicrobials, compression, absorptive, odour reducing.
www.convatec.co.uk
Although this is a company website it also has some good educational sections on
types of wound etc.
Formulary of Wound
Management Products.
Morgan D.
NEXIS National
Extravasation
Information Service
www.extravasation.org.u
k
Has information on recognising and treating extravasation and a database of
drugs, their pH and known reactions following extravasation. Website is not
currently updated but still a useful resource.
The first search page only searches for information on cytotoxic drugs. To search
for information on non-cytotoxic drugs, click the link provided.
A national extravasation protocol for cancer chemotherapy is currently in
development.
Online bibliographic
databases
Consider British Nursing Index (BNI) and CINAHL both of which have a nursing
focus.
Local resources
Trust tissue viability
nurse
Answering the enquiry

If advising on choice of wound management product you will need to be familiar with the dressings you
have on contract/formulary.

Make sure factors that will influence wound healing have been addressed e.g. can drugs that delay
wound healing be stopped/reduced, is any infection being treated?
Keywords: WOUND HEALING, WOUNDS, DRESSINGS and terms specific to wound type e.g. WOUND
INFECTION, ODOURS, DIABETIC COMPLICATIONS
Contributers: Christine Proudlove, Helen Davis, Christine Randall, Joanne McEntee, Karoline Brennan,
Simone Henderson, Lindsay Banks, Jill Rutter, Ashley Marsden North West Medicines Information Centre
Comments gratefully received from: Dave Abbott, Jill Bloom, Anna Burgess, Sonia Bradley, Davina
Wraight, Margaret Gibb, Hayley Johnson, Laura Kearney, Julia Kuczynska, Paul Mooney, Agatha Munyika,
Veronica Newland, Sue Street, Simon Wills.
- 72 -