PRACTICE OF

PHARMACY

Prepared by: Jelly mae t. Oviedo, rpH

 Clinical Pharmacy

- branch of pharmacy where the pharmacist provides patient care that optimizes the use
of medications and promotes health, wellness and disease prevention.
Clinical pharmacist
• Interact with the health care team
• Interview and assess the patient information
• Design and implement a therapeutic plan
• Make therapeutic recommendation
• Monitor Patient’s response to therapy
• Provide drug information
Pharmaceutical care
- is the responsible provision of drug therapy for the purpose of achieving definite
outcomes that improve a patient’s QOL
-A patient-centered practice
Major Functions of Pharmaceutical Care:
• Identifying potential and actual drug-related problems
• Resolving actual drug-related problems
• Preventing potential drug-related problems
Pharmaceutical care
Expected Outcomes:
• Cure a disease
• Elimination or reduction of patient’s symptoms
• Arresting or slowing the disease process
• Preventing disease and symptoms
Parts of a Prescription
 Incorrect Prescription (DOH AO no. 62)
Erroneous:
• BN preceded GN ex. (Lipitor) Atorvastatin
• GN is in parenthesis ex. (Atorvastatin) Lipitor
• BN is not in parenthesis ex. Atorvastatin Lipitor
Violative
• GN is not written
• BN is written, GN is not written legibly
• Terms that hinder Generic dispensing
Impossible
• Only GN is written (not legible)
• GN does not correspond to the BN
• Both GN and BN are written, but not legible
Note:
• Erroneous prescription should be filled, kept and reported to nearest DOH.
• Violative and Impossible prescriptions should not be filled but kept, and
reported to the nearest DOH
• In Violative and Impossible prescriptions, ask the patient to return to
prescriber to get proper prescription.
 Evidenced-based Medicine (EBM)

-The conscientious, explicit and judicious use of current best evidence in

making decisions about the care of the individual patient.
Heirarchy of Evidence:
• Systematic Reviews
• Randomized Clinical Trials
• Non-Randomized Trials
• Observational Studies
• Expert Opinions
Drug Information sources:
Primary Source
• Provide the most current information
• Ex. Journal Articles
Secondary Source
• For quick and selective screening of the primary literature
• Ex. Abstracting and Indexing Services
Tertiary Sources
• Provide easy and convenient access: information may be outdated
• Ex. Textbooks
 DRUG DEVELOPMENT
Pre-Clinical Stage Animal Studies

Assess safety in healthy human volunteers

Phase 1 (Screening for Safety)
(20-100)

Evaluate effectiveness of drugs in patients with disease or

condition
II-a Identification of doses
Phase 2 (Establishing the Test Protocol) II-b Assess efficacy
(100-300)
-Double Blinded Randomized Clinical Trials

Large-scale multicenter clinical studies

-Confirmation of doses
-Expanded tolerability profile
Phase 3 (Final Testing)
Benefit-risk ration
(100-3000)
-Double Blinded Randomized Clinical Trials

Phase 4 (Post Marketing) Post-marketing studies

-Detect previously unknown AE and DI
 PHARMACOEPIDEMIOLOGY STUDY DESIGN

• - study of use and effects of drugs in a large population

Case Report
- About a single case or a series of related cases
Cross- sectional Study
- Prevalence studies
- Survey the population at single point in time
Case-control Study
- Retrospective Study
- Observational study
- Samples chosen based on presence or absence of cases
- Information recollected about risk factors
- Advantage: Inexpensive
- Disadvantage: Recall bias
Cohort Study
• Prospective or Retrospective follow up Study
• Observational study
• Samples chosen based on presence or absence of risk factors
• Subjects are followed over time for development of disease
• Advantage: Inexpensive
• Disadvantage: Recall bias
Randomized Controlled Clinical Trial
• Gold Standard in assessing effects of drugs
• Experimental Study Design-intervention
• Randomization
• Advantages: Decreases/ reduces bias Disadvantages: Expensive, time-consuming
• Eliminates confounding factors Ethical considerations
 Clinical Pharmacy Services

