PHARMCARE 3/30 DISPENSING BY NGILAY, OCTAVIO, RASGO

TOPIC 1: DOSING SCHEDULE AND (1 am, 5 am, 9 am, 1 pm,

EXTEMPORANEOUS COMPOUNDING 5 pm, 9 pm)

Dosing schedule/Dosage Regimen Every 6 hours 0600, 1200, 1800, 2400

(6 am, 12 pm, 6 pm, 12
- The schedule of doses of a therapeutic midnight)
agent per unit of time, including: the time
between doses (ex. Every 6 hours) or the Every 8 hours 0800, 1600, 2400 (8 am,
time when the dose (s) are to be given ( ex. 4 pm, 12 midnight)
At 8am and 4 pm daily), and the amount of
Every 12 hours 0900, 2100 (9 am, 9 pm)
medicine (ex. Number of capsules) to be
given at each specific time. Every 24 hours Time will default to hour
profiled (ie, 1™ order
Standard Dosing schedule by Brown processed)

● Standard “bid” = 10 am and 10 pm Bedtime 2100 (9 pm)

● Standard “tid”= 9am-1pm-5pm
● Q6h= 9am-3pm-9pm-3am With meals 0800, 1200, 1700 (8 am,
● Qid= 9am- 1pm-5pm-9pm. 12 pm, 5 pm)
● Hs- 9 pm
With meals and at 0800, 1200, 1700, 2100
bedtime (8 am, 12 pm, 5 pm, 9
Dosing schedule according to Drug and pm)
Therapy Bulletin, University of Florida
Injectable antibiotics Times determined by the
STANDARDIZED DOSING TIMES time the 1“ dose is
processed
Interval Standard Times
EXTEMPORANEOUS COMPOUNDING
Daily 0900 (9 am)

2 times a day (BID) 0900, 2100 (9 am, 9 pm) Objectives:

3 times a day (TID) 0900, 1400, 2100 (9 am,
2 pm, 9 pm)
0800, 1200, 1700 (52
Psych) (8 am, 12 pm, 5
pm)
● To define extemporaneous compounding
● To discuss the risks associated with
extemporaneous compounding
● To discuss importance of extemporaneous
compounding

4 times a day (QID) 0900, 1300, 1700, 2100 United States Pharmacopeia (USP 795) define
(9 am, 1 pm, 5 pm, 9 pm) compounding as:

“The preparation, mixing, assembling, altering,

5 times a day 0500, 0900, 1300, 1700, packaging, and labeling of a drug, drug-delivery
2100 (5 am, 9 am, 1 pm, device, or device in accordance with a licensed
5 pm) practitioner's prescription, medication order, or
initiative based on the practitioner—patient-
Every 3 hours 0000, 0300, 0600, 0900, pharmacist-compounder relationship in the course
1200, 1500, 1800, 2100
of professional practice”
(12 am, 3 am, 6 am, 9
am, 12 pm, 3 pm, 6 pm,
9 pm) Extemporaneous compounding

