Rational Drug Therapy For The Management of Asthma Disease at MMCTH, Mardan

RATIONAL DRUG THERAPY FOR THE MANAGEMENT OF ASTHMA
AN INTERNSHIP BASED PROJECT AT MARDAN MEDICAL COMPLEX, MARDAN

By
ZAWAR HUSSAIN
Reg. No. PHR120091104
Doctor of Pharmacy (Pharm-D)

DEPARTMENT OF PHARMACY
KOHAT UNIVERSITY OF SCIENCE AND TECHNOLOGY KOHAT, KHYBER
PAKHTUN KHWA, PAKISTAN
Session (2008-2013)
CERTIFICATE OF APPROVAL

This project entitled RATIONAL DRUG THERAPY FOR THE MANAGEMENT OF
ASTHMA in the Medical-A ward of Mardan Medical Complex, Mardan, prepared by
ZAWAR HUSSAIN submitted to the Department of Pharmacy in the partial fulfillment of the
requirements for the degree of Doctor of Pharmacy is hereby approved for submission.

SUPERVISOR: ___________________________
Mr.Ghayour Ahmed,
Lecturer,
Department of Pharmacy, KUST

HOSPITAL CHIEF PHARMACIST: ___________________________
Ms. Bushra Khan
Mardan Medical Complex, Mardan

EXTERNAL EXAMINER: ___________________________

INTERNAL EXAMINER: ___________________________
Mr.Ghayour Ahmed
Lecturer,
Department of pharmacy, KUST.

CHAIRMAN: ___________________________
Dr. Abdul Wahab
Assistant Professor,
Department of Pharmacy, KUST.

DEDI CATI ON
I would like to dedicate this study to the Almighty Allah,
to my beloved family specially to my father, to my friends
and my relatives. I would also like to dedicate
this project to my fellows who were & will be,
very important part of my life.

ACKNOWLEDGMENT

I owe my deepest gratitude to Almighty ALLAH for He is the source of our strength and power.
It is a pleasure to thanks those who made this thesis possible. I am deeply grateful to Ministry of
Health and Dr. Abdul Wahab, Chairman Department of Pharmacy, Kohat University of Science
& Technology for their struggles to arrange the Clinical Pharmacy clerkship in Government
Teaching Hospitals..
I wish to express sincere gratitude to my supervisor Mr. Ghayour Ahmed who has supported me
throughout my thesis with his patience and knowledge while allowing me the room to work in my
own way. He has been the ideal thesis supervisor. His sage advice, insightful criticisms, and
encouragement aided the writing of this thesis in innumerable ways. He has made available his
support in a number of ways. I also thankful to my ALL Teachers, who ornaments & facilitate
me with grate knowledge, during my university life.
I would like to extend my warmest thanks to Ms. Bushra Khan, Chief Pharmacist Mardan
Medical Complex, Mardan
Where would I be without my family? It is an honor for me to take this opportunity to thank my
affectionate, sympathetic and respectable father Mr. Muatabar Khan & my Mother who
brought me up with their love; and Sister for their prayers and support throughout my career.
My sincerest thanks to my brothers Mansoor Akhter and Asad Ali for their patience, assistance,
continuous support and encouragement during the completion of this work.
I would like to give my heartfelt appreciations to my best friends Shabab Hussain, M.Bilal and
Amin ur Rahman for their friendly assistance and kind suggestions throughout the completion
of this thesis. I pay A cordial thanks to my romates, best friends & everything for me, Salman
Khan & Sajid Ali for being a special part of my university life. Last but not the least, thanks to
Tauseef Ahmad, Shabih ul Hassan, Zia ullah, Sardar Ali, Tanveer Ahmad and All of my class
fellows, J uniors and seniors for being an important part of my Universitys life.
Thanks to all of my friends and everyone, who have been contributing by supporting my work,
and helped me during the final year project.
May ALLAH bless them all and give me the strength to serve the humanity. Aameen!
Zawar Hussain
Pharm-D
CONNTENTS

TITLE

PAGE NO:
List of abbreviations I
List of figures III
List of tables IV
Summary V

CHATER# 01 INTRODUCTION 01
1.1 Difinition 01
1.2 Etiology 01
1.3 Signs & Symptoms 02
1.4 Prevelence 02
1.5 pathophysiology 02
1.6 Clinical Presentation 04
1.7 Classification of Asthma Severity 05
1.8 Diagnose 07
1.9 Desire Outcomes 09
1.10 Standard Treatment Guide Lines 10
1.10.1 Non Pharmacotherapy 10
1.10.2 Pharmacotherapy 10
1.11 Aims and Objectives 20

CHAPTER# 02 METHODOLOGY

21
2.1 Methodology 21
2.2 Case Histories 29

CHAPTER# 03 RESULTS

90
3.1 Results 90

CHAPTER# 04 DISCUSION & CONCLUSION

99
4.1 Discussions 99
4.2 Conclusions 100

REFRENCES

102
5.1 References 102

I

LIST OF ABBREVIATIONS

ABBREVIATIONS

ACRONYMES
EIB Exercise Induced Bronchospasm
ESBL Extended Spectrum Beta Lactamase
PEF Peak Expiratory Flow
IL Inter Leukins
ICU Intensive Care Unit
MDR Multi Drug Resistance
NAEPP
National Asthma Education and Prevention Program
PAF Platelet Activating Factor
SARS Severe Acute Respiratory Syndrome
SaO2 Oxygen saturation
IV Intravenous
IM Intramuscular
PaO2 Partial Pressure Of Oxygen In Arterial Blood
T-HC T-helper Cell
BHR Broncial Hyper Responsiveness
SOB Shortness of breath
HTN Hypertension
LRTi Lower tract respiratory infection
MOH Ministry of health
TDM Therapeutic drug monitoring
ADRs Adverse drug reactions
COPD Chronic obstructive pulmonary disease
& And

II

OD Once a day
TSF Tea spoon full
TDS Thrice in a day
SoS Si opus sit (if needed)
BiD Bis in die (twice a day)
NB Nebulisation
pt Patient
M Male
F Female

III

LIST OF TABLES

S. No: Name Of Table Page. No
01 Classification of severity of chronic stable asthma 06
02 Classification of severity of asthma exacerbations 07
03 Step wise approaches of managing asthma 12
04 Quick relief medication of asthma 18
05 Patients demographic data 90
06 Age wise distribution of patients 92
07 Frequency of drug related problems 93
08 Causes of hospitalization 95
09 Concurrent diseases 96
10 Occurrence of drug interactions 97

IV

LIST OF FIGURES
S. No NAME OF FIGURE Page No.
01 Patients demographic data 91
02 Age wise distribution of patients 92
03 Frequency of drug related problems 94
04 Causes of hospitalization 95
05 Concurrent diseases 96
06 Occurrence of drug interactions 98

V

SUMMARY

Thesis report is based on Clinical Pharmacy Clerkship rotation, on the management of asthma,
completed in Mardan Medical Complex, Mardan, KPK. The data of 15 patients was collected
and analyzed. The treatment prescribed at hospital of individual patient was compared with the
standard pharmacotherapy and analyzed for any untreated condition, improper drug selection
,drug interaction, adverse drug reaction, drug without indication, sub therapeutic or excessive
dosing, and cost related problems
The goals of asthma therapy are to minimize chronic symptoms that impair normal activity
(including exercise), to prevent recurrent exacerbations, to minimize the need for emergency
department visits or hospitalizations, and to maintain near-normal pulmonary function. During
the clinical pharmacy clerkship, rational pharmacotherapy of the Asthma disease was the main
focus.
To record & analyze medication-histories (medications used before admission); to analyze
pharmacotherapy provided in the hospital; to evaluate the outcomes; to identify drug related
problems; to analyze their management and to report drug information/therapeutic-consultation
or patient education and counseling that were provided during rotations.
The treatment provided in the hospital was according to the standard protocol however, some
drug related problems were detected which include excessive doses, drug-drug interactions, 28
(42%) total drugs interaction were count, most common drug interactions were b/w cefotaxime
and furosemide, adverse drug reactions were 06 (9.09%), untreated conditions were 5 (7.57%)
and Cost related problems. Due to maximum number of patients in hospital and lack of proper
interaction and cooperation between health care professionals, the goal and vision of rational
pharmacotherapy is still far away. In order to rationalize overall pharmacotherapy of individual
patient, professional mutual interaction among physicians, pharmacists and nurses is required.
The patient education, counseling and information are also important parameter so that patient
can be provided with complete pharmaceutical care. Patient must be educated properly in order
to increase the compliance level. Ministry of Health is required to provide cost effective drugs to
the respective hospitals. Free of cost medicines should be distributed among the needy patients.

CHAPTER ONE
INTRODUCTION

Chapter One I ntroduction

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1.1 INTRODUCTION
The National Asthma Education and Prevention Program (NAEPP) define asthma as a chronic
inflammatory disorder of the airways in which many cells and cellular elements play a role. In
susceptible individuals, inflammation causes recurrent episodes of wheezing, breathlessness,
chest tightness, and coughing. These episodes are usually associated with airflow obstruction that
is often reversible either spontaneously or with treatment. The inflammation also causes an
increase in bronchial hyper responsiveness (BHR) to a variety of stimuli. ( Kelly.W et al 2009)

Asthma violence almost all age will begin, but mostly occurs often in childhood. It is a disease
that may be seen as repeated violence of breath lessness and wheezing, which alter in extent and
price for each particular person. Someone whom can be carried out each hour, and each day.
This disorder is attributable to swelling in the air tract in the voice and has effects on this level of
responsiveness in the nerve endings within the air tract so that they are often excitable. Your
assault, this covering in the parts provides the air tract enlarge and minimizes circulation of fresh
air in and from voice. (www.who.int)
1.2 ETIOLOGY
Asthma is in the very least the partially heritable complex syndrome that will require the gene-
byenvironment connection intended for phenotypic term. Environmentally, friendly risk
variables for the improvement of asthma include things like socioeconomic rank, family
members measurement, along with exposure to used cigarette smoke in childhood along with in
utero, allergen publicity, urbanization, along with lowered exposure to frequent childhood
infectious providers. Possibility variables intended for beginning (<3 years of age) recurrent
wheezing regarding virus-like attacks include things like small delivery bodyweight, guy gender,
along with parental smoking. On the other hand, that beginning style is a result of smaller
airways, along with these kind of danger variables are certainly not automatically danger
variables intended for asthma in the future. (Kelly. W et al 2008)


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1.3 SIGNS & SYMPTOMS
The characteristic signs and symptoms of asthma is:
Difficulty in breath (Shortness of breath)
Chest pain or chest tight ness
Wheezing
Coughing

