Transcript Pharmacy 332KB PPT - Migraine in Primary Care Advisors

MIGRAINE IN PRIMARY CARE ADVISORS
Development of pharmacist guidelines for
migraine management
Overview
• Review of the MIPCA guidelines for
migraine management
• Customisation of the MIPCA guidelines
to produce pharmacy guidelines
• Discussion of prescription-only acute
migraine drugs (POM) switching to
pharmacy prescription (P)
• Affiliation of MIPCA with the RPS
The MIPCA guidelines for migraine
management in primary care
Overall diagram for migraine
management
Management individualised
for each patient
Consultation
•Specific
consultation
•Treatment
history
•Patient
education,
counselling
and
commitment
Diagnosis
•Screen for
headache type
• Differentiate
migraine from
other
headaches
Assess
severity
•Attack frequency
and pain severity
•Impact on
patient’s life
(MIDAS / HIT)
•Non-headache
symptoms
•Patient factors
Treatment
plan
•Establish goals
•Behavioural
therapy
•Acute therapy
•Possible
prophylactic
therapy
•Complementary
therapy?
Follow-up
Assess outcome
of therapy
Processes
• First consultation
–
–
–
–
–
–
Screening
Patient education and commitment
Diagnosis
Assessment of illness severity
Tailoring management to the needs of the individual patient
Prescribe only treatments that have evidence base for
effectiveness
• Pro-active long-term follow up
– Monitor success of therapy and modify treatment if
necessary
• Team approach to care
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
Screening procedures
Taking a careful history is essential
– Use of a headache history questionnaire is
recommended
• Patient education
– Advice, leaflets, websites and patient
organisations
• Patient commitment
– Patients to take charge of their own management
– Effective communication between patient and
physician
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
Headache diagnosis
• MIPCA proposal: a simple screening
questionnaire to distinguish between
common headache subtypes
• Hypothesis: any episodic, high-impact
headache can be given a default
diagnosis of migraine
Dowson AJ et al. Headache Care 2004;1:137-9
Four-item questionnaire
A. Exclude sinister headaches
New-onset, acute headaches
associated with other symptoms
– e.g. rash, neurological deficit, vomiting,
pain/tenderness, accident/head injury,
infection, hypertension
– Neurological change/deficit does not
disappear when the patient is pain-free
between attacks
Dowson AJ et al. IJCP 2003;57:492-507
Four-item questionnaire
1. What is the impact of the headache on
the sufferer’s daily life?
(screens for migraine/chronic
headaches and episodic TTH)
•
Impact questionnaires, e.g. MIDAS or
HIT, are useful
Dowson A. Curr Med Res Opin 2001;17:298-309
Four-item questionnaire
2. How many days of headache does the
patient have every month?
(screens for migraine and chronic
headaches)
> 15 = chronic headaches
 15 = migraine
Headache Classification Committee of the IHS.
Cephalalgia 2004;24 (Suppl 1):1-160
Four-item questionnaire
B. Consider short-lasting chronic
headaches
15 min - 3 hours may be cluster
headache
Dowson AJ, Cady RC. Rapid Reference to Migraine 2002
Four-item questionnaire
3. For patients with chronic daily headache,
on how many days per week does the
patient take symptomatic medication?
(screens for medication*-dependent
headaches)
 2 = medication dependent
< 2 = not medication dependent
* analgesics, ergots and triptans
Silberstein SD, Lipton RB. Curr Opin Neurol 2000;13:277-83
Olesen J. BMJ 1995;310:479-80
Four-item questionnaire
4. For patients with migraine, does the
patient experience reversible sensory
symptoms associated with their
attacks?
(screens for migraine with aura and
migraine without aura)
Headache Classification Committee of the IHS. Cephalalgia
2004;24 (Suppl 1):1-160
Exclude sinister
Headache (<1%)
ETTH
(40-60%)
low
Patient presenting
with headache
Q1. What is the impact of the headache
on the sufferer’s daily life?
High
Migraine/CDH
 15
> 15
CDH (5%)
Q2. How many days of headache
does the patient have every month?
Consider short-lasting
Headaches (<1%)
Migraine (10-12%)
Q3. For patients with chronic daily
Q4. For patients with migraine, does the
headache, on how may days per week
patient experience reversible sensory
does the patient take symptomatic medications?symptoms associated with their attacks?
