This document provides guidance for primary care pharmacists on obtaining medicines information to answer patient queries. It outlines various reference sources available both online and through local medical libraries. These include the British National Formulary, Medicines and Healthcare products Regulatory Agency, Clinical Knowledge Summaries and National Institute for Health and Care Excellence. The document also describes the types of queries best referred to Medicines Information Centers and important questions to consider when contacting these centers.

1. Medicines Information
for the
Primary Care Pharmacist
Noshi Iqbal
Lead Pharmacist
Clinical Training & Development
November 2007

2. Learning Outcomes
� By the end of this session, you will be able
to:
� Use the most appropriate reference
source to answer common MI enquiries
� Know when to refer enquiries to Medicines
Information Centres

3. Problems faced by Primary Care
Pharmacists
� Don’t have access to general resources
that would be available in a Pharmacy or
Med Info Centre.
� Limited to the Internet, most websites
need registering or subscriptions.
� Doubt over reliable and trustworthy sites
for information.

4. Types of MI Enquiries in Primary
Care
� General medical & pharmacy enquiries (dosage,
frequency, formulation)
� Immunisation & travel advice
� Adverse drug reactions & drug interactions
� Drugs in Pregnancy & Lactation
� Renal & hepatic disease
� Paediatrics (off-licence use of drugs)
� Specialist queries (mental health, cancer)
� Miscellaneous (out of stock)

5. Joining the Bradford & Airedale
Medical Libraries
� Joining any of the four libraries below automatically provides access to all four
facilities, including borrowing rights and other services. Show your ID badge
to join.
� Bradford & Airedale tPCT Library Service
Library Team, Ground Floor, Douglas Mill, Bowling Old Lane, Bradford, BD5
3JR Tel: 01274 237484 Fax: 01274 539232
� E-Mail - rebecca.hewitt@bradford.nhs.uk
� Airedale NHS Trust Library and Information Service
Medical Education Centre, Airedale General Hospital, Skipton Road,
Keighley, BD20 6TD. Tel: 01535 294412 Fax: 01535 292196
E-mail - airedale.library@anhst.nhs.uk
� Library & Health Promotion Resources
Lynfield Mount Hospital, Heights Lane, Bradford, BD9 6DP
� Tel: 01274 363194 Fax: 01274 363194 E-Mail -
library.lynfield@bdct.nhs.uk
� Bradford Teaching Hospitals Health Library & Information Service
� Field House, BRI.
� NHS staff in Bradford & Airedale are also permitted to join and borrow from:
Universities of Leeds & Bradford

6. Obtaining an athens log-in
� Access hundreds of journals online
� Wealth of information
� Most key journals offer full text (though available after 6
months)
� Library services will allow photocopy of current journals
(within copyright guidelines)
� Need to contact Rebecca Hewitt (let her know that you
work for Bradford & Airedale tPCT):
rebecca.hewitt@bradford.nhs.uk or 01274 237484
� Webpage: http://www.athensams.net/ and click on
‘MyAthens’ on left hand side.
� Once you have joined the library service it will be easier
to obtain an athens password. The libraries have many
publications on athens access and registration.

7. Internet
Medicines Information
Resources

8. British National Formulary
� Most important reference source
� Available online at www.bnf.org
� Need to log-in with athens or
personal log-in (need to register
for)
� Advantage of online BNF that can
copy & paste info from webpage
straight into patient’s records
� Can link straight through to a drug
monograph from SystmOne (right
click on drug, scroll down to BNF
information). Will need to log-in at
BNF screen (some practices can
do straight link without log-in).
� Children’s BNF available online at
http://bnfc.org/bnfc/

9. Online Medicines Compendium
� Full Summary of
Product Characteristics
(SPC’s) and Patient
Information Leaflets
(PILs) available for the
majority of drugs
� No log-in needed
� Information can be
copied and pasted in
patient records
� PILs can be
downloaded and saved
in pdf
� SPC’s and PILs can be
printed
� Contact telephone
numbers for drug
manufacturer’s med info
dept or customer
services provided

