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12 TH EDITION
DIPIRO’S
PHARMACOTHERAPY
A PAT H O P H YS I O LO G I C A P P R O AC H
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Assistant Editors
Angela L. Bingham, PharmD, BCPS, Rena A. Gosser, PharmD, BCPS
BCNSP, BCCCP Clinical Ambulatory Pharmacy Manager
Harborview Medical Center
Vice Chair and Clinical Associate Professor
Seattle, Washington
Philadelphia College of Pharmacy
Saint Joseph’s University
Philadelphia, Pennsylvania Lisa M. Holle, PharmD, BCOP
Clinical Professor of Pharmacy Practice
Scott Bolesta, PharmD, BCPS Department of Pharmacy Practice
School of Pharmacy, University of Connecticut
Professor
Storrs, Connecticut
Department of Pharmacy Practice
Nesbitt School of Pharmacy, Wilkes University
Wilkes-Barre, Pennsylvania Amy M. VandenBerg, PharmD, BCPP
Clinical Associate Professor
Robert J. DiDomenico, PharmD, FCCP, College of Pharmacy, University of Michigan
Ann Arbor, Michigan
FHFSA, FACC
Associate Professor and Assistant Head
Department of Pharmacy Practice
College of Pharmacy, University of Illinois Chicago
Chicago, Illinois
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12 TH EDITION
DIPIRO’S
PHARMACOTHERAPY
A PAT H O P H YS I O LO G I C A P P R O AC H
Editors
Joseph T. DiPiro, PharmD Thomas D. Nolin, PharmD, PhD, FCCP,
Professor, School of Pharmacy FCP, FASN
Associate Vice President for Health Sciences
Associate Dean for Research and Sponsored Programs
Virginia Commonwealth University
Associate Professor of Pharmacy and Therapeutics
Richmond, Virginia
School of Pharmacy, University of Pittsburgh
Pittsburgh, Pennsylvania
Gary C. Yee, PharmD
Professor, College of Pharmacy
Vicki L. Ellingrod, PharmD, FCCP
Associate Vice Chancellor for Academic Affairs Dean and John Gideon Searle Professor of Pharmacy
University of Nebraska Medical Center College of Pharmacy
Omaha, Nebraska Professor of Psychiatry, Medical School
University of Michigan
Ann Arbor, Michigan
Stuart T. Haines, PharmD, BCPS, BCACP
Professor, Department of Pharmacy Practice L. Michael Posey, BSPharm, MA
Director, Pharmacy Professional Development President
School of Pharmacy, University of Mississippi PENS Pharmacy Editorial & News Services
Jackson, Mississippi Santa Rosa, California
New York Chicago San Francisco Athens London Madrid Mexico City Milan New Delhi Singapore Sydney Toronto
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Dedication
To our patients and students, who have challenged and inspired us and given meaning to all our endeavors.
To practitioners who continue to improve patient health outcomes and thereby serve as role models for their colleagues
and students while clinging tenaciously to the highest standards of practice.
To our mentors, whose vision provided educational and training programs that encouraged our professional growth and
challenged us to be innovators in our patient care, research, and education.
To our faculty colleagues for their efforts and support for our mission to provide a comprehensive and challenging educational
foundation for the pharmacists of the future.
And finally to our families for the time that they have sacrificed so that this twelfth edition would become a reality.
—The Editors
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PAST EDITORS OF DIPIRO’S PHARMACOTHERAPY
Peggy E. Hayes, PharmD

Editions 1 and 2
Gary R. Matzke, PharmD, FCP, FCCP, FASN, FNAP

Editions 2–10
Robert L. Talbert, PharmD, FCCP, BCPS, FAHA

Editions 1–10
Barbara G. Wells, PharmD, FCCP, FASHP

Editions 3–10
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Contents
Contributors�� xiii
Foreword��xxxiii
e12. inor Otic Disorders (Cerumen Impaction,
M
Otitis External)��29
Preface�� xxxv
Lea S. Eiland
e13. onspecific Respiratory Tract Symptoms
N
SECTION 1 Foundation Issues 1 (with Cough)��31
Brandon Sucher
Section Editors: Stuart T. Haines, L. Michael Posey, and Thomas D. Nolin e14. Allergic Rhinitis��33
1. Patient Care Process�� 1 J. Russell May
Stuart T. Haines, Mary Ann Kliethermes, e15. Oral Health and Systemic Conditions��35
and Todd D. Sorensen Lisa M. Palmisano and Jennifer L. Mazan
e2. Health Literacy and Medication Use�� 9 e16. Oral Hygiene and Minor Oral Disorders��37
Oralia V. Bazaldua, Norbert Rosario, and Erica Torres Anna S. Milone, Kristyn M. Williamson, and Maren Hall
e3. E xploring Cultural Diversity and Equity in e17. S kin Care and Minor Dermatologic
Healthcare��11 Conditions ��39
Amanda M. Loya, Jeri J. Sias, Lakesha M. Butler, Rebecca M. Law and Howard I. Maibach
Christopher G. Medlin, and Jessica M. Shenberger-Trujillo
e18. T ravel Health ��41
e4. Medication Safety��13 Douglas Slain and Scott E. Kincaid
Robert J. Weber
19. Contraception��43
e5. Medication Adherence ��15 Shareen Y. El-Ibiary
Fang-Ju Lin, Yen-Ming Huang, and Yunn-Fang Ho
e6. linical Pharmacokinetics and
C
Pharmacodynamics ��17
SECTION 3 Special Populations 67
Kristin M. Janzen and Samuel M. Poloyac
Section Editors: L. Michael Posey and Thomas D. Nolin
e7. Clinical Pharmacogenomics ��19
Roseann S. Gammal, Larisa H. Cavallari, and e20. ediatrics: General Topics in Pediatric
P
Y. W. Francis Lam Pharmacotherapy ��67
Milap C. Nahata and Carol K. Taketomo
e8. Clinical Toxicology��21
Bryan D. Hayes and Natalija M. Farrell e21. ediatrics: Oral Nutrition and Rehydration of
P
Infants and Children��69
Katherine H. Chessman
e22.
section 2 Common Health Problems 23 Pediatrics: Neonatal Critical Care��71
Kirsten H. Ohler and Jennifer T. Pham
Section Editors: L. Michael Posey, Joseph T. DiPiro, and Vicki L. Ellingrod e23. Geriatrics: Physiology of Aging��73
Krista L. Donohoe, Elvin T. Price, Tracey L. Gendron, and
e9. Fever ��23 Patricia W. Slattum
Jamal Brown and Juan Mosley II
e24. Geriatrics: Medication Use in Older Adults��75
e10. Pain and Headache��25 Emily R. Hajjar, Lauren R. Hersh, and Shelly L. Gray
Ryan C. Costantino, Krista B. Highland, and Laura C. Tilley
e25. eriatrics: Assessing Health and Delivering
G
e11. Minor Ophthalmic Disorders��27 Healthcare to Older Adults��77
Jared Ostroff Leigh Ann Mike, Zachary A. Marcum, and Shelly L. Gray
vii
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viii
e26. ritical Care: Considerations in Medication

C 45. Chronic Obstructive Pulmonary Disease�� 393
Selection, Dosing, Monitoring, and Safety�� 79 Sharya V. Bourdet and Dennis M. Williams
Erin F. Barreto and Amy L. Dzierba 46. Pulmonary Arterial Hypertension�� 419
e27. Critical Care: Pain, Agitation, and Delirium�� 81 Rebecca L. Attridge Rebecca Moote, and Deborah J. Levine
Caitlin S. Brown and Gilles L. Fraser 47. Cystic Fibrosis�� 437
e28. Palliative and End-of-Life Care �� 83 Kim G. Adcock, Ha K. Phan, and David Josey Jr.
Mary Lynn McPherson and Jessica E. Geiger e48. Drug-Induced Pulmonary Diseases�� 455
CONTENTS
Margaret A. Miklich and Mojdeh S. Heavner
SECTION 4 Cardiovascular Disorders 85

SECTION 6 Gastrointestinal Disorders 457
Section Editor: Stuart T. Haines
Section Editor: Joseph T. DiPiro
e29. Evaluation of Cardiovascular Function�� 85
Brent N. Reed, Kristin Watson, and Gautam Ramani e49. Evaluation of the Gastrointestinal Tract�� 457
Keith M. Olsen
30. Hypertension�� 87
Eric J. MacLaughlin and Joseph J. Saseen 50. Gastroesophageal Reflux Disease�� 459
Dianne W. May, Devin L. Lavender, and Satish C. Rao
e31. Acute Hypertensive Crisis �� 119
Jeffrey J. Mucksavage, Danielle M. Tompkins, and 51. Peptic Ulcer Disease and Related Disorders �� 479
Eric J. MacLaughlin Bryan L. Love
32. Dyslipidemia�� 121

52. Inflammatory Bowel Disease �� 503
Brian A. Hemstreet
Dave L. Dixon, Daniel M. Riche, and Michael S. Kelly
33. Stable Ischemic Heart Disease�� 143
53. Nausea and Vomiting �� 525
Leigh Anne H. Gravatt, Krista L. Donohoe, and
Paul P. Dobesh, Robert J. DiDomenico, and
Mandy L. Gatesman
Kelly C. Rogers
34. Acute Coronary Syndrome �� 167
54. Diarrhea, Constipation, and Irritable Bowel
Syndrome �� 539
Robert J. DiDomenico, Paul P. Dobesh, and
Patricia H. Fabel and Kayce M. Shealy
Shannon W. Finks
55. Portal Hypertension and Cirrhosis�� 557
e35. Peripheral Arterial Disease�� 197
Julie M. Sease
Kristin Watson and Sarah L. Anderson
e56. Drug-Induced Liver Injury �� 573
36. Chronic Heart Failure�� 199 William R. Kirchain and Rondall E. Allen
Robert B. Parker and Jo E. Rodgers
57. Pancreatitis�� 575
37. Acute Decompensated Heart Failure�� 231 Scott Bolesta
Brent N. Reed, Stormi E. Gale, and Zachary L. Cox
58. Viral Hepatitis�� 591
38. Venous Thromboembolism�� 251 Paulina Deming
Daniel M. Witt, Nathan P. Clark, and Sara R. Vazquez
59. Celiac Disease�� 611
39. Stroke�� 283 Priti N. Patel and Robert A. Mangione
Melody Ryan and Melissa A. Nestor
40. Arrhythmias�� 297
41.
Jessica J. Tilton, Stephen T. Phillips, and Jerry L. Bauman
Cardiopulmonary Arrest�� 335
SECTION 7 Renal Disorders 619
Jeffrey F. Barletta Section Editor: Thomas D. Nolin
e42. Shock Syndromes�� 353 e60. Evaluation of Kidney Function�� 619
Seth R. Bauer, Robert MacLaren, and Brian L. Erstad Linda Awdishu and Thomas C. Dowling
61. Acute Kidney Injury�� 621
SECTION 5 Respiratory Disorders 355 Jenana H. Maker, Lauren K. Roller, and William Dager
62. Chronic Kidney Disease �� 641
Section Editor: Stuart T. Haines Lori D. Wazny
e43. Evaluation of Respiratory Function�� 355 63. Chronic Kidney Disease: Management of
Megan L. Carreon, Maria I. Velez, Stephanie M. Levine, and Secondary Complications�� 653
Jay I. Peters Joanna Q. Hudson
44. Asthma�� 357 64. Hemodialysis and Peritoneal Dialysis �� 679
Kathryn V. Blake and Jean Y. Moon Kevin M. Sowinski and Mariann D. Churchwell
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ix
65. Drug-Induced Kidney Disease�� 699 e83. Eating Disorders��1023
Thomas D. Nolin and Mark A. Perazella Steven C. Stoner, Valerie L. Ruehter, and Melissa C. Palmer
e66. Glomerular Diseases�� 719 e84. Introduction to Substance Use Disorders�� 1025
Duncan B. Johnstone Jessica L. Moreno, Patrick Leffers, and Vicki L. Ellingrod
67. Personalized Pharmacotherapy for Patients with 85. Substance Use Disorders I: Opioids, Cannabis,
Chronic Kidney Disease �� 721 and Stimulants��1027
Morgan A. Butrovich and Thomas D. Nolin Patrick Leffers, Brittany N. Johnson, and Patrick Aaronson
CONTENTS
68. Disorders of Sodium and Water Homeostasis �� 737 86. Substance Use Disorders II: Alcohol, Nicotine,
Katherine H. Chessman and Jason S. Haney and Caffeine��1047
69. Disorders of Calcium and Phosphorus Lori H. Dupree and Robin Moorman Li
Homeostasis�� 763 87. Schizophrenia ��1073
Angela L. Bingham M. Lynn Crismon, Tawny L. Smith, and Peter F. Buckley
70. Disorders of Potassium and Magnesium 88. Depressive Disorders��1107
Homeostasis�� 783 Amy M. VandenBerg
Rachel W. Flurie
89. Bipolar Disorder ��1133
71. Acid–Base Disorders �� 801 Jordan C. Haygood and Shannon J. Drayton
Anne M. Tucker and Tami N. Johnson
90. Generalized Anxiety Disorder, Panic Disorder,
and Social Anxiety Disorder��1151
SECTION 8 Neurologic Disorders 823 Sarah T. Melton and Cynthia K. Kirkwood
Section Editor: Vicki L. Ellingrod

91. Posttraumatic Stress Disorder and Obsessive-
Compulsive Disorder��1173
e72. Evaluation of Neurological Illness�� 823 Kristen N. Gardner, Jolene R. Bostwick, and
Melody Ryan and Stephen J. Ryan Ericka L. Crouse
73. Alzheimer Disease �� 825 92. Sleep Disorders��1187

Ericka L. Crouse, Kristin M. Zimmerman, Emily P. Peron, John M. Dopp and Bradley G. Phillips
Lana J. Sargent, and Sarah E. Hobgood e93. Developmental Disabilities��1201
Steven R. Erickson
74. Multiple Sclerosis�� 845
Jacquelyn L. Bainbridge, Augusto Miravelle, Pei Shieen
75.
Wong, Matthew J. Makelky Sr., and Sarah Rajkovic
Epilepsy�� 869
SECTION 10 Endocrinologic Disorders 1203
Viet-Huong V. Nguyen, Sunita Dergalust, and Section Editor: Stuart T. Haines
Edward Chang
94. Diabetes Mellitus ��1203
76. Status Epilepticus�� 905 Jennifer M. Trujillo and Stuart T. Haines
Elizabeth A. Hall, Stephanie J. Phelps, and
James W. Wheless e95. Acute Hyperglycemia��1239
Paul M. Szumita, James F. Gilmore, and Jennifer M. Trujillo
77. Acute Management of the Brain Injury Patient�� 921
Bradley A. Boucher and G. Christopher Wood 96. Thyroid Disorders��1241
Michael P. Kane and Gary Bakst
78. Parkinson Disease�� 935
Jessa M. Koch, Khashayar Dashtipour, and Jack J. Chen 97. Adrenal Gland Disorders ��1267
Steven M. Smith, Christopher R. Piszczatoski, and
79. Pain Management �� 953 John G. Gums
Christopher M. Herndon, Courtney M. Kominek, and
Amanda M. Mullins e98. Pituitary Gland Disorders��1289
Joseph K. Jordan, Amy Heck Sheehan, and Kashif M. Munir
80. Headache Disorders�� 981
Kimberly B. Tallian and Natalie T. Heinrich
SECTION 11 Gynecologic and Obstetric
SECTION 9 Psychiatric Disorders 1001 Disorders 1291
Section Editor: Vicki L. Ellingrod Section Editor: Vicki L. Ellingrod
e81. Evaluation of Psychiatric Illness��1001 99. Pregnancy and Lactation��1291

Mark E. Schneiderhan, Leigh Anne Nelson, Alicia B. Forinash and Kylie N. Barnes
Jeffrey R. Bishop, and Steven J. Bauer
100. Menstrual-Related Disorders ��1313
82. Attention Deficit Hyperactivity Disorder��1003 Kathleen M. Vest and Danielle C. Mayer
Danielle L. Stutzman, Julie A. Dopheide, and Steven
Pliszka
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x
101. Endometriosis��1333 e116. Drug-Induced Ophthalmic Disorders��1609
Kathleen M. Vest and Sarah E. Lynch Rena A. Gosser
102. Menopausal Hormone Therapy��1343
Devra K. Dang and Judy T. Chen
SECTION 16 Dermatologic Disorders 1611
Section Editor: L. Michael Posey
SECTION 12 Urologic Disorders 1365
CONTENTS
117. Acne Vulgaris��1611

Section Editor: L. Michael Posey Debra Sibbald and Cathryn Sibbald
103. Erectile Dysfunction��1365 118. Psoriasis��1639
Mary Lee and Roohollah Sharifi Rebecca M. Law and Wayne P. Gulliver
104. Benign Prostatic Hyperplasia��1393 119. Atopic Dermatitis��1661
Mary Lee and Roohollah Sharifi Rebecca M. Law and Wayne P. Gulliver
105. Urinary Incontinence��1413 120. Alopecia��1677
Eric S. Rovner, Kristine M. C. Talley, and Sum Lam Rebecca M. Law, Le Hanh Dung Do, and
Howard I. Maibach
e121. ermatologic Drug Reactions,
D
SECTION 13 Immunologic Disorders 1431 Contact Dermatitis, and Common
Skin Conditions ��1693
Section Editors: Gary C. Yee and Thomas D. Nolin Rebecca M. Law, David T. S. Law, and Howard I. Maibach
e106. Function and Evaluation of the

