Pharmacist

Side effects of drugs are often misdiagnosed as symptoms of another medical condition, and as a result, patients may be prescribed one or more drugs to treat the adverse drug reactions (ADRs). This is called a prescribing cascade. Prescribing cascades may contribute to unnecessary or potentially unsafe medication use. This has several risks, such as drug interactions, increased frequency or severity of further side effects, unnecessary drug costs, and poor medication adherence. Prescribing cascades can also impact a patient’s quality of life and lead to avoidable emergency room visits, hospital admissions and health system costs. Health practitioners should always question whether a new symptom or problem is a potential side effect of a current medication , especially in older adults, and avoid prescribing  or recommending  additional drug treatment until this possibility has been thoroughly investigated.

There is no evidence to support the use of low-dose codeine pain medication over non-opioid analgesics. Codeine also has  potential for abuse and dependence within a short time frame of regular or excessive use.  Non-prescription codeine products are often supplied in combination with non-opioid analgesics (i.e., NSAIDs and acetaminophen). In addition to concerns regarding codeine abuse and dependence, misuse of these codeine-containing combination analgesics may also result in serious adverse effects due to high doses of the non-opioid  analgesic component (ibuprofen, acetaminophen or ASA), which may include liver toxicity, gastric perforation, haemorrhage and peptic ulcer, renal failure, chronic blood loss anaemia and low blood potassium (with potential fatal heart and neurological complications), as well as the potential for allergic reactions in some populations (those with asthma). In addition, a high percentage of patients may not metabolize codeine to active morphine due to an altered CYP2D6 enzyme, which may increase the risk of adverse effects from codeine.

One in four Canadians over the age of 65  are prescribed 10 or more different medications.. With each new drug, the risk of adverse drug reactions and subsequent hospitalization of the patient increases. In order to ensure the safety and appropriateness of therapy, all health care practitioners should  assess to the therapeutic indication for a patient’s drug therapy and start or renew medication only once they have determined that the benefits of therapy outweigh the risks to the patient. Remember the acronym IESU -Indicated/ Effective/ Safety/ (Patient) Use.

Proton pump inhibitors (PPIs) are among the most commonly prescribed drugs in Canada, and many are becoming available as non-prescription medications. While generally safe and well-tolerated for short-term use/ as needed use in treating gastro-esophageal reflux disease (GERD), PPIs are often used longer than needed. Further, PPIs have been associated with a number of adverse effects which may increase with a patient’s age or long-term use though the causality of many of these adverse effects is uncertain. Some adverse effects associated with long-term use of PPIs include increased risk of fracture, Clostridium difficile infection and diarrhea, community-acquired pneumonia (CAP), vitamin B12 deficiency, and hypomagnesemia. Guidelines recommend short-term use of PPIs (e.g. < 8-12 weeks) for most patients treated for GERD or peptic ulcer disease. They also suggest regular attempts at deprescribing PPIs when patients do not have a valid indication for continued use. This might include reducing the dose, tapering and stopping, or switching to on-demand PPI use. These guidelines do not apply to patients with Barrett esophagus, severe esophagitis grade C or D, chronic NSAID/anticoagulant use with bleeding risk, a documented history of bleeding gastrointestinal ulcers,  or those on triple antithrombotic therapy, who have an indication for continued PPI use.

Between 2005 and 2012, the sedating properties of certain atypical antipsychotics have led to a 300% increase in their off-label use for insomnia. Guidelines report a lack of evidence of benefit for atypical antipsychotics for the treatment of insomnia and warn against their possible adverse effects, including weight gain, fall risk and metabolic disorders. While antipsychotics may be appropriate in some patients with insomnia when there is another indication for their use ( e.g., as adjunctive treatment in depression), the use of these medications as first-line therapy for insomnia is discouraged due to potential harm that outweighs their benefits  Deprescribing guidelines suggest that antipsychotics used for insomnia can be safely stopped with or without taper.