10. MIMS
� Available online at
www.healthcarerepublic.
com//home/pharmacist
� Registration required
� Unfortunately, cannot
access clinical tables /
guides without
subscription
� However, can obtain info Can sign up to receive free
weekly email bulletins which have
on latest products and a summary of the best pharmacist
licence changes clinical features, jobs and news

11. PACE Guidelines
� Available online at
http://www.learnonline.nhs.uk/P
ACE
� PACE are responsible for
bringing together national
guidance and local specialist
expertise in Bradford and
Airedale around the promotion of
good health and the prevention
and treatment of ill health. This
consists of a guidance
document, educational learning
events, evidence-based tool kits
and district wide clinical audit. PACE Team
� Guidelines and toolkits are 2nd Floor
available on site to be viewed Douglas Mill
and downloaded. Bowling Old Lane
� Pharmacists are encouraged to Bradford
attend PACE educational events BD5 7JR
(as long as practices are not Tel: 01274 237406
disrupted significantly and work
is covered) Email: pace@bradford.nhs.uk

12. ADRs & Yellow Card data
� As pharmacists we have duty to fill in
yellow cards if we come across an
ADR with any drug during med
reviews with patients.
� Keep a copy for yourselves and send
CMS a copy (looks good on record).
� Sometimes need to know if a
particular drug is cause for an ADR –
can look at yellow card data though
bear in mind that this info is not a true
reflection of incidence, but is info on
reports submitted
� Yellow card data is (for the majority of �Availableon the MHRA website
cases) better than ringing the
company med info dept as they then �www.mhra.gov.uk
have a legal right to know about �Monographs are called:
patient details, and there is a risk of ‘Drug Analysis Prints (DAPs)’
breaching patient confidentiality and
obtaining consent could alarm patient
etc. Example of monograph (fluoxetine)
� Yellow card data provides an Key tip – MHRA website is awful to
alternative source of info when the use. To find DAPs go to main site,
BNF & SPC does not mention the and change last digit of web
ADR. address ‘5’ to ‘742’. Will take you
direct to the DAPs page.

13. Product Availability
� Common enquiries via patients
that cannot get hold of their
medicines, or referred from GP
asking about supply problem
and whether worth switching
patient to alternative
� UCLH Solutions website
detailed list of product
problems
� www.uclhsolutions.com
� Username & password:
cmspharmacists
� Click on – solutions – product
shortage list for list of drugs Can print off whole list as pdf document
with supply problems and date (updated weekly) to give to
for resolution community pharmacists / GPs
� Can confirm discontinuations
� MHRA drug recalls all
available

14. UKMi national website
� UK Medicines Information
Network homepage
� www.ukmi.nhs.uk
� Most clinical areas are
password protected for MI
pharmacists
� Useful to know as a
pharmacist which clinical areas
available to help with enquiry
(can then ring MI to ask
answer)
� Website has a fridge database
and a latex database – big lists
of products
� Most other clinical sections are
directed to other websites
(mostly NeLM)

15. National electronic Library for
Medicines (NeLM)
� www.nelm.nhs.uk
� Need to register
� Previously known as
‘druginfozone’
� Registration enables daily MI
email alerts
� One of the best MI sites
available
� Previously NPA resources
(travel immunisation, malaria
prophylaxis, diluents, sugar
Q and A section has reviewed and
contents, E-numbers) all
critically evaluated answers to
available to download, now
common questions. Have all been
removed
updated (currently 129 Qs available).
� Info on drugs on the horizon Examples:
� Large section for prescribing 1) Is it safe to use metformin in HF?
(for pharmacists) 2) Switching between antidepressants

16. Primary Care Question Answering
Service
� www.clinicalanswers.
nhs.uk
� Similar to NeLM Q&A
but more specific to
primary care
� All questions are
answered with
references but are
limited in depth (are
not systematic
reviews)
� Can view questions References are common primary care
by speciality sources like prodigy and CKS,
(condition) or can but summarised concisely
search site

17. Clinical Knowledge Summaries
(CKS)
� Incorporates Prodigy
� Part of NHS Libraries
� Useful info on disease
management
� Covers drug
treatments
� Easy to use site
� Can print leaflets for
patients
� Need to register

