Drug utilization review (DUR) involves a comprehensive evaluation of a patient's prescription medications before, during, and after dispensing to ensure appropriate use and positive outcomes, with the goals of improving quality of care, preventing adverse drug reactions, and reducing unnecessary costs through three categories of review: prospective, concurrent, and retrospective. Pharmacists play an important role in DUR programs by directly improving patient care through activities like identifying drug interactions, monitoring prescriptions for safety and effectiveness, and providing feedback and education to physicians.

1. Drug Utilization
Review

2. Drug Utilization Review
Drug utilization review (DUR) is defined as an authorized,
structured, ongoing review of prescribing, dispensing and
use of medication.
DUR encompasses a drug review against predetermined
criteria that results in changes to drug therapy when
these criteria are not met.
It involves a comprehensive review of patients'
prescription and medication data before, during and after
dispensing to ensure appropriate medication decision-
making and positive patient outcomes.
As a quality assurance measure, DUR programs provide
corrective action, prescriber feedback and further
evaluations.

3. DUR is classified in three categories:
Prospective - evaluation of a patient's drug
therapy before medication is dispensed
Concurrent - ongoing monitoring of drug
therapy during the course of treatment
Retrospective - review of drug therapy after
the patient has received the medication

4. DUR is an ongoing, systematic process designed to
maintain the appropriate and effective use of medications.
It involves a comprehensive review of a patient’s
medication and health history before, during, and after
dispensing in order to attempt to achieve appropriate
therapeutic decision-making and positive patient
outcomes.
Pharmacists participating in DUR programs can directly
improve the quality of care for patients, individually and as
populations, by striving to prevent the use of unnecessary
or inappropriate drug therapy, prevent adverse drug
reactions and improve overall drug effectiveness.

5. Issues Commonly Addressed by Prospective DUR:
• Clinical abuse/misuse
• Drug-disease contraindications (when a prescribed
drug should not be used with certain diseases)
• Drug dosage modification
• Drug-drug interactions (when two or more different
drugs interact and alter their intended effects, often
causing adverse events)
• Drug-patient precautions (due to age, allergies,
gender, pregnancy, etc.)
• Formulary substitutions (e.g., therapeutic
interchange, generic substitution)
• Inappropriate duration of drug treatment

6. Example: Identification of drug-drug
interactions are a common outcome of a
prospective DUR.
For example, a patient being treated with
warfarin to prevent blood clots may be
prescribed a new drug by another specialist to
treat arthritis. If taken together, the patient
could experience internal bleeding. Upon
reviewing the patient's prescriptions, the
pharmacist would note the potential drug
interaction and contact the prescriber to alert
him/her to the problem.

7. Issues Commonly Addressed by Concurrent DUR:
• Drug-disease interactions
• Drug-drug interactions
• Drug dosage modifications
• Drug-patient precautions (age, gender, pregnancy, etc.)
• Over and underutilization
• Therapeutic Interchange
Example: Concurrent DUR often occurs in institutional settings,
where patients often receive multiple medications. Periodic review
of patient records can detect actual or potential drug-drug
interactions or duplicate therapy. It can also alert the pharmacist
to the need for changes in medications, such as antibiotics, or the
need for dosage adjustments based on laboratory test results.
The key prescriber(s) must then be alerted to the situation so
corrective action can be taken.

8. Issues Commonly Addressed by Retrospective
DUR:
• Appropriate generic use
• Clinical abuse/misuse
• Drug-disease contraindications
• Drug-drug interactions
• Inappropriate duration of treatment
• Incorrect drug dosage
• Use of formulary medications whenever
appropriate
• Over and underutilization
• Therapeutic appropriateness and/or duplication

9. Example: An example of a retrospective DUR
may be the identification of a group of patients
whose therapy does not meet approved
guidelines. For example, a pharmacist may
identify a group of patients with asthma, who
according to their medical and pharmacy history,
should be using orally inhaled steroids. Using
this information, the pharmacist can then
encourage prescribers to utilize the indicated
drugs.

