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\def\RunningAuthor{Kameswari K et al.}
\firstPage{366}
\articleType{Original Article}
\receivedDate{12 Nov 2020}
\acceptedDate{19 Dec 2020}
\revisedDate{13 Dec 2020}
\journalVolume{2020, 11 (SPL4)}
\journalDoi{ijrps.v11iSPL4.3817}
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\title{\textbf{Analysis on the clinical study of drug related problems in pulmonology department at tertiary care hospitals}}
\author{Kameswari~K\textsuperscript{*}\textsuperscript{1},  
            Mohammed~Abdul~Salaam\textsuperscript{2},  
            Punita~P\textsuperscript{3}, 
            Muthulakshmi~R\textsuperscript{3}~\\[5pt]{\textsuperscript{1}Department of OBG, Konaseema Institute of Medical Sciences Research Foundation, Amalapuram, Andhra Pradesh, India}~\\{\textsuperscript{2}Department of Psychiatry, Konaseema Institute of Medical Sciences Research Foundation, Amalapuram, Andhra Pradesh, India}~\\{\textsuperscript{3}Department of Physiology, Meenakshi Academy of Higher Education and Research, Chennai, Tamil Nadu, India}}

\begin{abstract}
The main aim of the study is to assess and evaluate the drug related problems in the pulmonology department. It was a Prospective Interventional study in PULMONOLOGY DEPARTMENT conducted at Manipal Super Speciality Hospitals, Vijayawada, Andhra Pradesh for a period of twelve (12) Months from February 2018 to February 2019. We have collected 115 cases from Pulmonology Department. During the study period, we have collected a total number of 115 cases under the pulmonology department. We found that Males are more effected than Females with percentage of 68\% (n=78) and 32\% (n=37). In the present study 27 DRP's were found in which 10 Adverse Drug Reactions, 4 Untreated conditions, 4 Inappropriate drug according to guidelines, 4 inappropriate timing of administration, 2 Drug dose too high, 2 No Drug treatment inspite of existing indication, 1 prescribed drug not available. The result of the present Interventional study shows that Clinical pharmacy services helps in identify and resolve drug related harms in discussion with health care professional. In our study we found 27 DRP's based on PCNE V8.02 classification in which 22 DRP's were informed to the physician, and 5 DRP's were identified by the physician. The study shows that there is a need for Clinical Pharmacist services in healthcare to reduce DRP's by monitoring patient's drug therapy by which Pharm. D (Doctor of Pharmacy) can be suggested as Clinical Pharmacist since they are well versed in the subject areas like Clinical pharmacy, Clinical Pharmacology, Clinical Toxicology and Pharmacotherapeutics. 
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Pulmonology department,\newline Adverse drug reactions,\newline drug related problems,\newline Pharmaceutical Care Network Europe (PCNE),\newline Pharmacovigilance
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Kameswari~K~\\ Phone:\ 9705420254~\\  Email:\ kameswari54@gmail.com
        \par}\vspace*{-11pt}\hrulefill\par{\fontsize{12}{14}\selectfont ISSN: 0975-7538}\par% 
        \textsc{DOI:}\ \href{https://doi.org/10.26452/\@journalDoi}{\textcolor{blue}{\underline{\smash{https://doi.org/10.26452/\@journalDoi}}}}\par%
        \vspace*{-11pt}\hrulefill\\{\fontsize{9.12}{10.12}\selectfont Production and Hosted by}\par{IJRPS |~\href{www.ijrps.com}{www.ijrps.com}}\par%
        \vspace*{-2pt}{\fontsize{9.12}{10.12}\selectfont\textcopyright\ \@copyrightYear\ $|$ All rights reserved.}\par%
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        \makeatother
        
