MODULE 3

CLINICAL PHARMACY
CLINICAL PHARMACY With re-existing kidney disease
Children and teenagers who are recovering from a viral
A health science discipline in which pharmacist provide infection
patient care that optimizes medication therapy and promotes
health, wellness, and disease prevention. (American College Cough medicines
of Clinical Pharmacy)
It includes broad responsibility for safe and appropriate use Important points to remember:
of drugs in patients which include: the ingredients whether it is an expectorant or antitussive
Rational selection Avoid using the cough preparations for more than 7 days
Monitoring Use only the correct dose. High doses of preparations can
Dosing cause serious problems such as brain damage, seizure or
Control of the overall drug therapy program death.
Use the correct dose for children. For ages 4-6, ask the
Pharmaceutical Care
Is a cooperative, patient-centered system for achieving
specific and positive patient outcomes from the responsible OTC drugs are safe but not risk-free
provision of medicines. (Hepler and Strand, 1990)
Misuse and abuse of OTC drugs can lead to:
Medicines optimization
Aims to ensure that the right patients get the right choice of Physical dependence
medicine at the right time. Phycological dependence
The purpose is to help patients take their medicines
appropriately and, by doing so, avoid unnecessary treatment, Examples of OTC drugs that can severely habit-forming:
improve safety and outcomes, and reduce wastage. (Royal
Pharmaceutical Society, 2013)
Decongestants
Laxatives
CHARACTERISTICS OF CLINICAL PHARMACY
Antihistamines
Sleep aids
1. Not product oriented but patient oriented Antacids
2. Primary objective: rational drug use
Ephedrine
3. Practice in both community and hospital setting
4. Multidisciplinary CLINICAL PHARMACY SETTINGS
RATIONAL DRUG USE Hospitals
Community pharmacies
Requires that patients receive medications appropriate to
Nursing homes
their clinical needs, in doses that meet their own individual Home-based care services
requirements for an adequate period of time, and at the Clinics
lowest cost to them and their community. (WHO, 1985)
Any other setting where medicines are prescribed and used
schedule, Route, and Cost and Patient APPLICATION OF DIFFERENT SCIENTIFIC PRINCIPLES:
RATIONAL USE OF OTC DRUGS Pharmacology
Toxicology
Over-the-counter (OTC) drugs, also known as
Therapeutics
nonprescription medicines, are drugs which are safe and Clinical pharmacokinetics
Pharmacoeconomics
prescription
Pharmacogenomics
They are primarily used for symptomatic relief and not as
substitutes for prescription drugs PHARMACEUTICAL CARE PROCESS
Pain relievers Assessment
Paracetamol or acetaminophen 1. Asses the patient for drug-related problems.
NSAIDs
2. Determine whether drug-related problems are being treated
3. Determine whether current drug therapy is appropriate
In using Paracetamol: 4. Determine whether additional drug therapy is needed
Taking a higher dose than recommended will not provide
5. Determine if any of the drug-related problems may have
more relief and can be dangerous been caused by medication
Overdose of paracetamol can lead to necrosis and death
Infant drops can be significantly stronger than regular
Care Plan
1. Approach normal physiology (i.e., normalize blood pressure)
2. Slow progression of disease (i.e., slow progression of
In using NSAIDs:
cancer)
With NSAIDs, too much can cause stomach bleeding and 3. Alleviate symptoms (i.e., optimize pain control)
risk is increased in people over 60 years of age, concurrently 4. Prevent adverse effects
taking blood thinners, steroid and other drugs which can
5. Control medication costs
cause GI irritation, and who have history of stomach bleeding 6. Educate the patient about his/her medication
or ulcers
For children, naproxen sod
Evaluate of outcome
age 1. progress
Ibuprofen is considered safe for children 6 months and older 2. Monitor potential adverse drug reactions
in the right dose
3. Determine desired end points for each parameter and the
Before taking NSAIDs, consider the following: frequency of monitoring
Over age 60
Taking diuretic
Have high BP and heart disease

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 OUTCOME OF PHARMACEUTICAL CARE Family History
-degree relatives
Social history
Modifying or curing of disease process Use of tobacco, alcohol, illicit drugs
Improve the prognosis of patients Computing for Pack years
Identifying and resolving drug related problems
Preventing drug misadventures
1 pack of cigarette = 20 sticks
KNOWLEDGE AND SKILLS OF CLINICAL PHARMACIST Occupation
Marital status
Expert knowledge on drug and non-drug therapy Sexual history
Knowledge on lab and diagnostic test Living conditions
Good understanding of disease process Review of Systems (RoS)
Physical assessment skills Summary of [patient complaints not included in
Therapeutic planning skills HPI
Drug monitoring
Provision of drug information 4. Physical Examination
Communication skills Short description
Vital signs
ROLES OF A CLINICAL PHARMACIST Body temperature
Pulse rate
Interact with health care team (MD, RN, paramedics) Respiration rate
Interview and assess patient (patient medication history) Blood pressure
Review medication order and make therapeutic Systemic examination
recommendations
Monitor patient response to drug therapy PHYSICAL ASSESSMENT TECHNIQUES

