Pharmaceutical Care - CPAN WORLD

HEALTH SUPPLY CHAINS IMPACT ON MEDICATION COMPLIANCE

CPAN admin — Thu, 04 Feb 2021 15:39:59 +0000

By Nathan Ohiomokhare.

Many a time the challenge health care providers face all over the world in is the patients lack of compliance with medication therapy regimens as agreed with prescriber. Various research have been done on medication compliance which is a major topic within the pharmaceutical care space. Several reasons are documented for patients non compliance.

Compliance issues are commonly faced by patients who are on medications for short term treatment of curable diseases such as infectious diseases - hypercholesteremia, Malaria, Typhoid, or for life long illnesses that are managed such as Diabetes, Phaechromocytoma, Hypertension, Congestive heart Failure, etc. During the process of dispensing and counseling patients on their medication the Pharmacist usually requests for information on previous medication being taken and compliance to the medication especially if it is a refill prescription. When the Pharmacist identifies a lack of compliance an inquiry is made as to reasons for non compliance. Excuses normally given by patients for not being able to follow medication regimen include:

1) Cost -drug is not affordable or there was an upward market review of the price.
2) Side Effects - the drug causes more discomfort than the patient can tolerate.
3) Forgetfulness - normally the patient forgets to take or apply a particular dose resulting in some missed doses.
4) Communication - patient was inadequately counseled and so did not fully understand how to use medication as well as the importance of the medication.
5) Concerns about Privacy - HIV positive patients on ARVs usually make this complaint related ti stigma and so have to travel long distances avoiding their nearest pickup location for bimonthly refills of prescriptions. When transportation affordability becomes a problem compliance becomes an issue.

Interestingly while looking at the available literature from the United states and Europe the reason of "availability with the medicine" (i.e patient could not find the drug in a Pharmacy) is not indicated as one of the common reasons for poor medication compliance. Rather such reason seems to be more common in the African setting.

One of the commonest excuses given by patients for non compliance is that the medicine was not accessible. Further drill down into this excuse will break the lack of accessibility to :

a) The medication is not affordable to the patient
b) Patient could not find the medication in any Pharmacy outlet.
c) Patient can not find the recommended brand or generic form.
d) The patient doubted the genuineness/authenticity or the brand seen.

This is a Health supply chain challenge. Research shows that health supply chain interruptions have a direct Compliance, Pharmacoepidemiological and Pharmacoeconomic impact on the patience medication therapy and National treatment planning. The specifics are :

1)It affects the patients ability to afford the drug. Scarcity increases value (Basic economics).
3) It impacts health supply chain data negatively by causing inaccuracy in drug consumption patterns across populations.
4) It impacts health planning at the facility, state and national level by its effect on (3) above.
5) It affects patients trust and confidence in the health system.
6) It compels Physicians to prescribe less desirable alternatives
7) It exposes patients to less efficacious or more expensive alternatives.
8) It increases the overall cost of the patients access to treatment.
9) It increases the overall cost of healthcare to the system.

Health Supply Chain expertise is important to patient medication compliance because it operates on the principle of bridging the gap between the drug and the patient. It is the movement of the drug product from the point of origin to the last mile where it is consumed. It involves several robust components such as manufacturing, inventory Management, Information management, distribution (logistics transportation), warehousing and service points or point of care.

A Supply chain that is well planned and working optimally will bring the right drug at the right quality from the manufacturer to the patient at the right location, the right time, in the right condition, at the right price. This is the concept of the 6 rights that serves as the fulcrum of Health Logistics and Supply chain management. They must be guaranteed and are non negotiable just like the fundamental human rights of an individual.

