Introduction to clinical pharmacy

1. Clinical Pharmacy
Definition, History, Scope and Activities
lecture by,
Dr. Prasanna Dahal
BpharmSc, PharmD, Msc (HC&HA)
Asst. Prof
Department of Pharmacy
PUCMAS

2. Definition
A health specialty in pharmacy which
through skills, activities and services provided to
patients and healthcare professionals promotes the
safe, effective and economic use of medicines.
Develops and promotes for the rational and
appropriate use of medicinal products and devices.

3. HISTORY OF CLINICAL PHARMACY
• The concept of clinical pharmacology started in 1960s with
two incidences.
• First, in 1962 "The Thalidomide Tragedy",
wherein it was found that consumption
of popular sedative thalidomide resulted in
birth of babies with sealed limbs.
• Second, in 1968 phenytoin toxicity was reported in
Australia which was because of change in formulation i.e.
switching over from calcium sulfate to lactose as an inert
excipient in the tablets

4. • During the 1970s and 1990s , the consequences of
drug misuse, such as
– poor health outcomes from drug treatment,
– antibiotic resistance,
– adverse drug reaction and economic loss of patients
the wider health care system were acknowledged
not just by the pharmacy profession but also by
the medical profession, consumer and patients
organization and the government.
• The 1990s were the period of awakening when the
profession recognized clearly that an urgent need
existed for pharmacist to contribute to improving
medication use in our community.

5. The need for clinical Pharmacy
• Clinical pharmacy is concerned with the promotion of
effective, safe and economical drug therapy. Clinical
pharmacy practice is the need of the hour. Drug use is
a complex process and there are many drug related
problems at various levels mainly involving
• Prescribers
• Patients
• Pharmacist
• The pharmaceutical industries
• Government

6. • Prescribers :
I. High patients load
II. A pill for every ill concept
III. Inadequate pharmacotherapeutic training in medical
curriculum
IV. Rely on handouts from pharmaceutical companies as
source of drug information.
V. Prescribing in brands ( risk in drug duplication)

7. • Pharmacist:
I. Retail pharmacy do not offer professional services.
II. Poor knowledge base (lack of clinical specific subject in
curriculum)
III. Lack of confident
IV. Lack of financial benefit
V. Non-pharmacist in pharmacy stores
• Pharmaceutical industry:
I. More than 100000 formulation available on market
II. Many irrational drug combinations
III. Doctors rely on promotional materials from company
IV. Lack of fully –fledged medical information departments in
company
V. Packet insert provides only technical information
(consumer information is often lacking)

8. • Government:
• Drug policies are mainly aimed at pharmaceutical
industry rather than patients e.g technical and
commercial matters like price control and licensing.
• Advertising and promotional claims are not strictly
regulated
• No policies related with pharmaceutical care practice in
hospital and clinics
• Patients:
• Illiterate
• Language barrier
• Poor adherence
• Low economy etc

9. • Clinical pharmacist play a crucial role in
management and preventing the drug related
problems arising from these areas.

10. GOALs of clinical pharmacy services
• to promote the correct and appropriate use of
medicinal products and devices.
These activities aim at:
• maximising the clinical effect of medicines
• minimising the risk of treatment-induced
adverse events
• minimising the expenditures for
pharmacological treatments.

11. Clinical Pharmacy requirements
Knowledge of
nondrug therapy
Therapeutic
planning
skills
Drug Information
Skills
Physical
assessment
skills
Patient
monitoring
skills
Communication
skills
Knowledge of
laboratory
and diagnostic skills
Knowledge of
the disease
Knowledge of
drug therapy
Patient care

12. Services and Scope–
Hospitals, community pharmacies, nursing homes, home
– based care services, clinics – all the settings where medicines
are prescribed and used (OTC included).
Also known as clinical pharmacist practitioner provides drug
therapy management under the supervision of a licensed
physician who provides the written prescription for the patients.
The drug therapy management includes – ordering, changing,
substituting therapies or ordering tests.

13. Functions
• Communication with healthcare professionals and patients regarding
drug therapy, wellness, and health promotion.
- Designing or modifying drug therapy, implementing, monitoring for
rational drug therapy.
- Counseling patients – disease condition; purpose, uses, effects of
medication; monitoring use of OTC, herbals or alternative medicine; use
of administering devices.
• Using the clinical data for optimization of therapy.
• Documentation of interventions and evaluate the outcomes.
• Training and education progs for all the healthcare practitioners and
general public.

14. Levels of action of the clinical
pharmacists in hospital
Three levels - Before, during and after
prescription.
1. Before the prescription:
• Clinical trials
• Formulary preparation
• Drug information

15. • Clinical trials- Ethical committee
participation; study monitoring;
dispensation and preparation of
investigational drugs.
- Decisions on which drug deserve to
be marketed.
• Formularies- Inclusion of drug in the
national and local formularies.
• Drug information and Counseling

16. 2. During the prescription:
• Influence attitudes and priorities of
prescribers for rational therapy.
• Monitors, detects and prevents harmful drug
interaction, ADRs and medication errors
through prescription evaluation (case sheet
review).
• Therapeutic drug monitoring.
• Direct decisions in case of drug selection in
the over the counter medications.

