Compilation of lectures

Reference:

Prof. Dr.Barkat Ali Khan

Prof. Dr.Sheikh Abdur Rashid

Written By:
Hafiz Abdulrehman
Session(2018-2023)
 PHARMACY PRACTICE-II
(DISPENSING, COMMUNITY, SOCIAL & ADMNISTRATIVE PHARMACY)

PART A: (DISPENSING).

1. BASIC PRINCIPLES OF COMPOUNDING AND DISPENSING INCLUDING:

Fundamental operations in Compounding, Containers and closures for Dispensed
Products, Prescription-Handing (Parts of Prescription, Filling, Interpretation, Pricing)
and Labeling of Dispensed Medication.

2. EXTEMPORANEOUS DISPENSING:
Solutions, Suspensions, Emulsions. Creams, Ointments, Pastes and gels,
Suppositories and pessaries. Powders and granules and Oral unit dosage form.

3. PHARMACEUTICAL INCOMPATIBILITIES:
Types of Incompatibilities, manifestations, Correction and Prevention with reference
to typical examples.

PART B: (COMMUNITY, SOCIAL & ADMINISTRATIVE PHARMACY): (60 MARKS)

1. DEFINITIONS AND BACKGROUND:

2. PUBLIC HEALTH AND COMMUNITY PHARMACY:
Epidemiology & its Control, Epidemiological methodology with a focus on specific
disease states, Pharmacoepidemiology (including Drug Utilization Review).
Preventive Health (EPI & CDC), Family Planning and Health Policy:

3. MEDICAL COMPLICATION OF DRUG TAKING:

General and Socio-econornic Aspects.

4. PATIENT EDUCATION AND COUNSELLING:

5. CONTROL OF DRUG ABUSE AND MISUSE

6. ROLE OF PHARMACIST:
As Public Health Educator in the Community for Drug Monitoring and Drug
Information.

7. HEALTH SYSTEM RESEARCH:

Knowledge skills of research methods, epidemiologic study design, experimental
study design, Pre- and post-marketing surveys, Application of various statistical
procedures in Pharmacy and Medical Research, causality assessment as well as the
sensitivity and specificity tests in pharmacy practice.

8. PHARMACOECONOMICS: Pharmacoeconomic modeling and interpretation.

9. ALTERNATIVE THERAPIES:
Background, philosophy and use of complementary and alternative therapies
including herbal medicines, homoeopathy, acupuncture, acupressure, Bach Flower
remedies, aromatherapy and reflexology.

10. PHARMACY LAYOUT DESIGN: Objectives of Layout Design, Types of Community

Pharmacies (Pharmaceutical Centre, Prescription-oriented Pharmacies, Traditional
Pharmacies and The Super Drug Store), Consumer goods and purchases, Classes
of Layout designs, Principles and characteristics of Layout Design and Traffic Flow
analysis
SUGGESTED BOOKS: Pharmaceutics-1 by R.M.Mehta, The Theory and Practice of I
ndustrial Pharmacy by Leon Lachman, Pharmaceutical Product Development by
N.K.Jain. Aulton’s Pharmaceutics by Michael E. Aulton.
 INDEX

NO. CONTENTS PAGE NO.

PART-A
(DISPENSING)
1. BASIC PRINCIPLES OF COMPOUNDING AND DISPENSING. 01
2. EXTEMPORANEOUS DISPENSING 28
3. PHARMACEUTICAL INCOMPATIBILITIES. 36
PART-B
(COMMUNITY, SOCIAL & ADMINISTRATIVE PHARMACY)
1. DEFINITIONS AND BACKGROUND. 43
2. MEDICAL COMPLICATION OF DRUG TAKING. 48
3. PATIENT EDUCATION AND COUNSELLING. 50
4. CONTROL OF DRUG ABUSE AND MISUSE. 52
5. ROLE OF PHARMACIST. 56
6. HEALTH SYSTEM RESEARCH. 60
7. PHARMACOECONOMICS. 63
8. PUBLIC HEALTH AND COMMUNITY PHARMACY. 68
9. ALTERNATIVE THERAPIES. 96
 PART-A
BASIC PRINCIPLES OF COMPOUNDING AND DISPENSING

Introduction to Pharmacy:
Dispensing:

