Clinical Pharmacy Lec 4 Therapeutic Planning PDF

Clinical Pharmacy I, PP904 Lecture 4: Therapeutic planning Dr. Sarah Sabry Lecturer of Clinical Pharmacy Egyptian Chinese University [email protected]  1. Introduction to clinical Pharmacy facilities 2. Clinical Case presentat...

Clinical Pharmacy I, PP904 Lecture 4: Therapeutic planning Dr. Sarah Sabry Lecturer of Clinical Pharmacy Egyptian Chinese University [email protected]  1. Introduction to clinical Pharmacy facilities 2. Clinical Case presentation 3. Clinical laboratory data and physical examination 4. Therapeutic planning 5. Drug-related problems 6. Medication errors & Reconciliation 7. Special care populations( geriatric, pediatric, Course Outline 8. obesity) Special care populations (pregnancy& lactation, Renal, Hepatic) 9. Supportive care of oncological diseases 10. Supportive care of blood disorders 11. Supportive care of nutritional deficiencies. 12. Medication Therapy management services  Lecture Objectives: ▪ Introduces students to definition of Therapeutic Planning ▪ Recognize the process of Therapeutic Planning ▪ Identify Types of Therapeutic Planning Format: ▪ Know components of SOAP ▪ Know components of FAST HUG MAIDENS Therapeutic planning ▪ Effective planning facilitates the selection of appropriate medication regimens for specific patient problem. ▪ The planning process consists of: 3- Selection of treatment 4- Development 1- Problem 1- Problem Identification Prioritization regimen for every problem of an Integrated monitoring plan. I. Problem identification 2- Create sets of 3- Determination 1- Identification of related of specific patient parameters parameters patient problems  I. Problem identification In this stage, all the available data is considered (patient’s history, PE, laboratory and diagnostic tests, pharmacist- acquired medication history). Group related subjective and objective parameters to determine specific problem. Step 1- Identification of patient parameters from the components of case presentation as PMH, MH , SH , FH and so on… Create a working list of all available subjective and objective data from the (medication history, HPI, PMH, SH, ROS, PE and laboratory and diagnostic tests) above data including both pertinent +ve data and the pertinent –ve data that are normal but would be expected to be abnormal given the patient’s condition (e.g., Long-standing type 1 diabetes have retinopathy, the fact that patient with long standing diabetes without diabetic retinopathy is important –ve data).  I. Problem identification Subjective parameters Objective parameters - Parameters which are describable but can’t be - Parameters that can be precisely described, precisely measured or quantified. - measured or quantified - These parameters are less obvious and more - - Parameters such as crackles, oedema, and difficult to identify. - muscle atrophy although can’t be precisely - quantified are considered objective parameters.  I. Problem identification Step 2- Create sets of related parameters Identify related parameters that combine to indicate specific problem. e.g., Fever, one episode of chills, productive cough combined with objective data of leucocytosis with an increased percentage bands, a chest X-ray film showing right middle lobe consolidation and sputum +ve for gram +ve cocci are related. Step 3- Determination of specific patient problems Evaluate each group of related subjective & objective parameters to determine specific problem 5 II. Problem Prioritization 2- Identification 1- Identification of the 3- RANKING the of the INACTIVE ACTIVE problems problems problems  II. Problem Prioritization This means ranking the identified problems (according to the acuteness of the problem) with the most urgent problems on the top of the list and the least urgent on the bottom. Step 1 Identification of the active problems These are the problems require some kind of drug or non-drug intervention (pneumonia, asthma, CHF, trauma, cerebrovascular accident, MI and anxiety).  II. Problem Prioritization Step 2 Identification of the inactive problems Those are the problems of historical interest only and don’t require any sort of intervention (history of an appendectomy, history of pneumonia, history of sulpha-associated rash). These inactive problems need to be identified and listed so that they can be considered when planning for treatment of active problems (e.g., history of splenectomy is at increased risk of infections with streptococcus pneumonia, Haemophilus influenza, Neisseria meningitis and some gram –ve bacteria. Knowledge of this risk will help in planning patient-specific antibiotic therapy if the patient presents with signs and symptoms consistent with infection).  II. Problem Prioritization Step 3 Ranking the problems The ranking starts with the problem that needs the most immediate intervention (Most Urgent) and then ranks the remaining problems in order of need for intervention. The number one problem is the problem that if left untreated will cause the most harm to the patient in the shortest amount of time, e.g., bacterial meningitis, obesity and a history of a broken leg.  