M1 Introduction and Objectives

Vastarel MR Trimetazidine Anti-angina

Medication Order & Prescription Analysis Versant XR Felodipine Anti-hypertensive

The prescription or medication order is written by a

licensed medical practitioner. The prescription
contains information about the treatment that is to DRUGS THAT SHOULD BE GIVEN ON AN EMPTY AND
be given to a patient. The pharmacist must be able FULL STOMACH
to accurately fill the prescription and give the patient
the necessary guidance for the patient to be able to In taking prescribed medications, it is important that
properly comply with the medication. Pharmacists patients be advised on the time to take their
must also be able to establish and maintain the trust medication in relation to food intake. Why?
of both the prescriber and patient within the Some drugs should be taken on a full stomach,
confines of confidentiality. meaning with food, to minimize GI discomfort while
drugs should be taken on an empty stomach,
M1L2: CIA. SPECIAL INSTRUCTIONS for meaning without food, for optimal absorption. An
PRESCRIPTION and MEDICATION ORDER empty stomach means taking the medication one
SPECIAL INSTRUCTIONS hour before eating or two hours after eating.
 Ampicillin Empty
“Do Not Crush Medications Mnemonic”  Amlodipine Full/Empty
Seniors Erroneously Crush Enteric-Coated Laxatives  Aspirin Full
 Sustained release  Bisacodyl Empty
 Extended release  Captopril Empty
 Controlled release  Erythromycin Empty
 Enteric coated  Griseofulvin Full
 Long acting  Metformin Full
 Metoprolol Full/Empty
DRUGS THAT SHOULD NOT BE CHEWED, CRUSHED or  Omeprazole Empty/Full
OPENED
Word/Letter Type of Product Drug. Full/Empty Reason
CR/Chrono Controlled Release Alendronate Empty Decrease
CRT Controlled Release absorption
EC/EN Enteric Coated
LA Long-Acting Ascorbic acid Full/Empty Avoid gastric
MR/Retard Modified Release irritation
SA Sustained Action
SR/Dur/Dural Sustained Release Aspirin Full Lessen gastric
XL/XR Extended Release side effects

Drug Generic Therapeutic Azithromycin Full/Empty Capsule/liquid

Name Classification – empty
Tablets – with
Adalat GITS Nifedipine] Anti-angina or without
food
Bisacodyl Dulcolax Laxative
Feldene Piroxicam Anti-inflammatory Captopril Empty Increase
Flash effectiveness

Glubitor OD Gliclazide Hypoglycemic Digoxin Full/Empty Better

agent absorption
Kalium Potassium Antihypokalemia
Durules chloride Metformin Full Prevent gastric
disturbances
Lipway SR Fenofibrate Antihyperlipidemia
Omeprazole Full/Empty Better
Plendil ER Felodipine Antihypertensive absorption
Prevacid Lansoprazole Antacid/Anti-ulcer
FDT
 Paracetamol Full/Empty Prevent
gastrointestinal
effects
Rosuvastatin Full/Empty No effect
DOSAGE FORMS THAT REQUIRE SPECIAL
ADMINISTRATION TECHNIQUES
 Ear drops
 Eye drops
 Eye ointments
 Inhalations or nasal sprays
 Aerosols
 Nebulizers
 Metered dose inhalers (MDIs)
 Nose drops
 Nose sprays
 Rectal suppositories
 Rectal creams or ointments
 Skin patches
 Vaginal medicines
M1L3: DOSAGE REGIMEN & Dosage Calculations
Dosage Regimen
 Is the schedule of doses of a medicine,
including the time between doses (dose
frequency), the duration of treatment and
the amount to be taken each time (dose
size).
 Also includes how a medicine is to be taken
(route of administration), and in what
formulation (dosage form).
Approaches in Designing Dosage Regimen
Empirical Dosage Regimen
 It is designed by physicians based on
empirical data, personal experience and
clinical observations. This method however
is not very accurate.
Individualization of Dosage Regimen
 It is the most accurate approach and is
based on the pharmacokinetics of drug in
the individual patient. The approach is
suitable for hospitalized patients but is
quite expensive.
Dosage Regimen on Population Averages
 Fixed Model – is based on population
average pharmacokinetic parameters are
used directly to calculate the dosage
regimen.
 Adaptive Model – is based on both
population average pharmacokinetic
parameters of the drug as well as patient
variables such as weight, age, sex, body
surface area and known patient
pathophysiology such as renal diseases.
CALCULATIONS INVOLVING MEASURES OF POTENCY
The potency of some antibiotics, endocrine products,
vitamins, products derived through biotechnology
like vaccines are based on their activity and are
expressed in terms of units of activity, in micrograms
per milligram (mcg/mg) or in other standardized
terms of measurement.
SAMPLE PROBLEM :
A pharmacist is asked to assists in determining the
correct dose of Epoeitin alpha injection (PROCRIT)
for a 76-year old, 165-lb male patient suffering from
anemia, in part due to chronic renal failure.
The patient’s initial hemoglobin is 9.2 g/dL. The
literature states that the starting adult dose of
Epoeitin alpha is “50-100 units/kg SC TIW” to
stimulate red blood cell production. Using Epoeitin
alpha injection, 10,000 units/mL, and the minimal
starting dose, calculate the number of milliliters
required for the initial dose and the total number of
milliliters to be administered during the first week of
treatment.
GIVEN:
Male: 76-year old, 165-lb
Anemia: Epoeitin alpha injection (PROCRIT) due to
Chronic Renal Failure ( Adult dose of Epoeitin alpha
is “50-100 units/kg SC TIW with available Epoeitin
alpha injection, 10,000 units/mL)
Hgb: 9.2 g/dL
X= Initial dose
X= total number of milliliters to be administered
during the first week of treatment
Solution:
165 lb / 2.2lb/kg = 75 kg
75 kg x 50 units/kg = 3750 units
Then 10,000 units/mL x 3750 units = 0.375 mL
=0.4mL
375 mL x 3 times in a week = 1.125 mL = 1.2 mL
M4 Introduction and Objectives
Pharmacists are the main provider of patient care
when it comes to medication utilization. In order to
provide the best patient outcome, a pharmacist
must navigate the road of medical documentation.
Vital information must be gathered and identified
through medical records prior to developing critical
assessment and individual patient care plans.
Collection and analysis of data must be
systematically done to permit pharmacists in
creating a comprehensive list of pharmaceutical care products should also be assessed, all in all in the
needs and alternatives for each individual patient. context of the patient’s lifestyle and dietary habits.”

