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Clinical Pharmacy By Sir.

Irfan Hamid
Lecture: Clinical Pharmacy Introduction

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CLINICAL PHARMACY
Definition:
 Clinical Pharmacy is a health specialty which describes the activities and services of a clinical pharmacist to develop and promote the rational and appropriate use of medicinal products and devices.  Clinical Pharmacy is the responsible provision of drug therapy for the purpose of achieving definite outcomes which improves the patient’s quality of life.

Discussion
  Clinical Pharmacy means a closer alliance of Pharmacist with Physician and Nurses. An alliance whose goal is to PATIENT provide safe and specific patientdrug information to medical and Nursing staff and critical eye in prescribing drug therapy Guidance of medical and Nursing Staff about monitoring of drug therapies and procedures necessary to observe , record and detect information used for clinical pharmaceutical judgment. The aim of health care team is to provide safe and effective medication to patient. Information provided to physician about patient medication ,drug monitoring , drug interaction ,adverse drug reaction , drug induced liver diseases and possible drug toxicities. Information provided Nursing staff about dosage time. Information provided to patient about drug ,using drinks ,food and other meal ,dose and duration of drug and all other instructions for safe medication.

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Aims of Clinical Pharmacy
 To maximize drug efficacy  To minimize drug toxicity  To promote cost effectiveness

Role of Clinical Pharmacist
These are the functions that a pharmacist would perform in clinical role: 1. Prescribing drugs 2. Dispensing drugs and administering drugs 3. Documenting professional activities 4. Direct patient involvement 5. Reviewing drug utilization 6. Education 7. Consultation 8. Clinical Trials

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Clinical Pharmacy By Sir. Irfan Hamid
Lecture: Clinical Pharmacy Introduction

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1. Prescribing Drugs

 Under certain circumstances , the pharmacist assist in planning drug therapy and may prescribe medication at request of physician.  Pharmacist involved in refilling of prescription may be regarded as performing a prescribing function.  Pharmacist in complying with standing order of the physician may be performing and independent prescribing function (Standing order refer to a pre-arranged plan between physician and pharmacist.  Prescribing Drugs  Pharmacist and pharmacy residence often help medical students to planned drug regimens.  Pharmacist prescribe OTC drugs.  Pharmacist prescribe medication in emergency situation.  Pharmacist after consulting with prescriber may select and dispensed a drug other then one prescribed by physician.

2. Dispensing and Administration of Drug
The responsibility for dispensing medication upon an order from a physician rests on the pharmacist and the staff.  Pharmacist receive and interprets the drug order and supervises the dispensing function.  Pharmacist should consult with the physician when the later prescribes products of suspected or of low quality.  Pharmacist has responsibility for dispensing or supervising the filling of orders that required technical skills(anticancer drugs, narcotics).  Pharmacist dispensing function in the hospitals overlaps with the administration of drugs performed by the nurse.  Pharmacist administer biological products for immunization e.g. vaccines , TPN

3. Documenting Professional Activities
    The Pharmacist is required to keep the certain record of his activities related to patients by checking of forms. Pharmacist should have a meeting with the patient for purpose of reviewing instructions and counseling for home use of medication. Pharmacist can make proper reporting of adverse drug reactions. Pharmacist prepare adequate record to assure himself of documented source of expending clinical experience which makes him drug specialist.

4. Direct Patient involvement
Pharmacist should have a direct contact with patient. Following functions can be performed by clinical pharmacist.  Conduct an admission interview.

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Clinical Pharmacy By Sir. Irfan Hamid
Lecture: Clinical Pharmacy Introduction
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Conduct a discharge interview. Provide patient education in personal health(smoking , drug reviews). Provide instruction in the use of appliances e.g. Inhalers. Interprets physician instructions as they relate to drug therapy as well as total treatment regimens.  Conduct a round in the hospital.

5. Reviewing Drug Utilization
   Developing or promoting plan for drug utilization review programme. Implementation of a local formulary system of a drug use control in the hospital and in community. Developing technique that will lead to identification of drug prescribing pattern by physician.

