A CPPE learning programme

Newmedicineserviceantihypertensives

CENTRE FOR PHARMACYPOSTGRADUATE EDUCATION

January 2013

CONTENTSThis programme contains the following sections:

How to use this learning programme

About New medicine service –antihypertensives

The NMS

Your NMS consultations

Learning objectives

Reflection point

Questions about antihypertensives

Antihypertensive therapies

Case studies

Next steps

Programme credits

Thank you for downloading this CPPE interactive learning programme. We hope that you will find it a fun and informative way to help you learn about the key points for conducting new medicine service (NMS) consultations with patients taking antihypertensives.

The Centre for Pharmacy Postgraduate Education (CPPE) offers a wide range of learning opportunities for the pharmacy workforce. We are based in the University of Manchester’s School of Pharmacy and Pharmaceutical Sciences and are funded by the Department of Health to provide continuing education for practising pharmacists and pharmacy technicians providing NHS services in England. http://www.cppe.ac.uk

Learning with CPPE

This document uses interactive features that may not be supported if you are using it on a mobile device. For best results, please use on your PC or laptop, using an up-to-date version of Adobe Reader.

Welcome toNew medicine service – antihypertensives 3

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Click on a title to go directly to that section.

How to use thislearning programmeThis programme uses an interactive PDF format. You

can navigate your way through by using the arrows in

the bottom right corner of each page. Where directed,

you can also navigate to sections by clicking on text or

images. The programme uses case studies and web

links to help you explore this topic. You will need to be

connected to the internet to access the web links. Text

which links to other sections or to the internet will be

in blue.

In some activities (such as the case studies), there will

be space for you to type answers to the questions. You

can save your answers by saving this document to your

computer. You can also view our suggested answers -

these are hidden behind the Reveal answer text.

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The programme contains two case studies that

highlight significant counselling points in patients

who are taking antihypertensives as new medicines.

We would recommend that you keep notes as you

go along as these could be ideal to generate CPD

records.

If you are using a printed version of this programme,

you will not be able to view our suggested answers.

To see these, either open this document on your

computer or download the separate answers

document from the CPPE website.

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About New medicine service – antihypertensives

NHS services are increasingly focused on delivering

the best possible outcomes for patients – the NMS

was set up with this in mind.

Adherence to medicines has been linked with better

patient outcomes.1,2 In delivering the NMS you will be

supporting patients in managing their newly prescribed

medicines. As well as helping them to optimise their

medicines use, the aim is to improve adherence

by engaging patients in shared decision making

and providing them with the knowledge needed to

make informed choices about treatment and self-

management.

You will also be contributing to the NHS aim of

providing high-quality healthcare for everyone, a key

cornerstone of the NHS constitution.

1. DiMatteo MR et al. Patient adherence and medical outcomes: a meta-analysis. Medical Care 2002;40(9): 794-811.2. Haynes RB et al. Interventions for enhancing medication adherence. Cochrane Database of Systematic Reviews 2008;2: CD000011.

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This programme will provide and signpost you to

key learning to help you conduct effective NMS

consultations. It will provide a record of your learning

of the key points to consider and share with patients

taking antihypertensives as new medicines. We

estimate that the whole programme will take you

three to four hours to complete.

The first few pages will provide you with learning to

ensure that you can provide an NMS. After that, we

will concentrate on antihypertensives, one of the four

medicine groups for which a first prescription qualifies

a patient for an NMS consultation. This programme

is the second in a series of interactive PDF learning,

following New medicine service – anticoagulants and

antiplatelets, which was published in October 2012.

We will be producing further learning in this format for

the other NMS groups in 2013.

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The NMSBefore you start, make sure that you have completed

enough learning to allow you to complete the

Pharmaceutical Services Negotiating Committee

(PSNC) and NHS Employers’ self-assessment form

to assure yourself, your employer (if appropriate)

and the NHS that you are ready to provide the NMS.

If you need to access the CPPE learning materials

for the NMS and complete the CPPE open learning

programme, you can do so by clicking on the images

of the learning programmes on the left.

