CHAPTER 17 –Clinical Pharmacy

CHAPTER 17–Clinical Pharmacy

17.1 Introduction
The term clinical pharmacy was first used in 1953, but it was not until in late 1960’s that
it become widely used among pharmacists. Clinical pharmacy as a separate discipline appears to
have emerged first as clinical pharmacology. The concept of clinical pharmacology started in
1960’s with two incidences. First, in 1962 ‘The Thalidomide Tragedy’, wherein it was found that
consumption of popular sedative thalidomide resulted in birth of babies with sealed limbs.
Second, in 1968 an outbreak of ‘Phenytoin Toxicity’ was reported in Australia which was
because of change in formulation i.e. switching over from calcium sulfate to lactose as an inert
excipient in the tablets. In the same year higher digoxin levels associated with digitalis toxicity
(ventricular arrhythmias) were reported in USA which again was due to use of different
formulations. Hence it was realized that studies must be done to investigate bioavailability,
pharmacokinetics and toxicity of different formulations.
Obviously, this job was mainly given to pharmacology and clinical pharmacology
developed as a subject in medical institutions. So, while dealing with different aspects like
pharmacokinetics, Pharmacodynamics, and pharmacotherapeutics, it was realized that a
pharmacist is needed there.
Pharmacist has expertise in analytical methods, knowledge about advancement of modern
analytical techniques, new drug delivery systems and formulations of drugs. They are necessary
for determining bioequivalence. Similarly, because of adequate knowledge on new drug
development. Molecular modeling etc. and a direct link with food and drug control
administration and drug legislation requirement of pharmacist in new drug discovery, clinical
drug trials etc. became obvious. Added to all these were ‘Drug explosion’ and ‘Information
explosion’.
In 1955, Dr. John Autian a US pharmacist suggested that pharmacist should act like
consultant to physician. In 1976, Dr. D. E. Francke wrote, “The dispensing function of the
pharmacist, while important and even vital, is essentially a superficial practice of the profession
which, by itself does not require knowledge or skills to merit professional recognition to the
depth that lies, within the grasp of hospital pharmacist”. This was a forecast for the concept of
clinical pharmacy.

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17.2 Concept of Clinical Pharmacy

Baker (1976) has defined clinical pharmacy as “pharmacist involvement in monitoring
patient’s therapy and giving advice which directly influence the decisions concerning drug
therapy and the way in which it is administered”.
Clinical pharmacy may be defined as “The active participation of the pharmacist in
patient care with the long-term aim of giving advice on medication with an individual patient in
mind and tailoring drug therapy for that individual”.
“Clinical pharmacy is a novel discipline that carries a traditional hospital pharmacist from
his product oriented approach to a healthier patient oriented approach, so as to ensure the patients
maximum well-being while on drug therapy”.
The concept of clinical pharmacy includes the range of services through which all
practicing pharmacists exercise their responsibilities towards the care of patients. Clinical
pharmacy is concerned with the rational selection and use of medications at the patient level. It
ensures the appropriate and safe use of drugs in patient care.
In the process of drug use several stages may be identified. The need for drug therapy
must be assessed. The appropriate drug and the dose, route, form, frequency and duration of
treatment must be selected. Drugs have then to be administered accurately. The whole process
must be monitored and the success or failure of the outcome carefully evaluated. Doctors, nurses,
pharmacists and patients must make both independent and shared decisions at each of these
stages. These decisions determine whether the prescribed therapy is appropriate for the patient.
Among the major activities covered under the term clinical pharmacy include
involvement in prescribing rounds, patient counseling, drug history taking, parenteral nutrition
service, pharmacokinetic advisory service and monitoring for adverse drug reactions /
interactions. Relatively minor activities are health education, training / education of own staff
and doctors / nurses, clinical trials, case references, research and clinical meetings.
A clinical pharmacist works side by side with the physician, on the patient’s bed side
where he monitors the drugs, dosage and the side effects and advices the physician on these.
Hence, we can say clinical pharmacy has brought the pharmacist into closer touch with the
prescribers and the details of treatment of patients.

