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Learn to be Safe – Medication Safety. A Guide for Pharmacists
Appendix D – Supplemental Topic: Children and Teens October 15, 2013
1
Appendix D – Supplemental Topic: Children and Teens
Patient Stories
Many people are aware that medicines should be safely stored out of the reach of children but, they may not be aware that even over-‐the-‐counter products that seem harmless, such as certain eye drops and nasal sprays, may be dangerous if swallowed. Examples of these products include Visine, Clear Eyes, Albalon, Otrivin, Dristan, and Claritin. If you are buying products like these, check the label to identify the ingredients they contain and ask your pharmacist for advice on their safe use and storage. Medicines and hazardous products should be stored in cabinets with safety locks.1
A 2-‐year-‐old boy was found unconscious 2 days after visiting a relative in a nursing home. He later died, and a patch containing fentanyl, a very strong pain killer, was found in his throat.2
Key Points There are two important messages for parents about medication safety for children and teens: 1. Differences in size and weight mean that extra caution needs to be taken when giving any
medication to children. This includes: prescription medication. non-‐prescription medication. vitamins. minerals. all natural health products.
2. Kids are curious and medications in the home can be hazardous when young children mistake them for candy or teens experiment with medication.
Children When parents give medications to their children, they have to remember that:
children’s medication dosages are often dependent on weight. Parents need to make sure that the pharmacist and doctor always have updated information about their child’s size.
they need to confirm all instructions with the pharmacist:
1 SafeMedicationUse.ca Alert. Vol. 3(6) December 6, 2012. [cited 2013 July 15]. Available at: http://www.safemedicationuse.ca/alerts/alerts_EyeDropsNasalSprays.html. 2 SafeMedicationUse.ca Alert. Vol. 3(4) July 4, 2012. [cited 2013 July 15]. Available at: http://www.safemedicationuse.ca/alerts/alerts_patches.html.
Learn to be Safe – Medication Safety. A Guide for Pharmacists
Appendix D – Supplemental Topic: Children and Teens October 15, 2013
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o how much to give. o how many times a day and for how long. o how to measure the dose and what measuring devices to use to provide an
accurate dose. o what to do if a dose is missed. o side effects that may occur. o what to do if the child spits out or vomits the medication.
children under the age of 6 should not be given cough and cold medication, and children should never be given acetylsalicylic acid (ASA).
children’s medications are often ordered by the “dropperful.” Parents should always use the dropper provided and ask the pharmacist how much to give the child.
liquid doses of children’s medications should be given by oral syringe. Children can choke on the caps of hypodermic syringes.
if the child is in school, parents need to find out the school’s policy on children receiving their medication. Parents should let the main office or child’s teacher know that they are on medication, and ask them to assist the child with his/her medication.
Tips: use child-‐resistant lids on all medication bottles – even one tablet of some medications
may seriously harm a young child. store medications securely, out of the reach of small children and out of the view of
teens and their friends. take extra precautions when visiting family and friends outside of the home or when
you have visitors who are taking medications. Teens • Teens are prone to curiosity, peer pressure, wanting to be accepted, engaging in risk-‐taking
behaviors and seeking pleasure and independence. • Some teens may have the misconception that prescription and non-‐prescription
medications are safe regardless of how they are used or who takes them. • Teens are smart. They know which prescription drugs are controlled substances. Abusing a prescription medication includes:
taking them without a prescription. sharing prescription drugs with friends. taking them in a way not intended.
Learn to be Safe – Medication Safety. A Guide for Pharmacists
Appendix D – Supplemental Topic: Children and Teens October 15, 2013
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The most commonly abused prescription drugs are: pain relievers such as narcotics. depressive drugs (benzodiazepines). stimulants (methamphetamines).
Parents need to dispose of unused, unwanted or expired medications found in the home. In Manitoba, return them to the pharmacy for disposal in an environmentally-‐safe manner through the Manitoba Medications Return Program. For more information, click here. Related tools and handouts
Appendix E – Aid 4: MIPS It’s Safe to Ask – Safe Use of Medications summarizes what to ask to answer the It’s Safe to Ask 3 important questions: What is my health problem? What do I need to do? Why do I need to do this? Space is available for writing additional questions and responses.
SafeMedicationUse.ca has a helpful article on how to prevent poisonings that can occur in the home. This article is available here.
