manitoba comprehensive medication review toolkit

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Manitoba Comprehensive Medication Review Toolkit

TABLE OF CONTENTS

INTRODUCTION 3

SECTION ONE: WHAT IS A COMPREHENSIVE MEDICATION REVIEW? 5

What is a Comprehensive Medication Review? Why Perform a Comprehensive Medication Review?

SECTION TWO: PREPARING FOR THE COMPREHENSIVE MEDICATION REVIEW 9

Staff Involvement Scheduling Appointments Tasks for the Patient Getting Consent

SECTION THREE: CONDUCTING A COMPREHENSIVE MEDICATION REVIEW 12

Medical Information Gathering A Systematic Medication Review Process Identification of a Drug Therapy Problem What if there are no Drug Therapy Problems? Care Plan Development Intervention Guideline

SECTION FOUR: FOLLOWING THE COMPREHENSIVE MEDICATION REVIEW 20

Communication with Health Care Practitioner(s) Follow-up with the Patient

SECTION FIVE: COMPREHENSIVE MEDICATION REVIEW SUMMARY 23

Systematic Patient Review Process: An Overview Comprehensive Medication Review Summary Checklist

APPENDICIES: A TO H 26

CASE EXAMPLES 60

Introduction

Welcome to Pharmacists Manitoba's Comprehensive Medication Review Toolkit. This guide

has been developed to assist Manitoba pharmacists with the implementation of the

medication review program in their pharmacies and provide support throughout the

process of performing medication reviews for patients.

How to use this guide

The Manitoba Comprehensive Medication Review Toolkit takes you through the medication

review process from initial patient contact through follow-up. We would recommend you read

through the guide to familiarize yourself with the basic process and take advantage of the tools

provided. See Appendices for forms, response guides, helpful links and resources to build a

medication review program that works best in your practice. The program has been designed to

allow you to select the tools that help you to best serve the needs of your unique patient

population.

While this guide does cover the medication review process in some degree of detail, it is

important to remember that it is only a guide. The pharmacist must internalize a process to

ensure accurate and comprehensive collection of relevant patient information and thorough

analysis of drug therapy problems. Build your process to fit your practice setting and provide

the best possible care for your patients. Please note that certain forms may be necessary to use

in order to uphold standards of practice with regard to documentation.

Thank you for participating!

Pharmacists Manitoba would like to thank you for making this effort to expand the patient

care services at your pharmacy. We hope you will find this guide helpful in preparation for

both the opportunities and challenges associated with comprehensive medication

reviews. Feedback is always appreciated as we endeavour to provide our

membership with the most relevant and up-to-date program possible.

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How to Guide

Acknowledgements

This toolkit was a joint initiative between Pharmacists Manitoba and the College of

Pharmacy, Faculty of Health Sciences, University of Manitoba Manitoba, 4th Year Elective

Program. The students involved in its creation were Alisha McCulloch and Sarah Stroeder. We

greatly appreciate the input and guidance from Pharmacists Manitoba preceptors Britt Kural,

Amy Oliver and Dr. Brenna Shearer. Thank you to our pharmacist reviewers, who

represented key stakeholders including the College of Pharmacists of Manitoba,

University of Manitoba, Pharmacists Manitoba's Professional Relations Committee and

practicing Manitoba pharmacists. Thank you also to the 4th year pharmacy students and

preceptors who were part of the pilot project in March 2013. We would like to acknowledge

the Ontario Pharmacists Association, New Brunswick Pharmacists Association and Canadian

Pharmacists Association for their excellent medication review toolkits that were a great

resource for us.

Disclaimer

The Manitoba Comprehensive Medication Review toolkit documents contain information

representing the opinions and experience of the individuals involved in program development.

Every effort has been made to provide useful and accurate information. However,

Pharmacists Manitoba and others involved in its development and review are not

responsible for the use or the consequences of the use of the tools and information in this

toolkit. Users are advised that the information presented is not intended to be all-inclusive.

Consequently, pharmacists and other users of the program are encouraged to seek additional

and confirmatory information to meet their practice requirements as well as the information

needs of their patients.

What is a comprehensive medication review?

During a comprehensive medication review, pharmacists perform a medication reconciliation

including prescription, non-prescription drugs, over the counter, and natural health products to

verify what medications a patient is taking and how they are taking them. It is also the

opportunity to reassess the appropriateness of the product (valid indication, appropriate

dosing) and screen for potential problems the medication may present to the patient (side

effects, drug interactions, etc).

Through this process, pharmacists may also discover medical issues that are not currently being

adequately treated, barriers to patient adherence and opportunities for further health

promotion, such as smoking cessation. If drug therapy problems (DTPs) are identified, some

may be addressed and corrected immediately or more time may be needed to develop a care

plan. This guide will assist you by helping you develop a process to resolve DTPs regardless of

the degree of complication.

In the event that no DTPs are identified, the review process is still a valid and important one as

patients better understand how to take their medications safely and appropriately. A

comprehensive medication review offers an opportunity to prevent future DTPs through

education and guidance.

Medication reviews are distinctly different from regular counseling sessions that occur day-to-

day on newly prescribed and refilled prescriptions. A comprehensive medication review

requires a sit-down, face-to-face interview between the pharmacist and the patient (with or

without a caregiver, as appropriate) in a private patient counseling area. It is important to

differentiate these two patient care services as future compensation for a medication review

may only be provided if the program process is carried out and properly documented.

Why perform a comprehensive medication review?

As a highly trusted and readily accessible health care provider, pharmacists are well-positioned

to help their patients achieve optimal drug therapy outcomes.

The goals and objectives of a comprehensive medication review are as follows:

Assist patients in gaining a better understanding of their medications which in turn

promotes medication adherence

Maximize benefits associated with a patient’s medication regimen

Minimize risks associated with a patient’s medication regimen and uphold patient safety

Identify aspects of patient health where further attention is required

Identify and address areas of patient concern with regards to medication

At the conclusion of a medication review, the patient can be provided with a Best Possible

Medication History (see Appendix A) to keep for their records. This record is a comprehensive

list of Prescribed Medications, Non-prescribed Medications (OTC’s), and Natural Health

Products (Herbal Products, Homeopathic Remedies, Alternative Therapies, etc) the patient

takes on a regular or intermittent basis. This record should be signed and dated by the

pharmacist and a copy retained for pharmacy records. Educate your patients to share their

comprehensive, accurate and up-to-date medication list with all health care professionals they

come in contact with.

Who is a candidate for a comprehensive medication review?

There are many opportunities for medication reviews. These include, but are not limited to:

Patients diagnosed with or at risk of developing chronic conditions such as diabetes,

hypertension, heart failure, asthma, COPD, rheumatoid arthritis, chronic pain, etc

Patients taking more than one chronic medication or is currently prescribed medication

from more than one HCP

Patients taking high-risk medications such as warfarin, immunosuppressant drugs,

antiepileptics medication, opioids and benzodiazepines, etc

Elderly (65+) patients (especially those at risk for falls)

Patients presenting medication adherence challenges

Situations where there is drug abuse or misuse potential

Patient being discharged from hospital

Patient who receives a new diagnosis

Patient is planning for an extended period of travel, such as moving south for the winter

Referrals for medication reviews may come from you and your pharmacy team, other health

care providers or patients and their families may self-refer.

Staff Involvement

It is important to have your pharmacy staff on board with the plan to implement a medication

review service at your pharmacy because the program will require their support and

involvement in order to run most efficiently. While pharmacists are the only staff members who

can perform the actual review, other staff members can assist you with identifying potential

medication review clients, appointment scheduling and patient reminders. Pharmacy students

and interns may also perform medication reviews under the supervision of the pharmacist.

Team members can also collect the necessary forms, print a recent medication profile, and

perform demographic information gathering in preparation for the review. We encourage a

team approach to providing a quality patient care program such as this one.

Scheduling appointments

To assist your pharmacy staff in booking appointments, design a scheduling system (either

electronic or paper-based) that fits with your pharmacy workflow. The schedule should

highlight the periods of time when there is a pharmacist available to perform a comprehensive

medication review. An average medication review will take between 30-60 minutes with the

patient, in addition to some time spent preparing for the meeting and any time spent

afterwards on care plan development and further communicating with the patient as well as

the prescriber and/or other health care providers. Separate follow-up appointments should

also be scheduled in this system. See Appendix B for a sample medication review schedule.

Pharmacists may wish to maintain a separate notebook with reminders or set up electronic

reminders for follow-up calls to patients and health care practitioners.

It would be valuable for a member of your pharmacy staff to provide reminder calls to patients

for the coming day’s appointments. You may wish to utilize reminder cards to send home with

patients after they book an appointment. For your convenience, these cards are included in

Appendix B. Ask patients to arrive 5-10 minutes early for their appointment in order to

complete the demographic information portion of the Best Possible Medication History.

Tasks for the patient

Prior to the medication review, you may wish to have your patient fill out the Screening Tool

(See Appendix A) This questionnaire helps the patient self-identify issues with respect to

medication adherence, understanding of their medication regimen and personal feelings about

medication. This document can be sent home with the patient to fill out and bring to their

appointment or it can be completed in the 5-10 minutes before their review is scheduled. This

document assists the pharmacist in identifying what issues may need to be addressed during

the patient interview.

When the appointment is made, the patient should be asked to bring all their medications to

the appointment (prescription, over-the-counter, natural health products) as well as any

devices that they require (inhaler, aerochamber, blood glucose monitor, dosette, etc). A

reminder for this task can also be given during the reminder call.

Getting Consent

Prior to beginning the medication review, direct your patient’s attention to the Consent section

of the Best Possible Medication History document.

Explain the medication review process, including the potential for future follow-up with

the patient to discuss any interventions put in place

Discuss the potential need to share the patient’s personal health information with other

health care providers (physicians, nurse practitioners, etc)

If a caregiver is present for the medication review, or is serving as the representative for

the patient, obtain consent for their involvement

It is important to obtain and document consent before proceeding with the medication review.

Medical Information Gathering

The information listed below follows the form Best Possible Medication History which can be

used to record all relevant patient background information. Keep in mind this is baseline

information only and referrals for further investigation to other professionals such as QUIT

trained pharmacists, Certified Diabetes Educators, and other areas of specialty may be

warranted.

1. Review completed Screening Tool to identify background problems and primary concerns of

the patient

2. Get consent from patient and caregiver, if present (see page 10 “Getting Consent”)

3. Collect other health information and lifestyle factors that may affect their medications and

overall health status

4. Document all patient disease states and medical conditions with relevant parameters

included

o E.g. Diabetes: include HgA1C, time of diagnosis, blood glucose readings, testing

frequency, history of hypoglycemia, etc.

