Achieving better outcomes from intervention by clinical pharmacists

Samyuktha D V

Group Clinical Pharmacist, Kauvery Hospital, Trichy, Tamil Nadu

Abstract

The role of clinical pharmacists has expanded significantly, positioning them as integral contributors to contemporary healthcare teams. Their advanced expertise in medication management, patient counselling, and therapeutic decision-making bridges essential gaps between prescribers and patients, fostering safer and more effective treatment outcomes. This article examines the evolving responsibilities of clinical pharmacists through a series of case studies, demonstrating their influence on medication safety, individualized care, and patient health. The analysis underscores the critical impact of clinical pharmacists in elevating healthcare quality, minimizing medication-related risks, and promoting evidence-based therapeutic practices across diverse clinical settings.

Introduction

Over recent years, the scope and impact of clinical pharmacy have expanded significantly, establishing the profession as a vital component within multidisciplinary healthcare teams. Clinical pharmacists now play an essential role in enhancing patient care by collaborating closely with both physicians and patients. Their partnership with clinicians forms a strong foundation for delivering high-quality, reliable healthcare services.

Clinical pharmacists offer valuable expertise in areas such as medication review, detection of drug-related issues, making therapeutic recommendations, and encouraging adherence to prescribed therapies. Their responsibilities include gathering detailed medical and medication histories, identifying and addressing prescription, dispensing, and administration errors, recognizing drug interactions, and monitoring for adverse drug reactions (ADRs). Additionally, they tailor dosage regimens to individual patient needs and provide thorough counselling to patients. Clinical pharmacists also educate patients and healthcare staff on the correct use of medications and medical devices, including inhalers, insulin pens, eye drops, and nasal sprays. Their active participation in ward or ICU rounds and clinical discussions is instrumental in minimizing the risk of drug interactions and ADRs ⁽¹⁾.

Furthermore, clinical pharmacists ensure that processes such as drug reconstitution, dilution, storage, compatibility, and administration are performed correctly and safely ⁽²⁾.

The role of clinical pharmacists continues to evolve beyond these core activities. They are increasingly involved in therapeutic drug monitoring and comprehensive management of pharmacotherapy, both of which contribute to improved patient outcomes. Clinical pharmacists are equipped to address a wide range of inquiries, including drug profiles, indications, dosing, adverse effects, patient management, drug interactions, medication use during pregnancy and lactation, toxicology, and drug storage requirements. By working collaboratively with patients and other healthcare professionals, clinical pharmacists also support patients in making beneficial lifestyle changes to further enhance health outcomes ⁽³⁾.

Figure 1: The Pharmacist process of care ⁽⁴⁾

The cases outlined below provide practical insights into the impact of Clinical Pharmacist interventions in enhancing the quality of healthcare delivery.

Case 1: Antibiotic dosing adjustment in renal impairment.

A 68-year-old male patient presented with Lower Respiratory Tract Infection (LRTI), Type 2 Respiratory Failure, DM, HTN, and Stage V Chronic Kidney Disease (CKD- V) and was undergoing Continuous Ambulatory Peritoneal Dialysis (CAPD). He was initially prescribed Inj. Cefoperazone-Sulbactam 1.5 g TDS.

Upon review, it was noted that the patient’s serum creatinine was 6.99 mg/dL, with an estimated creatinine clearance of 10 mL/min, indicating severe renal impairment. According to the guidelines for patients with significantly reduced renal function, the frequency of Cefoperazone – Sulbactam should be reduced to BD to prevent drug accumulation and potential toxicity.

This case highlights the importance of adjusting antibiotic dosing based on renal function and demonstrates the critical role of clinical pharmacists in reviewing and optimizing medication regimens for patients with complex comorbidities.

Case 2: Drug Interaction

A 74-year-old male was admitted with community-acquired pneumonia, Type 1 respiratory failure, acute STEMI, Congestive heart failure, Sepsis, and MODS involving both acute kidney injury and liver dysfunction. His treatment regimen included Tab. Sodium Bicarbonate 500 mg and Tab. Prednisolone 10 mg, both administered once-daily in the morning.

It was identified that co-administration of sodium bicarbonate can increase gastric pH, which may reduce the absorption and effectiveness of corticosteroids such as Prednisolone. This interaction is classified as risk rating D, indicating that therapy modification should be considered. If unaddressed, this interaction could diminish the therapeutic benefits of prednisolone, potentially impacting patient outcomes.

This case underscores the importance of evaluating potential drug interactions and highlights the clinical pharmacist’s role in optimizing medication therapy for complex patients.

Case 3: Beyond Recommended Dose

A 67-year-old male with Acute Pulmonary Edema, Coronary Artery Disease (CAD-DDD), Type 2 DM, HTN was prescribed Tab. Cilnidipine 20 mg BD.

However, the recommended maximum dose of cilnidipine 20 mg/day, typically administered as a single dose due to its 24-hour duration of action.

In this case, the patient received double the safe daily limit, increasing the risk of adverse effects. This highlights the importance of adhering to dosing guidelines, especially with the medications with prolonged action.

Case 4: Dose adjustment

A 43-year-old male presented with rat poison ingestion and was found to have a markedly elevated serum phosphorus level of 12.5 mg/dL. To manage this hyperphosphatemia, he was prescribed Tab. Sevelamer 400 mg BD.

However, according to clinical guidelines, patients with phosphorus levels ≥12.5 mg/dL should receive a much higher dose of sevelamer – typically 1600 mg TDS with meals. The prescribed dose in this case was considerably lower than recommended, potentially resulting in inadequate phosphate binding and suboptimal control of hyperphosphatemia.