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17.3 Objectives of Clinical Pharmacy

The clinical pharmacy program is set with the aim of providing the student pharmacist
with educational experiences in clinical setting. The program is designed to help the student
better prepare for his future role as a health professional. The objectives of clinical pharmacy are
as follows:
 The program gives an opportunity to the student to develop himself for using his
independent judgment by following a drug therapy of selected patients and through case
presentation technique.
 It gives the student experience in small group presentations and in answering questions
regarding therapy asked by his professional colleagues and physicians and / or nurses.
 It also gives an opportunity to the student to observe and interact with physician to get a
better understanding of current medical practice.
 It gives opportunity to students to work with paramedical personnel and increase his
knowledge about their attitudes and contributions to patient care.
 It helps the student to gain a patient orientation towards drug therapy so that he may
fulfill better professional services to his patients.
 It gives the student a better knowledge of the effects of drugs on diagnostic tests and
various drug interactions which may occur in multiple drug therapy so that he may give a
better service to his patients.
 It gives the students an experience about the drug information retrieval through drug
evaluation.
 It also gives the student an experience of institutional environment by recognizing that
most pharmacists practice in an institute.

17.4 Qualities of Clinical Pharmacist

 Communication skills: The clinical pharmacist should have good communication skills,
in order to communicate with the patient and co-professionals freely and effectively.
 Clinical skills: The clinical pharmacist should have thorough knowledge about etiology
of a disease, signs, symptoms, Pathophysiology, laboratory tests, pharmacokinetics, etc.
He should be clinically trained for providing information on rational drug use, related
drug therapy, and for reviewing drug doses.

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 Professional relationship: He should be able to understand and appreciate the role of

medical and paramedical staff wherever possible. He must accompany physician on
medical rounds to assists him by providing drug information’s. The physician,
pharmacists and nurses should develop an inter-professional relationship with each other
to enhance the quality of patient care.
 Empathy: Clinical pharmacist should possess a deep sense of shared responsibility
towards medical care of patients. It will help him in taking medication history and
gaining patient’s confidence.
 Monitoring drug therapy: Clinical pharmacist must help in monitoring drug therapy
because it is an ongoing process and keeps on changing depending upon patient’s
conditions.

17.5 Functions and Responsibilities of Clinical Pharmacist

 Taking medication history of the patient: A clinical pharmacist must take and maintain
the medication history of patient by interacting with him. He should document the
hypersensitivities or allergy to certain drugs, food habits, drug dependence or
intoxications with chemicals, side effects of some drugs, incorrect drug administration,
etc. This will help in saving physicians efforts and will result in faster and more accurate
therapy.
 Drug interactions: Many OTC drugs have potential to interact with prescription drugs.
After receiving the prescription, pharmacist checks the drug interaction and patients
habits with the help of patient’s history record.
 Selection of proper drug therapy: Clinical pharmacist can assist in selection of a proper
drug product / generic formulation, depending on the considerations of bio-availability
and bioequivalence of such products.
 Drug monitoring: Clinical pharmacist can help in monitoring drug therapy for safety and
efficacy. Therapeutic drug monitoring is very essential for those drugs with narrow
therapeutic index or those which are administered chronically. He can also help in
determining various pharmacokinetic parameters based on plasma concentration of drugs,
enzymes and measurement of glucose levels in blood.

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 Adverse drug reaction: Patients with hepatic disorders or kidney impairment are more
prone to adverse drug reactions. Patients having more than one pathological complaint
with multiple drug therapy generally face such problems. Clinical pharmacist can help in
detection, prevention and reporting of adverse drug reactions. He can suggest physician
for alternate therapy wherever necessary.
 Management of drug policies: Clinical pharmacist can participate in formulating health
and drug policies, and serve as sources of information for health care professionals, and
to the public. They are responsible for drug management which includes their selection,
requirement, procurement, distribution and use.
 Research and development programmes: The clinical pharmacist can participate in
research for development of various formulations particularly in biological availability of
active ingredients. He can help in conducting clinical trials based on sound principles of
bio-statistical methods of evaluation.
 Drug information: Clinical pharmacist has the knowledge and expertise to provide
detailed information on medicines to members of health profession and the public.
Through effective selection, utilization and retrieval of drug literature, he can
communicate with health care team. He can abstract the information from periodic
bulletins or newsletters and provide the same to physicians on matters pertaining to
pharmacokinetics and dynamics of drugs.
In this way clinical pharmacist is totally patient oriented and deals with rationale of drug therapy.
Participates in patient education programmes, drug use profiles, research and development
programmes of the hospital etc., apart from many other activities. Hence, a clinical pharmacist
can maintain his daily routine with following duties:
 Assist in pharmacokinetic consultation with necessary follow-up.
 Monitors drug therapy schedules.
 Takes rounds with ‘Health Care Team’.
 Teaching pharmacy students.
 Patient counseling.
 Review of hospital pharmacy.
 Preparing of drug monographs to be reviewed by pharmacy and therapeutic committee.