Dispensing is an important part of the practice of pharmacy, in which the

pharmacist or the pharmacy technician (under the direct supervision of the
pharmacist) interprets the physician's requirements on the prescription and
accordingly supplies medicines for the treatment of his patient (s).This usually
involves interpreting a written prescription but may, on occasions, also include taking
instructions given by word of mouth or by telephone from the physician

The various activities involved in Dispensing are

Receiving and confirming orders

Checking prescription and interpretation

Verifying and consulting if required

Removing medicines for issue and assembling

Billing and counterchecking

Issuing medicines to the client with clear instructions and counseling

Dispensing modules for good pharmacy practice:

1. Dispensing environment
a) Prescription Counter
b) Waiting Area
c) Requirements of a good dispensing environment
d) Barriers, noise and distractions that can affect dispensing

2. Handling of Prescriptions
a) Receiving the prescription
b) Reading the prescription and checking for
(i)Legality
(ii) Legibility
(iii)Completeness and correctness

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 3. Processing a prescription
a) Filling a prescription
b) Removal of medicines from shelves.
c) Assembling of medicines.
d) Billing.
e) Packing.
f) Refilling a prescription
4. Other aspects of dispensing
a) Dispensing errors
b) Role of pharmacists in promoting correct dispensing
c) Refusal to dispense prescriptions
d) Alternatives to conventional prescriptions.

(1) DISPENSING ENVIRONMENT

a) Prescription counter:

❖ Ideally the prescription counter should:

❖ Be accessible to the client
❖ Preferably be separate and in a quite location. If there are other separate
sections (e.g cosmetics, general items, OTC section), it should be slightly
away from them
❖ Be calm. Orderly, attractive and marked with an identifying sign or symbol
which can be easily identified and seen from other parts of the pharmacy.
❖ A different color, appearance, demarcation etc may be given to the
prescription section, to provide added emphasis.
❖ Have a waiting area for clients who wait for their prescriptions to be dispensed
or filled

b) Waiting area:

1) What should and ideal waiting area provide?

2) Comfortable chairs/place to sit (especially for elderly/disabled/sick patients to
rest).
3) Current popular health magazines and carefully selected material to good
health, to keep the client busy/occupied and prevent boredom while waiting to
receive medicines.
4) Pamphlets and posters related to public, family and other individual health
problems prominently displayed (as the waiting area could be used as a
health education center)

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 c) Requirements of a Good Dispensing Environment:
1. Be clean: To give a professional impression and outlook to the pharmacy.
2. Be organized: To provide for a safe and efficient working area. (Such that
things are found in the right place at the right times and there are minimum
obstructions and hurdles).
3. Have sufficient space For easy movement of personnel in the pharmacy, and
to prevent congestion and physical contact among staff while working.
4. Temperature and humidity controlled As appropriate temperature and
humidity are necessary for stability of medicines till the expiry date.
5. No loud music playing, gossiping, talking, or television (e.g. a cricket match or
a movie) : To avoid distractions during dispensing.
6. Have medicines stored in an organized way on shelves in alphabetical order
or using the method normally employed in that particular pharmacy: To
ensure quick, but safe selection of the correct medicines from the shelves to
minimize dispensing errors.
BE CLEAN, GET ORGANISED!! GIVE THE PHARMACY A PROFESSIONAL
LOOK

Maintaining a clean environment requires

A regular routine of cleaning shelves, medicines/products, and a daily
cleaning of floors. A regular schedule for checking, cleaning and defrosting the
refrigerator. Immediate wiping of accidental spills due to breakage, etc, during
dispensing
Advantages of a good dispensing enviroment
1) Reduces dispensing errors.
2) Reduces fatigue among pharmacy staff.
3) Enhances services.
4) Improves the image of pharmacy
5) Increases clients
6) Increases speed.
7) Creates a professional image
Working in a clean and an organized environment in a pharmacy, aids in
accuracy while dispensing, and also gives a professional look to the pharmacy.
Presence of a separate prescription counter and waiting area can further Highlight
professionalism and competence of the pharmacist. Pharmacists handle medicines,
and a slight dispensing error could result in serious consequences i.e. health -wise
for the patient, and for the pharmacy – a loss of reputation. Thus a good dispensing
environment is recommended for every pharmacy.

