Therapy-I

Fuad A. Mohammed
Clinical Pharmacist & Lecturer
(Fuadamoh2017@gmail.com)
 Introduction

Pharmacy practice is;

o Moving toward a model that integrates patient-focused care (also known as
patient centered care) and drug distribution services

The term clinical pharmacy historically described

o patient oriented rather than product-oriented pharmacy practice

2
 Intro…. Cont’d…

Clinical pharmacy practice

o is a practice of pharmacy as a part of a multidisciplinary health care team directed at
- achieving quality use of medicines

How ?
o Participation in the management of individual patients
o Application of the best available evidence in daily clinical practice
o Contribution of clinical knowledge and skill to health care team 3
 Intro….Cont’d…
o Identification and reduction in risks associated with medicine use

o Involvement in education of patients, attendant and other health

professionals

o Involvement in research
4
 Intro….Cont’d ….
The term clinical pharmacist was used to describe a pharmacist
whose primary job was
o To interact with the health care team
o Interview and assess patients
o Make patient specific therapeutic recommendations
o Monitor patient response to drug therapy and
o Provide drug information 5
 Pharmaceutical care (PC)

Definition
o is the responsible provision of drug therapy for the purpose of achieving definite outcomes that
improve or maintain patient’s quality of life”

The four outcomes identified include the following:

oCure of disease
oElimination or reduction of symptoms
oArrest or slowing of a disease process
oPrevention of disease or symptoms 6
 Pharmaceutical care (PC)…

Pharmacists tasks is to ensure;

o Pts drug therapy is appropriately indicated the most effective available,
Safest possible and convenient for the pt
 Unique contribution for : Drug Therapy outcome and pts Quality of life

A pharmacist practices PC
o when he/she finds and fixes or prevents drug therapy problems in patients.
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 PC Cont’d…

What required is ?
o Expert knowledge of therapeutics
o A good understanding of disease process
o Knowledge of pharmaceutical products
o Drug monitoring skills
o Provision of drug information
o Strong Communication skills
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PC cont’d…..

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 Cont’d…
 Pharmaceutical Care - Benefits
o Decrease medication misadventures
o Increase patient compliance to therapy –
o Empowers patients to take in-charge of their own health and treatment
o Decrease healthcare cost
o Decrease morbidity/ mortality
o Increase patients’ quality of life
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 PC cont’d…
Pharmaceutical Care – How can be performed ?

Through Patient care process -

o Assess needs
o Identify problems
o Develop care plan
o Implement plan
o Monitoring - evaluation for efficacy & safety
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The Pharmaceutical Care Cycle

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 Activities and Responsibilities in the Patient Care
Process

Assessment
o (assess drug related needs & identifying DRP)

Construct Care plan

o Knowing the cause of a drug therapy problem helps to create a plan to fix it

Follow-up evaluation (monitoring)

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 Assessment

A systematic review of the patient’s drug-related needs

Performed by the pharmacist with the patient to ensure that;

o all drug therapy is indicated, effective, safe, patient is compliant, and
o to identify drug therapy problems (DTP)

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 Asses…

The assessment interview influences all other components of the patient care process
o It influences communication,
o data accuracy,
o clinical decision-making,
o ethical judgements,
o patient compliance, patient satisfaction,
o practitioner satisfaction, and
o clinical outcomes
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 Asses…

Skills required
o inquiry, listening, and observational skills

Responsibilities during assessment

o developing the therapeutic relationship
o assessing drug-related needs
o identifying drug therapy problems
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 Asses…

Developing the therapeutic relationship

o Meeting and greeting your patient
o Introduce yourself as a pharmacist
o Determine the patient’s primary spoken language
o demonstrating genuine interest in the person acceptance, and establishing
rapport

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Asses…
o Address people using their preferred name

o A semi-private or private space must be provided for you to conduct an

assessment of your patient's drug-related needs

o Keep the area clean and organized

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 Collecting Relevant Patient-Specific
Information

The practitioner collects relevant patient-specific information

o to use in decision making concerning all drug therapies

 Only data that are required and used by the practitioner are elicited from the
patient

