Theoretical knowledge of clinical pharmacy

2. Topical Subjects
• Therapeutical Process
• Rational Treatment
• Process of Rational Treatment

3. THERAPEUTICAL PROCESS
P-Drugs & P-Treatment

4. Example: patient 1 (GP)
You sit in with a general practitioner and
observe the following case :
A 52-year old taxi-driver complains of a sore
throat and cough which started two weeks
earlier with a cold. He has stopped sneezing
but still has a cough, especially at night. The
patient is a heavy smoker who has often been
advised to stop. Further history and
examination reveal nothing special, apart
from a throat inflammation. The doctor again
advises the patient to stop smoking, and
writes a prescription for codein tablets 15 mg,
1 tablet 3 times daily for 3 days.

5. • Choosing a treatment and writing a prescription
seems easymore difficult than it seems
• Requires a quite complex process of
professional analysis, knowledge & systematic
thinking
scientific process  clinical process
therapeutic process
The result of treatment optimal/ maximal
 no risk (slight)

6. RATIONAL TREATMENT
The process of choosing a treatment
Scientific process
•Problem
•Therapeutic Objective
•Choose treatment
•Start treatment
•Monitor and Evaluation

7. In that case  first choice tratment
for dry cough
Treatment for suppress dry cough
advice & drug therapy /P-drug
P-drugs base on efficacy, safety,
suitability, cost
How & not What to choose treatment
Therapeutics Process
l l
process of rational treatment

8. Step 1. Define the patient’s problem
Step 2. Specify the therapeutic objective
What do you want to achieve with the
treatment
Step 3. Verify the suitability of your P-treatment
Check effectiveness and safety
Step 4. Start treatment
Step 5. Give information, instructions and warning
Step 6. Monitor (and stop ?) treatment
THE PROCESS OF RATIONAL TREATMENT

9. 1. Define the patient’s problem.
•Disease or disorder
•Sign of underlying disease
•Psychological or social problems, anxiety
•Side effect of drugs
•Refill request (polypharmacy)
•Non-adherence to treatment
•Request for preventive treatment
•Combinations of the above
Pathophysiology, manifestation of disease

10. 2.Specify the therapeutic objective.
What do you want to achieve with the
treatment
•prevent a lot of unnecessary drug use
•avoid unnecessary prophylactic prescribing
•to discuss your therapeutic objective with
the patient before starting the treatment
pharmacotherapy, non pharmacotherapy,
or combination
No drugs as a placebo

11. PLACEBO REACTIONS IN
• Headache 62 %
• Diarrhea 58 %
• Cold 45 %
• Neurosis 34 %
• Dysmenorrhea 24 %
• Hypertension 17 %
• Sea – sickness 58 %
• Rheumatism 49 %
• Cough 41 %
• Migraine 32 %
• Angina Pectoris 18 %
Beecher : 35 % in average
(Geneesm. Bulletin, 23 Nov. 79)

12. • Case 1 :
• Girl, 4 years, slightly undernourished. Watery
diarrhoea without vomiting for three days. She has not
urinated for 24 hours. On examination she has no
fever (36.8oC), but a rapid pulse and low elasticity of
the skin.
• Therapeutics objective : prevent dehydration
 rehydration

13. • Case 2 :
• Woman, 24 years. Consulted you 3 weeks ago, complaining of
constant tiredness after delivery of her second child. Slightly
pale sclerae, but normal Hb. You had already advised her to
avoid strenuous exercise. She has now returned because the
tiredness persists and a friend told her that a vitamin injection
would do her good. This is what she wants.
• Problem  ?
• Ther. objectives  help her reduce physical and
emotional overload.  non pharmacotherapy
(it may be necessary to involve other
members of the family)
Intervention of therapy

14. 3.Verify the suitability of your P-treatment
Not all desease need treatment with a drug
P-treatment not always P-drug
• P-Treatmentadvice & information
non drug treatment
drug treatment
referral for treatment
combination of the above
P-Treatment & P-Drugs

15. Cases  P-treatment:
• Constipation
– Advice  Drink a lot of fluids, eat fruit and high
fibre food. Only go to the toilet when the need is
felt. Do not try to pass stools by force. Reassure
patient that nothing points to serious disease
– Non drug  physical exercise
– Drug tx  laxant
– Referral  Not indicated
• Acute watery diarrhoea with mild
dehydration in a child
– Advice  cont breast feeding, observation
– Non drug fruit juice
– Drug tx  rehydration solution (oral, NGT)
– Referral  not necessary.