CLINICAL PHARMACY SERVICES Vital Signs

I. MEDICATION HISTORY TAKING AND DOCUMENTATION Body Temperature (37 0.5 )

Can be measure in:
Patient Medication Profile (PMF) Oral most accessible and accurate
Written summary of all the medicines taken regularly, Rectal accurate but uncomfortable
including over-the-counter and complementary medicines Axillary least accurate, most safe
Assist to understand and manage medicines by informing Tympanic
how, why and when to take medicine Abnormal findings:
Hyperthermia
Medication Reconciliation Process Hypothermia
Medication reconciliation is the process of creating the
most accurate list possible of all medications a patient is Pulse rate (60 100 beats/ minute)
taking including drug name, dosage, frequency, and route Radial pulse most easily accessible
Femoral or carotid pulse palpitate in emergency cases
transfer, and/ or discharge orders, with the goal of providing Abnormal findings:
correct medications Irregular pulse rhythm Bradycardia, Tachycardia
the ideal medication reconciliation process begins with
conducting a thorough patient medication interview and Respiratory rate (16 20 breaths/ minute)
obtaining an accurate list of all current medications from the Abnormal findings:
patient and/ or caregiver Prolonged expiration suggesting narrowing in
bronchioles (asthma)
Patient Medical Chart (PMC) Sounds: wheezing or stridor
Contains all significant clinical information which enables the Apnea no breathing
physician to give effective continuing care to the patient Bradypnea abnormally slow
Used as basis for drug therapy plan for patient Tachypnea abnormally fast

Part of PMC Blood pressure (<120 and <80)

Abnormal findings:
1. Patients Data Sheet Hypertension may caused by anxiety
Patient demographics Cardiac disease difference of 15mmHg or more
identification and sociological data between arms
Admission & Final diagnosis Orthostatic hypotension drop of 20 mmHg or more
Condition upon discharge from sitting to standing position
Discharge summary Venous congestion or hypertension silent period
Autopsy (auscultatory gap between systolic and diastolic
sounds)
2. Consent form
Permission or approval given by patient for admission, IPPA
testing, procedure and access to health related or
personal information Inspection
Consent must be given freely and without coercion Visual examination of the patient
It includes use of the 5 senses
3. History
Chief Complaint (CC) Palpation
Reason/s the patient is seeking medical care or The use of the hand to feel skin texture and contour, and
attention masses below the surface.
History of Present Illness (HPI) Temperature and vibration can also be detected by
Narrative palpation.
Current medical problem Light palpation to check muscles tone and assess for
Past Medical History (PMH) tenderness
Current and previous patient problems
Unrelated to present illness

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 Deep palpation to identify abdominal organs and Drug interactions
abdominal masses. Also, for hard-to-reach organs (liver, Adverse drug reactions
spleen, kidney) Medication errors

Percussion PRESCRIPTION
Is used to elicit a sound which reflects the density of
underlying tissue and structures. Written order and instruction of validly registered physician,
Tapping the body directly or tapping a finger placed on the dentist, veterinarian for use of specific drug for specific
body patient
Determine size and shape of underlying structures by
establishing their borders and indicates if tissue is air- Prescription or ethical drugs
filled, fluid filled, or solid Prescribed by a doctor
Dull percussive sounds indicative of abnormal lung Bought at a pharmacy
density; presence of a solid mass under the surface Prescribed for and intended to be used by one person
Hyperresonance on percussion indicates too much Regulated by FDA through the New Drug Application (NDA)
air is present within the lung tissue. process
Non-prescription of OTC drugs
Auscultation Over-the-counter drugs
listening to sounds produced by the body originating in Dispensed without prescription and for prevention of
internal organs symptomatic relief of minor or self-limiting illness
Direct auscultation use of unaided ear
Indirect auscultation using stethoscope

General sequence: Ins Pal Per Aus 1

Abdomen assessment: Ins Aus Per Pal .

5.
progress notes are located in the left part,
written in SOAP format 3
are written at the right part directly .
opposite the progress notes 2
.
6. Consultation, Examination and Findings 4
.
7. Graphic chart
8. Fluid input and output record
9. Medication Administration record 5
Accomplished by the bedsides nurses every shift .
10. Multidisciplinary Progress Notes 6
Used by all other medical professionals except for .
physicians for documentation 7
.
11. Laboratory results