Learn to be Safe – Medication Safety. A Guide for Pharmacists Appendix D – Supplemental Topic: High Alert Medications
October 15, 2013 1
Appendix D – Supplemental Topic: High Alert Medications Patient Stories
A patient received a prescription for warfarin, and was to take one 5 mg tablet every day for 5 days, then have a Prothrombin Time and International Normalized Ratio (INR) test. The INR result was too low, so the dose was increased to 7 mg (one 5 mg tablet and two 1 mg tablets). The next INR was too high, so the dose was reduced to 3 mg (three 1 mg tablets). The results of the next INR were even higher. The warfarin was stopped altogether, and restarted once the INR fell to a safe level. The warfarin was restarted at 0.5 mg daily (half of a 1 mg tablet). The INR was checked again after 2 and 4 days, and was found to be in the correct range. Later, while cutting a tablet in half for another dose, the patient noticed the tablet was marked with the number 5. The patient then checked the tablets in the bottle labelled as "warfarin 5 mg" and found that they were marked with the number 1. The patient visited the pharmacy where the prescriptions had been filled and it was confirmed that the container labels had been switched.1 A patient was discharged from the hospital and transferred to a long-‐term care facility. At the long-‐term care facility, the receiving nurse reviewed the transfer information. The receiving nurse mistakenly listed the insulin concentration of 100 units/mL as the insulin dose. The nurse contacted the patient’s physician, whose instructions were to continue the same orders that the patient received while in hospital. Despite the unusually high dose, the insulin order was filled by the pharmacy. The patient received one dose of 100 units, experienced severe hypoglycemia and was transferred back to the hospital. Unfortunately, the patient died soon-‐after.2
Key Points
Below is a list of medications that have the potential to result in complications. For your presentation, choose to include all, some or none of these medications. Although these medications have been proven to be safe and effective, they can cause serious injury if they are taken incorrectly. When a patient is on a high alert medication, they need to:
check with their pharmacist or doctor before taking any non=prescription medication or natural health products.
inform a new physician or pharmacist that they are on these medications.
1 SafeMedicationUse.ca Newsletter. Vol. 1(7) November 11, 2010. [cited 2013 July 15]. Available at: https://www.safemedicationuse.ca/newsletter/newsletter_warfarin.html. 2 ISMP Medication Safety Alert Newsletter. Vol. 18(15) July 25, 2013. [cited 2013 August 23]. Available at: http://www.ismp.org/newsletters/acutecare/showarticle.asp?id=54.
Learn to be Safe – Medication Safety. A Guide for Pharmacists Appendix D – Supplemental Topic: High Alert Medications
October 15, 2013 2
Warfarin When patients are taking warfarin, they need to:
know the exact dose to take. take exactly as directed. keep a dated record of dose changes made by the physician to avoid confusion between
new and old instructions. keep instructions on how to take their medication. keep their usual eating habits and exercise regularly. avoid eating foods that are high in vitamin K. get regular blood tests. call their doctor if they experience any signs of bleeding or clotting. do not start or stop any prescription medications without consulting their doctor and
pharmacist. consult with their pharmacist or doctor before using any non-‐prescription medications
or natural health products to prevent drug interactions.
Too much warfarin can lead to bleeding, while too little can result in blood clots. Patients need to know the signs of bleeding or blood clot formation. Signs of bleeding include:
unusual pain, swelling or discomfort. unusual or easy bruising. pink or brown urine. prolonged bleeding of gums or cuts. persistent, frequent nosebleeds that don’t stop within 7 minutes. unusually heavy/long menstrual flow. coughing up blood. vomit that is bloody or looks like coffee grounds. severe dizziness, weakness, headache, fainting, unusual or persistent tiredness. bloody or black stools. pain in joints or back.
Signs of a clot (examples):
in the lung: chest pain, fast breathing or heart rate, coughing, shortness of breath, fever. in the arm or leg: sudden leg, arm or back pain, swelling, redness, warmth, tenderness. in the brain: headache, vision changes, seizure, slurred speech, weakness on one side of
body, dizziness. in the heart: chest pain, shortness of breath, sweating, nausea and vomiting. in the abdomen: abdominal pain, vomiting, diarrhea.
