Drugs Recommended by Pharmacy Professionals in “Real Life” Pharmaceutical Practice

Pharmaceutical consultation is an integral part of modern information services provided in pharmacy organizations around the world. The functions of pharmaceutical specialists can vary significantly depending on the legislation of the countries and the needs of visitors. However, pharmacy workers are effective and accessible sources of information for visitors.

So, in 2012, the National Agreement of Pharmacists was initiated in France, and then in 2013 it was amended to introduce the “Pharmaceutical Consultation.” These consultations should be conducted by the pharmacist with the patient in a confidential area in the pharmacy or at the patient’s place of residence. The goal is to reduce the incidence of negative side effects of medical treatment (Vitamin K antagonists, direct oral anticoagulants, and inhaled glucocorticosteroid) and to improve the proper use of drugs, so to ensure patient safety. On its own, the number of non-subsidized talking initiatives carried out by pharmacists (anti-tobacco, pregnancy, diabetes) is increasing.¹ In accordance with the bill “Hospital, patients, health, territories” recommendations of July 21, 2009, community pharmacists are heavily investing in new missions concerning, as well as prevention and screening as therapeutic patient education. Pharmaceutical conversations are aimed, on the one hand, at improving compliance with chronic drugs available in elderly patients, and, on the other hand, at preventing iatrogenias, polypragmasy.²

Evidence from a systematic literature review conducted in Spain demonstrated that of the identified pharmaceutical interventions, medication review has been the most frequently studied activity, followed by patient education, risk and prevention and medication reconciliation. Only 36% had outcome measures with an impact score. 48% had a positive effect.³

The experience of consulting services of community pharmacists in nutrition and weight management is interesting (Portugal). The results of this study show that satisfaction among those attending nutritional consultations is high, particularly due to the availability and proximity of pharmacies hinting at the idea of efficacy as an important determinant of demand for new health services.⁴

Four consultation tools (Calgary-Cambridge guide, MRCF, MUR and NMS advanced services and PaCT) were analyzed in the UK. None of the identified tools provided a suitable format or sufficient guidance to address all the components necessary to conduct a person-centered consultation with a patient in practice.⁵ The results of another review (UK) showed that in terms of the contribution of community pharmacy staff to consultations for Over-the-Counter (OTC) drugs, non-pharmacist staff dealt with a significant proportion of consultations and pharmacists were routinely engaged in referral consultations from non-pharmacist staff. Where advice was provided, it was not always of sufficient quality. Consultations were much better when symptoms were presented compared to when people made a direct request for a product. Pharmacists provide better advice than non-pharmacists. There was evidence that where consultation was appropriately provided, it provided a safe environment for the person to use their OTC.⁶ Another study assessed the number and nature of urgent care requests presented in a sample of community pharmacies in three counties in southern England. 95% of customers surveyed were satisfied with the service and will use the⁷ pharmacy again. One alternative source of medical and pharmaceutical information may be a health kiosk (UK). Its other functions are a collection of clinical measurements, self-registration of patients, telemonitoring and teleconsultation.⁸

According to a review (Canada) conducted (January 2020-July 2007), the provision of sexual reproductive health information services by pharmacists was feasible, able to reach vulnerable and high-risk groups, and the interventions were highly valued by users.⁹ A cross-sectional study was conducted in 11 community pharmacies in Quebec (Canada), with a total of 4994 consultations conducted. Patients seek advice from pharmacists on various health issues; pharmacists can manage most of these consultations with high levels of patient satisfaction.¹⁰

Pharmaceutical consultation is also in demand in Asia. Based on research in Saudi Arabia and the United Arab Emirates, expectations for pharmacist duties included: treating minor illnesses, consulting on over-the-counter drugs and parapharmaceutical products, and checking the accuracy of dispensed drugs. The most reported recommendations to improve pharmacy practice were the provision of diagnostic, screening and monitoring services, the maintenance of patient records at the pharmacy, counseling for minor diseases, and the provision of a private consultation area.¹¹

According to the Japan Revitalization Strategy (2013), “pharmacies should become a community-based center for providing information, advising on the correct use of OTC drugs, etc., and offering health consulting and information services.” “Demanded Function and Ideal Form of Pharmacy” (January 2014) demanded a change from pharmacies specializing in dispensing drugs to pharmacies that serve as whole medical points, providing pharmaceutical care based on patient history, including the consumption of dietary supplements.¹²