<2
2
Yes
No
Medication
Not medication
Without aura
With aura
dependent
dependent
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
Management individualised for each
patient
Assess illness severity
• Attack frequency and duration
• Pain severity
• Impact on daily living
– MIDAS/HIT questionnaires
• Non-headache symptoms
• Patient factors
– History, preference and other illnesses
Silberstein SD et al. Neurology 2000; www.neurology.org
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
Assessment of severity
Mild-to-moderate migraine Moderate-to-severe
migraine
Headaches mild-tomoderate in intensity
Headaches moderate or
severe in intensity
Non-headache symptoms
not severe in intensity
Significant non-headache
symptoms, possibly
severe
Low headache impact:
MIDAS Grade I or II
HIT Grade 1 or 2
High headache impact:
MIDAS Grade III or IV
HIT Grade 3 or 4
Silberstein SD et al. Neurology 2000; www.neurology.org
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
Provision of treatment plan tailored
to the individual’s needs
•
•
•
•
Evidence-based medicine (Duke database)
suggests:
Behavioural therapy recommended for all
Acute therapy recommended for all
Prophylactic therapy recommended for
certain patients
Complementary therapies may be useful as
adjunctive therapy
Silberstein SD et al. Neurology 2000; www.neurology.org
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
Individualising care – behavioural and
physical therapy
Duke recommended therapies
• Behavioural:
–
–
–
–
Biofeedback and relaxation
Stress reduction
Avoidance of triggers
Food restriction diets?
• Physical
– Cervical manipulation
– Massage
– Exercise
Silberstein SD et al. Neurology 2000; www.neurology.org
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
Individualising care – acute medications
• Goals: to rapidly relieve the headache and
other symptoms, and permit the return to
normal activities within 2 hours
• Acute medications should be provided for all
patients
• Strategy: individualised care, patients have a
portfolio of medications to treat attacks of
differing severities, and have access to
rescue medications if the initial therapy fails
Silberstein SD et al. Neurology 2000; www.neurology.org
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
Tailored care for migraine
Migraine
diagnosis
Stratified care
Severity
assessment
Migraine attack
Mild to moderate migraine
Moderate to severe migraine
Initial therapy
Initial therapy
If unsuccessful
Rescue
Rescue
Staged care
Dowson AJ et al Int J Clin Pract 2003;57:492-507
Acute medications: Duke
recommended treatments (UK)
• Mild-to-moderate migraine
• Initial therapies
– Paracetamol, Aspirin or NSAIDs (high
doses)
– Aspirin/paracetamol plus anti-emetics
– Use if possible before headache starts
• Rescue medications
– Oral triptans
– Use for any headache severity
Silberstein SD et al. Neurology 2000; www.neurology.org
Acute medications: Duke
recommended treatments (UK)
• Moderate-to-severe migraine
• Initial therapies
– Oral triptans (tablet/ODT)
– Use after the headache starts, if possible when it
is mild in intensity
• Rescue medications
– Second dose, alternative oral triptan, nasal spray
or subcutaneous triptans
– Symptom control
• Issues with triptans: cost, safety and
tolerance
Silberstein SD et al. Neurology 2000; www.neurology.org
Assess migraine severity
Impact
Attack frequency and duration
Pain severity
Non-headache symptoms
Patient history and preferences
Intermittent
Mild-to-moderate
Evaluation
Intermittent
Moderate to severe
Initial treatment
Behavioural therapy
Analgesic-based therapies
Rescue
Behavioural therapy
Appropriate triptan
Failure
Failure
Success
Behavioural therapy
Analgesic-based therapies
Success
Rescue
Behavioural therapy
Appropriate triptan
Lipscombe S et al. Headache Care 2004;1:147-57
Second dose /
alternative
formulation triptan
Symptomatic
treatment
Failure
Prophylaxis /
Referral
Follow-up treatment
Rescue and follow-up medications
Initial medication
Rescue or follow-up
medications
Analgesic-based medications
Try a second dose
Triptan tablets*
Oral triptans*
Try a second dose
Alternative triptan tablets
Nasal spray or sc triptan
Nasal spray triptan
Try a second dose
sc sumatriptan
sc sumatriptan
Try a second dose
Symptomatic treatment
* Conventional tablet or ODT
Lipscombe S et al. Headache Care 2004;1:147-57
Caveats on triptan use
• Most patients are effectively treated with an oral
triptan
– Differences between the oral triptans are small and of
uncertain clinical significance
• Patients with unpredictable or fast-onset attacks
may benefit from ODT or nasal spray formulations
• Patients with severe attacks and/or with vomiting
may benefit from nasal spray or subcutaneous
formulations
• Subcutaneous sumatriptan is an effective rescue
