Pharmacists work in a wide range of hospital and community settings, with varying levels of clinical experience and practice specialisation. Although patient blood management has not been seen as a “traditional” pharmacist role, our training equips us to select the most suitable pharmaceutical formulations, doses and routes of administration for each patient’s clinical situation. In partnership with doctors and other healthcare professionals, we assess safety and efficacy of all drug therapy and provide medicines usage and self-care advice to our patients.
Pharmacists can contribute to each “pillar” of the patient blood management matrix, as follows:
Optimise red cell mass: 1) seek symptoms, signs and causes of anaemia based on a patient’s medical history, prescription medicines and “over the counter” medicine use; 2) select appropriate products, doses and timing for repletion of haematinic deficiencies; 3) optimise erythropoiesis by ensuring adequate availability of iron and other haematinics (especially with blood loss and/or epoetin use); 4) avoid drug side effects or interactions which can cause or worsen anaemia.
Minimise blood loss: 1) identify and review use of medicines which increase bleeding risk, especially preoperatively; 2) advise and plan use of haemostatic agents, such as tranexamic acid; 3) monitor perioperative withholding and recommencement of anticoagulation; 4) prevent GI haemorrhage; 5) avoid/treat infections promptly; 6) minimise frequency and volume of blood sampling for drug levels and other tests.
Optimise physiological tolerance of anaemia: 1) consider anaemia rate of onset (acute versus chronic) when selecting treatment regimens; 2) avoid fluid overload (minimise infusion volumes for IV medicines); 3) avoid/ treat infections promptly; 4) remind patients to report symptoms such as dizziness or chest pain on exertion.
“Think five” is a simple approach to bloodless medicines management for anaemia: IV iron, epoetin (if Hb < 100g/L), vitamin B12, folic acid and vitamin C (ascorbic acid) are considered. Indications, drug safety issues, dosing and routes of administration are assessed for each patient. Dosing frequency is adjusted according to severity of anaemia and patient factors. Reticulocyte rise can be a useful early indicator of therapeutic response.
Future treatments may include drugs which antagonise hepcidin-induced anaemia of inflammation or stimulate erythropoietin production whilst increasing intestinal iron absorption. These will need to be used with care.