The case studies on pages 36 to 44 assume that you

know what questions are included in the intervention

stage of the NMS. If you’re not sure what these are,

view them on the PSNC website.

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Your NMS consultationsIf you have already worked through this exercise in

other programmes in this NMS iPDF series, then move

on to the next section.

Now that the NMS is up and running, what is stopping

you conducting more NMS consultations?

Type your answer in the box below.

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How are you going to overcome these barriers?

Complete the table below by adding the barriers you identified

above in the left-hand column and typing in possible solutions in

the right-hand column. There is more space on the next page.

Barriers to the NMS Solutions Barriers to NMS Solutions

No consultation area

No medicines use review

(MUR) accreditation

Too few patients

Not enough experience

A bit scared to approach

patients

GPs are against the idea

Move to a pharmacy that has one. Get one built or installed. Improvise to create a private area.

Get MUR accreditation with CPPE or another HEI provider.

Try advertising the service or mobilising staff to recognise new medicines at prescription receipt. Contact your local hospital to discuss how they can refer patients to community pharmacy.

You’ve got to start somewhere! Do this learning.

Set up a system so that new medicines are recognised by you or a member of staff and automate it as far as possible. Then talk to your patient.

Set up a meeting and convince them of the benefits. View the resources on PSNC and CPPE websites, such as the GP detailing card.

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Barriers to NMS Solutions Barriers to NMS Solutions

Another pharmacist nearby does them all

I’m a locum

I don’t know the patientsI see

I don’t have time

Complicated and confusing payment system

There is plenty of opportunity if you get a system set up to recognise new medicines.

Then you have more time available to offer these services than employed pharmacists who are concerned with staff and management issues. Help them out and get invited back!

You can soon establish a relationship if you sell patients the benefits of the NMS, even if you don’t complete the three interviews.

Pharmacy staff can do more to free you up to offer the services that matter to patients. Mobilise them to do this. Undertake CPPE’s Skill mix e-learning programme.

This has been simplified: you will now receive payment for every NMS conducted. The payment system is explained on the PSNC website.

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Now that we have looked at the NMS in general, we

are ready to move on to antihypertensives specifically.

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Learning objectives The overall aim of this learning programme is

to provide and signpost you to key learning to

increase your confidence in providing effective

NMS consultations for patients newly prescribed an

antihypertensive medicine.

By the end of this learning programme, you should be able to:

discuss the key issues in the drug management of

hypertension

find key resources to help you plan and complete

NMS consultations for patients taking

antihypertensives

list the key counselling points for patients taking

antihypertensives as a new medicine

provide advice for patients presenting with questions

and concerns at an NMS consultation.

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Name the major groups of antihypertensive medicines.

At what step of hypertension is each of these groups likely

to be introduced? Write your answers in the space below.

Reflection pointAngiotensin-converting enzyme (ACE) inhibitors or

low-cost angiotensin-II receptor angiotensin

(AIIRAs) / angiotensin-II receptor blockers (ARBs):

at step 1 (under-55s) or at step 2 with the over-55s

or in people of African or Caribbean family origin in

combination with calcium-channel blockers.

Calcium-channel blockers: at step 1 with the over-

55s or in people of African or Caribbean family origin

or at step 2 in patients under 55 in combination with

ACE inhibitors or low-cost AIIRA.

Thiazide-like diuretics: at step 3 in combination with

both the above groups.

Spironolactone: at step 4 (resistant hypertension) in

combination with all three of the above groups.

Alpha or beta-blockers: at step 4 (resistant

hypertension) if diuretic therapy is ineffective,

contraindicated or not tolerated.

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Questions aboutantihypertensivesLet’s see what you already know before you look at antihypertensives in more depth. Do you know the answers to the following questions? Reveal our suggested answers to see if you are right.

Under what circumstances is antihypertensive therapy started?

Antihypertensive therapy should be offered to people under 80 years with stage 1 hypertension (clinic blood pressure of 140/90 mmHg or higher, and ambulatory or home blood pressure of 135/85 mmHg or higher) and one or more of the following: damage to blood vessel in the target organs (heart, brain, kidneys or eyes) established cardiovascular disease renal disease diabetes a ten-year cardiovascular risk of 20 percent or higher.

