Pharmacy Practice

Lecture (1)

By Prof. Yahya El-emam

18-2-2018
• Over the past four decades there has been a
trend for pharmacy practice to move away
from its original focus on medicine supply
towards a more clinical focus on patient care.
• The role of the pharmacist has evolved from
that of a compounder and supplier of
pharmaceutical products towards that of a
provider of services and information and
ultimately that of a provider of patients care.
• Increasingly , the pharmacist task is that the
patient drug therapy is :
1) Appropriately indicated.
2) The most effective available.
3) The safest possible.
4) Convenient for the patient.
• The new approach has been given the name
pharmaceutical care . The most generally
accepted definition of this new approach is:
• “pharmaceutical care is responsible provision
of drug therapy for the purpose of achieving
definite outcomes that improve or maintain a
patients quality of life
• In order to fulfill this obligation, the
pharmacist need to be able to assume many
different functions.
• The concept of the seven-star pharmacist
introduced by WHO sees the pharmacist as a:
• Care giver , communicator. Decision-maker,
teacher , life-long learner, leader , and
manager.
• Definition:
• Patient Counseling may be defined as
providing medication information orally or in
written form to the patient or their
representative or providing proper directions
of use, advice on side effects ,storage, diet and
lifestyle modifications.
• The importance of patient counseling:
• Patient counseling is a critical component of
the dispensing process, in order to ensure that
the patient receives and understand
important information such as the name of
the drug and the purpose of the medication.
• Patient counseling also provide a key
opportunity to identify potential dispensing
errors.
• Dispensing errors contributing factors:
1. Poor physician hand writing.
2. Failure to check the patient medication
history.
3. Assuming that the patient had take the
medication before.
4. Failure to check the prescribed dosages for
appropriateness.
• Counseling steps:
1) Introduce yourself as a pharmacist , explain
the purpose and expected length of the
session and obtain the patient agreement to
participate.
2) Assess the patient knowledge about his or
her health problems and medications,
physical and mental capability to use the
medication appropriately.
• Asked the patient to describe or show how he or
she will use the medication.
Patient returning for refill medications:
i. should be asked to describe or show how they
have been using their medications.
ii. They should also be asked to describe any
problems, concerns or uncertainties they are
experiencing with their medications.
3) Provide information orally and use visual aids
or demonstrations to fill patient's gaps in
knowledge and understanding.
• Open the medication container to show the
patient the colors, sizes shapes, and markings
on oral solids. For oral liquids and injectables ,
show the patients the dosage marks on
measuring devices.
• Demonstrate the assembly and use of
administration devices such as nasal and oral
inhalers.
As a supplement to face-to-face oral
communication, provide written handouts to
help the patient recall the information
4) Verify patient's knowledge and
understanding of medication use.
• Prime questions approach:
Three essential questions form the foundation
for the medication consultation. Each of these
questions probes the patients knowledge of a
specific area of comprehension needed.
• 1) What did the doctor tell you what the
medication was for?
• This question allows the pharmacist to prompt
the patient to discuss the purpose of the
medication in regards to:
• What it is supposed to do.
• What problems or symptoms it is supposed to
help.
2) How did the doctor tell you to take the
medication?
This question promotes discussion of how to use
the medication. Concerns that can be addressed
include:
How often the medication should be taken.
How much is to be taken and for how long.
What to do if a dose is missed.
3) What did the doctor tell you to expect?
This question allows the patient to discuss
expectations about the medication including:
• Good and bad effects.
• What precautions need to be taken.
• How to know if the medication is working.
• What should be done if there is a bad
reaction.
• If the patient does not know the answer to
any of these questions the pharmacist should
fill in the gaps with specific information before
moving on to the next essential question.
• This alternating question and answer formats
keeps the patient actively involved in the
consultation process, which for the adult
learner is crucial to knowledge retention and
recall.
• Inappropriate responses should alert the
pharmacist to possible problems with
comprehension due to hearing , Vision , or
language problems.
• Content of patient counseling:
• Several guidelines have been published
regarding's the points to be covered while
counseling the patient's.
• The pharmacist should discuss at least the
following points while counseling the patient:
1. Name and description of medication.
2. Dosage form.
3. Route of administration.
4. Duration of therapy.
5. Special directions and precautions for
preparation.
6. Administration and use of prescribed drugs
by the patient.
7. Common side effects or interactions and
therapeutic contraindications that may be
encountered, including their avoidance and
the action required if they occur.
8. Techniques of self-monitoring of drug
therapy.
9. Proper Storage.
10.Prescription refill information.
11. Action to be taken in case of missed dose.
12.The medications expected onset of action
and what to do if the action does not occur.
