In patient pharmacy service

Therapeutic drug monitoring

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 In patient pharmacy services
Drug distribution services
I.V admixtures and TPN
Drug therapy monitoring

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CONCEPT OF THERAPEUTIC DRUG MONITORING (TDM)

 TDM is based on the principle that for some drugs

there is a close relationship between the plasma level
of the drug and its clinical effect.
 If such a relationship does not exit TDM is of little
value.
 The measurement of plasma level is justified only
when the information provided is of potential
therapeutic benefit.

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Drug therapy monitoring (DTM)
Basic subfunctions:
1.Clinical data collection
2.Evaluation of drug action (cause-effect
relationship)
3.Communication of information

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 1- clinical data collection
 First step to drug monitoring
1- Patient characteristics
obtained from patient interviews, patient observations and review of
clinical chart
 age, sex, weight, race, occupation, national origin
 Blood pressure, pulse, temp.
 drug and food allergies
 Food patterns or dietary habits
 Beverage habits
 Nicotine patterns (no. Of cig./day)
 Physical disability (hearing, sight, arthritic...etc)
 History of anemia, headache, or signs related to drug side effects
 Primary and secondary diagnosis (when signs and symptoms are
available)
 Length of time patient on drug being monitored and compliance
 Patient’s knowledge level of drug expected effects and side effects

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 Drug Therapy Monitoring
 Clinical data collection
2- Basic characteristics of drugs
a. Level of allergic potential
b. Cummulative properties
c. Patterns of resistance
d. Known teratogenic effects
e. Hepatotoxic properties
f. Nephrotoxic prop.
g. Ototoxic properties (streptomycin)
h. Oculotoxic properties.
i. Time req. For onset of action
j. Half life
k. Rate of metabolism
l. Rate of excretion
m. Target effect of drug on cells, organ and system
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 Clinical data collection
3- Review of initial drug order:
prescribed drug, time of order, time of first dose
4- Drug dosage strength:
method of dose calc., dose alteration, lab data
5- Route of drug administration:
e.g. I.V fluids, diluent used, injection site
6- Drug dosage schedule:
In drug-drug interaction, or drug-food interaction.. Dose
spacing suggested
7- Drug maintenance patterns:
according to lab. Test, renewal orders
8- Directions for use:
e.g. Do not give medication if bp falls below 100/70
e.g. Give aspirin only if temp rises above 39 ºC
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Drug therapy monitoring
1. Clinical data collection
2. Evaluation of drug action
a- drug effectiveness
onset of drug action should be mentioned on
different chart forms: e.g. T-P-R (temp., pulse and
respiration) sheet, diabetic record, vital signs record,
lab results ....etc
b-documented side effects
e.g. On CVS (cardiovascular system), CNS (central
nervous system) or RS (respiratory s) or GIT. In
progress sheet, consultant sheet, nurse’s note or
pharmacist’s note.
c-drug interaction detection

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Drug therapy monitoring
1. Clinical data collection
2. Evaluation of drug action
3. Communication:
A- Monitoring of drug therapy by pharmacist
Pharmacist should be given the responsibility
and authority to interview patients, review
charts, advise patient, consult with other
members of health care team and make
documentation

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 Drug therapy monitoring (DTM)
 Communication
2- Need for DTM
 Patients on 8 different medications (up to 20)
 Modified drug response (dynamic and pharmacokinetics) due
to pathological and physiological changes in patient
including:
1) Decreased hepatic and renal function
2) Alteration in body lean muscle mass and fat
3) Alteration in blood flow to vital organs
4) Decreased protein binding of drugs
 Incidence of ADRs (adverse drug reactions) increased from
24-67% with age and multiple drug use
 Drugs that mostly cause ADRs include, diuretics,
antihypertensives, antiparkinsonian and psychotropic agents.

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TDM is unnecessary when

1) Clinical outcome is unrelated either to dose or to plasma

concentration
2) dosage need not be individualized
3) the pharmacological effects can be clinically quantified
4) when concentration effect relationship remains unestablished,
5) drugs with wide therapeutic range such as beta blockers and
calcium channel blockers.

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 The process of drug therapy monitoring
 It is necessary to monitor patients with high risk of
developing drug-induced problems:
1. Pediatric patients
2. Elderly patients
3. Patients taking potent medications with narrow
therapeutic index
4. Patients with heart disease, renal failure, liver failure
and chronic lung disease
5. Patients taking high toxicity medications e.g.
Aminoglycosides, antiarrhythmics, anticonvulsants,
antineoplastics, theophylline, anticoagulants and
lithium
6. Cancer patients

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 Patient’s medical record
 Source of info. About patient’s past and present medical
status.
 Data bank providing the basis for health care professionals
review and assessment of drug therapy
 Written by any of health care team (physician, nurse,
therapist, clinical pharmacist or dietician)
 It includes:
1. Admission record
2. History and physical examination
3. Physicians orders and progress notes
4. Nurse’s notes
5. Lab. Tests and results
6. Medication administration record
7. Graphics section on patients data sheets
8. Patient’s plan

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 Step guidelines of drug therapy monitoring
 Step I: Identifying the reason for patient admission
 Step II: Reviewing patient’s social and medical history
 Step III: assessing diagnostic test results
 Step IV: compiling patient’s current list of medications,
treatment and diet
 Step V: Drug and/ or disease monitoring parameters
 Step VI: Preparing patient’s problem list
 Step VII: Matching diagnosis with medications
 Step VIII: Evaluating drug therapy and documenting
finidings
 Step IX: Communicating review findings and follow-up.

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