Learn to be Safe – Medication Safety. A Guide for Pharmacists Appendix D – Supplemental Topic: High Alert Medications
October 15, 2013 3
Dalteparin/Enoxaparin When patients are taking dalteparin or enoxaparin, they need to:
take exactly as directed. prepare the exact dose if not using pre-‐filled syringes. inject the medicine properly. rotate injection sites. never re-‐use or recycle syringes. always tell their doctor and pharmacist about new medications. call their doctor if experiencing signs of bleeding or clotting. call their doctor if they develop injection site redness. dispose of needles properly.
Fentanyl Patches When patients are using fentanyl patches, they need to:
safely dispose of used or unneeded patches by folding the sticky sides together and flushing them down the toilet.
only use for long-‐term chronic pain. use intact patches. avoid applying patches to broken skin. follow directions when wearing fentanyl patches. do not warm the patches. never wear their fentanyl patch during an MRI. report signs of overdose. store patches safely out of the reach of children. dispose of patches safely.
Methotrexate When patients are using methotrexate, they need to:
tell the pharmacist why they are taking methotrexate – the dosage regimen is different depending on the medical condition being treated.
tell their doctor and pharmacist about all medications they are using. never use during pregnancy or when breastfeeding. pick a certain day of the week to always pick up their prescription. ask their pharmacist for education on the drug. clarify their medication schedule with the pharmacist. Dosing schedules differ
depending on what the medication is being used for. never take extra doses.
Learn to be Safe – Medication Safety. A Guide for Pharmacists Appendix D – Supplemental Topic: High Alert Medications
October 15, 2013 4
avoid direct sunlight. report side effects to the doctor such as rash, fever, chills, trouble breathing, cough,
racing heart beat or bleeding.
Oxycodone with Acetaminophen When patients are taking oxycodone with acetaminophen, they need to:
never take with Tylenol products (acetaminophen). prevent and treat constipation. dispose of unused or expired medication safely. call their doctor or pharmacist if their pain gets worse. call their doctor or pharmacist if they are experiencing intolerable side effects. watch for signs of overdose. watch for signs of withdrawal.
Insulin When patients are taking insulin, they need to:
know what type of insulin they use and how it works (short versus long acting). be sure to prepare their insulin properly. never reuse or recycle syringes. avoid mix-‐ups with other types of insulin. know how to treat low blood sugar (hypoglycemia). test their blood sugar levels regularly. follow up regularly with their physician for assessment and blood work.
Signs of hypoglycemia include:
hunger feeling shaky fast heartbeat light headedness dizziness sweating headache confusion irritability
Learn to be Safe – Medication Safety. A Guide for Pharmacists Appendix D – Supplemental Topic: High Alert Medications
October 15, 2013 5
Relevant tools and handouts
The It’s Safe to Ask Medication Card is a tool to improve medication safety. This card can be downloaded and saved to a home computer. Hard copies are available at the Manitoba Institute for Patient Safety, local pharmacies and local senior resource councils. The card is part of the E.R.I.K. (Emergency Response Information Kit). Patients and families can call 1-‐800-‐665-‐6565 to find out the phone number of the senior resource council nearest them in local communities. Kits are also available from Fire and Paramedic stations.
Appendix E – Aid 4: MIPS It’s Safe to Ask – Safe Use of Medications summarizes what to ask to answer the It’s Safe to Ask 3 important questions: What is my health problem? What do I need to do? Why do I need to do this? Space is available for writing additional questions and responses.
Pharmacists can provide information on the Manitoba Medications Return Program or information is available here.
Learn to be Safe – Medication Safety. A Guide for Pharmacists Appendix D – Supplemental Topic: Seniors
October 15, 2013 1
Appendix D – Supplemental Topic: Seniors Patient Story
It's best not to rely on your memory when providing information about the medications you are taking. In one incident, a consumer called a pharmacy to request a refill but did not refer to the prescription bottle for the name of the medicine and the prescription number. The consumer relied on memory and asked for a medicine taken in the past to treat a different condition. Even though it had been over a year since the consumer had taken the requested medicine, the pharmacy contacted the consumer's doctor and got approval to dispense it. When picking up the medicine, the consumer checked the prescription and noticed the mistake.1
As people age, they tend to develop more health problems and are prescribed more medications. This increases the chance of drug interactions, mix-‐ups and the potential for unwanted side effects. Seniors are vulnerable to overdosing and side effects because their bodies process and respond to medications differently. Inappropriate use of medication can include, for example:
unintentionally taking the wrong medication. taking a medication twice. forgetting to take a medication.
