Special Issue: Focus on Pharmacy and Formulary

 

 

 

 

 

This special issue of Renal News is devoted to renal medications – including what’s being done to help prevent errors, news about our community pharmacy partners, and the latest medications under consideration for the renal formulary. Since medication plays a major role in the lives of all renal patients, these articles will be of interest to renal team members across the province.

Also in this issue, check out the community photos and extensive media coverage from World Kidney Day celebrations across the province (see sidebar articles)!

Ensuring Best Use of Medications for Renal Patients

The Pharmacy and Formulary Review Committee, a standing committee of the Renal Agency, is responsible for improving the appropriate and safe use of medications for renal patients in BC. This includes deciding which medications are on the Agency’s formulary, developing best practice guidelines, and designing a reliable distribution system to make sure renal patients across the province receive their medications.

Renal patients rely heavily on medications for their treatment: the average dialysis patient in BC is on 12 different ones. When combined with medications received during dialysis, a patient’s total can easily reach 20.  Examples of medications recently added to the formulary by the committee include lanthanum carbonate and cinacalcet. Both of these medications are restricted – a last resort for patients who cannot tolerate or weren’t benefiting from other medications – based on cost and available evidence to support their use.

The committee has also helped develop guidelines for alteplase and IDPN (a protocol for managing anemia), and will soon examine guidelines for pain management. Also on the committee’s agenda is the implementation of a medication reconciliation process (see below for more information on "med rec"). 

Log onto the Pharmacy & Formulary section of the Renal Agency’s website where you can find:

Preventing Adverse Reactions and Errors through Medication Reconciliation

If you work with renal patients, you may well have run into medication mix-ups, for instance where a prescriber’s medication order isn’t clear or seems to conflict with a previous order. At best, such a situation can take a number of phone calls and a great deal of time to clear up. At worst, medication errors can result in serious consequences for patients.

Here’s where medication reconciliation comes in - a process designed to bring more clarity and precision to medication orders. Good communication about medications among caregivers and with patients is considered so critical, it’s now required as an organizational practice by the Canadian Council on Health Services Accreditation (see sidebar). Hospitals are starting to implement medication reconciliation as a key measure for meeting the accreditation standard – and of course to improve patient safety.

Medication reconciliation demands keeping an accurate and current medication list for every patient. All members of a patient’s health care team should be involved in this process: wherever a medication list is kept, the "keeper" – including the patient – should ensure it is up to date. The need for strong communications in this situation – especially when updates or changes may occur frequently – is critical. Ideally, the patient’s pharmacist will hold the master list, and would be consulted in the event of discrepancies.

One example of where discrepancies may occur, and when patients are particularly vulnerable to medication errors, is at key transition points in their care (e.g. admission to and discharge from hospital, and transfer within hospital). For renal patients, the medication reconciliation process helps prevent medication errors by:

  1. Ensuring that an accurate list of all the patient’s home and dialysis medications is kept up to date;
  2. Reminding renal team members and patients to refer to that list whenever new medication orders are written;
  3. Standardizing a process for checking the list against the physician’s admission, transfer, and/or discharge orders. This process will identify discrepancies and bring them to the attention of the physician for necessary changes.

Implementing Medication Reconciliation for BC’s Renal Community

The Renal Agency is committed to supporting medication reconciliation across the continuum of renal care – from clinic, to admission, to transfer, to discharge, and back to the clinic – through refinements to the PROMIS database.

Medication reconciliation reports are available through PROMIS, and while each region, clinic or team may use these reports in different ways, the hope is that all renal teams will enhance their medication reconciliation efforts with these tools. (Click here for a tutorial on accessing medication reconciliation reports through PROMIS.)