Immune System ��1431
Daniel A. Zlott and Geoffrey M. Thiele
SECTION 17 Hematologic Disorders 1695
107. Systemic Lupus Erythematosus��1433 Section Editor: Gary C. Yee
Beth H. Resman-Targoff
122. Anemias��1695
e108. Drug Allergy ��1455 Kristen M. Cook and Devon M. Greer
Mary L. Staicu, Christopher M. Bland, and Bruce M. Jones
123. Coagulation Disorders ��1715
109. Solid-Organ Transplantation��1457 Heidi Trinkman, Timothy L. McCavit, and Lauren Duran
Nicholas W. Lange, David M. Salerno, and
Douglas L. Jennings
124. Sickle Cell Disease ��1733
Jin Han, Santosh L. Saraf, and Victor R. Gordeuk
e125. Drug-Induced Hematologic Disorders��1753
SECTION 14 Rheumatologic Disorders 1481 Elisa M. Greene and Tracy M. Hagemann
Section Editors: L. Michael Posey and Thomas D. Nolin
110. Osteoarthritis��1481
SECTION 18 Infectious Diseases 1755
Lucinda M. Buys and Sara A. Wiedenfeld Section Editor: Joseph T. DiPiro
111. Rheumatoid Arthritis��1501 e126. L aboratory Tests to Direct Antimicrobial
Stephanie Gruber, Bianca Harris, and Susan Hylland
Pharmacotherapy��1755
112. Osteoporosis ��1523 Jordan R. Smith, Brian J. Werth, and Katie E. Barber
Mary Beth O’Connell, Jill S. Borchert, Erin M. Slazak, and 127. Antimicrobial Regimen Selection��1757
Joseph P. Fava Katie B. Olney and David S. Burgess
113. Gout and Hyperuricemia��1555 128. Central Nervous System Infections��1771
Michelle A. Fravel and Michael E. Ernst Delaney E. Hart, Christina Koutsari, Michael A. Wankum,
and Ramy H. Elshaboury
129.
SECTION 15 Ophthalmic Disorders 1577 Lower Respiratory Tract Infections��1791
Evan J. Zasowski and Martha G. Blackford
Section Editor: L. Michael Posey 130. Upper Respiratory Tract Infections��1813
Grace C. Lee, Bradi L. Frei, and Christopher R. Frei
114. Glaucoma ��1577
Richard Fiscella, Ohoud Owaidhah, and 131. Influenza ��1825
Deepak P. Edward Jessica C. Njoku
115. Age-Related Macular Degeneration ��1595 e132. Coronavirus Disease (COVID-19) ��1839
Alisa K. Escano and Casey S. Washington Jason M. Pogue, Erin K. McCreary, and Julie Ann Justo
FM.indd 10 13-02-2023 16:51:55

xi
133. Skin and Soft Tissue Infections��1841 152. Lung Cancer��2255
Douglas N. Fish Keith A. Hecht and Eve M. Segal
134. Bacteremia and Infective Endocarditis��1869 153. Colorectal Cancer��2277
Daniel B. Chastain Lisa M. Holle, Jessica M. Clement, and Lisa E. Davis
135. Tuberculosis��1893 154. Prostate Cancer��2303
Rocsanna Namdar and Charles A. Peloquin Daniel J. Crona and Amber B. Cipriani
136. Gastrointestinal Infections and Enterotoxigenic 155. Lymphomas��2323
CONTENTS
Poisonings��1913 Alexandre Chan, Chia J. Tan, and Shawn P. Griffin
Andrew M. Roecker and Brittany N. Bates
156. Ovarian Cancer ��2351
137. Intra-Abdominal Infections��1929 Grace A. Martin and Judith A. Smith
Alan E. Gross, Jamie L. Wagner, and Keith M. Olsen
157. Acute Leukemias��2369
e138. Parasitic Diseases��1947 David DeRemer and Tara A. Higgins
Alireza Fakhriravari, Ana Elizabeth Markez, and
Jason M. Cota
158. Chronic Leukemias��2391
Karen M. Fancher and Jill M. Comeau
139. Urinary Tract Infections��1949
Julianna M. Fernandez and Elizabeth A. Coyle
159. Multiple Myeloma ��2411
Amy M. Pick and Jared E. Matya
140. Sexually Transmitted Infections��1967
Yvonne J. Burnett and Humberto R. Jimenez
e160. Myelodysplastic Syndromes ��2429
Jill S. Bates and Jolynn Knoche Sessions
141. Bone and Joint Infections ��1989
Bryan T. Alexander and Scott J. Bergman
e161. Renal Cell Carcinoma��2431
Erin B. Bailey and David D. Stenehjem
142. Sepsis and Septic Shock��2003
S. Lena Kang-Birken and Sul R. Jung
162. Melanoma��2433
Cindy L. O’Bryant and Christina M. Davis
143. Superficial Fungal Infections ��2021
Thomas E. R. Brown and Linda D. Dresser
e163. Hematopoietic Cell Transplantation��2453
Elizabeth Dimaggio and Janelle Perkins
144. Invasive Fungal Infections��2039
Peggy L. Carver and Gregory A. Eschenauer
145. Infections in Immunocompromised Patients��2067
Scott W. Mueller and Douglas N. Fish
SECTION 20 Nutritional Disorders 2455
146. Antimicrobial Prophylaxis in Surgery ��2099 Section Editor: Thomas D. Nolin
Salmaan Kanji
164. Assessment of Nutrition Status
147. Vaccines and Immunoglobulins ��2115 and Nutrition Requirements��2455
Mary S. Hayney Katherine H. Chessman and Angela L. Bingham
148. Human Immunodeficiency Virus Infection��2129 165. Parenteral Nutrition��2481
Peter L. Anderson, Kristina M. Brooks, and Todd W. Mattox and Catherine M. Crill
Courtney V. Fletcher
166. Enteral Nutrition��2501
Diana W. Mulherin
167. Obesity��2519
SECTION 19 Oncologic Disorders 2155 Amy Heck Sheehan, Judy T. Chen, and Jack A. Yanovski
Section Editor: Gary C. Yee
Index 2545
149. Cancer: The Disease and Treatment��2155
Lisa M. Cordes and Sandra Cuellar
150. Supportive Care in Cancer��2209
Amber B. Clemmons and Ashley E. Glode
151. Breast Cancer��2229
Bonnie Lin Boster, Neelam K. Patel, and Jaime Kaushik
SI unit conversions were produced by Ed Randell, PhD, DCC, FCACB, Division Chief and Professor of Laboratory Medicine,
Department of Laboratory Medicine, Eastern Health Authority and Faculty of Medicine, Memorial University of Newfoundland,
St. John’s, Newfoundland, Canada
FM.indd 11 13-02-2023 16:51:55

Conflict of Interest Disclosure and Mitigation
Contributors to Pharmacotherapy: A Pathophysiologic Approach must disclose relevant financial and other interests with entities that
produce, market, sell, or distribute medications, health products, or services related to the medication use process. All contributors com-
pleted, signed, and submitted a conflict of interest (COI) disclosure statement to the Editors. Starting with the 11th edition, the COI
disclosure was submitted after an invitation has been extended and before a contributor agreement was signed.
After reviewing the COI disclosure statement submitted by a contributor, the Editors developed and approved a plan to mitigate any
and all potential COIs that might be reasonably perceived by the readers of Pharmacotherapy: A Pathophysiologic Approach to unduly
influence the contributor’s favorable or unfavorable portrayal of any product or service. The mitigation plan included, but was not
limited to, assigning a coauthor with no COIs to work with the contributor, subjecting the contribution to external peer review, or asking
the contributor to divest the interest(s).
No contributor may receive a payment or services from a third party (commercial entity, government agency, professional o rganization,
private foundation, etc.) for any work product submitted to Pharmacotherapy: A Pathophysiologic Approach.
Starting with the 11th edition, potential contributors who are employees of a commercial entity that produces, markets, sells, or
distributes medications or healthcare products are not invited or re-invited to contribute.
COI disclosures for all contributors to Pharmacotherapy: A Pathophysiologic Approach will be made available to readers online. The
internet address for the COI disclosure page will be published in the Contributors section of the text.
FM.indd 12 13-02-2023 16:51:56

Contributors
Patrick Aaronson, PharmD, DABAT Linda Awdishu, PharmD, MAS
Clinical Associate Professor and Emergency Medicine Practitioner Professor of Clinical Pharmacy, Division Head of Clinical
University of Florida Health Pharmacy, Director of Simulation and Interprofessional
Jacksonville, Florida Education
Chapter 85 Skaggs School of Pharmacy and Pharmaceutical Sciences,
University of California, San Diego
Kim G. Adcock, PharmD, CCRC La Jolla, California
Professor of Pharmacy Practice and Director of Faculty and Chapter e60
Academic Affairs
School of Pharmacy, University of Mississippi Erin B. Bailey, PharmD, BCOP
Professor of Pediatrics and Director of the Office of Clinical Pharmacist
Interprofessional Education University of Utah Health, Huntsman Cancer Institute
University of Mississippi Medical Center Salt Lake City, Utah
Jackson, Mississippi Chapter e161
Chapter 47
Jacquelyn L. Bainbridge, PharmD, MSCS
Bryan T. Alexander, PharmD, BCIDP, AAHIVP Professor, Departments of Clinical Pharmacy and Neurology
Pharmacy Coordinator, Outpatient Antimicrobial Therapy Skaggs School of Pharmacy and Pharmaceutical Sciences,
Program University of Colorado, Anschutz Medical Campus
Nebraska Medicine Aurora, Colorado
Omaha, Nebraska Chapter 74
Chapter 141
Gary Bakst, MD
Rondall E. Allen, BS, PharmD Head, Division of Community Endocrinology
Provost and Vice President for Academic Affairs Albany Medical Center
University of Maryland Eastern Shore Albany, New York
Professor, Pharmacy Practice and Administration Chapter 96
Salisbury, Maryland
Chapter e56 Katie E. Barber, PharmD
Associate Professor
Peter L. Anderson, PharmD School of Pharmacy, University of Mississippi
Professor Jackson, Mississippi
University of Colorado Anschutz Medical Campus Chapter e126
Aurora, Colorado
Chapter 148 Jeffrey F. Barletta, BS, PharmD
Professor and Vice Chair of Pharmacy Practice
Sarah L. Anderson, PharmD, BCACP, BCPS College of Pharmacy, Midwestern University
Scientific Director Glendale, Arizona
Clinical Care Options Chapter 41
Denver, Colorado
Chapter e35 Kylie N. Barnes, PharmD, BCPS
Rebecca L. Attridge, PharmD, MSc, BCPS, BCCCP University of Missouri–Kansas City School of Pharmacy
Principal, Pharmacotherapy Kansas City, Missouri
The Craneware Group Chapter 99
Colorado Springs, Colorado
Chapter 46
xiii
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xiv
Erin F. Barreto, PharmD, MSc Jeffrey R. Bishop, PharmD, MS, BCPP
Associate Professor of Medicine and Pharmacy Associate Professor
Mayo Clinic College of Pharmacy
Rochester, Minnesota University of Minnesota
Chapter e26 Minneapolis, Minnesota
Chapter e81
Brittany N. Bates, PharmD, BCPS
CONTRIBUTORS
Assistant Professor of Pharmacy Practice Martha G. Blackford, PharmD, BCPS

Ohio Northern University Clinical Pharmacologist and Toxicologist
Ada, Ohio Akron Children’s Hospital
Chapter 136 North Canton, Ohio
Chapter 129
Jill S. Bates, PharmD, BCOP
National PHASER Pharmacy Program Manager Kathryn V. Blake, PharmD, BCPS
Durham VA Health Care System Director, Center for Pharmacogenomics and Translational Research
Associate Professor of Clinical Education Nemours Children’s Health
Eshelman School of Pharmacy Jacksonville, Florida
Durham VA Health Care System Chapter 44
University of North Carolina
Chapter e160 Christopher M. Bland, PharmD, BCPS
Clinical Professor
Seth R. Bauer, PharmD, BCCCP College of Pharmacy, University of Georgia
Critical Care Clinical Specialist Antimicrobial Stewardship Pharmacist
Cleveland Clinic St. Joseph’s/Candler Health System
Clinical Assistant Professor Athens, Georgia
Cleveland Clinic Lerner College of Medicine Chapter e108
Cleveland, Ohio
Chapter e42 Scott Bolesta, PharmD, BCPS
Professor
Steven J. Bauer, MD Nesbitt College of Pharmacy, Wilkes University
Medical Director of Certified Community Mental Health Clinic Wilkes-Barre, Pennsylvania
Human Development Center Chapter 57
Duluth, Minnesota
Chapter e81 Jill S. Borchert, PharmD, BCPS, BCACP
Professor and Vice Chair
Jerry L. Bauman, PharmD College of Pharmacy
Dean Emeritus and Distinguished Professor Emeritus Midwestern University
College of Pharmacy, University of Illinois at Chicago Downers Grove, Illinois
Chicago, Illinois Chapter 112
Editor-in-Chief
Journal of the American College of Clinical Pharmacy Bonnie Lin Boster, PharmD, BCOP
Lenexa, Kansas Clinical Pharmacy Specialist
Chapter 40 University of Texas MD Anderson Cancer Center
Houston, Texas
Oralia V. Bazaldua, PharmD, BCACP Chapter 151
Professor/Clinical
The University of Texas Health Science Center Jolene R. Bostwick, PharmD
Ambulatory Care Clinical Pharmacy Specialist Assistant Dean for Co-curriculum and Professional Development
University Health System San Antonio and Clinical Professor of Pharmacy, Department of Clinical
San Antonio, Texas Pharmacy, and Clinical Pharmacist, Michigan Medicine
Chapter e2 University of Michigan College of Pharmacy
Ann Arbor, Michigan
Scott J. Bergman, PharmD, BCIDP Chapter 91
Nebraska Coordinator Antimicrobial Stewardship, Clinical
Professor Bradley A. Boucher, PharmD, MCCM
College of Pharmacy Interim Dean and Professor
University of Nebraska Medical Center Department of Clinical Pharmacy and Translational Science
Omaha, Nebraska College of Pharmacy
Chapter 141 University of Tennessee Health Science Center
Memphis, Tennessee
Angela L. Bingham, PharmD, BCPS, BCNSP, BCCCP Chapter 77
Vice Chair and Clinical Associate Professor
Philadelphia College of Pharmacy Sharya V. Bourdet, PharmD, BCPS
Saint Joseph’s University Associate Chief of Pharmacy for Acute Care and Education
Philadelphia, Pennsylvania San Francisco VA Medical Center
Chapters 69, 164 Associate Professor of Clinical Pharmacy
University of California San Francisco School of Pharmacy
San Francisco, California
Chapter 45
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xv
Kristina M. Brooks, PharmD Megan L. Carreon, MHA, RRT, RRT
Assistant Professor-Research Assistant Professor, Division of Respiratory Care
University of Colorado Anschutz Medical Campus UT Health San Antonio
Aurora, Colorado University of Texas Health Science Center
Chapter 148 San Antonio, Texas
Chapter e43
Caitlin S. Brown, PharmD, BCCCP
CONTRIBUTORS
Neurocritical and Emergency Medicine Pharmacist Peggy L. Carver, PharmD
Mayo Clinic Associate Professor
Assistant Professor of Pharmacy & Emergency Medicine College of Pharmacy
Mayo School of Medicine University of Michigan
Minneapolis, Minnesota Clinical pharmacist, Infectious diseases
Chapter e27 Ann Arbor, Michigan
Chapter 144
Jamal Brown, PharmD, BCGP
Associate Professor of Pharmacy Practice Larisa H. Cavallari, PharmD
College of Pharmacy, Florida A&M University Professor of Pharmacotherapy and Translational Research
Tampa, Florida College of Pharmacy
Chapter e9 University of Florida
Gainesville, Florida
Thomas E. R. Brown, PharmD Chapter e7
Associate Professor
Leslie Dan Faculty of Pharmacy Alexandre Chan, PharmD, MPH, BCPS, BCOP
University of Toronto Founding Chair and Professor of Clinical Pharmacy
Toronto, Ontario University of California, Irvine
Chapter 143 Clinical Pharmacist
Chao Family Comprehensive Cancer Center
Peter F. Buckley, MD Irvine, California
Chancellor Chapter 155
University of Tennessee Health Science Center
Memphis, Tennessee Edward Chang, MD, PhD
Chapter 87 Clinical Neurophysiology Fellowship Program Director
Harbor UCLA Medical Center
Yvonne J. Burnett, PharmD, BCIDP West Carson, California
Associate Professor of Pharmacy Practice Chapter 75
University of Health Sciences and Pharmacy in Saint Louis
Clinical Pharmacy Specialist, Infectious Diseases Daniel B. Chastain, PharmD, BCIDP, AAHIVP
Missouri Baptist Medical Center Clinical Associate Professor
St. Louis, Missouri College of Pharmacy
Chapter 140 University of Georgia
David S. Burgess, PharmD Athens, Georgia
Professor and Chair, Department of Pharmacy Practice & Science Chapter 134
College of Pharmacy
University of Kentucky
Jack J. Chen, PharmD, BCPS, BCGP
Consultant
Lexington, Kentucky
Clinical Movement Disorders
Chapter 127
Chino Hills, California
Lakesha M. Butler, PharmD, BCACP, CDFT Chapter 78
Associate Vice President, Inclusion, Diversity and Health Equity
and Clinical Professor Judy T. Chen, PharmD, BCPS, BCACP, CDCES
College of Pharmacy Clinical Associate Professor
University of Florida College of Pharmacy
Gainesville, Florida Purdue University
Chapter e3 Clinical Pharmacy Specialist, Women’s Health
Indianapolis, Indiana
Morgan A. Butrovich, PharmD Chapters 102, 167
PhD Candidate
University of Pittsburgh School of Pharmacy Katherine H. Chessman, BS-Pharm, PharmD, BCPS,
Pittsburgh, Pennsylvania BCNSP
Chapter 67 Professor and Chair, Clinical Pharmacy and Outcome Sciences
College of Pharmacy
Lucinda M. Buys, PharmD, BCACP
Medical University of South Carolina
Clinical Pharmacist and Clinical Services Director
Clinical Pharmacy Specialist, Pediatrics/Pediatric Surgery/
Siouxland Medical Education Foundation
Intestinal Rehabilitation
Sioux City, Iowa
MUSC Shawn Jenkins Children’s Hospital
Chapter 110
Charleston, South Carolina
Chapters e21, 68, 164
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xvi
Mariann D. Churchwell, PharmD, BCPS Ryan C. Costantino, PharmD, MS, BCPS, BCGP, CPHIMS
Professor Chief, Data Science Branch
University of Toledo College of Pharmacy and Pharmaceutical Enterprise Intelligence & Data Solutions Program Management
Sciences Office
Clinical Pharmacy Specialist Program Executive Office, Defense Healthcare Management Systems
Toledo, Ohio San Antonio, Texas
Chapter 64 Chapter e10
CONTRIBUTORS
Amber B. Cipriani, PharmD, BCOP Jason M. Cota, PharmD, MS, BCIDP

Precision Medicine Pharmacy Coordinator Vice Chair and Professor of Pharmacy Practice
UNC Health Medical Center Feik School of Pharmacy. University of the Incarnate Word
University of North Carolina San Antonio, Texas
Clinical Assistant Professor Chapter e138
UNC Eshelman School of Pharmacy
Chapel Hill, North Carolina Zachary L. Cox, PharmD
Chapter 154 Professor
Lipscomb University College of Pharmacy
Nathan P. Clark, PharmD, BCPS Heart Failure Clinical Pharmacy Specialist
Clinical Pharmacy Cardiovascular Services Manager Vanderbilt University Medical Center
Kaiser Permanente Colorado Nashville, Tennessee
Denver, Colorado Chapter 37
Chapter 38
Elizabeth A. Coyle, PharmD, BCPS
Jessica M. Clement, MD Associate Dean for Academic Affairs, Clinical Professor
Medical Director of Oncology Research College of Pharmacy, University of Houston
Hartford HealthCare Cancer Institute Houston, Texas
Hartford, Connecticut Chapter 139
Chapter 153 Catherine M. Crill, PharmD, FCCP, BCNSP
Amber B. Clemmons, PharmD, BCOP Associate Professor
Clinical Professor Departments of Clinical Pharmacy & Translational Science and
College of Pharmacy Pediatrics
University of Georgia Director of Experiential Learning and International Programs
Clinical Pharmacy Specialist - Hematology/Bone Marrow College of Pharmacy, University of Tennessee Health Science Center
Transplantation Memphis, Tennessee
Augusta University (AU) Medical Center Chapter 165
Augusta, Georgia M. Lynn Crismon, PharmD, DABCP, BCPP
Chapter 150 Behrens Centennial Professor of Pharmacy
Jill M. Comeau, PharmD, BCOP College of Pharmacy
Associate Professor of Clinical Sciences University of Texas at Austin
College of Pharmacy Professor of Psychiatry
University of Louisiana Monroe Dell Medical School
Gratis Assistant Professor of Internal Medicine University of Texas at Austin
Feist-Weiller Cancer Center Austin, Texas
LSU-Health Shreveport Chapter 87
Monroe, Louisiana Daniel J. Crona, PharmD, PhD, CPP
Chapter 158 Associate Professor
Kristen M. Cook, PharmD, BCACP Division of Pharmacotherapy and Experimental Therapeutics
Clinical Associate Professor, College of Pharmacy Eshelman School of Pharmacy
University of Nebraska Medical Center Clinical Pharmacist Practitioner
Ambulatory Care Pharmacist Genitourinary Malignancies, Department of Pharmacy
Nebraska Medicine University of North Carolina Medical Center
Omaha, Nebraska Chapel Hill, North Carolina
Chapter 122 Chapter 154
Lisa M. Cordes, PharmD, BCACP, BCOP Ericka L. Crouse, PharmD, BCPP, BCGP
Oncology Clinical Pharmacy Specialist Associate Professor
Office of Clinical Research and National Cancer Institute, National Virginia Commonwealth University School of Pharmacy
Institutes of Health Clinical Pharmacy Specialist – Psychiatry
Washington, D.C. VCU Health
Chapter 149 Richmond, Virginia
Chapters 73, 91
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xvii
Sandra Cuellar, PharmD, BCOP Robert J. DiDomenico, PharmD
Clinical Associate Professor Associate Professor and Assistant Head of Pharmacy Practice
College of Pharmacy University of Illinois Chicago
University of Illinois Chicago, Illinois
Clinical Oncology Pharmacist Chapters 33, 34
UI Health
Chicago, Illinois Elizabeth Dimaggio, PharmD, BCOP
CONTRIBUTORS
Chapter 149 Clinical Pharmacy Specialist
Blood and Marrow Transplantation and Cellular Immunotherapy
William Dager, PharmD, BCPS, MCCM H. Lee Moffitt Cancer Center
Cardiovascular Pharmacist Specialist Tampa, Florida
University of California, Davis Medical Center Chapter e163
Clinical Professor of Pharmacy
University of California San Francisco School of Pharmacy Dave L. Dixon, PharmD, BCACP, CLS
Clinical Professor of Medicine Nancy L. and Ronald H. McFarlane Professor of Pharmacy
University of California Davis School of Medicine Virginia Commonwealth University School of Pharmacy
Sacramento, California Chair
Chapter 61 Department of Pharmacotherapy & Outcomes Science
Richmond, Virginia
Devra K. Dang, CDCES, FNAP Chapter 32
Associate Clinical Professor of Pharmacy Practice
Department of Pharmacy Practice Le Hanh Dung Do, MD
University of Connecticut College of Pharmacy Attending Physician
Storrs, Connecticut Hiep Loi Cosmetic Surgery Hospital
Chapter 102 Ho Chi Minh City, Vietnam
Chapter 120
Khashayar Dashtipour, MD, PhD
Associate Professor of Neurology and Basic Sciences Paul P. Dobesh, PharmD, BCCP
Loma Linda University Professor of Pharmacy Practice and Science
Loma Linda, California College of Pharmacy
Chapter 78 University of Nebraska Medical Center
Cardiology Clinical Pharmacy Specialist
Christina M. Davis, PharmD, BCOP Nebraska Medicine
Clinical Oncology Pharmacy Specialist Omaha, Nebraska
University of Colorado Hospital Chapters 33, 34
Denver, Colorado
Chapter 162 Krista L. Donohoe, PharmD, BCPS, BCGP
Associate Professor
Lisa E. Davis, PharmD, FCCP, BCPS, BCOP Virginia Commonwealth University School of Pharmacy
Clinical Professor Richmond, Virginia
R. Ken Coit College of Pharmacy Chapters e23, 53
University of Arizona
Clinical Pharmacist Julie A. Dopheide, PharmD, BCPP
University of Arizona Cancer Center Professor of Clinical Pharmacy, Psychiatry and the Behavioral
Tucson, Arizona Sciences
Chapter 153 University of Southern California School of Pharmacy
Keck School of Medicine
Paulina Deming, PharmD Los Angeles, California
Clinician Educator—Associate Professor Chapter 82
University of New Mexico Health Sciences Center
Albuquerque, New Mexico John M. Dopp, PharmD
Chapter 58 Associate Professor
School of Pharmacy
David DeRemer, PharmD, BCOP University of Wisconsin
Clinical Professor Madison, Wisconsin
College of Pharmacy, University of Florida Chapter 92
Assistant Director, Experimental Therapeutics Group
University of Florida Health Cancer Center Thomas C. Dowling, PharmD, PhD
Gainesville, Florida Assistant Dean and Professor
Chapter 157 Director, Office of Research and Sponsored Programs
College of Pharmacy
Sunita Dergalust, PharmD Ferris State University
Neurology Pharmacist Grand Rapids, Michigan
Department of Veterans Affairs Chapter e60
Ventura County, California
Chapter 75
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xviii
Shannon J. Drayton, PharmD, BCPP Steven R. Erickson, PharmD
Associate Professor Associate Professor
College of Pharmacy College of Pharmacy
Medical University of South Carolina University of Michigan
Charleston, South Carolina Ann Arbor, Michigan
CONTRIBUTORS
Linda D. Dresser, BScPhm, PharmD Michael E. Ernst, PharmD

