Introduction and Definition of Basic Terms
In the name of Allah, peace and blessings be upon the Messenger of Allah. First, I welcome everyone and thank the organizers of this conference and the distinguished attendees. Our topic, as presented by my colleague Dr. Shadi, is "Treatment-Related Problems: Facts and Solutions."
There are some terms and abbreviations that will be repeated, and I want them to be clear from the beginning:
- Medication-Related Problems (MRPs) or Drug-Related Problems (DRPs): drug-related problems.
- Preventable Adverse Events: preventable side effects.
- Medication Review: conducting a review of the medications a patient is taking to resolve any anticipated issues.
- Home Medication Review: reviewing medications but at the patient's home.
To make our discussion practical, we will take practical examples of what we mean by treatment-related problems:
- Unnecessary Therapy: a patient taking medications they do not actually need.
- Untreated Condition: a patient who needs treatment for a certain condition (such as hypertension or diabetes) but is not receiving it.
- Ineffective or Incomplete Drug Therapy: taking an ineffective drug or an insufficient dose.
- Inappropriate Dosage Regimen: inappropriate repetition or timing of the medication.
- Adverse Drug Effects: existing or expected side effects (potential).
- Drug Interactions: drug interactions.
- Non-adherence: the patient's failure to take the medication for various reasons.
We chose the term "Treatment-Related Problems" (TRPs) in our research because it is more comprehensive than "drug." For example, if the patient does not adhere to regular liver function tests while taking "statin" drugs, or does not adhere to the allowed salt intake, these are problems related to the entire treatment process and not limited to the drug tablet alone.
Evidence-Based Medicine
What qualifies me as a clinical pharmacist to say that the dose is wrong or the diagnosis is inaccurate? It may be said that the matter is relative, but the principle is to follow scientific principles. We suffer from a problem of not activating "treatment guidelines" in many medical sectors.
When we say there is a problem, we must rely on evidence-based medicine. This concept is not rigid or robotic; it is an intersection of three circles:
- Healthcare Practitioner's Personal Judgment (HCP Judgment): whether a doctor or pharmacist.
- Best Scientific Evidence: focusing on the latest and strongest studies.
- Patient Preferences and Circumstances: where the treatment plan can be modified based on the patient's specific condition.
Practical Examples from Clinical Reality
1. Use of Aspirin for Primary Prevention
Let's take an example: a male patient, 52 years old, has had type 2 diabetes for 5 years, his blood pressure is 132/85, and his cholesterol tests are normal or slightly elevated. Should we give him "baby aspirin" (75 mg) for prevention?
According to the 2019 updates, aspirin is no longer given routinely to everyone. There are precise conditions:
- It is prohibited for primary prevention above the age of seventy.
- In the case of our patient, the risk of heart disease (ASCVD Risk) should be calculated. If the percentage is low (less than 10%, for example), aspirin is not recommended because it significantly increases the risk of bleeding (Bleeding Risk), and we may have to give other drugs such as (PPIs) which have their own problems such as osteoporosis or kidney failure.
2. Treatment of Hypertension
Another example: a person with blood pressure of 135/85 and aged 44. According to the 2017 guidelines of the American Heart Association (AHA), this is considered high blood pressure, but should drug treatment begin immediately?
The answer: no. If the risk percentage (ASCVD Risk) is less than 10%, we start by changing the lifestyle (exercise, diet, reducing salt) and do not resort to drugs directly to avoid entering a vicious cycle of side effects without urgent need.
3. Cholesterol Drugs (Statins)
A friend of mine was prescribed "rosuvastatin" by his doctor based on slightly elevated cholesterol numbers. When calculating the risk for the next ten years, it turned out to be only 3.3%. According to European guidelines, the recommendation here is "lifestyle advice" only, and there is no need for medication at this stage.
The Scale of the Problem Globally and Locally
Treatment-related problems are not just minor errors but a matter of life or death:
- In America, studies indicate that TRPs are the third leading cause of death after heart disease and cancer, causing approximately 250,000 to 400,000 deaths annually.
- Economically, the United States spends more than $200 billion annually due to these problems.
- In Jordan: A study conducted in 2011 in hospitals showed a very high rate of up to 9 treatment-related problems per patient.
A study conducted in 2011 in hospitals showed a very high rate of up to 9 treatment-related problems per patient.
Why do we find this large scale of problems? There are objective and structural reasons in our healthcare system:
- Short Medical Visit Time: In global studies, it was found that the time a patient spends with the doctor may reach only 48 seconds in some countries. In Jordan, the time is very short (about 3-4 minutes), which is not enough to evaluate the patient's comprehensive condition or review their medications accurately.
- Drug Dispensing Time in Pharmacies: The global rate in some studies indicates only 28 seconds for drug dispensing. The pharmacist sometimes works as a "dispensing machine"; they receive the prescription with one hand and give the drug with the other without providing adequate advice.
- Absence of a "Family Doctor" System: The family doctor is the safety valve; they know the medical history of the family as a whole. Their absence makes the patient move between specialists (doctor shopping), taking a drug from an orthopedic doctor, another from a neurologist, and a third from a psychiatrist, without a central authority to coordinate these treatments, leading to drug conflicts and accumulation.
We conducted a field study (outside hospitals) with the participation of 167 fifth-year pharmacy students at the Applied Science University. The students made home visits to patients suffering from multiple diseases (polypharmacy) to review their medications.
Key Findings:
- We found that the rate of treatment-related problems (TRPs) is 7 problems per patient.
- Most common problems:
- Taking medications unnecessarily (unnecessary drug therapy).
- Untreated medical conditions (untreated conditions).
- Non-adherence to treatment, which is a global problem responsible for the failure of nearly half of treatment cases.
- Drugs most associated with errors: metformin (for diabetes), atorvastatin (for cholesterol), and enalapril (for blood pressure).
Recommendations and Proposed Solutions
To move beyond this reality, we need practical steps that go beyond mere theorizing:
1. Activating the Role of the Clinical Pharmacist
Studies have shown that the presence of a clinical pharmacist within the medical team significantly reduces TRPs and treatment costs, provided there is an effective feedback system between the pharmacist and the doctor.
2. Monitoring and Documentation
Monitoring systems should be activated before and during treatment. It is unreasonable for a patient to start taking blood pressure medications (such as ACE inhibitors) without checking kidney function and potassium levels as baseline data for future comparison.
3. Leveraging Technology and Digital Content
We have an excess of pharmacists and unemployment among them, while there is a lack of serious and simplified scientific content.
- Recommendation for Universities: Teach courses on how to create targeted medical content (Medical Content Creation).
- Call to Pharmacists: We need pharmacist "YouTubers" who present beneficial knowledge, simplify medical concepts for the public, build community trust in the pharmacist's efficiency, and increase acceptance of their advice.
4. Proving Field Efficiency
Doctors and the community will accept the role of the pharmacist when he proves himself scientifically and practically. When a doctor sees that a pharmacist's note saved a patient from a serious drug interaction or avoided an unnecessary cost, the pharmacist will become an indispensable partner in the treatment process.
In conclusion, saving one patient from a therapeutic problem that could cost him his life is an application of His saying, may God be pleased with him: "And whoever saves a life, it is as if he has saved all of humanity." Thank you for your kind attention, and I apologize for the length.