From the lungs may be sputum produced but it is hard to bring them out. During the recovery
from the 1
st
, when the sputum is bring out, its look white, due to high number of white blood
cells, eosinophils in it. At the morning an also at the night the symptoms are severe or response
to cold air or exercise. Some people rarely experience the symptoms, usually it is due to the
response of triggers, where many people have persistent and marked
symptoms. (Ronald. G et al 2005)

1.4 PREVELANCE OF ASTHMA
As of 2011 235-330 million people were affected of asthma worldwide. 250,000-345,000 People
die annually from the asthma worldwide, different countries have different rates. It is more
common in developed countries than in developing countries. Asthma is same common to males
and females. (www.who.int)
In Pakistan nearly 20 million person have asthma. It is the 12% of the adult population that is
suffering from Pakistan. (www.lahorerealestate.com)

1.5 PATHOPHYSIOLOGY
Asthma gets the significant trait include bronchial hyper responsiveness, airway redness along
with a variable amount of air movement obstruction (related to bronchospasm, edema, as well as
hypersecretion). Inhaled things that trigger allergies bring about a great early-phase
hypersensitive reaction seen as a activation of cellular material bearing allergen-specific
immunoglobulin Electronic (IgE) antibodies. There exists fast activation of airway mast cellular
material as well as macrophages, which usually generate pro-inflammatory mediators such as
histamines as well as eicosanoids that creates contraction of airway smooth muscle mass, mucus
release, vasodilation, as well as exudation of plasma inside the airways. Plasma healthy proteins

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leakage induces a new thickened, engorged, edematous airway wall membrane along with a
narrowing with the airway lumen using decreased mucus clearance.
The particular late-phase inflammatory effect occurs 6-9 hours following allergen provocation
along with entails recruitment along with activation associated with eosinophils, basophils, T-
lymphocytes neutrophils, along with macrophages. This migration, associated with eosinophils
occurs to airways along with inflammatory mediators (leukotrine along with granule proteins),
cytokines, along with cytotoxic mediators usually are secretes. Your generate associated with
cytokines occurs with the activation associated with T-lymphocyte, through variety two T-helper
(TH2) solar cells of which mediate sensitive redness (interleukin [IL]-4, IL-5, along with IL-13).
On the other hand, variety 1 T-helper (TH1) solar cells generate IL two along with interferon-
which might be needed for mobile immune system. A great disproportion involving TH1 along
swith TH2 solar cells may well final results Allergic asthma suffering redness. Your generate
associated with mediators such as histamine; eosinophils, along with neutrophils chemo strategy
variables; leukotrines C4, D4, along with E4; prostaglandins, along with platelet-activating issue
(PAF) final results due to mast cell degranulation in a reaction to contaminants in the air.
Histamine can be able to inducting even muscle mass constriction along with bronchospasm and
may even play a role in mucosal edema along with mucus release. Alveolar macrophages
generate quite a few inflammatory mediators including PAF along with leukotrienes B4, C4,
along with D4. Manufacturing associated with neutrophil chemotactic issue along with
eosinophil chemotactic issue furthers this inflammatory procedure. Neutrophils will also be a
new way to obtain mediators (PAFs, prostaglandins, thromboxanes, along with leukotrienes) of
which give rise to BHR along with air passage redness.
Your 5-lipoxygenase path associated with arachidonic acid solution fat burning capacity is in
charge of output associated with cysteinyl leukotrienes. Leukotrienes C4, D4, along with E4
usually are introduced throughout inflammatory techniques inside lung along with generate
bronchospasm, mucus release, microvascular permeability, along with air passage edema.
Bronchial epithelial solar cells engage in Infection simply by delivering eicosanoids, peptidases,
matrix proteins, cytokines, along with nitric oxide. Epithelial dropping ends in raised air passage
responsiveness improved Permeability of the air passage mucosa, lacking associated with
epithelial-derived enjoyable variables, along with Loss of digestive support enzymes liable for
degrading inflammatory neuropeptides.

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Your exudative inflammatory procedure along with sloughing associated with epithelial solar
cells in to the air passage Lumen affects mucociliary transfer. Your bronchial glands usually are
improved in space, along with thegoblet solar cells usually are improved in space along with
number. Expectorated mucus through sufferers along with asthma tends to have high viscosity.
Your air passage can be innervated simply by parasympathetic, sympathetic, along with neo
adrenergic inhibitory anxious feelings. The normal slumbering firmness associated with air
passage even muscle mass can be looked after simply by vagal efferent activity, along with
bronchoconstriction can be mediated simply by vagal excitement inside small bronchi. Air
passage even muscle mass is made up of neo innervated 2-adrenergic receptors of which
generate bronchodilators. Your neo adrenergic, neo cholinergic tense method inside trachea
along with bronchi may well increase redness in asthma simply by delivering nitric
oxide. (Kelly. W at al 2009)

List of agents and events triggering asthma
Breathing contamination: Breathing syncytial virus (RSV), rhinovirus, influenza, parainfluenza,
Mycoplasma Pneumonia.
Contaminants in the air: Airborne pollens (grass, timber, weeds) house-dust mites, pet danders,
cockroaches, fungal spores.
Atmosphere: Cold air flow, fog, ozone, sulphur dioxide, nitrogen dioxide, tobacco light up,
wooden light up.
Inner thoughts: Stress, strain, fun.
Exercising: Particularly throughout cool, dried up local climate.
Drugs/preservatives: Aspirin, non-steroidal, anti-inflammatory drugs (cyclooxygenase
inhibitors), sulphides, benzalkonium chloride, nonselective -blockers.

Occupational stimuli:
Bakers (flour dust); farmers (hay mold); liven along with enzyme individuals; ink jet printers
(Arabic gum); Chemical industry individuals (azo inorganic dyes, anthraquinone,
ethylenediamine, toluene diisocyanates, polyvinyl chloride); pouches, rubberized, along with
wooden individuals (formaldehyde, American forest, dimethylethanolamine, anhydrides.
(Kelly. W et al 2008)

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1.6 CLINICAL PRESENTATION
CHRONIC ASTHMA
Classic asthma is usually seen as an episodic dyspnea along with wheezing, though the
Specialized medical presentation involving asthma is usually diverse. Individuals have complaint
Dyspenia episodes, tightness of chest, and coughing (particularly on night), wheezing, or maybe
a whistling seem any time during breathing. These often take place using exercising however
may possibly take place spontaneously or even in association with the known things that trigger
allergies. Signs include expiratory wheezing on auscultation, dry out hacking cough or even
symptoms involving atopy (e. g., allergic rhinitis or even eczema). Asthma may differ from
chronic day-to-day signs and symptoms to be able to just spotty signs and symptoms. This
intervals in between signs and symptoms are from days to weeks, several weeks, or even a long
time. This seriousness is determined by lung operate, signs and symptoms, night time
awakenings, in addition to disturbance using normal activity ahead from the therapy. Individuals
can easily existing using mild spotty signs and symptoms that want simply no medicinal drugs or
even just irregular by using short-acting inhaled 2-agonists, in the severe chronic conditions the
individuals may receive multiple medications. (Kelly. W et al 2009)

ACUTE SEVERE ASTHMA
Out of control asthma can advance a great serious condition wherever inflammation, airway
edema, increased mucus piling up and also serious bronchospasm bring about profound airway
narrowing that is certainly the wrong way attentive to usual bronchodilator therapies. Patients
can be restless inside serious hardship and also protest of serious dyspnea, shortness of breath,
chest tightness as well as burning. Symptoms are generally unresponsive to usual actions.
Symptoms consist of expiratory and also inspiratory wheezing in auscultation, dry cough,
tachypnea, Tachycardia, pallor as well as cyanosis, and also hyper inflammed chest muscles
together with intercostal and also supraclavicular retractions. Air sounds can be diminished
together with extremely serious blockage. (Kelly. W et al 2009)
Affected individual is able to say only some phrases devoid of ending to adopt any breathing.
Misunderstandings, lethargy, and blue skin (cyanosis) are the signals that how the persons
breathable oxygen significantly restricted, along with crisis remedy is necessary. Generally, a

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patient recovers completely having proper remedy, also at a severe asthma attack.
(www.merckmanuals.com)

1.7 CLASSIFICATION OF ASTHMA SEVERITY
The classification system is developed by NAEPP which might be beneficial throughout guiding
asthma therapy and also determining sufferers on high-risk pertaining to building life-threatening
asthma attacks. Table 1.1 is employed to help classify this extent connected with chronic, stable
asthma; table 1.2 is employed to help classify the extent connected with asthma exacerbations. A
Patients scientific capabilities previous to treatment are employed to help classify the patient.
This occurrence connected with solely among the extent capabilities is sufficient to use the
patient in this clasification; sufferers should be issued for the most severe level by which just
about any characteristic happens. ( Chessnutt. M et al 2006)


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1.8 DIAGNOSIS
Any time asthma is suspected from scientific capabilities and other diseases have been regarded
and ruled out (e.g. tumors within grownups, foreign body within children; dont believe the
particular existence regarding wheeze implies asthma), confirm the particular diagnosis by
simply target methods regarding variable airflow impediment as well as asss severity. Generally
the subsequent criteria might suffice since target evidence of variable circulation obstruction:


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Spirometery:
o A 12 % or greater improvement in forced expiratory volume (FEV1) in children
and adults, and more than 200ml in adults from the baselines 15 minutes after use
of an inhaled short acting beta 2 agonist.
o PEF- Serial measures of peak expiratory flow (PEF): A more than 20 % change
after administration of a bronchodilator in asthmatic patient.
When there is some probability of asthma and above test are non- diagnostic, the following tests
may be used in the diagnosis of asthma:
o Methacoline challenge
o Exercise challenge
o Inhaled corticosteroid trial: appropriate doses of inhaled steroids for 4-6
weeks.. (www.bcguidelines.c0m)
The particular medical diagnosis of asthma is a professional medical one particular; there is
absolutely no standardized classification with the sort, severity or perhaps frequency of
symptoms, none with the results with exploration. The particular lack of a gold regular
classification means that isn't achievable to generate distinct evidence primarily based
endorsement with making an analysis of asthma. ( Thoracic. B 2009)
Core to all explanations is the reputation associated with signs (more than certainly one of
wheeze, breathlessness, chest tightness, cough and also associated with varying ventilation
impediment). Modern account associated with asthma with young children and also older people
have involved respiratory tract hyper responsiveness and also respiratory tract irritation because
component of the sickness. Precisely how these functions relate to every single other people, the
way they are usually finest tested and also the way they bring about the particular medical
manifestation associated with asthma remains unclear. ( Thoracic. B 2009)