13.Proper disposal of contaminated or
discontinued medications and used
administration devices.
14.Potential drug-drug (including non-
prescription) ,drug- food and drug-disease
interactions or contraindications.
• Then ask the patient if he or she has any
additional questions. close the consultation
with an offer to help when questions arise.
• The pharmacist responsibility :
• The pharmacist must play an active role in the
proper use of prescription medication by the
patient.
• The pharmacist is often the last member of the
health-care team to see the patient before he
takes the drug without direct medical
supervision.
• Therefore, it is the responsibility of the
pharmacist to ensure the safe and appropriate
use of the medication and to answer
questions of concern to the patient.
• The responsibility also encompasses non -
prescription (OTC) products.
• As the health-care provider, the pharmacist is
obligated morally and legally and is, perhaps ,
in the best position to provide patients with
adequate understandable information on the
drugs they take or use to maximize the
therapeutic outcome and prevent convievable
problems during therapy.
• To prevent these problems, the pharmacist
must first understand how a patient misuses
prescribe medications.
• Medication misuses:
• The misuses are as follows:
1. Overdosage:
a) Taking more than the prescribed dose at
any one Administration.
b) Taking more than the prescribed number of
doses in any one day.
c) Taking a dose, prescribed as needed, at a time
other than when needed.
d) taking the same medication from two or more
different containers simultaneously.
2. Under dosage:
a) Taking less than the prescribed dose at any
one administration.
b) Omitting one or more doses.
c) Discontinuing the drug before the
prescribed time.
d) Omitting the dose of medication
prescribed as needed when it is needed.
3) Taking the dose at different time if the time
has been specified in the directions.
4) Taking a dose in a form other than that
specified in the directions.
5) Using the wrong route of administration.
6) Taking medication that has been
discontinued.
7) Taking outdated medications.
8) Taking two or more medications which are
contraindicated therapeutically.
9) Failing to get the prescription filled.
10) Failing to understand how to properly use the
administration unit ( e.g. inhaler).
11) Failing to understand how to properly use or
administer the dosage form.

* The types of misuse committed most frequently

were overdosage and omission of doses.
• Who and when to counsel:
The amount and type of information provided
to the patient will vary based on the patient
needs and practice setting.
• Patients who should always be counseled:
• Confused patients and their caregiver.
• Patients who are sight or hearing impaired.
• Patients with poor literacy.
• Patients whose profile shows a change in
medication or dosing.
• New patients, or those receiving a medication
for the first time.
• Children and parents receiving medication.
• Patients receiving medication with special
storage requirements, complicated directions ,
significant side effects.
• Removing the drug from the package:
• Removing the drug from its package may
seem to be a simple procedure to the
pharmacist but not always to the patient.
• Removing the rapping from a suppository
before insertion is quite obvious to the
pharmacist, but not to some patients.
• Opening " safety containers" has presented
considerable problems to patients.
• Administering the drug :
• The pharmacist should ensure that the patient
understands the details of using the medicine.
• Tablets:
• The most common method to administer a tablet is to
place on the tongue and to swallow with water.
• Most patients understand this method of
administration. Some , however , need to be reminded
to take the tablet with a glass full of water.
• This is very important with those drugs that
are irritating to the stomach e.g. ferrous
sulphate , aspirin, tetracycline or potassium
chloride.
• The patient should be told not to chew
enteric -coated or sustained- release tablets.
• Place the medication well back on the tongue.
• Administration of sublingual and buccal
tablets:
1) Wash hands.
2) Place the medication:
under the tongue (sublingual) or between the
upper molar teeth and the cheek (buccal).

* Do not administer with water.

* Allow the drug to dissolve where placed.
• Ophthalmic preparations :
• How to use eye drops:
1) Wash hands.
2) As appropriate , remove exudate from the
eyelid and eyelashes using sterile saline
solution. Always use separate cotton ball for
each wiping motion. Start at the inner
canthus and wipe outward.
3) With one hand , gently pull lower eyelid
down.
4) Holding dropper above eye , drop medicine
inside lower lid while looking up; don't touch
dropper to eye or fingers.
5) Release lower lid . Try to keep eye open and
do not blink for at least 30 seconds.
6) After instilling the drops, apply gentle
pressure, using a cotton ball ,to the inner
corner of the eyelid on the bone for
approximately 1-2 minutes.
• This prevents the medication from entering
the canal where it would be absorbed in the
vascular mucosa of the nose and produce
systemic effects.
• It also ensures an adequate concentration of
medication in the eye.
• Never use eye drops that have changed color,
become cloudy or contain particles.
• If you have more than one bottle of the same
kind of drops open only one bottle at a time.
• If you are using more than one kind at the
same time, wait several minutes before use of
other drops.