medication
• Beware contraindications (age; pregnancy; heart
disease)
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
Individualising care – prophylactic
medications
• Goals: to reduce headache frequency by
>50%
• Prophylactic medications should be
provided:
– For patients with frequent, high-impact migraine
attacks (4/month)
– Where acute medications are ineffective or
precluded by safety concerns
– For patients who overuse acute medications
and/or have CDH
• However: acute medications should also be
provided for breakthrough attacks
Silberstein SD et al. Neurology 2000; www.neurology.org
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
Prophylactic medications: Duke
recommended treatments (UK)
• First-line medications:
– Beta-blockers (propranolol, metoprolol,
timolol, nadolol)
– Anticonvulsants (topiramate, valproate*)
– Antidepressants* (amitriptyline)
• Second-line medications
– Serotonin antagonists (pizotifen,
methysergide, cyproheptadine)
– Poor efficacy / high side effects
* Not licensed for migraine in the UK
Silberstein SD et al. Neurology 2000; www.neurology.org
Individualising care – complementary
therapies
Effective therapies
•
•
•
•
•
•
Feverfew*
Magnesium*
Vitamin B2*
Butterbur*
Acupuncture*
Low-dose aspirin*
• However: use only accredited complementary
practitioners
* Not licensed for migraine in the UK
Dowson AJ, Cady RC. Rapid Reference to Migraine 2002
Assess migraine severity
Impact
Attack frequency and duration
Pain severity
Non-headache symptoms
Patient history and preferences
Intermittent attacks
Evaluation
Suspect CDH
Frequent attacks
Initial treatment
Acute treatments
Prophylaxis
Suspect CDH
Success
Taper /
withdraw
Acute treatments
Failure
Treat for ≤ 6 months
Suspect CDH
Try second prophylactic drug
Lipscombe S et al. Headache Care 2004;1:147-57
Refer
Follow-up treatment
Follow-up procedures
• Instigate proactive long-term follow-up
procedures
• Monitor the outcome of therapy
– Headache diaries
– Impact questionnaires (MIDAS/HIT)
• Make appropriate treatment decisions
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
Follow-up treatment decisions
• Acute medications
– Patients effectively treated should continue with the original
therapy
– Patients who fail on original therapy should be offered other
therapies
• Prophylactic medications
– Ensure medication is provided for an adequate time period
at an adequate dose (up to 3 months)
– If effective, treatment can continue for 6 months, after which
it may be stopped
– If ineffective, another prophylactic medication may be tried
– Usual contraindications apply
• Patients refractory to repeated acute and
prophylactic medications should be referred to a
specialist
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
Implementation of guidelines
• Primary care headache team
– GP, practice nurse, ancillary staff and practice
pharmacist (core team)
– Community pharmacist
– Community nurses
Associate team
– Optician
members
– Dentist
– Complementary practitioners
– Specialist physician (additional resource)
– And . . . The patient
• Model for NSF in chronic diseases
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
Primary care
Community nurse
Optician
Pharmacist
Practice
nurse
Specialist
care
Ancillary
staff
Primary care
physician
Physician with expertise
in headache:
GP; PCT; specialist
Dentist
Complementary
practitioner
Patient
Associate team
Copyright MIPCA 2002,
all rights reserved
Core team
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
New MIPCA algorithm
Initial consultation and
treatment
Copyright MIPCA 2002, all rights reserved
Detailed history, patient education/commitment
Diagnostic screening and differential diagnosis
Assess illness severity
Attack frequency and duration
Pain severity
Impact (MIDAS or HIT questionnaires)
Non-headache symptoms
Patient history and preferences
Intermittent
mild-to-moderate migraine
(+/- aura)
consultation
Intermittent
moderate-to severe migraine
(+/- aura)
Behavioural/complementary therapies
Paracetamol/Aspirin/NSAID (large dose)
Aspirin/paracetamol plus anti-emetic
Initial
Rescue
Initial treatment
Oral triptan
Rescue
2nd dose/alternative oral triptan/
Nasal spray/subcutaneous
triptan
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
New MIPCA algorithm
Follow-up consultation and
treatment
Copyright MIPCA 2002, all rights reserved
Oral triptan
Paracetamol/Aspirin/NSAID (large dose)
Aspirin/paracetamol plus anti-emetic
If unsuccessful
Oral triptan
Initial
Initial
treatment
treatment
Rescue
Follow-up treatment
2nd dose/Alternative oral triptan
Nasal spray/sc triptan/
Symptomatic
If unsuccessful
Frequent headache
(i.e.  4 attacks per month)
Migraine
Consider prophylaxis +
acute treatment for
breakthrough migraine
attacks
If unsuccessful
Chronic daily
headache (CDH)?
