Introduction To The Clinical Pharmacy

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Introduction To The Clinical Pharmacy

• By
• Amgad A. Ragab, Pharm D, CCP
• New York University Medical College
• New York University Cancer Center
• New York USA

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Human Body

• 44,701,295 VS 17.00
• 1000 gm of Bone Marrow (23,ooo/gm) Total
  23,000,000
• 7.5 gm of DNA (1.300,000/gm) Total 9.700,000
• 109.2 gm of Immune globulin IgG (67,000/gm)
  Total 7,316,400
• 210 units of erythropoietin hormone (5/u)
• Total 1050.00

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Human Body Organs

• The Heart 57,000
• The Liver 54,110
• The Lung 58,200 X 2 116,400
• The Kidney 45,700 X 2 194,000
• The Pancrease 43,900
• The Cornea 4,000 X 2 8,000
• The Egg 7,000 each
• The Sperm 75.00 each ejaculation

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Human Chemistry

• Iron 0.30 Potassium 5.95
• Carbon 1.98 Calcium 0.18
• Chloride 0.17 Phosphours 7.12
• Iodide 0.01 Sulphur 1.60
• Zinc 0.03 Sodium 0.11
• TOTAL 17.00

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CASE STUDY

• A 52-year-old male was admitted to the hospital
  with fever and fatigue. Lab tests revealed that
  he was pancytopenic
• WBC 1000, ANC 300, HGB 5.7, HCT 17 Platelets
  97,000, BUN 63, Creatinine 2.2
• PMS Orthotopic heart transplant 14 months before
  this event
• Medications Cyclosporine 100mg PO BID
  Azathioprine 150mg PO BID Prednisone
  10mg PO QD

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CASE MANAGEMENT

• Pt. was admitted to ICU with precautions related
  to neutropenia
• He received a blood transfusion (4 units) for
  anemia
• Broad-spectrum AB for neutropenia
• Fluconazole and Ganciclovir for possible fungal
  or viral infections
• BM biopsy for possible CMV infection

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MEDICAL PROBLEM DISCOVERY

• Clinical pharmacist interviewed the pt.
• It was discovered that pt. was being treated with
  allopurinol 300mg PO QD for hyperuricemia
  (disorder associated with cyclosporin therapy) 2
  months before the hospitalization
• Drug-drug interaction between allopurinol and
  azathioprine causes pancytopenia
• Naranjo score is 7

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MECHANISM OF ACTION

• Azathioprine is metabolized to 6 mercaptopurine
  6-MP and then to inactive products by xanthine
  oxidase
• Allopurinol is a xanthine oxidase inhibitor
• Toxic effects on the bone marrow due to higher
  plasma concentration of 6-MP
• Pt. remained in hospital for 31 days till the
  bone marrow slowly recovered
• Total cost of this stay was 180,995,73

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Intervention

• It is recommended changes in the drug therapy for
  any of the following reasons
• Untreated indication.
• Drug use without an indication.
• Improper drug selection.
• Failure to receive drug
• Subtherapeutic dosage
• Overdose
• Adverse Drug Reaction
• Drug interaction
• Inappropriate route
• Monitoring required

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ADVERSE DRUG EVENT (ADE)

• Definition Any injury that results from the
  use of a drug

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CLASSIFICATIONS OF ADE

• Adverse Drug Reaction (ADR) Any response to
  a drug that is noxious and unintended and that
  occurs at doses normally used in humans for
  prophylaxis, diagnosis, or therapy of disease
• Medication Error Any preventable drug event
  that may cause or lead to inappropriate
  medication use or patient harm
• Therapeutic Failure
• A suboptimal response to drug therapy

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ADE CLASSIFICATIONS (CONT.)

• Adverse Drug Withdrawal Event (ADWE)
• A noxious or unintended response that
  occurs when a drug is discontinued (eg,
  benzodiazepines withdrawal, rebound hypertension
  with abrupt discontinuation of clonidine
• Accidental/Intentional Overdose
• A drug event due to a supratherapeutic level
  of a drug, either accidental (childhood
  poisoning) or intentional (suicide attempt)

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INTERVENTION TO RESOLVE PATIENTS DRUG THERAPY
PROBLEM

• The dose of azathioprine should be reduced by
  25-50
• Azathioprine dosing should also be reduced in
  patients that have a renal insufficiency
• Azathioprine ½ life elimination Parent drug
  12 minutes
• 6-MP 0.7-3hrs
• May be taken with food,3 hrs difference at least
  between azathioprine and allopurinol

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CLASSIFICATION OF ADR

• Type I Augmented reactions Related to
  pharmacologic effects eg hypoglycemic
  coma from insulin hypoprothrombinemia
  from warfarin 80-85 of all ADRs, considered
  predictable
• Type II Bizarre reactions Related to
  hypersensitivity or immune mediated
  reactions 15-20 of all ADRs, considered
  unpredictable

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ADEs HEALTH CARE SETTINGS

• A Community
• 18 of patients experience an ADE
• More than 50 of office visits due to ADEs are
  preventable
• 1.7-28 of ED visits are related to medication
  mismanagement (70 are preventable)
• 5-10 of all hospitals admissions are related to
  ADEs
• 1/3 of drug related hospitalizations involve
  patient noncompliance issues

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CONT.

• B. Hospitals
• 10-30 of hospitalized patients experience an
  ADE, 1-3 significant
• Each ADE costs approximately 5000
• 30-50 of ADEs in hospitalized patients are
  preventable

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CONT.

• C. Long-term Care
• 1.89 ADEs per 100 residents occur
• More than 50 of ADEs are preventable
• Polypharmacy The average number of medications
  taken by elderly patients 5-8 per day
• The ADE rate among patients receiving 1-3 drugs
  6
• More than 6 drugs the rate is 52

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ADEs STATISTICS

• Warfarin 95
• Antidiabetic agents 94
• NSAIDs 89
• Digoxin 82
• Antiepileptic drugs 69
• Inadequate monitoring of drug therapy 67
• Inappropriate dose 51
• Patient compliance 33
• Drug-drug interaction 26
• Contraindication 3
• Allergy 1

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CONCLUSION

• THE ANNUAL COST OF DRUG- RELATED MORBIDITY AND
  MORTALITY EXCEEDS 136 BILLION

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