Inappropriate use of medications is a risk for seniors because they take more medications and often have multiple doctors treating their health conditions. This prevents any one doctor from knowing all of the medications that the patient takes and increases the likelihood of medication incidents. For this reason, it is beneficial for patients to get all of their medications from one pharmacy. A common cause of poisoning among seniors is medication overdose. All medications have the potential for accidental poisoning, but some more than others, including:
heart and blood pressure medication. diabetes medication. sedatives and sleep aids. pain relievers. iron pills. cough and cold medication.
1 SafeMedicationUse.ca Newsletter. Vol. 3(7) December 19, 2012. [cited 2013 July 15]. Available at: http://www.safemedicationuse.ca/newsletter/newsletter_DoNotRelyOnMemory.html.
Learn to be Safe – Medication Safety. A Guide for Pharmacists Appendix D – Supplemental Topic: Seniors
October 15, 2013 2
All of the questions for patients to ask their pharmacist are listed in the core content of this guide. In particular, seniors need to ask their pharmacist:
how should the medication be taken and are there any special instructions for use? what are some common side effects of the medications and which side effects should
be reported to my doctor or pharmacist right away? is this medication safe to take with my other medications and/or natural health
products? are there any activities I should avoid while taking this medication? what do the symbols and stickers on the container mean? I have trouble swallowing pills. Can this medication be taken in any other form? I have difficulty opening child-‐resistant containers. Does the pharmacy have any
containers that are easier to open? is this prescription medication an eligible drug under the Pharmacare Program (in
Manitoba)? patients can request that the label on their medication bottle be printed in a larger font
if needed. Elderly patients may need to ask for help with their medications from their family, advocate, caregiver or healthcare provider if they:
live alone. take three or more medications. have memory problems. get prescriptions from more than one doctor.
Falls Prevention Falls are a major safety concern for the seniors. Falls account for over half of all injury-‐related hospitalizations.2 The majority of hip fractures are a result of falls. Hip fractures in the elderly result in significant loss in the ability to conduct activities of daily living. Twenty percent of seniors who experience a hip fracture die within a year of the fracture.3 There are many risk factors for falls including:
age lower body weakness balance problems cognitive impairment arthritis history of falls
2Canadian Institute for Health Information. National Trauma Registry, 2005 Injury Hospitalizations Highlights Report. [cited 2013 July 15]. Available at: https://secure.cihi.ca/free_products/ntr_highlights_2005_en.pdf. 3Tinetti, M. E. and C. S. Williams, C.S. (1997). Falls, injuries due to falls, and the risk of admission to a nursing home. New England Journal of Medicine, 337(18), 1279-‐1284.
Learn to be Safe – Medication Safety. A Guide for Pharmacists Appendix D – Supplemental Topic: Seniors
October 15, 2013 3
house clutter medications
Several medications, generally because they can cause dizziness, increase the risk of falls in seniors including:
antipsychotics antidepressants anti-‐anxiety medications sleep medications alcohol blood pressure medications heart medications diabetes medications antihistamines
Seniors can help prevent falls by:
not using carpets and rugs that can result in tripping. not leaving clutter on the floor. rearranging furniture. wearing properly fitted shoes with good support and non-‐slip soles. exercising regularly to maintain strength and balance (e.g.walking, swimming). using a support to walk such as a cane or walker as necessary. telling their doctor, nurse and pharmacist about previous falls. talking to their pharmacist about their medications and risk of falls. talking to their pharmacist about calcium and vitamin D supplementation.
Driving The combination of prescription medications and/or alcohol with driving a motor vehicle can result in a greater risk for accidents. Certain medications and drugs such as the ones noted above, even when taken in appropriate dosages, can affect a person’s ability to drive. This is because they can:
reduce concentration. impair judgment. blur vision.
Patients should know what they are taking, and ask their doctor, nurse or pharmacist if it is safe to drive while taking their medications.
Learn to be Safe – Medication Safety. A Guide for Pharmacists Appendix D – Supplemental Topic: Seniors
October 15, 2013 4
Bubble Packs Seniors who take multiple medications or have trouble remembering when to take them should consider using a bubble pack. Bubble packs or blister packs are prepared by the pharmacy team and consist of individual bubbles packaged in a card that contain the patient’s medications organized by day and time. Considerations for bubble pack patients include:
is the patient taking any “as needed” medications that may not be in the bubble pack? is the patient taking any liquid medication or using any creams/ointments/patches? does the patient know how to use their bubble pack?