10. Steps in Conducting a Drug Use Evaluation
Most authorities agree the following five steps are essential when conducting any
quality-related DUR program.
1. Identify or Determine Optimal Use. An organization’s established criteria
are defined to compare optimal use with actual use. The criteria should focus
on relevant outcomes within a delineated scope for DUR and identify the
relevant drugs to be monitored for optimal use in advance. For example, if the
use of a drug class prescribed to treat a patient with diabetes is being
evaluated, then standards should be determined to identify all drugs within the
drug class and to evaluate each drug’s effectiveness, such as a decrease in
blood glucose or A1c (glycosylated hemoglobin) levels to within normal limits.
2. Measure Actual Use. This step is where data are gathered to measure the
actual use of medications. These data can be obtained from medical and
prescription records or electronic claim forms. It may require the organization to
build an algorithm to identify all members who fit the criteria.

11. 3. Evaluate. Acceptable thresholds (percent of patients meeting the indicator)
should be determined prior to the comparison. This step involves applying the
algorithm, identifying members who meet the DUR criteria and the comparison
between optimal or appropriate and actual use. During this process, the evaluator
determines causes for any discrepancies and whether findings are expected. In
this process, patterns or aberrations can be identified and interpreted.
4. Intervene. This is the step where corrective action is implemented. Action
should be targeted to areas of concern such as prescribing patterns, medication
misadventures, and quality of drug therapy or economic consideration.
5. Evaluate the DUR Program. This step assesses the effectiveness of the DUR
program. Efforts should be made to evaluate the outcomes and document
reasons for positive and negative results. Implementing appropriate changes to
the DUR program and continued observation should be undertaken.
6. Report the DUR findings. The final step is to report these findings to the
appropriate team within the organization (e.g., the pharmacy & therapeutics
committee) and/or individual prescribers when appropriate.

14. The aim of the present study was to evaluate the pattern of
vancomycin administration in the hematology-oncology ward
of Nemazee Hospital, Shiraz, Iran.
Study criteria were developed to assess the several
parameters involved in vancomycin therapy.
These parameters include the appropriateness of drug
usage, dosage, duration of therapy, monitoring for toxicity
and serum concentration monitoring.
The serum concentration was measured by an automated
Fluorescence Polarization Immunoassay.
Clinical and preclinical parameters such as Glomerular
Filtration Rate (GFR), microbial culture, antibacterial
sensitivity, WBC count and fever were collected and
recorded for analysis.

15. Sixty patients were enrolled in the study, consisting of 45 males
and 15 females.
The age range was 15 to 68 years. In this study, 68.63% of the
vancomycin used for the patients with febrile neutropenia was
compatible with the Infectious Disease Society of America (IDSA)
guideline.
The initial dosage of vancomycin in 68.63%, rate of infusion in
100%, and dilution of vancomycin in100%, were appropriate.
Inappropriate use was more evident in the continuation of
vancomycin in 50% of the patients.
No appropriate dosage adjustment was done for 50% of the
patients with increased serum creatinine.

16. Based on the results, the indication of vancomycin in
febrile neutropenia was satisfactory.
However, there were some required factors such as
continuation of vancomycin, adjustment of dosage or
interval, microbial culture, antibiotic sensitivity test
before the first dose administration, measurement of
serum concentration and monitoring which had to be
revised in order to achieve an effective treatment.

18. Background:
Corticosteroids being widely used powerful
anti-inflammatory & immunosuppressive agents and have
become cornerstone of therapy in acute and chronic
inflammatory diseases. Corticosteroids though they are lifesaving
drugs, produce adverse reactions which may be
mild or life threatening. Considerable attention should be
given to relative risks & benefits, benefits definitely
outweighing the risks & individualization of treatment is
necessary.
Objective: This study was aimed to evaluate the utilization
of corticosteroids in OPD patients with the secondary
objective to assess co-prescription with corticosteroids, the
nature and severity of drug-drug interactions, with an
intention to prevent the inappropriate use of
corticosteroids.
Methods: A prospective observational study was carried
out in 109 Out-patients from various departments of the
hospital during 6 months period and subjected to
statistical analysis.