Every 4 hours 0100, 0500, 0900, 1300, - Describes the use of traditional
1700, 2100 compounding techniques to manipulate
chemical ingredients to produce appropriate
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dosage forms when no commercial
medicine form is available.
Extemporaneous compounding
- “The timely preparation of a drug product
according to the physician's prescription, in
which the amounts of the ingredients are
calculated to meet the needs of a particular
patient or a group of patients according to
Good Manufacturing Practice”
Compounding
● Extemporaneous Compounding
- On-demand preparation of a drug
product.
- According to a physician’s
prescription.
- Meets the unique needs of an
individual patient.
● Manufacturing
- The production or processing of a
drug in a LARGE quantity by various
mechanisms.
In compounding, an individualized medicine is
prepared at the request of a prescriber on a small
scale basis.
They are not required to report adverse events to
FDA.
Drugs, Dosage forms, equipments and techniques
are the variables.
BY NGILAY, OCTAVIO, RASGO
Why Compound?
● Pediatric patients requiring diluted adult
strengths of drugs.
● Patients needing an oral solution or
suspension of a product that is only
available in another form.
● Patients with sensitivity to dyes,
preservatives, or flavoring agents found in
commercial formulations.
● Dermatological formulations with fortified
(strengthened) or diluted concentrations of
commercially available products.
● Specialized dosages for therapeutic drug
monitoring.
● Care for hospice patients in pain
management.
● Compounding for animals.
Prescription Analysis Compounding
Considerations:
1. Always consider the use of commercially
available products as far as possible.
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2. If no suitable commercial product exists,
consider a therapeutic alternative that is
available in a suitable dosage form. This
must be discussed with the physician.
3. Extemporaneous preparations should be
done based on evidence-based
references.
4. Always check for the suitability of the
product/brand for extemporaneous
preparations.
5. Preparations should be done according to
what is stated as far as possible unless
stated otherwise in the product leaflet.
6. When no information is available,
compound an oral medication by
dispensing a tablet and/or capsule and
directing the caregiver to mix just prior to
administration.
7. Stability for shelf storage in the pharmacy is
applicable without opening. Once
opened, the stability of the preparation
should be no longer than 30 days.
Maximum quantity of the extemporaneous
preparations to be dispensed should not
exceed one month.
8. Refrain assumptions on the therapeutic
equivalence in the case of suggesting
alternative agents as the possibilities and
supporting data may be limited.
9. Techniques in compounding preparations
and manipulations should always be in line
with the standard Good Preparation
Practice as delivering an accurate dose is
paramount
10. Staff and facilities are challenged to
undertake intermittent competency
assessments in order to achieve the
standards requirement.
11. Documentation after each preparation
should include details on the materials
used, processes involved and the
responsible personnel in-charge.
CONSIDERATIONS FOR PREPARING
EXTEMPORANEOUS COMPOUNDS
1. Pharmacy personnel are reminded not to
empirically change flavourings or
suspending agents because they can
affect the pH and stability of the product
and result in an unstable product.
BY NGILAY, OCTAVIO, RASGO
2. Please consider ingredients in the
formulations that require special
precautions in neonates.
3. Mixing of a compounded formulation should
always be in line with the following
principles:
a.) Ensure that all ingredients used are
within the expiry date.
b.) Ensure that all utensils are clean;
including mortar and pestle, graduates, pill
cutters and stirring rods.
c.) Product should be labelled clearly and
stored as recommended within the
formula.
d.) For solution or suspension products,
emphasise on the importance of thorough
shaking before administration.
4. If compounding a preparation using
contents from an ampoule, remember to
withdraw the solution (medication) from
the ampoule using a filter needle to
ensure no glass particles are incorporated
into the compound.
5. Place tablet(s) within mortar and pestle to
grind tablets to a fine powder. For
film-coated tablets, it may be necessary to
add a small amount of diluents such as
water, to soften the coating prior to
grinding the tablets. This will ensure that the
compound will not have an eggshell
appearance from the film coating floating
throughout the suspension. If you are using
capsules, open the capsule and empty the
powder into the mortar and discard the
capsule shell.
6. Solutions will have a clearer appearance
versus a compounded Suspension.
Considerations before compounding:
● Commercially available of drug in dosage
form, strength and packaging
● Ingredients, intended use, dosage and
method of administration concern
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● Education, skill and expertise to drug Equipments

compounding
● Proper equipment, supplies, chemicals and ● Laminar flow hoods
the guidelines set in USP ● Weighing balance
● Safety of the compounded product ● Ointment slabs along with spatulas
● Storage facility ● Mortar and pestle
● Necessary calculations ● Volumetric glassware (chips, cracks,
● Necessary documentation leveling lines)
● Literature references (use, preparation, ● Calibrated and Validated
stability and administration)
● Expected duration of therapy Environment
● Quality control checks (weight variation, pH)
● Ingredient identity, quality and Purity ● Clean, Neat, well-lit and quiet working area
● Physico-chemical incompatibilities ● If aseptic compounding is considered, a
clean air environment is needed
Sources of Formulae ● Measures must be taken to avoid cross
contamination
● Compendia e.g. BP, Martindale 28th ● Environmental conditions such as
/USP/NF etc temperature, humidity and lighting to limit
● Hospital-often continuation of treatment in degradation of product
primary care ● Areas and equipment should be cleaned
● GP’s own e.g. Dr Ives wart paint etc. before and after use
● Published literature/journal articles available ● Critical surfaces should be sanitized with
on internet. Often American/ European 70% alcohol
● Adequate pest control measures should be
Quality control taken

● Oral and topical liquids (solutions, Formulas

suspensions and emulsions)- pH, sp.
Gravity, assays, rheological properties,
physical observation, physical stability
● Hard gelatin capsules- weight variation,
dissolution and disintegration
● Ointments, creams and Gels- pH, sp.
Gravity, assay, rheological properties
● Suppositories, Trouches- melting points,
dissolution test, physical stability
● Parenteral Preparation- pH, sp. Gravity,
osmolality, color, clarity, particulate matter,
sterility
Training and Experience
● Provide knowledge and skills in good
extemporaneous practice, assessment of
risk and medication error potential,
formulation, quality assurance
● Demonstrate competency in the necessary
extemporaneous' preparation’ skills and
pharmaceutical calculations and dilutions
● Should be developed or obtained
● Methods used, ingredients added and order
of steps is documented.
1.) Provides methodology for each person
involved or requested to provide such
service the info. Necessary to do so
properly.
2.) It provides consistency from batch to batch
3.) If the product does not turn out the way
expected, a stepwise methodology exists for
reviewing and determining what happened
and if revisions and improvement are
needed.
Chemical and Supplies
● Proper dispensing container for the
medications
● Pharmaceutical-grade chemical is
necessary

