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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5739_Библиотеки_им_академика_М_И_Перельмана.pdf
Pharmacy Practice18
PRAPRA
PRAPRA
PRA
CTICE QUESTIONSCTICE QUESTIONS
CTICE QUESTIONSCTICE QUESTIONS
CTICE QUESTIONS
VV
VV
V
erer
erer
er
y Shory Shor
y Shory Shor
y Shor
t Answer Tt Answer T
t Answer Tt Answer T
t Answer T
ype Questionsype Questions
ype Questionsype Questions
ype Questions
1. Define hospital pharmacy.
2. Draw the typical layout of hospital pharmacy.
3. What is floor space requirement for a hospital pharmacy in
a hospital?
4. How the pharmacist requirement in a hospital calculated
based on bed strength?
5. Write any two functions of hospital pharmacy.
ShorShor
ShorShor
Shor
t Answer Tt Answer T
t Answer Tt Answer T
t Answer T
ype Questionsype Questions
ype Questionsype Questions
ype Questions
1. Write a note on organization structure of hospital phar-
macy.
2. Write the functions of a hospital pharmacist.
3. What are the functions and objectives of hospital pharmacy?
4. Write a note on personal/staff requirements in hospital.
5. Write the procedure for material management in a hospital
pharmacy.
LL
LL
L
ong Answer Tong Answer T
ong Answer Tong Answer T
ong Answer T
ype Questionsype Questions
ype Questionsype Questions
ype Questions
1. Write a note on location, layout, and staff requirements in
hospital pharmacy.
2. What are the roles and responsibilities of hospital pharma-
cist in the various areas of a hospital?
3. Describe the organizational chart of hospital pharmacy.
4. Define hospital pharmacy. Write a detailed note on:
a. Administrative and professional equipment used for
hospital pharmacy.
b. Floor space requirement for a hospital pharmacy.
Objective TObjective T
Objective TObjective T
Objective T
ype Questionsype Questions
ype Questionsype Questions
ype Questions
1. The practice of hospital pharmacy in India started in the
year.
A. 1932 B. 1955
C. 1941 D. 1960
2. In a multi-storey hospital, the pharmacy should preferably
be located on:
Hospital Pharmacy 19
A. 1st
floor B. 2nd
floor
C. 3rd floor D. Ground floor
3. The organization of a hospital pharmacy consists of:
A. Dispensing section and quality control
B. Manufacturing section
C. Clinical pharmacy section
D. All of these
4. How many pharmacists are required for a bed strength up
to 200 beds?
A. 15 B. 8
C. 5 D. 10
5. What is the minimum required area for any sized hospital?
A. 100 sq.feet B. 180 sq. feet
C. 250 sq. feet D. 400 sq. feet
6. What is minimum qualification required for quality control
pharmacist?
A. B Pharm B. M Pharm
C. D Pharm D. Pharm D
AnswersAnswers
AnswersAnswers
Answers
1. A 2. D 3. D 4. B 5. C 6. B
IIINNNTTTRRROOODDDUUUCCCTTTIIIOOONNN
Drugs are prescribed with specific intension and a physician
would expect a drug to act effectively and selectively without
any undesirable phenomenon in the organism. To certain
extend such side effects are tolerated but they become
problematic when the side effects are also as potent as
therapeutic effect and particularly when they cause distress to
the patient and treating physician. All such side effects of drugs
are generally classified as adverse drug reactions (ADRs).
“An adverse drug reaction (ADR) is a harmful, unintended
result caused by taking medication. ADRs may occur
following a single dose or prolonged administration of a drug
or may result from the combination of two or more drugs”.
and
According to World Health Organization adverse drug
reactions are defined as: “Any noxious and unintended effect
of drug which occurs at doses normally used in man for the
prophylaxis, diagnosis or therapy of disease or for the
modification of physiological functions”.
Most of the adverse drug reactions occurring in the hospital
are minor. Around 70% of the reported adverse drug reactions
include; rash, headache, GIT disturbance, itching, insomnia,
drowsiness, weakness, etc.
CCCAAAUUUSSSEEESSS FFFOOORRR AAADDDVVVEEERRRSSSEEE RRREEEAAACCCTTTIIIOOONNNSSS
Most of the incidences of adverse drug reaction may be due to:
1. Errors in dispensing and the administration of medications: In
many instances, the medications that a patient is prescribed
Adverse Drug Reactions
3
Adverse Drug Reactions 21
are excessive. In general, these prescriptions contain
antibiotics that are very effective. In a similar vein, the
patient’s self-medication might result in the patient
overusing or misusing the medications, which can then lead
to an adverse drug reaction.
