The Pharmaceutical Journal
Vol 279 No 7478 p564
17 November 2007

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• Retention fees (3)
• Pack sizes
• Supervision (2)
• Safety (3)
• Locum pharmacy
• NHS and pricing (3)
• The Society (2)

Letters to the Editor

Safety

Echinacea should not be used by people with AAT deficiency

From Mr C. A. Deeny, MRPharmS

AAT deficiency, or alpha-1, is a hereditary disorder characterised by decreased levels of the serum protein alpha-1 antitrypsin (AAT). AAT is the primary blocker of neutrophil elastase. Neutrophils are the first cells recruited to the site of an infection.

Neutrophil elastase is a protease enzyme released from activated neutrophils that helps to eliminate infection or inhaled particles. However, without the protective effect of AAT, neutrophil elastase causes lung damage. Thus AAT deficiency leads to deterioration of lung function over time. People with AAT deficiency have an increased risk of early-onset chronic obstructive pulmonary disease.

Infection may lead to increased neutrophil activation, increased neutrophil elastase release and thus hasten lung damage progression in people with AAT deficiency. They are therefore advised to reduce their chance of getting infection, for example, by avoiding people known to have respiratory bacterial or viral infections.

Given this fact it is not surprising that a patient whom I serve chose to take echinacea, assuming that it may help prevent infection and the progression of disease.

However, there is evidence that echinacea acts by increasing the number and the phagocytic activity of neutrophils in vivo,^1–3 although at least one in vitro study suggested that neutrophils are not activated by echinacea.⁴

If echinacea does act by this method, and thus causes an increased release of neutrophil elastase, then this will increase lung damage. I therefore suggest that echinacea should not be used by people with AAT deficiency until proven safe.

Colin Deeny
Inish Health Ltd
Donegal, Ireland

References

1. Melchart D, Linde K, Worku F, Sarkady L, Holzmann M, Jurcc K, et al. Results of five randomized studies on the immunomodulatory activity of preparations of echinacea. Journal of Alternative and Complementary Medicine 1995;1:145–60.

2. Jurkstiene V, Kondrotas AJ, Kevelaitis E. Compensatory reactions of immune system and action of purple coneflower (Echinacea purpurea (L.) Moench) preparations. Medicina 2004;40:657–62. [article in Lithuanian]

3. Goel V, Lovlin R, Chang C, Slama JV, Barton R, Gahler R, et al. A proprietary extract from the echinacea plant (Echinacea purpurea) enhances systemic immune response during a common cold. Phytotherapy Research 2005;19:689–94.

4. Khanom A, Blackburn J. The effect of herbal tinctures on neutrophil activity in vitro. Immunology 2002;107 (Suppl 1):72.

Differential drug packaging could cut down errors

From Dr T. U. Qazi, MRPharmS

Dispensing errors and “near misses” are a serious problem in a busy pharmacy. These errors are mostly caused by drug packaging being too similar, leading to the wrong dosage or medicine being dispensed.

It cannot be denied that environmental factors such as stress and fatigue also contribute to dispensing errors.

Recently, most of the generics manufacturers realised that to promote patient safety they would have to design a new generics range with drug packaging of different colours and shapes. These changes to drug packaging were made in order to minimise dispensing errors and improve compliance, while providing clear patient information.

Examples of well known generics manufacturers which have made these changes include: Actavis, Almus, Alpha, Genus, Ivox and Teva. These new product ranges use many different colours to signify the particular drug and dosage.

With patient safety in mind, it is hoped that this new drug packaging will enhance patient compliance and make dispensing safer.

Elderly patients will be most affected by the introduction of this new packaging because they are commonly subject to polypharmacy. Many of them suffer with memory loss, poor health and a lack of motivation to take medicines.

Teva Pharmaceuticals has introduced extensive colour-coded packaging into its generics range. However, I noticed that a couple of its new products appear almost identical and this can have a negative effect on drug compliance of elderly patients who rely on appearance of packaging to differentiate between different medicines.

In the past few months I have come across a few patients confused over their medicines due to similarity in drug packaging, eg, prednisolone 5mg tablets and bendroflumethiazide 5mg tablets. In addition, among some of my elderly patients I observed non-compliance with their medication due to the similar packaging of amitryptyline 25mg tablets and codeine phosphate 30mg tablets.

Therefore, I think that colour coding of generic products should not be too similar in order to avoid confusion, errors and non-compliance.

T. U. Qazi
Halifax, West Yorkshire

Reducing medication errors in hospital wards

From Mr K. D. Ball, MRPharmS

Having read the paper on drug history errors by Stuart Rees et al (PJ, 27 October 2007, p469), I would like to give my own perspective on medication safety.

We have just adapted our recording mechanisms to incorporate the National Patient Safety Agency definitions but have retained the HATOUM scale as a qualifier. The reason for this is that this gives an idea of the scale of what has been prevented rather than actual harm suffered. I believe this is a more realistic way of assessing the work we do rather than what would be an artificially low set of scores under NPSA rules.

We have also just incorporated further enhancements which allow capture of other related data such as unlabelled syringes of liquids found on wards, medicines available to any who walk past and cupboard codes printed on the outside of the door. What we have tried to do is develop a system that records interventions, adverse drug reactions, medicines errors and other medicines risk related issues.

A further enhancement has been a facility to record the number of errors under a single or multiple entry. Such an example (just a few months ago) of two patients on the admissions unit admitted at 7pm on a Friday night and both being reviewed on Monday morning at 8am with 10 medicines missed on the clerking in of each patient. This resulted in a huge number of errors since each missed dose is an error but nobody is going to record each one so we needed a pragmatic way to record these.

Such matters raise the issue of when our clinical services are provided. To expand this further I would like to use my own work as an example.

I work for two consultants in care of the elderly and attend all their ward rounds. After an on-call or on-take period this may cover as many as 10 different wards and be up to six or seven hours long. This entails large numbers of retrospective and proactive interventions and is seen as a valuable service but also crosses over the work of other clinical pharmacists.

Where it fails, however, is in the fact that I do this between the hours of 8am and 4.30pm Monday to Friday. If my consultants are on call should I not be on call with their team? This poses a different way of thinking about how pharmacy on-call services and clinical services are provided. If we provide real value then we really should have the resources to provide it when it is needed.

We also need to change the way we operate on the wards. We are doing this by becoming consultants rather than ward-based. We still have our specialties but follow our team rather than leaving work on other wards to other specialty pharmacists. This has been received with great enthusiasm by the consultant teams at all grades but can we really break the nine-to-five mould in our provision of services?

Great opportunities but have we the resources to meet what is an undoubted need? All in all, Rees et al have written a good article that should stimulate more work in such areas but from differing angles.

Ken Ball
Care of the Elderly Unit
West Cumberland Hospital

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