CLINICAL PHARMACY

Clinical pharmacy

• Clinical Pharmacy
• Introduction to Clinical Pharmacy,
• Concept of clinical pharmacy,
• functions and responsibilities of clinical pharmacist,
• Drug therapy monitoring –
• medication chart review,
• clinical review, pharmacist intervention,
• Ward round participation,
• Medication history and Pharmaceutical care.
• Dosing pattern and drug therapy based on Pharmacokinetic & disease pattern.
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Clinical pharmacy

• clinical pharmacy is concerned with patient care, dispensing of drugs, and advising patient
about safe and rational use of drugs.
• Clinical pharmacy is a specialized branch of pharmacy focused on optimizing medication
use and improving patient health outcomes through direct patient care.
• Clinical pharmacists work collaboratively with healthcare teams, including physicians and
nurses, to ensure safe and effective medication management across various healthcare
settings.
• “the active participation of the pharmacist in patient care with the long -term aim of giving
advice on medication with an individual patient in mind and tailoring drug therapy for that
individual”.

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• Definition of Clinical pharmacy –

• Clinical pharmacy is a new born discipline that carries traditional hospital pharmacist
from his product oriented approach to more healthier patient oriented approach, so as to
ensure maximum well-being of the patient while on drug therapy.
• OR
• It is the branch of pharmacy which is concerned with various aspects of patient care &
deals not only with dispensing of drug but also advising the patients on safe & rational use
of drugs.

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 ROLE OF CLINICAL PHARMACIST
1. Prepare medication histories for patient’s permanent medical record.
2. Helps in selecting and monitoring of drug therapy-Deciding the dose
and dosage schedule by using pharmacokinetic consideration of the drug
and patient disease status,
3.Arranging educational and training programme- Arranging seminars on
drug use,review and patient care programme.
4.They provide consultation regarding IV therapy,TPN,clinical
pharmacokinetics selection of drug therapy.
5. Clinical pharmacist is involved in Drug administration and drug
distribution in patient care area.

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 ROLE OF CLINICAL PHARMACIST
6. Establishes and monitor a system to insure proper storage of pharmacy
items such as insulin and other biological products.
7. Detects and diagnoses adverse drug reactions and drug interactions
8. Participating in emergency situations of patients e.g. drug overdose,
toxic reactions in the body,poisoning ,providing first aid treatment.
9. Participation in clinical investigation- It involve clinical drug trial on
animal .He participate in such activity with physician investigator

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FUNCTION AND RESPONSIBILITIES OF
CLINICAL PHARMACIST
 supervises drug distribution-related activities to ensure controlled use of
drug and patient safety.
 He/she opts for therapeutically effective drug products prescribed for
patients at reasonable cost
 records patient’s medication history, including drugs prescribed earlier
and any adverse reactions.
 detects and diagnoses adverse drug reactions and drug interactions.
 does patient counselling on use of drugs to assure compliance.
 Assist the patients in selecting OTC drugs

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FUNCTION AND RESPONSIBILITIES OF
CLINICAL PHARMACIST
 frames a dosage regimen for the patients.
 encourages rational drug therapy.
 deals with psycho-socio-economic aspects of healthcare.
 participates in the management of patients having acute and
chronic diseases.
 detects and corrects the incompatibilities observed in drug
mixtures.
 prepares patient specific drug formulation
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FUNCTION AND RESPONSIBILITIES OF
CLINICAL PHARMACIST
 Directs the dispensing assistants in dispensing of
prescriptions.
 evaluation of the drug literature.
 reviews drug utilisation.
 promotes healthcare knowledge in public.
 prescribes drugs to patients having mild and self-limiting
diseases.
 monitors how the patients respond to drugs using patient
medicine profile, etc.
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 HISTORY/ BACKGROUND
Life threatening incidence happened:
Thalidomide tragedy (1962)
Phenytoin toxicity (1968)
Digitalis toxicity – USA (1968)
Becomes Necessary:
To check Bioavailability – pharmacokinetics- toxicity
Pharmacist need arises:
due to expertise in analytical methods, modern analytical techniques
Analysis and Reporting Medication errors:
Pharmacist report and analyze the different cases and medication errors
Collaboration between health care professionals:
To discuss this problems physicians, nurses pharmacist works collaboratively
Outcome:
Rational medicine use, patient care

