Principles of Side Effect Management

Principles of Side Effect Management

Author: Mark Parkinson BSPharm:  President  AFC-CE

Credit Hours 2- Approximate time required: 120 min.

 

Educational Goal:

To explain the principles of side effect management.

Educational Objectives:

Define what a side effect is and list what causes them.

List possible action the doctor may take to manage the side effect.

Provide caregiver side effect management strategies.

Procedure:

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Disclaimer

   The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

 

 

                                Principles of Side Effect Management

Adult Foster Care providers are in an unusually ambiguous area of the care giving spectrum. On the one hand they are viewed as the very bottom of the professional spectrum, being less than CNAs. They have absolutely no medical decision-making power and must defer almost everything to someone else. On the other hand, they are almost as powerful as the resident’s family members in getting things done. I have seen adult foster care providers say something to effect of “I will do anything you tell me to do but I demand that you do this or that and do it now.” And the amazing thing is the doctor listens and obeys.

Why is that? You are the primary caregiver, 24 hours a day, 7 days a week. You are in the best position to see and react to the needs of the patient. Any doctor worth his salary knows this and respects it. You are also the patient’s representative or advocate. It’s part of your job to look out for the interests of the patient. Being both on the medical care team and yet having the responsibility to get the medical team moving creates some challenges for the in-home care giver.

No other aspect of medical care illustrates this unusual caregiving position than that of managing the side effects of drugs and other therapies. You are in the position to see side effects occur before anyone else. You are also the one who is responsible for activating the health care team to take care of the problem. To help make you more skillful in this area I present to you the following lesson.

 

What is a side effect?

A side effect is any reaction or effect that the drug or therapy was not originally approved for. Approved for is a key phrase we’ll cover later. All drugs can have multiple responses in the body. This happens due to several factors.

Some of the mains ones are:

 

 

1. The chemical (drug) stimulates reactions all over the body. It is very hard to guide a drug to a specific part of the body. Once in the blood stream it goes everywhere. If you wanted the drug to control swelling in the legs, it’s also going to affect the glands that control water flow into the eyes. Thus, a potential effect of water pills is vision problems.
2. The body over reacts or under reacts to the drug. If you take a diabetes drug to get rid of extra blood glucose and the body over reacts and takes out too much blood glucose, then the body doesn’t have enough fuel to keep going. The side effect then would be being tired and mental confusion.
3. The body breaks down the drug poorly. Iron containing drugs are hard to digest. It flows through the digestive tract never making into the blood stream. This can cause an upset stomach and constipation.
4. The body can break the drug down in unusual ways (metabolization). It can cut the drug at point b instead of point a. Thus, the body has created a new drug that flows through the body causing different actions. Some blood pressure meds can cause a dry cough that won’t go away because of a certain metabolite.
5. The body can overreact to the drug as a harmful substance and our body’s defenses kicks in. Nausea and Vomiting is the stomach stomach’s way of getting rid of troublesome substances fast. Diarrhea is the same effect.
6. The immune system can be hypersensitive to a substance causing an allergic response. The body throws up defensive walls of inflammatory responses that results in swelling, redness and itching.
7. Everyone body is built differently. Those variations can cause drugs to act differently in different people. As a pharmacist I have seen drugs that are supposed to make you drowsy make some people hyper active.
8. Interactions between other medications or food being taken. Drinking coffee or other caffeinated drinks make theophylline produce side effects more often. Taking Ibuprofen and Warfarin makes it easier to bruise the patient.

Not all side effects happen with the same severity. The reaction could be mild to very severe, temporary verses constant. They also can change over time. The reaction could range from fading until it disappears by itself to increased intensity until it becomes life threatening or causes permanent damage. Some are even helpful and therapeutic. Regardless of the side effects presentation medical professional must react to them.

 

 

The Doctors Reaction

With all these possible reactions, you can see why every drug has the potential of having effects in the body that are different than the one the government has approved the drug for. If side effects do occur the doctor has four choices.

