Clinical Pharmacy (part1) Dr. J. Domenech

1. Clinical Pharmacy (part1) Dr. J. Domenech

2. Composed of physician (including other medical and dental staffs), pharmacist , nurse and other paramedics Physician ; diagnosis, prescription, monitoring, medical care Pharmacist; prescription*, dispensing, counseling, monitoring, pharmaceutical care Nurse ; administering, monitoring, nursing care Other paramedics ; their own work Load to physician & nurse ; high due to the system of "physicians are all in all in hospital for the treatment of patient, with the help of nurse." Concept of normal public/patient ; same Health Care System

3. Perceptions of Pharmacists How do others see us?

4. “They just count a few tablets”

5. “They just weigh and measure things”

6. “A bunch of shop-keepers”

7. “Tell me how and when to use the Medicine”

8. “Counter-prescribing”

9. “Not really health care practitioners – they’re businessmen”

10. “Do you need a degree to be a pharmacist?”

11. For practising Clinical Pharmacy • Competence of health care practitioners -BPharm to Mpharm to PharmD* -PharmD+ Pre-registration + registration -Residency programs -Continuing Professional Development • Informed general public – increased expectation

12. Introduction; Clinical Pharmacy Clinical pharmacy may be defined as the science and practice of rationale use of medications, where the pharmacists are more oriented towards the patient care rationalizing medication therapy promoting health , wellness of people. It is the modern and extended field of pharmacy. “ The discipline that embodies the application and development (by pharmacist) of scientific principles of pharmacology, toxicology, therapeutics, and clinical pharmacokinetics, pharmacoeconomics, pharmacogenomics and other allied sciences for the care of patients”. (Reference: American college of clinical pharmacy)

13. History Until the mid 1960’s ; Traditional role. The development of clinical pharmacy started in USA. More clinically oriented curriculum were designed with the award of PharmD degree. These developments influenced the practice of pharmacy in U.K., Initially prescription and drug administration records were introduced followed by an increasing pharmacy practice in hospital wards. Master degree programs in clinical pharmacy were introduced for first time in 1976. The progress of clinical pharmacy development remained at low profile in the first decade after its birth in U.K. However, Nuffield report in1986 geared up the momentum for progression of clinical pharmacy. Until today, the clinical pharmacy practice in Nepal is in embryonic stage.

14. The discipline of pharmacy embraces the knowledge on synthesis, chemistry and preparation of drugs Clinical pharmacy is more oriented to the analysis of population needs with regards to medicines, ways of administration, patterns of use ,drugs effects on the Patients, ‘the overall drug therapy management’. The focus of attention moves from the drug to the single patient or population receiving drugs. How does clinical pharmacy differ from pharmacy?

15. Clinical Pharmacy Requirements

16. Clinical pharmacy activities may influence the correct use of medicines at three different levels: Before the prescription During the prescription and After the prescription is written. Level of Action of Clinical Pharmacists

17. Clinical trials Formularies Drug information Drug-related policies 1. Before the prescription

18. Counselling activity Clinical pharmacists can influence the attitudes and priorities of prescribers in their choice of correct treatments. The clinical pharmacist monitors, detects and prevents the medication related problems The clinical pharmacist pays special attention to the dosage of drugs which need therapeutic monitoring. Community pharmacists can also make prescription decisions directly, when over the counter drugs are counselled. 2. During the prescription

19. Untreated indications. Improper drug selection. Subtherapeutic dosage. Medication Failure to receive Medication Overdosage. Adverse drug reactions. Drug interactions. Medication use without indication. Medication-related Problems

20. Counselling Preparation of personalised formulation Drug use evaluation Outcome research Pharmacoeconomic studies 3. After the prescription

21. Functions of Clinical Pharmacists • Taking the medical history of the patient • Patient Education 3. Patient care 4. Formulation and management of drug policies 5. Drug information 6. Teaching & training to medical and paramedical staff

22. 7.Research and development 8.Participation in drug utilization studies 9.Patient counseling 10.Therapeutic drug monitoring 11.Drug interaction surveillance 12.Adverse drug reaction reporting 13.Safe use of drugs 14.Disease management cases 15.Pharmacoeconomics

23. Define clinical pharmacy Differentiate between traditional pharmacists role and Clinical Pharmacist Explain the qualification required for clinical pharmacists List the clinical pharmacists responsibility Describe the daily work activity of clinical pharmacists Define what is Therapeutic Drug Monitoring Discuss the different types of Therapeutic Drug Monitoring Objective