Consider the following to assess renal function

o Are they likely to have decreased renal function? (E.g. Elderly, diabetic, known

renal disease, etc.)

o Calculate Creatinine Clearance (CrCl) using the most recent serum Creatinine

(sCr) level if available (see Appendix E)

5. Conduct a head-to-toe assessment of bothersome symptoms, complaints, and other health

related concerns (see Appendix D)

o Note: Further targeted line of questioning may be necessary when a patient

reports conditions/symptoms

6. Ask about Prescribed Medications, Non-prescribed Medications (OTC’s), Natural Health

Products (Herbal products, Homeopathic Remedies, and Alternative Therapies) that are

taken on a regular and intermittent basis

Why are they taking this medication?

How do they take their medication?

How long have they been taking this medication?

Inquire about their experience with medication

o How has it been working for them?

o Have they been experiencing any unwanted side effects?

7. Have they recently stopped taking any of their medications?

This will conclude the medication reconciliation process. Ensure all other medications discussed

are included on the Best Possible Medication History for both patient and pharmacy records.

The pharmacist may require additional time to review the information gathered and to

complete the process outlined in this document. Please note that these problems can be

complex and may require contacting or referral to the patient’s family physician and/or other

health care practitioner. The pharmacist may wish to consider requesting the patient to

return for a second session to complete the medication review and discuss potential care

plans.

A Systematic Medication Review Process

Once data has been collected and documented, it is essential that the pharmacist utilize a

comprehensive and systematic approach to identifying, preventing, and resolving potential and

actual drug therapy problems. This is an invaluable tool for pharmacists to develop as it

encompasses the core purpose of a comprehensive medication review, and is a skill set specific

to the pharmacist. The document titled A Systematic Medication Review Process (see

Appendix C) should be used as an aid to develop this step-by-step approach.

1. Is there a documented indication for each drug?

Are all medications still necessary?

Are all medications at the appropriate dose for the given indication?

Are the medications that do have indications the most appropriate choice of therapy for

this patient?

o If taking more than one medication for the same condition, should they be?

2. Are there any conditions which are currently untreated that may require medication?

3. For each medical condition or symptom:

Is the problem being caused by a drug?

o Consider: What drugs could cause similar signs/symptoms to this? What is the

time frame of the problem relative to current or recent drug use?

Have non-pharmacologic strategies been attempted?

Is the chosen therapy optimal for this patient?

o Consider: drug, dosing regimen, dosage form, safety, efficacy, drug interactions,

cost, convenience, adherence, time to onset, coverage by third party payers

4. Are there any drug interactions that may exist within their current drug regimen?

Judge the relevance and necessity for intervention if drug interactions do exist

o Consider: Drug-Drug, Drug-Food, Drug-Disease

5. Is the patient receiving maximum benefit and minimal adverse effects from each medicine?

o Consider: efficacy, toxicity, drug interactions

6. Is the patient on any medications that require regular monitoring/adjustments?

Are all medications at the appropriate dose for the patient’s renal function?

o See Appendix E

Are there any medications that are hepatotoxic and require regular monitoring of liver

function tests?

Is the patient taking any medications that require assessment of drug levels?

o See Appendix F

Do any of their medications put them at risk of ototoxicity or oculotoxicity?

o See Appendix F

See Appendix G for link to normal lab values

7. How is the patient‘s drug-taking behaviour?

o Consider: attitude, knowledge, physical/sensory/cognitive limitations, adherence

to therapy, daily routine, social situations

8. Are there any other issues that affect medication use in this client?

o Consider: lack of knowledge, outdated label, caffeine/alcohol/nicotine use,

degree of communication with health care professionals, multiple health care

practitioners/pharmacies, primary prevention strategies (e.g., osteoporosis,

immunization, tobacco cessation), drug storage, drug cost, drug hoarding,

financial constraints

Sources (pp 12-15): Grymonpre, R., et al. Pharmacy Interview Guidelines, PHRM 3110 Pharmacy Skills Lab III. Faculty of Pharmacy, University of Manitoba, Winnipeg, Manitoba.; The NB Department of Health, the New Brunswick Pharmacists’ Association, and the Canadian Pharmacists Association. (2010). Program Guidance Document, NB Pharmacheck.; Amy Oliver, B.Sc.Pharm 4th Year Elective Project – Home Care Chart Review

Identification of a Drug Therapy Problem

When a drug therapy problem is identified, it is important to recognize the urgency of the

situation and decide whether or not it can be dealt with in the pharmacy or if health care

practitioner referral is required. Some cases may require simple patient counseling and

clarification of current medications. Other issues may require further research by the

pharmacist and suggestions for interventions that will involve the physician and/or other health

care practitioners. Interventions and recommendations do not need to be complicated, but rely

heavily on communication.

Drug therapy problems that arise throughout the interview can be documented on the form

Drug Therapy Problems Identified (see Appendix A) and later prioritized in order of importance

and urgency. For those drug therapy problems which can be corrected with immediate action

and no further research or consultation, documentation can be completed at the bottom of this

form. Discussion with the patient and intention for follow-up should be indicated as well. For

those drug therapy problems requiring further research, contact with other health care

providers and care plan development, the form Pharmacy Care Plan (see Appendix A) can be

utilized and is discussed further below.

What if there are no Drug Therapy Problems?

Commend these patients on their effective management of their medications and conditions.

Remember that the review process is still a valid and important one as patients better

understand how to take their medications safely and appropriately. A comprehensive

medication review offers an opportunity to prevent future DTPs through education and

guidance.

Care Plan Development

A care plan is a tool to synthesize information collected, issues identified and prioritized,

planned interventions, desired outcomes, and strategies for monitoring and patient follow-up.

The Pharmacy Care Plan worksheet uses the DAP (data, assessment, plan) format to organize a

concise care plan. Each drug therapy problem requiring further work-up will have a separate

care plan.

D = DATA

This section includes both subjective information to communicate the issue or complaint

expressed by the patient as well as outlines the relevant objective data collected during the

interview to support the proposed problem, assessment and plan. Avoid adding extra

information that isn’t relevant as it will make the note longer and more likely that others will

miss your point. Important information may include:

A list of the medications (drug, dose, route, frequency, etc.) the patient takes relevant

to the drug therapy problem

Objective measures such as blood pressure, lab results, etc.

Patient’s own drug taking habits and issues that may affect therapy

A = ASSESSMENT

This section is to provide a statement of the drug therapy problem based on the pharmacist’s

assessment. This is one sentence outlining who is experiencing (or at risk of experiencing), what

due to a drug related issue.

______________________________________________________________________________

P = PLAN

This section should be specific and outline the recommendation of how to resolve or prevent

the problem identified. If a new drug is being introduced or changed, the plan should be

justified for each specific case by including information about the efficacy, dosing, side effects,

drug interactions, convenience, cost, adherence, patient desires and third party coverage of

the option chosen. However, in other cases a suggestion may be made to stop a medication

which must also be justified. Monitoring is essential to the care plan and should include both

desired positive endpoints (efficacy) and potentially negative endpoints (adverse effects) that

are being monitored, to what magnitude, how frequently, and for how long they should be

monitored. Alternatives may also be listed, however in less detail, considering different drug

classes and regimens as well as non-drug interventions that may be beneficial. These allow for

patient and health care practitioner input to identify the ideal patient centered care plan.

A planned follow-up date is also crucial to have with the patient to monitor and gauge the

effectiveness of the chosen care plan.

Intervention guideline

The concept of patient-centered care holds exceptional value in engaging patients to

participate and take responsibility for their own health care. Pharmacists are role models in

actively including patients in making changes to their current health care regimens, as well as

developing new health care plans.

It is recommended that the patient should be involved as much as possible and have

input in suggested interventions

o Explain the situation to the patient in a way that does not undermine the health

care practitioner-patient relationship

o Avoid medical jargon and tailor your explanation to the level of the patient

o Verify patient’s understanding of plan: Ask patient to repeat information back, or

to demonstrate how to use medications and devices

See that the patient has necessary drugs and supplies

o Consider financial and insurance status

Make sure the patient understands the need for follow-up and will participate in

monitoring

o Monitoring may involve tools such as blood pressure monitors, peak flow meters,

home glucose monitors, pain diaries, etc.

Lifestyle related interventions are common and require ongoing contact, reassurance,

and support

o E.g. Smoking Cessation

Ensure that the patient understands and is aware of proposed changes before

discussion with physician and/or other health care practitioners

Source (pp 17, 18): Grymonpre, R., et al. Pharmacy Interview Guidelines, PHRM 3110 Pharmacy Skills Lab III. Faculty of

Pharmacy, University of Manitoba, Winnipeg, Manitoba.

Communication with Health Care Practitioner(s)

After the medication review and care plan(s) are complete, the pharmacist should complete

and send the Health Care Practitioner Communication Form (see Appendix A) for prescriber

input and authorization along with relevant sections of the Best Possible Medication History

(Section 4 – Medical Conditions, Section 5 – Medication List, etc) and the Pharmacy Care

Plan(s). The Health Care Practitioner Communication Form allows the pharmacist to

summarize the top priority drug therapy problems along with their recommendation, which

should be explicit in communicating the discontinuation of a drug (i.e. STOP drug A) or if

beginning a new medication where a prescription is required. This form can then be filled out

and signed by the physician and/or other health care practitioner on the right hand side and

sent back to the pharmacy for prescription communication purposes.

When using the Health Care Practitioner Communication Form, any therapies that the

pharmacist is recommending must include the drug name, strength, instructions (including

treatment goal depending on the HCP) and quantity to be dispensed including refills (and

interval information, when applicable) according to the College of Pharmacists of Manitoba’s

Joint Statement on Facsimile Transmission of Prescriptions. If the pharmacist includes all of this

information, this form can serve as a legal prescription.

Follow-up with Patient

Follow-up appointments, either by phone or in person, should be made with patients following

the comprehensive medication review. All follow-up appointments can be documented on the

Patient Follow-up Record (see Appendix A) and used for multiple follow-up arrangements if

necessary. Ensure the patient is given an up to date Best Possible Medication List (Part 5, page

4 of Best Possible Medication History Form) if changes are made after contact with the

physician and/or other health care practitioners.

You may wish to provide your patient with a Patient Action Plan (see Appendix A). This is a

summary of actions to be taken as a result of the comprehensive medication review developed

in collaboration with the patient. For example, if the pharmacist discovered that the patient

was taking calcium at the same time as their levothyroxine, the pharmacist may suggest taking

these medications at separate times. This can be recorded on the Patient Action Plan as a

reminder for the patient.

For convenience, the charts found on pages 23 and 24 can be found in Appendix C and printed

as a two-sided summary page on performing a comprehensive medication review. This would

be useful to keep in your patient counseling room for quick reference while performing

comprehensive medication reviews.

Systematic Patient Review Process: An Overview

Source: The NB Department of Health, the New Brunswick Pharmacists’ Association, and the Canadian Pharmacists Association.

(2010). Program Guidance Document, NB Pharmacheck.

Comprehensive Medication Review Summary Checklist

As you progress through your medication review, utilize this checklist as a guide to ensure all components of the review are addressed.

