Transcript 4- Pharmaceutical ca..

PHCl 429: Pharmaceutical Care I
Pharmacotherapy Workup Process:
Assessment
GHADA A BAWAZEER.
Spring 2010
MSC, PHARMD, BCPS
PHARMACEUTICAL CARE PROCESS
ESTABLISH A THERAPEUTIC RELATIONSHIP
ASSESSMENT
CARE PLAN
1. Ensure all drug therapy
is indicated, effective,
safe (patient need)
2. patient can and will
comply with
instructions
1. Resolve drug therapy
problems
2. Achieve goals of therapy
3. Prevent drug therapy
problems
3. Identify drug therapy
problems
Continuous Follow-up
EVALUATION
1. Record actual patient
outcomes
2. Evaluate status as progress
in meeting therapeutic
goals
3. Reassess for new problems
Figure 9-4
(.. “I thought I was going to suffocate”..)


SR is a 76 years old male with a medical history is
significant for heart failure, high blood pressure,
atrial fibrillation, hypothyroidism, dyslipidemia, s/p
myocardial infarction.
HSR was brought in to ED after almost fainting, and
symptoms of shortness of breath, dizziness. He said
he had “ hard time breathing..I thought I was going
to suffocate”
(.. “I thought I was going to
suffocate”..)
He reported sleeping on 2 pillows and
find it difficult to walk same distance
without getting tired and short of breath.
 He has no known drug allergy
 Patient was admitted to the ward, lab
and investigation were ordered.

(.. “I thought I was going to
suffocate”..)
Today is the second day of admission
 His condition is stable and the attending
physician is planning to discharge him as
soon as lab tests come back normal
 Because patient is on warfarin a consult
for warfarin management was requested.

Medications List noted by the Nurse..








Synthroid 120 mcg every day
Warfarin 5 mg orally every other day
Vitamin E 1000 I.U. orally everyday
Digoxin 0.25 mg orally everyday
Clonidine 0.05 mg orally everyday
Hydrochlrorothiazide 25 mg orally everyday
Dofetilide 250 mcg orally two times a day
Aspirin 1 tablet once daily
In ED…


BP: 156/102, HR: 110 bpm and irregular, afebrile
and in no acute distress.
Ordered labs:
 BMP,
lipid profile, renal function, hematological tests,
glucose, albumin, prealbumin, PT/INR, TSH
Lab Results








Hgb =14 g/dl, HCt=42%, Plt =350K, PT=16, INR 1.4
stool guaiac –ve
BMP: Na 136 mEq/L, K 3.8, Sr Cr= 1.1 mg/dl, BUN 14
mg/dL
Lipid profile: TC 250 mg/dl, HDL= 35 mg/dL, TG=200
mg/dl
Glucose: 88 mg/dL
Prealbumin=25mg/dl
Albumin=3.7 g/dl
TSH= 0.25 microunits/mL
the start….



You are the pharmacist assigned to the internal
medicine ward
You were consulted to manage Mr. SR
anticoagulation.
Patient SR in room 5 bed 5 insist on the Nurse that
he should be getting his blood thinner medication
this morning and it is already noon.
Which of the following is the best
approach at this time?
A.
B.
C.
You should review the patient file, see the patient
and counsel him on warfarin and write your note in
patient file
You should interview the patient, counsel him on
warfarin therapy and write your note in patient file
At this time it is better to only collect information
The Patient Care Process
Three major steps in the patient care
process are:
Continuous

Assessment
• Signs & symptoms
Care Plan
• Goals of Therapy
Follow-Up
Evaluation
• Patient outcomes
Assessment-Why?

To Know your patient by understanding his/her
medication experience before making any
decisions about his/her drug therapy.

To understand the patient well enough to make
rational drug therapy decisions with and for the
patient.
The most important and crucial step.
What decisions should come out of the
assessment?
1.
2.
Are each of the patient’s drug therapies
appropriately indicated, effective, safe,
and is the patient compliant.
Are any drug therapy problems present?
What skills you need to accomplish
assessment part?

MEETING THE PATIENT
 Introducing
Yourself
 The Physical Environment
 Taking Notes

Inquiry
 open-ended



questions
listening
Observational skills
Knowledge
How to conduct the assessment part ?