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17.6 Drug Therapy Monitoring

Therapeutic drug monitoring (TDM) refers to the measurement and interpretation of
principally blood or plasma drug concentration measurements with the purpose of optimizing a
patient’s drug therapy and clinical outcome while minimizing the risk of drug-induced toxicity.
TDM involves tailoring a dose regimen to an individual patient by maintaining the plasma or
blood concentration within a particular range. To achieve optimal drug therapy 3 objectives
should be met:
 To attain desired pharmacological effect of the drug.
 To reach the maximal effect in shortest possible time.
 To decrease the risk of toxicity.
Therapeutic drug monitoring (TDM) is useful in drugs:
 With a narrow therapeutic index.
 Which is highly protein bound.
 Which are liable to interact?
 In which the metabolite might be toxic.
Role of Pharmacist in TDM
A reliable and responsive TDM service depends on team work between nurses, doctors,
pharmacist, scientist and technical staff. The clinical pharmacist should provide advice to
medical staff on the appropriate use and timing of TDM and assist with the interpretation of
results. In addition the pharmacist maybe involved in:
 Initial selection of drug regimen. This may involve decisions about drug choice, dose,
dosing interval, route of administration and dosage form of the drug, taking into account
factors such as sex, age, body weight, race, metabolism status, renal function, plasma
albumin concentration, use of other drugs and laboratory results.
 Adjustment of the dosage regimen based on TDM results and the patient’s clinical
response.
 Assessment of possible causes for unexpected results, such as non-compliance,
bioavailability problems, medication errors, drug interactions or pharmacogenetic
variability.
 Dose adjustment for patients on hemodialysis or peritoneal dialysis.
 Provision of poisons information.

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17.7 Medication Chart Review

 It is a fundamental responsibility of a pharmacist to ensure the appropriateness of
medication orders.
 It serves as starting point for other clinical pharmacy activities (medication counseling,
TDM, DI, and ADR).
 Organizing information according to medical problems (example disease) helps
breakdown a complex situation into its individual parts.
Goals of medication chart review
 To optimize the patients drug therapy.
 To prevent or minimize drug related problems/medication errors.
Procedure of medication chart review
The patient’s medical record should be reviewed in conjugation with the medication
administration record. Recent consultations, treatment plans and daily progress should be taken
into account when determining the appropriateness of current medication orders and planning
each patient’s care. All current and recent medicate on orders should be reviewed.
Components of medication order review
 Checking that medication order is written in accordance with legal and local
requirements.
 Ensuring that the medication order is comprehensible and unambiguous, that appropriate
terminology is used and that drug name are not abbreviated. Annotate the chart to provide
clarification as required.
 Detecting orders for medication to which the patient may be hypersensitive /intolerant.
 Ensuring that medication order is appropriate with respect to:
• The patient’s previous medication order.
• Patient’s specific considerations e.g. disease state, pregnancy.
• Drug dose and dosage schedule, especially with respect to age, renal function, liver
function.
• Route, dosage form and method of administration.
 Checking complete drug profile for medication duplication, interactions or
incompatibilities.

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 Ensuring that administration times are appropriate e.g. with respect to food, other drugs
and procedures.
 Checking the medication administration record to ensure that all ordered have been
administered.
 Ensuring that the drug administration order clearly indicates the time at which drug
administration is to commence.
 Special considerations should be given especially in short course therapy as in antibiotics
and analgesics.
 Ensuring that the order is cancelled in all sections of medication administration record
when the drug therapy is intended to cease.
 If appropriate follow up of any non-formulary drug orders, recommending a formulary
equivalent if required.
 Ensuring appropriate therapy monitoring is implemented.
 Ensuring that all necessary medication is ordered. E.g. premedication, prophylaxis.
 Reviewing medication for cost effectiveness.
 Identification of drug related problems.
• Untreated indication.
• Inappropriate drug selection.
• Sub therapeutic dose.
• Adverse drug reaction.
• Failure to receive drug.
• Drug interactions.
• Drug use without indication.
• Over dosage.
Medication chart endorsement
 Another important goal of treatment chart review is to minimize the risk of medication
errors that might occur at the level of prescribing and / or drug administration.
 A medication error is any preventable error that may lead to inappropriate medication use
or patient harm.

