Clinical Pharmacy (Introduction )

Core Definition: Clinical pharmacy comprises functions that promote the safe, effective, and economic use of medicines for individual patients. It shifts the focus from product-oriented roles to direct patient engagement.

1. Fundamental Concepts

Pharmaceutical Care: A cooperative, patient-centered system for achieving specific and positive patient outcomes from the responsible provision of medicines. The three key elements are:

  • Patient Assessment
  • Determining the Care Plan
  • Evaluating the Outcome

Medicines Management: Encompasses the selection, procurement, delivery, prescribing, administration, and review of medicines to optimize patient care outcomes.

2. The Drug Use Process (DUP) Indicators

DUP Stage Action
Need for a drug Ensure appropriate indication and therapeutic address of all medical problems.
Select drug Recommend the most appropriate drug based on goals, patient variables, formulary, and cost.
Select regimen Choose the best regimen for goals at least cost without toxicity.
Provide drug Facilitate accurate, timely dispensing in ready-to-administer form.
Drug administration Ensure appropriate devices and techniques are used.
Monitor drug therapy Monitor for effectiveness or adverse effects to maintain, modify, or discontinue.
Counsel patient / Evaluate effectiveness Educate patient/caregiver and review previous steps to ensure goals are achieved.

3. Medication-Related Problems (MRPs)

When outcomes are not optimal, they often fall into these categories:

  • Untreated indication
  • Treatment without indication
  • Improper drug selection
  • Too little drug / Too much drug
  • Non-compliance
  • Adverse drug reaction (ADR)
  • Drug interaction

4. Pharmaceutical Consultation Process

Effective consultation requires a therapeutic relationship and a patient-centered approach. It moves beyond simple mnemonics to a four-phase process:

Phase Goal
Introduction Building a therapeutic relationship; negotiating a shared agenda.
Data Collection Identifying patient needs, medication history, and understanding of illness.
Actions & Solutions Establishing an acceptable management plan; involving the patient in decisions.
Closure Negotiating safety netting strategies and follow-up points.

Traditional Mnemonics

  • WWHAM: Who is it for? What symptoms? How long? Action taken? Medicines taken?
  • AS METTHOD: Age? Self? Medicines? Exactly what symptoms? Time/Duration? Taken action? History? Other symptoms? Doing anything to worsen/alleviate?

5. Steps in Delivering Pharmaceutical Care

Step 1: Establishing the Need

Includes gathering relevant patient details (Age, Gender, Ethnicity, Social history, Working diagnosis, Lab findings) and a complete Medication History.

Step 2: Selecting the Medicine

Identify interactions: Drug-Patient (e.g., allergies, organ function), Drug-Disease (e.g., drug making a condition worse), and Drug-Drug (e.g., enzyme induction/inhibition).

Step 3: Administering the Medicine

Focuses on dose calculations, preferred routes (oral vs. parenteral), and suitable dosage forms.

Step 4: Providing the Medicine

Ensuring legal, legible prescriptions and accurate labeling tailored to patient needs (e.g., large print for visually impaired).

Step 5: Monitoring Therapy

Close scrutiny for drugs with narrow therapeutic indices (e.g., Digoxin, Warfarin, Phenytoin).

Step 6 & 7: Advice and Evaluation

Providing tailored information and reviewing progress against intended outcomes.

Case Study: Case 1.1 (Mr JB)

Patient Profile: Mr JB, 67-year-old retired plumber.
PMH: Coronary Heart Disease (CHD), recent coronary artery stent.
Co-morbidity: Long history of asthma (well controlled).

Step 1. Establishing the need for drug therapy

Mr JB takes his medicines as prescribed, has no allergies, but suffers from dyspepsia associated with NSAIDs. Lab tests show normal blood chemistry and liver function.

Step 2. Selecting the medicine (Potential Interactions)

Drug-patient interactions Drug-disease interactions Drug-drug interactions
History of dyspepsia (Aspirin/Clopidogrel risk) Aspirin caution in asthma Antiplatelet combo increases bleeding risk
Nitrate side effects (headache/flushing) Beta-blocker contraindicated in asthma Simvastatin + Diltiazem = Myopathy risk
Inhaler technique ability B2-Agonists/Antimuscarinics can cause tachycardia Antimuscarinics may reduce effect of sublingual nitrates (dry mouth)

Steps 3 and 4. Recommendations

Recommendation Rationale
Aspirin 75mg daily + Clopidogrel 75mg daily Benefit outweighs risk if used with PPI for stent protection.
Lansoprazole 15mg daily Decreases risk of GI bleeds with combination antiplatelets.
Simvastatin 20mg daily Low dose selected due to diltiazem reducing its metabolism.
Diltiazem 90mg twice a day Used for rate control as Beta-blockers are contraindicated in asthma.
Ramipril 10mg daily To reduce progression of CHD and heart failure.

Steps 5, 6, and 7. Monitoring & Advice

  • Aspirin/Clopidogrel: Ask about dyspepsia or worsening asthma.
  • Simvastatin: Liver function tests at 3 months; monitor for unexplained muscle pain.
  • Diltiazem: Monitor blood pressure and pulse regularly.
  • Salbutamol: Monitor frequency of use; increase may indicate need for higher steroid dose.