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Role of the pharmacist

Patient education

and therapy optimisation

Patients and the healthcare system can benefit greatly from the involvement of pharmacists in anticoagulation therapy, patient education and counselling and therapy optimisation

Oweikumo Eradiri PhD FRSPH FFRPS Principal Pharmacist Quality Assurance Colchester Hospital University NHS Foundation Trust, Colchester, UK

As experts in medicines, pharmacists have a crucial role in ensuring the quality, efficacy and safe use of medicines. Anticoagulant medicines are classified as ‘high risk’, because of the potential for bleeding and other significant interactions that could occur with their use. Anticoagulation therapy therefore requires great care in the choice of medicinal agent, dosing, monitoring and encouraging adherence by patients.

Critical stages

The role of the pharmacist in anticoagulation therapy may be considered in seven critical stages1


● Ensuring safe prescribing ● Prescription validation and supply ● Patient education ● Monitoring treatment ● Multidisciplinary communication ● Discharge planning ● Compliance auditing.

Ensuring safe prescribing Pharmacists review new anticoagulant medicines, considering the evidence for their use, as well as their safety profile, prior to the drugs being introduced into an organisation. This informs the development of therapeutic guidelines, indicating the most appropriate medicine for a particular clinical condition. The review also involves a cost–benefit analysis, to ensure that the most cost-effective treatment is selected. The assessment of a new drug would normally be made by a multidisciplinary

pharmacists play a role in screening the drug chart for prescription accuracy and completion of VTE risk assessments (in line with local policy), and providing feed back on any concerns to doctors and nurses, as appropriate. They also ensure supply of prescribed medicines, and review the charts for any missed doses, which can help to identify any potential adherence issues on the part of the patient. Any such adherence issues can then be addressed before discharge.

Patient education

medicines management/therapeutics committee. The choice of agent and the conditions under which the agreed agents are used by prescribers, usually following a risk assessment, can be effectively established and monitored by pharmacists.

Prescription verification and supply In pharmacist-led anticoagulation clinics, pharmacists perform risk assessment of patients, such as for VTE prophylaxis, and prescribe appropriate doses of treatment, in line with agreed protocols. These prescriptions are then clinically screened and dispensed by the pharmacy team. The clinical screening highlights any potential drug–drug, food–drug or drug–disease interactions, and other pharmacokinetic considerations that may affect dosage, such as renal function. Pharmacist-led clinics have been associated with ‘excellent care’,2

and demonstrated ‘significantly better’ control of the international normalised ratio (INR) for patients taking the vitamin K antagonist, warfarin, than a physician-led service.3

In the in-patient hospital setting,

Anticoagulation medicines are very potent drugs, often with narrow therapeutic index, risk of bleeding, significant side-effects, and complex dosing schedules. Their pharmacokinetic profiles and mechanisms of action mean that they are prone to significant interaction with foods and other medicines the patient may be taking for their comorbidities. This presents a classical scenario for a pharmacist’s input to ensure medicines optimisation – treatment within target INR range, for instance, minimal side-effects, and continued efficacy of other treatments with potential for interaction with the anticoagulant. These targets can only be achieved by a flourishing partnership between the patient and their clinician.

The pharmacist provides expert patient education and therapeutic counselling for the use of medicines, giving the patient reasons for the treatment (indication, with respect to their disease), dosage, duration of treatment, foods and medicines to avoid (or take at different times), side-effects to expect and what to do to cope with them, the need to attend clinics for monitoring purposes, and an opportunity to ask


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