Chapter 2 Chapter 2 -- Drug Drug Therapy ProblemsTherapy Problems

Literature definition of Literature definition of pharmaceutical care pharmaceutical care

.... .... ““the responsible provision of drug the responsible provision of drug therapy for the purpose of achieving therapy for the purpose of achieving definite outcomes that improve a patientdefinite outcomes that improve a patient’’s s quality of life. These outcomes include: quality of life. These outcomes include: (1) cure of a disease; (2) elimination or (1) cure of a disease; (2) elimination or reduction of a patientreduction of a patient’’s s symptomatologysymptomatology; ; (3) arresting or slowing of a disease (3) arresting or slowing of a disease process or; (4) preventing a disease or process or; (4) preventing a disease or symptomatologysymptomatology..””

Operational definition of Operational definition of pharmaceutical carepharmaceutical care

A pharmacist practices A pharmacist practices pharmaceutical care when he/she pharmaceutical care when he/she finds and fixes or prevents drug finds and fixes or prevents drug therapy problems in patients.therapy problems in patients.

DonDon’’t we do that now?t we do that now?Consider what you have seen in Consider what you have seen in pharmacies so far in your career.pharmacies so far in your career.Most problems are discovered when Most problems are discovered when a pharmacist thinks a pharmacist thinks ““that canthat can’’t be t be right!right!”” or when the computer goes or when the computer goes beep, beep, beep!beep, beep, beep!Did the pharmacist find the problem Did the pharmacist find the problem or did the problem find the or did the problem find the pharmacist?pharmacist?

Therefore....Therefore....Pharmacists can and do already find drug Pharmacists can and do already find drug therapy problems, but we typically do so therapy problems, but we typically do so coincidentally while filling prescriptionscoincidentally while filling prescriptionsFew pharmacists approach practice with Few pharmacists approach practice with the intent of deliberately finding drug the intent of deliberately finding drug therapy problems.therapy problems.We We partiallypartially provide pharmaceutical care provide pharmaceutical care and only part of the timeand only part of the time

Incidence of drug therapy Incidence of drug therapy problems problems -- Currie JAPhA1997Currie JAPhA1997Traditional Traditional RPhRPh uncovers 3 drug therapy uncovers 3 drug therapy problems per 100 patientsproblems per 100 patientsPharmPharm care care RPhRPh uncovers 57.5 drug uncovers 57.5 drug therapy problems per 100 patients therapy problems per 100 patients Traditional Traditional RPhRPh -- drug drug interxninterxn #1 (52%)#1 (52%)PharmPharm care care RPhRPh -- wrong drug #1 (24%)wrong drug #1 (24%)PharmPharm care care RPhRPh -- 7.5x more likely to find 7.5x more likely to find a problem & 8.1x more likely to try & fix ita problem & 8.1x more likely to try & fix it

Medical problemsMedical problemsA disease stateA disease stateA change in physiology that A change in physiology that (potentially) results in clinical (potentially) results in clinical evidence of damage to an organ evidence of damage to an organ systemsystemSome examples include.......Some examples include.......

Drug therapy problemsDrug therapy problemsA patient problem that is either A patient problem that is either caused by a drug or may be caused by a drug or may be treated/prevented by a drugtreated/prevented by a drugSome examples include ........Some examples include ........

Medical vs. drug therapy Medical vs. drug therapy problemsproblems

So how does this differ from a So how does this differ from a medical problem?medical problem?Who in the health care system finds Who in the health care system finds and fixes medical problems?and fixes medical problems?Who in the health care system finds Who in the health care system finds and fixes drug therapy problems?and fixes drug therapy problems?

MinicaseMinicase --11You are the pharmacist at You are the pharmacist at Kensington Pharmacy and Kensington Pharmacy and Mrs.TerningMrs.Terning comes in to ask you to comes in to ask you to recommend an OTC sleep aid. In recommend an OTC sleep aid. In your conversation with her, you learn your conversation with her, you learn her husband has recently passed her husband has recently passed away and she is not coping well. You away and she is not coping well. You believe she is probably depressed believe she is probably depressed and feel you should probably call her and feel you should probably call her physician, Dr. Feldman.physician, Dr. Feldman.

MinicaseMinicase -- 22What is Mrs. What is Mrs. TerningTerning’’ss medicalmedicalproblem?problem?What is her What is her drug therapydrug therapy problem?problem?How do you contact Dr. Feldman and How do you contact Dr. Feldman and not appear to benot appear to be““practicing practicing medicinemedicine””??Case shows that drug therapy Case shows that drug therapy problems often develop out of problems often develop out of medical problemsmedical problems

Patient needs of drug therapyPatient needs of drug therapyDrug therapy problems occur when Drug therapy problems occur when one or more of a patientone or more of a patient’’s needs for s needs for drug therapy are not metdrug therapy are not met

5 patient needs for drug therapy5 patient needs for drug therapy(1) every drug has an appropriate (1) every drug has an appropriate indicationindication(2) drug therapy is effective(2) drug therapy is effective(3) drug therapy is safe(3) drug therapy is safe(4) patients can comply with drug (4) patients can comply with drug therapytherapy(5) no untreated indications are (5) no untreated indications are present.present.

Practicing pharmaceutical carePracticing pharmaceutical carePharmaceutical care practitioners use an Pharmaceutical care practitioners use an organized approach to determine if all organized approach to determine if all these needs are metthese needs are metHow many of these problems will current How many of these problems will current modes of practice uncover?modes of practice uncover?If they are, the patient has no drug If they are, the patient has no drug therapy problemstherapy problemsIf they are not, drug therapy problems If they are not, drug therapy problems existexist

Etiology of Drug Therapy Etiology of Drug Therapy Problems Problems -- Strand et al. 1998Strand et al. 1998

P a t ie n t N e e d D r u g T h e r a p yP r o b le m

A p p r o p r ia t e in d ic a t io n 1 . U n n e c e s s a r y d r u gth e r a p y

E f f e c t iv e n e s s 2 . W r o n g d r u g3 . D o s e to o lo w

S a f e ty 4 . A d v e r s e d r u g r x n5 . D o s e to o h ig h

C o m p l ia n c e 6 . I n a p p r o p r i a t ec o m p l ia n c e

N o u n t r e a te din d ic a t io n s

7 . N e e d s a d d i t io n a lth e r a p y

Problems have causes Problems have causes -- 11Need Problem Cause

Appropriateindication

Unnecessarydrug therapy

1. no m edicalindication2.addiction/re-creational use3.nondrugtherapy m oreappropriate4.duplicatetherapy5.treatingavoidableADR

Problems have causes Problems have causes -- 22Need Problem Cause

Effectiveness Wrong drug 1. dosage forminappropriate2. contraindic-ation present3. conditionrefractory todrug4. drug notindicated forcondition5. moreeffective drugavailable

Problems have causes Problems have causes -- 33Need Problem CauseEffectiveness Dose too low 1. wrong dose

2. frequencyinappropriate3. durationinnapropriate4. incorrectstorage5. incorrectadministration6. drug interxn

Problems have causes Problems have causes -- 44Need Problem CauseSafety Adverse drug

rxn1. unsafe drugfor pt2. allergic rxn3. incorrectadministration4. drug interxn5. dose inc/dectoo fast6. undesirableeffect

Problems have causes Problems have causes -- 55Need Problem Cause

Safety Dose too high 1. wrong dose

2. frequencyinappropriate3. doseinappropriate4. drug interxn

Problems have causes Problems have causes -- 66Need Problem Cause

Compliance Inappropriatecompliance

1. drug notavailable2. pt cannotafford drug3. pt cannotswallow/take4. pt doesn’tunderstand5. pt prefersnot to take

Problems have causes Problems have causes -- 77Need Problem Cause

No untreatedindications

Needsadditional Rx

1. untreatedindication2. synergistictherapy3. prophylactictherapy

A few more things to noteA few more things to noteDrug interactions show up in 3 places Drug interactions show up in 3 places (dose too low, ADR, dose too high)(dose too low, ADR, dose too high)Some people list an 8th problem Some people list an 8th problem -- ““no no drug therapy problem founddrug therapy problem found”” which may which may be useful for payment for preventive be useful for payment for preventive servicesservicesKnowing the Knowing the causecause of a drug therapy of a drug therapy problem helps to create the plan to fix itproblem helps to create the plan to fix itDisagreements common Disagreements common -- use judgmentuse judgment

Actual Actual vsvs potential problems? potential problems? --MinicasesMinicases

While working at MedWhile working at Med--rite Pharmacy, you rite Pharmacy, you accidentally fill an Rx for penicillin for accidentally fill an Rx for penicillin for Howard Howard PrinzPrinz who is allergic to penicillin. who is allergic to penicillin. Before you can call him heBefore you can call him he takes the takes the penicpenicillinillin. He claims he. He claims he’’s fine when you s fine when you reach him by phone that evening.reach him by phone that evening.Before you can call him he takes the Before you can call him he takes the penicillin. When you reach his home his penicillin. When you reach his home his neighbor tells you heneighbor tells you he’’s in the s in the emergency emergency roomroom!!!!

Actual Actual vsvs potential problems potential problems Actual problems have occurred. The best Actual problems have occurred. The best you can do is treat themyou can do is treat themPotential problems have not occurred. Potential problems have not occurred. They can be prevented. Prevention is a They can be prevented. Prevention is a HOT topic and a great professional HOT topic and a great professional opportunity!opportunity!How pharmacists and doctors view actual How pharmacists and doctors view actual vsvs potential problemspotential problemsItIt’’s easier with actual problemss easier with actual problems

Communications tipsCommunications tipsDocs do Docs do notnot care about drug therapy care about drug therapy problems. They care about problems. They care about patientspatients with with problemsproblemsWording is critical to success Wording is critical to success -- ““Dr, I think Dr, I think I have discovered the drug therapy I have discovered the drug therapy problem of WRONG DRUG in your problem of WRONG DRUG in your patient!!!patient!!!””ReRe--phrase them ALL as phrase them ALL as patientpatient problemsproblems

Suggested homeworkSuggested homeworkTake this list of drug therapy Take this list of drug therapy problems to work. As you/problems to work. As you/RPhRPh find find problems with patients and problems with patients and prescriptions, use this list to identify prescriptions, use this list to identify the problem, its cause and whether it the problem, its cause and whether it is an actual or potential drug therapy is an actual or potential drug therapy problem.problem.

Suggested homeworkSuggested homeworkA patient presents a new Rx for A patient presents a new Rx for NorvascNorvasc (amlodipine)10mg (amlodipine)10mg popo qdqd for for BP of 164/102. He has never had it BP of 164/102. He has never had it before. You think this is too high a before. You think this is too high a dose (usual initial dose is 2.5dose (usual initial dose is 2.5--5mg 5mg qdqd) How do you re) How do you re--phrase the phrase the ““dose dose too hightoo high”” problem in words that will problem in words that will not offend the Doctor.not offend the Doctor.i.e. whati.e. what’’s the s the patientpatient problem?problem?