INTRODUCTION TO CLINICAL

PHARMACY
 Health Care System
• Composed of physician (including other medical and dental staffs), pharmacist , nurse
and other paramedics

• Physician ; diagnosis, prescription, monitoring, medical care

• Pharmacist; prescription*, dispensing, counseling, monitoring, pharmaceutical

care

• Nurse ; administering, monitoring, nursing care

PERCEPTION ABOUT PHARMACISTS

“A BUNCH OF SHOP-KEEPERS”
PERCEPTION ABOUT PHARMACISTS

“THEY JUST COUNT A FEW TABLETS”

PERCEPTION ABOUT PHARMACISTS

“TELL ME HOW AND WHEN TO USE THE MEDICINE”

 PERCEPTION ABOUT PHARMACISTS

“NOT REALLY HEALTH CARE PRACTITIONERS – THEY’RE BUSINESSMEN”

 Introduction; Clinical Pharmacy

Clinical pharmacy is a branch of pharmacy focused on optimizing patient care through the safe and
effective use of medications. It involves direct interaction with patients and healthcare teams to
manage medication therapy, monitor drug efficacy and safety, and provide education about
medications. Clinical pharmacists work in various settings, including hospitals, clinics, and
community health environments, aiming to improve health outcomes and minimize medication-
related issues. Their expertise is vital in developing personalized treatment plans and ensuring
adherence to therapies.
 Introduction; Clinical Pharmacy

Clinical pharmacy may be defined as the science and practice of rationale use of medications,
where the pharmacists are more oriented towards the patient care rationalizing medication therapy
promoting health, wellness of people.

• Abridged Version
• The area of pharmacy concerned with the science and practice of rational medication use.

• Unabridged Version
• Clinical Pharmacy is a health science discipline in which pharmacists provide patient care that
optimizes medication therapy and promotes health, wellness, and disease prevention.
 History
• The history of clinical pharmacy began in the late 19th and early 20th centuries, shifting from a
focus on compounding and dispensing medications to a patient-centered approach.
1. Early 20th Century: Pharmacists started to engage more directly with healthcare teams,
particularly in hospital settings.
2. 1970s and 1980s: Clinical pharmacy education programs were established, and professional
organizations promoted pharmacists' roles in patient care and medication management.
3. 1990s to Present: The field expanded to include outpatient care and specialized practices,
with a strong emphasis on evidence-based medicine and improving patient outcomes.
• Today, clinical pharmacy is recognized as essential to healthcare, focusing on optimizing
medication therapy and enhancing patient care.
 How does clinical pharmacy differ from
pharmacy?

The discipline of pharmacy embraces the knowledge on synthesis, chemistry and

preparation of drugs.

Clinical pharmacy is more oriented to the analysis of population needs with regards to
medicines, ways of administration, patterns of use, drugs effects on the Patients, ‘the
overall drug therapy management’.

The focus of attention moves from the drug to the single patient or population receiving
drugs.
 Level of Action of Clinical Pharmacists

• Clinical pharmacy activities may influence the correct use of medicines at three different
levels: before, during and after the prescription is written.

1. Before the prescription

2. During the prescription
3. After the prescription
 1. Before the prescription

• Clinical trials

• Formularies

• Drug information

• Drug-related policies

• Clinical pharmacists have the potential to implement and influence drug related policies, i.e.
making decisions on which drugs should be included in national and local formularies, which
prescribing policies and treatment guidelines should be implemented.

• Clinical pharmacists are also actively involved in clinical trials at different levels: participating in
ethical committees.
 2. During the prescription

• Clinical pharmacists can influence the attitudes and priorities of prescribers in their

choice of correct treatments.

• The clinical pharmacist monitors, detects and prevents medication related problems.

• The clinical pharmacist pays special attention to the dosage of drugs which need

therapeutic monitoring.
• Community pharmacists can also make prescription decisions directly, when over the

counter drugs are dispensed.

 3. After the prescription

• Counselling
• Preparation of personalised formulation
• Drug use evaluation
• Pharmacovigilance
• Pharmacoeconomic studies
 Activities of Clinical Pharmacists

• The principle activities of a clinical pharmacist include:

Consulting:
Analysing therapies, advising health care practitioners on the correctness of drug therapy.

