# Pharmacy practice

Welcome to the Wikiversity Introduction to Pharmacy practice module Joel Lamoure 14:54, 24 December 2006 (UTC)

## Learning

To learn the overview of Pharmaceutical care in accordance with current observations with the underlying premise of the patients basic Bill of "Rights". That is for the practitioner to get the right drug to the right patient at the right time for the right condition with a a minimum of adverse effects.

## Pharmacy Practice,Patient Care and Drug Related Problems

Joel Lamoure 14:22, 24 December 2006 (UTC)
Joel Lamoure RPh., B.Sc.Phm., FASCP
Assistant Professor, Department of Psychiatry University of Western Ontario
Teaching Associate,Faculty of Pharmacy University of Toronto
Mental Health Pharmacist, London Health Sciences Centre, South St Hospital
"I, Joel Lamoure, am the author of this article, Pharmacy Practice and I release its content under the terms of the GNU Free Documentation License, Version 1.2 and later."\heloopppppp

## Introduction

Pharmaceutical care is a methodology of working with patients and their caregivers and their medication(s) including herbals and over the counter agents and the providers there of. It is a concept that deals with the way patients, their families , healthcare providers, should receive and use medication, information about medication and instructions for use. Pharmaceutical care encompasses information, assimilation of data and interpretation of the data using best possible medication histories to get the right drug to the right patient at the right time for the right condition with a minimum of adverse effects. One point to take into consideration when working with patients is that they experience not only a DISEASE but a DIS-EASE. Thus we have a physical and physioogical component to every patient and diagnosis. This also impact as to why no 2 patients' course of disease remains the same.
Hepler and Strand, in the 1980’s, developed a new definition in which the patient’s position in the triad of patient, physician and pharmacist receives even more emphasis. Pharmaceutical Care is that component of pharmacy practice which entails the direct interaction of the pharmacist with the patient for the purpose of caring for that patient's drug-related needs In 1997, Strand redefined pharmaceutical care as: “A practice for which the practitioner takes responsibility for a patients drug therapy needs and is held accountable for this commitment.”

## Classification of Drug Related Problems

Why Pharmaceutical Care?
a. A minimum of 1-4% of new prescriptions in pharmacy will have a problem. Incidence of an ADR depends on the situation, but may account for 1/5 patients on a general medicine unit in a teaching hospital
b. These problems or Drug Related Problems are categorized into one of eight possibilities, although the patient may experience multiple DRP’s with 1 medication.
c. There is a new approach since 2004 that looks not at the drug itself but at the underlying DISEASE. That the condition is impacted or a condition is impacted real or potentially with the introduction or use of a drug. The number of DRP’s in this case is reduced to 7.
However, as pharmacy students (refernecing the University of Toronto Faculty of Pharmacy) at the Faculty of Pharmacy whom graduate before the class of 2008 , that the Drug is central to the DRP remains the cornerstone of approach between 1989 to date. As such, the DRP’s we will focus on will be the DRUG-focused DRP versus the ones by Strand and Cipolle. If anyone has an interest in this new approach, the text is called Pharmaceutical Care Practice: The Clinicians Guide by Robert J. Cipolle, Linda M. Strand, Peter C. Morley (Authors) May 2004 ISBN 0071362592
Drug Related Problems Encountered in the Provision of Pharmaceutical Care
1-The patient has an undesirable sign or symptom because they are taking a drug for which there is no valid indication Examples here might include the use of an acute agent for an extended length of time. Also, where a patient uses a societal or recreational substance such as marijuana, alcohol or tobacco. Also for example patients are using a drug where non-drug options would be indicated
2-Patient has undesirable sign/symptom because they need drug therapy but are not receiving Patients in this case are in need of therapy as a result of a disease or disorder or adverse effect but are not receiving appropriate medication management. The condition that they have may not yet be diagnosed or is diagnosed but not receiving adequate and appropriate pharmacological management. Also, this includes medications where additional medications may be needed for synergistic effect to treat the condition, or preventative therapies.
3-Patient not taking appropriate drug or drug product This is a large consideration in the mental health population. The major reasons that people do not take their medications are due to cost, stigma or adverse effects. The current drug is not the most cost effective for this patient, such as patient non-compliant but may need a depot injection.
4-Patient has undesirable sign/symptom from taking/ receiving too little drug In this instance, there is a resumption of the underlying disease or condition as the dose is inappropriate, frequency/ timing inappropriate or there is a drug- disease interaction. There may be ADME mediated mechanisms at play here for example enzymatic induction of the Cytochrome P450 system secondary to the patient smoking or co-ingestion of another agent.
5-Patient has undesirable sign/symptom because they are taking/ receiving too much drug In this instance, there is an adverse effect or toxicity as the dose is inappropriate, frequency/ timing inappropriate or there is a drug- disease interaction. There may be ADME mediated mechanisms at play here for example enzymatic inhibition of the Cytochrome P450 system secondary co-ingestion of another agent. Also, a medication that is renally excreted may build up due to reduced renal issues (medications, age, disease).
6-Patient has undesirable sign/ symptom because not taking/ receiving prescribe drugs appropriately Patients may experience economic restraints, administration or distribution error or non-compliance. This is of particular importance and concern with patients taking medications for mental health. Patients receiving antipsychotics took an average of 58 percent (range 24-90%) of prescribed medications with a varying degree of intervals which may not make this study portable to ADHD specifically. In patients with a variety of physical disorders was 60-92% compliance with a mean of 76%. Compliance With Medication Regimens for Mental and Physical Disorders -- Cramer and Rosenheck 49 (2): 196 -- Psychiatr Serv
7-Patient has undesirable sign/symptom because experiencing adverse drug reaction (non-dose related) The patients may be experiencing an effect to be associated with the medication either in idiosyncratic manner or via extension of pharmacological effect These patients may be Type a or Type B. Type A is an anticipated reaction and a direct extension of the medication whereas Type B or bizarre reactions may be immunological in nature (e.g. penicllin anaphylaxis)
8-Patient experiencing undesirable sign/ symptom because experiencing drug-drug, drug-food or drug-lab interaction
These reactions encompass drug-food reactions that cause the medications to become less effective (calcium salts and quinolones) or more potent (grapefruit juice and calcium channel blockers). As well, there are some drug-lab interactions, especially seen with illicit substance making agents such as finasteride or epitestosterone, dextran , diuretics or probenicid.Types of prohibited drugs

