Pharmacy Technician in Pharmaceutical Care

Introduction to Pharmaceutical Care

Definition of Pharmaceutical Care: The responsible provision of drug therapy intended to achieve specific outcomes that improve a patient’s quality of life. (Source: ASHP Statement on Pharmaceutical Care, Am J Hosp Pharm 1990).
Primary Goals of Pharmaceutical Care: - Curing a Disease: For example, taking antibiotics to cure a bacterial infection. - Elimination/Reduction of Patient’s Symptoms: For example, taking antihypertensives to reduce blood pressure in hypertension. - Slowing of a Disease Process: For example, taking antidiabetics to slow the development of diabetic complications. - Preventing a Disease or Symptoms: For example, taking vaccinations or prophylaxis treatments to prevent influenza.
Pharmaceutical Journey: A drug must reach a targeted "site of action" to modulate biological activities. This involves: - Pharmaceutical Phase: Disintegration of the dosage form. - Pharmacokinetic Phase: Absorption, Distribution, Metabolism, and Excretion (ADME). - Pharmacodynamic Phase: Drug-target interactions and molecular signaling. - Outcomes: Determination of efficacy and safety (Side effects, ADRs, and DDIs).

The Pharmaceutical Care Landscape in Singapore

Healthier SG Initiative: A national initiative focused on preventive healthcare to proactively manage health and prevent chronic diseases. Pharmacies serve as accessible community hubs for all drug-related matters.
Preventive Care Services: Includes health promotion, education, immunization, and screening.
Routine Care Services: Includes interventions, medication dispensing, packaging, and labeling.
Pharmaceutical Care Services: Includes Medication Therapy Management (MTM), chronic disease management, telepharmacy, and smoking cessation clinics.
Levels of Care: - Primary Care: First point of contact (Retail, Community, Polyclinic, and Telepharmacy). - Secondary Care: Collaborative care with GP doctors for specialized services. - Tertiary Care: Specialized medical care (Hospital outpatient/inpatient, clinical pharmacy services, and compounding).

The Dispensing Workflow in Routine Care

Registration (Typist): Receive the prescription ( $Rx$ ) and confirm medication supply.
Intervention: Identify Drug-Related Problems ( $DRPs$ ) or legal issues on the $Rx$ . Contact the doctor to correct errors and document findings.
Packer: Prepare drug labels, verify they make sense, and pack the correct drug, dose, strength, and quantity.
Checker: Physically verify that packed drugs match the label and the $Rx$ system.
Dispensing: Counsel patients regarding the proper use of the drug.

Medication Therapy Management (MTM)

Definition: Service components that empower patients or caregivers to manage medication needs and achieve optimal health outcomes.
Components of MTM: - Medication Reconciliation: Creating the most accurate list of medications the patient is currently taking. - Adherence & Knowledge Assessment: Evaluating how well the patient follows instructions and understands their meds. - Medication Optimization & Clinical Interventions: Resolving potential or actual drug-related problems. - Patient Counseling & Education: Strategy for managing medication issues through communication.
Role of the Pharmacy Technician: Techs are integral to the "Intervention" and "Dispensing" parts of routine care. They specifically: - Identify actual/potential $DRPs$ . - Communicate with prescribers for interventions. - Educate patients on management strategies.

Essential Skills for Pharmacy Technicians

Medication Management Processes: Interpreting $Rx$ , using $eMRs$ , knowledge of healthcare laws, and dispensing workflows.
Pharmacotherapy Knowledge: Evidence-based medicine approach utilizing clinical practice guidelines ( $CPGs$ ), clinical expertise, and patient values.
Pharmacology Knowledge: Understanding generic names, indications, dosing, mechanism of action, and properties (Pharmacokinetics/Pharmacodynamics).
Communication Skills: Documentation and verbal communication with physicians and pharmacy staff.
Interview & Questioning Skills: Using frameworks like SCHOLAR-MAC to obtain patient information.

Pharmacotherapy and Evidence-Based Medicine

Pharmacotherapy: Selection, dosing, administration, and monitoring of medications for optimal therapeutic outcomes.
The Tenets of Pharmacotherapy: - Scientific Evidence: Outcomes from clinical trials, meta-analyses, and systematic reviews found in Clinical Practice Guidelines ( $CPGs$ ). - Clinical Expertise: Applying pharmacology and understanding patient conditions. - Patient Values: Beliefs, lifestyle, financial situation, and treatment goals.
Pharmacological Property Profile (Example: Oseltamivir): - Drug Class: Neuraminidase Inhibitor (Anti-viral). - Indication: Treatment/Prophylaxis of Influenza $A/B$ . - Mechanism: Inhibits viral replication by acting on neuraminidase to prevent mature virus release. - Treatment Dose: $75\,mg$ BD for $5\,\text{days}$ . - Prophylaxis Dose: $75\,mg$ OD for $7\,\text{days}$ . - Adverse Reactions: Common: Nausea, Vomiting, Diarrhea, Headache ( $H/A$ ); Rare: Suicidal thoughts. - Cautions: Renal impairment, weight $\le 40\,kg$ . - Drug Interaction: Dichlorphenamide (may increase Oseltamivir levels).