In the Russian Federation, one of the main documents regulating pharmaceutical activities is the Good Pharmacy Practice standard. The main functions of pharmaceutical workers include: selling pharmacy assortment goods of proper quality; providing reliable information about the products of the pharmacy assortment, their cost, pharmaceutical consultation; informing about the rational use of drugs for the purpose of responsible self-medication. The duties of pharmacy workers include: improving knowledge about drugs, including reproduced and interchangeable ones, the ability to provide comparative information on prices, new drugs, dosage forms, indications for the use of drugs.¹³

Many studies are conducted aimed at studying the satisfaction of visitors, and insufficient attention is paid to the drugs recommended in the process (information component). However, errors are possible when conducting pharmaceutical counseling, which can lead to serious health consequences for the visitor. Prospective studies and experiments are needed to evaluate the conduct of pharmaceutical counseling in “real” conditions. At the same time, for an objective assessment of the content, a “blind” study is most appropriate, as well as recreating situations with the most common causes of treatment, with further analysis and identification of errors, for subsequent optimization of drug care. The purpose of this study is to analyze the recommendation of drugs by pharmacy professionals in the conditions of “real” pharmaceutical practice.

A prospective study in pharmacy organizations in Khabarovsk city. The subject of the study was a pharmacy organization. The sample of pharmacies was 100 organizations. The location of the pharmacies covered all areas of the city. There were no strict criteria for the inclusion and exclusion of a pharmacy in the study, due to the obligation to provide this information service in all organizations, regardless of turnover, form of ownership, the presence of a separate service area and other indicators. In addition, the presence of its own developed standard operating procedure dedicated to pharmaceutical consulting is also a condition for the implementation of pharmaceutical activities.

As “secret” simulated patients, students of the 5th year of the Faculty of Pharmacy and Biomedicine (specialty 33.05.01 Pharmacy) of the Far Eastern State Medical University were involved.

The basis for the study was the passport of the “Pharmaceutical Consultation” station, which is used for accreditation of specialists in the specialty “Pharmacy”.¹⁴ To simplify and realism, a modification of the algorithm was carried out.

The simulated patient had to:

Say hello,
Ask to recommend the drug in accordance with the legend,
Listen and answer questions about the visit to the doctor and the availability of the prescription (if any were asked by a specialist),
Listen to and answer questions about other complaints, symptoms, age, taking other drugs/having other diseases, pregnancy, breastfeeding (if any were asked by a specialist),
After receiving a recommendation to remember the drugs,
Clarify how these drugs/drug will help in the indicated state (in order to clarify the mechanism of action), select one drug, if necessary,
Clarify how to use the product and the course of use,
Clarify the possibility of developing side effects, including serious ones,
Say thank you for the consultation.

After the experiment, the simulated patient filled out a checklist for the provision of information service (yes/no). The obtained primary documentation was entered into a single database of the study. Patient legends were also taken based on the “List of practical skills in the specialty” Pharmacy”.¹⁵

Runny nose and nasal congestion (of unknown origin, possibly autumn allergy).
Back pain (after exercise).
Heartburn (after eating, at night).
Laxative (for a child 3 years old).
Sore throat (redness of the throat, pain).
Cold on the lips (exacerbation of herpes).
Increased immunity (disease prevention).
Insomnia (emotional stress).
Nail fungus (nail and skin on the legs, itching, redness).
Diarrhea (suspected food poisoning).

The sample was 10 experiments for each of the situations. In all tasks, except for 7, there were adult patients, without concomitant diseases, taking drugs, pregnancy, lactation, did not visit a doctor, the prescription, in this case, was absent.

In order to neutralize the impact on the content of pharmaceutical consultation of marketing services, as well as own preferences of employees of specific brands (brands), the obtained primary data were analyzed in accordance with the international non-proprietary names of drugs.

Primary documentation was processed using data encoding and Microsoft Excel 365. Statistical data processing was performed using IBM SPSS Statistical 25. For 10 independent samples, within each of the questions, the Kruskal-Wallis test was used. The null hypothesis of equality of distributions was rejected with significance less than 0.05. Spearman’s rank correlation coefficient and factor analysis were used to assess the relationship between drugs and the frequency of recommendations. Correlation was considered significant if less than 0.05. For a summary assessment of reliability Cronbach’s alpha was used. For 17 elements, it was 0.72, which is permissible in sociological research.

The first part of the results of this study was published in the journal “FARMAKOEKONOMIKA. Modern Pharmacoeconomics and Pharmacoepidemiology”. Reference: Soboleva M.S. Providing pharmaceutical consultation to visitors of pharmacy organizations in routine pharmaceutical practice. FARMAKOEKONOMIKA. Modern Pharmacoeconomics and Pharmacoepidemiology. 2023;16(2):258-265. (In Russ.) https:// doi.org/10.17749/2070-4909/farmakoekonomika.2023.176.