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 Asses…

Information elicited during Assessment

 Patient Demographics
o needed to see each patient as a unique individual
 Age of the Patient
o Importance of age
oTo determine whether drug therapy is indicated or not
oMedical problems and goal of therapy varies by age
oTo select appropriate product and dosage form 20
 Asses…

 Drug dosing
o Dosage requirements vary greatly with age

o Absorption, metabolism, and elimination of most drugs changes with age

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Asses…
Gender
Importance
To determine risk of the patient for the disease
o Hypothyroidism, anemia, and osteoporosis requiring drug therapy
are more common in females

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 Asses…

Drug selection
Height and Weight
o used for dosage individualization

Body surface area (m2) = ((height in cm) x (weight in kg/3600))1/2

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 Asses…

 Living Situation
o occupation and socioeconomic status can have a dramatic influence on drug-
related needs and subsequent outcomes

o Who lives with the patient and who cares for the patient?

o Who is responsible for administering medications and making health care

decisions?
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 Asses…
 Do other family members have a history of certain diseases, or other risk factors (smoking,
alcohol use);

that may negatively affect your patient's drug therapy outcomes for
o(coronary artery disease, depression)?

 Pregnancy and Breast-Feeding

o Affects drug selection
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 Asses…

The medication experience(ME)

ois the patient's personal approach to taking medication

oME is the sum of all the events in a patient's life that involve medication use

oThe medication experience is first and foremost;

• the patient's beliefs, perceptions, understandings, attitudes, and behaviors
about drug therapy 26
 Asses…

The medication experience includes more technical aspects as well;

o the patient's current medications, social drug use, immunizations, allergies, and
medication history

Includes the patient's preferences, attitudes, general understanding of his or her

drug therapy, concerns about it,
o expressed expectations of desired outcomes, and the patient's medication taking
behavior
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You will need to inquire and make judgments about the
following questions:
o What is your patient's level of understanding of his/her disease or illness,
drug therapies, and therapeutic instructions?

o What concerns does your patient have about his/her health in general or
medical conditions and drug therapies in particular?
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 Asses…
What concerns does your patient have
about side effects, toxicities, adverse events, or allergies ?

What does your patient dislike about his/her drug therapies?

To what extent does your patient want to be an active participant in his/her care?

To what degree is the cost of drug therapy, clinic visits, hospitalizations, or treatment failures, a
concern for your patient?
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 Asses…
Medication History
include immunization status, social drug use, allergies, adverse reactions and other
special needs, and a history of relevant medication use

History of relevant medication use

o to determine if the present problem has been treated before, with medications

o to determine previous treatment failures and unwanted SE to medications used in the

past 30
 Asses…
Current Medication Record
includes:
 (1) the indication for drug therapy;
(2) all of the drug products your patient is taking for that indication;
(3) specifically how the patient is actually taking them; and
(4) the patient's response to the drug therapy
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 Asses…

Indication can be for

Cure a disease or illness;
Prevent a disease or illness;
Slow the progression of a disease or illness;
Supplement nutritional, electrolyte, hormonal, or other deficiencies;
Correct abnormal laboratory test results;
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 Asses…

Chief Complaint(s)
o The one or more symptoms or concerns causing the patient to seek care

The history -
 severity, context, location, timing, modifying factors, and associated signs and
symptoms

 Includes patient’s thoughts and feelings about the illness 33

Asses…

History of Present Illness

Amplifies the Chief Complaint, describes how each symptom

developed
May include medications, allergies, habits of smoking and alcohol,
since these are frequently pertinent to the present illness

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 Asses…

Medical History
information about past serious illnesses, hospitalizations, surgical
procedures, pregnancies, deliveries, accidents, or injuries

Important to identify
o risk or predisposition to develop a serious condition,
o a contraindication to future drug therapies
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 Asses…

Review of Systems
is a survey of various bodily systems to uncover significant symptoms or
problems (drug-related) -
othat have not already been revealed during the assessment interview
include
o physical findings,
o descriptions and experiences offered by your patient, and
o Laboratory values
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 Asses…

