Just an attempt to promote pharmacy practice in India. It helps for the students and professionals of pharmacy in healthcare, especially Doctor of Pharmacy and Pharmacy Practice students

1. Pharmacy Practice – A Spiritual
Transformation
Gopinath K Vinayakam
M Pharm PhD CPhT
Assistant Professor & Pharmacist-Clinical
Andhra Pradesh
India
gopinath.karnam@gmail.com

2. Pharmacy Practice– A Transformation
• Pharmacy Practice need a transition?
yes. Traditional compounding to dispensing to “therapy
manager”.
When I was a intern with Diploma in Pharmacy through
years 1985-87 civil surgeon ordered me and one of my colleague
to attend the rounds in the ward ignoring other interns besides
my routing dispensing practice. He himself realized that
pharmacists need to change their working atmosphere in sitting
in a pharmacy counter & in dispensing practice. The physicians
are expecting much more from the pharmacists, need to be a “
effective therapy manager “ in healthcare. Now it is almost 28
years and still working in the same skills although there is a
transition from 2 year diploma in pharmacy to 4 year B Pharmacy
to 6 year doctor of pharmacy / M Pharm – Pharmacy Practice. I
hope with this higher qualifications, the profession will move to a
independent professionals with more patient centered and
product oriented and collectively with other healthcare members
to work for the patients. I am always indebted to all patrons Dr B
Suresh , Prof K Chinnaswami , Dr Lakshmi, Doctors and Friends in
assuming me as a clinical pharmacist and I am proud to be a “
Good Pharmacist / Clinical Pharmacist “ with all the skills to meet
the current demand in healthcare. And it is the right time that the
government of India or respective state governments need to
appoint clinical pharmacists in government healthcare to meet
current demand
– Gopinath K Vinayakam , Pharmacist – Clinical T T D Tirupati
Andhrapradesh India.

3. Pharmacy Practice – Global
perspective

4. Transition from compounder to
Pharmacist to a Therapy manager
• Although the term “Compounder” was removed
long back as per the gazette and officially
designated as “pharmacist” . Still the skill
“compounding “ is needed in pediatrics, geriatrics
and also in chemotherapeutic practice.
Compounding is a “ART” an official procedure in
pharmacy practice to have a better patient
compliance. But the present universal practice is
based on individualization theory – genetic
based. There is a need of clinical skills to
maximize the therapeutic outcome of a drug
rather just compounding and dispensing. So
pharmacist need to have all three skills to
strengthen healthcare. If you need recognition
one need independent status / service provider
status…. Therefore “SKILLS” are important.
• How skills are
important. Need
a recognisition –
one need to
equip with
compounding,
dispensing and
clinical ….

5. Pharmacist – Eight Star in Cap
• More than Dispensing or
Inventory Management of
drugs- a Clinical Pharmacist:
- a Care Giver
- Communicator
- Decision-Maker
- Teacher
- Life – Long
Learner
- Leader
- Therapy
Manager
- A Researcher

6. Generic VS Brand - II
• Yes.
Many people talk about generic vs
brand in clinical practices. One cannot
ignore the effect and consequences of ‘
Narrow therapeutic index’ drugs in
biological system. Marginal changes in
optimal therapeutic concentration lead
to co-morbid and mortality. Thereby
time, cost and “LIFE” cannot be control
+Z. Evidences and practices along with
documentation are important in clinical
therapeutics. Selection is a wisdom,
surely “BRAND” for narrow index.

7. Generic vs Brand - I

8. Pharmacist –An Antibiotic Guardian
• “F R A I S “ is a pnemonic. It relate
F = Finish the course ; R = Right Dose
A = Take after, with or before food
I = Be aware of drug interaction
S = Side Effects
• Antibiotic Resistance is increasing , with no action
taken on resistance, within10-15 years routine
procedures become impossible.
• The average infections lasts for e.g. ear 4 days,
common cold 1 ½ weeks, Sinusitis lasts for 2 ½
weeks, bronchial cough last for 3 weeks
• Take antibiotics exactly as prescribed, never save
them for later, never share them with others
• In general , Antibiotics are used in hip and knee
replacement, cancer surgery and organ
transplantation etc.

9. Urinary Tract Infections
• Urinary Tract Infections (UTI) are common
in women.
• These are bacterial infections caused by
E.Coli.
• The alarm symptoms like back ache,
vomiting, and fever that would require
immediate referral.
• The recommended antibiotic regimen for
UTI is Trimethoprim 200 mg BID for 3 days
/ Nitrofurantoin 50 mg qid for 3 days /
Ciproflaxacin 500 mg BID for a day when
treating uncomplicated UTI’s.
• Alkalinizing agents markedly reduce the
efficacy of Nitrofurantoin and should
theref0re be avoided during treatment,
• It is a good advise to tell patients to drink
more water than normal

10. Complementary & Alternative
Medicine – New Challenges
• - Patients need reliable information on
natural products.
• - Need proof of efficacy, safety or quality
before commercial supply
• - Herbal medicines have many unknown
and undocumented risks. E.g. Nithyam
tablet – a laxative having “croton tiglium”-
induces heat, gas trouble, dry cough,
gingivitis, eyes burn, IBM.
• - Disclose all medicines on every visit.
• - Herbal medicines may interact adversely
with allopathic medicines.
• - If any one fails to achieve specified goals
after a specified / sufficient time, suggest
to consider conventional
pharmacotherapy.