Patient Record/ Databases

1. Medical History
General Patient Information- name, sex, etc.
Chief complaint (CC)- reason for seeking medical care
History of Present Illness (HPI)- narrative that describes the patient’s current medical problem
Past Medical History (PMH)- brief description of current and previous medical conditions that
may or may not be related to present illness
Personal/ Social History/ Lifestyle – diet, use of tobacco, alcohol drinking habits, illicit drugs
Family Medical History (FMH)- medical history of the patient’s first degree relative
Medication History- current and past medication, OTC drugs, ADR, compliance
Review of System- Patient’s complaint not included in the HPI
 Pharmacogenomics Studies

• -comparing value of drug or therapy with another

1. Cost of Illness (COI)- measure of cost attribute to a specific disease
• Direct Medical Costs- related to the therapy ex. Drug, insulin, syringe
• Indirect Medical Costs- not related to the therapy ex. Fare, loss in productivity
• Direct Non-medical Costs- ex. Salary of the health care professional

2. Cost Benefit Analysis (CBA)- identify and measure all the costs in providing treatment and comparing with the benefits to the
result.
3. Cost Minimization Analysis (CMA)- compare two or more treatment with the same therapeutic oiutcome, / look for the
treatment with the lowest possible cost

4. Cost Utility Analysis (CUA)- assess the perceived mental, physical and general functioning of the patrient / Integrates
patient’s QALY (physical, social and emotional aspect of patient’s well-being)
Ex. Chronic diseases- maintenance (Integrates patient preference in health related decisions
Therapeutic Drug Monitoring

• Encompasses the measurement of serum drug levels and the

application of clinical pharmacokinetics to improve patient care.
• Determination of plasma concentration of drugs to adjust therapy
• Optimizes individual drug therapy
• Maintain the drug concentration in the blood
• Trough Level- lowest drug level in the body
• Peak Level- highest drug level in the body
 Patient Medication Counselling

• QUESTIONS:
Close –narrow
-used when direct answer is needed
-answerable by Yes or No
-decreased quality and quantity of information
-decreased opportunity to develop rapport with the patient
Open – wide-ranging
-not directly answerable by Yes or No
- increased quality and quantity of information
-can develop rapport, assess disposition of the patient
Leading- usually closed
• -contqain their own answer
• -imply judgement on the patient
• Not fruitful
• Must be avoided
Double or Multiple
• -presents the patient with two or more inquiries at the same time
• -traps the patient in a barriage of questions
• -patients get confused, irritated
Preventive Model:
• Primary Level of Prevention
• - is concerned to prevent onset of disease and reduce incidence
• Secondary Level of Prevention
• -is concerned to prevent development of existing disease, minimize its severity, reverse its progress
and reduce prevalence
• Tertiary Level of Prevention
• -is concerned to prevent deterioration, relapse, and complications, promote rehabilitation and help
adjust to terminal conditions
 HOSPITAL PHARMACY

• -is an organized structure which pools together all the health professionals, the diagnostic and
therapeutic facilities, equipment and delivering health care to the public
• Jonathan Roberts – Father of Hospital Pharmacy

Functions:
• Patient care(pay or charity)
• Education
• Research
• Public Health
• Classifications:
A. Type of Service
General
• patient with any type of illness
• Atleast 6-bed capacity for 24 hours admission
Special
• Address special condition
• With specialized clinical services
• Ex. San Lazaro – Infectious diseases
• Heart center- cardiovascular cases
• NICI- renal and neurologic cases
Long Term Health Care Facility
• Continuous nursing services
• Medical care to individuals needing long term healthcare
• Resident Treatment Facility
• Regular and emergency health services and supportive services
Integrated Heath Care
• Hospitals merged with other hospitals and other patient care services like home health
care, long term and wellness facilities
Clinic
• Facility or area where ambulatory patients are seen for special study, appointments and
treatment by a group of physcians practicing together, and where the patient is not
confined in the hospital
B. Length of Stay:
• Short term- less than 30 days
• Long term- more than 30 days
C. Ownership
• Governmental
• Non-governmental
D. Bed Capacity
• By 50’s
• E. Levels of Services
1. Primary
• Primary medical use
• For providing emergency care and hospitalization in simple cases
2. Secondary
• Primary level with surgical care or specialization
• Experties of physicians with not less than 6 months training
• Departmentalized
• Tertiary
• Secondary level with sub specialization
• Teaching hospital
• Tertiary Level 1- for cases requiring sophisticated diagnostic
• Tertiary Level 2- has training and research capabilities/ provides residency training programs
• Tertiary Level 3- with teaching , training, and research functions
• Tertiary Level 4- expensive and sophisticated diagnostic
• Provincial- Provides tertiary level 1
• Regional- Provides tertiary level 2
• Medical Center- Provides tertiary level 3
• District- front-line hospital: secondary medical care
 DIAGNOSTIC LABORATORY
EXAMINATION