Medical records are documents that provide detailed Sample MUR Practice Around the World
information of a patient's history, clinical findings,
diagnostic test results, pre and postoperative care, Name of the Description
patient’s progress and medication. A well made Country Program
medical record serves as a crucial document for
every allied health practitioner, for this would be
their basis for the diagnosis, treatment plan and Australia Domiciliary Pharmacists
management of patient care. medication meet patients,
management review their
A medication review is defined as ‘a structured, review (home medication
critical examination of a patient's medicines with the medicines management
objective of reaching an agreement with the patient review) or needs, consult
about treatment, optimizing the impact of residential with additional
medicines, minimizing the number of medication- medication allied
related problems and reducing waste. management healthcare
review professionals,
Pharmaceutical care plan (PCP) is a patient - and suggest
centered systematic approach. Clinical pharmacists their changes to
design a written format to ensure proper drug use, medication
achieve a definite outcome and improve patient care therapy to the
through assuring the safety, effectiveness and cost- general
effectiveness. practitioner.
The review aims
At the end of the module, you are expected to: to optimise
medication
1. Perform a medication review based on patient therapy and
cases prevent
2. Conduct patient medication history additional
3. Create an effective patient care plan medication-
related harm,
M4 Lesson 1 Medication Review: especially in
Pharmacists are the main team player of the allied patients at risk
health professions when it comes to tackling of medication
medication errors. They are the most accessible errors due to,
health care profession that can easily interact, advise for example,
and educate patients through medication recent changes
partnership. Since pharmacists are experts in the to their health
pharmaceutical field, they can easily identify or treatment
plan. The
possible and actual drug related problems and
medication
provide evidence-based clinical intervention to
management
optimize medication therapy and reduce risk of
review is
medication errors/ harm.
initiated by the
general
Pharmacist leading medication use review is a
practitioner.
contributory solution in ensuring patient safety by
reducing possible or actual medication harm due to
polypharmacy.
Canada MedsCheck In the Canadian
Based on FIP, “Medication Use Review represents
province of
an opportunity for the healthcare team to assess a
Ontario,
patient’s current medicines in light of various clinical
MedsCheck is an
factors, such as their current health condition, past
interview
medical and surgical history, and actual treatment
conducted
plan, all the while considering the patient’s
between the
preferences and concerns. Through MUR, the use of
pharmacist and
over-the-counter medicines and natural health
 the patient as a Program electronic
form of MUR. information
Certain criteria system that
must be met for sends real-time
patients to be alerts to
eligible for this physicians when
service, including prescribing and
a minimum to pharmacists
number of when dispensing,
prescription alerting them of
medicines and potential
specific time- medication-
frames, such as a related adverse
recent hospital effects.
discharge,
referral from a Spain REVISA study The Medicines
physician or for MUR Use Review
nurse Subcommittee of
practitioner, or a the Spanish
pharmacist’s Society of Family
clinical and Community
judgement. The Pharmacy
service is conducted the
remunerated by REVISA project to
the provincial oversee the
government. implementation
of the MUR
Japan Brown Bag service. The main
Programme Led by the results of the
Hiroshima study included
Pharmaceutical referral to a
Association, the physician
brown bag following the
programme is an consultation in
MUR service close to one-
conducted by third of
community encounters. In
pharmacists, addition, there
where patients was a high
from the region degree of
are invited to satisfaction by
take all patients with the
medicines they service and their
are taking to the willingness to
pharmacy (in the pay for the
commonly used service in the
brown paper majority of cases.
bags).. A study
conducted on
the programme Sweden High The high
showed that performance performance
pharmacists medicines medicines
intervened in management management
approximately programme
half of cases. offers a hospital-
based audit of
South Korea Drug The drug medicines use,
Utilization utilisation review and its findings
Review programme is an notably
 contribute to management
improving encompasses a
patient safety variety of
and favouring healthcare
costeffectiveness services
with regard to
medicines use. Principles of Medication Review

