Counselling customers at risk of the triple whammy effect at community pharmacies – A feasibility study

The combination of diuretics, angiotensin-converting enzyme inhibitors (ACE-i)/angiotensin II receptor blockers (ARBs) and non-steroidal anti-inflammatory drugs (NSAID) involves a risk of acute renal failure known as the triple whammy effect (TWE). NSAID can be provided by prescription or over the counter (OTC) and community pharmacies counsel on this medication every day to contribute to medication safety. The objective of this study is to test the feasibility of an intervention where community pharmacies identify and counsel customers at risk of the TWE. Participating pharmacies were recruited across Denmark and the Faroe Islands. In April to May 2021, all staff at 13 community pharmacies chose 10 workdays to collect data in an electronic tool on their risk assessment, the customers' medication, and counselling about the TWE for customers asking for NSAID. Pharmacy staff were instructed in correct data collection and received learning material and a patient information leaflet on the TWE. These data were analysed descriptively. Staff evaluated the learning material and patient information leaflet in a questionnaire. The quantitative answers from the questionnaire were analysed descriptively and the qualitative answers were analysed using content analysis. According to the pharmacies' risk assessment, 12.1% (n = 215) of customers asking for NSAID were at risk of the TWE. The data on customers' medication showed that only 8.0% (n = 142) were actually at risk of TWE. Of those, 43.0% (n = 61) asked for NSAID on prescription and 57.0% (n = 81) for OTC. In the evaluation of materials pharmacy staff reported overall satisfaction with the learning material, which they reported increased their knowledge of TWE and helped them in their counselling. They also reported satisfaction with the patient information leaflet. Despite pharmacy staff reporting satisfaction with the learning material, it still did not educate staff well enough in assessing the risk of TWE for customers asking for NSAID. More research is needed on TWE interventions in community pharmacies because this study shows that there is a potential for community pharmacies to identify and counsel persons at risk of the TWE.