 

 

1. Take advantage of the side effect. A side effect is not necessarily a bad thing. A doctor has the right to make his own choices how to use a drug despite what the government thinks. If the doctor sees a benefit, why not take advantage of it. The drug trazadone (Deseryl) is used just as often as a sleeping aid as for an antiseizure pill even though it has never been approved as a therapy for insomnia. When a doctor uses a drug for a use other than the government approved one it’s called an “off label” use.
2. Wait and see. Often side effects are only temporary reactions and go away by themselves. The body either compensates for the reaction or just gets used the effect. This fading of side effect usually happens by 2-3 weeks. Often you will see a doctor only react to a report of a problem on the 3rd or 4th week of therapy.
3. Do nothing. If a side effect occurs, it becomes a balancing act between benefit and side effect. This is seen a lot in short term therapies like antibiotics or PRN meds. Killing off the infection is much more important than being tired from the drug. Adult Foster Care providers sometimes has to fight with the doctor over this one. What the doctor sees as not a problem can be a big issue for the care provider. It is okay to be aggressive with the doctor as long as you’re professional about it and communicate clearly.
4. Change the drug regime. If a side effect becomes troublesome a change can come into two forms. 1. Change the drug to an alternative therapy or change the dose, and 2. Add a drug to manage the side effect. I’ve seen care providers and patient’s do this a lot. They see a reaction and ask for a pill to take care of it. The “a pill for every ill” mentality. Soon there are a lot of drugs being taken. In my opinion it would be wise to ask, is that pill really all that necessary? Why not just change the med that’s causing the problem in the first place and get rid of all the extra baggage.

Allergic reactions

An allergy is a reaction to any substance (antigen) that triggers the production of antibodies called Immunoglobulin E (IgE). These antibodies travel to immune cells that produce chemicals that cause the allergic response in the body. First time exposure to an antigen may not produce an allergic response, but the body has become sensitized to it. More exposure to the antigen can create a greater sensitivity. The greater sensitivity the greater the allergic response. The allergic response may become so intense that lungs swell, breathing becomes difficult and possibly death may occur. Such a deadly response is called anaphylaxis. That is why allergic response side effects should be taken very seriously. Even the mild allergic responses may be a precursor to something more serious later on.

Obviously not all side effects are allergic responses though the patient may call it that. I have heard it over and over again. Side effects like an upset stomach was called an allergy. The main difference is that true allergic responses involve antibodies and may turn deadly. True allergy symptoms are:

* hives (itchy red spots on the skin)

* itching

* nasal congestion (known as rhinitis)

* rash

* scratchy throat

* watery or itchy eyes

* swelling

* wheezing

* flushing of the face

* difficulty swallowing

Do not hesitate to call the doctor if these symptoms occur. Record these reactions in the patients file. I recommend recording the specific reaction that occurred. Example, allergic response to Vicodin, hives and itching occurred. If the last four on the above list happens it might be wise to skip the doctor and call 911. It all depends on the severity of the reaction. When in doubt call it out.

 

 

The Caregivers Reaction

Managing side effects is part of a caregiver’s job. It’s not “if” side effects will occur, it’s “when” the side effects happen. The caregiver must be prepared to react appropriately. Being prepared to act involves; 1. Knowing what to look for, 2. Monitoring for effect, 3. Knowing when and how to report, 4. Therapeutically managing the side effect.

 

 

Knowing what to look for

 

The most common occurrences make it on the list given to the patient. Less common but significantly important occurrences are also added, usually with a disclaimer that they do not occur as often. All the noted side effects including the less common ones are noted on the drug information sheet given out with each stock bottle of the drug. Drug information sheets are intended for medical professionals and include much more details. It takes some practice to be able to understand them but usually if asked for the pharmacist will give you one and answer any questions you have. I recommend that every caregiver take a look at a drug information page and compare it to the patient information page a couple of times. I think you’ll gain some important insights on how to spot side effects.

Non-drug therapies also can have unintended side effects but there is rarely and conveniently patient information sheet listing them. If there is patient information provided scan it for what to monitor for. If no information is provided I recommend getting in the habit of calling the therapist and asking about what to monitor for, including side effects.

Monitoring for Effect

Monitoring for effect may seem to be a straight forward proposition but it’s not. It’s more complicated than it appears. Doing it well is what separates the good homes from the mediocre ones. Side effects usually don’t pop up with a sign saying, “look at me, I’m a side effect”. They can occur gradually, are hidden or mimicking something else. It takes a practice eye and a concerted effort to catch side effects as they start to occur. I recommend the following caregiver techniques.