Step 1: Collection of Patient-Specific Information

Step 2: Assessment of Drug-Related Needs


Pharmacotherapy Workup
Step 3: identifying Drug related problems

Pharmacotherapy Workup
What information is sought during the
assessment

Step 1: Collection of Patient-Specific Information
Sources of Patient data
 Primary sources of information:
 Patient
 Family
 Caregivers
 Texts
 Literature
 Other sources of information:
 Prescribers
 Medication profiles
 Medical chart
 Laboratory test results
Pages 294-295
How does Age influence Drug therapy
decision?
 risk of diseases changes with age.
 risk of exposure to various drugs is different with
age.
 Dosage requirements vary greatly with age.
 Absorption, metabolism, and elimination of most
drugs changes with age.
 Different age groups have different medical
problems and different goals of therapy.
 Frequency and severity of drug therapy problems
change with age.
Age groups

Patient ages are grouped as:
 infants
(birth to 12 months)
 children (1–2 up to 11–12 years)
 adolescents (11–18 years)
 adults, (18-<65)
 elderly (65 and older)
How does Gender influence Drug
therapy decision?
 Gender can influence disease risk and frequency.
 Hypothyroidism, anemia, and osteoporosis requiring drug
therapy are more common in females.
 Cardiovascular disorders requiring drug therapy management
develop more often in adult males.
How does Pregnancy influence Drug
therapy decision?
 Teratogenicity of certain drugs
 additional needs for vitamins and other supplements.
 Some medical condition may develop because of
pregnancy such as gestational diabetes,
hypertension, pre-eclampsia, thromboembolic events.
 Infant safety must be considered before adding any
medication to a nursing mother's regimen.
 Postpartum depression can require short-term
management with medications.
How does Occupation influence Drug
therapy decision?
 Medications that can cause central nervous system
depression, drowsiness, or confusion may interfere with
patients' ability to concentrate or make judgments
required in their jobs.
 Some occupations restrict medications that employees
are allowed to use to manage illnesses. Examples
include airline pilots, police, and other safety officers.
How does Living Arrangement
influence Drug therapy decision?


Family support and to assist with
drug administration.
household members maybe be
exposed to medications known to be
potentially dangerous.
 Young children in the house.
Patient Height and weight information


Much of the drug dosing literature considers a normal
or average adult body weight to be 70 kg and a
body surface area of 1.73 m2.
Some medications are dosed based on Lean body
weight.
Back to Patient SR…
What do you know about the
patient??
SR the Person..




SR is a retired bus driver of black ethnicity.
He lives alone. His wife passed away one year ago.
His wife used to oversee everything about his
medications and health issues. Ever since she died
he had trouble managing his medications.
He has 2 daughters who resides in another part of
the country.
His neighbor, is becoming his companion ever since
his wife died.
SR the Person..


SR is a smoker, 1-2 packs per day for the past 20
years, he doesn’t drink alcohol.
He also mentioned that it is difficult to prepare his
meals, so he eats at the nearby local dinner most
days of the week.
You now know Mr. SR…
anything else you need to know or
should you proceed with step
2:patient drug related need??
How about patient
medications at home??
SR Medication Taking Behavior






Synthroid 120 mcg every day
Synthroid 120 mcg every day (bottle is almost full
although the label indicate that it was filled 3 months
ago) >> patient doesn’t know why he is taking it
Warfarin 5 mg orally every other day
Warfarin 5 mg orally everyday Monday through
Saturday
Vitamin E 1000 I.U. orally everyday
Vitamin E 1000 I.U. orally everyday. Vit E which his
wife recommended to help his heart
SR Medication Taking Behavior








Aspirin 1 tablet once daily
Aspirin 81 mg orally everyday
Ibuprofen 200 mg tablets (1-2 tab/wk)
Multivitamin
Digoxin 0.25 mg orally everyday
Clonidine 0.05 mg orally everyday
Hydrochlrorothiazide 25 mg orally everyday
Dofetilide 250 mcg orally two times a day
The Effective assessment

Step 2: Assessment of Drug-Related
Needs
Indication
Drug
Product
Dosage
Regimen
appropriate
Outcomes
Safe drug
Effective drug
and dose
Evaluating the Appropriateness of the
Indication
Avoid assuming what the indication might
be from knowing only the drug product
 Drug therapy:

