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SECOND EDITION
MAC 2024

Published by:
Pharmaceutical Services Programme
Ministry of Health Malaysia
Lot 36, Jalan Prof Diraja Ungku Aziz,
46200 Petaling Jaya,
Selangor, Malaysia
Tel: 603-7841 3200
Website: www.pharmacy.gov.my

© All Rights Reserved

This document is copyrighted. The publication of the Neurology Medication Therapy
Adherence Clinic Protocol was coordinated by the Pharmaceutical Care Branch of the
Pharmacy Practice & Development Division, Ministry of Health Malaysia. The publisher
reserves copyright and renewal on all published materials and such material may not be
reproduced in any form without permission from the publisher.

Disclaimer

This protocol is designed to serve as a guide for pharmacists managing neurology pharmacy
services. All information presented in this protocol is constantly evolving concurrently with
ongoing research and clinical experiences, which are often subjected to professional
judgements and interpretation according to specific clinical situations. The editors and
publisher of this protocol have made every effort to ensure the accuracy and completeness
of the contents. However, the editors and publisher are not responsible for any errors or
omissions, and/or consequences arising from the use of this pocket guide. The application of
information from this protocol in any situation remains the professional responsibility of the
practitioner.
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 PREFACE
YBrs. Hajjah Wan Noraimi Binti Wan Ibrahim
Director of Pharmacy Practice and Development Division
Pharmaceutical Services Programme
Ministry of Health

Welcome to the Neurology Medication Therapy Adherence Clinic

Protocol second edition 2024. This document has been meticulously crafted
to serve as a comprehensive guide for pharmacist involved in the management
of neurological conditions.

Neurological disorders present unique challenges and effective management

often hinges on the precise and consistent adherence to prescribed medication
regimens. The medication therapy adherence clinic (MTAC) is designed to
address the multifaceted aspects of neurology patients’ care, emphasizing the
critical role that adherence plays in achieving optimal outcomes.

This protocol encompasses a synthesis of evidence-based practices, clinical insights and collaboratives
strategies aimed at enhancing medication adherence among neurology patients. By adopting this
protocol, pharmacist and other healthcare providers can streamline their approach, foster patient
engagement and ultimately improve the overall quality of care provided within the realm of neurology.

A heartfelt appreciation is extended to the editorial committee for their hard work and contributions to
the publication of this protocol. We acknowledge the dedication and expertise of healthcare providers
involved in neurological care and express our gratitude for their commitment to improving patient
outcomes. Together, lets us continue to advance the standards of care for neurology patients through the
Neurology Medication Therapy Adherence Clinic Protocol.
 EDITORIAL BOARD

ADVISOR

HAJJAH WAN NORAIMI BINTI WAN IBRAHIM

Director
Pharmacy Practice and Development Division
Pharmaceutical Services Programme
Ministry of Health Malaysia

REVIEWER

SYAHIDA BINTI CHE EMBI MASFIZA BINTI ABDUL HAMID

Deputy Director Senior Principal Assistant Director
Pharmacy Practice and Development Division Pharmacy Practice and Development Division
Pharmaceutical Services Programme Pharmaceutical Services Programme
Ministry of Health Malaysia Ministry of Health Malaysia

EDITORIAL COMMITTEE

DR. ALIZA BINTI ALIAS

Senior Principal Assistant Director
Pharmacy Practice and Development Division
Pharmaceutical Services Programme
Ministry of Health Malaysia

PARIMALA VIJAI INDRIAN HO CHEE WAH

Pharmacist Pharmacist
Hospital Tengku Ampuan Rahimah Hospital Raja Permaisuri Bainun

ZIRAN NADIAH BINTI GHAZALI SITI HAJAR BINTI RAZALI

Pharmacist Pharmacist
Hospital Kuala Lumpur Hospital Sultanah Nur Zahirah

CHEW BENG HOONG

Pharmacist
Hospital Pulau Pinang
TABLE OF CONTENTS

PREFACE ................................................................................................................................................
EDITORIAL BOARD .................................................................................................................................
1 OVERVIEW ................................................................................................................................... 1
1.1 Introduction ................................................................................................................................. 1
1.2 General Objective ........................................................................................................................ 2
1.3 Scope of Service ........................................................................................................................... 2
1.4 Types of Neurology MTAC ........................................................................................................... 3
1.5 Location and Setting of Service ................................................................................................... 3
1.6 Manpower Requirement ............................................................................................................. 3
1.7 Procedure .................................................................................................................................... 3
1.7.1 Workflow ............................................................................................................................. 3
1.7.2 Patient Selection .................................................................................................................. 4
1.7.3 Registration.......................................................................................................................... 4
1.7.4 Appointment and Missed Visit (s)........................................................................................ 4
1.7.5 Activities during MTAC Session............................................................................................ 5
1.7.6 Documentation .................................................................................................................... 6
1.7.7 Outcome Measures ............................................................................................................. 6
2 STROKE ........................................................................................................................................ 7
2.1 Introduction ................................................................................................................................. 7
2.2 Objectives .................................................................................................................................... 8
2.3 Treatment Goals/Outcomes ........................................................................................................ 8
2.4 Patient Criteria............................................................................................................................. 9
2.5 Procedure .................................................................................................................................... 9
2.5.1 Appointment........................................................................................................................ 9
2.5.2 Missed Appointment ........................................................................................................... 9
2.5.3 Teleconsultation .................................................................................................................. 9
2.5.4 Activities and Outcome Measures ..................................................................................... 10
2.5.5 Education Outline for Stroke Patient ................................................................................. 11
2.5.6 Discharge Criteria .............................................................................................................. 12
2.6 References ................................................................................................................................. 13
3 EPILEPSY..................................................................................................................................... 15
3.1 Introduction ............................................................................................................................... 15
3.2 Objectives .................................................................................................................................. 17
3.3 Patient Criteria........................................................................................................................... 17
 3.4 Treatment goals ......................................................................................................................... 17
3.5 Specific Monitoring Parameters/Activities ................................................................................ 18
3.6 Education Outline for Patient with Epilepsy .............................................................................. 18
3.7 Outcome Measures ................................................................................................................... 19
3.8 Discharge Criteria ...................................................................................................................... 19
3.9 References ................................................................................................................................. 20
4 PARKINSON’S DISEASE (PD) ........................................................................................................ 21
4.1 Introduction ............................................................................................................................... 21
4.2 Objective.................................................................................................................................... 22
4.3 Treatment Goal/Outcome ......................................................................................................... 22
4.4 Patient Criteria........................................................................................................................... 22
4.5 Activities & Outcome Measures ................................................................................................ 23
4.6 Education Outline for Patient with Parkinson’s Disease............................................................ 24
4.7 Discharge Criteria ...................................................................................................................... 24
4.8 References ................................................................................................................................. 25
APPENDICES....................................................................................................................................... 26
Appendix 1: Workflow for Initial Visit.................................................................................................... 27
Appendix 2: Workflow for Subsequent Visit ......................................................................................... 28
Appendix 3: Medication Therapy Adherence Clinic (MTAC) Neurology Form ...................................... 29
Appendix 4: Laboratory Values.............................................................................................................. 31
Appendix 5: Epilepsy Evaluation and Medication Review ..................................................................... 33
Appendix 6: Parkinson’s Disease Evaluation & Medication Review ...................................................... 35
Appendix 7: Parkinson’s Disease Patient’s On & Off Chart ................................................................... 37

