Drug Therapy Monitoring

Introduction to daily activities of clinical pharmacist.
Drug therapy monitoring,
Medication chart review
Clinical Progress
Pharmacist intervention
Detection and management of ADRs

1. INTRODUCTION TO
DAILY ACTIVITIES OF
CLINICAL PHARMACIST
Dr. Ramesh Bhandari
Asst. Professor
Dept. of Pharmacy Practice
KLE College of Pharmacy, Belagavi

2. Daily activities of Clinical Pharmacist
Drugtherapymonitoring(medicationchartreview,clinical
review,pharmacistinterventions)
Wardroundparticipation
Adversedrugreactionmanagement
Druginformationandpoisoninformation
Medicationhistory
Patientcounselling
Drugutilisationevaluationandreview
Qualityassuranceofclinicalpharmacyservices

3. Drug Therapy Monitoring
Itinvolvesthereviewofapatient’smedication
regimentoensurethattherapyisappropriate,
safe,efficaciousandcosteffective.
Alsoknownasdrugtherapyreviewor
medicationreview.

4. Goals of Drug Therapy Monitoring
Identifyingandsolvingdrugrelated
problemsinordertooptimizethedrug
therapyandpatienthealthoutcome.
Toensurealltherapeuticsobjectives
arebeingachieved.

5. Significance of Drug Therapy Monitoring
Assesswhetherdesiredtherapeutic
outcomesarebeingachieved.
Monitorfordrugrelatedproblems
Ensurerationalandqualityuseofmedicine
Assesspatientcompliance
Assessthecompletenessofmedication
charts

6. Components of Drug Therapy Monitoring
A.Medicationchartreview(MCR)or
Medicationorderreview(MOR)or
Treatmentcharreview(TCR)
B.Clinicalreview/dailyprogressreview
C.Detectionandmanagementofadverse
drugreactions

7. A. MEDICATION CHART REVIEW
Fundamental responsibilityofclinical
pharmacist.
Itisasystematicreviewofapatient’sdrug
therapytoensurethattheprescribed
medicationisappropriateforthepatient.
Involvesassessmentofallcurrentandrecent
medicationordersincludingroutinemedication
andoverthecounterdrugsandtheuseofother
systemofmedicines(unani,ayurvedic,siddha).

8. Goal of Medication Chart Review
Ensuringthatthepatientreceive
Rightdrug
Rightdose
Rightfrequency
Rightduration
Rightdosageform

9. Steps of Medication Chart Review
1)Collectionandinterpretationofpatientspecific
information,includingmedicationhistoryinterview
2)Assessmentoftherapeuticgoals
3)Identificationofdrugrelatedproblems
4)Individualisingmedicationregimen
5)Monitoringtreatmentoutcomes
6)Medicationchartendorsement
7)Documentation

10. 1. Collection and interpretation of patient specific
information, including medication history interview
Firststepinsettingthetherapeuticgoal
Needtocollectinformationthatwillassistthemtodetermine
theappropriatenessofdrugtherapy.
Includespatient’sdemographicdetailssuchasage,sexand
bodyweight,socialhistory,presentingcomplaints,past
medicalhistory,allergyandsensitivitystatus,current
medicationsandresultsofrelevantlaboratorytestsandother
investigations.
Enablesthepharmacisttounderstandthepatientdisease
condition,indicationofdrugsanddailyclinicalprogress.

11. 1. Collection and interpretation of patient specific
information, including medication history interview
Sources:Patient,casenotes,medicationchart,
observationalcharts,laboratoryresultsandthrough
discussionswithmedicalandnursingstaff.
Furtherpharmacistcanobtainmoreinformationwhichisof
importancetotheongoingmedicalmanagementofthe
patient.(MedicationHistoryInterview).
Patient’smedicationhistoryshouldbeobtainedatthe
beginningofthehospitaladmissioninordertoprovidethe
additionalusefulinformationtotheprescriber.

12. 1. Collection and interpretation of patient specific
information, including medication history interview
Aspectsofmedicationusewhichmaybeobtainedfrom
Medicationhistoryinterview:
Historyofpreviousallergies/ADRs
Indicationofeachmedications
Dosingregimenincludingdose,route,frequencyand
durationoftherapy
Perceivedsideeffects
Adherencetomedicationregimen
Useofmedicationaids
Treatmentwithothersystemofmedicine(Ayurveda,
siddha,unani)
UseofOTCdrugs
Socialdruguse(tobacco,alcohol,panmasalaetc)

13. 1. Collection and interpretation of patient specific
information, including medication history interview
Followinginterview,datacollectedshouldbecomparedwith
themedicationchartsforanydiscrepancies(medication
reconciliation)inordertoidentifydrug-relatedproblems.
Ifanyproblemexistsconcernedphysicianshouldbe
contactedtoovercomethosedrugrelatedproblemsortodo
anychangesinthemedicationchart.

