Patient counseling

Patient counseling is a process wherein pharmacist implements face-to-face interaction with the patient to provide information, orally or in written form, on directions of use & advice on side effects to help them to use their medications appropriately

1. Patient Counseling

2. Patient Counseling Definition “Patient counseling is a process wherein pharmacist implements face-to-face interaction with the patient to provide information, orally or in written form, on directions of use & advice on side effects to help them to use their medications appropriately.” Patient counseling is a – Type of talk therapy Professional advice

3. Methods of Patient counseling Face-to-face interactions Telephone calls Make an appointment Counsel at refill Referrals Drug information aids- Pictures, posters, leaflets, brochures Qualities of a good patient counselor Good listener Flexible Non judgmental Tolerant Empathetic Communicate confidently

4. Counseling process uses… Verbal communication- Language, tone, volume & rate of speed Non verbal communication- Body language, movement, proximity, eye contact & facial expression. Effects of poor/no patient counseling Adverse effects Therapeutic failure Drug interactions Poor medication adherence Misuse or overdose of drugs

5. Benefits of Patient counseling To understand the patients & their illness To frame strategies to deal with the health issues Helps to ensure that correct medicine is supplied to the correct patient Helps in improving patient adherence to the treatment plan Helps to decrease medication errors & misuse Provides an educational experience to both pharmacist & a patient To build trusting relationship with patients To encourage patients to learn about their treatment Prevention of adverse events, drug interactions, drug food interactions. Patient will have a better understanding of the purpose for the prescribed therapy & appropriate use of the medication.

6. Patient Counseling Stages of Patient counseling

7. Introduction It is the first stage of counseling initiated by the pharmacist Welcome the patient with smile Pharmacist introduces himself to the patient Review the patient record Explain the purpose of counseling Obtain information related with patient, his symptoms, medications, allergies, use of herbals etc. Assess the patient’s understanding of the reasons for therapy Assess any actual or potential problem.

8. 2. Counseling content Counseling content is the heart of the counseling session. Pharmacist explains treatment regimen as well as lifestyle changes including diet, exercise & habits . Counseling content includes- Issues regarding medication Generic name, brand name & strength of medicine The reason why it has been prescribed How it helps the patient How much to take at one time Frequency of dose When to take it (before, during, after meals; at bedtime) How to take it (With water, milk or fruit juices) What to do if patient miss a dose Possible side effects & how to minimize side effects

9. 2. Issues regarding manner of conveying Use of simple words & language Use of appropriate counseling aids Use of open ended questions Don’t pass any opinion directly to patient on medications prescribed by patient’s doctor Emphasizing the necessity of medication adherence. Counseling aids

10. 3. Counseling process The counseling process is a plan that the pharmacist & the patient work on together. The pharmacist must demonstrate- Removal of medicines from the container Use of inhalers Instillation of an eye drop or eye ointment Pharmacist should provide information on route of administration, dose of drug, time of administration, storage conditions of medications. He should clearly advise patient about the possible interaction of drug with food , tobacco, alcohol. He should provide other supportive information asked by patient.

11. 4. Closing the counseling session It is the final stage. The characteristics of good closure include- Verifying the patients understanding by means of feedback Summarizing by highlighting key points Giving an opportunity to the patient to put forward any concerns Helping the patient to plan follow-up . Pharmacist should document counseling points in patient’s medical records, pharmacy’s patient profile, medication order or prescription form.

12. Barriers to effective counseling A . Effective patient counseling in community pharmacy is a difficult task, due to the following barriers:

13. Pharmacist/Provider related barriers Lack of confidence or skill Problem with language Lack of enthusiasm by the pharmacist Business motives of pharmacist Lack of training & time Lack of knowledge about patient’s disease condition Wrong perception of the pharmacist’s role Attitude & beliefs of pharmacist Judgmental attitude Religious difference Lack of cooperation from patient

14. 2. Patient related barriers Illiteracy or lower educational level to learn medication knowledge Poor listening & physical inability Lack of time Lack of trust Patient may feel shy Emotions Difficulty to understand the language of pharmacist Gender difference Failure to disclose