In the first situation, the pharmacy worker had to recommend the drug for a runny nose, while the simulated patient clarified the alleged allergic origin of rhinitis. The results are presented in Figure 1.

The most recommended therapeutic classes of drugs were decongestants (xylomethazoline, oxymetazoline, phenylephrine in combinations)-their total proportion is more than 25%. The leader of the group was the drug xylomethazoline-the frequency of its recommendations was 26%. The other most commonly recommended group were sodium chloride drugs. Despite the indication of the allergic origin of rhinitis, histamine blockers and nasal glucocorticosteroids were recommended relatively rarely-their total proportions were 12% and 8%, respectively. 4% of recommendations were for interferon drugs, which, in this case, do not correspond to the indications for use. In situation No. 2, a visitor with back pain turned to the pharmacy. The results are presented in Figure 2.

The total proportion of recommendations of the therapeutic class of non-steroidal anti-inflammatory drugs was 88%. Diclofenac (32%) and nimesulide (24%) were the most commonly recommended. Other anti-inflammatory drugs, as well as local irritants, were offered to the visitor relatively rarely (p=0.13 Kruskal-Wallis test, p=0.01 Spearman’s rank correlation coefficient, p=0.011 factor analysis).

Figure 1:
Drug recommendations for runny nose (suspected allergic origin).

Figure 2:
Drug recommendations for back pain. *-p<0.05-statistically significant difference.

In the third situation, a patient complained of heartburn to the pharmacy. Drug recommendations are presented in Figure 3.

In the structure of recommendations, 97% accounted for the therapeutic class of antacids, which is rational and the safest in this case. The leading drugs were combinations of calcium carbonate+magnesium carbonate-they were recommended in more than 25% of cases. Nevertheless, in 3% of cases, a dietary supplement was recommended, which cannot be advisable, with an abundance of drugs in a pharmacy.

In the fourth situation, pharmacy workers had to recommend a laxative drug for a 3-year-old child. The distribution of responses is presented in Figure 4.

In 100% of cases, recommendations were given considering age characteristics. The combination of sodium laurylsulfoacetate+sodium citrate+sorbitol was most often recommended-more than 30%. Glycerin suppositories (29%) were also in demand.

Figure 3:
Recommendations of drugs for heartburn.

Figure 4:
Recommendations of a laxative drug for a 3-year-old child.

In the next situation, pharmaceutical specialists had to recommend a preparation for sore throat (presumably tonsillitis). The distribution of employee responses is presented in Figure 5.

In 73% of cases, antiseptics were recommended, the most popular was hexetidine. The group of non-steroidal anti-inflammatory drugs, as well as stimulants of immunity, rarely sounded in the recommendations. In the 6^th situation, the visitor turned to the pharmacy with complaints of a cold on his lips (manifestation of herpes). The frequency distribution of recommendations is presented in Figure 6.

In 72% of cases, acyclovir-based drugs were recommended, in addition, tilorone and interferon-based drugs were offered.

Distribution differences were statistically significant (p=0.001 Kruskal-Wallis test, p=0.001 Spearman’s rank correlation coefficient, p=0.001 factor analysis).

In the following situation, a pharmacy visitor asked to recommend a means to stimulate immunity (prevention of acute respiratory viral diseases). The frequency distribution of recommendations is presented in Figure 7.

The most often recommended multivitamin complexes (22%); the total proportion of interferon synthesis stimulants was 41%. Among the recommendations of pharmaceutical workers, there were also dietary supplements (11%), as well as Eleutherococcus preparations (4%).

Figure 5:
Drug recommendations for sore throat (presumably tonsillitis).

Figure 6:
Drug recommendations for cold on lips (herpes). *-p<0.05-statistically significant difference.

Figure 7:
Recommendations of drugs to stimulate immunity (so as not to get sick).

Figure 8:
Drug recommendations for insomnia. *-p<0.05-statistically significant difference.

In the situation, the eight simulated patients asked to recommend the drug for insomnia. The frequency distribution of recommendations is presented in Figure 8.

Melatonin-based drugs were the most popular (39%). The total proportion of herbal sedatives was 43%, in 11% of cases the tranquilizer fabomotisol was recommended, in 4% dietary supplement. Distribution differences were statistically significant (p=0.001 Kruskal-Wallis test, p=0.044 Spearman’s rank correlation coefficient, p=0.001 factor analysis).

In the next situation, the visitor needed a recommendation when choosing a drug for nail fungus (on the legs). The frequency of drug recommendations is presented in Figure 9.