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 (2) HANDLING PRESCRIPTIONS
a) Receiving the Prescription :
❖ As clients come into the pharmacy, they must be made to feel attended
to and comfortable by :
❖ Friendly gestures.
❖ A smile.
❖ Eye-to-eye contact.
❖ A friendly welcome.
❖ Courtesy. Feeling of caring .
Communication should be initiated in such a manner that it encourages the client to
convey his/her needs by producing a prescription or by asking for other products or
advice

Upon receiving the prescription, the pharmacist should confirm:

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 ✓ Whether the client is the patient himself or has come on the patient's behalf.
✓ The relation of the client with the patient.
✓ The client may politely be requested to wait, while the pharmacist reviews the
prescription for:
▪ Legality and completeness of prescription.
▪ Therapeutic aspects
▪ Appropriateness for the individual
After receiving the prescription, it is important for the pharmacist to read the
prescription to verify whether :
▪ It is legal and complete with respect to the various parts of the
prescription, and therefore
▪ It can be dispensed as such, or not.

b) Reading the Prescription and Checking for Completeness and Correctness:

While reading and checking the prescription, the pharmacist Should

❖ Be alert, and concentrate on the prescription.

❖ Not be distracted.

❖ Not engage in talking or chatting.

❖ Engage/ use his professional/ experience in assessing the prescription.

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Legality
A prescription is legal when:

• It is written (can also be typed) by a R.M.P.

• Signed by the R.M.P.

• Has all the information required to be contained with respect to parts of

prescription
Legibility
Handwritten names of patients and medicines are often difficult to read. In
case of illegibility of name, age, etc, ask the patient for the correct spelling tactfully.
For example the pharmacist may ask
Always use “excuse me” or “please” etc and be polite

Never dispense Guess work:

Legibility is a problem requiring alertness and critical judgment on the part of
the pharmacist. Careless handwriting and similarity in spelling of names of different
drugs add to the difficulty.
Example of a Reading error:
Arlidin and Artidin - Due to illegible handwriting of doctors, Artidin could be
read as Arlidin. Artidin is a brand containing Diclofenac whereas Arlidin contains
Nylidrin two different drugs used for two different conditions. When handwriting is
illegible, the best thing to do is to contact the physician over the phone and confirm.
Remember:

• you are dealing with medicines and thus, the lives of patients so be sure of
what you are dispensing. Imagine the disastrous consequences of dispensing
the wrong medicine ‘NEVER DISPENSE GUESS.
• The dosage form, the dosage and the quantity to be dispensed have to be
legible so that dispensing becomes easier for the pharmacist.
• The instructions written for administration should state clearly what the
physician expects from the patient so that the pharmacist can counsel the
patients efficiently.
• All terminology, including units of measures (metric, apothecary or English)
and Latin abbreviations should be properly interpreted

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Completeness and correctness
The prescription serves as a vehicle for communication from the licensed
practitioner to the pharmacist about the pharmaceutical care of the patient.
Details to be checked for
❖ Physician's details.
❖ Patient's details.
❖ Check the product details
Checking the product details will include checking:
❖ Name of the product.
❖ Dosage form.
❖ Strength/ potency of the medicine.
❖ Total amount to be dispensed and its availability
❖ Dosage and directions for use.
❖ Frequency of administration

General dispensing procedure:

1) Work on your own place.
2) Wear freshly laundered overall coat.
3) Provide yourself with a clean glass-cloth, a duster and either sponge.
4) Work in a clean and tidy manner.
5) Read the prescription carefully, make sure you understand it and that it is legally
correct.
6) If necessary, find out the formula of the prescription in an appropriate source of
information.
7) Check the doses of internal preparations.
8) Find, from an appropriate source, if any ingredient is a poison.
9) Conform that there are no pharmaceutical or therapeutic incompatibility in the
preparation.
10) if you are unsure of correct method of preparation refer to your practical notebook.
11) Look up the storage conditions for the preparations.
12) Work out the calculations.
13) Check the calculations.
14) Collect the correct container and closure.
15) If necessary, trim the label to fit the container but do not remove the name of
suppliers.
16) Write the main label and collect any special labels that are required.
17) Make the preparation, pack it in the containers and polish the label.
18) Check the label and fix them to the container.
19) Check the finished preparation.
20) Wrap the container and write the patient’s name and address on the wrapper.
21) Make the appropriate records
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 Fundamental Operations in compounding
Compounding:
Preparation of medicine from the basic ingredients. It is of two types

1. Extemporaneous compounding

❖ On-demand preparation of a drug product.

❖ According to a physician’s prescription.
❖ Meets the unique needs of an individual patient.