An example is HIV treatment drugs known as ARVs (Anti retroVirals) which are used extensively and in different Fixed Dose Combinations (FDC) in HAART (Highly Active Anti Retroviral Treatment). A cardinal principle being that treatment with ARVs can not be interrupted as the consequences are huge and ranges from drug resistance and cross resistance, treatment failure to death. Same goes for Tuberculosis (TB). I personally experienced the impact of supply chain interruptions on HIV positive patients who were meant to refill bimonthly supplies of ARV FDCs at the Special Treatment Clinic. Patients on regimens that had Lopinavir as part of the combination had issues because the drug was out of stock for almost 3 months. This was because Lopinavir had been touted as one of the Antiviral drugs effective against the nCovid-19 Virus. Consequently this caused an instant shortage of the drug as the main source China stopped exporting it and National governments started redirecting remaining supplies in stock towards managing Covid-19 treatment in Isolation centers. There was a national shortage in Nigeria. We were helpless in the treatment clinic. One patient even told me she had gone without the drug for the second month running and it was part of a second line regimen recommended for her since the first line FDC had failed due to resistance. All I had to give at that point was empathy. It was almost a month later that I saw on a friends status who is a warehouse manager at GHSC-PSM that Chemonics had been able to secure fresh supplies of Lopinavir for the country.

The above are ample reasons public health experts and health policy makes in the executive arms of government and legislature should prioritize optimizing and integrating Pharmaceutical supply chains in both private and public sectors nationwide towards maximizing utilization of funds and reducing the overal cost of healthcare.

References

Cennimo D.J, 2020, What is the role of the antivirals lopinavir/ritonavir in the treatment of coronavirus disease 2019 (COVID-19)?, Medsacpe, accessed at url https://www.medscape.com/answers/2500114-197452/what-is-the-role-of-the-antivirals-lopinavirritonavir-in-the-treatment-of-coronavirus-disease-2019-covid-19 on 4th February 2021.

McGrail S, 2020, Fundamentals of Pharmaceutical Supply Chain, Supply Chain News, Pharmanews intelligence, Xtellingent Healthcare Media, accessed at https://pharmanewsintel.com/news/fundamentals-of-the-pharmaceutical-supply-chain on 4th February 2021.

Ross M, What is Medication Compliance: 5 Things Providers Should Know, Medication Compliance, Cureatr (Comprehensive Medication Management), Accessed at url https://blog.cureatr.com/what-is-medication-compliance-5-things-providers-should-know on 4th February 2021.

Resnick R, 2018, How Medication Compliance Affects Patient Outcomes, Cureatr (Comprehensive Medication Management), accessed at https://blog.cureatr.com/how-medication-compliance-affects-patient-outcomes on 4th February 2021

The post HEALTH SUPPLY CHAINS IMPACT ON MEDICATION COMPLIANCE first appeared on CPAN WORLD.

WHY DOES SHE LIKE THE PEDIATRIC PHARMACEUTICAL CARE SPECIALTY.

CPAN admin — Sat, 16 Jan 2021 16:47:42 +0000

By Nathan Ohiomokhare

Last year before the lockdown during a brief visit to Benin I visited a close friend, colleague and former classmate at the University Of Benin Teaching Hospital. She is a Deputy Director at the hospital and unit head at the Paediatrics Pharmacy Unit. One of the many things we talked about was the evolution of Clinical Pharmacy practice and inpatient Pharmaceutical care management. She spoke so passionately about her pediatrics unit and displayed a vast knowledge of drug therapy management in various pediatric conditions and then she expressed a need. She wished there is a specialty course in Pediatric Pharmaceutical care she could attend. I was so proud of her passion for Pediatric Pharmaceutical care. I recomended she check with one of the special centers between College of Medicine and Faculty of Pharmacy UNIBEN maybe they might point her in the right direction. Though I had never heard of any in Nigeria she may eventually need to do the certification online or abroad.

Pediatric Pharmaceutical care is a Clinical Pharmacy specialty that basicaly narrows down medication therapy management to specific age range of 0 to 12 years. Opara 2020 et al'., describes it as Pharmaceutical care in a heterogenous group with infants ageing from birth to 1 year and Children 1 to 12 years, and also includes neonates ageing from birth to 4 weeks and preterm babies. It is the provision of drug therapy (Pharmacotherapy) management to this specific age group based on their anatomical and physiologic peculiarities (age, body mass, organs at various stages of development and maturity, disease condition, genetic predisposition, pharmacodynamics and intersubject variability) with the ultimate purpose of achieving definite outcomes that improve quality of life. In plain English "you dont manage drug therapy for children the same way you manage for adults"

It explores dosage administrations and routes of administration based or peculiarities and disease conditions in children at various developmental stages.