14. 2. Assessment of Therapeutic goals
Todeterminetheappropriatenessofdrugtherapyitis
essentialtounderstandthetherapeuticgoalsforthe
individualpatient.
Mayincludeoneormoreofthefollowing:
oCureofthedisease
oReductionoreliminationofsignsandsymptoms
oArrestingorslowingdiseaseprogression
oPreventingdisease/symptoms

15. 2. Assessment of Therapeutic goals
Therapeuticgoalsshouldbasedonpatientindividual
circumstancesandmaydifferfrompatienttopatientbasedon
theirage,co-morbiditiesandthenatureandseverityoftheir
illness.
Eg:patientwithhypertensionwithdiabetes
40yearoldpatient–goalshouldbe<130/85mmofHg
>60yearsofage–goalshouldbe>150/90mmofHg

16. 3. Identification of drug related problems
Reviewingdrugtherapyshouldbeaimedatidentifyingand
resolvinganydrugrelatedproblems.
Adrugrelatedproblemisanyeventorcircumstance
involvingdrugtreatmentthatinterferesorpotentially
interfereswiththepatientachievinganoptimumoutcomeof
medicalcare.
CharlesheplersandLindastrandcategorizedrugrelated
problemsinto8categories.

17. 3. Identification of drug related problems
i.Untreatedindication
ii.Improperdrugselection
iii.Sub-therapeuticdose
iv.Overdosage
v.Adversedrugreactions
vi.Failuretoreceivedrugs
vii.Druginteractions
viii.Drugusewithoutindication

18. 3. Identification of drug related problems
i.UntreatedIndications:
Examples:
RApatientsusingNSAIDsforsymptomsreliefandmaypresent
symptomsofGastritis,thissituationrequiresanadditionaldrug
suchasH2blockersranitidineORPPIOmeprazole,Pantoprazoleto
controlgastritissymptoms.
InTBpatientsINHtherapyadvisedpyridoxinetoprevent
peripheralneuropathycausedbyINH.

19. 3. Identification of drug related problems
ii.Improperdrugselection:
EG:anygivendrugregimenbeconsideredaswrongforaspecific
patientatgiventimeifthedosageformisinappropriate(eg:a55
yearoldpatientwithmildanginareceivingnitoglycerinpatchesto
beappliedondailybasis.
Contraindicationsarepresent(eg:apregnantwomenreceiving
Isotretinoin20mgBDfor2weeksforacnevulgaris.

20. 3. Identification of drug related problems
iii.Subtherapeuticdose:
Anydruggiveninlowerdosethantherecommended.
Eg.,Atwoyearoldchildreceivingamoxicillin40mg
PO(40mg/5ml)forherfirstepisodeofotitismedia.

21. 3. Identification of drug related problems
iv.Overdosage:
Eg.,Anydruggivenmoredosethanrecommendedfor
individualpatient.

22. 3. Identification of drug related problems
v.Adversedrugreactions:
a)Eg:Ofloxacininducedthrombocytopenicpurpura
b)Insulininducedhypoglycemia
c)Penicillininducedhypersensitivity

23. 3. Identification of drug related problems
vi.Failuretoreceivedrugs:
a)Eg.,Despitetheprescriberorder,dutynursemayfailto
administerthedrugs.
b)Duetohighcostofthedrugpatientmaynotpurchasethe
medication.
c)Duetoforgetfulnesssometimepatientmayforgettotakethe
drugs.

24. 3. Identification of drug related problems
vii.Druginteractions:
a)Eg,Ciprofloxacinandantacidsconcomitantusecancausefailure
ofciprofloxacintherapy.
b)Mostofthedrugswithgrapesjuicecancausetoxicityofthe
drugs.

25. 3. Identification of drug related problems
viii.Drugusewithoutindication:
EG:Nebulizationsalbutamol200mcgTID+Budesonide100mcg
BID,thenpatientalsoRxwithTabpantoprazole40mgODfor10
days,patienthasnotcomplainedanysymptomsofgastritisorPUD

26. 4. Individualising medication regimens
OnceDRPrelatingtotheindividualdrugsonthemedication
charthavebeenresolved,thenextstepistoconsiderthe
patient’soverallmedicationregimen.
Importantforpatientswithchronicdiseasesorthosewho
areonmanydrugsonlongtermbasis.
Considerpatientdataincludingpastmedicalaswellhistory,
co-morbidconditions,allergichistory,andconcurrentillness.
Aimshouldbetosimplifytheregimenandtoadjustthe
regimentomaximizelongtermmedicationadherence.

