CLINICAL PHARMACY

PRACTICE
(PND 501)
Dr. Nashwa Fouad
Pharm D, BCPS, Senior Clinical Pharmacist at AMUH.

Faculty of Pharmacy
Pharos University
2024/2025
COURSE OUTLINE

1- Therapeutic planning, MTM and assessment of dosing, Administration and

compliance.
2- Principles of Special care population (Geriatrics)
3- Principles of Special care population (Pediatrics)
4- Principles of Special care population (Pregnancy)
5- Oncology supportive care.
6- Principles of management of blood disorders.
 LET’S GO IN A JOURNEY WITH A.M

A. M is 55-year-old female with a history of Rheumatoid Arthritis (RA), Type 2 Diabetes
Mellitus, Hypertension, and Hyperlipidemia.

Primary Complaints: Joint pain, stiffness, and recent flares of RA despite her current
medication regimen.
She works as an accountant. Non-smoker, and struggles with weight management.
Her Medical History:
 Rheumatoid Arthritis: Diagnosed 12 years ago, currently on Methotrexate, but with
suboptimal control of symptoms.
 Type 2 Diabetes: Diagnosed 8 years ago, on insulin therapy.
 Hypertension: Diagnosed 10 years ago, controlled with antihypertensive medications.
 Hyperlipidemia: Diagnosed 5 years ago, previously controlled on statin therapy.

Her current medications:

Methotrexate 15 mg once weekly, Prednisone 5 mg daily, Insulin Glargine once daily at
bedtime, Lisinopril 20 mg once daily, and Atorvastatin 40 mg once daily.
Clinical Examination
 Vitals: BP 142/90 mmHg, BMI 31 (obese category).
 Physical Exam: Bilateral swelling in hands, knees, and ankles. Reduced range of motion in
fingers and knees.

Lab Findings:
 HbA1C: 8.5% (above target)
 Rheumatoid Factor: Positive, with elevated inflammatory markers (CRP and ESR)
 Lipid Profile: LDL 160 mg/dL (elevated)
 X-ray: Shows joint space narrowing and early erosions in the hands and wrists.
 MULTIDISCIPLINARY TEAM
(PHYSICIAN, CLINICAL PHARMACIST, SPECIALIZED PHYSICIANS)
Management Plan:
1- Rheumatoid Arthritis:
 Switch to Adalimumab (Humira): Biologic therapy, 40 mg subcutaneous injection every 2
weeks.

 Adalimumab is a TNF inhibitor, often used when Methotrexate alone is not sufficient for
RA control.
 Continue Methotrexate to reduce potential antibody formation against Adalimumab.
 Discontinue Prednisone after the initiation of Adalimumab if the patient shows improvement to
reduce steroid-related side effects.
2- Diabetes:
 Switch from insulin glargine to Insulin Degludec (Tresiba), a longer-acting insulin with a more
stable glucose control profile, dosed once daily based on blood glucose levels.
3- Hyperlipidemia:
 Add Evolocumab (Repatha), a PCSK9 inhibitor administered as a subcutaneous injection
every 2 weeks to lower LDL cholesterol levels significantly for patients who are not reaching
target with statins alone.
4- Lifestyle Adjustments:
 Diabetes management: Low-carb diet and increased physical activity tailored to her joint
limitations.
 RA-specific exercises: Physical therapy to maintain joint flexibility and reduce stiffness.
AFTER THREE MONTHS:

A.M case worsen badly!!

What happened?!
 DID YOU DISCUSS THE FOLLOWING?:

 Cost and Access: Discuss the financial burden of biologic and specialty medications and
explore assistance programs.
 Polypharmacy Management: Consider drug-drug interactions, especially as the patient is on
medications affecting the immune system, lipid metabolism, and glucose control.

 Patient Monitoring: Highlight the importance of regular lab checks for RA markers, lipids, and
kidney function to monitor the efficacy and safety of high-cost medications.
 S.C administration Adalimumab. (is there a problem with S.C injection for the patient?)
 DID YOU DISCUSS THE FOLLOWING?:

 Educate on the proper administration of Adalimumab and Evolocumab injections, side effects,
and the importance of adherence.

 Discuss the risks of immunosuppression with Adalimumab, emphasizing the need to avoid
infections.

 Emphasize the importance of monitoring blood sugar level with insulin therapy adjustments,
especially as RA medications may influence glucose levels.
 HERE COMES THE RULE OF MTM
WHAT IS MTM?
Medication Therapy Management (MTM) is pharmaceutical care service:
Patient-centered service provided by pharmacists and qualified health-care professionals that
include a comprehensive review of a patient’s medications to determine:
Appropriateness, safety, and efficacy.
It’s goal is to optimize drug therapy and improve therapeutic outcomes for patients.

MTM empower patients to take an active role in managing their medications.

 ROLE OF MTM:

 Performing patient assessment and a comprehensive medication review (prescription, over-the-

counter, vitamins, etc).
 Formulating a medication treatment plan, monitoring efficacy and safety of medication therapy.

 Enhancing medication adherence through patient empowerment and education: (Provide the
patient with educational material and resources).
 Documenting and communicating patient’s physician as needed for recommendation.
 AS A PATIENT; HOW WOULD YOU BENEFIT
FROM MTM SERVICE?

