Establishing pharmaceutical care services in an HIV clinic

OBJECTIVE: To present a brief overview of human immunodeficiency virus (HIV) infection and to describe the implementation of pharmaceutical care services for adult patients with HIV infection. SETTING: University hospital clinic. PRACTICE DESCRIPTION: A pharmacist joined a multidisciplinary team serving HIV-infected patients in January 1994. PRACTICE INNOVATION: Current pharmacy services include taking medication histories, educating patients, counseling patients on compliance, monitoring response to therapy, identifying drug-related problems, documenting all interventions, and making therapeutic decisions and formulary choices. The pharmacist also participates in research. INTERVENTIONS: The pharmacist sees patients immediately after their physician appointments. Patients with one or more of the following characteristics are targeted to receive pharmaceutical care: multiple drugs, history of noncompliance, initiation of new drug therapy, recently discharged from hospital or emergency department, identification of potential adverse effects, identification of potential drug-drug interactions, and presence of drug toxicities. CONCLUSION: Pharmacists are uniquely qualified to provide a wide range of pharmaceutical care services to HIV-positive patients. Pharmacy interventions should lead to improved outcomes and decreased costs for a chronic and very expensive disease.     

Drug-induced disorders

Recent estimates suggest that each year more than 1 million patients are injured while in the hospital and approximately 180,000 die because of these injuries. Furthermore, drug-related morbidity and mortality are common and are estimated to cost more than $136 billion a year. The most common type of drug-induced disorder is dose-dependent and predictable. Many adverse drug events occur as a result of drug-drug, drug-disease or drug-food interactions and, therefore, are preventable. Clinicians' awareness of the agents that commonly cause drug-induced disorders and recognition of compromised organ function can significantly decrease the likelihood that an adverse event will occur. Patient assessment should include a thorough medication history, including an analysis of all prescribed and over-the-counter medications, vitamins, herbs and "health-food" products to identify drug-induced problems and potentially reversible conditions. An increased awareness among clinicians of drug-induced disorders should maximize their recognition and minimize their incidence.     

Asthma treatment during pregnancy. What can be safely taken?

'Safe' pharmacological therapy for gestational asthma is defined as therapy during which the apparent risks of the drug appear to be lower than the maternal and potential fetal risks of uncontrolled asthma that could result if the drug were not used. Major malformations occur in 2 to 4% of all newborns, 1% of which can be attributed to medication in general. Information regarding the effects of drugs administered during pregnancy may come from animal studies, human case reports, and prospective cohort studies. Based on a review of the available information, it is recommended that mild asthma during pregnancy be managed with inhaled beta 2-agonists, as required; step therapy for moderate asthma would include inhaled sodium cromoglycate (cromolyn sodium), inhaled beclomethasone dipropionate and oral theophylline. Severe gestational asthma should be treated with oral corticosteroids at the lowest effective dosage. The pharmacological management of acute asthma during pregnancy should include nebulised beta 2-agonists and ipratropium bromide, and intravenous methylprednisolone. Intravenous aminophylline would not generally be recommended, unless the patient requires hospitalisation. Optimal medical practice medico-legal considerations demand that the patient's informed consent be obtained for that recommended gestational management programme.     

The new antidepressants. Selective serotonin reuptake inhibitors

This article provides a resource for choosing among available SSRIs to treat pediatric patients. SSRIs are addressed according to five areas of interest: treatment efficacy data, untoward effects profile, pharmacokinetic characteristics, potential drug-drug interactions, and cost. Strategies for SSRI dosing and pretreatment work-up are also discussed. Included in the article is a reference table for SSRI dosing, available preparations, and cost per dose. Also included is an abbreviated reference table of important cytochrome P-450 isoenzymes, isoenzyme inhibition by SSRIs, and selected psychotropic and somatic medication substrates.     

Multiple medication use among seniors

OBJECTIVES: This article examines the prevalence of medication use among Canadian seniors. Indicators of patient-physician and patient-pharmacist communication were also investigated. DATA SOURCE: Health Canada-sponsored supplementary questions to the 1994/95 National Population Health Survey (NPHS) were used in this analysis. ANALYTICAL TECHNIQUES: All estimates were weighted to represent the Canadian population on the data of the survey. Summary rates by sex were age-standardized to the estimated survey population for both sexes. Respondents who reported taking five or more drugs in the two days before their NPHS interview were considered to be multiple-medication users. MAIN RESULTS: In 1994/95, 10% of Canadians aged 65 to 74, and 13% of those aged 75 and older were multiple-medication users. For certain drug-related information, there was a decline with advancing age in the percent of the population who reported that they received this information from their physician and from their pharmacist.     

A practical guide to when (and how) to withdraw antiepileptic drugs in seizure-free patients

Most patients with epilepsy will become seizure-free on antiepileptic drugs (AEDs) within a few years of diagnosis. More than 60% will remain so when the medication is withdrawn. After assessing the risks and benefits for the individual patient, withdrawal may be considered by the physician and informed patient or parent if the patient meets the following profile: normal neurological examination, normal IQ, normal electroencephalogram (EEG) prior to withdrawal, seizure-free for 2 to 5 years or longer, and no juvenile myoclonic epilepsy. AEDs can be safely withdrawn in the seizure-free patients over the course of 6 months, possibly even faster, especially in children.     

Family pharmacy and family medicine: a viable private practice alliance

The association of the new roles of the family physician and the family pharmacist in a model private practice is described. The pharmacist works closely with the family physician to offer personalized patient education and follow-up for therapeutic effectiveness. He also serves as a consultant to the physician for up-to-date drug information and assists in solving difficult therapeutic problems. Reimbursement for pharmacy services occurs for consultative time as well as by traditional methods. Initial response by the professionals themselves as well as the patients and staff has been very positive. An appropriate physical plant and ongoing communication between physician and pharmacist are mandatory for the success of this model. Some specifics of this practice at its present stage of development are included.     

Drug-drug interactions in pediatric psychopharmacology

Serious consequences caused by drug-drug interactions continue to plague contemporary pharmacotherapy. The possibility of a drug-drug interaction should be suspected anytime a new or unexpected effect occurs that complicates the clinical management of a patient in the setting where the patient is receiving more than one drug. In this article, the authors address the mechanisms of pharmacokinetic-based drug-drug interactions focusing on important interactions that may occur with the common medications a pediatrician may prescribe to the child receiving psychoactive medication(s) prescribed by a child psychiatrist.