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 To prevent potential morbidity and mortality associated with these errors, pharmacists
should systematically review the medication chart and write annotations on the chart
where the medication orders are unclear.

17.8 Clinical Review

Clinical review is one of the integral components of medication review and should
preferably be performed on a daily basis. It is the review of the patients’ progress for the purpose
of assessing the therapeutic outcome. The therapeutic goal for the specific disease should be
clearly identified before the review.
Goals of Clinical Review
The primary aims of the clinical review are to:
 Assess the response to drug treatment.
 Evaluate the safety of the treatment regimen.
 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).

17.9 Pharmacist Intervention

Interventions by the pharmacists have always been considered as a valuable input by the
health care community in the patient care process by reducing the medication errors,
rationalizing the therapy and reducing the cost of therapy. The role of pharmacist has been
diversified from dispensing medications to patient care, patient counselor, health care educator,
and community service to clinical practice. All prescriptions must be reviewed by pharmacists
before dispensing and stressed that the outcomes should be documented as a result of direct
patient care by the pharmacy
Any error in ordering, transcribing, dispensing, administering and monitoring in the
process of medication is called medication error. Intervention by the pharmacist is warranted to
detect these medication therapy problems, after which, solutions for these problems can be
invented or drug therapy optimized for each patient. These interventions have developed by time
and their forms; vary from the simplest handwritten form to the computerized databases.

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Furthermore, many of these problems can be prevented by educating health care providers about
them.
Health care professionals expecting the pharmacists and pharmacies to have diversified
responsibilities include monitoring medication for people with acute and chronic disease,
operating repeat prescription services, reviewing medication for long-term users, prescribing
under protocols, advising on the management of common conditions and participating in local
and national health promotion or disease prevention activities. Documentation of their
interventions is important for justifying pharmacist’s services to the patient, healthcare
administrators and providers, patient care takers, to strengthen the profession and the society.
These clinical interventions of pharmacists not only have a positive impact on patient care but
also decreased cost. Recently, electronic systems and commercially available products and
software packages are used for documentation of clinical pharmacy interventions more
efficiently than paper systems. However, most out-patient pharmacies do not have a central
database for capturing interventions at observed locations.

17.10 Ward Round Participation

A ward round is a visit made by a medical practitioner, alone or with a team of health
professionals and medical students, to hospital inpatients at their bedside to review and follow up
the progress in their health. Usually at least one ward round is conducted every day to review the
progress of each inpatient, though more than one is not uncommon. In certain practice settings
such as psychiatry, the “ward round” may be conducted away from the patient’s bedside in a
non-traditional fashion, where the team meets elsewhere to review each case.
Goals and objectives for clinical pharmacists on ward rounds
As an important member of the healthcare team, pharmacists should attend ward rounds and
clinical meetings whenever possible. This enables pharmacists to contribute prospectively to
patient care through the provision of drug therapy.
The goals of a clinical pharmacist’s participation in ward rounds are to:
 Gain an improved understanding of patient’s clinical status and progress, current planned
investigations and therapeutic goals.

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 Provide relevant information on various aspects of the patient’s drug therapy such as
pharmacology, pharmacokinetics, drug availability, cost, drug interactions and adverse
reactions.
 Optimize therapeutic management by influencing drug therapy selection, implementation,
monitoring and follow-up.
 Investigate unusual drug orders or doses.
 Assimilate additional information about the patient such as co-morbidities, medication
compliance or alternative medicine use that might be relevant to their management.
 Detect adverse drug reactions and drug interactions.
 Participate in patient discharge planning.
Ward round participation also provide many learning opportunities for pharmacists. It
allows pharmacists to see firsthand how drugs are used and prescribed and to see the effects of
these drugs on patients. With time, pharmacists develop an appreciation of how the patient’s own
wishes and their social, cultural and economic circumstances may influence therapeutic choices.
Even for experienced clinical pharmacists in teaching hospitals, it is very rare to finish a ward
round without gaining new perspectives on some aspect of therapeutics or patient care. For those
involved in academia and research, ward rounds allow identification of cases for clinical
teaching and publication. Not the least, ward round participation strengthens the inter-
professional relationship among various health professionals, leading to better healthcare
practice and research.

