An Introduction To

Pharmacoepidemiology

Dr. Furqan K. Hashmi

Assistant Professor
Punjab University College of Pharmacy
Definition

•Pharmacoepidemiology is the study of the use of and the effects

of medicines in large numbers of people.

•New applied field bridging between clinical pharmacology and

epidemiology.

•Pharmacoepidemiology started with increasingly frequent

accusations about adverse drug reactions, often arising out of
spontaneous reporting system, followed by formal studies proving
or disproving those associations.
Potential Contributions Of
Pharmacoepidemiology
• Information which supplements the information available
from premarketing studies—better quantization of the incidence
of known adverse and beneficial effects

• Higher precision (e.g.. Digoxin)

• In patients not studied prior to marketing, e.g. the elderly,

children, pregnant women

• As modified by other drugs and other illnesses (eg. Timolol)

• Relative to other drugs used for the same indication

Potential Contributions Of
Pharmacoepidemiology
• New types of information not available from premarketing
studies

(1) Discovery of previously undetected adverse and beneficial

effects, uncommon effects, delayed effects

(2) Patterns of drug utilization

(3) The effects of drug overdoses

(4) The economic implications of drug use

Pharmacoepidemiology

•One of the most pressing problems facing public health providers

and administrators in many countries is ensuring the rational use
of drugs.

•In recent years, the term rational itself has gone through drastic
changes:

•Rational use…………. Quality use…………. Responsible us

Pharmacoepidemiology

• In practice, success of treatment largely depends on the ability

of a physician to diagnose, prescribe, foresee probable adverse
reactions and prevent unnecessary or dangerous duplication
therapy.

• Further success depends on performance of the pharmacy and

nursing departments in preparing and administering drugs.

• However, the existence of a rationally derived list of drugs

approved for procurement and health care consultants
performance does not ensure that they are prescribed and
used correctly.

• One mechanism to ensure correct prescribing and use is the

drug utilization evaluation (DUE)/ Drug Utilization Review.
Responsible Use Of
Medicines
Responsible Use Of
Medicines
 About $ 500 Billion can be avoided through better responsible
medicine use, worldwide.
Responsible Use Of
Medicines
 The term ‘responsible use of medicines (RUM)’ implies that the
activities, capabilities, and existing resources of health system
stakeholders are aligned to ensure patients receive the right
medicines at the right time, use them appropriately, and benefit from
them.

 The concept of RUM incorporates the importance of stakeholder

responsibility and recognizes the challenge of finite resources.

 RUM is essential to avoid or reduce avoidable adverse events, worse

quality of life, and inferior health outcomes.

 RUM is essential to contain the escalating pharmaceutical

expenditure.
DUE/DUR

• DUE is an ongoing, systematic process designed to maintain

the appropriate and effective use of medicines.

• It involves a comprehensive review of patients' prescription and

medication data before, during, and after dispensing in order to
assure appropriate therapeutic decision making and positive
patient outcomes.
DUE/DUR

• Pharmacists participating in DUE programs can directly improve

the quality of care for patients, individually and as populations,
by preventing the use of unnecessary or inappropriate drug
therapy and by preventing adverse drug reactions.

• The process of DUE goes by many names. In certain settings, it

may be referred to as drug utilization review (DUR). At one
time, a distinction was drawn between DUE and DUR based on
the notion that the former was prospective and the latter
retrospective. However, most experts agree that there is little
difference between the two and favor use of the term DUE.
DUE/DUR

• DUE is defined as an authorized, structured, ongoing review of

practitioner prescribing, pharmacist dispensing, and patient use
of medications.

• The purpose of a DUE is to ensure that drugs are used

appropriately, safely, and effectively to improve patient health
status.

• DUE is typically classified in three different categories:

prospective, concurrent, and retrospective
Prospective DUE/DUR

• Prospective review involves evaluating a patient's planned drug

therapy before a medication is dispensed.

• This process allows the pharmacist to identify and resolve

problems before the patient has received the medication.

• Pharmacists routinely perform prospective reviews in their daily

practice by assessing a prescription medication's dosage and
directions and reviewing patient information for possible drug
interactions or duplicate therapy.
Issues Commonly Addressed by
Prospective DUE

• Drug-disease contraindications
• Therapeutic interchange
• Generic substitution
• Incorrect drug dosage
• Inappropriate duration of drug treatment
• Drug-allergy interactions
• Clinical abuse/misuse
Concurrent DUE

• Concurrent review is performed during the course of treatment

and involves the ongoing monitoring of drug therapy to ensure
positive patient outcomes.