• It may be helpful in use of the medicine to
practice use by positioning yourself in front of
the mirror.
• How to use ophthalmic ointments:
1) Wash hands.
2) With one hand, gently pull lower eyelid
down.
3) While looking up, squeeze a small amount of
ointment (about ¼ to ½ inch ) inside lower
lid.
* Be careful not to touch tip of the tube to eye ,
eyelid ,fingers...etc.
4) Close eye gently and roll eyeball in all
directions while eye is closed. Temporary
blurring may occur.
5) The closed eyelid may be rubbed very gently
by a finger to distribute the drug throughout
the formix.
6) Replace cap on tube.
• When opening ointment tube for the first time
squeeze out the first ¼ inch of ointment and
discard as it may be too dry.
• Never touch tip to any surface.
• If you have more than one tube of the same
ointment open only one at a time.
• If you are using more than one kind at the
same time, wait about 10 minutes before use
of other ointment.
• To improve follow of ointment , hold tube in
hand several minutes to warm before use.
• It may be helpful in use of the medicine to
practice use by positioning yourself in front of
the mirror.
• Inhalations:
• It is essential that the patient is taught the
technique of using the inhaler if the treatment is to
be effective.
1) Remove the cover from the mouthpiece and
Shake the inhaler vigorously.
* Many patients forget, or are unaware of, the need
to shake the container. This should be emphasized
when counseling patient on inhaler technique.
2) Breathe out slowly.
3) Place inhaler in the mouth and close the lips
around the mouthpiece.
4) Breathe in deeply and press the canister
firmly.
5) Hold breath for 10 seconds or as long as
patient can comfortably manage.
6) Breathe out normally.
7) Check your Technique in front of a mirror. If
you see a fine mist check actions 3 and 4 .
8) If another dose has to be taken at least one
minute should elapse before repeating the
exercise.
*Unfortunately, some patients find these
devices difficult to use and because of poor
technique many patients do not get the
expected response.
• There are several reasons for patients problems.
These include:
1) Patients may not be able to synchronize
breathing in and firing the aerosol.
2) Some patients have difficulty pressing hard
enough to fine the aerosol.
3) The inhaled drug does not travel in a straight
line which results in desposition of the drug
droplets in the mouth and pharynx.
• The breath in, therefore, must be slow, as this
will reduce the impaction of particles in the
mouth and pharynx.
4) The breath must be held at the end of the
inspiration period to allow the particles to
deposit on the site of action.
5) When the propellant hits the back of the
throat it causes the " cold Freon effect". This
interrupts breathing in some patients and
renders this type of inhaler device useless in
these cases.
* Inhalers are unsuitable for use by children
under 5 years of age.
• For these reasons much work has gone into
developing devices which will overcome the
various problems.
• The Haleraid:
• This is a simple device which fits over certain
makes of pressurized aerosols. Instead of
firing aerosol by pressing down on the canister
with the forefinger, the Haleraid is gently
squeezed using the whole hand.
• It is useful for certain elderly or arthritic patients
who have difficulty pressing the canister.
• The spacer inhaler:
• It is a standard pressurized inhaler with an
elongated mouthpiece. The benefit of this device
is that the delivered dose of drug and propellant
is more diffuse when it arrives at the mouth and
the "cold Freon effect" is considerably reduced.
• However, they are slightly awkward to
manipulate for some patients, particularly the
elderly and those with arthritic hands.
• Nebulizers :
• Nebulizers are devices that transform liquid
medicine into mist. The mist is inspired to
treat respiratory disorders.
• There are two kinds of nebulizers (Ultrasonic
and Compressor).
• Compressor nebulizers use air to transform the
liquid medication into mist, while ultrasonic
nebulizers use vibration to turn the medication
into mist.
• How to use a nebulizer:
1) Wash hands and keep them clean.
2) Make sure the nebulizer is clean.
3) Open the cup and place the medication inside
the cup and close it.
4) Turn the nebulizer on and make sure mist is
coming out of the mouthpiece or mask.
5) a) If you are using a mouthpiece, hold the
mouthpiece with your mouth and gently bite
on it. Gently breathe in and out using your
mouth. keep holding the nebulizer cup in an
upright position.
5) b) If you are using a mask, place The mask
over mouth and nose. keep holding the
nebulizer cup in an upright position.
6) If the nebulizer starts to sputter, that means
most of the medication is gone. Tapping the
nebulizer cup can help the remaining
medicine to drop to where it can be turned
into mist.
7) Clean and dry the nebulizer after use.
• Make sure the nebulizer is completely dry
before storing it in a cool and dry place.
* A typical treatment lasts about 10 to 15
minutes.