III. Selection of specific therapeutic regimens 3- Selection of an 2- Eliminate appropriate 4- Identification of 1- Create list of therapeutic therapeutic therapeutic alternative options for each problem options from the regimen for each regimens created list problem  III. Selection of specific therapeutic regimens Step 1 Create list of therapeutic options for each problem Identify all classes of drugs and possible therapeutic approaches for each problem. Step 2 Eliminate therapeutic options from the created list Elimination will be based on: Comparative effectiveness of the drugs The impact of the therapeutic option on Suitability of the drug for the patient. other problems (beta-blockers Ability of the patient to comply with the antihypertensives on patients with asthma) regimen The influence of other problems on the Effectiveness of previous treatments therapeutic options (reduce the medication Cost dose in renal impairment) Formulary restrictions III. Selection of specific therapeutic regimens Step 3: Selection of an appropriate Step 4: Identification of alternative therapeutic regimen for each regimens problem Alternative medication regimen for common The selection based on: potential problems should be included Past patient experience Allergy Assessment of the severity of the problem ADRs Drug specific factors Lack of therapeutic responses Patient factors (chronic renal and hepatic Additional patient problems influencing diseases) that may influence the elimination the effectiveness/pharmacokinetics of initial and metabolism regimen IV. Development of an integrated monitoring plan Types of Therapeutic Planning Format: 1. SOAP (an acronym for Subjective, Objective , Assessment , Plan) 2. FAST HUG (Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Hyperactive or Hypoactive delirium, Ulcer prophylaxis, Glucose intolerance ) 3. FARM (Finding, Assessment, Resolution, Monitoring) 4. TITRS (Title, Introduction, Text, Recommendation, Signature)  SOAP Note ▪ The SOAP note is the basic template for a pharmaceutical care plan. ▪ A format for documentation that is familiar to health care professionals. ▪ SOAP is an acronym for Subjective, Objective, Assessment, and Plan.  SOAP FORMAT The process of identifying the subjective and objective data, assessing the problem, and developing a specific therapeutic and monitoring plan is called SOAPing the problems. The term SOAP is an acronym for 1- Subjective 2- Objective 3- Assessment 4- Plan. The SOAP format provides a formal organizational structure. The steps for SOAPing a problem include the following: 1. Creating a list of the related subjective parameters 2. Creating a list of the related objective parameters 3. Assessing and documenting the problem 4. Documenting the therapeutic plan for addressing the problem. Commonly, each problem is SOAPed individually, although some clinicians prefer to integrate all data and plans into a single SOAP note.  SOAP FORMAT ▪ The subjective section will include; The patients’ complaint or reason for visit. A description of the problem (onset of symptoms, pain intensity, location, duration, and what makes symptoms better or worse). ▪ This information is elicited from interviewing the patient. It is imperative to investigate past episodes of similar symptoms and treatment received on prior occasions. ▪ This section is where you would document past medical history, social history, and allergies. Examples of questions to ask the patient include: Is there anything that makes this better or worse? Why are you here today? (This is the chief complaint, Is there a family situation that may be contributing to your presented in quotation marks.) health/illness? How are you feeling today? What do you do for work? How have you been feeling? How long has this been going Is there anything else you would like to add? on? Tell me exactly when you feel this started, is it better N.B: This list is not inclusive. You will need to develop your at some times than others? own style of interview.  SOAP FORMAT The objective section It is for documenting measurements that are observed (seen, heard, touched, smell) by the clinician. Examples include blood pressure, pulse, temperature, skin colour, and important laboratory values. If a physical examination is completed, it will be documented here as well. Information in this section is based on diagnostic and monitoring measurements. Current medications will be listed in this section, including start dates and last refilled.  SOAP FORMAT The assessment section It is for documenting and prioritizing the patient’s problems. Be sure to assess the level of therapeutic efficacy, differential diagnosis with relation to drug problems, potential confounders to efficacy or adherence, pertinent positive or negative signs, and symptoms related to the condition. You will also want to identify the goal(s) of therapy. The assessment and plan are the most important aspects of your clinical note. Some clinicians will combine the assessment and plan into one section  SOAP FORMAT The plan section It is where recommendations based on your assessment are documented. If you would like more information on documenting patient This includes; care, refer to American Society of Health-System Pharmacist ✓ Therapy additions. Guidelines on Documenting Pharmaceutical Care in Patient ✓ Deletions or modifications. Medical Records and Guidelines on a Standardized Method ✓ Lifestyle changes. for Pharmaceutical Care. ✓ Requests for laboratory and diagnostic assessments. ✓ Standards of care. ✓ Special directions and referrals. ✓ Self-monitoring recommendations. ✓ Medical personnel emergency contacts; and time to follow up appointments. If medication counselling is recommended, it will be documented here and provided before the patient leaves the office.  