 Prescriber
initiated (Rx)
 Patient initiated (OTC, others)
Student Interaction
•
How would you know the appropriateness of the indication
of patient’s drug therapy?
•
•
•
•
Written on the prescription or patient medical record
Communication with the prescriber
The patient
The patient care giver
Why is it important to determine the
intended indication?
To assess the effectiveness or safety of a
drug product
To establish goals of therapy
Example
Diagnosis






Hypertension
chronic obstructive
pulmonary disease
(COPD)
Depression
osteoporosis
Gout
GERD
Medication List








HCTZ, 25 mg PO daily
Lisinopril, 40 mg PO daily
Fosamax, 70 mg PO q
week
Colchicine, 0.6 mg PO
QOD
Pepcid, 20 mg PO BID
Klonopin, 0.5 mg PO BID
Zoloft, 50 mg PO daily
Combivent, 2 puffs QID
Example
Hypertension


HCTZ, 25 mg PO daily
Lisinopril, 40 mg PO
daily
COPD

Combivent, 2 puffs QID
Depression
• Klonopin, 0.5 mg PO BID
• Zoloft, 50 mg PO daily
Osteoporosis
• Fosamax, 70 mg PO q week
GERD
• Pepcid, 20 mg PO BID
Gout
• Colchicine, 0.6 mg PO QOD
Determining the Effectiveness of the
Drug Regimen
Signs & Symptoms
Abnormal Laboratory Values
Labs
Goals of Therapy
Indication
Drug product
Dosage regimen
Clinical
Effectiveness
Outcomes
Student Interaction
•
How would you know the effectiveness of the drug
therapy?
•
•
•
•
patient is taking the best product
Patient is taking the drug at the effective dosage
patient's response: clinical (S&S), lab value
desired goals of therapy for each indication are
reached
Student Interaction
What would you consider to determine the effectiveness of the
drug therapy?



Is it the best drug? (EBM)
 Clinical practice guidelines
 Primary literature
 Pharmacotherapy textbooks
Is it the effective dosage?
 Patient factors (age, wt, organ fxn, comorbidities,
patient medication list, etc)
 Effective clinical trial of the drug was established
Patient response/desired goal:
 Subjective and Objectives parameters
 Lab values
For Patient S.R. hypertension problem
Is
the patient receiving the best drug
therapy?
Is the dosage regimen appropriate?
What is the goal of therapy?
Is the drug therapy effective?
Establishing the Safety of the Drug
Regimen
Signs & Symptoms
Abnormal Laboratory Values
Labs
Goals of Therapy
Indication
Drug product
Adverse Drug Reaction
Dosage regimen
Toxicity
Clinical
Effectiveness
Outcomes
Safety
Labs
Clinical
Student Interaction







If you knew that patient BP at diagnosis was
160/104 mmHg.
His BL goal was set as 110-138/70-88 mmHg.
He was prescribed HCTZ 25 mg qd .
2 weeks later, his BP in the clinic was 152/98
No adjustment in dose was made.
2 weeks later, BP was 148/96 mmHg
How would you determine therapy outcomes
(effectiveness and safety), gaps
Understanding Patient Compliance



Assess indication, effectiveness, and safety issues
before evaluating the patient's compliance.
Non-compliance describes the behavior of the
patient.
noncompliant patient
 someone
who is not able or willing to take an
appropriate, effective, and safe medication as intended
Assessment

Step 3: identifying Drug related
problems “Pharmacotherapy Workup”
Drug therapy problems
Drug therapy problems
Effectiveness
Indication
Drug product
Drug therapy problems
Dosage regimen
Outcomes
Drug therapy problems
Safety
DRP vs. Medication Error

Which of the following is true?
 DRP
is a type of medication error
 DRP is a medical problem
 DRP is a consequence of drug-related needs that have
gone unmet
 All of the above are true
What is Drug therapy Problem?

Any undesirable event experienced
by a patient which involves, or is
suspected to involve, drug therapy,
and that interferes with achieving the
desired goals of therapy .
Physician
Pharmacist
Diagnosis
Identification of DRP
Drug related Problems are Not Medication Error

DRPs are Not Medication Error
Medication Errors:
Focuses on prescribing & dispensing
accuracy
 describe
the correct drug, correct dose, correct route,
correct frequency, and correct duration (or the 5 R’s)
Patients have drug therapy
problems
Drug products do not have drug
therapy problems
DRP vs. Medical Problem

Medical problem:
A
disease state (related to altered physiology)
resulting in clinical evidence of damage
 Diagnosed by physician, nurses and ph. assistance

DRP:
 Developed
out of medical problems
 a problem a patient has that is either caused or can be
treated with a drug
 Pharmacists and other providers
Rovers & Currie. A practical guide to pharmaceutical care: a clinical skills primer
Identification of DRP

Pharmacists identify DRP during:
Routine
filling of a prescription
Organized
approach as part of
pharmaceutical care practice
How to describe DRP?