2
1 OVERVIEW

1.1 Introduction

Neurological diseases are often multifactorial, involving different biological systems

within a single disease spectrum and resulting from nonlinear interplay of risk genes,
dynamic biological determinants, and environmental factors (Hampel et al., 2023). Also,
neurological diseases in particular can have extensive consequences on the physical,
emotional and cognitive level. Patients have to cope with symptoms, treatments,
functional impairment, comorbidity and uncertainty about the course of the disease
(Kristofferzon et al., 2018). For neurological diseases especially chronic in nature,
adherence to medication is the central pillar of treatment (Franke et al., 2021).
Medication management of neurologic disorders can be challenging in an ambulatory
care setting, which require close monitoring due to multiple medication related issues
such as complex titration and tapering schedule, use of multiple agents, unique monitoring
parameters and broad range of potential side effects that may be harmful to the patients.

Medication Therapy Adherence clinics (MTAC) are well established in some areas of
ambulatory care and have been beneficial in treatment aspect of the patient by improving
drug compliance, decreasing inappropriate prescribing and providing positive therapeutic
outcomes by monitoring patients' treatment plans (Alrasheedy et al., 2017). Involvement
of Clinical pharmacists in MTAC can assist with the medication adjustments and improve
laboratory monitoring that are often necessary for these conditions (Darby & Mazyck,
2021) (Martin et al., 2019).

Expansion of clinical pharmacy services in the ambulatory neurology clinic via Neurology
MTAC is a good platform for pharmacist to play their role in extending the provision of
pharmaceutical care to the target group. This updated protocol will outline architecture of
MTAC Neurology, which cover 3 common neurological diseases that have high prevalence
of medication non-adherence namely stroke, epilepsy and Parkinson’s disease at an
ambulatory setting (Junaid Farrukh M, 2021).

1
1.2 General Objective

• To empower patients with knowledge on medications and disease.

• To improve and sustain adherence towards quality use of medications.
• To optimise patients’ pharmacotherapy towards predictive, participatory,
preventive, and personalized (P4) medicine.
• To minimise risk of adverse drug reactions and side effects of medications.

1.3 Scope of Service

Neurology MTAC service will be provided to the patients who are managed in the
Neurology clinic, MOPD clinic or clinic focusing on specific conditions (e.g. Stroke Clinic,
Rehabilitation Clinic, etc.) and patients who fulfil the enrolment criteria. Patients can
either be referred by healthcare professionals or selected by Neurology MTAC
pharmacists.

2
1.4 Types of Neurology MTAC

Currently, there are three (3) types of Neurology MTAC:

a) Stroke,

b) Epilepsy, and

c) Parkinson’s Disease

Each Neurology MTAC protocol comprises of topics, counselling points and monitoring
parameters for specific disorders. It is important to note that the selection of topics and
the number of MTAC sessions should be tailored to individual patient’s needs.

1.5 Location and Setting of Service

The Neurology MTAC service will operate in the clinic area during clinic day. Subsequent
visits can be carried out in either the pharmacy or clinic area whichever deemed suitable
depending on local setting.

1.6 Manpower Requirement

• Neurology MTAC service shall be provided by trained pharmacist(s).

• A minimum of one pharmacist will be required during MTAC session. However, the
number of pharmacists shall depend on the number of patients scheduled per day.
In the case where dispensing is done in Neurology MTAC service, a minimum of
two pharmacists will be required.
• A coordinator may be appointed to facilitate the continuity of the service.

1.7 Procedure

1.7.1 Workflow

Refer Appendix 1 & 2

3
1.7.2 Patient Selection

Criteria for patient selection will depend on specific neurologic conditions. Generally,
patient with the following criteria will be selected:

a) Patients who is not adhering to their medications

b) Patients with drug-related problem, e.g. suboptimal drug therapy, medication

overdose, inappropriate drug therapy etc.

Referral for MTAC between pharmacists will use CP4 form while referral for MTAC from
other healthcare providers will use standard forms in the facility. For Virtual Session (only
allowed for subsequent/follow up visit if deemed suitable). In general, patient that are
having difficulties to attend physical MTAC session following condition below (KKM,
2021):

a) Bedridden patient with caretaker

b) Pediatric patient with parent/caretaker

c) Patient that required frequent monitoring before clinic appointment e.g.

Levodopa timing adjustment, side effect affecting the adherence.

1.7.3 Registration

A registry of all MTAC patients must be maintained.

1.7.4 Appointment and Missed Visit (s)

Appointment

All MTAC appointments shall be scheduled by the MTAC pharmacist using a suitable tool
e.g. calendar, planner, electronic record (e.g. eHIS, PhIS).