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DRUG THERAPY MONITORING

 Drug therapy monitoring is a process by which a clinical pharmacist

reviews the patient treatment regimen to ensure effective, safe and
economical therapy.
 To do the drug therapy monitoring clinical pharmacist must be
knowledgeable in pharmacokinetics, pharmacodynamics, therapeutics,
ADR, lab data analysis and clinical reasoning.
 Clinical pharmacist must be able to interpret and utilize them properly.

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DRUG THERAPY MONITORING

Purpose Scope:
 Effective , safe and economical therapy for  to arrive at a correct conclusion, the clinical
all patients. pharmacist should know the previous and present
 Pharmacist is able to identify condition of patient
Patients who are in need of counselling.  there are chances for development of complications
such as non-responsiveness, sub therapeutic dose,
Patients who require special attention. over dosage, ADR, drug interactions with the
Patients with the risk of medication error. medicine use.
Hence TDM/ DTM studies are useful to provide
rational use of medicine

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MEDICATION CHART REVIEW:

 Medication chart review is a critical process in healthcare that involves systematically

evaluating a patient's medication orders to ensure their appropriateness, safety, and
efficacy.
 Medication errors are preventable errors that may occur during prescription writing and
drug administration. To prevent this errors, pharmacist must systematically review the
medication charts.
 Medication chart review is serves as starting point for other clinical pharmacy activities
( medication counselling, TDM, DI, and ADR)

Goals
1) It optimises the patient‟s drug therapy.
2) It prevents or minimises drug-related problems or medication errors
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MEDICATION CHART REVIEW:

 Drug-related problems can be identified by systematic review of each drug order on the
patient’s medication chart, and this process is referred to as medication or drug chart
review.
 Medication order should be reviewed after considering all the important patient specific
information such as presenting complaints, past medical history, clinical assessment,
results of laboratory investigations, treatment plans, and the patient‟s daily progress.

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MEDICATION CHART REVIEW: Objectives

 Optimize Drug Therapy:

Ensure that medications prescribed are effective for the patient's condition and are
being used appropriately.

 Prevent Medication Errors:

Identify and rectify potential errors such as incorrect dosages, drug interactions, or
allergies.

 Enhance Patient Safety:

Minimize risks associated with medication administration by ensuring accurate
documentation and communication among healthcare providers.
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MEDICATION CHART REVIEW: Components

Legal Compliance: Verify that medication orders comply with legal and
institutional requirements.
Clarity and Comprehensibility: Ensure that orders are clearly written, avoiding
ambiguous terminology and abbreviations.
Patient-Specific Considerations: Assess the appropriateness of medications based
on the patient's medical history, current health status, age, and renal or hepatic
function.
Drug Interactions and Duplications: Check for potential drug-drug interactions
or duplications in therapy.
Administration Timing: Confirm that the timing of doses aligns with food intake,
other medications, and necessary therapeutic monitoring.
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MEDICATION CHART REVIEW: Process

Review Current Orders: Examine all current medication orders in conjunction with
the patient's medical record and progress notes.
Assess Clinical Data: Analyze laboratory results and clinical observations to
evaluate the effectiveness of current therapies.
Document Findings: Annotate the medication chart with findings, recommendations,
or clarifications needed for ambiguous orders.
Collaborate with Healthcare Team: Communicate any concerns or
recommendations to the prescribing physician or healthcare team to ensure timely
adjustments to therapy.

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MEDICATION CHART REVIEW: Process

The following possibilities should be taken into account by the pharmacists to

identify drug-related problems during medication order review:
1) Untreated indication,
2) Inappropriate drug selection,
3) Sub-therapeutic dose,
4) Overdosage,
5) Adverse drug reactions,
6) Failure to receive drugs,
7) Drug interactions,
8) Drug use without indication.

