Clinical Pharmacy Clinical Pharmacy ServicesServices

Prepared by :Prepared by :

Nehad AhmedNehad Ahmed

What is Clinical Pharmacy?What is Clinical Pharmacy?

• Clinical Pharmacy is a commonly used Clinical Pharmacy is a commonly used term in pharmacy practice and in term in pharmacy practice and in pharmacy literature.   It is a health pharmacy literature.   It is a health specialty, which describes the activities specialty, which describes the activities and services of the clinical pharmacist to and services of the clinical pharmacist to develop and promote the rational and develop and promote the rational and appropriate use of medicinal products and appropriate use of medicinal products and devices. devices.

• Clinical Pharmacy includes all the services Clinical Pharmacy includes all the services performed by pharmacists practising in performed by pharmacists practising in hospitals, community pharmacies, nursing hospitals, community pharmacies, nursing homes, home-based care services, clinics homes, home-based care services, clinics and any other setting where medicines are and any other setting where medicines are prescribed and used.prescribed and used.

• The term “clinical” does not necessarily The term “clinical” does not necessarily imply an activity implemented in a imply an activity implemented in a hospital setting. A community pharmacist hospital setting. A community pharmacist may perform clinical activities as well as a may perform clinical activities as well as a hospital practitioner. hospital practitioner.

How does clinical pharmacy differ from pharmacy? How does clinical pharmacy differ from pharmacy? • the discipline of pharmacy embraces the the discipline of pharmacy embraces the

knowledge on synthesis, chemistry and knowledge on synthesis, chemistry and preparation of drugs preparation of drugs

• clinical pharmacy is more oriented to the clinical pharmacy is more oriented to the analysis of population needs with regards to analysis of population needs with regards to medicines, ways of administration, patterns of medicines, ways of administration, patterns of use and drugs effects on the patients.use and drugs effects on the patients.

The focus of attention moves from the drug to the The focus of attention moves from the drug to the

single patient or population receiving drugs single patient or population receiving drugs

Pharmaceutical CarePharmaceutical Care

Pharmaceutical care is the responsible Pharmaceutical care is the responsible provision of drug therapy for the purpose of provision of drug therapy for the purpose of achieving definite outcomes that improve a achieving definite outcomes that improve a patient's quality of life. these outcomes are:patient's quality of life. these outcomes are:

• Cure of diseaseCure of disease

• Elimination or reduction of a patient's Elimination or reduction of a patient's symptomatologysymptomatology

• Arresting or slowing of a disease processArresting or slowing of a disease process

• Preventing a disease or symptomatology.Preventing a disease or symptomatology.

Clinical Pharmacy - Overall Clinical Pharmacy - Overall Goal            Goal            

The overall goal of clinical pharmacy activities is to The overall goal of clinical pharmacy activities is to promote the correct and appropriate use of promote the correct and appropriate use of medicinal products and devices. These activities medicinal products and devices. These activities aim at: aim at:

• maximising the clinical effect of medicines, i.e., maximising the clinical effect of medicines, i.e., using the most effective treatment for each type of using the most effective treatment for each type of patientpatient

• minimising the risk of treatment-induced adverse minimising the risk of treatment-induced adverse

events, i.e., monitoring the therapy course and the events, i.e., monitoring the therapy course and the patient’s compliance with therapy patient’s compliance with therapy

• minimising the expenditures for minimising the expenditures for pharmacological treatments born by the pharmacological treatments born by the national health systems and by the national health systems and by the patients, i.e., trying to provide the best patients, i.e., trying to provide the best treatment alternative for the greatest treatment alternative for the greatest number of patients.number of patients.

Clinical Pharmacy Clinical Pharmacy RequirementsRequirements

For patient care clinical pharmacy should For patient care clinical pharmacy should have :have :

• Knowledge of drug therapyKnowledge of drug therapy• Knowledge of the diseaseKnowledge of the disease• Knowledge of laboratory and diagnostic Knowledge of laboratory and diagnostic

skillsskills• Communication skillsCommunication skills

• Patient monitoring skillsPatient monitoring skills

• Physical assessment skillsPhysical assessment skills

• Drug Information SkillsDrug Information Skills

• Therapeutic Planning skillsTherapeutic Planning skills

• Knowledge of non-drug therapyKnowledge of non-drug therapy

Level of Action of Clinical Level of Action of Clinical PharmacistsPharmacists

• Clinical pharmacy activities may influence Clinical pharmacy activities may influence the correct use of medicines at three the correct use of medicines at three different levels: before, during and after the different levels: before, during and after the prescription is written.prescription is written.