Splitting and Crushing Pills Elderly patients often have trouble swallowing large pills. Not all medication can be split or crushed.
Some medications are specifically prepared to deliver the medicine to the body slowly. If these pills are crushed, the medication may go into the body too fast, which may cause harm to the patient.
Some medications have outer coatings to protect the patient’s stomach or delay absorption until the drug gets into the patient’s intestines, so it won’t be destroyed by stomach acids.
Patients need to ask their pharmacist before splitting or crushing their medication. A clue that the medication should not be tampered with is if any of the following letters are found in the product name (ie. Adalat XL) or are inscribed on the tablet:
CR: controlled release SR: sustained release CD: controlled dose TD: time delayed ER: extended release LA: long acting XL: extended release XR: extended release
Relevant tools and handouts
The It’s Safe to Ask Medication Card is a tool to improve medication safety. This card can be downloaded and saved to a home computer. Hard copies are available at the Manitoba Institute for Patient Safety, local pharmacies and local senior resource councils. The card is part of the E.R.I.K. (Emergency Response Information Kit). Patients
Learn to be Safe – Medication Safety. A Guide for Pharmacists Appendix D – Supplemental Topic: Seniors
October 15, 2013 5
and families can call 1-‐800-‐665-‐6565 to find out the phone number of the senior resource council nearest them in local communities. Kits are also available from Fire and Paramedic stations.
Appendix E – Aid 4: MIPS It’s Safe to Ask – Safe Use of Medications summarizes what to ask to answer the It’s Safe to Ask 3 important questions: What is my health problem? What do I need to do? Why do I need to do this? Space is available for writing additional questions and responses.
Partners Seeking Solutions for Seniors has many helpful resources for seniors with an interest in their health and medications. These resources are available here.
Learn to be Safe – Medication Safety. A Guide for Pharmacists Appendix D – Supplemental Topic: Travelling with Medications
October 15, 2013 1
Appendix D – Supplemental Topic: Travelling with Medications Patient Story
Spotlight on Acetaminophen: In proper doses, acetaminophen is a safe drug, but overdose is a common cause of acute liver failure. The recommended maximum daily dose of acetaminophen for healthy adults is 4 grams, and is much lower for children and elderly patients. The safe dose is easily exceeded when consumers take a little extra of one product or take a number of products that contain acetaminophen. This problem could be encountered when travelling to other countries where the over-‐the-‐counter medications may be different. For example, people can purchase acetaminophen (Tylenol) in Canada but in the UK, it is called paracetamol. Not knowing that the drug has different names in different countries could lead to serious problems such as overdose and liver failure. The best advice is to read every label carefully to be sure you know the ingredients of any product you use. If in doubt, ask your pharmacist!1
Preparing for vacation To prepare for an upcoming vacation, patients need to:
visit their doctor and pharmacist to get an adequate supply of all of their prescription medications including an extra supply if there happens to be a delay during their trip.
pack a supply of commonly used non-‐prescription medications such as: o anti-‐inflammatory medication. o anti-‐histamines. o anti-‐diarrhea medication. o anti-‐motion sickness medication. o medication for pain and fever. o laxatives or stool softeners. o antifungal and antibacterial creams.
ensure that they know when to take their medication if travelling to a different time zone.
ask about any food-‐drug interactions that may occur, since their diet may change while on vacation.
pack the phone numbers and contact information of their doctor and pharmacist. bring a letter from their doctor if they are on a controlled substance (sedative, narcotic,
etc) and are crossing the border to another country.
1 SafeMedicationUse.ca Safety Tools and Resources. Get Medication Safety Tips. [cited 2013 July 15]. Available at: http://www.safemedicationuse.ca/tools_resources/tips_acetaminophen.html.
Learn to be Safe – Medication Safety. A Guide for Pharmacists Appendix D – Supplemental Topic: Travelling with Medications
October 15, 2013 2
prepare and take a current and complete list of all their prescription and non-‐prescription medications as well as any natural health products they may take (use a medication card).
ask the pharmacist how to ensure proper temperature control for the medication. Some medications require special storage such as refrigeration or if travelling to an especially hot or humid climate.