19. Results:
Out of total 109 prescription scrutinized, both
male and female were almost equally prescribed and
maximum were from mid aged group. Most of patients
were from dermatology ward (60.5%) and were prescribed
of corticosteroids with monotherapy (90.8%). The total
number of drug prescribed was 3 to 4 in most of the
patients and the average number was 3.67. Most of the
patients were prescribed corticosteroids for not more than
1-2 weeks. The clobetasone was found to be most widely
prescribed through the topical route. The drug interaction was found to be
considerably low and most concurrent drug administered was antibiotics.
Conclusion: We found all the prescriptions were
rational. Most of all patients were diagnosed well
and were prescribed corticosteroids by maintaining
pharmacokinetic and pharmacodynamic parameters.
Educational interventions among physician, patients
as well as students should be carried out to in
order to further enhance rational drug use.

20. Protocol of use of few very low
therapeutic index drug groups
Cimetidine
Duodenal Ulcer (Active)
ADULTS: PO 800 mg at bedtime for 4 to 6 weeks. ALTERNATE REGIMENS
PO 300 mg qid w/meals and at bedtime or 400 mg bid. MAINTENANCE
THERAPY PO 400 mg at bedtime.
Active Benign Gastric Ulcer
ADULTS: PO 800 mg at bedtime.
Gastroesophageal Reflux Disease
ADULTS: PO 1600 mg daily in divided doses (800 mg or 400 mg) for 12
weeks, although some patients may require chronic therapy.
Pathologic Hypersecretory Conditions
ADULTS: PO 300 mg qid w/meals and at bedtime. If needed, 300 mg doses
may be given more often (maximum 2400 mg/day).
Prevention of Upper GI Bleeding
ADULTS: Continuous IV infusion of 50 mg/hr. For hospitalized patients with
pathologic hypersecretory conditions or intractable ulcers, or patients unable to
take PO medication. USUAL DOSE: IM/IV 300 mg q 6 h to 8 h (maximum
2400 mg/day).

21. Assessment/Interventions
•Obtain patient history, including drug history and any known allergies.
•Establish baseline vital signs.
•Avoid administering antacids within 1 hr of medication.
•Review periodic monitoring of serum concentrations and clinical effects for other
drugs affected by cimetidine.
•Renal/liver function studies and blood counts are all especially important in elderly.
•Assess patient for abdominal pain, confusion and GI bleeding (blood in stools or
emesis).
•Assess gastric pH q 8 hr, when possible.
Patient/Family Education
•Counsel patients to stop smoking, since smoking reduces ulcer-healing efficacy of
cimetidine.
•Instruct patients to keep appointments for laboratory testing and physician follow-up.
•Advise patients not to take otc medications without consulting physician.
•Instruct patients to report to physician immediately any black tarry stools, coffee-
ground emesis, abdominal pain or confusion.
•Counsel patients regarding need for lifestyle changes, stress reduction programs
and dietary modifications (eg, avoid spicy foods and alcohol).

22. Vancomycin
ADULTS: PO 500 mg to 2 g/day in 3 or 4 divided doses for 7 to 10 days.
CHILDREN: PO 40 mg/kg/day (up to 2 gm/day) in 3 or 4 divided doses for 7 to 10
days. NEONATES: PO 10 mg/kg/day in divided doses. ADULTS: IV 500 mg by IV
infusion q 6 hr or 1 g q 12 hr. CHILDREN: IV 10 mg/kg/dose q 6 hr. INFANTS &
NEONATES: IV 15 mg/kg initially, followed by 10 mg/kg q 12 hr for neonates in
first week of life, and q 8 hr for ages up to 1 month.
Assessment/Interventions
Obtain patient history, including drug history and any known allergies.
Assess results of culture and sensitivity to determine sensitivity.
Assess hearing acuity before and after therapy. Anticipate ototoxicity.
Monitor for signs of superinfection.
Monitor skin for Red Man Syndrome with each dose infused.
Notify health care provider of elevated BUN and creatinine, which indicate
nephrotoxicity.
Document hematuria and notify health care provider.
Monitor I & O, BP for hypotension, and respirations for wheezing or dyspnea.
Maintain adequate fluid intake.
Obtain blood levels, new order or protocol. Keep blood levels between 10 to 20
mcg/ml.
Ensure that resuscitation equipment is available