Making Diagnosis in Children:
Initial Clinical Assessment:
The diagnose of asthma is recognizing a characteristic pattern of episodic respiratory sign and
symptoms. ( Thoracic. B 2009)


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Clinical features that increase the probability of Asthma
The symptoms more than one: cough, wheeze, difficulty in breath, tightness of chest, particularly
if these symptoms;
Are recurrent and frequent
Are worst at the early and night time
occur in response to, are worse after, exercise or other triggers, such as exposure to
pets, cold or damp air, or with emotions or laughter
Occur apart from cold:
Personal history of atopic disorder
Family history of atopic disorder and/or asthma
Widespread wheeze heard on auscultation
History of improvement in symptoms of lung function in response to adequate
therapy. ( Thoracic. B 2009)
Clinical features that lower the probability of Asthma
Symptoms with cold only, with no interval symptoms
Isolated cough in the presence of wheeze or difficulty breathing
History of moist cough
No response to a trial of asthma therapy
Normal peak expiratory flow (PEF) or spirometery when symptomatic Clinical
features pointing to alternative diagnosis. ( Thoracic. B 2009)
1.9 DESIRE OUTCOME
CHRONIC ASTHMA:
The NAEPP provides the following goals for chronic asthma management:
Reducing impairment:
(1) Stop persistent and difficult signs and symptoms (e. grams., breathing problems or even
breathlessness within the day time, in the evening, or even soon after exertion);

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(2) Involve infrequent use (2 days/wk) regarding inhaled short-acting 2-agonist regarding
speedy relief regarding signs and symptoms (not including deterrence regarding exercise-induced
bronchospasm [EIB]).
(3) Preserve (near-) standard pulmonary functionality;
(4) Preserve standard activity degrees (including exercise and attendance at the office or even
school);
(5) Meet up with patients and families requirement regarding and satisfaction after due thought.

Reducing risk:
(1) Prevent recurrent exacerbations and lessen the importance regarding goes to as well as
hospitalizations;
(2) Prevent decrease in lung operate; regarding children, avoid reduced lung progress;
(3) Little as well as absolutely no adverse effects associated with remedy. (Kelly. W et al 2009)
ACUTE SEVERE ASTHMA:
The aims regarding treatment method include things like:
(1) Static correction regarding substantial hypoxemia;
(2) Rapid letting go regarding throat blockage (within minutes) along with;
(3) Decrease regarding the possibilities of recurrence regarding extreme air flow blockage.

1.10 STANDARD TREATMENT GUIDELINES
1.10.1 NON PHARMACOLOGIC THERAPY:
Sufferer education and also the instructing involving self-management ability ought to be the
essence from the cure. Self-management plans increase adherence to help treatment sessions,
self-management ability, in addition to use of professional medical services.
Objective proportions involving circulation impediment which has a property maximum
circulation meter might not automatically increase affected person effects. Your National
Asthma Education and Prevention program (NAEPP) supporters use of Top expiratory
circulation (PEF) monitoring only for patients having severe lingering asthma who have trouble
perceiving air passage impediment.

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Deterrence involving acknowledged allergenic triggers may increase signs, lower treatment
work with, in addition to minimize Bronchial hyper responsiveness (BHR). Environmental
triggers (e. g., animals) should be avoided throughout hypersensitive patients, and people whom
smoking should be prompted to quit.
Sufferers having acute severe asthma really should obtain extra O2 remedy to help keep arterial
O2 vividness earlier mentioned 90%. Important dehydration should be remedied; urine distinct
gravity can help guidebook remedy throughout small children, throughout whom analysis
involving hydration rank might be difficult. (Kelly. W et al 2009)

1.10.2 PHARMACOTHERAPY:
o Approach to Long-Term Treatment:
The actual aims connected with asthma treatment tend to be to minimize continual signs or
symptoms that damage regular task (including exercise), to avoid repeated exacerbations, to
minimize the necessity pertaining to emergency team trips or perhaps hospitalizations, and to
sustain near-normal pulmonary operate. These kinds of aims must be fulfilled while supplying
best pharmacotherapy with all the fewest adverse effects although assembly individuals and also
family members expectations connected with pleasure together with asthma care.
Latest strategies to prolonged asthma concentrate on everyday anti-inflammatory treatment
together with inhaled corticosteroids. Treatment method algorithms use both seriousness of your
person's baseline asthma along with the seriousness connected with asthma exacerbations. The
amount of prescription medication and also regularity connected with dosing tend to be
determined through asthma seriousness and also focused toward suppression connected with
growing air passage swelling. To ascertain fast management, treatment must be caused earlier for
a greater power amount compared to anticipate pertaining to long-term treatment.
Pharmacotherapy will then end up being cautiously set foot lower when asthma management is
usually attained and also sustained; this will give pertaining to id from the lowest prescription
medication important to sustain long-term management. (Chessnutt. M et al 2006)

o Pharmacologic Agents for Asthma
Asthma prescribed drugs might be separated directly into a couple of categories: agents that
provide quick reduction regarding symptoms along with agents delivered to showcase long-term

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asthma handle. Quick-relief prescription drugs tend to be delivered to showcase immediate
reversal regarding serious ventilation blockage along with relieve enclosed symptoms by simply
immediate peace regarding bronchial even muscle. Long-term handle prescription drugs tend to
be consumed everyday independent regarding symptoms to achieve and observe after handle
regarding chronic asthma. These types of agents also called preservation, controller, or maybe
preventative prescription drugs work largely to attenuate neck muscles redness. A lot of asthma
prescription drugs tend to be applied orally or maybe by simply inhalation. Breathing associated
with an correct real estate agent leads to an increasingly swift attack regarding pulmonary
consequences in addition to fewer systemic consequences in comparison with common
supervision with the very same dose. Metered-dose inhalers (MDIs) propelled by simply
chlorofluorocarbons (CFCs) are actually the preferred shipping program. (Chessnutt. M et al
2006)


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A. LONG-TERM CONTROL MEDICATIONS
Anti-inflammatory agents, long-acting bronchodilators, in addition to leukotriene modifiers
encompass the important medicinal drugs within this number of agents (see table: 1. 7). Other
instructional classes involving agents are usually pointed out temporarily down below.

1. Anti-inflammatory agents
Corticosteroids shows great, powerful and also prolong effect on pain relieving and also shows
anti- inflammatory action. These people minimize equally serious and also serious infection,
contributing to fewer asthma indicators, progress with airflow, decreased throat
hyperresponsiveness, fewer asthma exacerbations, and also a smaller amount throat redecorating.
These kinds of providers can also potentiate this activity connected with -adrenergic agonists.
Inhaled corticosteroids are usually preferred for that long-term command connected with
asthma and they are firstline providers with regard to patients along with persistent asthma.
People along with persistent indicators or maybe asthma exacerbations who definitely are
certainly not taking inhaled corticosteroids needs to be commenced when using inhaled
corticosteroid; symptomatic patients currently taking a great inhaled corticosteroid needs this
dosage greater.

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Systemic corticosteroids (oral or maybe parenteral) are usually most effective with attaining
immediate command connected with asthma while in exacerbations or maybe any time
beginning long-term asthma treatment. Throughout patients along with significant persistent
asthma, systemic corticosteroids tend to be required for this long-term suppression connected
with indicators. Duplicated attempts needs to be built to reduce the dosage towards the minimum
amount needed to command indicators. Alternate-day remedy is preferred to help regular
remedy. Fast discontinuation connected with systemic corticosteroids after serious work with
may well precipitate adrenal deficiency. Contingency remedy along with supplements and also
vitamin supplements Deborah needs to be opened up to avoid corticosteroid-induced bone
vitamin burning with long term administration. (Williams. L et al 2009)

2. Long-acting bronchodilators
a. Mediator inhibitors: Cromolyn sodium along with nedocromil tend to be long-term handle
medicines in which avoid asthma signs along with enhance air passage function throughout
people with minor lingering asthma or even exercise-induced asthma. Payday cash brokers
modulate mast mobile or portable mediator launch along with eosinophil recruitment along with
inhibit each first along with delayed asthma suffering answers to help allergen challenge along
with exercise-induced bronchospasm. The actual scientific a reaction to these kind of brokers can
be fewer expected as opposed to a reaction to inhaled corticosteroids. Nedocromil may help slow
up the measure prerequisites for inhaled corticosteroids. Each brokers get exceptional protection
single profiles.. (Williams. l et al 2009)
b. -Adrenergic agents: Long-acting 2-agonists present bronchodilation for as much as 12 hrs
after having a single measure. Nonetheless, since his or her attack of actions will be overdue,
these are definitely not powerful and also must not be found in the treating serious
bronchoconstriction. (Williams. l et al 2009)
c. Phosphodiesterase inhibitors: Theophylline delivers moderate bronchodilation within
asthmatic people. This specific substance also can get anti-inflammatory qualities, improve
mucociliary clearance, in addition to reinforce diaphragmatic contractility. Sustained-release
theophylline preparations work well within preventing nocturnal asthma and they are typically
appropriated for utilize since adjuvant therapies within people together with mild or perhaps
severe chronic asthma. Many people could also be used since choice long-term preventive

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therapies within people together with moderate chronic asthma. Theophylline serum conc. ought
to be supervised directly due to the particular drug's slim deadly healing selection, personal
dissimilarities within metabolism, along with the effects of many elements upon substance
absorption in addition to metabolism. (Williams. l et al 2009)

3. Leukotriene modifiers
This can be a hottest course associated with medicines with regard to long-term handle
associated with asthma. Leukotrienes tend to be efficient biochemical mediators that contribute
to neck muscles blockage in addition to asthma signs or symptoms by simply getting neck
muscles clean muscle tissue, escalating vascular permeability in addition to mucus secretion, in
addition to attracting in addition to activating neck muscles inflammatory cellular material.
Zileuton is really a 5- lipoxygenase inhibitor that diminishes leukotriene generation, in addition
to zafirlukast in addition to montelukast tend to be cysteinyl leukotriene receptor antagonists.
That they bring about moderate advancements throughout lung perform in addition to reductions
throughout asthma signs or symptoms. Most of these real estate agents can be regarded as
solutions to help low-dose inhaled corticosteroids throughout affected individuals together with
mild chronic asthma. Zileuton increase the amount of aminotransferase in plasma reversibly.
(Williams. L et al 2009)

4. Miscellaneous agents
By mouth sustained-release 2agonists usually are earmarked pertaining to patients using
bothersome evening time asthma signs and symptoms as well as average to be able to serious
persistent asthma which the other therapies usually dont give the response. Omalizumab is
really a recombinant antibody that will binds IgE without activating mast cellular material. Inside
clinical studies, the idea minimizes the importance pertaining to corticosteroids inside average to
be able to serious asthma suffering patients using improved IgE levels. Corticosteroid-sparing
anti-inflammatory agencies such as troleandomycin, methotrexate, cyclosporine, 4
immunoglobulin, and gold should be employed only inside decided on serious asthma suffering
patients. These kind of and also other agencies include adjustable benefit and a concern
toxicities. (Williams. l et al 2009)