• 1. Before the prescription 1. Before the prescription

• Clinical trials Clinical trials

• Formularies Formularies

• Drug information Drug information

• Clinical pharmacists have the potential to Clinical pharmacists have the potential to implement and influence drug-related implement and influence drug-related policies, i.e., making decisions on which policies, i.e., making decisions on which drugs deserve to be marketed, which drugs deserve to be marketed, which drugs should be included in national and drugs should be included in national and local formularies, which prescribing local formularies, which prescribing policies and treatment guidelines should policies and treatment guidelines should be implemented. be implemented.

• Clinical pharmacists are also actively Clinical pharmacists are also actively involved in clinical trials at different levels: involved in clinical trials at different levels: participating in ethical committees; study participating in ethical committees; study monitoring; dispensation and preparation monitoring; dispensation and preparation of investigational drugs.of investigational drugs.

2. During the prescription 2. During the prescription • Counselling activity Counselling activity Clinical pharmacists can influence the Clinical pharmacists can influence the

attitudes and priorities of prescribers in attitudes and priorities of prescribers in their choice of correct treatments. their choice of correct treatments.

• The clinical pharmacist monitors, detects The clinical pharmacist monitors, detects and prevents harmful drug interaction, and prevents harmful drug interaction, adverse reactions ad medication errors adverse reactions ad medication errors through evaluation of prescriptions’ through evaluation of prescriptions’ profilesprofiles

• The clinical pharmacist pays special The clinical pharmacist pays special attention to the dosage of drugs which attention to the dosage of drugs which need therapeutic monitoring. need therapeutic monitoring.

• Community pharmacists can also make Community pharmacists can also make prescription decisions directly, when over prescription decisions directly, when over the counter drugs are counselled. the counter drugs are counselled.

Medication-related ProblemsMedication-related Problems

• Untreated indications. Untreated indications. • Improper drug selection. Improper drug selection. • Subtherapeutic dosage. Subtherapeutic dosage. • Medication Medication Failure to receive Failure to receive • Medication Overdosage.Medication Overdosage.

• Adverse drug reactions. Adverse drug reactions.

• Drug interactions. Drug interactions.

• Medication use without indicationMedication use without indication

3. After the prescription 3. After the prescription

• Counselling Counselling

• Preparation of personalised formulation Preparation of personalised formulation

• Drug use evaluation Drug use evaluation

• Outcome research Outcome research

• Pharmacoeconomic studies Pharmacoeconomic studies

• After the prescription is written, clinical After the prescription is written, clinical pharmacists play a key role in pharmacists play a key role in communicating and counselling patients. communicating and counselling patients.

• Pharmacists can improve patients' Pharmacists can improve patients' awareness of their treatments, monitor awareness of their treatments, monitor treatment response, check and improve treatment response, check and improve patients' compliance with their patients' compliance with their medications. medications.

• As members of a multidisciplinary team, As members of a multidisciplinary team, clinical pharmacists also provide clinical pharmacists also provide integrated care from 'hospital to integrated care from 'hospital to community' and vice versa, assuring a community' and vice versa, assuring a continuity of information on risks and continuity of information on risks and benefits of drug therapy. benefits of drug therapy.

Activities of Clinical Activities of Clinical PharmacistsPharmacists

The principle activities of a clinical pharmacist The principle activities of a clinical pharmacist include: include:

Consulting Consulting Analysing therapies, advising health care Analysing therapies, advising health care practitioners on the correctness of drug therapy practitioners on the correctness of drug therapy and providing pharmaceutical care to patients and providing pharmaceutical care to patients both at hospital and at community level. both at hospital and at community level.

• Selection of drugs Selection of drugs Defining "drug formularies" or "limited lists of Defining "drug formularies" or "limited lists of drugs" in collaboration with hospital doctors, drugs" in collaboration with hospital doctors, general practitioners and decision makers. general practitioners and decision makers.

Drug information Drug information Seeking information and critically evaluating Seeking information and critically evaluating scientific literature; organising information scientific literature; organising information services for both the health care practitioners services for both the health care practitioners and the patients. and the patients.

• Formulation and preparation Formulation and preparation Formulation and preparation of medicinal Formulation and preparation of medicinal products and devices according to acceptable products and devices according to acceptable standards to meet specific patients' needs.standards to meet specific patients' needs.

• Clinical Trials Clinical Trials Planning, evaluating and participating in Planning, evaluating and participating in clinical trials. clinical trials.

• Drug use studies and research Drug use studies and research Drug use studies and outcome research : Drug use studies and outcome research : collecting data on drug therapies, their collecting data on drug therapies, their costs and patient outcome through costs and patient outcome through structured and scientific methods structured and scientific methods

• Pharmacokinetics/ therapeutic drug Pharmacokinetics/ therapeutic drug monitoring monitoring Studying the kinetics of drugs and Studying the kinetics of drugs and optimising the dosage. optimising the dosage.

