Medicosnext
Words by Sadhana Dahal
The pharmacist assumes the role of a health professional directly responsible for providing medication-related care with the goal of achieving specific outcomes to enhance a patient’s quality of life.
Rather than blaming anyone for the patient safety issues, finding out the root cause for issue and working on it helps prevent similar issues from harming the patient in the future.
A study focusing on pediatric acute lymphoblastic leukemia patients revealed a 10% oral medication error rate, predominantly during prescribing and administration. These findings underscore the need for heightened vigilance which can be provided by pharmacist in medication management, especially in critical healthcare scenarios, to mitigate the risk of adverse events.
My journey in oncology care at Patan hospital
During my short tenure at Patan Hospital as a clinical pharmacist in the oncology department, I had the privilege of working closely with the esteemed oncologist, Dr. Arun Shahi. His mentorship proved to be instrumental in my professional development within the field. Working alongside him, I gained invaluable insights into the intricacies of oncology, fostering a deeper understanding of patient care and treatment strategies. Analyzing prescriptions and understanding the nuances of anticancer medications enhanced my comprehension of oncology pharmacy for which Dr. Saurav assisted me a lot in the initial days. I am grateful to Patan Hospital for the collaborative experience that significantly contributed to my journey in the oncology department.
Identifying, resolving, and preventing medication-related problems such as untreated indications, improper drug selection, inadequate dosing, adverse drug reactions, interactions, and medication use without a valid indication.
I assumed a pivotal role in tackling the intricate challenges inherent in acute cancer therapy. The daily responsibilities encompassed the management of drug related adverse effects and navigating through complex dosing schedules with precision and diligence. I believe that I diligently provided crucial dosing and administration considerations, looking into the dosing needs of the patients and advising patients on whether medications should be taken with or without food, recognizing the profound impact on absorption and, consequently on drug efficacy.
A significant focus of my attention was directed towards patients with difficulty swallowing. I ensured that vital information regarding the potential opening of capsules or dissolving their contents was communicated effectively. This meticulous attention to detail was crucial in empowering patients to receive their medication optimally and manage their treatment journey with confidence.
In the realm of chemotherapy administration, I undertook a comprehensive approach to patient well-being. This involved assessing their ability to tolerate hydration regimens, monitoring for electrolyte abnormalities, and vigilantly identifying potential tumor lysis syndrome. Additionally, I played a key role in managing acute side effects, particularly the common challenges of nausea and vomiting associated with anticancer drugs.
Oncopharmacists play significant roles in ensuring patient safety, decreasing polypharmacy, formulating and administering drugs, providing education and counseling for medication adherence, contributing to training and research, functioning as a group member, acting as a consultant, and participating in palliative care medical settlement and medication management.
I recall a memorable case involving a patient who traveled all the way from Jumla due to severe vomiting. Upon reviewing his medication history, I discovered that he was taking ondansetron after meals, contrary to the recommended protocol of taking the medicine before food. Resolving this discrepancy by advising him to take the medication before meals successfully alleviated his vomiting issues. This experience made me realize the significance of small things in medicine like the timing of medication administration and the impact it can have on patient outcomes. Through dedicated patient interviews and routine monitoring of chemical levels and vital signs, I did my best to track and address the critical aspects of patient care.While the side effects such as nausea, vomiting, diarrhea, and mucositis in chemotherapy may appear as routine occurrences, my experience at Patan Hospital help me underscore that patients often experienced considerable distress due to these common and specific adverse reactions. I tried my best to address the anxieties within the patient community, extending moral support, delivering clinical practice recommendations, and guiding medication choices to manage symptoms for those fighting cancer.
Whether situated on patient-care floors or within IV compounding areas, I meticulously documented cumulative doses, especially for drugs like doxorubicin, cisplatin which posed a greater risk of toxicity. My commitment extended to providing recommendations for further diagnostic tests, such as pulmonary function tests for drugs like bleomycin with pulmonary toxicity concerns. I believed that the comprehensive monitoring and documentation were integral components contributing to the overall safety and well-being of patients undergoing chemotherapy. I also took an active participation in the process of reconstitution of anticancer medications and performed the associated calculations for ensuring that the dosing errors do not creep in. Medication errors due to wrong dose make up a substantial number of errors occurring in the hospitals.
Recognizing the tendency of mucositis to coincide with neutropenia, I actively contributed to proactive measures by recommending prophylaxis by counseling patient to use various mouth rinses and local anesthetics. This approach aimed at maintaining optimal oral hygiene, minimizing the risk of oral fungal infections, and alleviating associated pain. While it is challenging to encapsulate my entire experience in this brief article, I believe, I offered my best to delivering optimal patient care and ensuring their safety and I took pride in being an integral part of a multidisciplinary team, contributing to the holistic care and well-being of cancer patients in Nepal. This is only a brief account of the work I did while working in the oncology department at Patan Hospital, in reality a lot many more things are being done by oncopharmacists throughout the world. Let us look into how and when pharmacists began traning in medical oncology practice and how did the practice evolve. Read below to find out what various roles can pharmacists play in the oncology practice and to help those in distress.
