Letter to the future pharmacists

Tariq Sainuddin

Acadia University (Research Assistant), Canada

Dear Pharmacy students,

I would like to share an insight about “know-how of the pharmacy practice” which is a gist of when, where and how to utilize your knowledge to the real life scenarios, so you can plan, improvise and execute to the best of your abilities. As you know the influence of the pharmacist in the Indian healthcare system has always been a topic of debate for both pharmacy students and pharmacists,though we pharmacists as a communityworking either in retail orin a community hospitalhas to integrate and contribute to the health care system.

There are many challenges in this profession that ranges from pharmacist compensation, public awareness and pharmacist competencies but one of the major drawbacksis the public awareness and about their understanding of what a pharmacist is capable of. The public perception of the pharmacistas a mere provider of medications overpharmacy shelves and countersis the most worrisome. As the world of medicine continues to expand, it is the prime responsibility of a pharmacist to be a key contributor to improve overall patient outcome and to reduce the burden of other healthcare professionals. Based on experience as a pharmacist in India, I would like to suggest three simple steps that a pharmacist can plan and execute for smooth functioning of a pharmacy.

1.       Work flow protocols

2.       Patient counselling

3.       Continuing education

Work flow protocols: Every pharmacist should properly design aworkflow (receiving prescription to delivering a medication) that can be efficiently managed in a pharmacy which also include designating work for pharmacy technicians and staffs. Theseare important steps to establish awell organized pharmacy because in real life scenarios a pharmacist may not be able to keep eyes on every detail of pharmacy work flow.For example; if a pharmacy assistant is involved in product preparation, the pharmacist should ensure that the pharmacy assistant/personnel areknowledgeable and aware of the type of prescription received and also about storage of medications so prepared. To provide these competencies to pharmacy technicians and staff, proper training must be imparted. In some instances, prescription drugsrequiremandatory pharmacist interventionat all stages of dispensingespecially for narrow therapeutic index drugs likeWarfarin, Levothyroxine, Carbamazepine, Lithium carbonate, Digoxin, Phenytoin and Theophylline. These drugs can cause high negative outcomes if there is a large variation in prescribed dosages.

Another major issue that a pharmacist should be aware is the use of unsupervisedOTC medications. This is an issue that poses a major ethical conflict for every pharmacist due to its profit-motive mostly associated with the sustainability of the pharmacy. Caution should be taken at all times when dispensing OTC drugs to children, geriatrics, patients with chronic diseases, pregnant women, and breast feeding mothers. It is in the best interest of the patients of these categories to avoid any OTC medication unless prescribed by a physician. There are few drug interactions mentioned (table 1) that pharmacists must know regarding the use of the OTC medications.

OTC drugs and prescription medications interaction

OTC medication	Prescription	Causes	Prevention
Fosinopril (ACE inhibitors)	Antacids (containing magnesium/aluminium hydroxide	Decrease the bioavailability of fosinopril by about one-third.	Separate its dosing from that of antacids by at least 2 hours.
Oral Acetazolamide (carbonic anhydrase inhibitors)	Aspirin	Metabolic acidosis can occur in those taking high-dose salicylates if they are given carbonic anhydrase inhibitors	NSAIDs or paracetamol (acetaminophen) may be safer alternatives.
Isotretinoin (treat severe cystic acne (also known as nodular acne)	Vitamin A	Vitamin A toxicity cause liver damage, osteoporosis, excessive calcium buildup in the body, kidney damage due to excess calcium	Higher doses of vitamin A (more than 4000 to 5000 units daily, the recommended daily allowance) should be avoided
Terfenadine (antihistamine)	Zafirlukast (oral leukotriene receptor antagonist (LTRA) for the maintenance treatment of asthma)	Terfenadine reduced the mean maximum serum levels of zafirlukast by about 70% and reduced its AUC by about 60%.	The combination need not be avoided, but be alert for a reduced response.

