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Module 3 Practice of Pharmacy Clinical Pharmacy, Hospital Pharmacy, Pharmaceutical Calculations Kathreen Mae D. Cascabel BSPharmacy

Clinical Pharmacy 

A practice in which the pharmacist utilizes his professional judgment in the application of pharmaceutical sciences to foster the safe and appropriate use of drugs, in or by patients, while working with members of the health care team (Francke 1969)



Health science specialty whose responsibility is to assure the safe and appropriate use of drugs in patients through the application of specialized knowledge and functions in health care

Pha Pharm rm rmac ac aceut eut eutic ic ical al Car Care e o o o o

The responsible provision of drug therapy for the purpose of achieving definite outcomes that improves a patient’s QOL (Helper and Strand 1990) A patient-centered practice in which the practitioner assumes responsibility for a patient’s drug related needs and is held accountable for this commitment (Cipolle 1998) Identify, resolve, prevent potential and actual drug related problems Knowledge and skills required: Diseases, drug therapy, non-drug therapy, lab and diagnostic testing

Out Outcom com comes es - Cure of disease - Elimination or Reduction of symptoms - Arrest of disease process - Prevention of disease or symptoms

Eviden videncecece-Ba Ba Based sed M Med ed edicin icin icine e (EB (EBM) M) o

The conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.

EB EBM M in integr tegr tegrat at ated ed co comp mp mpon on onen en ents ts Clinical expertise  clinician’s cumulated experience, education and clinical skills Patient values  personal and unique concerns, expectations, and values Best evidence  clinically relevant research with sound methodology Hier Hierarc arc arch hy of EEvid vid viden en ence ce Systematic reviews Randomized Clinical Trials Non-randomized Clinical Trials Observational Studies Expert Options

Phases of Product Development Animal studies Pre-clinical Healthy humans Phase 1 Patients with disease Phase 2 Large scale Phase 3 Post-marketing surveillance Phase 4

Dru Drugg IInf nf nfor or ormatio matio mation n Sour Sources ces Most current information Pri Prima ma mary ry For quick and selective screening of 1° sources Sec Secon on onda da dary ry Easy access; may be outdated Tertia ertiary ry

Safety Effectiveness

Journal articles Abstracting and Indexing Services Textbooks

Stud Studyy Desi Design gn gnss

Typ ype e Sam Sampl pl ples es bas based ed on

Cas Case e Con Contr tr trol/ ol/ Retr etrospe ospe ospecti cti ctive ve Observational Presence (c (cas as ases) es) or absence (c (con on ontrols) trols) of a disease

Adv Advant ant antage age

Inexpensive

D/ D/A A

Recall bias

Coho Cohorrt/ Pr Prospe ospe ospectiv ctiv ctive e Observational Presence or absence of risk ffac ac acto to tors rs (monitor for disease development) Less recall bias

Time-consuming, expensive

Cr Cros os oss-s s-s s-secti ecti ection on onal/ al/ Pr Preva eva evalen len lence ce Stu Studi di dies es Survey Disease prevalence and prevalence factors

Ran Rando do domi mi mizzed Con Contr tr trolled olled Cli Clini ni nica ca call TTrrial Experimental (gold st.) Compares 2 or more tx or tx and placebo

Decreased bias and confounding Blin Blinded ded or Dou ouble ble blind blinded ed Costly and timeintensive, ethical considerations

Th Ther er erapeu apeu apeutic tic G Gu uid idel el eline ine iness o o

Provide clear and concise, independent and evidence-based recommendations about patient management that have been developed by experts Objective: Reduce chance of error by establishing standard protocol for how care is carried out

Th Ther er erapeu apeu apeutic tic Dr Drug ug M Mon on onit it itor or oring ing o

Encompasses the measurement of serum drug levels and the application of clinical pharmacokinetics to improve patient care