The uncontrollable division of aberrant cells leading to potential infection of nearby tissues is known as cancer, a leading global cause of sickness and mortality. Nepal is no exception to its impact. Recent publications by the Nepal burden of disease 2019, malignant neoplasm (cancer) was responsible for 11.1% of total deaths in both sexes, 10.8% of total deaths in males and 11.5% of total deaths in females. Early detection of cancer remains a major global challenge, and even post-diagnosis, patients face intricate treatment regimens involving radiation therapy, cytotoxic drug use, surgery, and adjuvant therapies. Treatment’s fundamental idea is to halt or destroy unchecked malignant cell proliferation, causing severe side effects on regular cells. Besides adverse effects, patients experience physical, psychological, social distress, and a dread of recurrence, often leading to non-adherence to medications due to the lengthy and complex nature of therapy.
History of Practice of Pharmacy in Oncology
Pharmacists began training and defining their role in medical oncology practice in 1976, when Morris and Hickman outlined a curriculum for pharmacy students at the University of Tennessee in the US to help prepare them to participate in the therapeutic care of cancer patients. This curriculum aimed to equip pharmacy students with the necessary knowledge for actively engaging in the therapeutic care of cancer patients (Morris, C. R., & Hickman, M. J. (1977). Distinguishing itself from other healthcare professions, the foundational curriculum for pharmacist training placed a particular emphasis on understanding the pharmacokinetics of drug behavior in the liver and kidneys. Additionally, extensive training in pharmacology and medicinal chemistry was incorporated into the curriculum. The American Society of Health-System Pharmacists (ASHP) played a pivotal role in shaping the pharmacist’s responsibilities. It published guidelines in 1990, 1993, 1996, and 2002, outlining the pharmacist’s role beyond the safe handling, preparation, and dispensing of drugs. According to these guidelines, the pharmacist assumes the role of a health professional directly responsible for providing medication-related care with the goal of achieving specific outcomes to enhance a patient’s quality of life. This responsibility encompasses identifying, resolving, and preventing medication-related problems such as untreated indications, improper drug selection, inadequate dosing, adverse drug reactions, interactions, and medication use without a valid indication. Thus, the role of an oncopharmacist becomes crucial in addressing these challenges. They serve as a source of support and play significant roles in ensuring patient safety, decreasing polypharmacy, formulating and administering drugs, providing education and counseling for medication adherence, contributing to training and research, functioning as a group member, acting as a consultant, and participating in palliative care medical settlement and medication management.
Role of Oncopharmacist in Patient Safety:
Safety is paramount in treating cancer patients due to potential medication-related issues like adverse reactions and drug interactions. Oncopharmacists act as safety officers, utilizing their extensive understanding of pharmacology to closely design, monitor, evaluate, and adjust therapy to prevent and detect drug-related issues. Rather than blaming anyone for the patient safety issues, finding out the root cause for issue and working on it helps prevent similar issues from harming the patient in the future. Accurate record-keeping and prompt reporting contribute to preventing the recurrence of similar incidents.
Role in Decrease of Polypharmacy:
The combination of medications in anti-cancer therapy often leads to polypharmacy, increasing the risk of drug-related issues. Oncopharmacists play a pivotal role in selecting necessary medications, deprescribing less essential ones, and making the pharmaceutical regimen more patient-friendly. This approach minimizes adverse drug reactions and enhances the safety of the drug regimen.
Role in Formulation and Administration of Drugs:
In addition to direct patient care, oncopharmacists actively participate in mixing, diluting, determining infusion rates, and monitoring patients during the administration of anti-cancer drugs. Their collaboration with oncologists ensures appropriate laboratory references and validates prescriptions, contributing to a smoother drug administration process.
Role as a Team Member:
Oncopharmacists assist in addressing pharmacoeconomic elements, facilitating information exchange, advising healthcare professionals, and reducing manual errors. Their involvement makes cancer therapy more accessible and cost-effective for community members.
Role as a Consultant:
With a high number of medications prescribed for cancer patients with chronic illnesses, oncopharmacists assess patients’ clinical states and assist in making informed medication choices. Their comprehensive understanding of risk factors contributes to more targeted drug therapy administration.
Role in Training and Research:
Oncopharmacists can contribute to ongoing research through training and education programs, collaborating with cancer research institutions to develop novel concepts for treatment and identify safer medication molecules. This multidimensional approach helps in achieving better outcomes for cancer patients.
Role in Palliative Care:
Oncopharmacists provide valuable assistance in palliative therapy for patients with advanced disease, addressing anxieties, offering moral support, providing clinical practice recommendations, and guiding medication choices for symptom management.
Role in Medical Settlement:
Oncopharmacists play a significant role in medical reconciliation, ensuring efficient procedures throughout the patient’s journey, from admission to discharge. Their services are essential for better patient care and support for oncologists and other healthcare professionals.
