Development of Clinical Pharmacy

·         Development of Clinical Pharmacy
Dr. R. S. Thakur

President
Federation of Indian Pharmacists’ Organizations
Email: fipo123@rediffmail.com

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·         History of pharmacy reveals that the term ‘clinical pharmacy’ is in use since
1953. However, with the objective of reorienting the role of pharmacist from
product oriented to patient oriented, the concept of “clinical pharmacy”
crystallized in late 1960s. The aim was to ensure safe and effective therapy with
optimum usage of medicines. This resulted in involvement of pharmacists in
rational usage of drugs in individual patient. The set objectives demanded that
pharmacists must acquire deep knowledge of biopharmaceutics, clinical
pharmacokinetics, Pharmacology, toxicology and therapeutics so that
individualization of medication and therapeutic drug monitoring can be
effectively achieved.

Historical perspectives
The reorientation of pharmacy practice in United Kingdom was pioneered by works
of two pharmacists. Graham Calder1 in Aberdeen introduced ward pharmacy services
undertaking review of medication orders to ensure safe prescribing. Another
pharmacist John Baker2 of Westminster hospital initiated formulary concept to
involve pharmacists as part of prescribing system. These initiatives were adopted
by other hospitals in UK during 1960s and 70s. This enabled presence of
pharmacist in the ward and actively associating with clinical team. Clinical
pharmacy developed from ward pharmacy in due course of time as reported by
Cousins and Luscombe.3 Slowly the practice of pharmacy embraced patient care into
its folds and pharmaceutical care evolved.4

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·         Similarly in the United States of America, pharmacy practice was innovated by
Harvey A.K. Whitney, Paul Parker, and Eugene White. Their determination and zeal
revisited the role of pharmacists in patient care, and introduced /prompted
innovations which were far beyond the conventional pharmacy practice. During the
past over half a century, there has been continuous and prolific innovations in
pharmacy services in USA. A timeline of innovations5 reported by Paul O. Gubbins
et al. is reproduced below:

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1928: Pharmacists at the University of Iowa Hospital began participating in
patient rounds.
1960: First use of patient medication profiles in community pharmacy practice was
done by Eugene White. First office-based pharmacy practice opened in Berryville,
VA, by Eugene White.
1962: University of Kentucky Medical Center opened Drug Information Center.
1965: University of Iowa Drug Information Service (IDIS) was created.
1966: Ninth-Floor Pharmaceutical Services Project in San Francisco, CA, brought
24/7 drug distribution to the patient care area.
1971: University of Missouri Kansas City began instructing medical students and
residents in the safe, effective, and economical use of drugs.
1972: Prescribing authority was granted to pharmacists in Indian Health Service
who completed Pharmacist Practitioner Training Program.

1974: Pharmacist-conducted drug regimen reviews were required once every 30 days
for all residents of skilled nursing facilities.
1977: Prescriptive authority was given to select pharmacists in California
involved in prespecified projects at University of Southern California and
University of California via CDTM
1979: First clinical pharmacokinetic service was recognized by third-party payer.
1981: California’s Pharmacy Practice Act was amended to allow pharmacists to
perform CDTM.

1985: ASHP launched an Anticoagulation Clinic Traineeship Program.
1992: AACP (Am Assoc Coll Pharm) House of Delegates voted to support an all-
Pharm.D. program.
1994: Pharmacists began training to administer immunizations in Washington State.
1996: Project ImPACT was published, demonstrating the beneficial impact of
pharmacists on hyperlipidemia management.
1997: The Asheville Project began using 12 community pharmacists to provide
diabetes management services to city employees.
2001: Pharmacists were represented on epilepsy treatment teams.
2004: UNOS mandated that a pharmacist be on all transplant teams.
2007: IDSA (Infect Dis Soc Am) recommended that pharmacists be core members of
antimicrobial stewardship teams.
2008: Pharmacists began serving as medication safety officers.

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·         The above phase wise developments led to establish the profession on sound
footing and maintained steady growth. History of pharmacy services shows that in
the late 1950s, less than 40% hospitals employed the services of a pharmacist.6
However, during the past six decades, slowly all hospitals retain the full-time
services of pharmacists, and pharmacy practice continues to expand. 7

The clinical pharmacy services include patient interviews on drug therapy,
participation in patient care rounds, adverse drug reaction assessment and
reporting, therapeutic drug monitoring and recommendations, answering drug
information queries, and patient counseling on discharge. A clinical pharmacist
is supposed to apply pharmacokinetics in therapy. A clinical pharmacist
endeavours to assess therapeutic regimen of a patient in light of absorption and
drug disposition kinetics observed in the patient and correlates these to
pharmacodynamic effects and therapeutic outcome. This effort ensures patient
specific therapy and ultimate safety from adverse effects. The net result
economic therapy by cost reduction as medicine induced problems are minimized or
avoided and thus recovery time as well as cost of therapy reduces substantially.

