CLINICAL PHARMACY

•Introduction to Clinical Pharmacy,

•Concept of clinical pharmacy,
•functions and responsibilities of clinical pharmacist,
•Drug therapy monitoring - medication chart review,
•clinical review, pharmacist intervention,
•Ward round participation,
•Medication history and Pharmaceutical care.
•Dosing pattern and drug therapy based on Pharmacokinetic &
 Definition
• Clinical pharmacy is defined as the branch of
pharmaceutical science dealing with utilization of
pharmacist knowledge, skills and judgments
related to biomedical and pharmaceutical
sciences, to prove the safety, the cost and the
precision of the drug usage in the patient care.
 Development of Clinical Pharmacy
• Clinical Pharmacy has already taken good shape. In India, it is in the
infancy stage.
• The role of the retail pharmacist is viewed by many people as simply
transferring pills from a large bottle to a small one - counting tablets,
typing labels and calculating the price.
• Much of his time is seen as devoted to routine merchandising of
cosmetics, skin, hair, dental products, stationery and other
commodities which have little or no relation to health care.
• India stands among top fifteen in the world in pharmaceutical market
with respect to pharmaceutical production, exports, imports etc.
• There is still a need to develop the concept of clinical pharmacy.
• Today there is 'drug-explosion' and 'information explosion' in relation
to the drugs.
• On one hand there is development of newer and more-effective drugs
and on other hand their potential hazards of side effects are on rise
 SCOPE OF CLINICAL PHARMACY:
• Clinical pharmacy has emerged as one of the latest
branches of pharmacy in 21st Century.
• It is where pharmacists deal with various aspects of
patient care, dispensing of drugs and advising patients
on the safe and rational use of drugs.
• It can also be explained as a part of pharmacy in which
the clinical pharmacist provides patient care that
optimizes the use of medication and promotes health,
wellness, and disease prevention.
• To elaborate the story we can say that clinical pharmacy
is to use drug control and the effective application of the
• Professional skills and ethics assure the optimal
safety in the distribution and use of medicine.
• The purpose of the Professional Education in Clinical
Pharmacy and Public Health is to qualify each
pharmaconomist (expert in pharmaceuticals) to
practice clinical pharmacy at a higher and more
professional level. Hence, ensures the patient’s
maximum well-being during the drug therapy.
• Clinical pharmacy describes the new role of the 21st
Century’s pharmacists.
• It doesn’t restrict the role of a pharmacist merely to
good manufacture practices, easy procurement,
proper preparation, distribution and control of drug
• In addition, it also comprises functions necessary to
discharge a particular set of social responsibilities
related to proper therapeutic use of drugs in the
aspects like prescribing, dispensing and
administrating drugs, documenting professional
services, direct patient involvement, reviewing drug
use, education, consultation and counseling.
• The aim of clinical pharmacy practice is to ensure
the patient’s maximum well-being and to play a
meaningful role in the safe and rational use of the
drugs.
 Qualities of clinical pharmacist
• Clinical pharmacists care for patients in all health care
settings but the clinical pharmacy movement initially began
inside hospitals and clinics.
• Pharmacists should be well served with the common
language used by the people in order to communicate with
the patient and co-professionals easily and effectively.
• Pharmacists are also expected to have thorough knowledge
of the etiology of the disease, its signs, symptoms,
pathophysiology, diagnostic tests, pharmacokinetics, etc.
• Proper clinical training should be given to the clinical
pharmacist to provide information regarding rational drug
use, drug therapy and drug doses
 Condition for a clinical pharmacy
• A clinical pharmacy professional should appreciate the role
of medical and para-medical staff.
• There should be enough bondage between the physician
and the pharmacist to visit the patients together.
• All of the medical staff should develop an interprofessional
relationship to enhance the quality of patient care.
• It helps in maintaining proper patient history and gaining
confidence.
• As drug therapy is an ongoing process it needs to be
checked by the clinical pharmacist timely.
• It may be changed according to the patient’s condition and
requirement.
 Health care team and a clinical pharmacist

