PHARMACOTHERAPY

The treatment of disease with drugs

OR
The healing and cure of illness by
the administration of drugs
Function of pharmacist to perform
The pharmacist ,who is the central figure of
pharmaceutical care, then he has the following
functions to perform;
• Collection of patient data.
• Identification of problems.
• Establishing outcome goals through a good therapeutic
plan.
• Evaluating treatment alternatives, by monitoring and
modifying therapeutic plan.
• Individualizing drug regimens.
• Monitoring outcomes.
 PHARMACISTS’ WORKUP OF DRUG
THERAPY (PWDT)
• The PWDT is a thought process which is meant to
serve as a systemic guideline for the documentation
of clinical pharmacy activities and is NOT intended as
a form to be completed on each patient seen by the
pharmacist.
• The thought process represented by the PWDT occurs
in a matter of minutes in the mind of the experienced
clinical pharmacist.
• This process represents what the clinical pharmacist
does by describing how the clinical pharmacist thinks
about what it is he has to do.
• The PWDT is a very effective process for pharmacists providing continuous
medication monitoring (CoMM) activities during the dispensing functions,
wherein efficient use of time is of absolute importance.
importance In this setting,
pharmacists need to make the most of brief encounters with their patients.
Pharmacists who are focused and follow a standardized process may be
surprised by how much information they can collect from patients.

• It’s not that the pharmacist needs to collect the same information with each
encounter, but that the information collected depends on the clinical situation
and the pharmacist’s concerns about the patient’s medications.

• Over time, by collecting information during each patient encounter, a

pharmacist creates a comprehensive patient record.
record This patient record
provides a clearer clinical picture so that pharmacists can confidently and
competently provide clinical recommendations to prescribers.
 Major Steps
1. IDENTIFYING ISSUES ASSOCIATED WITH THE PATIENT'S DRUG
THERAPY:
• During this process the information gathered by the pharmacist is
interpreted within the context of a specialized knowledge base ranging
from organic chemistry to advanced therapeutics to determine what is,
and what is not, a therapeutic problem for the patient. Effective clinical
reasoning requires that the pharmacist establish a strong database,
including:
(a) General patient data such as age, sex, height, weight, medical
problems, present medications, past and present medical history,
medication history, allergies, smoking/alcohol history, and compliance
behavior history.
(b) A pharmacological review of systems including a review of vital signs
and pertinent laboratory results; each organ system must be evaluated
for the effect drugs may have on it and for the possible effects that
organ system dysfunction may have on the disposition of drugs.
(c) An assessment of the patient's existing drug therapy, drawing on
therapeutic and pathophysiological databases.
2. PHARMACIST'S LIST OF PATIENT-SPECIFIC,
DRUG-RELATED PROBLEMS:
• The collection and processing of relevant data should
result in a list of patient-specific, drug-related problems
that the pharmacist is uniquely prepared to address
and for which he assumes responsibility.

3. STATEMENT OF DESIRED THERAPEUTIC

OUTCOME:
• It is necessary to identify the desired therapeutic
outcome for each problem identified above.
4. IDENTIFYING THERAPEUTIC ALTERNATIVES:
• Most therapeutic problems have more than one empirically
acceptable solution. The pharmacist must identify the multiple
alternative solutions to each identified problem with a list of
alternatives that goes beyond the commonly accepted drug-of-
choice.
• Upon identifying and passing clinical judgment on all available
options, the pharmacist applies skills in comparative analysis,
which requires a critical review of the medical literature, a
comparison of clinical experiences, and the application of clinical
decision-making skills.
5. PHARMACIST'S DRUG RECOMMENDATION AND
INDIVIDUALIZATION OF THERAPY:
• This stage of the PWDT requires the pharmacist to select the
most appropriate solution to the drug-related problem. This
decision should range from no drug therapy to the best
pharmacotherapy for the patient.