Subjective Data
o What the patient tells you
o From patient demography to review of systems

Example: BT is a 35-year-old driver who complains productive

cough with blood strike sputum for the past three weeks
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 Asses…

Objective Data
o What you detect on the examination
o All physical examination findings

Example: vital sign

o BP - 160/80, HR – 96bpm, RR- 24
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 Review of Laboratory and Diagnostic Tests

Data from laboratory and diagnostic tests and procedures

provide important information
o Regarding the response to drug therapy
o The ability of patients to metabolize and eliminate specific therapeutic agents
o The diagnosis of disease, and
o The progression and regression of disease

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 Assessment of Drug-Related Needs
Determine if the patient's drug-related needs are being met:
 all the patient's medications are appropriately indicated
 most effective available
 safest possible and
 patient is able and willing to take the medication as
intended

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 Asses…
 A. Evaluating the appropriateness of the Indication for the
Patient's Drug Therapy
o make the connections between the indication (medical condition), the
drug product, the dosage regimen, and the outcome

o If the patient has an inappropriate indication or needs drug therapy,

o then you have identified a drug therapy problem
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 Asses…
 B. Determining the Effectiveness of the Drug Regimen
 Effectiveness is determined by evaluating the patient's response compared to the
desired goals of therapy for each indication

 To evaluate effectiveness you should have established goals of therapy

 When the drug therapy is not effective for the patient: the problem could be, wrong
product or too low dosage
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 Asses…
 C. Establishing the Safety of the Drug Regimen
o adverse drug reactions and/or toxicities

dose-related problems (a high dose) are resolved by lowering the

dose,
o while those reactions not dependent on the amount of a drug the patient
takes are resolved by switching to another drug product
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 Asses…
 D. Understanding Patient Compliance
o describes the behavior of the patient
o Check whether your patient is able and willing to take medication
o Does the patient taking the medication as prescribed?

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 Drug Therapy Problem
A drug therapy problem is any undesirable event experienced by a
patient
o which involves, or is suspected to involve, drug therapy, and that interferes
with achieving the desired goals of therapy

1. An undesirable event or risk of an event experienced by the patient

o {medical complaint, S/S, Dx, d/ses, illness, impairment, disability, abnormal
laboratory value, or syndrome 45
 Cont’d …
 2. The drug therapy (products and/or dosage regimen) involved.

3. The relationship (exists or is suspected to exist) b/n the undesirable patient event
and drug therapy.

The r/n ship can be

o the consequence of drug therapy, suggesting a direct association or even a cause and effect
relationship, OR
o to require the addition or modification of drug therapy for its resolution or prevention
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 Components of a Drug Therapy Problems

1. The drug therapy is unnecessary because the patient does not have a clinical
indication at this time.
2. Additional drug therapy is required to treat or prevent a medical condition
in the patient.
3. The drug product is not being effective at producing the desired response in
the patient.
4. The dosage is too low to produce the desired response in the patient.
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 DTP…
5. The drug is causing an adverse reaction in the patient.

6. The dosage is too high, resulting in undesirable effects experienced by

the patient.

7. The patient is not able or willing to take the drug therapy as intended
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 Drug-related needs Vs Categories of drug
therapy problems
 1. Patients need every medication they are taking to have an appropriate
indication.
o If a drug does not have an appropriate indication, the DTP “unnecessary drug therapy” will
be identified. OR
o Un treated indication – The DTP is Need additional DT

 2. Patients need their drug therapy to be effective

o When a patient’s need for medication to be effective is not met, two possible DTPs can arise.
oThey are “Ineffective drug” and “dosage too low”
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 Drug related Needs Vs DTP Cont’d …

3. Patients need their drug therapy to be safe

o Not meeting a need for medication safety can result in
o the DTPs of “dosage too high” or “adverse drug reaction.”