If
management
unsuccessful
Consider referral
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
‘10 Commandments’ of
headache management
Screening/diagnosis
1. Almost all headaches are benign and
should be managed in general
practice
(However, monitor for sinister
headaches and refer if necessary)
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
Copyright MIPCA 2002, all rights reserved
Screening/diagnosis
2. Use questions / a questionnaire
assessing impact on daily living for
diagnostic screening and to aid
management decisions
(Any episodic, high impact headache
should be given a default diagnosis of
migraine)
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
Copyright MIPCA 2002, all rights reserved
Management
3. Share migraine management between
the doctor and the patient
(The patient taking control of their
management
and
the doctor providing education and
guidance)
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
Copyright MIPCA 2002, all rights reserved
Management
4. Provide individualised care for
migraine and encourage patients to
treat themselves
(Assess migraine severity: Migraine attacks should
be divided into mild-to-moderate and moderate-tosevere intensity on the basis of impact and
symptom intensity)
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
Copyright MIPCA 2002, all rights reserved
Management
5. Follow-up patients, preferably with
migraine diaries
(Invite the patient to return for further
management and apply a proactive
policy)
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
Copyright MIPCA 2002, all rights reserved
Management
6. Adapt migraine management to
changes that occur in the illness and
its presentation over the years
(e.g. migraine may change to chronic
daily headache over time)
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
Copyright MIPCA 2002, all rights reserved
Treatments
7. Provide acute medication to all migraine
patients and recommend it is taken as early
as possible in the attack
(Triptans are the most effective acute
medications for migraine. Avoid the use of
drugs that may cause analgesic-dependent
headache, e.g. regular analgesics, codeine
and ergotamine)
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
Copyright MIPCA 2002, all rights reserved
Treatments
8. Prescribe prophylactic medications to
patients who have four or more
migraine attacks per month or who
are resistant to acute medications
(First-line prophylactic medications
are beta-blockers, sodium valproate
and amitriptyline)
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
Copyright MIPCA 2002, all rights reserved
Treatments
9. Monitor prophylactic therapy regularly
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
Copyright MIPCA 2002, all rights reserved
Treatments
10. Ensure that the patient is comfortable
with the treatment recommended and
that it is practical for their lifestyle
and headache presentation
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
Copyright MIPCA 2002, all rights reserved
Production of pharmacy guidelines
for migraine management
Screening and information provision
•
•
•
•
Pharmacists can provide advice,
leaflets, and information on websites
and patient organisations
Take advantage of outputs from MAA
and MIPCA
Patients may find it easier to talk to
the pharmacist than to their GP
Role in diagnostic screening
– MIPCA / MAA checklist
Role in diagnostic screening
•
MIPCA and MAA have developed a
new checklist to aid headache
diagnosis
–
–
–
–
–
•
Migraine
TTH
CDH
MOH
Other headaches
Aim is to aid diagnosis at first point of
medical contact
MIPCA / MAA diagnostic checklist
1.
2.
3.
4.
5.
6.
7.
8.
Has the pattern of your headaches been generally stable (i.e.
no change or only small changes in frequency and severity)
over the past few months? (Yes / No)
Have you had headaches for longer than 6 months? (Yes / No)
Are you aged between 5 and 50 years? (Yes / No)
Does the headache interfere to a noticeable extent with your
normal daily life (work, education and social activities)? (Yes /
No)
On average, how many days with headache do you have per
month? (Less than 1 / 1 / 1–4 / 5–15 / 15–30 / Every day)
On average, how long do your headaches last? (Less than 15
minutes / 15 minutes to 1 hour / 1–2 hours / 2–4 hours / over 4
hours / My headaches are always there)
On average, on how many days per week do you take
analgesic medications? (Less than 1 / 1 / Up to 2 / 2 or more /
Every day)
Do changes in your senses (sight, taste, smell or touch) occur
in the period immediately before the headache starts? (Yes /
No)
MIPCA / MAA diagnostic checklist
1. Has the pattern of your headaches been
generally stable (i.e. no change or only
small changes in frequency and severity)
over the past few months? (Yes / No)
2. Have you had headaches for longer than 6
months? (Yes / No)
3. Are you aged between 5 and 50 years? (Yes
/ No)
‘Yes’ = likely benign headache
‘No’ = check for possibility of sinister headache
MIPCA / MAA diagnostic checklist
4. Does the headache interfere to a
noticeable extent with your normal
daily life (work, education and social
activities)? (Yes / No)
‘Yes’ = high impact (i.e. migraine or CDH)
‘No’ = low impact (i.e. TTH)
MIPCA / MAA diagnostic checklist
5. On average, how many days with
headache do you have per month?