DOCUMENTATION

Means by which healthcare professionals communicate with

one another 8
.
Soap
1.
Non-reproducible 2. Date of prescription was written
3.
Objective 4.
The observations of the physician during the examination 5. Inscription medication prescribed
and the laboratory results 6. Subscription dispensing instruction to pharmacists
Measurable and reproducible 7. Signa direction to the patient
8.
Assessment
The Yellow Prescription
diagnosis Partial filling is allowed
Not all dangerous drugs require a yellow prescription for it to
Plan be dispensed (especially all tablets except oxycodone and
The treatment plan to correct the illness or problem morphine)
There should be a plan for each assessment made and the Brand name is not required in prescribing the drug
plan will follow the same numerical format as assessment
Prohibited drug
II. MEDICATION ORDER REVIEW Opium and its active components and derivatives (heroin
and morphine)
Medication order review by pharmacists is a multistep Coca leaf and its derivatives (cocaine; alpha and beta
process in which pharmacists evaluate orders (prescriptions) eucaine)
for safety, efficacy, and appropriateness by examining drug- Hallucinogenic drugs (mescaline, lysergic acid diethylamide,
and patient-related factors Indian hemp and its derivatives
And other drugs, whether natural or synthetic, with the
Patient
physiologic effects of a narcotic drug

Physician Pharmacist

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Regulated drug Drugs with Narrow TI:
Carbamazepine Cyclosporine
Self-inducing sedatives (secobarbital, Phenobarbitals, Phenytoin Anticonvulsant Levothyroxine
barbital, amobarbital and any other drug which contains a Valproic acid Vancomycin
salt or derivative of a salt of barbituric acid) Digoxin Isotretinoin
Amphetamine salts and isomers (Benzedrine or Dexedrine) Lithium Amphotericin B
Hypnotic drugs, such as methaqualone or any other Warfarin Amiodarone
Heparin Aminoglycosides
compound producing similar physiologic effects
Theophylline Clomipramine
Methotrexate Amitriptyline TCAs
Restricted Antimicrobials Clozapine Rifampicin

Amikacin Chloramphenicol Piperacillin +

Therapeutic Index (TI)
IV/PO* Tazobactam
Amphotericin B Flucytosine Sodium fusidate IV
Ratio of TD50 and ED50
Aztreonam Linezolid Tobramycin Determines how safe or toxic the drug is
Ciprofloxacin* Meropenem Cefuroxime
Ceftazidime Nalidixic acid Ertapenem Drug TD50 ED50 TI
These antimicrobials may only be prescribed and supplied after A 50 10 5
approval from a consultant Microbiologist. Pharmacist are required B 100 25 4
to confirm Microbiology approval of formulary indication before C 30 3 safest
dispensing restricted antimicrobials Therapeutic
effect Toxic
effect
III. REPORTING AND EVALUATING ADRs

Adverse Drug Reactions (ADR) TI

Any response to a drug that is noxious and unintended, 50%
which occurs at doses normally used (vs toxicity) in man
for prophylaxis, diagnosis, or therapy of disease, or for the
modification of physiologic function

Serious adverse event (events relating to drugs or devices)

The patient outcome is death, life-threatening (real risk of
dying), hospitalization (initial or prolonged), disability
(significant, persistent, or permanent), congenital anomaly, ED50 TD50
or required intervention to prevent permanent impairment or
damage. V. MONITORING OF LEGAL, INSTITUTIONAL AND OTHER
GUIDELINES FOR DRUG USE
ASHP Guidelines on Adverse Drug Reaction Monitoring and
Reporting STANDARD TREATMENT GUIDELINES (STGs)

Is a systematically developed statements to assist

Pharmacist should exert leadership in the development,
practitioners and patient decisions about appropriate health
maintenance, and ongoing evaluation of ADR programs
café for specific circumstances.
STGs list the preferred pharmaceutical and
The pharmacist should facilitate:
nonpharmaceutical treatments for common health problems
1. Analysis of each reported ADR
experienced by people in a specific health system
2. Identification of dugs and patients at high risk for being involved in
ADRs STGs are disease-oriented whereas formulary manuals are
3. The development of policies and procedures for the ADR- medicine-oriented documents.
monitoring program
4. A description of the responsibilities and interactions of pharmacists, ADVANTAGES OF STG
physicians, nurses, risk managers, and other health professionals Healthcare Provides standardized guidance to
in the ADR program providers practitioners
5. Use of the ADR program for educational purposes Utilizes formulary or essential medicines
6. Development, maintenance, and evaluation of ADR records within Provides valuable assistance to all
the organization practitioners
7. The organizational dissemination and use of information obtained Enables providers to concentrate on making
through the ADR program the correct diagnosis
8. Reporting of serious ADRs to FDA or the manufacturer (or both) Healthcare Provides a basis for evaluating quality of care
officials provided by the health care professionals
SPECIAL POPULATIONS Provides the most effective therapy in terms of
quality
Pediatrics Underdeveloped organs Provides a system for controlling cost by using
Examples of ADRs in pediatrics associated funds more efficiently
with UDP-glucuronosyl acetyltransferase
Can be a vehicle for integrating special
deficiency are Gray baby syndrome
programs
(Chloramphenicol) and Kernicterus
Patients Patients receive optimal pharmaceutical
(Sulfonamides)
therapy
Geriatrics Comorbidity Enables consistent and predictable treatment
Polypharmacy from all levels of providers and at all locations
Pharmacokinetics
within the health care system
Less functional organs Allows for improved availability of medicines
Pregnant Teratogenic agents
DISADVANTAGES OF STG
IV. THERAPEUTIC DRUG MONITORING Inaccurate or incomplete guidelines will provide the wrong
information for providers and therefore do more harm than good
Individualization and optimization of dosage by maintaining Developing and updating guidelines is difficult and time-consuming
blood drug concentration within the target range and must be done on a regular schedule or they will become
obsolete very quickly
It is used mainly for monitoring drugs with narrow therapeutic Guidelines provide false sense of security
ranges, drugs with marked pharmacokinetic variability,
medications for which target concentrations are difficult to
monitor, and drugs known to cause therapeutic and adverse
effects