Prior to the Review*: Initials Provide patient with Screening Tool to complete at home before appointment

Request patient bring all medications to the appointment – including OTCs & NHPs

Print a list of patient’s active medications from your pharmacy software and/or DPIN

Assemble basic patient demographic information, acquire copies of health and insurance cards

* The above tasks may be completed by any pharmacy team member

During the Review: Initials Explain nature of review process, discuss confidentiality and obtain patient consent

Review patient’s completed Screening Tool, take note of issues raised

Complete Best Possible Medication History form o Add medications not on pharmacy file to medication history as they are

reviewed

Review each medication fully (including OTCs and NHPs) with the patient

Identify drug therapy problems (DTPs) based on preceding information and list on the Drug Therapy Problems Identified form

Consult list of DTPs identified o If no other input necessary, discuss the care plan with the patient and

implement immediatelyo If more time is required, work up DTPs on Pharmacy Care Plan formo Contact health care practitioner and/or other health care providers as

appropriate using the Health Care Practitioner Communication Form

Following the Review: Initials Schedule follow-up with the patient – utilize Patient Follow-up Worksheet

Provide patient with a comprehensive, accurate, up-to-date medication list (signed by the pharmacist – retain a copy for your pharmacy records)

If warranted, provide patient with a Patient Action Plan

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Appendices

Appendices – Table of Contents

Appendix A – Medication Review Forms

Screening Tool

Best Possible Medication History

Drug Therapy Problems Identified

Pharmacy Care Plan

Patient Action Plan

Patient Follow-up Record

Health Care Practitioner Communication Form

Appendix B – Program Implementation Support

Medication Review Reminder

Sample Medication Review Schedule

Appendix C – A Systematic Medication Review Process

Process flow chart and checklist

Appendix D – Head to Toe Patient Assessment Guide

Appendix E – Considering Kidney Function

Calculating creatinine clearance, eGFR

Manitoba Renal Program Resources

Appendix F – Medication Reference Lists

High alert medications

List of ototoxic and oculotoxic medications

Appendix G – Clinical Resources

Selected Clinical Practice Guidelines, Link to Clinical Practice Guidelines Database

Beers Criteria, STOPP tool

Link to Normal Lab Values

Appendix H – Public Health Resources

Manitoba Vaccination Schedule

CCMB Cancer Screening Schedule

Lung Association

Smokers Help Line

What is a Medication Review?

A Medication Review is a service

that involves your pharmacist

performing a complete assessment

of your medications

What benefits are there from having a

Medication Review?

Address any questions or concerns

that you have about your medicine

Ensure that you are receiving the

best medicine therapy possible

Increase your knowledge about

your medicine

Increase your confidence in using

your medicine

Reduce your risk of problems from

your medicine

Are You Getting the Most

from Your Medications?

Are you taking several medications

(including natural products and non-

prescription products)

Do you have more than one doctor or

other health care provider

Do any of your medications make you

feel unwell

Does the cost of your medicine make it

hard for you to take it as prescribed

Do you have trouble understanding or

remembering how to take your

medicine

Do you ever have trouble using your

medicines (swallowing, puffers, eye

drops, patches)

Do you feel that you are taking too

many medicines

Do you worry that your medicines are

working against each other

Have you recently been discharged

from the hospital

Do you wish you knew more about your

medicine

* If any oIf any of these apply to you, talk to your pharmacist about whether a Medication Review is right for you.

Patient Name: PHIN: DOB: Phone:

Pharmacy Contact Information Here

Pharmacist: _____________________


1. Patient Information

Name Age Third Party Coverage

Gender Male Female Undifferentiated

Family Physician

Address City/Province Other Physician/Specialist

Postal Code Phone # Caregiver (if applicable) Phone #

Reason for Med Review Pharmacist Completing Review License No.

What is your primary concern about your medications today?

What are your expectations from your medications, and what would like to achieve from your med review today?

2. Consent

I have received information on, and have consented to review processPatient Signature:______________________________________________

I have agreed that information may be shared with my physician and other healthcareproviders

Patient Signature:______________________________________________

I consent to having my patient representative/caregiver involved in medication review(if applicable)

Name of Representative(s):_______________________________________ Patient Signature:_______________________________________________



Pharmacist: _____________________ 3. Health Information and Lifestyle Factors

Inquiry Yes/No Details/Comments Allergies Y N Reaction:

Smoker Is now a good time to quit?

Y NFormer Smoker

Cigarettes/day: x____years

Alcohol Consumption Y N Drinks/week:

Caffeine Intake Y N Cups/day:

Grapefruit (Juice) Consumption Y N

Nutritious Diet Y NRestricted Diet

Physically Active Y N Type of activity:

Minutes/week:

Recreational/Other Drug Use Y N

Yearly Influenza Immunization Y N

Pneumococcal Immunization (if over 65)

Y N

Other Vaccinations (travel, routine, etc.)

Y N Please list:

Screening Completed (breast, colon, cervical, etc.)

Y N What/When:

Eye Exam, Hearing test within last year

Y N

Regular or recent lab tests (copy & attach results if possible)

Y N Date/Result:

Body Mass Index (BMI) Normal Overweight

Underweight

Height: Weight:

Do you live alone? Y N

Aids, Alerts, Devices, etc. Other



Pharmacist: _____________________

4. Medical Conditions (List medical conditions in numbered spaces with relevant information/parameters)

Kidney Disease? Liver Disease? BP = HR = RR = CrCl =

Y N NA Pregnant? Trimester:Y N NA Breastfeeding?

E.g. Diabetes

Type II, diagnosed in ___HgA1C = 7.2% (mm/yyyy)Tests 3 times daily (blood glucose diarycopied and attached), sees foot specialiston regular basis

1. 2. 3.

4. 5. 6. 7.

8. 9. 10. 11.

Head to toe Assessment regarding other complaints/concerns/bothersome symptoms: Do any ever require self treatment?

Family History



Pharmacist: _____________________

5. Medications (Prescription, Non-Prescription, Natural Health Products, Homeopathic Remedies)

Medication Name, Strength

How Taken Dose, Route, Frequency, Time

of Day, Special Instructions

Purpose for Use How long taken Issues Identified

Additional Comments

Yes: Proceed to DTPs Identified

No: Verify to continue as per



Pharmacist: _____________________

6. Recently Discontinued Medications


How Taken Dose, Frequency, Time of Day,

Special Instructions

Purpose for Use How long taken? When was stopped?

Who stopped it? Reason for Stopping?

Require Further Action?





Pharmacist: _____________________


No drug therapy problems were identified

Priority Number Drug Therapy Problem (DTP)

_____ _________________________________________________________________

_____ __________________________________________________________________

_____ __________________________________________________________________

_____ __________________________________________________________________

_____ __________________________________________________________________

_____ __________________________________________________________________

For those drug therapy problems above which can be corrected with immediate action and no further research or consultation, document your plan below:

DTP #

Proposed solution Discussed with

patient

Follow-up Plan

For those drug therapy problems requiring further research, contact with other health care providers and care plan development, utilize the Pharmacy Care Plan worksheet.

____________________________________ __________________________ Pharmacist signature Date of Review



Pharmacist: _____________________

Pharmacy Care Plan

Data: Subjective information provided by the patient and/or objective data that you have

collected.

Assessment: State the drug therapy problem.

Plan: For each alternative, consider treatment efficacy, safety, drug interactions, adherence, cost, drug coverage and non-pharmacological interventions.

Alternative #1:

Alternative #2:

Monitoring:

Planned date of follow-up: ____________________________

____________________________________ __________________________

Pharmacist signature Date of Review



Pharmacist: _____________________

Patient Action Plan

Date of Comprehensive Medication Review: _________________________

As a result of my comprehensive medication review, I will do the following:

1.

2.

3.

4.

5.

6.

7.

Source: The NB Department of Health, the New Brunswick Pharmacists’ Association, and the Canadian Pharmacists Association. (2010). Program Guidance Document, NB Pharmacheck.



Pharmacist: _____________________


Date of Follow-Up Reason for Follow-up Results Pharmacist Comments & Plan

Any new concerns?

Intervention complete? Yes No

Pharmacist signature: _______________

Any new concerns?



Any new concerns?



THIS TELECOPY IS CONFIDENTIAL AND IS INTENDED TO BE RECEIVED BY THE ADDRESSEE ONLY. IF THE READER IS NOT THE INTENDED RECIPIENT THEREOF, YOU ARE ADVISED THAT ANY DISSEMINATION, DISTRIBUTION OR COPYING OF THIS FACSIMILE IS STRICTLY PROHIBTED. USE OF THIS FORM FOR PURPOSES OR BY PERSONS, NOT AUTHORIZED UNDER THE CONTROLLED DRUGS AND SUBSTANCES ACT AND ITS REGULATIONS IS A CRIMINAL ACT. PRACTITIONER CERTIFICATION: THIS PRESCRIPTION REPRESENTS THE ORIGINAL OF THE PRESCRIPTION DRUG ORDER, THE PHARMACY ADDRESSEE NOTED ABOVE IS THE ONLY INTENDED RECIPIENT AND THERE ARE NO OTHERS, THE ORIGINAL PRESCRIPTION HAS BEEN INVALIDATED AND SECURELY FILED AND IT WILL NOT BE TRANSMITTED ELSEWHERE AT ANOTHER TIME, QUANTITY MUST BE STATED IN WORDS AND NUMERALS

Form adapted from: The Ontario Pharmacists Association, MedsCheck.


Pharmacist: _____________________


Date:_______________________

Dear Dr._____________________,

Your patient had a Comprehensive Medication Review completed on ________________. Listed below are my assessment(s) and recommendation(s). Please provide a response below (if indicated) at your earliest opportunity. Should you like to discuss any of the information contained don’t hesitate to contact me.

Drug Therapy Problem Pharmacist Recommendation Make Changes as Recommended

Prescriber Comments/Revisions

Information Only Action Required

Yes No


Yes No

Pharmacist Name: License #:

Prescriber Signature: License #: Date:

Health Care Practitioner Re: (Patient’s Name) PHIN

Address Address

Phone # Fax # DOB Phone #

Appendix B •

Program Implementation Support

MED REVIEW REMINDER

We have scheduled a medication review for _________________

on _________________ at ______________. Please bring:

Your completed Medication Review questionnaire

ALL the medication you take (prescription, over-the-counter, natural health products)

ALL medical devices (aerochamber, glucose monitors, dosettes, etc.)

Please arrive 5-10 minutes before your appointment time. Please call the pharmacy if you cannot make your appointment or if you have any questions.

MED REVIEW REMINDER

We have scheduled a medication review for _________________

on _________________ at ______________. Please bring:

Your completed Medication Review questionnaire

ALL the medication you take (prescription, over-the-counter, natural health products)

ALL medical devices (aerochamber, glucose monitors, dosettes, etc.)

Please arrive 5-10 minutes before your appointment time. Please call the pharmacy if you cannot make your appointment or if you have any questions.