• Selection of drugs:
Defining "drug formularies" or "limited lists of drugs" in collaboration with hospital doctors, general
practitioners and decision makers.

• Drug information:
Seeking information and critically evaluating scientific literature; organising information services for
both the health care practitioners and the patients.
 Activities of Clinical Pharmacists

• Medication Review
Review medication chart, Review medication history
• Attending Rounds
• Drug use studies and research
collecting data on drug therapies, their costs and patient outcome through structured and scientific
methods.
• Pharmacokinetics/ therapeutic drug monitoring
Studying the kinetics of drugs and optimising the dosage.
• Clinical Trials
Planning, evaluating and participating in clinical trials.
 Activities of Clinical Pharmacists

• Pharmacoeconomics
Using the results of clinical trials and outcome studies to determine cost- effectiveness evaluations.

Teaching & Training:

Pre- and post-graduate teaching and activities to provide training and education programmes for
pharmacists and other health care practitioners
 Functions of Clinical Pharmacists

1. Taking the medical history of the patient 8. Participation in drug utilization studies

2. Patient Education 9. Patient counseling

3. Patient care 10. Therapeutic drug monitoring

4. Formulation and management of drug 11. Drug interaction surveillance

policies
12. Adverse drug reaction reporting
5. Drug information
13. Safe use of drugs
6. Teaching & training to medical and
paramedical staff 14. Disease management cases

7. Research and development 15. Pharmacoeconomics

 Patient Counselling

• Patient counseling is defined as providing medication information orally or in written

form to the patients or their representatives on directions of use, advice on side effects,
precautions, storage, diet and life style modifications.
 Objectives of Patient Counseling
1. Patient should recognize the importance of medication for his well being.
2. A working relationship and a foundation for continuous interaction and consultation
should be established.
3. Patient's understanding of strategies to deal with medication side effects and drug
interactions should be improved.
4. Should ensure better patient compliance.
5. Patient becomes an informed, efficient and active participant in disease treatment and
self care management.
6. The pharmacist should be perceived as a professional who offers pharmaceutical
care.
7. Drug interactions and adverse drug reactions should be prevented.
 Patient Compliance
(Adherence or Persistence)

• Patient compliance describes the degree to which a patient correctly follows medical
advice.
• Most commonly, it refers to medication or drug compliance, but it can also apply to other
situations such as medical device use, self care, self-directed exercises, or therapy
sessions.
 Patient Compliance
(Adherence or Persistence)

• The terms ‘Compliance’, ‘Adherence’, and ‘Persistence’ are used to characterize the patients
behavior with respect to a physicians recommendations and prescriptions.
• Physicians and pharmacists often solely rely on the term ‘compliance’. However, to be compliant,
a patient must be adherent and persistent.
• Compliance: extent to which a patient takes a prescribed medication. (Yes, I am taking my
medication).
• Adherence: Extent to which a patient self administers medication exactly as prescribed. (yes, I
am taking my medication as prescribed, the correct number of drops in the correct eye, at the
correct time of day).
• Persistence: Length of time over which a patient continues to take a medication correctly. (Yes, I
have been taking my medication for the past 6 months as prescribed).
 When is Adherence Important?

• Maintenance of pharmacological effect – antihypertensive drugs

• Maintenance of serum drug concentration to control a particular disorder – anticonvulsants
• To control diseases of public health – HIV, TB
• In chronic diseases
• Contraceptive pills
• Overdose which causes serious health hazards
 Methods to Detect Non-Adherence

• measure blood or urine levels of drugs

• pill count
• Prescription refill
• BP control, asthma severity
• clinic attendance
• Appointment making
• patient interview & diary keeping
 Role of Pharmacist in Patient Compliance

• The role of the pharmacist has widens and it also include identifying drug-related issues and
providing patient consultations regarding drug therapy.
• Medication information should be provided to patients during the counseling session. This
information includes, the common and severe adverse effects, drug interactions and
contraindications and appropriate direction of use by the patient.
• The role of the pharmacists is to warn the patients of the side effects of a drug.
• Pharmacists are engaged in counseling the patient at the time of dispensing medications.
Pharmacists can contribute to patients' safety by advising them of the risks posed by certain
medications.
• Before counseling the pharmacist should review the patient's prescription and nonprescription
drug history. The medication review must include an assessment of any increase in side effects
from any individual drug or drug combinations.
 Clinical Drug Literature

• The pharmacist role as a drug information provider is most significant, Drug information is needed
for health professionals and consumers.