2. The failure to establish a therapeutic end point: When
administered in an inappropriate manner or abused,
powerful medications can result in adverse consequences or
even death. It is the failure of the physician to establish the
therapeutic end point that is the cause of unpleasant
reactions to medications such as digitalis, corticosteroids,
diuretics, and other similar medications.
3. Variations in bioavailability: Variations in the bioavailability
of the drug that result from different formulations or brands
of the drug may potentially be a contributing factor in the
development of adverse drug reactions. The bioavailability
of different brands of digoxin, phenytoin, and oxytetra-
cycline has been shown to vary, which has led to the
development of hazardous effects in certain instances.
4. Patient factor: In addition, bad medication reactions are
influenced by the patient’s physiological state as well as the
disease status of the patient. Patients who are very young
or very old are more likely to experience adverse medication
responses than it is for adults to experience them. The
reason for this is that there is a significant difference in the
pattern of excretion and metabolism at this age. Along the
same lines, patients who have renal or hepatic impairment
or dysfunction are more likely to experience adverse
reactions because their metabolism and excretion of
medications are disrupted. It is possible that adverse
medication reactions are caused by a genetic lack of
particular enzymes or a deficiencies in those enzymes.
CLCL
CLCL
CL
ASSIFICAASSIFICA
ASSIFICAASSIFICA
ASSIFICA
TION OF ADTION OF AD
TION OF ADTION OF AD
TION OF AD
VERSE DRUG REAVERSE DRUG REA
VERSE DRUG REAVERSE DRUG REA
VERSE DRUG REA
CTIONSCTIONS
CTIONSCTIONS
CTIONS
1. Predictable:
a. Excessive pharmacological effects.
b. Secondary pharmacological effects.
Pharmacy Practice22
2. Unpredictable:
a. Allergic reactions and anaphylaxis.
b. Idiosyncrasy.
c. Genetically determined effects.
PREDICTPREDICT
PREDICTPREDICT
PREDICT
ABLEABLE
ABLEABLE
ABLE
Excessive Pharmacological EffectsExcessive Pharmacological Effects
Excessive Pharmacological EffectsExcessive Pharmacological Effects
Excessive Pharmacological Effects
Generally most common adverse drug reaction which may
occur due to excessive pharmacological effect of the drug.
Excessive pharmacological effect generally appears due to over
dosage of a drug. This is particularly troublesome with cardio
active, hypertensive, hypoglycemia and central nervous system
depressive agents. For example, hypertensive agent used in
hypertension, in excess dose cause profound hypotension.
Adverse reaction due to excess pharmacological effects may
also appear at usual therapeutic dose in certain condition. These
include:
• Patients with kidney disease particularly those who have
lost more than 70% kidney function.
• Hypoalbuminemia which may be due to failure of albumin
production as in liver disease or albumin loss as in nephrotic
syndrome.
• Patient at the extremes of the age range, i.e. infants and
neonates.
Adverse reaction in these conditions can be minimized by
dose adjustment after knowing the pharmacokinetic behavior
of an administered dose.
SecondarSecondar
SecondarSecondar
Secondar
y Pharmacological Effectsy Pharmacological Effects
y Pharmacological Effectsy Pharmacological Effects
y Pharmacological Effects
The effects which are associated with a drug besides the desired
effects are called secondary effects. For example:
• Loss of potassium or extracellular fluid concentration
following thiazide diuretics therapy in treating
hypertension.
• Antihistamines are prescribed for their anti-allergic skin
reactions or for their anti-nausea effects, but they also
produce drowsiness due to central nervous system
depression (secondary pharmacological effects).
Adverse Drug Reactions 23
• Therapeutic dose of salicylates is as potent as some of the
sulfonylureas in lowering blood glucose levels in both
diabetic and non-diabetic patients.
UNPREDICTUNPREDICT
UNPREDICTUNPREDICT
UNPREDICT
ABLEABLE
ABLEABLE
ABLE
Allergic Drug RAllergic Drug R
Allergic Drug RAllergic Drug R
Allergic Drug R
eactions and Anaphylaxiseactions and Anaphylaxis
eactions and Anaphylaxiseactions and Anaphylaxis
eactions and Anaphylaxis
Allergy is an adverse response to a foreign substance resulting
from a previous exposure to that substance. Only a small
proportion of the population exposed to the drug exhibits
allergic reactions. Characteristics of allergic adverse drug
reactions are as follows:
a. The reaction does not resemble the expected pharma-
cological action of the drug.
b. There is delay between the first exposure to the drug and the
development of a reaction.
c. The reaction recurs on repeated exposure even to the
minute quantities of the drug.