17.11 Medication History

A medication history is a detailed, accurate and complete account of all prescribed and
non-prescribed medications that a patient had taken or is currently taking prior to a newly
initiated institutionalized or ambulatory care. It provides valuable insights into patients’ allergic
tendencies, adherence to pharmacological and non-pharmacological treatments, social drug use
and probable self-medication with complementary and alternative medicines. Availability of a
detailed medication history, particularly at the prescribing stage of the medication use process, is
critical to the success of the diagnostic and patient management tasks. This is because the
occurrence of medication errors is strongly associated with inadequate or incomplete medication
history.

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The documentation of medication history has historically been undertaken mainly by

physicians and sometimes nurses. However, several studies which were done mainly in
developed setting showed that the medication history information documented by physicians are
often inaccurate, incomplete; and lack information regarding medication allergies, past
prescription /nonprescription medications and patients’ adherence to prescribed doses.
The participation of pharmacists in the documentation of medication history has been
shown to result in significant improvement in its accuracy and comprehensiveness. Pharmacists
acquired medication histories are often free of error of commission, omission and more
frequently document past prescription / OTC medicines, allergy history and use of alcohol.
However, this concept has been tested only in developed countries. There is no published
information on impact of pharmacists’ participation in the documentation of medication history
in developing countries. Like other developing countries, is beset with poorly organized drug
distribution system, poorly controlled access to both orthodox and herbal medicines, distribution
and sale of counterfeit medicines, and pervasive self-medication with prescription-only, over-
the-counter and herbal medicines.
Goals of Patient Medication History Interview
The goal of medication history interview is to obtain information on aspects of drug use that
may assist in overall care of patient. The information gathered can be utilized to:
 Compare medication profiles with the medication administration record and investigate
the discrepancies.
 Verify medication history taken by other staffs and provide additional information where
appropriate.
 Document allergies and adverse reactions.
 Screen for drug interactions.
 Assess patient medication compliance.
 Assess the rationale for drug prescribed.
 Assess the evidence of drug abuse.
 Appraise the drug administration techniques.
 Examine the needs for medication aids.
 Document patient initiated medication administration.

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Importance of accurate medication history

 Medication histories are important in preventing prescription errors and consequent risks
to patients.
 Apart from preventing prescription errors, accurate medication histories are also useful in
detecting drug-related pathology or changes in clinical signs that may be the result of
drug therapy.
 A good medication history should encompass all currently and recently prescribed drugs,
previous adverse drug reactions including hypersensitivity reactions, any over-the counter
medications, including herbal or alternative medicines, and adherence to therapy for the
better health care plan.
 A full medication history identifies patients’ needs and explores the patient’s perspective
of illness and its treatment (needs and concerns).

17.12 Pharmaceutical Care

Pharmaceutical care is the responsible provision of drug therapy for the purpose of
achieving definite outcomes that improve a patient’s quality of life. These outcomes are:
 Curing a disease,
 Elimination or reduction of a patients’ symptomatology,
 Arresting or slowing down a disease process, or
 Preventing a disease or symptomatology.
Pharmaceutical care involves the process through which a pharmacist co-operates with a patient
and other professionals in designing, implementing, and monitoring a therapeutic plan that will
produce specific therapeutic outcomes for the patient. This, in turn, involves three major
functions:
 Identifying potential and actual drug-related problems,
 Resolving actual drug-related problems, and
 Preventing drug-related problems.
Pharmaceutical care is a necessary element of healthcare, and should be integrated with other
elements. Pharmaceutical care is, however, provided for the direct benefit of the patient. The
pharmacist is directly responsible to the patient for the quality of that care. The fundamental
relationship in pharmaceutical care is mutually-beneficial exchange, in which the patient grants