• Drug literature is an extensive heterogeneous collection of resources which provides information

about drugs.

• Clinical drug literature is defined as ‘Clinical drug literature comprises primary, secondary and
tertiary literature that can be applied to optimize the use of drugs in patients’.

• A major objective of professional education is the preparation of the future practitioner for
intelligent and effective use of literature relevant to his professional practice.
 Drug Interactions

Drug interaction is defined as the pharmacological activity of one drug is altered by the
concomitant use of another drug or by the presence of some other substance.

The pharmacological result, either desirable or undesirable, of drugs interacting with

themselves or with other endogenous chemical agents, components of the diet, or with
chemicals used in or resulting from diagnostic tests.
 Drug Interactions
A drug interaction is a situation in which a substance affects the activity of a drug when both are
administered together. This action can be synergistic (when the drugs affect is increased) or
antagonistic (when the drugs effect is decreased) or a new effect can be produced.

Drug interactions may be the result of various processes. Processes may include alterations in the
pharmacokinetics of the drug, such as alterations in the absorption, distribution, metabolism and
excretion of a drug. Alternatively drug interactions may be the result of pharmacodynamics
properties of a drug e.g. the co-administration of a receptor antagonists and agonist for the same
receptor.

• The Drug whose Activity is effected by such an Interaction is called as a “Object drug.”

• The agent which precipitates such an interaction is refered to as the “Precipitant”.

 Laboratory Data Interpretation

• Hematologic testing:
• For patients with hematologic disorders, the following tests may be used:
• Hemoglobin and hematocrit testing: These tests evaluate for anemia, polycythemia vera, and
malignancy.
• White blood cell count: An abnormal number of white blood cells may suggest acute infection,
malignancy, or immunodeficiency states.
• Platelet count: An abnormal platelet count may indicate thrombocytopenia or thrombocytosis.
• Reticulocyte count: Reticulocytes are expected to be elevated in response to anemia.
• Complete Blood Count (CBC):
• A complete blood count or CBC is a blood test that provides several pieces of information
about a person's state of health based on the content of certain components within the blood.
The CBC is one of the most routinely performed laboratory tests. It is a valuable screening tool
for a wide variety of disorders, including:
• anemia,
• infection,
• blood diseases,
• excessive menstrual bleeding, internal bleeding or problems with blood clotting.
• Erythrocyte Sedimentation Rate:
• Anticoagulated blood is placed in a thin tube to stand for two hours. The red blood cells (RBCs)
settle to the bottom of the tube and a top layer of plasma is left in the tube. The result is seen
through the the number of millimeters the RBCs fall in one to two hours. The speed at which the
RBCs fall is determined by the concentration of a number of plasma proteins which rise during
acute illnesses. A high sedimentation rate is a nonspecific, but highly sensitive, indicator for the
presence of organic diseases of all sorts.
 Endocrine
• Diabetes mellitus:
• For patients with diabetes mellitus, the following tests may be used:
• Serum fasting blood glucose and oral glucose tolerance tests: These tests can be used to
diagnose prediabetes and diabetes.
• Hemoglobin A1c test: This test is used to monitor glycemic control. It provides an estimation of the
patient's average glycemic levels in the past 2-3 months. This test was recently approved for use in
the diagnosis of diabetes.
• Urinary albumin excretion (UAE): This test screens for microalbuminuria and overt albuminuria,
which are earlier indicators of diabetic nephropathy than changes in serum creatinine:
• Short term: ACE-inhibitor or ARB therapy may decrease UAE.
• Long term: ACE-inhibitor or ARB therapy
• may reduce progression of diabetic kidney
• disease.
 Thyroid Disease
For patients with thyroid disorders, the following test may be used:
Thyroid-stimulating hormone testing: This test is currently the most commonly used test for
screening and monitoring thyroid disease. With a functioning pituitary gland, elevated TSH reflects
hypothyroidism, and low TSH reflects hyperthyroidism.
Thyroxine (T4) hormone testing: The T4 test can be either a total or free level. Free levels are
unaffected by changes in thyroid-binding globulin. However, free T4 is expensive and has a longer
turnaround time than total T4 levels or TSH. Thyroxine is a precursor to the more active form,
triiodothyronine.
Triiodothyronine (T3) hormone testing: The T3 test detects total levels of activated thyroid
hormone. The assay tends to be less reliable in the lower range than in the higher range (better in
detecting hyperthyroidism). However, normal T4 and depressed T3 levels may suggest impaired
physiologic conversion of T4 to T3.
 Renal

