This document discusses clinical pharmacy and provides information on how clinical pharmacists perceive their roles differently than traditional pharmacy roles. It outlines the requirements, goals, and levels of action for clinical pharmacists. Some key roles of clinical pharmacists during inpatient stays include reviewing medication charts, contributing to prescribing decisions, and educating patients. The document also discusses functions of clinical pharmacists like counseling, therapeutic drug monitoring, and adverse drug reaction reporting. It provides examples of clinical pharmacy practice areas and uses case studies to illustrate how clinical pharmacists can assess patients and make therapeutic recommendations.

1. CLINICAL PHARMACYDr. Atef Gabr

2. HOW DO OTHERS SEE US?!!!
Perception Of Pharmacist

3. HOW DO OTHERS SEE US?!!
▸ “They just count a few tablets”
▸ “They just weigh and measure
things”
▸ “Tell me how and when to use
the Medicine”
▸ “Counter-prescribing”
▸ “Not really health care
practitioners- They’re
businessmen”

4. CONTENTS
▸ Overview Of Clinical Pharmacy
▸ Clinical Pharmacy Requirements
▸ Clinical Pharmacy Goal
▸ Level of Action of Clinical Pharmacists
▸ Roles of Clinical pharmacist during inpatient stay
▸ Functions of Clinical Pharmacists
▸ Clinical Pharmacy Practice areas
▸ Case Studies
▸ Role of computer in clinical pharmacy
▸ Professionalism in Clinical Pharmacy Practice
▸ QUALITY ASSURANCE OF CLINICAL PHARMACY SERVICES
▸ Case Study
▸ Clinical Pharmacist and pharmacology
▸ Case Study

5. LEARNING OUTCOMES
▸ At the end of this tutorial you
should be able to:
Develop professional practice as clinical
practitioners involved in making decisions
about patient care.
Get analytical thinking about
pharmaceutical profession
Recognise Roles of Clinical pharmacist
during inpatient stay

6. WHAT IS CLINICAL PHARMACY?
Clinical pharmacy may be defined as the science and practice of
rationale use of medications, where the pharmacists are more
oriented towards the patient care rationalizing medication therapy
promoting health, wellness of people.
It is the modern and extended field of pharmacy.
The discipline that embodies the application and development (by
pharmacist) of scientific principles of pharmacology, toxicology,
therapeutics, and clinical pharmacokinetics,
pharmacoeconomics, pharmacogenomics and other allied sciences
for the care of patients”.
(Reference: American college of clinical pharmacy)

7. HOW DOES CLINICAL PHARMACY DIFFER FROM PHARMACY?
The discipline of pharmacy embraces the knowledge on
synthesis, chemistry and preparation of drugs.
Clinical pharmacy is more oriented to the analysis of population
needs with regards to medicines, ways of administration,
patterns of use, drugs effects on thePatients,
‘the overall drug therapy management’.
The focus of attention moves from the drug to the single patient
or population receiving drugs.

8. PHARMACEUTICAL CARE
*The practice embraces the philosophy of pharmaceutical care.
“Pharmaceutical care is the responsible provision of drug
therapy for the purpose of achieving definite outcomes that
improve or maintain patient’s quality of life”
(Hepler and Strand, 1990 & FIP 1999)
* * Cure of the disease
* * Elimination or reduction of symptoms
* * Arrest or slowing of a disease process
* * Prevention of disease or symptoms

9. PHARMACEUTICAL CARE
▸ Accordingly, the policy sees pharmacists as a member of the healthcare
team. “WHO and FIP 2000 Good Pharmacy Education Practice”.
▸ From a compounder of pharmaceutical products to a provider of services and
information.
▸ FROM —————————> TO
▸ Drug Product —————————> Drug Therapy
▸ Pharmacy —————————> Bedside
▸ Dispenser —————————> Caregiver
▸ Solo —————————> Team
▸ Knowledge —————————> Information
▸ As Ordered —————————-> As best prescribed

