North East London Local Pharmaceutical Committee

Introduction to MUR workshop
Welcome!

Here are 20+ MURs to practice with.

The medication the patient is taking is listed, talk to the 'patient' and conduct an MUR as discussed, talk about the points raised such as side effects, understanding and how they actually take the medication.

Do you notice anything else? Are there any other problems?

What do you do now? Do you give a copy to the patient only? Does the GP need to know about any of the issues? Does the GP need to make any changes? Is a full medication review required?
- How did you come to these decisions?

What do you do if the patient refuses to let you share the information? (consent should have been given at the start of the review, if the patient refuses an MUR should not of been claimed for, but remember the patient is still entitled to be counselled on their medication)

Its really important to remember that this is not a clinical medication review. It can't be, because we do not have access to the patients medication record.
Therefore, you may believe that a patient should be taking a statin or aspirin but there may well be a very good reason that they aren't taking it and without the medical notes we will just discredit ourselves in the eyes of the GP if we presume they have made a mistake and start making recommendations.
Any suggestions you want to make need to be done very sensitively for your own protection. Always consider that there may be a medical reason the patient is unaware of and which you are unaware of, which explains why the GP appears to have done something 'silly'.

Some of the points below are clinical and therefore not in the remit of a MUR, but in the real world you may well come across these issues and its important to know how to deal with them, it is in the patients best interests to highlight areas for concern to the GP. These must be mentioned sensitively so as not to worry the patient. If there is anything serious then the GP should be called for advice.

The points below are ideally what should be noted from each MUR.

Mur 1 = Diabetic patient

NICE (May 2008) has recommended that, if insulin is required in patients with
type 2 diabetes, insulin glargine may be considered for those:
" who require assistance with injecting insulin or
" whose lifestyle is significantly restricted by recurrent symptomatic hypoglycaemia or
" who would otherwise need twice-daily basal insulin injections in combination with oral antidiabetic drugs.

- Not taking metformin with food can lead to gastric side effects as a result - Suggest he take it with food and perhaps a modified release formulation would be useful?
- Amlodipine - leg oedema, refer to GP
- Is lowering blood pressure at night contributing to falls, is he feeling dizzy? Also, could they be making him more drowsy & liable to fall?
- Bendroflumethiazide at night is causing him to get up for the loo a lot, in combination with the lower blood pressure and tiredness this is a very risky situation.
- Temazepam - increasing to tiredness and falls at night but after so many years and his age its probably not worth trying to withdraw it.

MUR 4 = Opioids in the elderly

- Renal function reduced in the elderly so risk of accumulation increased.
- Patient is taking lots of opiods - buprenorphine, codeine, dihydrocodeine and morphine.
- Pain is not controlled and they need a pain management review to ideally be stepped up the pain ladder with a reduction in the number of opioids prescribed.
- Patient is feeling drowsy all of the time but pain is not being managed, potential build up of the opioids.
- No laxatives??? What are the bowels like with so much constipating medication?


MUR 5 = Asthma patient

- Prescribed as acute medication and left as chronic?
- It would not be suitable to tell him to re-start the beclomethasone after so long when the asthma scale does not support its use.
- Recommend a full medication review with the GP or asthma nurse.
- Smoking cessation and referral for a VRA.

MUR 6 = COPD patient

- Encourage to quit smoking but remember nicotine interaction with aminophyline
- Ensure pt can recognise symptoms of an exacerbation
- Ensure steroids & antibiotics are used appropriately
- Check steroid useage. Do they need a steroid card?
- Check inhaler technique
- Are they using oxygen? Dangers of smoking at the same time! Shouldn't increase the air flow, it is v.v. dangerous in COPD as oxygen is retained in the lungs.
- Able to use neboules ok but how many? s/e of salbutamol overdose? Tremor. Which mouth piece is being used? What is the relevance of this?
- Flu vaccination
- He is experiencing palpitations, these could be due to low K or high theophylline levels, safer to refer to GP?
- Encourage him to start pulmonary rehabilitation.
- Ipratropium can cause constipation so check bowel habits.


MUR 8 = Pregnant women

- Long term laxative use for last 6 months
- Pregnant - are all the laxatives suitable? What about bulk forming ones?
- Co-dydramol use for back pain - shouldn't be used close to term due to risks to babies respiration during labour. Discuss alternatives. Is the suggestion appropriate?
- Folic acid being taken for last 6 months, guidance suggests it was only necessary for the first 12 weeks and only at the higher dose if she were still taking the antiepileptics.
- Epileptic, but has stopped her medication with the support of her consultant due to the risks to her baby. Could advise her that if fits become more frequent she should see her consultant again.


MUR 9 = Levothyroxine patient

- She is very overweight and her BMI classes her as obese. With the hypothyroid problems she is at an even greater risk of diabetes. Encourage her to join a weight management programme.
- Whilst the advice is that thyroxine should be taken in the morning before food, there are studies which suggest that taking it in the evening actually results in better blood levels. This is not true if there is food, etc in the stomach which prevents absorption so advise cautiously.
- Repeat dispensing referral?

MUR 10 = Multiple medications

- Dose of amlodipine is higher than that recommended by the BNF or SPC. How is this referred to the GP so as to not affect the patients confidence? Dose is not dangerous according to the SPC.
- Blood pressure is not controlled - refer to GP for review.
- Alendronic acid but no calcium supplement. She complies with directions except that she takes it in the afternoon. Advise her that her stomach may not be completely empty at that time and the medication may not be absorbed properly.
- Trimethoprim 100mg at night to prevent recurrent UTI (any kidney function issues?)
- Specials - the aspirin and trimethoprim ordered as a special is unnecessary and VERY expensive. Would a different brand of atenolol be easier for her to swallow?


