Chapter 2 - Drug

Therapy Problems
 Literature definition of
pharmaceutical care
.... “the responsible provision of drug
therapy for the purpose of achieving
definite outcomes that improve a patient’s
quality of life. These outcomes include:
(1) cure of a disease; (2) elimination or
reduction of a patient’s symptomatology;
(3) arresting or slowing of a disease
process or; (4) preventing a disease or
symptomatology.”
 Operational definition of
pharmaceutical care
A pharmacist practices
pharmaceutical care when he/she
finds and fixes or prevents drug
therapy problems in patients.
 Don’t we do that now?
Consider what you have seen in
pharmacies so far in your career.
Most problems are discovered 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?
 Therefore....
Pharmacists can and do already find drug
therapy problems, but we typically do so
coincidentally while filling prescriptions
Few pharmacists approach practice with
the intent of deliberately finding drug
therapy problems.
We partially provide pharmaceutical care
and only part of the time
 Incidence of drug therapy
problems - Currie JAPhA1997
Traditional RPh uncovers 3 drug therapy
problems per 100 patients
Pharm care RPh uncovers 57.5 drug
therapy problems per 100 patients
Traditional RPh - drug interxn #1 (52%)
Pharm care RPh - wrong drug #1 (24%)
Pharm care RPh - 7.5x more likely to find
a problem & 8.1x more likely to try & fix it
 Medical problems
A disease state
A change in physiology that
(potentially) results in clinical
evidence of damage to an organ
system
Some examples include.......
 Drug therapy problems
A patient problem that is either
caused by a drug or may be
treated/prevented by a drug
Some examples include ........
 Medical vs. drug therapy
problems
So how does this differ from a
medical problem?
Who in the health care system finds
and fixes medical problems?
Who in the health care system finds
and fixes drug therapy problems?
 Minicase -1
You are the pharmacist at
Kensington Pharmacy and
Mrs.Terning comes in to ask you to
recommend an OTC sleep aid. In
your conversation with her, you learn
her husband has recently passed
away and she is not coping well. You
believe she is probably depressed
and feel you should probably call her
physician, Dr. Feldman.
 Minicase - 2
What is Mrs. Terning’s medical
problem?
What is her drug therapy problem?
How do you contact Dr. Feldman and
not appear to be“practicing
medicine”?
Case shows that drug therapy
problems often develop out of
medical problems
Patient needs of drug therapy
Drug therapy problems occur when
one or more of a patient’s needs for
drug therapy are not met
5 patient needs for drug therapy
(1) every drug has an appropriate
indication
(2) drug therapy is effective
(3) drug therapy is safe
(4) patients can comply with drug
therapy
(5) no untreated indications are
present.
Practicing pharmaceutical care
Pharmaceutical care practitioners use an
organized approach to determine if all
these needs are met
How many of these problems will current
modes of practice uncover?
If they are, the patient has no drug
therapy problems
If they are not, drug therapy problems
exist
 Etiology of Drug Therapy
Problems - Strand et al. 1998
P a tie n t N e e d D ru g T h erap y
P ro b lem
A p p ro p riate in d icatio n 1 . U n n ecessary d ru g
th erap y
E ffectiv en ess 2 . W ro n g d ru g
3 . D o se to o lo w
S afety 4 . A d v erse d ru g rx n
5 . D o se to o h ig h
C o m p lian ce 6 . In ap p ro p riate
co m p lian ce
N o u n treated 7 . N eed s ad d itio n al
in d icatio n s th erap y
 Problems have causes - 1
N eed Problem Cause
Appropriate Unnecessary 1. no medical
indication drug therapy indication
2.addiction/re-
creational use
3.nondrug
therapy more
appropriate
4.duplicate
therapy
5.treating
avoidable
ADR
 Problems have causes - 2
Need Problem Cause
Effectiveness Wrong drug 1. dosage form
inappropriate
2. contraindic-
ation present
3. condition
refractory to
drug
4. drug not
indicated for
condition
5. more
effective drug
available
 Problems have causes - 3
Need Problem Cause
Effectiveness Dose too low 1. wrong dose
2. frequency
inappropriate
3. duration
innapropriate
4. incorrect
storage
5. incorrect
administration
6. drug interxn
 Problems have causes - 4
Need Problem Cause
Safety Adverse drug 1. unsafe drug
rxn for pt
2. allergic rxn
3. incorrect
administration
4. drug interxn
5. dose inc/dec
too fast
6. undesirable
effect
 Problems have causes - 5
Need Problem Cause
Safety Dose too high 1. wrong dose
2. frequency
inappropriate
3. dose
inappropriate
4. drug interxn
 Problems have causes - 6
Need Problem Cause
Compliance Inappropriate 1. drug not
compliance available
2. pt cannot
afford drug
3. pt cannot
swallow/take
4. pt doesn’t
understand
5. pt prefers
not to take
 Problems have causes - 7
Need Problem Cause

No untreated Needs 1. untreated

indications additional Rx indication
2. synergistic
therapy
3. prophylactic
therapy
 A few more things to note
Drug interactions show up in 3 places
(dose too low, ADR, dose too high)
Some people list an 8th problem - “no
drug therapy problem found” which may
be useful for payment for preventive
services
Knowing the cause of a drug therapy
problem helps to create the plan to fix it
Disagreements common - use judgment
Actual vs potential problems? -
Minicases
While working at Med-rite Pharmacy, you
accidentally fill an Rx for penicillin for
Howard Prinz who is allergic to penicillin.
Before you can call him he takes the
penicillin. He claims he’s fine when you
reach him by phone that evening.
Before you can call him he takes the
penicillin. When you reach his home his
neighbor tells you he’s in the emergency
room!!
 Actual vs potential problems
Actual problems have occurred. The best
you can do is treat them
Potential problems have not occurred.
They can be prevented. Prevention is a
HOT topic and a great professional
opportunity!
How pharmacists and doctors view actual
vs potential problems
It’s easier with actual problems
 Communications tips
Docs do not care about drug therapy
problems. They care about patients with
problems
Wording is critical to success - “Dr, I think
I have discovered the drug therapy
problem of WRONG DRUG in your
patient!!!”
Re-phrase them ALL as patient problems
 Suggested homework
Take this list of drug therapy
problems to work. As you/RPh find
problems with patients and
prescriptions, use this list to identify
the problem, its cause and whether it
is an actual or potential drug therapy
problem.
 Suggested homework
A patient presents a new Rx for
Norvasc (amlodipine)10mg po qd for
BP of 164/102. He has never had it
before. You think this is too high a
dose (usual initial dose is 2.5-5mg
qd) How do you re-phrase the “dose
too high” problem in words that will
not offend the Doctor.
i.e. what’s the patient problem?