Antihypertensive therapy should be offered to people of any age with stage 2 hypertension.

How do calcium-channel blockers work?

Calcium-channel blockers relax smooth muscle in blood vessels by blocking calcium movement through the channels in these vessels, resulting in dilation which reduces resistance to blood flow and therefore blood pressure.

How do ACE inhibitors and AIIRAs (or ARBs) work?

ACE inhibitors inhibit the conversion of angiotensin I to angiotensin II which acts as a vasoconstrictor. AIIRAs directly antagonise the effects of angiotensin II. In addition, the reduction in angiotensin II blocks the secretion of aldosterone, thus lowering sodium and water reabsorption in the kidneys.

How do thiazide-like diuretics work?

Thiazide-like diuretics inhibit sodium reabsorption at the beginning of the distal convoluted tubule. They promote the excretion of sodium, potassium and water, thus reducing the volume of fluid circulating in the body and reducing the preload on the heart, so that cardiac output is diminished and blood pressure is reduced.

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How do beta-blockers work?

Beta-blockers block the beta-adrenoreceptors in the heart, peripheral vasculature, bronchi, pancreas and liver. This results in relaxation of smooth muscle in arteries, thus reducing peripheral vascular resistance and lowering blood pressure.

How do alpha-blockers work?

Alpha-blockers block postsynaptic alpha-receptors and relax smooth muscle in arteries, thus reducing peripheral vascular resistance and lowering blood pressure.

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Well, how well did you do? You can find more

learning resources with detailed information

on these areas by clicking on the topics on the

following page.

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Antihypertensive therapies

starting pointmanagement

lifestyle interventions treatment pathway

care pathway

monitoring

principles of treatment

definitions

side-effects

Click on the titles below to reveal more information on that topic. We suggest you begin with ‘starting point’. You will be able to return to this menu by clicking the link at the bottom of the page at the end of each section. You can also work through the topics in sequence using the navigation tabs at the bottom of the page.

patient supporthypertension in pregnancy

key priorities for treatment in pregnancy

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Starting pointBefore you get to grips with the key learning and case studies in this programme, you may feel that you need to refresh your knowledge on the medicines, their uses, appropriate doses, side-effects and interactions. Although there are other groups of antihypertensive drugs, we concentrate in this programme on medicines that are referred to in the latest clinical guidelines from the National Institute for Health and Clinical Excellence (NICE) on hypertension (CG127, August 2011) and hypertension in pregnancy (CG107, August 2010).

The British National Formulary (BNF) is a good starting point. Here you will find key information. If you have not already done so, you will need to register with the BNF website to access the information within.

Click on the BNF logo to access the BNF website, then log in. Read through: Section 2.2 to find out about diuretics Section 2.4 to find out about beta-blockers, including labetalol (used in pregnancy)

Section 2.5 to find out more about hypertension, methyldopa (used in pregnancy), alpha-blockers and drugs affecting the renin-angiotensin system (ACE inhibitors and AIIRAs)Section 2.6 to find out about calcium-channel blockers.

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Some of these medicines have indications other than hypertension which are not part of the NMS. When you see a new prescription, how will you establish what the medicine has been prescribed for?

Reflection point

There is no easy answer to this but looking at co-

prescribed medicines may help (if the patient is

prescribed glyceryl trinitrate then the indication may

be angina). In addition to this, having a knowledge

of the treatment pathway for hypertension may give

you some indication.

The best way is to find out is to talk to the patient!

Enter into a discussion as follows: ‘You’ve been

prescribed X. Do you know why the doctor has

prescribed this?’

Return to antihypertensive therapies menu

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Before you go on to read about the management of hypertension it may be helpful to define some of the terms used to describe hypertension and antihypertensive therapy. Hover your cursor over the terms below to read more about each.