16. • How do you manage to choose the
right drug for each patient in a
relatively short time?
By using P-drugs!
Personal Formulary

17. P-Drugs
• The drugs you have chosen to prescribe
regularly, and with which you have become
familiar. They are your priority choice for given
indications  personal , priority
• Not only the name of drugdosage form,
dosage schedule, duration of treatment
• Formulary  essential drugs
• Enable you to avoid repeated searches for a
good drug in daily practice
• You must up date your P-drugs evidence base

18. How to select a P-drug:
1. Define the diagnosis
2. Specify the therapeutic objective
3. Make an inventory of effective groups
4. Choose a group according to criteria:
Efficacy, Safety, Suitability, and Cost
Conclusion: Active substance, dosage form,
Standard dosage schedule,
Standard duration
How & not What to choose treatment

19. • Drug Efficacy :
Site of action Angina Pectoris
preload contractility frequency afterload
• Nitrates ++ - - ++
• Beta Blockers + ++ ++ ++
• Ca Antagonists + ++ ++ ++
An inventory of effective groups of
drugs  Angina Pectoris

20. Comparison between the three drug groups
used in angina pectoris
1.Nitrates
Efficacy Safety Suitability
Pharmacodynamics Side Effects Contraindications
2.Beta Blokers
Efficacy Safety Suitability
Pharmacodynamics Side Effects Contraindications
3.Ca Antagonist
Efficacy Safety Suitability
Pharmacodynamics Side Effects Contraindications

21. Comparison between drugs within the group of nitrates
Efficacy Safety Suitability Cost
Glyceril Trinitrat
Sublingual Tab. O.4-1 mg 0.5-30 min no difference
OralTab. 2,6 mg Cap1-2.5 mg 0.5-7 hours
Transdermal 16-50mg 1 - 24 hours
Isosorbid Dinitrat
Sublingual Tab 5 mg 2-30 mnit
OralTab. 10-20 mg 0.5-4 hours
Retard Oral Tab 20-40mg 0.5-10 hours
Pentaeritritol Tetranitrat
Oral Tab. 5 mg 1-5 hours
Isosorbid Mono Nitrat
Oral Tab 10-40 mg 0.5-4 hours
Retard OralTab /Caps -10 hours

22. 4.Start treatment
write prescribing
Prescribing must be complete & every country
has its own regulations
Name and address of the prescriber, with
telephone number (if possible)
Name of drug, dosage form, dosage scedule
& duration of treatment
Clear hand writing  may be print out

23. doctor-patient communication
Information
Instructions
Warnings
}Drug & treatment
?
5.Give information, instruction & warning

24. •Doctor explained
about taking drugs
(why & how). The
doctor just keeps
on talking & talking
doesn’t encourage
a dialogue.
•50% Px do not
take prescribed
drugs correctly
(irregularly or not
at all)
Patient adherance
Therapeutic success

25. Non adherence to treatment
• Elderly patients / too young patients
• Long time therapy
• Doesn’t understand the aim of treatment
• Dosage schedule (regiment dose) is complicated
for patients, particularly the elderly
• Side effects have occured
• Kurang percaya pada obat dan cara pengobatan
• Previuos bad experienced on take drugs
• Expensive drugs
• Symptoms have ceased
• etc

26. How to improve patient
adherence to treatment
1. Prescribe a well-chosen treatment
2. Create a good doctor-patient
relationship
3. Take the time to give information,
instructions and warnings

27. How to improve patient adherence
to treatment (con’t)
A well chosen drug treatment consists of
• Considered P-drug
• Few drugs as possible (preferably only
one), with rapid action, with as few side
effects as possible
• Appropriate dosage form, with a simple
dosage schedule (one or two times daily),
and for the shortest possible duration

28. How to improve patient adherence to
treatment (con’t)
A good doctor-patient relationship
• Respect for the patient's feelings and viewpoint
• Try understanding and willingness to the patient
• In a dialogue, empowers the patient as a
partner in therapy.
Patients need
“information”, “instructions”, “warnings”
to provide them with the knowledge to accept
and follow the treatment and to acquire the
necessary skills to take the drugs appropriately

29. Information
• In some studies less than 60% of patients had
understood how to take the drugs they had received.
• Information should be given in clear, common language
• Ask patients to repeat in their own words some of the
core information, to be sure that it has been
understood.
• Information A functional name, such as a ‘heart pill’ is
often easier to remember and clearer in terms of
indication.
• Make a simple aids (leaflet, figure etc)
• Information to family/ other person  for baby/elderly
patients, invalid patients or non cooperative  should
be assitance to take drugs