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● Pharmacist use different chemicals from
reliable sources
Availability of Raw Materials
1.) Need to obtain a Pharmaceutical Grade, BP
, PhEur or USP
2.) Laboratory Grades AnalaR may be all that’s
available.
3.) May be using a licensed medicine e.g.
crushing tablets, diluting a steroid cream
such as Betnovate
4.) Difficult to obtain small quantities of pure
drug powders
5.) Need to consider TSE-Transmissible
Spongiform Encephalopathy e.g Lanolin
6.) Good practice to obtain a Certificate of
Analysis
7.) May need to use another unlicensed
medicine e.g. imported tablets. Need to be
assured of Quality
Labeling
The label of an extemporaneously prepared
product should include {in the exceptional
circumstances of batch manufacture some
information may not be relevant):
● Name of the patient
● Name, address and telephone number of
the pharmacy
● Date of preparation
● Date on which the product was dispensed
● Name of the product, if applicable. Cra
description of the product
● Generic name of the active substance f(s).
strength and quantity
● Name, strength and quantity of any other
ingredient
● Total quantity of the final product to be
supplied
● Directions for the appropriate use of the
product
● Route of administration
● Relevant cautionary and advisory tables
● Warning “Keep out of the reach of children'”
● Expiry date (including an in-use expiry date
as appropriate) or information about lirmits
for use
● Special storage or handling requirements
e.e. for certain liquid preparations ‘Shake
well before use”
BY NGILAY, OCTAVIO, RASGO
● Batch number, if applicable
Documentation
● It gives processing, packaging and release
instructions.
● For products regularly prepared, master
documents should be prepared and
checked
● It should be clear and detailed
● Worksheets: name and formula of the
product, source of formula, unique ID
number, manufacturer, batch number of
each starting material, date of preparation
Record Keeping
The following must be recorded each time a
medicine is extemporaneously prepared for supply
to a patient:
1. Patient’s name
2. Pt.’s address and contact details
3. Name and address of the patient’s
prescriber
4. Date of preparation
5. Formulation used and source.
6. Calculations
7. Details of each preparation step
8. Name, strength and quantity of each
ingredient of material used
9. Source of starting ingredients or materials
10. Batch number and expiry date of each
ingredients or material used
11. Storage conditions
12. Expiry date of finished product
13. Identity of the pharmacist
14. Results of QC test conducted
________________________________________
CHECKLIST 2:
HANDLING OF PRESCRIPTIONS WITH
EXTEMPORANEOUS PREPARATION
MEDICINES IN THE PHARMACY
1. Receive prescription
2. Check availability of medicine
3. Discuss with medical practitioner on
alternative medicine
4. Check commercially available status at
retail pharmacy outlet
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5. Search for evidence-based reference to 4. Starting materials

prepare extemporaneous medicine
6. instruct patient/caregiver on how to prepare - risk of using ingredients that are no longer
prior to administration of medicine, if suitable
needed to prepare stat each time - Some ingredients are age-specific,
7. Dispense medicine and counsel unsuitable for religious groups
patient/caregiver accordingly - List down all excipients used

5. Patient Accessibility issues

- Palatability and presentation of oral liquid

medicines

6. Health and Safety Risk

- Risk to the operator should be considered

- When handling hazardous substances, it
should be equipped suitable container and
system should be implemented to avoid
cross contamination

