Clinical Pharmacy Confere Clinical Pharmacy Confere nce , Port Dickson, 9-11 nce , Port Dickson, 9-11 Jan 2003 Jan 2003 Respiratory Pharmacy Respiratory Pharmacy & the Ward & the Ward Pharmacist Pharmacist experience experience by by Abdol Malek bin Abd Aziz, Abdol Malek bin Abd Aziz, MSc MSc
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Respiratory Pharmacy & the Ward Pharmacist experience
Respiratory Pharmacy & the Ward Pharmacist experience. by Abdol Malek bin Abd Aziz, MSc. Respiratory pharmacy. Emphasis on pharmaceutical care of respiratory patients plus Other conditions that the patient is concurrently suffering. Respiratory Pharmacy. Covers: Asthma COPD - PowerPoint PPT Presentation
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Clinical Pharmacy Conference , Port Clinical Pharmacy Conference , Port Dickson, 9-11 Jan 2003Dickson, 9-11 Jan 2003
Respiratory Pharmacy & the Respiratory Pharmacy & the Ward Pharmacist experienceWard Pharmacist experience
by by
Abdol Malek bin Abd Aziz, Abdol Malek bin Abd Aziz, MScMSc
Respiratory pharmacy
• Emphasis on pharmaceutical care of respiratory patients
plus
• Other conditions that the patient is concurrently suffering
• Generally non-compliance rate ~ 50% (out patients)
• 56% in Melaka (1999)*• Leads to hospital admission• 51.7% in Hospital Melaka **• 13.3% were asthmatics (6/45 patients)• Non-compliance to inhaled medications: 50%
(McGann & Elizabeth. Am J Nursing 1999)
• Aziz AMA, Ibrahim MIM. Med J Malaysia 1999.• ** Aziz AMA, Senthil N, Jenny W. J Pharm Sci. 2003 (in press)
Some avenues to patient care…
• Patients with allergic rhinitis often experience symptoms of asthma (Linneburg.
Allergy 2002,57)
• Allergic rhinitis preceded or developed at the same time as allergic asthma
• Tx of allergic rhinitis reduced asthmatic symptoms or reduce risk of asthma
Inhaler technique
• “good” rating ranged from 5-86% using MDIs• Technique improved after proper training*• 37.5% of pharmacy staff & 45.4% (15/33)
outpatients having good technique€
€Inhaler technique survey among pharmacy staff and patients at the specialists clinic pharmacy, Hospital Melaka. Abstract of the Konferens R&D Farmasi, Kota Bharu 2002.
* Cochrane MG, Bala MV, Downs KE et al. Inhaled corticosteroids for asthma therapy: patient compliance, devices , and inhalation technique. Chest 2000;117(2):542-550
Lung deposition of medication
• Terbutaline: MDI – 8%, DPI – 22%*• Effect of spacer device:Lung deposition increase from 9 to 21%Oropharynx deposition reduced from 81 to 17%#
* Borgstrom L, Derom E, Stahl E, et al. The inhalation device influences lung deposition and bronchodilating effect of terbutaline. Am J Respir Care Med 1996;153:1636-1640.
#Newman SP, Millar AB, Lennard-Jones TR et al. improvement of pressurised aerosol deposition with Nebuhaler spacer device. Thorax 1984;39:936-941.
* National Health and Morbidity Survey Vol. 11, Public Health Institute. 1996
Children:• Dry powder inhalers has greater systemic
effects than MDIs§
• Pharmacists: recommend MDI with spacer device for children.
§ Kereem E . Ann Allergy Asthma International 2002;89.
Pharmacist’s roles
• As educator and support person• Counsel on role of each medication• Difference between preventer – reliever• Emphasise safety of inhaled c’steroids• Discuss adverse effects – ways to minimise• Check and correct proper use of inhalers• Encourage use of spacers and peak fl. meters
AMA Aziz, MIM Ibrahim. Medication noncompliance - a thriving problem. Med J Malaysia 1999;54:192-5.
