OUR LADY OF FATIMA

UNIVERSITY
College of Pharmacy

Clinical Pharmacy and

Pharmacotherapeutics 1
(PSMA 411)
CHECKLIST
• Concepts of Pharmacotherapy Care Planning
• Documentation of Pharmacotherapy Interventions
• Pharmacotherapy of Hematologic Disorders
• Pharmacotherapy of Coagulation Disorders
• Pharmacotherapy of Nervous System Disorders
• Pharmacotherapy of Cardiovascular Disorders
• Pharmacotherapy of Renal Disorders
• Pharmacotherapy of Autonomic System Disorders
 UNIT OUTCOMES
• Demonstrate Understanding on the Concepts
of Pharmacotherapy Care Planning
• Demonstrate understanding on the
documentation of pharmacotherapy
interventions
• Demonstrate Competence on Disease State
Management of Hematologic disease,
Coagulative disorders, Neurologic Nervous
system disorders, Psychiatric Nervous system
disorders, Cardiovascular disorders, Renal
disorders and Autonomic system disorders
TOPIC OUTLINE

• Concepts of Pharmacotherapy Care Planning

• Documentation of Pharmacotherapy Interventions
• Pharmacotherapy of Hematologic Disorders
• Pharmacotherapy of Coagulation Disorders
• Pharmacotherapy of Nervous System Disorders
• Pharmacotherapy of Cardiovascular Disorders
• Pharmacotherapy of Renal Disorders
• Pharmacotherapy of Autonomic System Disorders
 OUR LADY OF FATIMA
UNIVERSITY
College of Pharmacy

Concepts of
Pharmacotherapy Care
Planning

CLINICAL PHARMACY &

PHARMACOTHERAPEUTICS 1
(PHMA 411)
 • A practice in which the pharmacist utilizes his
professional judgment in the application of
pharmaceutical sciences to foster the safe and
CLINICAL PHARMACY appropriate use of drugs, in or by patients, while
working with members of the health care team
(Francke 1969)
GENERAL CLINICAL
PHARMACIST
FUNCTIONS
• Providing drug
information to physicians
& other health
professionals
• Medication history taking
• Medication profile
preparation
• Drug therapy monitoring

7
PATIENT COUNSELING
• Patient Counseling - provision of oral
or written information about drugs &
other health-related information to a
patient or his / her representative
during the dispensing process or stay
in hospital