17. 3. After the prescription:
• Counseling.
• Preparation of personalized formulation viz;
unit dose, I.V preparations, investigational
drugs, etc.
• Drug use evaluation.
• Outcome research.
• Pharmacoeconomics studies.
• Check and improve the patients’ compliance
with their medications.

18. Activities/ Scope of Clinical
Pharmacists
• Patient interview
• Case-note review
• Medication chart review
• Ward round participation
• Patient counseling
• Drug information
• Therapeutic drug monitoring
• ADR monitoring
• Drug utilization evaluation

19. Patient Interview
• Carried out on a daily basis.
• Aim: Patients’ past medical history, past
medication history, social habits, allergies are
assessed.
• Important inputs given to the attending
physician that aid in the planning the present
therapeutic regimen.
• Compliance of patient is assessed.

20. Case note review
Involves:
• Review of patients clinical progress notes
• Discussion with other members of the health team
• Discussion with the patient
Information obtained evaluated for
• The clinical and pathophysiological condition treated
• Time frame of drug related effects
• The planned outcome of treatment
• Indication of an investigation and its need

21. Ward Round Participation
• Ward rounds with consultants/specialists
• Multi-disciplinary approach
• Medical and pharmacy students often present
Aim is to:
• Be present when prescribing decisions are made
• Provide information and advice relevant to
patients’ drug therapy – drug related reactions or
ADR
• Improve pharmacist’s own understanding of
therapy objectives

22. Medication Chart Review
• Correct patient identification
• Legibility of drug orders, generic name use,
dose
• Appropriate drug, dosage, route of
administration and duration of therapy
• Allergy documentation
• Additional directions for administration
• Drug interactions and duplications
• Legal requirements

23. Patient Counseling
• During admission and discharge
• May need to involve patient’s family
• Aim is that every patient should leave hospital knowing what
their medications are for and how to take them
• Compliance aids may be required eg. Written instructions,
medicine measures, tablet cutters
Attention to patients:
• With serious/unstable disease states
• Chronic diseases
• Co morbidities (mainly renal/hepatic) and multiple drugs
• Narrow therapeutic index drugs
• Special populations: Elderly, Paediatric , Pregnant, Lactating
mother
• Non-intentional non-compliers

24. Therapeutic Drug Monitoring
• Drugs with a narrow therapeutic index
Eg: Digoxin, theophylline, lithium, gentamicin, phenytoin etc.
• Drugs with a high incidence of adverse effects
• Difficult to define the therapeutic endpoint.
• Drugs associated with clinically significant interactions
• Diseases requiring constant monitoring (hepatic/renal
impairment, diabetes, obesity, burns, cystic fibrosis etc)

25. Medical Audit :
• The clinical pharmacist is either the initiator or a very active
member of a functioning committee. Following are the
activities, concerning medical audit:
i. Legislation and Contractual obligation.
iii.Regulation and registration of pharmacotherapy orders and
administration.
iv. Regulation of clinical experiments with drugs
v. Information per subject and per patient
vi.Pharmacotherapy-committee policy
vii.Regulation of information from the pharmaceutical
industry
ix. Formulary policy
x. Retrospective study of drug use patterns
xi. Medical audit committee work.

26. Education and training
One of clinical pharmacist’s main roles
• Patient education
• Education and training of staff and students
• Informal or formal meetings, lectures
• Guidelines and protocols
• Newsletter
• Continue medical education program
• training programs for pharmacists, nurses and
interns.

27. Clinical research
• The clinical pharmacist can participate in an
evaluation program on investigational drugs.
• He can help in conducting clinical trials based
on sound principles of clinical research and
biostatistical methods of evaluation.

28. Clinical Pharmacy Practice areas
• Ambulatory care
• Critical care
• Drug Information
• Geriatrics and long –term
care
• Internal medicine and
subspecialties
• Cardiology
• Endocrinology
• Gastroenterology
• Infectious disease
• Neurology
• Nephrology
• Obstetrics and gynecology
• Pulmonary disease
• Psychiatry
• Rheumatology
• Nuclear pharmacy
• Nutrition
• Pediatrics
• Pharmacokinetics
• Surgery

29. Limitations
Nepal scenario
Clinical pharmacy services not recognized in
the hospitals.
Even Regulatory frameworks/guidelines
does not recognize the need of clinical
pharmacist.
• Migration of the CP to the industries or
other countries.
• Lack of clinical pharmacy oriented practical
trainings in curriculum .

30. Thank you
Smile it makes you healthier


31. For presentation (Journal Club)
• JollyFrancis., SujaAbraham. Clinical pharmacists: Bridging the gap between patients and
physicians. Saudi Pharmaceutical Journal Volume 22, Issue 6, December 2014, Pages 600-602