Introduction to Clinical Pharmacy PDF

Introduction to clinical pharmacy Definition The area of pharmacy concerned with the science and practice of rational medication use. ( Patient oriented ) Where to practice clinical pharmacy ? Clinical Pharmacy includes all the services performed by pharmacists practicing in hospital...

Introduction to clinical pharmacy Definition The area of pharmacy concerned with the science and practice of rational medication use. ( Patient oriented ) Where to practice clinical pharmacy ? Clinical Pharmacy includes all the services performed by pharmacists practicing in hospitals, community pharmacies, nursing homes, home- based care services, clinics and any other setting where medicines are prescribed and used The term “clinical” does not necessarily imply an activity implemented in a hospital setting. What are clinical pharmacy Requirements? Qualifications to be expert clinical pharmacist 1- Clinical Pharmacy Fellowship 2- Board of Pharmacy Specialties 3-Clinical Pharmacy Diploma 4-PharmD 5- Clinical pharmacy Master, and PhD 6- Clinical pharmacy Bachelor Clinical pharmacists work area in the hospital How a Clinical pharmacist can be effective in outpatient? ❖Responsibilities 1. Medication reconciliation 2. Adjust medication doses as necessary 3. Improve patient compliance 4. Report medication errors 5. Educate patients and providers about medications Drug information center ( DIC ) 1. Provision of specific comprehensive drug information upon request from healthcare providers, and consumers from the general public in a timely manner, based on a complete analysis of available evidence. 2. Maintenance of resources to provide the most current and accurate information to inquirers. 3. Publishing a drug information newsletter. 4. Educating pharmacy students, and professionals about resources and medical literature analysis and enhancing the skill of accurately communicating response (both verbally and in-writting). Inpatient care ❖Ward Clinical pharmacist role : 1) Involved in medical rounds with the other health care professionals 2) Documenting patient information on a specially designed record 3) Creating a pharmaceutical care plan 4) Identify Medication related problems. 5) Answering Medication information queries to physicians & other health professionals. 6) Patient education and counseling. Examples of clinical pharmacy practice areas Ward clinical pharmacists work directly with Patient Files Management  The pharmaceutical care plan is a written, individualized, comprehensive medication therapy plan based on clearly defined therapeutic goals. The pharmaceutical care plan, which is available to all pharmacists caring for a patient, is updated with each major change in patient status. It is important that the physician be informed about the care plan to ensure common goals. Patients should also be informed about the general content of the care plan as means of gaining their agreement regarding drug therapy. A) Create patient database The first step in the care planning process is the creation of a comprehensive patient database, which includes at minimum, the following information: 1. Patient demographics 2. Diagnoses and past medical history 3. Present medications and medication history 4. Medication allergies/intolerances 5. Smoking/alcohol/caffeine/drug use history 6. Abnormal laboratory and physical exam results 7. Renal and liver function B) Assess drug-related problems Following the creation of a comprehensive patient database, the pharmacist should evaluate the patient's drug therapy Most drug-related problems are the result of: 1. Not receiving an indicated drug 2. Receiving the wrong drug 3. Receiving too little of the drug (Subtherapeutic dose) 4. Receiving too much of the drug (Supratherapeutic dose) 5. Experiencing an adverse drug reaction 6. Experiencing a drug interaction 7. Not receiving the prescribed drug 8. Drug without indication C) Establish a therapeutic goal Therapeutic goals should be definite, realistic and, if possible, measurable. Most therapeutic goals relate to: 1. Approach normal physiology (i.e., normalize blood pressure). 2. Slow progression of disease (i.e., slow progression of cancer). 3. Alleviate symptoms (i.e., optimize pain control). 4. Prevent adverse effects. 5. Educate the patient about his or her medication. D) Specify monitoring parameters Finally, monitoring parameters must be specified so that the patient's progress can be followed. Monitoring parameters must also include potential adverse effects. Determine desired end points for each parameter and the frequency of monitoring. E) Document patient's progress The pharmacist evaluates and documents the patient's progress in achieving the desired therapeutic goals and avoidance of potential adverse effects. The pharmaceutical care plan is updated with each major change in patient status.  In summary, the general steps involved in creating a pharmaceutical care plan are: 1. Create comprehensive patient database. 2. Assess for actual and potential drug-related problems. 