scope of clinical pharmacy

Scope of clinical pharmacy

Dr. Laxman Wagle B.pharm,PharmD

Medicine use process

• Prescribing • Dispensing • Administering • Use

Pharmacist vs prescription

• Horizontal – Route, dosage form, dose, frequency,

duration,

• Vertical – List of drugs

Questions from clinical pharmacist perspectives

• More than 5 drugs in prescription? • High risk drugs in prescription?• Drugs given to very old patients?• Drugs given to paediatric patient?• Drugs given to pregnant women?• Drugs given to renal failure patient?• Drugs given to hepatic impair patient?• Adverse drug reaction to patient?

More than 5 drugs? polypharmacy

• There is chance of drug interaction • There is chance of adverse drug reaction• There is chance of transcribing, dispensing,

administration error

Number of drugs

Drug interaction

No drug interaction Total P value

<5 drugs 55(14.51%) 324 379 0

>5 drugs 85(41.06%) 122 207

Highly risk drugs in prescription Specific High-Alert Drugs:• Insulin, subcutaneous and intravenous • Intravenous amiodarone• Opiates and narcotics • Injectable potassium chloride (or phosphate) concentrate • Injectable colchicine • Intravenous (unfractionated) heparin• Injectable, low molecular weight heparin • Sodium chloride solutions above 0.9% • Intravenous lidocaine • Injectable magnesium sulphate• Oral methotrexate, for non-oncologic use• Injectable nitroprusside, sodium• Warfarin

Follow patient with these drugs as pharmacist

High-Alert Drug Categories:

• IV Adrenergic agonists (i.e., epinephrine) • IV Adrenergic antagonists (i.e., propranolol) • Inhaled and IV Anesthetic agents (i.e., propofol) • Cardioplegic solutions (hypothermic and hyperkalemic solutions administered to the myocardium

during cardiac surgery) • Chemotherapeutic agents• Hypertonic Dextrose (20% or greater) • Dialysis solutions • Epidural or Intrathecal medications• Glycoprotein IIb/IIIa inhibitors (i.e., eptifibatide)• Oral hypoglycemics• IV Inotropic medications (i.e., digoxin)• Lipososmal forms of drugs (i.e., liposomal amphotericin B) • IV Moderate sedation agents (i.e., midazolam) • Oral Moderate sedation agents for children • IV/Oral Narcotics/Opiates• Neuromuscular blocking agents (i.e., succinylcholine) • IV Radiocontrast agents • IV Thrombolytic/Fibrinolytics • Total parenteral nutrition solutions

Drugs in elder patient

• Patient pharmacokinetic changes.

• Beers criteria: list of drugs to be used cautionally in elders

Drugs use in paediatric patient?

Dose calculationYoung rule • Child dose=adult dose*(age/age+12)Clark rule • Child dose=adult dose*(weight(lbs)/150)BSA methods• Child dose= adult dose* child BSA/1.7m2

BSA=√(height*weight/3600)

Drugs used in renal impair patient?• Estimate the creatinine clearance cl Cr (ml/minute) = [140-age] X body weight (Kg) /7.2 X

Ccr (mg/dl)In case of female, the value is multiplied by 0.85

• Calculate dosage Dose of renal failure patient* creatinine clearance =Normal

dose*creatinine clearance of normal• Calculate dosage interval

Dose interval of renal impair patient* creatinine clearance of normal patient =Normal dose interval *creatinine clearance of renal impair patient

Drugs use in hepatic impair patient?

• Vigil for drugs which impair the hepatocytes.

• Isoniazid, amoxicillin, paracetamol, alcoholic, diclofinac, etc..etc..

• Give at same dose with prolonged interval• Give at decreased dose with same interval

Adverse drug reaction to patient?

• Assess causality: naranjo, WHO scale• Assess type : A or B• Assess severity: Hartwig scale • Assess preventability: Existing literature

Record history of reaction in patient medication profile form.

Drugs used in pregnant women?

• Assessing A,B,C,D,X drugs...• A= Levotthyroxine, folic acid,• B= Metformin,HTZ, Amoxicillin, pantoprazole• C= Tramadol, gabapentin • D= Lisinopril, alprazolam,losartan• X= Atorvastatin, simvastatin, warfarin,

finasteride, methotrexate,

Other X categories• ACE inhibitors• B blockers• Corticosteroids• Antithyroid drugs• Antineoplastics • Lithium • NSAIDs• Phenytoin • Carbamazepine• valproic acid • Trimethoprim • Tetracycline • Ciprofloxacin • Streptomycin• Misoprostol • Vaccines • Cigerette smoking • Alcohol intake• Thalidomide

Drugs contraindicated in lactation

• Amphetamine –irritability • Antineoplastics-immune supression• Ergotamine –supressing lactation • Immunesuppresants-immune supression• Lithium – lithium toxicity • Misoprostol- diarrhea• Phenindione –scrotal hematoma

Procedures of clinical pharmacy services

• Medication history taking/Patient medication record keeping procedure

• Prescription review/ monitoring procedure • Medication error reporting procedure • ADR reporting procedure • Drug interaction reporting procedure • Patient counselling/ambulatorty care • Drug /poison information• Therapeutic drug monitoring/ Patient dosage regimen

check/ calculation procedures

Thank you