Having a specialist knowledge of the practice of pharmacy in the clinical setting, clinical pharmacists are key members of the patient care team. They also play a very important role by acting as drug consultants to doctors and providing information on drugs to patients. The target of our study in this regard was the administration of the α-glucosidase inhibitor acarbose which offers a novel approach in the treatment of disbetes mellitus. Increased flatulence, a recognized adverse reaction of acarbose, is very unpleasant for patients and causes them discomfort. Further, many other disgestive tract-related adverse reactions are known and acerbose has also been reported to cause severe hepatic disease. In the case presented here, we observed that the alanine aminotransferase (ALT) level steadily increased after the administration of acarbose and that all laboratory tests produced negative results at 40 days after administration. The above findings suggest that the clinical pharmacist should monitor parameters to prevent acarbose-induced hepatic injury. Our results also show that the period of increased flatulence due to acarbose could be significantly shortened through such monitoring, and we were thus able to provide patients with useful information concerning the drug acarbose. In conclusion, consultations between doctors and clinical pharmacists are necessary for improving the effectiveness of clinical pharmacy practice.
The establishment in 2002 of additional remuneration for the use of branded generic drugs in medical treatment has led to an increase in their use. However, debate continues on various issues, a major one the availability of drug information (DI) on such products, since DI is such a vital component in all assessments of the safety and effectiveness of pharmaceuticals. We therefore conducted an objective evaluation of the adequacy of DI on branded generic forms of pravastatin sodium and simvastatin, using the media of drug package inserts and interview forms. On a scale setting the amount of DI provided for the original drugs at 100, the quantities of DI available for generic pravastatin sodium and simvastatin were 34.1±11.0% (Mean±SD) and 37.3±12.2% (Mean±SD), respectively. Comparison of the amounts of DI available at present with those at the time the original drugs first appeared on the market showed increases of 39.4 % for pravastatin sodium and 47.1% for simvastatin. The branded generic forms of the drugs considered in this study have only recently become commercially available. So, information gained through experience of using such drugs in the clinical setting hereafter will be incorporated into future package inserts and interview forms, providing healthcare professionals with fuller descriptions of their uses, interactions, and adverse reactions.
Diethylhexyl phthalate (DEHP) is used in administration sets made of polyvinylchloride (PVC) as a plasticizer and such PVC administration sets are used frequently for intravenous drip infusions. However, it has been reported that the DEHP in administration tubes is dissolved by intravenous solutions containing solubilizing agents to aid continuous intravenous infusion. Since DEHP is suspected of being an endocrine disruptor, it should be prevented from entering the human body. With this in mind, we examined the DEHP leaching characteristics of a model solution containing the surfactant polyoxyethylated castor oil as the solubilizing agent. DEHP began to be leached from the administration set when the continuous infusion was started and the amount of DEHP leaching was found to increase in proportion to the concentration of the solubilizing agent, but decrease when the rate of flow was increased. The DEHP leaching pattern was similar when the model solution contained drugs. From these findings, we inferred that DEHP leaching is greatly influenced by the solubilizing agent. Though there have been no reports of DEHP having adverse effects, it should be prevented from entering the human body through the use of administration sets that do not contain it or changing the administration procedure.
Conducting clinical pharmacy practice in consideration of inpatient needs is one of the most important activities of pharmacists. In view of this, we conducted a pilot study at the National Cardiovascular Center to evaluate the effectiveness of our practice of clinical pharmacy. During the study period, 892 drug compliance instructions were given to 312 patients and there were 1, 785 events that had to be managed. In order to manage these events, we provided information in 2, 007 instances to patients (65 %) or medical staff (35%). Among the events, the frequency of adverse reactions was 6.3 %, with a rate per drug compliance instruction of one in eight. Medical errors accounted for 1.9% of the events, giving a rate of one error per 24 drug compliance instructions. Twenty percent of all prescription changes arose from information provided by pharmacists and 6.0 % of changes in prescriptions were attributable to the medication errors detected by pharmacists. Thus, pharmacists were involved in about 25 % of prescription changes. As our conclusion, clinical pharmacy practice which helps to avoid adverse reactions and provides useful information to patients and medical staff is a prerequisite for effective pharmacotherapy.
Checking prescriptions is one of the most important tasks of the pharmacist. For this purpose, we have developed a computer database for answering pharmacist inquiries using Microsoft Access 97. This database allows us to search past records quickly and to check the details of inquiries that we made before. We used it to determine the frequency that prescriptions needed to be clarified by physicians. We also worked out the percentage of prescriptions that had been corrected after inquiries for each clinical department, and according to the nature of inquiries. It was found that pharmacists verified 0.26% of all prescriptions and that physicians changed 50.4% of these prescriptions based on the advice of pharmacists. Interestingly, prescription correction rates varied greatly among clinical departments. We also noted that there were some mistakes that arose as result of our current order-entry system. In conclusion, we consider our pharmacist inquiry database to be a useful tool for risk management in the clinical setting and that it will help us to reduce medication errors.
In the wards of our hospital, the primary disinfection of medical apparatus had been performed immediately after use. Glutaraldehyde (GA) preparations are used at many medical institutions for disinfection but their use in places with poor ventilation produces high concentrations of aldehyde vapor, which may affect the health of medical staff. In our hospital, primary disinfection in wards was discontinued after the introduction of washer-disinfectors in our central supply department. As a result, disinfection costs in 2001 were about 7 million yen less than the mean annual cost of GA preparations from 1996 to 1999. In the endoscopy room, the disinfectant was changed from a GA preparation to an orthphtaladehyde (PA) preparation. Though this brought about an increase of about 5.3 million yen on the mean annual cost of the GA preparation from 1996 and 1999, since disinfection with PA required less time, more endoscopy examinations could be conducted, resulting in an increase in hospital revenue.