Missed visits

Patients shall be contacted by pharmacist or clinic staff if he/she missed any visit to

4
 reschedule the appointment and document in registry.

1.7.5 Activities during MTAC Session

The following activities will be performed by MTAC Pharmacist during MTAC session:
a) Initial Visit

• Discussion with patient on:

§ Introduction to Neurology MTAC & its objectives

§ Anticipated benefits to the patients or caregivers

§ Goals for patient

§ Patient’s specific drug therapy-related needs

§ Patient’s rights and responsibilities in the programme

• Initial assessment of patient’s baseline on:

§ Demographic data

§ Medical / medication history

§ Social / family history

§ Medication knowledge

§ Patient’s understanding of medication & adherence

• Counselling and patient education on the topics listed for respective

neurologic conditions (refer to respective modules).
§ The topics should be delivered at a pace suitable to patient’s knowledge and
understanding.

• Identification of pharmaceutical care issues and communication of

pharmaceutical care plan to the physician and document comprehensive plan
for the subsequent follow-up or visit.

5
 b) Second & Subsequent Visits

Activities during subsequent visits include managing pharmaceutical care issues

and providing patient education. Subsequent visits shall be scheduled based on
patients’ needs, current health status, other clinic visits and medication refill
appointments. MTAC pharmacist should document comprehensive plan for the
subsequent follow-up or visit for the continuity of patient’s care.

In cases where by patients having difficulties or it is impossible for them to attend

the visit (e.g. bedridden due to stroke, restricted daily activities due to movement
disorder), the subsequent visits can be done through virtual session to the
identified caregiver who is directly involve in managing patient’s medication.

1.7.6 Documentation

• All relevant MTAC Forms must be updated during the MTAC sessions and the record
should be kept in the pharmacy department.

• A copy of relevant forms will then be attached together with the patient’s case
notes.

• All type of neurologic conditions (strokes / epilepsy / Parkinson’s disease) will be

using the similar assessment forms with additional form for specific activities for
respective disease.

1.7.7 Outcome Measures

The following measures shall be monitored

• Medications adherence status

• Medication knowledge
• Relevant laboratory investigations/ responses to treatment
• Impact on pharmaceutical care issues identified

6
2 STROKE

2.1 Introduction

Stroke is the leading cause of disability worldwide (Tsao et. al, 2023). The Global Stroke
Fact Sheet released in 2022 reveals that lifetime risk of developing a stroke has increased
by 50% over the last 17 years and now 1 in 4 people is estimated to have a stroke in their
lifetime (Feigin et. al, 2022). In Malaysia, stroke represents a major health concern ranking
as one of the top 10 reasons for hospitalisation and the third leading cause of death (Sin
et. al, 2022). In 2019 there were 47,911 incident cases, 19,928 deaths, 443,995 prevalent
cases, and 512,726 Disability Adjusted Life Years (DALYs) lost due to stroke was reported
in Malaysia (GBD Stroke Collaborators, 2019).

Though the majority of cases do occur in individuals at an advanced age, a persistently

increasing portion of the patient cohorts is affected early in life. Current studies provide
alarming statistics for the incidence of “young” strokes including adolescents (Hwang et.
al, 2021). These concerning trends among young adults are likely due to the increasing
trends in the prevalence of modifiable risk factors amongst this population including
hypertension, hyperlipidemia, obesity and diabetes, highlighting the importance of early
detection and aggressive prevention strategies in the general population at early ages
(Yahya et. al, 2020).

About thirty-six percent of stroke patients recovered independently at discharge while

53% of survivors suffered due to various degrees of physical or cognitive disability, which
may inflict additional social issues affecting the family members in coping with their daily
activities (Chen et. al, 2019). Up to 80% of strokes can be prevented through healthy
lifestyle changes and working with healthcare practitioners to control stroke risk factors
(Sherzai et. al, 2015).

Hypertension (72%), diabetes (47%), hyperlipidaemia (32%) and cigarette smoking (31%)
were the commonest risk factors of stroke in the Malaysian population (Hwong et. al,
2017). Early identification of risk factors and modification of certain behaviour could
decrease stroke incidence and prevent stroke recurrence (Diener & Hankey, 2020).

7
 Awareness on recognising the signs and symptoms of strokes are a necessity for prompt
emergency stroke care can also minimise the chance of getting a stroke, limit the brain
damage as well as the level of disabilities it causes (Ching et. al, 2019, Soto-Cámara et. al,
2020).

The pharmacist as an integral part of the healthcare team can play a significant role in
improving patients’ awareness and knowledge about the disease and medications. A
pharmacist's involvement can improve disease and disability prevention, leading to fewer
physician visits, decrease the need for medical treatment, lower healthcare costs and
most importantly can improve a patient's quality of life.

2.2 Objectives

• To empower patients with knowledge on stroke (e.g. type, sign & symptom, risk factor
and secondary prevention of stroke).
• To improve knowledge and sustain adherence towards medications.
• To optimise pharmacotherapy in order to achieve therapeutic outcomes.
• To reduce risk of adverse drug reactions and side effects of medications.

2.3 Treatment Goals/Outcomes

The following shall be monitored and assessed during MTAC visits:

• Blood pressure and/or blood glucose profile.

• Adherence towards medications for chronic illnesses (myMAAT or any appropriate
tools).
• Medication knowledge (DFIT score).
• Other laboratory parameters e.g. lipid profile, renal profile, liver function test, HbA1c
etc.
• Fagerstrom score for nicotine dependence.

8
2.4 Patient Criteria

Patient who has been diagnosed with stroke with any of the following criteria:

• Recent first or recurrent stroke event with uncontrolled risk factors.

• Patient suspected of having non-adherence towards medication.
• Patient suspected of having poor knowledge on disease and medications.
• Patient who has drug-related problems and suspected adverse drug reactions.
• Patient who are referred by healthcare providers for counseling and close monitoring
i.e. specialist, medical officers, pharmacist, speech therapist.