‘Anaphylaxis’ is the most serious type of drug allergic
reaction. It occurs only after second or subsequent exposure of
the drug causing allergy. It is generally due to immunoglobulin
E (Ig). Anaphylactic reactions are shown by penicillin,
anaesthetics, dextran and iodine containing compounds. In
most severe form of anaphylaxis, ‘anaphylactic shock’ death
may occur within a few minutes due to complete obstruction
of respiratory passages and lowering of blood pressure..
IdiosyncrasyIdiosyncrasy
IdiosyncrasyIdiosyncrasy
Idiosyncrasy
Idiosyncrasy comes from the Greek words idios, which means
“one’s own,” and synkrasis, which means “a mixing together.”
The word has been used for a long time to describe both a
quantitative and a qualitatively abnormal drug reaction.
Idiosyncrasy refers to strange, bizarre, or surprising drug
effects that cannot be explained or predicted for each person
who experiences them. The list also includes birth defects
caused by drugs, like phocomelia, which happened to children
whose parents were exposed to thalidomide. Here are some
other examples of idiosyncrasies:
• Analgesic may induce tumor of kidney pelvis in patients with
renal disease. Long-term therapy with immunosuppressive
Pharmacy Practice24
agents like azathioprine, cyclophosphamide may induce
lymphoid tumors.
• Thyroid cancer may develop in patients who have received
therapy in the past.
Genetically Determined TGenetically Determined T
Genetically Determined TGenetically Determined T
Genetically Determined T
oxicityoxicity
oxicityoxicity
oxicity
Patients of selected genetic makeup are at substantially greater
than average risk for some specific drug toxicities. For example,
glucose-6-phosphate dehydrogenase is involved in degradation
of glucose for producing energy. Certain population in Africa
and South East Asia are deficient in glucose-6-phosphate
dehydrogenase and, therefore, there are substantial risk of
developing haemolytic disease after the use of antimalarial
drug-primaquine, sulphonamides, guanidine and nitro-
furantoin. Similarly, there is other genetically determined
toxicity. These include:
• Patients with porphyria are susceptible to CNS depression
agents like barbiturates.
• Many drugs are detoxified in liver by acetylation. The ability
of acetylation of many drugs in liver is variable between
individuals. Slow acetylators have greater risk of toxicity for
some drugs like isoniazid, procainamide, hydralazine,
phenelzine and dapsone.
TT
TT
T
oxicity Foxicity F
oxicity Foxicity F
oxicity F
ollowing Sudden Wollowing Sudden W
ollowing Sudden Wollowing Sudden W
ollowing Sudden W
ithdrawal of Drugsithdrawal of Drugs
ithdrawal of Drugsithdrawal of Drugs
ithdrawal of Drugs
Tolerance occurs after prolong use of variety of drugs of
narcotic analgesics, hypnotics, ethyl alcohol, some hypotensive
agents (clonidine) and corticosteroid drugs. Sudden with-
drawal of such drugs shows severe adverse effects.
When patients who are familiar to central nervous system
depressants such as ethyl alcohol, barbiturates, and some
benzodiazepines stop taking their customary dose, they may
experience significant restlessness, rapid heart rate, confusion,
delirium, and seizures. Clonidine is prescribed for the treatment
of hypertension, however, abruptly stopping its use might lead
to the development of severe hypertension.
The occurrence of long-term corticosteroid therapy is infre-
quent due to its potential to induce atrophy in the recipient’s
Adverse Drug Reactions 25
adrenal glands. Hence, an abrupt cessation might trigger an
acute adrenal crisis (Addison’s disease) characterized by severe
weakness, low blood pressure, and collapse in patients. To
prevent such situations, it is recommended to gradually reduce
the intake of corticosteroids over several weeks, taking into
account the duration of their use.
Drug InteractionDrug Interaction
Drug InteractionDrug Interaction
Drug Interaction
Drug interaction may be defined as an alteration of the effects
of one drug by prior or concurrent administration of another
drug. A part from interaction of drug with another drug (drug-
drug interaction), with food (drug–food interaction) and
disease state (drug–disease interaction) it also includes.
Drug interaction becomes clinically more significant in
patients with renal impairment, alcoholics, and patients
receiving chronic medication or having metabolic abnor-
malities. Drug interaction may become harmful to the patient
by increasing efficacy or toxicity or by decreasing the thera-
peutic effect of an administered drug. But sometimes
interactions may prove beneficial; when it allows reduction in
dose by enhanced efficacy without increased toxicity.
Certain drug groups like; anticoagulants, oral hypoglycemic
agents, cytotoxic drugs, digitalis and monoamine oxidase
inhibitors show large number of drug interactions. Drug
interactions are classified in the following ways.
Pharmacokinetic Drug InteractionPharmacokinetic Drug Interaction
Pharmacokinetic Drug InteractionPharmacokinetic Drug Interaction
Pharmacokinetic Drug Interaction
It occurs as a result of altered drug absorption, distribution,
metabolism and excretion.
