No more dispensing ‘in the dark’

With the coming requirement for pathology providers to upload all test results to My Health Record, pharmacists will be able to ‘see’ patients more clearly.

Until this year, many pathology test results were not visible to pharmacists, patients or indeed anyone other than the referring doctor. They were generally not uploaded to My Health Record (MHR) by pathology providers, who instead sent them directly only to prescribers.

This is about to change. In the coming months, following federal government intervention, pathology providers will be required to upload pathology to MHR by default. This will be visible to all health professionals in MHR – including pharmacists.

It is hoped this will mean pharmacists will no longer have to dispense ‘in the dark’, blind to critical information required to determine whether a medicine is ‘safe and therapeutically appropriate’.

AP asked three pharmacists how using pathology results has already made a difference to the clinical decisions they make in supporting their patients to use medicines safely and effectively.

Case 1

Lee McLennan MPS Owner LiveLife Pharmacy, Cannonvale, Queensland

Mrs B, aged 58, was referred to me for a HMR due to instability with blood pressure control. She had been commenced on atenolol 50 mg daily about 6 months ago, and had recently been increased to 50 mg twice daily to reduce blood pressure to < 130/80 mmHg.

Her medicines:

• atenolol 50 mg twice daily
• metformin XR 500 mg at night
• thyroxine 50 mcg each morning
• paracetamol MR 665 mg 2 three times daily
• rosuvastatin 10 mg at night
• meloxicam 15 mg daily

Mrs B is a retired schoolteacher and lives with her husband. They’d recently moved from Victoria to the warmer Whitsundays.

Using dispense history, records provided by her prescriber and also physical reconciliation, I determined she adhered to her medicine regimen. I wanted to double-check this, as she presented several brands of her atenolol medication. However, this turned out to be a result of recent travel, and she was confident with taking them as prescribed.

Her blood pressure at the HMR was 153/97 mmHg.

I considered adding an ACEI or ARB. An ACEI would have reno-protective effects, slowing the progression of diabetic kidney disease in the future. In the HMR report, I recommended commencing perindopril 5 mg daily, titrating up to 10 mg if required. The prescriber then initiated Mrs B on 5 mg and conducted bloods to confirm renal function and electrolytes prior to ACEI commencement, with a review to be conducted in 2 weeks’ time. 

The review showed an increase in serum creatinine of 35% over baseline and a reduction in eGFR (estimated glomerular filtration rate) of 29%. On further discussion with the prescriber, we agreed to withhold meloxicam (NSAID). Meloxicam had been continued after a knee replacement 2 years prior, without review since. Mrs B confirmed her pain levels had significantly decreased and she was willing to trial ceasing meloxicam, particularly with the potential impact on her serum creatinine levels.

In terms of full-scope practice, having access to blood level results is crucial, particularly with patient participation in the CVD risk-reduction program.

For a prescribing pharmacist to fully assess a patient and provide optimal outcomes, it will be important to have these details so we can determine appropriateness of therapy. 

Case 2

Dr Natalie Soulsby FPS, Adv Prac Pharm Head of Clinical Excellence, Embedded Health Solutions Senior Consultant Pharmacist, Clinical Pharmacology, Royal Adelaide Hospital

A 54-year-old gentleman attended his regular clinic appointment in the hospital.

He was very excited having recently started a new job, which was going well.

He was HIV-positive and had been on antiretroviral therapy since his mid-20s. With a reaction to abacavir in the past, his current treatment was with bictegravir/emtricitabine/tenofovir, and he had been stable on this for the last 2 years.

He also had hyperlipidaemia, hypertension, was hypothyroid and took rosuvastatin, candesartan and levothyroxine. With difficulty controlling pain, he had started on medicinal cannabis (both CBD and THC) and felt this was helping with his pain.

During my conversation with him, he complained of increasing fatigue and the need for daily naps and was worried that this might affect his new job, which involved shift work. He wondered if it was connected with his diagnosis or his medicines or something else. When I asked him about sun exposure, he admitted he didn’t spend as much time outdoors as he used to and he always wore sunscreen.

I asked about recent blood tests, as his last available results on our hospital system did not show anything abnormal, nor did they include vitamin D. He said he had some done a few weeks ago by a different pathology group, which did not automatically upload onto our system.

I asked his permission to access My Health Record to see if his recent pathology results had been uploaded into the system and they had.

