“Quatrain-Style”: Anatoly Evgenievich, what issues of safe use of medicines are the most difficult to explain to the patient?
Anatoly Krasheninnikov: Of course, it is difficult to speak for the patient. However, one of the issues not always clearly observed by non—specialists is the issue of storage. Firstly, because the shelf life is limited even for tablet drugs. Secondly, a number of medicines have special storage formats, special temperature regimes. Unfortunately, the patient does not always follow the recommendations for storage in the refrigerator or in a place protected from light. At the same time, the myth is very popular that after the expiration date of the pill, you can take up to six months. I emphasize that it is a myth, it has nothing to do with reality! But it is often taken as the right recommendation. An expired drug may not have external violations. A tablet or capsule may look like new. However, the effectiveness of the drug, its bioavailability decreases by a multiple — but the frequency of side effects, on the contrary, increases.
“KS”: What other ambiguous points can be found in the process of pharmaceutical consulting?
A. K.: It is always difficult for a pharmacy specialist to combine two tasks: to give the patient recommendations for the most effective use of the drug — and at the same time justify the safety requirements contained in the instructions for the drug. Since the instructions specify the entire list of possible side effects (including extremely rare adverse reactions), this information can sometimes make not only the pharmacy visitor think, but also the pharmacist.
It is the responsibility of the manufacturer to include in the instructions absolutely all possible adverse reactions that have even a minimal risk of manifesting themselves when using the drug. And the manufacturer must fulfill it without any abbreviations and reservations. However, the probability of an undesirable reaction in itself does not mean that it appears in this particular patient. The risk of side effects is reduced many times when the medicine is taken correctly, strictly according to its intended purpose. And strictly in accordance with the instructions.
The time of admission, the duration of the course, interaction with food and beverages, drug interactions — compliance with all these rules is a serious prevention of the occurrence of adverse reactions. The correct mode of use of the drug not only reduces the likelihood of side effects, but also enhances the therapeutic effect. There are no “little things” here: the therapeutic effect, for example, of antibiotics is weakened if a person carries an infection “on his feet”.
Explaining all these points to a pharmacy visitor is an important and rather difficult task. So, it is necessary to develop the right approaches to its solution. In the process of pharmaceutical consulting, it is important for the pharmacist and pharmacist to pay attention to the rules for the use of the drug in accordance with the instructions for medical use, the features of its storage, the most likely side effects, contraindications to use. And, accordingly, it is really important to give the patient an understanding that it is necessary to follow the instructions and not deviate from its recommendations.
This is a “minimum task” for a pharmaceutical specialist – pharmacist — within the framework of his training, higher professional education.
However, there is one “but”: if the patient is standing in line, if several more people are waiting for him, the task of the pharmacy employee is to release the necessary drugs very quickly. Therefore, a pharmacist or pharmacist may not be able to physically devote sufficient time to detailed counseling. The right algorithm is needed, which will make it possible to tell about all the key points.
“KS”: What should such an algorithm of pharmaceutical consulting include? What will help a pharmaceutical specialist in conditions when there is very little time for consultation?
A. K.: The first part of the algorithm is to identify a specific problem in the patient. The second part is an element of monitoring the recommendations of healthcare professionals. The specialist needs to understand whether the drug will help at the moment in this condition, whether it is suitable for the patient now, taking into account the observed symptoms and the doctor’s recommendations. Of course, we are talking about over-the-counter products now. At this stage, the pharmacist helps to choose the most effective and safe drug — including its dosage form.
If the drug was prescribed by prescription, then the question is how to take it in accordance with the recommendations to ensure the best effectiveness.
And the third part of the algorithm is the question of safety: in order to prevent side effects of a drug (or minimize them if their probability is high), it is important to ensure its proper storage, proper transportation and proper use.
The pharmacist’s task is to tell the patient how to take the medicine, how to protect himself from side effects, how to store the drug, how to transport it so that the risk of side effects is minimal. The task of the university course of pharmaceutical consulting is to form expert advice from pharmacists regarding the selection and use of a particular drug. This training course is mandatory for future pharmacists — and within its framework, students study, among other things, approaches to patient counseling regarding the safety of the use of those medicines that they release from pharmacies. Students also get acquainted with the good practice of pharmacovigilance — now we are adding additional information to the training course about how this process is organized, including at drug manufacturing plants.
During the training course, students solve practical problems in pharmaceutical consulting. In these tasks, as a rule, there is a patient who can ask the pharmacist about certain issues of using the drug — or simply reports on his condition. For example, what if drug X showed a particular side reaction? What rules should be followed if a child needs medicine? What should I remind a visitor with certain chronic diseases — for example, diabetes mellitus or coronary heart disease?
“KS”:What should a pharmacist tell a pharmacy visitor about drug interactions?
