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					             Respiratory Pharmacy & the Ward
                   Pharmacist experience
                                                        by
                                Abdol Malek bin Abd Aziz, MSc
                               Respiratory pharmacy
• Emphasis on pharmaceutical care of respiratory patients
plus
• Other conditions that the patient is concurrently suffering
                              Respiratory Pharmacy
                              NHMS 1996 - Findings
•   High percentage (62.4%) not on inhalers
•   Mild asthmatics: 65.3%
•   Moderate : 52.1%
•   Severe : 23.7%
                            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)

                   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
                                     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

                       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.




                                      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
                                     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.

                                     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
                        Pharmacist‟s roles
•
  Check compliance – 56% noncompliance rate1
• Check usage of medications for other illnesses, OTC products,
  GP‟s drugs, etc
• Dispels myths about asthma and inhaler use
• Encourage asthma action plan
                              Objective
• To have an influence on prescribing and related
  clinical practice
                           How to start?
• Ward pharmacy

• then

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

                    Ward rounds
• Consultant‟s rounds: already have a high level
  of interest in optimising drug therapy

• Vigilant on ADR and side effects
                   Preparation before rounds
• Very, very important
• May take an hour or more initially

Objective:
‡ to anticipate areas where information is likely to be requested
‡ To identify topics for discussion



• Becoming prepared

              provides…

                                                             Confidence
                                  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
                            Things to do…
• Estimate creatinine clearance ClCr 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
                         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
                      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
        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
                    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
                                      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
                 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.

                                      Specialisation
•   Extra qualifications preferable
•   Sometimes not necessary
•   MSc, MPharm
•   PhD

• Experience, confidence, way of thinking, networking,
  research-oriented, etc
                                 Specific situations
• Asthma
• Counselling
• Pharmacoherapy issues ie. Drug of choice: â-2 agonists
  (short-acting, long-acting, corticosteroids (inhaled , oral),
• Drug forms: inhalers, oral tablets, nebs
                                         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

                         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.



                                                      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.

                                              COPD
                                          C.O.P.D.-X Plan
• C = Confirm diagnosis, severity, complications
• O = Optimise patient function (impairment, disability and
  handicap)
• P = Prevent deterioration
• D = Develop self-monitoring and self-management care plan
• X = guide for managing exacerbations
                                            C….confirm...
• Exclude asthma, cardiac disease etc
• Assess severity
• Assess reversible components
• Identify complications and co-existing conditions
    – history, examination, spirometry, xray chest, FBE
                           O….optimise….
    – Smoking cessation
    – Optimise drugs
      • safe and effective - don’t over-prescribe
    – Treat complications
    – Optimise psychosocial issues
    – Optimise nutrition (consider dietician)
    – Encourage exercise (consider physio gym)
    – Pulmonary rehabilitation
    – Lung reduction surgery or transplantation
                            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
                            P….prevent….
    – Check for complications & concurrent conditions
      • osteoporosis, depression, cor pulmonale, OSA/hypoventilation
    – Consider oxygen if hypoxaemic
    – Regular review
      • lung function
                   D….discuss, develop….
•   Educate patient and carers
•   Pulmonary 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
                       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)
                      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

                    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
                    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…}
          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”
                               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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