On checking his results, I saw that he had a recent vitamin D level of 18 nmol/L (reference range 50–200 nmol/L). I thought that would explain his symptoms.

We started him on vitamin D supplements at a dose of 5,000 IU per day for 3 months and then to reduce to 1,000 IU per day after that. I booked him in for a follow-up appointment in 3 months’ time. On his return, he was happy to report that his energy levels had improved, and he no longer needed daytime naps.

Case 3

Joanne Gross MPS MMR-Credentialed and Senior Specialist Pharmacist – Quality Use of Medicines, Department of Health, Tasmania

Mr S, an 80-year-old male reported that he only took the night-time dose of his twice daily dabigatran about half the time. His GP wanted advice regarding how to safely swap to a different DOAC – maybe rivaroxaban due to its once-daily dosing.

The GP specifically wondered if a washout was needed during the transition. His history included atrial fibrilliation, CABG (1997), hypertension, dyslipidaemia, type 2 diabetes, CKD (Stage 2), fatty liver, BPH, diverticulosis and gout.

Medicines

• dabigatran 110 mg twice a day
• aspirin 100 mg each morning
• empagliflozin-metformin 12.5 mg-1,000 mg each morning
• irbesartan 300 mg each morning
• diltiazem MR 360 mg each morning
• furosemide 40 mg each morning
• ezetimibe-simvastatin 10 mg-40 mg each morning
• allopurinol 100 mg each morning
• pantoprazole 20 mg each morning
• colecalciferol 25 mcg each morning
• rosuvastatin 10 mg at night
• meloxicam 15 mg daily.
  

Pathology

The referral included pathology results from 3 months’ prior showing estimated glomerular filtration rate (eGFR) of  61 mL/min/1.73 m². However, Mr S had undergone a trans-urethral resection of a bladder tumour (TURBT) 1 week prior and My Health Record revealed pre-operative pathology results including an eGFR of 48 mL/min/1.73 m². Mr S reported ongoing frank haematuria, (bright red urine and  passing of large clots) 7 days post-TURBT.

I called the clinic to flag the ongoing frank haematuria with the clinic nurse so the GP could promptly review the patient.

Recommendations 

1. Switch dabigatran twice daily to rivaroxaban once daily to improve adherence. No overlap or ‘washout’ required. Commence rivaroxaban when next (morning) dose of dabigatran is due.² Monitor adherence. Poor adherence increases stroke risk. eGFR 1 week ago was 48 mL/min/1.73 m². Repeat electrolytes, urea and creatinine (EUC) prior to commencing rivaroxaban to inform dosing:

• a reduced dose of 15 mg once daily is recommended if eGFR remains below
  50 mL/min/1.73 m² and dilitiazem is continued.³ Diltiazem is a moderate CYP3A4 inhibitor and increases rivaroxaban levels.
• a dose of 20 mg once daily is recommended if eGFR re-stabilises above 50 mL/min/1.73 m², and diltiazem is changed to an alternative (e.g. amlodipine).³

2. Cease aspirin if bleeding continues. Evidence increasingly supports DOAC monotherapy in patients with AF and stable coronary artery disease (cardiologist advice might assist).³

3. To reduce lipids further, a swap to ezetimibe-rosuvastatin 10 mg-20 mg is recommended – the longer half-life of rosuvastatin enables efficacy with morning dosing.

4. Consider Shingrix vaccination. Mr S’s AIR history via MHR did not report varicella vaccinations. 

References

1. Pharmaceutical Society of Australia. Professional Practice Standards. 2023. At: psa.org.au/wp-content/uploads/2023/07/5933-Professional-Practice-Standards_FINAL-1.pdf
2. Leung LLK. Direct oral anticoagulants (DOACs) and parenteral direct-acting anticoagulants: dosing and adverse effects. UpToDate 2024. At: uptodate.com/contents/direct-oral-anticoagulants-doacs-and-parenteral-direct-acting-anticoagulants-dosing-and-adverse-effects
3. Australian Product Information. Xarelto [registered trad mark] (rivaroxaban). 2024. At: https://resources.bayer.com.au/resources/uploads/PI/file9466.pdf
4. Heart Foundation. Atrial fibrillation clinical guidelines. 2018. At: www.heartfoundation.org.au/for-professionals/atrial-fibrillation-for-professionals