23. Patient/Family Education
Explain that IV medication is given at regular intervals to maintain blood
levels.
Tell patient to report hearing loss, ringing in ears, or vertigo to health care
provider.
Explain signs of superinfection (eg, vaginitis).
Identify symptoms of potential adverse reactions.
Tell patient to maintain adequate fluid intake.

24. Dexamethasone
DEXAMETHASONE
Initial dose: PO 0.75 to 9 mg/day. SUPPRESSION TESTS: Cushing's syndrome:
PO 1 mg at 11 PM. (The overnight dexamethasone suppression test checks to
see how taking a steroid medicine called dexamethasone changes the levels of
the hormone cortisol in the blood. This test checks for a condition in which large
amounts of cortisol are produced by the adrenal glands (Cushing's)
Alternate: PO 0.5 mg q 6 hr for 48 hr. To distinguish Cushing's syndrome–caused
pituitary ACTH excess from other causes: PO 2 mg q 6 hr for 48 hr. ACUTE
MOUNTAIN SICKNESS: PO 4 mg q 6 hr. ANTIEMETIC: PO 16 to 20 mg.
DIAGNOSIS OF DEPRESSION: PO 1 mg.(Dexamethasone does not suppress
plasma cortisol levels in depressed patients as compared with normal subjects.)
HIRSUTISM: PO 0.5 to 1 mg/day.
DEXAMETHASONE ACETATE
SYSTEMIC: IM 8 to 16 mg; may repeat in 1 to 3 wk. INTERLESIONAL: IM 0.8 to
1.6 mg. INTRA-ARTICULAR AND SOFT TISSUE: IM 4 to 16 mg; may repeat at 1
to 3 wk intervals

25. Assessment/Interventions
Obtain patient history, including drug history and any known allergies.
Obtain baseline weight and vital signs.
Assess involved system before and periodically during therapy.
When used in child, periodically assess child's growth.
Monitor intake and output.
Assess patient regularly for signs of infection (delayed wound healing, WBC
count) because steroids can mask other common signs of infection such as
fever, swelling and redness.
Notify physician if signs of fluid overload develop (peripheral edema, weight
gain, rales/crackles, dyspnea).
If emotional changes occur, such as depression, take safety measures such
as suicide precautions.
If side effects develop with long-term therapy, expect to change to alternate-
day therapy. Check medication record and document well

26. Caution patient that stopping drug abruptly is dangerous and may cause
adrenal insufficiency.
Explain rationale for tapering off medication when that time comes.
Teach patient or family procedures for correctly administering specific form of
drug (ophthalmic, inhalation, topical, etc.).
Caution patient against receiving immunizations while drug is being taken.
Advise patient on long-term therapy to carry medication identification card or to
wear bracelet. In case of emergency, this information is important for treatment.
Instruct patient to avoid people with infections, particularly respiratory.
If form patient is receiving is intranasal, instruct him/her to clear nasal passages
of secretions before administering drug.

27. If topical, advise patient not to use occlusive dressings such as plastic wrap more
than 12 hrs a day. Occlusion may lead to sweat retention and bacterial and fungal
infections. Remember that tight-fitting plastic diapers on infants may also be
occlusive.
Teach patient to take oral forms with meals or snacks if GI irritation occurs.
Review guidelines for missed doses of particular product with patient.
Teach patient on long-term therapy how to keep a weight record.
Instruct patient to inform other physicians that he/she is taking a steroid.
Review signs of infection and remind patient that fever, swelling and redness may
be masked in infection.
Review possible side effects of dexamethasone with patient and instruct him/her
to report these to physician.