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authority to the provider and the provider gives competences and commitment (accepts
responsibility). The fundamental goals, processes and relationships of pharmaceutical care exist,
regardless of practice-setting.
Medication is the most frequent intervention within healthcare systems worldwide.
Achieving the best possible outcome of medication for the quality of life of patients should be
the primary aim of all health professionals involved in the medication process, as well as carers
and patients, depending on their abilities and capacities.
Often, the benefits of medication cannot be realized in patients (e.g. due to treatment failures),
and even worse, considerable mortality and morbidity are related to the inappropriate use of
medicine use, for example:
 Inappropriate prescription (“prescribing errors”),
 Inappropriate delivery (“dispensing errors”/“administration errors”),
 Inappropriate patient behavior (“non-adherence with treatment regimen”),
 Inappropriate monitoring and reporting,
 Patient idiosyncrasy,
 Lack of (medication-related) health literacy in the public.
Pharmaceutical care is a quality philosophy and working method for professionals within
the medication process. It is indispensable for helping to improve the good and safe use of
medicines, thus realizing the best possible outcome of medicines for the patient. It contributes to
the optimization of outcomes from medicines and the prevention of harm and inappropriate use.
This is achieved through the promotion of medication-related health literacy, the involvement
and participation of patients in their medication, and the assignment and acceptance of
responsibilities in an appropriate manner within the medication process. Together, these factors
improve the quality of life of patients and their families, the utilization of resources and help
reduce inequalities in healthcare. By increasing the cost-efficiency of medicine use,
pharmaceutical care will contribute to efficient and effective consumption of existing resources.

17.13 Drug Utilization Review

Drug utilization review (DUR) is defined as an authorized, structured, ongoing review of
prescribing, dispensing and use of medication. DUR encompasses a drug review against
predetermined criteria that results in changes to drug therapy when these criteria are not met. It

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involves a comprehensive review of patients' prescription and medication data before, during and
after dispensing to ensure appropriate medication decision-making and positive patient
outcomes. As a quality assurance measure, DUR programs provide corrective action, prescriber
feedback and further evaluations.
Why DUR is important
DUR programs play a key role in helping managed health care systems understand, interpret,
evaluate and improve the prescribing, administration and use of medications. Employers and
health plans find DUR programs valuable since the results are used to foster more efficient use of
scarce health care resources. Pharmacists play a key role in this process because of their
expertise in the area of medication therapy management. DUR affords the managed care
pharmacist the opportunity to identify trends in prescribing within groups of patients whether by
disease-state such as those with asthma, diabetes or high blood pressure, or by drug-specific
criteria. Pharmacists can then, in collaboration with prescribers and other members of the health
care team, initiate action to improve drug therapy for patients.
DUR is classified in three categories:
 Prospective - Evaluation of a patient's drug therapy before medication is dispensed
 Concurrent - Ongoing monitoring of drug therapy during the course of treatment
 Retrospective - Review of drug therapy after the patient has received the medication
17.13.1 Prospective DUR
Prospective review involves evaluating a patient's planned drug therapy before a
medication is dispensed. This process allows the pharmacist to identify and resolve problems
before the patient has received the medication. Pharmacists routinely perform prospective
reviews in their daily practice by assessing a prescription medications dosage and directions
while reviewing patient information for possible drug interactions or duplicate therapy. When
part of an online claims adjudication process, prospective DUR often relies on computerized
algorithms to perform key checks including drug interactions, duplications or contraindications
with the patient’s disease state or condition.
Issues Commonly Addressed by Prospective DUR
 Clinical abuse/misuse
 Drug-disease contraindications (when a prescribed drug should not be used with certain
diseases)

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 Drug dosage modification

 Drug-drug interactions (when two or more different drugs interact and alter their intended
effects, often causing adverse events)
 Drug-patient precautions (due to age, allergies, gender, pregnancy, etc.)
 Approved by AMCP Board of Directors November 2009
 Formulary substitutions (e.g., therapeutic interchange, generic substitution)
 Inappropriate duration of drug treatment
17.13.2 Concurrent DUR
Concurrent review is performed during the course of treatment and involves the ongoing
monitoring of drug therapy to foster positive patient outcomes. It presents pharmacists with the
opportunity to alert prescribers to potential problems and intervene in areas such as drug-drug
interactions, duplicate therapy, over or underutilization and excessive or insufficient dosing. This
type of review allows therapy for a patient to be altered if necessary.
As electronic prescribing becomes more widely adopted, the concurrent DUR process may be
performed by the prescriber at the time of prescription transmission to the pharmacy, allowing
interventions before the drug is dispensed. An important component of DUR will require
complete and current drug and allergy records for the patient, as well as knowledge of
appropriate therapeutic interchanges for individuals. As a safety net, pharmacists will perform a
similar role as prescribers on the dispensing side of these transactions.
Issues Commonly Addressed by Concurrent DUR
 Drug-disease interactions
 Drug-drug interactions
 Drug dosage modifications
 Drug-patient precautions (age, gender, pregnancy, etc.)
 Over and underutilization
 Therapeutic Interchange
17.13.3 Retrospective DUR
A retrospective DUR reviews drug therapy after the patient has received the medication.
A retrospective review aims to detect patterns in prescribing, dispensing or administering drugs.
Based on current patterns of medication use, prospective standards and target interventions can
be developed to prevent recurrence of inappropriate medication use or abuse. Outcomes of this