App Applic lic licaatio tions ns  Time to maximal response  Need for loading dose  Dosage alterations  Choosing a formulation Dru Drugs gs re requ qu quirin irin iringg TD TDM M  Intensity of pharmacologic effect is proportional to the drug concentration at the site of action  Drugs have an established therapeutic plasma range  Relationship between plasma drug concentration & clinical effect rather than relation between dose & effect  Drug toxicity and disease presentation are difficult to distinguish from clinical assessment alone Therapeutic Range – the range of drug conc within which the drug exhibits max efficacy and min toxicity in px majority Commonly Monitored Drugs:  Aminoglycosides: gentamicin, tobramycin, netilmicin, amikacin, vancomycin  Cardioselective agents: digoxin, procainamide, lidocaine, disopyramide, flecainide

Revi eview ew of a Pre rescr scr scrip ip iptio tio tion n

Dru Druggg-R Relat elated ed PPrroble oblems ms edication ation Er Errror orss 1. Medic Any preventable event that may lead to inappropriate medication use or cause harm to the patient while the medication is in the control of a health care professional, patient or consumer A

Have the capacity to cause error

B

Did not reach the patient

C

Reached the patient

D

Increased patient monitoring

E

Treatment or intervention

F

Initial or prolonged hospitalization

G

Permanent harm

H

Near-death

I

Death

Adve ve verrse Dru Drugg EEven ven vents ts 2. Ad a. Patient Factors (ADRs, patient’s reaction to drug) b. Drug Factors (D-D, D-F, D-Dis interactions, other incompatibilities) ADE ADR

- any injury resuling from medical intervention - response that is noxious or unintended

Pr Pregna egna egnanc nc ncyy C Categ ateg ategories ories Ca Cate te tego go gory ry

Hum Human an SStudi tudi tudies es

Ani Animal mal SStudi tudi tudies es

Eff ffe ect

A B C

✓ X X

✓ ✓ ✓

SA SAFE FE

D X

✓

✓

Ex Exaampl mples es

SA SAFE FE

Amoxicillin, Paracetamol

UNSA SAFE UN SA FE

Rifampicin, Theophylline

Benefits outweigh risks

Phenytoin, Tetracycline

TER ATOG ENI C TERA OGENI ENIC

Isotretinoin, Thalidomide

Patie atien nt C Case ase Gen Gener er eral al PPaatien tientt Inf Inform orm ormati ati ation on Chi Chief ef Co Comp mp mplai lai laint nt HPI PM PMH H SH FH Me Medic dic dicaatio tion nH His is isto to tory ry ROS Ph Physic ysic ysical al EExxamin aminatio atio ation n Lab an and dD Dia ia iagno gno gnosstic Tes estt Px PPrrob oblem lem LList ist aand nd Pla Plans ns

Date and time of admission, patient name, age, race, gender Reason for seeking medical care Narrative that described the current medical problem Current and previous problems unrelated to present illness Use of tobacco & illicit drugs, occupation, marital status, sexual history, living condition Medical histories of first degree relatives Demography, diet, social habits, current and past Rx and non-Rx drugs, allergies, ADRs All patient complaints not included in the HPI VS, systemic exam (HEENT, skin, ear, chest, abdomen, genitalia, neurologic)

Pha Pharm rm rmac ac aceut eut eutic ic ical al Car Care e Pl Plan an 1. As Asses ses sessm sm smen en entt 2. Pla Plan n 3. Mo Moni ni nito to torin rin ringg

- review of the medical conditions and symptoms to determine the need for drug therapy - decision of an appropriate drug therapy based on assessment - review of outcomes of therapy to determine if patient is obtaining desired outcomes

Dru Drugg U Util til tiliz iz izatio atio ation nR Revie evie eview w (DU (DUR) R) o o

Ongoing study of the frequency of the use and cost of drugs Prospective DUR (before dispensing) or Retrospective DUR (after dispensing), Concurrent DUR (IDEAL)

Advantages:  Identify drug-drug interaction  Prevent duplication  Prevent under/overdose  Improve quality of care  Encourage physicians to use formulary/generic drugs