Assistant Professor, Teaching Stream Clinical Professor
Leslie Dan Faculty of Pharmacy College of Pharmacy
University of Toronto University of Iowa
Elgin, Ontario Iowa City, Iowa
Lori H. Dupree, PharmD, BCPS Brian L. Erstad, PharmD, MCCM, BCPS

Clinical Assistant Professor Professor and Head
College of Pharmacy R. Ken Coit College of Pharmacy
Mercer University University of Arizona
Suwanee, Georgia Tucson, Arizona
Lauren Duran, PharmD, MBA, BCPPS Alisa K. Escano, PharmD, BCPS

Clinical Pharmacist – Hematology/Oncology Clinical Assistant Professor
Cook Children’s Medical Center Virginia Commonwealth University, Inova campus
Fort Worth, Texas Clinical Pharmacy Specialist, Internal Medicine
Chapter 123 Richmond, Virginia
Chapter 115
Amy L. Dzierba, PharmD, BCCCP Gregory A. Eschenauer, PharmD
Clinical Pharmacist, Adult Critical Care
NewYork–Presbyterian Hospital
College of Pharmacy
New York, New York
Chapter e26
Clinical Specialist, Infectious Diseases
Deepak P. Edward, MD FACS FARVO Michigan Medicine
Professor of Ophthalmology Ann Arbor, Michigan
Department of Ophthalmology and Visual Sciences Chapter 144
Chicago, Illinois Patricia H. Fabel, PharmD, BCPS
Chapter 114 Clinical Associate Professor
Lea S. Eiland, PharmD, BCPS, BCPPS University of South Carolina College of Pharmacy
Clinical Professor and Associate Department Head Columbia, South Carolina
Harrison College of Pharmacy Chapter 54
Auburn University Alireza Fakhriravari, PharmD, BCPS, BCIDP, AAHIVP
Auburn, Alabama Clinical Assistant Professor and Director of Advanced Pharmacy
Chapter e12 Practice Experiences
School of Pharmacy, Loma Linda University
Shareen Y. El-Ibiary, PharmD, BCPS
Loma Linda, California
Professor and Department Chair
Chapter e138
College of Pharmacy
Midwestern University Karen M. Fancher, PharmD, BCOP
Glendale, Arizona Associate Professor of Pharmacy Practice
Chapter 19 School of Pharmacy, Duquesne University
Clinical Pharmacy Specialist, Oncology
Vicki L. Ellingrod, PharmD, FCCP University of Pittsburgh Medical Center Passavant
Dean and John Gideon Searle Professor of Pharmacy, Pittsburgh, Pennsylvania
College of Pharmacy Chapter 158
Professor of Psychiatry, Medical School
University of Michigan Natalija M. Farrell, PharmD, BCPS, DABAT
Ann Arbor, Michigan Clinical Coordinator—Emergency Medicine & Toxicology
Chapter e84 Boston Medical Center
Assistant Professor of Emergency Medicine
Ramy H. Elshaboury, PharmD, BCPS Boston University School of Medicine
Director—Clinical Pharmacy Services Boston, Massachusetts
Massachusetts General Hospital Chapter e8
Boston, Massachusetts Joseph P. Fava, PharmD, BCACP
Chapter 128 Clinical Assistant Professor
Wayne State University
Detroit, Michigan
Chapter 112
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xix
Julianna M. Fernandez, PharmD, BCPS, BCGP Christopher R. Frei, PharmD, MS, BCPS
Clinical Associate Professor and Vice Chair of Pharmacy Practice Professor and Pharmacotherapy Division Head
and Translational Research University of Texas at Austin College of Pharmacy
College of Pharmacy Pharmacotherapy Education and Research Center Director
University of Houston University of Texas Health Science Center at San Antonio Long
Houston, Texas School of Medicine
Chapter 139 Boerne, Texas
CONTRIBUTORS
Chapter 130
Shannon W. Finks, PharmD, BCPS, BCCP, ASHCP-CHC
Professor of Clinical Pharmacy and Translational Science Stormi E. Gale, PharmD, BCCP, BCPS
College of Pharmacy, University of Tennessee Health Science Center Clinical Pharmacist, Cardiology
Memphis, Tennessee Novant Health Matthews Medical Center
Chapter 34 Charlotte, North Carolina
Chapter 37
Richard Fiscella, PharmD, MPH
Clinical Professor Emeritus Roseann S. Gammal, PharmD, BCPS
University of Illinois at Chicago Associate Professor of Pharmacy Practice
Chicago, Illinois Massachusetts College of Pharmacy and Health Sciences
Chapter 114 Boston, Massachusetts
Chapter e7
Douglas N. Fish, PharmD, BCCCP
Professor and Chair, Department of Clinical Pharmacy Kristen N. Gardner, PharmD, BCPP
Skaggs School of Pharmacy and Pharmaceutical Sciences Clinical Pharmacy Specialist – Behavioral Health
University of Colorado Kaiser Permanente Colorado
Aurora, Colorado Denver, Colorado
Chapters 133, 145 Chapter 91
Courtney V. Fletcher, PharmD Mandy L. Gatesman, PharmD, BCOP
Professor Clinical Pharmacy Specialist, Hematology & Oncology
College of Pharmacy VCU Health
University of Nebraska Medical Center Richmond, Virginia
Omaha, Nebraska Chapter 53
Chapter 148
Jessica E. Geiger, PharmD, MS, BCPS
Rachel W. Flurie, PharmD, BCPS Pharmacy Coordinator, Palliative Care
Assistant Professor
OhioHealth
Virginia Commonwealth University School of Pharmacy
Columbus, Ohio
Richmond, Virginia
Chapter e28
Chapter 70
Alicia B. Forinash, PharmD, BCPS, BCACP Tracey L. Gendron, MS, PhD
Professor, Pharmacy Practice Associate Professor and Chair, Department of Gerontology
Pharmacy Practice Virginia Commonwealth University
University of Health Science and Pharmacy Executive Director, Virginia Center on Aging
St. Louis, Missouri Richmond, Virginia
Gilles L. Fraser, PharmD, MCCM James F. Gilmore, PharmD, BCCCP, BCPS

Professor of Medicine (ret.) Pharmacy Manager
School of Medicine, Tufts University Adult Critical Care and Emergency Department Medicine
Boston, Massachusetts Cedars-Sinai
Clinical Specialist in Critical Care (ret.) Los Angeles, California
Maine Medical Center Chapter e95
Portland, Maine
Chapter e27 Ashley E. Glode, PharmD, BCOP
Associate Professor
Michelle A. Fravel, PharmD, BCPS Skaggs School of Pharmacy and Pharmaceutical Sciences
Clinical Associate Professor of Pharmacy Practice and Science University of Colorado
University of Iowa College of Pharmacy Aurora, Colorado
Clinical Pharmacy Specialist Chapter 150
University of Iowa Hospitals and Clinics
Iowa City, Iowa Victor R. Gordeuk, MD
Chapter 113 Professor of Medicine
Department of Medicine
Bradi L. Frei, PharmD, MSc, BCPS, BCOP University of Illinois at Chicago
Professor Chicago, Illinois
Feik School of Pharmacy Chapter 124
University of the Incarnate Word
San Antonio, Texas
Chapter 130
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xx
Rena A. Gosser, PharmD, BCPS Tracy M. Hagemann, PharmD
Clinical Ambulatory Pharmacy Manager Professor and Associate Dean, Nashville
Harborview Medical Center College of Pharmacy
Seattle, Washington University of Tennessee Health Science Center
Chapter e116 Nashville, Tennessee
Chapter e125
Leigh Anne H. Gravatt, PharmD, BCPS
CONTRIBUTORS
Associate Professor, Vice-Chair of Education of The Department of Stuart T. Haines, PharmD, BCPS, BCACP
Pharmacotherapy and Outcomes Sciences Professor, Department of Pharmacy Practice
VCU School of Pharmacy Director, Pharmacy Professional Development
Clinical Specialist, Internal Medicine School of Pharmacy, University of Mississippi
Chesterfield, Virginia Jackson, Mississippi
Chapter 53 Chapters 1, 94
Shelly L. Gray, PharmD, MS
Emily R. Hajjar, PharmD, MS, BCPS, BCACP, BCGP
Professor and Plein Endowed Director
Professor
Plein Center for Geriatric Pharmacy Research, Education and
Jefferson College of Pharmacy
Outreach
Philadelphia, Pennsylvania
School of Pharmacy, University of Washington
Chapter e24
Seattle, Washington
Chapters e24, e25 Elizabeth A. Hall, PharmD, BCPS, BCPPS
Assistant Professor and Director of Assessment
Elisa M. Greene, PharmD, BCACP
College of Pharmacy, University of Tennessee Health Science Center
Associate Professor of Pharmacy Practice
Memphis, Tennessee
College of Pharmacy
Chapter 76
Belmont University
Nashville, Tennessee
Maren Hall, DDS
Chapter e125
General Dentist
Devon M. Greer, PharmD, BCOP Elk Plaza Dental
Clinical Pharmacy Specialist - Medical Oncology Maple Grove, Minnesota
Barnes-Jewish Hospital Chapter e16
St. Louis, Missouri
Jin Han, PharmD, PhD, BCPS
Chapter 122
Clinical Associate Professor and Clinical Pharmacist
Shawn P. Griffin, PharmD, BCOP College of Pharmacy, University of Illinois at Chicago
Health Sciences Assistant Clinical Professor Chicago, Illinois
School of Pharmacy & Pharmaceutical Sciences Chapter 124
University of California, Irvine
Jason S. Haney, PharmD, BCPS, BCCCP
Irvine, California
Associate Professor
Chapter 155
College of Pharmacy, Medical University of South Carolina
Alan E. Gross, PharmD, BCIDP, BCPS Charleston, South Carolina
Clinical Associate Professor Chapter 68
Department of Pharmacy Practice, University of Illinois at Chicago
Bianca Harris, PharmD
College of Pharmacy
Clinical Pharmacy Practitioner
Infectious Diseases Pharmacist
William S. Middleton Memorial Veteran’s Hospital
University of Illinois Hospital and Health Sciences System
Madison, Wisconsin
Chicago, Illinois
Chapter 111
Chapter 137
Delaney E. Hart, PharmD, BCIDP
Stephanie Gruber, PharmD, BCACP Clinical Pharmacist
Allina Health
William S. Middleton Memorial Veterans Hospital
Minneapolis, Minnesota
Madison, Wisconsin
Chapter 128
Chapter 111
Bryan D. Hayes, PharmD, DABAT
Wayne P. Gulliver, MD, FRCPC Clinical Pharmacy Manager
Professor of Dermatology and Medicine
Massachusetts General Hospital
Memorial University of Newfoundland
Associate Professor of Emergency Medicine, Division of Medical
Toxicology
Chapters 118, 119
Harvard Medical School
John G. Gums, PharmD Boston, Massachusetts
Associate Dean for Clinical and Administrative Affairs and Chapter e8
Professor of Pharmacy and Medicine
College of Pharmacy
St. John’s, Newfoundland and Labrador, Canada
Gainesville, Florida
Chapter 97
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xxi
Jordan C. Haygood, PharmD, BCPP Yunn-Fang Ho, BPharm, MD, PhD
Clinical Assistant Professor Associate Professor
University of South Carolina College of Pharmacy Graduate Institute of Clinical Pharmacy, College of Medicine
Psychiatric Clinical Pharmacist National Taiwan University
Columbia, South Carolina Taipei City, Taiwan
CONTRIBUTORS
Mary S. Hayney, PharmD, MPH, BCPS Sarah E. Hobgood, MD
Professor Associate Professor Internal Medicine and Assistant Dean for
School of Pharmacy Clinical Medical Education
University of Wisconsin Virginia Commonwealth University
Madison, Wisconsin Richmond, Virginia
Mojdeh S. Heavner, PharmD, BCPS, BCCCP Lisa M. Holle, PharmD, BCOP
Associate Professor and Vice Chair for Clinical Services Clinical Professor
School of Pharmacy, University of Maryland School of Pharmacy, University of Connecticut
Baltimore, Maryland UConn Health Carole & Ray Neag Comprehensive Cancer Center
Chapter e48 Storrs, Connecticut
Chapter 153
Keith A. Hecht, PharmD, BCOP
Associate Professor, Pharmacy Practice Yen-Ming Huang, BPharm, PhD
School of Pharmacy Assistant Professor
Southern Illinois University Edwardsville Graduate Institute of Clinical Pharmacy, College of Medicine
St Charles, Missouri National Taiwan University
Chapter 152 Taipei City, Taiwan
Chapter e5
Natalie T. Heinrich, PharmD
Medication Therapy Management (MTM) Pharmacist Joanna Q. Hudson, PharmD, BCPS
M Health Fairview Professor
Minnesota College of Pharmacy, University of Tennessee Health Science Center
Chapter 80 Clinical Pharmacy Specialist – Nephrology
Memphis, Tennessee
Brian A. Hemstreet, PharmD, BCPS
Chapter 63
Associate Dean for Student Affairs and Professor
Skaggs School of Pharmacy and Pharmaceutical Sciences Humberto R. Jimenez, PharmD, MPH, BCPS, AAHIVP
University of Colorado Clinical Assistant Professor and Director of Diverse Scholar
Aurora, Colorado Engagement and Advancement
Chapter 52 Ernest Mario School of Pharmacy, Rutgers University
Clinical Pharmacist – HIV / Ambulatory Care
Christopher M. Herndon, PharmD, BCACP
St. Joseph’s University Medical Center
Professor
Piscataway, New Jersey
Southern Illinois University Edwardsville
Chapter 140
Edwardsville, Illinois
Chapter 79 Susan Hylland, MD
Attending Physician—Rheumatology Clinic
Lauren R. Hersh, MD
William S. Middleton Memorial Veterans Hospital
Associate Professor
Madison, Wisconsin
Department of Family and Community Medicine, Thomas
Chapter 111
Jefferson University
Philadelphia, PA Kristin M. Janzen, PharmD, BCPS
Chapter e24 Clinical Assistant Professor, Pharmacy Practice
College of Pharmacy
Tara A. Higgins, PharmD, BCPPS
University of Texas
Assistant Professor
Clinical Pharmacy Specialist, Internal Medicine
School of Pharmacy
Dell Seton Medical Center at the University of Texas
Lake Erie College of Osteopathic Medicine
Austin, Texas
Bradenton, Florida
Chapter e6
Chapter 157
Douglas L. Jennings, PharmD, BCPS
Krista B. Highland, PhD
Associate Professor of Pharmacy
Research Associate Professor
Clinical Pharmacist, Heart Transplant & LVAD Team
Uniformed Services University of the Health Sciences
Arnold & Marie Schwartz College of Pharmacy and Health Sciences
Henry M. Jackson Foundation for the Advancement of Military
Long Island University
Medicine
New York-Presbyterian Hospital
Washington, D.C.
Columbia University Irving Medical Center
Chapter e10
New York, New York
Chapter 109
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xxii
Brittany N. Johnson, PharmD, CPh S. Lena Kang-Birken, PharmD, AAHIVP
Pain and Palliative Care Stewardship Pharmacist and Clinical Associate Professor
Assistant Professor Thomas J. Long School of Pharmacy
UF Health Jacksonville University of the Pacific
University of Florida Santa Barbara, California
Jacksonville, Florida Chapter 142
Chapter 85
CONTRIBUTORS
Salmaan Kanji, BScPharm, PharmD

Clinical Pharmacy Specialist
Tami N. Johnson, PharmD, BCPS The Ottawa Hospital
Clinical Pharmacy Specialist, Emergency Medicine
Associate Scientist
University of Texas MD Anderson Cancer Center
The Ottawa Hospital Research Institute
Houston, Texas
Ottawa, Ontario
Chapter 71
Chapter 146
Duncan B. Johnstone, MD, PhD Jaime Kaushik, PharmD, BCOP

Clinical Associate Professor Clinical Pharmacy Specialist
School of Medicine, University of Buffalo University of Texas MD Anderson Cancer Center
Buffalo, New York Houston, Texas
Chapter e66 Chapter 151
Bruce M. Jones, PharmD, BCPS Michael S. Kelly, PharmD, BCACP, CLS

Infectious Diseases Clinical Pharmacy Specialist Assistant Professor
St. Joseph’s/Candler Health System, Inc. School of Pharmacy, Chapman University
Savannah, Georgia Irvine, California
Joseph K. Jordan, PharmD, BCPS Scott E. Kincaid, PharmD, BCPS

