Drug Related Problems

(DRPs)

Didik Setiawan, PhD., Apt

- Faculty of Pharmacy,
- Center for Health Economic Studies,
Universitas Muhammadiyah Purwokerto, Purwokerto, Indonesia
Introduction

• What a pharmacist for

• The problems are increasing due to the increase of drugs and
medication problems
• Pharmacotherapy workup:
1. Unnecessary drug therapy

There is no valid medical indication for the drug therapy at this time.
• A patient is using a low dose of aspirin without a high risk of cardiovascular disease or any
signs of a cardiovascular disease.

Multiple drug products are being used for a condition that requires single
drug therapy.
• A patient is using three different laxative products in an attempt to treat his constipation.

The medical condition is more appropriately treated with nondrug

therapy.
• A patient is using a benzodiazepine every night as a hypnotic drug for three years while it is
better to recommend alternative sleeping patterns, sleep hygiene and exercise
• A patient is using furosemide to prevent swollen ankles.
1. Unnecessary drug therapy

Drug therapy is being taken to treat an avoidable

adverse reaction associated with another medication.
• A patient is using paracetamol combined with codeine (500/10)
and is suffering from constipation which is treated with lactulose
and bisacodyl occasionally.

Drug abuse, alcohol use, or smoking is causing the

problem.
• A patient uses a protonpump inhibitor to treat dyspepsia
associated with alcohol abuse
Task

• Aspirin: antiplatelet/fibrinolitik, how are the mechanism? What is

the differences?.
• Dispepsia? what is this.
• Constipation: Codein/paracetamol/both? Mechanism?
• Mechanism PCT as antipyretic?
 2. Needs additional drug therapy

Don’t look the prescription, or drug consumed by the patient only

2. Needs additional drug therapy

A medical condition requires the initiation of drug

therapy.
• The patient is suffering from pain with no analgesic therapy.

Preventive drug therapy is required to reduce the risk of

developing a new condition.
• A patient with chronic heart failure due to left ventricular systolic
dysfunction, without an ACE-inhibitor or an angiotensin receptor
blocker.
• A patient with atrial fibrillation without antithrombotic therapy.
 Preventive drug
Clinical indication
therapy
Aspirin Prevention of heart attack and/or stroke
Calcium supplements Prevention of osteoporosis
Folic acid supplement
Prevention of neural tube defects
(during pregnancy)
Pneumococcal vaccine Prevention of pneumococcal pneumonia
Prevention of infection in selected patients
Neupogen (filgrastim)
receiving anti-cancer drug therapies
Dimenhydrinate Prevention of motion sickness
Oral contraceptives Prevention of pregnancy
Endocarditis prophylaxis in dental patients
Amoxicillin
with cardiac lesions or prosthetic heart valves.
Prophylactic therapy for patients with frequent
Colchicine
attacks of gouty arthritis
2. Needs
additional
drug therapy

A medical
condition
requires
additional
pharmacotherapy
to attain
synergistic or
additive effects.
2. Needs additional drug therapy

A medical condition requires additional

pharmacotherapy to attain synergistic
or additive effects.
• Calcium and vitamin D supplements for a patient
with osteoporosis who is already taking a
bisphosphonate.
Trial finding untreated medical
condition (1009 patients,
19.6%)

1947
(37.9%)
5136
patients To prevent a medical
patients
required condition (809 patients,
receive
additional 15.8%)
PC
drug
therapy
Need addition of drug
therapies to achieve an
additive or synergistic
effect (680 patients,
13.2%)
Task

• What is Atrial Fibrilation?

• Connection between atrial fibrilation with antitrombolitic
• Neural tube defect
• Vitamin D vs calcium vs biphosphonate and bone metabolism
 3. Ineffective Drugs
Example: What is the most effective drug’s for hyper triglyceridemia
A. Statin
B. Fibrate
C. Resin
D. Omega 3 fatty acids
3. Ineffective drug

The drug is not the most effective for the medical

problem.
• A patient is using an antibiotic for a common cold (viral
infection).

The medical condition is refractory to the drug

product.
• A patient with benign prostatic hyperplasia uses doxasozine
for more than four years.
3. Ineffective drug

The dosage form of the drug product is inappropriate.

• A patient with severe COPD uses salbutamol in a turbuhaler.