Definitions

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You need to be aware of these further definitions when considering hypertension in pregnancy:

Return to antihypertensive therapies menu

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The key resource for anyone wanting to learn about the management of hypertension is NICE’s clinical guideline 127. This learning programme draws heavily on that resource and on the corresponding clinical guideline 107, which concerns the management of hypertension in pregnancy. You may want to read these now – click on the links above to be taken to them.

For each, you will find a list of links to the guidelines in formats to suit you. You may find the quick reference guide a good starting point. The full guidance is comprehensive. To help you structure your learning, in the remaining pages of this programme we will highlight the key points from the NICE guidance.

Management

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Additional resourcesThe National Prescribing Centre (now the NICE Medicines and Prescribing Centre) published a review of CG127 (which replaced CG34) in a MeRec Rapid Review in October 2011. The centre’s MeReC Monthly No. 45 summarised the changes further in December 2011. You can view a useful diagram showing antihypertensive treatment at each step in MeReC Extra No. 51 from November 2011.

Another good resource is the PRODIGY website. This has lots of information on clinical topics, including sections on hypertension in people with type 2 diabetes and hypertension in pregnancy.

Return to antihypertensive therapies menu

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The care pathway for patients with hypertension has developed with the growing evidence base over the last few decades. As treatment of hypertension has long been recognised as a priority for the NHS, for its role in preventing cardiovascular morbidity and mortality, the care pathway, as developed by the British Hypertension Society and adopted in its guidance by NICE, is extremely well evidenced and established. The upside of this is that preventing and treating hypertension is a priority for successive health ministers, with better outcomes for patients. The downside is that the care pathway is complex and may be difficult to understand for patients and others encountering it for the first time. The quick reference guide to NICE clinical guideline 127 has a useful summary diagram, reproduced here, which you will find useful both for your own learning and for explaining to patients.

Care pathway

NICE clinical guideline 127 Quick reference guide6

Hypertension Care pathway for hypertension

3 Signs of papilloedema or retinal haemorrhage.4 Labile or postural hypotension, headache, palpitations, pallor and diaphoresis.5 Ambulatory blood pressure monitoring.6 Home blood pressure monitoring.

Care pathway for hypertension

Refer sameday forspecialist

care

Offer to check bloodpressure at least every5 years (see page 9) Offer annual review of care (see page 14)

Offer lifestyle interventions (see page 10)

Offer patient education and interventions to supportadherence to treatment (see page 14)

Consider alternativecauses for targetorgan damage(see page 9)

Offer to assess cardiovascular risk andtarget organ damage (see page 8)

If acceleratedhypertension3

or suspectedphaeochromocytoma4

If evidenceof targetorgandamage

If target organdamage present

or 10-yearcardiovascularrisk > 20%

If younger than40 years

Clinic blood pressure≥ 180/110 mmHg

(see page 8)

Consider startingantihypertensive drugtreatment immediately

(see page 8)

Clinic blood pressure≥ 140/90 mmHg(see page 8)

Offer ABPM5 (or HBPM6 if ABPM isdeclined or not tolerated) (see page 8)

Considerspecialist referral(see page 10)

ABPM/HBPM< 135/85 mmHgNormotensive

ABPM/HBPM≥ 150/95 mmHg

Stage 2 hypertension

ABPM/HBPM≥ 135/85 mmHg

Stage 1 hypertension

Offer antihypertensive drugtreatment (see pages 11–14)

Clinic blood pressure< 140/90 mmHg(see page 8)

Normotensive

ExerciseFor the next five prescriptions that you see, try to see where the patient is likely to be on the care pathway.

Check your answer with the patient or the GP and, if necessary, ask questions to improve your understanding of how the GP has reached the decision to prescribe.

Return to antihypertensive therapies menu

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Obviously, by the time you are conducting an NMS consultation, the patient will already be taking at least one medicine for hypertension. However, you should still offer advice to help lower blood pressure by changing lifestyle patterns.

NICE clinical guideline 127 recommends offering lifestyle advice initially and then from time to time. You will want to do this to reinforce the message that while medicines are important, they are not the only treatment for high blood pressure.

Lifestyle interventions

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What do you think your lifestyle advice should be for people with hypertension?

You should ask people about their diet and exercise and

offer advice with supporting materials as appropriate.

