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Scope of clinical pharmacy services
- 1. Scope of clinical pharmacy Dr. Laxman Wagle B.pharm,PharmD
- 2. Medicine use process • Prescribing • Dispensing • Administering • Use
- 3. Pharmacist vs prescription • Horizontal – Route, dosage form, dose, frequency, duration, • Vertical – List of drugs
- 4. 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?
- 5. 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
- 6. 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
- 7. 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
- 8. Drugs in elder patient • Patient pharmacokinetic changes. • Beers criteria: list of drugs to be used cautionally in elders
- 12. Drugs use in paediatric patient? Dose calculation Young 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)
- 13. 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
- 14. 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
- 15. 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.
- 16. 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,
- 17. 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
- 18. Drugs contraindicated in lactation • Amphetamine –irritability • Antineoplastics-immune supression • Ergotamine –supressing lactation • Immunesuppresants-immune supression • Lithium – lithium toxicity • Misoprostol- diarrhea • Phenindione –scrotal hematoma
- 19. 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
- 20. Thank you