Pediatric Pharmaceutical care is necessary because though studies show that Nigeria has ample supply of medications for primary care use, there is a deficiency of pediatric dosage forms for prescription only medications used for secondary and tetiary care. Consequently extemporanous reconstitution of prescribed medicines in the Pharmacy becomes necessary. Recostitution of pediatric medications is a highly sensitive but commonly overlooked area. Hospitals which take it seriously have had to locate a Pediatric Pharmaceutical Care unit within the Special Care Baby Unit (SCBU) and/or the Paediatrics Unit.

The American Society of Health-System
Pharmacists and the Pediatric Pharmacy Advocacy Group in 2018 published a gudeline titled "ASHP–PPAG Guidelines for Providing Pediatric Pharmacy Services in Hospitals and Health Systems" to guide Clinical Pharmacists in meeting the special needs of the pediatric population. This underscores the importance of Pediatric Pharmaceutical Care as a specialty in Hospital Pharmacy practice. This is because studies show the pediatric population is a more vulnerable group to Adverse Drug Reactions (ADRs) than the adult population, exhibit higher variability in Pharmacokinetic and pharmacodynamic profiles of drugs and have pharmacogenetic variations such as Glucose-6-phosphate dehydrogenase(G6PD) deficiency, short gut syndrome and lactose intolerance. There is also a lesser tendency for recipients to report ADRs either because they are too young to recognise the injury(children), are too young to communicate (Babies) or are not being monitored by a vigilant caregiver. Pediatric Pharmaceutical care specialty is important because many drugs that are safe for adults are not safe for children.

There is even the school of thought which intends to include unborn children in pediatric pharmaceutical care by trying to prevent genetic anomalies or irreversible damage to the unborn baby as a result of substances consumed by the mother during pregnancy. For example, an eight month pregnant mother taking Tetracycline capsules as antibiotic treatment for her infective cough will likely cause bone distortion in the child as a result of calcium/phosphorus chelation and Dental dysplasia (brownish/yellow coloring of teeth). There is neonatal death due to chloramohenicol induced "grey baby" syndrome and Kernicterus from taking Sulphonamides. So should this be included in paediatric pharmaceutical care or left to the OBGYN?

A recent study by Tareq 2017' et al'., insists that Pharmacists must have a baseline knowledge of Pharmaceutical care in pediatrics not only for the purpose of councelling care givers but also for dosage form reconstitution and inpatient interventions to correct medication errors that could result in ADRs (Adverse Drug Reactions) or suboptimal dosing.

For example, at the National Hospital Abuja in Nigerias Federal Capital Territory the Pediatric Pharmacy unit is tasked with the responsibility of carrying out interventions. The Clinical Pharmacists :

- recomend dose adjustments where necessary,
- proactively intercept medication errors during prescription review and revert back to prescriber, (dosage calculation errors are known to be the most common sources of medication error)
- Track patient adherence and persistence,
- identify drug therapy problems based on known classifications, and
- take appropriate action where necessary
- educate parents and children themselves.

In all these clinical pharmacokinetic parameters such as age, weight, Body Mass Index(BMI), Renal function, Cardiovascular impairments, Drug elimination rates, Bioavailability, Volume of Distribution etc are considered. The pharmacist actually takes a wholistic picture of the situation and arrives at a care plan which will also involve the patients parents or care givers upon discharge. This is all done in collaboration with the entire inpatient management team at the hospital. Nurses are very fond of crosschecking and reviewing medication administration plans with the pharmacist and it is not uncommon for them to frequently seek clarification for routes and modes of administration. Post discharge the parents or caregivers also maintain close collaboration with the pharmacists and report on progress and any unwanted effects observed. Communication is maintained effectively via phone and wattsap chats which also enable sending photos and screen shots as visual aids.