(Less than 1 / 1 / 1–4 / 5–15 / 15–30 /
Every day)
Up to 15 = episodic headaches (i.e.
migraine)
Over 15 = chronic headaches (i.e. CDH
or cluster)
MIPCA / MAA diagnostic checklist
6. On average, how long do your
headaches last? (Less than 15 minutes
/ 15 minutes to 1 hour / 1–2 hours / 2–4
hours / over 4 hours / My headaches
are always there)
Under 15 minutes = primary stabbing headache or
cluster variants?
15 – 60 minutes = possible cluster headache
Over 2 hours = migraine / CDH
Constant headaches = CDH
MIPCA / MAA diagnostic checklist
7. On average, on how many days per
week do you take analgesic
medications? (Less than 1 / 1 / Up to 2
/ 2 or more / Every day)
Up to 2 = no MOH
2 or more = MOH
MIPCA / MAA diagnostic checklist
8. Do changes in your senses (sight,
taste, smell or touch) occur in the
period immediately before the
headache starts? (Yes / No)
‘Yes’ = migraine with aura
‘No’ = migraine without aura
Checklist validation
•
•
•
Study in 80+ headache sufferers
completing the checklist
Patients completed checklist and
diagnosis compared with those from
pharmacist, GP and headache
specialist (gold standard)
Initial results indicate
– Diagnosis from checklist was more
accurate than that from pharmacist
– When pharmacists used the checklist
their diagnosis was as accurate as that of
the GP
Initial assessment of the patient
•
Obtain diagnosis from the checklist
– Possible migraine
•
Ask about illness severity
– Mild-to-moderate
– Moderate-to-severe
•
•
•
Ask about current medications taken
Ask about co-morbidities
Treatment decision
– Provide OTC medications
– Recommend GP consultation
Pharmacy algorithm for initial
assessment
Patient visits
pharmacy
Completes checklist
ETTH
Migraine
Mild-tomoderate
Treat with OTC
medications
Chronic
Headache*
Possible
sinister
ModerateTo-severe
Refer to the GP
* = CDH, MOH, cluster headache
Pharmacy algorithm for initial
assessment
•
Pop-up menus at each stage
–
–
–
–
Diagnostic checklist
Choice of medications for each diagnosis
Co-morbidities
Drug interactions
Choice of acute medications
•
Only sell migraine medications that have objective
evidence of efficacy
–
–
–
Aspirin or Paracetamol (high dose)
NSAIDs (e.g. ibuprofen – high dose)
Combination medications
•
•
•
•
•
•
Aspirin / Paracetamol
Aspirin / Codeine
Aspirin / Paracetamol / Caffeine (Anadin Extra®)
Paracetamol / Codeine (e.g. Solpadeine, Migraleve)
Sumatriptan 50 mg tablets (only to appropriate patients)
Recommend:
–
–
Take analgesics before the headache starts if possible
Take sumatriptan as early as possible after headache onset
(when mild)
Caveats with acute medications
•
Check if the patient has used the drug
before
–
–
•
Check on the patient’s consumption of
analgesics
–
–
•
If effective, use again
If ineffective, use another, or refer to GP
Beware of CDH if current use on ≥ 2 days/week
Warn of dangers of overusing codeine
Check on co-morbidities and concurrent
medications
–
Current good practice in pharmacies
Choice of preventive medications
•
Lifestyle options
– Stress reduction
– Avoidance of triggers
•
Behavioural and physical therapies
– Relaxation / biofeedback
– Cervical manipulation / acupuncture
– Massage / exercise
•
Complementary therapies
–
–
–
–
Feverfew
Magnesium 200-600 mg
Vitamin B2 400 mg
Butterbur
Caveats with preventive medications
•
•
•
•
Advise that treatment needs to be
taken every day
Advise that the patient may not see an
improvement for several weeks
Check that the patient has acute
medications for breakthrough attacks
Some complementary medications
may not be found in pharmacies, but in
health food shops
– Education may be required for
pharmacists as to appropriate use
Follow up
•
•
Ask the patient to return after 1 month
Check effectiveness of acute medications
–
–
–
•
Check effectiveness of preventive
medications
–
–
•
Patients effectively treated should continue with