Check alcohol consumption and offer advice or support as

necessary.

Encourage people to reduce caffeine intake if this is

excessive.

Encourage low salt intake.

Offer smokers help to stop smoking.

Signpost to local lifestyle initiatives.

Do not offer calcium, magnesium or potassium supplements.

Signpost to relaxation therapies if patients want to try them.

Return to antihypertensive therapies menu

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Principles of treatmentIn clinical guideline 127, NICE lists its principles of antihypertensive drug treatment. It recommends that prescribers:

offer drugs taken once a day, when possibleuse non-proprietary drugs if available, to minimise costoffer those with isolated systolic hypertension (160 mmHg or higher) the same as those with raised systolic and diastolic blood pressureoffer people aged over 80 the same as those aged 55-80, taking into account co-morbiditiesdo not combine ACE inhibitors and AIIRAsoffer treatment to women of child-bearing potential in line with guidance in Hypertension in pregnancy (CG107).

ExerciseWhen you see a patient with a new prescription for an antihypertensive drug, ask yourself whether the prescriber has followed these principles and query the prescription if you are unsure.

Return to antihypertensive therapies menu

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Treatment pathwayAs mentioned earlier, the care pathway for hypertension is well evidenced and well established. Similarly, the treatment pathway has also been subject to intensive development, based on the need to manage a symptomless condition to prevent major morbidity. Although the treatment pathway is not set in stone and is likely to develop further in future, it represents the best evidence currently available and is straightforward to follow.

NICE has produced a summary of the drug treatment pathway, reproduced here.

ExerciseFor the next five prescriptions that you see, try to see where the patient is likely to be on the treatment pathway.

Check your answer with the patient or the GP and, if necessary, ask questions to improve your understanding of how the GP has reached the decision to prescribe.

Quick reference guideNICE clinical guideline 127

Hypertension Antihypertensive drug treatment

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18 Choose a low-cost ARB.19 A CCB is preferred but consider a thiazide-like diuretic if a CCB is not tolerated or the person has oedema, evidence of heart

failure or a high risk of heart failure.20 Consider a low dose of spironolactone21 or higher doses of a thiazide-like diuretic.21 At the time of publication (August 2011), spironolactone did not have a UK marketing authorisation for this indication.

Informed consent should be obtained and documented.22 Consider an alpha-blocker or beta-blocker if further diuretic therapy is not tolerated, or is contraindicated or ineffective.

Summary of antihypertensive drug treatment

Also see ‘Initiating and titrating antihypertensive drug treatment’ on pages 11–12.

Key

A – ACE inhibitor or angiotensin IIreceptor blocker (ARB)18

C – Calcium-channel blocker(CCB)19

D – Thiazide-like diuretic

A + C

Step 1

Step 4

Step 3

Step 2

A

Aged under 55 years Aged over 55 years orblack person of African

or Caribbean family originof any age

C

A + C + D

Resistant hypertension

A + C + D + consider further diuretic20,21

or alpha-blocker or beta-blocker22

Consider seeking expert advice

Return to antihypertensive therapies menu

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MonitoringMonitoring a patient on blood pressure medication is fairly straightforward. The clinic blood pressure reading is used to monitor the response to treatment, using ABPM or HBPM to supplement this information if the patient is known to have a ‘white coat’ response to blood pressure measurement.

Blood pressure targets:

ExerciseThe next time you counsel a patient taking an antihypertensive medicine, check whether they know how their blood pressure measurement has changed since starting treatment and ask them how often it is measured.

Under 80 years(mmHg)

Over 80 years(mmHg)

Clinic blood pressure

ABPM or HBPM averages

Below 140/90

Below 135/85

Below 150/90

Below 145/85

Return to antihypertensive therapies menu

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Side-effectsThe NMS consultation is the ideal place for patients to mention any side-effects that they have read about or may be experiencing, so it will be useful for you to have this information at your fingertips.

The table on the next page summarises some of the commonest side-effects of each of the groups of drugs commonly used in hypertension treatment.

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Drug group Commonest side-effects What to do?

