Journal of Pharmaceutical Care is an open access journal officially published by the Research Center for Rational Use of Drugs (RCRUD) of the Tehran University of Medical Sciences, and Iranian Society of Clinical Pharmacists which is focused on experimental and clinical pharmaceutical practices to present researches, hot topics, requirements and regulations of the pharmaceutical practice area. Manuscript in Clinical Pharmaceutical Practice, Pharmaceutical Care Regulations, Pharmaceutical Care in hospitals and community pharmacies, Pharmacotherapy, Pharmacoepidemiology, Pharmacogenomics, Pharmacokinetics, Pharmacoeconomics, Clinical pharmacokinetics, Drug Utilization Evaluation review, Medication safety, Drug and Poison Information Services and Health services research are welcome.Content includes Original Articles, Systematic Review or Meta-Analysis, Review Articles, Case Reports and Letters to the Editor.

JPC is an open access, peer-reviewed, and quarterly journal that considers for publication articles in all fields and specialties ofpharmaceutical care in English language. This journal has both online and print versions and no charges are levied for publication.

Journal of Pharmaceutical Care is indexed and abstracted in: Dimensions, Google ScholarMagiranDirectory of Open Access Journal (DOAJ) and Islamic World Science Citation Center (ISC).

Current Issue

Vol 9, No 3 (Summer 2021)

Editorial

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    The coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has challenged health systems to find innovative ways of delivering patient care.

    Pharmaceutical care and team-based care which include the patient along with their other healthcare providers are designed to promote health, prevent disease, and ensure safe and effective use of medicine which is an essential component for fighting against COVID-19 pandemic (1).

    Clinical pharmacy is defined as “a health science discipline in which pharmacists provide patient care that optimizes medication therapy and promotes health, wellness, and disease prevention” and "embraces the philosophy of pharmaceutical care”(2)

    Clinical pharmacists (CPs) are practitioners with advanced education and training, providing direct patient care and comprehensive medication management for both patients and health-care providers, they also perform pharmaceutical care to ensure patients' safe and effective medication use. (3) However, in case of public health emergencies, such as COVID-19 pandemic, the strategies of CPs need to be remodeled to face with rapid spread of the disease, and lack of evidence-based information.

    CPs activities can promote the rational use of drugs (RUDs) to reduce the rate of side effects, drug costs and optimize patient outcome by selecting the most appropriate medication, dosage form, route of administration, and appropriate monitoring.(4)

    Roles of pharmacist to enhance pharmaceutical care during COVID-19 pandemic can be characterized as fallow:

     

    1. Pharmacotherapy evaluation: By assessment of the patients in routine visits, the pharmacotherapy recommendations can be given based on medication review, data from medical documents, and interview with the physicians, and the patient.
    2. Preparation of hospital treatment protocols: Providing updates on the latest evidence to guide health care team regarding COVID-19 management.
    3. Establishment of evidence-based medicine and guidelines: By contribution to improve pharmaceutical policies and decision-making process.
    4. Providing education on pharmacotherapy of COVID-19 for healthcare professionals: through pharmacotherapy classes, face to face education and utilization of virtual space.
    5. Establishment of drug registration research and clinical trials: pharmaceutical scientists, clinicians and pharmacists are actively conducting registered studies to explore effective treatment options. (figure1)

      CPs can collaborate with other healthcare providers to apply their knowledge and pharmacological expertise to manage pharmacotherapy challenges in COVID-19 patients and actualize pharmacists’ value and responsibility through the pandemic (4).

      Clinical pharmacy services aimed improving the quality use of medicines which could lead to better patient outcomes and reducing health care costs.(1) The implementation of RUD is a reasonable opportunity for CPs to make a significant impact on patient management, reducing healthcare costs, since they have the expertise to identify, resolve, and prevent medication errors and DRPs.(5)

      Notably, COVID-19 treatment protocols are rapidly changing, CPs should constantly keep their scientific information up to date so that they could play an active role in the pandemic. We need to implement creative methods to deal with this little known disease. Employment of CPs can affect the proper use of financial resources which is particularly important for developing countries.