10. CLINICAL PHARMACY REQUIREMENTS
Patient Care
Knowledge Of
Drug Therapy
Communication
Skills
Knowledge Of
The Disease
Knowledge
Of Laboratory
And Diagnostic
Skills
Knowledge Of
Nondrug
Therapy
Therapeutic
Planning Skills
Drug
Information
Skills
Physical
Assessment
Skills
Patient
Monitoring
Skills

11. CLINICAL PHARMACY GOAL
▸ Maximising the clinical effect of medicines, i.e., using the
most effective treatment for each type of patient.
▸ Minimising the risk of treatment-induced adverse events.
▸ Minimising the expenditures for pharmacological
treatments, trying to provide the best treatment alternative
for the greatest number of patients.

12. LEVEL OF ACTION OF CLINICAL PHARMACISTS
Before the prescription
During the prescription
After the prescription

13. BEFORE THE PRESCRIPTION
▸ Clinical trials
▸ Formularies
▸ Drug information
▸ Drug-related policies

14. CLINICAL TRIALS
▸ Pharmacist has a vital role in relation to
clinical research, which is to safeguard
participants, healthcare professionals and
the Trust by ensuring Investigational
Medicinal Products (IMP’s) are appropriate
for use and are procured, handled, stored
and used safely and correctly
▸ Review the clinical trial protocol:
▸ • Is the dose appropriate for all trial participants?
▸ • Are all contra-indications listed in exclusion
criteria?
▸ • Are all drug/disease interactions listed in exclusion
criteria?
▸ • Have all expected side effects been included in
protocol/patient information leaflet?

15. DEFINITION OF DRUG INFORMATION
▸ Drug information is the process of providing information on
the safe and effective use of therapeutic and diagnostic
pharmaceuticals.
▸ Medicine Information is the same meaning.
▸ Knowledge of facts through; reading, study, or practical
experience on chemical substance that is used in Diagnosis,
Prevention and treatment of a disease.

16. DRUG INFORMATION CENTRE
▸ The primary function of the a drug information centre is to respond
to enquiries on therapeutic drug use.
▸ They offer services to healthcare professionals and some also offer a
service to the public.
▸ In some cases toxicology information is also provided.
▸ Drug Evaluation is an important function.
▸ Therapeutic Advice which require an adequate understanding of
disease state and therapy.
▸ Pharmaceutical Advice including availability ,formulation, storage
and stability.

17. DRUG INFORMATION SPECIALIST
▸ Answer any drug related questions
▸ Drug Interaction
▸ Product availability
▸ Drug-induced adverse effect
▸ Pharmacokinetics
▸ Pregnancy/Lactation
▸ IV compatibility

18. WE KNOW A SUBJECT
OURSELVES, OR WE
KNOW WHERE WE CAN
FIND INFORMATION
AKNOWLEDGE IS OF
TWO KINDS.

19. DURING THE PRESCRIPTION
▸ Counselling activity
▸ Clinical pharmacists can influence the attitudes and priorities of
prescribers in their choice of correct treatments.
▸ The clinical pharmacist monitors, detects and prevents the
medication related problems.
▸ The clinical pharmacist pays special attention to the dosage of
drugs which need therapeutic monitoring.
▸ Community pharmacists can also make prescription decisions
directly, when over the counter drugs are counselled.

20. ▸ Pharmacist use to make a record on
patient’s symptoms, genetic disorders
and physiological parameter (like Blood
Sugar, blood Pressure…..etc) and sent to
the specific doctor.
COUNSELLING

21. COMMUNICATION SKILLS
Things to avoid:
–Using medical terminology
–Switching between brand & generic drug names
–Ignoring patient emotion
The patient should be the focus!
–Use verbal & non-verbal communication
Verbal Expressions tone modulation, and choice of words.
Nonverbal Expression (( body movement, facial expression, dress and
professionalism ))
–Ask patient to repeat key messages to assess comprehension

22. MEDICATION-RELATED PROBLEMS
▸ • Untreated indications.
▸ • Improper drug selection.
▸ • Sub-therapeutic dosage.
▸ • Medication Failure to receive.
▸ • Medication Overdosage.
▸ • Adverse drug reactions.
▸ • Drug interactions.
▸ • Medication use without indication.

