CLINICAL PHARMACY for D.pharm PCI syllabus.pptx

“Clinical pharmacy is a health science discipline in which pharmacists are involved in direct patient care to ensure rational and safe use, to optimize medication therapy and to promote health, wellness and disease prevention”

*scope of clinical pharmacy
*role of clinical pharmacist
*daily activities of clinical pharmacist
*ward round participation
patient counseling
ADR monitoring
*medication history
*treatment chart review

1. CLINICAL PHARMACY Archana Chavhan M.Pharm (QA)

2. “Clinical pharmacy is a health science discipline in which pharmacists are involved in direct patient care to ensure rational and safe use, to optimize medication therapy and to promote health, wellness and disease prevention” Definition

3. SCOPE OF CLINICAL PHARMACY Clinical pharmacy establishes drug information centre to promote the rational use of drug It involves providing information to the patient about drug therapy and disease Along with the physician, clinical pharmacist actively involved in reporting of ADR Clinical pharmacist involves in taking past prescription drugs, dietary supplements of patient It involves evaluation of drug therapy, optimizing it for fast recovery of patient With physician he should be participate in ward round to observe patient and decide dug therapy Drug information Ward round participation ADR management Medication history Monitoring drug therapy Patient counselling

4. Common abbreviations used in medical practice 1 2 5 6 7 8 4 3 ACE- Angiotensin converting enzyme ATP- adenosine triphosphate ADP- Adenosine diphosphate BMI- body mass index CCU- coronary care unit WBC- white blood cell RBC- red blood cell WHO- World health organization

5. Pharmaceutical Latin terms For dosage form Syrup Syrupus Powder Pulvis Tablet Tableta Capsule Capsula Mixture Mistura Ointment unguentum Cream Chrisma Paste Pasta Eye drop Auristille Nasal drop Naristillae For time of administration Bis in die Two times a day Hora somni At bed time quaque die Every day quater in die Four times a day quantum satis As much needed ter in die Three times a day ut dictum As directed ante cibum Before meal Post cibum After meal quaque die ante meridiem Every morning

6. Common terminologies used in clinical settings Benign Not cancerous Defibrillator Device that use electric shock to restore normal heartbeat Malignant Indicate presence of cancerous cells Antimicrobial Drugs that kill/inhibit the growth of microorganisms Hypothermia Low body temperature Hypoxia Deficiency of oxygen into the blood Antidiuretic Drug which increases urine output Alopecia Loss of hair from scalp Anorexia Loss of appetite Bradycardia Slowness of heartbeat Bacteriostatic Agent that inhibits growth of bacteria Bactericidal Agent that kills the bacteria Chemotherapy Treatment of disease by chemical agent Dermatitis Inflammation of skin Insomnia Inability to sleep Palpitation Sensation of irregular or fast heartbeat Oliguria Decreased urine formation

7. Abbreviations commonly used in measure of capacity & weight Symbol English Equal to m Minim 1 minim  ʒ  or “f ʒ ” Fl. Drachm 60 minim oz or “ fl oz ” Fl Ounce 29.57ml “O” Pint 16 fl ounce gr Grain 1 grain “℈” Scruple 20 grain lb Pound 5760 grain or 12 drachm

8. 01 02 03 04 05 06 Role of clinical pharmacist Management of ADR Identification and management of drug interaction & adverse drug reaction Ward round participation taking part in ward round for optimizing therapeutic management with drug therapy selection, taking past medical history, follow up etc. Drug information service In drug and poison information center preparation and development of guidelines and formularies to improve patient compliance Patient counselling Patient counselling includes advice given by pharmacist to the patient for safe use of prescribed drug. medication history Taking medication history interview to obtain information on aspects of drug use that may assist in overall care of patient Treatment chart review Treatment chart review includes review of patient’s drug treatment for evaluation of therapeutic efficacy of each drug

9. Daily activities of clinical pharmacist Ward round participation Patient counselling Treatment chart review Monitoring of ADR Drug and poison information Medication history

10. Ward round participation A ward round is a visit made by a medicinal practitioner, alone or with a team of health professionals to hospital inpatients to review and follow up progress in their health. Types of ward rounds 01 Teaching round Academic medical staff conducts teaching rounds for medical PG students, interns, UG students & pharm D students. A clinical pharmacist can join during such rounds. 02 Chief physician round These type of ward round involves experienced doctors specialized for discussing complex & complicated problems 03 Pharmacy round The inclusion of clinical pharmacists in ward rounds can reduce adverse drug events, improve communication and enable collaborative decision-making.  04 Resident round Visiting patient ward daily at a fixed time by residents individually or team depending on the seriousness of the patient’s disease. 