Ph

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P

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e

SAMPLE MEDICATION REVIEW SCHEDULE

Monday Tuesday

NAME NUMBER NAME NUMBER

8:oo 8:oo

9:00 9:00

10:00 10:00

11:00 11:00

12:00 12:00

1:00 1:00

2:00 2:00

3:00 3:00

4:00 4:00

5:00 5:00

Wednesday Thursday


8:oo 8:oo

9:00 9:00

10:00 10:00

11:00 11:00

12:00 12:00

1:00 1:00

2:00 2:00

3:00 3:00

4:00 4:00

5:00 5:00

Friday Saturday/Sunday


8:oo 8:oo

9:00 9:00

10:00 10:00

11:00 11:00

12:00 12:00

1:00 1:00

2:00 2:00

3:00 3:00

4:00 4:00

5:00 5:00

1. Is there a documented indication for each drug?

Are all medications still necessary?

Are all medications at the appropriate dose for the given indication?

Are the medications that do have indications the most appropriate choice of therapy for this

patient?

o If taking more than one medication for the same condition, should they be?

2. Are there any conditions which are currently untreated that may require medication?

3. For each medical condition or symptom:

Is the problem being caused by a drug?

o Consider: What drugs could cause similar signs/symptoms to this? What is the time

frame of the problem relative to current or recent drug use?

Have non-pharmacologic strategies been attempted?

Is the chosen therapy optimal for this patient?

o Consider: drug, dosing regimen, dosage form, safety, efficacy, drug interactions, cost,

convenience, adherence, time to onset, coverage by third party payers

4. Are there any drug interactions that may exist within their current drug regimen?

Judge the relevance and necessity for intervention if drug interactions do exist

o Consider: Drug-Drug, Drug-Food, Drug-Disease

5. Is the patient receiving maximum benefit and minimal adverse effects from each medicine?

o Consider: efficacy, toxicity, drug interactions

6. Is the patient on any medications that require regular monitoring/adjustments?

Are all medications at the appropriate dose for the patient’s renal function?

o See Appendix F

Are there any medications that are hepatotoxic and require regular monitoring of liver

function tests?

Is the patient taking any medications that require assessment of drug levels?

o See Appendix G

Do any of their medications put them at risk of ototoxicity or oculotoxicity?

o See Appendix G

See Appendix H for normal lab values

7. How is the patient‘s drug-taking behaviour?

Consider: attitude, knowledge, physical/sensory/cognitive limitations, adherence to therapy,

daily routine, social situations

8. Are there any other issues that affect medication use in this client?

Consider: lack of knowledge, outdated label, caffeine/alcohol/nicotine use, degree of

communication with health care professionals, multiple health care practitioners/pharmacies,

primary prevention strategies (e.g., osteoporosis, immunization, tobacco cessation), drug

storage, drug cost, drug hoarding, financial constraints

Source: Pharmacy Practice 1998;14(5):71. Grymonpré R., Geriatric Care. How pharmacists can optimize

medication use by elderly patients.

Systematic Patient Review Process: An Overview

Source: The NB Department of Health, the New Brunswick Pharmacists’ Association, and the Canadian Pharmacists Association. (2010).

Program Guidance Document, NB Pharmacheck.

Medication Reconciliation

• Check that patient’s list matches what they should be taking according toprescriptions and doctors orders, and that they are indeed taking themedications

• Ensure patient understands the indication and how to take each medicationsafely and appropriately for their circumstances

Medication Checklist

• Check for drug duplication

• Check for drug interactions (drug-drug, drug-food, drug-disease, drug-lab,etc.)

• Check that medications and diseases correspond

• Check that patient has been renewing prescriptions and that they have beentaking their medications according to prescription

Identification of Drug Therapy

Problems

• The patient is taking/receiving a drug for which there is no valid indication

• The patient requires therapy for an indication and is not receiving therapy

• The patient is taking/receiving the wrong drug or drug product

• The patient is taking/receiving an inappropriate dose of a drug

• The patient is not taking/receiving the prescribed drug appropriately

• The patient is experiencing an adverse drug reaction

• The patient is experiencing a drug interaction

• The patient requires certain lab tests and monitoring

• The patient is currently taking a medication that is ineffective for thecondition being treated (treatment failure)

Collaborative Resolution of Drug Therapy

Problems

• If interaction with other health care practitioner(s) is required, report DTP topatient’s physician and/or health care practitioner using the Health CarePractitioner Communication form for collaborative resolution. Informpatient of care plan and of outcome when response received, ensuring thepatient is given a comprehensive, accurate and up- to-date medication listfrom the Best Possible Medication History form along with the PatientAction Form.

Comprehensive Medication Review Summary Checklist

As you progress through your medication review, utilize this checklist as a guide to ensure all components of the review are addressed.

Prior to the Review*: Initials Provide patient with Screening Tool to complete at home before appointment

Request patient bring all medications to the appointment – including OTCs & NHPs

Print a list of patient’s active medications from your pharmacy software and/or DPIN

Assemble basic patient demographic information, acquire copies of health and insurance cards

* The above tasks may be completed by any pharmacy team member

During the Review: Initials Explain nature of review process, discuss confidentiality and obtain patient consent

Review patient’s completed Screening Tool, take note of issues raised

Complete Best Possible Medication History form o Add medications not on pharmacy file to medication history as they are

reviewed

Review each medication fully (including OTCs and NHPs) with the patient

Identify drug therapy problems (DTPs) based on preceding information and list on the Drug Therapy Problems Identified form

Consult list of DTPs identified o If no other input necessary, discuss the care plan with the patient and

implement immediatelyo If more time is required, work up DTPs on Pharmacy Care Plan formo Contact health care practitioner and/or other health care providers as

appropriate using the Health Care Practitioner Communication Form

Following the Review: Initials Schedule follow-up with the patient – utilize Patient Follow-up Worksheet

Provide patient with a comprehensive, accurate, up-to-date medication list (signed by the pharmacist – retain a copy for your pharmacy records)

If warranted, provide patient with a Patient Action Plan

Head to Toe Assessment Guide Source: Regional Pharmacy Services, Alberta Health Services, (2011). Patient Care Process. Faculty of Pharmacy and Pharmaceutical Sciences. University of Alberta, Edmonton Alberta.p.3,5.

A head to toe assessment is a basic review of systems to identify any further problems or symptoms that a patient may be experiencing. This assessment should be kept relevant and brief, and it is important to note that the following is just an example of considerations for each system and not all may require review.

General energy levels, weight changes, ailments, pain

Integument rashes, dryness, pruritus, hair loss, nails

Head/Neurologic mental status, headache, syncope, seizures, tremor, weakness, vertigo, sleep changes, anxiety, depression

Eyes redness, discharge, blurring, vision, pain, glaucoma, cataracts

Ears hearing loss, tinnitus, earache, discharge

Nose/Sinuses rhinitis, sinus congestion, discharge

Mouth/Pharynx dentition, hoarseness, pharyngitis, ulcerations

Neck swollen lymph nodes/glands, goiter, pain

Chest/Lungs cough, dyspnea, wheezing, sputum, asthma, bronchitis, pneumonia

Cardiovascular chest pain, murmurs, palpitations, hypertension, myocardial infarction

Gastrointestinal dysphagia, odynophagia, reflux, nausea, vomiting, bowel movements, stool

Urinary pain, frequency, urgency, incontinence, retention, bleeding

Hepatic/Renal organ function, infection (hepatitis, pyelonephritis)

Reproductive libido, discharge, infection, menstrual, menopause

Musculoskeletal stiffness, pain, motion, swelling, redness, deformities

Endocrine thyroid, diabetes, adrenals, estrogen, testosterone Source: Longe RL et al. Physical Assessment- A Guide for Evaluating Drug Therapy. Balitmore, MD: Lippincott Williams & Wilkins, 1994.Table 1.3, page 1-9 to 1-10.

Note that further targeted line of questioning may be necessary when a patient reports symptoms or unveils an underlying condition. The following line of questioning can be used for further symptom assessment.

Location Where is the symptom?

Quality Severity What is the symptom like? Does it interfere with the patient’s lifestyle? What is the severity of the symptom? (mild, moderate, severe)

Quantity What is the frequency of the symptom?

Timing What is the duration of the symptom? When did it first present?

Setting What was the patient doing when the symptom first presented?

Modifying factors Are there any relieving or aggravating factors? What makes it better or worse?

Associated symptoms Are there any associated symptoms? (Include absence of symptoms if relevant- i.e. no fever, no cough, no dyspnea, etc.)

Source: Giberson S, Stein E. Performing patient assessment: a pharmacy perspective. Pharmacy Times 2002;68(12):44-48..

Estimating Renal Clearance: Practical Tips for the Pharmacist

Estimating Creatinine Clearance for Drug Dosing Adjustments

Cockcroft and Gault1:

Normalized for weight: (140−𝑎𝑔𝑒)𝑥 88.4

𝑠𝐶𝑟 (𝑢𝑚𝑜𝑙

𝐿)

x 0.85 if female

Patient weight included: (140−𝑎𝑔𝑒)𝑥 𝑤𝑒𝑖𝑔ℎ𝑡(𝑘𝑔) 𝑥 1.23

𝑠𝐶𝑟 (𝑢𝑚𝑜𝑙

𝐿)

x 0.85 if female

Assumptions

The Cockcroft and Gault equation is used in the development of drug dosing adjustmentsfor patients with impaired renal function and therefore should be the primary equationused when dose adjustments may be necessary2

This equation assumes a normal adult body weight and composition. This excludespatients with amputations, elite athletes, neonates/children, catechetic patients or obesepatients.3

This equation also assumes serum creatinine is stable (steady state). This excludes acuterenal failure/injury, pregnant patients or patients with renal allografts (transplants).3

Some institutions use a multiplier of 80 (vs 88.4) due to laboratory standardization ofserum creatinine analysis. Using 88.4 can overestimate ClCr by 5-10%2

If patient bodyweight is available, can be used as a variable in the Cockcroft and Gaultequation to estimate creatinine clearance

Special Populations

Normal Renal Function Patients with normal renal function usually do not require dosage adjustments. It is important to note that the Cockcroft and Gault equation usually overestimates clearance in patients with normal renal function. The CKD-EPI equation has been shown to estimate eGFR well in patients with normal renal function.4

Underweight In patients who are below their Ideal Body Weight (IBW), use actual weight in any calculations

Obese In obese individuals the Cockcroft and Gault equation greatly overestimates renal function when total body weight (TBW) is used. Lean body weight (LBW) can be substituted into the Cockcroft and Gault Equation to estimate ClCr.5 Or the Salazar-Corcoran Equation developed for obese patients can also estimate ClCr.6 Also, always check the drug monograph to see if specific dose recommendations are made for obese patients as some drugs have been studied.