7. Therapeutic risks and clinical consequences

- It is important to review both the inherent

properties of the drug and the patient’s
Risks associated with extemporaneous clinical condition.
compounding: - Risk assessment of the patient is very
important
1. Formulation Failure
Managing the risk
- Validated and stability date
- Occurs when a formulation has not been 1. Clinical Risk Reduction
adequately validated > toxicity and
therapeutic incompatibilites a. Identify extemporaneous compounding as
- Overdose and Underdose may occur high- risk therapy
- Example: Suspension b. Carry out a risk assessment
c. Consider alternative therapies
2. Microbial contamination d. Review all the available evidence to support
the use of preparation
- by-products of microbial degradation can e. Evaluate drug toxicity
lead to physical and chemical changes in f. Monitor patient for clinical effect, toxicity and
the preparation ADR
- Microbial growth can lead to spoilage and g. Documentation
producing foul odor
2. Technical Risk Reduction
3. Calculation errors
2.1 Formulation
- pose greatest risk of serious patient harm
- (arrow up) complexity of calculations (arrow a. Use standard, validate formula
up). risk of an error b. Evaluate data using first principles
- Should be documented in worksheet c. Gather information on or evidence use
- Common errors such as conversion of units d. Use of information resources
e. Restrict the shelf —life to limit degradation
and spoilage
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2.2 Preparation
a. Ensure facilities comply with guidance and
subject to audit
b. Use QA approved worksheets and
procedures
c. Ensure facilities and equipments are
validated/calibrated
d. Ensure all operatives are trained
e. Use license or approved starting materials
Role of Pharmacist
● There is a growing need to compound
certain medications because they are not
available through conventional
manufacturing methods.
● Compounding pharmacists give many
options with regard to drug therapy, have
appropriate resources and references to
compound quality medications.
● Pharmacists are responsible for ensuring
that extemporaneous preparations are
compounded according to compounding
guidelines and standards with respect to
purity, quality, stability, packing, and record
keeping.
Commonly Requested Dosage Forms-Non
Sterile
● For Application to the skin
● Creams, Ointments, Pastes, Lotions,
External Solutions
● For Oral Ingestion-Liquids
● Suspensions, Solutions, Mucilage
● Traditional terms: Elixir, Mixture, Linctus
● Now all referred to as
Solution/Suspension unless using
compendial title.
Oral Liquids
● Is drug soluble in the vehicle at dose
required?
● |f not could a suspension be prepared
● Crush tablets or use Powder
● Use highest strength tablets to reduce
overall excipients
● Check tablet characteristics: Controlled
Release, Sugar Coated, Film Coated,
Enteric Coated
BY NGILAY, OCTAVIO, RASGO
● Good Practice: Always use the same brand
and strength. Care with generics.
● Good Practice: Standardise to dose/5ml or
dose/iml
● May dilute injection fluid from ampoules
Making a Suspension From Tablets
● Crushing, grinding
● Wetting and pasting
● These steps are vital to give homogeneous
product
EQUIPMENT FOR WEIGHING, MEASURING,
AND COMPOUNDING
● Balances: An electronic balance is easier
to learn and use and is more accurate than
other types of balances.
● Forceps and Spatulas: Forceps should be
used when picking up weights so that
moisture and oils are not transferred to the
weights. Spatulas are used in compounding
tasks such as preparing ointments and
creams or loosening material from the
surfaces of a mortar and pestle.
● Compounding Slab: This is an ideal
surface for mixing compounds because of
its nonabsorbent surface.
● Mortar and Pestle: The coarser the surface
of the mortar and pestle, the finer the
triturating, or grinding, that can be done.
● Graduates and Pipettes: A pipette is used
for measuring liquids with a volume less
than 1.5 mL
● Master Formula Sheet: Prepared by the
pharmacist, this sheet indicates the amount
Oral of each ingredient needed, lists the
a procedures to follow, and provides the
labeling instructions.
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TECHNIQUE FOR WEIGHING
PHARMACEUTICAL INGREDIENTS
● Weighing of the product is one of the most
essential parts of the compounding process.
● Weighing the exact amount prescribed is
essential in compounds for several reasons:
the product cannot be “checked” for content
once mixed, the quantities weighed out are
often very small, and a slight overage could
mean a serious overdose for the patient.
TECHNIQUE FOR MEASURING LIQUID
VOLUMES
● A general rule of thumb is to always select
the device that will give you the most
accurate volume. Selecting a container that
will be at least half full when measuring, or
using the smallest device that will hold the
required volume, is considered good
practice.
COMPOUNDING ISSUES
Safety Note!
● Use the smallest device that will hold the
required volume when measuring a liquid.
● Always measure liquids on a solid, level
surface at eye level
● Compounding should never be rushed
COMMINUTION AND BLENDING OF DRUGS
● Geometric Dilution Method: A way to
combine drugs using a mortar and pestle.
● Examples of Compounding
Preparations: solutions, suspensions,
BY NGILAY, OCTAVIO, RASGO
ointments and creams, powders,
suppositories, and capsules.
● Labeling, Record Keeping, and Cleanup:
After compounding, the product must be
labeled with a prescription label, and a
careful record of the compounding operation
should be kept. Once the compounding
operation is finished, the equipment and
area should be cleaned and everything
should be returned to their proper places in
storage.
2. ALLOPURINOL SUSPENSION 20MG/ML
● Generic Name : Allopurinol
● Indication : Gout or uric acid and calcium
oxalate renal stones
● Dosage Form : Suspension
● Strength : 20mg/mL
● Stability : 60 days
● Storage : Refrigerate (preferable) or at room
temperature
INGREDIENTS STRENGTH QUANTITY
Allopurinol 300mg 8 tablets
Vehicle qs 120 mL
VEHICLE OF CHOICE:
● Ora- Sweet : Ora-Plus (1:1) or
● Ora Sweet SF : Ora-Plus (1:1) of
● Ora-Blend or
● Ora-Blend SF or
● Cherry syrup or
● Equivalent vehicle to Ora Sweet” :
Ora-Plus® (1:1)
● Methylcellulose 1% : Simple Syrup (1:1)
PROCEDURE:
1. Crush tablets in a mortar to fine powder.
2. Levigate the powder with small amount of vehicle
until smooth paste is formed.
3. Add more vehicle to the paste until liquid is
formed and transfer the liquid into a container,
4. Use additional vehicle to rinse the remaining
drug from the mortar and pour into the container.
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5. Make up to final volume with vehicle. 5. Make up to final volume with vehicle,

