GIVING OUT MEDICATION
1: Call out the patient’s identifier and invite them to the counselling room if there is one available, or a private area at the hatch. Introduce yourself to the patient and confirm the patient’s identity by checking their date of birth and name.
2: Check the patients allergy status and whether the patient is on any other
prescribed medication, medication bought over the counter, recreational drugs, herbal, homeopathic or vitamin/mineral supplements.
Specifically ask about inhalers, nasal sprays, eye drops, injections, (even if only given once) and creams.
If the patient is taking anything new, first check the HIV specialist drug interaction resources for any potential interactions and then consult with a specialist HIV pharmacist if you are unsure how to proceed.
3: Always show the patient the medication and quantity you are giving them. If there are any short-dated items, bring this to the attention of the patient. Advise them to use any short-dated medication first and use longer dated packs later to ensure that they will not expire before they can be used.
4: Ask the patient how they are managing with their medication and check for any missed doses e;g how many doses did you miss in the last week. If there is time and it is appropriate review their adherence.
5: Once the medication has been given out, direct them to make another appointment (if not already done so) or wait for another member of staff to call them if appropriate.
For patients starting ART (For switching can use an abbreviated form of this)
Have the following ready
-Patients notes and samples of the medication
-Patient information leaflets (PILs) for the ART (see www.hivpa.org)
-Supporting information from NAM, i-base or locally produced information and details about opening hours and contact details.
–Counselling checklist (see below two possible versions)
The counselling checklist can be kept close by, though a consultation flows better when you don’t need to look at the sheet. Review the checklist before seeing the patient and when the appointment is over, document the consultation in the notes and tick everything that was discussed on the counselling checklist. Throughout the consultation remember to use simple language that the patient can understand and avoid using medical jargon and abbreviations. Ensure the patient has the chance to ask questions and have their concerns addressed during the consultation. Try to ascertain the patient’s understanding of what is explained as you go along and give the patient opportunity to ask questions.
Ask the patient what they already know and what they would like or expect from treatment.
Ensure they understand CD4 counts and viral load measurements and what the virus does to the immune system and the risk of opportunistic infections.
General information on ART – Check patients understanding of…
Why they are starting combination therapy.
How the anti-retroviral therapy (ART) works and why combination ART is used. Use visual aids (from the i-base book or own drawings) to explain their action against the virus.
ART is a long-term treatment and not a cure, however if you are undetectable and remain so you are uninfectious, U = U. This is an important point to stress as it can help with stigma and provide a focus for taking ART. It can be useful to relate HIV to other chronic illness such as CHD where therapy needs to be taken for life. Advise to take it a day at a time and not to focus on the lifelong aspect of therapy, as this can be very overwhelming.
Individual drugs: (see the full training module or the individual drug sheets or the SPC for specific details)
Discuss the dose and show the actual number of tablets so the patient has a visual image of their regimen. Explain that generic tablets may look different if suppliers change.
Food restrictions- Explain any food requirements, some examples:
–Efavirenz should be taken on an empty stomach to minimise side effects but in practice some patients find that taking it with food helps to reduce the side effects, hence advise the patient that they can do whichever works best for them.
–Tenofovir SPC states for it to be taken with food but explain to the patient that this is not necessary for therapeutic levels and that in practice it is ok to be taken without food
–Eviplera needs to be taken with a meal, but it can be a small meal such as breakfast, but not a protein shake. Supply the patient with the information sheet for Eviplera and if appropriate show them how to make up the food requirement.
–Boosted Atazanavir, Boosted Darunavir, Etravirine, Stribild and Genvoya should be taken with food.
–Raltegravir, Dolutegravir, Bictegravir, Doravirine, Abacavir, Lamivudine, Emtricitabine, Zidovudine, Nevirapine, Maraviroc and Kaletra can be taken with or without food.
