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» ACCREDITED PHARMACIST SPECIAL INTEREST GROUP
Katja Naunton-Boom MPharm MPSis a
Canberra-based pharmacist and is the ACT APSIG
Accredited pharmacists do not need reminding of the benefits
Home Medication Reviews (HMRs) can provide patients – anecdotal
evidence demonstrating the benefits of medication reviews has been
growing steadily in Australia for almost two decades since pharmacists
commenced performing them.
In the eyes of some countries, like my
native land, The Netherlands, Australia
has led the way with developing
programs of pharmacist-conducted
medication reviews. The Netherlands
has been slowly developing its own
evidence on the benefits of HMRs.
For example, my husband Dr Mark
Naunton, recently attended the PhD
defense of Dr Henk-Frans Kwint in
Utrecht who completed, interalia,
a randomised control trial of home
medication reviews in The Netherlands.
Dr Kwint found that, like many
Australian and international studies,
pharmacists could effectively identify
and resolve drug-related problems.
Consequently, there are now funding
mechanisms in The Netherlands
by which private health insurance
companies reimburse pharmacists for
performing medication reviews. In
fact, I have had several patients ask me
how much they had to pay me at the
end of the HMR. So, as some countries
develop their own models of pharmacist
conducted medication reviews, it seems
Australia, with the recent changes
to the HMR program, has taken a
I moved to Australia in late 2006 and
registered as pharmacist 2007. In 2008
I became an accredited pharmacist.
Like many pharmacists in Australia,
my background in pharmacy included
community pharmacy, with some time
spent managing a rural community
pharmacy, as well as research. I was also
involved with local general practitioner
(GP) networks to develop medication
guidelines. To date, I have worked
part-time completing HMRs and RMMRs.
I have enjoyed the opportunity to
work with GPs, specialists, nurses, and
community pharmacists to identify
problems (medication as well as social
issues) and provide practical solutions to
support patients. I have lost count of the
number of medication related problems
I have resolved which I am reasonably
certain would have resulted in patient
harm had the problem not been
identified. Some examples are: a patient
who was taking two brands of the same
beta blocker; a patient with worsening
heart failure due to restarting verapamil/
diltiazem which had been ceased
while hospitalised; a patient falling
asleep during the HMR because they
were using three benzodiazepines, an
antidepressant and two antipsychotics.
A recent HMR related to metformin-
associated lactic acidosis (MALA).
The patient I was asked to review had
been having episodes of nausea and
vomiting for about 12 months. The man
aged in his 70s had an extensive medical
record which included diabetes (type
2), hypertension, depression, valvular
heart disease, hypercholesterolaemia,
and Meniere’s disease. His regular
medications included: Janumet
(metformin 1000mg/sitagliptin 50mg)
twice daily, transdermal fentanyl, iron
supplement, atorvastatin, prazosin,
The benefits of HMRs
BY KATJA NAUNTON-BOOM, MPS
mirtazapine, reboxetine, betahistine,
ramipril, diltiazem, and domperidone.
The patient stated he did not derive
any benefit from domperidone. The GP
provided laboratory tests from two weeks
before the HMR which included: eGFR
34ml/min, bicarbonate level 19mmol/L
[ref:22–31], and an elevated anion gap
22 mmol/L [ref: 8-16]. I was concerned
that the patient may have had lactic
acidosis at worse, or experiencing
intolerable side effects from metformin,
particularly given his dose of metformin
usual guidelines (eTG recommends
1g/day of metformin if CrCl is
30–60 ml/min).2 Following a telephone
call to the GP the patient had bloods
taken by a practice nurse to assess lactate
levels and blood pH. These tests showed
an elevated lactate level (4.9 mmol/L)
and an arterial pH of 7.24 (ref: 7.34–7.44).
The patient was subsequently admitted
to the emergency department where
he was discharged the same day with
cessation of metformin. His lactate levels
normalised after approximately three
days. The patient is now using insulin.
In my experience conducting HMRs
many patients, like the one described
above, require close attention from a
pharmacist. Let us hope that recent
capping of HMRs is a temporary speed
bump in the provision of this valuable
service. Pharmacists performing HMRs
must continue to demonstrate to the
government, as well as patients and
health professionals, that tax payer
money spent on HMRs is a valuable
investment. Otherwise, accredited
pharmacists across the country may be
left uttering the Dutch words ‘Lekker is
slechts een vinger lang’ (translated: tasty
is just one finger long – that is, all good
things come to an end).
1. Kwint, HF. Improving appropriate medication use for older
people in primary care. Thesis. Utrecht University, The
2. Metformin in type 2 diabetes [revised Oct 2013]. In : eTG
Complete. Melbourne:Therapeutic Guidelines; 2014 at:
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