Pharmacist’s roles
• Check compliance – 56% noncompliance rate1
• Check usage of medications for other illnesses, OTC products, GP’s drugs, etc
• Dispels myths about asthma and inhaler use
• Encourage asthma action plan
Objective
• To have an influence on prescribing and related clinical practice
How to start?
• Ward pharmacy
• then
• Respiratory pharmacy
Ward pharmacy
• Back to basics
• Supplies, inventory, pricing,
• Dosage, category of drug in MOH list
• List A, std item
• Synergistic activity with in-patient pharmacist/satellite pharmacist
At the ward…
• Familiarise with the ward- acquaint with ward staff ie. sister & nurses
• Ward procedures• Own reading on common drugs used
• develop confidence
Ward rounds
• Consultant’s rounds: already have a high level of interest in optimising drug therapy
• Vigilant on ADR and side effects
Preparation before rounds
• Very, very important
• May take an hour or more initially
Objective:
‡ to anticipate areas where information is likely to be requested
‡ To identify topics for discussion
• Becoming prepared
provides…
Confidence
Clerking
• Same as any other pt• Biodata, diagnosis, investigations, lab results, x-
rays, etc, • Document using card or form • Monitor, • Identify drug-related problems or issues• Plan for solution - check-up- talk to Dr or specialist, nurse
Things to do…
• Estimate creatinine clearance ClCr if the serum creatinine is >150µmol/l in adults less than 70 yrs using Cockcroft and Gault equation
• Abnormal levels of urea or albumin may alter the disposition of some drugs
Patient parameters
• Pt. with liver disease – elevated liver function tests
• Severe cardiac failure may affect both renal and hepatic clearance of drugs may necessitate dose individualisation
• Calculate predicted blood levels if therapeutic monitoring of a drug is required
Attending ward rounds
• Be PUNCTUAL
• Degree of involvement and pharmacist’s role depend on the leading physician
• Doctors may undertake management or teaching role or both
• They may not ask for pharmacist’s comments
A successful attendance in ward rounds
• Adequate preparation• Being tactful, yet
assertive• prioritise
• Regular attendance• Present info on a
problem concisely• Provide adequate
follow up
Pharmacist’s comments
• Unlikely to be a personal insult and no offence should be taken
• The advice may be used on a similar pt in future• Occasionally it may be used by the consultant
against his junior staff – communicate with the houseman to avoid unnecessary embarrassment
• Follow up on pts where comments have been accepted ie. supplies and instructions on usage
Specialisation
• Collins English Dictionary and Thesaurus:defines special as ‘distinguished’ or ‘set apart from’
• Specialisation ~ characteristics that distinguish a clinical pharmacist from other pharmacists
• Pulmonary Rehabilitation and Pulmonary Rehabilitation and Patient Support GroupsPatient Support Groups
• Assess self-management capacity
• Develop a collaborative care plan– monitor to identify exacerbations early– how to self-initiate treatment– what to do in an emergency
X… Exacerbations
• Inhaled bronchodilators and systemic glucocortocoids are effective treatments for acute exacerbations (Evidence A)
• Patients with clinical signs of infection(change in sputum colour and/or fever, leucocytosis) benefit from antibiotics (Evidence A)
Asthma Action Plan
• Designed for pts with asthma to:^ recognise deterioration and^ respond appropriately• Action Plan will prevent ^ delay of initiation of preventer dose
increases^ prolonged exacerbation^ adverse effects on pts life
Peak Flow Monitoring
• Peak Expiratory Flow (PEF) – the greatest flow velocity which can be generated during a forced expiration starting with fully inflated lungs
• Simple, quantitative, reproducible measure of airway obstruction
• Meters are cheap, lightweight and portable• Repeated measures highly reproducible with
each individual patient, if the same meter is used
Peak Flow Monitoring
• Actual number not important, but the trend is• Measures response to bronchodilator therapy –
increase by 20% post treatment (provided the baseline reading > 300ml/min adults)
• Measures early deterioration before pt. feels the change in his disease