Page 17

B. QUICK-RELIEF MEDICATIONS
The quick relief medications for asthma are the important medication in Antiasthmatics, which
includes;

Short acting Bronchodilators, and
Systemic corticosteroids. (BNF for children. 2009)


Page 18


Page 19

1.11 AIMS AND OBJECTIVES

The aims and objectives of this clerkship are:
Screening of Prescription for potential drug related problems.
Estimate the frequency of drug related problems.
Optimize rationality of prescriptions.
Identify patient risk factors for drug related problems.
To interpret, describe and apply the knowledge of pathophysiology and
Therapeutics, based on diseases.
Compliance monitoring.
To obtain information from the patients and healthcare professionals to ensure
Appropriate pharmacotherapy.
To know about the effect of drug related problem on treatment cost.
To compare the standard treatment guidelines with hospital treatment.
To resolve the actual drug related problems.
The main purpose of conducting clinical pharmacy training project is to rationalize drug
therapy and ensure safe and appropriate and cost medicines. To determine drug use is a
problem with management and prevention to improve the results of treatment. The World
Health Organization defines rational use of drugs, "the judicious use of drugs requires
that patients receive medications appropriate to their clinical needs, in doses that meet
their individual needs for an appropriate period of time at the lowest cost to them and
their community.

CHAPTER TWO
METHODOLOGY

Chapter Two Methodology

Page 20

2.1 METHODOLOGY
The study was comprised of 12 weeks duration and considering 15 cases of Asthma at
Government Post Graduate Medical Institute Mardan Medical Complex Mardan.
The proforma used for data collection included the following information;
(1). Patient Information: This portion of the data collection form shows some characteristic of
the patient like; name, gender, age, area, pregnancy and lactation status, occupation and living
conditions.
Importance: It provides useful information for the physician, pharmacist all health
professionals as well as the attendants of the patient which distinguish certain patient from other
patients. It helps out to dispense appropriate, inappropriate and correct dose and dosage form. It
also helps in forensic and legal purposes.
(2). Chief Complaints: These are the clinical features or symptoms which are mentioned by the
patient in his/her own wordings/language due to which patient visit their physicians and patient
are further treated which is based on these sign of the patient.
Importance: It shows the reason for which the patient has come to the physician. It provides
data why patient is admitted to a certain ward. It provides clue for the physician about the
diagnosis of specific disease.
(3). History of Present Illness: This is a brief discussion of the patients symptoms which is
reported by the physician in their own medical language.
Importance: It provides brief information about the anatomical location, nature of onset,
severity and duration of disease.
(4). Past Medical History: The past medical history includes information about any serious
disease that the patient has experienced in the past and any previous hospitalization.
Importance: It provides information about the final diagnosis of the patient if he had faced such
type of symptoms in the past.

Page 21

(5). Past Surgical History: This portion includes information about surgical procedures.
Importance: It provides information about the co-morbid conditions of the specific surgical
procedure.
(6). Social History: It includes the living status/behavior, occupation, economical status,
education status, social drug use and physical activities.
Importance: It may be helpful to identify the source of the disease.
(7). Personal History: It provides information about personal daily routine like bowel habits,
sleep, regularity of meal and marital status.
Importance: It provides information about individual routine with the disease status.
(8). Medication History: This portion includes all the medications/ medicines prescribed during
the previous hospitalization.
Importance: It provides information between the previous medications prescribed and current
medications.
(9)Laboratory Data: This portion of the data collection form includes all the tests performed by
the patient for the finding of the disease status.
Importance: It provides information in the confirmation of final diagnosis of the disease.
(10). DRUG RELATED PROBLEMS (DRPs):
(10.1). Untreated Condition(s): It is any type of the disease condition or manifestation among
the chief complaints of the patient for which no drug is prescribed by the Physician.
(10.2). Drug(s) without Indication: The drugs prescribed for which no pathological condition is
present among the complaints of the patient is called drug without indication.
(10.3). Improper Drug Selection: The drug prescribed to treat a particular health problem is
not the drug of choice for that problem.

Page 22

(10.4). Sub-therapeutic dosage: It is the amount or strength of the drug prescribed that lies
below the minimum therapeutic dose and fails to produce the desired therapeutic effect.
(10.5). Excessive Dose: It is the quantity of a drug prescribed above the therapeutic dose which
produces harmful/ untoward effects.
(10.6). Improper Duration: When the drug is prescribed unnecessarily for a long or short
period of time instead of the recommended duration for a specific disease.
(10.7). Drug Interaction: Modification or alteration of the action/ effect of a drug in the body
due to the presence of another drug, food, herbal, drink or an environmental chemical agent is
called drug interaction. The drug interactions may lead to:
1. Synergism or additive effect.
2. Antagonism
3. Alteration of the effects of one or more drugs or production of idiosyncratic effects.
(10.8). Inappropriate Dosage Form: It is the prescription of wrong dosage form instead of the
correct and appropriate dosage form which may give rise to adverse drug reactions.
(10.9). Cost related Problems: It is the prescription of high cost drugs instead of cost effective
and good standard drug..
(10.10). Non-compliance: A state in which the patient fails to follow the instructions of the
physician about drug use either accidentally or willingly.
(11). Requiring Dose Adjustment in Hepatic Impairment: Liver plays a major role in the
biotransformation and then excretion of drugs. In case of hepatic diseases/ impairment the
adverse effects of these drugs appear rapidly therefore needs dose adjustment and proper
monitoring of the patient.
(12). Requiring Dose Adjustment in Renal Impairment: Kidney is the most important organ
for excretion of drugs. In renal diseases/ impairment the excretion of drugs is reduced which
leads to appearance of adverse effects of these drugs therefore needs dose adjustment and proper
monitoring of the patient.

Page 23

(13). Therapeutic Duplication: When two or more drugs with the same effect or formula are
prescribed for a certain condition at the same time is called therapeutic duplication. The side
effects may be intensified.


Page 24

EXPANDED MEDICATION HISTORY/ PATIENT INTERVIEW
Patients Name: Sex: Age:

Address:

Consultant/ Physician: Ward and admission No:
B. No:

Admission date: Interview date:

Chief Complaints:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_______________________
Biochemical tests advised: (mention details; state whether positive or negative.)
DATE TEST RESULTS NORMAL RANGE

Diagnosis:
______________________________________________________________________________
__________________________________________________________________

Page 25

Prescribed medications (you may attach a separate sheet for complete record date wise):

Date Therapy advised
Medicines trade name &
strength
Generic Name Signa Intervention by
physician /
Pharmacist


Page 26

*intervention may be a change in the therapy (either in its dosage forms, doses, type of therapy or addition of
another drug(s)) by the respective ward physicians with a clear reason for change to be mentioned in remarks

column.
Complaints about current drug therapy, if any:
_____________________________________________________________________________________________________________________
___________________________________________________________________________________________________
________________________________________________________________________
Non-prescribed medication, if any:
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________
Past Medications:
(State whether the medication relates to current illness or to any other past disease, In case of past illness, mention disease)
_______________________________________________________________________
______________________________________________________________________________
______________________________________________________________
Do you have any other concurrent ailment / disease?
______________________________________________________________________________
_____________________________________________________________
Previous Surgery, if any? (Mention date/ year)
______________________________________________________________________________
_________________________________________________________
Response to present drug therapy:
* Based on % resolution of signs & symptoms or % improvements in patients clinical conditions etc.

Social Drugs, if any: (Like Smoking, Snuff, Alcohol, illicit drugs etc.)
____________________________________________________________________________________________________________

%
Response

since
date of
admission
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
1

2 3 4 5 6 7 8


Page 27

____________________________________________________________________________________________________________

What have you been told about your medicine and by whom?
______________________________________________________________________________
_____
Side effects / adverse effects, if any:

Patients Compliance:
1. How do you remember to take your medication?
______________________________________________________________________________
_______
2. What do you do when you miss a dose?
______________________________________________________________________________
_______
Drug Interactions, if any:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________

Comments and recommendations (You may attach another sheet):

ADRs /

With the
therapy
Date wise
1
Ist day
2 3 4 5 6 7


Page 28

2.2 CASE HISTORIES

HISTORY# 01
Patients Name: Khursheed khan Sex: Male Age: 65 yrs

Address: Amazi, gadon, sawabi Ward & admission No: A & 1164/72

Consultant/ Physician: Dr.Shams ur rahman B. No: 5

Admission date: 12/03/2014 Interview date: 14/03/2014
Chief Complaints:
Shortness of Breath
Continues Cough
Pulse: 72/min
B.P: 140/9 mm of Hg
12/03/2014 HiB 12.5 mg/dl 14-16 mg/dl
12/03/2014 TLC 32600/ul 4000-11000/ul
12/03/2014 DLC: Ploys 85% 40- 75%
12/03/2014 Lampho 10% 20-45%
12/03/2014 Meno 03% 0-6%
12/03/2014 Esono 02% 0.6-1.2
Diagnosis:
Asthma

Page 29

COPD
Recurrent CVA
Core-Pelmonale


strength
physician /
Pharmacist
12/03/2014 Inj.Astexone-1gm Cefotaxime OD

12/03/2014 Inj.Klaricid-500 mg in 100
ml Pladix
Clarithromycin BiD

12/03/2014 O2 inhalation Pure Oxygen BiD

12/03/2014 Ventolin NB Solbutamol QiD

12/03/2014 Inj.Lasix-40 mg Furosemide State then
OD

12/03/2014 Inj.Zentac 50 mg Ranitidine-Hcl BiD

12/03/2014 Inj.Solucartef -250 mg Hydrocartisone BiD

12/03/2014 Tab.Lenoxin 0.25 mg Digoxin OD

14/03/2014 Inj.Fortum 1 gm Ceftazidine BiD

14/03/2014 Tab Flagyl-400 mg Metronedazole TDS

14/03/2014 Tab Relispa-40 mg Drotaverine-HCL BiD

Page 30

18/03/2014 Tab Cardnit-6.4 mg Glyceryl Triniterate BiD

18/03/2014 Tab Norplate-75 mg Lopadogril OD

No complaint in the current drug therapy
NSAIDs etc are used by the patient.
Past Medications:
(State whether the medication relates to current illness or to any other past disease, In case of past illness, mentions disease)
Used anti-hypertensive medicines.
Concurrent CVA.
Appendix 8 years ago.

