The objective of this mini-review is to examine collaborative prescribing between pharmacists and physicians as a means of enhancing the professional status of pharmacists. It considers the history of such collaboration, the current status of healthcare and the pharmacists' impact on patients' health, defines collaborative drug therapy management (CDTM), discusses the legal considerations in CDTM and the requirements for CDTM, and gives a Japanese perspective. We found that many pharmacists in the United States have concluded collaborative practice agreements with physicians under a written legal protocol regarding the selection, adoption and monitoring of new dosage forms and types of medications, management of routine follow-up with patients, and refill medications. Through collaborative drug therapy management, pharmacists can contribute to increasing compliance with drug therapy regimens and reducing the rate of adverse drug events. However, pharmacists in the United States and Japan face several obstacles in becoming fully successful in their efforts in these regards. Among them are gaining physicians' support and current regulations that prevent pharmacists from prescribing in many areas. In Japan, the prohibition of pharmacists having physical contact with the patients by law is another obstacle. These obstacles can be overcome by documenting the benefits for costs and clinical outcomes arising from allowing pharmacists to play a greater role in the medical literature.
Generally, patients receiving chemotherapy for the first time are anxious that strong adverse reactions may occur because they have heard that anticancer agents cause stronger adverse reactions than other drugs. For this reason, it is important to provide them with quality information to alleviate their concern. It is common practice for physicians to inform patients about chemotherapy verbally, and to evaluate their satisfaction with this method, we gave a questionnaire to 52 patients undergoing chemotherapy. Among 45 of these patients, we found that 20% (9/45) had not understood the explanation of chemotherapy given by their physician and that 22% (10/45) were not satisfied with the information they had been given on adverse reactions. Ninety-three percent of them (42/45) said that they would prefer to have explanatory leaflets on chemotherapy. In consideration of these findings, we prepared a leaflet on chemotherapy and during the period January 2003 through June 2004, we asked 44 patients to evaluate it. We found that 100% of the patients understood the information on chemotherapy in the leaflet and 95% (42/44) were satisfied with the information on adverse reactions. These findings suggest that leaflets prepared by clinical pharmacists can improve patients' understanding of chemotherapy and alleviate their concern about adverse reactions.
To avoid postponement of surgery following hospital admission due to prior administration of antithrombotic drugs, beginning in 2002, we developed a system for surveying outpatients to determine all drugs taken by those scheduled for surgery. The system involves an expanded version of the preoperative drug administration survey previously conducted at the time of hospital admission, and we started using it for some outpatients scheduled for surgery. For the system, we prepared a list of drugs whose discontinuation should be considered prior to operations, software for inputting drugs discovered by the survey, and a pamphlet for distribution to patients, all of which made the operation of the system more effective. In 2003, 725 outpatients were subjected to the survey and the time required for each one to complete it was approximately 9 minutes. It showed that 5.1% of the outpatients were taking antithrombotic drugs, and with the assistance of pharmacists, administration was discontinued in 75 % of these patients. As a result, there was no postponement of surgery after hospital admission due to administration of antithrombotic drugs. Our survey allows all drugs being taken by outpatients to be determined at an early stage, including supplements and drugs prescribed by other hospitals, and it has thus been useful in preventing postponement of surgery after hospital admission.
In the treatment of infectious diseases, the antimicrobial susceptibility test is an important laboratory test in the selection of appropriate antimicrobial agents. In most hospitals, the antimicrobial susceptibility test is carried out by the method stipulated by NCCLS (National Committee for Clinical Laboratory Standards), a U.S. organization, and thus the standard (break point) used for interpreting the result is based on dosage regimens in that country. In the present study, we calculated time above MIC (T >MIC) for the dosage regimen indicated by Japanese drug packages inserts for ceftazidime (CAZ) and piperacillin (PIPC). T >MIC is a PK/PD parameter related to the effect of beta-lactams and is calculated using Japanese serum concentration measurement data for them. We determined that this parameter covered the full range judged by the susceptibility test to be sensitive (S) and concluded that, based on T >MIC, sufficient efficacy might not be achieved under the Japanese dosage regimen even though the result had been S in the susceptibility test. This is because there are many differences in dosage regimens between Japan and the U.S. Despite the fact that Japan has its own dosage regimens, the break point used is the one in NCCLS, which is based on dosage regimens in the U.S., and thus the results of susceptibility tests in Japan may cause susceptibility to be overestimated.
In recent years, the spread of generic drugs (GE) has attracted attention in order to reduce medical costs stemming from their use. Though GE are guaranteed to be bioequivalent to their brand name counterparts, only a few medical institutions have fully adopted them. To evaluate measures taken by companies against problems preventing the spread of GE, we performed a questionnaire survey in 33 companies selling a GE of omeprazole, pravastatin sodium or dextromethorphan hydrobromide. It revealed that most of the companies could provide the information needed by medical institutions when adopting GE, such as results of stress testing and records of supply to other medical institutions. It also showed that the problems associated with GE, such as measures for ensuring supplies in an emergency and insufficient information in package inserts, had already been solved, or were in the process of being solved, though there was a difference in the extent to which this had been done. To ensure the greater spread of GE in the future, it may be necessary for manufacturers to be more active in providing information and for medical institutions to collect information on them as well.
