Pharmacy practice is progressing toward the future with the addition of 2 years to the Japanese pharmacy school curriculum by the year 2006. With a 6-year pharmacy degree, graduating pharmacists can provide more pharmaceutical care to patients in hospitals and community pharmacies than ever before. In the United States, the clinical pharmacy movement began to evolve during the 1960's. Several key philosophical changes and structural modifications to the pharmacy curriculum prepared graduates for new roles in patient education, communication with physicians, independent learning, and problem-solving. Patient case discussions through the small group, problem-based learning (PBL) approach are essential courses for the development of analytical thinking skills. Students are required to justify their choices with evidence-based primary literature. The curriculum is also strengthened by including participatory experiences, such as clinical rotations, within the curriculum structure prior to graduation. The clinical pharmacy movement was successful and now pharmacists in the United States perform a broad scope of patient-oriented clinical practice activities, such as preventative healthcare screening and monitoring of cholesterol, blood glucose, and hemoglobin Alc blood levels, taking blood pressure measurements, administering immunizations and providing more patient education than ever before.
With warfarin there are many factors that reduce or enhance the anticoagulant effect. We retrospectively studied the risk factors of prolongation of International Normalized Ratio (PT-INR) of prothrombin time for patients receiving warfarin by the pharmacoepidemiological method. We targeted patients whose PT-INR was 4.5 or more from a review of medical charts. For each of these patients, we selected two control patients who were matched in terms of age (±5 years), sex, duration of taking warfarin, diagnosis and department prescribing the warfarin. We compared patient backgrounds, clinical laboratory test result and the concomitant drugs prescribed between the cases and the controls. Of the 740 patients taking warfarin during the investigation period, 39 (5.27%) had a PT-INR of 4.5 or more and were selected as the cases. Between the cases and the controls, no statistically significant differences were seen in dosage, duration of taking warfarin, or prescribing reason. In the case group, serum albumin levels were significantly lower than in the control group (P<0.05). The drug amiodarone was a significant risk factor for PT-INR prolongation with an odds ratio of 11.32 (95% confidence interval 1.27-100.64). Thus, low serum albumin and concomitant administration of amiodarone were significant risk factors for PT-INR prolongation.
The usefulness of ticlopidine in preventing re-stenosis (stent thrombosis) after percutaneous coronary intervention (PCI) is being evaluated but it has been reported that ticlopidine causes adverse effects, such as thrombotic thrombocytopenic purpure, granulocytopenia and liver failure. In July 2002, the 2 nd Emergency Safety Information Notice (Dear Dr. Letter), which gives prescribing rules and stresses the importance of blood tests, was distributed. However, since the stipulations in it have not been fully observed, in consultation with doctors, we made our own rules for patients taking ticlopidine PCI which are : 1. Ensure that blood tests are carried out during hospitalization, 2. Reduce administration period after PCI from four weeks to two weeks, 3. Have pharmacists provide information on adverse effects and drug information on ticlopidine. We investigated the number of prescription days, extent of conducting blood tests and manifestation of adverse effects at the time of discharge from hospital for before (n=27) and after (n=42) implementing the rules and compared the findings. We also investigated re-stenosis rates and from this determined whether there was any disadvantage in treatment with ticlopidine for before and after implementing the rules (n=23) and after (n=20). As our findings, the frequency of carrying out blood tests improved and there was no significant rise in re-stenosis rates. These results suggest that there are no problems with treatment using ticlopidine. Furthermore, we consider our efforts to have ticlopidine used properly have been useful from the points of both safety and efficacy.
The usability of two types of insulin delivery devices (HumaPen® Luxura and NovoPen® 300) was evaluated using a clinical questionnaire and a basic test. The objective of this study was to provide important information to diabetic patients who are going to start insulin therapy using these devices. The clinical questionnaire was given to 30 inpatients with diabetes in the diabetes center of our hospital by a crossover method. The basic test targeted the following items : font size of dose number, interdigitation torque required to load cartridge into pen body, depression of the injection button, injection force, and volume of click. According to the results of the clinical questionnaire, HumaPen® Luxura was significantly easier to use in terms of set up, visibility of dose number, ease of correcting dose, ease of depressing injection button, and ease of replacing pen cap than NovoPen® 300. The results of the basic test revealed that dose number of HumaPen® Luxura was slightly larger than that of NovoPen® 300 and the injection force was lower. Though the volume of click for HumaPen® Luxura was smaller than that of NovoPen® 300, it was larger than that of HumaPen® Ergo. The interdigitation torque needed to load a cartridge into the pen body of HumaPen® Luxura was about 3 times that of NovoPen®300. In conclusion, HumaPen® Luxura is the most suitable device for patients of all ages because of its ease of use in all operations from set up to injection. NovoPen® 300, on the other hand, is suitable mainly for younger patients because of the difficulty in correcting the dose and the large injection force as compared with HumaPen® Luxura, despite its better portability.
Recently, Kampo medicines (Japanese traditional herbal medicines) have been contributing greatly to patient treatment but there have been cases in which the patient's symptoms deteriorated during treatment and they had to discontinue the Kampo medicines. We investigated the reasons for discontinuing Kampo medicines at our institute, and discussed the improvement of continuance through giving patients better instructions. The most frequent reason for discontinuance was aggravation of symptoms by the medicines and we determined this by making a classification of the reasons for discontinuation. The next most frequent reason for discontinuance was digestive tract-related and other symptoms, for example rash and/or itch, and diarrhea. Next, we examined these symptoms to see if they were related to the adverse effects of Kampo medicines. Based on the results of our investigation, we devised measures for improving continuance for Kampo medicines. In 2004, when these measures were implemented, the annual number of cases of discontinuation decreased from 96 to 78. This resulted from the clarification of the reasons for discontinuance of Kampo medicines, and the improvement of pharmacists' instructions to patients.