    
\section{Introduction}
 Clinical Pharmacy Practice is concerned with the promotion of effective, safe and economical drug therapy. Pharmacy practice is broad term which includes Clinical Pharmacy and other patient care related activities performed by pharmacists in the hospital and community settings. These include dispensing and drug distribution, drug information, health promotions, patient counselling, Pharmacovigilance, medication reviews, academic detailing and sterile and nonsterile manufacturing. Drug use is a complex process, and there are many drug related problems at various levels, involving prescribers, patients, pharmacists, the pharmaceutical industry and the government\unskip~\citep{964714:21056794}\ensuremath{^{}}According to WHO Chronic respiratory diseases are diseases of the airways and other structures of the lungs. Some of the most common diseases are asthma, bronchitis, chronic obstructive pulmonary disease, pneumonia occupational lung diseases and pulmonary hypertension. Chronic respiratory diseases are not curable. Not only tobacco smoke, there are some other risk factors that cause chronic respiratory diseases which Incorporate air pollution, streamlined chemicals furthermore dust, and incessant bring down respiratory infections Throughout youth. There would a few types of medication that can help should widen real aviation route passages and enhances wail can help to decrease manifestations What's more build nature from claiming existence for kin with ailments.

 An Interventional ponder outlines additionally called Likewise test investigation designs\unskip~\citep{964714:21056796}. A intercession will be characterized Likewise it the methodology the place An possibility or existing medication related issue may be recognized What's more tended to by those clinical drug specialist bringing about An transform to patient's restorative oversaw economy Also prevention\unskip~\citep{964714:21056791}. Clinical pharmacy interventions are a part of the clinical pharmacist activity. Even though, medications play a major role in the cure, palliation and inhibition of disease, they also expose patients to drug-related problems (DRP's)\unskip~\citep{964714:21056789}\ensuremath{_{.}} A medication related issue will be characterized Likewise an occasion alternately situation directing, including different medication help that alternately possibly meddles with well being outcomes\unskip~\citep{964714:21056788}. 

Order about DRP's could serve as a cynosure to Creating a deliberate procedure to pharmacists on set for appreciably on certain tolerant outcomes\unskip~\citep{964714:21056793}. Numerous approaches about characterizations are accessible should code DRP's in any case every last bit the individual's characterizations have not been tried to legitimacy What's more reproducible. DRP's can be classified as per different classification systems. These include the American Society of Hospital Pharmacists System, Cipolle et al., Granada consensus, Helper/Strand, Pharmaceutical Care Network Europe (PCNE) classification, problem- intervention documentation (PI-OC), and Westerlund classification. Among all classifications, the most commonly tested were PCNE and Charles and Linda\unskip~\citep{964714:21056797}. Those PCNE fundamental order presently need 3 elementary domains for problems, 8 grade domains for 5 grade domains for intercessions. To V7 another section, called 'Acceptance of the mediation Proposals' might have been added, including 3 domains. However, once a all the more point by point level there would 7 aggregated sub-domains to problems, 35 gathered sub-domains to reasons and 16 gathered sub-domains for interventions, Furthermore 10 sub-domains for intercession acknowledgement. Naranjo Adverse Drug Reaction Probability Scale\unskip~\citep{964714:21056795} ``It is a method for estimating the probability of ADR''. The Centres for Disease Control and Prevention (CDC) says tobacco use is the leading cause of preventable illness and death and produces 480,000 deaths a year (including deaths from second-hand smoke). Avoiding sick people and places with a lot of dust or harsh chemicals. ``Finally, be kind to yourself and be kind to others. Having that type of outlook will help you avoidillness\unskip~\citep{964714:21056790}. 
    
\section{Materials and Methods}
\textbf{Study site, study design and duration of the study}

The study was conducted in the medical wards of Manipal Super Speciality Hospital, with 500 bed capacity. It was a Prospective Interventional study in Pulmonology Department conducted for a period of twelve (12) Months from February 2018 to February 2019.