Although current guidelines recommend regularly scheduled administration of inhaled corticosteroids for patients with mild persistent asthma, medication records suggest that most patients only use such controller therapy intermittently. While the START (inhaled steroid treatment as regular therapy in early asthma) study found that daily treatment with inhaled corticosteroids decreased the risk of severe exacerbation and improved asthma control in patients with mild persistent asthma, the IMPACT (Improving Asthma Control) study found that intermittent treatment with inhaled steroids had about the same rates of severe exacerbation and asthma-related lung function decline as those on the recommended standard daily controller medication. To determine whether these findings were valid and representative, we critically appraised the START study and the IMPACT study according to CONSORT. The START study was generally of high methodological quality but the IMPACT study had some weaknesses in study design, clinically relevant outcomes, and participant flow. Accordingly, most patients with mild persistent asthma should be recommended to follow daily treatment with inhaled corticosteroids. The intermittent-treatment approach would be feasible for patients with a long history of mild persistent asthma who have good adherence to medication regimens.
Medication errors frequently occur, some of them having a high grade. In our hospital, we established a daily staying system under which clinical pharmacists are on hand in wards for the safety management of drugs. Doing this showed that serious cases of medication errors occurred at the points of input (when doctors write prescriptions) and output (when nurses prepare medications and administer them to patients). Therefore, the clinical pharmacists made timely checks (we refer to them as “real-time checks”) on prescription details and the preparation and administration of medications. Thanks to these real-time checks, medication errors of grade 3 could be avoided. When we asked doctors and nurses to evaluate the daily staying system, 86 % of them said that the real-time checks in wards by clinical pharmacists were necessary, and we were able to demonstrate that the daily staying system was effective for the safety management of medications.
The separation of dispensing and prescribing (SDP) has moved from the conceptual stage to the implementation stage in Japan, with a current mean national implementation rate of 53.2%. However, since the extent of complete SDP is more indicative of the true situation of SDP than the implementation rate, we devised a survey for determining this and used it to determine the rate in Chiba. Our objective was to try and improve the SDP system. The survey targeted Chiba Pharmaceutical Association national health insurance pharmacies having a fax machine (1706 out of a total 1824) and we defined the rate for complete SDP as the number of pharmacies receiving less than 70% of prescriptions from a specific medical institution. A total of 65.7% of the pharmacies received 70% or more of prescriptions from a specific medical institution. Analysis using the X2 test revealed a significant difference (p< 0.01) between the less than 70% group and the 70% or greater group and the rate of complete SDP in Chiba was determined to be 20.9%. One of the aims of the SDP system is to ensure safer and more effective medical treatment by having prescriptions from several medical institutions dispensed at one pharmacy. The current state of SDP is properly indicated not by number of prescriptions being received by pharmacies but by the rate for complete SDP. The 39.9 % rate for complete SDP revealed by our survey suggests that the potential of the SDP system is not being realized. To remedy this, SDP must be implemented jointly by pharmaceutical and medical associations in the future, not by pharmaceutical associations alone.
We investigated the way that health foods (including those for specified health uses) are sold at pharmacies, awareness of interactions and the extent of information gathering when health foods are dispensed together with prescription drugs. To obtain data for our study, we sent a questionnaire by mail to 176 pharmacies belonging to the Chiba Pharmaceutical Association. The questionnaire asked for background information on pharmacies, and about how health foods are sold, the information given on them, awareness of interactions, information gathering methods and status of interactions in the case that health foods are dispensed together with prescription drugs. We next analyzed the results for a relationship between the dispensing status and methods of gathering information on interactions in the case of concomitant use of health foods and pharmaceutical products. In doing this, we investigated the independence among groups using the Wilcoxon rank sum test, specifying the average numbers of prescriptions dispensed per day and share of prescription drug sales as dependent variables, and whether or not information on interactions was sought using the internet or by making inquiries to pharmaceutical companies as explanatory variables. We received completed questionnaires from 77 pharmacies (response rate 43.7%). Based on their responses, the average monthly number of prescriptions per pharmacy was 1, 738.9, dispensing accounted for 68% of sales, and the average man-hours per day was 26.1 hours. The rate for conducting checks concerning health foods at the time of dispensing was 53.2 %. As for the average number of prescriptions handled per day, we concluded that more inquiries were made to pharmaceutical companies as the number of prescriptions handled increased since there was a significant difference between the with and without inquiries to pharmaceutical companies groups (p=0.0037).
The Nanopass®33 micro-tapered needle (MT 33 G, Terumo Corp., Tokyo, Japan) is tapered in form : 33 G at the tip end and 28 G at the cartridge end. We examined the structure of insulin crystals in insulin suspensions before and after passing through the MT 33 G needle to determine if there were any changes in it that might adversely affect the pharmacodynamics and action of insulin. We also examined the hypoglycemic effect of insulin in dogs after it had passed through a MT 33 G needle to see if it had been modified by it. No changes were observed in the insulin crystal structure when the insulin preparation in a syringe was discharged at a rate of 10 units/sec through the MT 33 G needle connected to it. Also, when insulin was administered to dogs, there was no significant difference between the MT 33 G and the Micro-FineTM Plus, 31G, Thin Wall needle (Nippon Becton Dickinson Co., Ld., Tokyo, Japan) as regards the blood insulin and blood glucose levels measured.
In the present study, we examined the significance of the pharmaceutical management of medicines which inpatients brought with them to the orthopedics department in Kumamoto University Hospital. Forty-one percent patients had brought medicines with them. Among the 260 patients surveyed, there were 19 with allergies to medicines and adverse effect records but the medicines responsible for them, administration periods, and grades of adverse effects could not be determined in most cases. In order to prevent such adverse effects, it was considered that management of the patients' overall medication by pharmacists would be essential. Thus pharmaceutical management was introduced into the clinical path so that pharmacists could efficiently check the prescribed drugs brought by patients when they were hospitalized. In the future, it will be important to have closer cooperation between those involved in pharmaceutical management and those concerned with the clinical path to facilitate the checking of medications brought by patients and gathering of information on adverse effects.