15. 3. System related barriers Lack of privacy in community pharmacy Lack of enough space Lack of time Lack of pharmacists Pharmacist not having access to to the patients full medication history

16. B. Barriers to effective patient counseling include: Physical barriers Mental/ situational barriers Physical barriers a) Pharmacy environment- Lack of privacy Insufficient space Absence of furniture between pharmacist & patient during counseling. b) Dispensing counter- Odd dispensing counter position c) Uncontrolled noise- Lot of noise Unfavorable atmosphere

17. 2. Mental or situational barriers Time constrain ts- Insufficient time Large no. of patients per pharmacist Patient’s eagerness to leave pharmacy b) Insufficient knowledge- Pharmacist may not have sufficient & upgraded knowledge of pharmaceutical technology & skills, new medications 7 their use. c) Lack of confidence- Pharmacist have little confidence in their medication related decision- making skills They don not feel responsible for their patients. d) Poor communication- Lack of good communication skills Inappropriate body language & voice Disinterest Nervous habits

18. e) Unrecognized language- Patient don’t understand pharmacist’s language f) Poor perception- Public has doubts about the pharmacist’s capabilities g) Embarrassed patients- Patients with privacy issues such as erectile dysfunction, birth control may feel embarrassed. h) Know –It –Alls- Patients discourage pharmacist’s concern by saying’ “I am taking this medication since long days” or “ The directions are right there on the label.” i ) Semantics- Pharmacist is not aware of the multiple meanings of the words or symbols. j) Negative attitude- Pharmacist’s & Patient’s negative attitudes towards counseling sessions.

19. Strategies to overcome the barriers of patient counseling Pharmacist should first identify the barriers & then offer to counsel a patient. Various strategies used to overcome barriers in effective patient counseling are: Use of multimedia materials Pictograms Oral or written information Compliance aids Follow up schedules Audio visual tapes Checking for understanding Seeking participation Effective questions Summarizing what has been said Body language Motivate the receiver

20. Strategies to overcome the physical barriers Innovative pharmacy design Easy access to the pharmacy Parking facility for patient’s vehicle Dispensing counter should be at front for easy access Pharmacy atmosphere should be warm & favorable Reasonable amount of privacy Computer should be available to provide information at all times. Provision of waiting area Leaflets providing information of various health topics

21. 2. Strategies to overcome the mental barriers Spare time- Allocating appropriate time for each patient This will increase in medication adherence Knowledge adequacy Acquiring adequate & updated knowledge about health problems & medications Develop confidence Encouraging patients to ask questions about their medication Participate in health camps Speaking slowly, using simple words & adult tone Limiting the message up to 3 main points Requesting for feedback Improve communication Pharmacist should improve communication skills, language fluency Make use of isolated counseling area Maintaining interpersonal space Appropriate use of body language, voice, positive attitude, eye contact

22. Eliminate language gap Pharmacist should have good command over language skills Appointing multilingual staff Translation service can be hired to provide interpreters over the phone Improve perception Pharmacist should not be only traders of medicines. They should work hard towards their consistent self- development in terms of knowledge & confidence Eliminate prejudice & preconceptions Pharmacist should be able to put preconceived prejudices aside & treat each patient with concern & understanding Improving ptient’s health literacy Provide simplified written instructions & visual aids such as pictograms & charts to improve medication adherence Provide sufficient staff There should be enough number of pharmacists dedicated for education & counseling

23. Learn to listen & understand It helps to gather all the information needed for best counseling Pharmacist should give the patient 100% of their attention Provide support & advice Recording visits Use of personalized video recording Help to recover information transmitted in past Increase compliance Improve patient satisfaction Others Refill reminder technology Medication synchronization program Multidose compliance packaging

24. Multi-dose compliance packaging

25. Patient counseling points for chronic diseases/ disorders Patient counseling is the process of providing information, advice & assistance to help patients to use their medications appropriately. Chronic diseases are conditions that last for year or more & require ongoing medical attention or limit activities of daily living or both.