\begin{table*}[!htbp]
\caption{\boldmath {Distribution of patients according to demographic details, and past history} }
\label{tw-c81ab1fc9d84}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.3724\linewidth-2\tabcolsep}p{\dimexpr.32989999999999995\linewidth-2\tabcolsep}p{\dimexpr.29770000000000003\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Age & \cAlignHack No. of patients & \cAlignHack Percentage\\
\tblmidrule 
{\textless}18 &
  \cAlignHack 1  &
  \cAlignHack 0.86\%\\
18-28 &
  \cAlignHack 10 &
  \cAlignHack 8.69\%\\
29-38 &
  \cAlignHack 8  &
  \cAlignHack 6.95\%\\
39-48 &
  \cAlignHack 21 &
  \cAlignHack 18.26\%\\
49-58 &
  \cAlignHack 23 &
  \cAlignHack 20\%\\
59-68 &
  \cAlignHack 25 &
  \cAlignHack 21.73\%\\
69-78 &
  \cAlignHack 22 &
  \cAlignHack 19.13\%\\
79-88 &
  \cAlignHack 4  &
  \cAlignHack 3.47\%\\
\textbf{Gender} &
  \cAlignHack \textbf{No. of patients} &
  \cAlignHack \textbf{Percentage (\%)}\\
Male &
  \cAlignHack 78 &
  \cAlignHack 67.82\%\\
Female &
  \cAlignHack 37 &
  \cAlignHack 32.17\%\\
Total &
  \cAlignHack 115 &
  \cAlignHack 100\%\\
\textbf{Comorbidities} &
  \cAlignHack \textbf{No. of patients} &
  \cAlignHack \textbf{Percentage (\%)}\\
Hypertension &
  \cAlignHack 13 &
  \cAlignHack 11.30\%\\
Diabetes mellitus &
  \cAlignHack 11 &
  \cAlignHack 9.56\%\\
Both DM and HTN &
  \cAlignHack 13 &
  \cAlignHack 11.30\%\\
Pulmonory tuberculosis &
  \cAlignHack 9  &
  \cAlignHack 7.82\%\\
Anemia &
  \cAlignHack 2  &
  \cAlignHack 1.73\%\\
Hyperthyroidism &
  \cAlignHack 1  &
  \cAlignHack 0.86\%\\
Hypothyroidism &
  \cAlignHack 6  &
  \cAlignHack 5.21\%\\
Asthma &
  \cAlignHack 4  &
  \cAlignHack 3.47\%\\
Hernia &
  \cAlignHack 3  &
  \cAlignHack 2.60\%\\
Copd &
  \cAlignHack 2  &
  \cAlignHack 1.73\%\\
Rvd positive &
  \cAlignHack 3  &
  \cAlignHack 2.60\%\\
Without comorbidities &
  \cAlignHack 48 &
  \cAlignHack 41.73\%\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Different types of diseases identified in respiratory system} }
\label{tw-cd8b7e46ca96}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.5351\linewidth-2\tabcolsep}p{\dimexpr.269\linewidth-2\tabcolsep}p{\dimexpr.19590000000000003\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Types of diseases identified & \cAlignHack Total number (n=115) & \cAlignHack Percentage \%\\
\tblmidrule 
COPD (Chronic Obstructive Pulmonary Disease) &
  \cAlignHack 33 &
  \cAlignHack 28.69\%\\
LRTI (Lower respiratory tract infection) &
  \cAlignHack 19 &
  \cAlignHack 16.52\%\\
Pneumonia &
  \cAlignHack 14 &
  \cAlignHack 12.17\%\\
ARDS &
  \cAlignHack 10 &
  \cAlignHack 8.69\%\\
Plueral effusion &
  \cAlignHack 9  &
  \cAlignHack 7.82\%\\
PTB(Pulmonary tuberculosis) &
  \cAlignHack 9  &
  \cAlignHack 7.82\%\\
Bronchial asthma &
  \cAlignHack 9  &
  \cAlignHack 7.82\%\\
Bronchitis &
  \cAlignHack 4  &
  \cAlignHack 3.73\%\\
DNS &
  \cAlignHack 2  &
  \cAlignHack 1.73\%\\
URTI (Upper respiratory tract infection) &
  \cAlignHack 1  &
  \cAlignHack 0.86\%\\
Type 2 respiratory failure &
  \cAlignHack 1  &
  \cAlignHack 0.86\%\\
Pneumothorax &
  \cAlignHack 1  &
  \cAlignHack 0.86\%\\
Lung abscess &
  \cAlignHack 1  &
  \cAlignHack 0.86\%\\
Bilateral consolidation &
  \cAlignHack 1  &