the original therapy
Patients who fail on original therapy can be
offered other therapies
Refer to GP if analgesics are clearly failing
Encourage patients to continue with therapy
Refer to GP if treatment is clearly failing
And . . . Be a mentor to the patient after they
have consulted with the GP
Switching of acute migraine
medications from POM to P status
Context
•
There is currently interest in the possibility
of switching some acute migraine
medications from POM to P status
–
•
Especially the triptans
Politicians and the self-medication industry
are lobbying for OTC switching
–
Fuelled by OTC switch of simvastatin in the UK
Scrip No. 2960, June 11 2004; p 6
Possible drugs involved
•
NSAIDS
– Voltarol Rapid
– Clotam rapid
•
Analgesic-anti-emetic combinations
– Domperamol
– Paramax
– Migramax
•
Triptan tablets
– Not nasal spray or injection formulations
Issues involved - 1
•
The migraine diagnosis must be
confirmed
– MIPCA – MAA checklist?
– GP diagnosis?
•
The patient should be a ‘typical’
migraine sufferer
–
–
–
–
Attacks impact on daily activities
Sufferers feel well between attacks
Age range 18-65 y
Exclude sufferers with frequent attacks
(≥ 4 per month)
Issues involved - 2
•
Current migraine medications should
be reviewed
–
–
–
–
–
•
Simple and combined analgesics
Opiates
Triptans
Ergots
Preventive medications
Review patient experience of efficacy
and safety
Issues involved - 3
•
Co-morbidities and relevant
medications should be reviewed
–
–
–
–
–
–
–
Risk factors for cardiovascular disease
Liver / kidney problems
Diabetes
Epilepsy
Psychiatric illness
Pregnancy / breast-feeding
Smoking status
Contraindications to medications:
NSAIDs
Drop-down menus
• Asthma / anti-inflammatory allergy
• Current or history of GI upset (e.g.
ulcer, bleeding)
• Cardiovascular disease
• Liver disease
• Kidney disease
• Pregnancy
• Breast-feeding
Contraindications to medications:
Analgesic-anti-emetic combinations
Drop-down menus
• Migramax (not recommended for OTC
as contains metoclopramide)
• Domperamol
–
–
–
–
Severe liver and kidney disease
Pregnancy
Lactation
Use of dopamine agonists
Contraindications to medications:
Triptans
Drop-down menus
• Existing cardiovascular disease or
presence of risk factors
• Hypertension
• Liver and kidney disease
• Pregnancy
• Breast-feeding
• Use of SSRIs
Discussion
•
Are pharmacists comfortable with
these POM to P switches?
– NSAIDs? (Yes)
– Analgesic-anti-emetic combinations?
(Domperamol – Yes; Migramax – No)
– Triptans? (Yes)
•
•
What needs to be done to implement
these changes? (educational
programme)
Can we develop an algorithm for
switching? (clear instructions
required)
Migraine treatment algorithm
Patient
Aspirin / NSAID
Initial treatment
Lifestyle options
Behavioural therapy
If initial treatment unsuccessful
Lifestyle options
Combination analgesic or
Behavioural
Sumatriptan 50 mg
therapy
Preventive
therapy
Alternative
preventive
therapy
If treatment unsuccessful
Refer to GP
Follow-up treatment
The role of the pharmacist in the
practice headache team
•
•
Act as a first point of contact for
patients with headache
Screen for diagnosis and medical need
– Treat appropriate patients with available
OTC medications
– Refer appropriate patients to the GP
•
•
Act as an extra advice and information
resource after patients have consulted
with the GP
Take part in practice activities
– Meetings
– Locality-based training
Primary care
Community nurse
Optician
Pharmacist
Practice
nurse
Specialist
care
Ancillary
staff
Primary care
physician
Physician with expertise
in headache:
GP; PCT; specialist
Dentist
Complementary
practitioner
Patient
Associate team
Copyright MIPCA 2002,
all rights reserved
Core team
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
Affiliation of MIPCA with the RPS
•
Discussion between MIPCA and
Christine Glover (CPPE)