Side effects- Discuss all commonly occurring side effects (headaches, nausea and vomiting and diarrhoea) and all significant ones (include risk of metabolic complications, renal, etc.). Explain about the possibility of a rash with all the integrase inhibitors and NNRTIs. Specific attention should be drawn to the following side effects:
Abacavir: Hypersensitivity reaction including rash
Efavirenz: CNS toxicity, sleep disturbance, drowsiness, nightmares and lightheadedness. The patient should avoid driving or operating machinery if experiencing these side effects.
Integrase Inhibitors: CNS issues with insomnia, dizziness and mood disturbances. The patient should avoid driving or operating machinery if experiencing these side effects.
Atazanavir: Often causes raised bilirubin levels which may cause yellow discoloration of the skin and/or eyes.
Discuss likely onset and duration of side effects and how they can be managed both pharmacologically and by adjusting timings, having them with food etc. Inform them that they can contact the clinic if they need any medication to help manage side effects such as loperamide. Also explain that they may not experience any side effects but if they do most only last a few days or weeks and improve over time. Usually this is the aspect of treatment that patients are most concerned about so take time to reassure the patient that they will be monitored and if necessary, medication can be changed.
Storage of tablets- Explain use of dosette box if required. Check individual manufacturers guidance on time out of original packing and refer to your local policy.
Explain to the patient when to start the medication, often patients won’t be started over a weekend as most clinics are closed for advice but if it is necessary then ensure the patient has access to emergency contact details and knows where to go.
Medication and lifestyle
Timing of the medication: Discuss a reasonable and realistic schedule that allows for lifestyle as far as possible (e.g. social, weekend waking times, meal times) whilst maintaining therapeutic drug levels. It is important for the patient to feel in control of the choice of the timings of the medication. For once daily medications, doses should be taken 24 hours apart and twice daily medications should be 12 hours apart.
Efavirenz – Usually advised to take at bedtime but if the patient experiences no drowsiness it can be taken any time. If they do suffer drowsiness help them fit dose times around evening activities.
Going abroad – Advise to bring enough supplies with a week extra to allow for delays. Carry most of their medication in hand luggage with a small amount in their suitcase in case hand luggage goes missing
For travel, discuss dosing schedule in detail moving times if necessary, for short durations it is normally good to keep to UK time. Check if there are any travel restrictions in the destination country.
Advise on vaccines and malaria prophylaxis. Many African patients believe they are protected from malaria because they use to live in the country so need to advise that they still need prophylaxis. See BHIVA guidelines on immunisation of HIV patients for guidance on which vaccines are safe to use. Use the Nathnac website for specific country advice on vaccines and malaria prophylaxis.
Stress the Importance of taking therapy at the correct time in the right way, each day because of the risk of resistance. Normally encourage patients to aim to take their ART within an hour either side of their set dose time.
Explain why patients need to have at least a 95% adherence rate(*) to reduce the chance of resistance. Use diagrams to explain receptors/mutations at a basic level. (pictures in i base booklet)
(i.e. *If patients are taking a once daily treatment, 95% adherence means missing no more than one dose a month. If patients are taking twice a day, 95% adherence means missing no more than three doses a month)
Memory tools: e.g.
Alarm on their mobile phone
Dosette boxes: Some patients find it helpful to know they have taken the medication so a small version may be useful for this purpose. They are also beneficial for when patients are going away or for those with difficulties reading bottles or taking many additional medicines. Check who will fill them? (Generally, nurses are not authorized to fill dosettes; ‘Carers’ and patients filling it together is probably the safest arrangement)
Small pill boxes: For nights out and for keeping an extra supply at work or partners/friend’s house
6) Interacting medication
There are many potential drug interactions with ART hence it is essential to take a thorough drug history asking specifically about
-Drugs prescribed by their GP
-Inhalers, injections, creams, eye/ear/nose drops particularly looking for steroid preparations including one off injections.
-Herbal and homeopathic remedies and supplements
-Recreational drugs (Important as their use is widespread in our patient cohort)
Discuss the relevant drug interactions that are listed on the individual drug sheet plus any that may arise from the patient’s drug history.
Explain that there can be a number of potential interactions with their medication and they should always check with the HIV pharmacy team before taking anything.
