Medication Review

Medication Review

Content

•       Role of medication review in patient care

•       Components of medication review

•       Types of drug related problems

Objective

After completion of this session, student will be able to:

•       Explain the role of medication review in patient care

•       Outline the components of medication review

•       List the types of drug related problems

Introduction

•       Medication review involves review of a patients medication regimen to ensure that therapy is safe, appropriate, efficacious and cost effective

•       This can be achieved by pharmacists attending ward rounds on a day-to-day basic and applying their knowledge of therapeutics

Goal of Medication review

•       Optimize drug therapy and patient health outcome by identifying and solving drug-related problems and

•       Ensuring that all therapeutic objectives are being achieved

Significance of Medication Review

Daily review enables

a)      Assess whether desired therapeutic outcomes are being achieved

b)      Monitor for drug related problems

c)       Ensure rational and quality use of medicines

d)      Assess patient compliance

e)      Assess the completeness of medication charts

Components of Medication Review

•       Medication order review/ Treatment chart review

•       Clinical review/ Daily progress review

•       Detection and management of ADRs

Medication order review (MOR)

•       It is a systematic review of a patients drug therapy to ensure that the prescribed medication is appropriate for the patient

•       This involves the assessment of all current and recent medication orders, including routine medication and OTC and use of other systems

Goal of MOR

•       To optimize the patients drug therapy by ensuring that patients receive the right drug, dose and dosage form for the right duration

Steps in MOR

•       Collection and interpretation of patient-specific information

•       Assessment of therapeutic goals

•       Identification of drug related problems

•       Individualizing medication regimens

•       Monitoring of treatment outcomes

•       Medication chart endorsement

•       Documentation 

Collection and interpretation of patient-specific information

1. Patients demographics
2. Social history
3. Presenting complaints
4. Past medical history
5. Allergy and sensitivity status
6. Current and recent medication
7. Lab investigations

Sources

•       Patient

•       Case notes

•       Observational charts

•       Lab results &

•       Discussions with medical and nursing staff

Medication history interview

•       Sometimes medical staff may collect incomplete or inaccurate information about drugs

•       Medication history interview (MHI) is defined as obtaining accurate information on patients’ medication use that may assist in the overall healthcare of the patient

Goal

• The ultimate goal of medication history interview is to individualize the medication order to ensure the rational drug use. This can be achieved by:

§  Gathering the accurate and relevant information on medication use

§  Comparing the obtained information with the information collected by the other healthcare professionals  (medication reconciliation)

Significance 

It enables the pharmacists to:

§  Establish the rapport with the patient

§  Explain their role in the patient management

§  Conduct preliminary medication counseling

§  Plan the ongoing patient management / pharmaceutical care

Aspects to be assessed

·         History of previous allergies and/or ADRs

·         Indication / purpose of drug use

·         Dosing regimen

·         Perceived efficacy of each drug

·         Perceived side-effects/ allergies to medicine

·         Adherence to drug regimen

·         Potential drug – drug or drug food interactions

·         Drug administration techniques

·         Use of medication aids

·         Use of prescription and /or non-prescription medications

·         Specific problems relating to medication use

·         Immunisation status (if relevant)

·         Possibility of pregnancy in women of childbearing age

·         Social drug use (alcohol, tobacco, pan masala etc)

·         Evidence of drug abuse

·         General attitudes towards illness and medication use

·         Treatment with other system of medicines (e.g., Ayurveda, Siddha and Unani)

Assessment of therapeutic goals

•       Cure of the disease

•       Reduction/elimination of signs and symptoms

•       Arresting or slowing disease progression

•       Preventing disease/symptoms

•       These goals should be tailored to the patients individual circumstances and may differ from patient to patient

Identification of drug related problems

•       A drug related problem is an event or circumstance involving drug treatment that interferes with patient achieving optimum outcome of medical care

•       Eight categories of drug related problems were outlined

Drug related problems

1. Untreated indication
2. Improper drug selection
3. Subtherapeutic dose
4. Overdosage
5. ADRs
6. Failure to receive drugs
7. Drug interactions
8. Drug use without indication

Individualisation

Individualising Medication Regimens

•       This is important for patients with chronic diseases who are on many drugs on a long term basis

•       The main aim is to simply the regimen as much possible and to adjust the regimen for long term medication adherence

These include

•       Switching to slow release formulations of same drug

•       Using a different route of administration

•       Changing the time at which doses are taken

•       Switching to cheaper but effective and safe medication

•       Combination formulation to replace two drugs

Monitoring of Treatment Outcome

•       This is the key to assess whether the therapeutic goals of drug treatment have been achieved

Involves review of

• Patients clinical status,
• Laboratory data
• Other markers of drug therapy response

Disease or condition	Some common outcome parameters
IHD/Angina	Occurrence of angina/B.P/Heart rate
DM II	Blood glucose levels, Body weight,HbA1c
Acute Gout	Uric acid levels,Pain,Redness

Medication Chart Endorsement

Medication Chart Endorsement

•       Chart endorsement is one of the primary responsibilities of the pharmacist in ensuring that medication orders are unambiguous, legible and complete

•       It is important to avoid medication errors

Examples

•       Is the identity of the patient (name and medication chart) on each medication chart?

•       Is the allergy status of the patient documented?

•       Is the medication name clear? (AZT)

•       Is the drug prescribed by the generic name?

•       Is the dose clear? (units)

•       Is the route, time and date of administration clear?

•       Is a minimal dose interval stated? (paracetamol)

•       Are additional dose administration instructions given when appropriate? (Aspirin)

•       Is there any over writing?

•       Has the medication chart signed by a nurse each time a dose was due?

Documentation

•       The pharmaceutical care provided by the pharmacist should be an integral part of the patients medical record

Daily progress review/Clinical review

•       Clinical review is the review of the patients  progress for the purpose of assessing therapeutic outcome

•       Should be performed on daily basis

Goals

•       Assess the response to drug treatment

•       Evaluate the safety of the treatment regimen

•       Assess the progress of the disease and the need for any change in therapy

•       Assess the need for monitoring, if any

•       Assess the convenience of therapy

Procedure

•       It should be done daily for all the patient

•       It is carried out every day by attending ward rounds

•       To evaluate patients response, we need to review biochemical, hematological, microbiological and other investigations

Sources

1. Case notes
2. Observational charts
3. Discussion with patient and health care professionals

•       This data should be interpreted to assess whether or not progress is being made towards the targeted objectives

Summary

•       MOR is a systematic review of a patients drug therapy to ensure that the prescribed medication is appropriate for the patient

•       MHI is defined as obtaining accurate information on patients’ medication use that may assist in the overall healthcare of the patient

•       Clinical review is the review of the patients  progress for the purpose of assessing therapeutic outcome

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