A. K: Of course, in the instructions for medical use it is noted with which other drugs it is strictly forbidden to take this medicine. But the pharmacist must also ask: what medications is the patient taking at the moment — or is he planning to take along with this drug? Based on his professional experience, a pharmacy specialist can suggest whether such a combination is reasonable or whether it carries certain risks. And again, to warn that any drug therapy is a medical intervention, which should be of a course and strictly dosed nature, and in case of adverse reactions, the patient is obliged to consult the attending physician in a timely manner.
“KS”: And what problems in the safety of use are common in the most popular groups of drugs — painkillers, “anti-cold”, gastrointestinal products?
A. K:It cannot be said that there is any “top” problem drugs. Rather, there are a number of medications that most often tend to give undesirable reactions. The drugs for symptomatic treatment that you have named are harmless enough in conditions of proper, controlled intake and compliance with the instructions. Here again, it is important to understand: the medicine, if it is prescription, should be used only as prescribed by a doctor. Then the risk of side effects will be significantly lower. You can’t do self-therapy.
“KS”: What is important for a pharmacist to consider in order to properly advise a patient when prescribing medications for symptomatic treatment — for example, the same painkillers?
A. K.: Probably, the main problem here is that many patients are quite susceptible to advertising. People really believe that a popular remedy can relieve pain in a matter of minutes or cure acute respiratory infections within a day. The issue, first of all, is compliance with the relevant rules and recommendations by manufacturing enterprises, but also a pharmaceutical specialist needs to be able to explain that expectations from the use of the drug should not be overstated. And tell the patient how such a small exaggeration differs from reality. Fewer distortions of perception — fewer mistakes in the use of necessary medications, including for symptomatic therapy.
“KS”: Today, such a direction as vitamin prophylaxis is popular. What should a pharmacy specialist say about vitamin preparations and vitamin-mineral complexes?
A. K.: The main recommendation is the correct selection of the set of vitamins and trace elements that is needed at the moment. A child needs some vitamins and minerals during the growth period, an adult patient who has suffered bronchitis or pneumonia needs others. And in case of skin problems, for example, it is important not only to use cosmetics, but also to replenish the reserves of those useful substances, the lack of which worsens the condition of the skin.
The next recommendation is that the intake of vitamin and mineral preparations should be a course. But not permanent, not 365 days a year! A person receives many trace elements and vitamins from food. Their shortage can be made up for by a balanced diet and the intake of high-quality food products. An excess of chemical vitamins in the body is not always useful. Everything should be in reasonable sufficiency.
It is worth paying attention to the specifics of the region — for example, iodine deficiency is widespread in some areas of our country. It is also important to correct this feature with a rational diet, and, if necessary, with medications with the presence of iodine.
Some vitamins are registered not as medicines, but as biologically active additives. However, even in this case, they still have their own bioavailability regime inherent in them and their own peculiarities of assimilation by the body.
KS”: What additional factors, in your opinion, affect the safety of the use of medicines?
A. K.: One of the problems of our time is a broad “consultation” about drugs and the rules of their administration. The term “consulting” is not taken in quotation marks for nothing: we are talking about the dissemination of public information not at all by medical and even pharmaceutical specialists. Non-professional bloggers or Internet sites can give recommendations and even prescriptions — including prescription medications. With the difficulties of access to medical care that periodically arise due to the epidemic situation, and given the lack of quality verification of the reliability of Internet information, it is easy to mislead a person. Non-specialist referrers sometimes pose as doctors or pharmacists in order to be more convincing and, therefore, more popular. Trusting such sources, a person begins to actively self-medicate. He uses both medications and dietary supplements (sometimes unregistered), not always paying due attention to the diagnosis and the doctor’s conclusion.
Принимая на веру информацию из интернета, пациент приходит с данной информацией к специалисту — врачу или фармацевту. And this is where new problems in the field of counseling and assistance begin. After all, the visitor begins to sincerely convince the specialist that he does not own modern medical data. Believing that unverified facts are not a delusion dangerous to health, but new trends in drug therapy, a person hardly hears a pharmacist or a doctor who is trying to help him.
Unfortunately, such information cuts very deeply into the minds of patients — and then these patients are at risk of being admitted to the hospital in a rather serious condition. The danger is that they are not engaged in vitamin prophylaxis, but in the treatment of serious diseases — and eventually launch them. In fact, treatment has not been started — and the same diabetes mellitus progresses and gives complications. Therefore, it becomes more difficult to correct the situation.
“KS”: What can a pharmacist do in such circumstances?
A. K.: Taking into account the epidemic situation and the limitations caused by it, the propensity of patients to self-medicate is largely understandable. Therefore, it is correct to note that the appointment of a drug, especially prescription, is the prerogative of only a specialist with a medical education — a doctor. And be prepared for the fact that a person may not hear such an argument at first.
Recommendations on the choice of over-the-counter medications can be given by a pharmacist, but only on the basis of sufficient data on the patient’s state of health, about his diseases. At the same time, it is important to talk about the advantages and disadvantages of each of the options, even if we are talking about comparing not different drugs, but different dosage forms. It is impossible to self—medicate without a high-quality primary diagnosis, even under the supervision of a pharmacy specialist.