2.5 Procedure

2.5.1 Appointment

All MTAC appointments will be scheduled and recorded by MTAC pharmacist into the
suitable records e.g. planner, registry book, calendar etc.

For patients who have a logistic issue and are incapable for monthly MTAC follow up),
subsequent visits can be scheduled for every 2 or 3 months.

2.5.2 Missed Appointment

All MTAC patients who missed the visit must be contacted by MTAC pharmacist to
reschedule the appointment. The MTAC pharmacist needs to check the patient’s
medication supply. If the medication is insufficient, the pharmacist should reschedule an
appointment for an earlier date or arrange for the medication to be supplied to the
patient until the new appointment date (whichever suitable).

2.5.3 Teleconsultation

Patients who are recruited into MTAC programme but unable for face-to-face visit will be
contacted by MTAC pharmacist for virtual teleconsultation during each appointment.

MTAC pharmacist must comply with ‘Garis Panduan Pelaksanaan Kaunseling Ubat-

9
 ubatan secara Maya/Virtual’.

MTAC pharmacist must advise patients who are suspected to have unresolved
pharmaceutical care issues to seek medical advice at hospital or nearest clinic instantly.

2.5.4 Activities and Outcome Measures

Monitoring
No Description Of Activity Parameters/ Outcome Measures
Tools
1. Swallowing function - Adherence to medication
● Review suitability and
appropriateness of medication
(types, dosage form etc.)
● Review handling of
medication by patient / - Adherence to medication
caregivers (method and time
of administration time, etc.)
2. Knowledge of medication ● DFIT Score Knowledge of medication
● Assessing patient’s knowledge
using validated tools
3. Adverse drug reaction (ADR) ● Signs & Safety issues
monitoring symptoms of
● Monitoring risk of side effects bleeding
related to medication given ● Liver function
● Renal profile
● Drug specific
ADR

4. Adherence to medication ● MyMAAT Adherence to medication

● Pill count
● Any appropriate
validated tools

10
 Monitoring
No Description Of Activity Parameters/ Outcome Measures
Tools
5. Minimizing risk factors for ● Blood pressure Adherence to medication
prevention of recurrent stroke ● Blood glucose
● Lipid profile
● HbA1c
● INR
6. Lifestyle modification
● Smoking reduction and ● Fagerstrom Smoking cessation
cessation score
● Healthy diet
● Exercise ● Dietary pattern
● Practice and promotion of
complete abstinence from
alcohol

2.5.5 Education Outline for Stroke Patient

No. Visit Education

1. First Visit 1. Brief overview about stroke and stroke subtypes
2. Stroke risk factors
3. Stroke symptoms
4. Specific discussion on drugs as secondary prevention of stroke
(indication, role of each drug and adverse effects)
• Antiplatelet (for ischaemic stroke and transient
ischaemic attack (TIA))
• Lipid lowering therapy
• Antihypertensive drug
• Anticoagulant for cardioembolic stroke
• Insulin or oral antidiabetic medications
5. Therapeutic goal for main parameters: blood pressure, heart
rate, blood glucose level, LDL, HbA1c and INR.

11
 No. Visit Education
2. Second 1. Education on risk factors (hypertension, diabetes mellitus, atrial
Visit fibrillation, ischaemic heart disease, hyperlipidaemia, smoking
cessation (if applicable), alcohol consumption (if applicable),
etc.)
3. Third Visit 1. Stroke complication and prevention
4. Forth Visit 1. Benefit of exercise
2. Basic nutrition and diet control
5. Subseque 1. How to maintain therapeutic goals and long-term plan
nt Visit 2. Revision of treatment goals
3. Specific drug counseling

2.5.6 Discharge Criteria

Patient who fulfilled two (2) of the following criteria can be discharged from MTAC
service:
• Medication knowledge evaluation is satisfactory (DFIT > 80%) and no changes in
treatment regime for at least two (2) visits.
• Therapeutic goals have been achieved, all pharmaceutical issues have been resolved
and no further monitoring is needed.
• Completed the MTAC modules.
• Discharged or transferred out to other facilities.
• Default two (2) consecutive appointments despite being contacted (effort must be
made to contact patient / caregiver by telephone call) or patient requests to exit
MTAC service.

12
2.6 References

1. Tsao CW, Aday AW, Almarzooq ZI, Beaton AZ, Bittencourt MS, Boehme AK, et al. Heart
Disease and Stroke Statistics-2023 Update: A Report From the American Heart
Association. Circulation. 2023;147:e93–e621.
2. Global Stroke Factsheet. International Journal of Stroke. 2022, Vol. 17(1) 18–29.
3. Sin KS, Venketasubramanian N. Stroke Burden in Malaysia. Cerebrovasc Dis Extra. 2022
May-Aug; 12(2): 58–62.
4. GBD 2019 Stroke Collaborators Global, regional, and national burden of stroke and its
risk factors, 1990–2019: a systematic analysis for the Global Burden of Disease Study
2019. Lancet Neurol. 2021 Oct;20((10)):795–820.
5. Hwang WY, Ang SH, Bots ML, Sivasampu S, Selvarajah S, Law WC, Abdul Latif L, Vaartjes
I. Trends of Stroke Incidence and 28-Day All-Cause Mortality after a Stroke in Malaysia:
A Linkage of National Data Sources. Global Heart. 2021; 16(1): 39.
6. Yahya T, Jilani MH, Khan SU, Mszar R, Hassan SZ, Blaha MJ, Blankstein R, Virani SS,
Johansen MC, Vahidy F, Cainzos-Achirica M, Nasir K. Stroke in young adults: Current
trends, opportunities for prevention and pathways forward. American Journal of
Preventive Cardiology 3 (2020) 100085
7. Chen XW, Shafie MN, Aziz ZA, Sidek NN, Musa KI. Trends in stroke outcomes at hospital
discharge in first-ever stroke patients: observations from the Malaysia National Stroke
Registry (2009-2017). J Neurol Sci. 2019;401:130-5.
8. Sherzai AZ & Elkind MS. Advances in stroke prevention. Ann NY Acad Sci. 2015; 1338:
1- 15.
9. Hwong WY, Aziz ZA, Sidek NN, Bots ML, Selvarajah S, Kappelle LJ, Sivasampu S, Vaartjes
I. Prescription of secondary preventive drugs after ischemic stroke: results from the
Malaysian National Stroke Registry. BMC Neurol 2017; 17(1): 203.
10. Diener HC & Hankey GJ. Primary and Secondary Prevention of Ischemic Stroke and
Cerebral Hemorrhage. Journal of the American College of Cardiology volume 75, Issue
15, 21 April 2020, Pages 1804-1818.
11. Ching SM, Chia YC, Chew BN , Soo MJ , Lim HM , Wan Sulaiman WA, Hoo FK, Saw ML,
Ishak A , Palanivelu T, Caruppaiya N & Devaraj NK. Knowledge on the action to be taken
and recognition of symptoms of stroke in a community: findings from the May
Measurement Month 2017 blood pressure screening Programme in Malaysia. BMC
13
 Public Health (2019) 9: 1602.
12. Soto-Cámara RR , J González-Bernal JJ , González-Santos J, Aguilar-Parra JM , Trigueros
R & López-Liria R. Knowledge on Signs and Risk Factors in Stroke Patients. Journal of
Clinical Medicines. 2020 Aug; 9(8): 2557.