While on Vacation While on vacation, patients need to:
keep medications in a dry place at room temperature. Medication can be very sensitive to temperature and humidity extremes.
keep medications in their original prescription containers. This will help the patient at border crossings or when flying, and will also allow them to keep track of their medications.
take precautions to prevent theft of medications. Patients should exercise caution if they:
are wearing medication patches and plan on being in extreme heat. are on a medication that is sun-‐sensitive. It may cause them to burn more easily and
severely in the sun. are travelling internationally and require a medication refill. Ask for the medication by
generic name, as the brand name drug may be used for different ailments and may contain different active ingredients.
Related Tools and Handouts
Health Canada’s website provides travel health fact sheets and notices for patients. The information is available here.
SafeMedicationUse.ca has a helpful article on how to travel safely with your medications. The article is available here.
Learn to be Safe – Medication Safety. A Guide for Pharmacists Appendix D – Supplemental Topic: Cancer Medications in the Home
October 15, 2013 1
Appendix D – Supplemental Topic: Cancer Medications in the Home Patient Story
The consumer had received a prescription for tamoxifen from a cancer specialist. Tamoxifen is a medicine that is used to treat certain types of breast cancer. Later, the consumer's family doctor prescribed duloxetine (brand name Cymbalta) to treat depression. Duloxetine can reduce the effectiveness of tamoxifen. The consumer took both of these medicines for several months before finding out about the drug interaction during visit with the cancer specialist. The cancer specialist told the consumer to stop taking the tamoxifen and prescribed a different breast cancer medicine that does not interact with duloxetine.1
The diagnosis of cancer is overwhelming to patients and their families. Upon diagnosis, the patient is provided with information about their specific cancer and treatment options while also dealing with the emotional stress of the diagnosis. The treatment process can be daunting for patients and their families. Many healthcare professionals play a role in the treatment of a cancer patient, however with the increase use of cancer medications in the home, the patient’s role has expanded in terms of monitoring, adherence and medication safety. The treatment of cancer will vary for each person depending on the type of cancer, the stage and location as well as local cancer centre guidelines and patient considerations. The patient is provided with information about the various options and benefits of each. The following is general information about anti-‐cancer therapies, treatment protocols, adverse effects of cancer medications and patient safety considerations. Types of Medications Used There are several types of medications used to treat cancer. Cancer medications can be divided into four groups. Medications in all four groups may be given orally, by IV or subcutaneous injections.
1. Cytotoxic chemotherapy: These drugs interfere with DNA or RNA processes and prevent cell replication and function. These drugs are non-‐specific and also kill healthy cells. Because of this, they are associated with significant side effects.
2. Hormonal agents: Some cancers require hormones to grow. Giving anti-‐hormonal agents interferes with the production or action of certain hormones and causes the cancer to stop or slow its growth. These medications often have less severe side effects.
1 SafeMedicationUse.ca Newsletter. Vol. 3(4) June 14, 2012. [cited 2013 July 15]. Available at: http://www.safemedicationuse.ca/newsletter/newsletter_drug_interactions.html.
Learn to be Safe – Medication Safety. A Guide for Pharmacists Appendix D – Supplemental Topic: Cancer Medications in the Home
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3. Immunotherapy: These medications alter the body’s response to the tumour, or stimulate the immune system to fight the cancer. Sometimes this may be a compound that is already produced in the body, but given in much larger quantities than a human body produces.
4. Targeted Therapies: These are newer agents that have been designed to bind to specific targets on cancer cells. These therapies are less toxic because they don’t kill healthy cells. However, they do have unique side effects that are not traditionally associated with chemotherapy.
Medications used to help with the side effects of cancer medications are often referred to as supportive care medications. They may be given before, during, or after cancer treatments. Sometimes a prescription will be given for the patient to take in the days immediately following or preceding a cancer treatment. Supportive care medications may include:
1. anti-‐nausea medications (also called anti-‐emetics) 2. medications used to prevent infusion reactions during IV administration of cancer
medications. 3. IV fluids to promote elimination of the medication or if a patient becomes dehydrated
due to vomiting or diarrhea 4. corticosteroids (also called steroids) may be used as an anti-‐nauseant, to prevent water
retention associated with certain cancer medications, to reduce swelling or even as an anti-‐cancer agent
5. antibiotics or antivirals may be used to prevent infections associated with some cancer treatments
6. medications to treat or prevent diarrhea or constipation associated with some cancer medications or pain medications. These may be prescription or non-‐prescription medications.
