PHARMACY PRACTICE EXPERIENCE

LECTURE-9

THERAPEUTICS PLANNING

Dr. Vinoth Prabhu Veeramani. Dr. Hanan Alshareef.

Assistant Professor, Assistant Professor,
Department of Pharmacy Practice, Department of Pharmacy Practice,
Faculty of Pharmacy, Faculty of Pharmacy,
University of Tabuk, University of Tabuk,
Kingdom of Saudi Arabia. Kingdom of Saudi Arabia.
Email: vveeramani@ut.edu.sa Email: halsharef@ut.edu.sa

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 PHARMACY PRACTICE EXPERIENCE (PDPP 0423)

THERAPEUTICS PLANNING
CONTENTS
Learning Objectives

1. Introduction

2. List of components of therapeutics planning process.

1. Identify the problems.

2. Prioritize the problems.

3. Select the patient-specific drug and non-drug intervention.

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 LEARNING OBJECTIVES
At the end of the lecture you should be able to/ understand:

1. List the components of the therapeutics planning process.

2. List the steps involved in patient problem identification.
3. List the steps involved in problem prioritization.
4. List the steps involved in the selection of specific therapeutic regimens.
5. Select patient-specific therapeutic regimens.

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1. INTRODUCTION
Effective planning facilitates the selection of appropriate drug and
nondrug interventions (including patient education) for specific patient
problems and provides a framework for monitoring a patient’s response
to the drug and nondrug interventions.

2. LIST OF COMPONENTS OF THERAPEUTICS PLANNING PROCESS.

1. Identify the problems

Step 1 — Obtain patient data
Step 2 — Group-related data
Step 3 — Determine each problem
Step 4 — Assess each problem

2. Prioritize the problems

Step 1 — Identify the active problems
Step 2 — Identify the inactive problems
Step 3 — Rank the problems
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3. Select patient-specific drug and nondrug interventions
Step 1 — Determine short-term and long-term goals of therapy
Step 2 — Create a list of options
Step 3 — Eliminate options based on patient-specific and external factors
Step 4 — Select appropriate drug and nondrug interventions
Select drug dosage, route, interval, and duration of therapy
Step 5 — Identify alternative interventions

4. Develop a monitoring plan

Step 1 — Determine specific monitoring parameters
Select specific target outcomes
Select monitoring intervals for each parameter
Step 2 — Integrate the monitoring plan
Step 3 — Obtain data
Step 4 — Assess the response to therapy

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1. IDENTIFY THE PROBLEMS
Seek out patient data from all sources; consider all available patient data.
Look for relationships among the data, then group the related subjective and
objective data together to determine the specific patient problems.
Assess each patient problem.

STEP 1 — OBTAIN PATIENT DATA

Consider all available patient data. Review all previously charted data (history,
physical examination findings, results of laboratory and diagnostic tests) and
interview the patient for the patient’s medication history.

Review all relevant data resources, including data from the current patient
chart (hard copy and electronic), data from past charts (e.g., previous hospital
admissions), data obtained from patient interviews or interviews with relatives

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 Pertinent positive data (abnormal findings) include abnormal laboratory
results, abnormal signs and symptoms described by the patient (e.g., the
patient’s description of the signs and symptoms of her migraine headache),
and abnormalities noted on physical examination (e.g., a blood pressure of
160/110 mm Hg), and are relatively easy to identify.

Pertinent negative data (findings that are normal but, given the patient’s
disease or condition, would have been expected to be abnormal) are more
difficult to recognize, and identifying them requires a good understanding
of human disease and pharmacotherapeutics.

For example, many patients with longstanding type 1 diabetes mellitus

develop diabetic retinopathy.

Subdivide the data into lists of subjective data and objective data.
Subjective data (Box 7-2).,and Objective data, (Box 7-3).

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STEP 2 — GROUP-RELATED DATA
Evaluate the list of objective and subjective data for possible relationships
among the data. This step requires comprehensive knowledge of the signs
and symptoms of disease and pharmacotherapy and becomes easier with
experience.

STEP 3 — DETERMINE EACH PROBLEM

Evaluate each group of related subjective and objective data items to
determine the specific patient problem or issue. The problem is not always a
specific diagnosis but may be a preliminary identification of the issue pending
acquisition of additional data (e.g., acute diarrhea, not shigellosis).

Patient problems include current medical problems such as hypertension,

pneumonia, asthma, diabetes, and gastrointestinal bleeding; past medical
problems such as a history of migraine headache and issues such as non-
adherence, obesity, illicit drug abuse, alcohol use, tobacco use, and
allergies.

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STEP 4 — ASSESS EACH PROBLEM
Each problem is then assessed in terms of each of the following characteristics:
• Acuity (acute or chronic)
• Severity (mild, moderate, or severe)
• Symptom level (symptomatic or asymptomatic)
• Treatment status (treated or untreated)
• Degree of control (controlled or uncontrolled)
• Classification (staging of disease)

2. PRIORITIZE THE PROBLEMS

The second step in the planning process is prioritization of the patient
problems.

Prioritization means ranking the patient problems with the most urgent
problems at the top of the list and the least urgent problems at the bottom
of the list.
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STEP 1 — IDENTIFY THE ACTIVE PROBLEMS
Active problems are problems that require some kind of drug or nondrug
intervention to resolve and/or manage the problem.

Examples of active problems include pneumonia, asthma, congestive heart

failure, dyslipidemia, osteoporosis, diabetes mellitus, trauma, anxiety,
cerebrovascular accident, hypertension, renal failure, hepatitis, leukemia,
migraine headaches, and myocardial infarction.

