DRUG THERAPY MONITORING AND

PHARMACEUTICAL CARE
Drug Therapy Monitoring

One of the fundamental activity of of the clinical pharmacist

working in hospital.

Individualisation of patient drug therapy

Rational usage of drugs

Appropriate drug

Appropriate patient

Appropriate dose

Appropriate route

Appropriate frequency

Appropriate duration
A reliable and responsive drug therapy monitoring
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 of drugs and assist them in obtaining
better therapeutic results.
 Goals

To optimise the drug therapy and patient

outcomes by implementing a strategy involving
fallowing components.

 Collation and interpretation of patient specific information.

 Identification of desired therapeutic outcomes.
 Review of drug therapy.
 Formulation and interpretation of monitoring strategy.
 Review of outcomes.
 Modification of patient monitoring if required.
COMPONENTS OF DRUG THERAPY MONITORING

 Medication order review

 Clinical review

 Pharmacist intervention
Medication Order Review

 It is a fundamental responsibility of a pharmacist to ensure the

appropriateness of medication orders.

 It serves as starting point for other clinical pharmacy activities

( medication counselling, TDM, DI, and ADR).

 Organizing information according to medical problems

helps breakdown a complex situation into its individual parts.
Goal

 To optimise the patients drug therapy.

 To prevent or minimise drug related problems/medication

errors
Procedure:
 The patients 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

 Checking that medication order is written in

accordance with legal and local requirements

Patient name and IP number

Age, gender
Drugs in capitals
Dose, ROA
Frequency
Duration of the treatment
Physician signature
Physician address and phone number
 Ensuring that the medication order is comprehensible
and unambiguous, that appropriate terminology is used
and that drug name are not abbreviated.

 Annotate the chart to provide clarification as required.

 Detecting orders for medication to which the patient may
be hypersensitive/intolerant.
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.

 Checking complete drug profile for medication
duplication, interactions or incompatibilities.

 Ensuring that administration times are appropriate e.g.

with respect to food , other drugs and procedures

 Checking the medication administration record to ensure

that all ordered have been administered.

 Ensuring that the drug administration order clearly

indicates the time at which drug administration is to
commence.
Special considerations should be given especially in short
course therapy as in antibiotics and analgesics.
 Ensuring that the order is cancelled in all sections of
medication administration record when the drug therapy
is intended to cease.

 If appropriate follow up of any non-formulary drug

orders, recommending a formulary equivalent if
required.
 Ensuring appropriate therapy monitoring is implemented.

 Ensuring that all necessary medication is ordered. E.g.

premedication, prophylaxis.

 Reviewing medication for cost effectiveness

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.

 Over dosage.
Medication chart Endorsement

 Another important goal of treatment chart review is to

minimise the risk of medication errors that might occur at
the level of prescribing and / or drug administration.

 A medication error is any preventable error that may lead to

inappropriate medication use or patient harm.

 To prevent potential morbidity and mortality associated with

these errors, pharmacists should systematically review the
medication chart and write annotations on the chart where
the medication orders are unclear.
National Inpatient Medication Chart

 The National Inpatient Medication Chart (NIMC) is a suite

of nationally standard medication charts, both paper and
electronic, that present and communicate information
consistently between healthcare professionals providing
care to patients on the intended use of medicines for an
individual patient.

 Reduces the risk of prescribing, dispensing and

administration error by health professionals through
standardised presentation of information on the intended
use of medicines
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:
The primary aims of the clinical review are to:

 Assess the response to drug treatment.

 Evaluate the safety of the treatment regimen.

 Assess the progress of the disease and the need for any
change in therapy.

 Assess the need for monitoring, if any.

 Assess the convenience of therapy(to improve compliance).

Procedure:

 Collection of patient specific data should be undertaken routinely.

 The data collected should be clinically relevant, and documented

in the pharmacy patient profile.

 Results of biochemical, haematological, microbiological,

radiological and other investigations should be reviewed.

 Information elicited from the patient should also be considered.

Information obtained must be interpreted and evaluated with
reference to

 Clinical features

 Pathological condition

 Indication for investigation

 Patient medication history

 Planned outcomes of therapy

Pharmacist intervention

Any action taken by the pharmacist that directly results in a

change in management or therapy.

Intervention by pharmacist to assist prescribing can be

Active --- Use of therapeutic guidelines

Passive --- Drug information service

Reactive --- Seeking amendment of those that are unclear

inadequate or inappropriate
 Interventions can also be classified in accordance with categories
of drug related problems.

 Documentation of each and every intervention is very important

That document should include the fallowing details

Patient details
Date, ward and pharmacist
Drugs involved
Description about the intervention
Details of response to intervention
Factors determining the success of intervention

 Effective Communication skills

 Appropriateness of the intervention
 Way of approach
PHARMACEUTICAL CARE:

The responsible provision of drug therapy for the purpose of

achieving definite therapeutic outcomes that improve the
patients quality of life.