Role in Medication management:
In context of chemotherapy, missing or inaccurately written premedication orders can lead to potentially severe adverse reactions. A study focusing on pediatric acute lymphoblastic leukemia patients revealed a 10% oral medication error rate, predominantly during prescribing and administration. These findings underscore the need for heightened vigilance which can be provided by pharmacist in medication management, especially in critical healthcare scenarios, to mitigate the risk of adverse events. ( 2,3) In Nepal, the inadequate documentation of medical errors presents a significant challenge. The recognition of medical errors often occurs only post fatality or unfortunate incidents, highlighting a deficiency in the existing record-keeping systems. Thus, proactive role can be played by oncopharmacist to generate long-term strategies to improve patient safety.
Role in Patient Education and Counseling Regarding Medication Adherence:
Oncopharmacists address medication non-adherence by creating educational materials like Patient Information Leaflets, pamphlets, posters, and newsletters. These materials enhance awareness and adherence to chemotherapy regimens, ultimately contributing to the success of the treatment plan.
In an outpatient setting, oncopharmacists have the opportunity to provide comprehensive counseling for new chemotherapy patients. This counseling involves a thorough review of the patient’s entire medication regimen, encompassing prescriptions, over-the-counter medications, vitamins, alternative therapies, and herbal products. This review identifies potential interactions between drugs and chemotherapy, assess for drug–drug interactions, detect duplicate therapy, and anticipate potential side effects.
Additionally, oncopharmacists can extend their counseling services to cover various aspects, including educating patients on what to expect during clinic visits, providing information on potential adverse effects, promoting compliance with supportive care medications, and offering guidance on lifestyle modifications. This may involve discussions about contraception, dietary considerations, and precautions for fall prevention. This comprehensive counseling approach aims to empower patients with knowledge and support to navigate their chemotherapy journey effectively.
Oncopharmacy in Nepal (Separate box)
In low- and middle-income countries, cancer-related mortality rates are notably high, predominantly due to unfavorable prognosis. This can be attributed to factors such as limited awareness, delayed diagnosis, disparities in health accessibility, and challenges associated with affordability(4,5). Thus, the absence of oncopharmacists in oncology settings in Nepal necessitates inclusion, as their presence would bring about a substantial and positive transformation in patient care. Nepal needs to establish a national plan for cancer treatment defining the role of oncopharmacists. Development of successful oncology pharmacy system includes competency training, cost-efficient procurement, proper storage, proper handling, preparation and administration of chemotherapy, and appropriate waste disposal. Also regular monitoring and evaluation of pharmacy operations within hospitals is essential to maintain the availability, storage, preparation and administration standards of chemotherapy.
Conclusion
The responsibilities of oncopharmacists encompass addressing acute management and supportive care matters such as nutrition support, pain management, infection control, hematology, anticoagulation and many others. This crucial role plays a vital part in assisting patients during the recovery phase between treatment cycles, ensuring adherence to chemotherapy treatment schedules for optimal outcomes. Recognizing the safety concerns associated with drugs featuring a low therapeutic index, pharmacists can dedicate their attention to various facets of patient care.
Precisely, the availability of oncopharmacy services in oncology hospitals is vital for the comprehensive care of cancer patients. Oncopharmacists bring a diverse skill set that significantly enhances patient outcomes across various aspects of cancer treatment and care. Numerous research publications affirm the invaluable contributions of oncopharmacists in cancer treatment facilities, underscoring their significance in the healthcare system. The multidimensional character of cancer pain requires comprehensive management by a multidisciplinary team of health care professionals. Pharmacotherapy is a cornerstone of cancer pain management hence pharmacists can play a pivotal role in the pharmacotherapy of cancer pain by optimizing medication therapy, monitoring outcomes, enhancing adherence through patient education regarding drug use, pain and symptom control, educating other health professionals and students, and conducting research. However, to fully meet therapeutic challenges of cancer pain, pharmacists need to improve their knowledge and attitudes about cancer pain and pain medications therapy.
References:
1.Morris, C. R., & Hickman, M. J. (1977). Medical oncology pharmacy: a new role for the clinical pharmacist. American Journal of Pharmaceutical Education, 41(3), 278-80.
2.Bates, D. W., Boyle, D. L., Vliet, M. B. V., Schneider, J., &Leape, L. (1995). Relationship between medication errors and adverse drug events. Journal of general internal medicine, 10, 199-
3.Goldspiel, B. R., DeChristoforo, R., & Daniels, C. E. (2000). A continuous-improvement approach for reducing the number of chemotherapy-related medication errors. American journal of health-system pharmacy, 57(suppl_4), S4-S9
4.Chalkidou, K., Marquez, P., Dhillon, P. K., Teerawattananon, Y., Anothaisintawee, T., Gadelha, C. A. G., & Sullivan, R. (2014). Evidence-informed frameworks for cost-effective cancer care and prevention in low, middle, and high-income countries. The lancet oncology, 15(3), e119-e131.
5.Khatiwoda, S. R., Dhungana, R. R., Sapkota, V. P., & Singh, S. (2019). Estimating the direct cost of cancer in Nepal: A cross-sectional study in a tertiary cancer hospital. Frontiers in public health, 7, 160.