MUR MUR may take  All patients should have a chance to raise
United place across questions and highlight problems about
Kingdom different their medicines.
healthcare  The medication review seeks to improve or
settings and, optimize the impact of treatment for an
when led by individual patient.
pharmacists,  The review is undertaken in a systematic
aims to optimise and comprehensive way, by a competent
medicines person.
therapy, address  Any changes resulting from the review are
adherence, and agreed with the patient.
ultimately  The review is documented in the patient’s
improve health notes.
outcomes.  The impact of any change is monitored.
Different
publications by Data and information
various MUR is a structured assessment of a patient’s
institutions, medication therapy. Access to the necessary
including the information to adequately analyse medication
Royal therapy, identify actual and potential medication-
Pharmaceutical related problems, and suggest the necessary
Society as well as interventions is critical.
the National
Health Service, It is important for the pharmacist to gather or have
have published access to the patient’s medication profile.
several reference Information on active and previous medication is
and guidance crucial and should include, but is not limited to, the
documents following elements:
United regarding this 1. Medicine names
States of provided by 2. Formulations
America pharmacists, 3. Doses
including 4. Regimens
medication 5. Routes of administration
therapy reviews. 6. Start date
Such services 7. Duration of treatment
have 8. End date
demonstrated 9. Name of prescriber
both clinical and
cost-
effectiveness. This information should be available for consultation
service.According and analysis of the patient’s records. If this
to the National information is not yet available,it should be directly
Pharmacy obtained from the patient together with any
Association, the prescriptions or other documents linked to the
remuneration for patient’s clinical and medication history.
MUR is GBP 27
per review. Beyond information on the patient’s medication,
data on investigations and past medical history are
also needed to ensure a proper understanding of the
Medication patient’s current health status. Data on lab results,
therapy
cultures and sensitivities, imaging reports, past
medical and surgical history, recent hospital
admissions, and social and lifestyle habits are all
useful information in conducting a comprehensive
MUR. This information can be accessed through
electronic interfaces, paper files, or by interviewing
the patient.
Steps of Medication Use Review Process
1. Collecting all necessary data with the
patient’s consent, if required.
 This includes any lab results, cultures and
sensitivities, imaging results, information on
past medical and surgical history, and
recent hospitalisations.
 If the patient was recently discharged from
a hospital or went through another
transition of care, it may be beneficial to
conduct a medicines reconciliation before
the MUR to obtain an accurate,
comprehensive understanding of the
patient’s current medication therapy.
2. Reviewing diagnoses and medication
 Is each medicine still indicated?
 Is each diagnosed disease being treated by
a medicine?
 If the patient has renal or hepatic
impairment, do medication dosages require
adjusting?
 For each medicine, are there any adverse
effects or laboratory markers to follow?
 Could there be there any medicine-
medicine, medicine-disease, or medicine-
natural product interactions?
 Can the dosing regimen or route of
administration be simplified?
 Are there any more cost-effective
alternatives to this medicine? Have new
guidelines reinforced or discouraged its
use?
 Are there any non-pharmacological
methods that may be used?
 Do any natural health products or
complementary or traditional medicines
require intervention?
3. Reviewing patient’s level of literacy and
self-monitoring
 Does the patient understand their
medicines and their indications?
 Is the patient capable of self-monitoring, if
required (blood glucose, blood pressure,
etc.)?
 Is the patient aware of red flag symptoms
that would require an urgent medical
consultation?
4. Reassessing medicines management and
adherence
 Are medicine formulations and dosing
schedules convenient for the patient?
 Can medication management be improved,
for example, through the use of pillboxes?
 Is the patient adherent to their dosing
schedules?
5. Organising follow-up visits to assess
symptoms, laboratory markers or other
features to monitor
 Communicating with prescribers and other
allied healthcare professionals regarding
suggested changes, and informing the
patient of the results.
M4 Lesson 2: Patient Care Plan
Pharmaceutical Care Plan (PCP) is a patient centered
systematic approach where clinical pharmacists will