LBW (kg) males = 9270 × 𝑇𝐵𝑊 (𝑘𝑔)

6680+216 ×𝐵𝑀𝐼 (𝑘𝑔 𝑚2⁄ )LBW (kg) females =

9270 × 𝑇𝐵𝑊 (𝑘𝑔)

8780+244 ×𝐵𝑀𝐼 (𝑘𝑔 𝑚2⁄ )

Salazar-Corcoran Equation for estimating creatinine clearance in obesity: Link to Calculator: http://www.globalrph.com/salazar.htm

Elderly The Cockcroft and Gault equation can underestimate renal function in the elderly due to the fact that this equation has a built-in propensity to make renal function worse with age. However, a conservative approach to drug dosing is warranted for this patient population to minimize adverse drug events,7,8 therefore the use of the Cockcoft and Gault equation is acceptable.

Children (<18 years old) Renal function estimation equations specific to children are used in practice. The most well-known equation is the Schwartz equation9, but other newer equations have also been developed.10 Therefore adult equations should not be used for this population to estimate renal function.

Link for Global RPh Calculator for multiple creatinine clearance methods (comparing different weight adjustments):

http://www.globalrph.com/multiple_crcl_2012.htm

http://www.globalrph.com/salazar.htm

http://www.globalrph.com/multiple_crcl_2012.htm

Estimation of Glomerular Filtration Rate (eGFR)

Note: eGFR is used to classify Stages of Renal Disease and SHOULD NOT be used to adjust drug dosages or dosing intervals. Drug companies list

dose adjustments in the drug monographs based on the Cockcroft and Gault equation.2 Please see the Manitoba Renal Program Resources

(below) on how to use eGFR in clinical practice.

Modification of Diet in Renal Disease (MDRD) 4-Variable Equation11

Link to Calculator: http://www.globalrph.com/crcl_idms.htm

Was developed for use primarily in diabetic patients with impaired renal function and chronic renal disease (ages 18-70 years)

Should NOT be used in patients with an estimated eGFR greater than 60mL/min/1.73m2 as it does not accurately predict eGFR in

patients with good renal function

Is standardized to a normal body surface area (BSA) of 1.73m2 – can adjust based on patient specific BSA.

Chronic Kidney Disease in Epidemiology (CKD-EPI) Equation12

Link to Calculator: http://www.globalrph.com/gfr-epi.htm

Was developed to improve some of the limitations of the MDRD equation

Can be used to predict eGFR in patients with renal function above 60mL/min/1.73m2

Manitoba Renal Program Resources How to Use eGFR http://www.kidneyhealth.ca/wp/healthcare-professionals/egfr-referral-pathways/how-to-use-egfr/

Stages of Chronic Kidney Disease Definitions (Stages 1-5)

http://www.kidneyhealth.ca/wp/healthcare-professionals/egfr-referral-pathways/mrp-chronic-kidney-disease-stages/

References

1. Cockcroft DW and Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron. 1976;16(1):31-41

2. Nyman HA, Dowling TC, Hudson JQ et al. Comparative Evaluation of the Cockcroft-Gault Equation and the Modification of Diet in Renal Disease (MDRD) Study Equation for Drug Dosing: An Opinion on the Nephrology Practice and

Research Network of the American College of Clinical Pharmacy. Pharmacotherapy 2011;31(11):1130-1144

3. Inker LA and Perrone RD. Assessment of Kidney Function. UpToDate. [Accessed December 9, 2013]

4. Stevens LA, Schmid CH, Greene T et al. Comparative Performance of the CKD Epidemiology Collaboration (CKD-EPI) and the Modification of Diet in Renal Disease (MDRD) Study Equations for Estimating GFR Levels Above 60 mL/min/1.73

m2. Am J Kidney Dis 2010:56:486-495.

5. Demirovic JA, Pai AB and Pai MP. Estimation of creatinine clearance in morbidly obese patients. Am J Health-Syst Pharm. 2009; 66:642-8

6. Salazar DE and Corcoran GB. Predicting creatinine clearance and renal drug clearance in obese patients from estimated fat-free body mass. Am J Med. 1988 Jun;84(6):1053-60

7. Flamant M, Hayman JP, Vidal-Petiot E et al. GFR Estimation Using the Cockcroft-Gault, MDRD Study, and CKD-EPI Equations in the Elderly. Am J Kidney Dis. 2012;60(5):847-849

8. Dowling T, Wang ES, Ferrucci L et al. Glomerular Filtration Rate Equations Overestimate Creatinine Clearance in Older Individuals Enrolled in the Baltimore Longitudinal Study on Aging: Impact on Renal Drug Dosing. Pharmacotherapy

2013;33(9):912–921

9. Schwartz GJ, Haycock GB, Edelmann CM Jr, Spitzer A: A simple estimate of glomerular filtration rate in children derived from body length and plasma creatinine. Pediatrics 58:259-263, 1976

10. Hoste L, Dubourg L, Selistre et al. A new equation to estimate the glomerular filtration rate in children, adolescents and young adults. Nephrol. Dial. Transplant. (2013) doi: 10.1093/ndt/gft277

11. Levey AS, Bosch JP, Lewis JB, et al. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med 1999;130(6):461-

70

12. Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF 3rd, Feldman HI, Kusek JW, Eggers P, Van Lente F, Greene T, Coresh J. A New Equation to Estimate Glomerular Filtration Rate. Ann Intern Med. 2009; 150:604-612.

http://www.globalrph.com/crcl_idms.htm

http://www.globalrph.com/gfr-epi.htm

http://www.kidneyhealth.ca/wp/healthcare-professionals/egfr-referral-pathways/how-to-use-egfr/

http://www.kidneyhealth.ca/wp/healthcare-professionals/egfr-referral-pathways/mrp-chronic-kidney-disease-stages/

Common High-Alert Medications

These medications often require close monitoring and special attention with respect to drug

interactions, side effects/toxicity and in some cases misuse potential. It may also be necessary to

order drug levels or other lab indices to assess therapy with these medications. Please note this is not

an exhaustive list.

Warfarin

Insulin

Antipsychotics (atypical and typical)

Opioids

Benzodiazepines

Antiepileptics

Digoxin

Amiodarone

Lithium

Immunosuppressant agents

Methotrexate

The Institute for Safe Medication Practices also maintains a list of high-alert medications. Follow the

link here: http://www.ismp.org/communityRx/tools/ambulatoryhighalert.asp

Drugs causing QT prolongation

An up to date list of drugs that cause QT prolongation can be found at www.qtdrugs.org

http://www.ismp.org/communityRx/tools/ambulatoryhighalert.asp

http://www.qtdrugs.org/

Common Ototoxic Medications:

Medication Effect

Furosemide Reversible hearing loss Salicylates Reversible hearing loss (bilateral)

Erythromycin Reversible hearing loss

Quinine Reversible hearing loss

Aminoglycosides Irreversible hearing loss

Cisplatinum Irreversible hearing loss If you have a patient on one or more of these medications, ensure they have been having regular

hearing tests.

Common Oculotoxic Medications:

Medication Effect/Action

Chlorpromazine Require annual eye exam

High-dose Corticosteroids Require eye exam every 6 months May also experience reversible cataracts, increased IOP

Quetiapine Cataracts

Tricyclic antidepressants Increased IOP in high-risk patients

Chloroquine/hydroxychloroquine Irreversible retinopathy Digoxin Reversible vision disturbances

Indomethacin Reversible color disturbances Retinotoxicity

Tamoxifen Permanent decrease in visual acuity

Vigabatrin Irreversible loss of peripheral vision Quinine Permanent blurred vision or blindness

Ethambutol Decreased contrast sensitivity Decreased color vision

IOP = Intraocular pressure; If you have a patient on one or more of these medications, ensure they

have been having regular eye exams.

Source: Amy Oliver 4th Year Elective – Home Care Chart Review

Selected Clinical Practice Guidelines:

2013 CHEP Recommendations for the Treatment of Hypertension:

http://hypertension.ca/images/CHEP_2013/2013_CompleteCHEPRecommendations_EN_HCP1009.p

df

Canadian Cardiovascular Society Guidelines for Diagnosis and Treatment of Dyslipidemia for

Prevention of Cardiovascular Disease (2012 update):

http://download.journals.elsevierhealth.com/pdfs/journals/0828-282X/PIIS0828282X12015103.pdf

Canadian Diabetes Association 2013 Clinical Practice Guidelines:

http://guidelines.diabetes.ca/

Canadian Thoracic Society Asthma Treatment Guidelines and Updates:

http://www.respiratoryguidelines.ca/guideline/asthma

Canadian Thoracic Society COPD Treatment Guidelines and Updates:

http://www.respiratoryguidelines.ca/guideline/chronic-obstructive-pulmonary-disease

CAN-ADAPTT – Canadian Smoking Cessation Clinical Practice Guideline:

https://www.nicotinedependenceclinic.com/English/CANADAPTT/Documents/CAN-

ADAPTT%20Canadian%20Smoking%20Cessation%20Guideline_website.pdf

SOGC Clinical Practice Guideline – Menopause and Osteoporosis Update 2009:

http://www.sogc.org/guidelines/documents/Menopause_JOGC-Jan_09.pdf

Canadian Neurological Sciences Federation – Canadian Guidelines on Parkinson’s Disease:

http://www.parkinsonclinicalguidelines.ca/sites/default/files/PD_Guidelines_2012.pdf

Always remember that clinical practice guidelines are being constantly updated. To find the

latest guidelines or to find a guideline for a condition not listed here, follow this link:

Canadian Medical Association - Clinical Practice Guidelines Database:

http://www.cma.ca/clinicalresources/practiceguidelines

http://hypertension.ca/images/CHEP_2013/2013_CompleteCHEPRecommendations_EN_HCP1009.pdf

http://hypertension.ca/images/CHEP_2013/2013_CompleteCHEPRecommendations_EN_HCP1009.pdf

http://download.journals.elsevierhealth.com/pdfs/journals/0828-282X/PIIS0828282X12015103.pdf

http://guidelines.diabetes.ca/

http://www.respiratoryguidelines.ca/guideline/asthma

http://www.respiratoryguidelines.ca/guideline/chronic-obstructive-pulmonary-disease

https://www.nicotinedependenceclinic.com/English/CANADAPTT/Documents/CAN-ADAPTT%20Canadian%20Smoking%20Cessation%20Guideline_website.pdf

https://www.nicotinedependenceclinic.com/English/CANADAPTT/Documents/CAN-ADAPTT%20Canadian%20Smoking%20Cessation%20Guideline_website.pdf

http://www.sogc.org/guidelines/documents/Menopause_JOGC-Jan_09.pdf

http://www.parkinsonclinicalguidelines.ca/sites/default/files/PD_Guidelines_2012.pdf

http://www.cma.ca/clinicalresources/practiceguidelines

Resources to Assess Medications for the Elderly:

American Geriatric Society Beers Criteria 2012 for Potentially Inappropriate Medication Use in

Older Adults:

http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_r

ecommendations/2012

Screening Tool of Older Persons’ potentially inappropriate Prescriptions (STOPP):

http://ageing.oxfordjournals.org/content/37/6/673.full.pdf+html

Evidence-Based Medicine Research Resources:

Trip Database: http://www.tripdatabase.com/

Essential Evidence Plus: http://www.essentialevidenceplus.com/

Laboratory Monitoring Resources:

Diagnostic Services of Manitoba - Normal Laboratory Values Database:

https://apps.sbgh.mb.ca/labmanualviewer/index.do

http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2012

http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2012

http://ageing.oxfordjournals.org/content/37/6/673.full.pdf+html

http://www.tripdatabase.com/

http://www.essentialevidenceplus.com/

https://apps.sbgh.mb.ca/labmanualviewer/index.do

Government of Manitoba Communicable Disease Control:

Immunizations and Vaccinations Homepage:

http://www.gov.mb.ca/health/publichealth/cdc/div/index.html

Manitoba Routine Immunization Schedules:

http://www.gov.mb.ca/health/publichealth/cdc/div/schedules.html

Cancer Care Manitoba’s Cancer Screening Programs:

BreastCheck:

http://www.cancercare.mb.ca/home/prevention_and_screening/general_public_screening_program

s/manitoba_breast_screening_program/

CervixCheck:


s/manitoba_cervical_cancer_screening_program/

ColonCheck:


s/manitoba_colorectal_screening_program/

Lung Association – Find a lung function testing lab or spirometry clinic in your area:

http://www.lung.ca/respDB/search-testing_e.php

Smoker’s Help Line:

http://www.smokershelpline.ca/

http://www.gov.mb.ca/health/publichealth/cdc/div/index.html

http://www.gov.mb.ca/health/publichealth/cdc/div/schedules.html

http://www.cancercare.mb.ca/home/prevention_and_screening/general_public_screening_programs/manitoba_breast_screening_program/

http://www.cancercare.mb.ca/home/prevention_and_screening/general_public_screening_programs/manitoba_breast_screening_program/

http://www.cancercare.mb.ca/home/prevention_and_screening/general_public_screening_programs/manitoba_cervical_cancer_screening_program/

http://www.cancercare.mb.ca/home/prevention_and_screening/general_public_screening_programs/manitoba_cervical_cancer_screening_program/

http://www.cancercare.mb.ca/home/prevention_and_screening/general_public_screening_programs/manitoba_colorectal_screening_program/

http://www.cancercare.mb.ca/home/prevention_and_screening/general_public_screening_programs/manitoba_colorectal_screening_program/

http://www.lung.ca/respDB/search-testing_e.php

http://www.smokershelpline.ca/

YOU MEDS

™


Case Examples

Case 1 - Elizabeth

You have scheduled a medication review with Elizabeth Martin, a patient of yours with asthma. Elizabeth was

recently hospitalized for an acute exacerbation of her condition. You have suggested a medication review to

her based on this fact, as well as because her frequency of salbutamol refills has steadily increased with 2

refills in the past month.

The date today is March 1, 2013. Your pharmacy assistant presents you with this demographic information:



Name Age

Elizabeth Martin 23

Third Party Coverage

Pharmacare


Family Physician

Dr. Cares – Mountain Medical

Address City/Province

423 Anywhere St Winnipeg, MB

Other Physician/Specialist

Dr. Woods – Respirologist, HSC

Postal Code Phone #

X0X 0X0 (204) 555-2053

Caregiver (if applicable) Phone #

Reason for Med Review

Recently hospitalized for asthma

exacerbation

Pharmacist Completing Review License No.

S. Robinson 123456


Patient is concerned about recent hospitalization and would like her breathing to

improve. What are your expectations from your medications, and what would like to achieve from your med review today?

She would like to be able to exercise without feeling short of breath. She does not

want to have to go to the hospital again.

You also have a print out of Elizabeth’s pharmacy medication profile:

Medication Strength Directions Made By

Quantity Dispensed

Date refilled Refills Remaining

Salbutamol 100 mcg 1-2 puffs prn APO 200 doses/MDI 14/02/2013 1





Fluticasone 250 mcg 1 puff BID GSK 120 doses/MDI 15/11/2012 5

Yasmin 30mcg/3mg UD BPC 84 13/01/2013 2

Yasmin 30mcg/3mg UD BPC 84 15/11/2012 3

Elizabeth is waiting for you in the private patient counseling area. She has brought all of the medication she

has at home with her today.

Before the medication review can commence, it is necessary for the pharmacist to obtain consent to carry out

the review. The pharmacist describes the process as follows:

“Elizabeth, today we have invited you in to the pharmacy for a comprehensive medication

review. I first want to let you know that everything we say here is private and confidential. I

know you have been recently hospitalized for your asthma and I am concerned you are not

getting the most out of your medications. During the review, we will look at each of your

medications one at a time and discuss them in detail. We want to be sure you have the most

benefit from the medication and minimize negative things like safety issues and side effects. I

also want to make sure you know what each of your medications is used for and how to use

them properly. These are important because we need you to be an active participant in

managing your asthma. We will also discuss the over-the-counter and natural health products

you may be taking in the same way. Do I have your consent to perform a medication review?”

The pharmacist must also receive consent from the patient to share any information relevant to

Elizabeth’s medical care with other members of the health care team, such as her family physician or

specialist. The pharmacist says:

“Elizabeth, in the event that we discover some issues with your medication today, I will need to

have your consent to communicate this information to Dr. Cares, your family physician and/or

Dr. Woods, your respirologist. We may need new prescriptions or different doses, or you may

need a follow-up appointment with another health care professional for reassessment. Do you

consent to me sharing this information in a confidential manner with other health care

professionals who are part of your health care team?”

2. Consent

Patient has received information on, and has consented to review process

Patient Signature:__ Elizabeth Martin ___________________________________

Patient has agreed that information may be shared with their physician and other healthcareproviders

Patient Signature:__ Elizabeth Martin____________________________________

Patient consents to having patient representative/caregiver present to receive service(if applicable)

Name of Representative(s):_______________________________________ Patient Signature:_______________________________________________

Having now received consent, the pharmacist may begin to collect applicable Health and Lifestyle

Information from Elizabeth. The pharmacist says:

“To begin, I would like to ask you a few questions about your general health and lifestyle. These

questions are not meant to pry or be judgmental, but there are certain aspects of a patient’s

lifestyle that can affect their chronic conditions and medications.”

3. Health Information and Lifestyle Factors

Inquiry Yes/No Details/Comments Allergies

Seasonal allergies

Y N Reaction:

Worst in spring, worsens asthma


Y NFormer Smoker

Cigarettes/day: 10/day

x_3_years


Caffeine Intake Y N Drinks/day: 2 cups/day

Grapefruit (Juice) Consumption

Y N


Tries to eat healthy, feels she

could do more

Physically Active

Worsens her asthma

Y N Type of activity: Gym 2-3x/week

Minutes/week: 90 mins/week




Y N

Other Vaccinations (travel, routine, etc.)

Y N Please list: Routine vaccinations up

to date


Y N When:

Has never had pap test


Y N


Y N Date/Result:


Underweight

Height: Weight:


Aids, Alerts, Devices, etc. Other No aerochamber for MDI

The pharmacist continues by asking Elizabeth about her current medical conditions. Note that it is not

sufficient to just list the condition; it is essential to ask further targeted questions in order to assess the

control of that condition, symptoms, etc and whether or not further action is necessary.


Kidney Disease? Liver Disease? BP = HR = RR =CrCl =


1. Asthma x 15 years

Used salbutamol at least BID for last 2

weeks, feels symptoms with exercise, has

missed work due to recent hospitalization

for exacerbation

2. Seasonal allergies x 5 years

Worst in spring, beginning just as snow begins

to melt; utilizes antihistamine prn for

symptoms


Occasional headaches from working too long on the computer

Family History

Heart disease, Father had MI (age 49)

Next, the pharmacist goes over each of Elizabeth’s medications with her one by one. This form is

revisited later when the pharmacist is analyzing the information to identify DTPs.



How Taken Dose, Route,

Frequency, Time of Day, Special

Instructions

Purpose for Use How long

taken

Issues Identified Additional

Comments Yes: Proceed to DTP Identified


Salbutamol MDI

100 mcg/inh

1-2 puffs

prn

Asthma –

Rescue inhaler

15

years

Has used BID x

last 2 weeks

Fluticasone MDI

250 mcg

1 puff BID Asthma –

Controller Medication

3

months

Patient is not

currently using,

dislikes taste

Yasmin 28-day 1 tab daily Oral contraceptive 7 years

Ibuprofen

400 mg tablets

Prn (OTC) Occasional headaches,

menstrual cramps

11

years

Takes with food,

no stomach pain

Buckley’s All-in-

One

Prn (OTC) For cold/flu

symptoms

Not

known

Last use 3

months ago

Cetirizine 10 mg 1 tab daily

Prn (OTC)

For seasonal allergies 4 years Only uses prn,

not regularly

Finally, the pharmacist asks Elizabeth about any medications that have been recently discontinued.

Once again, the “Require Further Action” section is left blank until after the session.



How Taken Dose, Frequency, Time of Day, Special Instructions

Purpose for Use

How long taken? When was stopped?





Budesonide 200 mcg

turbuhaler

1 inhalation

BID

Asthma –

controller

Used x 15 y

Stopped 3

months ago

Respirologist

switched to

Fluticasone MDI

At this point, the pharmacist has collected all the necessary information from Elizabeth. In order to

have time to review the information and do some more reading with regard to treatment guidelines

for asthma, the pharmacist asks Elizabeth to come back in 3 days to discuss the DTPs identified.

After review, the pharmacist completes the above charts as follows:



How Taken Dose, Route,

Frequency, Time of Day, Special

Instructions

Purpose for Use How long taken

Issues Identified Additional Comments

Yes: No:

Salbutamol MDI

100 mcg/inh

1-2 puffs

prn

Asthma –

Rescue inhaler

15

years

Yes Has used BID x

last 2 weeks

Fluticasone MDI

250 mcg

1 puff BID Asthma –

Controller Medication

3

months

Yes Patient is not

currently using,

dislikes taste

Yasmin 28-day 1 tab daily Oral contraceptive 7 years No

Ibuprofen

400 mg tablets

Prn (OTC) Occasional headaches,

menstrual cramps

11

years

No Takes with food,

no stomach pain

Buckley’s All-in-

One

Prn (OTC) For cold/flu symptoms Not

known

No Last use 3

months ago

Cetirizine 10 mg 1 tab daily

Prn (OTC)

For seasonal allergies 4 years Yes Only uses prn,

not regularly



How Taken Dose, Frequency, Time of Day, Special Instructions

Purpose for Use

How long taken? When was stopped?



Yes: No:

Budesonide 200 mcg

turbuhaler

1 inhalation

BID

Asthma –

controller

Used x 15 y

Stopped 3

months ago

Respirologist

switched to

Fluticasone MDI

Yes

Using the form, the pharmacist must now list the DTPs identified for Elizabeth and prioritize them to

determine what to address first.



1 Elizabeth is experiencing poorly controlled asthma due to non-use of

fluticasone (controller medication).

2 Elizabeth smokes cigarettes, despite having asthma, and thus risks

worsening her asthma symptoms.