2. Manufacturing

❖ The production or processing of a drug in a LARGE quantity by various

mechanisms.

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What are fundamental operations in compounding?
1 .Weighing
2. Measurement of liquids
3. Dissolution
4. Size Reductions
5. Filtration
6. Size separation
7. Mixing

1. Weighing:
1. Balances are used which are in prescribed limits of error.
2. Electronic balances are used.
3. The minimum weigh able amount for class A balances are 50 mg and for
class B 100mg.
4. Approximation should be avoided as possible.
5. Weights use should also comply the regulations of shape, compositions
and limits of error.

2. Measurements of liquids:
a. Conical or beaker shaped measures are used for large volumes. The minimum
measure able quantity for a small is 10ml and conical measure is 1ml.
Why conical or beaker shape measures are used? Advantages and limitations
➢ Easy to fill without spilling of liquid of prep and easy to rinse out after
draining.
➢ Difficult to read meniscus accurately
b. Difficult to estimate volumes b/w graduations.

3. Dissolution:
⋆ Conversion of solute into solution is dissolution

Factors that increase the rate of dissolution?

1. Finely powdering of solids.

2. Agitation.

3. Raising temp

4. Decreasing viscosity.

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4. Reasons for size reductions:

1. To increase dissolution rate

2. Increase absorption
3. Perpetrators are free from ritiness.

5. Filtration:
Use for separation of suspended particles in solution.

Factors that increase rate of filtration:

1. Osmosis (increasing osmosis).

2. Decreasing viscosity of liquids.
3. Increasing surface area of filter media. (Pleated filter is used)
4. Using a filter paper of high porosity.

Filter papers are used:

➢ Whatman filter paper : 1,50,54

➢ Sintered glass filter paper: no 3 , no 4

6. Mixing:
➢ Use for prep of mixtures of solid, semi solid and liquids.

➢ Homogeneous mixture: solution - done by shaking and steering.

➢ Heterogeneous mixtures: emulsions and suspensions - continuously
mixing

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 PRESCRIPTION
Prescription may be defined as,
An order written by a doctor, physician, surgeon, dentist or veterinary doctor
to a pharmacist to compound and dispense a specific medication for the patient is
called prescription.” The prescription order is a part of the professional relationship
among the prescriber the pharmacist and the patient.

On the basis of prescription, all the medications can be classified in to two main
groups.
1. Prescription drug
2. Non prescription drugs.

1. Prescription Drugs:
The medications that may be legally dispensed only on prescription are known as
prescription drugs. They are also known as ethical drugs or legend drugs or legal
drugs.

2. Non Prescription Drugs:

The medications that may be purchased without a prescription are called non
prescription drugs. They are also known as OTC drugs.

PARTS OF PRESCRIPTION:
Following are the important parts of prescription.
A. Name and Address of the Patient.
The name and address of the patient is of importance in case a family doctor is
treating the patients with the help of the name the physician may identify the patient
and the treatment if he / she had been carrying out on that patient.
B. Date of Prescription.
C. Age
The age is also important b/c the dose for child is different from the dose of an adult.
D. Sex.
Sex is also important b/c certain drugs are contraindicated in pregnancy.
E. Super scription.
This is the sign which is an instruction to the pharmacist. “Rx” is an abbreviation for
the latin word “recipe” meaning“take thou” or you take.

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 F. Inscription or medication supplied.
This is the main part or main body of the prescription which consists of active
ingredients and their quantities.
G. Subscription.
This part of the prescription consists of directions to the pharmacist for preparing the
prescription.
H. Signa.
In this part the prescriber indicates directions for the patient use of medication. It also
includes the.
➢ Methods of administration or application.
➢ Dose, if the preparation is for internal use.
➢ Time of administration or application.
➢ The diluents such as water or other mean of application such as brush etc.
➢ If it is for external use, then the part of the body to which it is applied.
I. Signature of the prescriber and registration number of pharmacy.
J. Renewal. Date of second examination.

