MEDICATION RELATED PROBLEMS

An event or circumstance involving drug therapy that actually or potentially interferes with desired
health outcomes

Adverse Drug Reactions - are noxious and unintended, and which occurs at doses normally used in
man for the prophylaxis, diagnosis, or therapy of disease, or for the modification of physiological
function

Adverse Drug Events - are ADR that result in an injury – due to the use or lack of intended use of a
drug

Medication Related Problem: Classification

The basic classification has:

- 6 primary domains for problems

- 6 primary domains for causes

- 5 primary domains for interventions

 Problems Causes Intervention
• ADR Drug/Dose selection No intervention
• Drug choice • Drug use process • At prescriber level
• Dosing • Information • At patient/care giver
• Drug use • Patient/psychological level
• Interactions • Pharmacy logistics • At drug level
• Other • other • other

Types of Adverse Drug Reaction

Type A: Augmented

Involves the pharmacological activity of the drug

• Common; predictable; dose-related

• Sub-types:

1. Extension effect – Insulin & Sulfonylureas, Salbutamol,

Anticoagulants

2. Adverse effect - Gentamicin, Opiates (HECk of a DREAM),

Nitroglycerin, ACE inhibitors, Minoxidil, Antihistamines

Type B: Bizarre

aBnormal effects

• Reactions unrelated to drug’s known action

• Uncommon; unpredictable; dose-related

Specific Subtypes of Bizarre ADR

Idiosyncrasy

- Genetically determined reactions

- E.g.:

• Antipsychotic drugs (Malignant hyperthermia)

• Antimalarial or Sulfonamides to G6PD patients (Hemolytic

anemia)

• Carbamazepine; Phenytoin; Sulfonamides (Steven Johnson

Syndrome)
• Hypersensitivity

- Immune responses to environmental antigens resulting in

symptomatic reactions upon secondary exposure to the same

antigen, commonly referred as ALLERGEN

Types of Hypersensitivity Reactions

Type 1: Immediate or Anaphylactic Immune Response

• Type 2: Cytotoxic Reactions

• Type 3: Immune Complex Hypersensitivity

• Type 4: Cell-mediated or Delayed

Type 1: Immediate or Anaphylactic Immune Response

- Most common type of allergic reaction

- Ig E mediated reaction

• Type 2: Cytotoxic Reactions

- Initiated by IgG or IgM directed against

antigen

- Result: complement – mediated lysis

- Examples: Methyldopa (hemolytic

anemia), Chloramphenicol (Aplastic

anemia), Blood transfusion reactions

Type 3: Immune Complex

- Tissue deposition of antigen-antibody complexes with

complement activation and tissue damage

- Examples:

- Blood dyscracias or serum sickness

- Arthus reaction (SC or Intradermal)

- Hydralazine, Phenytoin, INH, Procainamides, Statins

(Systemic lupus erythematosus) (SHIPS)

Type 4: Cell-mediated or delayed type

- Immune system response is mediated by T cells

- Delayed reaction (2 to 3 days after exposure to

antigen)

- Examples:

- Poison ivy (contact dermatitis)

- Organ transplantation

- Tuberculin skin test

Types of Adverse Drug Reaction

Type C: Continuous

• Long term effects are usually related to the dose and

duration of treatment

• Associated with cumulative dose of the drug

Types of Continuous Reaction

Addiction

- Condition where a person takes a drug compulsively, despite

potential harm to themselves, or their desire to stop

- Examples: Marijuana, Opiates

• Dependence

- Compulsion to take the drug repeatedly

and experience unpleasant symptoms

if discontinued

- Examples: Benzodiazepines, Caffeine,

Cocaine

• Tolerance

- Reduced effect with repeated use; increasing dose to achieve

the same effect

- Example: Nicotine

Types D: Delayed Reaction

Carcinogenicity

- Ability of any substance to CAUSE or INDUCE cancer

- Examples:

Antineoplastic Nitrosamines

Heterocyclic amines Aflatoxin

Aromatic hydrocarbons

Teratogenicity

- Ability of any substance to CONGENITAL MALFORMATIONS

or BIRTH DEFECTS
Drugs with Human Teratogenic Potential

 •Thalidomide
 Valproic acid
 Isotretinoin
 Lithium
 •Warfarin
 ACE inhibitors
 •Methotrexate
 ARBs
 •Aminopterin
 Alcohol
 •Phenytoin
 Diethylstilbestrol
 •Carbamazepine
•Methimazole

•Tetracycline

•Aminoglycoside

•Quinolone antibiotics

• Immunosuppressants

Type E: End of Use

Uncommon

•Withdrawal syndrome

•Generally occur shortly after stopping the drugs

•Examples:

- Opioids

Nasal decongestants

- Clonidine (rebound HTN)

Corticosteroids (adrenal crisis)

- Benzodiazepine (rebound insomnia and excitation)

Type F: Failure of Efficacy

•Common; dose-related; unexpected failure of efficacy

•May result from:

- Drug-drug interactions

Patient’s non-compliance

- Drug instability

Drug resistance

- Wrong route of administration

- Counterfeit drugs

MRP: Drug Choice Problem

•Patients gets or is going to get a wrong (or no dug) drug for

his/her disease
- Need for additional drug

- Unnecessary drug

- Inappropriate drug choice

•Too high or too low doses

•Sub-optimal dosing scheme/formulation

MRP: Drug Interactions

•Occurs when the effect of drug is changed by the presence of

another drug, food, or some environmental chemical agent.