* Establish a base line or determine what is normal. It is a common medical practice to take measurements of patient’s vital signs. Care homes could also do a simpler version of vital signs. When a person moves in, consult with the doctor to determine what needs to be monitored then take measurements periodically. Without such directions from the doctor I recommend you consider the following easy to measure items, Weight, Ankle circumference, Blood pressure and temperature.

* To determine what’s normal on items harder to measure, establish a routine of daily living and take note of when it becomes harder to maintain that routine. For example, to notice side effects like dizziness pay attention how long it takes you to get a resident dressed in the morning. If it takes longer than normal, then investigate why. Variations from normal routines can give you a wealth of information.

* PRN logs can also tell you when things have changed. Pay attention to the frequency of the entries.

* Always look deeper into annoying circumstances. Events that stand out. When they occur ask yourself first, “is this a side effect talking”.

* When a resident complains include in your thought process, is this a side effect starting to manifest itself.

* Be vigilant for at least three weeks after a med change. Read the patient information page to know what to watch for.

Know When and How to Report

There are two purposes to report a side effect to the doctor. First being to inform the doctor. The more information he has the better therapy he can administer. Second is to start the needed medical intervention. If you don’t

report, the doctor thinks that everything is fine, the resident suffers, and your job gets harder.

If you are new to the profession of caregiving I suggest that you report every suspected side effect to the doctor. Pay attention to what kind of reaction the doctor has. After a while you’ll start to get a feel for what is important and what is not. Of course, what is important to a doctor and what is important to you are two different things. It’s okay to push a doctor if things are not going well for the resident or your home.

Those with more experience will know to have patience before reporting a side effect. Unless it is a significant reaction or instructed otherwise it is wise to see if the side effect goes away be itself. Two or three weeks should be a sufficient time to wait. If it goes beyond that, note the length of time the side effect has manifested itself and if it is getting stronger as time passes.

When reporting a side effect, you could report it to a home health nurse or to the doctor’s office themselves. I always found it easier to get a hold of the doctor’s nurse. Give sufficient details in your report. Include measurable facts. Always report in such a way that you get a response. Here are a few examples:

* Jane Smith has requested prn constipation relief pills daily for the past 3 weeks. It started shortly after the recent medication “name of drug”. The complaint has continued despite the prn laxative and an increase of fluid intake. Do you wish for me to continue the extra constipation pills?

* Robert Jones has developed a dry cough that has increased in frequency since taking the new blood pressure medication. Could this be the side effect listed on the patient information list that came with the new med?

 

Managing the Side Effect

Managing side effects entails reducing or eliminating the unwanted effect the medication or therapy has produced. This get a bit tricky for a caregiver who has no authority to make any therapeutic decisions. Yes, reporting the side effect and pushing the doctor to respond is in effect managing the side effect. But; what can you do if you’re waiting to see if the side effect goes away by itself? What if the side effect reaction is not very significant, just annoying? What if the doctor decides to do nothing? What do you do if the resident wants to refuse taking the medication because of the side effect? There has to be other things you can do beside wait for the doctor to respond. Here are some things that you can do as an adult foster care provider.

Refusing to take meds

A patient has the right to refuse any therapy for any reason. It’s part of their resident’s right. But they’re not free to avoid the consequences of that decision. The most poignant example I can think of is cancer therapy. Chemotherapy can be very rough on the patient. It’s easy to understand why a patient would want to refuse therapy if their hair is failing out and they’re throwing up several times a day. But if the residents refuse therapy they will suffer horribly and die from the cancer. When a resident wants to refuse a medication, the caregiver can do several things.

* Let the resident know that you are taking their complaint seriously. Often the refusal is just an awkward plea for respect and help. Tell them you have contacted the doctor and you’re doing something to help while we wait. Show the resident that you are writing down and recording their complaint.

* Educate the resident on the consequences of refusing. Do it in such a way that it appears to be a wise decision to take the therapy despite the side effects. Everyone likes to think they are smart.

* Educate the resident on why they are taking the medication. A rational person will sacrifice comfort if the reason is good enough.

* Distract the resident’s attention away from the side effect. If you dwell on a side effect of course you’ll feel it more.

* Use the habit of routine to reinforce the taking of meds. Use phrases like, “But, this is always what you have done, you sure you want to change?”