The following are some examples that should be discussed with the relevant product:
All proton pump inhibitors are contraindicated with boosted Atazanavir and Eviplera/Rilpiverine.
H2 receptor antagonists (once daily regime) should be taken 10 hours before or 2 hours after Atazanavir and 12 hours before or 4 hours after Eviplera/Rilpiverine.
Antacids/alginates and anti-foaming agents should be taken 1 hour before or 2 hours after Atazanavir and 1 hour before or 4 hours after Eviplera/Rilpiverine.
Divalent cations such as Magnesium, Aluminium, Calcium, Iron and Zinc interfere with the absorption of integrase inhibitors. These can be found in antacids and multivitamin and mineral supplements. Each integrase inhibitor has different recommendations: Dolutegravir needs to be taken 2 hours before or 6 hours after Magnesium and Aluminium containing products. Stribild and Raltegravir should be separated by 4 hours either side of Magnesium and Aluminium containing products. Bictegravir should be taken 2 hours before or with food 2 hours after Magnesium and Aluminium containing products There are variations in the advice on calcium and iron so check the specific integrase SPC for administration information.
7) Missed doses and vomiting
Explain to the patient what to do if any doses are missed. A general rule is to take them as soon as they remember and that late is better than not at all although if it is close to the next dose it is best just to wait until the next dose is due. Do not take a double dose
The SPCs for most ART have specific guidance for missed doses. But as a general rule, for once daily dosing medication if the patient forgets to take their usual dose and remembers within a 12 hour period, advise them to take their missed dose. However, if the patient remembers after 12 hours have lapsed, the patient should wait for their next dose. For twice daily dosing medication the above rule applies, however for a 6 hour period.
Explain the ‘vomiting rule’. For most medication, this is if you vomit within one hour of taking the medication it is necessary to retake it, with the exception of Eviplera / Rilpiverine that has a 4 hour ‘vomiting rule. Assure them to wait until they feel well enough before attempting to retake the medication.
Explain that if the patient has prolonged or profuse diarrhea that it may interfere with the absorption of their medication and to contact the clinic for advice.
Advise the patient to bring their medications into hospital with them if they are admitted for any reason.
8: Additional information
Make sure a patient information leaflet (PIL), (available on www.hivpa.org) has been included for each drug and inform the patient that it will contain the information that has been discussed. Ask if they would like any of the information written out for them including potential drug interactions.
For Abacavir (also in Kivexa and Triumeq) inform the patient of the alert card and its contents, stating it is advisable for them to carry it with them.
Explain to the patient about the potential of newly prescribed or bought medicines/herbal remedies/supplements interacting with their ART. Tell them that they should always inform prescribers in community/hospital and community pharmacies about the ART that they are taking and not to assume they know. If the prescriber is unsure about interactions, the patient or prescriber should contact the clinic before starting anything new even if just a one off dose (e:g a steroid injection).
Emphasise the importance of attending their doctor appointments and blood test appointments.
Explain how they will obtain future supplies of their medication and what to do if they run out.
Check the patient has a GP and the contact details are up to date as you may need information on co –prescribed medication.
Sign and file the checklist in the patients notes and endorse notes as per checklist using black ink
This is an opportunity to review how the patient is managing with their ART and to check their adherence and any potential new drug interactions.
Enquire about their adherence in an open way such as “it can be tricky to remember to take the medicines all the time, how many have you missed in the last week?” Ensure the patient will feel at ease telling you if they have missed any. If there are concerns around adherence, these will need to be addressed at this visit or an appointment booked if there is insufficient time,
Ask the patient when and how they take their medication and record it on the prescription or notes.
Ask the patient if they have experienced any side effects or if there are any problems and record them on the prescription or notes. If a patient has encountered problems that need attention, it may be necessary to direct them to a Doctor.
Check for any new or discontinued medication, herbals, recreational drugs etc.
Click here for the Checklist for adherence
Click here for the Pharmacy counselling checklist
Click here to return to eHive