The drug product is not an effective product for the

indication being treated.
• A patient with renal impairment uses a thiazide to lower the blood
pressure.
More effective drugs developed every
time

1970’s  the drugs therapy for Peptic Ulcer was Antacids

1980’s  changed into H2 Blocker

1990’s  changed into combination antibiotic therapy due to H.

pylori involvement

2002  the 3rd and 4th leading prescription drug sales in the US
were Prevacid (lansoprazole) and Prilosec (omeprazole)  to
prevent and treat PU
What Does it mean?

Pharmacists
By Evidence
must be up to How
Based Medicine
date
Task

• Doxasozine,  what is the sollution?

• Salbutamol turbuhaler 
• Thiazide contraindication with renal failure??
4. Dosage too low

The dose is too low to produce the desired response.

• A patient is prescribed simvastatine 10 mg every other day after a
myocardial infarction.

The dosage interval is too infrequent to produce the

desired response.
• A patient uses 500 mg paracetamol, only twice a day, to control
chronic pain in osteoarthritis.
• A patient uses 375 mg amoxicilline, only once a day, to treat an
airway infection.
4. Dosage too low

A drug interaction reduces the amount of

active drug available.
• A patient uses acenocoumarole and vitamin K.

The duration of drug therapy is too short to

produce the desired response.
• A patient uses paroxetine for 4 days to treat anxiety.
5. Adverse drug reaction and Interaction

The drug product causes an undesirable reaction that is not dose-

related.
• A patient on a low dose of aspirin is experiencing bruises.

A safer drug product is required due to risk factors.

• An elderly patient uses flurazepam to sleep and is experiencing drowsiness at day
time.

A drug interaction causes an undesirable reaction that is not dose-

related.
• A patient who uses methotrexate gets prescribed co-trimoxazole for an infection
(increase of anti-folate effect which can result in haematopoietic suppression).
5. Adverse drug reaction and Interaction

The dosage regimen was administered or changed

too rapidly.
• A patient who uses prednisolone 20 mg every day for the last 6
months for arthritis symptoms iss instructed to take 10 mg for 2
more days and then discontinues the medication.

The drug product causes an allergic reaction.

• A patient is prescribed flucloxacillin for a dermal infection and
develops a rash after the second dose.
5. Adverse drug reaction and Interaction

The drug product is contraindicated due to risk factors.

• A patient gets prescribed indometacin to control chronic pain, which
is contraindicated because of his/her history with a peptic ulcer.

A drug alters the patient's laboratory test results due to

interference from a drug he/she uses.
• A patient had high blood glucose levels, due to the start of
prednisolone therapy.
• Positive ketone test in urine due to captopril use.
6. Dosage too high

Dose is too high.

• A patient develops bradycardia resulting from a high (0.5 mg) daily
dose of digoxine.
The dosing frequency is too short.
• Hyperkaleamia after a dose of amiloride 10 mg three times a day.

The duration of drug therapy is too long.

• A patient who experienes nasal congestion uses a nasal spray with
xylometazoline for four weeks.
6. Dosage too high

The drug dose is too high in the patient because of its characteristics
(excretion).
• A patient with impaired renal function (CrCl: 20 ml/min) is prescribed a normal dose of 300
mg allopurinole a day, which causes nausea.

A drug interaction occurs resulting in a toxic reaction to the drug product.

• A patient has an increased INR after given metronidazole while also using acenocoumarole.

The dose of the drug was administered too rapidly.

• Cardiac arrest after infusion of a bolus of potassium phosphate (5 ml intravenously) instead
of slow infusion.
Task

• The ideal Duration for xylometazoline

• Analyze allopurinol for renal failure patients
• Metronidazole dan acenocoumarole drug interaction
• The use of potassium phoshate
7. Noncompliance

The patient does not understand the instructions.

• The patient uses naproxen only when pain is unbearable while it is prescribed
three times a day.
The patient prefers not to take the medication.
• The patient is afraid of taking fluvoxamine because of possible side-effects.

The patient forgets to take the medication.

• The patient forgets to take his antihypertensive medication.

The drug product is too expensive for the patient.

7. Noncompliance

The patient cannot swallow or self-administer the drug product appropriately.

• The patient is unable to administer the timolol eyedrops for her glaucoma.

The drug product is not available for the patient.

The drug therapy does not comply with the lifestyle of the patient.
• A patient does not take furosemide because of attending activities at home.

The patient has no access to the medication.

• A patient is not able to fetch the medication at the pharmacy.
 How To Resolve DRP?

Continued
Didik Setiawan, PhD., Apt

Email: d.didiksetiawan@gmail.com
WA: +31 631 254575
Phone: 081 226 700 119
www.ches.ump.ac.id