• Suppositories:
• There are several helpful items of information
that the pharmacist should relate about the
proper use of Suppositories.
1) If they have to be stored in the refrigerator,
they should be allowed to warm to room
temperature before insertion.
2) The patient should be advised to rub cocoa
butter suppositories gently with fingers to help
melt the surface to provide lubrication for
insertion.
3) glycerinated gelatin or polyethylene glycol
suppositories should be moistened with water
to enhance lubrication.
4) Vaginal inserts (Compressed tablets) should be
dipped into water quickly before insertion.
• Rectal suppositories used with the patient
lying on the left side with hips and knees
flexed.
• Vaginal pessaries are inserted with the
patient lying on her side or back.
• Pessaries are best inserted last thing at night
as they tend to become dislodged.
• Transdermal systems:
these have the advantage of affording
continuous therapy.
• The pharmacist should instruct the patient on
the proper use of this tropical system.
• The patient should place the adhesive side of
the system on a clean, dry, hair free area of
the skin on the trunk of the body preferably
the abdomen.
• He should be told to rotate the site of
application to minimize the possibility of
irritation.
• The area selected should not be oily,
damaged or irritated.
• The transdermal system should not be applied
to waistline because tight clothing may rub
the system off.
• The patient should be encouraged to apply
the system as soon as it is removed from the
protective liner and press it firmly with the
palm of the hand for about 10 seconds.
• It is important to make sure there is good
contact, especially around the edges.
• With these systems it is inevitable that it will
be worn during sleep ; Thus the patient should
be told to inspect the patch after awaking.
• Application of skin preparations:
• Many patients will be required to apply their
skin preparations over long periods so that it
will be necessary that they are taught the
correct technique.
• Adverse effects, such as redness and soreness
and relapse, may require a change of
treatment.
• Creams and Ointments:
1) Apply sparingly.
2) Do not rub unless specifically prescribed.
3) Smooth the preparation on, gently in the
direction of the hair fall.
4) A 10 cm strip of cream or ointment from a
standard nozzle of a tube of medication is the
equivalent of 2 g.
• Administration of ear drops:
1) Wash hands.
2) When administering ear drops, pull the ear
lobe up and back to straighten the canal for
adults and down and back to straighten the
canal in children.
3) Avoid touching the ear dropper tip to the ear
; this prevents recontamination of the
external ear if treating otitis.
4) Remain on the side for a few minutes
following installation.
5) One should instruct patients using a bulb
syringe for ear irrigation to direct the solution
up against the upper portion of the ear canal
and not directly against the tympanic
membrane.
6) The adult ear canal can hold about 17 drops
(0.85 ml ) of fluid.
7) Worm ear drops in hands to body
temperature for 1-2 minutes. Too cold or too
warm drops may cause vertigo dizziness.
8) Tilt the head sideways with affected ear
upward when applying the drops.
* Repeat the procedure if ear drops are ordered
for both ears.
• Capsules:
1) Drink small amount of water to moisten the
mouth to make swallowing medication easier.
2) Place the medication Well back on the tongue.
3) Drink water to swallow the medication, keeping
the head forward while swallowing (drinking a
full glass of fluid ensure that the medication
reaches the stomach and to dilute the drug to
decrease the potential for irritation).
• General principles of liquid -form oral
medication administration:
• For an adult or child:
1) Give the most important medication first.
2) Never dilute a liquid medication unless
specifically ordered to do so.
• For an infant:
1) Be certain the infant is alert.
2) Position the infant so that the head is slightly
elevated.
3) Administration:
• a) Oral syringe or dropper:
I. Place the syringe or dropper between the cheek
and gums, half way back into the mouth.
• This placement will lessen the chance that the
infant will spit out the medication with the
tongue movements.
II. Slowly inject, allowing the infant to swallow
medication.
* Rapid Administration may cause choking and
aspiration.
• b) Nipple:
When the infant is awake(and preferably
hungry), place the nipple in the infant mouth.
When the baby starts to suck, Place the
medication in the back of the nipple with a
syringe or dropper and allow the baby to suck
it in.
• Administration of topical powders:
1) Wash hands.
2) Expose the surface where the powder is to
be applied.
3) Wash and thoroughly dry the affected area
before applying powder.
4) Apply powder by gently shaking the
container.
• This distributes the powder evenly over the
area. Gently smooth over the area for even
coverage.
5) Avoid inhaling the powder during application.
• Administration of nasal drops :
1) Wash hands.
2) Blow the nose gently.
3) Lie down and hang the head backward over
the edge of the bed.
4) Hold the dropper just above the nostril and
instill the medication.
5) Remain in this position for 2 or 3 minutes to
allow the drops to remain in contact with the
nasal mucosa.