"Mr. M.'s elbow pain is not being effectively
controlled because the dosage of ketoprofen he
has been taking for the past three days is too low
to provide relief."
Components of DTP

"Mr. M.'s elbow pain (a problem) is not
being effectively controlled because the
dosage of ketoprofen (a product /dosage
regimen) he has been taking for the past
three days is too low to provide relief
(relationship)“
Does it matter how to state the DRP?

Proper terminology ….. implies
cause and effect…. better
intervention to resolve
– 29-year-old patient is having continued
breakthrough seizures due to subtherapeutic
phenytoin concentrations
requires an increase in the patient's phenytoin dosage
– 29-year-old patient is noncompliant with
phenytoin therapy as she forgets to take her
medication, and she is experiencing
continued seizure activity
providing the patient with a daily medication reminder
device or a medication diary to help keep track of her
medication use
Patient needs vs. drug related
problems
 Appropriate
indication for each medication
 Unnecessary drug therapy
 An
effective drug product
 Wrong drug, low dose
A
safe drug product
 ADR or high dose
 Be
able to use and comply with the drug regimen
 Inappropriate compliance the drug regimen
 Receive
drug therapy for untreated conditions
 Need additional drug therapy
Categories of drug therapy problems


INDICATION
 Unnecessary drug
therapy
 Needs additional
drug therapy
EFFECTIVENESS
 Ineffective drug
 Dosage too low


SAFETY
 Adverse drug
reaction
 Dosage too high
COMPLIANCE
 Noncompliance
Why is it important to categorize DRP?




To develop a systematic process of problem solving.
To clarify the professional responsibilities and
accountability of the pharmaceutical care
practitioner
To match the proactive nature of pharmaceutical
care practice (identify, resolve and prevent)
To provide the clinical work of the pharmaceutical
care practitioner with a vocabulary consistent with
that used by other healthcare professionals
Drug Therapy
Problem
Unnecessary Drug
Therapy
Needs Additional Drug
Therapy
Description of the Drug Therapy
Problem
The drug therapy is unnecessary because the
patient does not have a clinical indication at this
time
Additional drug therapy is required to treat or
prevent a medical condition
Ineffective Drug
The drug product is not being effective at
producing the desired response
Dosage too low
The dosage is too low to produce the desired
response
Adverse Drug Reaction
The drug is causing an adverse reaction
Dosage too high
The dosage is too high, resulting in undesirable
effects
Non-compliance
The patient is not taking the drug regimen
appropriately
Causes of DRP
1. Drug Unnecessary





no valid medical indication for the drug therapy at this
time.
Multiple drug products are being used for a condition
that requires single drug therapy.
The medical condition is more appropriately treated
with nondrug therapy.
Drug therapy is being taken to treat an avoidable
adverse reaction associated with another medication.
Drug abuse, alcohol use, or smoking is causing the
problem
Example

The patient is taking three different laxative
products in an attempt to treat his constipation
2. Drug Needs to be Added

A medical condition requires the initiation of drug
therapy.

Preventive drug therapy is required to reduce the risk
of developing a new condition.

A medical condition requires additional
pharmacotherapy to attain synergistic or additive
effects
Example

Prevention is a major objective of pharmaceutical
care practice
3. Ineffective Drug

The drug product is not the most effective for the
indication being treated.

The medical condition is refractory to the drug product.

The dosage form of the drug product is inappropriate.

The drug is not effective for the medical problem
Example

JT's hypertrigylceridemia is not being effectively treated
with Colestid (colestipol) 8 grams two times daily because
this drug is not effective at reducing high levels of
triglycerides.

if a drug product is thought to be the first line therapy or
the "drug of choice," it will not be effective for all patients
4. Dosage Too Low

The dose is too low to produce the desired response.

The dosage interval is too infrequent to produce the
desired response.

A drug interaction reduces the amount of active drug
available.