4 Elizabeth has not received her annual flu shot.

3 Elizabeth experiences uncontrolled seasonal allergies due to irregular

use of an antihistamine.


DTP #


patient

Follow-up Plan

2 Assess patient readiness to quit

Refer to QUIT trained pharmacist on staff

3 Suggest patient utilize daily antihistamine

during allergy season as opposed to prn

Utilize non-pharm approaches

(doors/windows closed, regular laundering of

outdoor clothes, etc)

4 Educate patient about the importance of flu

shot; direct to local flu shot clinics

The care plan to address Elizabeth’s asthma control is much more complex, so the pharmacist employs the Pharmacy Care Plan form.

Pharmacy Care Plan

Data: Subjective information provided by the patient and/or objective data that you have collected.

Elizabeth has been using her salbutamol rescue medication at least BID for the last 2 weeks, has

symptoms when she exercises and was recently hospitalized for an acute asthma exacerbation.

All of these facts indicate poor asthma control. Her respirologist switched her controller

medication from a budesonide turbuhaler to a fluticasone MDI in November 2012. Elizabeth

used fluticasone for 2 weeks and then stopped using it because she did not like the taste of the

spray. Since then, she has only been using salbutamol for relief of acute symptoms.


Elizabeth is experiencing poorly controlled asthma and requires a daily inhaled corticosteroid to

regain control and decrease the need for rescue doses of salbutamol.

Plan: For each alternative, consider treatment efficacy, safety, drug interactions, adherence, cost, drug coverage and non-pharmacological interventions. Alternative #1:

Start fluticasone MDI – 1 puff BID. Equally efficacious to budesonide, ICS will decrease

inflammation in the lung. Respirologist had previously prescribed this option. Plan to assess MDI

technique, may need to utilize an aerochamber to improve drug delivery and minimize the “bad

taste” Elizabeth was experiencing. Potential for oral candidiasis will be decreased with rinsing

mouth after each dose. Fluticasone (Flovent) listed under Part 1 of Pharmacare, aerochamber

will not be covered.

Alternative #2:

Re-start budesonide turbuhaler – 1 inhalation BID. Patient had previous experience and success

with this medication, it still satisfies the requirement for an ICS. Budesonide is Part 1 of

Pharmacare, no need for an aerochamber with this option.

Monitoring:

To assess asthma control: < 4 doses of salbutamol/week, no symptoms with exercise, no further

hospitalizations, no missed work (after 2-3 weeks and ongoing). Assess adherence to regular

dosing of ICS after 1 week. Reassess for inhaler technique/patient satisfaction at each refill.

Candidate for peak flow meter. Planned date of follow-up: 1 week after implementation of plan

S. Robinson____________________ March 1, 2013__


Having developed potential solutions to the DTPs identified as well as a care plan to resolve the DTPs

related to asthma control, the pharmacist discusses these issues with Elizabeth at their next meeting,

March 4, 2013.

The pharmacist begins by discussing the care plan developed to regain control of Elizabeth’s asthma.

The pharmacist re-educates Elizabeth about the importance of using the regularly scheduled ICS to

control underlying lung inflammation and minimize the need to employ the salbutamol inhaler.

Elizabeth understood that her recent hospitalization was likely due to her not using the fluticasone.

Next, the pharmacist outlines the treatment alternatives to Elizabeth so she could decide which she

would prefer. She expressed concern about the taste of the fluticasone spray, but was interested in the

potential use of an aerochamber to help her receive more of the medication with a more diffuse spray.

She tells the pharmacist that Dr. Woods, her respirologist, really wanted her to switch from

budesonide to fluticasone and she already has the fluticasone inhaler at home anyway. Ultimately,

Elizabeth and the pharmacist agree upon Alternative #1 above.

The pharmacist does a quick assessment of Elizabeth’s inhaler technique with the MDI and also

counsels her on how to use her new aerochamber. They then discuss the monitoring parameters based

on the care plan – what Elizabeth needs to watch for and within what time frame.

The pharmacist turns their attention to the other DTPs identified during the medication review. As

each other DTP is addressed, the pharmacist updates the chart as follows:

DTP #


patient

Follow-up Plan

2 Assess patient readiness to quit

Refer to QUIT trained pharmacist on staff

Yes, not

ready to

quit

Ongoing at refills

Provided pt with

reading material

3 Suggest patient utilize daily antihistamine during

allergy season as opposed to prn

Utilize non-pharm approaches (doors/windows

closed, regular laundering of outdoor clothes, etc)

Yes,

patient

agrees

Phone reminder

mid-March when

snow begins to melt

4 Educate patient about the importance of flu shot;

direct to local flu shot clinics

Yes Will direct to flu

shot clinic in fall

The pharmacist informs Elizabeth that her physician will be made aware of the results of the

medication review for information purposes. The pharmacist also tells Elizabeth to expect a follow-up

call in about a week to discuss how the fluticasone inhaler has been working for her. Before Elizabeth

leaves, the pharmacist confirms that the contact information they have on file is up-to-date.

The pharmacist provides Elizabeth with an up-to-date medication list for her records.

As discussed, the pharmacist completes a Health Care Professional Communication Form to update the doctor about the medication review.

The DTPs identified, Pharmacy Care Plan and Medication List are also included. In this case, there is no action required from the prescriber,

but the pharmacist is communicating their findings to ensure all members of the health care team are well-informed about the patient.


Date:_March 4, 2013__

Health Care Practitioner

Dr. Cares

Re: (Patient’s Name) PHIN

Elizabeth Martin 123456789

Address

Mountain Medical Clinic – 42 White Blvd

Address

423 Anywhere St

City/Province Postal Code

Winnipeg, MB Y1Y 1Y1


Winnipeg, MB X0X 0X0

Phone # Fax #

(204) 555-6379 (204) 555-6378

DOB Phone#

14/01/1990 (204)555-2053

Dear Dr.___Cares_______,

Your patient had a Comprehensive Medication Review completed on __March 1/13___. Listed below are my assessment(s) and recommendation(s). Please

provide a response below (if indicated) at your earliest opportunity. Should you like to discuss any of the information contained don’t hesitate to contact me.



Patient wasn’t using fluticasone

inhaler due to unpleasant taste.


Plan to restart fluticasone with

aerochamber, follow-up in 1 week

Yes No


Yes No

License #: 123456

Pharmacist Signature: S. Robinson

Prescriber Signature: License #: Date:

Your pharmacy business card goes here

Pharmacist: S. Robinson

The pharmacist follows up with Elizabeth in 1 week to check in about her inhaler use and the aerochamber as well as improvement of

asthma symptoms. The pharmacist also calls her in about 3 weeks to remind her about taking a daily antihistamine to prevent seasonal

allergy symptoms. The Patient Follow-up Form is completed as follows:


Date of Follow-up

Reason for Follow-up Results Pharmacist Comments & Plan

11/03/2013 Medication review 1 week

ago, follow-up re: use of

fluticasone inhaler,

aerochamber use, control

of asthma symptoms

Aerochamber working well, 0

bad taste; only using rescue

medication once/day – still

needs improvement

Improved exercise, generally

feeling better

Any new concerns?


Should be using salbutamol <4x

per week, will contact in 2

weeks

Pharmacist signature: S. Robinson

25/03/2013 Second follow-up to assess

asthma control, hope to

have decreased use of

salbutamol

Now only needing salbutamol

inhaler approx once/week

No issues with exercise,

asthma symptoms <4x/week

Any new concerns?


Plan to refer to CRE for further

asthma monitoring


04/04/2013 Reminder call to start daily

antihistamine to control

seasonal allergies

Patient planning to use

cetirizine 10 mg daily,

starting tomorrow

Any new concerns?



Case 2 – Steve

On December 28 2012, you completed a comprehensive medication review with Steve Wilkinson. Steve is a

regular client at your pharmacy and is planning to go to Arizona for a few months in the New Year. Steve’s

physician referred him for a medication review to ensure that all of his medications are in order before going

away.

The completed forms from the initial comprehensive medication review appointment are shown below. For

more detail on collecting background information during the initial appointment, please see Case 1 –

Elizabeth.



Name Age

Steve Wilkinson 72

Third Party Coverage

Pharmacare, Blue Cross


Family Physician

Dr. Johnson – Lakeside Clinic

Address City/Province

123 Somewhere Ave Winnipeg, MB

Other Physician/Specialist

Dr. Howard – Cardiologist

Postal Code Phone #

X0X 0X0 (204) 555-5555

Caregiver (if applicable) Phone #

Lila Smith (daughter) (204)123-4567

Reason for Med Review

Vacationing in Arizona for 3 months

Pharmacist Completing Review License No.

M. Anderson 999000


Steve is concerned about having all medications and vaccinations up to date before

leaving for Arizona.

What are your expectations from your medications, and what would like to achieve from your med review today?

He would like to understand what all of his medications are used for, and make

sure he is using everything correctly for his conditions.

Steve’s medication profile printout:

Medication Strength Directions Made By

Quantity Dispensed

Date refilled Refills Remaining

Sulfamethoxazole/ Trimethoprim

800/160mg 2 tablets twice daily for 3 days

APO 12 tablets 22/12/2012 0

Latanoprost 0.005% 1 drop in each eye at

bedtime

CO 1 bottle 16/12/2012 5

Tamsulosin 0.4mg 1 cap daily RAT 60 caps 16/12/2012 3

Ramipril 5mg 1 cap daily APO 90 caps 08/12/2012 2

Metoprolol 25mg 1 tablet twice daily

APO 180 tablets 08/12/2012 2

Atorvastatin 20mg 1 tablet daily APO 90 tablets 08/12/2012 2

Clopidogrel 75mg 1 tablet daily APO 90 tablets 08/12/2012 2

2. Consent

Patient has received information on, and has consented to review process

Patient Signature:__ Steve Wilkinson ___________________________________

Patient has agreed that information may be shared with their physician and other healthcareproviders

Patient Signature:__ Steve Wilkinson____________________________________

Patient consents to having patient representative/caregiver present to receive service(if applicable)

Name of Representative(s):___Lila Smith (daughter)___________________

Patient Signature:____ Steve Wilkinson _________________________

3. Health Information and Lifestyle factors

Inquiry Yes/No Details/Comments Allergies

Penicillin

Codeine

Y N Reaction:

Hives

Stomach Pain


Y NFormer Smoker

Cigarettes/day: 1 pack (25)

x_10_years


Caffeine Intake Y N Drinks/day: 3

Grapefruit (Juice) Consumption

Y N Drinks GF Juice occasionally


Tries to follow DASH diet, wife

makes sure he eats healthy

Physically Active Y N Type of activity: walks dog, curls

Minutes/week: 20 mins/night

(walk), 2-3 hours/week (curling)




Y N

Other Vaccinations (travel,

routine, etc.) Doesn’t know

Y N Please list:


Y N When:

Colon check - April 2012


Y N


Y N Date/Result:


Underweight

Height: Weight:


Aids, Alerts, Devices, etc. Other Penicillin Allergy Bracelet


Kidney Disease? Liver Disease? BP = 137/84 HR = RR =

CrCl =


1. Hypertension

-checks own BP regularly with

at home monitor

2. High cholesterol

-unknown recent LDL/HDL

levels

3. BPH

- Dr has ruled out cancer

4. Glaucoma

-five year history

-unsure which type

5. Hx of MI

-2010

6. 7. 8.