4. Patients need to be able to comply with drug therapy and other aspects of
their care plans
o Not meeting a need for compliance can result in the DTP of “non-compliance”
results.
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 Summary - Needs Vs DTP

 INDICATION
o 1. Unnecessary drug therapy
o 2. Needs additional drug therapy

 EFFECTIVENESS
o 3. Ineffective drug
o 4. Dosage too low
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 Cont’d..
 SAFETY
o 5. Adverse drug reaction
o 6. Dosage too high

COMPLIANCE
o 7. Noncompliance
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 Identifying Drug Therapy Problems
A PC practitioner should have a tacit understanding of the
common causes of DTPs
o identification is the essence of PC practice.

 Once DTP identified, the practitioner & patient can rationally construct a care
plan to resolve that DTP -
o and achieve his/her goals of therapy.
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 Cont’d…
The DTPs are identified during the assessment process,
 so that they can be resolved through individualized changes in the patient's drug therapy
regimens.
Using
o knowledge (pt, d/se), identified in the assessment step of drug therapy
information

The synthesis and application of this knowledge occurs in a logical, systematic manner.
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 The Process Used to Identify Whether or Not the Patient Is
Experiencing a Drug Therapy Problem Requires a…

 Continuous Assessment of Four Logical Questions:

 1. Does the patient have an indication for each of his/her drug therapies,
and is each of the patient's indications being treated with drug therapy?
 2. Are these drug therapies effective for his/her medical condition?
 3. Are the drug therapies as safe as possible?
 4. Is the patient able and willing to comply with the drug therapies as
instructed?
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 Common Causes of Drug Therapy Problems

 1. Unnecessary drug therapy

 no valid medical indication
 duplication of therapy
 Non-drug therapy more appropriate
 Treating an avoidable ADR associated with other drug
 Addiction/recreational use
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 Cont’d …
2. Need for additional drug therapy
condition requires initiation of DT
Preventive/prophylactic DT is required
additional DT for synergistic/additive effects
Clinical Questions to consider
Is there an untreated indication? Why?
Does the patient need synergistic therapy to supplement therapy already being administered?
Does the patient need prophylactic therapy?
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 Cont’d…

3. Ineffective drug

 The drug product is not the most effective for medical condition

 The medical condition is refractory to the drug product.

 The dosage form of the drug product is inappropriate.

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 4. Dosage too low

The dose is too low to produce the desired response.

The dosage interval is too infrequent to produce the desired response.

The duration of drug therapy is too short to produce the desired response.

A drug interaction reduces the amount of active drug available

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 5. Dosage too high
 Dose is too high

 The dosing frequency is too short

 The duration of drug therapy is too long

 A drug interaction occurs resulting in a toxic reaction to the drug product

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Questions to consider
Are the dose, dosage interval and duration of therapy
appropriate for each medication the patient is taking?

How long has the patient been receiving the current dose of
each medication?

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Questions to consider
Is there evidence of adverse effects that is dose related ?

Are medications being administered correctly?

Are there any potential or actual drug interactions?

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 6. Adverse drug reaction
The drug product causes an undesirable reaction that is not dose-related

A drug interaction causes an undesirable reaction that is not dose-related

The dosage regimen was administered too rapidly

The drug product causes an allergic reaction

The drug product is contraindicated due to risk factors.
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 7. Inappropriate compliance
The patient does not understand the instructions.
The patient prefers not to take the medication.
The patient forgets to take the medication.
The patient cannot swallow or take appropriately.
The drug is too expensive for the patient.
The drug is not available for the patient.

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Questions to consider
Is the patient complying with drug therapy, and if not, why not?

If the patient finds a therapy too expensive, what alternatives are
possible?

What are the possible disadvantages to switching therapy?