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 VI. DRUG USE EVALUATION
Cost/ unit
Intervention A cost Outcome
Authorized, structured, on-going system for monitoring drug outcome
use through comparison with specific standards and initiation
on appropriate actions when results are inconsistent with the
standards Intervention B cost Outcome
Cost/ unit
outcome
Drug utilization review
Authorized, structured, continuing program which analyses
and interprets patterns of drug use in a given health care Cost/ unit
Intervention C cost Outcome
outcome
delivery system against a predetermined standard

VII. REVIEW OF COST-EFFECTIVENESS

Treatment Cost Effectiveness
PHARMACOECONOMICS A $A 3 years
B $B 4 years
Tool that measures, identifies and compares costs (inputs)
and outcomes (outputs) of different pharmacotherapies and e. Cost Utility Analysis (CUA)
medical interventions to HC systems and society Integrate patient performance and health related quality of
life. Measures consequences in terms of quality adjusted life
PHARMACOECONOMICS year (QALY) gained

Economic: Humanistic:
Cost benefit Quality of life
cost effectiveness Patient preferences
Cost minimization patient satisfaction
Involves evaluation of the value of a pharmaceutical product
or drug therapy compared to its effect
Used for effective formulary management, individual
treatment, medication policy determination and resource
allocation

TYPES OF HEALTH ECONOMIC EVALUTIONS

a. Cost of Illness Studies

Determines all types of cost associated with the illness
Provides baseline of different treatment options

Type of Costs
Direct costs Indirect costs Intangible costs Treatment Cost Effectiveness Utility QALY
Medical cost - Result from loss - Difficult to
A $A 3 years 0.8 2.4
- Easy to of earning measure like
measure during suffering, pain, B $B 4 years 0.7 2.8
- Spent for hospitalization anxiety,
providing drug inconvenience VII. SELECTION OF DRUG THERAPY
therapy and grief during
- E.g., cost for the treatment PHARMACOEPIDEMIOLOGY
drugs, - Difficult to
investigations, quantify in terms
The study of utilization and effects of drugs in large numbers
physician visits, of monetary
hospitalizations units of people.
It provides an estimate of the probability of beneficial effects
Non-medical cost of a drug in a population and the probability of adverse
- Associated with effects.
treatment but
not in medical IX. DRUG INFORMATION SERVICES
nature
- E.g., cost for
transportation, DRUG INFORMATION SOURCES
food and lodging
Primary Source
b. Cost benefit (CB) analysis Provide most current information
Identify, measure and compare benefits and costs of a E.g., journals
program regarding treatment alternative, where both costs
and consequences are measured in monetary terms Secondary Source
For quick and selective screening of primary literature
c. Cost Minimization (CM) analysis E.g., abstracting and indexing sources
Determine least costly alternative when comparing treatment
alternatives with same/ equal outcome Tertiary Source
Provide easy and convenient access, information may be
d. Cost Effectiveness Analysis (CEA) outdated
Compare benefits and resources used of alternative E.g., textbooks
treatment with different outcomes
X. PARTICIPATE IN INTERDISCIPLINARY CLINICAL MEETINGS,
AUDITS AND ROUNDS

XI. PATIENT COUNSELLING

XII. LIASON WITH COMMUNITY SERVICE

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 COMMON LABORATORY TESTS Melena
Black, tarry stool, upper GIT bleeding
URINALYSIS
Hematochezia
Normal urine: Red, bloody, lower GIT bleeding
Should be sterile
Color: pale yellow Fecal Occult blood
pH: 4.5 8 (generally acidic) Ulcer, colorectal cancer, recurrent abdominal pain,
Sp. Gr.: 1.002 1.030 alternating diarrhea and constipation