6. Shake well and label. 6. Shake well and label,

NOTES: NOTES:

5. AMLODIPINE SUSPENSION 1MG/ML

3. ALPRAZOLAM SUSPENSION 1 MG/ML
● Generic Narve Amlodipine
● Generic Name : Alprazolarn ● Indication : Hypertension
● Indication : Anxiety disorders ● Dosage Form: Suspension
● Dosage Form : Suspension ● Strength: 1 mg/mL
● Strength: 1mg/mL ● Stability: 30 days
● Stability : 60 days ● Storage: Refrigerate
● Storage : Room temperature and protect
from light
INGREDIENTS STRENGTH QUANTITY

INGREDIENTS STRENGTH QUANTITY Amlodipine 10 mg 6 tablets

Alprazolam 1 mg 60 tablets Distilled Water 3-4 mL
Vehicle qs 60 mL Vehicle qs 60 mL

VEHICLE OF CHOICE: VEHICLE OF CHOICE,

● X-Temp” Oral Suspension System
PROCEDURE:
1, Crush tablets in a mortar to fine powder.
2. Levigate the powder with small amount of vehicle
until srmooth paste is formed.
3. Add more vehicle to the paste until liquid is
formed and transfer the liquid into a container.
4. Use additional vehicle to rinse the remaining
drug from the mortar and pour into the container.
● Temp” Oral Suspension System
PROCEDURE:
1. Crush tablets in a mortar to fine powder,
2. Add 3-4mL of distilled water to disintegrate the
tablets.
3. Levigate the powder with a small amount of
vehicle until smooth paste is formed.
4. Acid more vehicle to the paste until liquid is
formed and transfer the liquid into a container.
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5 Use additional vehicle to rinse the remaining drug ● To identify different steps involve in the
trom the mortar and pour into the container, Medication Review Process

6. Make up to final volume with vehicle. Definition

7. Shake well and label. ● defined by the Pharmaceutical Care

Network Europe (PCNE) as “a structured
NOTES: evaluation of a patient's medicines with the
aim of optimizing medicines use and
improving health outcomes. This entails
detecting drug related problems and
recommending interventions”

Definition

● A structured, critical examination of a

patient’s medicines with the objective of
reaching an agreement with the patient
about treatment, optimising the impact of
medicines, minimizing the number of
medication-related problems and reducing
waste.’

Principles of Medication Review

The “Peppermint Water’ Case (1) 1. All patients should have a chance to raise
questions and highlight problems about their
Involved “Peppermint Water", which needed to be medicines.
compounded extemporaneously within a 2. Medication review seeks to improve or
community pharmacy and was accidently mace-up optimize impact of treatment for an
with twenty-times the required amount of individual patient
chloroform by a pre- registration trainee. 3. The review is undertaken in a systematic
way, by a competent person
Both the pre-registration trainee and the 4. Any changes resulting from the review are
supervising pharmacist were charged with agreed with the patient
manslaughter. However, this charge was changed 5. The review is documented in the patient’s
on the day of the trial (which took place nearly two notes
years after the initial event) to an offence under 6. The impact of any change is monitored
section 64 of the Medicines Act 1968, of supplying
a medicinal product not of the nature and quality Benefits of Medication review
specified. ;
● Improving the current and future
After both pleaded guilty, they received fines of management of the patient’s medical
£1,000 and £750 (the pharmacist and the condition
pre-registration trainee respectively). ● Opportunity to develop a shared
understanding between the patient and
TOPIC 2: MEDICATION REVIEW practitioner about medicines and their role
in the patient’s treatment
Objectives ● Improved health outcomes through optimal
medicines use
● To define Medication review ● Reduction in adverse events related to
● To discuss different Principles of Medication medicines
Review