11. Role of pharmacist in ward round participation Roles Gain an improved understanding of patient’s clinical status and progress, currently planned investigations & therapeutic goals Detect, manage & prevent adverse drug reactions and drug interactions. Also provide additional information about medication compliance. Provide relevant information on optimizing drug therapy by selecting right drug, therapy monitoring and follow up Also provide opportunity to participate in the in-patient discharge planning and preparation of treatment chart review 01 02 03 04

12. Treatment chart review Treatment chart review is a process where a pharmacist reviews the patient’s drug treatment during his hospital admission involves an evaluation of therapeutic effect of each drug and the progress of the condition being treated. Goals of treatment chart review 01 02 To optimize the patient’s drug therapy To minimize or prevent drug related problems (medication errors) Components of medication order review Ensuring that appropriate medical terminology is used Checking complete drug profile for medication duplication, interactions or incompatibilities Ensuring that medication order is appropriate with respect to patient’s medication history, drug dose & dosage schedule, disease state or pregnancy, dosage route and time of administration Reviewing medication for cost effectiveness Identification of drug related problems.

13. Treatment chart review form Medication history

14. Adverse drug reaction monitoring What is Adverse Drug Reaction? WHO defines an “ Adverse drug reaction (ADR) as any response to a drug which is noxious and unintended, and which occurs at doses normally used in man for prophylaxis, diagnosis or therapy of disease.”

15. Reason / factors for ADR Patient related factors Age 01 Patient non-compliance 07 Hereditary factors 06 Allergy status 05 Gender 02 Maternity status 03 Body weight 04

16. Drug related factors 01 Polypharmacy 02 Pharmacokinetic of drug 03 Drug Dose & frequency 04 Therapeutic index

17. Social factors Disease related factors Drinking alcohol Smoking tobacco Multiple disease state D isease state

18. Excessive pharmacological effect 01 Secondary pharma- cological effect 02 03 06 05 04 Classification of ADR Rebound response after discontinuation Idiosyncrasy (unusual behaviour of a person) Allergic response Genetically determined toxicity This type of reaction will develop in patient if excessive dosage is given. e.g. 1) Excessive dose of digoxin produce bradycardia 2)Excessive dose of morphine produce respiratory depression A drug may have more pharmacological actions to commonly administered dosage. e.g. a patient receiving antihistamines for prevention of allergic skin reaction may become drowsy. After long use of many medications, tolerance may get developed at cellular level. Sudden withdrawal of such medicines may give rise to sever adverse effects. Long term use of CNS-depressants like benzodiazepines, after sudden withdrawal results in confusion, tachycardia and convulsion. An uncommon & abnormal response to drug.Usually due to genetic abnormality. Affect drug metabolism & receptor sensitivity. e.g.Anemia (hemolysis) by antioxidant drugs or (G6PD deficiency) Drug allergy includes antigen antibody reactions involving lymphocytes. e.g. penicillin or streptomycin causes skin rashes There is increased risk of drug toxicity specially in case of patients with special genotype e.g. corticosteroid causes toxicity in glaucoma patient

19. Methods of detecting ADR Passive surveillance system: Health professionals are encouraged to report adverse reactions which they believe to be drug-related directly to the regulatory authority or the company marketing the suspected product on a voluntary basis SPONTANEOUS CASE REPORTS 1

20. The spontaneous reporting system process

21. India - 'Suspected Adverse Drug Reaction Reporting Form’ UK - 'Yellow Card', since 1964 Australia - 'Blue Card', since 1964 US- 'Med Watch' ADR reporting form;

22. Cohort means identifying a group of recipients of drug and observing these patients for varying length of time for what happens to them. It is used when detection of events occur with frequency more than 1 in 500 exposed. COHORT STUDIES 2

23. It involves the comparison of group of patients with a disease which is thought to be due to a drug (called case) and with a group of patients who do not have the disease (called control) . The drug histories of cases and controls are obtained and compared CASE CONTROL STUDIES CASE CONTROL 3

24. Role of pharmacist in ADR management They are trained to identify potential ADRs by reviewing medication profiles, patient histories, and reported symptoms. They play role in reporting ADRs to regulatory authorities and contributing to pharmacovigilance programs Pharmacists collaborate with healthcare teams to ensure effective management of ADRs. They communicate with prescribers, nurses, and other healthcare professionals to discuss ADRs, & develop appropriate treatment plans. Pharmacists assess and evaluate ADRs to determine their severity, & impact on patient well-being. They use their expertise to analyze drug dose, potential drug interactions, and patient-specific factors to identify the causative medication. They provide clear and concise information about potential side effects, signs of ADRs, and steps to take if they occur. Pharmacists address patient concerns, promote medication adherence.  01 02 03 04 Identification and Reporting of ADRs Assessment and Evaluation of ADRs Patient Education and Counselling Collaboration with Healthcare Teams

