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• Systematic approach to patient therapy assessment What is systematic approach to patient therapy assessment? Patient therapy assessment is the process whereby a clinical pharmacist integrates general diagnosis & therapeutic knowledge with medical & social information obtained from an individual to develop an optimal patient – specific therapeutic plan. Why is systematic approach to patient therapy assessment? To relate knowledge base to the solution of therapeutic problems by formulating advice to prescribers & patients to maximize efficacy, safety & cost effectiveness. Construct & defend rational arguments in support of the advice so formulated. When and Where? In response to a request of a prescriber. In ward rounds. In selected patients of high risk factors. Ability to interpret laboratory data. Knowledge of medical abbreviations. Clinical Pharmacy & Therapeutics, pp863-870. Clinical pharmacy & therapeutics, Roger Walker & Clive Edward, Latest edition. Clinical pharmacy & therapeutics, eds. Herfindal ET Gourly DR, Hart LL, Latest edition. Applied Therapeutics. The clinical use of drugs, Young LY, Koda-Kimble MA, Latest edition. Pharmacotherapy, A pathophysiological approacgh, Dipiro, JT etal., Fifth edition. Pathophysiology : Biological & Behavioral perspective, eds. Copstead & Banasik. Davidson’s principles & practice of medicine, eds. Edwards CRW, Bourchier LAD, Haslet C, Chilvers ER, latest edition. Clinical medicine, eds. Kumar P & Clark M, latest edition. Organizing information according to medical problems helps breakdown a complex situation into its individual parts. Each medical problem is identified , listed sequentially, and assigned a number. Subjective data & objective data in support of each problem are delineated, an assessment is made , & a plan of action identified [SOAP] A 'problem' can be defined as anything relating to a patient which may influence the medical management of that patient. Thus a problem can be:i) A disease state. ii) An abnormal finding which is not attributable to a diagnosed disease state. iii) Any other factor which may influence the patients management. A disease state should be confirmed by relevant objective findings before it s listed as a definite problem. Once this is done, symptoms, signs or results of investigations are then related to the disease state and are not problems in their own right. For example, a patient admitted to hospital with chest pain may have had a myocardial infarction or may have severe acute angina. Initially his problem is 'chest pain', but after investigations of ECG and serum cardiac enzymes, the ,diagnosis of myocardial infarction can be confirmed or refuted. His problem then becomes either 'myocardial infarction' or 'acute angina'. Chest pain is then a symptom of a diagnosed disease state and is not a problem in its own right. Abnormal findings of any sort, symptoms, signs or results of investigations which are not known to be due to any disease state already diagnosed in this patient are problems in their own right. In addition some findings may be related to existing disease states but may be sufficiently important to warrant being classed as separate problems. For example, a patient with hypertension may have a degree of renal dysfunction which is known to be due to his hypertension, but this is important for the management of the patient and may cause further symptoms itself, thus it is classed as a separate problem. Other factors which may influence a patient's management are wide ranging and may include:smoking, excess alcohol intake, low intelligence, confusion, history of poor compliance, inability to swallow, previous adverse drug reactions, poor social circumstances etc. Problems can be subdivided into active or inactive. Active problems are those which currently require treatment. For example a patient diagnosed as having hypertension adequately controlled by bendrofluazide, who has developed hypokalaemia would have two problems, hypertension and hypokalaemia, both of which are active, despite the fact that he is at present normotensive. Inactive problems are those which have been treated and treatment has been discontinued or the problem is resolved by some other means. Adverse drug reactions are also inactive problems, provided the reaction has resolved. It is important to be aware of inactive problems, since despite no longer requiring therapy they may well influence present and future management of a patient. INTERACTIONS BETWEEN PROBLEMS, DRUGS AND GOALS OF THERAPY Interactions may occur between drugs, between drugs and problems and between problems. Any type of interaction may affect the achievement of goals of therapy by altering handling, toxicity or efficacy of drugs or by worsening or causing problems. 1. Problems which may affect other problems:Examples are:Renovascular disease causing or worsening hypertension Cardiac failure causing reduced renal function. Smoking causing chronic bronchitis. Poor compliance with drugs worsening any problem for which drugs are prescribed. 2. Problems which may affect the achievement of goals of therapy:- This may include examples such as:Smoking reduces symptom relief in asthma Inadequate knowledge of medication may prevent effective use of drug therapy 3. Drugs which may affect the achievement of goals of therapy:Drugs which alter handling, toxicity or efficacy of other drugs or worsen problems will clearly affect the achievement of goals of therapy. In addition, some drugs or, more commonly, drug combinations by being administered together can actually preclude the achievement of goals. An example would be the product Burinex K causing hypokalaemia which it is simultaneously attempting to rectify. 4. Goals which are not being achieved:The whole point of setting goals of therapy for patients is that they should as far as possible be achieved. If any identified goal is not being achieved, can any contributing factor such as a problem or drug be identified, or should drug thereby be altered to improve its effectiveness? 