FAST HUG - MAIDENS FORMAT A standardized, structured approach to identifying drug- related problems in the intensive care unit  FAST HUG - MAIDENS Feeding Patients in the ICU may receive nutrition by various methods, such as parenteral nutrition, tube feeding, sips of fluids, diet as tolerated, and no oral intake. There are several opportunities to optimize drug therapy, as changing medications to the oral route from the parenteral route or vice versa, depending on how the patient is fed. If the patient is not tolerating enteral feeding and is experiencing high gastric residual volumes, the pharmacist should assess whether the problem is related to a medication. Prokinetic agents such as metoclopramide or erythromycin may be considered in these situations. For patients receiving PN, the pharmacist can monitor various laboratory parameters and suggest modification of the ingredients as appropriate.  FAST HUG - MAIDENS Feeding The pharmacist should also assess the possibility of an interaction between a drug and a nutritional formulation administered by feeding tube that might affect absorption of the drug. CR, ER, and SR-preparations should not be crushed. Crushing the enteric coating defeats the purpose of the dosage form and could lead to efficacy or adverse events. It is generally not recommended to mix medications directly into EN formula because physical incompatibilities might lead to tube occlusion. Location of feeding tubetip is important when considering medication administration. For example, sucralfate and antacids act locally in the stomach; therefore, administration through a duodenal or jejunal tube is illogical.  FAST HUG - MAIDENS Feeding Phenytoin: Most studies have shown significant decreases in phenytoin absorption when administered enterally to patients receiving EN (protein bound + bound to the tube itself). 1. Hold tube feedings for 1 or 2 hours before and after administration of phenytoin. 2. Tube flushing 3. Use of IV phenytoin or another anticonvulsant medication may be prudent.  FAST HUG - MAIDENS Feeding Warfarin: EN formulas contain vitamin K, which can antagonize the pharmacologic activity of warfarin. Component of certain tube feedings, perhaps protein, may bind to warfarin and result in suboptimal activity. Feedings should be held for 1 hour before and after warfarin  FAST HUG - MAIDENS Feeding Fluoroquinolones: Absorption of antimicrobial agents such as fluoroquinolones and tetracyclines that can be bound by divalent and trivalent cations potentially could be compromised by administration with EN formulas containing these cations. 1. Then, hold tube feedings for 1 to 2 hours 2. or administrate before and after enteral dosages of fluoroquinolones. ❑ Ciprofloxacin absorption has been shown to be decreased with jejunal administration, this drug probably should not be given by jejunal tube.  FAST HUG - MAIDENS Analgesia Patients in the ICU often require analgesia to treat various sources of pain, such as trauma, surgery, or other pre-existing medical conditions. level of pain should be checked routinely. Ideally, a patient will receive an amount of analgesic that is adequate (so that pain is not an issue) but not excessive (so that unwanted sedation and respiratory depression are avoided the pharmacist can assess the patient’s situation and make suggestions about the most appropriate method for delivering analgesic medications, such as infusions, intermittent doses, or longer-acting forms combined with PRN doses.  FAST HUG - MAIDENS FORMAT It is important to ensure that the appropriate sedative medications are being used when indicated. Why do patients need sedation ? Lack of self control , Time disorientation , Intubation , Isolation , Sleep deprivation , Pain. The pharmacist should be involved in the decision to initiate, discontinue, and adjust doses of sedative medications, according to the clinical situation and the patient’s score on a sedation scale. For example, propofol may be suitable if the patient requires only short-term sedation. However, benzodiazepines may be more appropriate if longer-term sedation is needed. The pharmacist should assess each patient daily to determine whether he or she would benefit from sedation therapy.  Thromboembolic FAST HUG - MAIDENS prophylaxis Almost all patients in the ICU should receive some form of thromboembolic prophylaxis. However, some critically ill patients may not be receiving chemical thromboembolic prophylaxis because of certain medical conditions (e.g., intracranial or active gastrointestinal bleeding). For these patients, the pharmacist can help to formulate a plan for the timing of initiation of appropriate thromboembolic prophylactic medications. The various types of prophylactic therapy include LMWH, unfractionated heparin and sequential compression devices.  Hyperactive or FAST HUG - MAIDENS Hypoactive delirium Untreated delirium can lead to an increased length of stay in the ICU, as well as increases in costs, morbidity, and mortality. When delirium is diagnosed, a search for the cause often relies on identifying potential drug-related causes of delirium. The pharmacist can provide guidance on the best choice of agent. Once an agent is chosen, the pharmacist should routinely assess whether the regimen and dose are optimal and should monitor the patient for efficacy and adverse reactions.  