Pharmacoeconomy Pharmacoeconomy Using the results of clinical trials and Using the results of clinical trials and outcome studies to determine cost- outcome studies to determine cost- effectiveness evaluations.  effectiveness evaluations. 

• Dispensation & Administration Dispensation & Administration Dispensing and administration of medicinal Dispensing and administration of medicinal products and devices: studying and products and devices: studying and developing systems for the dispensing and developing systems for the dispensing and administration of medicinal products and administration of medicinal products and devices that can guarantee a higher security devices that can guarantee a higher security in administration, a reduction of expenditure in administration, a reduction of expenditure and a reduction in medication errors. and a reduction in medication errors.

• Teaching & TrainingTeaching & Training Pre- and post-graduate teaching and Pre- and post-graduate teaching and activities to provide training and education activities to provide training and education programmes for pharmacists and other programmes for pharmacists and other health care practitioners health care practitioners

Information SourceInformation Source

• Medical recordMedical record

• PatientPatient

• FamilyFamily

• Health care teamHealth care team

From medical record you can find the From medical record you can find the following:following:

• Admission InformationAdmission Information• Initial historyInitial history• physical examinationphysical examination• Progress notes Progress notes • ConsultationsConsultations

• Nursing notesNursing notes

• Laboratory dataLaboratory data

• Diagnostic Procedures Diagnostic Procedures

• RadiologyRadiology

• SurgerySurgery

• OrdersOrders

• MedicationMedication

• administration ordersadministration orders

• Consent formsConsent forms

Clinical Pharmacy Practice Clinical Pharmacy Practice areasareas

• Ambulatory careAmbulatory care• Critical careCritical care• Drug InformationDrug Information• Geriatrics and long –term careGeriatrics and long –term care• Internal medicine and subspecialtiesInternal medicine and subspecialties

• CardiologyCardiology

• EndocrinologyEndocrinology

• GastroenterologyGastroenterology

• Infectious disease Infectious disease

• NeurologyNeurology• NephrologyNephrology• Obstetrics and gynecologyObstetrics and gynecology

• Pulmonary diseasePulmonary disease• PsychiatryPsychiatry• RheumatologyRheumatology

• Nuclear pharmacyNuclear pharmacy

• NutritionNutrition

• PediatricsPediatrics

• PharmacokineticsPharmacokinetics

• SurgerySurgery

Practice Guidelines for Practice Guidelines for Pharmaco - therapy SpecialistsPharmaco - therapy Specialists

• The pharmacotherapy specialist designs, The pharmacotherapy specialist designs, implements, monitors, evaluates, and implements, monitors, evaluates, and modifies patient pharmacotherapy to modifies patient pharmacotherapy to ensure effective, safe and economical ensure effective, safe and economical patient carepatient care..

• The pharmacotherapy specialist retrieves , The pharmacotherapy specialist retrieves , analyzes, evaluates, and interprets the analyzes, evaluates, and interprets the scientific literature as a means of scientific literature as a means of providing patient- and population-specific providing patient- and population-specific drug information to health professionals drug information to health professionals and patientsand patients

• The pharmacotherapy specialist participates in The pharmacotherapy specialist participates in the generation of new knowledge relevant to the generation of new knowledge relevant to the practice of pharmacotherapy, clinical the practice of pharmacotherapy, clinical pharmacy and medicinepharmacy and medicine

  

• The pharmacotherapy specialist educate health The pharmacotherapy specialist educate health care professionals and students, patients, and care professionals and students, patients, and the public regarding rational drug therapythe public regarding rational drug therapy

  

• The pharmacotherapy specialist The pharmacotherapy specialist continually develops his/her knowledge continually develops his/her knowledge and skills in applicable practice areas and and skills in applicable practice areas and demonstrates a commitment to continued demonstrates a commitment to continued professional growth by engaging in a professional growth by engaging in a lifelong process. lifelong process.

How to Pursue a Profession in How to Pursue a Profession in Clinical Pharmacy in Saudi Clinical Pharmacy in Saudi

ArabiaArabia

• Most clinical pharmacists have a Doctor of Most clinical pharmacists have a Doctor of Pharmacy (Pharm.D.) degree or Master Pharmacy (Pharm.D.) degree or Master degree in clinical pharmacy and many degree in clinical pharmacy and many have completed one or more years of have completed one or more years of post- graduated training (e.g. a general post- graduated training (e.g. a general and/or specialty pharmacy residency). and/or specialty pharmacy residency).

• Many clinical pharmacists also choose to Many clinical pharmacists also choose to become Board Certified through the Board become Board Certified through the Board of Pharmaceutical Specialties (BPS) which of Pharmaceutical Specialties (BPS) which was organized in 1976 as an independent was organized in 1976 as an independent certification agency of APhA (American certification agency of APhA (American Pharmacists Association). Pharmacists Association).