  \cAlignHack 0.86\%\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Naranjo adverse drug reaction probability} }
\label{tw-e6824996fe32}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.40959999999999994\linewidth-2\tabcolsep}p{\dimexpr.3042\linewidth-2\tabcolsep}p{\dimexpr.1761\linewidth-2\tabcolsep}p{\dimexpr.11010000000000002\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Drug & ADR & Severity & Score\\
\tblmidrule 
Fluconazole &
  Increased bilirubin level &
  Probable &
  07\\
Budesonide &
  Decreased potassium level &
  Probable &
  05\\
Hydrocortisone &
  Decreased potassium level &
  Probable &
  05\\
Amoxicillin / Clavulanic Acid &
  Hematuria &
  Possible &
  03\\
Budesonide &
  Decreased potassium level &
  Probable &
  05\\
Tolvaptan &
  Abdominal distension &
  Possible &
  02\\
Doxycycline &
  Itching &
  Possible &
  04\\
Doxycycline &
  Itching &
  Possible &
  04\\
Clarithromycin &
  Vomitings &
  Possible &
  03\\
Aspirin/ Rosuvastatin/ Clopidogrel &
  Blood in sputum &
  Probable &
  05\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Total no.of drug related problems identified} }
\label{tw-2c43a71af928}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.6731\linewidth-2\tabcolsep}p{\dimexpr.32690000000000005\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}DRP & \cAlignHack No of DRPS\\
\tblmidrule 
Untreated condition &
  \cAlignHack 4 \\
ADR's &
  \cAlignHack 10\\
Inappropriate drug according to guidelines &
  \cAlignHack 4 \\
No drug treatment in spite of existing indication &
  \cAlignHack 2 \\
Drug dose too high &
  \cAlignHack 2 \\
Prescribed drug not available &
  \cAlignHack 1 \\
Inappropriate timing of administration &
  \cAlignHack 4 \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Percentage of the planned Interventions} }
\label{tw-138c3e95ce7c}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.34900000000000006\linewidth-2\tabcolsep}p{\dimexpr.09839999999999998\linewidth-2\tabcolsep}p{\dimexpr.29439999999999994\linewidth-2\tabcolsep}p{\dimexpr.14350000000000003\linewidth-2\tabcolsep}p{\dimexpr.11469999999999999\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Primary Domain & \cAlignHack Code & Intervention & \cAlignHack No. of DRP's & \cAlignHack \% \\
\tblmidrule 
No intervention &
  \cAlignHack I0.1 &
  No Intervention &
  \cAlignHack -  &
  \cAlignHack - \\
\multicolumn{1}{p{\dimexpr(.34900000000000006\linewidth-2\tabcolsep)}}{\multirow{4}{\linewidth}{1. At prescriber level}} &
  \cAlignHack I1.1 &
  Prescriber informed only &
  \cAlignHack 05 &
  \cAlignHack 18.51\%\\
 &
  \cAlignHack I1.2 &
  Prescriber asked for information &
  \cAlignHack -  &
  \cAlignHack - \\
 &
  \cAlignHack I1.3 &
  Intervention proposed to prescriber &
  \cAlignHack 17 &
  \cAlignHack 62.96\%\\
 &
  \cAlignHack I1.4 &
  Intervention discussed with prescriber &
  \cAlignHack 05 &
  \cAlignHack 18.51\%\\
2. At patient level &
  \cAlignHack -  &
  \cAlignHack -  &
  \cAlignHack -  &
  \cAlignHack - \\
3. At drug level &
  \cAlignHack -  &
  \cAlignHack -  &
  \cAlignHack -  &
  \cAlignHack - \\
4. Other intervention or activity &
  \cAlignHack -  &
  \cAlignHack -  &
  \cAlignHack -  &
  \cAlignHack - \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
\textbf{Inclusion Criteria}