6. Education
 Education refers to those ongoing activities that are designated to influence the prescribing , dispensing and use of drugs,  Participates in continuing education through self-directed study.  Organize seminars and lectures for hospital staff  Participate in health education of the patient  Participate in public information programme to promote the respect for drug  Educate in hospital through grand round, teaching round and nursing conference

7. Consultation
   Pharmacist should exert a consultative function by being available to physician for advice and guidance. Some consultation with physician and patient are Screening process e.g. blood pressure determination Selection of drugs and monitoring of drug therapy

SCOPE OF CLINICAL PHARMACY

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There is a wide scope of clinical pharmacy. The need is the pharmacist practicing in clinical setting must be equipped with knowledge about drug therapy and can provide the latest and current information about each and every aspect of drug. He must be familiar with latest literature of medical & pharmaceuticals e.g. journals & researches in both fields Clinical pharmacist must be confident in providing information to physician Clinical pharmacist hopes to improve drug prescribing practicing by promoting safe and efficacious drug usage. Act as a resource person for drug therapy Can detect & prevent drug interactions and ADRs. Can detect & prevent possible drug interactions Can detect and prevent possible drug induced diseases Can detect & prevent possible drug toxicities

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Clinical Pharmacy By Sir. Irfan Hamid
Lecture: Clinical Pharmacy Introduction
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Can offer more services about handling, storage, distribution of drugs& can manage proper administration of drug The most common clinical pharmacy role model is that clinical pharmacist provides intensive services to patient in a hospital. Another role model for clinical pharmacist services as faculty for medical , nursing and pharmacy students about drugs. Another role model is associated with unit dose drug distribution system services provided that pharmacist is available at patient beside for maintenance of clinical reason. Safe handling & administration of drug will be ensured Proper choice of drug therapy & patient education & compliance

HISTORY OF PHARMACY
 In the catholic countries of Europe, the pation saint of pharmacy & medicine were Domain & Cosmos, twin brothers, practicing together about 300 years A.D.  Their healing powers of therapy were known throughout Asia.  Domain was serving as a pharmacist while Cosmos was a Physician.  The member of society of Apothecaries were found in 1617 not only dispense for physician but also recommend themselves for prescribing medicine  Despite the protest from physician, the Apothecaries legal right was to give medical advice was upheld in the house of Lords judgment in 1703  Under the Apothecaries act of 1815, they were allowed to charge for medical advice as well as for medicine they dispense  In this period, there is a close association b/w physician, pharmacist & patient; this was analogy to clinical pharmacy today.  There are several examples of clinical pharmacy practice.  In 1969, announcing change in title of journal drug intelligence to clinical pharmacy  Clinical pharmacy practice was analogous to clinical practice.  Development of unit dose drug distribution system  Development of drug information center

PATIENT TAKING HISTORY
WWHAM
Who is it for? What are the symptoms? How long has it been going on? Action taken? Medicine taken? CASE STUDY MR.JOHNSTONE, A young man who asks you to recommend something for Diarrhea.

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Clinical Pharmacy By Sir. Irfan Hamid
Lecture: Clinical Pharmacy Introduction

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You question Mr. Johnstone using the WWHAM structure W- Who is for? It is for himself. W- what are the symptoms? He is passing regular watery stools. H- how long have the symptoms persisted? Since late last night. A- action taken already? none,, but he has not eaten anything today. M- medicines being taken for other problems? Occasional Antacids for dyspepsia  From this information, as a pharmacist, you would want to explore :  What may have triggers the symptoms?  Obtain more detail about severity of symptoms  Any accompanying symptoms?  Mr. Johnstone tells you that he had Pub meal in the early evening yesterday and wonder whether this is?  What may have triggered the diarrhea?  When question about other symptoms, he tells you  He has also been sick, but there is no abdominal pain  He is passing stools less frequent now.  From this information you can conclude that it is likely due to:  He has eaten food which has been microbiologically contaminated Note:  This could be confirmed by locating other people who eat the same food with Mr. Johnstone at the pub last night, to find out if they are suffer from similar symptoms.  You recommend an oral rehydration sachet to Mr. Johnstone and advise him to fast for a day, although if he does feel hungry he may eat , but to avoid milk and dairy products as lactase is temporarily inactivated in the gut.  He should drink plenty of fluids and the diarrhea should subside completely in the next 2 days.  If it does not, he should visit his G.P.  He should also be advised to avoid taking Antacids that contain Mg2+ ion as they tend to have a laxative action which may aggravate his current condition.