The duration of drug therapy is too short to produce the
desired response
Example

The patient's 10 mg daily dose of
glipizipe (Glucotrol) is too low to provide
adequate control of her blood glucose
Drugs do not have doses,
people have doses
5. Adverse Drug Reaction






The drug product causes an undesirable reaction
that is not dose-related.
A safer drug product is required due to risk
factors.
A drug interaction causes an undesirable reaction
that is not dose-related.
The dosage regimen was administered or
changed too rapidly.
The drug product causes an allergic reaction.
The drug product is contraindicated due to risk
factors.
Example

The patient has developed a rash covering
his upper torso and arm caused by the
cotrimoxazole he was taking to treat a
wound infection
6. Dosage Too High

Dose is too high.

The dosing frequency is too short.

The duration of drug therapy is too long.

A drug interaction occurs resulting in a toxic
reaction to the drug product.

The dose of the drug was administered too
rapidly
Example

The patient developed bradycardia and second
degree heart block resulting from a 0.5 mg daily
dose of digoxin used for congestive heart
failure. This dose was too high for his advanced
age and declining renal function.
7. Noncompliance






The patient does not understand the instructions.
The patient prefers not to take the medication.
The patient forgets to take the medication.
The drug product is too expensive for the
patient.
The patient cannot swallow or self-administer
the drug product appropriately.
The drug product is not available for the patient.
Example

The patient is not able to remember to instill her
timolol eye drops twice daily for her glaucoma

The cause, or reason, for noncompliance
determines the interventions and care that are
necessary to alter or improve the patient's
behavior.
Example

patient stops taking a drug because it was not
being effective
 an
effectiveness problem—not a compliance
problem.

patient stopped taking her medication because it
was making her too dizzy to stand up
 likely
a safety problem and not a compliance
problem
What if you didn’t find any DRP?





all the patient's drug therapies are clinically
indicated
the dosage regimens are producing the desired
results
and they are not causing any intolerable side
effects
patient understands, agrees with, and is compliant
with all of his/her drug regimens and instructions
all of the patient's drug-related needs are being
met, and no adjustments in drug products or drug
dosage regimens are required
Patient with No DRP

require a care plan and follow-up evaluation to
ensure that goals of therapy continue to be met and
no new drug therapy problems develop.
How to state DRP?

Identifying DRP add new information to patient
case
1.
The patient’s problem
2.
The drug therapy involved
3.
The relationship (cause and effect)
PRIORITIZING DRUG THERAPY
PROBLEMS

prioritization depends upon
 the
extent of the potential harm each problem might
inflict on the patient
 the
patient's perception of the potential harm
 the
rate at which this harm is likely to occur
After prioritization Consider the
following questions

Which problems must be resolved (or prevented)
immediately and which can wait

Which problems can be resolved by the practitioner
and patient directly

Which require the interventions by someone else
(perhaps a family member, physician, nurse, or some
other specialist)
Categorization of DRP
Communication Tip
 Pay attention to words used to communicate DRP to
non-pharmacists
 Wrong
drug
 Duration in appropriate



Negative connotation
Some people may feel personally criticized
Rephrasing to more socially acceptable terms
Exercise

Rephrase the following DRP to a more accepted
statement:
A
patient with migraine headache has been
prescribed acetaminophen with codeine 30 mg but is
still bothered by painful headaches.


DRP: wrong drug
When communicating with other healthcare providers:
Patient in not having an adequate therapeutic
response, a change in her medication may be beneficial
Actual vs. Potential DRP

Some drug therapy problem cannot be
determined without additional information

Physician response varies with the DRP viewed
as actual or potential
 Actual:
already occurred >>>>>>> resolve
 Potential:
likely to occur if pharmacist didn’t intervene
>>>>>> Prevent
Actual vs. Potential DRP


Contact physician if the consequence of DRP is
serious.
to deal with physician refusal to act on a
potential DRP:
Monitor the patient and educate them on what
to watch for and when to call for help
 Avoid damaging physician-patient relationship

Example

A pharmacist is counseling a patient about a
new amoxicillin prescription and he learned
that he has a history of immediate
hypersensitivity reaction to penicillin
Documenting DRP

each problem identified is added to the patient's
record and includes
 the
medical condition, illness, or complaint involved
 the drug therapy or therapies involved
 the likely cause of the drug therapy problem and
 the interventions required to resolve the drug therapy
problem
Documenting DRP

In some occasions when DRP resolution
prevented a hospitalization or death or
associated to less cost to the patient need to
be recorded.