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Pharmacy and Pharmaceutical Sciences
Hospital
Pharmacy
Tute
3
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Learning Objectives
 To understand the pharmacist’s role in monitoring:
– the patient’s response to therapy
– adverse drug reactions (ADR)
 To understand the pharmacist’s use of clinical and biochemical
laboratory data to optimise patient health outcomes
 To understand the pharmacist’s role in modifying treatment and
contributing to clinical decision making in the multidisciplinary
healthcare team
Learning Outcomes
 At the end of this tutorial you should be able to:
– Think critically and apply clinical knowledge to optimise
medication use (in simple cases)
– Understand the role of the pharmacist in monitoring patient
response to therapy and adverse drug reactions (ADRs)
– Understand the pharmacist’s role in contributing to clinical
decision-making in the multidisciplinary healthcare team
Clinical Pharmacist inpatient role
 Review chart daily
– Medication and other charts such as:
• IV fluid records
• fluid balance chart
• general observation chart with temperature, blood pressure
 Contribute to prescribing decisions
– Choice of drug, dose, route of administration, monitoring
requirements
 Monitor patient response to therapy
– Modify patient therapy based on response and ADRs
Monitor patient’s response to therapy
 Subjectively:
– Question the patient directly
– Observe the patient’s clinical status (e.g. oedema, jaundice)
 Objectively:
– Review measurement charts of
• drug concentrations in plasma, urine, cerebrospinal fluid
(CSF), bronchial fluid
• surrogate markers (e.g. BP, blood glucose)
Scenario 3
 Jenny, 60 yo female, with endocarditis
– Admitted to General Medical ward after methicillin-resistant
Staphylococcus aureus (MRSA) septicaemia
 Past medical history
–
–
–
–
Mitral valve disease
Atrial fibrillation
Hypertension
Ischaemic heart disease
 Prescribed vancomycin 750 mg every 12 hours (started 2 April)
– also on multiple regular medications: warfarin, perindopril,
amiodarone, isosorbide mononitrate
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Antibiotic therapy
via PICC
 To be discharged on 4 weeks
of vancomycin
 Using Hospital in The Home
(HITH) program
http://health.vic.gov.au/hith/
 Requires a Peripherally
Inserted Central Catheter
(PICC line)
 Activity: 5 mins
Discuss HITH & PICC use
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Group discussion:
 What factors may influence Pharmacist’s
monitoring decisions in hospital setting?
– Understanding of patient’s clinical situation and individual factors
• Renal/liver function
– Expert knowledge of drug, therapeutics and diseases
– Good understanding of physical assessments, lab and diagnostic
tests
– Access to and knowledge of quality resources
Therapeutic Drug Monitoring (TDM)
 Provides information to multidisciplinary team to guide treatment
decisions
 Type of monitoring required depends on
– drug pharmacokinetics
– patient adherence
– Different software available
 See various tests at Royal College of Pathologists of Australia
http://www.rcpamanual.edu.au/
Therapeutic Drug Monitoring (TDM)
 Provides information to multidisciplinary team to guide treatment
decisions
 Type of monitoring required depends on
– drug pharmacokinetics
– patient adherence
– Different software available
 Therapeutic Guidelines has quality information
 See various tests at Royal College of Pathologists of Australia
http://www.rcpamanual.edu.au/
Therapeutic Guidelines:
Antibiotic
Royal College of Pathologists
of Australia information for
vancomycin
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Jenny’s laboratory data
 6 April: Vancomycin dose 750mg IV bd
–
–
–
–
Na 133 mmol/L; K 4.8 mmol/L
eGFR 43 ml/min
WCC 17.8; Neut 12.6
Serum vancomycin pre-dose (trough) 16.5 mg/L (12 – 18 mg/L)
 9 April: Vancomycin dose of 750 mg IV bd
–
–
–
–
Na 134 mmol/L; K 3.9 mmol/L
eGFR 44 ml/min
WCC 15.2; Neut 10.5
Serum vancomycin pre-dose (trough) 28 mg/L (12–18 mg/L)
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Activity: 10 minutes
 What factors can influence vancomycin concentrations?
 What would you recommended for Jenny’s vancomycin therapy?
 Look online at Therapeutic Guidelines
– in PPS use link via All Programs (not library access)
– Start menu – All Programs – Therapeutic Guidelines
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Role of Clinical Pharmacist in TDM
 Contribute to monitoring decisions
– Advise multidisciplinary healthcare team (doctors, nurses)
• when TDM is required and suggest times to take TDM
samples
• how to interpret TDM results & suggest drug therapy options
– eg reduce dose/frequency or possibly change drug
– Determine what factors may contribute to unexpected TDM levels
• unusual timing of doses
• other drug involvement
• whether blood is taken through a lumen used by a
contaminating agent (blood or other drug)
• Other???