26. Hypertension Blood pressure is the force exerted by circulating blood against the walls of the body’s arteries, the major blood vessels in the body. Hypertension is when blood pressure is too high . Type Systolic pressure (mm Hg) Diastolic pressure ( mm Hg) Normal blood pressure 120 80 Elevated blood pressure From 120 to 129 Below 80 Stage 1 hypertension From 130 to 139 From 80 to 89 Stage 2 hypertension From 140 or higher 90 or higher Hypertensive crisis Higher than 180 Higher than 120 Table: Blood pressure measurements

27. a. Non- medication measures Weight reduction Regular exercise Meditation & relaxation Use of supplementary diet containing potassium, calcium, magnesium Restriction of sodium intake Stress reduction Increased intake of dietary fibers Restriction of alcohol intake, smoking Self- monitoring of blood pressure

28. Take your medications exactly as prescribed- don’t skip days or cut tablets in half b. Medication treatments Drug category Counseling points Diuretics ( Thiazides, Furosemide) Monitor for muscle weakness, confusion, dizziness Explain about the possibility of drug interactions with ACE inhibitors Select appropriate dose timing to avoid frequent urination in the night. Beta blockers ( Propranolol, Atenolol ) Monitor for hypotension, dizziness, headache, bradycardia, nocturnal dreams, impotence & CNS problems. ACE inhibitors ( Enalapril , Captopril ) Monitor for hypotension, dizziness, cough, taste disturbances & rash

29. Drug category Counseling points Calcium channel blockers (Amlodipine, nifedipine ) Monitor for swollen gums, chest pain, swollen joints, constipation, dizziness, light- headedness Educate the patient to swallow the extended release tablets as a whole Alpha blockers ( Prazosin , Terazosin ) Monitor for hypotension Do not crush or chew gastrointestinal tablets Antihyperlipidemic drugs ( Simvastatin, Lovastatin ) This drug may cause nausea, vomiting, dizziness, headache, cough, hypotension Advice patients against sudden discontinuation of drug

30. 2. Diabetes Mellitus Diabetes Mellitus is a metabolic disorder characterized by hyperglycemia, abnormal lipid & protein metabolism along with specific long- term complication affecting the retina, kidney, & nervous system. Type 1 (Insulin dependent) - Pancreas produces little or no insulin Type 2 (Non- insulin dependent)- Impairment of the Sugar utilization

31. a. Non- medication measures Weight reduction Regular exercise Meditation & relaxation Stress reduction Restriction of alcohol intake, smoking Use of supplementary diet containing potassium, calcium, magnesium Provide information about Acupuncture, hydrotherapy, massage therapy, yoga, etc. Help patients in creating their meal plan in consultation with registered dietitian Recommend on fasting & post- meal blood glucose level testing Help to reduce diabetes- related distress & depression through counseling Pharmacist can give an overview of diabetes; family involvement & social support.

32. b. Medication treatments Drug Counseling points Sulfonylureas Explain methods for preventing, detecting & managing hypoglycemia Monitor for symptoms of jaundice Discuss dose timings Insulin Explain methods for preventing, detecting & managing hypoglycemia Instruct to rotate injection site Instruct patient to monitor for symptoms of hyperglycemia Advice patient to never share insulin pens or cartridges Consult doctor in case of unfortunate i.v. dosing Metformin Monitor for muscle pain, unusual sleepiness, nausea, stomach pain, weight loss Patient should take tablets with meals Instruct patient to maintain hydration to prevent renal dysfunction

33. Drug Counseling points Glimipride Instruct patient to take drug with breakfast or with first main meal of the day Monitor for hypoglycemia Consult doctor prior to new drug use Sitagliptin Advice patient to report severe joint pain Instruct patient to report symptoms of pancreatitis Inform about side effects of this drug that may include headache, nasopharyngitis , or upper respiratory infection.

34. Asthma causes inflammation in the airways in the lungs. The resulting swelling & narrowing of the airways make it harder to breathe. Patient counseling points for Asthma Pharmacist can play an active role in counseling the patient regarding life style modifications & self monitoring of drug treatment & use of metered dose inhalers, dry powder inhalers, spacers.

