Introduction to individual drug evaluation services

My name is Fan-Hsiu Chao and I am a clinical pharmacist in Taipei Veterans General Hospital. I am going to present to you about Clinical Pharmacy Services.

We will continue on introducing Individual drug evaluation services in clinical services. We also accept on-line Drug Therapy Evaluation Service Requested by physician for in-patient. Subjects may include pharmacokinetic consultation, dosage regimen evaluation, adverse drug reaction evaluation, drug interaction evaluation, medication therapy evaluation, or others specify by physician. Pharmacist will evaluate the medication therapy considering patient diagnosis and specific needs. For example, the physician requests a drug evaluation service for a geriatric patient who is taking digoxin and spironolactone. The pharmacist will evaluate the possible drug interactions between digoxin and spironolactone in regard to serum potassium concentration and patient’s renal function. Then the pharmacist will need to write down the suggestion in pharmacy note format as a final report.

Then physicians can read the report through the electronic medical record system. We found monitoring medication therapy rank almost one fourth of all intervention and dose adjustment were the most frequent intervention by clinical pharmacist. There were other types of intervention, such as therapeutic drug monitoring, adverse drug reaction evaluation, inappropriate choice of medications, insufficient medications, inappropriate frequency, lack of indication, or interaction. Every year, our clinical pharmacists provide about 7,000 interventions for all clinical pharmacy service. Once we have introduced of some of the SOAP, So, we can practice some more SOAP examples. This is a prescribing of a wrong medication case of neomycin in a male who had open wound.

Under subjective, this is a 53-year old male who had motorcycle accident and get some skin abrasions and open wound on his upper arms. Currently, he was giving neomycin 250 mg PO every six hours. Under objective, we found out that he is weighted 70 kilograms, and his serum creatinine was 1.0 mg/dl and his estimated creatinine clearance was about 84 ml/min. You may also want to include the result of blood cell count data. Under assessment, we wrote evaluate the indication of neomycin oral capsule for open wound patient. Under plan, according to package insert, neomycin 250 mg capsule is indicated for bowel sterilization in pre-operation or liver encephalopathy patient.

Therefore, please consider to change to neomycin ointment 0.5% X 1 tub topical applied twice daily. Next, this is a prescribing of a wrong dosage form case of nitrate in a male who is using nasogastric tube. Under subjective, this is a 53-year old male who had old cerebral vascular accident, bed ridden with nasogastric tube and having chest pain. Currently, he was giving Imdur controll-relased form 60 mg PO QD. Under objective, we found out that he was weighted 60 kilograms, and his serum creatinine was 0.8 mg/dl and his estimated creatinine clearance was about 90 ml/min. You may also want to include the result of blood pressure, pulse rate, cardiac enzymes, etc.

Under assessment, we wrote evaluate the appropriateness of controlled-released form of isosorbide mononitrate for nasogastric administration. The controlled-released form of isosorbide mononitrate tablet can be split, but not crush. Once crushed, the delayed-released dosage form will turn into immediate-released form. It is likely to cause overdose and lead to some adverse drug reaction, such as hypotension. Under plan, according to package insert, the controlled-released form of isosorbide mononitrate tablet can be split, but not crush. So, please consider to change to Isormol 20 mg nasogastric twice daily.