14
3 EPILEPSY

3.1 Introduction

The International League Against Epilepsy (ILAE) classification has defined three diagnostic
levels including seizure type, epilepsy type and epilepsy syndrome (Scheffer IE, et al 2017).
Identification of the syndrome is important to provide the guide for medical management
and prognosis. Epilepsy syndromes begin during childhood age of 2-12 years. The childhood
onset syndromes are focal epilepsy, generalized epilepsy syndromes and developmental
and/or epileptic encephalopathies including Lennox–Gastaut syndrome, developmental
epileptic encephalopathy and epileptic encephalopathy or may have generalized seizures
alone, such as epilepsy with myoclonic atonic seizures, or focal/multifocal seizures alone,
such as hemiconvulsion–hemiplegia–epilepsy syndrome and febrile infection-related
epilepsy syndrome (Scheffer et al 2017).

An epileptic seizure as a transient occurrence of signs and/or symptoms due to abnormal

excessive or synchronous neuronal activity in the brain while epilepsy is a disorder of the
brain characterised by an enduring predisposition to generate epileptic seizures that is, a
seizure is an event and epilepsy is the disease involving recurrent unprovoked seizures
(Scheffer et al 2017, Consensus Guidelines on Management of Epilepsy 2017). It is a
neurological disorder due to abnormal electrical activity in the brain which could be caused
by various factors such as brain injury, infection, or genetic predisposition. The condition
normally diagnosed through evaluation of medical history of seizure occurrence, physical
examination and diagnostic test such as electroencephalogram (EEG) or brain imaging.
Although epilepsy is thought to be uncurable, it can be often managed effectively by
targeted medications and lifestyle changes.

Epilepsy is a common neurologic condition that affects the personal quality of life and
which becomes the societal, medical and economic burden. It is often found that care giver
or patients poorly understood or misunderstood regarding this neurologic condition that
some may find wrong non-pharmacologic way to cure this condition such as spiritual or
traditional ways. This resulted to misdiagnosed and improperly treated which later on
causes medical distress and enormous economic burden. In many parts of the world, people
with epilepsy and their families suffer from stigma and discrimination and the risk of
15
premature death in people with epilepsy is up to three times higher than for the general
population (WHO 2023).

Epilepsy is responsible for an enormous amount of suffering, affecting some 50 million

people of all ages (WHO 2023). The estimated proportion of the general population with
active epilepsy at a given time is between 4 and 10 per 1000 people and about 5 million
new cases occur each year (WHO 2023). The prevalence of epilepsy was about 1.5-14.0
per 1000 persons among the Asian countries. The prevalence of lifetime epilepsy in
Malaysia is 7.8 per 1000 persons (Fong et al 2021). Epilepsy is universal and the most
common serious neurological disorder, which accounts for 0.5% of the global burden of
disease (WHO 2023).

Epilepsy is treatable where 70% of patients could respond to treatment with appropriate
use of cost-effective anti-seizure medicines (WHO 2023). Failure to comply with drug
regimens is prevalent amongst patients with epilepsy and the consequence of this, is often
an increased risk of further seizures (Malek et al 2016). The epilepsy treatment gap is
defined as the proportion of people with epilepsy who require treatment but who do not
receive it (Meyer et al 2010). In Malaysia, with multi-racial and socioeconomic disparities
for the access of epileptic treatment and care, the gap of specialty care is imminent. This
may indirectly cause the delay to recognise the type of seizures and hence causes the
inadequate treatment.

Patient with epilepsy are often noncompliant with their medication regimens for variety
reasons. Rate of recurrence of seizures are closely linked to nonadherence to their
medication. The therapeutic effect which is related to the desired antiepileptic medication
concentration in blood can be accessed via the use of therapeutic drug monitoring (TDM).
A complete care with involvement of pharmacist in approaching epilepsy patients has the
potential to improve care and increase the quality of life for those who have epilepsy
(Fountain et al 2011).

Further implementation of educational programme for people with epilepsy would help to
improve medication compliance thereby reducing the risk of unnecessary and preventable
seizures. Pharmacists may educate patient on the importance of adherence to drug therapy
and management of patient’s medication which include proper administration of
16
 medication, dosing interval, proper storage of medication, possible drug-drug interaction
and possible side effects.

3.2 Objectives

• To Individualised approach that is tailored to the patient's needs and circumstances,

considering their ability to access services, personal preferences and coexisting
conditions.

• To maximise the benefits of medication and minimise the adverse effect and
complications resulting from antiepileptic medications

• To improve patient’s adherence towards medication and epilepsy management

3.3 Patient Criteria

Patient who has been diagnosed with epilepsy with the following criteria:

• Newly diagnosed/newly initiated with antiepileptic medications.