Municipal Ikeda Hospital established a palliative care team consisting of physicians, pharmacists, and nurses in February 2002. We investigated the amounts of narcotics used during a period of 5 years, and evaluated the role of pharmacists in the palliative care team based on the trend in the amounts used. The total amounts of narcotics administered varied irregularly during the period but the use of rapid-release morphine hydrochloride products rapidly increased after fiscal 2002. On comparison of the numbers of administration days and the amounts of narcotics used between fiscal 1999 and 2003, the distributions were similar with no significant differences. The proportion of patients treated with rescue prescriptions, both internal and external use preparations, was about 10% until fiscal 2001, but this rapidly increased after fiscal 2002, and reached 71.4% in fiscal 2003. Rescue prescriptions are essential for setting dose escalation for narcotics and sudden appearance of severe pain, and thus the rescue prescription rate could be a means of evaluating the palliative care team. The rapid increase in the amount of rapid-release morphine hydrochloride products administered and the increase in the rescue prescription rate may have resulted from case study meetings, inauguration of cancer pain therapy programs, and subsequent instruction provided by pharmacists to the palliative care team.
The purpose of this study was to investigate the situation of intravenous vancomycin (VCM) prescribing as well as the effect of implementing recommendations in this regard at Kobe City General Hospital where no such investigation had been done before. All intravenous VCM prescriptions were monitored prospectively over a 6 month-period in 2001 and then based on an analysis of the first 100 cases, the hospital infection control committee and hospital pharmacy drafted recommendations for the proper use of VCM. After they were implemented hospital-wide, VCM prescribing was prospectively monitored for another 100 cases in 2002 and the impact of the recommendations was evaluated. Pneumonia and wound infections were the major indications for VCM both before and after the recommendations. The duration of intravenous VCM use (19.5 days vs.13.1 days ; p<0.01) and hospitalization (100.1 days vs.83.1 days ; p<0.05) were significantly shorter after the recommendations. Frequency of death and clinical success, defined as improvement in symptoms or cure, remained the same, however. Frequency of therapeutic drug monitoring increased significantly after the recommendations (56 vs.71 ; p<0.05) and the incidence of adverse reactions such as flushing decreased accordingly (12 vs. 1 ; p<0.01). Implementation of the recommendations was effective in promoting the proper use of VCM and reducing the duration of VCM therapy, length of hospital stays, and overall cost of patient care.
The handling of narcotic drugs is strictly regulated by the Narcotics and Psychotropics Control Law in which the legal obligations and responsibilities in the management of such drugs are outlined with a view to ensuring that they are used properly. As the keeping of manual records on the use of narcotic drugs is a time-consuming task, Hokkaido University Hospital, introduced a computerized drugs order-entry system in October 2003 to increase efficiency in the management of narcotic drugs. In creating the system, data on orders for narcotic injections, numbers of injections used and records of returned narcotics were input. Using this data, the system is able to automatically print out various ledgers, such as narcotics ledgers and discarded narcotics ledgers, and other documents. The introduction of this system has simplified the procedure of keeping records on narcotics, which has considerably shortened the time required to prepare various ledgers, and increased efficiency in the management of narcotics in the pharmacy. The work load in returning narcotics at each ward has also been reduced.
Early Post-marketing Phase Vigilance for prescription drugs was enforced in October 2001. Under this system, hospitals and other medical institutions are considered as facilities for investigation, while dispensing pharmacies are not subject to investigation. However, considering the progress that has been made in the separation of dispensing from medical practice, we feel that the dispensing pharmacy can play an important role in the collection of safety information on prescription drugs. With this in mind, we began the collection of drug monitoring information in 1985 and more recently, we have been actively participating in Early Post-marketing Phase Vigilance as one of our activities in this regard. We have collected information on adverse drug reactions due to 20 prescription drugs in 12, 881 subjects. The number of subjects who reported adverse drug reactions was 213, and the number of adverse drug reactions reported was 220. Elderly patients of 60 years or more accounted for 36 % of the collected cases. Among adverse reactions involving body organs, the alimentary system (116 cases) came top with 52.7% of all cases and next came adverse reactions of the mental and nervous systems, accounting for 28.6% (63 cases) of the total. Since medical institutions issue over 50% of all of Japan's prescriptions, we must continue to actively participate in Early Post-marketing Phase Vigilance in the future through the collection of information on adverse drug reactions.
Drug interactions broadly fall into two categories : drug-drug interactions, which occur when two or more drugs react with each other, and drug-food/beverage interactions, which occur when drugs react with a food or beverage taken concurrently. These interactions may profoundly affect drug pharmacokinetics, pharmacologic actions and efficacy, and may cause adverse reactions. To avoid the risks of drug interactions, it is important that not only medical professionals but also patients be fully aware of potential interactions, and also that consistent information be given to patients. The achievement of these two objectives can reduce the frequency of the adverse effects and improve outcomes. We selected the example of the widely discussed interactions between grapefruits and certain drugs and investigated the extent to which medical staff (doctors, nurses, dietitians, and pharmacists) were aware of them and informed their patients about them, by means of a questionnaire. From the findings, it was clear that awareness of the interactions among medical professionals varied greatly and the amount of information given to patients also varied greatly, implying that awareness of the interactions and the information provided to patients on them were both inadequate. The absence of consistent information will lead to patient confusion and is disadvantageous from a therapeutic viewpoint. We therefore believe that an important role of pharmacists' in drug therapy is to proactively provide appropriate information on drug interactions to medical professionals and patients before they have the chance to occur.