%
Response

since
date of
admission
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
1

2 3 4
Feeling
Comfortable
5 6 7 8


Page 31

Snuff
Smoking

My Consultant told me about medication.

My nurse gives me, my medication.
I take at the time when I know.
Interaction is positive between:
Cafotaxime and Furosemide
Clarithromycin & Digoxin
Hydrocortisone & Digoxin
Hadreocortison & Solbutamol
Omeprazole & Digoxin. (www.drugs.com)

ADRs /

With the
therapy
Date wise
1
Ist day
2
Diarrhea
+
Headche
3 4 5 6 7


Page 32

This history is a poly pharmacy due to two antibiotics, cefotaxime & Clarithromycin are
prescribed. The narrow therapeutic index drug Digoxin is also prescribed, that can require the
TDM and a special care, that is more potent & toxic. There are also 5 drug interactions that can
required the special care from the health care professionals. The Clarithromycin and
hydrocortisone increase the digoxin blood level and may produce the toxicity of Digoxin.
Hydrocortisone and Solbutamol have a miner drug interaction & the interaction b/w Cefotaxime
and Furosemide causes the nephrotoxicity, the Furosemide decreases the clearance of cefotaxime
and increases the level in the blood. So required the dose monitoring or the therapeutic
alternative. So the history is irrational.


Page 33

HISTORY# 02
Patients Name: Tariq Jaan Sex: Male Age: 43 years

Address: Takht Bhai, Mardan. Ward & admission No:A &1361/380

Consultant/ Physician: Dr.Amir khan B. No: 12


Chief Complaints:
SOB
Dry Cough
12/03/2014 Chest x.ray
12/03/2014 RBS 80mg/dl 65-155mg/dl
12/03/2014 Urea 32mg/dl 20-40mg/dl
12/03/2014 Creatanine 0.6mg/dl 0.6-1.3mg/dl

Diagnosis:
Bronchial Asthma


Page 34


strength
physician /
Pharmacist
12/03/2014 Inj.Astexone- 1gm Cefotaxime OD

12/03/2014 Inj.Klaricid- 500mg Clyrithromycin BiD

12/03/2014 Inj.Decadron-4mg Dexamethasone
sodiumbiphosphate
TDS

12/03/2014 Ventolin NB Salbutamol QiD

12/03/2014 O2 Inhalation Pure Oxygen BiD

12/03/2014 Syp. Epitize Amino Acid (liver tonic) 2TSF x
TDS


column.
Diarrhea(Due to anti-biotics)
Non-prescribed medication is not used by the patient.
Past Medications:
Indication used by the patient is anti-pyratics and anti-asthmetics .


Page 35

No other disease currently.
Appendix -5 years ago.

No social drug.

My physician told me to take medication.

My nurse gives me medication.

%
Response

since
date of
admission
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
1

2
Feeling
Good
3 4 5 6 7 8

ADRs /

With the
therapy
Date wise
1
Ist day
Diarrhea
2 3 4 5 6 7


Page 36

I take the next dose.
No Interations.

This history is according to the complaints of the pt, in this history also the two antibiotics are
prescribed so poly pharmacy case & have no drug interactions. There is diarrhea induced by
antibiotics, that can be managed by counsel the patient to take medication on empty stomach,
beside this the prescription is totally rational.


Page 37

HISTORY# 03
Patients Name: Sikandar Khan Sex: Male Age: 75

Address: Rustam, Mardan. Ward & admissionNo: A & 1254/262

Consultant/ Physician: Dr.Amir Khan B. No: 4

Admission date: 17/03/2014 Interview date: 18/0302014

Chief Complaints:
SOB
Cough
Talklessness
Diarrhea
17/03/2014 RBS 103mg /dl 65-155 mg/dl
17/03/2014 ECG Normal
17/03/2014 Chest-X ray
17/03/2014 Urea 28mg/dl 20-40 mg/dl
17/03/2014 Creatanine 0.9 mg/dl 0.6-1.3 mg/dl
17/03/2014 Echo RV Diastolic
Dysfunction

Diagnosis:
Asthma
CAD

Page 38

strength
physician /
Pharmacist
17/03/2014 Inj.Klaricid-500mg in
100ml Pladix
Clyrithromycin BiD

17/03/2014 Inj.Solucartef-250 mg Hydrocortisone TDS

17/03/2014 Ventolin NB Solbutomol QiD

17/03/2014 Inj.Risek -40 mg Omeprazol OD

18/03/2014 Atem NB Iprotropium Bromide BiD

18/03/2014 O2 inhalation Pure Oxygen BiD

18/03/2014 Tab.Norplast-s-75 mg Clopidogril+Aspirin OD

18/03/2014 Tab.Capril-125 mg Captopril OD


column.
No complaint.
Non-prescribe medication that is used by the patient is NSAIDs.

Page 39

Past Medications:
No past medication.
Bow l pass surgery, more than 20 years ago.

Snuff
The consultant told me about my medication.

%
Response

since
date of
admission
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
1

2 3 4 5 6 7 8

ADRs /

With the
therapy
Date wise
1
Ist day
2 3 4 5 6 7


Page 40

My nurse and children give me, my medication.
The following interactions:
Clarithromycin & Omeprazole
Hydrocortisone & Solbutamol. (www.drugs.com)

This history have no poly pharmacy, the history is according to the complaints of the pt, but still
there are two miners interactions b/w Clarithromycin/Omeprazole & Hydrocortisone/Solbutamol
that dont have significant adverse effect, but required attention and care from the health care
professionals. There is no adverse effect found. To prescribe the therapeutic alternative, that can
overcome the drug interactions. The history is counted to be rational, b/c the drug interactions
are of miner type.


Page 41

HISTORY# 04
Patients Name: Ameer Zada Sex: Male Age: 85

Address: Baghicha Deri Ward & admission No: A & 1259/267

Consultant/ Physician: Dr. Amir Khan B. No: 3


Chief Complaints:
SOB
Cough with sputum
Body aches
Fever
Pulse 72/min
B.P 120/90
19/03/2014 Echo Normal
19/03/2014 Special smear
19/03/2014 ALT 50g/L 42 g/L
19/03/2014 AST 40 g/L 35 g/L

Diagnosis:
Known Asthma
Acute exacerbation of COPD.

Page 42

strength
physician /
Pharmacist
19/03/2014 Inj.Klaricid 500mg in
100ml pladix
Clyrithromycin BiD

19/03/2014 Inj.Astexon-1gm Cefotoxime OD

19/03/2014 Inj.Solucartef-250mg Hydrocartisome BiD

19/03/2014 Inj.Lasix-60mg state then
40mg OD
Furesomide State then
OD

19/03/2014 Ventoline NB Solbutomol QiD

19/03/2014 O2 inhalation Pure Oxygen QiD

19/03/2014 Syp.Pulmonol-120ml Chlorpheniramin 2TSFxT
DS


column.
No Complaints.
No Self medication.
Past Medications:
No past medication.

Page 43

No disease currently.
No previous surgery.

Smoking
My physician


%
Response

since
date of
admission
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
1

2
Feeling
Good
3 4 5 6 7 8

ADRs /

With the
therapy
Date wise
1
Ist day

2 3 4 5 6 7


Page 44

Interactions between:
Cefotaxime and Furosemide
Hydrocortisone & Solbutamol. (www.drugs.com)

This history is poly pharmacy b/c the two antibiotics are prescribed. There are 2 interactions b/w
hydrocortisone/Solbutamol that is a minor interaction and have no cosequences & the interaction
b/w cefotaxime/Furosemide causes the nephrotoxicity, the Furosemide decreases the clearance of
cefotaxime in kidney, so increases cefotaxime level and may required dose adjustment. We can
overcome the drug interactions by prescribing the therapeutic alternative of the drugs. The
prescription is irrational.


Page 45

HISTORY# 05
Patients Name: D/O Ahmad Sex: Female Age: 70

Address: Rashaki, Mardan Ward & admission No: B & 1451/325

Consultant/ Physician: Dr.Naveed Ahmad B. No: 16


Chief Complaints:
SOB
Dry Cough
B.P: 140/90
19/03/2014 RBS 147 mg/dl 65-155mg/dl
19/03/2014 Urea 37 mg/dl 20-40 mg/dl
19/03/2014 Creatanine 1 mg/dl 0.6-1.3mg/dl
19/03/2014 Chest X.ray

Diagnosis:
Asthma


Page 46


strength
physician /
Pharmacist
19/03/2014 O2 Inhalation-2 liter Pure oxygen Per day

19/03/2014 Inj. Solucartef -250mg Hydrocortisone Bid 20/03/2014
Inj.Solucortef -
100mg

19/03/2014 Inj. X.cien-40mg Ciprofloxacin OD

19/03/2014 Clomid NB Clomenefene citrate BiD

19/03/2014 Inj. Sulbaxon -20mg Cefroperazone+
sulbactum
QiD

19/03/2014 Inh. Restor Probiotics+FOS BiD

20/03/2014 Inj. Deltacartel 5mg Dexamethasone OD

20/03/2014 Tab. Zotonix 20mg Pantoprazole OD


column.
No complaints in current therapy

Page 47

No self medications.

Past Medications:
No past medication used by the patient.
No past surgery.

No social is used by the patient.

My physician told me, to take medication regularly

%
Response

since
date of
admission
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
1

2
Feeling
Good
3 4 5 6 7 8


Page 48


My nurse told me, and also gives the medication regularly.
Then I take the next dose.
Interactions is between:
Hydrocortisone & Solbutamol
Dexamethasone & Solbutamol (www.drugs.com)

This is also a poly pharmacy prescription, in this the two corticosteroids is prescribed, that cant
improve the pt compliance and also produce the financial problem to the pt. There are two drug
interactions of minor type and have no adverse effects, but required a special attention from the
health care professionals, to over come this problems by giving the therapeutic alternatives of the
drugs. There are two drug interactions of miner type and also have poly pharmacy, so we well
count the history as irrational.

ADRs /

With the
therapy
Date wise
1
Ist day
2 3 4 5 6 7


Page 49

HISTORY# 06
Patients Name: Dil raz Sex: Female Age: 47

Address: Shergarh, Mardan Ward & admissionNo: A & 1260/265

Consultant/ Physician: Dr.Amir khan B. No: Extra bed


Chief Complaints:
Chest pain
SOB
Cough
Wheezing
Bp: 130/80
19/03/2014 RBS 110 mg/dl 65-155mg/dl
19/03/2014 Chest X ray
19/03/2014 Echo. Normal
19/03/2014 ALT 43g/l 42g/l
19/03/2014 AST 38g/l 35 g/l

Diagnosis:
Asthma
COPD

Page 50

LRTi

strength
physician /
Pharmacist

19/03/2014 Atem NB Ipratropium bromide BiD

19/03/2014 Inj.Klaricid-500mg in 100
ml pladix
Clyrithromycin BiD

19/03/2014 Inj. Racephin-1gm Ceftriaxone OD

19/03/2014 Tab.Serc -16mg Betahistidine
dihydrochloride
BiD

19/03/2014 Inj.Decadron-4mg Dexamethasone sodium
phosphate
TDS


column.
No complaint
NSAIDS & Anti-Hypertensive


Page 51

Past Medications:
Anti-hypertensive medications are used by the patient.
Hypertension
No previous surgery

No social drugs.

