Pharmacists are known to work in the background and have become unknown to the present services of pharmacist obscure for the healthcare team India. In healthcare delivery, the role of pharmacist is ignored and in India, the pharmacists are working only in the area of manufacturing related activities. It is very strange; despite of several lapses in healthcare delivery, neither the consumer nor the healthcare professionals have felt the need of pharmacist in clinical services. These are mainly due to overconfidence in the healthcare team, due to lack of transparency and accountability for the healthcare providers.
The healthcare services focus on efficacy rather than safety of the patient. The government and administrators along with healthcare providers are observing as silence, as the primary stakeholders are not competent and technically well versed to understand and question the rationality of the drug treatments. This type of the situation is very much conducive for the pharmaceutical industry to sell the medicines with the help of healthcare providers by giving them kick back in the form of cash and kind. There are reports that pharmaceutical industry having direct trade understanding for the prescribers of medicine. For understanding the gravity of the situation the Medical Council of India has warned its members not to have any business relationship with pharmaceutical industry. They also warned the so called key opinion leaders are not to advocate or endorse any particular companies’ products. Further due to various business pressures, the retail pharmacists in drug stores are indulged in sale of prescription of medicines to the public without any respect and regards to the law of the country. The apex law of the country like Drug and Cosmetic Act 1940 and Pharmacy Act 1955 clearly bans the sale of prescription of medicines without prescriptions in the absence of a registered pharmacist. As this practice of illegal sale of medicines will improve the earnings of retail pharmacist. The prescription drugs are sold along with these confusions. Indian public although innocent engages in wide spread irrational self medication. Lawlessness and lack of transparency and accountability for healthcare providers have caused irrevocable damage to the public health. As many things go unnoticed due to lack of documentation, it is presumed that everything is okay; however drugs being chemical weapons against diseases are also capable of harming humans. Hence, it mandates that drugs being used with discretion to optimize the outcomes are a distinct dream in India.
The government of India under the agency of Pharmacy Act 1955 has introduced a programme, called as Doctor of Pharmacy (Pharm D) in 2008. The first batches of Doctor of Pharmacy have come out in 2014 and are added every year into the healthcare system. These pharmacists are oriented to take up the responsibility of clinical pharmacist and fill the gap of pharmacy practice in the healthcare delivery. It is just a trend that many corporate hospitals are recruiting doctor of pharmacy as clinical pharmacist in healthcare team. These pharmacists are engaged in several important activities like prescription audit, antibiotic stewardship, drug information services, therapeutic drug monitoring, patient counseling and pharmaceutical care. The inclusion of above services is definitely going to make a difference in the cost of treatment, quality of life of the patient and obviously with improved clinical outcomes.
The corporate hospitals were first to realize the value of clinical pharmacy in therapeutics. The contribution of the clinical pharmacy services can be understood by following examples. The practice of generic substitution of brand medicine would save cost of medication. The insistence of pharmacokinetic and pharmacodynamic (PK/PD) principles shall bring about wonderful outcomes. The clinical pharmacist, knowing the importance of PK/PD shall advice and insists the patients to follow the timings of administration of the drugs as per the regimen. The dose of a drug is usually for 24 hours in a day, if the doctor has prescribed once a day, that means the patient should be taking every 24 hours with due importance for the timings. If the drugs are prescribed two times in a day, which means doses should be taken every 12 hours once. Similarly three times means every 8 hours. But in practice the patients are not following this timing principle. They are taking medicines as per their presumption in using the medicines with no regard to PK/PD. Not abiding to the timings shall not only bring down the efficacy but endanger the safety for a patient. Indiscriminate and abrupt stopping of antibiotics has resulted in emergence of wide spread multi drug resistant microbes. These microbes can withstand any antibiotic, as they have developed the antibiotic resistance. Antibiotic resistance can cause epidemics and it is a ticking time bomb, which can cause many deaths of human lives. The simple organism like Escherichia coli can become as super bug which is difficult to treat with existing antibiotics. Although many warnings and efforts are given in mass media regarding control of antimicrobial resistance. It is not effective because the antibiotic usage has to be monitored and checked by clinical pharmacist in hospitals. Clinical pharmacist in collaboration of microbiologist can make appropriate strategy and implement antibiotic usage so that antimicrobial resistance can be measured and controlled effectively.
Clinical pharmacist are suppose to implement therapeutic drug monitoring services through which they will be able to adjust the doses of the narrow therapeutic index drugs within the therapeutic window. For exampledrugs like gentamycin, digoxin, phenytoin, lithium incognite which are known to cause various drug induced injuries. In several instances the patient might have an altered liver and kidney functions. In such instances there is a need for readjustment of dose and dosing schedules. It is critical to measure plasma concentration of the drug and advice the health care team that the dose is either above minimum toxic concentration or below the minimum effective concentration. Establishment of therapeutic drug monitoring services in the hospitals shall strengthen the doctor’s capabilities for providing therapeutics; otherwise the doctors are not sure whether the dose is more or less. They merely do a mental guess and decide the dose of the drugs in the plasma which is vague and dangerous for the patient. The clinical pharmacist are also likely to be engaged in ward rounds along with doctors and nurses as a pharmacist being experts in the aspects of drugs and their responsibilities are focused on checking the doses of the medicine given to the patient. The appropriateness of the prescribed medicines of patient condition and also any skips and errors in the prescription order for a patient are routinely checked.
Clinical pharmacy services
• Provide a consistent process of patient care that ensures the appropriateness, effectiveness and safety of the patients medication use.
• Consult with the patient’s physician and other health care providers to develop and implement a medication plan that can meet the overall goals of patient care established by the healthcare team.
• Apply specialized knowledge of the scientific and clinical use of medications, including medication, action, dosing, adverse effects and drug interactions, in performing their patient care activities in collaboration with other members of health care team
• Call on their clinical experience to solve health problems through the rational use of medications
• Rely on their professional relationships with patients to tailor their advice to best meet individual patient needs and desires.
(Authors are with Department of Pharmacy Practice, C G Hospital, Davengere, Karnataka 583 127)