Professor of Pharmacy Practice Assistant Dean for Student Affairs
Butler University School of Pharmacy, Presbyterian College
Drug Information Specialist Clinton, South Carolina
Indiana University Health Chapter e18
Indianapolis, Indiana
Chapter e98 William R. Kirchain, PharmD, CDCES
Clinical Associate Professor and Director Xavier University Health
David Josey Jr., MD and Wellness Center
Associate Professor of Pediatrics Xavier University of Louisiana
University of Mississippi Medical Center New Orleans, Louisiana
Jackson, Mississippi Chapter e56
Chapter 47
Cynthia K. Kirkwood, PharmD, BCPP
Sul R. Jung, PharmD, BCPS, BCCCP Professor and Executive Associate Dean for Academic Affairs
Associate Director of Pharmacy Services Virginia Commonwealth University
Ventura County Medical Center Richmond, Virginia
Ventura, California Chapter 90
Chapter 142
Mary Ann Kliethermes, BS Pharm, PharmD, FAPhA,
Julie Ann Justo, PharmD, MS, BCPS-AQ ID FCIOM
Clinical Associate Professor Director of Medication safety and quality
University of South Carolina College of Pharmacy American Society of Health-System Pharmacists
Infectious Diseases Clinical Pharmacy Specialist Bethesda, Maryland
Prisma Health Richland Hospital Chapter 1
Columbia, South Carolina
Chapter e132
Jessa M. Koch, PharmD, BCPP
Associate Professor
Michael P. Kane, PharmD, BCPS, BCACP School of Pharmacy, Loma Linda University
Professor, Department of Pharmacy Practice Loma Linda, California
Albany College of Pharmacy and Health Sciences Chapter 78
Albany Medical Center Division of Community Endocrinology Courtney M. Kominek, PharmD, BCPS, CPE
Albany, New York Clinical Pharmacy Specialist in Pain Management
Chapter 96 Harry S. Truman Memorial Veterans’ Hospital
Columbia, Missouri
Chapter 79
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xxiii
Christina Koutsari, PharmD, PhD, BCPS, BCIDP Patrick Leffers, PharmD, DABAT
Antimicrobial Stewardship and Infectious Disease Pharmacist Emergency Medicine Pharmacist
Children’s Minnesota University of Florida Health Jacksonville
Minneapolis, Minnesota Clinical Assistant Professor
Chapter 128 College of Pharmacy, University of Florida
Jacksonville, Florida
Sum Lam, PharmD, BCPS, BCGP Chapters e84, 85
CONTRIBUTORS
Clinical Professor
College of Pharmacy and Health Sciences, Saint John’s University Deborah J. Levine, MD
Clinical Pharmacotherapy Specialist, Geriatrics Professor
NYU Langone Health Medical Director Lung Transplantation
YU Langone Hospital—Long Island Director of Pulmonary Hypertension Center
Queens, New York University of Texas Health Science Center at San Antonio
Chapter 105 San Antonio, Texas
Chapter 46
Y. W. Francis Lam, PharmD
Professor of Pharmacology Stephanie M. Levine, MD
University of Texas Health Science Center at San Antonio, Professor
San Antonio, Texas Medical Director Lung Transplantation
Clinical Associate Professor of Pharmacy Director of Pulmonary Hypertension Center
University of Texas at Austin University of Texas Health Science Center
Austin, Texas San Antonio, Texas
Chapter e7 Chapter e43
Nicholas W. Lange, PharmD, BCTXP Robin Moorman Li, PharmD, BCACP

Clinical Pharmacy Manager Clinical Associate Professor
NewYork–Presbyterian Hospital College of Pharmacy, University of Florida
New York, New York Gainesville, Florida
Devin L. Lavender, PharmD, BCPS, BCACP Fang-Ju Lin, BPharm, MClinPharm, PhD
Clinical Assistant Professor Associate Professor
College of Pharmacy National Taiwan University
University of Georgia Deputy Director, Department of Pharmacy
Athens, Georgia National Taiwan University Hospital
Chapter 50 Taipei City, Taiwan
Chapter e5
David T. S. Law, BSc, MD, PhD, CCFP
Assistant Professor Bryan L. Love, PharmD, MPH
Department of Family and Community Medicine Associate Professor
Temerty Faculty of Medicine, University of Toronto University of South Carolina College of Pharmacy
Staff, Department of Family Practice Columbia, South Carolina
The Scarborough Hospital and Rouge Valley Health System Chapter 51
Scarborough, Ontario, Canada
Chapter e121 Amanda M. Loya, PharmD, BCPS
Clinical Associate Professor and Founding Chair of Pharmacy
Rebecca M. Law, PharmD Practice & Clinical Sciences Dept.
Associate Professor College of Pharmacy, University of Texas at El Paso
Memorial University of Newfoundland El Paso, Texas
St. John’s, Newfoundland Chapter e3
Chapters e17, 118, 119,120, e121
Sarah E. Lynch, PharmD, BCACP
Grace C. Lee, PharmD, PhD, BCPS Clinical Associate Professor and Director of Skills Education
Assistant Professor School of Pharmacy and Pharmaceutical Sciences, Binghamton
College of Pharmacy University
University of Texas at Austin Binghamton, New York
Austin, Texas Chapter 101
Chapter 130
Robert MacLaren, BSc, PharmD, MPH, MCCM
Mary Lee, PharmD, BCPS Professor
Vice President and Special Assistant to the President Skaggs School of Pharmacy and Pharmaceutical Sciences,
Midwestern University University of Colorado
Professor of Pharmacy Practice Aurora, Colorado
College of Pharmacy, Midwestern University Chapter e42
Downers Grove, Illinois
Chapters 103, 104
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xxiv
Eric J. MacLaughlin, PharmD, BCPS Dianne W. May, PharmD, BCPS
Professor and Chair, Department of Pharmacy Practice Clinical Professor and Campus Director for Pharmacy Practice
Texas Tech University Health Sciences Center Experiences
Amarillo, Texas College of Pharmacy
Chapters 30, e31 University of Georgia
Athens, Georgia
Howard I. Maibach, MD Chapter 50
CONTRIBUTORS
Professor
University of California San Francisco
Danielle C. Mayer, PharmD, BCACP
Assistant Professor, Department of Pharmacy Practice and
San Francisco, California
Director, Pharmacy Practice Laboratories
Chapters e17, 120, e121
Jefferson College of Pharmacy
Matthew J. Makelky Sr., PharmD, MSCS Philadelphia, Pennsylvania
Operations Manager Chapter 100
UCHealth, University of Colorado Jennifer L. Mazan, PharmD
Fort Collins, Colorado Professor
Chapter 74 Midwestern University
Jenana H. Maker, PharmD, BCPS Chapter e15
Professor
Thomas J. Long School of Pharmacy, University of the Pacific Timothy L. McCavit, MD, MSCS
Santa Barbara, California Staff Hematologist
Chapter 61 Director, Bleeding Disorder Program
Cook Children’s Medical Center
Robert A. Mangione, BPharm, EdD Fort Worth, Texas
Provost Emeritus, Professor of Pharmacy (retired) Chapter 123
College of Pharmacy and Health Sciences, Saint John’s University
Erin K. McCreary, PharmD, BCPS, BCIDP
Queens,
Director of Infectious Diseases Improvement and Clinical Research
New York
Innovation
Chapter 59
University of Pittsburgh Medical Center
Clinical Assistant Professor
Zachary A. Marcum, PharmD, PhD
University of Pittsburgh School of Medicine
Associate Professor
Chapter e132
Seattle, Washington
Chapter e25 Mary Lynn McPherson, PharmD, MA, MDE, FAAHPM
Professor and Executive Director, Online Graduate Studies in
Ana Elizabeth Markez, MD, LTC, MC, USA Palliative Care
Internal Medicine, Infectious Disease, Fellow ACP and IDSA University of Maryland, Baltimore
Brooke Army Medical Center, United States Army Baltimore, Maryland
Chief, Infectious Disease ServiceDeputy Chief of Operations and Chapter e28
Administration, Department of Medicine
San Antonio, Texas
Christopher G. Medlin, PharmD, BCPS
Chapter e138
College of Pharmacy, University of Texas at El Paso
Grace A. Martin, PharmD, BCOP El Paso, Texas
Clinical Pharmacy Coordinator - Cancer Care Chapter e3
The University of Kansas Cancer Center Sarah T. Melton, PharmD, BCPP, BCACP, CGP, FASCP
Kansas City, Kansas Professor of Pharmacy Practice
Chapter 156 Gatton College of Pharmacy at East Tennessee State University
Clinical Pharmacist
Todd W. Mattox, BS, PharmD, BCNSP
Highpower, PC in Lebanon, Virginia and the Johnson City
Medicine/Surgery Clinical Pharmacist
Community Health Center
Moffitt Cancer Center
Johnson City, Tennessee
Tampa, Florida
Chapter 90
Chapter 165
Leigh Ann Mike, PharmD, BCPS, BCGP
Jared E. Matya, PharmD, BCOP Clinical Associate Professor and Assistant Director for Education,
Clinical Pharmacist Practitioner - BMT and Cellular Therapy
Plein Center for Pharmacy Research, Education & Outreach
Nebraska Medicine
Omaha, Nebraska
Seattle, Washington
Chapter 159
Chapter e25
J. Russell May, PharmD Margaret A. Miklich, PharmD, BCACP
Clinical Professor and Assistant Dean for Extended Campuses Clinical Associate Professor of Pharmacy Practice
College of Pharmacy, University of Georgia School of Pharmacy, Temple University
Athens, Georgia Philadelphia, Pennsylvania
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xxv
Anna S. Milone, PharmD, BCPS Kashif M. Munir, MD
Teaching Specialist and Director of Pharmacy Learning Professor of Medicine
Collaborative School of Medicine, University of Maryland
College of Pharmacy, University of Minnesota Baltimore, Maryland
Minneapolis, Minnesota Chapter e98
Chapter e16
CONTRIBUTORS
Milap C. Nahata, PharmD
Augusto Miravelle, MD
Director, Institute of Therapeutic Innovations and Outcomes;
Associate Professor of Clinical Neurology University of Colorado,
Professor Emeritus of Pharmacy, Pediatrics and Internal
Anschutz Medical Campus
Medicine
Aurora, Colorado
Colleges of Pharmacy and Medicine, Ohio State University
Chapter 74
Columbus, Ohio
Chapter e20
Jean Y. Moon, PharmD, BCACP
Associate Professor and Postgraduate Year One Pharmacy
Residency Program Director Rocsanna Namdar, PharmD
College of Pharmacy, University of Minnesota PGY1 Residency Director; Strategic Planning and Learning
Minneapolis, Minnesota Resources Director
Chapter 44 New Mexico Veterans Affairs Health Care System
Rebecca Moote, PharmD, MSc, BCPS Albuquerque, New Mexico
Clinical Associate Professor and Assistant Division Head Chapter 135
University of Texas at Austin College of Pharmacy
Internal Medicine Clinical Pharmacy Specialist Leigh Anne Nelson, PharmD, BCPP
University Hospital, San Antonio, Texas Professor of Pharmacy Practice and Administration
Chapter 46 University of Missouri-Kansas School of Pharmacy
Kansas City, Missouri
Jessica L. Moreno PharmD, BCPP Chapter e81
Psychiatric Clinical Pharmacist
Integrated Behavioral Health Melissa A. Nestor, PharmD, BCCCP
Detroit Michigan Clinical Pharmacist, Critical Care/Stroke Neurology
Chapter e84 UK HealthCare
Assistant Professor
Juan Mosley II, PharmD, CPh, AAHIVP College of Pharmacy, University of Kentucky
Chair and Associate Professor Lexington, Kentucky
College of Pharmacy, Larkin University Chapter 39
Miami, Florida
Chapter e9 Viet-Huong V. Nguyen, PharmD, MPH, MSc, BCCCP
Associate Professor (Neurology)
Jeffrey J. Mucksavage, PharmD School of Pharmacy, Chapman University, Irvine, California
Clinical Assistant Professor Clinical Pharmacy Specialist, Neurology and Critical Care
Department of Pharmacy Practice Harbor UCLA Medical Center
University of Illinois at Chicago College of Pharmacy West Carson, California
Chicago, Illinois Chapter 75
Chapter e31
Jessica C. Njoku, PharmD, MPH, BCPS
Scott W. Mueller, PharmD, BCCCP System Formulary Coordinator
Burn Services and Critical Care Pharmacy Specialist Harris Health System
University of Colorado Hospital Pearland, Texas
Clinical Associate Professor Chapter 131
University of Colorado Skaggs School of Pharmacy and
Pharmaceutical Sciences Thomas D. Nolin, PharmD, PhD
Denver, Colorado Associate Dean for Research and Sponsored Programs
Chapter 145 University of Pittsburgh School of Pharmacy
Diana W. Mulherin, PharmD, BCNSP, BCCCP Chapters 65, 67
Clinical Pharmacist Specialist, Nutrition Support
Cindy L. O’Bryant, PharmD, FCCP, FHOPA, BCOP
Vanderbilt University Medical Center
Professor of Clinical Pharmacy
Nashville, Tennessee
Skaggs School of Pharmacy and Pharmaceutical Sciences
Chapter 166
University of Colorado Anschutz Medical Campus
Aurora, Colorado
Amanda M. Mullins, PharmD, BCPS Chapter 162
Clinical Pharmacist Practitioner
VA St. Louis Healthcare System, St. Louis, Missouri
St. Louis, Missouri
Chapter 79
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xxvi
Mary Beth O’Connell, PharmD, BCPS Charles A. Peloquin, PharmD
Professor Professor and Division Head, Translational Research
Wayne State University, Eugene Applebaum College of Pharmacy College of Pharmacy
and Health Sciences University of Florida
Detroit, Michigan Gainesville, Florida
CONTRIBUTORS
Kirsten H. Ohler, PharmD, BCPS, BCPPS Mark A. Perazella, MD, MS

Clinical Associate Professor, Pharmacy Practice; Program Director, Professor of Medicine
PGY1 Pharmacy Residency Yale University School of Medicine
College of Pharmacy, University of Illinois at Chicago New Haven, Connecticut
Clinical Pharmacist, Neonatal Intensive Care Unit Chapter 65
University of Illinois Hospital & Health Sciences System
Chicago, Illinois Janelle Perkins, PharmD, BCOP
Chapter e22 Professor
Taneja College of Pharmacy
Katie B. Olney, PharmD, BCIDP University of South Florida
Infectious Diseases Clinical Pharmacist
Tampa, Florida
University of Kentucky HealthCare
Chapter e163
Lexington, Kentucky
Chapter 127 Emily P. Peron, PharmD, MS, BCPS, BCGP
Keith M. Olsen, Pharm.D Associate Professor
Dean and Professor Virginia Commonwealth University School of Pharmacy
College of Pharmacy Richmond, Virginia
University of Nebraska Medical Center Chapter 73
Omaha, Nebraska Jay I. Peters, MD
Chapters e49, 137 Professor and Chief (Retired) Division of Pulmonary and Critical
Jared Ostroff, PharmD, MBA, BCACP, BCGP Care
Ambulatory Pharmacy Supervisor UT Health San Antonio
Baystate Health University of Texas Health Science Center
Granby, Connecticut San Antonio, Texas
Ohoud Owaidhah, MD Jennifer T. Pham, PharmD, BCPS, BCPPS