25. Clinical pharmacy specialists • Usually requires residency in a specialty area, in addition to a pharmacy practice residency • Job functions depend on the specialty and the institution • Usually has teaching and/or research responsibilities • Represent pharmacy for medication use meeting/committee in specialty areas

26. Investigational Drugs Pharmacoeconomics Nephrology Obstetrics and gynecology Pulmonary disease Psychiatry Rheumatology Nuclear pharmacy Pediatrics Pharmacokinetics Surgery Clinical Pharmacy Practice areas • Ambulatory care • Critical care • Drug Information • Geriatrics and long –term care • Internal medicine and subspecialties • Cardiology • Endocrinology • Gastroenterology • Infectious disease • Neurology • Nutrition Support • ADR/DUE • Transplant

27. Various ambulatory services • Anticoagulation Management • Cholesterol Management • Renal Management (CKD) • Oncology Services • Home Health Pharmacy Services • Impact Pharmacy Services (Drug Conversion Program) • Neonatal ICU • Hypertension Management • Integrated Coronary Vascular Disease (CVD) • HIV/ID • New Member Program (assist new MD in prescribing NF to formulary drugs) • Heart Failure Management • Asthma Management

28. Hospital pharmacist Vs Clinical pharmacist

29. The service including clinical pharmacy/clinical pharmacist -Patients get right care from all the facets (all the drug related problems can easily be eliminated) -Physicians n other health care professionals get more focused in their own, work-load to them is low -Patients feel more comfortable • "Every drug is poison, it’s the dose that differentiate poison or drug the substance is." • "To kill ill by pill, not by bill" • The last person to be involved in health care team with the patient; Pharmacist, so the system has to rely upon him/her.

30. The service without clinical pharmacy/clinical pharmacist -Due to high load to physicians and other health care professionals, the quality of patient care will be low -Most of the drug related problems cannot be easily eliminated -Patients may not feel comfortable • "In developing countries like Nepal; Physicians are incompetent, Nurses are careless, Pharmacists don’t know anything(??), System is corrupted, Public is foolish, Patient load is high."...Prof FurqanHashmi • "Medicine is for those who need them, not for those who want them." • "If your medicine is not working it may not be your medicine, it may be you"

31. Medicines are Dangerous

32. Pharmaceutical care • “ A practice in which a practitioner takes responsibility for a patient’s drug related needs and holds him or herself accountable for meeting these needs.”....... Linda Strand 1997 • It describes specific services & activities through which an individual pharmacist cooperates with patients and other health care professionals in designing, implementing & monitoring a therapeutic plan that will produce specific outcomes for the patient.

33. Wherein the pharmacist is engaged in; Drug monitoring, Disease monitoring, Drug therapy & disease management/collaborative practice • Pharmaceutical care is that component of pharmacy practice which entails the direct interaction of pharmacist with the patient for the purpose of caring for that patient’s drug related needs Goal of Pharmaceutical Care • Goal of pharmaceutical care is to optimize the patient’s health-related quality of life and achieve positive clinical outcomes, within realistic economic expenditures

34. Essential Components of Pharmaceutical Care 1.Pharmacist-patient relationship Collaborative effort between pharmacist & patient 2.Pharmacist’s workup of drug therapy (PWDT) Provision of pharmaceutical care is centered around this, although the methods used for this purpose may vary. Components are: I.Data collection; Collect, synthesize & interpret relevant information Patient’s demographic data: age, sex, race etc. Pertinent medical information

35. Medical history (current & past) Family history Dietary history Medication history (prescription, OTC, allergies) Physical findings (weight, height, B.P) Lab results (serum drug levels, potassium levels, serum creatinine levels relevant to drug therapy) Patient complaints, symptoms & signs II. Develop or identify the CORE pharmacotherapy plan C = condition or patient need O = outcome desired for that condition R = regimen selected to achieve that outcome E = evaluation parameters to assess outcome achievement

36. III.Identify PRIME Pharmacotherapy Problems This includes pharmacist's intervention The goal is to identify actual or potential problems that could compromise the desired patient outcome P = pharmaceutical based problems R = risks to patient I = interactions M = mismatch between medication & condition or patient needs E = efficacy