23. AFTER THE PRESCRIPTION
▸ Counselling
▸ Preparation of personalised formulation
▸ Drug use evaluation
▸ Outcome research
▸ Pharmacoeconomics studies

24. ROLES OF THE CLINICAL PHARMACIST DURING INPATIENT STAY
▸ –Review charts daily Medication & other charts – e.g. IV fluids,
observation & fluid-balance charts Identify & prioritise
medication-related issues.
▸ –Contribute to prescribing decisions regarding: Medication,
dose, administration route, monitoring needs.
▸ –Monitor patient response to therapy Modify patient therapy
based on response & ADRs
▸ –Inform & educate patient/carers about medication changes To
prepare them for managing medicines at home after discharge.

25. FUNCTIONS OF CLINICAL PHARMACISTS
▸ 8. Participation in drug utilization studies
▸ 9. Patient counselling
▸ 10. Therapeutic drug monitoring
▸ 11. Drug interaction surveillance
▸ 12. Adverse drug reaction reporting
▸ 13. Safe use of drugs
▸ 14. Disease management cases
▸ 15. Pharmacoeconomics
▸ 1. Taking the medical history of the
patient
▸ 2. Patient Education
▸ 3. Patient care
▸ 4. Formulation and management of
drug policies
▸ 5. Drug information
▸ 6. Teaching & training to medical and
paramedical staff
▸ 7. Research and development

26. CLINICAL PHARMACY PRACTICE AREAS ▸Cardiology
▸Psychiatry
▸Endocrinology
▸Gastroenterology
▸Rheumatology
▸Infectious disease
▸Nuclear pharmacy
▸Neurology
▸Pediatrics
▸Nutrition Support
▸ADR/DUE
▸Pharmacokinetics
▸Transplant
▸Surgery
▸ Investigational Drugs
▸ Ambulatory care
▸ Critical care
▸ Pharmacoeconomics
▸ Drug Information
▸ Nephrology
▸ Geriatrics and long –term care
▸ Obstetrics and gynecology
▸ Internal medicine and
▸ Pulmonary disease subspecialties

27. CLINICAL PHARMACY CASE
STUDIES

28. CASE STUDY 1
▸ A patient visits his physician because he has complain of
hypertension, headache, fever and abdominal cramp.
Physician prescribed him Atenolol 50mg, Ibuprofen
400mg, and Buscopan.
After 2days the patient reports about high blood pressure,
that his hypertension not got treated yet.
What would you suggest him and what change should be
done in the prescription of the patient?

29. ANSWER
▸ Treatment for this patient is improper.
Atenolol is a selective B1-receptor antagonist. It produces negative
ionotropic and negative chronotropic effects. Hyoscine butylbromide
Buscopan is non selective drug. It is peripherally acting antimuscarinic
agent, used as an abdominal specific spasmodic. It causes relaxation
of of gastro- intestinal tract, but in heart it acts on cardiac muscles or
muscarinic receptor, and produce the positive chronotropic and
positive ionotropic effects. This effect is against Atenolol.
Buscopan should be replace by Mebverine, which is musculotropic
agent and directly acts on gut wall and causes relaxation.

30. CASE STUDY 2
▸ Mr.B is 57-year-old who was admitted yesterday after starting to pass
black stool.
He has two-day history of sever stomach pains and has suffered on
and off with indigestion for some months, he is life long smoker with
mild chronic cardiac failure (CCF) for which he has been taking Enapril
5mg twice daily for 2 years.
He is recently started taking Naproxen 500mg twice daily for arthritis
Yesterday his haemoglobin is 10.3 g/dl(12-18 g/dl).
He was mildly tachycardia 87 bpm, slightly low blood pressure 115/77
mmhg, he was given 1.5 L saline.
He is just returned from endoscope and has been newly diagnosed as
have bleeding duodenal ulcer.
He has been written up for his usual medication for tomorrow if he has
eating or drinking again.