ACE inhibitors and AIIRAs

Calcium-channel blockers

Diuretics

Beta-blockers

Alpha-blockers

Centrally acting antihypertensivedrugs (eg, methyldopa)

Postural hypotension

Persistent dry cough

Angioedema with pruritus and urticaria

Gastrointestinal disturbances

Facial flushing, headache, dizziness

Ankle oedema

Gastrointestinal disturbances, high blood glucose, hyperlipidaemia, low potassium or sodium levels, gout

Postural hypotension

Cramp

Cold extremities, chest tightness or breathing difficulty, thirst, tiredness, excessive urination, bradycardia

Sleep disturbances and nightmares

Drowsiness, hypotension, headache, dizziness, dry mouth, blurred vision, gastrointestinal side-effects

Drowsiness, dry mouth, bradycardia, gastrointestinalside-effects

Take initial doses in the evening when patient can check effect. Stand up slowly.

Refer to GP to try another ACE inhibitor or low-cost AIIRA.

Refer urgently if angioedema suspected.

Advise patient these are short-lived effects. Use over-thecounter remedies.

Space doses as directed.

Refer to GP

Refer to GP

Take initial doses in the evening when patient can check effect.Stand up slowly

Drink more fluids to rehydrate but not too much

Refer to GP

Refer to GP for switch to water soluble atenolol or sotalol

Advise not to drive or operate machinery if patient thinks they are affected. Refer to GP if necessary.

Advise not to drive or operate machinery if patient thinks they are affected. Refer to GP if necessary.

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For further learning on side-effects, try out CPPE’s Adverse drug reactions e-learning series – particularly Part 2: Reporting adverse drug reactions. You can access this now by clicking on the icon opposite.

Return to antihypertensive therapies menu

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During your NMS consultations you have the opportunity to counsel on lifestyle, monitoring, side-effects, interactions and anything else that comes up in the consultation.

NICE encourages prescribers to provide educational materials about drugs and their side-effects but you can supplement this information during the NMS consultations.

You can encourage patients to read more about their condition and treatment using the following resources:

Patient support and signposting

NHS Choices pages on hypertensionPatient.co.uk page on hypertension British Heart Foundation website – here patients can find useful advice on lifestyle interventions.

You can also signpost people to local branches of national patient support groups such as the British Heart Foundation and to local support networks.

ExerciseWhere are you going to signpost patients to? Conduct an internet search to identify groups of which you arenot already aware.

Return to antihypertensive therapies menu

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Hypertension in pregnancyThe key information source for you is NICE’s clinical guideline 107, Hypertension in pregnancy. This contains a series of care pathways for the various situations in which hypertension may develop or manifest itself in pregnancy.

The key facts are:

high blood pressure can develop for the first time in pregnancy with (pre-eclampsia) or without (gestational hypertension) significant proteinuriamost hypertensive disorders during pregnancy develop for the first time in the second half of pregnancyhypertensive disorders can occur in women with pre-existing hypertensionhypertensive disorders during pregnancy are among the leading causes of maternal death and the cause of higher rates of perinatal mortality, pre-term birth and low birth weight.

Return to antihypertensive therapies menu

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Key priorities for treatment in pregnancy

The key priorities for management of hypertension in pregnancy are listed here. We have highlighted points for you to recognise in counselling patients who have hypertension in pregnancy.

Reduce the risk of hypertensive disorders in pregnancyWomen at risk of pre-eclampsia may be advised to take75 mg aspirin daily (unlicensed indication) from 12 weeks until birth. You may see them present with a new prescription for this. What key counselling points wouldyou include?

Management of pregnancy with chronic hypertension

there is an increased risk of congenital abnormalities if these drugs are taken during pregnancythey should discuss other antihypertensive treatment with their doctor or other prescriber if they are planning pregnancy.

NICE advises that you should tell women who take ACE inhibitors or AIIRAs to manage hypertension that:

In pregnant women with uncomplicated chronic hypertension, aim to keep blood pressure below 150/100 mmHg.

Hypertensive disorders in pregnancyThese are managed in secondary care.