Senior Consultant, Glaucoma Division Clinical Associate Professor, Department of Pharmacy Practice,
King Khaled Eye Specialist Hospital College of Pharmacy
Riyadh, Saudi Arabia Department of Pediatrics, College of Medicine
Chapter 114 University of Illinois at Chicago
Clinical Pharmacist, Neonatal Intensive Care Unit
Melissa C. Palmer, PharmD, BCPS, BCPP University of Illinois Hospital & Health Sciences System
Clinical Pharmacist Practitioner Chicago, Illinois
Alaska VA Healthcare System Chapter e22
Eagle River, Alaska
Chapter e83 Ha K. Phan, PharmD, CDCES, BCACP
Lisa M. Palmisano, PharmD, BCACP School of Pharmacy, University of Mississippi
Associate Professor and Clinical Pharmacist
Jackson, Mississippi
College of Pharmacy, Midwestern University
Chapter 47
Chapter e15 Stephanie J. Phelps
Emeritus Professor
Robert B. Parker, PharmD
University of Tennessee Health Science Center College of Pharmacy
Professor
Memphis, Tennessee
College of Pharmacy, University of Tennessee Health Science Center
Chapter 76
Memphis, Tennessee
Chapter 36 Bradley G. Phillips, PharmD, BCPS, FCCP
Neelam K. Patel, PharmD, BCOP Clinical and Administrative Pharmacy
Clinical Pharmacy Specialist Professor
The University of Texas MD Anderson Cancer Center Director, Biomedical and Translational Sciences Institute
Houston, Texas University of Georgia
Chapter 151 Augusta, Georgia
Chapter 92
Priti N. Patel, PharmD, BCPS
Clinical Associate Professor and Director of Personal and Stephen T. Phillips, MD
Professional Development Cardiac Electrophysiologist
College of Pharmacy, University of Florida Advocate Christ Medical Center
Gainesville, Florida Oak Lawn, Illinois
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xxvii
Amy M. Pick, PharmD, MS, BCOP Beth H. Resman-Targoff, PharmD
Associate Professor Clinical Professor
College of Pharmacy Department of Pharmacy, Clinical and Administrative Sciences
University of Nebraska Medical Center University of Oklahoma College of Pharmacy
Omaha, Nebraska Oklahoma City, Oklahoma
CONTRIBUTORS
Christopher R. Piszczatoski, PharmD, BCPS Daniel M. Riche, PharmD, CLS, ASH-CHC
Clinical Pharmacy Specialist, Ambulatory Care Professor
UF Health Shands Physicians, University of Florida School of Pharmacy, University of Mississippi
Gainesville, Florida Associate Professor
Chapter 97 University of Mississippi Medical Center
Jackson, Mississippi
Steven Pliszka, MD Chapter 32
Dielmann Distinguish Professor
Chair of the Department of Psychiatry Jo E. Rodgers, PharmD, BCPS, BCCP
University of Texas Health Science Center at San Antonio Professor and Director of Postdoctoral Programs
San Antonio, Texas Eshelman School of Pharmacy
Chapter 82 University of North Carolina
Chapel Hill, North Carolina
Jason M. Pogue, PharmD, BCIDP Chapter 36
Clinical Professor of Pharmacy
College of Pharmacy Andrew M. Roecker, PharmD, BCPS
University of Michigan Professor and Chair – Department of Pharmacy Practice and
Ann Arbor, Michigan Director of Continuing Pharmacy Education
Chapter e132 Ohio Northern University
Ada, Ohio
Samuel M. Poloyac, PharmD, PhD Chapter 136
Dean & James T. Doluisio Regents Chair
University of Texas at Austin College of Pharmacy Kelly C. Rogers, PharmD, BCCP
Austin, Texas Professor of Clinical Pharmacy and Translational Science
Chapter e6 College of Pharmacy, University of Tennessee Health Science Center
Cardiology Clinical Pharmacy Practitioner
Elvin T. Price, PharmD, PhD VA Medical Center, Memphis
Victor A. Yanchick Associate Professor and Director of the Lakeland, Tennessee
Geriatric Pharmacotherapy Program Chapter 33
Richmond, Virginia Lauren K. Roller, PharmD, BCCCP
Chapter e23 Clinical Pharmacist, Critical Care and Addiction Medicine
Alameda Health System, Highland Hospital
Sarah Rajkovic, PharmD Oakland, California
Senior Clinical Instructor Clinical Associate Professor of Clinical Sciences
Skaggs School of Pharmacy and Pharmaceutical Sciences Touro University California
University of Colorado Vallejo, California
Aurora, Colorado Chapter 61
Chapter 74
Norbert Rosario, PharmD, BCPS
Gautam Ramani, MD Ambulatory Care Clinical Pharmacist Practitioner
Associate Professor of Medicine H-E-B Wellness Primary Care Clinics
University of Maryland San Antonio, Texas
Director, Pulmonary Hypertension Program Chapter e2
Baltimore, Maryland
Chapter e29 Eric S. Rovner, MD
Professor of Urology
Satish C. Rao, MD, PhD, ABIM Medical University of South Carolina
Professor of Medicine Charleston, South Carolina
Augusta University Chapter 105
Augusta, Georgia
Chapter 50 Valerie L. Ruehter, PharmD, BCPP
Clinical Associate Professor and Assistant Dean of
Brent N. Reed, PharmD, MS, BCCP, BCPS Experiential Learning
Clinical Associate Professor University of Missouri-Kansas City
School of Pharmacy, University of Maryland Kansas City, Missouri
Baltimore, Maryland Chapter e83
Chapters e29, 37
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xxviii
Melody Ryan, PharmD, MPH, BCPS, BCGP Roohollah Sharifi, MD
Professor and Assistant Provost for Global Health Professor
University of Kentucky College of Medicine
Lexington, Kentucky University of Illinois Chicago
Chapters 39, e72 Section Chief of Urology
Jesse Brown Veterans Affairs Medical Center
Stephen J. Ryan, MD, MA
Chicago, Illinois
CONTRIBUTORS
Professor of Neurology
Chapters 103, 104
University of Kentucky
Lexington, Kentucky Kayce M. Shealy, PharmD, BCPS, CDCES
Chapter e72 Professor of Pharmacy Practice
David M. Salerno, PharmD, BCPS, BCTXP School of Pharmacy
Clinical Pharmacy Manager | Liver Transplantation Presbyterian College
NewYork–Presbyterian Hospital/Weill Cornell Medical Center Clinton, South Carolina
New York, New York Chapter 54
Chapter 109 Amy Heck Sheehan, PharmD
Santosh L. Saraf, MD Professor of Pharmacy Practice
Associate Professor of Medicine College of Pharmacy, Purdue University
College of Medicine Indianapolis, Indiana
University of Illinois at Chicago Chapter e98, 167
Director of Translational Research, Sickle Cell Center
Chicago, Illinois
Jessica M. Shenberger-Trujillo, PhD
Chapter 124
University of Texas at El Paso
Lana J. Sargent, PhD, RN, CRNP, FNP-C, GNP-BC El Paso, Texas
Assistant Professor Chapter e3
School of Pharmacy Jeri J. Sias, PharmD, MPH
Richmond, Virginia Clinical Professor
Chapter 73 College of Pharmacy
University of Texas at El Paso
Joseph J. Saseen, PharmD, BCPS, BCACP El Paso, Texas
Professor and Associate Dean for Clinical Affairs Chapter e3
University of Colorado Anschutz Medical Campus
Clinical Pharmacy Specialist, Family Medicine Cathryn Sibbald, MD MSc
University of Colorado Health Dermatologist
Aurora, Colorado The Hospital for Sick Children
Chapter 30 Assistant Professor
Mark E. Schneiderhan, PharmD, BCPP University of Toronto
Associate Professor Toronto, Ontario
College of Pharmacy Chapter 117
University of Minnesota
Psychiatric Pharmacist Debra Sibbald, BScPhm, ACPR, RPh, MA, PhD
Human Development Center, Department of Psychiatry Academic Lead – Admissions, PharmD Program
Minneapolis, Minnesota Associate Professor, Teaching Stream, Division of Pharmacy Practice
Chapter e81 Leslie Dan Faculty of Pharmacy
University of Toronto
Julie M. Sease, PharmD, BCPS, CDCES, BCACP
Education and Competence Assessment/Evaluation Consultant
Senior Associate Dean and Clinical Professor
Mississauga, Ontario
University of South Carolina College of Pharmacy
Chapter 117
Columbia, South Carolina
Chapter 55
Douglas Slain, PharmD, BCPS
Eve M. Segal, PharmD, BCOP Professor
Lead Clinical Pharmacist, Hematology/Oncology West Virginia University
Fred Hutchinson Cancer Center/UW Medicine Infectious Diseases Clinical Specialist
Seattle, Washington Morgantown, West Virginia
Jolynn Knoche Sessions, PharmD, BCOP, CPP
Oncology Program Manager, Clinical Pharmacist Practitioner Patricia W. Slattum, PharmD, PhD
Department of Veterans Affairs Professor and Co-Director, Geriatrics Workforce Enhancement
Western North Carolina Health Care System Program
Associate Professor of Clinical Education Virginia Center on Aging
Eshelman School of Pharmacy Virginia Commonwealth University
University of North Carolina Richmond, Virginia
Chapel Hill, North Carolina Chapter e23
Chapter e160
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xxix
Erin M. Slazak, PharmD, BCPS, BCACP Danielle L. Stutzman, PharmD, BCPP
Clinical Associate Professor Psychiatric Pharmacist
School of Pharmacy and Pharmaceutical Sciences Pediatric Mental Health Institute and Department of Pharmacy
University of Buffalo Children’s Hospital Colorado
Buffalo, New York Clinical Assistant Professor
Chapter 112 Skaggs School of Pharmacy and Pharmaceutical Sciences,
University of Colorado
CONTRIBUTORS
Jordan R. Smith, PharmD
Denver, Colorado
Assistant Professor of Clinical Sciences
Chapter 82
High Point University
High Point, North Carolina Brandon Sucher, Pharm.D., BCACP, CDCES, AE-C
Chapter e126 Professor of Pharmacy Practice
Judith A. Smith, BS, PharmD, BCOP, CPHQ Regis University School of Pharmacy
Professor and Director of WHIM Research Program Denver, Colorado
UT Health McGovern Medical School at Houston Chapter e13
Oncology Clinical Pharmacy Specialist Paul M. Szumita, PharmD, BCCCP, BCPS
Memorial Hermann Cancer Center—TMC Director, Clinical Pharmacy and Director, PGY2 Critical Care
Houston, Texas Pharmacy Residency
Chapter 156 Brigham and Women’s Hospital
Steven M. Smith, PharmD, MPH Boston, Massachusetts
Assistant Professor Chapter e95
Department of Pharmaceutical Outcomes and Policy Carol K. Taketomo, PharmD
College of Florida, University of Florida Adjunct Assistant Professor of Pharmacy Practice, School of
Gainesville, Florida Pharmacy
Chapter 97 University of Southern California
Tawny L. Smith, PharmD, BCPP Chief Pharmacy Officer
Associate Professor of Psychiatry Children’s Hospital Los Angeles
University of Texas Health Science Center at Austin Los Angeles, California
Austin, Texas Chapter e20
Chapter 87
Kristine M. C. Talley, PhD, CNP, RN
Todd D. Sorensen, PharmD, FAPhA, FCCP Associate Professor
Professor and Senior Executive Associate Dean for Strategic School of Nursing
Initiatives and Faculty Affairs University of Minnesota
University of Minnesota College of Pharmacy Minneapolis, Minnesota
Minneapolis, Minnesota Chapter 105
Chapter 1
Kimberly B. Tallian, PharmD, APh, BCPP
Kevin M. Sowinski, PharmD Advanced Practice Pharmacist—Neuropsychiatry
Professor of Pharmacy Practice and Associate Head for Faculty Affairs Adjunct Clinical Professor
College of Pharmacy, Purdue University UC San Diego—Skaggs School of Pharmacy & Pharmaceutical
Adjunct Professor of Medicine Sciences
Indiana University School of Medicine Scripps Mercy Hospital
Indianapolis, Indiana San Diego, California
Mary L. Staicu, PharmD, BCIDP Chia J. Tan, BPharm(Hons), PhD, BCOP
Infectious Diseases Clinical Pharmacy Specialist Postdoctoral Research Fellow
Rochester General Hospital University of Utah College of Pharmacy
Rochester, New York Salt Lake City, Utah
David D. Stenehjem, PharmD, BCOP Geoffrey M. Thiele, PhD
Associate Professor and Associate Department Head Umbach Professor of Rheumatology
Department of Pharmacy Practice and Pharmaceutical Sciences College of Medicine
University of Minnesota University of Nebraska Medical Center
College of Pharmacy Omaha, Nebraska
Minneapolis, Minnesota Chapter e106
Chapter e161
Laura C. Tilley, MD
Steven C. Stoner, PharmD, BCPP Assistant Professor
Clinical Professor and Associate Dean for Student Affairs
Uniformed Services University of the Health Sciences
School of Pharmacy
Washington, District Columbia
University of Missouri Kansas City
Chapter e10
Psychiatric Pharmacy Specialist
Kansas City, Missouri
Chapter e83
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xxx
Jessica J. Tilton, PharmD, BCACP Jamie L. Wagner, PharmD, BCPS
Clinical Assistant Professor and Clinical Pharmacist Clinical Associate Professor
College of Pharmacy, University of Illinois at Chicago Department of Pharmacy Practice
Chicago, Illinois School of Pharmacy, University of Mississippi
Chapter 40 Jackson, Mississippi
Chapter 137
Danielle M. Tompkins, PharmD, BCCCP
CONTRIBUTORS
Clinical Assistant Professor Michael A. Wankum, PharmD, BCIDP, BCPS

Ernest Mario School of Pharmacy, Rutgers University Clinical Pharmacy Coordinator – Infectious Diseases
Piscataway, New Jersey Allina Health
Chapter e31 Minneapolis, Minnesota
Chapter 128
Erica Torres, PharmD, BCACP
Ambulatory Care Clinical Pharmacy Specialist Casey S. Washington, PharmD, BCPS
University Family Health Center—Southwest Medical Writer
San Antonio, Texas Medscape Education
Chapter e2 New York, New York
Chapter 115
Heidi Trinkman, PharmD, BCOP
Clinical Pharmacy Specialist Kristin Watson, PharmD, BCCP
Pediatric Hematology/Oncology and Stem Cell Transplant Associate Professor
Cook Children’s Medical Center School of Pharmacy, University of Maryland
Fort Worth, Texas Baltimore, Maryland
Chapter 123 Chapters e29, e35
Jennifer M. Trujillo, PharmD, BCPS, CDCES, BC-ADM Lori D. Wazny, BSc(Pharm), PharmD
Professor Clinical Pharmacist
Skaggs School of Pharmacy and Pharmaceutical Sciences, Manitoba Renal Program
University of Colorado Winnipeg, Manitoba, Canada
Aurora, Colorado Chapter 62
Chapters 94, e95 Robert J. Weber, PharmD, MS, BCPS, FASHP, FNAP
Administrator, Pharmaceutical Services
Anne M. Tucker, PharmD, BCNSP
The Ohio State University Wexner Medical Center
Clinical Pharmacy Specialist - Critical Care / Nutrition Support
Assistant Dean for Medical Center Affairs
University of Texas MD Anderson Cancer Center
The Ohio State University College of Pharmacy
Houston, Texas
Columbus, Ohio
Chapter 71
Chapter e4
Amy M. VandenBerg, PharmD, BCPP Brian J. Werth, PharmD
Associate Professor
College of Pharmacy
Seattle, Washington
Ann Arbor, Michigan
Chapter e126
Chapter 88
James W. Wheless
Sara R. Vazquez, PharmD, BCPS, CACP Professor and Chief, Department of Pediatric Neurology
Clinical Pharmacist
Director, Le Bonheur Comprehensive Epilepsy Program
University of Utah Health
The University of Tennessee Health Science Center
Adjunct Associate Professor in Pharmacotherapy
Pediatric Neurology
University of Utah College of Pharmacy
Memphis, Tennessee
Salt Lake City, Utah
Chapter 76
Chapter 38
Sara A. Wiedenfeld, PharmD, BCPS, BCACP
Maria I. Velez, MD Clinical Assistant Professor
Assistant Professor
College of Pharmacy, University of Iowa
University of Texas Health Science Center at San Antonio
Iowa City, Iowa
San Antonio, Texas
Chapter 110
Chapter e43
Dennis M. Williams, PharmD, BCPS
Kathleen M. Vest, PharmD, CDCES, BCACP
Associate Professor
Professor of Pharmacy Practice
Eshelman School of Pharmacy, University of North Carolina
College of Pharmacy
Clinical Specialist
Midwestern University
Chapel Hill, North Carolina
Clinical Pharmacist
Chapter 45
Northwestern Medicine
Chapters 100, 101
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xxxi
Kristyn M. Williamson, PharmD, BCACP Jack A. Yanovski, MD, PhD
Teaching specialist Chief, Section on Growth and Obesity and Associate Scientific
College of Pharmacy Director for Translational Medicine
University of Minnesota Eunice Kennedy Shriver National Institute of Child Health and
Clinical pharmacist Human Development, NIH
Minneapolis, Minnesota Bethesda, Maryland
Daniel M. Witt, PharmD, BCPS Evan J. Zasowski, PharmD, MPH, BCPS, BCIDP
CONTENTS
Professor and Chair Associate Professor
University of Utah College of Pharmacy, Department of College of Pharmacy
Pharmacotherapy Touro University California
Salt Lake City, Utah Vallejo, California
Pei Shieen Wong, PharmD, BSPS Kristin M. Zimmerman, PharmD, BCACP, BCGP
Principal Clinical Pharmacist Associate Professor
Singapore General Hospital Virginia Commonwealth University School of Pharmacy
Lecturer Richmond, Virginia
National University of Singapore Chapter 73
Singapore
Chapter 74 Daniel A. Zlott, PharmD, BCOP
Senior Vice President
G. Christopher Wood, PharmD, BCCCP Education and Business Development
Professor of Clinical Pharmacy and Translational Science American Pharmacists Association
College of Pharmacy Washington, D.C.
University of Tennessee Health Science Center Chapter e106
Memphis, Tennessee
Chapter 77
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Foreword
Thirty-five years have passed since the publication of the first edition (CMM) in the patient-centered medical home. The American
of Pharmacotherapy: A Pathophysiologic Approach. During those College of Clinical Pharmacy (ACCP) published Standards of
years we have witnessed dramatic changes in healthcare delivery Practice for Clinical Pharmacists and the Joint Commission of
and advances in the prevention and treatment of many diseases and Pharmacy Practitioners approved the Pharmacists’ Patient Care
disorders. Also, new diseases such as COVID-19 and monkeypox Process. These documents described a consistent process for the
have become public health emergencies. delivery of pharmacy patient care services. The ACCP Standards
As summarized in the Foreword to the 10th edition, major of Practice added details to CMM such as the setting (eg, clinical
changes in the pharmacy profession have also occurred during our pharmacist working as part of a healthcare team) and qualifications
professional journey. We have seen the emphasis on pharmaceutical (eg, board certification) of the clinical pharmacist providing CMM.
care, the change to the entry-level doctor of pharmacy degree, and And the 2016 ACPE Standards added new requirements for schools
the growing acceptance of credentials (eg, residency and board cer- and colleges to teach students about the Pharmacists’ Patient Care
tification) for pharmacy specialists. Reimbursement for patient care Process. The ACCP CMM study results and publications have accel-
services (through Medicare provider status or other means) has not erated the growth and adoption of CMM worldwide.
advanced as quickly. As the profession has recognized the importance of practice
As the pharmacy profession promoted patient care services to standards and practice consistency, implementation science is being
payers and the public, some fundamental questions became evident applied to clinical pharmacy service delivery. The CMM in Primary
and still challenge us today. What services do clinical pharmacists Care Study funded by ACCP was the first large-scale study to apply
provide to improve patient care? Do pharmacists apply a uniform this relatively new science to the delivery of CMM, further defining
process of care for a given service? What patient care services do the CMM patient care process with the degree of specificity required
payers, providers, and the public need and want? Should some to ensure consistent clinical and economic outcomes (fidelity). As
services be performed by pharmacists with specialized training or we look into the near future, we can expect that the application
advanced credentials? of implementation science will accelerate growth and adoption of
We didn’t think about those questions in the early days of CMM worldwide to optimize medication use and patient health.
the clinical pharmacy movement. The term “clinical pharmacy” Although pharmacy education and practice has changed dramat-
described the role of the pharmacist in patient care and “clinical ically, the importance of pharmacotherapy knowledge has remained
pharmacist” was someone who provided those services. Over time, the same. In its 2017 update, ACCP listed in-depth pharmacother-
many healthcare professionals and patients came to value the ser- apy knowledge as one of the six competencies necessary to provide
vices provided by clinical pharmacists. However, it was difficult to CMM in team-based, direct patient care environments. Patient-
explain to others the services provided by clinical pharmacists, in centered pharmacotherapy knowledge represents 65% of the board
part because the process of care and its goals were not uniform. certification examination for the Pharmacotherapy Specialty. And
Clinical pharmacy services varied between institutions and could Pharmacotherapy (or “Therapeutics” or “Pharmacotherapeutics”) is a
entail a general service such as drug information or a specialized major part of the doctor of pharmacy curriculum, usually a series of
service such as nutrition support or pharmacokinetic dosing. Most courses with the most credit hours. Indeed, it is this in-depth knowl-
clinical pharmacists served primarily as consultants to physicians in edge of pharmacotherapy, combined with the clinical experience
the acute care setting and were not ultimately responsible to patients gained through postgraduate training in direct patient care practice,
for their care. Whatever you called the service that pharmacists pro- that allows the pharmacist to be the “medication therapy expert” on
vided, hospitals and healthcare systems wanted more, and clinical the healthcare team and to proactively address medication-related
pharmacy expanded dramatically over the next few decades. When problems. Some have argued that preventing, identifying, and man-
Medicare Part D benefits were implemented in 2006, the term “med- aging medication-related problems should be at the very core of a
ication therapy management” (MTM) became popular to describe pharmacist’s professional identity.
a new service for pharmacists. However, the confusion continued Pharmacotherapy: A Pathophysiologic Approach remains as rele-
because pharmacists and pharmacies offered different services vant today as it was when originally published 35 years ago. The 12th
labeled as MTM, delivered using different processes of care. edition provides students, pharmacists, and other health profession-
In the last 10 years, the profession has finally begun to address als with the core pharmacotherapy knowledge necessary to prevent,
the important questions about the fundamental role of pharmacists. identify, and manage disease and medication-related problems.
A Task Force of the Patient-Centered Primary Care Collaborative
described the integration of comprehensive medication management Gary C. Yee, PharmD, and Joseph T. DiPiro, PharmD
xxxiii
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Preface
Remington’s, Stedman’s, Goodman & Gilman’s, Harrison’s, and are current as new drugs are approved, guidelines are issued, and
Koda-Kimble—a few textbooks in the medical and pharmacy fields recommendations change on the best use of pharmacotherapeutic
have become so well known that students often refer to them by the agents in prevention, management, and cure of diseases. Also, we
name of a chief editor or author rather than book titles. published the 12th edition online in AccessPharmacy long before
This book, Pharmacotherapy: A Pathophysiologic Approach, the print version could be released.
quickly reached that stature in pharmacy education and practice To handle this added responsibility, the editors needed help. A
following the publication of the first edition in 1988. By changing group of six assistant editors, each with unique expertise to comple-
our title to DiPiro’s Pharmacotherapy with this 12th edition, we make ment that of the section editors, were recruited. Scott Bolesta (assist-
permanent the association of this work with the important leader- ing Dr. DiPiro), Lisa Holle (Yee), Robert DiDomenico (Haines),
ship and vision of our founding editor, Joseph T. DiPiro, PharmD, Angela Bingham (Nolin), Amy VandenBerg (Ellingrod), and Rena
who had the initial discussions with our original publisher, Elsevier, Gosser (Posey) have provided invaluable assistance to the contribu-
in 1983. By 1985, a cohesive team of founding editors came together tors and editors to produce the final manuscript for this 12th edition.
with a unified vision of pharmacotherapy and how it fit into the We are pleased to acknowledge their efforts.
practice of clinical pharmacy. DiPiro, along with Michael Posey, For the 12th edition, the editors chose not to make extensive
Robert Talbert, Peggy Hayes, and Gary Yee, took on the difficult changes in the chapter structure and content. One refinement was
chore of identifying more than 200 recognized experts from across to replace the preclass and postclass learning activities that appeared
the United States who would write, from scratch, 111 chapters. Just in the 11th edition with a single “Beyond the Book” box placed at
two years later, the team began to funnel chapters to the publisher the beginning of each chapter. The intent is to prepare and stimulate
and through to publication. learners by pointing them to multimedia resources that can deepen
Gary Matzke, after serving as an author and section editor in the their understanding of the material.
first edition, joined the masthead for the second edition, and Barbara Two of our founding editors are retiring from the book after the
Wells replaced Peggy Hayes beginning with the third edition. That edi- 12th edition. Drs. DiPiro and Yee have worked on all 12 editions and
torial team would remain together through the 10th edition, assuring helped make this work the gold standard textbook in pharmacy and
continuity and cohesiveness for the Pharmacotherapy project. health professions education. The editors are pleased to welcome two
Our founding editors set several lofty goals for Pharmacotherapy. new editors to the team: Jennifer Cocohoba, PharmD, MAS, of the
The work needed to meet the educational standards of emerg- University of California, San Francisco, for the chapters managed by
ing postbaccalaureate doctor of pharmacy programs, serve as an Dr. DiPiro, and Lisa M. Holle, PharmD, BCOP, FHOPA, FISOPP, of
authoritative reference for clinical pharmacists and other clinicians the University of Connecticut, for Dr. Yee’s chapters.
involved in direct patient care, and support the recognition of phar- We acknowledge the many hours that numerous authors—
macotherapy as a board-certified specialty in pharmacy by provid- including the many contributors since the first edition—have
ing evidence of the field’s unique and extensive body of knowledge. devoted to this labor of love. Without their dedication to the cause
Those goals made the book an immediate success and have stood the of improving pharmacotherapy and maintaining the accuracy, clar-
test of time by guiding the editors for more than 30 years. ity, and relevance of their chapters, this text would unquestionably
Turning to this 12th edition, the current editors met in Atlanta not be possible.
in early January 2020. Nearby, the Centers for Disease Control and A special thanks go to Michael Weitz and Juanita Thompson
Prevention was responding to the emergence of a novel pneumo- of McGraw Hill and Poonam Bisht of MPS Limited for their input
nia of unknown etiology. By the time we departed just two days and support and for enhancing the online authoring tools needed to
later, Chinese authorities had identified and isolated a previously maintain the textbook on the AccessPharmacy website.
unknown coronavirus, then known as Wuhan-Hu-1. Despite the Many thanks to Terry Schwinghammer for his insights during
changes, challenges, illnesses, and losses the ensuing pandemic our editor meetings and continued devotion to the Pharmacotherapy
would bring, the editors and more than 300 authors of the 12th edi- Casebook: A Patient-Focused Approach companion to this work and
tion persevered to complete a record number of chapters (167) on the tools, chapter updates, and innovations he has shepherded onto
time, online, and in print, including a new chapter regarding the the AccessPharmacy website. Finally, we thank James Shanahan, Peter
ever-changing topic of COVID-19. Boyle, and their colleagues at McGraw Hill for their ongoing support of
At that 2020 meeting, the editors decided to dive deeper into the Pharmacotherapy family of resources, insights into publishing and
the digital world. Working with our publisher, we created a process higher education trends, and critical attention to detail.
for keeping online chapters updated on a continual basis, so they The Editors, October 2022
xxxv
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SECTION
1 FOUNDATION ISSUES
Patient Care Process