My consultant told me.

%
Response

since
date of
admission
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
1
A little bit
feeling
good
2 3 4 5 6 7 8


Page 52

My nurse and children.
I take at the time, when I know.
The interaction is b/w:
Ceftriaxone & Clarithromycin. (www.drugs.com)

The history is according to the complaints of pt, but the two antibiotics are prescribed thats why
the history is poly pharmacy. There is the interaction b/w Ceftriaxone and Clarithromycin.
Clarithromycin decreases the clearance of the Ceftriaxone in kidney. By giving the therapeutic
alternative or to monitor the dose we can over come this problem. There is no adverse drug
reactions but still the history is irrational due, have poly pharmacy and have potent drug
interaction.

ADRs /

With the
therapy
Date wise
1
Ist day
2 3 4 5 6 7


Page 53

HISTORY# 07
Patients Name: Pasanda Sex: Female Age: 70 years

Address: Dubian, Mardan Ward & admission No: A & 1275/283



Chief Complaints:
SOB
Chest tightness
Restlessness
Pale color
19/03/2014 Urea 40mg/dl 20-40mg/dl
19/03/2014 DLC: polys 78% 40-75%
19/03/2014 Chest x.ray

Diagnosis:
Asthma
Anemia
Patient have known hypertensive


Page 54


strength
physician /
Pharmacist
19/03/2014 Inj. Astexone-2mg Cefotaxime OD

19/03/2014 Inj. Solucortef-250mg hydrocortisone BiD


19/03/2014 Tab. Spirimid-6.25mg Ferosemide+Spiranolacto
ne
OD

19/03/2014 Tab.Carvid-6.25 mg Cavidilol OD

19/03/2014 Inj.Risek-40mg in 100ml
pladix
Omeprazole OD

19/03/2014 Inj. Klaricid-500mg in
100ml pladix
Clyrithromycin BiD

19/03/2014 Inj.Gravinate/Nalbin Dimenhadrinate S.O.S

19/03/2014 Tab.ALP-0.5mg Benzodiazepine OD at
night
time


column.
No complaint in current drug therapy.

Page 55

NSAIDs & Anti-hypertensive.
Past Medications:
Not related to current illness.
Hypertension
No previous surgery

Nil

My physician told me about my medication.

%
Response

since
date of
admission
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
1

2
Feeling
Good
3 4 5 6 7 8


Page 56


My nurse told me & also gives the medicines.
Interactions b/w:
Hydrocortisone & Solbutamol
Omeprazole & Clarithromycin
Benzodiazepine & Clarithromycin
Cefotaxime & Furosemide (www.drugs.com)

This prescription is a poly pharmacy due, two antibiotics are prescribed. This history has 4 drug
interactions. The two miners b/w hydrocortisone/Solbutamol & Clarithromycin/Omeprazole,
these have no adverse effect. The benzodiazepine has interaction with Clarithromycin and
required special care. The interaction b/w cefotaxime/Furosemide causes the nephrotoxicity; the
Furosemide decreases the clearance of cefotaxime in kidney, so increases cefotaxime level and
may required dose adjustment. By giving the therapeutic alternative, we can overcome the
problem of drug interactions. The prescription is irrational.

ADRs /

With the
therapy
Date wise
1
Ist day
2 3 4 5 6 7


Page 57

HISTORY# 08
Patients Name: Parooa Sex: Female Age: 63 years

Address: Sawabi Ward & admission No:A & 1323/331



Chief Complaints:
SOB
Dyspenia
High Temp.
Dry cough
Tachypenia
24/03/2014 Echo. L.V. Diastolic
dysfunction

24/03/2014 P.smear

Diagnosis:
Asthma


Page 58


strength
physician /
Pharmacist

24/03/2014 O2 inhalation Pure oxygen BiD

24/03/2014 Inj. Solucortef -250mg Hydrocortisone TDS

24/03/2014 Inj. Astexone-2gm Cefotaxime OD

24/03/2014 Inj.Rapid-40mg in 100ml
pladix
Omeprazole +
Sodiumbicorbonate
OD

24/03/2014 Inj.Klaricid-500mg Clyrithromycin BiD



column.
No non-prescribed medication is used by the patient.


Page 59

Past Medications:
(State whether the medication relates to current illness or to any other past disease, In case of past illness, mentions disease).
Medication used for the asthma.
2 times optic surgery & 3 times DNS.


Nil

My consultant told me, to take medication regularly.

%
Response

since
date of
admission
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
1

2 3
Feeling
60% good
4 5 6 7 8


Page 60

My nurse told me.
Interaction b/w:
Hydrocortisone/Solbutamol
Clarithromycin/Omeprazole (www.drugs.com)


This history is according to the complaints of the pt, there are two miners drug interactions that
are b/w Salbutamol & hydrocortisone, and Clarithromycin & Omeprazole, thats have no serious
adverse effect. This pt has no adverse effect records found. By giving the therapeutic alternative
we can overcome the problem of drug interactions. The two anti biotics are prescribed, so have
poly pharmacy, and the prescription is irrational.

ADRs /

With the
therapy
Date wise
1
Ist day
2 3 4 5 6 7


Page 61

HISTORY# 09
Patients Name: Zulki fal Sex: Male Age: 35 yrs

Address: Rustam, Mardan Ward &admission No: B & 1559/433

Consultant/ Physician: Dr.Naveed khan B. No: 07


Chief Complaints:
SOB
Chest pain
Cough
24/03/2014 Chest pain
24/03/2014 Urea 31mg/dl 20-40mg/dl
24/03/2014 Creatanine 1.0 mg/dl 0.6-1.3mg/dl
24/03/2014 RBS 120mg/dl 65-155mg/dl
24/03/2014 P.smear Normal

Diagnosis:
Acute several attack of seasonal bronchial asthma
HTN


Page 62

strength
physician /
Pharmacist
24/03/2014 Inj.solucortef-250mg Hydrocortisone TDS

24/03/2014 Tab.Deltacortel-5mg Dexamethasone OD

24/03/2014 Tab.Whizix-10mg Montelocast OD

24/03/2014 Cap.Azomax-250mg Azithromycin BiD

24/03/2014 Inh.sertide Xinafoate + Fluticasone
propionate
2 puff x
Bid

24/03/2014 Telfast -120mg Fexofenasdine OD



column.
No complaints.
Non prescribed medication used by the patient is NSAIDs, Antihypertensive &
Antiasthmatics.
Past Medications:

Page 63

For hypertension & Asthma.
HTN
No previous surgery record.

Nill
My consultant told me, to take medications.


%
Response

since
date of
admission
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
1

2
Feeling good
3 4 5 6 7 8

ADRs /

With the
therapy
Date wise
1
Ist day
2 3 4 5 6 7


Page 64

My nurse gives me, & also myself.
I take the dose at that time when I know.
Interaction is b/w:
Solbutamol & Hydrocortisone (www.drugs.com)


In this history the physician prescribed the 3 corticosteroids, thats why the history is poly
pharmacy. Their also have a miner dreg interaction b/w hydrocortisone & Solbutamol, thats
dont have significant effect. There have no adverse effect found. Two mange the drug
interaction by giving the therapeutic alternative, or to adjust the dose. The occurrence of the poly
pharmacy has a burden on pt, due to medication error and also has financially. This prescription
is irrational.


Page 65

HISTORY# 10
Patients Name: Noor ul Huda Sex: Female Age: 45 years

Address: Shawi ada, Sawabi Ward&admissionNo:A&1322/330

Consultant/ Physician: Dr.Amir Khan B. No: 10


Chief Complaints:
SOB
Cough
Wheezing
Chest tightness
24/03/2014 RBS 110 mg/dl 65-155mg/dl
24/03/2014 Chest X ray
24/03/2014 Urea 44mg/dl 20-40mg/dl
24/03/2014 DLC: Polys 78% 40-75%

Diagnosis:
Asthma
Fever
Low grade urethral carcinoma.

Page 66


strength
physician /
Pharmacist
24/03/2014 Inj.Astexone -2gm Cefotaxime OD

24/03/2014 Inj.Decadron-1.c.c Dexamethasone sodium
phosphate
TDS


24/03/2014 Inj.Lasix-40mg Furosemide OD

24/03/2014 Syp.Combinol-D 120ml Dextromethorphan HBr
Ephedrine Hcl,Amonium
2TSF x
TDS

25/03/2014 Inj.Risek-40mg in 100 ml
pladix
Omeprazole OD


column.
Patient doesnt use the non-prescribed medication.

Past Medications:

Page 67

Dialysis after every 3 months , since from 1 year.
Kidney failure.
The patient has done a surgery.

No social drugs.

My consultant told me about my medications.

%
Response

since
date of
admission
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
1

2
Feeling
comfortable

3 4 5 6 7 8

ADRs /

With the
therapy
Date wise
1
Ist day
2 3 4 5 6 7


Page 68

My nurse and my husband give me my medications & also advise to take medication on
time.
I take the dose at the time when I know.
Interactions are b/w:
Cefotaxime and ferosemide
Solbutamol & Dexamethasone (www.drugs.com)

This history is according to the complaints of the pt. this history have no poly pharmacy. There
are two interaction b/w cefotaxime/Furosemide causes the nephrotoxicity, the Furosemide
decreases the clearance of cefotaxime in kidney, so increases cefotaxime level and may required
dose adjustment. The other one is b/w Solbutamol/Dexamethasone that has a miner one. There
are no adverse effects recorded. By adjusting the dose or giving the therapeutic alternative, we
can overcome the drug interactions. The history is irrational.


