Issues that require pharmacist intervention

Drug utilization review (DUR)

A drug utilization review (DUR) is a structured review of a patient’s medical condition(s) and medication-use history, typically performed by a pharmacist. The purpose is to optimize medical therapy.

DUR is an ongoing quality-assurance process. Reviews may occur multiple times per year, especially when:

• New medications are started
• Doses are changed

DUR helps to:

• Prevent adverse drug reactions
• Avoid harmful drug-drug and drug-food interactions
• Reduce cost
• Improve patient adherence to therapy
• Increase efficiency

As part of DUR, the pharmacist may also collaborate with prescribers to optimize drug therapy.

DUR can be classified as prospective, retrospective, or concurrent.

Prospective DUR: Done before the medication is dispensed. Examples include evaluating drug abuse or misuse potential (e.g., when prescribing opioid analgesics) and considering generic substitutions. For example, if a patient taking warfarin is prescribed another blood thinner like heparin, the combination may increase the risk of internal bleeding. During DUR, the pharmacist can identify this risk and contact the prescriber to adjust therapy before treatment begins.

Retrospective DUR: Done after the medication is dispensed. This helps identify patterns of under- or overtreatment. For example, a pharmacist may notice that a patient with asthma may need an inhaled steroid or a step-up in therapy and can inform the physician.

Concurrent DUR: Done during the course of current medical therapy. For example, hospitalized patients may receive multiple medications. The pharmacist can review the regimen, identify duplication of therapy or drug interactions, and inform the physician.

OTC recommendation

OTC (over-the-counter) drugs can be purchased without a prescription. In some situations - such as when a prescription drug is out of stock - the pharmacist may recommend an OTC substitution, depending on availability.

Like prescription drugs, OTC products can cause adverse effects. Some OTC drugs (e.g., dextromethorphan, loperamide) are also associated with drug abuse.

Key factors that affect OTC recommendations include:

• The patient’s age
• Drug allergies
• Medical history
• Potential drug-drug interactions

Therapeutic substitution

Therapeutic substitution replaces the initially prescribed drug with a different molecule that is expected to provide therapeutic equivalence. The alternative may be:

• Within the same drug class, or
• From a different class with assumed therapeutic equivalence

Therapeutic substitution may be used to:

• Lower drug costs
• Prevent adverse effects
• Address unavailability of the prescribed medication

Consulting the prescriber is always recommended before making a therapeutic substitution.

Generic substitution

Generic substitution occurs when a different formulation of the same drug is substituted. The licensing authority considers all generic versions of a drug equivalent to each other and to the original drug.

Generic drugs are typically cheaper than brand-name drugs. Unless the prescriber selects “dispense as written,” the pharmacist can make a generic substitution.

For example, rosuvastatin is a generic substitution for Crestor (brand name). A therapeutic substitution for Crestor can be simvastatin, which is in the same class of drugs as Crestor.

Post-immunization follow-up

Pharmacists - and, in some cases, pharmacy technicians - may be trained to administer vaccinations. Post-immunization follow-up focuses on adverse events related to vaccination and on medical errors.

Examples include:

• Injecting at the wrong site
• Loss of potency
• Injection-site reactions (e.g., swelling, pain)
• General symptoms (e.g., fever)
• Allergies to vaccine components (e.g., egg, polyethylene glycol (PEG))

Apart from the functions discussed above, the pharmacist is also responsible for monitoring and preventing adverse drug events, identifying drug abuse or misuse, identifying drug interactions and allergies, and actively promoting adherence to medical therapy.

Hygiene and cleaning standards

Maintaining cleanliness and hygiene is essential in the pharmacy. The following methods help keep the pharmacy clean, support safe drug dispensing, and reduce contamination risk.

1. All pharmacy professionals must keep their hands clean by washing with soap and water and using gloves when appropriate (e.g., when counting and packing drugs or administering immunizations). Hand sanitizers are an add-on to handwashing. Liquid soaps are preferred over bar soaps.
2. Pharmacy countertops, workstations, and equipment like counting trays should be disinfected daily with alcohol-based products.
3. The pharmacy countertops and floor should be frequently dusted, including vacuum cleaning carpets and floors.
4. Storage areas should be kept clean, organized, and properly labeled.
5. Personal protective equipment (PPE) like gloves and masks is recommended to avoid contamination during immunization, COVID testing, and compounding medications for immunocompromised patients. PPE is also used for disposing of hazardous drugs.
6. Pill counting trays should be cleaned with isopropyl alcohol after each use. Hazardous drugs like chemotherapy drugs, warfarin, penicillin, etc., should have separate pill counting trays.
7. Pharmacies that compound injectables, infusions, and eye drops need sterile compounding areas where, apart from PPE use and disinfection of surroundings, proper ventilation and building design are vital to maintain decontamination.
8. Color-coded disposal bins must be used to separate medications and sharps from general pharmacy waste.