37. 3.Documentation of pharmaceutical care Formulate a FARM note or SOAP note to describe or document the interventions needed or provided by pharmacist FARM Progress Note Description & documentation of interventions intended or provided by pharmacist F = Findings, pt-specific information—gives basis for recognition of pharmacotherapy problems or indication for pharmacist intervention. A = Assessment, The pharmacist’s evaluation of the findings, including a statement of: Any additional information needed to best assess the problem to make recommendation The severity, priority or urgency of the problem The short term & long term goals of the intervention proposed

38. Short term goals: elimination of symptoms , Lowering of BP ,Management of acute asthma without requiring hospitalization Long term goals:Prevent recurrence of disease,Control B.P.,Prevent progression of diabetes R = Resolution, including prevention Observing & reassessing Counseling or educating the patients & care givers Informing the prescriber Making recommendation to prescriber Withholding medication or advising against use M = Monitoring to assess the efficacy, safety & outcome of the intervention This should include The parameters to be followed (e.g. pain, depressed mood, serum levels) The intent of monitoring e.g. efficacy, toxicity, adverse events How the parameters will be monitored e.g. interview patients, serum drug level, physical examination

39. Frequency of monitoring—weekly or monthly Duration of monitoring e.g. until resolved, while on antibiotics,then monthly for one year Anticipated or desired finding e.g. no pain, healing of lesion Decision point to alter therapy when or if outcome is not achieved e.g. pain still present after 3 days, mild hypoglycemia more than 2 times a week. SOAP Note ; This is used primarily by physicians, S=subjective findings O=objective findings A=assessment P=plan

40. Clinical skills & pharmacist’s role in Pharmaceutical Care Patient assessment Physical assessment Barriers to adherence Psychosocial issues Education & counseling Interview skills Communication skills (e.g. empathy, listening, speaking or writing at patient's level of understanding) Ability to motivate & inspire Develop & implement patient education plan based on an initial education assessment Identification & resolution of compliance barriers

41. Patient Specific Pharmacist Care Plan Recognition, prevention & management of drug interactions Pharmacology & therapeutics Interpretation of lab tests Knowledge of community resources, professional referrals Communication & support with community medical providers Drug Treatment Protocol Develop & maintain (update) protocols Follow protocols as pharmacist-clinician Monitor,aggregate adherence to the treatment protocols e.g. drug utilization evaluation, especially for managed care or health system facility

42. Dosage adjustment Identify patients at high risk for exaggerated or subtherapeutic response Apply pharmacokinetic principles to determine patient specific dosing Prescriptive authority In designated practice site and positions

43. Will the patient take the therapy? What does the patient view as an improved quality of life? Safe drug therapy Effective drug therapy Aims of Pharmaceutical Care Economic drug therapy Improve quality of life

44. A case Pharmaceutical problems Common organisms for URTI? History of asthma – risk vs benefit? Need for acid suppression? Why is she nauseous ? Benefit of brochodilation? Does she know what to take? Will she take it? • 44 year old lady with fever and green sputum and cough – no known previous medical history – Diagnosed with URTI, Prescribed: • Co-Amoxiclav 1 tds • Doxycycline 100mg D • Prednisolone 40mg D • Theophylline 200mg bd • Omeprazole 20mg D • Metoclopramide 10mg tds • Salbutamol 2 puff inhale prn

45. Question? • Think of someone in your family or a friend that has had something go “wrong” with their medicines? • Caused an adverse or unwanted effect ? • Had medicines stopped when should have continued? • Not worked? • What happened ? • Could it have been avoided ?

47. High Profile Examples • A patient with leukaemia received Intrathecal vincristine instead of intravenously. Died beginning of February 2001. 14th such case over the last 16 years. • Patient being operated for a AAA received bupivicaine intravenously rather than epidurally. Patient died 3 days later. • A 3 year old girl, who had a convulsion post flu vaccine. Attended hospital to get “checked out”. Received nitrous oxide instead of oxygen in casualty

48. Elderly lady was prescribed Methotrexate in 1997 for her rheumatoid arthritis. Dose increased to 17.5mg WEEKLY over a 6 month period. • Jan 2000 patient undergoes right TKR in hospital. MTX given as one tablet a week (only 2.5mg). Prescription for MTX 10mg/daily written and dispensed. • 30th April patient dies.

49. Deaths from medicines in the UK1999 - 2000 (ICD9 & 10 data) A spoonful of sugar - Audit Commission (2001)

50. So drugs are safe ……………….. Photosensitivity from Amiodarone Severe extravasation of amiodarone infusion