7. medications used to increase white blood cells after cancer medications are given 8. medications used to treat blood clots. Blood clots can occur as a result of having cancer,
or from the treatment of cancer. Cancer Treatment Protocols Treatment protocols are determined by the type of cancer, stage of cancer, goal of treatment (cure or disease control), other chronic diseases or conditions that the patient has as well as other patient-‐specific needs. Treatments given after surgery or removal of cancer are used to reduce the chance of the cancer coming back (relapse). These treatments are referred to as “adjuvant”. If the cancer has spread or is not able to be removed by surgery, the goal may be to shrink or control the
Learn to be Safe – Medication Safety. A Guide for Pharmacists Appendix D – Supplemental Topic: Cancer Medications in the Home
October 15, 2013 3
tumour growth. These treatments may be referred to as metastatic or palliative. Treatments given to shrink the tumour before surgery are called “neo-‐adjuvant”. Cancer treatment protocols are referred to as “regimens”. This is usually a combination of several cancer medications as well as supportive care medications given on a pre-‐defined treatment schedule. Medications may be given orally, by intravenous (IV) or a combination of both oral and IV medications. Each time the scheduled medications are given is called a cycle. Blood test results and side effects are assessed before each cycle. The results of these tests help to determine if the patient will go on for the next cycle of medications. Sometimes dose adjustments are made, depending on organ function, blood tests or side effects. Changes occur frequently, and it is therefore imperative that prescriptions are only filled for the quantity of medication required for one cycle. Refills should not be permitted on cancer medications. Patients often receive three or four cycles of a cancer treatment before a response is evaluated with CT scans or other tests. Treatment schedules are often complex, and it is important that patients understand when to take medications at home in relation to any treatments administered at the cancer centre. Medication calendars may be provided at the cancer centre, pharmacy or even put together at home using a standard calendar to help patients follow complex treatment schedules. Some medications included in various treatment schedules may be used in dosages exceeding or different from dosages printed on the drug manufacturer’s labels or packaging material. It is important that patients understand the correct dosage of each medication included in their treatment schedule. If medication dosages or instructions on how or when to use each medication is unclear, patients need to feel comfortable in asking their cancer specialist, nurse or pharmacist to review their individual treatment schedule. Adverse Effects All medications have the potential to cause unwanted or adverse effects. Cytotoxic chemotherapy medications commonly cause a decrease in white blood cells and/or platelets, nausea/vomiting/diarrhea and hair loss. These adverse effects occur because chemotherapy medications kill rapidly dividing cells in the body which include both cancerous cells and healthy cells. Blood cells (in the bone marrow), cells in the gastro-‐intestinal tract and hair follicles are all rapidly dividing healthy cells in the body. Patients need to understand that not all chemotherapy medications cause the same severity of adverse effects. It is important for patients to know what the expected adverse effects of their individual treatment will be.
Learn to be Safe – Medication Safety. A Guide for Pharmacists Appendix D – Supplemental Topic: Cancer Medications in the Home
October 15, 2013 4
Targeted Therapies often cause very different adverse effects than cytotoxic chemotherapy medications. These can include skin rashes, sun sensitivity, diarrhea, changes in blood pressure or heart function. Hormonal and Immunotherapies cause adverse effects associated with the specific process in the body that is altered and depending on the function of that hormone or immune component. Sometimes, it may be difficult for patients to differentiate between symptoms of the cancer, adverse effects from the medications they are receiving, or symptoms of another illness. It may be helpful for patients to write down symptoms they experience such as fever, severity of nausea or vomiting or any other unusual feelings on a calendar. This information can then be provided to their healthcare providers at each visit to help determine whether their treatment needs to be modified. Patients need to feel comfortable in contacting their cancer specialist, nurse or pharmacist or other healthcare provider whenever they have concerns or questions about the symptoms they are experiencing. Patients often believe that cancer medications taken orally have less adverse effects or are safer however, this is not correct. Cancer medications have the potential to cause adverse effects because of the specific drug’s effect on cells in the body and this effect is the same whether the medication is taken orally, by IV or subcutaneous injection. All dosage forms of a cancer medication need to be handled with the same level of care and administered according to the dose and schedule prescribed. Drug Interactions Drug interactions can occur between prescription, over-‐the-‐counter or non-‐prescription medications, vitamin and mineral products, herbal or other natural products, and with specific foods or alcohol. This includes cancer medications and supportive care medications. Some drug interactions can be harmful while other drug interactions may reduce the effectiveness of treatment. Some drug interactions require that a different medication be prescribed while other drug interactions may be managed with closer monitoring or dosage adjustments. It is important that all members of a patient’s healthcare team are aware of all medications that a patient may be receiving so that drug interactions can be identified and dealt with appropriately. In the situation of a patient receiving cancer medications from a cancer specialist and other medications from a family physician, there must be a heightened awareness of the potential for drug interactions to occur. Working with their pharmacist, patients can play a vital role in keeping all of their healthcare providers informed about all of the medications, vitamins and other natural health products they may be taking.