Steatorrhea
High sp.gr. means more solute than water and vice versa Fat in stool, no bile acid, malabsorption, defective enzyme,
In DM, nephrosis drugs (Orlistat)
(High sp.gr. - concentrated urine)
In DI HEMATOLOGY
(Low sp.gr. - diluted urine)
Laboratory test Reference range
FBC
Hemoglobin 115-165 g/L
White Blood Cell (WBC) 4.0-11.0 x 109/L
Platelets 150-450 x 109/L
Red Blood Cell (RBC) 3.8-4.8 x 1012/L
Reticulocytes 50-100 x 109/L
Packed Cell Volume (PVC) 0.36-0.46 L/L
If your urine matches the colors numbered 1, 2, or 3, you are Mean Cell Volume (MVC) 83.101 FL
hydrated. Mean Cell Hemoglobin (MCH) 27-34 pg
Mean Cell Hemoglobin Concentration (MCHC) 31.5-34.5 g/dL
If your urine matches the colors numbered 4 up to 8, you are
dehydrated and need to drink more fluid
Cell type % Of WBC count Reference range
MAIN FUNCTION OF KIDNEYS WBC
Neutrophils 40-75% 2.0-7.0 x 109/L
Lymphocytes 5-15% 1.5-4.0 x 109/L
Monocytes 2-10% 0.2-0.8 x 109/L
Basophils <1% <0.1 x 109/L
Eosinophils 1-6% 0.04-0.4 x 109/L
Coagulation
PT 10-14 seconds
APTT 35-45 seconds
Fibrinogen 1.5-4 g/L
RED BLOOD CELLS (RBC)
Aka Erythrocytes
Responsible for transporting oxygen from your lungs to your
Your tissues produce energy with the oxygen
Parameters Normal findings Possible indications of and release waste, identified as carbon dioxide
anormal findings
RBCs take the carbon dioxide waste to your lungs for you to
Protein Negative Renal disease, pre-eclampsia.
exhale
eclampsia
Glucose Negative Hyperglycemia, renal
glycosuria
Blood Negative Presence of bleeding in the
urinary tract system
Ketone Negative Diabetic ketoacidosis
Bile Negative Liver dysfunction
Urobilinogen Trace to 1mg/dL Liver diseases, hemolytic
anemia
Nitrites Negative Bacterial infection
WBC Male: 0-2/hpf Bacterial infection
Female: 0-5/hpf
RBC Male: 0-3/hpf Blockages, stone, or internal
Female: 0-4/hpf injuries
Casts 0-1 Hyaline/ lpf Renal injuries
Squamous Varies Bacterial infection or not a
epithelial cells clean catch
Transitional 0-2 Some disease process going
epithelial cells on HEMATOCRIT or PACKED CELL VOLUME
Bacteria (clean Occasional Bacterial infection
Number of RBCs in 100mL blood; percentage of RBCs in the
catch)
blood
Ratio of the volume occupied by RBCs to the total volume of
FECALYSIS
blood

Decreased production Increased production

of RBC of RBC
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Hematocrit and blood volume b. Mean Cell Hemoglobin (MCH)
Reduced blood volume (dehydration, DI) = HIGH Average weight of hemoglobin contained in an RBC and is
HEMATOCRIT measured in picograms (10-12g is calculated from the
Increased blood volume (overhydration, SIADH) = LOW relationship:
HEMATOCRIT Hyperchromic, Normochromic, Hypochromic

Hyperchromic Normochromic Hypochromic

MCH: >31 pg/cell MCH: 27-31 pg/cell MCH: <27 pg/cell

RETICULOCYTES
Aka Baby RBCs
Earliest non-nucleated RBCs; immature RBCs
Normally represent between 1% and 2% of the total RBC
count
Increased production (reticulocytosis) can be detected in
times of rapid RBC regeneration
As occurs in response to Hemolysis, Hemorrhage and Iron
Deficiency Anemia (IDA) adult RBC (adult
Reticulocytes

HEMOGLOBIN

c. Mean Cell Hemoglobin Concentration (MCHC)

Measure of the average concentration of hemoglobin per unit
weight of RBC

WHITE BLOOD CELL (WBC) COUNT

WBC differentials in order of abundance

The hemoglobin concentration in men is Leukocytes

normally greater than women. Lower Agranulocytes
concentration in women is due to menstrual Lymphocyte Increased in typhoid, sub-acute bacterial
loss. endocarditis, infectious mononucleosis and
tuberculosis
Polycythemia, dehydration = High Hgb levels Monocyte Increased in viral infections
Granulocytes
Anemia = Low Hgb levels Eosinophil Increased in allergic conditions, such as asthma,
hay fever and drug sensitivity reactions
Basophil Increased in hypersensitivity reactions
Symptoms of Anemia Neutrophil Increased in bacterial and fungal infections

PLATELETS
Platelets or thrombocytes are anucleated cells derived from
the megakaryocytic cells in the bone marrow that, besides
being one of the key players in maintaining hemostasis, are
involved in developing non-hemostatic immune functions.
RBC INDICES 8-12 days

a. Mean Cell Volume (MVC) Thrombocytopenia (decreased platelets)

Average volume of a single RBC and is measured in Depressed synthesis in the marrow or consumption of
femtoliters (10-15L) formed platelets
Microcytic, Normocytic or Macrocytic May be seen in pregnancy and following viral infections
Severe Thrombocytopenia = spontaneous bleeding
Causes of Anemia according to MCV
Low MCV Normal MCV High MCV DRUGS KNOWN TO CAUSE PLATELET DYSFUCNTION
(<83 fL) (83-101 fL) (>101 fL) Caffeine NSAIDs
Microcytic Normocytic Normocytic Colchicine Penicillin
Iron deficiency Acute blood loss B12 deficiency Furosemide Theophylline
Thalassemic Early iron deficiency Folate deficiency Hydroxychloroquine TCAs
disorders Hydralazine Vincristine
Chronic renal Alcohol abuse
insufficiency