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MEDICATION CHART REVIEW: Process

Inappropriate drug selection

The pharmacists should confirm if the patient has a medical condition for which
different drug(s) are more appropriate.
For example, a short course of NSAID is the first-line treatment for a patient having
acute gout; but, if the patient also has renal impairment, a short course of
prednisolone is more appropriate.
Sub-Therapeutic Dose: (a dose of a drug that does not achieve a particular
therapeutic effect.)
Individualize the dose and dosing regimen according to the patient's medical
condition.
To perform TDM and interpret the serum concentration of drug- useful to decide the
therapeutic dose
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MEDICATION CHART REVIEW: Process

Overdosage:
Occur if a patient takes the drug for a longer period than prescribed.
For example, some patients continue taking antibiotics even after an infection has resolved,
thus, they are exposed to the risk of adverse drug reactions and additional expense.
Use of same drug due to various brand names.
Adverse Drug Reactions:
The pharmacists should confirm if the patient has a medical condition that resulted from an
adverse drug reaction.
They should first check that the patient is not allergic to the prescribed drug(s), or had any
adverse reaction to a drug in the past
Detect ADR, Monitor ADR, Report ADR.

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MEDICATION CHART REVIEW: Process

Failure to receive drug:

The pharmacists should confirm if the patient has a medical condition that resulted of not
receiving a drug due to non-adherence, poor administration technique, missed doses,
medication errors, sub-standard drugs, or the patient's inability to pay for the prescribed
drug.
For example, a patient diagnosed with hypertension has been prescribed an ACE inhibitor,
but he/she still continues to have high blood pressure. When the pharmacist spoke to the
patient, it was discovered that the patient is not taking the drug because it is expensive. So,
a more affordable and effective low dose of thiazide or a β-blocker is prescribed to the
patient, provided he/she has no other co-morbidities.

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MEDICATION CHART REVIEW: Process

Drug interactions:
The pharmacists should confirm - potential medical condition that resulted from a drug-
drug or drug-food interaction.
Drug interactions have different clinical significances, and the pharmacists should make a
professional judgement regarding a change in drug therapy.

Drug Use without Indication:

The pharmacists should confirm if the patient has a current or potential medical condition
that resulted from taking a drug with no valid indication.

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CLINICAL CHART REVIEW

Clinical review is the review of patient -specific clinical information including patient
parameters to estimate their response to medication therapies and to detect and manage
potential or actual medicine -related problems.
It may also include deducing biochemical and other tests, assessing the patient's signs and
symptoms identified from interviews with the patient, and reviewing the health record.
Goals
The clinical review aims to:
1) Evaluate the response to drug treatment,
2) Evaluate the safety of treatment regimen,
3) Evaluate the disease progress and the need for any change in therapy,
4) Evaluate the need for monitoring, and
5) Evaluate the convenience of therapy to improve compliance
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CLINICAL CHART REVIEW
Information about the signs, symptoms and progress of the patients may be obtained as follows:
1) From their medication history or medication reconciliation documentation,
2) By reviewing their health record,
3) By discussing with other healthcare team members, and
4) By reviewing the patients clinical data and laboratory investigations.
Examples of patient-specific clinical information may include:
1) Routine observations, e.g., temperature, blood pressure,
2) Weight,
3) Fluid balance,
4) Urine output,
5) Biochemistry results, e.g., electrolytes, creatinine,
6) Haematology results,
7) Microbiology results,
8) Radiological investigations, 9) Bowel charts,
10) Peak flow/spirometry, 11) Nutrition, and 12) Pain scores.
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Pharmacist intervention

• Pharmacist interventions refer to actions taken by pharmacists to optimize medication therapy and
improve patient outcomes.
• These interventions can occur in various healthcare settings, including hospitals, community
pharmacies, and outpatient clinics, and often involve medication management, patient education,
and collaboration with other healthcare providers.
• Objectives
• Reducing medication errors.
• Rationalizing the therapy and reducing the cost of therapy.
• prescriptions review.
• Medication error
• Any error in ordering, transcribing, dispensing, administering and monitoring in the process of
medication is called medication error.
• Pharmacist intervention can minimize the medication errors.