9. 10. 11. 12.


Difficulty sleeping – developing over past few years, getting worse in last couple months and has started using diphenhydramine to

try and resolve, takes 1-2 hours to fall asleep and wakes up frequently, feels tired throughout day and naps in afternoon, 2 cups

coffee in morning and 1 in afternoon, usually has nighttime snack, goes to bed at 9-10pm

Urinary Symptoms – has been increasingly difficult to go to the bathroom, burning while he pees, recently treated for a UTI with

TMP/SMX

Family History

Cancer






Additional Comments



Ramipril 5 mg 1 cap daily with

breakfast

blood pressure, protect

heart

3 years no HTN, post-MI

Metoprolol 25mg 1 tab twice daily with

breakfast and supper

protect heart 2 years no Post-MI

Atorvastatin 20mg 1 tab daily with supper lower cholesterol 3 years yes Drinks GF juice

Clopidogrel 75mg 1 tab daily with

breakfast

thin blood 2 years yes Post-MI

ASA 81mg 1 tablet daily with

breakfast

thin blood, protect

heart

3 years no Buys OTC

Latanoprost 0.005% 1 drop each eye at

bedtime

Glaucoma 5 years no

Tamsulosin 0.4mg 1 cap daily at supper BPH 4 years no

Diphenhydramine 50mg 1 cap at bedtime Sleep disorder 1-2 months yes Started taking because it

makes him drowsy

Vitamin E 800IU 1 cap daily with

breakfast

Supplement, keep

heart healthy

1 year yes Buys OTC, heard it was

good for his heart

Mens Multivitamin 1 tab daily with

breakfast

Supplement 5 years no Buys OTC

Acetaminophen 325mg PRN Headaches, pain, etc. PRN no Buys OTC

6. Recently Discontinued Medications - None

As of January 3, 2013 the pharmacist has reviewed the information from the initial appointment with Steve

and met to discuss the identified DTP’s and solutions which are outlined below. With Steve’s agreement to

these proposed solutions, the Drug Therapy Problems Identified form is updated, a Pharmacy Care Plan is

made, and a Health Care Practitioner Communication form is sent to Steve’s family physician along with the

care plan and medication history.

In addition to reviewing these DTP’s, the pharmacist ensures that Steve’s primary concerns at the initial

appointment are addressed including reassurance that there are no specific vaccinations required for travel to

Arizona and that each medication has been reviewed for his understanding.



4 Steve is at risk of receiving inadequate therapy in the future due to

misidentification of codeine allergy.

5 Steve is a candidate for the pneumococcal vaccination.

2 Steve is at risk of experiencing a drug-food interaction with statin therapy

use and grapefruit juice consumption.

1 Steve is experiencing urinary symptoms and bladder infections due to

anticholinergic effects of diphenhydramine use.

3 Steve is at risk of an adverse event secondary to Vitamin E use without a

valid indication.


DTP #


patient

Follow-up Plan

2 Educate Steve on interaction and advise him to

avoid drinking GF juice while on atorvastatin.

yes None- patient

agrees to avoid GF

consumption

3 Inform Steve on current evidence for vitamin E

and advise he discontinue use. Ensure him that

cardiac medications he is currently prescribed are

ideal for his conditions.

yes None- patient

agrees to stop

taking vitamin E

4 Explain difference between allergy and

intolerance regarding codeine to clarify possibly of

benefit if needed for future treatment.

yes Update pharmacy

profile

5 Educate Steve about the importance of the

pneumococcal vaccination and how he is a

candidate for getting this shot

yes Direct to local

vaccination clinics

Pharmacy Care Plan

Data: Subjective information provided by the patient and/or objective data that you have collected.

Steve has been experiencing urinary symptoms over the past month including burning while he

pees and increasing difficulty going the washroom. Steve was recently treated on December 22,

2012 for a UTI with SMX/TMP 2 tabs twice daily for 3 days. Steve has recently started using

diphenhydramine to help him sleep over the past 1-2 months, and has not spoken to the

doctor about his difficulty with sleeping. Steve has had trouble sleeping for the past few years,

and it is becoming increasingly worse. It takes him 1-2 hours to fall asleep and he wakes up

several times during the night. Steve also has a history of MI (2010), hypertension,

hypercholesterolemia, glaucoma, and BPH.


Steve is experiencing a drug-disease interaction between diphenhydramine and BPH that may

be causing urinary problems due to inappropriate therapy for sleep difficulty and requires a

change in treatment.

Plan: For each alternative, consider treatment efficacy, safety, drug interactions, adherence, cost, drug coverage and non-pharmacological interventions.

Alternative #1: Steve should stop using diphenhydramine to help him sleep due to the

anticholinergic side effects that may be causing urinary problems, including urinary tract

infections. This medication is also concerning for use in those with glaucoma and is a drug that

is deemed not appropriate for use in the elderly by Beer’s criteria. Steve should instead try

Zopiclone at an initial dose of 3.75mg to be taken at bedtime as needed which can be tapered

up every 1-2 weeks if needed to a maximum dose of 15mg. Zopiclone is the drug of choice for

the elderly population as it has a short half life of 5 hours, convenient dosing just prior to

bedtime due to its quick onset, and it may have less tolerance and withdrawal than other

insomnia medications making it ideal for long term management. Zopiclone does not interact

with Steve’s current drug regimen, it costs around $0.23/half tab of 7.5mg (3.75mg) and is

covered under part one of pharmacare.. Steve will also receive information on better sleep

hygiene to compliment this therapy.

Monitoring: Steve should experience decreased time to fall asleep to less than 1-2 hours,

decreased frequency of awakenings, and increased overall duration of sleep which he should

notice in 7-10 days with maximal benefits in 2-4 weeks. He should monitor for side effects

including agitation and anxiety, anterograde amnesia, confusion, signs of dependence, and any

impact on his daily functioning.

Planned date of follow-up: 1-2 weeks after initiation with zopiclone therapy.

__ MAnderson December 28, 2012___


After a response is received from Steve’s family physician on January 8, 2013, a follow-up appointment with Steve is conducted and recorded to counsel him on the proper use of his new medication zopiclone as well as educate him on changes he can make to his sleep behavior patterns to improve his sleep cycle. Steve is given an up-to-date medication history form and a Patient Action Plan to help him remember everything discussed during the medication review. These forms mentioned, as well as subsequent follow-ups, are shown below to conclude Steve’s case.


Date:_January 3, 2012__

Health Care Practitioner

Dr. AlexJohnson

Re: (Patient’s Name) PHIN

Steve Wilkinson 123456789

Address

Lakeside Clinic – 497 Crescent Ave

Address

123 Somewhere Ave


Winnipeg, MB Y1Y 1Y1


Winnipeg, MB X0X 0X0

Phone # Fax #

(204) 555-1111 (204) 555-2222

DOB Phone#

23/05/1971 (204)555-5555

Dear Dr.___Johnson_______,

Your patient had a Comprehensive Medication Review completed on __December 28/12___. Listed below are my assessment(s) and recommendation(s).

Please provide a response below (if indicated) at your earliest opportunity. Should you like to discuss any of the information contained don’t hesitate to contact me.



Steve is experiencing urinary

problems due to diphenhydramine

use and a history of BPH, and

requires appropriate therapy for

sleep difficulty.


Initiate therapy with Zopiclone 3.75 mg

Mitte: 30 (thirty)

Sig: Take 1 tablet by mouth at bedtime

Refills:2

Discontinue diphenhydramine

Yes No


Yes No

License #: 999000

Pharmacist Signature: MAnderson

Prescriber Signature: AJohnsonLicense #: 12345 Date: January 8, 2013

Your pharmacy business card goes here

Pharmacist: M. Anderson

Patient Action Plan

Date of Comprehensive Medication Review: December 28/2012, January 9/2013

As a result of my comprehensive medication review, I will do the following:

1. Stop using diphenhydramine to help me sleep and start using zopiclone instead

-take it just before bedtime if I need to

-watch for side effects and improvements talked about with pharmacist

2. I will work on my sleep hygiene

-don’t drink afternoon coffee, try to avoid afternoon nap and nighttime snacking,

keep regular schedule of going to bed/waking up, keep going for after supper

walks, make sure room is dark, comfortable, and quiet for sleeping

3.

Don’t drink grapefruit juice or eat grapefruit while I’m on Lipitor

4.

I will get my pneumococcal vaccination

5.

I will stop taking vitamin E

6.

I will talk to the doctor about codeine allergy

Medications (Prescription, Non-Prescription, Natural Health Products, Homeopathic Remedies)

Updated: January 9, 2013





Additional Comments



Ramipril 5 mg 1 cap daily with

breakfast

blood pressure, protect

heart

3 years no HTN, post-MI

Metoprolol 25mg 1 tab twice daily with

breakfast and supper

protect heart 2 years no Post-MI

Atorvastatin 20mg 1 tab daily with supper lower cholesterol 3 years no

Clopidogrel 75mg 1 tab daily with

breakfast

thin blood 2 years no Post-MI

ASA 81mg 1 tablet daily with

breakfast

thin blood, protect

heart

3 years no Buys OTC

Latanoprost 0.005% 1 drop each eye at

bedtime

Glaucoma 5 years no

Tamsulosin 0.4mg 1 cap daily at supper BPH 4 years no

Mens Multivitamin 1 tab daily with

breakfast

Supplement 5 years no Buys OTC

Acetaminophen 325mg PRN Headaches, pain, etc. PRN no Buys OTC

Zopiclone 1 tab at bedtime Sleep disorder new no Follow-up required


Date of Follow-up

Reason for Follow-up Results Pharmacist Comments & Plan

9/01/2013 Medication review 2 weeks

ago, follow-up regarding

counseling on initiation of

new treatment with

zopiclone and changes to

sleep hygiene.

Steve has been counseled and

understands how to use

zopiclone to manage his sleep

disorder, and has been given

information to improve his

sleep hygiene. Any new concerns?


Follow-up in two weeks to assess

effectiveness and side effects of

zopiclone.

Pharmacist signature: MAnderson

23/03/2013 Follow-up call to assess

improvement in sleep

pattern.

Steve has noticed it doesn’t

take him as long to fall asleep

but still finds he is waking up

frequently throughout the

night. Any new concerns?


Contact physician for increase in

dose to 5mg of zopiclone.


01/02/2013 Follow-up call to assess

improvement in sleep

pattern with increase in

dose.

Large improvement in Steve’s

sleep schedule, and he is no

longer having the same

urinary symptoms described

earlier in med review. Any new concerns?


Update medication history

forms to reflect increased dose

of zopiclone.
