Intro 1

• Clinical Pharmacy


  The area of pharmacy concerned with the science and practice of rational medication use. (Patient oriented)
• Where to practice clinical pharmacy

  • Hospitals
  • Community pharmacies
  • Nursing homes
  • Home-based care services
  • Clinics
  • Any other setting where medicines are prescribed and used
• The term "clinical" does not necessarily imply an activity implemented in a hospital setting
• Qualifications to be an expert clinical pharmacist

  • Clinical Pharmacy Fellowship
  • Board of Pharmacy Specialties
  • Clinical Pharmacy Diploma
  • PharmD
  • Clinical pharmacy Master, and PhD
  • Clinical pharmacy Bachelor
• Responsibilities of a clinical pharmacist in outpatient care

  • Medication reconciliation
  • Adjust medication doses as necessary
  • Improve patient compliance
  • Report medication errors
  • Educate patients and providers about medications
• Drug information center (DIC)


  • Provision of specific comprehensive drug information upon request from healthcare providers, and consumers from the general public in a timely manner, based on a complete analysis of available evidence
  • Maintenance of resources to provide the most current and accurate information to inquirers
  • Publishing a drug information newsletter
  • Educating pharmacy students, and professionals about resources and medical literature analysis and enhancing the skill of accurately communicating response (both verbally and in-writing)

  
• Ward clinical pharmacist role

  • Involved in medical rounds with the other health care professionals
  • Documenting patient information on a specially designed record
  • Creating a pharmaceutical care plan
  • Identify Medication related problems
  • Answering Medication information queries to physicians & other health professionals
  • Patient education and counseling
• Pharmaceutical care plan


  • A written, individualized, comprehensive medication therapy plan based on clearly defined therapeutic goals
  • The pharmaceutical care plan, which is available to all pharmacists caring for a patient, is updated with each major change in patient status
  • It is important that the physician be informed about the care plan to ensure common goals
  • Patients should also be informed about the general content of the care plan as means of gaining their agreement regarding drug therapy
• Information included in the patient database for the pharmaceutical care plan

  • Patient demographics
  • Diagnoses and past medical history
  • Present medications and medication history
  • Medication allergies/intolerances
  • Smoking/alcohol/caffeine/drug use history
  • Abnormal laboratory and physical exam results
  • Renal and liver function
• Types of drug-related problems


  • Not receiving an indicated drug
  • Receiving the wrong drug
  • Receiving too little of the drug (Subtherapeutic dose)
  • Receiving too much of the drug (Supratherapeutic dose)
  • Experiencing an adverse drug reaction
  • Experiencing a drug interaction
  • Not receiving the prescribed drug
  • Drug without indication
• Therapeutic goals


  • Approach normal physiology (i.e., normalize blood pressure)
  • Slow progression of disease (i.e., slow progression of cancer)
  • Alleviate symptoms (i.e., optimize pain control)
  • Prevent adverse effects
  • Educate the patient about his or her medication
• Monitoring parameters must also include potential adverse effects
• General steps in creating a pharmaceutical care plan

  • Create comprehensive patient database
  • Assess for actual and potential drug-related problems
  • Establish therapeutic goals
  • Specify monitoring parameters with end points and frequency
  • Document the patient's progress towards therapeutic goals

  
• Items in the drug checklist for the ICU

  • Drug interactions
  • Medication without indication
  • Right dose
  • Dosage adjustment according to hepatic and renal functions
  • Right preparation and administration
  • Monitoring ADR
  • Monitoring of treatment response
  • Lab values monitoring
  • Indication without medication
  • Stress ulcer prophylaxis
  • DVT prophylaxis
  • Feeding
  • Analgesia and Sedation
  • Head of bed elevation
  • Glycemic control

  
• Risk rating scale for drug interactions

  A, B, C, D, X
• Use of antibiotics in case of viral infections is an example of medication without indication
• The dose of enoxaparin for VTE prophylaxis in critically ill patients is 40 mg SC daily
• The dose of enoxaparin for treatment of VTE is 1 mg/kg q12hr or 1.5 mg/kg q24hr
• Equations for dosage adjustment in renal impairment

  • Acute Renal Failure: JELLIFFE multi-step
  • Chronic Renal Failure: Cockcroft-Gault, Modification of Diet in Renal Disease (MDRD), and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI)
• Some drugs require special equations to calculate dosage in renal impairment
• Examples of drugs adjusted according to Child-Pugh score

  • Metronidazole
  • Tigecycline
  • Caspofungin