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, including drug interactions, increased frequency or severity of further side effects, unnecessary drug costs, and poor medication adherence. Prescribing cascades may also impact a patient’s quality of life and lead to avoidable emergency room visits, hospital admissions and health system costs. Prescribing cascades can be prevented and corrected by careful indication-based prescribing and screening during pharmacist-led medication reviews. 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. If the symptom is determined to be a side effect of a patient’s medication, assess whether this medication can be stopped, changed, or reduced before prescribing or recommending additional drug treatment for symptom management.

There is no evidence to support the use of low-dose (8mg) codeine products over non-opioid analgesics. There are several risks with codeine use. These include   potential for abuse and dependence within a short time frame of regular or excessive use; increased incidence of sedation, falls and memory impairment in older adults; and unpredictable effects ranging from suboptimal pain control to opioid toxicity due to individual differences in codeine metabolism. Furthermore, non-prescription codeine products are often supplied in combination with non-opioid analgesics (i.e., NSAIDs/ASA and acetaminophen) creating potential for serious adverse effects due to high doses of the non-opioid analgesic component. These adverse effects may include liver toxicity, peptic ulcer, renal failure, anemia 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).  As with all opioids, if these products are deemed necessary, patients should be appropriately cautioned about short- and long-term risks of use.

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 drug-related hospitalization of the patient increases. In order to ensure the safety and appropriateness of therapy, all health care practitioners should regularly assess for ongoing  therapeutic indication of a patient’s drug therapy and start or renew medication only once they have determined that the benefits of therapy continue to outweigh the risks to the patient.

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 or as needed use in treating gastro-esophageal reflux disease (GERD), PPIs are often used longer or at a higher dose than guidelines recommend. Unnecessary long-term PPI use can also contribute to medication burden, drug costs and potential drug interactions. Further, long-term use of PPIs has been associated with a number of adverse effects which include increased risk of enteric infections and diarrhea, vitamin B12 deficiency, and hypomagnesemia. Other potential harms such as fractures, and community-acquired pneumonia (CAP) have been reported however, it is not clear that the medication directly causes these effects. Guidelines recommend short-term use of PPIs (e.g. < 8-12 weeks), at lowest effective dose for most patients treated for GERD or peptic ulcer disease and suggest regular attempts to deprescribe PPIs when patients no longer 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 who have an indication for ongoing PPI use, such as those with Barrett esophagus, severe esophagitis grade C or D, Zollinger-Ellison syndrome, chronic NSAID/anticoagulant use with bleeding risk, a documented history of bleeding gastrointestinal ulcers, or those on triple antithrombotic therapy.

Between 2005 and 2012, the sedating properties of certain atypical antipsychotics led to a 300% increase in their off-label use for insomnia. Guidelines report a lack of evidence for benefit of atypical antipsychotics for the treatment of insomnia and warn against their possible adverse effects, including weight gain, fall risk and metabolic disorders. In certain populations, such as in patients with dementia, they can also increase the risk of cerebrovascular events and death. 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 in any age group 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 strategies such as cognitive behavioural therapy for insomnia (CBT-I) and maintaining good sleep hygiene prior to prescribing benzodiazepines for insomnia. If determined to be necessary for the patient, benzodiazepines should not be prescribed for long-term use without valid long-term indications (e.g., seizures) and discontinuation strategies, such as gradual dose tapering, should be built into the patient’s treatment plan before initiation of benzodiazepine therapy.

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, preferences, and drug coverage to determine if lower carbon intensive inhaler device(s) (Dry Powder Inhalers (DPIs), or soft-mist inhalers (SMIs)) are clinically appropriate as both are often preferred by patients and are as effective as MDIs. The use of inspiratory flow meter can help assess which inhaler device is efficient. 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 and, subsequently, use of rescue MDIs. Additionally, multi-modal strategies (e.g. smoking cessation, 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 contain hydrofluoroalkane (HFA) propellants which have global warming potential and are known to contribute to climate change. Thus prescribing low carbon footprint inhalers when medically indicated, ensuring adequate patient inhaler technique and incorporating multi-modal 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, potential interactions, and hospital admissions. Re-evaluating prescriptions on a regular basis to discontinue unnecessary medications can reduce adverse events, healthcare burdens, drug costs, and enhance quality of patient care. Opportunities to deprescribe include situations where there is a change in patient’s clinical condition, goals of care, and upon refill requests or transition of 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. Pharmacists can further reduce polypharmacy and waste by reassessing “as needed” medications that have not been used in some time.

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, ecological harm, and water contamination. The improper disposal introduces pharmaceutical residue into water systems, threatening aquatic life. Furthermore, aerosol inhalers are often discarded before empty, releasing harmful greenhouse gases. 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.