      Finally, the role of a CPs is not only being an academic leader to develop practice guidance and recommendations, but also a practitioner of pharmacy services who is at the frontline of fighting against COVID-19 to ensure the rational use of drugs during the pandemic. Involvement of CPs in the healthcare setting should not be overlooked in the pandemic, since it is a pragmatic step to improve safe and effective use of medication.

Original Article(s)

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    Background: Infections caused by multidrug-resistant (MDR) pathogen have caused a resurgence of interest in colistin. To date, information about the effectiveness of Aerosolized Colistin (AS) is very limited in the treatment of Ventilator-Associated Pneumonia (VAP). The aim of this study is to evaluate the efficacy and safety of AS in conjunction with intravenous (IV) colistin in patients with VAP, caused by MDR Gram-Negative Bacteria (GNB).Methods: This parallel randomized clinical trial was conducted on patients with VAP in the Intensive Care Unit (ICU) ward. 27 patients allocated to the intervention or the control group. Patients in the intervention group received IV Colistin based on glomerular filtration rate along with aerosolized Colistin, 2 million units three times a day. In the control group, only IV Colistin was administered. For all patients, Procalcitonin (PCT), sputum culture, and Clinical Pulmonary Infection Score (CPIS) were evaluated and compared as outcome measures at the specified period of time.Results: Negative sputum culture was achieved in 9 (80%) out of 11 patients in the AS-IV Colistin group after seven days of therapy versus 9 (56.25%) out of 16 in the control group (P= 0.01). PCT and CPIS scores were not significantly different between two groups (P=0.21, P= 0.62). Furthermore, nephrotoxicity and neurotoxicity were not seen.Conclusion: AS Colistin lead to earlier negative sputum culture without increasing risk of nephrotoxicity and neurotoxicity, and could potentially be a beneficial adjunctive approach in the management of MDR-VAP.

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    Background: Direct oral anticoagulants (DOACs) are increasingly used due to fewer side effects, predictable pharmacokinetics, lower potential for drug interactions. Different levels of awareness among health care professionals have been reported.Methods: The main objectives of this study were to investigate the knowledge and attitude of pharmacists about direct oral anticoagulants. The present study was a descriptive cross-sectional study performed in Kermanshah province, Iran. The validated researcher-made questionnaire included questions about demographic characteristics and specialized questions that assessed the knowledge and attitude of pharmacists towards new oral anticoagulants. Results: Out of 126 pharmacists participating in this study, 67 (53.2%) were male. The mean scores of knowledges and attitude in pharmacists were 64.94±5.84 and 28.62±3.98, respectively. The most common oral anticoagulant with a direct effect dispensed by pharmacists was rivaroxaban (77.4%). There was also a significant relationship between pharmacists' attitudes and their place of activity (P = 0.024).Conclusion: The results of this study showed that pharmacists had an acceptable knowledge and low attitude about DOACs.

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    Backgrounds: Due to the critical role of antibiotics and increasing trend of resistance in developing countries, comprehensive methods of antibiotic use is necessary to limit the threat of resistant microorganisms. In this study we compare antibiotics consumption by Defined Daily Dose (DDD) per 100 bed-days in Shahid Ghazi hospitals during three months in Tabriz, Iran.Methods: This is a retrospective study, which enrolled patients with malignancy who admitted to Shahid Ghazi hospital from January till March 2016. From all, 58 patients diagnosed with malignancy and received antibiotics for prophylaxis and/or treatment. For the purpose of Drug Utilization Evaluation (DUE) all antibiotics, antifungals and antiviruses consumption for any reason (prophylaxis, empiric therapy, targeted therapy) were recorded. Data on administered medications such as indication, duration, and dose were compared according to the guidelines of the NCCN 2.2016. The accuracy of antibiotics consumption was assessing by NCCN (2.2016) guideline. Anatomical Therapeutic Chemical (ATC) code J01 was explained as defined daily doses per 100 bed-days (DDD/100) according to the ATC/DDD classification. The amount of consumption was assessed with DDD per 100 bed-days in three months. Results: from 56 patients, 46 of them had hematologic malignancy and 10 of them had solid tumors. The indication of antibiotics and antifungal prophylaxis were wrong in 19.6% of indications. The prophylaxis dosage of antibiotics, antifungal, antiviral and PCP were wrong in 8.8%, 41.7%, 80% and 50%, respectively. The prophylaxis duration of antibiotics, antifungal, antiviral and PCP were wrong in 69.4%, 61.2%, 80% and 100% respectively. The dose adjustment of antibiotics with GFR and renal status of patients, in 8 of 9 patients (88.88%) who received meropenem, and in 9 of 23 patients (39.13%) who received imipenem, were not applicable according standard guidelines. The total consumption of systemic antibiotics in Ghazi Hospital during 3 months was 5091From all patients 75% of them received antibiotics according to the ATC/DDD classification System. Conclusion: Specific strategies should be employed in infection control development and engage rational antibiotic utilization in order to reduce future resistant strains and increase anti-microbial efficacy.