For more information on the management of hypertension in pregnancy, read the quick reference guide to NICE’s clinical guideline 107.

Return to antihypertensive therapies menu

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Case studiesThis programme contains two case studies.

Click on an image below to go to that case, or use the navigation tabs at the bottom to work through them one after the other.

HypertensionHypertension in

pregnancy

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Hypertension MartinMartin Reeves is an apparently fit and healthy 44-year-old man steadily rising through the ranks at a company that installs goods lifts in industrial and commercial premises. He spends his time driving between appointments or completing paperwork in his office at home. One of the benefits of his new grade in the job is a ‘well man check’ every two years.

At his first appointment, he was annoyed to find that he was not given a clean bill of health; three successive blood pressure checks gave him an average reading of 164/102 mmHg. He was referred to his GP who in turn referred him for assessment of cardiovascular risk and target organ damage. As a result, he has come to you, presenting a prescription for simvastatin 40 mg and ramipril at initiation dose. He doesn’t have time to talk now as he is parked outside and due at a customer appointment 50 miles away in half an hour. After minimal counselling, you persuade him to book in for an NMS intervention appointment in a week’s time.

A week later, he arrives late and says he only has ten minutes.

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381. What are your key priorities for this first interview with Martin?

1. If Martin only has ten minutes for this interview, then you will have to think on your feet. The most important aspect of the NMS is to establish whether the patient is taking the antihypertensive medicine as prescribed, so you need to check that first. You should try to speak in a calm way so that Martin relaxes and gives you as much time as you need. You can’t ignore the fact that he is also starting simvastatin but make it clear that this is mainly about the ramipril.

We suggest the following priority areas for this ten-minute meeting:

Check if Martin has started taking the ramipril as prescribed and that he understands the dose titration. It is very important that he understands the need for blood tests to check renal function 10 to 14 days after initiation and at every dosage increase and annually, once stable. This ensures the safety of this group of medicines for him.Allow Martin to tell you what he thinks he is taking the medicine for and encourage him to talk about his health.Explore any potential side-effects from the medicine and provide advice on how to manage these. Has he started the ramipril in the evening to reduce postural hypotension?

continued on next page

Don’t forget to save your answers

391. What are your key priorities for this first interview with Martin? continued

1. continued

If you have the time you should always cover at least the questions in the NMS interview schedule.

Ask Martin if the GP told him what his cardiovascular risk was. Point out the benefits he will see from taking the medicine as prescribed and making small changes to his lifestyle to secure those benefits.The discussion should be based around shared-decision making. If Martin has ownership of the decision to take the ramipril as prescribed he is more likely to adhere to the regime. Finish by asking for his commitment to continue taking the medicine as prescribed, even if he can’t see a benefit at present, and to coming back for a follow-up appointment.

Don’t forget to save your answers

402. During the consultation, Martin tells you that his cholesterol ratio is six. He also lets slip that he smokes.

What is Martin’s current cardiovascular risk based on his initial blood pressure reading, the fact he is a smoker and that he has a TC:HDL (total cholesterol to high-density lipoprotein) ratio of six? Does this influence decisions about whether or not treatment is needed?

2. Martin has a blood pressure which is persistently above 160/100 mmHg and so antihypertensive medication is recommended regardless of cardiovascular risk. However, cardiovascular risk is sometimes a useful tool to motivate patients in making lifestyle changes.

Based on Martin’s age (44), his untreated systolic blood pressure being above 160 mmHg, his smoking and his TC:HDL ratio of six mean that he has a cardiovascular risk greater than 20 percent over the next ten years. This means he is a higher risk individual. It is interesting to note that if he were a non-smoker this would be reduced to moderate risk greater than ten percent over the next ten years. This could be a powerful motivator to persuade him to stop smoking.

Don’t forget to save your answers

41Martin agrees to come back for a follow-up appointment and, as he is leaving the pharmacy, says: “I suppose you’ll be on at me to give up smoking as well”.