Pha Pharm rm rmac ac aco oec econ on onom om omic ic Me Meth th thod od odolo olo ologies gies Cos Cost-E t-E t-Efffectiv ectiven en eness ess Cos Cost-Min t-Min t-Minimi imi imizzation Cos Cost-Utili t-Utili t-Utility ty Cos Cost-Bene t-Bene t-Benefi fi fitt Cos Costt of Ill Illnes nes nesss

Lowest cost for a given level of effectiveness Comparison of drugs that are generically equivalent Incorporates a measure of QOL into outcomes being measured Uses monetary value in comparing costs and consequences All direct and indirect cost attributable to a certain disease

Et Ethic hic hicss Aut Auton on onom om omyy Non Nonma ma male le lefi fi ficen cen cence ce Ben Benef ef efic ic icen en ence ce Co Confid nfid nfiden en enti ti tiality ality

Respect px as individual Do no harm Act in the best interest of the patient Respects px privacy and autonomy

Co Comm mm mmon on LLabo abo aborrat ator or oryy TTes es ests ts He Hema ma matol tol tologi ogi ogicc Test

Incr Increase ease

RB RBC/Ery C/Ery C/Erythr thr throcyt ocyt ocytes es

He Hema ma mato to tocr cr crit it

Reti eticu cu culocy locy locyte te

Polycythemia Dehydration Vomiting

Hemolytic Anemia Blood loss

He Hemo mo moglob glob globin in

De Decr cr creas eas ease e Macrocytic Anemia (B9 & B12) Microcytic Anemia (IDA & thalassemia) IDA Aplastic Anemia Bone Marrow Supp IDA, blood loss

ES ESR R

Inflammation Rheumatic Fever Infection

Polycythemia Sickle cell anemia Corticosteroids

aP aPTT TT

Heparin (Intrinsic)

Hypercoagulation

PT

Warfarin (Extrinsic 2, 7, 9, 10)

INR

Warfarin

WBC

Infection (leukocytosis)

Marrow suppress (leukopenia)

Neu Neutr tr trophil ophil ophilss PMN’s

Infection Neutrophilic leukocytosis

Overwhelming infections

Bas Basoph oph ophils ils ils/M /M /Mas as astt Cel Cells ls

Chronic myelogenous leukemia

Eos osinop inop inophil hil hilss

Acute allergic reactions Parasitic infections

Mon Monocy ocy ocyttes

TB Subacute bacterial endocarditis

Lymph ymphocy ocy ocyte te tess

Viral infections

Immunodeficiency

Pla Plattele elett

Thrombocytopenia

Marrow suppression Chemotherapy

Ren enal al Test

Incr Increase ease

De Decr cr creas eas ease e

BUN

Renal failure

Hepatic failure

Cr Crea ea eatin tin tinin in ine e

Renal failure

------------------

Cr Crea ea eatin tin tinin in ine e cl clea ea earran ance ce

------------------

Renal failure

Ser Serum um EEnzy nzy nzyme me mess Test Cr Crea ea eatin tin tinin in ine e Ki Kinas nas nase e (CK) CK MB CK MM CK BB

Incr Increase ease Myocardial Infarction Rhabdomyolysis

Lact Lactat at ate e De Deh hydr ydro ogen genase ase LDH 1 and 2 LDH 3 LDH 4 and 5

Acute injury of cardiac muscles Liver dysfunction Lung disease, Hemolytic anemia

Alk Alkaline aline Ph Phosp osp ospha ha hatase tase

Biliary obstruction Paget’s disease HyperPTH, Osteomalacia

Alan Alanin in ine eA Ami mi minotr notr notrans ans ansffer erase ase (A (ALLT)

De Decr cr creas eas ease e

Clofibrate and Fluoride

Liver disease

B6 deficiency

Serum Glutamic-Oxaloacetic Transaminase (SGOT)

Myocardial Infarction Liver disease

B6 deficiency

Car Cardi di diac ac Tropon oponins ins

Myocardial Infarction

Rhabdomyolysis

Serum Glutamic-Pyruvic Transaminase (SGPT)