MUR 11 = Antipsychotic medication

- 29yr old male, schizophrenic, positive and negative symptoms, works as a part time delivery
Driver - check out drowsiness side effects!
- Alcohol interaction, Extrapyramidal side effects
- Fluoxetine can alter the plasma level of risperidone, as he is taking it randomly it might be fluxuating the risperidone dose?
- If all happy then may be suitable for repeat dispensing.

MUR 12 - HIV patient

- Rash common with efavierenz but mild, CNS s/e also likely so best to take at nighttime.
- Given liquids for the antiretrovirals but taking simvastatin tablets? Patient can swallow tablets and would rather have them but has always been prescribed liquids, it makes it very hard to bring when out for an evening and very hard if flying anywhere!
- Taking simvastatin for high cholesterol as a result of s/e and insulin for resistance caused by the s/e of the antiretrovirals.
- She knows the risk of pregnancy, would need to talk to doctor about a change in med's.
- She has regular blood tests for viral load, diabetes and cholesterol.
- Avoid grapefruit juice
- Contraception - suggest progesterone only as oestrogen effect is reduced.
- Lifestyle advice on loosing weight to help manage diabetes.

MUR 13 = AF patient

- Amiodarone has recently been added in preparation for cardioversion.
- The dose of digoxin needs to be halved due to amiodarone interaction and the dose of warfarin will probably need to be lowered as well. Increased monitoring required.
- Before starting amiodarone the patient should have undergone a number of tests e.g. chest xray, blood tests - thyroid function, LFT's, etc and regular eyesight tests are required.
- Warn patient to keep out of direct sunlight and use high factor sun lotion, hat, etc if being exposed.
- The dose of amiodarone is TDS only for the first week, then reduced to BD for 1 week and then down to once daily. Ensure this is explained.
- Warfarin should not be labelled with a dose, always 'as directed by yellow book' or something similar.
- Digoxin was not written on the discharge report and has therefore not had the dose halved. Is this a mistake by the hospital or has it been stopped?
- Refer to GP for medication review.


MUR 14 = Intervention MUR as she was buying interacting products whilst waiting for Rx.


- Warfarin added after the pt has been using herbal supplements for over 20yrs. Her body is used to the herbal medication and the warfarin should be titrated safely against it.
- Warfarin + aspirin - aspirin is used for arterial risk and warfarin for venous effect. Her risk of stroke means she may need arterial antiplatelet action. This combination can lead to an increased risk of bleeding and she should be made aware of the risks and benefits.


MUR 15 = Interaction based

- Cimetidine interacts with erythromycin to give potentially dangerous plasma levels leading to increased risk of deafness, etc. suggest change to another abx?
- Cimetidine also interacts with phenytoin to increase the plasma levels. The patient has been feeling confused and dizzy for a few days which could be a symptom of phenytoin overdose.
- Refer to GP asap.
- Contraceptive effect of microgynon is reduced by both the phenytoin and erythromycin. Probably sensible to use another form of contraception such as a coil.
- Note penicillin allergy.

MUR 16 =eye drops.

- Intervention MUR as she has been collecting the drops on a weekly basis for ages.
- Mrs Wright is over 90yrs old and her vision is not perfect. She has arthritis in her hands and finds it very hard to get the drops into her eyes. She has been collecting a prescription almost every week because she wastes so much down her face.
- Supply her with a compliance aid, a device which the bottle is attached to so that it is easier for her to squeeze the bottle.
- Concerned about overdose of xalatan - SPC says any overdose would be treated symptomatically and she has had no symptoms.
- Using diclofenac regularly for RA but no PPI cover?
- Co-proxamol is being used for occasional pain relief - unlicensed. Would paracetamol regularly be better?

MUR 19 =stroke -&

- Use non -click lock bottles and pop tablets into the bottles to help with physical problems
- Enteral guidelines suggest that amlodipine can dissolve in water whilst simvastatin and clopidogrel can be crushed and dispersed in water to help with swallowing difficulties. These are all unlicensed uses, but requesting a specials company to produce a suspension would also be unlicensed.
- Can the patient crush the tablets with the aid of a crusher?
- Her sudden disability has meant her weight has increased dangerously and she needs support with a better diet and exercise to learn to manage her weight.
- Smoker - smoking is a huge risk factor for stroke. Due to her mobility problems and the extreme boredom leading her to smoke so much a specialist stop smoking team would probably be needed as her case would be too complicated for the pharmacist to give her the best care support available.

MUR 20 =Eczema

- Mild - moderate eczema over the body.
- She is currently applying the emulsifying ointment before the hydrocortisone cream. This will reduce the absorption of the cream. Applying the steroid, waiting a few minutes and then applying the ointment would be the better method. The ointment should also form a seal over the cream to prevent it being wiped off accidentally.
- The chlorpheniramine is prescribed as piriton, is the family happy to try the generic version and save the NHS some money?
- Salbutamol is being used more than once every day, according the asthma ladder this should mean a steroid inhaler is required. She is already very worried about the amount of steroids being used.
- It might be a good idea to give Yasmin a steroid card.