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Pharmacy practice – a spiritual transformation

Just an attempt to promote pharmacy practice in India. It helps for the students and professionals of pharmacy in healthcare, especially Doctor of Pharmacy and Pharmacy Practice students

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Pharmacy practice – a spiritual transformation

  1. 1. Pharmacy Practice – A Spiritual Transformation Gopinath K Vinayakam M Pharm PhD CPhT Assistant Professor & Pharmacist-Clinical Andhra Pradesh India gopinath.karnam@gmail.com
  2. 2. Pharmacy Practice– A Transformation • Pharmacy Practice need a transition? yes. Traditional compounding to dispensing to “therapy manager”. When I was a intern with Diploma in Pharmacy through years 1985-87 civil surgeon ordered me and one of my colleague to attend the rounds in the ward ignoring other interns besides my routing dispensing practice. He himself realized that pharmacists need to change their working atmosphere in sitting in a pharmacy counter & in dispensing practice. The physicians are expecting much more from the pharmacists, need to be a “ effective therapy manager “ in healthcare. Now it is almost 28 years and still working in the same skills although there is a transition from 2 year diploma in pharmacy to 4 year B Pharmacy to 6 year doctor of pharmacy / M Pharm – Pharmacy Practice. I hope with this higher qualifications, the profession will move to a independent professionals with more patient centered and product oriented and collectively with other healthcare members to work for the patients. I am always indebted to all patrons Dr B Suresh , Prof K Chinnaswami , Dr Lakshmi, Doctors and Friends in assuming me as a clinical pharmacist and I am proud to be a “ Good Pharmacist / Clinical Pharmacist “ with all the skills to meet the current demand in healthcare. And it is the right time that the government of India or respective state governments need to appoint clinical pharmacists in government healthcare to meet current demand – Gopinath K Vinayakam , Pharmacist – Clinical T T D Tirupati Andhrapradesh India.
  3. 3. Pharmacy Practice – Global perspective
  4. 4. Transition from compounder to Pharmacist to a Therapy manager • Although the term “Compounder” was removed long back as per the gazette and officially designated as “pharmacist” . Still the skill “compounding “ is needed in pediatrics, geriatrics and also in chemotherapeutic practice. Compounding is a “ART” an official procedure in pharmacy practice to have a better patient compliance. But the present universal practice is based on individualization theory – genetic based. There is a need of clinical skills to maximize the therapeutic outcome of a drug rather just compounding and dispensing. So pharmacist need to have all three skills to strengthen healthcare. If you need recognition one need independent status / service provider status…. Therefore “SKILLS” are important. • How skills are important. Need a recognisition – one need to equip with compounding, dispensing and clinical ….
  5. 5. Pharmacist – Eight Star in Cap • More than Dispensing or Inventory Management of drugs- a Clinical Pharmacist: - a Care Giver - Communicator - Decision-Maker - Teacher - Life – Long Learner - Leader - Therapy Manager - A Researcher
  6. 6. Generic VS Brand - II • Yes. Many people talk about generic vs brand in clinical practices. One cannot ignore the effect and consequences of ‘ Narrow therapeutic index’ drugs in biological system. Marginal changes in optimal therapeutic concentration lead to co-morbid and mortality. Thereby time, cost and “LIFE” cannot be control +Z. Evidences and practices along with documentation are important in clinical therapeutics. Selection is a wisdom, surely “BRAND” for narrow index.
  7. 7. Generic vs Brand - I
  8. 8. Pharmacist –An Antibiotic Guardian • “F R A I S “ is a pnemonic. It relate F = Finish the course ; R = Right Dose A = Take after, with or before food I = Be aware of drug interaction S = Side Effects • Antibiotic Resistance is increasing , with no action taken on resistance, within10-15 years routine procedures become impossible. • The average infections lasts for e.g. ear 4 days, common cold 1 ½ weeks, Sinusitis lasts for 2 ½ weeks, bronchial cough last for 3 weeks • Take antibiotics exactly as prescribed, never save them for later, never share them with others • In general , Antibiotics are used in hip and knee replacement, cancer surgery and organ transplantation etc.
  9. 9. Urinary Tract Infections • Urinary Tract Infections (UTI) are common in women. • These are bacterial infections caused by E.Coli. • The alarm symptoms like back ache, vomiting, and fever that would require immediate referral. • The recommended antibiotic regimen for UTI is Trimethoprim 200 mg BID for 3 days / Nitrofurantoin 50 mg qid for 3 days / Ciproflaxacin 500 mg BID for a day when treating uncomplicated UTI’s. • Alkalinizing agents markedly reduce the efficacy of Nitrofurantoin and should theref0re be avoided during treatment, • It is a good advise to tell patients to drink more water than normal
  10. 10. Complementary & Alternative Medicine – New Challenges • - Patients need reliable information on natural products. • - Need proof of efficacy, safety or quality before commercial supply • - Herbal medicines have many unknown and undocumented risks. E.g. Nithyam tablet – a laxative having “croton tiglium”- induces heat, gas trouble, dry cough, gingivitis, eyes burn, IBM. • - Disclose all medicines on every visit. • - Herbal medicines may interact adversely with allopathic medicines. • - If any one fails to achieve specified goals after a specified / sufficient time, suggest to consider conventional pharmacotherapy.
