Managing your own reaction to an ADR (Paul Forsyth)

Through university we learn about the physiological effects of drugs on the body, desired or otherwise. As pharmacist prescribers, our decision-making is therefore influenced by both the potential benefit a medicine may offer to a patient and the likelihood that the same medicine may cause adverse drug reactions (ADRs). In the clinic, I normally try to discuss potential ADRs with my patients and ask them to report any problems.

In recent years a large number of clinical guidelines have been published to facilitate the optimal medical management of patients with heart failure. Many guidelines also contain useful sections on practical problem-solving, such as how to deal with ADRs (incorporating tips on managing renal dysfunction, hyperkalaemia and angiotensin-converting enzyme inhibitor-induced cough, among others). But what the guidelines do not tell you is how to manage your own reaction to such ADRs.

A good example was a 55-year-old woman who I reviewed in clinic around a year ago. She had a previous history of myocardial infarction and had subsequently developed both heart failure and diabetes, so she seemed an ideal candidate for an ACE inhibitor. I reviewed her medical notes and could find no obvious contraindications. After checking her blood pressure and U&Es, we chatted through things and both decided it was in her best interests to start an ACE inhibitor. I wrote her a prescription for ramipril 1.25mg daily and asked her to come back in a week for follow-up monitoring.

After four days the woman telephoned to ask if I would see her sooner because things “were not right”. I arranged to see her later that day. She arrived bright pink from head to toe — it seemed she had developed quite a pronounced skin reaction to the ramipril. It was so bad that her thermal regulation was impaired and the GP and I even considered having her assessed at A&E. In the end we decided simply to stop the ramipril and monitor her closely over the next few days. Thankfully things improved quickly and she was back to normal within a couple of days.

Although I had not done anything wrong in this situation, and I could not have predicted the patient’s ADR, I felt terrible about things. Although she was very understanding about the incident, I felt that in some way I had let her down. I now realise that this was not the case and that ADRs are often beyond the control of the prescriber.  Nevertheless, I believe it is only once you have gained confidence as a prescriber — and encountered this kind of situation — that you learn how to manage your own reaction to such events.

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