## Goals of Pharmaceutical Care

1. Pharmacist as a provider – To move beyond the premises of a product and extend the clinical knowledge to the delivery of a clinical service. This does not mean that counseling itself is pharmaceutical care, but a part of the general approach. Although to counsel the patient or caregiver is essential and required by Provincial Colleges, an overview of the patient and appropriateness of the medication must be employed. This includes knowledge of or access to references that provides information such as interactions, compatibilities (drug and disease) as well as absorption, distribution, metabolism and excretion.
2. Role of the pharmacist- Will be determined by the practice, but it keeps the patient or caregiver in the centre of the triad using the pharmacists’ drug and clinical knowledge to maximize the outcomes. This mainly shifts focus from a reactive role to a proactive team based patient-centered clinical methods model. Ideally, there will be overlap between treating teams within the circle of care to maximize patient outcomes and improve patients quality of life.
3. Responsibilities of the pharmacist- To practice pharmaceutical care by reviewing and analyzing the patient‘s medication regimens to identify and solve within the team approach solutions to the identified problems. As well, after the solution has been mutually reached, the requirement exists to monitor outcomes by example through compliance monitoring which is poor in mental health conditions.

## Section references

* United Kingdom Psychiatric Pharmacy Group (UKPPG) www.ukppg.org.uk/
* J. Rovers et al.: A Practical Guide to Pharmaceutical Care Am. Pharm. Assoc. 1998 ISBN 9780917330902
* University of Toronto Faculty of Pharmacy Teaching Associate Program 2003 Updates pp 22-24
* University of Toronto Structured Practical Experience Program Update November 3 2006
* The Peters Institute of Pharmaceutical Care http://www.pharmacy.umn.edu/centers/peters/about/home.html
* Strand LM, Cipolle RJ. Challenges for pharmaceutical care. Am J Hosp Pharm 1993 Aug;50:1618-21.
* Strand LM, Cipolle RJ, Morley PC, Perrier DG. Levels of pharmaceutical care: needs based approach. Am J Hosp Pharm 1991 Mar;48:547-50
* Pharmaceutical Care Practice : The Clinician's Guide (ISBN 0071362592) Robert J. Cipolle; Linda M. Strand; Peter C. Morley May 2004
* http://pharmpractice.uonbi.ac.ke/