AS METTHOD
Age of the patient? Self or for someone else? Medicine being taken? Exactly what do you mean by the symptoms? Time & duration of the symptom? Taken any action( medicine or seen the doctor)? History of any disease?

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Clinical Pharmacy By Sir. Irfan Hamid
Lecture: Clinical Pharmacy Introduction
Other symptoms? Doing anything to alleviate or worsen the symptoms?

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CASE STUDY Miss Anderson, She asks to speak the pharmacist in private she looks embarrassed, worried She tells you that she has had a vaginal discharge that is curdy and irritating for the last 2 days. Your question to Miss Anderson using the ASMETTHOD A- Age and appearance of the patient? She is a student who looks healthy but is embarrassed about this problem S- self or someone else? She is suffering from the symptoms herself. M- medication the patient is taking? She is taking the contraceptive pills and recentally had a course of antibiotics for chest infection. E-Exactally what does the patient mean by the symptoms The discharge is thick and creamy but not colored or smelly. There is no bleeding T- Time/ duration of the symptoms? She has noticed the symptoms from last 2 days. T- Taken anything for it or seen the doctor? No H-History of any disease or condition? No O- Other symptoms being experienced? The vulval area is itchy and it is quite painful when she passes water D- Doing anything to aggravate or alleviate the conditions? She has been having hot baths to try to relieve the symptoms, but this has not helped much.  The pharmacist suspects that Miss Anderson is having an attack of the fungal infection, thrush, caused by the organism Candida albicans  This infection commonly follows a course of antibiotics, which kills the commensal bacteria of the vagina which normally keep the growth of Candida under control. The symptoms confirm this:  There may also be a link b/w the use of oral contraceptives and candidiasis b/c the vaginal environment may be altered making it more susceptible to overgrowth of Candida There is no suggestion that there is any other vaginal infection as there is,  No offensive smell or coloured discharge  Now blood in the discharge  Which might indicate a more serious underlying cause.

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Clinical Pharmacy By Sir. Irfan Hamid
Lecture: Clinical Pharmacy Introduction

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The pharmacist asks Miss Anderson  If she has ever suffered from vaginal thrush b/f or she has not, to her knowledge  As this is 1st time she has suffer from the symptoms  She is advised to visit her G.P for confirmation of the suspected diagnosis  An intra vaginal Imidazole treatment such as pessary or cream, is the most effective drug of choice but, must be prescribed by the G.P in this case  Hot bathes, especially if she has use perfumed bath additives, will probably aggravate and irritate the condition.  Warm salt baths or showers may be more soothing.  Miss Anderson can also be advised to avoid tight fitting and synthetic clothing such as tights and to wear cotton under wear.  Topically application of vinegar or yogurt should be discouraged as this can reduced the effectiveness of the Imidazoles.

SITDOWNSIR
Site or location? Intensity or severity? Type or nature? Duration? Onset? With other symptoms? aNnoyed or aggravated by? Spread or radiation? Incidence or frequency pattern? Relieved by?

ENCORE

E = Explore→ NOCEO
Nature of symptoms? Obtain identity of the patient? Concurrent medication or treatment? Exclude possibility of serious disease? Other associated symptoms?

N → No medication C→ GPPL
Geriatric patient (the patient at recovery stage) Pediatric patient Pregnant women Lactating mother

( During pregnancy B.P is increased called pre-eclampsia in this disease the foetus may be aborted, the foetus is considered as foreign body. During 1st trimester no hypotensive drug should be used

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Clinical Pharmacy By Sir. Irfan Hamid
Lecture: Clinical Pharmacy Introduction

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O→ ODD
Other telltale sign Demeanor of the patient (general condition) Dramatization of the patient

R = Refer → PPP
Potentially serious case Persistent symptoms Patient at increased risk

E = Explain ( discuss with the patient why this treatment given. The symptoms are relieved
or not. It is decided by the physician which information should be given to the patient).

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