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Coagulation c. Iron deficiency
Caused by blood loss, malabsorption
Monitoring coagulation Fe meat, fish and poultry
Signs & symptoms:
a. Prothrombin (PT) Restless leg syndrome
Tests the extrinsic and common pathways Frequent headache
Time taken to fibrin strand formation in platelet-poor plasma Increased sensitivity to cold
Reported in seconds Brittle nails
Most commonly employed in the monitoring of warfarin anti- Hair loss
coagulation therapy Depression
Shortness of breath
b. International Normalized Ratio (INR) Fatigue and tiredness
ISI
2. DEFECTIVE NUCLEAR MATURATION
Target PT-INR under warfarin in therapy: 2-3
In atrial fibrillation: 2.5 Megaloblastic anemia (macrocytic, normochromic
Recurrent DVT and PE: 3.5 Caused by Vitamin B12 deficiency can be caused by
Pernicious Anemia
c. Activated partial thromboplastin time (APTT) B12
Tests the intrinsic and common pathways and is the time, in Can caused by Vitamin B9 deficiency
seconds, to fibrin formation
Detect deficiencies in factor VIII, IX and XI most common 3. INCREASED DESTRUCTION
method for monitoring unfractionated heparin (UFH) therapy
Desirable APTT for optimal heparin therapy: 1.5-2.5x the Hemolytic anemia (normocytic, normochromic)
normal control

d. Fibrinogen
Normal concentration in the blood varies between individuals
Increases in inflammation because it is an acute-phase
reactant
When fibrinogen is less than 1 g/L in severe bleeding,
cryoprecipitate is given.

TYPES OF ANEMIA
Based on mechanism

1. HYPOPROLIFERATIVE Drugs that can cause:

Methyldopa
a. Marrow failure Acetaminophen (Tylenol)
Antibiotics: Cephalexin, Ceftriaxone, Penicillin, Ampicillin, or
Aplastic Anemia severe marrow aplasia or pancytopenia Methicillin
Chlorpromazine (Thorazine)
Ibuprofen (Advil, Motrin B)
Interferon alpha
Procainamide
Quinidine
Rifampin (Rifadin)

Hemolytic Anemia
Can also be caused by inherited conditions such as Sickle
cell anemia, thalassemia, or G6P deficiency

Drugs that can cause:

Chloramphenicol
Felbamate
Phenylbutazone

b. Renal failure

detects Ab coating RBCs and

Ig against RBCs

4. ABNORMAL PRODUCTION AND DESTRUCTION

a. Sickle cell anemia

Inherited Hgb disorder characterized by (-) charged Hgb
A which favors Hgb aggregation and polymerization sickle
shape

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 hyperparathyroidism, osteomalacia

Lactate dehydrogenase
Total LDH activity is rarely measured because of the lack of
tissue specificity
Levels of activity are elevated following damage to the liver,
skeletal muscle and kidneys, in both megaloblastic and
immune hemolytic anemias, and in intravascular hemolysis
as seen in thrombic thrombocytopenic purpura and
paroxysmal nocturnal hemoglobinuria

b. Thalassemia
Are a heterogenous grouping of genetic disorders that result
from a decreased synthesis of alpha or beta chains of Hgb

Troponin I and T
Regulatory proteins that control the calcium-mediated
interaction between actin and myosin in cardiac muscle
Both are comparable in diagnostic and prognostic efficacy,
and the local decision may be a balance between cost and
specific assay performance
BLOOD CHEMISTRY

BUN: 8 18mg/ dl Troponins offer extremely high

cardiac tissue specificity and clinical
BUN levels in the blood increased in: sensitivity for myocardial necrosis
Renal dysfunction but do not discriminate between
High protein intake ischemic and non-ischemic
Upper GI bleeding (blood converts to NH3 and BUN in GUT) mechanisms, including myocarditis,
cardiac surgery and sepsis
Cystatin C: 0.62 1.15mg/L
Cystatin C levels in the blood increased in renal dysfunction
Aspartate transferase (AST) Alanine transferase (ALT)
Creatinine

Creatinine clearance glomerular filtration rate; for dose adjustment

in renally impaired patients

Cockcroft-Gault formula
They may be raised in all forms or viral and non-viral, acute
and chronic liver disease, most markedly in acute viral, drug-
induced (e.g., paracetamol poisoning), alcohol-related and
ischemic liver damage; non-alcoholic fatty liver disease

Bilirubin
U = amt of Cr excreted in the urine Breakdown product of hemoglobin
V = volume of urine Bound to albumin, conjugated in the liver
P = amt of Cr in the blood An elevation of serum bilirubin concentration above 50
mmol/L = Jaundice