Patient Counselling:It is one of the key elements of the pharmaceutical care process that the pharmacist should offer to patients.  According to Prince Edward Island College of Pharmacists it is defined as “a one -to-one interaction between a pharmacist and a patient and/or caregiver. To ensure a positive therapeutic outcome a pharmacist must develop necessary skills for efficient counselling. The ultimate objective for any pharmacist is to accurately identify the patient’s needs (i.e. Severity of his/her condition) and improve patient understanding of their medications and thereby increase the patient compliance.Thepharmacist should also be prepared to clarify any drug related questions that the patient may come across during the therapy. For example; A woman coming to a pharmacy mentioning about a missed dose of combined oral contraceptive pills. In this case the pharmacist should be knowledgeable to know out of 28 pills it has only 21 active pills in a single strip. So it is the pharmacist’s duty to inquire which day the women have missed the dose whether it’s in the first 21 days or the latter 7. If the woman has missed one active pill of a day’s dosethat happenedwithin first 14day schedule. The pharmacist solution should be to advise her to take 2 pills the next day.Then continue to take one pill a day until it finishes the pack. In the same manner, the pharmacist should be prepared for these type of scenarios depending upon the patient and drug category. It is very important to note pharmacist should have full knowledge in dealing with these cases. If apharmacist is not sure it should be definitely referred to the respective physician.

Continuing Education:

To provide the best pharmacy practice,the pharmacist should expand their knowledge and update competencies with the present day changes and challenges facing the health care system. Through the access to internet pharmacist havecredible information at their fingertips. Gathering credible information about each disease through national and international therapeutic guidelines (e.g. International Diabetes Federation) would provide pharmacist essential tools to equip themselves for better pharmacy services. A pharmacist should be knowledgeable in three basic aspects of treatments along with the assessment of therapeutic targets it needs to achieve during and after treatment.

1.     Non pharmacological intervention (prevention, diet or exercise)

2.     Pharmacological intervention (1^stdrug of choice, 2^nd drug of choice and drug of choice for pregnant women, drug interactions, polypharmacy)

3.     Medication use

For example, according to Compendium of Therapeutic Choices (CTC) for Asthma. The non pharmacological intervention would be to identify and avoid precipitating factors such as environmental allergens and occupational irritants. The second factor is smoking cessation and also avoidance of exposure to second-hand smoke whenever possible.This is a very good counselling point for a pharmacist to initiate a conversation with the patient about strategies to minimize asthma

Pharmacological intervention is to choose the initial level of treatment with Inhaled therapy that maximizes the delivery of drugs to the respiratory tract and minimizes systemic side effects is the cornerstone of asthma management. Salbutamol and terbutaline are selective beta₂-agonists and are agents of first choice for treatment of acute exacerbations and for prevention of exercise-induced asthma. Other medications choice includes bronchodilators and anti-inflammatory agents.Medication use would be selection of either pressurized metered dose inhalers (pMDI) with spacers or dry powder inhalers (DPI) deliver the drugs as effectively as nebulized therapy.

As pharmacy students you might think these are simple aspects of pharmacy practice that has already been learnt but, imagine if a random patient walks into your pharmacy giving you a prescription where you have to consider the category of drug, interactions, side effect and even adverse effects. Even I was of the attitude while studying at Al Shifa College of Pharmacy that these aspects would be easily manageable until I started working and began learning the same through practice and real life problems.  Looking back at college days, I still remember my first labwhere I studied how to prepare aspirin in the organic lab.  Understanding the importance of TEAM work that our Vice Principal and Prof. Mr. Mohammed Haneefa explained as “Together Everyone Achieves More”. That made more sense that you can’t work alone just by dispensing medication, but you need an entire group of healthcare professionals from physicians, nurses, medical biochemists and finally the pharmacist who is the final authority to dispense the medication to the patients. I have always been thankful to Prof. Prasanth Sunder who taught me the mystery of analytical chemistry that I can proudly synthesize and interpret NMR data ofpseudo octahedral inorganic complexes with MW greater than 1500 and containing more than 40 protons. Prof. JuniseVazhayilalso played a significant role in showing me the art of dispensing and the importance of attention to detail while preparing medication by specific units (neither a unit more nor a unit less).  Thanking my professors Prof. Christopher Varghese and Prof. Prashant who taught me pharmacology basics which I still analyze my compound on cancer cell lines. Prof. Mirkasim Abu who has always assured me that there is always room for improvement in every aspect of life. Finally, thankingProf. Dilip C for inviting me to write this letter and reminding me that punctuality is part of professionalism which I always try to emulate when I teach my students. So to all future pharmacy students I urge you to understand “the know-how of the pharmacy practice” rather than chasing marks for your exams. I was no good at marks during my studies and now in giving marks too.