Drug Therapy Monitoring

INTRODUCTION TO
DAILY ACTIVITIES OF
CLINICAL PHARMACIST
Dr. Ramesh Bhandari
Asst. Professor
Dept. of Pharmacy Practice
KLE College of Pharmacy, Belagavi

Daily activities of Clinical Pharmacist
 Drug therapy monitoring (medication chart review, clinical
review, pharmacist interventions)
 Ward round participation
 Adverse drug reaction management
 Drug information and poison information
 Medication history
 Patient counselling
 Drug utilisation evaluation and review
 Quality assurance of clinical pharmacy services

Drug Therapy Monitoring
It involves the review of a patient’s medication
regimen to ensure that therapy is appropriate,
safe, efficacious and cost effective.
Also known as drug therapy review or
medication review.

Goals of Drug Therapy Monitoring
Identifying and solving drug related
problems in order to optimize the drug
therapy and patient health outcome.
To ensure all therapeutics objectives
are being achieved.

Significance of Drug Therapy Monitoring
Assess whether desired therapeutic
outcomes are being achieved.
Monitor for drug related problems
Ensure rational and quality use of medicine
Assess patient compliance
Assess the completeness of medication
charts

Components of Drug Therapy Monitoring
A. Medication chart review (MCR) or
Medication order review (MOR) or
Treatment char review (TCR)
B. Clinical review/daily progress review
C. Detection and management of adverse
drug reactions

A. MEDICATION CHART REVIEW
Fundamental responsibility of clinical
pharmacist.
It is a systematic review of a patient’s drug
therapy to ensure that the prescribed
medication is appropriate for the patient.
Involves assessment of all current and recent
medication orders including routine medication
and over the counter drugs and the use of other
system of medicines (unani, ayurvedic, siddha).

Goal of Medication Chart Review
Ensuring that the patient receive
Right drug
Right dose
Right frequency
Right duration
Right dosage form

Steps of Medication Chart Review
1) Collection and interpretation of patient specific
information, including medication history interview
2) Assessment of therapeutic goals
3) Identification of drug related problems
4) Individualising medication regimen
5) Monitoring treatment outcomes
6) Medication chart endorsement
7) Documentation

1. Collection and interpretation of patient specific
First step in setting the therapeutic goal
Need to collect information that will assist them to determine
the appropriateness of drug therapy.
Includes patient’s demographic details such as age, sex and
body weight, social history, presenting complaints, past
medical history, allergy and sensitivity status, current
medications and results of relevant laboratory tests and other
investigations.
Enables the pharmacist to understand the patient disease
condition, indication of drugs and daily clinical progress.

Sources: Patient, case notes, medication chart,
observational charts, laboratory results and through
discussions with medical and nursing staff.
Further pharmacist can obtain more information which is of
importance to the ongoing medical management of the
patient. (Medication History Interview).
Patient’s medication history should be obtained at the
beginning of the hospital admission in order to provide the
additional useful information to the prescriber.

Aspects of medication use which may be obtained from
Medication history interview:
History of previous allergies/ADRs
Indication of each medications
Dosing regimen including dose, route, frequency and
duration of therapy
Perceived side effects
Adherence to medication regimen
Use of medication aids
Treatment with other system of medicine (Ayurveda,
siddha, unani)
Use of OTC drugs
Social drug use (tobacco, alcohol, pan masala etc)

Following interview, data collected should be compared with
the medication charts for any discrepancies (medication
reconciliation) in order to identify drug-related problems.
If any problem exists concerned physician should be
contacted to overcome those drug related problems or to do
any changes in the medication chart.

2. Assessment of Therapeutic goals
To determine the appropriateness of drug therapy it is
essential to understand the therapeutic goals for the
individual patient.
May include one or more of the following:
oCure of the disease
oReduction or elimination of signs and symptoms
oArresting or slowing disease progression
oPreventing disease/symptoms

2. Assessment of Therapeutic goals
Therapeutic goals should based on patient individual
circumstances and may differ from patient to patient based on
their age, co-morbidities and the nature and severity of their
illness.
 Eg: patient with hypertension with diabetes
 40 year old patient – goal should be <130/85 mm of Hg
 >60 years of age – goal should be >150/90 mm of Hg

3. Identification of drug related problems
Reviewing drug therapy should be aimed at identifying and
resolving any drug related problems.
A drug related problem is any event or circumstance
involving drug treatment that interferes or potentially
interferes with the patient achieving an optimum outcome of
medical care.
Charles heplers and Linda strand categorize drug related
problems into 8 categories.