35. Non medication measures Advice on controlling stress & other intense emotions such as anger Deep breathing exercises & meditation Suggest about identifying & eliminating triggers of asthma attacks Suggest lifestyle practices such maintaining body weight, getting enough sleep Provide information about acupuncture, massage & hypnotherapy Advise to wear warm clothes during the winter season to avoid asthma attack Suggest wearing mask to protect against exposure to asthma triggers.

36. Drug Counseling points Beta receptor agonists Short acting drugs belonging to this category should be used mainly for symptom relief Patients on long acting drugs should be informed about delayed action of these drugs Theohylline Take exactly as directed by doctor. Do not take more or less of it Take this medication with a full glass of water on an empty stomach, at least 1 hour before or 2 hours after a meal. Swallow the extended-release tablets whole; do not chew or crush them Salbutamol Advice patient on proper inhalation technique Advice patient to report symptoms of atrial fibrillation, supraventricular tachycardia or hypokalemia b. Medication treatment

37. Drug Counseling points Anticholineergics Monitor for dry throat, nausea, headache, blurred vision, & painful urination Montelukast The drug may cause aggressive behavior, agitation, dream disorder or hallucination The drug may cause palpitations, headache, seizures, tremors, & nervousness Mast cell stabilizers ( Cromolyn sodium, nedocromil sodium) This medicines should not be used during an acute asthma attack, pregnancy, & in breast feeding women.

38. Patient counseling for Tuberculosis Tuberculosis is a potentially serious infectious disease that mainly affects the lungs. Caused by Mycobacterium tuberculosis Spread from person to person through tiny droplets

39. Non- medication measures Patient must be informed of all relevant information about the disease, its symptoms, the tests, duration of treatment, follow- up Once TB is diagnosed, patient should be screened for HIV & other conditions such as diabetes Patients should be made aware of fact that TB is fully curable & treatable disease Patients must be informed of adverse events during therapy Patient must be provided with free/ public services available to patients

40. Drug Counseling points Ethambutol If patient takes antacids containing aluminium , instruct them to take this medication at least 4 hours before the antacid. Ask to continue to take this medication until the full prescribed amount is finished, even if symptoms disappear. Isoniazid Instruct to take this medication on an empty stomach, at least 1 hour before or 2 hours after a meal Instruct to take this medicine for the full prescribed length of time Counsel on if doses are skipped may increase resistance to this medication Instruct to take this medicine for the full prescribed length of time Instruct not to drink alcohol while taking this drug b. Medication treatment

41. Drug Counseling points Pyrazinamide Make an enquiry if patient is allergic to pyrazinamide, or any other drugs Enquire if patient ever had gout, liver or kidney disease, or diabetes. Instruct to avoid prolonged exposure to sunlight or use sunlight protection aids Rifampicin Instruct patient not to take this drug with praziquantal If patient is taking antacid, instruct to take rifampicin at least 1 hour before they take antacid Instruct patient not to take hormonal contraceptives during treatment with rifampicin as it decrease the effectiveness of hormonal conraceptives . Pharmacists should use Directly Observed Therapy (DOT) to ensure efficacy & minimize resistance Strictly monitor patient medication adherence, nutrition & infection control

42. COPD is a chronic inflammatory lung disease that causes obstructed airflow from the lungs. Patient counseling points for Chronic Obstructive Pulmonary Disease (COPD)

43. Non medication measures Pharmacist should provide advice & education on dosage, treatment expectations & he importance of adherence. Instruct patient to stop smoking & also provide nicotine replacement advice Encourage patients with long- term COPD to eceive a yearly flu vaccination Demonstrate the use of inhalers Provide support using ‘self management’ plans Provide advice on lifestyle adaption such as diet, nutrition & exercise Make patients aware of significance of air quality