Learn to be Safe – Medication Safety. A Guide for Pharmacists Appendix D – Supplemental Topic: Cancer Medications in the Home
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Some additional ways that patients can help to prevent harm from drug interactions include: using the same pharmacy for all their medication needs and consulting with a
pharmacist before selecting non-‐prescription medications, vitamin and mineral products and herbal or other natural products.
keeping a list of all of the medications taken and showing the list of medications to all healthcare providers. Pharmacists can help patients keep their medications lists up-‐to-‐date.
reading labels on medication vials and other containers and paying special attention to auxiliary labels.
Safe Prescriptions There are many factors that can contribute to errors in dispensing prescription medications to patients. Healthcare providers use various processes to help reduce this possibility. Some of these processes include:
avoiding the use of abbreviations when writing prescriptions. spelling out drug names clearly to differentiate between similar sounding medications. referring to medications by generic names, instead of brand names.
Patients can also help reduce the possibility that an error will occur when receiving their prescription medication by:
knowing the generic name (and brand name if applicable) of the medications they are receiving.
knowing what the tablets or capsules look like if they are oral medications. spelling out drug names when communicating with healthcare providers. checking the 5 Rs of a medication or prescription – right patient, right medication, right
dose, right time, right route – whenever receiving a drug in the hospital or clinic or when picking up a dispensed prescription at the pharmacy.
when something does not look or sound right, telling their pharmacist or other healthcare provider so that it can be re-‐checked to make sure it is correct.
Patient and Caregiver Safety in the Home With the emergence of many new oral cancer therapies, administration of these medications has moved from the traditional hospital setting to the comfort of the patient’s home. As many chemotherapy medications work by being toxic substances, even contact through touching or handling of these medications can be hazardous and harm patients, their family members or caregivers and therefore special handling measures are needed to prevent possible exposure. Everyone in the home needs to receive proper training on how to handle chemotherapy medications and body wastes that may be contaminated with these medications in order to keep the home safe.
Learn to be Safe – Medication Safety. A Guide for Pharmacists Appendix D – Supplemental Topic: Cancer Medications in the Home
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All cancer medications need to be properly labelled and stored securely and separate from other medications in the home. Patients, family members and caregivers need to know which cancer medications are hazardous and require special handling. Patients and caregivers should wear gloves when taking or administering these medications and make sure to wash their hands afterwards to prevent exposure. Tablets should not be split or crushed and capsules should not be opened as this may lead to inhalation of the powder from these hazardous medications. If a patient is having difficulty swallowing a cancer medication, the pharmacist or healthcare provider at the cancer clinic will be able to provide advice on other ways to help swallow the medication. As is the case with all unwanted, unused or expired medications in the home, it is important to immediately take unwanted cancer medications to the pharmacy for safe disposal. When a patient is receiving cancer medications, small amounts of the medications can be found in all of the patient’s bodily fluids and the medications are eliminated from the body in the urine and feces. Therefore, special handling precautions are also needed for clean-‐up and disposal of a patient’s contaminated waste. Patients should cover toilets before flushing and caregivers should wear gloves when cleaning up any bodily fluids including vomit. Soiled laundry should also be handled with gloves and washed separately from other clothes. Any soiled surfaces should be cleaned with soap and rinsed with large amounts of water while wearing gloves. Upon exposure to either medication or contaminated waste, the caregiver should wash the affected area with soap and running water as soon as possible and seek medical attention if necessary. For additional information regarding the safe management of cancer medications in the home, patients may find the handout prepared by CancerCare Manitoba helpful. This handout can be found at the end of this Appendix.