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● Opportunity to empower patient and carers
to be actively involved in their care and
treatment
● Reduction in unwanted or unused
medicines.
Approach to Medication Review
● Reviews that are carried out without patient
involvement have value but are not as
effective as face-to-face discussion with the
patient.
● Face-to-face review also provides the
opportunity to discuss the patient’s values
and beliefs, and how taking medicine fits in
with the patient’s daily life. It provides an
opportunity to assess patient’s knowledge of
their medication.
Type of Medication review
● Type 1: Prescription Review
● Type 2: Concordance and Compliance
Review
● Type 3: Clinical Medication Review
Type 1: Prescription Review
● Primary purpose: Address. practical
medicine management issues that can
improve clinical and cost-effectiveness of
medicines and patient safety.
● It can take place without the presence of the
patient.
● Any changes in the medication should be
made with the consent of the patient/carer.
Other purpose:
● Identify Rx anomalies ex. Rx still prescribed
which is intended for short term use only
● Identify unmet and under met therapeutic
need
● Identify meds that was prescribed but not
dispensed
When to do it:
● Pt. is in the hospital or transferred between
care settings
● Reviewing practice for a class of medicine
BY NGILAY, OCTAVIO, RASGO
Type 2: Concordance and Compliance Review
● Takes place in partnership with the
patient/carer
● Enables patient and practitioner to explore
patient’s medicines-taking, including the
patient’s actual pattern of medicine-taking
and patient’s belief about medicine.
Purpose:
● Opportunity for the patient to ask questions
● Offer and share information about the
medicines with the patient
● Establish whether the patient and health
professional have similar or different views
about medicines
● Checks the patient’s readiness, ability and
intent in taking the medicines
● Ensure that patients know if symptoms
change or problem persists
When to do it?
● Patient is discharged from the hospital
● Patient has new medicine
● Patients with long term conditions with
multiple medications
● Clinician identified a medication related
problem
Type 3: Clinical Medication Review
● Takes place with the patient and access to
patient’s medical notes and relevant
laboratory results
● Also takes place in the context of recent
indicator’s of the patient’s underlying
conditions and with the patient’s self report
of their current symptom experience or a
report made by health or social care
professional
● Focus on treatment of specific condition
Purpose:
● A periodic review of the patient’s medical
condition and treatment to ensure that
conditions are managed optimally.
● Obtain feedback in response for treatment
for symptomatic condition
● Review medical and self management of
long-term conditions
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● Provide full and accurate info about pros ● Current management

and cons of treatment plan is outdated due to
the availability of new
When to do it? evidence

● Patient’s with long-term conditions

● Patient with recently diagnose long-term Specialist drugs**
conditions ● Drugs with narrow
● Patient experienced an adverse event therapeutic range eg
associated with medicine-taking digoxin, warfarin
● Patient/Carer requests a review or reports ● Drugs on red/amber lists
● Drugs which require
they have stopped taking prescribed
special monitoring eg
medicine. lithium
Review Process
Nursing/Residenti
1. Identify patients al Homes ● Use of commercial sip
2. Carry out the review feeds as an ‘easy’
3. Record review outcomes / Feedback results alternative to liquidised or
4. Audit / Quality assurance pureed foods
● Polypharmacy
Identifying patients ● Poor utilisation of ‘Home
Remedies’
- Medication review may initially need to be ● Reordering systems can
be time-consuming
prioritized to patients who are at risk of
● Overuse of
medicine related problems. antipsychotics/sedatives

HIGH RISK EXAMPLES OF REASONS FOR

GROUP HIGH RISK
Elderly (>75 years)
● Complex medication
regimen
● Polypharmacy
● Multiple pathologies
● Compliance issues
● Physical problems (eg
swallowing, arthritis)
● Resident in care home
● Mental states eg
confusion, dementia,
depression, anxiety
Chronic diseases
● Polypharmacy
● Recent discharge from
hospital
● Medicines from more
than one source
● Adverse effects /drug
interactions
● Taking drugs requiring
special monitoring
Polypharmacy
● Taking four or more
regular medicine daily
● Complex regimes
● Compliance problems
● Adverse effects or drug
interactions
● Current management
plan is outdated due to
the availability of new
evidence
● Older People
● Care Homes
● Mental issues
● Learning Disability
● Minority ethnic background
● Language and communication Issues
● Poor social support
● >4 medicines daily
● Drugs requiring special monitoring
● Transfer of Care
● Multiple carers
● Multiple prescribers
● Poor disease control
● New guidelines
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Drug Suggested Monitoring Additional Information

Cardiovascular System (BNF Chapter 2)

Angiotensin converting Baseline: Consider modifying /

enzyme inhibitors - BP, renal function stopping treatment if:
(ACEI) and and serum - Serum creatinine
Angiotensin-II receptor potassium concentration
antagonists increases by 50%
Routine: or more
- BP, renal function - Serum potassium
and serum is 5.0 mmol/l or
potassium 1 week more
after initiation, 1
week after
significant dose
increases, and on
an annual basis

Diuretics (loop and Baseline: If serum potassium falls

thiazide) - Serum potassium below 3.0mmol/l consider
and U&E adding potassium
Routine: sparing diuretic
- Serum potassium
within 4-6 weeks Thiazides may induce
of starting diabetes mellitus.
treatment
- Annual U&E
- Annual urinalysis
for glucose if on
thiazide