3. What are you going to tackle in the follow-up interview?3. Martin has given you the opening to suggest support for stopping smoking, but first you need to check whether he has had any further difficulties or untoward effects from taking his ramipril. If he mentions a cough, explain that this could be due to the ramipril but could also be as a result of his smoking.

Do go through all the questions in the follow-up interview schedule to make sure that you cover all the necessary areas, as well as listening to what he has to say and responding to his expressed needs. Remember that the primary aim of the NMS is to improve adherence to prescribed medicines to take advantage of the attendant benefits to health.

In addition to offering support to stop smoking, this is the ideal opportunity to discuss other lifestyle interventions which may have a positive outcome for Martin. Make sure you have available resources in the consultation room for Martin to take away and consider.

The most important part of the consultation is to let Martin know that while this is the end of the NMS consultation pathway, your door is always open if he feels the need to talk about any of his medicines or if he would like some support once he makes the decision to quit smoking.

Don’t forget to save your answers

Click here to return to the case studies menu

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Hypertension in pregnancy ClareClare Baxter is very overweight with a body mass index matching her age of 31. She has two children and is pregnant again. She has been prescribed methyldopa by her GP because her blood pressure has been raised throughout her second trimester. You counselled her as normal when you issued the first prescription and now, a week later, she has come to see you.

She confesses that she hasn’t started the medication because her mum has warned her not to. Her mum is apparently worried because she works in a different GP surgery and hasn’t seen a methyldopa prescription for years. She told Clare most people are on ramipril or amlodipine. Clare says that she thought she’d speak to you to get you on her side so that you could help her complain to the surgery.

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431. What advice are you going to give Clare about taking her medicine?

1. You should reassure Clare that methyldopa is used in women who have high blood pressure in pregnancy, as it has been for many years. Agree with her that it is not much used in other cases of high blood pressure, which is why her mum won’t see prescriptions for it very often, particularly if she is only handling repeat prescriptions at the surgery. Remind Clare how important it is that she takes her blood pressure medication as prescribed to prevent pre-eclampsia, which can occur in pregnant women with high blood pressure, or heart attacks and strokes, which can result from high blood pressure in anyone.

2. What other advice might you offer Clare?

2. You should remind Clare how important it is to take care of herself when pregnant, something she may have forgotten about with two children to look after. Eating a healthy diet, not drinking alcohol and taking gentle exercise can all help her in pregnancy and reduce her blood pressure as well. Ask sensitively whether she is smoking at present and offer help to quit if possible.

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44Clare returns after a couple of reminders for the follow-up appointment. She tells you that she decided after your last meeting to start taking the methyldopa and is fairly happy with it. She wonders whether it can cause the burning pain at the top of her stomach that she has been experiencing recently.

3. How are you going to address Clare’s question?

3. Methyldopa can cause gastrointestinal disturbances but this pain may be due to the reflux common in many pregnancies. Advise her to eat little and regularly, to space the doses of methyldopa to minimise the chances of reflux and to let the doctor know if it is still a problem in a week or so.

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CreditsCPPE programme managers Geraldine Flavell, regional manager

Lesley Grimes, senior pharmacist learning development

CPPE reviewersMaria Bell, regional manager

Ceinwen Mannall, regional manager

External reviewKathleen Pritchard, pharmacist, Boots

Piloted byClaire Hough, local tutor, CPPE

Paul Jenks, local tutor, CPPE

Penny Mosley, local tutor, CPPE

Samantha Scragg, local tutor, CPPE

Samantha White, local tutor, CPPE

CPPE editorNeil Condron, editor

DisclaimerWe have developed this learning programme to support your

practice in this topic area. We recommend that you use it in

combination with other established reference sources. If you are

using it significantly after the date of initial publication, then you

should refer to current published evidence. CPPE does not accept

responsibility for any errors or omissions.

Acknowledgements CPPE is not responsible for the content of any non-CPPE websites

mentioned in this programme or for the accuracy of any information

to be found there.

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Published in January 2013 by the Centre for Pharmacy Postgraduate Education, School of Pharmacy and Pharmaceutical Sciences, University of Manchester, Oxford Road, Manchester M13 9PT.http://www.cppe.ac.uk

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