6) After a brief time turn the head to other side
and repeat the administration process in the
second nostril, if needed.
• Overuse of nose drops can cause a "rebound
effect" which causes the symptoms to become
worse.
• If symptoms have not resolved after a week of
nasal drop therapy, the Physician should be
consulted again.
• Administration of nasal spray:
1) Wash hands.
2) Gently blow the nose.
3) Sit upright.
4) Block one nostril.
5) Holding the spray bottle upright, shake the
bottle.
6) Immediately after shaking, insert the tip into
the nostril.
7) Inhale through the open nostril and squeeze
a puff of spray into the nostril at the same
time.
• Overuse of nose spray can cause a "rebound
effect" which causes the symptoms to become
worse.
• If symptoms have not resolved after a week of
nasal spray therapy, the physician should be
consulted again.
• Action to be taken in case of missed dose:
• Teaching a patient what to do if a dose is
missed and providing strategies to minimize
the number of missed doses appears a
sensible approach.
• Assessing the importance of a missed dose:
• The severity of the patient's condition and the
characteristics of the medication should be
considered when deciding the most
appropriate strategy following a missed dose.
• Vulnerable patients are easily recognizable in
many practice and include:
1) Those on medication of low therapeutic
index. or
2) Suffering from conditions which require
constant maintenance of therapeutic
concentrations (for example epilepsy and
thromboembolic diseases).
• On the other hand, for most people with
hypertension or hypercholesterolemia a single
missed dose will be of little consequence.
• knowledge of a drug half-life, a major
determinant of the fluctuation in interdose
concentrations at the steady-state, is useful for
making recommendations on what to do if a dose
is missed.
• Upon cessation of therapy, it takes four to five
half-lives for the drug to be completely
eliminated.
• In general, medications, or their active
metabolites, with a long half-Life tend to
create less problems when a dose is missed
than medication with a short half-life.
• However, the clinical effect of some drugs is
not related to the half-life. This usually occurs
when the drug is acting via an:
• Irreversible mechanism ( for example aspirin
effect on platelets) or via an indirect
mechanism ( for example the effect of
Warfarin on blood coagulation).
• When the drug is a pro-drug (in which case it
is the half-life of the active species that is
important), when the drug is converted to an
active metabolite which has a long half-life.
• Overall surprisingly few studies have examined
the clinical significance of a missed dose.
• Antibiotics:
• Take your missed dose as soon as you
remember or, if it is nearly time to your next
dose, skip your missed dose altogether.
• Taking a double dose of antibiotics will
increase risk of getting side effects.
• If you find it difficult to remember to take your
antibiotics, you may find some of the ideas
below useful:
• Combine taking your antibiotics with another
daily activity, such as brushing your teeth or
having a meal.
• After taking each dose, make a note in your
dairy or in your calendar.
• Set an alarm to remind you when your next
dose is due.
• Ask about "compliance aids" These are boxes
with labeled compartments that you can put
your medicines in.
• Oral contraceptives
• Combined oral contraceptives
• If one or more tablets are missed from the
inactive tablets, no additional contraceptive
precautions are necessary and tablet taking
should be recommended ignoring the missed
tablet(s).
• However, if all the inactive tablets are missed and
then the next back is not started one time, start
as soon it is remembered.
• Additional contraception (such as condom) must
be used for the next seven days.
• If an active tablet is forgotten, take it as soon
as it is remembered, within 12 hours after the
time that it is normally taken. Then take the
next and subsequent tablets at the usual time.
• If there is a delay of more than 12 hours,
contraceptive protection in this cycle maybe
reduced. There is more risk in becoming
pregnant if tablets are missed during the first
week, or at the end of the current back.
• Take the missed tablet as soon as it is
remembered, even if this means taking two
tablets at the same time.
• Continue taking a daily tablet as usual and use
additional contraceptive precautions for the
next seven days. If these seven days extend
into the inactive section, skip the inactive
section and start a new back in the active area
on the next day instead.
• Progestogen-only oral contraceptives
• For women using Progestogen-only pills the
recommendation for the use of other
methods of contraception is extended to 14
days if the dose is delayed by three hours or
more.
• Missed insulin dose: once -a- day , intermediate
or long-acting insulin
• If you miss your once -a- day, intermediate or
long-acting insulin dose, and realize it within 4
hours, the full dose can still be taken.
• If it is more than 4 hours late:
1) Calculate the number of hours late.
2) Divide by 24 and multiply by your usual insulin
dose.
• For example:
• Patient wake up at 2 a.m. and realizes he missed
his 8 p.m. dose of 34 units.
• - Number of hours late = 6 hours.