Understanding Drug-Related Problems (DRP)

Definition: An event involving drug treatment that actually or potentially interferes with optimal patient outcomes.
Impact: Increased healthcare costs, hospital stays, and mortality. Approximately $90\%$ of $DRPs$ are preventable.
Statistics: $38.3\%$ of patients with $\ge 1$ $DRP$ were hospitalized. Managing a single incident costs roughly $SGD\$1424$ ( $SGD\$1068$ – $SGD\$2678$ ).
IESA Classification System: - Indication (I): "Is the medication serving its intended purpose?" - Effectiveness (E): "Is the medication effective for the patient?" - Safety (S): "Is the medication safe for the patient?" - Adherence (A): "Is the patient using the medication properly?"

Clinical Intervention Frameworks

SCHOLAR-MAC (Patient Assessment)

Symptoms: What are the symptoms?
Characteristics: What is the nature of the symptoms?
History: What has happened before?
Onset: When did it start?
Location: Where is the problem?
Aggravation: What makes it worse?
Relief: What makes it better?
Medicine: Current medications.
Allergy: Any known drug allergies ( $NKDA$ ).
Conditions: Co-morbidities (e.g., Asthma).

SBAR (Communication with Prescribers)

Situation: Who is the patient and why are you calling?
Background: Patient profile and context of the $Rx$ .
Assessment: Identify the specific IESA classification of the $DRP$ or legal issue.
Recommendation: Suggest a specific course of action to resolve the issue.

Detailed IESA Classification Categories

1. Indication (I)

1A. Untreated Indication: Patient has a condition requiring therapy but is not receiving it (Example: Miyeon - Diagnosed with influenza but no antiviral prescribed).
1B. Therapeutic Duplication: More drugs than required for the same indication (Example: Minnie - Prescribed both Oseltamivir and Zanamivir).
1C. No Indication for Drug: Taking a drug without valid medical reason (Example: Soyeon - Prescribed Simvastatin for high cholesterol but doesn't have the condition).

2. Drug Selection (E/S)

2A. Ineffective Drug (E): Wrong drug for the condition (Example: Yuqi - Amoxicillin [antibiotic] prescribed for Influenza [viral]).
2B. Contraindication (S): Drug is unsafe due to patient factors (Example: Shuhua - Prescribed Panadol while having a known Panadol allergy).
2C. Inappropriate Dosage Form (E/S): Wrong delivery method (Example: Minji - Suppository prescribed when only oral formulation is available).
2D. Inappropriate Change in Brand (E/S): Brand substitution that affects bioequivalence or legality.

3. Dosing Regimen (E/S)

3A. Dosage Too Low (E): (Example: Danielle - $30\,mg$ BD Oseltamivir instead of $75\,mg$ BD).
3B. Dosage Too High (S).
3C. Inappropriate Frequency/Route (E/S): (Example: Haerin - $75\,mg$ QDS instead of BD).
3D. Duration Too Short (E): (Example: Hyein - $3\,\text{days}$ instead of $5$ ).
3E. Duration Too Long (S).

4. Adverse Drug Reaction (S)

4A. Adverse Drug Event: Patient experiences Type A (pharmacological extension) or Type B (idiosyncratic) reactions (Example: Yu-jin - Intolerable N/V/D and dizziness from Oseltamivir).

5. Drug Interactions (E/S)

5A. Drug-Drug Interaction: Concomitant drugs interact (Example: Rei - Oseltamivir + Dichlorphenamide).
5B/C/D. Food, Lab, and Disease Interactions: - Drug-Food: Milk + Doxycycline (Calcium interferes with absorption). - Drug-Lab: Radioactive contrast + Metformin (Renal elimination risk). - Drug-Disease: Paracetamol + Liver Failure (Risk of worsening condition).

6. Adherence (A)

6A. Drug Administration Issues: Physical inability to take medication (Example: Won-young - Cannot swallow tablets).
6B/D. Forgets / Lack of Understanding: Unintentional deviation due to communication barriers (Example: Liz - Taking OD instead of BD due to English language barrier).
6C. Prefers Not to Take: Intentional deviation (Example: Leeseo - Admits to not taking medication despite no improvement).

Prescription Legality and Documentation

Legal Requirements for a Valid Prescription: - Location and address of practice. - Doctor’s Name and Signature. - Date of Prescription (Validity $\le 1\,\text{year}$ for standard $Rx$ ; $\le 30\,\text{days}$ for Controlled Drugs ( $CD$ )). - Patient’s Full Name and IC number (e.g., $S29009888A$ ). - Patient’s Address and HP number. - Patient Allergy Status. - Drug details: Item Name, Dose/Strength, Frequency, Quantity, and Dosing Instructions.
The Golden Rule of Documentation: "If you didn’t document properly and legally, you didn’t do it!" Documentation must follow a "Problem and Solution" structure, identifying the $DRP$ and verifying the accepted change with the doctor (e.g., "Called Dr. Chee Rou Tong and verified change from 1d to 5d duration").