27. 4. Individualising medication regimens
Eg:
Switchingtoslowreleaseformulationofthesamedrug
Differentrouteofdrugadministration
Changingtimeofthedosestaken
Switchingtoacheaperbuteffectivemedications
Combinationformulation

28. 5. Monitoring treatment outcome(s)
Keytoassesswhetherthetherapeuticgoalsofdrug
treatmentachievedornot.
Includesreviewofthepatient’sclinicalstatus,laboratorydata
andothermarkersofdrugtherapyresponse.
Whileevaluatingpatient’sresponsetodrugtherapy,the
pharmacistmayneedtoreviewinformationanddatafroma
numberofsources.

29. 5. Monitoring treatment outcome(s)
Eg:
Monitoringantibiotictreatmenteffectsinclude
examiningthepatient’stemperaturechart,laboratory
data(changestoindicessuchaswhitecellcountand
inflammatorymarkerssuchasESRandCRP)andcase
noteentrieswhichdescribechangesinthesignsand
symptomsofthepatient’sinfection.
Alsoobtainedbypatientinterview

30. 5. Monitoring treatment outcome(s)
Sometherapeuticgoalsrequirelongtermfollow-up.
Eg:Responsetoantidepressantsmaytakeupto4-6weeks
tobecomeevident.
Iftherapeuticgoalsarenotachievedwithintheexpected
timeframe,pharmacistshouldtrytoidentifypossiblecauses
beforeconsideringtheneedforchangeintherapy.

31. 6. Medication Chart Endorsement
Chartendorsementisoneoftheprimaryresponsibilitiesof
thepharmacistinensuringthatmedicationordersare
unambiguous,legibleandcomplete.
Itisessentialtoavoidmedicationerrors,includingthosethat
mightoccuratthelevelofprescribingandoradministration
duetoincompletenessoftheorder,lackofadequate
instructionsandillegibility.

32. 6. Medication Chart Endorsement
Ifchartendorsementisrequired,preferablywithimmediate
noticetotheconcernedprescriber,allthenecessarydetails
areendorsedonthecharttoavoidanyconfusionindrug
administrationandalsotopreventorminimisemedication
errors.

33. 6. Medication Chart Endorsement
Followingannotationsshouldbeconsidered:
Istheidentityofthepatient(nameandIP/OPnumber)on
eachmedicationchart?
Istheallergystatusofthepatientdocumented?
Isthemedicationnameclear?Abbreviationshouldbe
avoided.
Isthedrugprescribedbythegenericname?
Isthedoseclear?Avoidusingabbreviationforunitsand
fractionaldosesshouldbewrittenwithzerobeforedecimal
points.

34. 6. Medication Chart Endorsement
Followingannotationsshouldbeconsidered:
Istherouteofadministrationspecified?
Isthedateandtimeofdrugadministrationclear?
Areanyadditionaldrugadministrationsinstructionsgiven
whereappropriate?
Isthereanyover-writingwhichmayleadtoconfusion?
Isthecancellationofmedicationorderclearand
unambiguous?
Istheprescriptionsignedbydoctor?

35. 7. Documentation
Pharmaceuticalcareprovidedshouldbeanintegralpartof
thepatient’smedicalrecord.
Documentationofpharmaceuticalcareprovidedcanbe
madeeitherinmedicationchartorincasenoteswithaclear
titlewithpharmacist’ssignature.
Documentationofservicesinthepatient’smedicalrecordis
thenaccessibletoallotherhealthcareprofessionals.
Computerisationofrelevantinformationishighlyappreciable
whichmakeseasyaccessibletohealthcareproviders.

36. B. CLINICAL/DAILY PROGRESS REVIEW
Integral componentof medication review
It is the review of the patient’s progressfor
the purpose of assessing therapeutic outcome.
Performed on daily basis

37. Goals of Clinical/Daily Progress Review
Assess the responseto drug treatment
Evaluate the safetyof the treatment
Assess the progress of the disease and the need for
any change in therapy
Assess the need for monitoring (if any)
Assess the convenienceof therapy (to improve
compliance)

38. Procedure for Clinical/Daily Progress Review
Ideally, clinical review should be done routinelyfor
all patients.
Usually carried out by attending doctorswhile
evaluating their patients to monitor the patient
outcome to drug therapy.
While evaluating, the pharmacist may need to review
biochemical, haematological, microbiological and
other investigationsas appropriate.