  11. 11. Auto Immune Disorders • SLE, Arthrities, Myasthenia gravis, Type I DM, Asthma, Goodpasture’s syndrome, Anaemia, Graves disease, Hashimoto’s thyroiditis, myxedema, Multiple Sclerosis, SLE, – Glucocorticoids inhibit MHC expression and IL-1, IL-2, IL-6 production so that helper T-cells are not activated. – Cytotoxic drugs block proliferation and differentiation of T and B cells. – Cyclosporine and tacrolimus inhibit antigen stimulated activation and proliferation of helper T cells as well as expression of IL-2 and other cytokines by them. – Antibodies like muromonab CD3, antithymocyte globulin specifically bind to helper T cells, prevent their response and deplete them. This particular area of application is yet to be research modality and lot many ethical constraints in mass application. It is just an involvement of ‘deregulation ‘ in the control net work to manage the disease. More over “VECTOR” introduction insitu a biggest a biggest challenge and lack of ‘specificity’ and ‘compliance ‘ give lot of complications even rejection.
  12. 12. Errors in Dispensing
  13. 13. Benzodiazepine Equivalency-Clinical Implications • Age • Elderly vs younger Sl.no Drug Dose In mg tmax T 1/2 hrs 1 Alprazolam 0.5-1 1-2 12 2 Bromazepam 3-6 1-4 20 3 Chlordiazepoxide 10-25 1-4 100 4 Clonazepam 0.25-0.5 1-4 34 5 Clorazepate 7.5-15 0.5-2 100 6 Diazepam 5-10 1-2 100 7 Flurazepam 15-30 0.5-2 100 8 Lorazepam 1-2 1-4 15 9 Nitrazepam 15-30 0.5-2 30 10 Oxazepam 10-20 1-4 8 11 Temazepam 10-20 1.5 25-41 12 Triazolam 0.25-0.5 2-3 11
  14. 14. Evidences and Practices are important
  15. 15. ADR Monitoring- PVPI • Why do Clinical Pharmacist need in healthcare ? – Recently an educated known patient came to be for a Framycetin skin ointment for wounds in the scalp. I said what happened. He told me that drug allergy to Tab Metformin XL 500 mg . I asked who told that ? He told me that doctor said and I have to accept it. This is the story in practice for quite few days. Although we have a spontaneous reporting and we need to figure it out whether symptoms are due to drug administration / not . It should be tested based on a standard protocol and then report to PVPI/ any other agency. In this instance that patient is using the same med for quite few years. And saying Drug allergy ? There could be separate pharmacy practice department and need to work with other healthcare members to reflect professional image rather “ Lip Service”. Let us join every member in healthcare to strengthen nations healthcare rather targeting pharmacy professionals ….
  16. 16. Steroid Toxicity - Choreoretinopathy • An uncontrolled diabetes or prolonged usage of steroids as in asthma lead to a state known as CSC/CSCR. • There will be a blurred vision and distorted vision lead to reversible or irreversible loss of vision. • Case Study: A known asthmatic and allergic rhinitis in 2008 changed to COPD although a good compliance in asthma drugs especially ICS. Recently he developed CSC. • And on consultation with ophthalmic specialist confirmed that CSC and referred back to allergy and chest specialist to stop using ICS’s. • Patient is on Maxiflow 250 mg / Maxiflow since 2008 that forced to develop a CSC due to increased permeability In the retina, but normal macula. There will be a increased toxicity to retina lead to reversible or irreversible blindness due to increased IOP.
  17. 17. Placebo – Miracle in Therapeutics Does it Effective / not • In general , placebo is mean to prove that effects- intrinsic is mainly due to active medicament. Not any other factor responsible for the therapeutic outcome . • Not 100% effective • Relativity • Miracles • 35% effective either with placebo / not • The term placebo itself taken us to different heights in clinical research
  18. 18. Case Study 1: Asthma in ED Problem • A 26 year pregnant woman attends ED with h/o chest tightness, wheezing and known asthma, managing with inhalers. She suddenly stopped her asthma inhalers after discovering she was 4 weeks pregnant. Her vital signs shown that heart rate 96 bpm, bp 110/70 mmHg, respiratory rate 26/min, oxygen saturations 94% and initial peak flow of 200 L/min. • What could be initial treatment in ED like dosages and routes of any drugs prescribed. If failure in response what would be next treatment? And what characteristics are used to calculate the predicted PEFR ? Solution • No variation in treatment for the pregnant women and other asthmatics. • Oxygenation to maintain > 94% saturations • Salbutamol neb. 5 mg repeated three times in a hour • Ipratropium neb. 500 mcg • Oral Prednisolone 40 mg • Standard charts are available based on ht and wt may be used to assess PEFR using peak flow/spirometer • If no response to the treatment , may MgSO4 IV 1.2 to 2 gms to avoid further complications.