i. Untreated indication
ii. Improper drug selection
iii. Sub-therapeutic dose
iv. Overdosage
v. Adverse drug reactions
vi. Failure to receive drugs
vii. Drug interactions
viii. Drug use without indication

i. Untreated Indications:
Examples:
RA patients using NSAIDs for symptoms relief and may present
symptoms of Gastritis, this situation requires an additional drug
such as H2 blockers ranitidine OR PPI Omeprazole, Pantoprazole to
control gastritis symptoms.
In TB patients INH therapy advised pyridoxine to prevent
peripheral neuropathy caused by INH.

ii. Improper drug selection:
EG: any given drug regimen be considered as wrong for a specific
patient at given time if the dosage form is in appropriate (eg: a 55
year old patient with mild angina receiving nitoglycerin patches to
be applied on daily basis.
Contraindications are present (eg: a pregnant women receiving
Isotretinoin 20mg BD for 2 weeks for acne vulgaris.

iii. Subtherapeutic dose:
Any drug given in lower dose than the recommended.
Eg., A two year old child receiving amoxicillin 40mg
PO(40mg/5ml) for her first episode of otitis media.

iv. Overdosage:
Eg., Any drug given more dose than recommended for
individual patient.

v. Adverse drug reactions:
a) Eg: Ofloxacin induced thrombocytopenic purpura
b) Insulin induced hypoglycemia
c) Penicillin induced hypersensitivity

vi. Failure to receive drugs:
a) Eg., Despite the prescriber order, duty nurse may fail to
administer the drugs.
b) Due to high cost of the drug patient may not purchase the
medication.
c) Due to forgetfulness sometime patient may forget to take the
drugs.

vii. Drug interactions:
a) Eg, Ciprofloxacin and antacids concomitant use can cause failure
of ciprofloxacin therapy.
b) Most of the drugs with grapes juice can cause toxicity of the
drugs.

viii. Drug use without indication:
EG: Nebulization salbutamol 200mcg TID+ Budesonide 100mcg
BID, then patient also Rx with Tab pantoprazole 40mg OD for 10
days, patient has not complained any symptoms of gastritis or PUD

4. Individualising medication regimens
Once DRP relating to the individual drugs on the medication
chart have been resolved, the next step is to consider the
patient’s overall medication regimen.
Important for patients with chronic diseases or those who
are on many drugs on long term basis.
Consider patient data including past medical as well history,
co-morbid conditions, allergic history, and concurrent illness.
Aim should be to simplify the regimen and to adjust the
regimen to maximize long term medication adherence.

4. Individualising medication regimens
Eg:
Switching to slow release formulation of the same drug
Different route of drug administration
Changing time of the doses taken
Switching to a cheaper but effective medications
Combination formulation

5. Monitoring treatment outcome(s)
Key to assess whether the therapeutic goals of drug
treatment achieved or not.
Includes review of the patient’s clinical status, laboratory data
and other markers of drug therapy response.
While evaluating patient’s response to drug therapy, the
pharmacist may need to review information and data from a
number of sources.

Eg:
Monitoring antibiotic treatment effects include
examining the patient’s temperature chart, laboratory
data (changes to indices such as white cell count and
inflammatory markers such as ESR and CRP) and case
note entries which describe changes in the signs and
symptoms of the patient’s infection.
Also obtained by patient interview

Some therapeutic goals require long term follow-up.
Eg: Response to antidepressants may take up to 4-6 weeks
to become evident.
If therapeutic goals are not achieved within the expected
timeframe, pharmacist should try to identify possible causes
before considering the need for change in therapy.

6. Medication Chart Endorsement
Chart endorsement is one of the primary responsibilities of
the pharmacist in ensuring that medication orders are
unambiguous, legible and complete.
It is essential to avoid medication errors, including those that
might occur at the level of prescribing and or administration
due to incompleteness of the order, lack of adequate
instructions and illegibility.

If chart endorsement is required, preferably with immediate
notice to the concerned prescriber, all the necessary details
are endorsed on the chart to avoid any confusion in drug
administration and also to prevent or minimise medication
errors.

Following annotations should be considered:
Is the identity of the patient (name and IP/OP number) on
each medication chart?
Is the allergy status of the patient documented?
Is the medication name clear? Abbreviation should be
avoided.
Is the drug prescribed by the generic name?
Is the dose clear? Avoid using abbreviation for units and
fractional doses should be written with zero before decimal
points.

Following annotations should be considered:
Is the route of administration specified?
Is the date and time of drug administration clear?
Are any additional drug administrations instructions given
where appropriate?
Is there any over-writing which may lead to confusion?
Is the cancellation of medication order clear and
unambiguous?
Is the prescription signed by doctor?

7. Documentation
Pharmaceutical care provided should be an integral part of
the patient’s medical record.
Documentation of pharmaceutical care provided can be
made either in medication chart or in case notes with a clear
title with pharmacist’s signature.
Documentation of services in the patient’s medical record is
then accessible to all other health care professionals.
Computerisation of relevant information is highly appreciable
which makes easy accessible to health care providers.