For patients with renal dysfunction, the following tests may be used:
Serum creatinine levels. If stable, serum creatinine can be used in various equations (e.g.,
Cockcroft-Gault, Modification of Diet in Renal Disease) for estimation of the glomerular filtration rate
and staging of chronic kidney disease (CKD). If serum creatinine is acutely changing, most
equations become inaccurate for estimating glomerular filtration. The test can also be used with 24-
hour urine collection for creatinine clearance measurement.
Blood urea nitrogen (BUN) level. The BUN level is elevated in renal failure. The BUN level tends to
increase to a greater extent than serum creatinine in conditions associated with decreased kidney
perfusion (e.g., dehydration).
 Hepatic
For patients with hepatic disorders, the following tests may be used:
Serum transaminase testing: The serum transaminases, aspartate aminotransferase (AST) and
alanine aminotransferase (ALT), are elevated in cases of liver injury, although they are also found in
several other tissues (e.g., renal, cardiac, muscle, brain, pancreas). AST, formerly known as serum
glutamic oxaloacetic transaminase (SGOT), classically presents as two or more times higher than
ALT in alcoholic liver disease. ALT, formerly known as serum glutamic pyruvic transaminase (SGPT),
is more localized to the liver than is AST, so it is considered a more specific marker of hepatic injury.
AST and ALT are commonly used to monitor for acute liver toxicity from drugs with known
hepatotoxic potential.
Total protein and albumin testing: Proteins, including albumin, are synthesized in the liver. Below-
normal levels may suggest reduced synthetic function of the liver.
Prothrombin time (PT) and INR testing: PT and INR elevations in the absence of vitamin K
antagonist therapy may suggest reduced synthetic function of the liver in producing coagulation
factors (factors II, VII, IX, and X).
Bilirubin testing: Biliary obstruction commonly presents with conjugated hyperbilirubinemia.
Unconjugated hyperbilirubinemia occurs more often with other etiologies, such as hemolysis.
 Respiratory

For patients with respiratory disorders, the following tests may be used:
Peak expiratory flow rate: This test monitors asthma severity. At-home handheld peak flow meters
can be used for this purpose.
Spirometry: This test is used for diagnosis and staging or monitoring in chronic obstructive
pulmonary disease; several parameters are measured. One parameter is forced vital capacity (FVC),
which is the volume of air exhaled as heavily and quickly as possible after maximal inhalation.
Another parameter is forced expiratory volume in 1 second (FEV1), which is used to assess large
airway function.
 Cardiovascular

Coronary artery disease

For patients with coronary artery disease, the following tests may be used:
Cardiac biomarkers: These include creatine kinase (CK), CK-MB, and troponin.
Lipid profiles: In general, pharmacologic interventions take at least 6 weeks to produce maximal
effects on lipids. Either fasting or nonfasting profiles can be performed: A fasting profile allows more
accurate measurement of serum triglyceride (TG) levels, which then allows use of the Friedewald
equation to calculate LDL cholesterol. The recommended period of fasting is 9-12 hours.
C-reactive protein (CRP) testing: High-sensitivity tests detect mild elevations that may correlate
with increased risk for future cardiovascular events. Such testing is not necessarily predictive in
patients with preexisting autoimmune diseases, which can directly cause elevated CRP.
Blood pressure measurement:
 Pharmaceutical care

• The pharmaceutical care is defined as “The responsible provision of drug therapy for the
purpose of achieving definite therapeutic outcomes that improve the patients quality of
life”

• “ A practice in which a practitioner takes responsibility for a patient’s drug related needs
and holds him or herself accountable for meeting these needs.”
 Pharmaceutical care

• It describes specific services & activities through which an individual pharmacist

cooperates with patients and other health care professionals in designing, implementing
& monitoring a therapeutic plan that will produce specific outcomes for the patient.

• Pharmaceutical care is that component of pharmacy practice which entails the direct
interaction of pharmacist with the patient for the purpose of caring for that patient’s drug
related needs.
THANK YOU