Page 69

HISTORY# 11
Patients Name: Tahira naz Sex: Female Age: 30years

Address: Shabaz Ghari Ward & admission #: A&1346/354

Consultant/ Physician: Dr.Amirkhan B. No: 04


Chief Complaints:
Chest pain
Shortness of breath
Wheezing
25/03/2014 RBS 125mg/dl 65-155mg/dl
25/03/2014 Urea 35mg/dl 20-40mg/dl
25/03/2014 Hbs Ag, HCV Normal
25/03/2014 DLC: polys 82% 40-75%
Diagnosis:
Asthma
COPD


Page 70


strength
physician /
Pharmacist
25/03/2014 Inj.Racephin-1gm Ceftriaxone OD Stop on 26/03/14

25/03/2014 Inj.Rapid-40mg in 100 ml
padix
Omeprazole + sodium
bicorbonate
OD

25/03/2014 Inj.varen-75mg Diclofenac-Na BiD

phosphate
TiD

25/03/2014 Syp.Eplyzyme-120ml Digestive enzyme
+ vitamins
2TSF x
TDS

25/03/2014 Tab. ALP-0.5mg Benzodiazepine Once at
night

26/03/2014 Inj.Astexone-1gm Cefotaxime BiD

26/03/2014 Inj.Gravinate Dimenhydraminate TDS

26/03/2014 Cap.Caricef-400mg Cefixime trihydrate OD

26/03/2014 Tab.Diagesic-p Paracetamol +
dextrapropoxyphene
TDS


column.

Page 71

No complaint.
Self medications are used by the patient.
Past Medications:
Medication used for asthma and also NSAIDs.
Appendix 4 years ago.

No social drugs.

The doctor told me to take medications.

%
Response

since
date of
admission
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
1

2 3
80% feeling
good.
4 5 6 7 8


Page 72

My nurse gives me my medications.
No interactions.

The history is a poly pharmacy. In the prescription at a time more than two antibiotics are
prescribed. There are no drug interactions, but have the adverse effect of antibiotics that is
diarrhea. To counsel the pt, to take anti biotics before the meal, we can over come this adverse
effect, besides this the history is rational.

ADRs /

With the
therapy
Date wise
1
Ist day
2
Diarrhea
3 4 5 6 7


Page 73

HISTORY# 12
Patients Name: Gul faraz Sex: Male Age: 55 yrs

Address: Lund khwarr, takht bhai, Mardan Ward & admission#: A&1260/290

Consultant/ Physician: Dr.Amirkhan B. No: 15


Chief Complaints:
Chest pain
SOB
Continues cough
25/03/2014 RBS 112mg/dl 65-155mg/dl
25/03/2014 Echo. Normal
25/03/2014 DLC: Polys 79% 40-75%

Diagnosis:
Asthma
COPD
LRTi


Page 74


strength
physician /
Pharmacist

25/03/2014 Inj.Klaricid-500mg in 100
ml pladix
Clyrithromycin BiD

25/03/2014 Inj. Racephin-1gm Ceftriaxone OD

25/03/2014 Tab.Serc -16mg Betahistidine
dihydrochloride
BiD

phosphate
TDS

25/03/2014 Syp.Pulmonol-120ml Chlorpheneramine 2TSF x
TDS


column.
No complaints in prescribed medication.
Not used by the patients.
Past Medications:
Used NSAIDs and Anti-asthmatic medication.

Page 75

No other current illness.
Optic surgery.


No social drug

My consultant told me, to take medication regularly.
My nurse gives me, and also myself I remembered.

%
Response

since
date of
admission
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
1

2
Feeling good
3 4 5 6 7 8

ADRs /

With the
therapy
Date wise
1
Ist day
2
Diarrhea
3 4 5 6 7


Page 76

I take at that time when I know.
drug interactions is b/w:
Ceftriaxone & Clarithromycin (www.drugs.com)

The history has according to the complaints of pt, but the two antibiotics are prescribed, that is
Ceftriaxone & clarithromycin. Have a severe drug interaction of clarithrimycin and Ceftriaxone.
It causes the nephrotoxicity by decreases the renal clearance of the ceftriaxone. We can
overcome this by giving the therapeutic alternative or adjust the dose. In the adverse effect also
have diarrhea due to anti biotics. To take the antibiotics before the meal, the antibiotics induced
diarrhea will not be occurs. The history is irrational.


Page 77

HISTORY# 13
Patients Name: Khan Zada Sex: Male Age: 65 years

Address: Baye khan , Mardan Ward&admission No: A&1361/369



Chief Complaints:
SOB
Dry cough
26/03/2014 RBS 140mg/dl 65-155mg/dl
26/03/2014 Urea 32mg/dl 20-40mg/dl

Diagnosis:
Bronchial asthma
Bronchial pneumonia


Page 78


strength
physician /
Pharmacist
26/03/2014 Inj.Astexone-1mg Cefotaxime OD

26/03/2014 Inj.Klaricid-500mg Clyrithromycin BiD

26/03/2014 Inj.Decadron -4mg Dexamethasone
Na.phosphate
TDS


26/03/2014 Syp.Epitize-120ml Amino Acid (liver tonic) 2TSF x
TDS


column.
No complaints in present medication
NSAIDs are used by the patient.
Past Medications:
No past medications.

Page 79

No surgery.

Snuff

My physician told me.


%
Response

since
date of
admission
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
1

2 3 4 5 6 7 8

ADRs /

With the
therapy
Date wise
1
Ist day
2 3 4 5 6 7


Page 80


I take the dose at the time when I know.
Interaction found b/w:
Dexamethasone/Solbutamol (www.drugs.com)

This history is according to the complaints of the pt, but the two antibiotic are prescribed , thats
why the history will be counted as poly pharmacy prescription. Interaction is b/w
Dexamethasone & Solbutamol, thats had no significant effects but required a little attention
from the consultant. There are no adverse effects found in the history. The interaction is miner,
but we can manage by giving the therapeutic alternative of the drugs. The history is ratinal, b/c
the drug interaction is of miner type.


Page 81

HISTORY# 14
Patients Name: Gul Muhammad Sex: Male Age: 80 yrs

Address: Bala Ghari, Mardan Ward&admission No: B&1743-103

Consultant/Physician: Dr.Naveed Khan B. No: 04


Chief Complaints:
SOB
Dry Cough
Constipation
05/04/2014 Chest X-ray
05/04/2014 Sputum AFB
05/04/2014 RBS 110 mg/dl 65-155 mh/dl
05/04/2014 P.Smear

Diagnosis:
Bronchial Asthma
LRTi


Page 82


strength
physician /
Pharmacist
05/04/2014 Inj.Amoxiclave -1.2gm Amoxicillin TDS

05/04/2014 Inj.Klaricid-500 mg Clyrithromycin BiD

05/04/2014 Syp.Epiteze-120mg Amino-Acid 2TSFxT
DS

05/04/2014 Ventoline-NB Sulbutomol QiD

05/04/2014 Inj.Decadron-4mg Dexamethasone Sodium
Phosphate
TDS

05/04/2014 Cap.Aerotes-200 mg Sulbutomol QiD

06/04/2014 Inj.Aminophylline-250 mg
in 500 ml saline
Aminophyline BiD

07/04/2014 Tab.BTNO-10 mg Bambuterol-Hcl OD

07/04/2014 Inf.5% Dextrose/Saline Dextrose+Saline OD

07/04/2014 Syp.Coferb-120ml Cough syrup 2TSFxT
DS


column.

Page 83

No complaints in current therapy.
NSAIDs.
Past Medications:
Medication used for Asthma.
No other disease.
No past surgery.

Snuff.

My physician told me.

%
Response

since
date of
admission
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
1

2 3 4
Feeling
Good
5 6 7 8


Page 84


I take at the time when I know.
Interaction is found b/w:
Dexamethasone & Solbutamol (www.drugs.com)

This history has a poly pharmacy b/cs prescribed two antibiotics. There one miner drug
interaction b/w Dexamethasone and Solbutamol, thats have no significant effect. There has no
adverse effect found. We can overcome the interaction by giving the therapeutic alternatives.
The interactions is of miner type so the prescriptions rational.

ADRs /

With the
therapy
Date wise
1
Ist day
2 3 4 5 6 7


Page 85

HISTORY# 15
Patients Name: Salman Khan Sex: Male Age: 42 years

Address: Toheed colony, Mardan. Ward & Admission No: A & 1324/442

Consultant/ Physician: Dr.Shams B. No: 03


Chief Complaints:
SOB
High temp.
Dry cough with sputum
Chills
07/04/2014 Chest X-ray
07/04/2014 Echo R.V Disfunction
07/04/2014 MP Positive
07/04/2014 DLC: Polys 88% 40-75%

Diagnosis:
Asthma
Malaria


Page 86


strength
physician /
Pharmacist
07/04/2014 Ventolin-NB Solbutomol QiD

07/04/2014 O2-inhalation Oxygen BiD

07/04/2014 Inj.solucartef-250mg Hydrocartisone TDS

07/04/2014 Inj.Astexone 1gm Cefotaxime OD

07/04/2014 Inj.Rapid -40 mg in 100ml
pladix
Omeprazole+sodium
dicarbonate
BiD

07/04/2014 Inj.Klaricid Clarithromycin TDS

07/04/2014 Tab.Arti-20/12 mg Artemether+Lumefontrin
e
TDS for
3 days

08/04/2014 Atem-NB Iprotropium bromide BiD

08/04/2014 Tab.ALP 0.5 mg Benzodiazepine OD at
night
time


column.
No complaints in present medication

Page 87

The patient use NSAIDs and anti-diarrheal agents.
Past Medications:
NSAIDs and anti-asthmatic and anti-melonial.
Malaria.
No previous surgery.

Smoking.

My consultant told me to take medication regularly.

%
Response

since
date of
admission
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
Nil /
Improving /
Deteriorating
1

2
Feeling
Better
3 4 5 6 7 8


Page 88


My nurse and wife my medication.
I take at that time when I remember.

Interactions founds b/w:
Clarithromycin & Omeprazole
Hydrocortisone & Salbutamol
Benzodiazepines & Clarithromycin (www.drugs.com)

This is also a poly pharmacy history due to the prescription of two antibiotics. The pt also has the
malaria. There are 3 miners drug interactions, thats have no significant effects and also have no
mechanism known. But have required a special attention from the health care professionals. We
can overcome the drug interactions by giving the therapeutic alternatives. have no adverse effects
found in the history. The prescription is irrational.

ADRs /

With the
therapy
Date wise
1
Ist day
2 3 4 5 6 7

CHAPTER THREE
RESULTS

Chapter Three Results

Page 89

3.1 RESULTS:
The data collected was thoroughly evaluated and different problems and irrationalities related to
the drug were identified. For evaluation process different standard drug literature and procedure
were followed. During this evaluation process the results obtained is presented table wise and
also graphically.