18. National Prescribing Centre (NPC)
� www.npc.co.uk
� Being updated at
moment
� MeReC bulletins,
therapeutic reference
sheets, info on new
medicines on horizon
� Medicines Management
& Partnership sections
etc
� Vast source of
information

19. National Service Frameworks (NSFs)
� Available on the
DoH website
� www.dh.gov.uk
� NSFs are long
term strategies for
improving specific
areas of care. They
set measurable
goals within set Can also download the ‘Green Book’
time frames. From DoH site (vaccination & immunisation
Guide)
� All available to
download from site

20. National Institute of Clinical
Excellence (NICE) � NICE is an independent
organisation responsible for
In the “Our Guidance” section, the providing national guidance on
different types of guidance that NICE promoting good health and
preventing and treating ill
produces (e.g. Technology Appraisals, health.
Clinical Guidelines and Interventional � Appraisals & guidelines
Procedures) can be found – both those available to download as full
finalised and those in progress. documents or summaries
The Guidance can be found by: � www.nice.org.uk
Looking at the list of ‘type’ i.e.
Technology appraisals, Clinical
Guidelines or Interventional
procedures.
Looking at the list of ‘topics’, which
categorise guidance into health topics.
Looking in the Compilation, which is a
summary of all the Guidance
produced.

21. Immunisation & vaccination
� www.immunisation.
nhs.uk
� Information on all
the vaccines and
immunisation
schedules
� Refers to other
sources for links
� Easy to use site –
good to recommend
to patients for
further information

22. Enquiries to refer to
Medicines Information
Centres

23. Enquires that need to be referred to
a MI Centre
� Pregnancy & Breastfeeding
� Complex renal & hepatic disease
� Paediatric (especially neonate) where off-licence
info is required
� IV enquiries
� Herbal interaction enquiries
� Specialist enquiries – psychiatric drugs,
chemotherapy

24. Ringing Medicines Information
� Each hospital has a MI Centre; then there are
regional (specialist centres e.g. Newcastle is
specialist for pregnancy & poisoning).
� Some hospitals (e.g. Bradford) are not funded to
provide a MI service to primary care so they may
try to brush you off (they have an overwhelming
number of enquiries to deal with). However,
they cannot refuse to take your call as this would
be against UKMi protocol.
� Try and ring MI only when the enquiry is
complex, and needs specialist input. The more
time you can give them to prepare the answer
the better response you will get.
� Bradford MI: 01274 364598

25. MI requirements
� MI Centres tend to ask a lot of
questions in order for them to
prepare a comprehensive answer
for you, so ensure you know all the
details and have done the basic
looking up.

26. Key questions to
think about
when doing MI
MI Centres will ask you these
questions so try to know their
answers before ringing them

27. General questions – for all enquiries
� Is this a general enquiry or is it about a
specific patient?
� What is your name?
� What is your job/your role/your interest
in this enquiry?
� How should I contact you?
� When do you need an answer?

28. Adverse drug reactions
� Establish patient’s age if relevant
� Ask about the indication for the drug and any relevant
medical history (e.g. renal function)
� List all current and recent drugs (include OTC products,
herbal medicines, drug abuse).
� Consider any history of ADRs and or allergies.
� Ask for the details of the suspected reaction including
signs & symptoms, and severity.
� Establish when the suspected reaction began (especially
in relation to starting drug treatment) and whether the
drug has been stopped.
� Ask how the patient has managed and how he/she is
now.
Remember to check yellow card data when dealing with
ADRs

29. Drug interactions
� Which of the drugs is the patient already taking?
How long have they been taken for?
� Has the enquirer or patient read about an
interaction somewhere? If so, where?
� If the patient is already taking both drugs, have
any problems been identified or investigated?
� If there is an interaction, is there any reason why
alternative drugs can’t be used instead?
� What is the patient’s liver and renal function?
� Is the patient taking any other medicines?
� If any ongoing or future monitoring would be
required, who would do this?