• 6/24 = 0.25
• 0.25×34=8.5
• 34 - 8.5 = 25.5
• Round down from 25.5 to 25 units for safety.
The patient could then take 25 units at 2 a.m.
• Missed insulin dose: twice- a- day
intermediate or long-acting insulin.
• If you missed your twice- a- day intermediate
or long-acting insulin dose, and realize it
within 4 hours, the full dose can still be taken.
• If it is more than 4 hours skip the dose entirely
and cover any high glucose levels with rapid -
acting insulin.
• Missed insulin dose : mealtime dose of rapid-
acting insulin.
• If you missed a meal time dose of rapid- acting
insulin and realized it within the hour, take
your normal dose.
• If it is within 2 hours later, take 75% of your
normal dose, and if it is 3 hours later, take half
of your normal dose.
• If you use a personalized sliding scale, you can
recheck your glucose and use a correction
factor instead.
• Storing insulin:
• General rules:
• To ensure that your insulin remains effective,
stable and undamaged you should discard ‘ in
use‘ insulin after 28 days, whether in a vial or
cartridge.
• Insulin that is not in use should be stored in
the refrigerator.
• If refrigeration is not possible it can be kept at
room temperature [15-25 C] for 28 days.
• The in use vial may be kept at room
temperature [15-25 C] for 28 days.
• In use cartridge should be kept at room
temperature and should not be kept in a
refrigerator.
• Insulin should never be stored above 40
degrees C.
• It is important that insulin is never frozen, or
exposed to a combination of high
temperature and excessive vibration.
• Brief exposure to temperature extremes need
not necessarily reduce it is efficacy.
• Guidelines for drug disposal
• Follow any specific disposal instructions on
the prescription drug labeling or patient
information that accompanies the medicine.
• Do not flush medicines down the sink or toilet
unless this information specifically instructs
you to do so.
• Take advantage of community drug take-back
programs that allow the public to bring
unused drugs to a central location for proper
disposal.
• If no disposal instructions are given on the
prescription drug labeling and no take-back
program is available in your area, throw the
drugs in the household trash following these
steps:
1. Remove them from their original container
and mix them with an undesirable substance,
such as used coffee grounds or Kitty litter (
this makes the drug less appealing to children
and pets and unrecognizable to people
intentionally go through the trash seeking
drugs).
2. Place the mixture in a sealable bag ,empty
can, or other container to prevent the drug
from leaking or breaking out of a garbage
bag.
• Before throwing out a medicine container,
scratch out all identifying information on the
prescription label to make it unreadable.
• Do not give your medicine to friends.
• Doctors prescribe medicines based on a
person's specific symptoms and medical
history. A medicine that works for you could
be dangerous for someone else.
• The same disposal methods for prescription
drugs could apply to over the counter drugs as
well.
• Chronic illnesses where pharmacist can play
active role through counseling:
• The management of Chronic illnesses needs
life-style modifications and Drug therapy for a
long period.
• Patient understanding regarding the illness
plays a very important role in management of
chronic illness.
• Effective patient counseling makes the patient
understand his/her illness, necessary lifestyle
modifications and pharmacotherapy in a
better way and thus enhance patient
compliance.
• The pharmacist has immense responsibility in
counseling the patients with chronic illness.
• The counseling pharmacist should possess
adequate knowledge and should be an
effective Communicator, making use of the
verbal and non-verbal communication skills.
1. Hypertension:
• 1.1. Non-pharmacological measures:
• In many occasions non-pharmacological
treatment alone may suffice in the management
of Hypertension.
• A pharmacist can counsel the patients regarding:
• Weight loss and regular exercise.
• Sodium and calorie restriction.
• Restriction of saturated fats and increases
intake of dietary fibers, restriction of alcohol
intake.
• Smoking cessation.
• Caution when using cold remedies containing
sympathomimetics.
• Self-monitoring of blood pressure…etc.
• 1.2.Drug counseling points in hypertension:
• 1.2.1.Diuretics:
• Monitor for muscle weakness, confusion,
dizziness.
• Ensure patient participation in dose modulation.
• Select appropriate dose timing to avoid frequent
urination in the night.
• Explain about the possibility of drug interactions
with ACEIs.
• 1.2.2.Beta blockers:
• Monitor for hypotension, dizziness, headache,
and bradycardia.
• Educate regarding possibility of nocturnal
dreams, impotence and CNS problems.
• Explain the need for dose tapering before
stopping the drug.
• 1.2.3.Alpha blockers:
• Monitor for hypotension.
• 1.2.4.ACEIs:
• Monitor for hypotension, dizziness, cough , taste
disturbances and rash.
• 1.2.5.Calcium channel blockers (CCBs) :
• Monitor for swollen gums , chest pain, swollen joints
( with nifedipine), Constipation, dizziness light-head
edness.