Stress Ulcer FAST HUG – MAIDENS Prophylaxis Patients receiving MV in the ICU are at risk of stress ulcers, and appropriate prophylactic medications should be administered. The most commonly used agents for this indication include histamine receptor antagonists and PPIs. The pharmacist should ensure that the patient is receiving a prophylactic agent and Once the patient’s condition improves and there is no longer a risk of stress ulcers, the pharmacist should reassess whether the prophylactic agent can be discontinued.  Glucose FAST HUG - MAIDENS control BG control is an important aspect of patient care in the ICU. Hyperglycemia is common in ICU due to the elevation of anti-insulin hormones (cortisol, adrenaline, nor- adrenaline) The pharmacist can play a significant role by helping to select the most appropriate pharmacological regimen. The blood glucose concentration of an ICU patient may fluctuate ,and the pharmacist can help to identify drug-related causes such as glucocorticoids, propofol, and atypical antipsychotics.  Medication FAST HUG - MAIDENS Reconciliation Medication reconciliation is an important aspect of care for any patient admitted to the hospital. 1. This process involves reviewing medications the patient received before admission and deciding which drugs need to be restarted to ensure continuity of care. 2. Another important issue is identifying DC medications for which there is a high risk of experiencing withdrawal symptoms (e.g., benzodiazepines and SSRI inhibitors). In the ICU setting, it is often difficult to obtain information about patients’ preadmission medications because patients may be sedated, confused, or unable to verbalize. Then, sources of info. include the patient’s family members, physician, medical or electronic health records, and visual inspection of pill bottles.  Antibiotics or Anti- FAST HUG - MAIDENS infective agents Patients admitted to the ICU either have an infection already or are at increased risk of acquiring an infection during their stay. As such, pharmacists can play a crucial role in antimicrobial stewardship. Stewardship activities include selecting the optimal antimicrobial agent and de- escalating treatment once culture and susceptibility results are available. Factors such as medical history (e.g., comorbid renal or hepatic dysfunction), allergies, recent antibiotic use, and recent admission to a health care facility must be considered before a regimen is chosen. In addition, the efficacy and safety of the regimen should be monitored, and the dosage or agents adjusted as needed.  Indications for FAST HUG - MAIDENS medications The pharmacist should review all regularly scheduled and PRN medications daily to ensure that each has an appropriate indication. Any medication that is no longer indicated should be discontinued, to reduce the risk of adverse events, drug interactions, medication errors, and cost. Conversely, the pharmacist should assess whether the patient has an untreated indication for which drug therapy would be appropriate.  Drug Dosing FAST HUG - MAIDENS In critically ill patients, renal and hepatic function may fluctuate frequently. 1. The pharmacist is in an ideal position to suggest dose adjustments based on clinical parameters, including indicators of renal and hepatic function, to prevent accumulation of drugs while ensuring adequacy of doses to achieve desired clinical end points. 2. It is also important that the pharmacist continually reassess and adjust doses as the patient’s condition begins to improve, to prevent under-dosing. Therapeutic drug monitoring may be required for some medications, and the pharmacist can provide such monitoring when appropriate.  Electrolytes, FAST HUG - MAIDENS Hematology, Labs Pharmacists should monitor patients related causes of abnormalities in electrolytes, hematology results, or other laboratory values and discuss treatment alternatives with the other members of the health care team. In addition, the Pharmacist may recommend initiation or discontinuation of electrolyte supplements, nutrients, minerals, blood, and fluid products if appropriate.  No FAST HUG - MAIDENS Drug Interactions, Allergies, Duplication, or Side Effects It is important to identify clinically important potential and actual drug–drug, drug– food, and drug–laboratory interactions immediately and to recommend alternative therapy. In addition, if a patient appears allergic to a particular medication, the pharmacist should perform an assessment to determine if the reaction is a true medication allergy or an Intolerance. Following the assessment, can assist in either recommending alternatives or monitoring for adverse drug reactions. The pharmacist should also look for duplication of medication therapy and stop unnecessary medications. Finally, the pharmacist should assess whether the patient is regularly experiencing adverse effects from a medication.  Stop dates FAST HUG - MAIDENS Not all medications prescribed for a patient are meant to continue indefinitely. For example, drugs that may require a stop or reassessment date include corticosteroids and anti-infective agents. The pharmacist should discuss the appropriate duration of medications with other members of the health care team. Conversely, the pharmacist should ensure that medications are not discontinued prematurely. Questions? Thank You