44. Drug Counseling points Levalbuterol Prescribed dose & frequency of taking this medication Do not change the dose unless doctor instructs to do so If dose of this medicine is missed, take it as soon as possible Corticosteroids Inform about possible side effects: sore throat, cough, mouth infections Direct patient to rinse & gargle the mouth with water on using inhaler Inform about pneumonia risk with long term use of inhaled steroids Methylxanthines Instruct not to discontinue taking this medication on initial side effects Inform to avoid caffeine- containing beverages with this medication b. Medication treatment

45. Drug Counseling points Azithromycin Instruct patient using oral tablets & regular suspension to avoid use of aluminium or management- containing antacids Advice patients to immediately report signs/symptoms of hepatotoxicity or Clostridium difficile - associated diarrhea Take medicine on an empty stomach Ciprofloxacin Instruct patients to report symptoms of tendonitis or tendon rupture, especially if elderly &/or using concomitant steroids Advice patients to use sunscreen, avoid tanning beds & avoid excessive exposure to sunlight as drug causes phototoxicity

46. Patient counseling for AIDS Human Immunodeficiency Virus (HIV) is a virus that attacks the body’s immune system. If HIV is not treated, it can lead to acquired immunodeficiency syndrome (AIDS). Symptoms: Rapid weight loss, recurring fever, night sweat, tiredness, swelling of lymph glands in the armpits, neck, diarrhea, sores of the mouth, anus or genitals & pneumonia.

47. Non- medication measures Patient must be informed of all relevant information about the disease, its symptoms, the tests Provide information about the prevention of HIV transmission Help patient by counseling & monitoring response to therapy Provide individual, relationship, & family counseling to prevent & reduce psychological morbidity associated with HIV infection & disease. Instruct patient to use an effective barrier method during sexual activity. Counseling should mainly focus on emotional & social issues related to infection with HIV & AIDS

48. Drug Counseling points Zidovudine Inform patient that this medication controls HIV but does not cure it. Ask patient to continue to take this medication even if they feel well. Ask patient if they ever had kidney disease. Advice patient to report anemia, or bone marrow problems, unusual bleeding, fever, chills during use of this drug. Tell to take this medication 2 hours before/after taking clarithromycin. Didanosine Instruct patient to take this medication on empty stomach Instruct patient too shake this oral liquid medication before taking Advice patient to take this drug on empty stomach Advice patient not to take didanosine with allopurinol or ribavirin medications. b. Medication treatment

49. Drug Counseling points Abacavir Enquire patients for allergic reactions to this medicine Ask patient for existence of any of the chronic disease. Inform interactions of this drug with alcohol, methadone & orlistat Advice patient to report sign/symptoms or side effects of this drug to doctor. Tenofovir Instruct patient not to mix tenofovir oral powder with liquid Advice patient for not to discontinue therapy as virus may become resistant to medications Advice patient for not to take a double dose to make up for a missed one.

50. Patient Package Insert can be defined as an officially approved technical document of prescription or OTC medications containing information about that medication & its use written in plain language intended for the end-user, the person who will take the drug or give the drug to another person, such as a minor. Patient Package Inserts (PPIs)

51. Importance of PPIs PPI is essential in cases when verbal means of communication are inadequate. Patient awareness & maintain medication adherance Patient health education To strengthen & supplement verbal counseling It is an effective means for conveying additional prescription drug information to patients. To obtain information relating to the medicine It helps doctors & pharmacists to give basic information about the amount of medicine to be taken, how often, with additionally a word of caution about side effects. It also presents drug information for patients such as dose, route & method of administration, precautions & storage It also provide information on storage & expiry date of medicines. Easy to understand without difficulty PPIs provided with regional language help average people to read them easily

52. Sections of the PPI Description - Proprietary name, Non- proprietary name, dosage form, ingredient information, pharmacologic & therapeutic class of drug, Chemical name & structural formula of drug Clinical pharmacology- Mechanism of medication in the body, drug absorption, metabolism, elimination, findings of clinical trials Indications & usage- It includes uses for which the drug has been approved, e.g. Asthma, Diabetes, Contraindications- List of conditions in which the medication should not be used. Warnings- Information on possible serious side effects Precautions- Information & guidelines for safe use of medication. E.g. Take this medication on empty stomach. Adverse reactions- List of all side effects

53. 8 . Nonclinical toxicology- It provides information about carcinogenesis, mutagenesis, impairment of fertility, animal toxicology & pharmacology 9. Drug abuse & dependence- information regarding prolonged use of drugs can cause physical dependence 10. Storage & handling- handling guidelines & special storage conditions 11. Name & address of Manufacturer 12. Date of Revision of package insert 13. References - List of various print & digital resources: regulatory agencies websites, journals, compendia etc used to collect information.