* If the resident is mentally impaired then discuss the issue with those with authority to act for the resident, like a son who has medical power of attorney.

* Defer to authority’s wisdom. Say things like, “The doctor thinks it’s wise for you to take this medication”. “Your family expects you to cooperate with therapy.”

* Take a temporary drug holiday. Refusal does not automatically mean not taking the drug from then on. Record in your MARS the refusal, then continue on as normal. If this occurs a lot notify the doctor with the details

Standing Orders and PRN medications

For those symptoms caused by the most common side effects, you could get standing orders and prn meds. You may never use them but being prepared just in case goes along way. Consider asking the doctor the following on all your residents. Medications or instructions for pain, fever, constipation, diarrhea, allergic reactions, dry mouth, dry eyes, and insomnia. Getting Standing Orders has to be weighed against having a lot of rarely used extra prescription bottles cluttering the medicine cabinet and their cost.

You could make it a form that all the doctor has to do is check a box and sign his name. You could use this form or make you own. Put the form in your computer so that you could customize it for each resident. Add or subtract from it as circumstances demand.

For example- (You have my permission to copy it for your own use)

 

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Dear Doctor, your patient has moved into a licensed care home. We need your permission to administer PRN medications that might be needed. Please review the following list and check the box if you agree or write down your own standing orders. Then sign it at the bottom to validate the standing orders. Please send a copy to the pharmacy for fulfillment.

Thank You

Pain, Fever, Inflammation

Acetaminophen 325 mg: 1-2 pills PO every 4-6 hours PRN for pain or fever. QTY ____

Ibuprofen 200 mg: PO 1-2 pills PO every 6-8 hours PRN for pain fever or inflammation. Qty _____

Other ____________________________________________

Constipation

Milk of Magnesium: 30-60 mL/day PO at bedtime PRN constipation. QTY 1 bottle

Senokot: 1 to 2 tablets PO up to twice daily PRN constipation. QTY ____

Other ______________________________________________

Diarrhea

Loperamide 2mg: 1-2 pills PO daily PRN Diarrhea Qty _____

Other ______________________________________________

Nausea

Tums Regular strength: 2-4 tabs PO prn, Max: 15 tabs/24h Qty _____

Other ______________________________________________

Doctors Signature:

___________________________________________________

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Home Remedies

Using home remedies to reduce the impact of side effects are a danger zone for adult foster care providers. Care providers are guaranteed to get in trouble if they make medical decisions or decide therapy. Home remedies may also mask how serious the side effects are becoming. In addition, some remedies are a complete waste of time with little more than old wife’s tales to back them up. Having said all that there are certain techniques that can be very useful in reducing the impact on the quality of life of your resident.

 

My list of home remedies for drug side effects

Here are some home remedies that I don’t think would land you in hot water.

Insomnia

The body wants to sleep but if the medication is causing issues then you can help by

* Keeping the bedroom quiet, cool and comfortable during sleep.

* Offer distracting activities that reduce anxiety and tension like gentle backrubs or foot massages near bedtime.

* Offer a light bedtime snack.

* Dim the lights before bedtime sending signals to the brain that it’s bedtime.

* Block out noises with soothing background sounds like a fan or white-noise machine.

* Lavender scents promote sleep

Nausea

Nausea is one of those side effects that usually goes away as the body gets use to a drug. Some things that can help reduce upset stomachs are; Give the medicine with bland foods like dry crackers, toast, or milk. Serve smaller, light meals, then augment with snacks. Avoid foods that are spicy or hard to digest. Watered down apple juice or warm sweetened watered-down milk can also help calm upset stomachs or try ginger ale or ginger tea. Drink clear liquids cold and sip slowly. Try Popsicles or gelatin. You can also try mental diversions, deep slow breathing, relation techniques and positive imagery.

Fatigue, Mental Confusion

Scheduled light activities like a walk wakes a person up. Engaging in conversations also helps fight mental fuzziness. Hold activities that require participation, like a card game, letter writing, puzzles, snacks etc…

Dry mouth

Often meds turn off saliva glands. The remedy is to stimulate them to function again. Try things that you have suck on like tart hard tack candy. Swabbing the mouth with glycerin and lemon juice also works. I also find that unsweetened carbonated drinks cut through a dry mouth very well. Ice chips work well too.

