Title slide without an image

1. Hospital Pharmacy Tute 3 Title slide without an image

2. Learning Objectives • To understand the pharmacist’s role in monitoring: • the patient’s response to therapy • adverse drug reactions (ADR) • To understand the pharmacist’s use of clinical and biochemical laboratory data to optimise patient health outcomes • To understand the pharmacist’s role in modifying treatment and contributing to clinical decision making in the multidisciplinary healthcare team

3. Learning Outcomes • At the end of this tutorial you should be able to: • Think critically and apply clinical knowledge to optimise medication use (in simple cases) • Understand the role of the pharmacist in monitoring patient response to therapy and adverse drug reactions (ADRs) • Understand the pharmacist’s role in contributing to clinical decision-making in the multidisciplinary healthcare team

4. Clinical Pharmacist inpatient role • Review chart daily • Medication and other charts such as: • IV fluid records • fluid balance chart • general observation chart with temperature, blood pressure • Contribute to prescribing decisions • Choice of drug, dose, route of administration, monitoring requirements • Monitor patient response to therapy • Modify patient therapy based on response and ADRs

5. Monitor patient’s response to therapy • Subjectively: • Question the patient directly • Observe the patient’s clinical status (e.g. oedema, jaundice) • Objectively: • Review measurement charts of • drug concentrations in plasma, urine, cerebrospinal fluid (CSF), bronchial fluid • surrogate markers (e.g. BP, blood glucose)

6. Scenario 3 • Jenny, 60 yo female, with endocarditis • Admitted to General Medical ward after methicillin-resistant Staphylococcus aureus (MRSA) septicaemia • Past medical history • Mitral valve disease • Atrial fibrillation • Hypertension • Ischaemic heart disease • Prescribed vancomycin 750 mg every 12 hours (started 2 April) • also on multiple regular medications: warfarin, perindopril, amiodarone, isosorbide mononitrate

8. Antibiotic therapy via PICC • To be discharged on 4 weeks of vancomycin • Using Hospital in The Home (HITH) program http://health.vic.gov.au/hith/ • Requires a Peripherally Inserted Central Catheter (PICC line) • Activity: 5 mins Discuss HITH & PICC use

9. Group discussion: • What factors may influence Pharmacist’s monitoring decisions in hospital setting? • Understanding of patient’s clinical situation and individual factors • Renal/liver function • Expert knowledge of drug, therapeutics and diseases • Good understanding of physical assessments, lab and diagnostic tests • Access to and knowledge of quality resources

10. Therapeutic Drug Monitoring (TDM) • Provides information to multidisciplinary team to guide treatment decisions • Type of monitoring required depends on • drug pharmacokinetics • patient adherence • Different software available • See various tests at Royal College of Pathologists of Australia http://www.rcpamanual.edu.au/

11. Therapeutic Drug Monitoring (TDM) • Provides information to multidisciplinary team to guide treatment decisions • Type of monitoring required depends on • drug pharmacokinetics • patient adherence • Different software available • Therapeutic Guidelines has quality information • See various tests at Royal College of Pathologists of Australia http://www.rcpamanual.edu.au/

12. Therapeutic Guidelines: Antibiotic

13. Royal College of Pathologists of Australia information for vancomycin

15. Jenny’s laboratory data • 6 April: Vancomycin dose 750mg IV bd • Na 133 mmol/L; K 4.8 mmol/L • eGFR 43 ml/min • WCC 17.8; Neut 12.6 • Serum vancomycin pre-dose (trough) 16.5 mg/L (12 – 18 mg/L) • 9 April: Vancomycin dose of 750 mg IV bd • Na 134 mmol/L; K 3.9 mmol/L • eGFR 44 ml/min • WCC 15.2; Neut 10.5 • Serum vancomycin pre-dose (trough) 28 mg/L (12–18 mg/L)

16. Activity: 10 minutes • What factors can influence vancomycin concentrations? • What would you recommended for Jenny’s vancomycin therapy? • Look online at Therapeutic Guidelines • in PPS use link via All Programs (not library access) • Start menu – All Programs – Therapeutic Guidelines

18. Role of Clinical Pharmacist in TDM • Contribute to monitoring decisions • Advise multidisciplinary healthcare team (doctors, nurses) • when TDM is required and suggest times to take TDM samples • how to interpret TDM results & suggest drug therapy options • eg reduce dose/frequency or possibly change drug • Determine what factors may contribute to unexpected TDM levels • unusual timing of doses • other drug involvement • whether blood is taken through a lumen used by a contaminating agent (blood or other drug) • Other???