B. CLINICAL/DAILY PROGRESS REVIEW
Integral component of medication review
It is the review of the patient’s progress for
the purpose of assessing therapeutic outcome.
Performed on daily basis

Goals of Clinical/Daily Progress Review
Assess the response to drug treatment
Evaluate the safety of the treatment
Assess the progress of the disease and the need for
any change in therapy
Assess the need for monitoring (if any)
Assess the convenience of therapy (to improve
compliance)

Procedure for Clinical/Daily Progress Review
Ideally, clinical review should be done routinely for
all patients.
Usually carried out by attending doctors while
evaluating their patients to monitor the patient
outcome to drug therapy.
While evaluating, the pharmacist may need to review
biochemical, haematological, microbiological and
other investigations as appropriate.

Clinical Parameters
Signs
Symptoms
Clinical Charts
Temperature Chart
Fluid Balance Chart
Observation Chart
Diabetic Chart
Laboratory Parameters
Biochemistry: Electrolytes, Renal function tests, liver function tests etc
Hematological: WBC, ESR, RBC, Platelets, Hb% etc
Microbiology: Culture tests, antibiotic susceptibility tests
Others: ECG, CT Scan, MRI etc.

Information obtained must be interpreted and
evaluated with reference to
Clinical features of the existing disease
Need for a laboratory investigation
Aspects related to the drug effects
Past Medication history of the patient
Desired therapeutic outcome(s)

If therapeutic objectives are not being achieved, the
clinical pharmacist should re-evaluate the
appropriateness of the treatment and discuss any
relevant issues with the clinicians.

C. Detection and management of Adverse Drug
Reaction
One of the most important causes of morbidity and
mortality.
Hence, it is essential that clinical pharmacist should
have knowledge of ADRs including their predictability,
preventability, frequency, severity, predisposing
factors and recognition their causality assessment,
management and prevention.

Definition of ADR
Any response to a drug which is noxious and
unintended, and which occurs at doses normally used
in man for prophylaxis, diagnosis or therapy of
disease, or for the modification of physiological
function. (WHO)

Goal of ADR Management
1) Identification and monitoring of patients susceptible
to ADRs
2) Detection and assessment of ADRs
3) Assisting in the management of ADRs
4) Documentation and prevention of ADRs

1) Identification and monitoring of Patient susceptible to
ADRs
Patients who are most susceptible to develop an ADR
should be identified and monitored on daily basis.
These can be identified during MCR, clinical review or
at the time of medication history interview.

1) Identification and monitoring of Patient susceptible to
ADRs
 Patients who are at high risk of developing an ADR;
 Those with Polypharmacy
 with multiple disease process
Geriatric and paediatric patients
Those with intercurrent diseases (renal/hepatic diseases)
Those treated with highly toxic drugs
Those who are treated with narrow therapeutic index drugs
Those who are treated with drugs that have potential to interacts with
other drugs.

 ADRs may be identified during ward rounds with the medical team and
review of patient’s chart.
 It should considered as part of the broader diagnosis hence, the
differential diagnosis should include the possibility of an ADR.
 Causality relationship between a suspected drug and a reaction, a
temporal or possible association is sufficient for a report to be made.
 The assessment of a causality relationship between a drug and an ADR
is often highly subjective, based on the clinician’s judgment and
experience.

 If an ADR is suspected, the assessment of ADR starts with the
collection of all relevant data pertaining to:
Patient demographics
Medications including non-prescription drugs (OTC)
Comprehensive ADR details (description of the reaction, time of
onset, and duration of the reaction, complication, treatment of the
reaction and outcome of the treatment)
Relevant investigation reports
 By using one or more available causality assessment scales,
correlation of suspected drug with an ADR can be established.

3) Assisting in the management of ADRs
 Based on the severity of an ADR, rapid treatment is necessary. For Eg:,
anaphylactic shock.
 If the culprit drug is obvious, risk-benefit decision needs to be taken
about the need for the drug.
 If several medicines may be due to the non-essential medicines should
be withdrawn.
 If the reaction is likely to be dose related, dose reduction should be
done.
 If the drug is necessary then symptomatic relief may be given while
continuing the essential treatment.

4) Documentation and Prevention of ADRs
 Necessary to prevent re-exposure from the same drug/class
 Attending pharmacist should complete appropriate documentation in the
patient medical record including alert cards or placing sheet in the front
of the patient case notes.
 Essential that medical staff, including the original prescriber are notified
of suspected ADRs

REFERENCE
 G. Parthasarathi, Karin Nyfort Hansen, Milap C Nahata. A textbook of
clinical pharmacy practice Essential concepts and skills. Universities
Press. 2nd edition.

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