Constipation

You can fight constipation with an increase in fluids, adding more fiber to the diet and or serving prune juice or lots of fruit. Adding more physical activities gets gravity and muscle movement to help keep bowels moving.

Metallic Taste

If a metallic taste is making it hard to have an appetite, give strong tasting snacks like lemon drops or mints before eating a meal. Use plastic utensils to eat. Rinse your mouth with a salt and baking soda solution before meals. Try a solution of ½ teaspoon of salt and ½ teaspoon of baking soda in 1 cup of warm water. It may help neutralize bad tastes in the mouth. Prepare foods with a variety of colors and textures.

Fluid Retention, Edema

Promote physical activities like walking. Lotion the skin or massage the edema area often. Keep the feet elevated.

Diarrhea

Short term diarrhea is a part of life. It’s the body’s way of getting rid of things it doesn’t like. If diarrhea continues past four or five days, it may be the medications. At this point you have to determine the impact on the quality of life of you resident and compensate. You could try one or more of the following; Utilize the BRAT diet, (Bananas, Rice, Applesauce, and Toast). It will provide the resident with more soluble fiber. Increase fluid intake to avoid dehydration. Serve constipating treats like bananas or cheese. Active cultured yogurt is a good remedy for antibiotic cause diarrhea. Pickled foods also contain natural probiotics that might help.

Conclusion

Side effects from medications and therapies are a reality of modern medicine. Managing them is part of the caregiver’s job. Not all side effects are the same. They can vary in severity, duration, helpfulness and harm. Managing them becomes a balancing act between, benefit of the medication or therapy and harm to the body and impact on the quality of life. For adult foster care providers managing the side effect it is a matter of detecting them, monitoring to see if they go away by themselves, help reduce their effect on the quality of life of the resident and reporting all information to the doctor. In addition, the caregiver must play the role of patient advocate to motivate the care team when a push is needed. Being prepared to handle all the above will turn a mediocre caregiver into great caregiver. I hope this lesson has helped.

 

As Always, good luck in your caregiving.

Mark Parkinson BSPharm

 

References:

Cancer Symptoms: Tips to Help You Feel Better. WebMD.com 2017. https://www.webmd.com/cancer/dx-next-steps-16/ease-cancer-side-effects?page=2

Managing Cancer Side Effects at Home WebMD.com. 2017. https://www.webmd.com/cancer/dx-next-steps-16/managing-cancer-side-effects

Managing Cancer-related Side Effects. American Cancer Society. https://www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects.html

Side Effects. Cancer.net, American Society of Clinical Oncology. 2018. https://www.cancer.net/navigating-cancer-care/side-effects

What to expect when a person with cancer is nearing death. American Cancer Society. 2018. https://www.cancer.org/treatment/end-of-life-care/nearing-the-end-of-life/death.html

Side Effects of Cancer Treatment. National Cancer Institute, NIH.August 9, 2018 . https://www.cancer.gov/about-cancer/treatment/side-effects.

Managing Common Side Effects. RxOutreach. http://rxoutreach.org/education-managing-common-side-effects/

David E.Kemp. Managing the side effects associated with commonly used treatments for bipolar depression.  Journal of Affective Disorder. Volume 169, Supplement 1, December 2014, Pages S34-S44. https://www.jad-journal.com/article/S0165-0327(14)70007-2/pdf

2018. Fookes, BPharm. Managing Common Drug Side Effects. Drug.com. Nov. 16,2018. https://www.drugs.com/article/drug-side-effects.html

Terry Matlen. The 5 Most Common Med Side Effects-and Their Fixes. Attitude, Inside the ADHD mind. https://www.additudemag.com/adhd-medication-side-effects/

Anthony Frew. General principles of investigating and managing drug allergy. Br J Clin Pharmacol. 2011 May; 71(5): 642–646.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3093070/

What Is an Allergic Reaction? Healthline.com. https://www.healthline.com/health/allergies/allergic-reaction#symptoms

Trisha Torrey. Do Patients Have the Right to Refuse Medical Treatment? Verywell Health.com April 08, 18. https://www.verywellhealth.com/do-patients-have-the-right-to-refuse-treatment-2614982

 

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