30. The minimum information that should
be given to the patient
1. Effects of the drug 
• Why the drug is needed
• Which symptoms will disappear, and which will not
• When the effect is expected to start
• What will happen if the drug is taken incorrectly or
not at all
2. Side effects
• Which side effects may occur
• How to recognize them
• How long they will continue
• How serious they are
• What action to take

31. The minimum information that should
be given to the patient
3. Instructions
• How the drug should be taken
• When it should be taken
• How long the treatment should continue
• How the drug should be stored
• What to do with left-over drugs
4. Warnings
• When the drug should not be taken
• What is the maximum dose
• Why the full treatment course should be taken

32. The minimum information that should
be given to the patient
5. Future consultations
• When to come back (or not)
• In what circumstances to come earlier
• What information the doctor will need at the next
appointment
6. Everything clear?
• Ask the patient whether everything is understood
• Ask the patient to repeat the most important
information
• Ask whether the patient has any more questions

33. Not Enough Time For Communication?
No, if doctor makes
personal formulary
- P-drug & P-treatment
- information that need for P-drug

34. 6. Monitor (and stop ?) the treatment.
Was the treatment effective ?
A. Yes, and disease cured  Stop the treatment
B. Yes, but not yet completed  Any serious side
effects ?
No : treatment can
continue
Yes: reconsider
dosage or drug choice
C. No, disease not cured  Verify all steps

35. Any Questions or Additions

37. Reference:
1. Clinical Skills for Pharmacists, A Patient-Focused Approach, 3rd Ed, ISBN 978-0-323-
05485-0, by Karen J Tetze, 2012
2. Clinical Pharmacy & Therapeutics, 5th Ed, ISBN – 978-0-7020-4294-2, by Roger Walker &
Cate Whittlesea, 2012
3. Clinical Anatomy and Physiology of the visual Views, 3rd Ed, ISBN: 978-1-4377-1926-0,
by Butterworth-Heinemann, 2012.
4. Clinical Guidelines : Diagnosis and Treatment Manual, 7th Ed, ISBN: 2-906498-69-6, By
L.Blok (MD) et al.
5. Clinical Pharmacology, 9th Ed, ISBN 0443064814, by P.N. Bennett and M.J. Brown, 2003

38. Study Questions
• Define the following generic terms of pharmacy:
• [Clinical Pharmacy, Oedema, Hypothyroidism, Dosage, Medication, Compliance, Pharmaceutical Care,
Apothecary, Pharmaceutical compounding, Ayurvedic Pharmacy, Antiquity Pharmacy, Middle Ages Pharmacy,
Modern Pharmacy, Retail pharmacy, Alchemy, Remedy, Drug, Medicine, Cure, Care, Trephining, Millennium,
Symptoms, Renaissance, Disease, Illness, Microbes, Civilization, Herbal remedies, Usage, Side effects, Quantities,
Dosages, Storage, Pharmacopeia, Pharmacology, Pharmaceutics, Pharmacokinetics, Therapeutics, Pathophysiology,
Evolution, Patient counseling, Nutrition, Antibiotics, Chemotherapy, Pain management, Semiotician, Physician,
Pharmacist, Diagnosis, Mutual respect, Honesty/ Authenticity, Open Communication, Cooperation, Collaboration,
Empathy, Sensitivity, Promotion, Competence, Assurance, Confidence, etc]
• Respond to the following questions:
 In line with historical background of originality of pharmacy, How was disease thought of in early civilization
and how was it treated.
 What are some of the contributions to the practice of pharmacy from around the world regions such as Asia,
Greece, Roman Empire, Arabia, Europe.
 Why has there been a trend toward fewer independent pharmacies in some world pharmaceutical
established operations as compared to those of national institutes
 Historically, how has the role of the pharmacist evolved overtime to its present time nature
 Write on the ways the modern-day pharmacist has impacted patients’ health and safety
 State and explain the critical role of clinical pharmacy in a designed health sector
 Describe in details what is considered when demographic data is compiled
 State and explain the essential considerations in patient medication process
 Explain in details the process of Pharmaceutical care and it role and stages in the provision of patient care
 State and explain the critical components of patient counselling during medication process and how it can
effectively be provided.

39. • Group work discussional questions for Journal Club
Meetings:
 State and explain the critical role of clinical pharmacy in a designed health
sector
 Describe in details what is considered when demographic data is compiled
 State and explain the essential considerations in patient medication process
 Explain in details the process of Pharmaceutical care and it role and stages in
the provision of patient care
 State and explain the critical components of patient counselling during
medication process and how it can effectively be provided.