In Pediatric Pharmaceutical care one thing is most improtant, VIGILANCE. Its simple, the Pharmacist must remain vigilant in prescription review, extemporaneous preparation or precribed medication reconstitution, medication administration, patient/care giver counceling and ADR monitoring. Hence Pharmacovigilance within the pediatric inpatient unit takes a different dimension. The Pharmacist is aware of common drug related problems identified with specific medicines and takes measures to look out for them.

Pharmacists should realise that after discharge and the patient becomes an outpatient the larger burden subsequently lies on the pharmacist who will be frequently contacted by the childs caregivers for clarification on various drug related issues.

Picture this : For a drug like Digoxin the optimal dose for a Baby may instantly kill an adult. We all observe that children are prescribed lower doses than adults. But do you know that children actually require higher drug doses than adults? Doses are determined on a milligram per kilogram (mg/kg) body weight basis. Anyways, that is a story for another day.

Let me know your thoughts by droping your comments below. As men of honour………!

References :

American Society of Health-System
Pharmacists, Inc., and the Pediatric Pharmacy Advocacy Group, 2018, ASHP–PPAG guidelines for providing pediatric pharmacy services in hospitals and health psystems. Am J Health-Syst Pharm. 2018; 75:1151–65.

Enato E, 2020, lecture notes, Sukthankar V, Individualization of dosage regimen, Clinical Pharmacokinetics, Mpharm 2020, Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, University of Benin.

Moles.R, Carter. S, 2028, Pharmaceutical Care in Pediatrics, Springer Link, downloaded at https://link.springer.com/chapter/10.1007/978-3-319-92576-9_31. on 16th January 2021.

Opara A, 2020, lecture notes in Pediatric Pharmaceutical care, Pharmaceutical care, Mpharm 2020, Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, University of Benin.

Tareq L. Mukattash, Anan S. Jarab, […], and James C. McElnay, Pharmaceutical Care in Children, Sultan Qaboos University Medical Journal, downloaded at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6443271/ on 16th January 2021.

The post WHY DOES SHE LIKE THE PEDIATRIC PHARMACEUTICAL CARE SPECIALTY. first appeared on CPAN WORLD.

WHY THE FEDERAL GOVERNMENT OF NIGERIA SHOULD THROW ITS FULL WEIGHT BEHIND CLINICAL PHARMACY & CONSULTANT PHARMACIST CADRE IMPLEMENTATION FOR THE SAKE OF THE HEALTH OF THE NIGERIAN PEOPLE

CPAN admin — Sun, 10 Jan 2021 23:13:07 +0000

Background.

It is no longer news that the health care indices of Nigeria has continued to deteriorate, thereby placing the country at about position 189 out of 191 countries surveyed in recent times. The life expectancy of Nigerians has also been put to about 54 years according to experts , while in some nations like the USA and UK, the average life expectancy is 98 and 97 years respectively. Many experts have attributed these differences between that of Nigeria and those of the nations mentioned to quality health care management by their governments. In those countries, the health care work force is viewed and related to as a real team similar to a football team whereby every player's input really matters for winning or scoring goals.

A onetime director general of World Health Organization in the person of Richardson, stated that: without drugs, a health service is without substance and credibility. This statement by Richardson is due to the fact that drugs(medications) must either be used in the beginning or at the end of almost all health care interventions in the care of the sick and even the healthy. In the same vein, it is important to reemphasize to our leaders that there is only one health care Professional recognized globally who excels on all drug matters than others. That health care Professional is no one other than the pharmacist. The training of Pharmacists at the first degree level is about 6 years or 5 years depending on whether the recipient graduates with doctor of pharmacy or bachelor of pharmacy degree respectively. That rigorous training is all about a unique set of skills that is not a replica of any other health care Professional's training. Hence the specific job that a Pharmacist is designed to do on graduation from the University cannot be done by any other health care Professional. Just equally as Pharmacists cannot do a replica of the job of other health care providers. Furthermore, Pharmacy training and practice extends its roots to other deeper aspects, one of which is known as Clinical Pharmacy.