• It should also encompass the patient-specific, individualized dose

of the drug, frequency of administration, appropriate method of
administration, and the duration of treatment. The pharmacist's
recommendation should incorporate therapeutic efficacy, safety,
comfort and convenience, and adherence to the therapeutic
regimen. Moreover, cost considerations must be incorporated
into the chosen therapeutic action plan.
6. THERAPEUTIC DRUG MONITORING PLAN:
• Clearly, the problem-solving process is incomplete until
the process of monitoring produces data that serve to
empirically support the recommended solutions. The
therapeutic drug monitoring process must reflect an
active involvement by the pharmacist.
• The therapeutic drug monitoring plan for each patient
consists of an active process together data documenting
that the desired drug effects are occurring and the
patient is not experiencing any undesirable drug effects.
Feedback is an essential part of the problem-solving
process. Data provided through comprehensive patient
monitoring should be reintegrated at all stages in the
process.
 Types of Pharmaceutical Care
1. SOAP Analysis.
2. CORE Pharmacotherapy plan.
3. FARM Analysis.
4. PRIME Pharmacotherapy plan.
 SOAP Analysis
• S= Subjective findings.
Exp-chief complaints and duration or severity of
symptoms.
• O= Objective findings.
Exp-laboratory data, weight, height, blood
pressure, and pulse.
• A= Assessment.
Exp-Diagnosis or possible explanations for the
patients medical problems.
• P= Plan.
Exp-Drug regimen or surgical procedure
Objective data
 Develop or identify the CORE
pharmacotherapy
• C=Condition or patient need.
it may include nonmedical conditions or need and is thus not
a reiteration of the current medical problem.
• O=outcome, desired for the condition or needs.
Patient outcomes (POEMS
POEMS: patient oriented evidence that
matters).
POEMs have to meet three criteria:
•They address a question that doctors encounter.
•They measure outcomes that doctors and their patients
care about: symptoms, morbidity, quality of life, and
mortality.
•They have the potential to change the way doctors practice.
Therapeutic end point
• A therapeutic end point represents the
pharmacological or therapeutic effects that is
expected, ultimately, to achieve the desired
outcome.
• More than one end point is usually needed to
achieve an outcome. for example, both near
normal glycemic control and normalization of
blood pressure are necessary to significant
reduce the risk of end-stage renal disease
• R=regimen to achieve desired outcome.
Therapeutic regimens (Existing therapy and
Initial therapy)
Goal setting and behavior regimens (Identify
the type of goal being set).
• E=Evaluation parameter to assess outcome
achievement.
Efficacy parameters.
Toxicity parameters (ADRs, allergic reactions, or
toxicity).
 Formulate a FARM progress note
Formulate a FARM note or SOAP note to describe
and document the interventions intended or
provided by the pharmacist.
• F= findings.
The patient-specific information that gives a basis
for, or leads to, the recognition of a
pharmacotherapy problem or indication for
pharmacist intervention, finding include
subjective and objective information about the
patient.
• A= assessment.
a) Any additional information that is needed to
best access the problem to make
recommendations.
B) The severity, priority or urgency of the
problem.
C) The short-term and long term goals of the
problem (Short term goals: eliminate
symptoms, lower BP to 120/80 mmHg within 6
weeks, manage acute asthma without
requiring hospitalization).
• R= resolution. (including prevention) The
intervention plan includes actual or proposed
action by pharmacist
1. observing, reassessing.
2. Counseling.
3. Making recommendations to the patients.
4. Informing the prescriber.
5. Making recommendations to the prescriber.
6. Withholding medication or advising against
use.
• M=monitoring and follow up.
1. The parameter to be followed (pain, depressed mood,
serum potassium level)
2. The intent of the monitoring (efficacy, toxicity,
adverse event).
3. How the parameter will be monitored (patient
interview, serum drug level, physical examination).
4. Frequency of monitoring (weekly, monthly)
5. Duration of monitoring (weekly, monthly)
6. Duration of monitoring (until resolved, while on
antibiotic, until resolved them monthly for 1 year).
7. Anticipated or desired finding (no pain, euglycemia,
healing of lesion).
8. Decision point to alter therapy when or if outcome is
not achieved. (pain still present after 3 days, mild
hypoglycemia more than two times a week).
• Pursue the role of drug therapy practitioner over that of drug therapy advisor.
1. Teamwork, communication and collaboration between health professionals are
important for the safe and effective delivery of health care.
2. Approximately 6% of hospital admissions are associated with adverse drug events and
high error rates during transfer of care.
3. Poor communication was the most important common factor contributing to
medication errors. Increased intraprofessional collaboration between doctors and
pharmacists could therefore reduce the considerable medication-related morbidity
and mortality.
4. Pharmacy practice in developed countries now involves patient-
patient-centered care
including counseling, providing drug information, monitoring drug therapy and patient
adherence, as well as the supply of medicines.
5. Over the last decade, the role of pharmacists in the community has expanded with the
provision of many professional services including medication reviews, diabetes and
asthma management programs, and patient medication profiles.
profiles
6. It is in the additional role of managing medication therapy, in collaboration with
prescribers, that pharmacists can now make a vital contribution to patient care. To do
so, the role of the pharmacist needs to be redefined and reoriented.
7. The traditional relationship between the doctor as prescriber, and pharmacist as
dispenser, is no longer appropriate to ensure safety, effectiveness and adherence to
therapy.
8. Pharmacists need to pay more attention to patient-centered, outcomes-focused care
to optimize the safe and effective use of medicines. Dispensing is, and must remain, a
responsibility of the pharmacy profession. By taking direct responsibility for individual
patients' medication-related needs, pharmacists can make a unique contribution to
the outcome of medication therapy and to their patients' quality of life.
 Participate in
pharmacotherapy
decision--making
decision
 Formulating decision rationale that
Proactively engaging decision
is the result of rigorous inquiry,
making opportunities.
scientific reasoning , and evidence.