Creatine kinase
Catalyzes transfer of phosphate groups
Primarily found in tissues that consume high ATP

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Alkaline phosphatase D-dimer
High amounts in bile ducts, placenta and bone Degradation products of fibrin clots
Levels of D-dimers in the blood are raised in conditions
associated with coagulation and are used to detect venous
thromboembolism

Tumor markers
Tumor marker Primary Clinical application
malignancy
Prostate-specific Prostate Primary screening, determining
Acid Phosphatase antigen (PSA) prognosis and monitoring
Prostate-specific antigen therapy
Secreted by prostate gland into seminal fluid CA 125 Ovarian Primary screening, determining
High levels in Benign Prostatic Hyperplasia (BPH) & prostate prognosis and monitoring
cancer therapy
CA 19-9 Pancreatic Monitoring therapy
Amylase and Lipase CA 15-3 Breast Monitoring therapy
Pancreatic enzymes Human chorionic Trophoblastic Primary screening, determining
gonadotropin (HCG) prognosis and monitoring
Synthesized primarily in the pancreas and salivary glands
therapy
Amylase: serum or urine amylase is the most important Human epidermal Breast Predicting response to therapy
laboratory test in cases of suspected acute pancreatic growth factor
disease receptor 2 (HER 2)
Lipase: destruction of pancreatic cells causes large amounts Alpha-fetoprotein Hepatocellular Primary screening and
of lipase to be release in the blood (AFP) monitoring therapy
Albumin Pepsinogen Gastric Primary screening
Produced in the liver
Hypoalbuminemia can be caused by liver disease, Electrolytes
malnutrition, protein wasting nephropathy and usually results
to edema and ascites a. Sodium (Na)
Ascites excess fluids in peritoneal cavity; tx is spironolactone,
paracentesis i. Hyponatremia low concentration of Na in the blood
Hyperalbuminemia is also reported in liver disease, Na loss Na depletion is a result of aldosterone deficiency,
hemolysis, kernicterus renal disease
NOTE: Important consideration in therapeutic monitoring of drugs Excessive water retention diluted blood can be caused
and electrolytes that are protein bound. Dose adjustments should be by CHF, cirrhosis
considered Drug-induced hyponatremia can be caused by
inappropriate secretion of ADH
HbA1C (Glycated Hgb) Antidepressants (SSRIs, TCAs)
Amphotericin
Lipid profiles Angiotensin-converting enzyme inhibitors
Carbamazepine
Total <200 Cisplatin
Triglycerides <150 Cyclophosphamide
LDL <130 Gliclazide
HDL >40 (M) >50 (F) Levothyroxine
NSAIDs
Inflammatory markers Proton pump inhibitors
Tolbutamide
a. Erythrocyte Sedimentation Rate (ESR) Vasopressin
Measures the rate of RBC settling of whole, uncoagulated Vincristine
blood over time
Increased ESR ii. Hypernatremia high concentration of Na in the blood
Inflammation Occurs when there is too much water loss or too much
Infection sodium gain in the body
Tissue necrosis or infarction
Malignancy b. Potassium (K)
Rheumatoid collagen disease excitability of nerve and muscle tissue, cardiac function and
acid base balance
b. C-reactive protein (CRP)
An acute phase protein i. Hypokalemia low concentration of K in the blood
Nonspecific acute-phase response is instigated by tissue Shift of K ions from the ECF into the cells
damage, infection, inflammation and malignancy B2 agonists (e.g., salbutamol)
Parenteral insulin
c. Procalcitonin Catecholamines (e.g., adrenaline, theophylline)
A polypeptide, is one of many bloodstream bio-markers Loss from GIT
investigated as an early predictor of sepsis Laxative abuse
Diarrhea
Uric acid Persistent vomiting
Product of purine metabolism Loss from the kidneys
Two main factors contribute to elevated serum uric acid
levels: an increased rate of formation or a reduced Renal tubular damage (e.g., gentamicin
excretion Thiazide and loop diuretics
Deposition usually precipitates an acute attack or gouty
arthritis ii. Hyperkalemia high concentration of K in the blood
Excessive intake of K+, decreased elimination or shift of K+
Immunoglobulins from cells to the ECF
Antibodies which are produced by B lymphocytes Renal failure (inability to excrete K+
Occurs in infections, chronic liver disease and K+ sparing diuretics (e.g., amiloride or spironolactone (ACE-
autoimmune disease inhibitors