Clinical Pharmacy is a special area of the Profession dealing with direct (a.k.a bedside) care of Patients. Clinical Pharmacy is recognized globally. Unfortunately, in Nigeria Clinical Pharmacy is yet to be fully recognized and instituted within our health care system. This lack of proper recognition and full implementation of clinical Pharmacy Practice in our health care sector has been at the detriment of the Nigerian health seeking Population, and by implication it has also negatively affected our health indices.

Though the Nigerian National Drug Policy of year 2005 makes reference to the promotion of clinical pharmacy in our health care institutions, together with the recent approval of consultancy Pharmacy Cadre by the national council on establishment, one is yet to see any aggressive implementation of this laudable factor that will hasten our health indices to return to enviable levels.

Should one be tempted to feel that some persons could be playing politics with that? Are we happy with the embarrassing level of medical tourism by Nigerians?

What really have other countries with good health indices done well that Nigeria has not been able to do? That one thing is the full recognition of Clinical Pharmacy Practice and Consultant Pharmacist Cadre implementation.

The following points below will make things clearer to our policy makers and FG so as to give Nigerians the best health care possible for both the sick and even the healthy.

Importance Of Clinical Pharmacy & By Extension Consultant Pharmacist Cadre.

1) Globally, Several Studies have shown that Clinical Pharmacy interventions could improve the economic and Clinical outcomes, playing a significant role in reducing medication errors by prescribers and consumers, reducing readmission rates, reducing length of hospitalizations, and reducing Medication quantity usage and costs.

2) Clinical Pharmacists are the recognized ultimate medication experts who ensure that hospitalized Patients take the right medication, for their diseases, for their age, and help to prevent complex drug interactions when the patient must take several drugs as is commonly seen in many cases. Clinical Pharmacists also provide appropriate drug information to other health care providers, to prevent irrational use of drugs that can result in medication harm and possible death.

Drug treatment is one of the most health care technological advancements. Pharmacists alone are trained and legally saddled to take all responsibilities emanating from drugs usage. As the last defence, the Clinical Pharmacist's expertise prevents medication errors, drug harm, medication confusion, and untimely death due to drug misuse or drug abuse. Pharmacists intervention can help reduce drug abuse in the society and consequently reduction in crime rate. Organ damage, failed health system etc cannot be quantified in monetary terms or values. It is not just fake drugs only that can cause such damage. Genuine drugs too, do create unquantifiable damage when misused by consumers or as oversight errors from other health care providers. It is the global practice to include and remunerate Clinical Pharmacists in the health care team as medication consultants .

While other health care providers such as Physicians focus on diagnosis, Clinical Pharmacists focus on what the drug can, might, or is doing to the Patient positively or negatively.

3) it is important to let the authorities know that Bachelor of Pharmacy degree holders alone who are Pharmacists and work in health care settings do not have the same training as Clinical Pharmacists who have acquired additional training. Clinical Pharmacists have the doctor of pharmacy degree or some other post bachelor degree such as Masters, PhD or Fellowship in Clinical Pharmacy. While Pharmacists with Bachelor's degree are good in handling drugs products expertise, Clinical Pharmacists possess both drug product expertise and direct Patient Care drug expertise at a more advanced level. Many Clinical Pharmacists are also Specialists in different aspects of Patient Care utilizing drugs. This is because no single person can be an expert on drugs for all diseases and all ages, just like someone cannot be a specialist in gynaecology and paediatrics at the same time.

Some of the subspecialties of Clinical Pharmacy include:

i. Oncology Pharmacists

ii. Paediatric Pharmacists

iii. Cardiology Pharmacists

iv. Renal Pharmacists

v. Critical care Pharmacists

vi. Ambulatory care Pharmacists etc,

Just to mention but a few. There is no medical field without a Pharmacist Specialist. It is necessary to always bear in mind that Life lost cannot be replaced, hence the duty of a clinical pharmacist is to ensure that the health care team gets it right the first time and always. Only an expert and most importantly a specialist can attain such a standard. In the interest of public health, both the Federal Government and all other stakeholders in healthcare should join hands towards a speedy and full institutionalization of clinical Pharmacy Practice and Consultant Pharmacist Cadre in all our health care facilities, just as obtainable in countries with quality health indices. This will bring medical tourism, morbidity and untimely death due to drugs misuse and abuse to the barest minimum.