11. Auto Immune Disorders
• SLE, Arthrities, Myasthenia gravis, Type I DM,
Asthma, Goodpasture’s syndrome, Anaemia,
Graves disease, Hashimoto’s thyroiditis,
myxedema, Multiple Sclerosis, SLE,
– Glucocorticoids inhibit MHC expression and IL-1, IL-2,
IL-6 production so that helper T-cells are not
activated.
– Cytotoxic drugs block proliferation and differentiation
of T and B cells.
– Cyclosporine and tacrolimus inhibit antigen
stimulated activation and proliferation of helper T
cells as well as expression of IL-2 and other
cytokines by them.
– Antibodies like muromonab CD3, antithymocyte
globulin specifically bind to helper T cells, prevent
their response and deplete them.
This particular area of application is yet to be research
modality and lot many ethical constraints in mass
application. It is just an involvement of ‘deregulation
‘ in the control net work to manage the disease. More
over “VECTOR” introduction insitu a biggest a
biggest challenge and lack of ‘specificity’ and
‘compliance ‘ give lot of complications even rejection.

12. Errors in Dispensing

13. Benzodiazepine Equivalency-Clinical
Implications
• Age
• Elderly vs
younger
Sl.no Drug Dose
In mg
tmax T 1/2 hrs
1 Alprazolam 0.5-1 1-2 12
2 Bromazepam 3-6 1-4 20
3 Chlordiazepoxide 10-25 1-4 100
4 Clonazepam 0.25-0.5 1-4 34
5 Clorazepate 7.5-15 0.5-2 100
6 Diazepam 5-10 1-2 100
7 Flurazepam 15-30 0.5-2 100
8 Lorazepam 1-2 1-4 15
9 Nitrazepam 15-30 0.5-2 30
10 Oxazepam 10-20 1-4 8
11 Temazepam 10-20 1.5 25-41
12 Triazolam 0.25-0.5 2-3 11

14. Evidences and Practices are important

15. ADR Monitoring- PVPI
• Why do Clinical Pharmacist need in healthcare ?
– Recently an educated known patient came to be for
a Framycetin skin ointment for wounds in the scalp. I
said what happened. He told me that drug allergy to
Tab Metformin XL 500 mg . I asked who told that ?
He told me that doctor said and I have to accept it.
This is the story in practice for quite few days.
Although we have a spontaneous reporting and we
need to figure it out whether symptoms are due to
drug administration / not . It should be tested based
on a standard protocol and then report to PVPI/ any
other agency. In this instance that patient is using the
same med for quite few years. And saying Drug
allergy ? There could be separate pharmacy practice
department and need to work with other healthcare
members to reflect professional image rather “ Lip
Service”. Let us join every member in healthcare to
strengthen nations healthcare rather targeting
pharmacy professionals ….

16. Steroid Toxicity - Choreoretinopathy
• An uncontrolled diabetes or prolonged usage of
steroids as in asthma lead to a state known as
CSC/CSCR.
• There will be a blurred vision and distorted vision
lead to reversible or irreversible loss of vision.
• Case Study: A known asthmatic and allergic rhinitis in
2008 changed to COPD although a good compliance
in asthma drugs especially ICS. Recently he
developed CSC.
• And on consultation with ophthalmic specialist
confirmed that CSC and referred back to allergy and
chest specialist to stop using ICS’s.
• Patient is on Maxiflow 250 mg / Maxiflow since 2008
that forced to develop a CSC due to increased
permeability In the retina, but normal macula. There
will be a increased toxicity to retina lead to reversible
or irreversible blindness due to increased IOP.

17. Placebo – Miracle in Therapeutics
Does it Effective / not
• In general , placebo is mean to
prove that effects- intrinsic is
mainly due to active medicament.
Not any other factor responsible
for the therapeutic outcome .
• Not 100% effective
• Relativity
• Miracles
• 35% effective either with placebo
/ not
• The term placebo itself taken us
to different heights in clinical
research

18. Case Study 1: Asthma in ED
Problem
• A 26 year pregnant woman
attends ED with h/o chest
tightness, wheezing and known
asthma, managing with inhalers.
She suddenly stopped her
asthma inhalers after discovering
she was 4 weeks pregnant. Her
vital signs shown that heart rate
96 bpm, bp 110/70 mmHg,
respiratory rate 26/min, oxygen
saturations 94% and initial peak
flow of 200 L/min.
• What could be initial treatment
in ED like dosages and routes of
any drugs prescribed. If failure in
response what would be next
treatment? And what
characteristics are used to
calculate the predicted PEFR ?
Solution
• No variation in treatment for the
pregnant women and other asthmatics.
• Oxygenation to maintain > 94%
saturations
• Salbutamol neb. 5 mg repeated three
times in a hour
• Ipratropium neb. 500 mcg
• Oral Prednisolone 40 mg
• Standard charts are available based on
ht and wt may be used to assess PEFR
using peak flow/spirometer
• If no response to the treatment , may
MgSO4 IV 1.2 to 2 gms to avoid further
complications.