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Types of Pharmacist Interventions

• Medication Review:
• Pharmacists evaluate a patient's medication regimen to identify potential issues such as drug interactions,
duplications, or inappropriate dosages. This is particularly common in hospital settings where patients may
be on multiple medications.
• Patient Education:
• Pharmacists provide counseling on medication adherence, proper administration techniques, and lifestyle
modifications. This is crucial for chronic disease management, such as diabetes and asthma.
• Disease Management:
• Involves pharmacists working with patients to manage specific conditions through tailored interventions.
For example, pharmacists may help manage cardiovascular risk factors by monitoring blood pressure and
cholesterol levels.
• Clinical Decision Support:
• Pharmacists collaborate with physicians to adjust medication regimens based on patient needs, clinical
guidelines, and evidence-based practices.

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Ward round participation

• Ward rounds (WRs) are essential for interprofessional collaboration in healthcare settings, allowing various
team members, including clinical pharmacists, to contribute to patient care.
• collaborate to design, implement and monitor a therapeutic plan for producing specific therapeutic effects
for the patient.
• A pharmacist’s prime responsibility is to make sure that each patient receives suitable treatment in the most
convenient and cost effective form.
• If the pharmacists have the knowledge and skills of combining therapeutic, pharmacological and
pharmaceutical data, it ensures optimal patient outcomes.
• Retrospective review of medication orders by the pharmacists on wards maximizes safe prescribing.
• if a pharmacist is taken along with the healthcare team to attend ward rounds in various practice settings, a
safe, effective and economic use of drugs can be established.
• This decreases the adverse drug events, improves patient care, reduces the length of hospital stay, and
minimizes the healthcare costs.

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Goals and Objectives for Clinical Pharmacists on Ward Rounds
Detect To understand
ADR clinical status,
progress, current
Drug Interactions planned investigations,
and therapeutic goals.
Provide information about
pharmacology,
pharmacokinetics, drug Optimization of drug
availability, cost, drug therapy
interactions and adverse influencing drug therapy
reactions selection, implementation,
monitoring, and follow-up.
To collect supplementary
information on
patient's co-morbidities,
medication compliance, Do Investigation of
or alternative medicine drug orders and doses
use.
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Ward round participation

• Participating in ward rounds also provides learning opportunities for pharmacists, allows them to see how
drugs are used and prescribed, and to see the effects of these drugs on patients.
• Ward round classification:
• Pre-rounds:
• Registrar/Resident Rounds:
• Professor/Chief Rounds:
• Professor/Unit chief rounds:
• Teaching rounds:
• Pre-ward round preparation:
• Pharmacists need to prepare adequately before participating in ward rounds.
• Accurate and up-to-date information on the patient’s health status, disease management and medical and
medication history is essential for active participation in clinical decision-making.
• To achieve this, a review of the medication chart and case record should be completed prior to the ward
round.

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Ward round participation

Pharmacist can obtain information about each individual during ward round participation by filling this type of
information

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Ward round participation

• WRP Important element of clinical pharmacy practice in the hospital setting.

• Key decisions regarding patient management are made during ward rounds
• Pre-ward round preparation and familiarity with each case is essential for active participation in the ward
round.
• Recommendations during ward rounds are most likely to be adopted if pharmacists communicate these in a
considered and respectful manner.
• Pharmacists may need to prioritise their recommendations during ward rounds depending on the medical
staff and time constraints.
• When identifying a drug-related problem during a ward round, pharmacists should be prepared to outline
solutions to the problem.
• Pharmacist interventions during ward rounds may be used as key performance indicators.
• Regular documentation of interventions is important for justifying the need for the service, and is also useful
for quality assurance.
• Requests for drug information and other outstanding issues should be followed-up promptly after the ward
round.