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    Backgrounds: There is no proven therapy for coronavirus disease 2019 (COVID-19) so far. The aim of this study was to evaluate the effect of interferon beta-1b combined with lopinavir/ritonavir and hydroxychloroquine in managing COVID-19.Methods: This is a non-randomized, open-label study on adult patients with moderate to severe COVID-19. The patients (≥ 18 years) received hydroxychloroquine 400 mg single dose, and lopinavir 400 mg/ritonavir 100 mg every 12 h (for 7-10 days) with or without subcutaneous interferon (IFN) beta-1b 250 mcg every other day for e primary outcome was clinical improvement in NEWS2 changes. Duration of hospital stay, mortality rate, and safety profile of therapeutic regimens were secondary outcomes.Results: Between March 20 and April 3, 2020, a total of 114 patients were recruited and 59 patients completed the study. The IFN group had a significant improvement in clinical symptoms due to a significant reduction in NEWS2 (83.3% (25) vs 48.3% (14), P= 0.004). The time to clinical response in the IFN group was shorter than the control group (7 (5-12) days vs 9.5 (7-18), P=0.037). The IFN group also showed a significantly lower rate of 28-day mortality (6.8% (2) vs 34.5% (10), P= 0.01) and a lower need for invasive ventilation (6.8% (2) vs 34.5 (10), P= 0.008). Although the duration of ICU stay was marginally shorter in the IFN group, the results were not significantly different between the two groups (P=0.06).Conclusion: IFN beta-1b could be a potential therapeutic option for patients with moderate to severe COVID-19. 

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    Background: An antimicrobial stewardship program can be defined as the set of actions performed in hospitals for the rational use of antibiotics. Early conversion from intravenous to oral antibiotics plays an important role in reducing the cost of treatment, shortening the length of hospital stay, and decreasing the workload of nurses. The purpose of this study was to evaluate the impact of the implementation of antimicrobial stewardship program on duration of hospitalization and medication costs. Methods: We performed an interventional study in Razi teaching hospital. All hospitalized patients aged 18 and older who met the inclusion criteria were included. This study comprised two groups. The interventional prospective group to assess the impact of intravenous to oral antibiotic conversion, and a retrospective group in which the intervention had not been applied, used as the comparator. Results: A total of 260 cases were enrolled; 47 in the interventional group and 213 in the retrospective one. The length of hospitalization was significantly shorter in the intervention group compared to the retrospective one (5.2 vs7.9 days, p<0.001). The cost of intravenous antibiotics and total medication costs significantly decreased in the intervention group. Conclusion: Our findings suggest that conversion from intravenous to oral antibiotics is effective for reducing the length of hospital stay, antibiotic cost, and excess use of intravenous antibiotics.

Review Article(s)