19. Case Study 2: Medication Burden: Age
& goals are important
A 95 year geriatric female is on
the following medications
• Lipitor 10 mg 1 OD
• Amlodipine 10 mg 1OD
• Diovan /HCT 160/12.5 mg 1
OD
• Remeron 15 mg 1 HS
• Metformin 500mg 1 OD
• Pantoprazole 40 mg 1 OD
• Ranitidine 150 mg 1 BD
• Tramadol 50 mg 1 TID
• Vitamin C 500 mg 1 OD
• Colace 100 mg 1 OD
What could be the unnecessary
medication in the Rx given
• Look at HbA1c. If < 7, possibly even < 8, one
could look to possibly discontinue the
Metformin
• Some significant GI problems as she is on PPI
& H2 blocker already
• Vitamins should always be looked at &
reviewing its indication
• Past cardiac /stroke should be looked at as
well as patient goals of therapy in regards to
the statins
• HT medications – readings are certainly be
important
• Tramadol may be used on SOS
• Note: geriatric patients are well tolerated the
gastritis : does a patient DM / Obese: all
other medications for morbid / co morbid /
age related physiological change
maintenance in the system

20. Case Study 3: Diarrhoea
• A 45 year female patient came in with
diarrhoea for a day with stomach ache and
she is treated with 1) Cap Racecadotril
100mg BID 2) Tab. Colimex and 3) ORS.
Next day she came in with dizziness but
improved out diarrhoea confined to normal
stools 2 times a day. Her bp measured
diastolic less than just normal < 80 mm Hg.
What could be the possible cause of
dizziness and its management in this case.
Facts about diarrhoea /
dehydration
• Symptoms : increased thirst, dry mouth, tired or
sleepy, decreased urine output, urine is low
volume ad more yellowish than normal, head
ache, dry skin, dizziness
• No avoid food for 24 hrs. Eat watery butter milk
and less or no spicy food with plenty of pure
water
• People with loose water stools should be
referred to GP if it continue for more than 3 to 5
days.
• Blood that is mixed in with the stool and is
black/tarry as opposed to blood on the surface
of the stool may be a sign of colon cancer and
needs urgent referal
• OTC medications for 3 to 5 days
• Conclusion : dizziness with a patient is due to
more fluid loss on dehydration / diarrhoea, itself
lead to hypotension and therefore supplement
with ORS or large volume parenterals may give
good rexults

21. • Case Study : A 80 year female patients has a
h/o HT, atrial fibrillation, falls with orthostatic
hypotension, OA, depression and anxiety.
Constipation, COPD and Insomnia. Her
present complaints are shortness of breath,
edema and falls. Her current med list include
• Warfarin (goal INR 2.3)
• Metoprolol tartrate 25 mg BID
• Losartan 100 mg 1 OD
• Lasix 40 mg 1 OD
• Amlodipine 10 mg 1OD
• Omeprazole 20 mg 1 OD
• Sertraline 25 mg 1 OD
• Duonebs BID
• Budesonide nebs 1 OD
• Colace 100 mg 1 OD
• Celebrex 100 mg 1 OD
• Senna S 1 tablet 1 OD
What could be the possible remarks & its
management
• An issue of a poly pharmacy. In this
instance Warfarin is a highly
liphophilic drug and there by it
elevates almost all the drugs that
present in the prescription.
• Secondly anti-hyperten.sitve drugs
amlodipine is used in maximum dose
although other anti HT are used ?
• Metaprolol tartrate 25 mg &
Celebrex 100 mg may be the reason
for shortness of breath.
• Losartan & Amlodipine dose may be
revised based on the present BP. And
responsible for edema.
• Close monitoring of the BP to avoid
recurrent falls.
• Senna S 1 may prescribed only for 7
days

22. Case Study 5 : Type II DM
• Q) Mr. 59/M patient presented with
chest pain. He was normal before 2 days
since then he developed chest pain and
was admitted in ED. K/C/O DM for 8
years. Not a K/C/O MI/CAD/CVA. He is
currently on Metformin 2000 mg/day
and Glimepride 4 mg/day. He was on
pioglitazone, and it was discontinued
because he had swelling on his ankles.
ECG normal. Lab report shown FPG:210
mg/dl; PPG:323 mg/dl; HbA1C 9.8%.
What could be the impression and
treatment
Ans) Impression : Type II DM , Angina
Treatment:

23. Only Finer People will become a Legal
Pharmacist

26. Thank You
GOPINATH K
VINAYAKA
M
Assistant
Professor
&
Pharmacis
t – Clinical
Andhraprade
sh India
gopinath.kar
nam@gm
ail.com