Altered drug absorption: It may be due to following reasons:
• Physiochemical interaction: Change in gastric pH by one
drug (e.g. antacids—cimetidine, ranitidine) which affects
the ionization of another drug and so absorption of aspirin
remains unionized at the stomach pH, so drug is rapidly
absorbed from stomach but use of antacid with aspirin
reduces the absorption due to alteration of pH.
• Chelation of tetracycline in patients receiving iron/calcium
preparation occurs, which results in poor absorption.
Pharmacy Practice26
• Metaclopramide increases gastric emptying and intestinal
motility and so causes rapid absorption of drug from the
upper small intestine.
• Blood flow: The better the blood supply to an area where a
drug being absorbed, the greater the concentration gradient
and faster the absorption rate.
Altered drug distribution: Some drugs are highly bound to
plasma proteins, e.g. coumarins, sulphonylureas and
phenytoin. Co-administration of a drug, which can displace
the former from their binding sites, will cause an increased
pharmacological activity and possible toxicity. For example:
• Trichloroacetic acid, a metabolite of chloral hydrate, may
displace warfarin from its binding sites (plasma proteins)
and so increases the anticoagulant activity which results in
bleeding tendency.
• Similarly, methotrexate, an anticancer drug, is displaced by
some sulphonamides and a granulocytosis may result.
Altered drug metabolism
• Induction of hepatic microsomal enzymes: Certain drugs, e.g.
barbiturates, alcohol, phenylbutazone and some anti-
convulsants are potent inducers of hepatic microsomal
enzymes. The simultaneous use of these drugs with any
other drug, which is normally metabolized by this route,
will result in increased metabolism or clearance of the latter
with reduced therapeutic efficacy if the parent compound is
the effect mediator but possibly increased if effect is due to
a metabolite. For example, interaction of barbiturates with
warfarin results in decreased anticoagulant effect. Inter-
action of tolbutamide with alcohol/phenytoin/rifampicin
results in decreased hypoglycemic effect.
• Inhibition of hepatic microsomal enzymes: Some drugs inhibit
the activity of microsomal enzymes and so the metabolism
of other drugs. For example, allopurinol, a potent inhibitor
of xanthine oxidase, reduces the metabolic or clearance rate
of 6-mercaptopurine which may cause bone marrow
depression if the dose of the latter is not reduced.
Altered drug excretion
Active tubular secretion of many drugs occurs in proximal limb
of the loop of Henle. If two drugs, which are normally secreted
Adverse Drug Reactions 27
in this way, are co-administered in large doses, competition
may lead to an interaction whereby greater than expected
amount of one or other are retained in the body. For example,
interaction occurs between probenecid and penicillin in which
probenecid is used to prolong the action of penicillin.
METHODS FOR DETECTING ADMETHODS FOR DETECTING AD
METHODS FOR DETECTING ADMETHODS FOR DETECTING AD
METHODS FOR DETECTING AD
VERSE DRUG REAVERSE DRUG REA
VERSE DRUG REAVERSE DRUG REA
VERSE DRUG REA
CTIONSCTIONS
CTIONSCTIONS
CTIONS
Many factors are responsible for the adverse effects of drugs
in patients receiving it. The adverse effects of the drug depend
on its dose, duration, toxicity and other individual factors such
as sex, age, genetics, compliance of patients and total number
of drugs administered. Whether a patient experiences the
toxicity of drug depends on its dose. The pharmacokinetics of
the drug may also affect the drug toxicity. Alteration in
pharmacokinetic of drug may result in abnormally higher
concentration of drug at receptor site, resulting in adverse
effect.
Therapeutic index of a drug is also responsible for the
adverse effects. The drug with small therapeutic index is more
prone to produce adverse effects than with large therapeutic
index, e.g. therapeutic index of amphotericin B is small while
that of acetaminophen is large. Hence, 75% of patients receiving
amphotericin B show the adverse effect while less than 1% of
patients receiving acetaminophen show the adverse effects. The
infants are more prone to adverse effects because of incomplete
development of liver enzyme system. Also, the elderly patient
shows higher incidence of adverse effects.
The common cause of drug-induced disease is the excessive
pharmacological effects of drug which is readily predictable,
whereas other types of drug-induced disease are more difficult
to detect and quantify (non-predictable). The various methods
are given below:
1. Spontaneous Case Reports
It is the common method of affecting doubts about drug-related
diseases. A prescriber suspects that a condition arising in a
patient may be drug-related. He therefore reports either in a
letter to the medical journals or to the manufacturer of drug.
By this means other prescribers are alerted to the possibility of