Thursday, November 23, 2017

Being a Wise Pharmacist

The Canadian Pharmacist Association (CPhA) just released a campaign called Choosing Wisely Canada for pharmacists.1 This campaign was created to help pharmacists have discussions with patients to identify if treatments are warranted, have evidence to support use, and/or can cause harm to patients.1 The recommendations were made by asking Canadian pharmacists and pharmacy researchers to provide their input, which were then reviewed by an expert committee.The final list was created considering the relevance to pharmacy practice, possible impact and supporting evidence.1 The six evidence-based recommendations were made for pharmacists to help optimize patient care and safety.1

1.   Don’t use a medication to treat the side effects of another medication unless absolutely necessary.2

It is important to clarify if a symptom is part of a medical condition or a side effect to a medication.2 You do not want to initiate a prescribing cascade, as it can lead to polypharmacy.2 The polypharmacy can then generate to more side effects, drug interactions, impact adherence and patient’s quality of life.2

For more information read: The prescribing cascade revisited.

2.   Don’t recommend the use of over-the-counter medications containing codeine for the management of acute or chronic pain.2 Counsel patients against their use and recommend safe alternatives.2

According to evidence, use of over-the-counter pain medication containing codeine is not supported over non-opioid options.2 Codeine has the potential to be abused and cause dependence.2 Furthermore, the codeine containing medications tend to have high doses of the simple analgesics (acetaminophen, aspirin or ibuprofen) which can cause adverse effects with misuse (i.e. liver toxicity, peptic ulcers and renal damage).2 
3.   Don’t start or renew drug therapy unless there is an appropriate indication and reasonable expectation of benefit in the individual patient. 2

About 66% of Canadians over the age of 65 take five or more drugs.2 Polypharmacy increases risk of adverse drug reactions and can lead to hospitalization.2 Pharmacists should clarify the therapeutic indication for all medications and only renew prescriptions if benefits of therapy are known to be greater than the risks.2

A tool to help with this task: Check up on “checking”

4.   Don’t renew long-term proton pump inhibitor (PPI) therapy for gastrointestinal symptoms without an attempt to stop or reduce (taper) therapy at least once per year for most patients.2

PPIs are safe and well-tolerated for short term use in of gastroesophageal reflux disease, but can cause adverse effects if used long term, such as: increased risk of fracture, C. difficile infection and diarrhea, community-acquired pneumonia (CAP), hypocobalaminemia and hypomagnesemia.2 Recommend H2-receptor antagonists or lifestyle changes for patients that have used PPIs for 4 weeks and are no longer symptomatic.2 Note: This recommendation does not apply for Barrett esophagus, severe esophagitis grade C or D, or known history of bleeding gastrointestinal ulcers.2

Tools to help with this task: Bye-Bye PPI and PPI Deprescribing Algorithm

5.   Question the use of antipsychotics as a first-line intervention to treat primary insomnia in any age group.2

Many people have been using antipsychotics for an off-label indication of insomnia.However, there is no evidence to support first-line use in guidelines and there are side effects to consider (i.e. weight gain and metabolic disorders).2

6.   Don’t prescribe or dispense benzodiazepines without building a discontinuation strategy into the patient’s treatment plan (except for patients who have a valid indication for long-term use).2

Benzodiazepines are often prescribed for anxiety disorders and insomnia.2 Long term use in elderly patients can lead to tolerance, dependence, adverse effects (i.e. sedation, impaired memory, falls) and hospitalization.2 Guidelines recommend using other options before benzodiazepines.2 If prescribed they should not be used long term and a treatment plan should be developed (i.e. taper schedule).2

A tool to help with this task: Benzodiazepine and Z-drug Deprescribing Algorithm

These six changes have the potential to make a large impact on patient care and safety. What do you think about these new recommendations? Email me to share your success stories.

A video of the recommendations available as well: 6 Things Pharmacists & Patients Should Question - Choosing Wisely Canada


     1. Canadian Pharmacists Association. (2017, November 21). Choosing Wisely Canada. Retrieved from

     2. Canadian Pharmacists Association. (2017, November). Six Things Pharmacists and Patients Should Question. Retrieved from