Classification and Mechanism of DI

I. Pharmacodynamic Interactions

II. Pharmacokinetic Interactions

DI: Pharmacokinetic Interactions

Process of ADME

• “what the body does to the drug?”

•Mechanisms include:

- Alteration in ABSORPTION

- Alteration in DISTRIBUTION

- Alteration in METABOLISM

- Alteration in EXCRETION

I. Alteration in Absorption
Alteration in pH

•Complex formation

•Decreased gastric emptying time (GET)

• Increased GET

• Increased GI motility
• Interruption of Enterohepatic Circulation

• Inhibition of GI flora

Absorption: Alteration in pH

Antacid + Bisacodyl

•Antacid + Ketoconazole

• Antacid + Salicylates

Absorption: Complex Formation

Tetracyclines + Metal-containing drugs

•Fluoroquinolones + Metal-containing drugs

•Penicillamine + metal-containing drugs

•Digoxin + Cholestyramine

•Warfarin + Cholestyramine

•Levothyroxine + Sucralfate

Absorption: Decreased GET

Atropine + Antacid

• Atropine + Amphetamine

Absorption: Increased GET

•Nicotine + antacid

Absorption: Increased GI Motility

Cathartic + any drug

Absorption: Enterohepatic Circulation

Antibiotics + OCP
Absorption: GI Microbial Flora

•Antibiotics + Digoxin

- Increased digoxin absorption

- Less active form: dihydro metabolites

II. Alteration in Distribution

•Displacement from protein binding site

- Phenylbutazone + warfarin (hemorrhage)

- Phenylbutazone + glibenclamide (hypoglycemia)

- ASA + OHA (hypoglycemia)

III. Alteration in Metabolism

Enzyme inducers

•Enzyme inhibitors

Take note: Most anticonvulsan t are INDUCERS except Valproic acid

Enzyme Inducers Enzyme Inducers

Carbamazepine Estrogen
Phenobarbital Omeprazole
Phenytoin Griseoflvin
Rifampicin Chronic alcoholism
Tolbutamide
Smoking

•Take note: Most antibiotics are enzyme inhibitors except: Rifampicin

Enzyme Inducers Enzyme Inducers

Cimetidine Itraconazole
Chloramphenicol Metronidazole
Clarothromycin Miconazole
Disulfiram Valproic acid
Erythromycin Acute alcoholism
Grapefruit juice Ketoconazole
Isoniazid

IV. Alteration in Excretion

•Alteration in urinary pH

•Alteration in active transport

IV. Alteration in Excretion: Urinary pH

•NaHCO3 + ASA

- Increased renal excretion ofASA

V. Alteration in Excretion: Active Transport

•Probenecid + Penicillin (decreased renal E of penicillin)

•Probenecid + Indomethacin (dec renal E of indomethacin)

•NSAIDS + Lithium salts, Methotrexate, Digoxin (decreased)

•Corticosteroid +ASA (increased renal E of ASA)

DI: Pharmacodynamic Interactions

Explains the MOA and pharmacologic effects of drugs

•“what the drug does to the body?”

- Additive

- Synergism

- Potentiation

- Antagonism

Additive
•1 +1 = 2

- Response in equal to the combined effects of individual drugs

- Barbiturates + Anti-histamines (increased sedation effect)

- Flecainide +Verapamil (increased negative inotropic and

chronotropic effects)
Synergism

•Response is greater than the combined effects of the individual

drugs

•1 + 1 = 3

- Sulfamethhoxazole +Trimethoprim (increased bactericidal

effect)

Potentiation

•A drug with no inherent activity will enhance the effect of

another drug

•1 + 0 = 2

- Amoxicillin + Clavulanic acid (Co-amoxiclav: augmentin®)

- Ampicillin + Sulbactam (Unasyn®)

- Piperacillin + Tazobactam (Tazocin®)

- Levidopa + Carbidopa (Sinemet®)

Antagonism

•A drug inhibits the effect of the other drug

•1 + 1 = 0

- Warfarin +Vitamin K

Atropine + Neostigmine

- Heparin + Protamine sulfate P

rocaine + Sulfonamides

- Opioids + Naloxone

- Bezodiazepine + Flumazenil

Risks of DI

Multiple drugs

•Multiple prescribers

•Patient risks factors

Prevention

•Review drug history and patient risks factors

•Avoid complex therapeutic regimens

Management

•Suggest a different drug for significant interactions

• Instruct the patient as to timing of the medication

• monitor the patient for response, adverse effects, and drug

Levels
PATIENT COUNSELING

Patient Medication Counseling

It is a two-way process whereby drug- and health-related

information is provided by a pharmacist to the patient during:

➢ the dispensing of (initial or refill) medications in a drugstore

or outpatient pharmacy setting

➢ discharge of a patient from the hospital

➢ the review of medications of a patient

Relevance

• To improve quality of life

• Quality of care

• Reduced:

1. Errors in using the medication

2. Non-compliance

3. Health-care costs to individual,

government and society

Process Steps

I. Opening the Discussion and Patient

History Taking

II. Basic Counseling points

III. Teach-back Method

IV. Closing the Discussion

Opening the Discussion and Patient History Taking

a. Greets the patient (hi, hello, good

day, handshake, eye contact, etc.)

b. Introduce yourself (name and

position)
c. Asks permission to do counseling

d. Explain the purpose of counseling

(to get the most benefit of the drug)

e. Review the Rx

- Confirm the patient name and date of

birth

- Verify the phone number and address

(for follow up)

- Check for the validity and errors

F. Collects past medical history

- Verify patient’s:

✓ Allergies (drug, foods, etc.)

✓ Rx medications (past and current)

✓ OTC medications (past and current)

✓ Vitamin use

✓ CAM (past and current)

F. Collects past medical history

- Verify patient’s:

✓ Social habits (alcohol, smoking, use of

illicit drug)

✓Occupation (nature of work)

✓Pregnancy/Breastfeeding (for female)

✓Medical condition/Surgeries (past and

current)

II. Basic Counseling Points

a. Provides medication name (generic

and brand name, color, description)

b. Assess patient’s knowledge (what

did the doctor tell you about the

medication?)

c. Provides indication for medication

(this was for..)

d. Assess patient’s knowledge (how did

the doctor tell you to take this?

II. Basic Counseling Points

a. Provides dose of the medication (mg

per tablet, mg per mL)

b. Address dosage form concerns (elderly

and children)

c. Provides regimen for medication

(should be tailored-fit to patient’s

schedule)

d. Explain anticipated duration of the

therapy (for how long the patient will

take the medication)

II. Basic Counseling Points

a. Assess patient’s prior knowledge (what

did the doctor tell you to expect about

this medication?)

b. Efficacy (what results to expect, when

to expect, what will the patient do to

manage these effects)

c. Provides adherence tips (use of pill box,

pill reminder, app reminder, posting the

schedule on a conspicuous place, etc.)

II. Basic Counseling Points

a. Describe missed dose instructions (give

specific time for missed dose, taken as

soon as remembered but if 1 to 2 hours

before the next scheduled dose, skip the

first dose and follow the next dose. Very

important not to double the dose!)

b. Provide common ADRs (at least 3,

don’t include life-threatening ADRs; if

so, tell the doctor first for possible

change of drug)

II. Basic Counseling Points

a. Provide tips how to manage side

effects and/or common ADRs

b. Discuss warnings and precautions

(pregnancy, liver and kidney failure,

heart problem, etc.)

c. Discuss drug-drug interactions (skip

if none; but need to verbalize)

II. Basic Counseling Points

a. Provide where to store the

medications

b. Beneficial non-drug activities (diet,

exercise, etc.)

c. Discuss (or demonstrate) the use of

devices/special instructions (for

medications requiring medical

devices)
III. Teach Back Method/Summarizing

a. Checks for patient understanding

b. Summarize key points (at least 3)

c. Return demonstration, if necessary

d. Correct any misinterpretation

e. Provides written instructions, if

necessary

IV. Closing the Discussion

a. Ask if there are clarifications or

questions the patient may want to

know

b. Provide contact details of the

pharmacy, if necessary

c. Say thank you for listening (have a

good day)

BARRIERS TO EFFECTIVE COUNSELING

a. Time

b. Physical

c. Economic

d. Patient’s perception to RPh

e. Lack of awareness of availability

f. Comprehension difficulties

g. Lack of confidence
a. Lack of trainings

b. Acceptability

c. Poor physician-pharmacist

relationship

d. Poor patient-pharmacist

relationship

e. Poor communication skills

HOW TO IMPROVE

a. Visibility of RPh (in small pharmacy

store)

b. Organization of the pharmacy

c. Access to counseling areas

d. Managing time/appointments

e. Promotion of roles and community

activities

Atmosphere

a. Provide a private/semi-private

patient counseling area

b. Use of non-verbal language to

create sense of personal

conversation (patient-pharmacist

relationship)

Approach

a. Use an organized approach and

protocols

b. Tailor counseling

c. Adopt a helping approach

d. Develop good communication skills

e. Use appropriate educational

methods and counseling aids

Attitude

a. Attend to nonverbal messages

(don’t ignore)

b. Be assertive

c. Be persuasive

d. Be confident

e. Be a life-long learner

f. Take advantage of new technologies

SPECIAL CONSIDERATIONS IN PATIENT COUNSELING

Public Health Issue: Pill Stigma

•Stigma - Defined as a set of negative beliefs that a group or society holds about a topic or group
of people

- Major cause of discrimination and exclusion and it contributes to the abuse of human rights

•Pill Shaming - Occurs when someone expresses negative opinions or disdain when you tell them
you’re using medication to treat mental health issue

- They assume - wrongly – that taking medication signifies weakness of character or an ability to
work tough times

These are true to patients with:

•Mental health problems

•Addiction

•HIV-AIDS

•TB patients