• Educate the patient to swallow the extended release
tablets as a whole.
• Explain to the patient how to monitor his heart rate by
measuring the pulse rate.
• 2.Diabetes mellitus DM:
• Often simply referred to as diabetes, is a
group of metabolic diseases in which a person
has high blood sugar, either because the body
does not produce enough insulin , or because
the cells do not respond to the insulin
produced .
• 2.1.Non-pharmacological approaches:
• The pharmacist can give an overview of
diabetes, stress and psycho-social adjustment,
family involvement and social support,
nutrition, exercise and activity, monitoring and
use of results, relationship between nutrition ,
exercise, medication and blood glucose level.
• Advice regarding the prevention ,detection
and treatment of acute/chronic complications,
foot, skin and dental care, Behavior change
strategies , goal setting, risk factor reduction ,
and problem solving, preconception,
pregnancy and postpartum management.
• Advice on medication:
1) Take the drugs half an hour before meals or
as instructed by your doctor- once the drugs
are taken, do not delay the meal time.
2) If you miss a dose take as soon as possible
unless it is almost time for the next
scheduled dose.
3) In case of frequent symptoms of low blood
sugar Such hunger, weakness , trembling cold
sweating and dizziness, inform your doctor.
4) As soon as symptoms of low blood sugar
occur , the patient should immediately take
some sugary food and drinks.
5) If you are taking other drugs as well, inform
your doctor to avoid medicinal interference.
• Life adaptations:
1) Stick to your dosing schedule and follow
instructions given by your doctor or dietitian
to control your diet.
• Avoid high-calorie and fatty food and do
moderate exercise to maintain optimal body
weight.
2) Receive regular urine blood tests to evaluate
the progress of your condition.
3) Maintain personal hygiene to prevent
complications such as skin infection.
4) Quit smoking and alcohol.
5) Eat the right amount at regular intervals.
• Do not delay meal time.
6) Lead a regular life.
• Avoid sudden excessive exercise.
• 2.2.Drug counseling points in diabetes:
• 2.2.1.Sulfonylureas:
• Explain the methods to prevent, detect and
manage hypoglycemia.
• Monitor for symptoms of jaundice.
• Discuss the administration time in relation to
food and need for alcohol abstinence.
• Ask for history of sulfur sensitivity.
• 2.2.2.Insulin:
• Explain the methods to prevent, detect and
manage hypoglycemia.
• Educated the patient regarding newer insulin
administration technique, proper storage
conditions for insulin.
• Ask the patient to carry chocolates or other
sweets during travel and ask him not miss the
meals.
• 2.2.3.Metformin:
• Advise the patient to take with / after food.
• Monitor for muscle pain, unusual sleepiness,
nausea, stomach pain, weight loss.
• 2.2.4.Thiazolidinediones:
• Take history of liver problems;
• Monitor the patients for yellow discoloration of
urine.
• Monitor the patient for peripheral edema.
• 2.2.5.Acarbose:
• Encourage the patient to take it with the first
bite of food.
• Monitor for abdominal pain and cramps.
• Advise the patient not to take sucrose (sugar)
during hypoglycemic attack as it may not be
absorbed when acarbose is taken.
• 3.Coronary heart disease:
• 3.1.Non-pharmacological measures:
• It includes education regarding diet, smoking,
and exercise and encouraging the patients to
maintain a diary on anginal attacks, pain
symptoms..etc..
• 3.2.Drug counseling points in coronary heart
disease:
• 3.2.1.Beta blockers:
• Monitor for hypotension, dizziness, headache
, and bradycardia.
• Educate the patient regarding possibility of
nocturnal dreams and CNS problems.
• Explain the need for dose tapering before
stopping the drug.
• 3.2.2.Nitrates sublingual Administration:
• Sublingual tablets should not be chewed or
crushed, use of transdermal patches, do not
stand up immediately while using this
medication.
• Monitor for bluish colored lips, fingernails or
palms.
• 3.2.3.Aspirin:
• Encourage the patient to take drug with food.
• Monitor for abdominal pain, tarry stools,
fever, spitting of blood.
• In case of enteric-coated preparations, ask
the patient not to crush or chew the tablets.
• 4.Dyslipidemia:
• 4.1.Non-pharmacological approaches:
• It includes regular exercise to reduce body
weight, use of unsaturated fats, fruits and
vegetables containing antioxidants, stress
management, avoidance of drugs that are
known to increase cholesterol level..etc..
• 4.2.Drug counseling points in dyslipidemia:
• 4.2.1.Statins:
• Educate the patient to take these drugs after
food.
• It is advisable to take these medications
during night ( except for atorvastatin).