The most recommended international non-proprietary name by pharmacy workers is naphthifine (69%). The total proportion of the therapeutic class of allylamines was 73%. In 19% of cases, drugs based on amorolfine (varnishes for a damaged nail) were offered, and in 4%-hygiene products. Distribution differences were statistically significant (p=0.001 Kruskal-Wallis test, p=0.001 Spearman’s rank correlation coefficient, p=0.001 factor analysis).

Figure 9:
Drug recommendations for nail fungus (on the legs). *-p<0.05-statistically significant difference.

Figure 10:
Drug recommendations for diarrhea (presumably of infectious origin).

In the tenth situation, pharmacy workers had to recommend the drug for diarrhea (presumably of infectious origin). The frequency distribution of recommendations is presented in Figure 10.

In 46% of cases, sorbents were recommended, in 25%-drugs based on nifuroxazide, which is advisable in this situation. In 13% of cases, loperamide was recommended. This drug can be used for infectious diarrhea only as an adjuvant. In 4% of cases, dietary supplements were recommended, as well as pancreatin preparations, which can be used in combination therapy, in the absence of infection.

The high frequency of recommendations of decongestants and sodium chloride drugs in the first situation can be explained by their versatility, since the patient suggested the origin of the cold, which may be incorrect. Nevertheless, attention is drawn to the low frequency of recommendations for histamine blockers and nasal glucocorticosteroids, as well as the appearance of interferon in the recommendations. The data obtained indicate the possible inattention of the pharmacy workers to the symptoms indicated by the visitor, the need to provide a patient-oriented information service.

The predominance of recommendations of non-steroidal anti-inflammatory drugs for back pain can be explained by a wide range of non-prescription drugs and dosage forms, the possibility of local use (ointments, patches), as well as the inhibitory effect on the inflammation response-the main cause of pain.

The high frequency of recommendations of sodium laurylsulfoacetate+sodium citrate+sorbitol and glycerol can be explained by the possibility of their one-time use, including for a child, as well as the lack of systemic action, the rate of onset of effect.

Recommendations of local antiseptics for sore throat can be due to a wide range of activity, convenience of use, over-the-counter dispensing, the presence of a large number of dosage forms (sprays, solutions, medicated lollipops).

The high frequency of recommendations for acyclovir-based drugs can be explained by the high efficacy of etiotropic therapy and the presence of topical dosage forms. The use of immune stimulants, in this case, can be considered not only as an option for pathogenetic, but also complex therapy.

Multivitamin drugs can be recommended for a large number of diseases and symptoms, including for the prevention of acute respiratory viral diseases. Interferon synthesis stimulants have traditionally been a sought-after pharmacological group in the pharmaceutical market. Eleutherococcus preparations are most rational to use not in the case of prevention, but in the case of recovery from an infectious disease.

Melatonin-based drugs are affordable and safe as a hypnotic, as well as to normalize biological rhythms. Sedatives and a tranquilizer may be recommended in order to reduce anxiety, which is often the cause of sleep disorders.

The frequent recommendation of naphthifine can be explained by the specific spectrum of drug activity and pharmacokinetics, the convenience of local dosage forms (solution, cream), and over-the-counter dispensing. Amorolfine is used in the form of nail polish, which can be convenient for use, due to the absence of the need for its daily use, but it cannot be applied to the affected skin, therefore it is most appropriate in complex therapy. Hygiene products can also be recommended only in combination, in combination with etiotropic drugs.

The recommendation of sorbents as drugs for infectious diarrhea is rational. Drugs have no systemic action, are safe, effective, easy to use. Nifuroxazide is an over-the-counter topical, antibacterial drug that is not absorbed in the gastrointestinal tract and does not disturb the balance of the intestinal microflora, therefore, it is also in demand during pharmaceutical counseling. The recommendations of loperamide and pancreatin by pharmacy workers, in this case, cannot be justified as “first-line” drugs in connection with the assumption of the visitor about the infectious origin of diarrhea.

Most of the recommendations of pharmaceutical specialists were the means of symptomatic therapy (decongestants, adsorbents, sedatives, etc.). Etiotropic therapy (acyclovir, naphthifine) was relatively rare used. In some cases, there was a recommendation of dietary supplements, hygiene products, as well as the proposal of drugs that can only be used as part of complex therapy. In order to optimize and eliminate errors, it is more rational to create/unify standard algorithms/standards for practitioners; it is possible to use/improve computer programs based on the assortment of a specific pharmacy organization, especially for the most frequent cases of patient treatment. The use of neural networks and artificial intelligence can become a promising and modern direction of further research in this area, as well as a means of correcting algorithms.