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review may aid prescribers in improving the care of their patients, either individually or within a
certain target population (e.g., patients with diabetes, asthma, or high blood pressure).
Issues Commonly Addressed by Retrospective DUR
 Appropriate generic use
 Clinical abuse/misuse
 Drug-disease contraindications
 Drug-drug interactions
 Inappropriate duration of treatment
 Incorrect drug dosage
 Use of formulary medications whenever appropriate
 Over and underutilization
 Therapeutic appropriateness and/or duplication

REVIEW QUESTIONS
MULTIPLE CHOICE QUESTIONS
1. The term clinical pharmacy was first used in _____.
A) 1953 B) 1963 C) 1973 D) 1983

2. The concept of clinical pharmacology started in _____.

A) 1960’s B) 1970’s C) 1980’s D) 1950’s

3. In which year Thalidomide tragedy was occurred?

A) 1960 B) 1972 C) 1963 D) 1962

4. In which year ‘Phenytoin Toxicity’ was reported in Australia?

A) 1968 B) 1978 C) 1983 D) 1993

5. Digitalis toxicity (ventricular arrhythmias) was reported in_____.

A) Australia B) India C) USA D) South Africa

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6. In which year Dr. John Autian a US pharmacist suggested that pharmacist should
act like consultant to physician?
A) 1966 B) 1955 C) 1975 D) 1985

7. Patients with _____ disorders are more prone to adverse drug reactions.
A) Hepatic B) Lymphatic C) CNS D) None of these

8. A ward round is a visit made by________.

A) Pharmacist B) Nurse C) Medical Practitioner D) None of these

9. Usually at least _____ ward round is conducted every day to review the progress of
each inpatient.
A) One B) Two C) Five D) None of these

KEYS
1. A 2. A 3.D 4. A 5. C 6. B 7. A
8. C 9. A

SHORT ANSWER QUESTION

1. Define Clinical Pharmacy According to baker?
Ans: “Pharmacist involvement in monitoring patient’s therapy and giving advice which directly
influence the decisions concerning drug therapy and the way in which it is administered”.

2. Define TDM.
Ans: Therapeutic drug monitoring (TDM) refers to the measurement and interpretation of
principally blood or plasma drug concentration measurements with the purpose of optimizing a

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patient’s drug therapy and clinical outcome while minimizing the risk of drug-induced toxicity.
TDM involves tailoring a dose regimen to an individual patient by maintaining the plasma or
blood concentration within a particular range.

3. For which kind of Drugs TDM is useful?

Ans:
 With a narrow therapeutic index.
 Which is highly protein bound.
 Which are liable to interact?
 In which the metabolite might be toxic.

4. Give the primary aims of clinical review.

Ans:
 Assess the response to drug treatment.
 Evaluate the safety of the treatment regimen.
 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).

5. Define Medication error.

Ans: Any error in ordering, transcribing, dispensing, administering and monitoring in the
process of medication is called medication error.

6. What do you mean by medication history?

Ans: A medication history is a detailed, accurate and complete account of all prescribed and
non-prescribed medications that a patient had taken or is currently taking prior to a newly
initiated institutionalized or ambulatory care.

7. Define DUR.

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 CHAPTER 17 –Clinical Pharmacy

Ans: Drug utilization review (DUR) is defined as an authorized, structured, ongoing review of
prescribing, dispensing and use of medication. DUR encompasses a drug review against
predetermined criteria that results in changes to drug therapy when these criteria are not met.

LONG ANSWERS QUESTION

1. Explain the concept of clinical pharmacy.
Ans: Refer Point 17.2
2. What are the objectives of clinical pharmacy?
Ans: Refer Point 17.3
3. What are the qualities of clinical pharmacists?
Ans: Refer Point 17.4
4. Add a note on Drug Therapy Monitoring.
Ans: Refer Point 17.6

VERY LONG ANSWERS QUESTION

1. What are the Functions and Responsibilities of Clinical Pharmacist?
Ans: Refer Point 17.5
2. Add a note on medication history.
Ans: Refer Point 17.11
3. Add a detailed note on note on Drug Utilization Review
Ans: Refer Point 17.13

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