design a written format to: ensure proper drug use,
achieve a definite outcome and improve patient care
through assuring the safety, effectiveness and cost-
effectiveness. Each PCP are formulated to identify,
resolve and prevent potential and actual drug
related problems
By following the proposed patient care plan
pharmacist expects that patient’s symptoms will be
alleviated or minimized, disease progression will be
arrested or slowed, cure the disease and most
specially prevent symptom or disease to occur.
General Steps in Pharmaceutical Care Plan
1. Create a comprehensive patient database.
 Patient demographic
 History of present and past medical history
 Present medication and medication history
 Allergies and intolerance
 ADR to drugs
 Lifestyle (smoking, alcohol and caffeine
consumption, drug abuse history)
 Compliance history
 Physical examination and abnormal
laboratory results including renal and
hepatic function
2. Assess for actual and potential drug-related
problems.
a. Assessment of actual problem can be done by SOP
format
S: Subjective: Chief complaint or why came to the
clinic, hospital or pharmacy
O: Objective: Traceable facts such as vital signs, lab
results
A: Assessment: the medical diagnosis on the given
date
P: Plan: Treatment plan including medication, lab
orders, referals, lifestyle management…
b. Assess the Pharmacotherapy
b.1 Relate all the drugs that have been ordered for
the patient to the list of medical problems. Review
the medication history to help identify drugs that the
patient was on prior to admission and which the
patient should continue to receive. Each drug
already being administered and each new drug
should be evaluated by asking questions such as:
* Is the use of this drug justified?
* Is there therapeutic duplication?
* Is this the drug of choice for this patient?
* What therapeutic alternatives are there?
* Is this therapy cost-effective?
* Has the dosage been adjusted for patient-specific
changes? (ie. renal or liver impairment, age, weight,
etc)
* What side effects are possible and are any of these
more likely to occur in this patient? Is the patient
currently experiencing any of these?
* Are there any clinically significant interactions
possible? Management?
b.2 Drug related problem :
 Untreated indication
 Improper drug selection
 Sub-therapeutic dosage
 Failure to receive medication
 Overdosage
 Adverse Drug Reaction
 Drug interaction
 Medication use without indication
c. Patient- specific drug related problems
 Lack of therapy for a drug/medical
indication ful
 Wrong drug for the medical condition
 Too little of the correct drug prescribed
 Too much of the correct drug prescribed
 Medical condition caused by adverse drug
reaction
 Medical condition caused by any type of
interaction
 Medical condition caused by lack of drug
prescribed
 Medical condition caused by inappropriate
drug therapy (no valid indication
 Establish therapeutic goals.
Therapeutic goals are developed and are particular
for each problems. It should be definite, realistic,
attainable and measurable. It is usually related to:
3. Approach to normalize physiology such as
normalizing blood pressure level and blood
sugar level
 Slow disease progress like that for cancer
 Prevent adverse drug reaction
 Consider medication cost
 Educate patient about drugs
4. Specify monitoring parameters with end points
and frequency.
 Establish the endpoints you are going to use
to monitor progress towards achievement
of those goals.
o What information do you need to
ensure that the drug therapy is
producing the desired effect?
o What information do you require
to ensure that the drug therapy is
not causing problems?
o With what frequency and for what
duration do you need to collect the
relevant information?
5. Document the patient's progress towards
therapeutic goals.
6. Evaluate and reassess the PCP base on the
patient's progress
The pharmacist should evaluate and review
database, medical care plan and the medication
progress of patient on a regular basis to re-prioritize
patients problems and required intervention
Considering the risks and benefits of all therapeutic
alternatives for each problem in this patient, what
drug regimen(s) should be instituted? What changes
need to be made in existing drug therapy (add,
delete, change drugs)? What specific dose, route of
administration, dosage formulation, regimen and
duration of therapy should be selected for each
drug? Is information/education required? It may not
be possible to make all interventions in one day,
particularly because of your patient load; therefore,
you may need to prioritize your interventions.
Depending on the acuity of the patient and the
priorities of your pharmacy team, you need to
review the database and medical care plan on a
regular basis, revise your pharmacy care plan, and
reprioritize your interventions.