Throughout the spring, we are presenting to health authority renal programs as well as meeting with various Renal Agency professional groups to find out how we can enhance your existing efforts in this area – or in some cases, work with you to begin them. You will also hear more about this important initiative at BC Nephrology Days in October 2008.  In the meantime, if you have any questions about medication reconciliation, please contact Dan Martinusen at dan.martinusen@viha.ca

BCPRA Community Pharmacy Partners

In January 2008, the Renal Agency awarded new, three-year contracts to 31 community partner pharmacies across the province, including contracts with seven new pharmacies. The new list of community partner pharmacies is available on the Renal Agency website. 

The new contract includes added responsibilities for the pharmacies and we will monitor their performance in a number of ways, including a survey to gauge the renal community’s satisfaction with their services. Training sessions are also being organized to introduce pharmacy staff to the special requirements of renal patients.

Our newest community pharmacy partners have told us they want to get more involved in renal care and to work closely with our renal teams.  We encourage you to welcome these new pharmacies to our community and engage their expertise where appropriate.

Do you have concerns about community pharmacies that can’t be resolved locally? Please email the Renal Agency (bcpra@bcpra.ca). We are happy to assist. 

Helping With the High Cost of Medications

The Renal Agency has a policy of being the "payer of last resort" for medications needed by our renal patients. This means that other payers (federal and provincial governments and private health plans) are expected to pay their usual component first. If money is still owing for any patient medication listed on the Renal Agency’s formulary, the agency steps in. In this way, we remove economic hardship as a barrier to accessing therapy.

Did you know?

Even though the Renal Agency is the payer of last resort (i.e. covering costs only if other health plans do not), fully a third of our budget is allocated to medications. 

Did you know?

BC is the only province with a coordinated approach to funding medications and to developing algorithms and guidelines to support the best use of these medications.

New Guidelines for Cinacalcet

A new process and guideline for cinacalcet was introduced on April 1, 2008.  Click here for the updated criteria and application forms.  To coordinate distribution of this expensive medication, all outpatient cinacalcet prescriptions in the province will be centralized at MacDonald’s Prescriptions in Vancouver.  MacDonald’s will coordinate compassionate stock (funded by Amgen) and BCPRA-funded cinacalcet. Once a patient has been approved for cinacalcet, prescriptions should be directed to MacDonald’s Prescriptions for processing (fax number 604 876-0242). Initial applications will continue to be processed for approval through the Renal Agency (fax 604-875-7366).

Current Medications Issues

Some of the issues currently being addressed by the Pharmacy and Formulary Committee include:

  1. Quinine: Both Health Canada  and the US Food and Drug Administration have issued warnings that quinine is not to be used for "off-label" indications, such as leg cramps.
  2. Sevelamer: An increasing amount of negative/null data from clinical trials suggests this drug should be either further restricted or deleted from the formulary.
  3. Aliskirin: This is the first direct renin antagonist on the market. It may have a role in managing hypertension and reducing proteinuria. The committee is examining whether this medication
  4. A new erythropoeitic stimulating agent (ESA) has recently been approved for use in Canada and will need to be assessed for use in BC renal patients.

  5. Anaesthetic creams to reduce needling pain. The suggestion of adding these creams to the formulary comes from patients who experience needling pain on dialysis. Before making such a change, however, the committee must address a number of questions, such as: If anaesthetic creams were part of the formulary, could we afford them? Do they really reduce needling pain? Would they be used appropriately? Would fewer patients choose catheters if anaesthetic cream helped overcome their fear of needling pain?

Profile in Kidney Care

The Challenges and Rewards of Pediatric Pharmacy

In her 25 years as a pharmacist, Kathleen Collin has worked in a wide range of clinical settings and jobs, but she says few have been as rewarding as her current position. Kathleen has been the pediatric pharmacist for the renal program at BC Children’s Hospital since April 2007, and although she enjoys her job, it is not without its challenges.

One of the most basic challenges of pediatric pharmacy involves simple communication. "With young children," says Kathleen, "you can’t always expect your patient will be able to tell you what you need to know."

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Links to other information

More information and other resources about renal medications and the formulary are available from the links provided below: