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Clinical Pharmacy Conference, Port Dickson, 9-11 Jan 2003 Respiratory Pharmacy & the Ward Pharmacist experience by Abdol Malek bin Abd Aziz, MSc.

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Presentation on theme: "Clinical Pharmacy Conference, Port Dickson, 9-11 Jan 2003 Respiratory Pharmacy & the Ward Pharmacist experience by Abdol Malek bin Abd Aziz, MSc."— Presentation transcript:


2 Clinical Pharmacy Conference, Port Dickson, 9-11 Jan 2003 Respiratory Pharmacy & the Ward Pharmacist experience by Abdol Malek bin Abd Aziz, MSc

3 Respiratory pharmacy Emphasis on pharmaceutical care of respiratory patients plus Other conditions that the patient is concurrently suffering

4 Respiratory Pharmacy Covers: Asthma COPD Idiopathic interstitial lung disease Pleural disorders Pneumonia Drug-induced pulmonary disease

5 NHMS 1996 - Findings High percentage (62.4%) not on inhalers Mild asthmatics: 65.3% Moderate : 52.1% Severe : 23.7%

6 Compliance / adherence Generally non-compliance rate ~ 50% (out patients) 56% in Melaka (1999)* Leads to hospital admission 51.7% in Hospital Melaka ** 13.3% were asthmatics (6/45 patients) Non-compliance to inhaled medications: 50% (McGann & Elizabeth. Am J Nursing 1999) Aziz AMA, Ibrahim MIM. Med J Malaysia 1999. ** Aziz AMA, Senthil N, Jenny W. J Pharm Sci. 2003 (in press)

7 Some avenues to patient care… Patients with allergic rhinitis often experience symptoms of asthma (Linneburg. Allergy 2002,57 ) Allergic rhinitis preceded or developed at the same time as allergic asthma Tx of allergic rhinitis reduced asthmatic symptoms or reduce risk of asthma

8 Inhaler technique “good” rating ranged from 5-86% using MDIs Technique improved after proper training* 37.5% of pharmacy staff & 45.4% (15/33) outpatients having good technique € € Inhaler technique survey among pharmacy staff and patients at the specialists clinic pharmacy, Hospital Melaka. Abstract of the Konferens R&D Farmasi, Kota Bharu 2002. * Cochrane MG, Bala MV, Downs KE et al. Inhaled corticosteroids for asthma therapy: patient compliance, devices, and inhalation technique. Chest 2000;117(2):542-550

9 Lung deposition of medication Terbutaline: MDI – 8%, DPI – 22%* Effect of spacer device: Lung deposition increase from 9 to 21% Oropharynx deposition reduced from 81 to 17% # * Borgstrom L, Derom E, Stahl E, et al. The inhalation device influences lung deposition and bronchodilating effect of terbutaline. Am J Respir Care Med 1996;153:1636-1640. # Newman SP, Millar AB, Lennard-Jones TR et al. improvement of pressurised aerosol deposition with Nebuhaler spacer device. Thorax 1984;39:936-941.


11 * National Health and Morbidity Survey Vol. 11, Public Health Institute. 1996 Bronchial asthma Defn: Reversible airways obstruction, airway inflammation, airways hyperreactivity to a variety of stimuli Incidence: 3-6% in Australia, 4.2% in Malaysia*, 2-5% in Africa Symptoms: Wheezing, dyspnoea, chest tightness, cough

12 Asthma in children Children: Dry powder inhalers has greater systemic effects than MDIs § Pharmacists: recommend MDI with spacer device for children. § Kereem E. Ann Allergy Asthma International 2002;89.

13 Pharmacist’s roles As educator and support person Counsel on role of each medication Difference between preventer – reliever Emphasise safety of inhaled c’steroids Discuss adverse effects – ways to minimise Check and correct proper use of inhalers Encourage use of spacers and peak fl. meters

14 AMA Aziz, MIM Ibrahim. Medication noncompliance - a thriving problem. Med J Malaysia 1999;54:192-5. Pharmacist’s roles Check compliance – 56% noncompliance rate 1 Check usage of medications for other illnesses, OTC products, GP’s drugs, etc Dispels myths about asthma and inhaler use Encourage asthma action plan

15 Objective To have an influence on prescribing and related clinical practice

16 How to start? Ward pharmacy then Respiratory pharmacy

17 Ward pharmacy Back to basics Supplies, inventory, pricing, Dosage, category of drug in MOH list List A, std item Synergistic activity with in-patient pharmacist/satellite pharmacist

18 At the ward… Familiarise with the ward- acquaint with ward staff ie. sister & nurses Ward procedures Own reading on common drugs used develop confidence confidence

19 Ward rounds Consultant’s rounds: already have a high level of interest in optimising drug therapy Vigilant on ADR and side effects

20 Preparation before rounds Very, very important May take an hour or more initiallyan hour Objective : ‡to anticipate areas where information is likely to be requested ‡To identify topics for discussion

21 Becoming prepared provides… Confidence

22 Clerking Same as any other pt Biodata, diagnosis, investigations, lab results, x- rays, etc, Document using card or form Monitor, Identify drug-related problems or issues Plan for solution - check-up - talk to Dr or specialist, nurse

23 Things to do… Estimate creatinine clearance Cl Cr if the serum creatinine is >150µmol/l in adults less than 70 yrs using Cockcroft and Gault equation Abnormal levels of urea or albumin may alter the disposition of some drugs

24 Patient parameters Pt. with liver disease – elevated liver function tests Severe cardiac failure may affect both renal and hepatic clearance of drugs may necessitate dose individualisation Calculate predicted blood levels if therapeutic monitoring of a drug is required

25 Attending ward rounds Be PUNCTUAL Degree of involvement and pharmacist’s role depend on the leading physician Doctors may undertake management or teaching role or both They may not ask for pharmacist’s comments

26 A successful attendance in ward rounds Adequate preparation Being tactful, yet assertive prioritise Regular attendance Present info on a problem concisely Provide adequate follow up

27 Pharmacist’s comments Unlikely to be a personal insult and no offence should be taken The advice may be used on a similar pt in future Occasionally it may be used by the consultant against his junior staff – communicate with the houseman to avoid unnecessary embarrassment Follow up on pts where comments have been accepted ie. supplies and instructions on usage

28 Specialisation Collins English Dictionary and Thesaurus: defines special as ‘distinguished’ or ‘set apart from’ Specialisation ~ characteristics that distinguish a clinical pharmacist from other pharmacists Obtained thru’ further education and training

29 Nursing profession development Shift in promotion ladder * Dual career pathway management ☞ sister – matron Clinical nurse ☞ advanced practice nurse (same ranking as sister/tutor) Similar to UK and Canada situation *Nafsiah Shamsudin. Specialisation of the clinical nurse in the Malaysian setting. Sept. 2000.

30 Specialisation Extra qualifications preferable Sometimes not necessary MSc, MPharm PhD Experience, confidence, way of thinking, networking, research-oriented, etc

31 Specific situations Asthma Counselling Pharmacoherapy issues ie. Drug of choice: β-2 agonists (short-acting, long- acting, corticosteroids (inhaled, oral), Drug forms: inhalers, oral tablets, nebs

32 Other roles Conformance to guidelines: MTS, GINA Research: eg. drug use clinical trials on outcomes of pharmacist-treated pt vs non-pharmacist pts, counselled vs non- counselled Inhaler technique – relate to outcomes Asthma clinic – check peak flow, compliance to tx, appointments for counselling, etc

33 What others have achieved… Pediatric asthma management programme Covenant Health System, Texas, US ± Found many asthma pts admitted for various reasons ie. Lack of medication, non-compliance, improper inhaler technique Remedy: face-to-face counselling. Pharmacists counselled pts and families Complete pt information leaflets given, videotapes Spent 30-60 mins per pt ± Razia M, Gordon H. Am J Health-Syst Pharm 2002;59. p. 1829.

34 results 69 pt counselled: 106 vs 51 ER visits or admissions pre and post counselling (↓52%) Cost avoidance: USD126,500/= → Counselling beneficial and reduces admission rates.


36 C.O.P.D.-X Plan ConfirmC = Confirm diagnosis, severity, complications OptimiseO = Optimise patient function (impairment, disability and handicap) PreventP = Prevent deterioration DevelopD = Develop self-monitoring and self-management care plan X = guide for managing exacerbations

37 C….confirm... Exclude asthma, cardiac disease etc Assess severity Assess reversible components Identify complications and co- existing conditions –history, examination, spirometry, xray chest, FBE

38 O….optimise…. –Smoking cessation –Optimise drugs safe and effective - don’t over-prescribe –Treat complications psychosocial –Optimise psychosocial issues –Optimise nutrition (consider dietician) –Encourage exercise (consider physio gym) –Pulmonary rehabilitation –Lung reduction surgery or transplantation

39 P….prevent…. –Smoking cessation (help and monitor) AAAAA –Occupation and other dusts –Stop unhelpful drugs –Prevent infections influenza vaccination (?Pneumococcal) relevant antibiotics for purulent sputum and fever –Pulmonary Rehabilitation –Transplantation

40 P….prevent…. –Check for complications & concurrent conditions osteoporosis, depression, cor pulmonale, OSA/hypoventilation –Consider oxygen if hypoxaemic –Regular review lung function

41 D….discuss, develop…. Educate patient and carers Pulmonary Rehabilitation and Patient Support GroupsPulmonary Rehabilitation and Patient Support Groups Assess self-management capacity Develop a collaborative care plan –monitor to identify exacerbations early –how to self-initiate treatment –what to do in an emergency

42 X… Exacerbations Inhaled bronchodilators and systemic glucocortocoids are effective treatments for acute exacerbations (Evidence A) Patients with clinical signs of infection(change in sputum colour and/or fever, leucocytosis) benefit from antibiotics (Evidence A)

43 Asthma Action Plan Designed for pts with asthma to: ^ recognise deterioration and ^ respond appropriately Action Plan will prevent ^ delay of initiation of preventer dose increases ^ prolonged exacerbation ^ adverse effects on pts life

44 Peak Flow Monitoring Peak Expiratory Flow (PEF) – the greatest flow velocity which can be generated during a forced expiration starting with fully inflated lungs Simple, quantitative, reproducible measure of airway obstruction Meters are cheap, lightweight and portable Repeated measures highly reproducible with each individual patient, if the same meter is used

45 Peak Flow Monitoring Actual number not important, but the trend is Measures response to bronchodilator therapy – increase by 20% post treatment (provided the baseline reading > 300ml/min adults) Measures early deterioration before pt. feels the change in his disease {diabetics monitor blood sugar, asthmatics measure lung function…}

46 Pulmonary Rehabilitation Program Established in the Repatriation General Hospital, Adelaide since many yrs ago A structured program using weekly lectures spanning over 3 months 2 hrs session ( 1 hr lecture each person ) @1.30pm Coordinated by the Resp. Rehab. Clinic Pharmacist Talked about “ Medications and Airways Disease”

47 PRP team Respiratory physician (Chairman), Technical officer, Respiratory Function Unit Clinical Nurse Consultant, Respiratory Rehab Clinic Clinical Pharmacist Physiotherapist Rehabilitation Counsellor Dietician Occupational therapist

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