30. Drugs in breast-feeding
� Identify drug, indication, dose, frequency, route of
administration and duration of treatment.
� What would happen if the drug is stopped, or not used?
� Has any alternative been considered or tried?
� Has mum already been taking the drug? Has the baby
already been exposed to it in pregnancy or breast-
feeding, and if so have any problems been identified?
� How old is the infant, and is he/she premature or full-
term?
� Is the baby well? Is there anything to suggest that the
infant may be at increased risk of drug harm – such as
impaired kidney or liver dysfunction?
� Who is in a position to change therapy if necessary or
document your advice in the patient’s notes? Who else
needs to know the answer to this enquiry?

31. Drugs in renal disease
� Establish age, weight and height of patient.
� Check the degree of renal failure, whether it is
acute or chronic, and whether renal function is
stable, deteriorating or fluctuating.
� Is the patient currently taking the drug in
question, if so what dose and frequency?
� What is the indication for the drug and have
alternatives been considered?
� Which if any, renal replacement therapy is being
used?
� Ask about the timing of any renal replacement
therapy as necessary.

32. Drugs in liver disease
� Establish the clinical condition of the patient, age, and
presumed diagnosis.
� Results of LFTs (including clotting screen), biopsies and
other diagnostic liver tests. Are the LFTs stable or
changing?
� What is the patient’s renal function?
� If drug-induced hepatotoxicity is suspected, is the
patient currently taking the drug in question, if so what
dose and frequency? What other drugs are being taken
or were taken recently?
� If requesting advice on dosage or suitability of a drug in
hepatic dysfunction, what is the indication for the drug
and have alternatives been considered? What agent
would normally be used if the patient did not have liver
dysfunction?

33. Pharmacokinetics
� Identify the drug, indication, dose, frequency,
route and duration of therapy.
� Check the patient’s age, gender, weight,
concurrent medication and medical history
including renal and hepatic function.
� Check if any previous drug levels have been
taken and if so, check the exact time they were
taken in relation to the drug and confirm the units
of measurement.
� Have any interacting drugs been started (or
stopped) which may affect levels?

34. Palliative care
� If enquirer asks about compatibility of drugs in
a syringe driver, check the drugs, doses,
diluent and volume. If you are unable to find
compatibility data, think about alternative
drugs, routes or separate syringe drivers.
� If enquirer asks about symptom control,
establish indication and what drug or non-drug
options they have tried already.
� If the patient is unable to tolerate oral
administration, explore other routes with
enquirer.
� Check concomitant medication and concurrent
disease including renal and liver function.

35. Alternative medicine
� Is the patient already taking the alternative
medicine or do they want to start taking it?
� Identify the alternative medicine, indication,
route, strength, dose and frequency. If
applicable, how long has it been taken for?
� Has the patient self-diagnosed the condition that
they are seeking to treat? If they have, perhaps
they should consider speaking to a healthcare
professional first.
� Does the patient take any conventional
medication? Is there any history of ADRs or
allergies?
� Check the past medical history.

36. Substance misuse
� How certain are you that the amount of drug taken and the
frequency of use is correct? Users may lie about the
quantities consumed and the purity of street drugs also
varies very widely.
� Has a urine screen been organised? What were the
results?
� Does use of the drug relate to a single exposure, short-
term use, or a persistent habit?
� How is the subject taking the drug (e.g. injection, oral)?
� Is the subject taking other drugs? It may be important to
know about other substances (e.g. tobacco, prescribed
drugs): some enquirers panic when they hear about an
illicit drug, or automatically blame it for all the patient’s
problems, and don’t ask further questions.
� If the enquirer has used drug slang terms that you are not
familiar with, ask them to clarify.
� Many enquiries concern side effects, interactions or use in
pregnancy.

37. Travel Medicine
� Identify the traveller(s).
� Check age, concurrent medication and medical history
(e.g. acute illness, immunosuppression, psoriasis,
epilepsy, neuropsychiatric disorders, renal or hepatic
impairment).
� Check whether any female travellers are pregnant or
breast-feeding.
� Identify the exact destination(s) to be visited.
� Find out about the nature of the travel and type of
accomodation (i.e. is traveller backpacking through
rural areas or staying in a good quality urban hotel?
� Check the length of stay and the proposed travel date.