8
COMMUNICATION SKILLS:
Attending and active listening
skills
1. Stop talking
2. Get rid of distractions
3. React to the ideas, NOT to
the person
4. Read non-verbal messages
5. Listen to how something is
said
6. Provide feedback to clarify
any message
Empathic Responding Skills
1. Reflecting - concentrating
on the emotional meaning
2. Paraphrasing - conveying
the essence of what was
said
3. Focusing - getting back to
the topic of conversation
9
PATIENT CARE
PROCESS
 Why is
therapeutic
planning
necessary?
Facilitates the selection of
appropriate drug and nondrug
interventions for specific
patient problems
Provides a framework for
monitoring a patient’s
response to the drug and
nondrug interventions
It incorporates a well-thought-
out alternative regimens
1. Problem
Identification
STEP 1: Obtain patient data
STEP 2: Group related data
STEP 3: Determine each problem
STEP 4: Assess each problem
2.) Problem
prioritization
Step 1—Identify the active problems
Step 2—Identify the inactive problems
Step 3—Rank the problems
3.) Selection of patient-
specific drug and nondrug
interventions
Step 1—Determine short-term and long-term goals of
therapy
Step 2—Create a list of options
Step 3—Eliminate options based on patient-specific and
external factors
Step 4—Select appropriate drug and nondrug
interventions
Step 5—Identify alternative interventions
4.) Develop a
monitoring
plan
Step 1—Determine specific monitoring
parameters
• Select specific target outcomes
• Select monitoring intervals for each
parameter
Step 2—Integrate the monitoring plan
Step 3—Obtain data
Step 4—Assess the response to therapy
MEDICAL ABBREVIATIONS
• AB Apex Beat
• ABG Arterial Blood Gas
• AFB Acid-fast Bacilli
• AF Atrial Flutter/Fibrillation
• AHF Anti-hemophilic Factor
• AKA Above Knee Amputation
• ALD Alcohol Liver Disease
• ALL Acute Lymphocytic Leukemia
• ALT Alanine Aminotransferase(formerly SGPT)
• AMI Acute Myocardial Infarction
• ANS Autonomic Nervous System
• ANST After Negative Skin Test
• AOG Age of Gestation
• AP Adynamic Precordium
• APTT Activated Partial Thromboplastin Time
• ARDS Acute/Adult Respiratory Distress
Syndrome
• ARF Acute Renal/Acute Respiratory Failure;
Acute Rheumatic Fever
• ASHD Arteriosclerotic Heart Disease
• AST Aspartate Aminotransferase (formerly
SGOT)
• ATN Acute Tubular Necrosis
• AVM Arteriovenous Malformation
• BA Bronchial Asthma
• BID Twice daily
MEDICAL ABBREVIATIONS
• BKA Below Knee Amputation
• BLE Both Lower Extremities
• BLF Both Lungs Field
• BM Bowel Movement
• BOV Blurring of Vision
• BPH Benign Prostatic Hypertrophy
• BPM Beats per minute
• BPP Biophysical Profile
• BSA Body Surface Area
• BSRTL Both sluggish reactive to light
• BT Blood Transfusion
• BUE Both Upper Extremeties
• BUN Blood Urea Nitrogen
• BUR Back-Up Rate
• CA Carcinoma; Community-acquired
• CABG Coronary Artery Bypass Graft
• CAD Coronary Artery Disease
• CAP Community-acquired Pneumonia
• CAT Computed Axial Tomography
• CBC Complete Blood Count
• CBG Capillaty Blood Glucose
• CBS Clear Breath Sounds
• CC/cc Chief Complaint
• CHF Congestive Heart Failure
• CHO Carbohydrate
• CHVD Chronic Hypertensive Vascular Disease
MEDICAL ABBREVIATIONS
• CK Creatinine kinase
• CLAD Cervical Lymph Adenopathy
• CNIL Cephalic not in labor
• COPD Chronic Obstructive Pulmonary
Disease
• CPAP Central Pulmonary Airway Pressure
• CrCL Creatinine clearance
• CRF Chronic Renal Failure
• CRT Capillary Refill Time
• CSF Cerebrospinal Fluid
• CT Computed Tomography
• CTT Chest Tube Thoracostomy
• CVA Cardiovascular/ Cerebrovascular Accident
• CVD Cerebrovascular Disease
• CVP Central Venous Pressure
• CVS Cardiovascular System
• CXR Chest X-ray
• D/C Discharge; discontinue
• DCMP Dilated Cardiomyopathy
• DHN Dehydration
• DHS Distinct Heart Sound
• DIC Disseminated Intravascular Coagulopathy
• DKA Diabetic Ketoacidosis
• DM Diabetis Mellitus
• DOB Difficultly of Breathing
MEDICAL ABBREVIATIONS
• DOE Dyspnea on Exertion • ESRD End-stage Renal Disease
• DOI Date of Injury
• ESR Erythrocyte Sedimentation Rate
• DTG Diffuse Toxic Goiter
• FBS Fasting Blood Sugar
• DTR Deep Tendon Reflex
• F/D Fairly developed
• Dx/Dxic Diagnosis
• FC Functional Class, Foleycath
• E/N Essentially normal
• FEP Full Equal Pulses
• ECE Equal Chest Expansion
• FHT Fetal Heart Tone
• EBRTL Equal briskly reactive to light
• FHx Family History
• EEG Electroencephalogram
• F/N Fairly nourished
• EF Ejection Fraction
• FT Full Term
• EOM Extra Ocular Movement
• FTSVD Full Term Spontaneous Vaginal
Delivery
MEDICAL ABBREVIATIONS
• FWB Fresh Whole Blood • HBP High Blood Pressure
• Fxn Function
• HDL High Density Lipoprotein
• GOPO Gravida para
• Hct Hematocrit
• GBS Guillain Barre Syndrome
• HEENT Head, Ear, Eyes, Nose, Throat
• GFR Glomerular Filtration Rate
• HF Heart Failure
• GI/GIT Gastrointestinal Tract
• Hgb Hemoglobin
• GIN Gastrointestinal Nutrition
• HHD Hypertensive Heart Disease
• GN Glomerulonephritis
• HPI History of Present Illness
• GS/CS Gram Stain/Culture Sensitivity
• HPN/HTN Hypertension
• HA Headache
• HR Heart Rate
• HAA Home Against Advice
• HSV Herpes Simplex Virus
