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• W2078960488 abstract "Recently, the New Zealand government began remunerating pharmacists for what they call Pharmaceutical Review services. As already occurs in a number of other countries (including New Zealand—it is just that we will now be paid for it!), the pharmacist makes a comprehensive review of the patient’s medications by documenting the medication-related problems and making recommendations. A pharmacist beginning to provide these services submitted a batch of cases for peer review. The standard was excellent. The reviews were carefully undertaken and well documented. The recommendations made were evidence based and showed a very good command of the relevant literature. In all, it was a credit to the profession, except for one thing. One patient in a rest-home facility was reported to be on phenytoin treatment for recurrent seizures, which were continuing. The plasma level had been measured and was reported as 6 mg/L (normal therapeutic range 5 10–20 mg/L). The attending physician had increased the total daily phenytoin dose by 15%. This had been accepted by the pharmacist with a simple recommendation to check the level again in a few days’ time. At nutrition conferences, the talk is ever more of “standard bags” and “off-the-shelf” formulations. Studies in the literature encourage the use of a standardized approach,1 as do the cost-conscious administrators of “managed-care”–based health businesses.2 In a recent commentary on how the managed-care model is affecting nutrition support,3 Kathleen Crocker’s poignant contribution, “How would Jay fare today?,” reviews some of the individual “one-off” things that were tried in the management of a long-term home-therapy patient through the 1980s and early 1990s and speculates on how the present standardized environment would have affected this patient’s management had he presented 10 y later. What is a pharmacist at the turn of the millennium? Pharmacists have moved away from being focused on product to being increasingly focused on the patient. Some will argue that the profession always was focused on the patient, but many who completed pharmacy training in the 1970s could have been forgiven for believing that, as long as the correct medication was in the bottle, the label was straight, legibly written (remember hand-written labels?), and the bottle was given a final polish, all was well. Discussions with patients and patient counseling were things that you learned later while doing the job. Comparatively little was taught about human disease, but there were enormous amounts of very detailed chemistry, both inorganic and organic, formulation science, molecular modes of action, and excruciating detail on metabolism and excretion. The past 20 to 30 y have seen a massive shift in emphasis, with a move away from secundum artem and toward original pack dispensing, with pharmacists increasingly applying their clinical skills; of course, this is entirely appropriate. The trend has been mirrored in nutrition support. The economies that can be gained when compounding of admixtures (and particularly the quality assurance aspects) are conducted at an industrial scale are considerable.4 Although we should not forget that the downside is the potential for problems in such units to affect much larger numbers of patients,5 it cannot be denied that, although adults range considerably in size and organ function, the “one dose fits all” approach works remarkably well for many patients, but not for all. Pharmacists have a good record of identifying some of those patients in whom the standard dose is inappropriate, but does the profession reach or even remotely approach its full potential in identifying such situations and making constructive recommendations for solving the problems? In the course of a year, most pharmacists are offered continuing education, but when was the last time most were offered an update in inorganic chemistry, medicinal chemistry, or detailed drug metabolism? In the United Kingdom for many years, the only people legally allowed to call themselves chemists were pharmacists, but how many practitioners of pharmacy could really make a legitimate claim to that title today? Does it matter? What practical use would it be ? In the day-to-day practice of nutrition support, questions of drug compatibility are constantly arising. For good clinical reasons, requests arise to administer drugs either in the same line or even in the same container as parenteral-nutrition solutions. Many such combinations have been studied and reported in the literature, although such studies range from a detailed analytical assessment of stability to “they were mixed and no precipitation of colour change was observed.” All too often, in practice, recommendations are based on whatever can be found in the literature, with many taking the findings at face value without considering how the information was derived. On other occasions, we simply report “there is no data on this.” However, in many cases, the combination of a sound knowledge of basic chemistry with the sort of data that can be found quite quickly in common textbooks or, increasingly, on the Internet would allow useful informed predictions to be made. If something is only soluble at low pH, it is unlikely to stay in solution in a heavily buffered pH 6 admixture, but how many of us actually have the confidence even to go this far? At the same time, are the consequences of administering the drug in this modified fashion always thought through? Is the drug now being administered faster or slower than normal? Will this make any therapeutic difference? What of the drug formulation itself? Is it adding significant amounts of electrolyte? Many immunosuppressed patients are administered multiple antibiotics with antiviral and antifungal medications. Does someone sit down and work out the total amount of additional fluid, electrolytes, and carbohydrates the patient is receiving through the concurrent therapy? Is the patient provided with a more concentrated nutrition solution to ensure that the full allowance is infused or adjust the electrolyte profile of the standard formulation? It is certainly not the intention of this column to suggest that all pharmacists should abandon the security of evidencebased practice and begin wild, barefoot exCorrespondence to: Patrick A. Ball, PhD, MCPP, Senior Lecture in Clinical Pharmacy, School of Pharmacy, University of Otago, PO Box 913, Dunedin, New Zealand. E-mail: patrick.ball@ stonebow.otago.ac.nz" @default.
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• W2078960488 title "Is there a pharmacist in the house?" @default.
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