Module 3 Clinical Pharmacy Page 10 of 12 RJAV 2022

c. Magnesium (Mg) Examples COPD DKA PE Diuretic
Essential cation, found primarily in bone, muscle and soft Guillain- Sepsis Anxiety use
tissue, with around 1% of the total body content in the ECF Barre Aspirin Severe
overdose vomiting
Critical in energy-requiring metabolic processes
Step 3: Metabolic Respiratory Metabolic Respiratory
Compensation HCO3- > pCO2 < 4.6 HCO3- < pCO2 > 6.1
i. Hypomagnesemia low concentration of Mg in the blood 28 mmol/L kPa 22 mmol/L kPa
GI losses COPD: Chronic obstructive pulmonary disease
Renal losses DKA: diabetic ketoacidosis
Surgery (e.g., esophageal) HCO3- bicarbonate
Trauma PaCO2 arterial partial pressure of carbon dioxide
Infection PE: pulmonary embolus
Malnutrition
Sepsis NUTRIONAL SUPPORT
Drug-induced
Cisplatin Malnutrition
Amphotericin B It can be described as a deficiency, excess, or imbalance of
Ciclosporin energy, protein, and other nutrients that causes measurable
Aminoglycosides adverse effects on body tissue, size, shape, composition,
Laxatives function and clinical outcome
Pentamidine
Tacrolimus Kwashiorkor Marasmus
Carboplatin
Furosemide
Hydrochlorothiazide
Digoxin

ii. Hypermagnesemia high concentration of Mg in the blood

Commonly caused by renal insufficiency

Calcium and Phosphate

Hormone Effect Too high levels will

result to
PTH (+) osteoclastic bone resorption Hypercalcemia,
(-) reabsorption of PO4 in the Hypophosphatemia
proximal tubule
Vit D (+) absorption of Ca & PO4 Hypercalcemia,
Hypophosphatemia
Calcitonin (-) osteoclastic bone resorption Hypercalcemia,
Hypophosphatemia
Cortisol (-) Vit D Hypercalcemia,
Hypophosphatemia
Estrogen (-) PTH bone resorption activity Hypercalcemia,
Hypophosphatemia

Arterial Blood Gases (ABG)

Normal blood pH: 7.25-7.45

Acidosis: pH less than 7.35
Alkalosis: pH greater than 7.45

Laboratory test Reference range

pH 7.35-7.45
PaCO2 4.6-6.1 kPa
PaO2 10.6-13.3 kPa
HCO3- 22-28 mmol/L

ABG Interpretation
Step 1: Acidosis (pH <7.35) Alkalosis (pH >7.4)
Acidosis/
Alkalosis
Step 2: Respiratory Metabolic Respiratory Metabolic
Primary cause pCO2 > 6.1 HCO3- < pCO2 < 4.6 HCO3- >
kPa 22 mmol/L kPa 28 mmol/L

Module 3 Clinical Pharmacy Page 11 of 12 RJAV 2022

 Components of PN

Oral diet Parenteral nutrition source

Water Water
Protein L-Amino acid mixture
Carbohydrates Glucose
Fat with essential fatty acid Lipid emulsions with essential fatty acids
Vitamins Vitamins
Minerals Trace elements
Electrolytes Electrolytes

Steps in mixing TPN components

1. Glucose to amino acids press the upper left chamber

(glucose) to mix with the lower chamber (amino acids)
2. Add electrolytes and trace elements add electrolytes &
trace elements in port
3. Lipid emulsion press the upper right chamber (liquid) to mix
with lower chamber
Nutrients can be introduced in the body by different routes such as enteral and 4. Add vitamins
parenteral routes. 5. Mix thoroughly mix thoroughly then hang it on the drip
Combinations of oral diet, enteral feeding and parenteral nutrition, either stand
peripherally or centrally, may be appropriate

Enteral Nutrition
A method of providing nutritional support via tubes inserted
into the stomach or small intestine

Parenteral Nutrition
It is nutritionally balanced aseptically prepared or sterile
physiochemically stable solution or emulsion for IV
administration
It is indicated whenever the GI tract is inaccessible or non-
functional or when enteral nutrition is inadequate or unsafe

Solution should be compounded in a pharmacy using a

laminar flow
Solution must be infused or discarded within 24hours after
hanging
Vitamins are only stable at room temperature for 24hours
so they are added to the PN solution at the time of
infusion

Peripheral/ Partial Parenteral Total Parenteral Nutrition (TPN)

Nutrition (PPN)
- A nutritional support that
supplies only part of daily
nutritional requirement, oral
intake in a peripheral vein
for short term nutritional
support (<14 days)
- Contains <10% final
concentration of dextrose
- Solution tonicity: <500
mOsm/L
- May be administered
through a larger peripheral
vein
- Supplies all daily nutritional
requirements and indicated
for long term use (>30 days)
and may be administered
continuously over a 24-hour
period
- Used for patients who
cannot get their nutrition
through eating
- >10% of dextrose and 5%
protein
- >500 mOsm/L
- Central line
- Designed to totally replace
enteral intake

ASPEN Guidelines

Universal principles that define the indications for nutritional

support

1. When specialized nutritional support Is required, enteral

nutrition should be used in preference to PN
2. PN should be used when GI tract is not functional or
cannot be adequately nourished by oral diets or enteral
nutrition
3. Specialized nutrition support should be initiated in patients
with inadequate oral intake for 7 to 10 days or in those
patients in whom inadequate oral intake is expected over a
7-to-14-day period

Module 3 Clinical Pharmacy Page 12 of 12 RJAV 2022