We evaluated the usage, effectiveness, and adverse reactions of micafungin (MCFG) in 17 patients with hematological disorders (6 with acute myelocytic leukemia, 2 with chronic myelocytic leukemia, 3 with aplastic anemia, 4 with myelodysplastic syndrome, 1 with multiple myelomas, and 1 with myelofibrosis) being treated in our hospital. Complete remission was achieved in 1 patient, and stabilization in 7, but the condition of 5 became aggravated. Three patients were excluded due to the administration of prophylactics and effectiveness could not be determined in 1 patient. For 9 patients with definite or suspected pulmonary aspergillosis, MCFG was effective in 3 of 4 treated at a dose of 150 mg and in 2 of 5 treated at a dose of 75 mg. The administration of MCFG was discontinued due to adverse reactions and associated symptoms in 7 patients (drug-induced fever in 3, nausea/vomiting in 2, abnormal liver function in 2, drug eruption in 1, and diarrhea in 1 including patients with more than 1 symptom). All adverse reactions and associated symptoms were mild in degree, however. From the above observations, we concluded that in the case of administering MCFG for pulmonary aspergillosis, a daily dose of 75 mg is inadequate and a daily dose of 150 mg or more is necessary. Our findings also suggested that for patients who do not respond to conventional antifungal drugs or cannot be treated with an adequate dose of such drugs due to adverse reactions, the high-dose administration of MCFG together with amphotericin B may be effective.
Ticlopidine has been reported to cause critical adverse reactions, among them thrombotic thrombocytopenic purpura, granulocytopenia and liver failure. In view of this, emergency safety information has been issued on two occasions and after it was issued for the second time in July 2002, a warning function was incorporated into the computerized order entry system. Under this function, a warning message is displayed on the screen when this drug is to be prescribed for a patient for the first time and physicians can only enter a prescription order for ticlopidine when they have acknowledged the message. We compared the frequencies of prescribing ticlopidine and of conducting blood tests, and the rate of adverse reactions before and after the issue of the emergency safety information and introduction of the warning function. Patients treated with ticlopidine were selected from the prescription database file created from the prescription order entry system, which contains details of all the prescriptions filled for outpatients between January 1998 and December 2002. Following the issue of emergency safety information for the second time, the prescription frequency of ticlopidine started to decrease and there was a significant increase in the frequency of blood tests, though there had been no difference in the amount of blood testing between before and after the issue of emergency safety information for the first time. This showed that the timely provision of safety information to physicians through the computerized order entry system has been effective in promoting the proper use of ticlopidine.
Pharmaceutical education has come to a major turning point when major changes are taking place, and training in hospitals is now obligatory for pharmacy students. It is therefore important for hospitals to offer a high quality of training. For this purpose, guidelines for pharmacist training in hospitals and a qualification system for hospitals offering such training have been proposed. Additional provisions for pharmaceutical education have been established under the title “Models for Pharmaceutical Education, Core Curriculum for Practical Training and Curriculum for Final Year Training”. However, except for those affiliated with medical schools, education is not a primary concern for hospitals, making it difficult to follow the above guidelines for many hospitals, of which ours is one. Every year, we receive several students who wish to do their training close to home but they cannot receive instruction in some of the subjects in the guidelines because we do not offer the related services, causing us great concern. To fill the gap, however, we have developed a system called “Support System for Pharmaceutical Training in Hospitals using the Internet” and it is now in operation. Since the amount of information on the Internet that can be used for training purposes is very limited, our system is still far from satisfactory but students have been finding it useful. A major limitation we face is the lack of teaching materials available for our system. Solving this problem is very important for hospitals such as ours that do not offer some of the services in the guidelines, as well as for improving the quality of pharmaceutical education. This problem will never be completely solved, however, unless individual hospitals start to offer the services that they now lack. It is thus necessary for the teaching hospitals and the Hospital Training Council to develop a system for augmenting the amount of teaching materials available. With the rapid spread of the Internet, many educational programs using it have been developed to fill gaps between the levels of education provided by different institutions, and they are highly regarded. Thus, in order to improve the quality of training programs in hospitals having similar problems to ours, it is necessary for general hospitals, universities, and teaching hospitals to collaborate on producing more teaching materials for pharmaceutical training.
During the period March 2000-February 2001, we conducted a study on prescriptions to determine how non-steroidal anti-inflammatory drugs (NSAIDs) were being used in Chikugo City Hospital, a medium-sized hospital, in order to promote rational drug use. The use of NSAIDs was evaluated for 10 clinical departments, together and individually. We found that Diclofenac (DIC) and sodium loxoprofen were used to about the same extent in almost all departments and that Acetaminophen (ACE) was also prescribed as frequently as DIC. Except for ACE, no NSAIDs were used for children, particularly in the case of those under 9 years in age. We also evaluated the co-prescription of NSAIDs with H2-receptor antagonists because NSAIDs are known to cause gastric adverse reactions. The number of patients who had been prescribed H2-receptor antagonists increased with patient age, especially for those over fifty years old. Zaltprofen was more frequently coprescribed with H2-receptor antagonists than other NSAIDs. The prescription of etodolac was also found to increase with patient age, particularly so for those over fifty. Thus, we consider that information obtained by studying prescriptions can be used to evaluate the intentions of those prescribing drugs and clarify problems in the use of NSAIDs.