Stuart T. Haines, Mary Ann Kliethermes, and Todd D. Sorensen
KEY CONCEPTS
1 A professional patient care practice is built on three essential
elements: a philosophy of practice, a patient care process, INTRODUCTION
Chapter 1
and a practice management system. The patient care process is a fundamental series of actions that guide
2 A professional patient care practice is predicated on a the activities of health professionals. All health professionals who
patient-practitioner relationship established through provide direct patient care should use a systematically and con-
respect, trust, and effective communication. Patients, sistently applied process of care in their practice.1 Until recently,
and when appropriate, caregivers and family, are actively the language to describe the process for delivering comprehensive
engaged in decision making. medication management services was ill-defined. In 2014, the Joint
3 Adopting a uniform patient care process—a consistently Commission for Pharmacy Practitioners (JCPP)—representing 11
implemented set of methods and procedures—serves as national pharmacy organizations—endorsed a framework for pro-
a framework for each patient encounter, increases quality viding clinically oriented patient care services called the Pharmacist’s
and accountability, and creates shared language and Patient Care Process.2 However, the framework and the language to
expectations. describe the process are not unique to the pharmacy profession.
Indeed, medicine, nursing, and dentistry all follow a putatively
4 The patient care process includes five essential steps: similar process of care3 (see Table 1-1). For example, the American
collecting subjective and objective information about the
patient; assessing the collected data to identify problems
and set priorities; creating an individualized care plan that is
evidence-based and cost-effective; implementing the care TABLE 1-1 Professional Standards of Patient Care and
plan; and monitoring the patient over time during follow-up Their Domains
encounters to evaluate the effectiveness of the plan and Specialty
Dietician’s Nursing:
modify it as needed. Primary Care Nutrition Standards of Physical
5 The patient care process is supported by three inter-related IPC-26,7 Care Process8 Practice9 Therapists10
elements: communication, collaboration, and documentation. Symptoms, Nutrition Assessment Examination
Interprofessional teamwork and information technology complaints assessment
facilitate the effective and efficient delivery of care. Diagnostic Nutrition Diagnosis Evaluation
screening, diagnosis
6 A practice management system includes the infrastructure prevention
to deliver care. This includes physical space, documentation
Treatment, Nutrition Outcome Diagnosis
systems, payment for services, and qualified support procedures, intervention identification
personnel. medication
Test results Nutrition Develop plan of Prognosis
monitoring care
and
BEYOND THE BOOK evaluation
Administrative Implement plan Plan of care
For an overview of the importance of applying a consistent
Other Co-coordination Reexamination
process of care in practice, listen to the following Pharmacy of care
Forward podcast episodes: Health
teaching and
• Pharmacists Patient Care Process – Episode I (Dr.Todd Sorensen) promotion
https://pharmacyforward.podbean.com/e/pharmacists- Prescriptive
patient-care-process-i/ authority and
treatment
• Pharmacists Patient Care Process – Episode II (Dr. Mary Ann
Diagnoses, Evaluation Discharge/
Kliethermes) https://pharmacyforward.podbean.com/e/
diseases Discontinuation
pharmacists-patient-care-process-ii/ summary
CH01.indd 1 06-12-2022 17:53:06

2
Nursing Association (ANA) outlines the nursing process with steps patient over time during follow-up encounters to evaluate the effective-
that include assessment, diagnosis, outcomes/planning, implemen- ness of the plan and modify it as needed (see Fig. 1-1). In addition to the
tation, and evaluation.4 The Academy of Nutrition and Dietetics col- five fundamental steps, a patient-centered approach to decision making
lapses these general steps into four steps, outlining the nutrition care is essential.16 To be patient-centered requires effective communication
process to include nutrition assessment, diagnosis, intervention, and and seeking to understand the patient’s needs, preferences, and values.
monitoring/evaluation.5 Although the care process is similar across It also requires interprofessional collaboration—working with other
disciplines, each health profession brings a unique set of knowledge, health professionals to develop and implement a shared plan of care.17
SECTION Foundation Issues
skills, attitudes, and values to the patient encounter. Each step of the process must be documented. These steps are interde-
Health professionals who provide direct patient care are often pendent, and completing all five steps is necessary to achieve the great-
called practitioners. To practice is what health professionals do to est impact. While a process of care is common to all, each profession has
bring their unique knowledge and skills to patients. A practice is not a unique body of knowledge and skills they bring to bear when assessing
a physical location or simply a list of activities. Rather, a professional the data and formulating plans.3
1 practice requires three essential elements: (1) a philosophy of prac- A practice must also have a practice management system that
tice, (2) a process of care, and (3) a practice management system.3 supports the efficient and effective delivery of services.3 Without a
These three inter-related concepts make the delivery of patient- well-defined practice management system, the practice would not be
centered care possible. sustainable. This includes the infrastructure—the physical, financial,
Health professionals have an ethical obligation to promote the and human resources—as well as policies and procedures to carry
health and well-being of the patients they serve. Thus, a philosophy—the out the patient care work. Successful practices have a clear mission
moral purpose and a commonly held set of values that guides the pro- statement that defines who the practice serves, the organizational
fession—is the critical foundation on which the practices of pharmacy, values, and what they hope to accomplish. Furthermore, to achieve
medicine, nursing, and dentistry are built.11 A philosophy of practice is its mission, a practice must implement quality improvement meth-
often formally articulated in the professional code of ethics endorsed by ods that measure, evaluate, and improve the actions of practitioners
professional organizations and an oath that is recited by members of the (individually) and the practice (collectively).
profession during rituals and ceremonies. In addition to a code of ethics, While every practice is built on three essential elements—a phi-
most professions have an informal set of beliefs and values that inform losophy of practice, a well-defined patient care process, and a prac-
self-proclaimed and societal expectations. For example, the concept of tice management system—the focus of this chapter is to describe
pharmaceutical care is not formally included in the code of ethics for the patient care process applied to drug therapy management and
the profession of pharmacy or the oath of a pharmacist.12,13 However, explore some environmental issues that are influencing the adoption
informally, pharmacists understand they have a unique responsibility and application of this process.
for addressing the drug-related needs of patients and should be held
accountable for preventing, identifying, and resolving drug therapy
problems.14 Similarly, dentistry, nursing, and medicine have both formal IMPORTANCE OF A CONSISTENT
and informal expectations that guide their professional practice.
A process of care that is systematically and consistently applied dur-
PROCESS OF CARE
ing each patient encounter increases the likelihood that optimal health It is well understood that healthcare is a complex business. Since the
outcomes are achieved.15 The patient care process used throughout this turn of the twenty-first century, much effort has focused on gain-
book includes five essential steps: (1) collecting subjective and objective ing control of a disparate, disjointed, costly health system that is not
information about the patient; (2) assessing the collected data to identify adequately producing desired patient outcomes despite the health-
problems, determine the adequacy of current treatments, and set priori- care workforce laboring harder than ever. Spurred by the Institute of
ties; (3) creating an individualized care plan that is evidence-based and Medicine’s Crossing the Quality Chasm report from 2001,18 which set the
cost-effective; (4) implementing the care plan; and (5) monitoring the framework for redesigning healthcare delivery, healthcare institutions
and practitioners have embraced the Triple Aim19 focusing on patient-
centeredness, safety, and quality improvement (see Fig. 1-2). The Triple
Aim can only be achieved with significant transformations in the deliv-
ery of care and by adopting payment models based on value.
To accelerate the requisite redesign of healthcare delivery, the
Institute for Healthcare Improvement has developed guiding prin-
ciples or “rules” for workforces and healthcare communities. Among
these principles is to consistently implement what works in order to
reduce unnecessary variation. Standardization is important because
healthcare systems are embedded in a network of providers in mul-
tiple institutions, settings, and practices.20 A lack of a consistent pro-
cess of care creates an environment that leads to unacceptable gaps in
care. Thus, a process of care must be sufficiently robust to address the
complexity that exists among patients and adaptable to varied settings
and different acuity levels. For a specific patient care service to be
widely adopted and valued, it is imperative that clarity exists both in
the execution of care and the terminology used to describe the care.
The stimulus for developing the patient care process for phar-
macy was the wide variation observed as pharmacists provided direct
patient care, often using the same terminology to describe diverse
services or, conversely, the same service is described using differ-
ent terminology. As patient care services provided by pharmacists,
physicians, nurses, and any healthcare practitioner cannot operate
FIGURE 1-1 The Pharmacist’s Patient Care Process endorsed by in a silo, the services must be clearly articulated and well understood
the Joint Commission for Pharmacy Practitioners (2014). by patients, their caregivers, payers, and other care team members.
CH01.indd 2 06-12-2022 17:53:10

3
CE
EN
CHAPTER Patient Care Process

ERI
RED
XP
UC
TE
ED
IEN
1
CO
PAT
ST
ED
OV
PR
IM
IMPROVED POPULATION HEALTH

FIGURE 1-2 The Triple Aim in healthcare.
Without a consistent patient care process, it has been challenging care to an individual patient in each of these disciplines is similar;
for the pharmacy profession to communicate the pharmacist’s role however, the focus of the process is distinct.
to groups external to the profession and establish the distinct value The second way in which each profession uniquely addresses
pharmacists bring to an interprofessional care team. Moreover, the a patient’s needs is the manner in which patient-specific information
patient must know and understand what is to be delivered and to is assessed. When assessing information collected from a patient (eg,
determine how best to receive the care provided. Likewise, other history of present illness, physical examination, laboratory data), physi-
healthcare team members must determine how best to integrate the cians employ a clinical reasoning process called “differential diagnosis”
pharmacist’s work into their efforts caring for the patient. to weigh the probability of one disease versus other diseases that pos-
Structure is essential to maintaining consistency. Systematically sibly account for the patient’s signs and symptoms. In the case of dental
implementing a framework for care that is consistently applied hygienists, the American Dental Hygienists Association notes that an
assures no important step is overlooked and actions that may lead to assessment includes not only a health history and clinical assessment
greater harm than benefit are reduced or eliminated. Defining a stan- but also a “risk assessment” that includes 11 areas of evaluation.5 For
dardized process of care enables data collection for quality assurance pharmacists providing comprehensive medication management, the
and research purposes to demonstrate the value of a service. In the assessment step involves a systematic examination of the indication,
hospital setting, care pathways and standard order sets are examples effectiveness, safety, and adherence for each of the patient’s medications.
of standardized care processes that have been used for many years. This is a unique way of approaching a patient’s health needs. No other
Creating a standardized patient care process is not intended to rein- discipline applies a systematic assessment process to a patient’s medica-
vent “the wheel” but to create a common framework and language. tions and their medication experience in this manner.
The process of care described throughout this text provides an easily Several publications and resources have outlined elements of
understood approach that is universally recognized. the patient care process to deliver comprehensive medication man-
agement services.2,11,17,22,23 There is relative consistency between
these sources regarding the core elements. What varies is the
PATIENT CARE PROCESS TO OPTIMIZE specificity of the operational definition of each of the process com-
ponents. Detailed operational definitions help to establish consis-
PHARMACOTHERAPY tency across all practitioners applying the patient care process.23
There are two aspects that typically differentiate a profession-specific This care process is not specific to a care setting—the process can
process of care. First, the application of the care process is defined be applied in any setting when providing comprehensive medica-
within the context of the profession’s knowledge and expertise. For tion management. What often varies is the information collected
pharmacy, the patient care process is focused on a patient’s medication- and its source, as well as the duration of time to complete the pro-
related needs and their experience with medication therapy.3 cess. For example, in an ambulatory care clinic, the patient is often
Dentists and dental hygienists employ a patient care process focused the most important source of information, but in a critical care
on a patient’s oral health needs.21 The nursing care process is applied unit of a hospital, there is a greater reliance on laboratory tests and
to provide a holistic approach to a patient’s health needs and include special diagnostic studies. Similarly, the process of care unfolds in
physical and mental health, sociocultural issues, spirituality, as well hours or days in acute care settings but may extend over weeks or
as economic and lifestyle factors.4 The general approach to providing months in chronic care environments.
CH01.indd 3 06-12-2022 17:53:11

4
Collect Information for the condition for which it is being taken and that each condition
that requires drug therapy is being appropriately treated. Then the
When initiating the patient care cycle, a practitioner assures the col-
practitioner determines whether each medication the patient is tak-
lection of the necessary subjective and objective information about
ing is effective, achieving the intended outcome. This includes assur-
the patient and is responsible for analyzing the data to understand
ing the medication is the most appropriate option for the patient and
the patient’s relevant medical needs, medication-related problems,
is at a dose that is expected to achieve the intended effect. Next, the
and clinical status. In some cases, this information is directly col-
practitioner considers the safety of each medication, assuring that the
lected by interviewing the patient or reviewing a medical record. In

patient is not experiencing or being exposed to an unnecessary risk
other cases, the practitioner may rely on other personnel to collect
of adverse effects or an unintended interaction. Finally, the practitio-
the information to be used in the assessment. This may include a
ner then evaluates each medication for adherence-related concerns.
blood pressure determined by a clinical assistant or a list of active
This includes determining if the patient can take the medication as
medications recorded by a nurse. However, it is ultimately the prac-
intended, considering issues such as access and affordability, as well
titioner’s responsibility to assure that all necessary information
1 is collected and that the data is accurate, regardless of the source.
as sufficient knowledge and ability to appropriately administer the
medication. Throughout the assessment process, practitioners must
This information is critical to the ability of the practitioner to com-
keep the patient’s goals for therapy at the forefront of their decision
plete an assessment that will appropriately address all of a patient’s
making. Table 1-3 outlines the assessment process applied when
medication-related needs (see Table 1-2).
optimizing pharmacotherapy.
It is critical that the practitioner completes their assessment and
TABLE 1-2 Collect Patient-Specific Information defines a problem list considering indication, effectiveness, safety, and
Functional Definition23
The practitioner assures the collection of the relevant and necessary
subjective and objective information about the patient and is TABLE 1-3 Assess Patient-Specific Information to
responsible for analyzing the data to understand the relevant medical/ Determine Health-Related Needs
medication history and clinical status of the patient.
Operational Definition The practitioner assesses the information collected and formulates
1. Conduct a review of the medical record to gather relevant information a problem list consisting of the patient’s active medical problems
(eg, patient demographics, active medical problem list, admission and and medication therapy problems to prioritize medication therapy
discharge notes, office visit notes, laboratory values, diagnostic tests, recommendations to optimize medication use and achieve clinical
medication lists). goals.
2. Conduct a comprehensive review of medications and associated health
and social history with the patient. The practitioner or team member Operational Definition
should: 1. Assess and prioritize the patient’s active medical conditions taking into
• Inquire as to whether the patient has any questions or concerns for account clinical and patient goals of therapy.
the visit. 2. Assess the indication of each medication the patient is taking. When
• Review social history (eg, alcohol, tobacco, caffeine, other substance assessing the indication of each medication, consider the following:
use). • Does the patient have an indication for the medication?
• Review social determinants of health relevant to medication use (eg, • Is the medication appropriate for the medical condition being
whether the patient can afford his/her medications, the patient’s treated?
education level, housing arrangements, or means of transportation • Does the patient have an untreated medical condition that requires
affect his/her ability to use medications as intended). therapy but is not being treated or prevented?
• Review past medication history, including allergies and adverse 3. Assess the effectiveness of each medication the patient is taking.
medication effects. When assessing the effectiveness of each medication, consider the
• Obtain and reconcile a complete medication list that includes all following:
current prescription and nonprescription medications as well as • Is the patient meeting clinical goals of therapy?
complementary and alternative medicine the patient is taking • Is the patient meeting personal goals of therapy?
(eg, name, indication, strength and formulation, dose, frequency, • Is the most appropriate drug product being used for the medical
duration, and response to medication). condition?
• Review the indication for each medication. • Are the dose and duration appropriate for the patient?
• Review the effectiveness of each medication. 4. Assess the safety of each medication the patient is taking. When
• Review the safety of each medication. assessing the safety of each medication, consider the following:
• Review the patient’s medication experience (eg, beliefs, expectations, • Is the patient experiencing an adverse event from a medication?
and cultural considerations related to medications). • Is the dose too high for the patient? Are the frequency and duration
• Review how the patient manages his/her medications at home (eg, appropriate for the patient?
independently or with help, pillboxes, calendars, reminders). • Do safer alternatives exist?
• Gather any additional information that may be needed (eg, physical • Are there any pertinent drug-disease, drug-drug, or drug-food
assessment, review of systems, home-monitored blood glucose, and/ interactions?
or blood pressure readings). • Do additional labs need to be obtained to monitor the safety of the
3. Analyze information in preparation for formulating an assessment of medication therapy?
medication therapy problems. 5. Assess adherence and the patient’s ability to take (eg, administration,
access, affordability) each medication. When assessing adherence,
consider the following:
• Is the patient receiving the most affordable option to optimize
Assess Information and Formulate a adherence?
Medication Therapy Problem List • Is the patient able to obtain the medication(s), and, if not, why?
• Are the medications taken at times during the day that is appropriate
Once all of the necessary information to conduct a comprehen- to optimize effectiveness and minimize harm but also convenient for
sive assessment of the patient and their medication-related needs the patient?
has been collected, the assessment is organized into a problem list • Is the patient taking the medication as prescribed/instructed, or are
doses missed? If doses are missed, why?
consisting of the patient’s active medical problems and medication • Are the frequency and formulation appropriate for the patient to
therapy problems. Once identified, problems are prioritized to make optimize adherence?
decisions regarding the patient’s medication therapy to offer the best 6. Formulate a medication therapy problem list in accordance with the
opportunity to achieve the patient’s overall health goals. In doing so, Pharmacy Quality Alliance Medication Therapy Problem Categories
Framework.26
the practitioner reviews each medical condition and medication to
7. Prioritize the patient’s medication therapy problems.
make sure that each current medication is indicated (or necessary)
CH01.indd 4 06-12-2022 17:53:11