• Some refer to this as case management or health

management. It presents pharmacists with the opportunity to
alert prescribers to potential problems and to intervene in areas
such as drug-drug interactions, duplicate therapy, over or
underutilization, and excessive or insufficient dosing.

• This type of review allows therapy for a patient to be altered if

necessary.
Issues Commonly Addressed By
Concurrent DUE

 Drug-drug interactions
 Excessive doses (High or low dosages)
 Duplicate therapy
 Drug-disease interactions
 Over and underutilization
 Drug-age precautions
 Drug-gender precautions
 Drug-pregnancy precautions
Retrospective DUE

• A retrospective DUE is the simplest to perform since drug

therapy is reviewed after the patient has received the
medication.

• A retrospective review may detect patterns in prescribing,

dispensing, or administering drugs to prevent recurrence of
inappropriate use or abuse and serves as a means for
developing prospective standards and target interventions.

• In retrospective DUE, patient medical charts or computerized

records are screened to determine whether the drug therapy
met approved criteria and aids prescribers in improving care for
their patients, individually and within groups of patients, such as
those with diabetes, asthma, or high blood pressure.
Issues Commonly Addressed by
Retrospective DUE

• Therapeutic appropriateness
• Over and underutilization (Appropriate generic use)
• Therapeutic duplication
• Drug-disease contraindications
• Drug-drug interactions
• Incorrect drug dosage
• Inappropriate duration of treatment
• Clinical abuse/misuse
Steps In Conducting A Drug Use
Evaluation
 Identify or Determine Optimal Use - Criteria are defined to
allow for comparisons of optimal use with actual use. Criteria
should focus on relevant outcomes. For example, if the use of a
drug prescribed to treat a patient with diabetes is being
evaluated, then set standards should be determined to evaluate
its effectiveness, such as a decrease in blood glucose or HbA1c
(glycosylated hemoglobin) levels.

 Measure Actual Use - This step is where data is gathered to

measure the actual use of medications. This data can be
obtained from medical and prescription records or electronic
claim forms.
Steps In Conducting A Drug Use
Evaluation
 Compare - This involves the comparison between optimal or
appropriate and actual use. During this process, the evaluator
determines whether findings are expected and causes for any
discrepancies. In this process, patterns or aberrations can be
interpreted.

 Intervene - This is the step where corrective action is

implemented. Action should be targeted to areas of concern
such as prescribing patterns, medication misadventures, the
quality of drug therapy, or economic consideration.

 Evaluate the DUE Program - The last step is to assess the

effectiveness of the DUE program. Efforts should be made to
evaluate the outcomes and document reasons for positive and
negative results. Implementing appropriate changes to the DUE
program and continued observation should be undertaken
Value of DUE Programs

• DUE programs play a key role in helping a health organization to

understand, interpret, and improve the prescribing, administration, and use
of medications. This is often accomplished by using DUE programs to
provide physicians with feedback on their performance and prescribing
behaviors as compared to pre-set criteria or treatment protocols.

• DUE information also allows physicians to compare their approach to

treating certain diseases with their peers. The "peer pressure" generated by
these comparisons is useful in stimulating physicians to change their
prescribing habits in an effort to improve care.

• DUE information also assists health policy makers in designing educational

programs that improve rational prescribing, formulary compliance, and
patient compliance.
Role of the Pharmacist In DUE

Home visit by hospital pharmacists identified the total cost of collected excessive medications from
103 patients’ house was RM 4,869.91(USD1623) with average cost RM 47.28 (USD15.76) per
patient
Conclusion

• Using DUE information, pharmacists can identify prescribing

trends in patient populations and initiate corrective action to
improve drug therapy for groups of patients, as well as
individuals.

• As the variety of health care professionals (pharmacists,

physicians, nurses, optometrists) involved in the medication use
process expands, DUE will require a more multidisciplinary
approach to improving patient care.

• This will lead to the next logical step, the evolution of DUE into
a more comprehensive "healthcare utilization evaluation."
Thank you