Asp Aspart art artat at ate eA Amin min minotr otr otrans ans anstter erase ase (A (AST) ST)

Ele Elect ct ctrrol olyt yt ytes es Test

Incr Increase ease

De Decr cr creas eas ease e

Sod Sodiu iu ium m

Hypertension Hypernatremia (imp. excretion)

Hyponatremia (renal failure)

Pot otassium assium

Renal dysfunction Acidosis Cellular breakdown

Diuretic use, alkalosis, vomiting, diarrhea, steroids, Amph B, Li

Chlo Chlorid rid ride e

Acute renal failure Hyperparathyroidism Dehydration

Chronic renal failure Adrenal Insufficiency Diuretic use (Thiazide & Loop)

Mi Mine ne nerral alss Test

Incr Increase ease Hyperparathyroidism Paget’s disease Thiazides

Calci Calciu um

De Decr cr creas eas ease e PTH or Vit. D deficiency Loop diuretics

Ma Magne gne gnesiu siu sium m

Hepatitis Addison’s disease

Malabsorption Hyperaldosteronism

Pho Phosph sph sphaate

Renal dysfunction, Hypoparathyroidism Increased Vit. D intake

Malnutrition Hyperparathyroidism Insufficient Vit. D intake

Oth Othe ers Test

Incr Increase ease

Acid PPhos hos hosph ph phaata tase se

Prostate CA

Gam Gamma ma glu gluttamyl tr tran an ansp sp spep ep eptid tid tidase ase (G (GGT GT GT))

Liver disease

Pr Protein otein oteinss Albumin Globulin Glu Gluco co cose se Normal DM (Fasting) Hypoglycemia Male Hypoglycemia Female

Liver disease

Gly Glycos cos cosyla yla ylatted He Hemo mo moglo glo globi bi bin n ((Hb Hb HbA1 A1 A1C) C) Chol Choles es estter erol ol LDL HDL Tryglycerides Biliru Bilirubin bin Direct Indirect Uri Uricc aacid cid

De Decr cr creas eas ease e

Diabetes Corticosteroid use

Insulin, ethanol, propranolol, hypoglycemic

Uncontrolled DM

Hemolytic anemia

Atherosclerosis (LDL)

Atherosclerosis (HDL)

Hemolysis Biliary obstruction Liver necrosis Gout Rapid cellular destruction

Wilson’s disease Malabsorption syndromes

Sig Signif nif nific ic ican an ancce Thyroid function test Liver function test Cardiac enzymes Lipids Clotting time CBC Stool exams, FOBT Urine exams Sputum exams

Establish level of thyroid function and response to suppressant or replacement therapy Designed to give information about the state of a patient's liver Used to diagnose Myocardial Infarction Hyperlipidemia and risk assessment for CAD Used to prevent blood loss. Normal clotting time 2 – 6 minutes hgb, hct, RBC, WBC count, MCV, MCH, mean corpuscular hgb concentration Diagnosis of certain conditions affecting the digestive tract Checks different components of urine, a waste product made by the kidneys Bacteria or fungi that are infecting the lungs or breathing passages

Hospital Pharmacy o Practice of pharmacy in a hospital o Department wherein the procurement, storage, compounding, manufacturing, packaging, controlling, assaying, dispensing, distribution and monitoring of medications take place o Min: 6 beds o CEO = hospital director

Primary Secondary Tertiary Quaternary

- emergency - no departments; level 1 + surgery; intermediate care - departmental; intense care - teaching & training; subspecialties

Long term HC facility Resident treatment facility Clinic/Infirmary Ambulatory surgery Birthing home

- for recovering - safe, hygienic, living arrangements for residents - ambulatory

HOSPITAL FUNCTIONS Patient Care Education Research Public Health

HO HOSPI SPI SPITTAL – organized structure which pools together all the health professionals, facilities, and supplies into a coordinated system for delivering health care

Type of Serv Service ice  General  Special

Len Lenggth of St Staay  Short term...