• HAP Hospital-acquired Pneumonia
• Hx History
• I&O Intake & Output
• ICM Intracostal Margin
MEDICAL ABBREVIATIONS
• ICS Intercostal Space • LDH Lactate Dehydrogenase
• IDDM Insulin Dependent Diabetes Mellitus
• LDL Low Density Lipoprotein
• IE Infective Endocarditis
• LE Lower Extremities
• IHD Ischemic Heart Disease
• LFT Liver Function Tests
• INR International Normalized Ratio
• LLE Left Lower Extremity
• ITP Idiopathic Thrombocytopenic Purpura
• LLL Left Lower Quadrant
• IVP Intravenous Pyelogram
• LLQ Left Lower Quadrant
• KUB Kidney, Ureter, Bladder
• LMCA Left Mid Carotid Artery
• KVO Keep vein open
• LMCL Left Mid Clavicular Line
• LA Left Atrium
• LMP Last Menstrual Period
• LAAL Left Anterior Axillary Line
• LOC Loss of Consciousness/Level Of
consciousness
MEDICAL ABBREVIATIONS
• LPF Lower power field
• LPM Liter per minute
• LPSB Left parasternal border
• LT Lumbar tap
• LUE Left Upper Extremity
• LUQ Left Upper Quadrant
• LV Left Ventricle
• LWI Latest Working Impression
• MG Myasthenia Gravis
• MGH May go home
• MOB Medications on Board
• MOI Mechanism of Injury
• MRI MagneticResonance Imaging
• MRS Methicillin-resistant Strain
• MV Mechanical Ventrilator
• MVP Mitral Valve Prolapse
• NABS Normoactive Bowel Sounds
• NBS Normal Bowel Sound
• NGT Nasogastric Tube
• NIAE Not in acute exacerbation
• NICRD Not in cardiorespiratory distress
• NIDDM Non-insulin Dependent Diabetes
Mellitus
MEDICAL ABBREVIATIONS
• NIL Not in labor
• NIR Non-insulin requiring
• NIRD Not in respiratory distress
• NNO No new orders
• NNS No new Suggestions
• NO Non-obese
• NORF No other remarkable findings
• NPO Nothing per orem
• NRRR Normal Rate Regular Rhythm
• NRTL Non-reactive to light
• NSAID Non-steroidal AntiinflammatoryDrug
• NSNI Non-septic non-induced
• NSTEMI Non-ST wave elevationMyocardial
Infarction
• NSSTWC Non-specific ST-wave changes
• NV Neurovascular
• NVE Neck Vein Engorgement
• OB Occult Blood
• OCP Oral Contraceptive Pill
• OD Once daily/ Right eye
• OF Osterized Feeding
• OS Left eye
• OU Both eye
MEDICAL ABBREVIATIONS
• P/SHx Personal/Social History
• PE Physical Examination
• PEEP Positive end expiratory Pressure
• PGO Partial Gut Obstruction
• PHx Personal History
• Plt Platelet
• PMP Post Menstrual Period
• PNB Pink Nail Beds
• PND Paroxysmal Nocturnal Dyspnea
• POI Place of Injury
• PRBC Packed Red Blood Cells
• PS Pressure Support
• PT Prothrombin Time
• PTA Prior to Admission
• PTB Pulmonary Tuberculosis
• PTC Prior to Consult
• PTH Parathyroid Hormone
• PTO/PTOR Prior to Operation
• PTT Partial Thromboplastin Time
• PU Pregnancy Uterine
• PUD Peptic Ulcer Disease
• PVC Premature Ventricular Contraction
• PVT Paroxysmal VentricularTachycardia
• PWI Present working Impression
• R/O Rule out
MEDICAL ABBREVIATIONS
• RA Right atrium • RRR Regular Rhythm and Rate
• RBC Red Blood Cells
• RTC Round the Clock
• RBS Random Blood Sugar
• RUE Right Upper Extremity
• RCM Right costal margin
• RUQ Right Upper Quadrant
• RF Renal Failure, Respiratory Failure
• RV Right Ventricle
• RHD Rheumatic Heart Disease
• RVR Rapid Ventricular Rate
• RLE Right Lower Extremity
• S/P Status Post
• RMCA Right mid-carotid artery
• SABE Sub-acute Bacterial Endocarditis
• RMI Regular Menstrual Interval
• SAH Sub-arachoid Hemorrhage
• ROR Red orange reflect
• SBP Systolic Blood Pressure
• ROS Review of Systems
• SC Spinal Cord
• RR Respiratory Rate
• SC/SQ Subcutaneous
• RRE Round, regular and equal
MEDICAL ABBREVIATIONS
• SCI Spinal Cord Injury
• SCN Sternocleidomastoid
• SGOT Serum Glutamic Ovalo-Acetic
Transaminase (also AST)
• SGPT Serum Glutamic PyruvicTransaminase
(also ALT)
• SIADH Syndrome of Inappropriate Antidiuretic
Hormone
• SLE Systemic Lupus Erythematosus
• SOB Shortness of Breath
• SrCr Serum Creatinine
• SSS Sick Sinus Syndrome
• SVT Supra-ventricular Tachycardia
• T/C To consider
• TCVS Thoracic Carrdiovascular Surgery
• TFI Total Fluid Intake
• TIA Transient Ischemic Attack
• TKVO To keep vein open
• TOH Time of Injury
• TPC Tonsilopharyngeal Congestion
• TPR Temperature, pulse, Respiration
• TSB Tepid sponge bathe
• TTHD Thyrotoxic Heart Disease
• TVP Transvenous pacemaker
• Tx/Txic Treatment
• U/A Urinalysis
MEDICAL ABBREVIATIONS
• UBP Usual Blood Pressure • WNL Within normal limits
• UE Upper Extremities
• WOF Watch out for
• UGIB Upper Gastrointestinal Bleeding
• 1,25-DHCC 1,25-dihydrocholecalciferol
• UO Urine Output
• 25-HCC 25-hydrocholecalciferol
• URTI Upper Respiratory Tract Infection
• 3P’s Polyphagia, Polydipsia, Polyuria
• UTI Urinary Tract Infection
• VA Vehicular Accident
• VF Visual field
• VS Vital signs
 Pop Quiz
1. Skill/ability to communicate clearly and effectively with patients,
significant others (SO/relative or family), physicians, nurses,
pharmacists, and other health care team?
2. It is the provision of verbal or written information about drugs and
other health related information by a pharmacist to a patient
representative of the patient?
3. This is a systematic and comprehensive method that is employed to
identify, solve, and prevent drug therapy problems?
 OUR LADY OF FATIMA
UNIVERSITY
College of Pharmacy