• A pharmacist may become a Board A pharmacist may become a Board Certified Pharmacotherapy Specialist Certified Pharmacotherapy Specialist (BCPS), a Board Certified Oncology (BCPS), a Board Certified Oncology Pharmacist (BCOP), Board Certified Pharmacist (BCOP), Board Certified Nuclear Pharmacist (BCNP), Board Nuclear Pharmacist (BCNP), Board Certified Nutrition Support Pharmacist Certified Nutrition Support Pharmacist (BCNSP), or a Board Certified Psychiatric (BCNSP), or a Board Certified Psychiatric Pharmacist (BCPP) through the Board of Pharmacist (BCPP) through the Board of Pharmaceutical Specialities (BPS).Pharmaceutical Specialities (BPS).

Clinical pharmacokineticsClinical pharmacokinetics

• Clinical pharmacokinetics is the process of Clinical pharmacokinetics is the process of applying pharmacokinetic principles to applying pharmacokinetic principles to determine the dosage regimens of specific drug determine the dosage regimens of specific drug products for specific patients to maximize products for specific patients to maximize pharmacotherapeutic effects and minimize pharmacotherapeutic effects and minimize toxic effects. toxic effects.

  

• TDM stands for therapeutic drug monitoringTDM stands for therapeutic drug monitoring

  

• Application of these principles requires an Application of these principles requires an understanding of the absorption, understanding of the absorption, distribution, metabolism, and excretion distribution, metabolism, and excretion characteristics of specific drug products in characteristics of specific drug products in specific diseases and patient populationsspecific diseases and patient populations

  

Drugs that can be monitored Drugs that can be monitored

• when the range between minimal when the range between minimal effectiveness and toxicity is narrow effectiveness and toxicity is narrow

  

• the results of the drug assay provide the results of the drug assay provide significant information for clinical decision-significant information for clinical decision-making. making.

Why request TDM?Why request TDM?

• NoncomplianceNoncompliance

• Inappropriate dosageInappropriate dosage

• Poor bioavailabilityPoor bioavailability

• Drug interactionDrug interaction

• Kidney and liver diseseKidney and liver disese

• Altered protien bindingAltered protien binding

• FeverFever

• CytokinesCytokines

• Genetically determined fast or slow Genetically determined fast or slow metabolizersmetabolizers

ResponsibilitiesResponsibilities

• Designing patient-specific drug dosage Designing patient-specific drug dosage regimensregimens

  

• Recommending or scheduling Recommending or scheduling measurements of drug concentrations in measurements of drug concentrations in biological fluidsbiological fluids

  

• Monitoring and adjusting dosage regimensMonitoring and adjusting dosage regimens

• Evaluating unusual patient responses to drug Evaluating unusual patient responses to drug therapy for possible pharmacokinetic and therapy for possible pharmacokinetic and pharmacologic explanations.pharmacologic explanations.

•   Communicating patient-specific drug therapy Communicating patient-specific drug therapy information to physicians, nurses, and other information to physicians, nurses, and other clinical practitioners and to patients orally clinical practitioners and to patients orally and in writing, and including documentation and in writing, and including documentation of this in the patient’s health record.of this in the patient’s health record.

• Educating pharmacists, physicians, nurses, Educating pharmacists, physicians, nurses, and other clinical practitioners about and other clinical practitioners about pharmacokinetic principles and pharmacokinetic principles and appropriate indications for clinical appropriate indications for clinical pharmacokinetic monitoring, including the pharmacokinetic monitoring, including the cost-effective use of drug concentration cost-effective use of drug concentration measurements.measurements.

• Developing quality assurance programs for Developing quality assurance programs for documenting improved patient outcomes documenting improved patient outcomes and economic benefitsand economic benefits

  

• Promoting collaborative relationships with Promoting collaborative relationships with other individuals and departments other individuals and departments involved in drug therapy involved in drug therapy

Pharmacists with specialized education, Pharmacists with specialized education, training, or experience may have the training, or experience may have the opportunity to assume the following opportunity to assume the following additional responsibilities:additional responsibilities:

• Designing and conducting research Designing and conducting research

  

• Developing and applying computer programs Developing and applying computer programs and point-of-care information systems to and point-of-care information systems to enhance the accuracy and sophistication of enhance the accuracy and sophistication of pharmacokinetic modeling and applications to pharmacokinetic modeling and applications to pharmaceutical care.pharmaceutical care.

  

• Serving as an expert consultant to Serving as an expert consultant to pharmacists with a general pharmacists with a general background in clinical background in clinical pharmacokinetic monitoring.pharmacokinetic monitoring.

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