Having your face and name known: priceless (Paul Forsyth)

Paul Forsyth

I experienced an example of this recently while reviewing a 75-year-old man with a history of rheumatic fever, atrial fibrillation (AF) and left-ventricular impairment. To the outside world he looked like a man who was coping wonderfully well with his medicines and, on first glance, his heart failure symptoms seemed relatively stable.

However, I chose to review this patient after I noticed on his GP’s computer system that he had not actually been ordering his prescription.

It turned out that during an episode of acute gout, 18 months previously, he had been advised by the GP to stop taking his loop diuretic. Unfortunately, he had been confused by these instructions and stopped taking a different medicine, his beta-blocker, instead. During my review it became apparent that, as a result, his AF had become uncontrolled, he was more short of breath than usual and his blood pressure had become markedly elevated.

Resolving this situation involved far more than simply restarting his beta-blocker and titrating it until the target dose was reached. Heart failure is a fragile condition that can deteriorate quickly, especially during periods of uncontrolled AF or when medicines are stopped abruptly. Restarting beta-blockers too aggressively in patients with fragile heart failure can sometimes exacerbate their condition. So, to ensure his heart failure had not worsened acutely, I arranged for the patient to be reviewed by his GP and his cardiologist.

I also arranged for his community pharmacist to monitor adherence from this point onwards and spend some time educating him about his medicines. As a team we eventually got him restarted on the correct medicines and back on track.

There are two lessons to be learnt from this situation. The first is that when a patient has, for whatever reason, stopped taking a medicine against medical advice, simply restarting the medicine is not always the right course of action. The second is to recognise where your professional limitations lie and know when to refer a patient to another healthcare professional.

Working as part of a multidisciplinary team allows great opportunity for networking — which aids the referral process. Having your face or name known by other members of the healthcare team, and having them appreciate both your role and your objectives, is invaluable.

Being an independent prescriber doesn’t mean prescribing independently!

Paul Forsyth is a heart failure pharmacist working in primary care for NHS Greater Glasgow and Clyde