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Actual and Potential Drug Therapy Problem

An actual problem

 is one that has already occurred. Action should be taken to resolve it
A potential problem
 is one that is likely to occur.
 The necessary steps should be taken prevent it.
Before deciding to contact the prescribing physician, they should
consider how severe the consequences of the potential problem could
be
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 Stating Drug Therapy Problems
Describe your patient's drug therapy problem in a concise, accurate, and
informative manner

A statement describing the patient's drug therapy problem(s) consists of three

components:
 A description of the patient's medical condition
 The drug therapy involved
 The specific association between the drug therapy and the patient's condition
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 Stating DTP Cont’d …
“the drug she is taking for her high cholesterol is not working.“

VS
"The Lipitor (atorvastatin) therapy that she has been taking for the
past 3 months for hyperlipidemia has only resulted in a 5%
reduction of her total cholesterol using an aggressive dosage of 80
mg daily."
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 Documenting Drug Therapy Problems

 Each problem identified is added to the patient's record and

includes;
the medical condition, illness, or complaint involved, the drug therapy or
therapies involved, and the likely cause of the drug therapy problem

Drug therapy problems are documented within the care plan for each medical
condition involved
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 Documenting DTP…

The interventions required

to resolve the drug therapy problem will also be associated with that care plan

The action that was taken

(ex; increase/decrease dosage, discontinue/initiate drug therapy, add
preventive drug to regimen) also needs to be recorded.

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 Prioritizing a DTP
 Prioritizing a DTP If a patient has ≥1 DTP, it is usually preferable to solve
them one at a time, not all at once

Acute problems VS serious problems

o #1 priority –
o DTP is acute and serious (DKA, serious infection, stroke). could be fatal,
o Note: possibly be life threatening and there is no time to waste in solving it
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 Cont’d…

Prioritizing a DTP
#2 priority --DTP is acute, but not serious (pain, diarrhea).
o Not fatal, but patient hurts now
o Note: may or may not be life threatening, but there is no time to waste in
solving it

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#3 priority --DTP is serious, but not acute (HTN, diabetes).
o May be fatal in the long run, but
o Note: you have time to spare solving it
 Care Plan
A care plan is the method by which the pharmacist helps the patient
achieve a pre--determined health care goal.

Care plans MUST be developed cooperatively between the

pharmacist and patient.

Physicians should always be informed, and usually be involved.

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 Care plan …
“The structure of care plan functions as;
- a frame work for the cooperative efforts of all those involved in the management
of a patients medication.
- Care plan should be documented
Components
Developing goals of therapy
Statement of intervention
Follow-up evaluation 75
 Care plan …

A. Goals for pharmacotherapy

Before you can develop a care plan, you must develop a goal
A goal - is simply the outcome you want the patient to achieve
Who has goals for therapy ?
How are they stated ?
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 Care plan Cont’d …
Your Goals Must be;
o Measurable,
o Achievable ,
o Considers your practice setting
o Consistent with the pharmacist’s Responsibilities

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 Care plan …Cont’d….
The best care plan is rarely the first one that comes to mind, i.e.,
THINK before you act.

What do you want to do? –

o Before answering, what are all your choices and which is best/least bad?

You may need to conduct additional search

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 Care plan …Cont’d …
Drug focused care plans:
o Require a change in a patient’s drug therapy
o Usually require physician’s cooperation (unless OTC)
 Add a drug, d/c a drug, change a dose, dosing interval or dosage form

 YOU HAVE TO BE SPECIFIC –

o “Let’s start to our patient a beta blocker” is NOT a care plan
oRather : Start him/her atorvastatin 80mg qd - IS a care plan
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 Care plan… Cont’d…
Lifestyle related care plans:
 Stop smoking, lose weight, start exercising, etc.

 Are the most difficult to implement and

are generally best handled as part of a formal disease management program,
not a routine intervention

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 Care plan …
 B. Implementing / Intervention
Care plans require pharmacist’s action to implement them

You need to make sure that all parties:

o Agree with the care plan
o Understand who is responsible for what & when
o Question to considers: are the patient capable of complying with the care plan?
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 Care plan …Cont’d …
 Implementing… Question ?
Does the patient agree with it and understand it?

Does the patient have everything necessary to put the care plan into action?

Does the patient know when to follow up and with whom?

Does the patient agree to follow up if needed?