• The clinical pharmacist should interact with the patients

and maintain their complete and exhaustible medical
history.
• The clinical pharmacist should also do proper
documentation of the hypersensitivities or allergy to certain
drugs, food habits, drug dependence or intoxications to
certain chemical substances, side effects of some drugs,
incorrect drug administration, etc about the patient.
• The prescribed drugs may interact with certain OTC drugs;
therefore, after receiving the prescription the clinical
pharmacist should check the patient’s medical history for
drug related interactions and patient’s habits.
• In the selection of a proper drug product/generic
formulation the clinical pharmacist can help the
physician.
• Clinical pharmacist can help in monitoring of drug
therapy to ensure safety and efficacy.
• Various pharmacokinetic parameters can also be
checked by the clinical pharmacist based on: plasma
concentration of drug, enzymes and measurement of
glucose quantity in blood.
• Patients with kidney impairment or hepatic disorders
are more prone to adverse drug reactions. Clinical
pharmacist can help in detection, prevention and
reporting of adverse drug reactions. He may advice the
physician for alternate drug therapy for the concerned
• The drug management greatly relies on the clinical
pharmacist to check the selection, requirement,
procurement, distribution and use of the drugs.
• can help in executing clinical trials
• is an expert to provide detailed information to the
health professionals and the general public.
• Effective selection, utilization and retrieval of drug
literature by the clinical pharmacist can enable in
the proper understanding of the facts by the
medical team.
• He can also abstract information from periodic
bulletins, newsletters or other pharmacy literature
 Scope of clinical pharmacy in India
• In hospitals the services regarding clinical pharmacy are
of considerable value because the concerned clinical
pharmacist serves as a guide to the physician for safe
and rational use of drugs.
• assists to achieve economy in the hospital by planning
safe drug policies, suggestive means of reduction of
waste, by preventing misuse or pilferage of drugs. In
addition to it the preparation of preventing forecasting
future drug requirements of the hospital, based upon
their drug utilization patterns.
• deals with ensuring safety and efficacy of the drugs after
marketing
 Functions and responsibilities of
clinical pharmacist
•Collection of patient data
•Identification of problems
•Establishing outcome goals through a good therapeutic plan
•Evaluating treatment alternatives by monitoring and
modifying therapeutic plan
•Individualizing drug regimens
•Monitoring outcomes
 COLLECTION OF PATIENT DATA:
• Demographics
• Current problems
• Past medical history
• Current medication
• Social habits
• Relevant laboratory data
• Subsequent modifications of therapy plan
 IDENTIFICATION OF PROBLEMS
The data collected can be used to identify actual or
potential drug related problems.
• ACTUAL: A condition that requires the initiation of a
new or additional drug.
• POTENTIAL: The patient may be at risk to develop a
new medical problem.
These problems may be related to the patient’s
current drug therapy, drug administration, drug
compliance, drug toxicity, ADR’s and a failure to
achieve desired outcomes by the treatment
 ESTABLISHING OUTCOME GOALS
• Drug therapy can produce positive outcome:
1. Cure of the disease
2. Elimination or reduction of patient’s
symptomology
3. Arresting or slowing of a disease process
4. Preventing a disease or symptoms
5. It may also produce negative result, i.e. resulting in
disease morbidity and sometimes mortality.
EVALUATING TREATMENT ALTERNATIVES BY MONITORING
AND MODIFYING THERAPEUTIC PLAN:

• Efficacy, safety, availability and cost of treatment

and suitability of the treatment to the patient
should be considered while evaluating.
• The risk-benefit ratio factors should also be
considered: seriousness of the disease,
complications if untreated, efficacy of drug, ADR’s
 INDIVIDUALISING DRUG REGIMENS:
• When more than one therapeutic alternatives exist,
the following factors to be considered:
1. Patient factors:- diagnosis, treatment goals, past
medical and medication history, contraindication,
allergies, compliance
2. Drug factors:- efficacy, adverse effects, dosage
form, cost, drug-drug interactions
 MONITORING OUTCOMES:
• The goals are: Cure of the disease, elimination or reduction of patient’s
symptomology, arresting or slowing of a disease process, preventing a
disease or symptoms.
• But often leads to suboptimal outcomes due to:- inappropriate or
unnecessary prescribing or drug regimen, dispensing error, non-
compliance, inappropriate monitoring
• To ensure good monitoring outcomes:
1. Regularly should review whether satisfactory progression is made or
not according to the therapeutic plan.
2. To determine whether original plan should continue or any treatment
modifications to be made or not.
3. Reviews ongoing progress and provides report to patient’s other
healthcare providers. Should regularly update patient’s
medical/pharmacy records with information concerning patient’s
PHARMACEUTICAL CARE IN HOSPITALS:

• Prescription monitoring
• Prescribing advice to medical and nursing staff
• Medication errors and adverse reaction monitoring
• Medication history interview
• Patient education and counselling
• Pharmacokinetics and therapeutic drug monitoring
• Hospital formulary
PHARMACEUTICAL CARE FOR THE COMMUNITY:

• Participate in health screening

• Participate in health promotion and education
• Serve as a source of drug and poison information
• Collaborate with other health care professionals to
develop treatment guidelines
• Design and monitor procurement and drug
distribution system including storage and disposal.
BARRIERS TO PHARMACEUTICAL CARE:
• Pharmacist barrier
• Practice setting constraints
• System impediments
• Intra professional barrier
 DRUG THERAPY MONITORING
• Drug therapy monitoring, also known as Therapeutic
Drug Monitoring (TDM), is a means of monitoring drug
levels in the blood.
• Therapeutic drug monitoring (TDM) refers to the
measurement and interpretation of principally blood or
plasma drug concentration measurements with the
purpose of optimising a patients drug therapy and
clinical outcome while minimising the risk of drug
induced toxicity.
• TDM involves tailoring a dose regimen to an individual
patient by maintaining the plasma or blood
• To achieve optimal drug therapy 3 objectives should
be met:
1. To attain desired pharmacological effect of the drug.
2. To reach the maximal effect in shortest possible
time.
3. To decrease the risk of toxicity.