1- Make sure your medications are safe. (dose, interactions, duplications, side effect,
affordability, ability to follow up).
2- Help support and answer your questions: medications, health conditions.
3- Cost saving.
4- Empowers you to take an active role in managing your medications.
 THE 5 CORE ELEMENTS OF AN MTM SERVICE
MODEL IN PHARMACY PRACTICE:
1- Medication Therapy Review (MTR)
2- Personal Medication Record (PMR)
3- Medication-related Action Plan (MAP)
4- Intervention and/or referral.
5- Documentation and follow-up
 1- MEDICATION THERAPY REVIEW
(MTR)
IS A SYSTEMATIC PROCESS OF:
 Collecting patient-specific information.
 Assessing medication therapies to identify medication-related problems.
 Developing a prioritized list of medication-related problems, creating a plan to
resolve them.
1- Medication Therapy Review (MTR):
Comprehensive (overall patient problems) or Targeted (Specific problem)
Preferably face-to-face.
Interview patient to gather data, medication history, and general health:
(a) Patient’s overall health, (b)Patient’s values, preferences, goals, and quality of life
(c)Cultural issues, education level, and language barriers, (d)Laboratory values and vital signs
(e)Medication-related problems:
 Adverse events, Appropriateness of each medication, Adherence to therapy, Untreated
conditions, Costs and access to medications and health care, Duplication of therapy.
Develop a plan for each problem identified, and provide patient education.
Which is the Result of MTR.
 2- PERSONAL MEDICATION RECORD
(PMR)
 Comprehensive record of the patient’s medications including; herbal products, over-the-
counter medications, and other dietary supplements.

 Intended for patients to use in medication self-management.

 Collaborative effort among patients, pharmacists, and other health care professionals.
 2- PERSONAL MEDICATION RECORD
(PMR)
 An updated PMR should be created with any medication change.
 May include the following:
(a) Patient name, date of birth, and telephone number.
(b) Name and telephone number of physicians and pharmacy or pharmacies
(c) Allergies
(d) Medication information: Medication name, dose, indication, instructions for use, start and
stop date, ordering prescriber, and special instructions.
 3- MEDICATION-RELATED ACTION
PLAN (MAP)
 Patient-centric document containing a list of actions for the patient to use in tracking progress
for self-management.
 Critical component of MTM.
 Collaborative effort between the patient and the pharmacist
 Includes only information the patient can act on and is within the pharmacist’s scope of
practice or agreed on by relevant health care team members.
 The MAP, in conjugation with education, encourages the patient’s active participation in the
health care plan.
 4- INTERVENTION AND/OR
REFERRAL.
 The pharmacist provides consultative services and intervenes to address medication-related
problems; when necessary, the pharmacist refers the patient to a physician or other health care
professionals.

 The intent of this core element is to optimize medication use, enhance continuity of care, and
encourage patients to use health care services to prevent future adverse events.
 EXAMPLES OF CIRCUMSTANCES THAT
MAY REQUIRE REFERRAL:
 A patient may exhibit potential problems discovered during the MTR that may necessitate
referral for evaluation and diagnosis.
 A patient may require disease management education to help him manage chronic disease such
as diabetes.
 A patient may require monitoring for high-risk medications (eg. Warfarin, phenytoin,
methotrexate)
 A patient had Dry cough side effect from ACEI therapy.
 5- DOCUMENTATION AND
FOLLOW-UP
 MTM services are documented in a consistent manner, and follow-up visits are scheduled
depending on the patient’s medication-related needs or if the patient is transitioning from one
care setting to another.

 Documentation is an essential element of the MTM service model, the pharmacist documents
services and interventions performed in a manner appropriate for evaluating patient progress.

 Write what you do and do what you write.

 BENEFITS OF MTM
(REMEMBER A.M)
1- Improved health outcomes including, a reduction in hemoglobin A1C (A1C), blood pressure,
and lipid profile values, rheumatoid arthritis symptoms.
2- Reduction in overall health care expenditure.
3- Improved medication adherence.
4- Decreased hospitalizations and emergency department (ED) visits.
5- Accurate and appropriate medication use.
6- Patient achievement of health-related goal.
7- Tailor medication therapy the suits each patient individually.
WHAT DO YOU KNOW ABOUT AMBULATORY
PHARMACY?
 CASE 1:
A patient has been referred to the pharmacist for albuterol inhaler and spacer technique education.
Which best describes the pharmacist’s responsibility as part of pharmaceutical care?

A. Inform the patient’s physician that the patient received inhaler technique education.
B. Call the patient in 1 week to remind him or her to use the inhaler with the spacer.
C. Ensure that the patient thoroughly understands the inhaler technique before leaving the visit.
D. Document your interaction in a file for your personal use, should the patient return to you for additional
education.
 QUESTION 2:

Which of the following statements about PMR is true?

A. The PMR never needs to be updated.

B. The patient should keep the PMR private and not share it with other healthcare providers.
C. The PMR should include only prescription medications.
D. The PMR is designed as a tool to help patients self-manage their medication.