Amiodarone Baseline: If biochem results are

- LFTs, TFTs borderline repeat in 6
- BNF weeks. If no
recommends a improvement refer back
chest X-ray to specialist.
- Serum potassium
and ECG Thyrotoxicosis can occur
Routine: years after stopping
- Check LFTs, amiodarone therefore a
TFT’s 6 monthly low threshold for TFT
- Annual testing is warranted.
ophthalmic Long term TFT testing is
examination required in all patients
- Repeat chest with a history of
x-ray if pulmonary thyrotoxicosis even after
toxicity suspected amiodarone is stopped.

Digoxin Baseline: Regular monitoring of

- Renal function digoxin levels is not
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and serum necessary unless signs

potassium and symptoms which
Routine: suggest toxicity or
- Patients taking a inadequate dose.
diuretic should
have serum
potassium
monitored

Warfarin As per NHSSB

“Guidance on Wartarin
Prescribing and
Monitoring
- notes for GPs”

Baseline: Treatment should be

- Fasting full lipid discontinued if serum
profile transaminases rise to
- TFT, U&E, LFT, and persist at 3 times the
blood glucose, upper limit of the normal
CK reference range.

Routine: Discontinue treatment if

- Fasting full lipid myopathy is suspected
profile 6-8 weeks or diagnosed and the CK
after initiation or is markedly elevated
dose increase (>10 times upper limit of
then annually normal)
- Check CK within
1-3 months of
initiation
thereafter
annually with
cholesterol
- Check LFTs
within 1 — 3
months of starting
treatment and
then check at 6
months and 12
months unless
signs of
hepatotoxicity.
See SPC for
specific
recommendation
for Simvastatin
and Atorvastatin

Respiratory System (BNF Chapter 3)

Theophylline Once maintenance dose

achieved check
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theophylline levels 6 —
12 monthly

Central Nervous System (BNF Chapter 4)

Carbamazepine Baseline: Frequent monitoring of

- LFTs, FBC, U&Es serum concentrations is
not required except when
Routine: using drugs which
- Periodic interact and when toxicity
monitoring of LFT, is suspected.
FBC and U&E

Phenytoin Baseline:
- LFTs and FBC
Routine:
- FBC and LFTs
regularly
- Folic acid 6
monthly
- Serum phenytoin
concentrations
may be
necessary for
optimal dosage
adjustments

Sodium Valproate Baseline: Monitoring serum

- LFTs and screen concentrations of sodium
for potential valproate is not required.
bleeding Sodium valproate can
complications cause thrombocytopenia.
Routine: Spontaneous bruising or
- LFTs should be bleeding is an indication
checked monthly to withdraw drug pending
for first 3 months investigations
then annually

Vigabatrin Baseline: Visual field defects

- Visual field testing reported in about one
by perimetry third of patients. Patients
Routine: who develop this should
- Visual field testing be referred to a specialist
by perimetry
every 6 months

● Is the reason clear from the history

Carrying out the review summary?
● Is the patient capable of taking this drug and
Ten-point medication review is compliance satisfactory?
● Are any tests required to monitor
● Why is this patient taking this drug? side-effects or dosage?

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● Are there any potential drug interactions

and are they of significance?
● What would happen if the drug was
stopped?
● Does the repeat need to be continued for
the next 6 or 12 months?
● Are any non-repeat items being prescribed
regularly?
● Should these be converted to formal
repeats?
● Set a date for the next review?