PATIENTS DEMOGRAPHIC DATA:
Table No. 3.1 patients Demographic Data
Characteristics Number of patients Percentage
Male 09 60%
Female 06 40%
All patients 15 100%


Page 90

FIGURE No: 3.1 patient demographic data

60%
40%
Patients demographic data
Male 09: 60%
Female 06: 40%

Page 91

AGE WISE DISTRIBUTION OF PATIENTS:

Table No. 3.2 Age wise distribution of patients
AGE IN YEARS NO OF PATIENTS PERCENTAGE
30-50 06 40%
51-70 06 40%
71-90 03 20%

FIGURE No: 3.2 Age wise Distribution of patients

Ages of patients

40% 40%
20%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
30-50 YEARS (06) 51-70 YEARS (06) 71-90 YEARS (03)
AGE WISE DISTRIBUTION OF PATIENTS
30-50 YEARS (06)
51-70 YEARS (06)
71-90 YEARS (03)

Page 92

Table # 3.3 drug related problems frequency & percentage wise

Drug related problems Frequency Percentage
Untreated condition 05 07.57%
Drug without indication 04 06.06%
Improper drug selection 00 00.00%
Adverse drug reaction 06 09.09%
Total drug interaction 28 42.42%
Non compliance 00 00.00%
Drug required dose adjustment in renal impairment 08 12.12%
Therapeutic duplication 01 01.52%
Impropriate dosage form 00 00.00%
Use of narrow therapeutic index drugs without monitoring 02 03.03%
Poly pharmacy 08 12.12%
Cost related problems 04 06.06%
Total number of drug related problems 66 100%


Page 93

FIGURE No: 3.3 frequency of drug related problems

7.57%
6.06%
0%
9.09%
42.42%
0%
12.12%
1.52%
0%
3.03%
12.12%
6.06%
Frequency of drug related problems
Untreated condition 05
Drug without indication 04
Improper drug selection 00
Adverse drug reaction 06
Total drug interaction 28
Non compliance 00
Drug required dose adjustment
in renal impairment 08
Therapeutic duplication 01
Impropriate dosage form
00
Use of narrow therapeutic index
drugs without monitoring 02
Poly pharmacy 08
Cost related problems 04

Page 94

CAUSES OF HOSPITALIZATION:
Table No: 3.4 Main Causes Of Hospitalization
Main cause of hospitalization Number of patients Percentage
SOB 15 100%
Cough 05 33.33%
Chest pain 05 33.33%
Wheezing 03 20.00%
Chills 03 20.00%

FIGURE No: 3.4 causes of Hospitalization

Causes of Hospitalization

100%
33.33% 33.33%
20% 20%
0%
20%
40%
60%
80%
100%
120%
SOB (15) Cough (5) Chest pain (5) wheezing (3) Chills 3: 20%
Causes of Hospitalization
SOB (15)
Cough (5)
Chest pain (5)
wheezing (3)
Chills 3: 20%

Page 95

CONCURRENT DISEASES:

Table No. 3.5 concurrent diseases
Disease No of Patients Percentage
COPD 05 33.33%
LRTi 04 26.66%
HTN 04 26.66%
MALARIA 01 06.67%

FIGURE No: 3.5 Concurrent diseases

Diseases

33.33%
26.66% 26.66%
06.67%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
COPD (05) LRTi (04) HTN (04) MALARIA (01)
CONCURRENT DISEASES
COPD (05)
LRTi (04)
HTN (04)
MALARIA (01)

Page 96

OCCURENCE OF DRUG INTERACTION:

TABLE NO: 3.6 OCCURRENCE OF DRUG INTERACTIONS PERCENTAGE WISE
Drug interactions Occurrence Percent
Hydrocartisone-Salbutamol 07 25.00%
Cefotaxime-Furosemide 05 17.86%
Salbutamol-Dexamethasone 05 17.86%
Clarithromycin-Omeprazole 04 14.29%
Clarithromycin-Benzodiazapine 02 07.14%
Clarithromycin-Ceftriaxone 02 07.14%
Clarithromycin-Digoxin 01 03.57%
Hydrocartisone-Digoxin 01 03.57%
Omeprazole-Digoxin 01 03.57%
Total interactions 28 100%


Page 97

25%
17.86% 17.86%
14.29%
7.14% 7.14%
3.57% 3.57% 3.57%
0%
5%
10%
15%
20%
25%
30%
OCCURENCE OF DRUG INTERACTION "PER CENT"
WISE
Hydrocartisone-Salbutamol 07: 25.00%
Cefotaxime-Furosemide 05: 17.86%
Salbutamol-Dexamethasone 05: 17.86%
Clarithromycin-Omeprazole 04: 14.29%
Clarthromycin-Benzodizaphene02: 07.14%
Clarithromycin-Ceftriaxone 02: 07.14%
Clarithromycin-Digoxin 01: 03.57%
Hydrocartisone-Digoxin 01: 03.57%
Omeprazole-Digoxin 01: 03.57%

Figure No: 3.6 Occurrence Of Drug Interaction Per Cent Wise

CHAPTER FOUR
DISCUSSION & CONCLUSION

Chapter Four Discussion & Conclusion

Page 98

DISCUSSION & CONCLUSSION

4.1 DISCUSSION
After analyzing these fifteen cases, it was noted that the overall prescribed therapy at hospital
was of standard nature but there were some short comings which requires proper mutual
understandings between health care professionals. There were 60 % male and 40 % female
patients in overall fifteen case histories. 33.33 % untreated conditions were left in overall 15 case
histories. Most of these conditions were of minor nature like fever, diarrhea and cough but still it
needs a therapy, if this condition were not be treated, it were prolonged the hospitalization.
26.67 % drugs were having cost related problems. There are safe, appropriate and cost effective
alternatives available which could be prescribed despite of expensive brands. There were 32 %
drugs which needed dose correction as the prescribed doses were high and the pt. have renal
impairment. Dose calculation has very much importance of the drugs that have narrow
therapeutic index or the patient have renal problems. 26.67 % drugs were prescribed without
indication, the drug that were prescribed without indication produce some ADRs, drug
interactions & also have cost problems to the patients. There was 00 % case with improper drug
selection. Adverse drug reaction was detected in 06 cases (40%) of asthma, The patient had
taken antibiotics in excessive dose of the drug, if antibiotics were takes before the meal then
these drug effects were not be occurs. There was no (00 %) drug which was administered
through wrong route. The drug interactions were found in 13 cases out of fifteen that have
86.67%. Some of them have miner interaction but some have potent interactions like Cefotaxime
and furosemide, furosemide decreases the renal clearance of the Cefotaxime and causes
nephrotoxicity. So this required a special attention from the health care providers. Therapeutic
duplications have in one case out of fifteen and have 06.67%, this also increases the cost
problems to the patient. In fifteen cases two narrow therapeutic drugs were prescribed, digoxin
and aminophylline, and have a percentage of 13.33%, the narrow therapeutics drug required the
dose calculation and some special care from the health care providers, to minimize the toxicity
and the effects on other drugs. The total drug related problems were 66. If the the health care
professionals work in a team, we can overcome these problems. The patient also have to take
medication on time, and follow the instruction of the physician to minimize the drug related
problems.

Page 99

4.2 CONCLUSION
This clerk ship report is made in Mardan Medical Complex, Mardan, on 15 cases of asthma and
have 12 weeks internship. The data together is about the rationality & irrationality of the
prescribed medication of asthma. The treatment provided in the hospital was according to the
standard protocol however, some drug related problems were detected which include excessive
doses, drug-drug interactions, improper drug selection, adverse drug reactions, untreated
conditions and cost related problems.
Due to maximum number of patients in hospital, lack of proper interaction and Co-operation
between health care professionals and burden on physicians, the goal and vision of rational
pharmacotherapy is still far away to be achieved. In order to rationalize overall pharmacotherapy
of individual patient, professional mutual interaction among physicians, pharmacists and nurses
is required. Based on this project report, it is concluded that there is lack of consideration among
the physicians regarding the proper dose calculation in Asthmatic medicines. Proper system of
dose calculation must be introduced in order to reduce the adverse drug reactions.
There were many drug interactions b/w the drugs, that is due to poly pharmacy, improper drug
selection, and duplication in dosage form e.g. the drug interactions b/w Clarithromycin and
Clarithromycin were observed that is due to poly pharmacy i.e. due to prescription of two
antibiotics.


Page 100

Table No: 4.1 Drug interactions and consequences

S.No Drug Interactions Consequences

01

Cefotaxime/Furosemide
Causes the nephrotoxicity, the
Furosemide decreases the clearance of
Cefotaxime in kidney, so increases
Cefotaxime level and may require dose
adjustment

02

Ceftriaxone & Clarithromycin
Clarithromycin may affect the function
of Ceftriaxone, so required the
monitoring

03

Hydrocortisone & Salbutamol
Miner interactions, mechanism is
unknown

04

Dexamethasone & Salbutamol
Miner interactions, mechanism is
unknown

The ADRs were also seen due lake of proper patient education and counseling by the physician,
e.g. antibiotics induced diarrhea, if antibiotics induced diarrhea then it will be taken on empty
stomach then this ADR will not be occurs. The patient education, counseling and information are
also important parameter so that patient can be provided with complete pharmaceutical care.
Patient must be educated properly in order to increase the compliance level. A proper and
computerized channel should be followed while supplying the drugs from hospital pharmacies to
the respective wards. Hospital pharmacies are required to be computerized in this regard.
Ministry of Health is responsible to provide cost effective drugs to the respective hospitals. Free
of cost medicines should be distributed among the needy patients in order to reduce the cost
related problems.

REFERENCES

References

Page 101

REFERENCES

BNF for children 2009, Pp.168
British Guidelines on the management of asthma by British Thoracic Society May
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George ronnald B Lippincott William and walkins, 2005, edition 5
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Kelly. W And Christine A. Sorkness, Asthma, Joseph T. DiPiro et al, Pharmacotherapy A
Pathophysiologic Approach, 7th Edition, Mc Graw Hill 2008, Pp 464,479
Kelly. W And Christine A. Sorkness, Asthma, Joseph T et al, Pharmacotherapy Handbook,
7th Edition, Mc Graw Hill, 2009, Pp- 906-909
Lippincotts pharmacology by Michelle A. cleck, Rched firrel, et al, 4
th
Edition, 2009, Pp 77
Mark S. Chesnutt et al, Lung, Daniel C. Adelman et al, Current Medical Diagnosis &
Treatment, 45th Edition, McGraw Hill, 2006, Pp 228-235,
Mark S. Chesnutt et al, Lung, Daniel C. Adelman et al,, Current Medical, Diagnosis &
Treatment, 45th Edition, McGraw Hill, (2006), Pp 250

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RATIONAL DRUG THERAPY FOR THE MANAGEMENT OF ASTHMA

AN INTERNSHIP BASED PROJECT AT MARDAN MEDICAL COMPLEX, MARDAN

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