Clinical evaluation of therapeutic outcomes is essential in patients suffering
from chronic diseases, who may have to take life long treatment. Undesirable
effects are common with almost every medicine and therefore, a successful therapy
can be achieved only by optimally balancing the desirable and undesirable
effects. In this perspective choice of drug, dose of the drug, dosage form,
appropriate route of administration, frequency of administration, duration of
therapy and clinical evaluation of therapeutic response are critical. How much?
How often? and how long? are the three important questions to be answered while
individualizing therapy. Actually no patient is replica of another. The
pathophysiological conditions affect individual pharmacokinetics and thus drug
absorption and disposition. This leads to variation in pharmacodynamics. The
therapeutic outcomes and toxic manifestations are accordingly affected.
Health care sector is growing very fast. Availability of more potent medicines
and well documented knowledge of drug interactions, drug food and beverages
interactions have drastically changed both the perception and practice of
medicine. The concept of pharmacy practice has accordingly changed from a
dispensing to clinical role. As soon as the patient centric role of Pharmacist
emerged his clinical involvement in therapy was recognized. This is in tune with
the progress in the knowledge of medicines and expectations of the patient from
the healthcare team.

Pharmacists’ vital role is to ensure accurate dispensing of prescribed medicines
and providing sound advice on responsible use of medicine. As an efficient health
care team member, clinical pharmacist needs skills and attitudes enabling to
assume seven star pharmacist’s role. WHO introduced this concept and FIP
incorporated it in its policy statement on Good Pharmacy Education Practice in
2000 to cover roles of caregiver, decision-maker, communicator, manager, life-
long learner, teacher and leader. The function of the pharmacist as a researcher
was later on added.

An equally important role for clinical pharmacist is to advise other healthcare
professionals on safe and rational use of medicines and to accept responsibility
for seeking to ensure that medicines are used safely and effectively by those to
whom they are supplied so that maximum therapeutic benefit is enjoyed from the
treatment. This activity contributes both to the welfare of the individual and
the overall improvement of public health.

The clinical pharmacist functions as medication experts in the treatment of
diseases and in health promotion. This assures desired outcomes of treatment by
medication. Clinical pharmacy service begins with the medicine therapy
development process and continues through medication’s ultimate benefit to the
individual patient and the society at large. As a practitioner clinical pharmacists work directly with patients and health
care providers like physicians to give information and guide patients about the
effects of prescription drugs, dosage and potential side effects. They also
educate patients or their care givers and give suggestions on how to plan an
effective and safe drug therapy program.

·         References

1. Calder G, Barnett JW. The pharmacist in the ward. Pharm J. 1967;198:584–586.
2. Baker J. Seventeen years experience of a voluntary based drug rationalisation
programme in hospital. Br Med J. 1988;297:465–469. [PMC free article] [PubMed]
3. Cousins HD, Luscombe D. Re-engineering pharmacy practice (1). Forces for
change and the evolution of clinical pharmacy practice. Pharm J. 1995;255:771–
776.
4. Heppler CD, Strand LM. Opportunities and responsibilities in pharmaceutical
care. Am J Hosp Pharm. 1990;47:533–543. [PubMed]
5. Paul O. Gubbins,* Scott T. Micek, Melissa Badowski, Judy Cheng, Jason
Gallagher, Samuel G. Johnson, Jason H. Karnes, Kayley Lyons, Katherine G. Moore,
and Kyle Strnad. Innovation in Clinical Pharmacy Practice and Opportunities for
Academic–Practice Partnership. Pharmacotherapy 2014;34(5):e45–e54. doi:
10.1002/phar.1427.
6. Franke DE, Latiolais CJ, Franke GN, et al. Mirror to hospital pharmacy: a
report of the audit of pharmaceutical service in hospitals, a study project
conducted under grant W-45. USPHS. Washington, DC: American Society of Hospital
Pharmacists, 1964.
7. Bond CA, Raehl CL. 2006 national clinical pharmacy services survey: clinical
pharmacy services, collaborative drug management, medication errors, and pharmacy
technology. Pharmacotherapy 2008;28:1–13.