5
adherence in this order. This order of assessment ensures that the most TABLE 1-5 Develop the Care Plan
relevant issue affecting the patient is identified. For example, there is
a great deal of emphasis placed on improving patient adherence to The practitioner develops an individualized, evidence-based care plan in
medications, with nonadherence rates reported to range from 28% to collaboration with other healthcare professionals and the patient or
65%.24,25 However, if a patient is prescribed a medication that is not indi- caregiver that is evidence-based and as affordable as possible for the
cated or is causing an adverse effect, focusing time and attention toward patient.

improving medication adherence is misguided and does not address Operational Definition
the most important medication therapy problem. Selection of the most 1. Develop a care plan in collaboration with the patient and the patient’s
appropriate medication for the indication is the primary medication- healthcare providers to address the identified medication therapy
problems.
related need that must be resolved.
2. Identify the monitoring parameters important to routinely assess
The output of the assessment is a medication therapy problem indication, effectiveness, safety, and adherence.
list, prioritized in the order of importance from both the patient’s 3. Review all medication lists to arrive at an accurate and updated
and practitioner’s perspectives. Typically, the problem list is framed medication list.
4. Determine and coordinate who will implement components of the
1
in a categorical system of medication therapy problems. A nation-
care plan (ie, patient, pharmacist, other healthcare providers).
ally recognized system for categorizing the output of a practitioner’s 5. Determine the type of follow-up needed.
assessment is now recognized by the Pharmacy Quality Alliance (see 6. Determine the appropriate time frame for patient follow-up.
Table 1-4). There are 10 medication therapy problem categories, and 7. Determine the appropriate mode for follow-up (eg, in person,
these align with the four areas of medication use assessment.26 electronically, by phone).
TABLE 1-4 Medication Therapy Problem Categories

Framework plan will likely include activities that the patient and other healthcare
providers will be responsible for; however, it is the duty of the practi-
Medication Therapy Problem
Medication-Related Needs Category tioner to ensure that each of the elements of the plan has been imple-
mented in a time frame that is reasonable and effective (see Table 1-6).
Indication Unnecessary medication therapy
There are many tools and resources that may be used to support
Needs additional medication therapy
a patient and/or their caregivers to successfully implement the care
Effectiveness Ineffective medication plan. It is in this part of the patient care process where practitioners will
Dosage too low employ strategies such as patient education, motivational interviewing
Needs additional monitoring techniques, tools that support medication adherence, and patient self-
Safety Adverse medication event monitoring technologies. These tools and resources are approaches to
Dosage too high
best meet the needs of the patient and their medication-related goals.
Needs additional monitoring
Convenience Adherence
TABLE 1-6 Implement the Care Plan
Cost
Data from Pharmacy Quality Alliance. Medication Therapy Problem Categories The practitioner implements the care plan in collaboration with other
Framework for PQA Measures. Alexandria, VA: Pharmacy Quality Alliance, 2017. healthcare professionals and the patient or caregiver.
Operational Definition
When this assessment approach is applied, a relatively consis- 1. Discuss the care plan with the patient.
tent pattern of medication therapy problems emerges.27-29 The cat- 2. Ensure patient understanding and agreement with the plan and goals
egories identified with the greatest frequency are “needs additional of therapy.
therapy” and “dose too low,” followed by “adherence.” The other cat- 3. Provide personalized education to the patient on his/her medications
and lifestyle modifications.
egories are observed less frequently. It should be noted that these 4. Provide the patient with an updated, accurate medication list.
reported trends all come from the application of this assessment 5. Implement those recommendations that you have the ability to
process in ambulatory care settings. The distribution of medication implement in your scope of practice.
therapy problems would likely differ in acute care settings. 6. Communicate the care plan to the rest of the care team. If you cannot
implement a recommendation(s) on your own, reach a consensus on
Develop the Care Plan where implementation is required by another team member.
7. Document the encounter in the electronic health record (eg, a
Upon completing the assessment and establishing a prioritized list summary of relevant patient information, assessment, and plan,
of medication therapy problems, an individualized patient-centered including rationale, monitoring, and follow-up).
8. Arrange patient follow-up.
care plan that is evidence-based and as affordable as possible for
9. Communicate instructions for follow-up to the patient.
the patient is created. The plan should be developed in collabora-
tion with the patient or caregiver to meet the patient’s expectations
and priorities. It should also be developed in collaboration with
other healthcare professionals to ensure that all healthcare providers Follow-up with the Patient
involved with the patient’s care agree and support the plan. After the initial implementation of a care plan, ongoing monitoring
The care plan will include goals of therapy and outline contin- and follow-up to evaluate the effectiveness and safety of the plan are
gencies to adjust medications, doses, or delivery, as well as monitor- essential. The plan should be modified as needed in collaboration
ing parameters. It will establish time frames for follow-up and clearly with other healthcare professionals and the patient or caregiver. This
state who will be responsible for each component of the care plan. follow-up process is critical and demonstrates the practitioner has
The steps for developing a patient-centered care plan are outlined in assumed responsibility for the patient’s medication-related needs.
Table 1-5. While a practitioner who serves as a consultant may not follow up to
determine if the problem has been resolved, this is inconsistent with
Implement the Care Plan the expectations of a comprehensive medication management prac-
Once a care plan is established, the practitioner implements the plan tice or the patient care process. As a healthcare practitioner who has
designed to prevent and resolve medication therapy problems. The care assumed an important role in a patient’s care, it is the responsibility
CH01.indd 5 06-12-2022 17:53:11

6
of the practitioner to determine the outcome of drug therapy and each patient encounter. The lack of clarity and consistency has been
take additional action if necessary. This follow-up process can occur the Achilles heel in the evidence to support the value of pharmacists’
through a variety of mechanisms, including face-to-face encounters, patient care services.32 The standard process gives pharmacists an
phone calls, electronic health record messaging, and telehealth tech- opportunity to show value on a large scale because the services are
nologies (see Table 1-7). comparable and clearly understood across practice settings.
The frequency to which follow-up occurs varies from setting
to setting. A practitioner practicing in an acute care environment
Workflow, Documentation, and
will possibly transfer responsibility for follow-up to other provid-

ers, including another pharmacist, when the patient transitions to Information Systems
another setting. In the ambulatory care setting, a practitioner should The generation and analysis of data regarding the care provided and
ensure that a patient has a comprehensive evaluation of their medi- the resulting health outcomes are becoming increasingly important
cations and health status annually, at a minimum. In some cases, the for organizations and individual providers. Healthcare systems are
1 nature of the patient’s medication therapy problems may be resolved rapidly embracing the power of technology to analyze information
to the degree to which the patient no longer requires ongoing moni- to gain important insights. This technology is only useful if clini-
toring. In such cases, the patient should be referred back to the pri- cal care is robustly documented, collected, and managed. Data is
mary care provider for ongoing follow-up and monitoring. optimally collected as part of the workflow process using IT tools.
Creating the requisite tools, however, requires a standard process
to build cohesive systems with uniform data sets. Thus, the data
elements can be collected using the same collection specifications
TABLE 1-7 Follow-up with the Patient using different technology systems in different organizations. This
Functional Definition23 allows the reporting of comparable information to providers, payers,
The practitioner provides ongoing follow-up and monitoring to optimize
the care plan and identify and resolve mediation therapy problems,
and others.
with the goal of optimizing medication use and improving care. A uniform patient care process sets a standard for the workflow
that allows IT systems to capture and extract data for analysis and
Operational Definition
1. Provide targeted follow-up and monitoring (eg, in person,
sharing. Imagine a patient encounter with a practitioner in any set-
electronically, or via phone), where needed, to monitor response to ting. The practitioner often has some patient information available
therapy and/or refine the care plan to achieve patient and clinical before the encounter; however, the practitioner will likely collect
goals of therapy. Targeted follow-up includes but is not limited to quick new information. This work can now be electronically captured in
check-ins to monitor blood sugar or blood pressure, adjust insulin,
the collect phase of the workflow. The practitioner will then assess
check INRs, and provide education.
2. Repeat comprehensive medication management (CMM) follow-up the information and identify new or unresolved medication-related
visits at least annually, whereby all steps of the CMM Patient Care problems. Likewise, this work is captured in the assessment phase of
Process are repeated to ensure continuity of care and ongoing the visit. The practitioner will then update or add to the care plan for
medication optimization. the patient, and the information can be electronically captured in the
3. If the patient is no longer a candidate for CMM, ensure that a plan for
continuity of care with other care team members.
planning phase. During the encounter, the practitioner may imple-
ment some or all of the plan, and the tasks or services performed are
captured during the implementation phase. During the follow-up
and monitoring phase, the resolution of identified problems and the
ENVIRONMENTAL ISSUES response to treatment are documented. The information collected
can now be exchanged, extracted, and analyzed at the provider,
The third critical element of practice is a practice management sys- population, organizational, and payer levels because it is defined and
tem. The specifics of any practice management system are based on collected in a uniform manner.
fundamental business principles and the requirements of the partic- The ability to capture clinical data is available through several
ular type of healthcare setting where the practice exists.30 In today’s coding systems (see Table 1-8). The Pharmacy Health Information
healthcare environment, there are several aspects of managing a
practice that practitioners must consider—the metrics to ensure
patient health outcomes are being achieved; efficient workflow; TABLE 1-8 Clinical Coding Systems
communication and documentation using the power of information System Name Contents
technology (IT); and data that accurately attributes and values the International Classification Coding for medical procedures and
work each practitioner brings to patient care. of Disease (ICD) encounters. The 11th edition was
published in 2019.
Quality Metrics Systematized Nomenclature A coding system of clinical terminology
Dr. Avedis Donabedian, considered the father of quality improve- of Medicine—Clinical representing the full scope of clinical
Terms (SNOMED-CT) information in healthcare.
ment in healthcare, defined standards as the desired and achievable
performance related to a specific parameter—an objective, definable, Logical Observation Vocabulary database of universal
Identifiers Names and identifiers for laboratory and clinical
and measurable characteristic of the structure, the process, or the
Codes (LOINC) test results.
outcome of the care.31 To determine quality, there must be a standard
Healthcare Common CMS established billing codes for
to measure the level of quality against. The patient care process sets Procedural Coding Medicare for medical procedures
a standard of achievable performance by defining the parameters System (HCPCS) that include CPT as well as codes not
of the process that can be measured. With the movement toward covered by CPT.
outcome-based healthcare models and value-based payment sys- Current procedure Coding system for medical procedures
tems, it is critical to objectively measure the impact a patient care terminology (CPT) developed and maintained by the
service has on a patient’s health and well-being. This allows the link- American Medical Association primarily
used for billing services.
age from the standard process, such as what health problems were
identified and how they were addressed during the patient encoun- RxNorm Standardized nomenclature for clinical
drugs created by the National Library
ter, to the desired outcomes. For the process to be measurable, each
of Medicine.
element must be clearly defined and performed similarly during
CH01.indd 6 06-12-2022 17:53:11

7
Technology Collaborative has been at the forefront in assuring CONCLUSION
pharmacist patient care services are part of the IT systems being
developed for the healthcare system in the United States.33 The col- A standard process of care provides the structure that all practi-
laborative has developed several documents demonstrating how tioners should follow and, when implemented correctly and con-
to uniformly document patient-care activities and enables shar- sistently, can improve the quality of care provided to patients. It
ing of patient-specific information across technology platforms. provides a common language that defines roles, responsibilities, and
expectations. Comprehensive medication management involves a

These data can be used to improve care coordination, workflows,
and quality. Examples include documentation templates that use five-step process: collect, assess, plan, implement, and follow-up. A
standard technology coding such as the Systematic Nomenclature standard process of care informs the creation of quality metrics and
of Medicine—Clinical Terms (SNOMED-CT) codes that convert is the foundation of practitioner workflow, the structure of health
a patient care note into an electronically transferable document information systems, and billing for patient care services.
(eg, pharmacist e-care plan). The information can then be used
to link patient outcomes attributable to the pharmacist-provided ABBREVIATIONS 1
care. The documents are easily accessible on the Pharmacy Health
Information Technology (HIT) website (http://pharmacyhit.org/). It CMS Centers for Medicare & Medicaid Services
is unnecessary for practitioners to know the specific codes or tech- CPT current procedure terminology
nology structure. However, clinicians should understand how IT HCPCS Healthcare Common Procedural Coding
operates behind the scenes when performing and documenting their System
clinical activities. This will enable practitioners to assist information ICD International Classification of Disease
technologists in effectively designing systems that accurately and IT information technology
efficiently capture the elements of the patient encounter that can be LOINC Logical Observation Identifiers Names and
used for care coordination, quality metrics, and payment in emerg- Codes
ing value-based payment models. SNOMED-CT CT Systematized Nomenclature of
Medicine—Clinical Terms
Documentation, Attribution, and SOAP subjective, objective, assessment, plan
Payment
Payment to healthcare providers for patient care services in the
United States has traditionally been based on the documentation
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CH01.indd 8 06-12-2022 17:53:13

Another random document with
no related content on Scribd:
THE BOY AND THE LARK.
music composed for merry’s museum; by
g. j. webb.
“Who taught you to sing, my pretty, sweet birds?

Who tuned your melodious throats?
You make all the woods and the vallies to ring,
You bring the first news of the earliest spring,
With your loud and your silvery notes.
“Who painted your wings, my pretty, sweet birds,

And taught you to soar in the air?
You rise and you dart through the region of light,
You look down on man from your loftiest height,
And your hearts know no troublesome care.
“And where are your fields, my beautiful birds?

And where are your houses and barns?
You sow not the ground, and you reap not the corn,
You spring from your nests at the earliest morn,
But you care not about the wide farms.”
“’Tis God,” said a lark, that rose from the turf,

“Who gives us the good we enjoy;
He painted our wings, and he gave us our voice,
He finds us our food, and he bids us rejoice;—
We’re his creatures, my beautiful boy.”
MERRY’S MUSEUM.
VOLUME II.—No. 2.
The Siberian Sable-Hunter.
CHAPTER II.
It is the character of young people to engage in new enterprises