• Requires changes in antiepileptic medications.

• Patient with drug-related problems and suspected adverse drug reactions.

• Patient with adherence problems towards antiepileptic medications.

• Patient with uncontrolled seizure or recently discharged from ward.

3.4 Treatment Goals

• To ensure that epilepsy patients are receiving optimal care and treatment results.
• To completely control seizure status without producing unacceptable medication side
effects.
• To reduce the rate of relapses and readmission due to seizure thus improving patient’s
quality of life.

17
3.5 Specific Monitoring Parameters/Activities

• Seizure Control: Seizure Diary (seizure profile, fitting frequency and trigger factors of
seizure)
• Therapeutic Drug Monitoring (Phenytoin, Carbamazepine, Sodium Valproate,
Phenobarbitone)
• Epilepsy specific safety issues – women of childbearing potential

3.6 Education Outline for Patient with Epilepsy

No. Visit Education

1. First Visit 1. Brief overview on epilepsy and types of epilepsy

2. Treatment of epilepsy – past medications / traditional

medication

3. Side effects of medications

4. Importance of adherence to antiepileptic medications

5. Management during and after seizure

6. Occupation and leisure activities: injury prevention,

appropriate driving restrictions or bathing

7. Seizure diary/ chart

8. Understanding of serum drug concentration and its

interpretation
2. Second and 1. Review seizure diary & adherence – re-advice of
subsequent importance of adherence
visits
2. Other suggested additional info:

§ Further explanation on medications (according to

types of medications)

§ Medication storage
§ Complications of seizure attack

18
 No. Visit Education

§ Antiepileptic medications in pregnancy (if relevant). All

female patients of childbearing potential (12–44 years
old) diagnosed with epilepsy

3.7 Outcome Measures

The following measures shall be monitored and assessed during MTAC visits:

• Adherence towards antiepileptic medications.

• Frequency and duration of seizure.

• Medication knowledge (DFIT score).

• Therapeutic Drug Monitoring of antiepileptic medications.

• Other laboratory parameters e.g. renal profile, liver function test etc.

3.8 Discharge Criteria

Patient who fulfilled two (2) or more of the following criteria can be discharged from MTAC
service:
• Medication knowledge evaluation is satisfactory (DFIT > 80%)
• Therapeutic goals have been achieved, no further monitoring is needed
• No seizure attack after stopping antiepileptic for at least two (2) visits.

• Discharged or transferred out to other facilities.

• Defaults two (2) consecutive appointments despite being contacted (effort must be
made to contact patient / caregiver by telephone call) or patient requests to exit
MTAC service.

19
3.9 References

1. Scheffer, I. E., Berkovic, S., Capovilla, G., Connolly, M. B., French, J., Guilhoto, L., Hirsch,
E., Jain, S., Mathern, G. W., Mosh, S. L., Nordli, D. R., Perucca, E., Orn Tomson, T.,
Wiebe, S., Zhang, Y.-H., & Zuberi, S. M. (2017). ILAE classification of the epilepsies:
Position paper of the ILAE Commission for Classification and Terminology. Epilepsia,
58(4), 512–521. https://doi.org/10.1111/epi.13709
2. Consensus Guidelines on Management of Epilepsy 2017, Malaysian Society of
Neuroscience.
3. WHO https://www.who.int/news-room/fact-sheets/detail/epilepsy
4. Fong, Si-Lei and Lim, Kheng-Seang and Tan, LeeAnn and Zainuddin, Nabilah Hanis and
Ho, Jun-Hui and Chia, Zhi-Jien and Choo, Wan-Yuen and Puvanarajah, Santhi Datuk and
Chinnasami, Suganthi and Tee, Sow-Kuan and Raymond, Azman Ali and Law, Wan-
Chung and Tan, Chong-Tin (2021) Prevalence study of epilepsy in Malaysia. Epilepsy
Research, 170. ISSN 0920-1211, DOI
https://doi.org/10.1016/j.eplepsyres.2021.106551.
5. Malek N., Heath C. A., & Greene J. (2016). A review of medication adherence in people
with epilepsy. Acta Neurologica Scandinavica, 135(5), 507–515.
6. Meyer AC, Dua T, Ma J, Saxena S, Birbeck G. (2010) Global disparities in the epilepsy
treatment gap: a systematic re- view. Bull World Health Organ;88:260 –266
7. Fountain NB, Van Ness PC, Swain-Eng R, Tonn S, Bever CT Jr (2011); American Academy
of Neurology Epilepsy Measure Development Panel and the American Medical
Association-Convened Physician Consortium for Performance Improvement
Independent Measure Development Process. Quality improvement in neurology: AAN
epilepsy quality measures: Report of the Quality Measurement and Reporting
Subcommittee of the American Academy of Neurology. Neurology.;76(1):94-9. doi:
10.1212/WNL.0b013e318203e9d1. PMID: 21205698.

20
4 PARKINSON’S DISEASE (PD)

4.1 Introduction

Parkinson’s disease (PD) was described by James Parkinson in his monograph 1817, “An
Essay on the Shaking Palsy”. PD is a neurodegenerative disease, which involves
degeneration of dopaminergic neurons at basal ganglia and causes movement disorder
symptoms. According to the Global Burden of Disease study, 6.2 million patients live with
PD and this frequency will double by 2040. Being chronic and disabling illness, especially
in elders, it imposes great financial burden to PD patients, their families and the
healthcare system. The incidence of Parkinson’s disease has been shown to rise with age,
with rapid increases after the age of 60 years (Orozco et al., 2020).

Globally, disability and death due to PD are increasing faster than for any other
neurological disorder. The prevalence of PD has doubled in the past 25 years (WHO
website). The numbers are likely even higher when the many people living with various
forms of parkinsonism are included, such as those caused by degenerative conditions
(atypical parkinsonism), vascular lesions in the brain or adverse effects of medications
such as neuroleptics. Global estimates in 2019 showed over 8.5 million individuals with
PD. The estimated prevalence is 94 cases per 100,000 people, or approximately 0.3
percent in the general population 40 years of age and older (Pringsheim, et al 2014). The
yearly incidence of new cases ranges from 8 to 18.6 per 100,000 person-years [De Lau &
Breteler, 2006].

