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MMI Scenario 15


Miss Kent, 25, comes to the pharmacy counter to collect her repeat prescription for her COCP Microgynon 30 tablets. After you issue her prescription, she hands you her shopping to settle her bill before leaving. On scanning you notice the product – St Johns Wort. What would you wish to explore further in this scenario?​
​

Example Answer

Clinical interactions: This is an example of a drug -drug interaction, whereby St Johns Wort (SJW) is an enzyme inducer which could lower the serum concentration of Oestrogen/progesterone given its increase in metabolic turnover. This could render the COCP ineffective.

Consultation Setting: It is important to handle this scenario sensitively and give Miss Kent some dignity by bringing her over to a quiet area or preferably offering the consultation room to confirm whether the chosen product is being used by herself, or is she buying for someone else, are they on other medications?

Patient Understanding: It is very important to explore her understanding of the drug-drug interaction between SJW and her COCP? Is she taking other medicines which are not in our clinical system which might be affected also?

Significance of the interaction: If it is for herself, is she aware of its interactions with her contraceptive pill? Has she used SJW previously, if so, when, has it improved her mood? Can she suddenly discontinue, or would this evoke depression relapse? It might be a good idea to devise a reduction strategy, as suddenly stopping SJW may create withdrawal and inform Miss Kent to use barrier contraception, see her GP, as well as exclude existing pregnancy if any UPSI took place.

Personal drug history taking: Once again, it might be important to explore her sexual history as use of COCP and SJW could leave Miss Kent at risk of unintended pregnancy? Has any UPSI occurred, does Miss Kent need to undertake a pregnancy test considering this? Could we signpost her to a sexual health clinic if needed for further services if this is necessary – provide her with a list of the local sexual health clinics as part of your care.

Health promotion: Is this an opportunity for further health promotion, given her age is she up to date with sexual health screening? 

Tackle the underlying cause: It is also important to sensitively explore how Miss Kent has been feeling? How long has she experienced low mood for? Is this its intended reason for use? Has she had any thoughts of self-harm/suicide – can we signpost her to NHS website for online resources, non-pharmacological talking therapies or online CBT? Is Miss Kent aware of charities, online resources which provide non-pharmacological methods of supporting her mood. Can discuss mindfulness app/exercise referral to support mindset and wellbeing.

Referral to other health care professional: Is this something we can support her with by referring her to her GP in case drug therapy is her preferred choice, and a suitable alternative drug could be indicated which wouldn’t interact with her medicines? How does this match with Miss Kent’s feelings and idea, is prescriptions an appropriate intervention or would she be better off exploring the non-pharmacological measure mentioned above?

Social and other health issues: Has Miss Kent been sleeping well, is she socially engaged and eating and drinking well? What social input/recommendation could be offered? Does she have home/family/friends support? Could we refer to support/group counselling which will get her to meet others in a similar scenario.

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