with ardor: it was so with Alexis, in his fur-hunting expedition. For a
time, indeed, after parting with his father and sister, his heart was
heavy, and tears more than once dimmed his eyes. He expected to
be absent for a year at least, and who could tell what might befall
him or them, during that space of time? Such thoughts came again
and again into his mind, and as fancy is apt to conjure up fears for
those we love, he pictured to himself many possible evils that might
beset his friends at Tobolsk.
But these images gradually faded away, and the young hunter
began to be occupied with the scenes around him, and with the
conversation of his companions. These consisted of two young men
of nearly his own age, and their father, an experienced and skilful
hunter. They were all equipped with rifles, and each had a long knife
like a dagger in his belt. Their design was to travel on foot to the
eastward, a distance of more than two thousand miles, and then
proceed northward into the cold and woody regions which border the
banks of the great river Lena, as it approaches the Arctic Ocean.
Hitherto Alexis had seen little of Siberia; his curiosity was
therefore alive, and he noticed attentively everything he met. Soon
after leaving Tobolsk, the party entered upon the vast plain of
Baraba, which spreads out to an extent of several hundred miles. It
is almost as level as the sea, with slight swells, resembling waves.
Such plains are called steppes in Siberia, and they are like the
prairies of our western country, being generally destitute of trees,
except low willows, and large portions having a marshy soil. Upon
this plain the travellers met with no towns, but miserable villages of
people, their huts half sunk in the mud. They also sometimes
encountered small bands of people called Ostiacks. These seemed
to be roving people, and in a state of barbarism. The old hunter of
the party, whose name was Linsk, seemed to be well acquainted
with the habits of these people, and as the four hunters were
trudging along, he gave the following account of them, taking care to
say something of himself in the course of his story.
“The Ostiacks are one of the most numerous of the tribes of
Tartars that inhabit Siberia. They spread over the country to the north
of Tobolsk, along the banks of the Obi, and the various streams that
flow into it. They do not like to dig the soil, so they live on fish, and
by hunting wild animals. Some of them eat so much fish, that they
smell like whale oil. I have been in their tents often, and one of these
fisheating families have a flavor as strong as a cask of herrings. Bah!
how well I remember them! It seems as if I could smell them now! I
shall never get them out of my head.
“You must know that I have been a hunter for twenty-five years,
and I have made several expeditions into the north country, where
the Ostiacks chiefly dwell. It is a cold and desolate region; no trees
but pines and willows grow there; there is no grass, and very few
shrubs. Still, it was once a good country for furs; but they are nearly
gone now, and I don’t wonder at it, for these Ostiacks are such
heathens. They are not Christians, but believe in little wooden
images, which they will place on their tables, and lay around them
snuff, willow bark, fish oil, and other things which they deem
valuable. Having done this, they call upon these images, which are
their gods, to make them lucky in fishing and hunting. If the gods
don’t send them good luck, then these foolish people do give them
such a banging! They cuff their heads, and knock them off the
tables, and switch them as if they were so many naughty school-
boys.
“Now, for my part, I wonder that fish, or sables, or bears, or any
other creatures that are useful, will stay in a country where such
stupid people live. And then you must know that the Ostiacks almost
worship a bear. They think that this creature is a kind of a witch or
wicked god, and such horrid notions of it have they, that, when they
take the oath of allegiance to the Russian government, they say, to
make it very strong—‘We hope we may be devoured by bears, if we
do not keep this oath.’
“Beside all this, the Ostiacks, as you see by those whom we have
met, are little short people, not more than five feet high. A great
many of the women are fat, and such little round dumplings I never
beheld! The hair of these people is of a reddish color, and floats
down their shoulders. Their faces are flat, and altogether they look
like animals, rather than human creatures. Their houses are made of
poles, set up in a circle, and thatched with bark. In winter, the
windows are covered with expanded bladders. The fire is made on
one side of the room, and the smoke circulates above, finding its
way out as it can. Generally, there is but one room in a hut, and all
the family are tumbled into it, by night and by day.
“Now all this shows what stupid people these Ostiacks are; but
there is one thing I have to say in their praise. They understand
fishing and hunting. In chasing the bears, they show courage and
skill, and in taking the sable so as not to break his skin, they display
true genius. I once knew an old Ostiack that was nearly equal to
myself in hunting. He could see the track of an ermine, marten, or
sable, upon the snow-crust, when nobody else could; he would
follow one of these creatures for a whole day, pretending he could
see the foot-prints; but I believe the old fellow could smell like a dog.
What beautiful sables and grey foxes he did get! He once got two
sable skins which were sent to St. Petersburgh, and sold for three
hundred dollars. The emperor bought them himself, and sent the old
fellow a knife ornamented with a silver plate, and the word “Nicholas”
engraved upon it. This the emperor said was to encourage the
hunter to get fine furs. But the old hunter died soon after, and the
people said it was from mere pride, because the emperor had paid
him so much honor. He never hunted any more, but strutted about,
brandishing his knife in the air, and saying, ‘Behold! this is what
Nicholas, the Czar of all the Russias, has sent to Dwaff Khizan, the
greatest hunter of Siberia!’”
Alexis listened with interest to this long account of the Ostiacks by
old Linsk: but his heart really palpitated when the hunter told of the
rich sable furs sent to St. Petersburgh by Dwaff Khizan, and which
not only brought a great price, but won the favor of the emperor. He
immediately remembered the injunction of his sister Kathinka, to be
particular and get rich sable furs; and he also remembered that she
had spoken of sending them to the princess Lodoiska. “After all my
thinking that the girl was romantic and conceited, to fancy that she
could send furs to a princess, and attract her attention, now that we
are poor exiles in Siberia, perhaps she is right, and has more sense
then I have. At all events, I will exert myself to procure some sable
furs finer than were ever seen before. We are going to the coldest
portions of Siberia, and there it is said are the most splendid furs in
the world. It will be something to please Kathinka, and to relieve my
father from his poverty; and, beside, I should like to beat old Linsk,
vain and boastful as he is!”
With this ambitious conclusion, Alexis stepped quicker and
prouder over the level road, and, without thinking of it, had soon
advanced considerably before his party. Coming to a place where
the road divided, he took that which led to the right, as it seemed the
best. He had not gone far, however, before he heard the loud call of
Linsk. Stopping till the party came up, Alexis found that he had taken
the wrong path. “That road,” said Linsk, “leads to the great town of
Tomsk; a place which has ten thousand people in it, and I may add
that one half of them are drunkards. This is the more wonderful, for
the people have enough to do; because the country in that quarter
abounds in valuable mines. All around Tomsk there are salt lakes,
and the waters are so impregnated with minerals, that the bottoms
are covered with a coat as white as snow.
“To the south of Tomsk, a great many miles, are some mountains,
called the Altai range. In these mountains there are mines of gold
and silver, and of platina, a metal more costly than gold. The mines
are wrought by exiles; and, master Alexis, some of your countrymen
are there, as they ought to be. You ought to thank the clemency and
mercy of the emperor, for not sending you and your father there!”
“Stop! stop! old man!” said Alexis; “say no more of that! say no
more of that! My father ought to be sent to the mines! for what? For
risking his life to save his country? For giving his wealth to Poland?
For shedding his blood for liberty? Is patriotism then a crime? Shame
on the emperor who makes it so!”
“Tut, tut, tut, tut!” said Linsk, with an air of authority; “why, you talk
rebellion, as if you had drank it in with your mother’s milk. Oh dear!
oh dear! what are we all coming to, when youngsters talk such
pestilent stuff about liberty and patriotism? Why, what have we to do
with liberty and patriotism? Let us take care to obey the emperor,
and his officers, and those who are in authority, and do as the priests
tell us: that’s all we have to do. But never mind, boy; I didn’t mean to
hurt your feelings. So don’t think any more of what I said about your
father and the mines. I believe he’s an honest and noble gentleman,
though I am sorry he’s so much misled. Liberty and patriotism—
indeed! Bah! When I hear about liberty and patriotism, I always look
well to my pockets, for they sound to my ear very much like roguery
and mischief. Liberty and patriotism, forsooth! as if we common men
were like wild animals, and, as soon as we are of age, had a right to
set up for ourselves! No! no! we are Christians, and it is our duty to
honor the emperor; we are his subjects, and he may do as he
pleases with us. God bless him.”
“I suppose it would be glory enough,” said Alexis, having
recovered his good humor, “to have our heads cut off, provided it
was done by command of the emperor.”
“Certainly,” said Linsk, not discovering the irony; and here the
conversation took another turn.
“You were speaking of the mines,” said Alexis. “Do they produce
great quantities of the precious metals?”
“Yes,” said the old hunter, in reply. “The mines produce the value
of more than ten millions of dollars a year. Not only do they yield
gold, and silver, and platina, but a great deal of copper. Beside
these, many precious stones are found, such as the topaz, beryl,
onyx, garnets, diamonds, and green crystals as beautiful as
emeralds. All these mines and all the minerals belong to the Czar,
and they are wrought by his serfs and slaves, and by such exiles as
are very bad and troublesome!”
“Those who talk about liberty and patriotism, I suppose,” said
Alexis.
“Yes,” said Linsk, snappishly.
“Well,” said Alexis, “I should like to go to that country, where there
are such rich minerals and precious stones. I think I could pick up
enough to make myself rich.”
“And get your head taken off besides,” said Linsk. “Let me tell
you, my young master, the metals and minerals belong to the
emperor, and it’s stealing for anybody to take them, and whoever
does so is sure to get punished. I know a story about that—”
“Tell it, I beg you,” said Alexis. So the hunter proceeded.
“There was once a young nobleman of Russia exiled to Siberia for
some offence to the Czar. This happened in the time of Paul, near
forty years ago. Well, when he came to Tobolsk, he was very poor,
so he thought how he might get money and become rich. At last he
heard of the mines of the mountains, and thither he went. He was
careful, however, not to let anybody know his plan. He proceeded
first to the Kolyvan mountains, but, as there were a great many
people at work there, he was afraid of being detected in his scheme;
so he proceeded farther east, until he came to a tall mountain called
the Schlangenberg, which is the loftiest of the Altai range.
“When he had got up to the very top of the mountain, being weary,
he laid himself down to get some rest, and here he fell asleep. While
in this state, a man, in the dress of a Tartar, seemed to stand before
him, and, making a low bow in the Eastern fashion, said, ‘What
would’st thou, son of a noble house?’ To this the young Russian
replied—‘Wealth—give me wealth: with this I can purchase my
liberty and return to Moscow, and live again in happiness. Give me
riches: with these I could buy the very soul of the emperor, for all he
desires is money.’
“When the young man said this, the image smiled on one side of
his face, and frowned on the other; but he answered fairly,—‘Your
wish shall be granted: follow me!’ Upon this the Russian arose and
followed the mysterious stranger. They descended to the foot of the
mountain, and entered a cave which was formed by nature in the
rocks. It was at first a dark and gloomy room, with grizzly images
around, and a fearful roar as of mighty waterfalls, tumbling amid the
gashes and ravines of the mountain. But as they advanced farther,
the scene gradually changed. The darkness disappeared, and at last
they came to a vast chamber, which seemed glittering with
thousands of lamps. The room appeared indeed like a forest turned
to crystal, the branches above uniting and forming a lofty roof, in the
gothic form. Nothing could exceed the splendor of the scene. The
floor was strewn with precious stones of every hue, and diamonds of
immense size and beauty glistened around. As the adventurer trod
among them, they clashed against his feet as if he was marching
amid heaps of pebbles. There were thousands of lofty columns, of a
pearly transparency, which seemed to send forth an illumination like
that of the moon; and these were studded with garnets, and
emeralds, and rubies.
“The Russian was delighted—nay, entranced. He walked along for
more than an hour, and still the vast room seemed to expand and
grow more gorgeous as he proceeded. The diamonds were larger,
and the light more lovely, and by-and-by there came a sound of
music. It was faint, but delicious; and our hero looked around for the
cause of it. At last he saw what seemed a river, and on going to the
border of it, he discovered that it was a stream of precious stones,
where garnets, and beryls, and diamonds, and emeralds, and rubies,
flowed like drops of water, in one gushing, flashing current; and as
they swept along, a sort of gentle but entrancing melody stole out
from them, and seemed to melt the heart with their tones.
“‘This is indeed most lovely—most enchanting!’ said the youth to
himself. ‘Well and truly has my guide performed his promise.’ Saying
this, he looked around for his guide, but he had disappeared. The
young man waited for a time, but his guide did not return. At last he
began to feel weary, and cast about for a place to lie down; but no
such place appeared. The floor of the mighty hall was covered with
precious stones, but they were so sharp and angular that they would
have cut his flesh, if he had attempted to lie upon them. Pretty soon,
hunger was added to the young man’s wants. But how could he
satisfy it? There were emeralds, and rubies, and sapphires, and
diamonds, but neither meat nor bread. At last he turned around, and
began to search for the way out of the grotto; first filling his pockets
with the richest and rarest gems he could find. But the more he
sought for the passage, the more remote he seemed to be from it.
He, however, continued to wander on, but all in vain. At last he
became frantic; he threw up his hands, and tore his hair, and ran
fiercely from place to place, making the arches ring with his frightful
screams. ‘Take your gold, take your jewels!’ said he; ‘and give me
rest, give me bread!’ And, repeating this by night and by day, the
young man continued to run wildly from place to place; and though
forty years have rolled away since he entered the enchanted cave,
he is still there, and is still unable to obtain rest or appease his
hunger!”
“Is that all?” said Alexis, as the hunter paused in his narration.
“Yes,” said Linsk; “and let it warn you and all others not to go into the
mountain, to steal the gems and the gold that belong to the
emperor.”
“The story is a good one,” said Alexis, “and no doubt it has been
used to frighten people from interfering with the emperor’s mines; but
it is an allegory, which bears a deeper meaning to my mind. It
teaches us that riches cannot bring rest or health, and that a person
surrounded with gold and gems may still be a most wretched being.
Those very gems, indeed, may be the cause of his distress, as they
may have been obtained by crime, or avarice, or other unlawful
means.”
(To be continued.)
The Lion and the Mouse;
a fable.
A lion was once going to war; he had buckled on his sword, and
gathered his forces, and, with the monkey and the bear supporting
his long robe behind, he was proudly marching over the plain at the
head of his army. As he was proceeding, it chanced that his majesty
encountered a mouse, dancing merrily over the ground. The king
paused, and observed the little dancer with a grim smile of
satisfaction. At this the bear grumbled, and the monkey sneered, for
his majesty being in a warlike humor, they thought it meet that
everybody else should be so too; but they were both speedily
silenced by the lion, who spoke as follows:
“Why do you grumble at this pretty little fellow? See how graceful
his movements are, and how cheerful is his countenance!
Remember that everything has its use, and nothing is more useful
than that which makes us cheerful, provided it is innocent. Even we
warriors have need of cheerful excitement, for by this means we are
better fitted to discharge our solemn duties. Let us not despise, then,
even such sports, and amusements, and trifles, as come in our way,
provided always that they are as harmless as the frisks and frolics of
this little dancing-master of the meadow; and provided, too, that we
never neglect business for pleasure.”
Merry’s Life and Adventures.
CHAPTER X.
A conversation about wealth and poverty.—People to be respected
according to their character, not according to their
circumstances.
As Paul Raymond was one of the best friends I ever had, it is my

desire to make my reader well acquainted with him. He was tall, thin,
and bent over, his figure seeming to indicate great humility; his face
was meagre and exceedingly pale; his hair black as jet, and hanging
in long, thin curls down his neck. His eye was very large, and of a
deep blue.
The whole aspect of my friend was marked with a childlike
gentleness and timidity, though his high forehead and prominent
Roman nose bespoke a manly intellect. A worldly person, judging
only by outward form and a first sight, had passed him by with
indifference; but one who looks upon mankind as beings of soul and
mind, would have been attracted by his appearance. It was so in
some degree with myself, for when I first saw poor Paul, as he was
called in the village, I scarcely noticed him. And for years after, I saw
nothing of particular interest in his person: but now that I was on a
sick bed, and had opportunity, as well as occasion, to observe him
closer, he seemed to me very interesting, both in looks and manner.
It was one morning after he had been putting my room in order,
and, taking his book, had sat down by my bedside, that I mentioned
to Paul the change of feeling I had undergone in respect to himself.
“I cannot but wonder,” said I, “how different you seem to me now,
from what you used to do, Mr. Raymond.”
Raymond. Call me Paul, boy, call me Paul! said he. We are
friends now, and mister is always a mischief-maker between friends.
You say I seem different now from what I once did. The change is in
you, not in me. I am the same poor Paul Raymond, as before. You
are something better than before this accident happened.
Merry. How am I better? I think I am worse: I have been guilty of
folly, and, though thoughtlessly, of crime; I have been disgraced
before the whole village; my poor arm broken; I am sick and
emaciated; and after all this, you tell me that I am better than before.
R. And I tell you the truth, boy. You have suffered, it is certain; but
that suffering has been like medicine to your mind and heart. You
were well in body, you were full of health and spirits, but there was
disease within. Your heart was full of selfishness and pride; you felt
that you could take care of yourself, and you cared not for the
sympathy of others. You have now learnt a good lesson; that pride
has been humbled, and you see your dependence upon others. You
see how poor and paltry pride is; and how vain is that independence,
which leads us to think only of self, and to be regardless of the
feelings of our fellow-men. You are more humble than before, and
therefore I say you are better than before.
M. Then you think humility is a good thing?
R. Certainly, and pride a bad thing. God looks down upon the
humble man with approbation and favor, and he sends to the humble
man peace and consolation which the world cannot give or take
away. God looks down upon the proud man as a fool, a creature as
silly as the moth that buzzes in the flame of the lamp, only to perish
in his folly.
M. But this is very different from the view generally taken by
mankind. The rich, the haughty, those who are successful in life, who
know no sickness or misfortune, and who are seldom or never
visited by sorrow—these are those who are esteemed happy by the
world at large. The proud are envied and the humble are despised.
You would reverse this, and regard the humble as the happy, and the
high and haughty as the miserable.
R. Yes, and this is nearly the truth. Health is given us for good;
but, strange to say, men seem to turn it to bad account. A person
who has always good health, is usually unfeeling: he sneers at those
who are feeble, and laughs those to scorn who cannot eat and drink
and work as well as he does. He is therefore deficient in one of the
greatest of blessings, a kind and tender heart, a heart that feels for
the misfortunes and sorrows of others, and that always is seeking to
soften them.
Riches are given for good, but these too are abused. The rich
man is likely to have very little regard for the poor; he is apt almost to
feel that the poor are not human: at all events, he knows and cares
little about them. He estimates men by their wealth: if a man is rich,
he respects him; if poor, he despises him. Thus wealth begets in its
possessor a gross stupidity of mind; it blinds a man to the most
useful pleasures and important truths. It makes a man ignorant of his
real duty and his true happiness.
M. You think then that health and wealth are misfortunes.
R. Certainly not, if rightly used: they are blessings in the hands of
the virtuous, and some such there are. But in too many cases,
mankind abuse them. The fortunate are very apt to be vicious; those
who go on in an unchanging tide of success, at last fancy that they
may indulge their pride and their passions with impunity. Such
persons have hard hearts; and though the world, judging of the
outside only, call them fortunate, and envy them—still, if we look
within and see their real character, we shall pity them, as in fact poor,
and destitute, and miserable in all that constitutes real goodness,
real wealth—a good heart.
It is for this reason that the Bible—a book more full of virtue than
mankind generally think—tells us that “whom the Lord loveth, he
chasteneth.” In other words, God sends sorrow and misfortune upon
men in real kindness. He takes away health, but he gives gentleness
and humility of soul, as a compensation; he takes away worldly
wealth—houses, lands, and merchandises—but he gives charity,
good will, kindness, and sympathy, in their stead. He takes away
external and earthly riches, and gives in exchange spiritual riches, of
infinitely greater price. He takes away dollars and cents, which only
pass in this world, and are wholly uncurrent in another, and gives
coin that bears upon it an image and superscription, which not only
makes it available in time, but in eternity.
M. Most people think very differently from you, on these matters:
they seem to imagine that the rich are not only the happiest, but the
wisest and best part of mankind.
R. Shallow people may think so, but wise men do not. Our Savior
appealed to the poor, not to the rich. Poverty, not wealth, was the soil
in which he sowed the seeds of truth; and he knew all things. History
justifies Christ’s judgment of human life, for all, or nearly all great
improvements in society have been begun and carried on by the
poor. For almost all useful inventions; for almost all that is beautiful in
poetry, and music, and painting, and sculpture, and architecture; for
almost all that has contributed to diffuse truth and knowledge and
liberty among mankind—we are indebted to those who have been
born and nursed in poverty. If you were to strike out of existence all
that the poor have created, and leave only what the rich have
created, you would make this world one vast scene of desolation,
vice, and tyranny.
Look around, and remark, who are the people that are tilling the
soil and producing the comforts and luxuries of life? The poor, and
not the rich. Who are paying the taxes and supporting the
government? The poor, for they pay, in proportion to their property,
much more than the rich. Who are the supporters of religion? The
poor, for it is by their prayers, and sacrifices, and efforts, that it is
propagated, not only at home, but in foreign lands. No Christian
Mission, no Bible Society, no Society for the distribution of Tracts,
was ever begun and carried on and supported by the rich.
The simple truth is, that, as the poor are the producers of all the
substantial comforts of life, of food, raiment, houses, furniture, roads,
vehicles, ships, and merchandises, so are they the cultivators of
those spiritual staples which make up the social wealth of the world
—religion, knowledge, charity, sympathy, virtue, patriotism, liberty,
and truth. Destroy the poor, and you destroy not only the source of
worldly wealth, but of that mental, spiritual, and social wealth, which
are far higher and better.
M. You think, then, that the poor are not only the wisest, but the
best part of mankind.
R. Certainly; but do not misunderstand me. I do not say all rich
men are bad, or that all poor ones are good. There are rich men who
are good, wise, kind, and virtuous—and those who are so, deserve
great praise, for, as a class, the rich are otherwise; and the reasons
are plain. In the first place, most men who become rich, do so by
being supremely selfish. They keep what they get, and get what they
can. A man who has no generosity, who seldom or never gives away
anything, who is greedily seeking all the time to increase his
possessions, is almost sure, in a few years, to accumulate large
stores. Such a man may be very stupid in intellect, and yet
successful in getting rich. Riches are no proof of wisdom, but they
are generally evidence of selfishness.
A man, by cultivating any passion, increases it. An avaricious
man, indulging his avarice, grows more and more so. He not only
becomes more greedy, but less regardful of the rights, feelings, and
interests of his fellow-men. Thus, as a man increases in riches, he
usually becomes vicious and depraved. His vices may not be open—
he may not break the laws of the land, but he breaks the laws of
conscience, and of God. There is hardly a spectacle more revolting
to the eye of virtue, then the bosom of the rich and avaricious man. It
is a machine, which grinds in its relentless wheels the limbs, the
bowels, the nerves, the hearts of such among his fellow-men as fall
within his grasp. He is a kind of moral cannibal, who feasts and
grows fat, not on the bodies of his species, but on their peace and
happiness.
M. You are severe.
R. But I hope not unjust: remember that Christ forgave the thief on
the cross, but declared that it was easier for a camel to pass through
the eye of a needle, than for a rich man to enter the kingdom of
heaven. He knew by what means men generally grow rich; he knew
the effect of riches on the heart; and, as a class, he denounces the
rich, as in the view of Heaven among the least favored of mankind.
They have their good things in this world, but a fearful penalty is
attached to the abuse of these good things—an abuse which is but
too tempting and too common.
But the only evil of wealth lies not in the danger which it threatens
to the future welfare of the soul; it is very apt to destroy or prevent
some of the sweetest pleasures of this life. Humility is the source of
more true happiness than wealth. A rich man may possess humility,
though he is more likely to be proud; poverty, disappointment,
sorrow, and misfortune, are the great producers of humility: and it
often happens that God, in taking away wealth and worldly
prosperity, and giving humility in return, greatly increases a person’s
true wealth and genuine peace. It is thus that he often deals with
those he loves. He thinks that a man may well afford to part with his
wealth, if he parts with pride at the same time, and obtains humility
as a reward; and surely he knows what is best for us.
Nor is peace of mind the only effect of humility. It not only wakes
up the heart of man to many kindly exercises of charity to his fellow-
men, but it clears his mind and his intellect, so that it is brighter and
stronger. Pride dims, dulls, and cheats the mind; the judgment of a
proud man is seldom good. Not only does pride beget meanness of
soul, but meanness of intellect. Greatness of mind, as well as of
soul, is usually associated with humility. For this reason it is, that you
find among the poor, who are usually humble, more true greatness of
both mind and heart, than among the rich; and it is thus that we see
the fact explained, which I have before stated, that for almost all the
great religious, benevolent, and social progress of the world, we are
indebted to the wisdom, charity, disinterestedness, and patriotism of
the poor.
M. Is it then a sin to be rich, or a virtue to be poor?
R. Certainly not: there is no virtue or vice in either poverty or
wealth. All I say is this, the usual means taken to get riches are
supreme selfishness or craft, or uncommon want of principle; and
riches, when once obtained, tend to corrupt and degrade the heart,
and stultify the mind. While, therefore, we admit that a rich man may
be wise and virtuous, still, as a class, the rich are the least to be
respected and trusted. We are borne out in this view by the

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Peggy E. Hayes, PharmD

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e26.  ritical Care: Considerations in Medication

Margaret A. Miklich and Mojdeh S. Heavner

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Section Editors: L. Michael Posey and Thomas D. Nolin

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e26. ritical Care: Considerations in Medication

32. Dyslipidemia�� 121

e81. Evaluation of Psychiatric Illness��1001 99. Pregnancy and Lactation��1291

117. Acne Vulgaris��1611

TABLE 1-4 Medication Therapy Problem Categories