Patients of both genders are considered. Smokers, alcoholics are also included in this study. Patients with comorbidities are also included in this study.

\textbf{Exclusion Criteria}

Those are not willing to participate in our study. Pregnancy women have and terminally ill are excluded. Unconscious and coma patients were excluded from the study.

\textbf{Study procedure}

\textbf{Data collection}

Regular pre ward rounds were carried out in all the wards during the study period and all the necessary information from the case sheets of patients was collected using a data collection form. The data collection form includes the columns for Patient details like Name, Age, Gender, Inpatient/ Hospital number, Date of admission, Medical condition, Social History, Vitals, Laboratory investigations, Final Diagnosis, Medications prescribed, Types of DRP identified, Intervention, Classification of intervention, Level of significance of DRP.

\textbf{Data analysis}

The collected data from the prescriptions was thoroughly analysed and screened for possible drug related problems using the Lexicomp (Up to date software) and ADR's from Naranjo scale. And all the DRP's were intervened under the PCNE Guidelines.
    
\section{Results and Discussion}
During the study period, we have collected a total number of 115 cases under pulmonology department in Table~\ref{tw-c81ab1fc9d84}. Out of which 27 DRP's were found. We found that most of the people were under the age group of 59-68 years with 21.73\% (n=25) and lowest percentage below 18 years with 0.86\% (n=1) this observation is same with the adult age group of the study conducted by Koh et. al., and also we found that Males were more effected than Females with percentage of 68\% (n=78) and 32\% (n=37) this observation is contrasted with the demographic reports of the study conducted by Koh et al in Table~\ref{tw-cd8b7e46ca96}.\unskip~\citep{964714:21056792} with the highest co-morbidity disease Hypertension with a number of 26(22.60\%), followed by diabetes with a number of 24(20.86\%) and the lowest disease is hyperthyroidism with a number of 1(0.86\%), this observation is same with the \textit{Yuki Imaizumi et al } shows that has increasingly been recognized that the incidence of cardiovascular events is high in patients with chronic lung disease and the results were tabulated in Table~\ref{tw-e6824996fe32}. We also found that most of the people were effected with the disease COPD with highest number of 34(29.56\%) followed by LRTI, Pneumonia, ARDS, Pleural Effusion, PTB, Asthma, Bronchitis etc and the results were tabulated in Table~\ref{tw-2c43a71af928}. Considering the etiological factors smoking is the highest possible cause with percentage of 42\%,followed by alcoholics 20\%, occupational 9\%, and inherited 2\% this observation is same with the \textit{Yuki Imaizumi et al } which tells that Smoking is an established risk factor for cardiovascular diseases and the results presented in Figure~\ref{f-def3188da2c7}.


\bgroup
\fixFloatSize{images/7c5d2f10-c563-4b7e-8d23-eaff595ab97e-upicture1.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/7c5d2f10-c563-4b7e-8d23-eaff595ab97e-upicture1.png}{\includegraphics{images/7c5d2f10-c563-4b7e-8d23-eaff595ab97e-upicture1.png}}{}
\makeatother 
\caption{\boldmath {Distribution of patients according to social history}}
\label{f-def3188da2c7}
\end{figure}
\egroup
In our study we found a total number of 27 Drug Related Problems in which 10 Adverse Drug Reactions, 4 Untreated conditions, 4 Inappropriate drug according to guidelines, 4 inappropriate timing of administration, 2 Drug dose too high, 2 No Drug treatment inspite of existing indication in, 1 prescribed drug not available and all these results were tabulated in Table~\ref{tw-138c3e95ce7c}.
    
\section{Conclusions}
The result of the present Interventional study shows that Clinical Pharmacy services helps in identifying and resolving drug related problems in consultation with health care professionals. In our study, we found 27 DRP's based on PCNE V8.02 classification in which 22 DRP's were informed to the physician, and 5 DRP's were identified by the physician. The study shows that there is a need for Clinical Pharmacist services in healthcare to reduce DRP's by monitoring patient's drug therapy by which Pharm. D (Doctor of Pharmacy) can be suggested as Clinical Pharmacist since they are well versed in the subject areas like Clinical Pharmacy, Clinical Pharmacology, Clinical Toxicology and Pharmacotherapeutics.

\textbf{Conflict of interest}

The authors declare that they have no conflict of interest for this study.

\textbf{Funding support}

The authors declare that they have no funding support for this study.
    

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