5. Drugs which can worsen or be a causative factor of problems:Any problem which is listed as a contraindication to a drug or for which the recommendation to use with caution is given suggests that the drug may contribute to or worsen the problem. There are therefore hundreds of examples of this type of interaction. A few are:Beta-adrenoceptor antagonists worsen cardiac failure Antipyschotics worsen or cause Parkinsonism. Hypnotics can worsen impaired cerebral function in acute liver failure. Diuretics can worsen or cause hypokalaemia Subjective data refers to information provided by the patient or another person which cannot be confirmed independently. Objective data refers to information observed or measured by the clinical pharmacist ,laboratory test , BP measurement. Results of investigations may include a wide range of general biochemical and haematological tests and also more specific tests selected to aid diagnosis, assess severity of disease states or monitor progress in individual patients. These may include other biochemical analyses (e.g. thyroid function tests), other haematological tests (e.g. INR), electrophysiological tests (e.g. ECG), radiological procedures (e.g. chest X ray), microbiological tests (e.g. antibiotic sensitivities). After the subjective & objective data have been gathered in support of specific listed problems , the clinical pharmacist should assess the acuity , severity & importance of these problems. The clinical pharmacist should then identify all factors that could be causing or contributing to the problem. The plan should consist of a diagnostic plan & a pharmaceutical care plan that includes patient education. Diagnostic plan:- could include further diagnostic tests, evaluation of drug –induced problems or referral to another health care provider. It describes desired clinical outcomes or therapeutic objectives. Examples of clinical outcomes or therapeutic objectives are:Curing disease [treatment of an infection] Elimination or reducing patient’s symptoms [pain control] Arresting or slowing the disease process [lowering a patient’s cholesterol or BP to reduce the risk of CHD]. Preventing an unwanted condition or disease [immunization, prophylactic antibiotics] Or improving the quality of life a) Pharmaceutical care issue, an element of a pharmaceutical need which requires to be addressed by a pharmacist. A pharmaceutical need is defined as a patient's requirement for a pharmaceutical product or service. The problem list which you will identify will contain all of the patient's pharmaceutical needs but in addition problems such as adverse drug reactions, biochemical abnormalities etc. b) Pharmaceutical action, an action by a pharmacist to address a pharmaceutical care issue for a patient. c) Desired pharmaceutical output, a statement of what the pharmacist aims to achieve for a patient in relation to a pharmaceutical care issue. a) Drug history taking Drug history taking basically involves interviewing the patient to obtain further information relating to drug therapy. b) Recommending changes to therapy c) Patient monitoring d) Patient counseling e) Ensuring seamless pharmaceutical care • Recommending changes to therapy General factors involved in rational drug selection a) Diagnosis, symptoms The actual severity and stage of the problem may alter the course of treatment. For example, a presentation of severe congestive cardiac failure may require use of high dose intravenous loop diuretics, possibly with the addition of metolazone initially. As symptoms resolve, treatment may alter. b) Comparative efficacy of the available therapies In patients with duodenal ulceration associated with Helicobacter pylori, a course of eradication therapy is more appropriate than sole use of an H2 antagonist. c) Patient's other problems Such situations may contraindicate the use of a particular drug or group of drugs. For example hypertensive asthmatic patients should not be treated with beta adrenoceptor antagonists. However, it is sometimes possible to choose one drug to treat more than one problem. For example, a tricyclic antidepressant would be most appropriate to use in a depressed patient with urinary incontinence. d) Patient's other drugs There are many examples of clinically important drug interactions. Some of these may render a particular treatment unsuitable, while others may simply increase the need for specific monitoring. e) Side effects of particular significance Drugs causing daytime drowsiness are not the most appropriate for many patients. f) Pharmacokinetic profiles This will determine rate and extent of absorption, excretion etc. g) Formulation h) Cost-effectiveness i) Response to therapy Having done this, you will be in a position to identify whether or not a pharmaceutical care issue exists. There are many types of such issues, including:Current therapy contra-indicated, clinically important ,drug-drug interaction ,adverse drug reactions being experienced ,no indication for therapy. Sub-therapeutic dose Excessive dose The next stage is to determine the most appropriate recommendation which may include:Drug addition Drug substitution Drug discontinuation Change in dose Change in route Change in formulation The final step is to discuss your recommendation with the prescriber. Once you have identified that the patient's therapy is appropriate or have recommended changes which have been accepted, the next stage of the pharmaceutical care plan is to formulate a monitoring plan to determine the efficacy and/or toxicity of treatment. The relevant pharmaceutical care issue is simply that there is a need for monitoring, which may be greater or less depending on the patient and the drug therapy. As with the previous aspects of case history analysis, it is important to use a systematic approach. By taking each problem in turn, you can identify those parameters to monitor to establish efficacy and those parameters to monitor for each drug to identify any drug toxicity. Reinstituting correct use of a prescription medication when it is being taken improperly. Educating & working with the patient to self-diagnose. Evaluate & solve therapeutic problems. Initiating non prescription drugs. Non-drug therapy Reinforcing continuation of already prescribed medications. Alerting physician to potential drug – related problems that can be solved only through an alteration of the original prescription[ these include discontinuing the medication , prescribing an alternative drug, altering the dosage or the route of the current medication, adding another medication] Referring the patient back to his primary care provider.