54. Benefits of Patient Package Insert PPI helps healthcare providers to prescribe a drug properly, including counseling patients for approved uses of drug, contraindications, adverse reactions, available dosage forms, administration of drug. PPI help patients to administer medications appropriately It provides vital medication data for use of OTC medications PPI improves patients’ learning about drugs PPIs are designed to assist or help patient by utilizing illustrations. Simplicity of PPI makes it easy to comprehend the data. Educated persons can easily understand information provided in PPI.

55. Scenarios of PPI use in India The concept of package insert in India is governed by the ‘Drugs & Cosmetics Act 1940 & Rules 1945.’[section 6 of schedule D(II)] Section 6.2 - Directs to provide package insert in English, information on posology , Method of administration, contraindications, special warnings & precautions, side effects, interactions, etc Section 6.3 - Directs to provide pharmaceutical information such as list of excipients , shelf life, incompatibilities, storage precautions, instructions for use/handling. There have been considerable improvements in the package inserts since 1996. The practice of self-prescription is prevalent in India & the concurrent increase in number of OTC drugs available specifies the need of a patient- oriented package insert.

56. Package insert must be in an understandable language Considering the lower level of literacy & diversity in language of Indian population , it is important to improve the range of package inserts. Package inserts in India have improved over the years optimizing them carefully for completeness of information contained before the respective drug is being marketed is essential to minimize the risks to patients. The format & contents of package insert followed in India needs to be revised for its effective utilization. At the same time, there is need to create awareness among the people towards use of package inserts for their health benefits .

57. Scenarios of PPI use in other countries In USA , the concept of a patient package insert is in practice since 1968. In USA this document is also called as “Prescribing information” or “Package Insert” Layman’s document is called the “Patient Package Insert” The PPI in USA is much more patient oriented & thus also known as ‘Patient-Oriented Package Insert.’ Since 1999, every medicine distributed within the European Union (EU) has been required to include . To insure package insert uniformity in each EU member state, content & layout are determined mainly by the European guidelines & recommendations.

58. The Australian model of package insert is developed in the 1990s. This model insists for package insert readability test The South African administration has made their approved package inserts available to the public, in an electronic format. In the Czech Republic & France the transition is still under discussion. Austria, Germany, Ireland, Italy & the UK have implemented the new rules.

59. Patient Information Leaflet (PIL) Patient Information Leaflets are defined as written or printed document in simple language that provides the essential information which patients need to enable them to use medicines safely & gain the most benefit.

60. The content of PIL must be clear, understandable & well- readable

61. Example of PIL

62. Uses Used as a good quality sources of medication & health information PILs provide information to patients about the administration, precautions & side effects of their prescribed medication Good practice to increase patient’s education Reading PIL, patients can understand their diagnosis, treatment & prognosis with much more clarity It is a part of health promotion It is used to encourage patients for their better participation in managing long-term conditions Used to support pharmacist- patient counseling Helps to improve treatment outcomes Helps to create patient awareness of the benefits of their medication

63. References Dr. Hajare A. Community Pharmacy & Management. Nirali Publication, 2022. 1 st edition. pp: 5.1-5.42. Mistry S. Patient counseling. Solution Pharmacy, 2022. Available from: https://solutionpharmacy.in/patient-counseling/ Dr. Yadav AV, Dubal A. Community Pharmacy & Management. Nirali Publication , 2022. 1 st edition. Chapter 5. Ganpisetti R. Strategies to overcome barriers of patient counselling . Slideshare , 2018. Available from: https://www.slideshare.net/rameshganpisetti/strategies-to-overcome-barriers-of-patient-counselling