Clinical Pharmacy Practice Overview

Clinical Pharmacy Practice

• Clinical pharmacy practice involves the selection and administration of medications, with consideration given to patient factors, drug factors, and disease management.
• A physician usually chooses the drug and therapy, though pharmacists' input is often sought for drug selections and dosing regimens.
• Drugs with similar therapeutic use may have disparate pharmacokinetic properties.

Intended Learning Outcomes

• Students should learn to assess cases, select drug therapies, and grasp disease management concepts.

Drug Prescribing Flowchart

• A flowchart outlining the process of drug selection and administration, encompassing patient history, clinical guidelines, dose calculation considerations, monitoring, patient education, and overall care plan adjustments.
• Factors like body weight (BW), body surface area (BSA), kidney function, and liver function are crucial for individualizing drug regimens.
• Adverse Drug Reactions (ADRs) and drug interactions are taken into account in the care plan.

Diabetes Management Summary

• Glycemic recommendations for nonpregnant adults with diabetes focus on A1C levels, preprandial capillary plasma glucose, and peak postprandial capillary plasma glucose.
• 7.0% A1C, 80-130mg/dL preprandial, and <180mg/dL peak postprandial.
• Individualization is key, taking into account duration of diabetes, age/life expectancy, comorbidities, cardiovascular disease, microvascular complications, and hypoglycemia awareness.

Diagnosis of Diabetes

• Diabetes is diagnosed based on blood glucose levels.
• Normal: <5.7% A1C, Prediabetes: 6.5% A1C, and Diabetes: >6.5% A1C.

Factors Affecting Drug Selection

• Patient factors influencing drug choice include age, weight, pathophysiology conditions, nutritional status, genetic variability, and gender.
• Drug factors include bioavailability, pharmacokinetics (absorption, distribution, and elimination), drug interactions, receptor sensitivity, and metabolism rates.

Patient Factors: Age, Weight, and Pathophysiology

• Age and weight influence drug dosage adjustments.
• Specific pathophysiological conditions require modified treatment plans (e.g., liver disease, renal disease, cardiac disease).

Patient Factors: Other Considerations

• Nutritional status and genetic variability need to be factored into decisions about drug selection and dosage.
• Gender plays a role in drug responses, and adjustments should be made appropriately.

Oral Anticoagulants

• Oral anticoagulants (e.g., warfarin) and their associated risks (bleeding) should be carefully considered.
• Conditions like thrombocytopenia and coagulation defects increase bleeding risk, which may discourage anticoagulant use.

Genetic Variability

• Genetic variations (e.g., CYP2C9 and VKORC1) can modify drug response and may warrant dosage adjustments for warfarin to prevent adverse effects.
• The FDA has provided expected therapeutic dosage ranges for warfarin based on genetic variations.

Patient Factors: Gender

• Gender-specific dosage guidelines should be considered.

Drug Interactions

• Drug-drug interactions can influence effectiveness and increase toxicity of the drugs.
• Specific cautions exist for combination use of certain drugs (e.g., ferrous sulfate with PPIs or omeprazole and various acid-reducing drugs.)

Formulation and Routes of Administration

• Extended-release drug products offer a longer duration of action.
• Orally disintegrating tablets may be beneficial for patients with swallowing difficulties.
• Patients experiencing profuse vomiting or diarrhea.

Dosage Regimen Design

• Regimen design aims to achieve the therapeutic concentration of the drug at the receptor site and considers average patients and individual variances in response to therapy.

Determination of Dosage Form

• Factors in dosage form selection include bioavailability, absorption, duration of action, and patient-specific factors like cost and compliance.
• The choice depends on administration concerns, desired onset, response duration and cost.

Renal Dosing

• Dosing regimens are tailored for patients with renal impairment.
• Adjustment of doses may be necessary due to altered kidney function.

Liver Dosing

• Dosage adjustments may be needed for patients with liver disease to prevent accumulation and toxicity due to impaired metabolism.

Determination of Dose and Dose Interval

• Dose selection depends on factors like average pharmacokinetics, toxicity levels, and minimum inhibitory concentrations.
• The elimination half-life of the drug often guides the dose interval.

Special Populations

• Patients in specific age groups (pediatrics, geriatrics), pregnancies, and certain conditions (obesity, renal, or hepatic disease) may necessitate adjustments to the dosage regimen based on their unique needs.

Disease Management

• Disease management (as blended learning) implies programs and plans for the care of chronic conditions such as diabetes.
• These programs may encompass patient education, self-management support, and coordination of care involving physicians, pharmacists, and other healthcare professionals.

References

• Various clinical reference materials are cited.

This quiz covers the essentials of clinical pharmacy practice, focusing on medication selection and administration tailored to patient specifics. Students will engage with concepts of drug therapy assessment, disease management, and comprehensive care planning, including the use of flowcharts to guide prescribing decisions.