  19. 19. Case Study 2: Medication Burden: Age & goals are important A 95 year geriatric female is on the following medications • Lipitor 10 mg 1 OD • Amlodipine 10 mg 1OD • Diovan /HCT 160/12.5 mg 1 OD • Remeron 15 mg 1 HS • Metformin 500mg 1 OD • Pantoprazole 40 mg 1 OD • Ranitidine 150 mg 1 BD • Tramadol 50 mg 1 TID • Vitamin C 500 mg 1 OD • Colace 100 mg 1 OD What could be the unnecessary medication in the Rx given • Look at HbA1c. If < 7, possibly even < 8, one could look to possibly discontinue the Metformin • Some significant GI problems as she is on PPI & H2 blocker already • Vitamins should always be looked at & reviewing its indication • Past cardiac /stroke should be looked at as well as patient goals of therapy in regards to the statins • HT medications – readings are certainly be important • Tramadol may be used on SOS • Note: geriatric patients are well tolerated the gastritis : does a patient DM / Obese: all other medications for morbid / co morbid / age related physiological change maintenance in the system
  20. 20. Case Study 3: Diarrhoea • A 45 year female patient came in with diarrhoea for a day with stomach ache and she is treated with 1) Cap Racecadotril 100mg BID 2) Tab. Colimex and 3) ORS. Next day she came in with dizziness but improved out diarrhoea confined to normal stools 2 times a day. Her bp measured diastolic less than just normal < 80 mm Hg. What could be the possible cause of dizziness and its management in this case. Facts about diarrhoea / dehydration • Symptoms : increased thirst, dry mouth, tired or sleepy, decreased urine output, urine is low volume ad more yellowish than normal, head ache, dry skin, dizziness • No avoid food for 24 hrs. Eat watery butter milk and less or no spicy food with plenty of pure water • People with loose water stools should be referred to GP if it continue for more than 3 to 5 days. • Blood that is mixed in with the stool and is black/tarry as opposed to blood on the surface of the stool may be a sign of colon cancer and needs urgent referal • OTC medications for 3 to 5 days • Conclusion : dizziness with a patient is due to more fluid loss on dehydration / diarrhoea, itself lead to hypotension and therefore supplement with ORS or large volume parenterals may give good rexults
  21. 21. • Case Study : A 80 year female patients has a h/o HT, atrial fibrillation, falls with orthostatic hypotension, OA, depression and anxiety. Constipation, COPD and Insomnia. Her present complaints are shortness of breath, edema and falls. Her current med list include • Warfarin (goal INR 2.3) • Metoprolol tartrate 25 mg BID • Losartan 100 mg 1 OD • Lasix 40 mg 1 OD • Amlodipine 10 mg 1OD • Omeprazole 20 mg 1 OD • Sertraline 25 mg 1 OD • Duonebs BID • Budesonide nebs 1 OD • Colace 100 mg 1 OD • Celebrex 100 mg 1 OD • Senna S 1 tablet 1 OD What could be the possible remarks & its management • An issue of a poly pharmacy. In this instance Warfarin is a highly liphophilic drug and there by it elevates almost all the drugs that present in the prescription. • Secondly anti-hyperten.sitve drugs amlodipine is used in maximum dose although other anti HT are used ? • Metaprolol tartrate 25 mg & Celebrex 100 mg may be the reason for shortness of breath. • Losartan & Amlodipine dose may be revised based on the present BP. And responsible for edema. • Close monitoring of the BP to avoid recurrent falls. • Senna S 1 may prescribed only for 7 days
  22. 22. Case Study 5 : Type II DM • Q) Mr. 59/M patient presented with chest pain. He was normal before 2 days since then he developed chest pain and was admitted in ED. K/C/O DM for 8 years. Not a K/C/O MI/CAD/CVA. He is currently on Metformin 2000 mg/day and Glimepride 4 mg/day. He was on pioglitazone, and it was discontinued because he had swelling on his ankles. ECG normal. Lab report shown FPG:210 mg/dl; PPG:323 mg/dl; HbA1C 9.8%. What could be the impression and treatment Ans) Impression : Type II DM , Angina Treatment:
  23. 23. Only Finer People will become a Legal Pharmacist
  24. 24. Thank You GOPINATH K VINAYAKA M Assistant Professor & Pharmacis t – Clinical Andhraprade sh India gopinath.kar nam@gm ail.com