This case underscores the importance of individualized phosphate binder dosing guided by laboratory values and evidence-based protocols. Failure to use an adequate dose may compromise the effectiveness of therapy, prolog hyperphosphatemia and increase the risk of adverse clinical outcomes. Regular monitoring and timely dose adjustments are critical to ensure optimal management of severe electrolyte disturbances in poisoning and other acute care settings.

Case 5: Risk of Hypernatremia

A 56-year-old female with Acute Respiratory Failure was found to have significant Hyponatremia and was treated with Tab. Tolvaptan 15 mg along with normal saline for sodium correction. Tolvaptan is a selective vasopressin V2 receptor antagonist that works by promoting free water excretion without sodium loss, effectively raising serum sodium levels in patients with hyponatremia.

After her sodium levels returned to normal, Tolvaptan was continued. Ongoing administration of tolvaptan after normalization of sodium can lead to excessive water loss, increasing the risk of hypernatremia, as the drug continues to increase serum sodium by removing free water.

This case highlights the importance of reassessing therapy and discontinuing tolvaptan once sodium levels have normalized, to prevent overcorrection and complications such as hypernatremia. Regular monitoring and timely adjustment of therapy are essential for safe and effective management of electrolyte disturbances.

Case 6: Inappropriate continuation of Therapy

A 90-year-old female patient with a post-operative wound infection and sepsis was started on empirical fluconazole therapy. Following urine culture, candida species were identified, but susceptibility testing revealed resistance to fluconazole. Despite this finding, fluconazole therapy was continued.

This case highlights the importance of promptly reviewing culture and sensitivity results and adjusting antifungal therapy accordingly. Continuing an antifungal agent to which the organism is resistant can lead to persistent infection, treatment failure, and unnecessary drug exposure. Timely modification of therapy based on laboratory findings is essential for effective infection management and optimal patient outcomes.

Table 1: Summary of Interventions.

Clinical Scenario	Identified Issue	Pharmacist Intervention	Impact
Antibiotic use in renal impairment	Antibiotic was prescribed at a standard frequency despite significant kidney dysfunction	Suggested adjusting the dosing interval to match renal function	Reduced risk of medication buildup and adverse effects
Drug interaction with corticosteroid	Co-administration of sodium bicarbonate and corticosteroid could lower steroid absorption	Detected potential interaction and recommended therapy adjustment	Ensured proper drug absorption and maintained treatment effectiveness
Antihypertensive dosing above guidelines	Antihypertensive medication was prescribed at a dose higher than recommended	Highlighted the excessive dose and advised guideline adherence	Minimized potential side effects and promoted safe medication use
Insufficient phosphate binder dose	Phosphate binder was prescribed at a dose too low for severe hyperphosphatemia	Recommended increasing the dose according to clinical protocols	Improved control of phosphate levels and better patient management
Prolonged use of tolvaptan after correction	Continued use of tolvaptan after sodium levels normalized, risking overcorrection	Advised stopping the medication once sodium was corrected	Prevented excessive sodium increase and ensured safe treatment
Ongoing use of ineffective antifungal agent	Continued antifungal therapy despite evidence of resistance from lab results	Recommended switching to an effective antifungal based on sensitivity	Enhanced infection control and avoided unnecessary drug exposure

Discussion

The case studies detailed in this article illustrate the substantial value clinical pharmacists bring to healthcare practice. Each scenario exemplifies how their specialized knowledge and proactive involvement can prevent medication errors, optimize therapeutic regimens, and enhance patient safety. Whether adjusting antimicrobial dosing in patients with compromised renal function, managing potential drug interactions, correcting inappropriate prescriptions, or updating therapy in response to laboratory findings, clinical pharmacists consistently contribute to improved clinical outcomes (5).

Beyond these specific interventions, clinical pharmacists are uniquely positioned to conduct comprehensive medication reviews, reconcile complex drug regimens during transitions of care, and implement adherence strategies—each of which can significantly affect patient health. Their active engagement in multidisciplinary rounds and clinical discussions enables early identification and resolution of drug-related problems, while also fostering a collaborative and safety-oriented culture among healthcare professionals.

Moreover, clinical pharmacists play a vital role as educators and advocates, empowering both patients and healthcare providers with the knowledge necessary for safe and effective medication use. Their ability to interpret current clinical guidelines, monitor for adverse drug reactions, and rapidly respond to changes in patient status ensures that therapy remains both evidence-based and patient-centered (6).

Collectively, these case studies provide practical insights into the tangible benefits of clinical pharmacist interventions, while also highlighting the broader potential of the profession. As medication regimens grow increasingly complex, the expertise of clinical pharmacists will remain indispensable—not only for preventing harm but also for driving continuous improvements in the quality and safety of healthcare delivery.

Conclusion

Clinical pharmacists have emerged as essential contributors to modern healthcare, transcending traditional dispensing roles to become leaders in patient safety, therapeutic optimization, and interprofessional collaboration. Their interventions, grounded in advanced pharmacological knowledge and direct patient care, consistently result in better health outcomes, fewer medication errors, and more efficient use of healthcare resources. As healthcare systems continue to evolve in complexity, the integration of clinical pharmacists into multidisciplinary teams is crucial for achieving high-quality, patient-centered care. The cases presented affirm that clinical pharmacists are instrumental in advancing medication safety, therapeutic efficacy, and overall excellence in healthcare delivery.

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Achieving better outcomes from intervention by clinical pharmacists