Documentation of
Pharmacotherapy
Interventions

CLINICAL PHARMACY &

PHARMACOTHERAPEUTICS 1
(PHMA 411)
PRINCIPLES OF
DOCUMENTATION

• Documentation is required to
record pertinent facts,
findings, and observations
about a patient’s health
history, including past and
present illnesses,
examinations, tests,
treatments, and outcomes.

Components of documentation:
• A complete and legible record;
• Documentation for each
encounter with a rationale for the
encounter, physical findings, prior
test results, assessment, clinical
impression/ diagnosis and plan for
care;
• Identified health risk factors, and
an easily inferred rationale for
ordering diagnostic tests or
ancillary services; and
• The patient’s progress, response
to and changes in treatment, and
revision of the original
diagnosis/assessment.
PHARMACEUTICAL CARE

• Responsible provision of drug therapy

for the purpose of achieving definite
outcomes that improves a patient’s
quality of life (Hepler and Strand 1990).
• A patient-centered practice in which the
practitioner assumes responsibility for a
patient’s drug-related needs and is held
accountable for this commitment
(Cipolle 1998)

46
PHARMACEUTICAL CARE PLAN
• Assessment: a review of the medical conditions and symptoms to
determine the need for drug therapy

• Plan: a decision of an appropriate drug therapy based on the

assessment of the patient

• Monitoring: a review of the outcomes of drug therapy (goals and

endpoints) to determine if the patient is obtaining the desired
outcomes

47
 • a distinct service or group of
services that optimize
therapeutic outcomes for
individual patients.
• patient centered assessment
and evaluation of the patient’s
full medication regimen and
not only individual
medications.

What is Medication
Therapy Management?
48
 • Medication therapy review (MTR)
• Personal medication record (PMR)
• Medication-related action plan
Core (MAP)
• Intervention and/or referral
Elements
• Documentation and follow-up
of an MTM
Service

49
1. Medication Therapy Review:

• A systematic process of
collecting patient-specific
information, assessing
medication therapies to
identify medication-related
problems, developing a
prioritized list of
medication-related
problems, and creating a
plan to resolve them.

50
Personal Medication Record:

• A comprehensive record
of the patient’s
medications
(prescription and non-
prescription
medications, herbal
products, and other
dietary supplements).

51
Medication-Related Action Plan:

• The medication-related action plan

(MAP) is a patient-centric
document containing a list of
actions for the patient to use in
tracking progress for self-
management.

52
 • MTM services are documented in a consistent manner, and a follow-up
MTM visit is scheduled based on the patient’s medication-related needs, or
Documentation the patient is transitioned from one care setting to another.
• Documentation is an essential element of the MTM service model. The
and Follow-up: pharmacist documents services and intervention(s) performed in a manner
appropriate for evaluating patient progress and sufficient for billing
purposes.