• Creatinine kinase (CK)

• CK-MM- Skeletal muscles
• CK-MB- Heart
• CK-BB- Brain
- Aid in the diagnosis of myocardial or skeletal muscle damage
 DIAGNOSTIC LABORATORY
EXAMINATION

• Lactate Dehydrogenase
• LDH1 and LDH2- Heart
• LDH3 – Lungs
• LDH-4 and LDH5- Liver and skeletal muscles

- Aid in diagnosing MI, hepatic disease, and lung disease

 DIAGNOSTIC LABORATORY
EXAMINATION

• Akaline phosphatase (ALP)

• IF increased, biliary obstruction, Paget’s disease, osteomalacia,
hyperparathyroidism
 DIAGNOSTIC LABORATORY EXAMINATION

• Alanine aminotransferase (ALT)

• AKA Serum Glutamic-Pyruvic Transaminase (SGPT)
• Relatively specific for liver cells
• If increased, there is acute myocardial Infarction

• Aspartate aminotransferase (AST)

• AKA Serum Glutamic-oxaloacetic transaminase (SGOT)
• If increased, there is acute hepatitis
• If super increased, there is liver cirrhosis and fatty liver
 DIAGNOSTIC LABORATORY
EXAMINATION
• Cardiac Troponins
• Troponin T: Cardiac and skeletal muscle
• Troponin I: Cardiac muscles
• Troponin C: Skeletal and cardiac muscles

• - Diagnosis of MI
 COMMON RENAL FUNCTIONS

• Blood Urea Nitrogen (BUN)

• End product of protein metabolism
• If increased, there is renal disease
• If decreased, there is liver disease

• Creatinine
• Metabolic breakdown product of muscle creatine phosphatase
• If increased, there is renal failure
 COMMON RENAL FUNCTIONS

• Creatinine Clearance
• The rate at which creatinine is removed from the blood by the kidneys
• Normal Creatinine clearance is 80-120mL/ min
• If decreased, there is renal failure

• Remember the Formula?

 Electrolytes

• Sodium
• If increased, hypertension
• Potassium
• If increased, renal dysfunction
• If increased, muscle weakness
• Chloride
• If increased, there is acute renal failure, renal tubular acidosis, primary
hyperparathyroidism, dehydration
• If decreased, there is chronic renal failure, adrenal insufficiency
 Minerals

• Calcium
• If increased, hyperparathyroidism, caused by increased diuretic use (Thiazide)
• If decreased, PTH or Vitamin D deficiency, caused by increased diuretic use (Loop)and osteoporosis
• Magnesium
• If increased, there is Addison’s disease
• If decreased, caused by severe diarrhea, hyperaldosteronism, and diuretic use
• Phosphate
• If increased, there is renal dysfunction, increased vitamin D intake
• If decreased, there is insufficient vitamin D intake
Vitamin and Mineral Deficiencies

Calcium Osteoprosis
Iron Anemia
Potassium Hypokalemia
Zinc Parakeratosis
Vitamin C Scurvy
Vitamin D Rickets
Vitamin B1 Beriberi
Vitamin B3 Pellagra
 Drugs to avoid in Pregnancy

• Sulfonamides
• Kernicterus (bilirubin in CNS)
• Aminoglycosides (Ototoxicity, damage to CN 8
• Fluoroquinolones
• Abnormal cartilage development
• Tetracyclines
• Discolored teeth
• Chloramphenicol
• Gray Baby Syndrome
 Drugs to avoid in Pregnancy

• Thalidomide
• Phocomelia (short)
• Amelia (None)
• Meromelia (Fused)
• Ace Inhibitors
• Renal dysgenesis
• Phenytoin
• Fetal hydantoin syndrome
 Drugs to avoid in Pregnancy

• Lithium
• Ebstein Anomaly
• NSAIDS
• Premature Closing of the PDA (Patent Ductus Arteriosus
• Decreased PGE, maintains the patency of ductus arteriosus
• Diethylstilbestrol
• Vaginal adenocarcinoma upon adolescence