Symptoms that occur in PD patients can be divided into motor and non-motor symptoms.
The common motor symptoms are tremor, bradykinesia and rigidity (Postuma et al.,
2015). Pharmacists in Neurology MTAC may help PD patients who suffer from motor
fluctuation complications through better management of medications and subsequently
improve their quality of life.

21
4.2 Objective

• To educate Parkinson’s disease patients towards better understanding of the disease

management
• To increase patients’ adherence towards Parkinson’s disease medication regimen
• To minimise adverse effects or complications resulting from multiple drug regimens
• To work in collaboration with Neurologist and other healthcare professionals in
pharmacotherapy management of Parkinson’s disease patients

4.3 Treatment Goal/Outcome

• Maintain optimum symptom motor control

• Avoid development of motor complications
• Maintain quality of life

4.4 Patient Criteria

Patient who has been diagnosed with Parkinson’s disease with the following criteria:

• Newly diagnosed and initiated with medication.

• Patient suspected of having non-adherence towards medication.

• Patient who has drug-related problems and suspected adverse drug reactions.

• Patient on levodopa therapy with motor fluctuation and dyskinesia.

• Patients referred by healthcare providers, i.e. specialists, medical officers,

pharmacists

22
4.5 Activities & Outcome Measures

Monitoring Parameters /
No. Description of Activity Outcome Measures
Tools
1. Patient education § Assessing patient’s § Medication knowledge
Knowledge of medication knowledge using (DFIT score) and
validated tools adherence towards
medications for
Parkinson’s disease
§ Changes in treatment § Patient’s response
regime after initiation /
adjustment of a
particular medication
regime (if any motor
fluctuation and
dyskinesia)
2. Assessment of motor § Bradykinesia, tremor § History of falls
symptoms and rigidity, swallowing
function
3. Assessment of non-motor § Constipation § Medication knowledge
symptoms (DFIT score) and
adherence towards
medications for
Parkinson’s disease
4. Minimising drug-food § Recent alteration in diet § Patient’s response
interactions (protein intake) and after adjustment of
time of medication protein intake (if any
intake (before or after motor fluctuation and
meal) in patients taking dyskinesia)
levodopa

23
4.6 Education Outline for Patient with Parkinson’s Disease

No. Visit Education

1. First Visit ● Brief overview on Parkinson’s disease and signs and
symptoms
● Treatment goal for Parkinson’s disease
● Medication used for treatment of Parkinson’s disease and
their mechanism
● Side effects of medication
● Food interaction with levodopa therapy
2. Second and ● Review patient’s response on treatment
subsequent ● Management of motor fluctuation, dyskinesia and wearing off
visits in levodopa therapy

4.7 Discharge Criteria

Patient who fulfilled two (2) of the following criteria can be discharged from MTAC service:

• Medication knowledge evaluation is satisfactory (DFIT > 80%) and no changes in

treatment regime for at least two (2) visits.
• Therapeutic goals have been achieved, all pharmaceutical issues have been resolved
and no further monitoring is needed.
• Discharged or transferred out to other facilities.

• Default two (2) consecutive appointments despite being contacted (effort must be
made to contact patient / caregiver by telephone call) or patient requests to exit
MTAC service.

In cases where discharged patients require continuation of MTAC service due to

progression of Parkinson's disease, patients may continue MTAC follow-up by using
previous registration.

24
4.8 References

1. GBD 2016 Neurology Collaborators. Global, regional, and national burden of

neurological disorders, 1990- 2016: A systematic analysis for the global burden of
disease study 2016. Lancet Neurol. 2019;18(5):459-480.
2. Pringsheim, T, Jette, N,Frolkis, A & Steeves, T.D.L. 2014. The Prevalence of Parkinson’s
Disease: A Systematic Review and Meta-analysis. Movement Disorder, 29 (13), 1583-
1590
3. Global health estimates 2020: Disease burden by cause, age, sex by country and by
region, 2000– 2019. Geneva: World Health Organization; 2020.
4. Postuma, R.B, Berg, D, Stern, M, Poewe, W. Olanow, C.W, Oertel, W. Obeso, J, Marek,
K, Litvan, I,Lang, A.E, Halliday, G, Goetz, C,G, Gasser, T.,Dubois, B, Chan, P, Bloem,
B,Adler, C.H & Deuschl, G, 2015. MDS Clinical Diagnostic Criteria for Parkinson’s
Disease.Movement Disorder, 30(12), 1591-1599.
5. Orozco JL, Valderrama-Chaparro JA, Pnilla-Monsalve GD, Molina-Echeverry MI, Castano
AMP, Ariza-Araujo Y, Prada SI, Takeuchi Y, 2020. Parkinson’s Disease Prevalence, Age
Distribution and Staging in Colombia, 12(1).

25
APPENDICES

26
Appendix 1: Workflow for Initial Visit
RESPONSIBILITY

Identify patient Physician/pharmacist/

other HCW

Registration Pharmacist

Initial assessment Pharmacist

Yes
Communicate Pharmacist
Intervention?
with physician

No

Medication counseling Pharmacist

Physician/nurse/MA
Provide next appointment date

Yes
Communicate Pharmacist
with physician Physical visit?