31. THERAPEUTIC PLAN FOR THE ANSWER
▸ What risk factors does Mr.B have for a bleeding peptic ulcer?
▸ Has his treatment so far been appropriate?
▸ What is the best recommended pharmacological drug for treatment
of bleeding duodenal ulcer?
▸ What is likely to be the next stage of treatment?
▸ What drug should Mr.b be discharged on?
▸ What counselling would you give him ?
▸ What follow up Mr.B have?

32. ROLE OF COMPUTER IN CLINICAL PHARMACY
Computers have played a vital role in the development of clinical
pharmacy practice and basic pharmacy research :-
▸ • Patient record Management
▸ • Entries of Medication Orders
▸ • Patient Medication Profile
▸ • Drug Therapy Monitoring & Problem Detection
▸ • Record Drug-Drug Interactions & ADR’S
▸ • Pharmacy Automated drug interaction screening
(PADIS) system
▸ • Teaching Techniques
▸ • Building Data Base
▸ • Inventory control
▸ • Medical Research
▸ • Computerising Drug Information System
▸ • Uses Of Computers In Other Fields Of Pharmacy

33. PROFESSIONALISM IN CLINICAL
PHARMACY PRACTICE

34. PROFESSIONALISM…
▸ “set of attitudes and behaviours believed to be
appropriate to a particular occupation”
▸ Comprised of attitudes and behaviours.
Attitudes often described and measured because of their
relationship to behaviours.
A professional attitude a feeling, emotion, or thought that
upholds the ideals of a profession and serves as the basis
for professional behaviour.

35. PROFESSIONAL ATTITUDES AND CORRESPONDING BEHAVIOURS
Attitude Behaviour
Accountability Takes responsibility for actions
Caring Volunteering Acts of service
Desire for Self- improvement Continued learning Self-instruction
Diversity
Fair treatment of all people regardless of
demographic characteristics
Honesty
Behaviors that demonstrate honesty and
trustworthiness
Open-minded Increased receptiveness to new ideas
Respect
Dresses appropriately Punctual Maintains
confidentiality
Responsibility to learn
Comes to workplace prepared Actively
participates in class activities, such as
engages in discussion
Team Player
Engages in constructive peer assessment
Accepts and applies constructive critique
Values new experience Desire to seek out, take on new challenges

36. QUALITY ASSURANCE OF
CLINICAL PHARMACY SERVICES

37. QUALITY ASSURANCE
▸ Quality assurance is a management technique used to
ensure the quality of practice and its outcome.
ASSESSMENT OF THE SERVICES
▸ Performance appraisal.
▸ Professional audit and clinical audit.

38. AUDIT
▸ Clinical audit-multidisciplinary in nature.
▸ It involves receiving the service and discover deficiencies.
TYPES OF AUDIT
▸ Self audit. eg: community pharmacist.
▸ Peer or group audit. eg: pharmacist from one hospital look
at the services provided from other hospital.
▸ External audit.

39. CLINICAL PHARMACY CASE
STUDIES

40. CASE STUDY 3
▸ A 28 years old, married woman, who presents a
prescription for Ciprofloxacin to a pharmacy to be filled.
When giving out the medicine, the pharmacist checks
whether Mrs KH takes any other medicines. She explains
she takes iron tablets each morning but nothing else.

41. ANSWER
▸ The pharmacist recommends that she takes Ciprofloxacin in the
morning and at night, avoiding milk at these times and take the
iron at lunchtime. Heavy meal ions such as iron or calcium can
bind with Ciprofloxacin to produce an insoluble salt that will not
dissolve and be absorbed from the git. The interaction could
cause therapeutic failure of the antibiotic. This could be avoided
by taking Ciprofloxacin at least 2 hours before or after iron or
calcium. Taking the iron at lunch time and avoiding milk (which
contains calcium) close to administration times will avoid this
interaction. Calcium in the other food sources in a normal diet is
not usually sufficient to impair absorption.