53
 Documentation elements for the
patient record may include, but are not
limited to, the following:

Documentation Examples
category
Patient demographics Basic information: address, phone, e-mail, gender, age, ethnicity,
education status, patient’s special needs, health plan benefit/insurance
coverage
Subjective observations Pertinent patient-reported information: previous medical history, family
history,
social history, chief complaints, allergies, previous adverse drug
reactions
Objective observations Laboratory results, vital signs, diagnostic
signs, physical exam results, review of systems

54
 Documentation Examples
category
Assessment Problem list, assessment of medication-related problems
Plan A care plan is the healthcare professional’s course of action for helping a
patient
achieve specific health goals
Education Goal setting and instruction provided to the patient with verification of
understanding
Collaboration Communication with other healthcare professionals: recommendations,
referrals, and
correspondence with other professionals (cover letter, SOAP note)

55
 Documentation Examples
category
PMR A record of all medications, including prescription and nonprescription
medications,
herbal products, and other dietary supplements
MAP Patient-centric document containing a list of actions to use in tracking
progress
for self-management
Follow-up Transition plan or scheduling of next follow-up visit
Billing Amount of time spent on patient care, level of complexity, amount
charged

56
MTM
flowchart:

57
58
 S = Subjective

O = Objective

SOAP NOTE
A = Assessment

P = Plan
EXAMPLE
• Pharmaceutical care including pharmaceutical care
plan process (CORE, PRIME and FARM/SOAP) is a
systematic method for recording the pharmacist’s
examination of patient pharmacotherapy and
subsequent modification of medication related
problems
FARM note is an alternative
approach to documenting drug-
related problems and plan which is
a pharmacist equivalent of a
physician progress note in a
systematized approach.
• It actually includes provisions for
identification and assessment of
actual or potential medication
related problems, description of
a therapeutic plan and
appropriate follow-up monitoring
of problems.
• F – Findings – patient specific information
• A – Assessment – evaluation of findings
(e.g) severity duration
• R – Resolution (including prevention) -
rationale for the intervention
• should be mentioned
• M – Monitoring (and follow up) – assess
efficacy, safety and outcome of the
intervention
FINDINGS
 ASSESSMENT
• It contains pharmacist evaluation of the present
situation.
• It should delineate the thought process that led
to the conclusion on problem whether it did or did
not exist and active intervention either was or
was not necessary.
• The severity or urgency of the problem should be
indicated by stating whether the interventions
should be made immediately or within one day,
one week or longer.
• Therapeutic endpoint or outcome stated may be
short term goals or long term goals.
 • It highlights the actions proposed to resolve drug
related problem based upon preceding analysis.
RESOLUTION • Common recommendations include non-
pharmacologic therapy like dietary modifications
or assisting devices.
• Rationale for selecting a particular therapy
should be clearly depicted. Alternative therapy
in case of emergency switching-off of drugs must
be enlightened.
• Patient counseling provided must be elaborated.
Monitoring
 P - Pharmaceutical based problems

PRIME R - Risks to the patient

I - Interactions

M - Mismatch between medication

and condition or patient needs

E - Efficacy issues
 Pop Quiz
1. A systematic process of collecting patient-specific information,
assessing medication therapies to identify medication-related
problems, developing a prioritized list of medication-related
problems, and creating a plan to resolve them.
2. A comprehensive record of the patient’s medications (prescription
and non-prescription medications, herbal products, and other
dietary supplements).
3. A highly structured format for documenting the progress of a
patient during treatment and is only one of many possible formats
that could be used by a health professional.
 OUR LADY OF FATIMA
UNIVERSITY
College of Pharmacy

Pharmacotherapy of
Hematologic Disorders

CLINICAL PHARMACY &

PHARMACOTHERAPEUTICS 1
(PHMA 411)
ANEMIA
• It is a condition characterized by a decrease in hemoglobin or RBC
mass which results to decreased oxygen-carrying capacity of the
blood.
• It may decrease due to blood loss, increased destruction of RBCs or
decreased production of RBCs
GENETIC ETIOLOGY
•Hemoglobinopathies
•Thalassemias
•Enzyme abnormalities of the glycolytic pathways
•Defects of the RBC cytoskeleton
•Congenital dyserythropoietic anemia
•Rh null disease
•Hereditary xerocytosis
•Abetalipoproteinemia
•Fanconi anemia
NUTRITIONAL and CHRONIC DISEASE ETIOLOGIES

• Iron deficiency
• Vitamin B-12 deficiency
• Stravation and Generalized Malnutrition
• Renal disease
• Hepatic disease
• Chromic infections
• Neoplasia
• Collagen Vascular disease
PHYSICAL ETIOLOGY
• Trauma
• Burns
• Frostbite
• Prosthetic valve and surface
INFECTIOUS ETIOLOGIES
• Viral
• Hepa, Infectious mononucleosis, Cytomegalovirus
• Bacterial
• Clostridia, GM(-) sepsis
• Protozoal
• Malaria, Leishmaniasis, Toxoplamosis
RBC life cycle
RBCs CHARACTERISTIC