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Case Study
 Chan Kang Hong, 73 yo on General Medical ward
 admitted for increased shortness of breath,
fatigue & ankle swelling
– bodyweight: 68 kg (66kg at GP visit 6 months ago)
– BP 140/70 mmHg
– lab data (4 weeks ago)
• urea, creatinine and electrolytes – normal
• estimated creatinine clearance – 60 mL/min
 Medical history
–
–
–
–
–
heart failure diagnosed 1 year ago (LVEF < 40%) after MI
dyslipidaemia
osteoarthritis
stable ischaemic heart disease
hypertension
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Mr Hong’s current medicines
 Perindopril arginine 2.5 mg (started for heart failure)
 Aspirin 100 mg once daily
 Atorvastatin 20 mg once daily
 Celecoxib 200 mg once daily
 Isosorbide mononitrate 60 mg CR once daily
 Frusemide 20 mg once daily
 Paracetamol 1 g four times daily for pain relief
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 Mr Hong moved into a retirement village 6 months ago after his wife
died.
 An active member of a walking group, but over the last 3 weeks he’s
had increased shortness of breath and fatigue after a steady 20min walk, so he has reduced his physical activity.
 He’s also noticed swelling in his ankles despite his usual fluid tablets.
 He tells you he’s eating packaged soups instead of regular meals for
convenience and is drinking more water than recommended, < 1.5
L/day was recommended after his heart failure diagnosis.
 He has missed some medicine doses since his GP visit 6 months ago.
 While reviewing his drug therapy, you find he is concerned about his
worsening symptoms and unsure how continuing his medicines
will help to manage his heart failure.
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Activity: 20 mins
 Remember the SOAP approach to clinical problem solving
 List 3 factors that may have exacerbated Mr Hong’s heart failure
 How would you modify his existing drug therapy to improve his
current condition?
– Would you increase the perindopril dose?
• List 2 parameters you would monitor if the dose of perindopril
was altered
– Would you start him on a heart failure specific beta blocker?
– List 2 adverse effects that he is likely to experience if started on a
heart failure specific beta blocker. How you would manage these
side effects?
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Three factors that may have exacerbated
Mr Hong’s heart failure
 increased fluid intake
 NSAID use
 increased salt intake
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 Modifications to existing drug therapy:
–
–
–
–
Stop or change the NSAID to an alternative analgesic
Increase the frusemide dose
Increase the perindopril dose
Introduce beta blocker
 Increase perindopril dose?
– increase to the target dose of 5–10 mg daily
 List 2 parameters you would monitor if the dose of perindopril was
altered
– If the dose was increased, monitor Mr Hong’s blood pressure,
renal function and electrolytes
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Starting Mr Hong on a heart failure specific beta blocker?
 He should be trialled on a beta blocker, both for secondary prevention
of ischaemic heart disease and heart failure
– Patients often experience significant side effects and worsening of
symptoms when started on a beta blocker. So introduce these
agents only when the patient is stable, and then at lowest dose
possible and titrate up slowly
 Review the patient 1 week after starting the beta blocker.
 If the drug is tolerated and the patient is stable, increase the dose after
4 weeks
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Adverse effects of heart failure specific beta blocker and
management
 Common adverse effects associated with beta blockers are:
– Bradycardia
– Hypotension
– Initial deterioration of heart failure symptoms
 Management strategies:
– start at a low dose and increase slowly
– maintain the same dose and monitor carefully
– reduce the dose or stop the beta blocker
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Activity: 10 mins
 Complete a ‘Report of Suspected ADR’ for Mr Hong, who developed
bradycardia and became hypotensive after taking 5mg bisoprolol
 Find an electronic copy of the form in the Hospital Tutorial Folder
(PAC3362)
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Strategies to encourage regular
medication use
 Provide information and education to the patient about:
– monitoring of weight, symptoms, diet, medications that can
worsen heart failure, appropriate fluid intake and exercise
 Use a reminder chart
 Simplify the dose
 Use a Dose Administration Aid such as a Websterpak
 Refer for a home medicines review
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Two activities: 10 mins
1. Speak with the doctor about your concerns about Mr Hong’s
deteriorating heart failure.
– Model the good communication seen in the videos over the
series of hospital pharmacy tutorials.
2. Counsel Mr Hong on discharge encouraging him to take his
medicines regularly and to manage his heart failure appropriately
 Perform these activities in groups of 3–4
– Take turns to role play the doctor/patient, and ask the
observer/s for feedback
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References
 SHPA Standards of Practice for Clinical Pharmacy
 Clinical Skills for Pharmacists, A Patient-Focused Approach (Tietze, J,
ed 3)
 Pharmacy Practice Experiences – A Students Handbook (Setlak, P)
 Hospital Pharmacy (Stephens, M ed 2)
 Medication Review: A Process Guide for Pharmacists (Chen, T et al,
ed 2)
 Australian Medicines Information Training Workbook (ed 1)
 National Prescribing Service Limited. Case study report. Case study 71:
Heart failure. Sydney: NPS, January 2012