42. CLINICAL PHARMACIST
AND PHARMACOLOGY

43. ACTIVITIES WITHIN THE BODY
PHARMACOKINETIC
ABSORPTION
INVOLVES THE WAY A DRUG ENTERS THE
BODY AND PASSES INTO THE FLUIDS AND
TISSUES.
▸ – Passive transport
▸ – Active transport
▸ – Pinocytosis
RATE OF ABSORPTION:
▸ – Drug Solubility
• water soluble drugs
• lipodystrophy
▸ – Route of Administration – IV, IM, SC, Oral
▸ – Degree of blood flow through the tissues
To obtain the best therapeutic value from a drug we should understand the
mechanism of absorption and it is better to explain to the patient the reason
for drug being taken in the correct way.
Ex. Before food or after food, which concentration, intervals.
CLINICAL
TIP

44. • Is defined as the way the drug moves from the circulating body fluids to its
site of action. Note: The greater the blood supply in a body organ, the faster
the medication is absorbed.
DISTRIBUTION
▸ – Therapeutic effect ——— certain blood level is
maintained for the drugs to be effective.
▸ – Toxic effect ——— when blood level increase
significantly over the therapeutic level
CLINICAL
TIP
You should be aware of the symptoms which the patient may
display if they become toxic with the drug.
Toxicology——— the branch of science concerned with the
nature, effects, and detection of poisons.

45. • Is defined as the process by which drug is converted by the liver to inactive
compounds through a series of chemical reactions.
Plasma,
kidneys and membranes of intestines.
METABOLISM OR BIOTRANSFORMATION
CLINICAL
TIP
Babies less than 6 months old may not have a mature
liver and therefore drugs are given with great caution.
Patients who have diseases which have an impact on
liver function
Ex. Congestive heart failure, their ability to metabolise a
given drug is impaired.

46. Is the elimination of drugs from the body
EXCRETION

47. Refers to the time required for the body to eliminate
50% of the drug.
HALF-LIFE
▸ – It is important in planning the frequency of dosing.
• Short half-life (2-4 hours): needs to be given frequently
• Long half life (21-24 hours): requires less frequent dosing
Note: It takes 5 to 6 half lives to eliminate approximately 98% of a drug from
the body
CLINICAL
TIPPeople who have renal impairment may require dosage
alteration to achieve a therapeutic level.
Older people also need special consideration, as the
kidney doesn’t perform as well as we get older, resulting
in a lower glomerular filtration rate.

48. CASE STUDY 4
▸ A 55-year-old man, presents to the emergency department of the local hospital
with a 4- day history of diarrhea associated with abdominal cramping. He
complains that he has experienced at least 6 bowel movements daily during that
time. And the stools have been watery, but now he is passing blood-tinged stools.
He admits to experiencing fatigue and chills, but no weight loss or change in
appetite. Upon further questioning, he admits that he recently finished a course of
antibiotics. Although he is unable to remember which antibiotic he took, the
emergency department pharmacist is able to contact the pharmacy that filled his
antibiotic prescription. According to the retail pharmacist, the patient received a
10-day supply of Cefuroxime. The physician decides to admit him. Among the
tests ordered, the culture is positive for Clostridium difficile. The culture is negative
for Salmonella, Shigella, and Campylobacter. The physician wants to initiate
antimicrobial therapy to treat his C difficile-associated diarrhea. Since the patient is
hospitalized, the physician wants to prescribe intravenous (IV) antibiotics. He
orders IV Vancomycin.
When the pharmacy receives the order, should the pharmacist make any
recommendations on patient’s antibiotic therapy?

49. ANSWER
▸ Metronidazole remains the treatment of choice for Clostridium
difficile.
Patient does not have any contraindications to oral medication, so
oral metronidazole should be considered.
Although oral Vancomycin is effective, the risk of Vancomycin-
resistant enterococci makes it a less desirable option.
As for intravenous (IV) therapy, IV Vancomycin is considered less
effective than IV Metronidazole.
IV Vancomycin does not achieve sufficient drug concentrations in the
intestinal lumen.

50. THANK YOU!
DR. ATEF GABR