No

Dispense medication and offer for

value added service Pharmacist

Documentation Pharmacist

27
Appendix 2: Workflow for Subsequent Visit
RESPONSIBILITY

Patient come for

follow up

Pharmacist/
Physical visit Virtual/Teleconsultation
Neurology Nurse/MA

Follow Up Assessment Verify patient information Pharmacist/

Neurology Nurse/MA

Follow Up Assessment Pharmacist

yes yes

Communicate
Intervention? Intervention? Pharmacist
with Physician

no no
Medication education & Pharmacist
Counselling

Provide Next Appointment

Date/Discharged Pharmacist

Documentation
Pharmacist

Post-MTAC session is accounted for the session involving pharmacist with other healthcare workers
Subsequent session in virtual involved only pharmacist is considered counselling session

28
Appendix 3: Medication Therapy Adherence Clinic (MTAC) Neurology Form

MEDICATION THERAPY ADHERENCE CLINIC (MTAC) NEUROLOGY

PATIENT DEMOGRAPHIC
Patient Name Gender Male / Female

MRN/ID no Race M / C / I / Others: ____

Age Allergy

Diagnosis Contact no

Date of recruitment
FAMILY AND SOCIAL HISTORY
Marital status Single / Married / Divorced / Widowed
No of children
Lives with Alone / Family members / Nursing homes / Others: _________________
Family history

Smoking status Yes: _______ sticks/day

No / Ex-smoker / Passive smoking
Alcohol intake Yes: ________ (amount)/day
No / Ex-alcoholic
Drug abuse Yes: _________
No
Pregnancy Yes: _________
No
Education level Primary / Secondary / Tertiary / Others: ______________________
Diet and lifestyle

MEDICAL HISTORY
Past medical history

Surgical history

29
 MEDICATION THERAPY ADHERENCE CLINIC (MTAC) NEUROLOGY
Diagnostic test

Medication history

Past medication
history and
indication
Non-prescription
medication (includes
herb / vitamin /
supplement &
reasons of taking
CURRENT MEDICATIONS
List of current
medications
DFIT Score

Level of adherence

Pharmacist name &

signature

30
Appendix 4: Laboratory Values

Laboratory Values

No of visit

Date

TDM Level/ drug

BP (mmHg)
PR (bpm) 60-100
RR (bpm) 12-18
Lipid Profile
T. Chol (mmol/l) <5.2
TG (mmol/l) 0.6-2.3
LDL (mmol/l) <1.8
HDL (mmol/l) >1.7
Renal Profile
Urea (mmol/l) 2.8-7.2
Na (mmol/l) 133-145
K (mmol/l) 3.3-5.1
SCr (umol/l) 45-84
CrCl (ml/min)
Liver Profile
T. Protein (g/L) 55-82
Albumin (mg/dl) 35-50
ALP (u/l) 30-120
ALT(u/l) <34
AST (u/l) <37
T. Bilirubin (umol/l) <21
Full Blood Count

31
 Laboratory Values

WBC (x103/uL) 4-11

Hb (g/dL) 13.5-18

Platelet (x103/uL) 150 - 450

Cardiac Enzymes
CK (u/l) 24-195
LDH (u/l) <247
AST (u/l) <45
Coagulation Profile
PT 10.6-15.0 sec
APTT 26-42 sec
INR
Blood Sugar Profile
FBS (mmol/l) 4-6
RBS (mmol/l) 6-8
HbA1c <6.5%
Others
Weight (kg)

32
Appendix 5: Epilepsy Evaluation and Medication Review

EPILESY EVALUATION & MEDICATION REVIEW

Date Visit No

EPILESY EVALUATION & MEDICATION REVIEW

Medication D F I T Remark

Score (%)
D = Dose, F = Frequency, I = Indication, T = Method of Administration

EPILESY EVALUATION & MEDICATION REVIEW

Description of
seizure

Type of seizure

Seizure control Trigger Factor

(since last visit)

Latest TDM result

Adherence status

Fit frequency/ Last

fit
Any adverse
effect(s) of AED?

33
 EPILESY EVALUATION & MEDICATION REVIEW
Pharmaceutical
Care Issue

Pharmacist
Intervention

Outcome/Plan:

Pharmacist Name &

Signature

34
Appendix 6: Parkinson’s Disease Evaluation & Medication Review

PARKINSON’S DISEASE EVALUATION & MEDICATION REVIEW

Date Visit No

PARKINSON’S DISEASE EVALUATION & MEDICATION REVIEW

Disease Motor symptoms • Tremor
Control • Bradykinesia
• Rigidity
• Postural instability
(Time of fall: ___)
• Others: __________________
Non-motor • Constipation
symptoms Current stool consistency (Type: ________ )
Current laxative dose: ______________
• Depression
• REM sleep behavior disorder
• Others: __________________
Medication Levodopa • Dyskinesia • Delayed-ON
Adverse Effect • Hallucination ( ____minutes)
• GI symptoms • OFF
• Others: ____________
Dopamine Agonist • Hallucination • Orthostatic
• Obsessive hypotension
behaviour • Headache
• Insomnia • Others: ____________
Anti- cholinergic • Tremor • Hallucination
• Dry mouth • Blurred vision
• Urinary • Others: ____________
retention

35
 PARKINSON’S DISEASE EVALUATION & MEDICATION REVIEW
Pharmaceutical Care Plan
Pharmaceutical Care Issue Pharmacist’s Outcome
Recommendations / Plan

Pharmacist Name & Signature

36
Appendix 7: Parkinson’s Disease Patient’s On & Off Chart

Date: PATIENT’S ‘ON & OFF’ CHART

Morning (AM) Afternoon (PM) Evening (PM)
MEDICATION D F I T 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2
0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3
– – – – – – – – – – – – – – – – – – – – – – – –
0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4

Score (%)

37
 Date: PATIENT’S ‘ON & OFF’ CHART
STATUS Morning (AM) Afternoon (PM) Evening (PM)

Date of recording: 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2
0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3
– – – – – – – – – – – – – – – – – – – – – – – –
0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4
ASLEEP
OFF

ON without dyskinesia

ON With non-troublesome
dyskinesia

ON with troublesome dyskinesia

Pharmacist’s note:

D = Dose, F = Frequency, I = Indication, T = Method of Administration * 2012 consensus Guidelines for the treatment of Parkinson's disease

38
Published by:
Pharmaceutical Services Programme
Ministry of Health Malaysia

Lot 36, Jalan Prof Diraja Ungku Aziz,

46200 Petaling Jaya,
Selangor, Malaysia
Tel: 603-7841 3200

www.pharmacy.gov.my