• TDM is useful in drugs:

1. With a narrow therapeutic index.
2. Which are highly protein bound.
3. Which are liable to interact.
4. In which the metabolite might be toxic.
• Drug therapy monitoring is an ongoing process in
which pharmacists actively review patients’ records,
identify and resolve drug therapy problems such as
adverse drug events (ADEs), and communicate with
prescribers when problems occur.
• Pharmacists educate patients and their caregivers
about potential adverse effects and work with
patients to ensure adherence to therapy and
attainment of therapeutic goals.
 MEDICATION CHART REVIEW
• It is a fundamental responsibility of a pharmacist to
ensure the appropriateness of medication orders.
• It is a fundamental responsibility of a pharmacist to
ensure the appropriateness of medication orders.
• Organizing information according to medical
problems ( example disease) helps breakdown a
complex situation into its individual parts.
• GOALS:
1. To optimize the patients drug therapy
2. To prevent or minimize drug related
 PROCEDURE
• The patient's medical record should be reviewed in
conjugation with the medication administration
record.
• Recent consultations, treatment plans and daily
progress should be taken into account when
determining the appropriateness of current
medication orders and planning each patient’s care.
• All current and recent medication orders should be
reviewed
COMPONENTS OF MEDICATION ORDER REVIEW
1. Checking that medication order is written in
accordance with legal and local requirements
2. Ensuring that the medication order is
comprehensible and unambiguous, that
appropriate terminology is used and that drug
name are not abbreviated.
3. Detecting orders for medication to which the
patient may be hypersensitive/intolerant
4. Checking complete drug profile for medication
duplication, interactions or incompatibilities
5. Ensuring that medication order is appropriate with
respect to:
• The patient’s previous medication order.
• Patient’s specific considerations e.g disease state,
pregnancy.
• Drug dose and dosage schedule, especially with
respect to age, renal function, liver function.
• Route, dosage form and method of administration
6. Ensuring that the drug administration order clearly
indicates the time at which drug administration is
to commence
7. Special considerations should be given especially in
short course therapy as in antibiotics and analgesics
8. If appropriate follow up of any non-formulary drug orders,
recommending a formulary equivalent if required.
9. Ensuring appropriate therapy monitoring is implemented.
10. Ensuring that all necessary medication is ordered. E.g.
premedication, prophylaxis.
11. Reviewing medication for cost effectiveness.
12. Identification of drug related problems:
• Untreated indication.
• Inappropriate drug selection.
• Sub therapeutic dose.
• Adverse drug reaction.
• Failure to receive drug.
• Drug interactions.
• Drug use without indication.
 CLINICAL REVIEW:
• Clinical review is one of the integral components of medication
review and should preferably be performed on a daily basis.
• It is the review of the patients’ progress for the purpose of
assessing the therapeutic outcome.
• The therapeutic goal for the specific disease should be clearly
identified before the review.
• GOALS: :
1. Assess the response to drug treatment.
2. Evaluate the safety of the treatment regimen.
3. Assess the progress of the disease and the need for any change
in therapy.
4. Assess the need for monitoring, if any.
5. Assess the convenience of therapy(to improve compliance)
PHARMACIST INTERVENTION
 ROLE OF PHARMACIST
• A reliable and responsive TDM service depends on team work
between nurses, doctors, pharmacist, scientist and technical staff.
• The clinical pharmacist should provide advice to medical staff on
the appropriate use and timing of TDM and assist with the
interpretation of results.
• In addition the pharmacist maybe involved in :
1. Initial selection of drug regimen: this may involve decisions
about drug choice, dose, dosing interval, route of administration
and dosage form of the drug, taking into account factors such as
sex, age, body weight, race, metabolism status, renal function,
plasma albumin concentration, use of other drugs and
laboratory results.
2. Adjustment of the dosage regimen based on TDM results and
the patients clinical response
 WARD ROUND PARTICIPATION
• ward round is a visit made by a medical practitioner,
alone or with a team of health professionals and
medical students, to hospital inpatients at their
bedside to review and follow up the progress in their
health.
• Usually at least one ward round is conducted every
day to review the progress of each inpatient, though
more than one is not uncommon.
• In certain practice settings such as psychiatry, the
“ward round” may be conducted away from the
patient’s bedside in a non-traditional fashion, where
Goals and objectives for clinical pharmacists on
ward round

1. Gain an improved understanding of patient’s

clinical status and progress, currentplanned
investigations and therapeutic goals.
2. Provide relevant information on various aspects of
the patient’s drug therapy such as pharmacology,
pharmacokinetics, drug availability, cost, drug
interactions and adverse reactions.
3. Optimize therapeutic management by influencing
drug therapy selection, implementation,
monitoring and follow-up.
4. Investigate unusual drug orders or doses.
5. Assimilate additional information about the patient such
as co-morbidities, medication compliance or alternative
medicine use that might be relevant to their
management.
6. Detect adverse drug reactions and drug interactions.
7. Participate in patient discharge planning

• Ward round participation also provides many learning

opportunities for pharmacists. It allows pharmacists to
see firsthand how drugs are used and prescribed and to
see the effects of these drugs on patients
• ward round participation strengthens inter-professional
relationship among various health professionals, leading