• RBC is highly deformable

and increase size from 7um
to 13 um when they
transverse capillaries with
3um diameter.
• They have negative charge
on their surface which
deflects the phagocytosis.
• They don’t have nucleus
that’s why they didn’t
undergo Kreb’s cycle.
• RBC relies on glycolysis via
Embden-Meyerhof and
Pentose Phosphate Pathway
FACTORS THAT DECREASES RBC PRODUCTION

• Inadequate erythropoietin
• Inadequate dietary intake
• Hypothyrodism
FACTORS THAT INCREASE RBC DESTRUCTION

• Hemorrhaging • Hemolysis
• Endometriosis • Disorder of spleen and liver
• Accidents • Genetic disorders (G6PD,
• GI lesions Thalassemia, Sickle cell anemia)
• Menstruation
• Chilbirth
• Excessive Uterine Bleeding
• Surgery
• Cirrhosis
• Fibrosis
 DAILY NUTRITIONAL REQUIREMENTS
IRON DAILY INTAKE FOR ADULTS (19-50 Y/O) DAILY INTAKE FOR AGE OVER 14 Y/O
MEN 8 mg MEN 400 mcg
WOMEN 18mg WOMEN 400 mcg
DURING PREGNANCY 27 mg DURING PREGNANCY 600 mcg
WHILE 9 mg WHILE 500 mcg
BREASTFEEDING BREASTFEEDING

DAILY INTAKE FOR ADULT

ADULT (MEN AND WOMEN) 2.4 mcg
DURING PREGNANCY 2.6 mcg
WHILE BREASTFEEDING 2.8 mcg
CLINICAL MANIFESTATION
• Palor
• Feeling of coldness
• Lightheadedness or dizziness
• Unusual cravings
• Trouble concentrating
• Constipation

• Severe form:
• Brittle nails
• Shortness of Breath
• Chest pains
• Fainting
COMPLICATIONS
• The most serious complications of severe anemia arise from tissue
hypoxia.
• Shock, hypotension or coronary and pulmonary insufficiency can
occur.
• This is more common in older individuals with underlying pulmonary
and cardiovascular disease.
Diagnosis
• Personal Health history
• Family health history
• Physical Exam
• Laboratory Assessment
PHYSICAL DIAGNOSIS
• Optic Fundi evaluation
• Blood pressure
• Heart rate
• Heart murmur
• Enlarged lymph nodes, spleen and liver
• Atrophic glossitis of tongue
• Color of the skin
• Pale
• Jaundice
LABORATORY ASSESSMENT
• CBC (Complete Blood Count)
• Serum Iron Levels
• Ferritin test
• Vitamin B-12 test
• Folic acid test
• Stool test for occult
• Measuring of RBC mass
• These are time consuming and expensive and usually require transfusion of
radiolabeled erythrocytes.
ADDITIONAL ASSESSMENT
• Upper GI
• Barium enema
• Chest X-rays
• CT scan of abdomen
CLINICAL INTERVENTION
• Nutritional supplements
• IV of Vitamin B12
• Erythropoietin
• Blood transfusion
SICKLE CELL ANEMIA
• SCD is a genetic disease of RBC.
• Crescent shaped like RBCs which gives flexibility to travel through
even the smallest blood vessel.
• However, this shape makes them sticky and rigid and prone to getting
trapped in small vessels.
• It blocks the blood which causes pain and tissue damage
SICKLE CELL ANEMIA
• SCD is an autosomal recessive condition.
• Hemoglobin in RBC is easily displace.
• Hb has 2 alpha chains and 2 beta chains.
•SCD has 4 main types:
•Hemoglobin SS
•Hemoglobin SC
•Hemoglobin SB+ (beta) thalassemia
•Hemoglobin SB 0 (beta-zero) thalassemia
•Sickle cell trait
SICKLE CELL SUBTYPES
• Hb SS
- Most common type of SCD. Severe anemia.
• Hb SC
-2nd most common SCD. Less severe anemia.
• Hb SB+ thalassemia
-defected beta globin gene production resulted to reduced cell size. Not sever
anemia
• Hb SB 0 thalassemia
-defected beta globin gene. Same with Hb SS, severe anemia
CLINICAL MANIFESTATION
• It appear in babies as early as 4 months old but generally occurs
around 6 month mark.
• They usually experience:
• Excessive fatigue or irritability
• Fussiness ( in babies)
• Bed wetting (due to kidney problems)
• Jaundice (yellow eyes and skin)
• Swelling and pain in hands and feet
• Frequent infections
• Chest pain, backpain, pain in arm and legs
AT RISK FOR SCD
• Children with both parent carrier.
• Regions that have endemic malaria:
• Africa
• India
• Mediterranean
• Saudi Arabia
CIRCUMTANCES THAT CAN INDUCE SCD