39. Procedure for Clinical/Daily Progress Review
Clinical Parameters
Signs
Symptoms
ClinicalCharts
TemperatureChart
Fluid Balance Chart
Observation Chart
Diabetic Chart
Laboratory Parameters
Biochemistry: Electrolytes, Renal function tests, liver function tests etc
Hematological: WBC, ESR, RBC, Platelets, Hb% etc
Microbiology: Culture tests, antibioticsusceptibility tests
Others: ECG, CT Scan, MRIetc.

40. Procedure for Clinical/Daily Progress Review
Information obtained must be interpretedand
evaluated with reference to
Clinical featuresof the existing disease
Need for a laboratory investigation
Aspects related to the drug effects
Past Medication history of the patient
Desired therapeutic outcome(s)

41. Procedure for Clinical/Daily Progress Review
If therapeutic objectives are not being achieved, the
clinical pharmacist should re-evaluatethe
appropriateness of the treatment and discussany
relevant issues with the clinicians.

42. C. Detection and management of Adverse Drug
Reaction
One of the most important causes of morbidity and
mortality.
Hence, it is essential that clinical pharmacist should
have knowledge of ADRs including their predictability,
preventability, frequency, severity, predisposing
factors and recognition their causality assessment,
management and prevention.

43. Definition of ADR
Anyresponsetoadrugwhichisnoxiousand
unintended,andwhichoccursatdosesnormallyused
inmanforprophylaxis,diagnosisortherapyof
disease,orforthemodificationofphysiological
function.(WHO)

44. Goal of ADR Management
1)Identification and monitoring of patients susceptible
to ADRs
2)Detection and assessment of ADRs
3)Assisting in the management of ADRs
4)Documentation and prevention of ADRs

45. 1) Identification and monitoring of Patient susceptible to
ADRs
Patients who are most susceptible to develop an ADR
should be identified and monitored on daily basis.
These can be identified during MCR, clinical review or
at the time of medication history interview.

46. 1) Identification and monitoring of Patient susceptible to
ADRs
Patients who are at high risk of developing an ADR;
Those with Polypharmacy
with multiple disease process
Geriatric and paediatric patients
Those with intercurrentdiseases (renal/hepatic diseases)
Those treated with highly toxic drugs
Those who are treated with narrow therapeutic index drugs
Those who are treated with drugs that have potential to interacts with
other drugs.

47. 2) Detection and assessment of ADRs
ADRsmaybeidentifiedduringwardroundswiththemedicalteamand
reviewofpatient’schart.
Itshouldconsideredaspartofthebroaderdiagnosishence,the
differentialdiagnosisshouldincludethepossibilityofanADR.
Causalityrelationshipbetweenasuspecteddrugandareaction,a
temporalorpossibleassociationissufficientforareporttobemade.
TheassessmentofacausalityrelationshipbetweenadrugandanADR
isoftenhighlysubjective,basedontheclinician’sjudgmentand
experience.

48. 2) Detection and assessment of ADRs
IfanADRissuspected,theassessmentofADRstartswiththe
collectionofallrelevantdatapertainingto:
Patientdemographics
Medicationsincludingnon-prescriptiondrugs(OTC)
ComprehensiveADRdetails(descriptionofthereaction,timeof
onset,anddurationofthereaction,complication,treatmentofthe
reactionandoutcomeofthetreatment)
Relevantinvestigationreports
Byusingoneormoreavailablecausalityassessmentscales,
correlationofsuspecteddrugwithanADRcanbeestablished.

49. 3) Assisting in the management of ADRs
BasedontheseverityofanADR,rapidtreatmentisnecessary.ForEg:,
anaphylacticshock.
Iftheculpritdrugisobvious,risk-benefitdecisionneedstobetaken
abouttheneedforthedrug.
Ifseveralmedicinesmaybeduetothenon-essentialmedicinesshould
bewithdrawn.
Ifthereactionislikelytobedoserelated,dosereductionshouldbe
done.
Ifthedrugisnecessarythensymptomaticreliefmaybegivenwhile
continuingtheessentialtreatment.

50. 4) Documentation and Prevention of ADRs
Necessarytopreventre-exposurefromthesamedrug/class
Attendingpharmacistshouldcompleteappropriatedocumentationinthe
patientmedicalrecordincludingalertcardsorplacingsheetinthefront
ofthepatientcasenotes.
Essentialthatmedicalstaff,includingtheoriginalprescriberarenotified
ofsuspectedADRs

51. REFERENCE
G.Parthasarathi,KarinNyfortHansen,MilapCNahata.Atextbookof
clinicalpharmacypracticeEssentialconceptsandskills.Universities
Press.2
nd
edition.