3. Establish therapeutic goals. 4. Specify monitoring parameters with end points and frequency. 5. Document the patient's progress towards therapeutic goals. Patient progress : Day 1 Day 2 Day 3 Interventions Drug checklist 1. Checklists provide a framework of standardization and regulation of interventions in a systematic manner, allowing individuals to assess the presence or absence of the items. 2. Provides structure to important ICU-related interventions in an effort to reduce errors of omission and increase compliance with evidence-based practices to improve outcomes in the ICU patient population Drug checklist in the ICU 1) Drug interactions 2) Medication without indication 3) Right dose 4) Dosage adjustment according to hepatic and renal functions 5) Right preparation and administration 6) Monitoring ADR 7) Monitoring of treatment response 8) lab values monitoring 9) Indication without medication 10) Stress ulcer prophylaxis 11) DVT prophylaxis 12) Feeding 13) Analgesia and Sedation 14) Head of bed elevation 1-Drug interactions ❖Four factors for assessment: Risk rating scale (A,B,C,D,X) Reliability (Excellent , good, fair , poor) Onset (delayed ,rapid) 2-Medication without indication Ceftriaxone added in pts with diabetic ketoacidosis without source of infection Use of antibiotics in case of viral infections. 3- Right dose Dose of enoxaparin in case of VTE prophylaxis in critically ill patients is 40 mg SC daily Dose of enoxaparin in case of treatment of VTE is 1 mg/kg q12hr or 1.5 mg/kg q24hr 4- Dosage adjustment according to hepatic and renal functions 1- Acute Renal Failure : JELLIFFE multi-step 2- Chronic Renal Failure : (Cockcroft-Gault, Modification of Diet in Renal Disease [MDRD], and Chronic Kidney Disease Epidemiology Collaboration [CKD-EPI]) ❖Note : Some drugs require special equations to calculate its dosage Cockcroft-Gault equation Dose adjustment according to hepatic function ❖Examples of drugs adjusted according to child-pugh score Metronidazole Caspofungin Tigecycline 5-Right preparation and administration ❖Teicoplanin (targocid ®) preparation: avoid vigorous shaking and froth formation should be diluted slowly at wall of vial  Caspofungin is stable only in saline and unstable in G5% Ceftriaxone and Ringer cannot be given at same line ✓ Correct is to separate both of them in separate lines or to flush line before & after ceftriaxone administration. Phenytoin can be prepared only in normal saline while Fosphenytoin can be delivered in normal saline solution or D5W (5% dextrose [in water] injection) quetiapine XR tablets, isosorbide dinitrate (sublingual, sustained release) and valproic acid cannot be crushed For Ryle administration 6- Monitoring ADR Macrolides can cause interstitial nephritis linezolid can cause thrombocytopenia furosemide can cause hypokalemia 7-Monitoring of treatment response ❖Hyperkalemia Monitoring potassium level until reaches normal level 3.5-5 mEq/L 8-Lab values monitoring Patient on ACEI & Spironolactone Potassium level Heparin Platelets Warfarin INR 9-Indication without medication Patient admitted to ICU with chest infection with history of gout Missed anti-hyperuricemic drugs in his drug sheet 10-Stress ulcer prophylaxis 1) Prophylactic medications are recommended for any one of the following major risk factors: a. Respiratory failure necessitating mechanical ventilation (for more than 48 hours) b. Coagulopathy, defined as platelet count < 50,000 cells/mm3 or INR >1.5 or aPTT greater than 2 times the control (Note: Prophylactic or treatment doses of anticoagulants do not constitute coagulopathy.) 2) Prophylactic medications or continuing home acid suppressive regimens are also recommended for any patient with a history of gastrointestinal (GI) ulceration or bleeding within 1 year before ICU admission. Medications for Stress Ulcer Prophylaxis  11-DVT prophylaxis Critically ill patients are usually at high risk of VTE. Initiate appropriate prophylaxis, considering VTE and bleeding risks Mechanical prophylaxis ( compression stockings or intermittent pneumatic compression devices) are alternative non- pharmacologic options in patients at high risk of bleeding 12) Feeding Malnutrition can lead to impaired immune function, in turn leading to increased susceptibility to infection, inadequate wound healing, bacterial overgrowth in the GI tract, and increased propensity for decubitus ulcers. 13) Analgesia and sedation Analgesic and sedative administration optimizes patient comfort and minimizes the acute stress response (hypermetabolism, increased oxygen consumption, hypercoagulability, and alterations in immune function) 14) Head of bed elevation Elevating the head and thorax above bed to a 30–45 degree angle reduces the occurrence of GI reflux and nosocomial pneumonia in patients who are receiving mechanical ventilation. 15) Glycemic control Glycemic control is necessary in critically ill patients to decrease the incidence of complications such as decreased wound healing, increased infection risk, and increased risk of polyneuropathy