38. Immunisation
� Identify the vaccine that is to be administered (is it live or
not?)
� If it’s not obvious, ask about why the vaccine is required,
and when.
� Is the vaccine really necessary? Even if it is necessary,
could delaying vaccination help solve the enquirer’s
problem? Does the patient require a primary course or a
booster dose?
� If relevant, enquire about which vaccines the patient has
had before.
� Does the patient have any contra-indication to
vaccination? Consider acute illness, previous allergy or
adverse reactions, pregnancy and immunosuppresion.
� Ask about concurrent disease and concomitant
medication.
Use the ‘Green Book’ available on the DoH website.

39. Product availability
� Why do you need this product? Why is an
alternative in the BNF not acceptable?
� What is the product to be used for?
� Establish where the enquirer heard about the
product.
� Ask for exact spelling, any known manufacturer,
strength, dosage form and country of origin.
� Ask how much is needed, and when it is required.
Remember to use UCLH website, can always ring
customer services at drug companies for
confirmation about availability.
Unlicensed specialists like IDIS & Durbin may be
able to source supply of drug.

40. Drugs in Pregnancy
� Assess whether prospective or retrospective exposure – is the woman
actually pregnant now, or planning to become pregnant?
� Identify the drug, indication, dose, frequency, route, and the duration
of exposure.
� How many weeks pregnant was the woman when she first started
taking the drug?
� How many weeks pregnant is she now?
� What drug has the woman taken during previous pregnancies for any
similar condition?
� Has the woman taken the drug in question during a previous
pregnancy?
� Has the woman had any previous pregnancies and what was the
outcome?
� Is there a family history of malformations or history of recurrent
abortions?
� Have any investigations been performed (e.g. ultrasound scans)?
� For chemical exposure enquiries additional questioning may be
needed to establish substance involved, approximate quantities,
duration of exposure per day, protective measures taken etc.

41. Administration of medicines
� If asked about administration of IV drugs think about: dose,
infusion fluid, fluid volume, rate, availability of intravenous
access and whether any other drugs are being given IV.
� For drugs put down enteral feeding tubes, ask about: type
of tube, where the end of the tube is, & the feeding
regimen. Think about alternative administration routes or
drugs.
� If the enquiry is about a patient who is NBM prior to surgery
establish the drugs & doses, and the duration of expected
NBM. Again, think about alternative routes or drugs.
� Similarly if a patient becomes dysphagic, ask about the
drugs & doses and when/whether their swallow is expected
to improve.
Hospitals have a Wrexham Maelor Hospital & NEEMMC
guidelines to deal with crushing tablets enquiries (can ring
company too).

42. Compatibility of parenteral drugs
� Which drugs are currently being mixed?
� Which drugs are you planning to mix?
� What are the concentrations of the drugs, and what diluents
are being used?
� How will the drugs be mixed and what types of IV lines are
being used?
� Which of the drugs to be mixed are essential? (if not obvious)
� What other drugs is the patient being given parenterally?
� Is the number of IV access points limited? If so, why?
� Can alternative routes of administration be considered? If
not, why?
� Establish how the patient is fed – an enteral feed tube offers
a potential alternative administration route; if TPN is being
used this can create additional compatibility problems.

43. Clinical trials
� If you are asked to identify a specific
clinical trial, gather as much data as
possible about the trial before trying to
look for it: drug name, manufacturer,
date of publication, disease area, any
acronym, authors’ names and so on.
� Check with the drug company / trial rep
for further info.
� Check NeLM website for info

44. Choice of therapy & drug dosing
� Check the indication even if it appears obvious
(e.g. don’t assume amitriptyline is for depression)
and the preferred route.
� Check the patient’s age and weight if appropriate.
� Check the patient’s renal and liver function.
� Check the past medical history to ensure the drug
is appropriate for the patient.
� Does the patient take any other medicines?
� Has the patient tried any other drug/non-drug
therapy already?
� Does the patient have any allergies?

45. Stuck?
� Give Noshi a ring
� New mobile number –
07515 278437
� Bradford’s ex-MI
Pharmacist (2.5 years)
Medicines Information is fun – providing information is an
important part of being a pharmacist