Title 2. INTRODUCTION TO DAILY ACTIVITIES OF A CLINICAL PHARMACIST.pdf ✅

PHARMD GURU Page 1 DRUG THERAPY MONITORING (MEDICATION CHART REVIEW, CLINICAL REVIEW, PHARMACIST INTERVENTIONS) Many times, same doses of a drug may produce satisfactory therapeutic activity in some people, whereas, it causes toxicity in others, and has little effect on some people. Hence to improve the situation, clinical pharmacokinetics and laboratory technology were integrated with clinical medicine, giving birth to “Therapeutic drug monitoring”. Therapeutic drug monitoring: It is defined as “a practice to individualize, the dosage regimen and the therapy such that it maximizes the benefit of the prescribed drug with minimum toxicity”. Thus, its main aim is to maximize the benefits of the prescriber drug simultaneously minimizing its toxicity. TDM benefits patient medically and financially. Objectives of Therapeutic Drug Monitoring:  To achieve optimal drug therapy.  To achieve desired pharmacological effect of a drug within shortest possible time with no toxicity.  To monitor serum concentration with clinical response, so as to modulate the therapy.  To benefit the patient, medically and economically by reducing hospital stay and drug related toxicity.  To monitor individual complicating factors like patient characteristics, diseases, and drug interactions. Stages in Therapeutic Drug Monitoring: 1. Development & validation of a suitable analytical technique. 2. Selection of appropriate samples for analysis & their preservation. 3. To establish the blood drug concentration correlation with Therapeutic efficacy & (or) toxicity of the drugs. INTRODUCTION TO DAILY ACTIVITIES OF A CLINICAL PHARMACIST
PHARMD GURU Page 2 TDM is useful in drugs: 1. with a narrow therapeutic index. 2. Which is highly protein bound. 3. Which are liable to interact? 4. In which the metabolite might be toxic. ROLE OF PHARMACIST IN THERAPEUTIC DRUG MONITORING: A reliable and responsive TDM service depends on team work between nurses, doctors, pharmacist, scientist and technical staff. The clinical pharmacist should provide advice to medical staff on the appropriate use and timing of TDM and assist with the interpretation of results. In addition the pharmacist maybe involved in: 1. Initial selection of drug regimen. This may involve decisions about drug choice, dose, dosing interval, route of administration and dosage form of the drug, taking into account factors such as sex, age, body weight, race, metabolism status, renal function, plasma albumin concentration, use of other drugs and laboratory results. 2. Adjustment of the dosage regimen based on TDM results and the patients clinical response. 3. Assessment of possible causes for unexpected results, such as non- compliance, bioavailability problems, medication errors, drug interactions or pharmacogenetic variability. 4. Dose adjustment for patients on hemodialysis or peritoneal dialysis. 5. Provision of poisons information. MEDICATION CHART REVIEW 1. It is a fundamental responsibility of a pharmacist to ensure the appropriateness of medication orders. 2. It serves as starting point for other clinical pharmacy activities (medication counseling, TDM, DI, and ADR). 3. Organizing information according to medical problems (example disease) helps breakdown a complex situation into its individual parts.
PHARMD GURU Page 3 AIMS: 1. To optimize the patients drug therapy. 2. To prevent or minimize drug related problems/medication errors. PROCEDURE: 1. The patient’s medical record should be reviewed in conjugation with the medication administration record. 2. Recent consultations, treatment plans and daily progress should be taken into account when determining the appropriateness of current medication orders and planning each patient’s care. 3. All current and recent medication orders should be reviewed. COMPONENTS OF MEDICATION ORDER REVIEW: It includes: 1. Checking that medication order is written in accordance with legal and local requirements. 2. Ensuring that the medication order is comprehensible and unambiguous, that appropriate terminology is used and that drug name are not abbreviated. Annotate the chart to provide clarification as required 3. Detecting orders for medication to which the patient may be hypersensitive/ intolerant. 4. Ensuring that medication order is appropriate with respect to: a) The patient’s previous medication order. b) Patient’s specific considerations e.g. disease state, pregnancy. c) Drug dose and dosage schedule, especially with respect to age, renal function, liver function. d) Route, dosage form and method of administration. 5. Checking complete drug profile for medication duplication, interactions or incompatibilities.
PHARMD GURU Page 4 6. Ensuring that administration times are appropriate e.g. with respect to food , other drugs and procedures. 7. Checking the medication administration record to ensure that all ordered have been administered. 8. Ensuring that the drug administration order clearly indicates the time at which drug administration is to commence. 9. Special considerations should be given especially in short course therapy as in antibiotics and analgesics. 10. Ensuring that the order is cancelled in all sections of medication administration record when the drug therapy is intended to cease. 11. If appropriate follow up of any non-formulary drug orders, recommending a formulary equivalent if required. 12. Ensuring appropriate therapy monitoring is implemented. 13. Ensuring that all necessary medication is ordered. E.g. premedication, prophylaxis. 14. Reviewing medication for cost effectiveness. 15. Identification of drug related problems. a) Untreated indication. b) Inappropriate drug selection. c) Sub therapeutic dose. d) Adverse drug reaction. e) Failure to receive drug. f) Drug interactions. g) Drug use without indication. h) Over dosage. MEDICATION CHART ENDORSEMENT: 1. Another important goal of treatment char review is to minimize the risk of medication errors that might occur at the level of prescribing and / or drug administration. 2. A medication error is any preventable error that may lead to inappropriate medication use or patient harm.