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    Firstly, a new coronavirus emerged in Wuhan, China, sparking a pandemic of acute respiratory syndrome in humans. Corona virus disease-19 (COVID-19) was declared as a pandemic after the infection spread globally and disease caused by the new type of coronavirus, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) was named as COVID-19. The virus originated from bats and has been passed to humans. Initially, SARS-CoV-19 infects respiratory system an acute serious viral infection mainly developed with over a million people worldwide were transmitted rapidly in a few months. SARS-CoV-19, progress a moderate to serious severe respiratory symptoms such as headache, cough, and breathlessness. Also, digestive system symptoms include nausea, vomiting, and stomach pain.  Although the precise of the mechanism of inflammation unclear but this virus firstly use the angiotensin converting enzyme 2 (ACE2) receptor of the alveolar cells of lung tissue causing inflammation and cell death.  Then virus spreads and affects other important organ and tissues with complex pathophysiological alterations, the coronary disease, pulmonary disease, chronic kidney disease and chronic liver disease are the most prevalent comorbidities among patients. In COVID-19 infection therapy lots agents recommended. Unfortunately, there is no clear effective drug for treatment. This review presented potential pathogenic pathway of the SARS-CoV-19 infection and symptoms in the patients and given the information about the negative effects on different systems in the respiratory, cardiac system, nervous system, gastrointestinal system, and urinary tract.

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    With the increase in the world's elderly population, age-related disorders such as cognitive disorders and dementia have increased in this group, and with the onset of the COVID-19 pandemic in 2019, many of the world's rules and regulations have changed, and personal protection recommendations against infection have been recommended by various medical centers, which is very challenging for patients with dementia and can even lead to the development or exacerbation of behavioral symptoms in their everyday life.

    On the other hand, caregivers of dementia patients are exposed to the burden of disease caused by the stress of transmitting infection along with the usual care needed for dementia patients, which has definitely increased this time during the pandemic. Therefore, caregivers of dementia patients, both at home and in care centers, need the advice to care for patients and prevent pandemic physical and psychological complications on themselves and their patients.

    Regarding the administration of drugs effective on COVID-19 infection and the possibility of their interaction with drugs prescribed in patients with dementia or cognitive complications, delirium, and exacerbation of dementia, there is a need for solutions that are briefly reviewed in this report. It is hoped to provide assistance and support in providing services and care to dementia patients, health care providers, and physicians.

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    A poly herbo-mineral preparation (Pill) (Vellai Venkaya Kulikai) which is used for treating painful menstruation, gastrointestinal disorders and abdominal pain in Siddha Medicine which is one of the traditional medical systems in Sri Lanka. Based on references, the preparation method of Vellai Venkaya Kulikai (VVK), which is mentioned in the Siddha Book of Pararajasekaram (Karppa roga nithanam) is commonly practiced in the health services of the Siddha medical system in Sri Lanka. Therefore, this preliminary step was taken to provide documentary evidence for the therapeutic effects of the ingredients which are used to the preparation of VVK. Data for the review of 28 ingredients were collected from relevant research sources from September 2020 to April 2021. Data entry form was prepared based on the characteristics of the ingredients such as families; morphology; parts used; siddha properties; pharmacological actions and phytochemical contents. Among these ingredients, all were identified as 25(89%) herbal, 2(7%) minerals and 1(4%) metal. These herbal ingredients are belonging to 15 families and 5(20%) of the species were found in the family of Umbelliferae. Based on the growth habit, these plant materials were classified as 17(68%) herbs and 9 (36%) species were used as seeds. Among 28 ingredients, siddha properties such as 15(48%) pungent taste, 21(81%) hot potency and 15(80%) pungent efficacy; carminative 17(11%) and stimulant 16(10%) actions and phytochemicals as volatile oil 20(15.87%) were found. Although this study provides the clear information for the therapeutic effects, further scientific studies for VVK and each medicinal ingredient should be performed in future.

Case Report(s)

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    Aluminum phosphide (AlP) has remained a chemical cause of completed suicides in some developing countries. ALP toxicity can cause multi-system damage. As far as we know, this is the first case of ALP-induced Thrombotic Thrombocytopenic Purpura (TTP) and its successful management. A 34-year-old man, who had attempted suicide with ALP was admitted to our hospital. On the 3rd day of admission, the patient developed hematuria, hemolysis, and thrombocytopenia. Based upon available evidence, TTP was diagnosed. Following a complete patient evaluation, ALP was recognized as the probable cause of TTP. Following the treatment using prednisolone and therapeutic plasma exchange, the patient substantially improved. Finally, he was discharged on the 22nd day. Toxin-induced intravascular hemolysis should be considered for patients presenting with ALP toxicity. As reported in this patient, TTP is another manageable consequence of ALP poisoning.

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