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Recording the review outcomes
● Level 1: Review of a list of the medication
under the direction of doctor, nurse or
pharmacist, but in the absence of the
patient
● Level 2: Treatment review under the
direction of a doctor, nurse or pharmacist, in
the absence of the patient but with
reference to the coding only patient’s clinical
record
● Level 3: Clinical medication review
specifically undertaken by a doctor, nurse or
pharmacist in the presence of the patient
with access to the patient’s clinical record
and laboratory test results as required
Quality Assurance / Audit
Quality Assurance
● One method of assessing the quality of the
review system is by evaluating the feedback
from patients or their carers who have
participated in the medication review
process. This might include an evaluation of
their experience of the review and the level
of satisfaction with its outcome.
Audit
● Medication review is an integral part of the
repeat prescribing process and many
practices undertake regular audits of their
repeat prescribing system.
(a) Implementing changes
(b) Documentation
(c) Communication of changes
(d) Follow up
Who does the Review?
● In practice doctors, pharmacists and many
nurses have the clinical skills and
therapeutic knowledge to perform all
aspects of medication review
What should the review cover?
For each drug: Check that
BY NGILAY, OCTAVIO, RASGO
1. The medication prescribed is appropriate for
the patient’s needs
2. The medication is effective for the patient
3. The medication is a cost effective choice
4. Any required monitoring has been done or
arrangements are in place
Consider:
1. Drug interactions
2. Contraindications to the drug
3. Side effects
4. Compliance
5. Concordance
6. Over-the-counter and complementary
medicines
7. Lifestyle and non-medicinal interventions
8. Unmeet need
The NO TEARS Mnemonic to Aid Medication
Review in a10 Minute Consultation 10
● N - Need and Indication
● O - Open Questions
● T - Tests and Monitoring
● E - Evidence and Guidelines
● A - Adverse Events
● R - Risk reduction or prevention
● S - Simplification and switches
_________________________________________
Quiz
Define medication review.
Medication Review is defined as a
structured/systematic and critical evaluation of the
medicines utilized in patient care. Its main purpose
is to attain the best health outcomes by optimizing
the impact of drug delivery and medicine use in
collaboration or agreement with the patient which
makes both parties including the carers understand
their role more in medication management and
treatment. More than that, it is a strategy that can
minimize drug-related problems through early
detection, reduce waste and allow the opportunity
to formulate recommended and necessary
interventions.
Give the 3 types of medication review and
DISCUSS IN YOUR OWN WORDS each type of
review.
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1. Type 1: Prescription Review - This type of
medication review is concerned primarily
about the aspect of practical medicine
management. It aims to improve clinical and
cost-effectiveness of medicines so that the
patients can be given optimum care and
treatment for the lowest or most affordable
price without sacrificing their safety and
expected efficacy of drugs. This review is
done to either identify anomalies in the
prescription, assess whether there are
unmet or under met therapeutic needs, or
identify if a medicine was not dispensed
although prescribed. Usually, this is done
when the patient is in the hospital or
transferred between care settings or
reviewing practice for a class of medicine, In
here, drugs can be reviewed without the
presence of the patient but in the case of
medication change, the patient or carer
must be notified and consent to it
beforehand.
2. Type 2: Concordance and Compliance
Review - This type of medication review is
done to assess the patient's knowledge,
compliance, readiness, ability and intent of
the patient in their treatment. By asking
open-ended questions, the pharmacist can
exchange information and beliefs with the
patient, crosscheck information with them
such as their pattern of medicine-taking and
assess whether they understand what they
are undergoing. It enables the patient to
take an active role by collaborating with the
pharmacist and carer through giving them
the liberty of monitoring their own conditions
including the signs and symptoms hence,
knowing when to take action. Usually, the
review is done upon discharge, prescription
of new medicine, with patients with long
term conditions with multiple medications
and when there is an identified
medication-related problem.
3. Type 3: Clinical Medication Review - This
type of medication review focuses on the
treatment of a specific condition and is done
periodically in order to continually reassess
the condition of the patient so as to ensure
again if their treatment is still managed in
the best way possible. In here, patient
feedback is vital in order to identify if the
treatment is effective or if there are any
individualized adverse effects or events that
BY NGILAY, OCTAVIO, RASGO
we need to take note of. This is especially
important in reviewing medical and
self-management of long-term conditions. If
the aforementioned reviews do not require
the presence of the patients themselves,
this review takes place with the patient
because they report their symptom
experience if not done by a care
professional. Parties have access to
medical notes and other relevant laboratory
results. Aside from patients with long-term
conditions, this is done for those who were
just recently diagnosed with the
aforementioned, those who experienced
adverse effects or if there is a request for a
review upon stopping intake.
Give 5 benefits of Medication review.
1. Since we can identify what drugs are not
effective for the patient, gives adverse
reaction or those that the patient does not
comply with, it can reduce unwanted or
unused medicines.
2. It enables the patient and carer to play an
active part in treatment and medication
management by giving them the liberty to
monitor their symptoms, reporting their
experiences and giving consent to any
medication change.
3. Since we are collaborating with the patient,
carer and other healthcare professionals,
we can establish a relationship with them
and develop a shared understanding about
the proper medicines and practices and
their role in the treatment.
4. It improves the current and future
management of the patient's medical
condition.
5. Since we technically screen the drugs, we
can reduce adverse events/effects.
Give 5 example of high risk people who needs
medication review and 5 drugs that we needed
to monitor constantly.
High Risk People
1. Older people or the Elderly (>75 years)
2. People with chronic diseases
3. People who take drugs that require special
monitoring or specialist drugs
4. People in nursing/residential homes
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5. People who take 4 or more medicines daily

or those who belong to a minority ethnic
background with poor social support
6. People with mental issues and learning
disability

5 Drugs
1. Warfarin
2. Digoxin
3. Phenytoin
4. Angiotensin Converting Enzyme Inhibitors
(ACE) or Angiotensin-II Receptor
Antagonists
5. Amiodarone

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