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Prescribing in the UK Session 1: Introduction malaika.haider@nhs.netr Agenda 01 02 03 Electronic Paper Overview Prescribing Prescribing 04 05 06 The PSA Practise Questions Dr Syeda Malaika Haider 01 Overview Prescribing Rights as an IMG Syeda Malaika Haider syeda.haider@student.manchester.ac.uk Ability to Prescribe FY1 and FY2/ F2 Standalone program ● NONE until you pass the PSA, this will be facilitated by your foundation school ● You can NOT write, edit or sign prescriptions PLAB ● You CAN prescribe once you’ve passed your PLAB ● HOWEVER - the right to this is being reviewed Syeda Malaika Haider Why is it being reviewed? 1. No formal assessment = varying degrees of competency 2. Disadvantage compared to UK peers 3. SHO roles often advise F1s on procedure 4. Expected to make decisions quickly Electronic Prescribing Many trust/hospitals have switched to electronic prescriptions PROS ● Can be accessed remotely ● Pre-populated, so easier to use ● Cost-saving and Time Saving CONS ● Deskilling ● System downtime - access issues ● Errors can still occurExample of Electronic Platform Paper Prescribing A PHYSICAL Paper chart that remains at the patient's bedside during their inpatient stay - Still used widely by many trusts, especially smaller ones PROS ● Information is all displayed in front of you CONS ● Time consuming ● Charts get lost ● Handwriting Errors ● ADRs possible (and more frequent) ONCE ONLY DRUGS STAT doses (except fluids) ● Acute medications e.g aspirin in ACS ● Antibiotics for a loading dose ● Enemas/Bowel Prep pre operationAntibiotic Prescription Oxygen Oxygen is a DRUG - should always be prescribed Unlikely to be on the PSARegular Chart PSA - The Basics Sat by anyone entering a Foundation Training Post or Standalone F2 Program ● 3 sittings - You’ll be sitting the September one most likely ● Your foundation school will arrange this ● NOTE - post starts in AUGUST Pass Mark - Usually 65% ● Don’t be fooled, it’s a difficult exam and UK students have 3 chances to pass, you might only have one before life gets more difficult ● 8 sections - 120 minutes Section 1 : Prescribing Reasoning and Judgement: Deciding on the most appropriate prescription (drug, dose, route and frequency) to write, based on the clinical circumstances and any supplementary information • Measurable Action: Writing a safe and effective prescription for a single medicine using the documentation provided, to tackle a specific indication highlighted by the question You’ll be provided with a short clinical scenario, and asked to prescribe a medication MOST suited to treat that condition You’ll be doing this every day as a doctor - so even if you AREN’T taking the PSA, this will be good practise How is it Scored? 10 marks per question ● Over 50% of the total marks are on this section ● You’re marked on 4 aspects of the prescription DRUG - 5 marks DOSE/ROUTE/FREQUENCY - 5 marks Suboptimal prescriptions will lower your marks Where to revise for this? Unfortunately, it’s not so straightforward ● BNF and Medicines Complete - often not available outside of the UK ● You’ll be provided a BNF during your PSA and during your revision time ● National Library/ PubMed often publishes articles with UK guidelines and the NICE guidelines should be available too ● Caution - using paper copies over 2 years out of date ● Regular revision - provided using UK guidelines will account for PSA revision too ● I’ll show you the Medicines Complete BNF MYTH You need to memories the treatment/management of EVERY SINGLE CONDITION All prescribing is situation, time and judgement based Knowing the BASICS is always useful, but in practise you always have more time than you think Practise Questions Some practise questions to introduce you to the types of common scenarios you’ll encounter in practise I’ll be covering these in further sessions in more depth, this is just an introduction for now Acute Management Scenario A 45 year old woman has presented to the Emergency Department with new onset abdominal pain and