25. As a professional responsibility pharmacist need to conduct interview of patient to obtain patient’s medication history This is done by conducting clinical interview with definite goals. The goals are to obtain complete and correct medication history on the patient For successful interview pharmacist need to have effective communication skills. Two major components of interview are collection of scientific information an interpersonal experience It is the responsibility of pharmacist to obtain and document the medication history and present it to the consulting physician Medication History

26. Objectives of M edication History To know about patient’s drug allergies and ADR 01 To develop more through pharmaceutical care plan 04 To identify potential medication problems 03 To know about patient’s dietary habits 02 To get know about patient’s prescription and non-prescription medicines 05

27. Sources of patient Data Patient interview 1 Medical records 2 Pharmacy dispensing records 3 Family members 4

28. Steps involved in medication history interview 01 Patient selection Ideally all Patient If not, possible priority should be given to those who are more likely to get benefit. Eg : Patient with polypharmacy, Multiple and chronic diseases. 02 Self-Preparation Collect all the relevant data including co-morbid conditions Provisional list of medications can be made through medical notes Preparation of list of questions can be helpful 03 Privacy and Confidentiality Consider privacy and confidentiality of the patient except for exchange of information with other health care professionals. 04 Conduct interview use proper communication skills for interview Close ended questions may be useful to confirm details 05 Documentation & follow up All information should be documented If any discrepancies - informed to the concerned physician

29. Drug Information and Poison Information

30. DRUG INFORMATION is the provision of unbiased , well referenced and critically evaluated information on any aspect of pharmacy practice. It is either provided in writing/ verbally. DRUG INFORMATION CENTER provides detailed accurate source of drug information to meet needs of physicians, pharmacist etc.

31. 04 03 02 05 01 Functions of drug information services Drug information mainly focuses on providing better patient care area and patient counseling Provides information on; Therapeutic use of drugs Dose & administration route Adverse effects & drug interaction Safety indications of drug in various disease condition Monitoring the adverse drug reaction & reporting it to the respective committee Drug information provides a choice for clinical pharmacist to conduct a drug therapy Developing policies of PTC committee. Preparing and maintaining hospital formulary

32. Sources of drug information Primary resources Tertiary resources Secondary resources 01 It includes results of research at all levels (clinical trials) e.g. Case reports Clinical study reports Research journal Thesis It consists of reviews of primary Reports. e.g. Meta analysis, systematic review, number of electronic knowledge system ( micromedex , pubmed , google scholar etc.) These are the summaries of pri & Sec. Published literature. e.g. Textbooks, Pharmacopoeias, encyclopaedia Dictionaries 03 02

33. ABILITIES REQUIRED FOR DRUG INFORMATION SPECIALIST Knowledge of institutional and library facilities, literature utilization etc. Possession of verbal and written communication skills Participation directly or indirectly in patient care Provision of professional services to the PTC Contribution to drug literature through appropriate research Familiarity with electronic data processing for information retrieval

34. Poison information center

35. It is a specialized area of drug information which includes information about the toxic effects of chemicals and pesticides, hazardous material spills, household products, overdose of therapeutic medicines, plants including mushrooms, animal toxins from the bites of snakes, spiders and other venomous creatures and Stings. Poison information Indian scenario In India, As of 2010 there was only 4 WHO recognized centers in India. in addition a few other centers established. The first national poison information Centre was established in December 1994 At 'All India Institute of Medical Sciences' (AIIMS), New Delhi. The Other centers were subsequently established at national institute of occupational health, Ahmedabad • government General Hospital, Chennai and • Amrita Institute of Medical Sciences and Research Cochin.

36. Research education and training Functions Provision of toxicological information and advise Management of poisoning cases Provision of laboratory analytical services Take part in toxicovigilance activities Prevention and treatment of poisoning

37. Interprofessional collaboration WHO Defines” multiple health workers from different professional backgrounds works together with patients, families, careers and communities to deliver the highest quality of care”

38. Benefits of collaboration 01 05 04 03 02 This reduces the probability of common errors and inaccuracies in medication and misdiagnoses.  Improved patient’s safety and quality care Promotes better communication between health workers Collaboration can lead to innovative approaches in patient care collaboration in healthcare systems creates a sense of attachment and bonding between the professionals.