CONCLUSION.

Why recognize Clinical Pharmacy and the Consultant Pharmacist cadre?

1) Clinical pharmacy is the branch of the pharmacy profession in which clinical pharmacists provide direct patient care that ensures the best use of medicines and promotes health, wellness, and disease prevention. Clinical Pharmacists practice in all health care settings by

utilizing and applying their advanced and in-depth knowledge of medications and disease states to manage medication therapy within a multi-professional healthcare team.

2) Clinical pharmacists are responsible and accountable for medication therapy and patients’ therapeutic outcomes. The Consultant pharmacist cadre is an advanced level of career position within the Pharmacy profession and they are leaders of the Pharmacy profession in education, research, and in the delivery of expert pharmaceutical practice.

3) This apex Consultant pharmacist cadre is necessary for the perpetual growth of the Pharmacy profession globally. Recognizing this cadre in-country is a welcome development as it gives the younger cadres in the Pharmacy profession a height of professional learning and practice to look up to.

4) Clinical Pharmacists contribute significantly towards basic healthcare delivery and optimizing healthcare outcomes. Some examples based on documented scientific research evidence are listed hereunder: Optimal medication therapy. Clinical pharmacist’s consultation service improves the effectiveness of treatment for Infectious Diseases and other diseases.

Edited By :

Dr Joseph Madu MCPAN, PharmD, FPCPharm, DCPharm, MAW.

National Chairman,

Clinical Pharmacists Association Of Nigeria.

(https://ejhp.bmj.com/content/ejhpharm/27/3/131.full.pdf);

(https://www.frontiersin.org/articles/10.3389/fphar.2020.575022/full);

(https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/410298).

• Medicines reconciliation and reducing medication discrepancies which

improve healthcare outcomes

(https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0193510);

(https://link.springer.com/article/10.1007/s00520-020-05400-5) and

patients’ length of hospitalization and readmission rate.

(https://link.springer.com/article/10.1007/s11096-020-00972-y).

• Improved patients’ medication adherence: as the experts in drugs and medicines pharmacist‐led interventions have been shown to contribute to improved adherence to medications and better disease control.

(https://onlinelibrary.wiley.com/doi/full/10.1111/ijpp.12462);

(https://onlinelibrary.wiley.com/doi/full/10.1111/jcpt.13126).

(https://onlinelibrary.wiley.com/doi/epdf/10.1111/ijpp.12462).

• Reduced healthcare costs: Clinical Pharmacists Services was associated with significant cost savings and generated positive economic value in the healthcare process. (https://bmjopen.bmj.com/content/bmjopen/10/1/e034862.full.pdf).

The participation of a clinical pharmacist in a multidisciplinary healthcare team reduces healthcare expenditures through the activities of Clinical Pharmacists towards treatment optimization and cost avoidance. (https://onlinelibrary.wiley.com/doi/epdf/10.1111/jcpt.13195).

• Medications Therapy Monitoring (MTM): Pharmacists' intervention during the healthcare process significantly improves medication appropriateness and rational medication use, primarily through medication reviews. Clinical Pharmacists effectively perform this role through skills acquired during advanced specialized training and experience.

(https://www.sciencedirect.com/science/article/abs/pii/S1544319119305217).

• Improved Public Health Services and responses during pandemics such

as COVID-19. (https://www.sciencedirect.com/science/article/pii/S155174112031202X).

• Managed Self-care and Chronic disease management. The integration of

clinical pharmacists into multidisciplinary teams improve the management of chronic diseases such as type 2 diabetes, hypertension, among others. (https://www.pharmacypractice.org/journal/index.php/pp/article/view/2000/834);

• (http://www.scielo.br/scielo.php?script=sci_arttext&pid

The post WHY THE FEDERAL GOVERNMENT OF NIGERIA SHOULD THROW ITS FULL WEIGHT BEHIND CLINICAL PHARMACY & CONSULTANT PHARMACIST CADRE IMPLEMENTATION FOR THE SAKE OF THE HEALTH OF THE NIGERIAN PEOPLE first appeared on CPAN WORLD.