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Medication history

• A Medication history is a detailed, accurate and complete account of all prescribed and non-
prescribed medications that patient had taken or is currently taking prior to a newly initiated
instutionalized or ambulatory care.
• An accurate medication history is essential for assessing the appropriateness of current therapies
and guiding future treatment decisions.
• It serves as a foundation for preventing medication errors, which can occur due to discrepancies in
drug administration, prescribing errors, and poor communication among healthcare providers.
• Occurrence of medication error is strongly associated with inadequate or incomplete medication
history.
• Medication history – pharmacist should participate for obtain the medication history.

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Medication history

• Importance of Medication History

• Error Prevention:
• Prescription error prevention, prevention of ADR and Drug drug or drug- food interaction
• Best Possible Medication History (BPMH):
• This concept involves creating a comprehensive list of all medications a patient is currently
taking, including over-the-counter drugs, supplements, and any recent changes in therapy. The
BPMH should be collected within 24 hours of hospital admission to ensure accuracy.
• Improvement in health status of patients:
• Every patient medication history record is useful for patients safety and for making decisions abou
therapy management.

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Medication history

• Steps in Collecting Medication History

• Gather Information: Collect data from various sources such as patient interviews, medical
records, and previous prescriptions.
• Cross-Check: Verify the information against multiple sources to ensure completeness and
accuracy.
• Document Findings: Record all medications, dosages, routes, and frequencies accurately.
• Identify Discrepancies: Look for inconsistencies or discrepancies in the reported medication
history that need clarification.
• Communicate with Care Team: Share the collected information with other healthcare providers
involved in the patient's care to facilitate informed decision-making.

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Pharmaceutical care.

• Pharmaceutical care defined as the pharmacist’s contribution to the care of individuals in order to
optimize medicines use and improve health outcomes
• The goal of pharmaceutical care is to optimize the patient’s health-related quality of life and to
achieve positive clinical outcomes, within realistic economic costs
• This practice emphasizes the importance of patient-centric care, focusing on optimizing
medication use through structured processes that involve assessment, planning, implementation,
and evaluation of drug therapy.
• How to fulfill the objectives of pharmaceutical care ?
• Pharmacist must establish a professional relationship with the patient and maintain it.
• Collect, record, organize and maintain patient specific medication information.
• Work collaboratively with other staff in hospital.

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Pharmaceutical care.

• Key Principles of Pharmaceutical Care:

• Patient-Centric Approach: The primary goal is to enhance patients' health-related quality of life
by ensuring appropriate medication use.
• Comprehensive Assessment: Pharmacists assess all medications a patient is taking, considering
interactions and overall health conditions
• Collaboration: Effective pharmaceutical care requires coordination with other healthcare
professionals to ensure comprehensive patient management
• Documentation: All aspects of the pharmaceutical care plan must be documented and
communicated among healthcare providers to maintain continuity of care

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Pharmaceutical care.

• Requirements for successful pharmaceutical care

• Knowledge, skill and function of personnel.
• System for data collection, documentation and transfer of information.
• Efficient workflow process.
• References, resources and equipment's.
• Communication skill
• Commitment to quality improvement and assessment procedures

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DOSING PATTERN AND DRUG THERAPY BASED ON PHARMACOKINETIC AND DISEASE
PATTERN

• Dosing pattern can be the one in which a dosage regimen for a patient is designed or arranged in such a way
to suit their condition.
• Dosing patterns and drug therapy are fundamentally influenced by pharmacokinetic principles, which
describe how drugs are absorbed, distributed, metabolized, and excreted (ADME) in the body.
• Understanding these processes is crucial for optimizing therapeutic outcomes and minimizing adverse
effects.

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Pharmacokinetics: Key Concepts

• 1. Absorption:
This refers to how a drug enters the bloodstream from its site of administration. Factors affecting absorption include the
drug's formulation, route of administration, and the patient's physiological conditions.
• 2. Distribution:
Once absorbed, the drug is distributed throughout the body. This process is influenced by blood flow to tissues, the
drug's affinity for tissues, and protein binding.
• 3. Metabolism:
Drugs are chemically altered in the body primarily by liver enzymes. Metabolism can convert active drugs into inactive
metabolites or sometimes into active forms (prodrugs).
• The metabolic rate can vary significantly among individuals due to genetic factors, age, and health status
• 4. Excretion:
Excretion primarily occurs through the kidneys but can also happen via bile or lungs. The efficiency of excretion affects
drug clearance from the body and is crucial for determining dosing intervals and amount