Identifying
opportunities for
decision-making.

Pursuing the highest level of

decision making, Seeking
independence in making decision
and accepting personal Personally enacting decisions.
responsibilities for the outcomes to
patients resulting from one`s
decisions.
• Pharmacists and general practitioners can work together in a primary care
environment, although a greater degree of trust and collaboration is required.
Trust appears to grow over time. When pharmacists are co-located with general
practitioners there is a greater opportunity for trust to develop. However, the full
effect of pharmacist integration may take longer than one year to perceive
clearly.
• Studies that have integrated pharmacists into primary care practices have shown
improved patient outcomes. Collaborative models have improved the treatment
of many diseases. Pharmacists have the potential to optimize drug therapy by
identifying medication-therapy problems and recommending solutions.
Prescribers are receptive to such recommendations.
• Pharmacist
Pharmacist––patient consultations in relation to medication management within
general practitioners' surgeries and in patients' homes have high acceptability to
patients.
• A role for a pharmacist within a general practice has been proposed to provide
multiple risk management strategies to improve medication safety.
safety The role
would focus on interventions to high-risk patient groups and disease states, and
would use practice information technology systems to detect potential safety
problems.
• Collaborative medication reviews are included in many general practitioner and
pharmacist practices, clinical practice guidelines and decision support tools.
Several randomized trials have shown improvements in prescribing, and reduced
healthcare use and medication costs following medication reviews in patients
with hypertension, hyperlipidameia and diabetes.
• The evidence supporting the benefits of home medicines
reviews continues to expand. They can be effective in
delaying the time to next hospitalization for heart failure,
identifying drug-related problems among people receiving
treatment for mental illnesses, and assisting in the
resolution of medication-related problems. Medication
reviews after discharge from hospital have reduced
morbidity and mortality in patients with heart failure.

• Despite this evidence and considerable support by the

Pharmacy Guild and Divisions of General Practice, home
medicine reviews are still underused. For example, they are
not used enough in the detection and prevention of
medication-related problems in cardiovascular disease.
CARE PLAN (GOAL)