20. Case Study • Chan Kang Hong, 73 yo on General Medical ward • admitted for increased shortness of breath,fatigue & ankle swelling • bodyweight: 68 kg (66kg at GP visit 6 months ago) • BP 140/70 mmHg • lab data (4 weeks ago) • urea, creatinine and electrolytes – normal • estimated creatinine clearance – 60 mL/min • Medical history • heart failure diagnosed 1 year ago (LVEF < 40%) after MI • dyslipidaemia • osteoarthritis • stable ischaemic heart disease • hypertension

21. Mr Hong’s current medicines • Perindopril arginine 2.5 mg (started for heart failure) • Aspirin 100 mg once daily • Atorvastatin 20 mg once daily • Celecoxib 200 mg once daily • Isosorbide mononitrate 60 mg CR once daily • Frusemide 20 mg once daily • Paracetamol 1 g four times daily for pain relief

22. Mr Hong moved into a retirement village 6 months ago after his wife died. • An active member of a walking group, but over the last 3 weeks he’s had increased shortness of breath and fatigue after a steady 20-min walk, so he has reduced his physical activity. • He’s also noticed swelling in his ankles despite his usual fluid tablets. • He tells you he’s eating packaged soups instead of regular meals for convenience and is drinking more water than recommended, < 1.5 L/day was recommended after his heart failure diagnosis. • He has missed some medicine doses since his GP visit 6 months ago. • While reviewing his drug therapy, you find he is concerned about his worsening symptoms and unsure how continuing his medicines will help to manage his heart failure.

23. Activity: 20 mins • Remember the SOAP approach to clinical problem solving • List 3 factors that may have exacerbated Mr Hong’s heart failure • How would you modify his existing drug therapy to improve his current condition? • Would you increase the perindopril dose? • List 2 parameters you would monitor if the dose of perindopril was altered • Would you start him on a heart failure specific beta blocker? • List 2 adverse effects that he is likely to experience if started on a heart failure specific beta blocker. How you would manage these side effects?

24. Three factors that may have exacerbated Mr Hong’s heart failure • increased fluid intake • NSAID use • increased salt intake

25. Modifications to existing drug therapy: • Stop or change the NSAID to an alternative analgesic • Increase the frusemide dose • Increase the perindopril dose • Introduce beta blocker • Increase perindopril dose? • increase to the target dose of 5–10 mg daily • List 2 parameters you would monitor if the dose of perindopril was altered • If the dose was increased, monitor Mr Hong’s blood pressure, renal function and electrolytes

26. Starting Mr Hong on a heart failure specific beta blocker? • He should be trialled on a beta blocker, both for secondary prevention of ischaemic heart disease and heart failure • Patients often experience significant side effects and worsening of symptoms when started on a beta blocker. So introduce these agents only when the patient is stable, and then at lowest dose possible and titrate up slowly • Review the patient 1 week after starting the beta blocker. • If the drug is tolerated and the patient is stable, increase the dose after 4 weeks

27. Adverse effects of heart failure specific beta blocker and management • Common adverse effects associated with beta blockers are: • Bradycardia • Hypotension • Initial deterioration of heart failure symptoms • Management strategies: • start at a low dose and increase slowly • maintain the same dose and monitor carefully • reduce the dose or stop the beta blocker

28. Activity: 10 mins • Complete a ‘Report of Suspected ADR’ for Mr Hong, who developed bradycardia and became hypotensive after taking 5mg bisoprolol • Find an electronic copy of the form in the Hospital Tutorial Folder (PAC3362)

29. Strategies to encourage regular medication use • Provide information and education to the patient about: • monitoring of weight, symptoms, diet, medications that can worsen heart failure, appropriate fluid intake and exercise • Use a reminder chart • Simplify the dose • Use a Dose Administration Aid such as a Websterpak • Refer for a home medicines review

30. Two activities: 10 mins • Speak with the doctor about your concerns about Mr Hong’s deteriorating heart failure. • Model the good communication seen in the videos over the series of hospital pharmacy tutorials. 2. Counsel Mr Hong on discharge encouraging him to take his medicines regularly and to manage his heart failure appropriately • Perform these activities in groups of 3–4 • Take turns to role play the doctor/patient, and ask the observer/s for feedback

31. References • SHPA Standards of Practice for Clinical Pharmacy • Clinical Skills for Pharmacists, A Patient-Focused Approach (Tietze, J, ed 3) • Pharmacy Practice Experiences – A Students Handbook (Setlak, P) • Hospital Pharmacy (Stephens, M ed 2) • Medication Review: A Process Guide for Pharmacists (Chen, T et al, ed 2) • Australian Medicines Information Training Workbook (ed 1) • National Prescribing Service Limited. Case study report. Case study 71: Heart failure. Sydney: NPS, January 2012