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Dosing Patterns

• Dosing patterns are tailored based on several factors:

• Initial Dose vs. Maintenance Dose:
• An initial loading dose may be given to quickly achieve therapeutic levels, followed by maintenance doses
to keep drug levels stable.
• Therapeutic Window:
• This is the range of drug concentration in which a medication is effective without being toxic.
Understanding this helps in determining dosing frequency and amount.
• Half-Life:
• The time it takes for the plasma concentration of a drug to reduce by half is critical for scheduling doses
appropriately.
• Special Populations:
• Considerations for populations such as children, elderly patients, or those with organ dysfunction (e.g., liver
or kidney) are essential for safe dosing

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• Loading dose
• This is a single or few quickly repeated doses given in the beginning to attain target concentration rapidly
• Maintenance dose
• This dose is one that is to be repeated at specified intervals after the attainment of target

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Drug Therapy Based on Disease Patterns

• The approach to drug therapy varies significantly depending on the disease state:
• Acute Conditions:
• Diseases like infections may require aggressive short-term treatment with higher doses.
• Chronic Conditions:
• Long-term management strategies are necessary for conditions such as hypertension or diabetes, often
involving lower doses over extended periods.
• Flare-Ups:
• Conditions like asthma may necessitate increased dosages during exacerbations.
• Progressive Diseases:
• In diseases such as Alzheimer's, treatment plans may evolve as symptoms worsen overtime.

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BIOTRANSFORMATION

• Biotransformation means chemical alteration of the drug in the body.

• nonpolar (lipid-soluble) compounds - polar (lipidinsoluble
• Not reabsorbed in the renal tubules and are excreted.
• hydrophilic drugs, are little biotransformed and are largely excreted unchanged. e.g. streptomycin,
neostigmine, pancuronium, etc.
• The primary site for drug metabolism is liver; others are—kidney, intestine, lungs and plasma.
• Biotransformation of drugs may lead to the following.
• Inactivation
• Active metabolite from an active drug
• Activation of inactive drug

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Active drug Active metabolite

• Chloral hydrate — Trichloroethanol • Diazepam — Desmethyl-diazepam, oxazepam

Digitoxin — Digoxin
• Morphine — Morphine-6-glucuronide
• Imipramine — Desipramine
• Cefotaxime — Desacetyl cefotaxime
• Amitriptyline — Nortriptyline
• Allopurinol — Alloxanthine
• Codeine — Morphine Spironolactone —
• Procainamide — N-acetyl procainamide
Canrenone
• Primidone — Phenobarbitone,
• Losartan — E 3174
phenylethylmalonamide

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(iii) Activation of inactive drug

• Few drugs are inactive as such and need conversion in the body to one or more active
metabolites. Such a drug is called a prodrug
• Prodrug Active form
• Levodopa — Dopamine • Prednisone — Prednisolone
• Enalapril — Enalaprilat • Bacampicillin — Ampicillin
• a-Methyldopa — a-methylnorepinephrine • Sulfasalazine — 5-Aminosalicylic
acid
• Dipivefrine — Epinephrine
• Cyclophos- — Aldophosphamide,
• Sulindac — Sulfide metabolite phamide phosphoramide mustard,
• Proguanil — Cycloguanil acrolein
• Mercaptopurine — Methylmercaptopurine ribonucleotide • Fluorouracil — Fluorouridine
monophosphate
• Acyclovir — Acyclovir triphosphate
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Biotransformation reactions

• (a) Nonsynthetic/Phase I/Functionalization reaction

• (b) Synthetic/Conjugation/ Phase II reactions:

• (a) Nonsynthetic/Phase I/Functionalization reaction

• a functional group is generated or exposed— metabolite may be active or inactive.
• (b) Synthetic/Conjugation/ Phase II reactions:

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Nonsynthetic

• (i) Oxidation

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THANK YOU