Benzodiazepines are commonly prescribed drugs in Canada for anxiety disorders and insomnia. Strong evidence shows that long-term use of benzodiazepines in  older persons is associated with tolerance, dependence and adverse effects, including sedation, impaired memory and cognition, falls, hip fractures, depression, and increased hospital admissions. Use in younger persons can lead to chronic dependence. Prescribing guidelines recommend exploring alternative non-pharmacological such as cognitive behavioural therapy for insomnia (CBT-I) prior to prescribing benzodiazepines for insomnia. If determined to be beneficial for the patient, benzodiazepines should not usually be prescribed for long-term use and discontinuation strategies should be built into the patient’s treatment plan, such as gradual dose tapering.

Before prescribing or recommending inhalers, providers should ensure a confirmed objective diagnosis of asthma and/ or COPD exists to reduce unnecessary inhaler use and patient exposure. When inhalers are indicated, consider patient-specific factors and preferences to determine if lower carbon intensive inhaler device(s) (Dry Powder Inhalers (DPIs), or soft-mist inhalers (SMIs)) is clinically appropriate as both are often preferred by patients and are as effective as MDIs. Once a device has been selected, ensure the patient is trained on proper inhaler device technique, and technique is reviewed intermittently, as inhaler education programs have shown to reduce exacerbation rates. Additionally, non-pharmacologic strategies (e.g. education, trigger avoidance, action plans) should also be included in airway management, as they not only improve patient outcomes, but can also reduce rescue inhaler use.
MDIs which contain hydrofluoroalkane (HFA) propellants known to contribute to climate change, account for 0.03% of global gas emissions annually. Thus prescribing low carbon footprint inhalers when medically indicated, ensuring adequate patient inhaler technique and incorporating nonpharmacologic strategies into airway management, can lead to better patient outcomes with environmental co-benefits.

Optimizing medication usage yields positive clinical outcomes for patients. In 2021, 25% of Canadian older adults were prescribed 10 or more medication classes, leading to polypharmacy and increased healthcare costs, adverse reactions, and potential interactions. Re-evaluating prescriptions to discontinue unnecessary medications can reduce adverse events, healthcare burdens, and enhance quality of patient care. Addressing polypharmacy enhances individual and healthcare system efficiency and sustainability. Furthermore, optimizing medication use reduces pharmaceutical waste and environmental impact. Close to 100000 million tonnes of CO2 emissions are released from unused medications and pharmaceutical waste every year. Medications account for a quarter of carbon emissions within the healthcare sector. By avoiding the prescribing of unnecessary or unindicated prescriptions healthcare providers may contribute to reducing the overall demand for raw materials and energy-intensive processes involved in pharmaceutical production.

Ensuring proper medication disposal is crucial to minimize health risks, preventing misuse and adverse effects. Less than 1% of patients return unused medication, increasing the likelihood of accidental ingestion by children and pets. Flushing medications down the toilet, a prevalent disposal method, poses risks of antibiotic resistance and water contamination. The improper disposal introduces pharmaceutical residue into water systems, threatening aquatic life. Education on safe disposal and encouraging return to designated collection sites can reduce these risks. Regulatory measures, such as those implemented in British Columbia, aim to address pharmaceutical waste through recycling regulations, highlighting the importance of comprehensive strategies to minimize environmental harm.

Reducing paper usage has been shown to minimize the risk of prescription errors. Decreasing paper prevents waste and recycling needs, hence is environmentally beneficial.

In pharmacy settings, when the risk of body fluids exposure and infection transmission is low, maintaining safety standards in most routine healthcare interactions can most often be achieved by using proper hand hygiene without additional precautions. Do not use gloves in place of hand hygiene or when hand hygiene alone is sufficient. The pharmacy staff should reserve the use of gloves to situations in which the safeguard of pharmacy staff is required due to risk of infection, or to comply with infection prevention and control (IPAC) and National Association of Pharmacy Regulatory Authorities (NAPRA) standards and/or guidelines. Refraining from using latex or nitrile gloves when not medically necessary is an important aspect of environmental stewardship to be considered by healthcare professionals. Minimizing the use of gloves can help reduce environmental waste associated with disposable medical supplies, contributing to sustainability efforts in healthcare facilities. Approximately 500 boxes of gloves were found to emit 2 tonnes of CO2 emissions. Limiting the use of gloves is highly effective in promoting environmental sustainability.