vomiting and has not opened her bowels for 3 days PMH: NONE Drug History: NONE Observations Temperature 37.8°C, HR 140/min and rhythm regular, BP 70/50 mmHg, RR 30/min, O2 sat 99% breathing air PR exam: Empty Rectum Write a prescription for the MOST APPROPRIATE FLUID to treat her condition 1. Drug Name 2. Volume 3. Route 4. Duration Answer Remember your principals of Acute Management ABCDE It’s possible and most likely this patient has a bowel obstruction HOWEVER She is currently in shock, her CIRCULATION needs to be restored BEFORE further treatment RESUSCITATION FLUIDS Adult: 500ml NaCL IV over <15 minutes or STAT Child: 10 mL/kg over <10 minutes or STAT Fluids - Maintenance An 85 year old man is admitted to hospital for an elective procedure, he’s not been eating or drinking properly for 2 days, he is unable to swallow PMH: Hypertension DH: Ramipril and Amlodipine On Exam: BP - 135/85, Temperature 37.0, HR 88, Sats 99% on Air Weight: 80kg estimated Test Results: Na+ 144 (135-144), K+ 4.0 (3.5-5), Urea and Creatinine are Normal, Blood Glucose 7.0 ( 3.9 - 5.6) What is the most suitable maintenance fluids regime for this patient? Water: 25-30mmol per kg per day Na/K : 1mmol/kg/day Glucose 50-100g / day Answer Look at the patients bloods: He’s likely dehydrated (borderline Sodium and High Glucose 25-30mmol/day = 2000ml to 3000ml per day Na/K = 80 mmol each per day Glucose - Not by weight! 50-100g per day as normal Be cautious in the Elderly, 2000ml is more than enough So 2000ml and 80mmol K+ Split over 24 hours = 0.9NaCl and 0.3% (40 mmols K+) over 12 hours Pain Management An 80 year old man has been struggling with controlling his pain whilst on the ward. He is prescribed regular oral morphine 5mg QDS and has had 4 doses of PRN oral morphine 2.5mg 5 times overnight You want to convert his medication to a modified release tablet to control his pain. Please write an appropriate prescription for a modified release preparation Name Dose Route Frequency Answer Modified Release - Given 12 hourly to provide better pain coverage over the whole day Total Pain Use: 20mg of Morphine Daily plus 12.5mg PRN = 32.5mg daily Converted to 2 modified release preparations = 15mg BD Note this is only 30mg, however we can still prescribe BREAKTHROUGH pain medication And remember formulation = Not advised to give half a tablet Primary Care A 67 year old woman presents to your practise with new onset calf swelling and tenderness after a long haul flight, on examination, the Left calf at >3cm more swollen than the right when measured below the tibial tuberosity Creatinine Clearance is Normal, HAS-BLED score of 1 What is the most appropriate drug to prescribe for the next 7 days to treat the condition Name Dose Route Frequency Contraception An 19-year-old patients presents to you following unprotected sexual intercourse 10 hours ago, she requests emergency contraception urgently, she would prefer a tablet, she doesn’t want a coil. She doesn’t take regular contraception This is her only episode of unprotected sexual intercourse since the start of her last period 10 days ago. She has a regular 28-day cycle. PMH: Poorly controlled severe asthma. DH: Salbutamol inhaler INH as required, montelukast 10mg PO once daily BMI - 23 Write a prescription for ONE drug that is the most appropriate emergency contraception for this patient. Emergency Contraception Copper Coil - Most Effective Can be used up to 5 days AFTER UPSI or up to 5 days post estimated Ovulation Levonorgestrel: Most effective within 72 hours of UPSI Ulipristal - Most Effective within 96 hours of UPSI HOWEVER - not indicated in severe asthma Note: not EVERY patient needs emergency contraceptionThank You Questions? VTE and PEs Wells Score - >4, likely a DVT Note the risk factors in the text BNF: Under Treatment Summaries - VTE treatment Apixaban anticoagulation regime: ● 10mg BD for 7 days ● followed by maintenance of 5mg twice daily Rivaroxaban anticoagulation regime: ● 15mg BD for 21 days ● followed by 20mg OD Apixaban is CHEAPER and the dosing is EASIER so optimal marks