STEP 2 — IDENTIFY THE INACTIVE PROBLEMS

Inactive problems are problems that do not require any kind of drug or
nondrug intervention and are of historical interest only.
Examples of inactive problems include a history of an appendectomy at age
12, a history of pneumonia 2 years ago.
inactive problems are still identified and listed on the patient problem list so
that they can be considered when planning drug and nondrug interventions
for active problems.
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STEP 3 — RANK THE PROBLEMS

Rank-order the active patient problems. One approach to ranking patient

problems is to identify the problem that needs the most immediate attention
and then rank the remaining active problems in order of need for intervention.

Lists are developed based on the clinical judgment and experience of the
practitioner.

3. SELECT PATIENT-SPECIFIC DRUG AND NONDRUG

INTERVENTIONS
Once the prioritized patient problem list is developed, the next step is to
select patient-specific drug and nondrug interventions for each patient
problem, including initial and alternative drug and nondrug interventions.

Determine appropriate nondrug interventions, including patient education.

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 Determine an appropriate medication regimen for each patient problem that
can be treated and/or managed with medications.

For each medication selected, include

The dosage (e.g., 50 mg, 1 g, a pea-sized drop of lotion, one teaspoonful,
two puffs),
The dosage formulation (e.g., tablet, capsule, liquid, suppository,
ointment, dry-powder inhaler),
The route of administration (oral, topical, ophthalmic, optic, intravenous,
rectal, inhaled),
Dosing interval (e.g., daily, two times a day, four times a day, every 8
hours, once a month),
Duration of therapy (e.g., 7 days, one time only, long term), and
Rationale (the evidence-based reason for selecting the patient-specific
therapeutic intervention).

The general approach is to develop the therapeutic plan for each problem and
then integrate the individual plans, with care taken to ensure that each
component of the plan is appropriate given the other plans and that the overall
integrated plan is achievable for the patient.
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 Selection of a specific regimen requires assessment of each patient
problem in the context of everything that is known about the patient such as
patient other problems and medications, social habits, cultural beliefs, and
willingness to commit to a course of therapy, as well as external factors
such as insurance coverage and access to refrigeration for storage of
refrigerated medications (Box 7-4).

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STEP 1 — DETERMINE SHORT-TERM AND LONG-TERM GOALS
OF THERAPY
All drug and nondrug interventions should be in the context of the specific
short-term and long-term goals of therapy, which may or may not be the
same depending on the specific patient problem.

For example, the short-term goal for a patient being treated for a
hypertensive emergency is to reduce the diastolic blood pressure to 100 to
105 mm Hg within 2 to 6 hours of presentation with a maximum reduction of
25% or less of the initial diastolic blood pressure.

The long-term goal is to reduce the diastolic blood pressure to 85 to 90 mm

Hg over the next 2 to 3 months to reduce the long-term morbidity and
mortality associated with the elevated diastolic blood pressure.

Consider the severity of disease and the short-term or long-term nature of

therapy when setting therapeutic goals.

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STEP 2 — CREATE A LIST OF OPTIONS
Identify all classes of drugs and possible therapeutic approaches for each
problem; do not eliminate any option at this stage of planning.

The options list is usually a mental list, although students and inexperienced
clinicians may find it helpful to create and then work from a written list.

STEP 3 — ELIMINATE OPTIONS BASED ON PATIENT-SPECIFIC

AND EXTERNAL FACTORS
Once all therapeutic options are identified, eliminate options based on the
comparative effectiveness of the drugs; the suitability of the drug for the
patient given the other patient medical conditions and drug therapies;

The ability of the patient to adhere to the proposed regimen; and other
factors such as the effectiveness of previous treatment regimens, cost, and
formulary restrictions.

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STEP 4 — SELECT APPROPRIATE DRUG AND NONDRUG
INTERVENTIONS
Decisions about appropriate drug and nondrug interventions are based on past
patient experiences, assessment of the severity of the problem, drug-specific
factors such as the therapeutic index of the drug, and specific patient factors
such as the presence of chronic renal or hepatic disease that may influence the
elimination or metabolism of the drug.

Determine the best drug and nondrug regimen, including each specific drug to
be used, dosage, route, duration of therapy, and rationale for the selection of
each drug and nondrug component of the regimen.
STEP 5 — IDENTIFY ALTERNATIVE INTERVENTIONS
An important part of the planning process is anticipation of potential patient
problems with the prescribed and/or recommended drug and nondrug
interventions (“what if”).

A well-thought-out plan includes alternative medication regimens for common

potential problems, such as the development of an allergy or ADR.
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 STANDARD REFERENCES
1.1 Clinical Skills for Pharmacists: A Patient-Focused Approach by Karen J
Tietze, Mosby Inc. (ELSEVIER), St. Louis.
1.2 Motivational interviewing in health care - Helping patients change behavior,
Stephen Rollnick, William R. Miller and Christopher C. Butler, The Guilford
Press, New York.
1.3 A practical guide to Contemporary pharmacy practice, Judith E. Thompson,
Lawrence W. davidow, Lippincott Williams & Wilkins.
1.4 Pharmacotherapy, A Pathophysiologic approach, by Joseph T. Dipiro,
Robert L Talbert, Gary C Yees, McGraw-Hill Companies.
All Books are available at www.amazon.com
Note: Apart from lectures PPTs Independent Self learning from the Textbooks
and Internet Web Resources are highly encouraged.

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