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 Care plan …

 C. Follow-up Evaluation
How else will you know if your goal has been achieved?

 Make sure the patient knows you will be following up

 Consider when you will follow up, where, and how (by phone, in person, by
email, by appointment, etc.)
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 Care plan …Follow-up…
Purpose
 to determine the patient's outcomes from drug therapy and to compare
these results with the patient's goals of therapy

The only way to know : whether the drug therapy your patient taking is
effective and/or safe
 Care plan …Follow-up ...
During Follow-up evaluation,
o the practitioner is looking for evidence of effectiveness, safety, and any new
problems that may have occurred since the last visit
 Care plan …Follow-up ...
 Evaluating Effectiveness of Drug Therapies

 Compare the goals of therapy with patient outcomes (GOAL Vs OUTCOMES)

 Initially set clinical and/or laboratory parameters used to monitor effectiveness

 Clinical Parameters
 change in Clinical parameters are determined by asking the patient
 + Ve clinical outcomes usually associated with disappearance of Sn & Sx
 Care plan …Follow-up ...
 Laboratory Parameters
Outcome evaluations often rely on changes in laboratory values.

In some diseases or conditions, there are few or no clinical manifestations

The timing , when to collect the sample for the laboratory test is an
important clinical decision
 Care plan …Follow-up ...

Evaluating the Safety of Drug Therapies

The preferable way to ensure safety is to determine whether the patient is
experiencing any negative effects

An adverse effects from drug therapies could manifest as clinical signs or
symptoms and/or as alterations in laboratory test results
Determining the Clinical Outcome Status
Adherence and Compliance
 Adh & Comp…..
 Compliance
The extent to which a person’s behaviour (taking medications, following a recommended
diet or executing lifestyle changes) coincides with medical or health advice’

Non-compliance: suggests that health professionals have the right to authority over the
patient’s behavior

patients have no right to participate in decisions about their health or the medicines they
take
91
 Adh & Comp ….
Adherence
The extent to which a person’s behaviour – (taking medication, following a
diet, and/or executing lifestyle changes), corresponds with agreed
recommendations from a healthcare provider

Health professionals have a responsibility to form a ‘therapeutic

relationship’ with patients, in order to encourage them to agree to a
recommended treatment regimen
92
 adh & compl…
Patients should be better informed - about their medicines and,
in theory, have greater power to decline treatment

93
 Adh & compl ….

 Primary vs secondary non-adherence

Primary non-adherence: patient does not have prescription for medicine

dispensed

Secondary non-adherence: patient has medicine dispensed but does not

take it according to the prescribed regimen
94
 Adhe & compl …
Intentional vs unintentional non-adherence
o Intentional non-adherence: patient chooses not to take their medicine
according to the prescribed regimen

o Unintentional non-adherence: patient either forgets, or is unable, to take

their medicine according to the prescribed regimen

95
 Adh & compl …
The factors thought to influence patient adherence
A. Social and economic factors
o include age, social class, level of education, employment status, income, level
of literacy, lack of effective social support networks, unstable living conditions,
and family dysfunction

o Poor adherence - is higher in adolescents and elderly patients (but still present
in all age groups) 96
 Adhe & compl …
B. Healthcare team and system-related factors
o good relationships and communication between patients and health
professionals are important in helping patients to adhere to their medication

97
 Adhe & compl …
C. Condition-related factors
o Patients with particularly severe symptoms or rapidly progressing disease
may be more likely to adhere to agreed treatment regimens,

- whilst patients with depression are often less likely to be adherent to

medication

98
 Adhe & compl …
D. Therapy-related factors
o Complex regimens are associated with poor adherence.

o Medication regimens can be complex because they contain multiple different

medicines, or because they need to be taken several times a day

99
 Adh & compl …
E. Patient-related factors
o include patients’ knowledge and beliefs about, and attitudes to, medicines
and disease.

100
 Cont …
Concordance
 describes the relationship between health professionals and patients.

 Instead of patients either submitting (compliance) OR agreeing (adherence)

to decisions made by health professionals,
 in a concordant relationship the patient is an equal partner with the health
professional in decision making.
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NO POISON WILL KILL A POSSATIVE PERSON

MANY THANKS !!!

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