Pharmaceutical Care:

The introduction

Didik Setiawan, PhD., Apt

- Faculty of Pharmacy,
- Center for Health Economic Studies,
Universitas Muhammadiyah Purwokerto, Purwokerto, Indonesia
Presenter

Didik Setiawan, PhD., Apt

(Health Economics)
• Research area:
• Pharmacoeconomics,
• Modeling,
• Economic evaluation,
• Cancer,
• Vaccines,
• Infectious diseases
Main references
Pharmaceutical Care
• 3 credits (sks)
• Lecturer
• Didik Setiawan, PhD., Apt
• Khafidz Nasrudin, S.Farm., Apt
• Nurul Latifah, S.Farm., Apt
• Purpose
• To introduce pharmaceutical care
practice. Covering its
requirements and practical
example from literature and real
world cases.
• Facilitate the implementation of
pharmaceutical care concept in
daily practice
Overview

Pharmaceutical Care as the

Medication Management Professional Practice for
Services Patient-Centered Medication
Management Services

Drug Related Problems Pharmaceutical Care Process

Real world example on DRPs

Evidence Based Medicine and the implementation of
PC (Practitioner)
Assessment

Assessment Proportion
component • Mid term 40%
•understanding • Final term 40%
•Activeness • Activeness 20% https://www.google.nl/url?sa=i&rct=j&q=&esrc=s&so

•Creativity
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Do we need a clinical pharmacists?
Some reports…

Patients visit the public school clinic in Missouri to receive influenza vaccine 1.Clogston J,
Hudanick L,
Suragh TA, et al.
2 of them complained of sweating and lightheadedness, other 2 require hospitalization due Unintentional
to their symptom, and 1 of them had s blood sugar level of 23mg/dL administration of
insulin instead of
influenza vaccine:
a case study and
the Saint Louis County Department of Public Health investigated and found that patients
mistakenly received Humalog U-100 insulin instead of the influenza vaccine review of reports
to US vaccine
and drug safety
Further investigation found that the influenza vaccine vial was kept in the nurse’s office monitoring
refrigerator along with a 10 mL vial of Humaog U-100 insulin. they were found to not be systems. Drugs
stored in separate, labeled containers or bins. Ther Perspect.
2016. 32: 439.
This incident was likely a result of ‘confirmation bias’ where a healthcare worker may rely on doi:10.1007/s402
familiar cues, such as the shape, colors, and markings on a vial to confirm preconceptions, 67-016-0333-2.
which may lead to reduced vigilance and an increased risk of medication errors.
Some reports…

1.Gado A, Ebeid
50 y.o women was scheduled a colonoscopy after an administration of what was B, Axon A.
believed to be midazolam 5mg Accidental IV
administration of
epinephrine
She then started to complain of chest tightness, difficulty breathing, and instead of
generalized tremors midazolam at
colonoscopy. Ale
xandria J of Med.
The procedure was postponed for several days until the patient recovered 2016;62(1).
doi:10.1016/j.ajm
e.2014.11.003.
Investigation found that a medication error occurred and the patient received
0.25 mg of epinephrine instead of midazolam

A root cause of the error revealed that the epinephrine ampule was mistakenly
placed in the box with the midazolam in the pharmacy following an instance
where a previous patient did not require the medication.
Some reports…

A 40 y.o male unable to sustain an erection for more than 1 minute starting at age 28 and Sathyanarayan
then prescribed 100 mg of sildenafil (max recommended dose) prior to intercourse. a Rao TS,
Kumar VA,
Raman R,
The patient was able to achieve an erection from 1 to 5 minutes; however, the benefit waned Andrade C.
within several months. Therefore, he started increasing the dose on his own Prolonged,
longstanding,
ultra-high-dose
By age 38, he was taking 8-9 tablets of sildenafil 100 mg per occasion. abuse of
sildenafil. India
n Journal of
At the time of consultation, he was self-medicating at a dose of 1300 mg per occasion, Psychiatry.
several times per week, which allowed him to sustain an erection for up to 5 minutes.
2015;57(3):311-
312.
Upon consultation, the patient reported experiencing transient blurred vision within 20 doi:10.4103/00
minutes of sildenafil ingestion in the last 2 years. 19-
5545.166626
The patient received a physical examination, comprehensive laboratory workup, and
ophthalmological examination; all identified no abnormalities.
 Goldner JA.
A 84 y.o patient with a history of hypertension and osteoarthritis who suffered Metoprolol-
from visual hallucinations for several years after starting metoprolol. Following induced visual
an extensive series of tests and workups to rule out other causes, the metoprolol hallucinations:
was stopped and her symptoms resolved within several days. a case series. J
Med Case Rep.
2012 Feb
A 62-year-old man who was discharged from the hospital from MI with a number 15;6:65. doi:
of medications, including metoprolol. After several months, he reported to his 10.1186/1752-
doctor that he had been seeing dead people at night, which began immediately 1947-6-65
following his discharge. Upon discontinuation of the metoprolol the visual
disturbances resolved within several days.

Although the mechanism behind beta-blocker induced hallucinations is unclear,

the researchers explain that metoprolol’s intermediate degree of lipophilicity
may allow for CNS drug penetration. In patients experiencing these types of CNS
effects, it may be beneficial to switch to a more hydrophilic beta-blocker such
as atenolol, or one of the newer third generation beta-blockers like carvedilol.
How about Indonesia??

• No official or published scientific report

• Some cases in Indonesia
• Dumolid
• Methamphetamine
• Tramadol
• etc
Indonesia's current health care services

Universal Health Coverage

Referral system
Health care flow
Assignment

• Find 10 problems in the current health care system and propose

the solutions with regards to pharmacists role
Issues with the current health care practice

Healthcare costs
• Medicine related errors are costly in terms of hospitalizations,
physician visits, laboratory tests and remedial therapy
Adverse drug reaction:
• 4%-10% of all hospital in-patients in developed countries.
• The 4th-6th leading cause of death in USA
• Estimated cost: upto US $ 139 billion a year in the USA
• £ 466 million (over $812 million): in the UK
Issues with the current health care practice

Up to 90% developed resistance to original first-line antibiotics

such as ampicillin and cotrimoxazole for shigellosis,

Up to 70% resistance to penicillin for pneumonia and bacterial

meningitis,

Up to 98% resistance to penicillin for gonorrhea, and

Up to 70% resistance to both penicillin and cephalosporin for

hospital-acquired S.aureus infections.
Issues with the current health care practice

The old reduce drug related problems,

“Physicians
Prescribe and ensure safety,
Pharmacists
Dispense” model ensure effectiveness and
is no longer fully
appropriate to: adherence to drug therapy.
The Increase of New Drug Approved
Statistics prove prescription drugs are
16,400% more deadly than terrorists
Adverse Drug Event/Reaction

• Murray, M.D., Ritchey, M.E., Wu, J., Tu,

W., 2009, Effect of a Pharmacist on
Adverse Drug Events and Medication
Errors in Outpatients With
Cardiovascular Disease , Arch Intern
Med. 9;169(8):757-763
Adverse Drug Event

• Murray, M.D., Ritchey, M.E.,

Wu, J., Tu, W., 2009, Effect of
a Pharmacist on Adverse Drug
Events and Medication Errors
in Outpatients With
Cardiovascular Disease , Arch
Intern Med. 9;169(8):757-763
Individual drug response

Non Physiologic Factors Pharmacologic Factors

Multiple disease states
Pharmacokinetics
Adverse drug reactions
Patient compliance
Pharmacodynamic
Psychosocial factors
 Drug Cost

Alxil 500 mg X Dexacef 500 mg X Rp Cefadroxil 500 mg X Rp

Rp 82.500,- 73.000,- 12.000,-
Ponstan 250 mg XV Rp Pondex 250 mg XV Rp As mefenamat 250 mg XV Rp
18.700,- 7.100,- 3.000,-
Max C 500 mg VII Rp Max C 500 mg VII Rp Max C 500 mg VII Rp
18.800,- 18.800,- 18.800,-
Total harga Rp 120.000,- Total harga Rp 98.900,- Total harga Rp 33.800,-
Drug Perception

Original Patent

Generic Branded
Wrong Perception in the community
Why Does PC Important?

multiple practitioners writing a high level of drug-related morbidity and

prescriptions for a single patient, often mortality which results in significant
without coordination and communication; human and financial costs

the large number of medications and

overwhelming amount of drug an increase in self-care through
information presently available to alternative and complementary medicine;
patients;

patients playing a more active role in the an increase in the complexity of drug
selection and use of medications; therapy;
What could be the solution?

• The pharmacy professional needed today is a knowledgeable drug

expert and skilled, persuasive communicator and not a pill
counter.
Why Indonesia?

Shortage of healthcare worker, particularly pharmacist

• 20% of total hospital and puskesmas (MoH, 2013)

HIV/AIDS is a major burden in developing countries

Life style is becoming westernized  DM, HF, CKD, chronic

illnesses  New meds are being imported to Indonesia 
demand to meds expert is clear

Though critical shortage of HC proffesionals but the existing

should be utilized to their fullest capacity including pharmacists
 Existing skills should be upgraded to cope up with
Pharmaceutical care in Indonesia

it has been set up, but not fully implemented

• Permenkes no 72 th 2016 ttg Standar Pelayanan Kefarmasian di
Rumah Sakit
Permenkes no 73 th 2016 ttg Standar Pelayanan Kefarmasian di
Apotek
Permenkes no 74 th 2016 ttg Standar Pelayanan Kefarmasian di
Puskesmas
What is the problem?
• Scientific evidence has not been provided
 Pharmaceutical care

a patient-centered practice in which the practitioner assumes responsibility for a

patient's drug-related needs and is held accountable for this commitment.
(Helper & Strand,1990)
Health Care Systems
Pharmaceutical Care in Health Care Systems
The Function of Pharmaceutical Care
Pharmaceutical care Cycle

Why do anything? (identify

the problems)

How will you know you did What do you want to do?
it? (monitor and follow up) (set goal)

How will you do it?

(develop a care plan)

Follow Up &
Assessment Care Plan
Evaluation
Pharmacist Activity

• Old paradigm • New paradigm

Outcome of Pharmaceutical care

Prevent the disease or symptomp of the disease

• Allergy in children, Breast cancer, Cervical cancer, etc

Cure the Disease

• Headache, diarrhea, fever, cough, etc

Reduce or eliminate the Symptom

• Pain in Rheumatic Arthritis, LES

Stop or slow down the progressivity of the disease

• Stage IV Cancer, Renal Failure, Hypertension
Pharmaceutical Care (WHO, 2006)

Individual Based PC Population Based PC

Establish formulary or medicine list
Individual drug therapy decision Develop and monitor pharmacy
Critical Patient Monitoring policy
Prescription Monitoring Develop and manage pharmacy
Ward Pharmacy network
Drug Counseling, etc Drug utilization/cost
Provider drug education , etc
What are the barriers of the implementation?
Some barriers of PC implementation

‘Pharmacist believes clinically Probably a combination of

and financially in increased inadequate
patient care, but pharmacists • Knowledge (easy to fix)
have not fully adopted a new • Skill (easy to fix)
practice philosophy. • Attitude (hard to fix)

PC is not the current standard of

practice. What you see at work
rarely reflects what you hear in
class
Consider what you have seen in almost all pharmacies so far in our country.

Meds without prescriptions, inadequate counseling, lack monitoring,

missing of DDI checker

Most problems are discovered only when a pharmacist thinks

“that can’t be right! or when the computer goes beep, beep, beep!

Did the pharmacist find the problem or did the problem find the
pharmacist?

‘’not safe to assume the practice we see today is the same practice w/c
will be few yrs from now’’ hope vs hard work?????
Basic Knowledge

Patophysiology

Pharmacology - Toxicology

Pharmaceutical products

Pharmacokinetics

Pharmacotherapy

Pharmaceutical Care
Basic Skill (in a network era)

English Language Skill

Provision drug information
Drug Monitoring skill
Communication Skill
Computer Skill
Internet Skill
Pharmaceutical Care - Benefits 45

• Decrease medication misadventures

• Increase patient compliance to therapy

• Empowers patients to take in-charge of their own health and treatment

• Decrease healthcare cost and demand

• Decrease morbidity of mortality

• Increase patients’ quality of life

Goal of Pharmacists: Clinical Training 46

• To make them experts in:

• identifing and solving medication therapy problems

• becoming patient educators

• selecting the most effective therapy

• monitoring the outcome of drug therapy

What is the Focus of the
New Pharmacy Curriculum? 47

Clinical Application of Drug Therapy

Treatment guideline, Disease state knowledge

Diagnostic procedures (to identify a drug problem)

Monitoring parameters (lab, physical exam, other diagnostic

tools) to follow efficacy and safety of drug therapy.
Change in Pharmacy Education 48

Pharmacists may be expert in

Are we behind by 20 years from the
medicinal chemistry and
rest of the world?
pharmaceutics – but is this enough?

Pharmacy education around the world

Need the knowledge to apply to has made a shift
patient care (direct patient care • From lab-based to practical or clinical based.
involvement) • From technical aspect to professional aspect of
pharmacy
Conclusion
Didik Setiawan, PhD., Apt

Email: d.didiksetiawan@gmail.com
WA: +31 631 254575
Phone: 081 226 700 119
www.ches.ump.ac.id