• Illness
• Changes in temperature
• Stress
• Poor hydration
• altitude
 COMPLICATION THAT INDUCE SCD
• Severe anemia • Lung disease
• Hand-Foot Syndrome • Priampism
• Splenic sequestration • Gallstones
• Delayed growth • Sickle cell chest Syndrome
• Neurological complication
• Eye Problems
• Skin Ulcers
• Heart Disease and Chest syndrome
DIAGNOSIS
• Hemoglobin electrophoresis
-measures different Hb level
• Sickle cell gene from amniotic fluid
• Detailed patient history
• Blood test
CLINICAL INTERVENTION
• Rehydration
• Symptomatic management
• Blood transfusion
• Supplemental Oxygen
• Pain Medication
• Bone marrow transplant
NON PHARMACOLOGIC
• Heating pads for pain
• Folic acid-rich food
• Diet regulation
• More fluids
• Exercise
• Less stress
• Contact your family doctor
 Pop Quiz
1. An iron protein complex which combines with oxygen and carbon
dioxide is?
2. A condition characterized by decreased production or increased
destruction of RBCs
3. The term thrombocytopenia indicates a/ an:
4. T/F: Vitamin deficiency can cause anemia.
5. The chief function of platelet is to?
 OUR LADY OF FATIMA
UNIVERSITY
College of Pharmacy

Pharmacotherapy of
Coagulation Disorders

CLINICAL PHARMACY &

PHARMACOTHERAPEUTICS 1
(PHMA 411)
FACTOR
• Factor I- Fibrinogen • Factor IX- Christmas factor
• Factor II- Prothrombin • Factor X- Stuart-Prowen factor
• Factor III- Thromboplastin • Factor XI
• Factor IV- Calcium • Factor XII
• Factor V- Labile F • Factor XIII
• Factor VI- (no longer used)
• Factor VII- Stable factor
• Factor VIII- Anti-hemophilic factor
HEMOPHILIA
• ROYAL DISEASE
• It affect royal families of England, Germany, Russia and Spain.
• Queen Victoria, Carrier of Hemophilia B. Passed the trait to her 3 out of 9 children.
• Leopold
• Alice and Beatrice

• A medical condition in which the ability of the blood clot is severely

reduced, causing the sufferer to bleed severely from even a slight injury
• The condition is typically caused by a hereditary lack of coagulation factor
of the FACTOR VIII or FACTOR IX.
• The severity of hemophilia that a person has is determined by the amount
in the blood.
• Lowering the factor in the blood, the more likely the bleed will occur.
HEMOPHILIA
• Majority of the population experiencing hemophilia are
• middle aged
• elderly people
• Young women who recently give birth
• It usually occurs in every 1 of 5,00 male births.
• Hemophilia A is 4x more common than hemophilia B.
GENETICS
• Hemophilia is caused by one of the genes that undergo changes or
mutation.
• These genes are located on the X chromosome
• Male have 1 X chromosome and 1 Y chromosome. X chromosome will be
inherited from their mothers.
• Female have 2 X chromosome and inherited from each parent.
• A female with 1 affected X Chromosome is a “ CARRIER” will
sometimes have hemophilia.
• She also can pass the affected X chromosome with a mutated clotting
factor on her children
Inheritance pattern for Hemophilia
PATHOPHYSIOLOGY
• FVIII mRNA is
detected in liver,
LIVER
spleen and tissue.
• Transfected cell lines
shows synthesis
which will move to
FVIII SPLEEN the lumen of ER.
• It will affect the
regulation of secretio
TISSUES proteins like the Ig
binding protein.
PATHOPHYSIOLOGY
• Part of FVIII in
endoplasmic LIVER
reticulum will be
degraded and the
others will be SPLEEN
transported to golgi
apparatus.
TISSUES
• Modifications will
occur.
CLOTTING CASCADE
• The main role of
coagulation system is to
produce stable fibrin clot at
sites of injury.
• There are 2 pathway
mechanism:
• Intrinsic
• extrinsic
CLOTTING CASCADE
Endothelial cell

Blood • Intrinsic pathway:

XII → XIIa
XI → Xia
IX→IXa
• Extrinsic pathway:
Platelet + Fibrin VII → VIIa

Fibrin Form into

Fibrin
Fibrinogen strand
CLASSIFICATION
• Hemophilia A (Classic Hemophilia)
• Lack or deficient of clotting factor VIII
• Hemophilia B (Christmas Disease)
• Lack or deficient of clotting factor IX
•Hemophilia C (Rosenthal Syndrome)
•Lack or deficient of clotting factor XI
CLINICAL MANIFESTATION
• Hemophilia can result in:
• Bleeding within joints that can lead to chronic joint disease and pain or tightness in
the joints.
• Bleeding into skin—which is bruising– or muscle and soft tissue causing building up
of blood in the area.
• Bleeding of the mouth and gums, and bleeding that is hard to stop.
• Bleeding after circumcision.
• Bleeding after having shots or vaccination.
• Bleeding in the head of an infant after difficult delivery
• Blood in urine or stool
• Frequent hard to stop nose bleeds.
• Bleeding in the head and sometimes in the brain which can cause long term
problems, such as seizures and paralysis.
• Death can occur if the bleeding cannot be stopped or if it occurs in a vital organ
LABORATORY EVALUATION
• Family history
• Usually right after birth, a blood from umbilical cord will be withdrawn and tested to determine the levels of clotting
factor.
• Factor VIII is readily available in the umbilical cord while the factor IX will fully developed until the baby is at least 6
months old.
• CBC (complete Blood count)
• Hemoglobin level
• Size and number of RBC and different WBC
• Platelets
• APTT (Activated Partial Thromboplastin time) test
• Measure the clotting time of factors VIII, IX, XI and XII.(Intrinsic pathway)
• PT (Prothrombin) Test
• Measure the clotting time of factors I, II, V, VII, and X. (Extrinsic pathway)
• Fibrinogen test
• AKA Clotting factor I
• Assessment on the ability of blood to form clot.
• It is alongside with PT or APTT or both.
SEVERITY IN HEMOPHILIA A
Level of Severity Levels of Manifestation
factor viii or ix
in blood
Normal (no hemophilia) 50-100% --------
Mild Hemophilia 5% - 50% Generally experience bleeding after serious
trauma
Moderate Hemophilia 1 - 5% Experience bleeding episodes after injury
Severe Hemophilia < 1% Spontaneous bleeding following an injury
often into their joints and muscles.
SEVERITY IN HEMOPHILIA A
Level of Severity Levels of Manifestation
Factor VIII in
the blood
Mild Hemophilia A 6-49%
Moderate Hemophilia A 1-5%
Severe Hemophilia A <1%
TREATMENT INTERVENTION
• Infusion of commercially prepared factor concentrates.
• Performing regular basis self-infusion or prophylaxis
•Inhibitors
• Commonly used in VWD (Von Willebrand’s Disease)
• Antibody that act as inhibitor to the factor concentrates.
• DDVAP (Desmopressin acetate)
• Synthetic version of vasopressin.
• Available in nasal spray and injectables.
• For ptx with mild hemophilia.
• Used for joint and muscle bleeding
• Aminocaproic acid
• Prevents the breakdown of blood clots.
• Used before dental procedures.
• Its available in tablet or oral liquid preparation.
 Pop Quiz
1. Also known as Labile F.
2. What factors are being measured in an APTT or Activated
Partial Thromboplastin Time test?
3. Hemophilia B is a condition typically caused by a hereditary
lack of coagulation factor
4. Fibrinogen test also known as ________ test.
5. Where does the gene mutation take place?
REFERENCES
• Walker, Roger & Whittlesea, Cate. (2012). Clinical Pharmacy & Therapeutics.
5th ed. Elsevier Ltd.
• American Pharmacists Association, National Association of Chain DrugStores
Foundation. Medication therapy management in community pharmacy practice:
core elements of an MTM service (version 1.0).J Am Pharm Assoc.
2005;45:573-9.
• Cipolle RJ. Strand LM, Morley PC. Pharmaceutical Care Practice: The
Clinician’s Guide. New York: McGraw Hill; 2004.
• The American Pharmacists Association and the National Association of Chain
Drug Stores Medication Therapy Management in Pharmacy practice Core
elements of an MTM service model.
• https://www.globalpremeds.com/blog/2015/01/02/understanding-soap-format-
for-clinical-rounds/
•
REFERENCES

• Walker, Roger & Whittlesea, Cate. (2012). Clinical Pharmacy & Therapeutics. 5th ed.
Elsevier Ltd.
• Market House Book, LTD., 2009. The Bantam Medical Dictionary, 6th edition
• https://emedicine.medscape.com/article/198475-overview#a4
• https://www.healthline.com/health/anemia#outlook
• https://www.healthline.com/health/sickle-cell-anemia#outlook
• www. Hemophilia.org/Bleeding-Disorders/Types-of-Bleeding-Disorders/Hemophilia-A