Pharmaceutical care involves the process through which a

pharmacist cooperates with a patient and other professional in
designing , implementation, and monitoring a therapeutic plan
that will produce specific therapeutic outcomes for the patient
Outcomes Of Pharmaceutical Care:

 Cure of a disease
 Elimination or reduction of patients symptomology
 Arresting or slowing of a disease process
 Preventing a disease or symptoms
Major functions of pharmaceutical care

 Identifying potential and actual drug related problems

 Resolving actual drug related problems

 Preventing potential drug related problems

Skills required for the clinical pharmacist for a better
pharmaceutical care

 He must possess knowledge and skill in pharmaceutics and

clinical pharmacology

 He must be able to mobilize the drug distribution system by which

drug use decisions are implemented

 He must be able to develop relationship with the patients and other

health care professionals needed to provide pharmaceutical care

 He must be available in the society /community for patient in time

 He should have commitment to quality improvement and

assessment procedure
Process of pharmaceutical care

 Establish pharmacist-patient relationship

 Collect data

 Interpret data

 Identify drug related problems

 Determine priority of drug related problems

 Determine desired outcomes(clinical or therapeutic)

 Develop therapeutic plan

 Develop monitoring plan

 Implement and follow up pharmaceutical care plan

Collection of patients data
The pharmacist must collect and generate subjective and
objective information regarding

 The patients general health and activity status

 Past medical history medication history
 Social history
 Diet, exercise
 Education
 History of present illness and
 Economic status

Sources of information may not necessarily the patient

medication records.
Elements of patient information data

 Demographics
 Age, sex, race,
 Height-weight
 Current problems
 Signs and symptoms
 Past medical history
 Allergies and intolerance
 Pregnancy and lactation status
 Social habits
 Economic conditions
 Relevant lab data
Identification of problems

The data collected can be used to identify actual or potential

drug-related problems. Since the main focus of pharmaceutical
care is patient.

Since the pharmacist attends the patient, it follows that the a

pharmacist only can tackle , all drug related problems.
Drug related morbidity:

DRM(drug related morbidity) is a phenomenon of therapeutic

malfunction . It is a failure of a therapeutic agents or
agents together to produce intended therapeutic outcome.

The concept of DRM includes both treatment failure

and production of a new medical problem , like ADR or toxic
drug effect. If DRM is not recognized in time it may lead
to drug related mortality which is ultimate disaster
Some examples of drug related problems:

*New or additional drug required

*Wrong drug
*Too little of the right drug
*Too much of the right drug
*Adverse drug reaction
*Drug not taken appropriately
*Medication not indicated
Establishing outcome goals:

Drug therapy can produce a range of positive clinical outcomes

it may also result in negative outcomes resulting in disease
morbidity and even in extreme case mortality. Clearly the
potential clinical outcomes are related to the disease being
treated and the efficacy of the available drug treatments should
be established.
Evaluating treatment alternatives by monitoring and modifying
therapeutic plan

While evaluating treatment alternatives or therapeutic options the

following factors have to be considered such as
Efficacy and safety
Availability
Cost of treatment and
Suitability of the treatment to the patient .

Efficacy and safety must be considered when evaluating the risk benefit
ratio of a particular treatment. The risk -benefit ratio will depend upon
many factors.
Factors Determining Risk Benefit Ratio

Seriousness of disease
Consequences of not treating the disease
The efficacy of the drug.
ADRs associated with the drug therapy
Efficacy of alternative drug or non-drug therapy
Side effect profile of alternative drugs.

 The pharmacists role especially clinical pharmacists role is

increasingly becoming more evident in evaluating therapeutic
options, modifying and monitoring therapeutic plan.
Individualisation of drug regimen:

Patient factors
 Diagnosis
 Treatment goals
 Physiological and pathological factors
 Past medical history, past medicines received
 Contraindication
 Allergies and adverse effects
 Patient compliance
 Patients cooperation and convenience
 Special consideration
Drug factors

 Efficacy
 Adverse effects
 Prevalence and ability to minimize ADRs
 Ability to monitor for efficacy and avoid ADR
 Drug-drug interactions
 Pharmacokinetics and pharmacodynamics
 Dosage form
 Route and method of administration
 Cost to the patient
 Government or insurance company payments,
presentation of bills in their formats.
Monitoring outcome:
The pharmacist regularly reviews subjective and objective
monitoring parameters in order to determine if satisfactory
progress is being made toward achieving desired outcomes
as outlined in the drug therapy plan.

The pharmacist reviews ongoing progress in achieving

desired outcomes with the patient and provides a report to
the patient's other healthcare providers as appropriate
The pharmacist updates the patient's medical and/or pharmacy
record with information concerning patient progress, noting the
subjective and objective information which has been considered,
his/her assessment of the patient's current progress, the
patient's assessment of his/her current progress, and any
modifications that are being made to the plan. Communications
with other healthcare providers should also be noted.