• Ask the patient to report to the doctor if any
signs of muscle pain appear.
• 4.2.2.Fibrates:
• Take with or immediately after food to lessen
stomach upset.
• Monitor for blood in urine, chest pain, and
shortness of breath, stomach pain.
• 4.2.3.Anion exchange resins:
• This medicine should never be taken in dry form.
• Mix the medicine with beverage or drinks.
• Monitor for stomach pain, nausea, and vomiting,
belching, bloating, diarrhea.
• 4.2.4.Nicotinic acid derivatives:
• Do not crush, break or chew the extended
release medication.
• Monitor for darkening of urine, loss of
appetite, severe stomach pain, and yellow
eyes.
• 5.Asthma:
• 5.1.Non-pharmacological measures:
• Safety measures while traveling , prophylactic
use of drugs before exercise , avoidance of
allergens, stopping cigarette smoking..etc..
• 5.2.Drug counseling points in asthma:
• 5.2.1.Beta receptor agonists:
• Short-acting drugs belonging to this category
should be used mainly for symptom relief.
• Patient on Long acting drugs should be told that
the medication may take some time period to
show the action.
• Patients also needs monitoring for tremors and
muscle pain.
• 5.2.2.Theophyllines:
• Patients on sustained release preparations
should be told not to crush/chew the tablets.
• 5.2.3.Anticholinergics:
• Monitor for dry throat, nausea , headache ,
blurred vision, and painful urination.
• 5.2.4.Corticosteroids:
• Medications should be administered regularly.
• They should not be stopped abruptly.
• It needs dose tapering before stopping.
• Emphasize gargling of mouth after use of
inhaled medications.
• 5.2.5.Mast cell stabilizers:
• Patient should be told that this medication is
used to prevent the asthma attack and it does
not relieve bronchospasm that has already
started.
• 6.Epilepsy:
• 6.1.Non-pharmacological measures:
• They include regular follow-ups, avoidance of
sleep deprivation, and avoidance of over-the-
counter (OTC) medications ; stress relieving
activities, psycho-social counseling etc.
• 6.2.Drug counseling points in epilepsy:
• 6.2.1.Barbiturates:
• Explain to the patient about the possibility of
dependence.
• Explain the possibility of drug interactions
especially with oral contraceptives.
• Monitor for fever , skin rashes, swelling of
eyelids, mental depression.
• 6.2.2.Benzodiazepines:
• Monitor for behavior problems, mental
depression, impaired memory, skin rash.
• Explain to the patient regarding the drug
interaction.
• Monitor for symptoms of overdose.
• 6.2.3.Hydantoins (phenytoin):
• The patient should be advised not to stop the
medicine or take other medicine without the
doctor's advice.
• Explain to the patients the various symptoms of
overdose.
• Monitor for gum bleeding, bone malformations,
headache and joint pain, learning problems in
children.
• Patients should be explained regarding the drug
interaction potential of the drug.
• 6.2.4.Valporates:
• Controlled release and sustained-release
preparations should not be chewed or crushed.
• They should be swallowed whole.
• 6.2.5.Succinimides:
• This should be taken with food or milk so as to
reduce the stomach upset.
• Patients should be advise to give their medication
history before undergoing surgery as this drug
can potentiate the CNS effect of anesthetics.
• 7.Rheumatoid arthritis:
• 7.1.Non-pharmacological measures :
• Patient education regarding physical therapy,
occupational therapy, exercise program,
screening for early detection and treatment of
the disease can be initiated by the
pharmacist.
• 7.2.Drug counseling points in rheumatoid
arthritis:
• 7.2.1.Methotrexate:
• Monitor for back pain, dark urine , drowsiness,
headache, yellow colored urine.
• Advise not to take alcohol.
• Take pregnancy history before initiation of the
drug.
• Ask the patient to consult the doctor before
taking non-steroidal anti-inflammatory drugs
(NSAIDs).
• 7.2.2.Non steroidal anti-inflammatory drugs
(NSAIDs):
• Monitor for abdominal pain, tarry stools,
fever, spitting of blood.
• Ask the patient to take the drug with full glass
of water and mention not to lie down for 15 to
30 minutes after taking the medicine.
• Advise the patient to take this medicine with
food.
• 7.2.3.Cyclooxygenase-2 (COX-2) inhibitors:
• Monitor for dark colored stool.
• Advise the patient to take the medicine after
food so as to reduce the stomach irritation.
• 7.2.4.Corticosteroids:
• Advise the patient to take with food.
• Monitor for blurred vision, frequent urination,
confusion, excitement, and infection at injection
site.
• Take diabetic history before initiation of the drug.
• Explain to the patient about dose tapering.
• Warn against missing of doses.