HANDLING OF PRESCRIPTION:
Handling of prescription involves following steps.
1. Receiving
2. Reading and checking.
3. Numbering.
4. Dating.
5. Labeling.
6. Pricing
7. Preparation
8. Packing
9. Rechecking.
10. Delivering
11. Recording.
1. RECEIVING
It is desirable that the patient should hand over the prescription order directly to the
pharmacist. This practice will enhance the patient - pharmacist relationship.
The lay man receives the prescription order in non professional manner while the
pharmacist receives the prescription order in professional manner, and check the
correct name ,address , and if necessary the age of the patient.
If the pharmacist is unable to receive the prescription order personally, he should be
available to give
✓ An estimated time required to fill the prescription order.
✓ If required by the patient and especially to avoid the subsequent discussion
(in case of costly medicines) concerning about the cost of the medication.
2. READING AND CHECKING:
The pharmacist should read the prescription order carefully and completely. There
must be no doubt about the ingredients, their quantities, and incompatibilities.
Pharmacist is usually faced in his interpretation of prescription order in the name of
drugs which look alike and sound alike such as,
✓ Marax ( anti asthmatic ) & atarax ( anti allergic).
✓ Valium ( CNS depressant ) & kalium ( anti coagulant)
✓ Losic ( anti ulcer) & lasix ( diuretics)
✓ Xanan ( CNS depressant ) & ranax ( anti ulcer)
Therefore about the written drugs the pharmacist must be sure that this that drug.
OMISSION OF DRUG POTENCY
Omission such as to specify the desired dosage form or the strength of the medicine
should be corrected. In such cases, the pharmacist should never dispense the usual
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 dose or dosage form, but should consult the physician. The pharmacist must be
familiar with the strength and dosage forms of the medicines available in order to
detect such omission & provide the physician with necessary information.
e.g. Capsule AMPICLOX
1+1+1
The strength is not given in this example. Since ampiclox is available in two
strengths i.e. 250 mg & 500 mg. so it must be cleared whether it is 250 mg or 500
mg.
FREQUENCY OF THE DOSE
The pharmacist must have to check the frequency of the dosage carefully. In
determining the safety and effectiveness of the drug the frequency of administration
must be considered
e.g. tablet PONASTAN (10)
Here time schedule of administration is missing. So the pharmacist should have
to clear it.
SIZE OF THE DOSE
The size of the dose always depends ways depends upon the age, weight and the
condition of the patient so it is very important e.g. ifin a prescription the dose is given
in spoonful, teaspoon full or ml.
Spoon full is not clear b/c there are variety of spoon full. If the dose is given in mls.
i.e. 4ml. 5ml it is more convenient & easy to measure and it also reduces the
chances of fetal doses.
3. NUMBERING
It is the universal practice to number the prescription order and to place the same
number on the label or package and to connect it with the original when necessary to
refer to the original order or when to continue the prescription order.
Numbering is important to
✓ Minimize the intermixing of prescription.
✓ To locate the prescription easily.
✓ To avoid medication error.
4. DATING
The dating of prescription on the date filled also helps in the identification. This can
also be used as alternate mean of locating the prescription of the number is lost by
the patient.
5. LABELLING
The prescription label is usually prepared by the pharmacist or by his assistant but in
either case; the pharmacist is responsible for the correctness of the information on
the label.
The prescription label should be type written to make them neat, attractive and
legible. This shows the careful work of the pharmacist. If the label and container are
not neat and clean and professional in appearance the patient may conclude that the
prescribed medication was compounded in a careless manner. A quality label should
be used with following characteristics.
• The size of the label should be according to the size of the container.
• The name address and telephone number must be present on the label.
• The prescribed label usually have the number, direction for use , date of
dispensing , patient name , prescriber name and the expiry date.
• The pharmacist should try to write the directions as clean and complete as
possible e.g. “take two tablets four times a day” is preferred to “two four times
a day??
• Auxiliary labels are those which are labeled under the main prescription or on
the either side of main prescription e.g. "SHAKE WELL BEFORE USE" label
is used for suspensions, lotions, emulsions etc. similarly, "FOR EXTERNAL
USE ONLY “is used special preparations.
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6. PRICING
Each pharmacy has a method for pricing prescription which is constantly applied for
the pharmacist. Pharmacist should be able to provide a high quality
product. Prescription is not an ordinary article of commerce but it is a professional
service. The pricing should be established to ensure profitable operation of the
prescription department. The cost applied to the prescription covers the cost of
ingredients including the container and label, time of the pharmacist and auxiliary
staff involved, cost of inventory maintenance & other operational costs of the
department plus reasonable margin of profit. There are many methods of pricing
prescription. The most commonly used are
✓ %age mark up:
Cost of ingredients + ( cost of ingredients x % mark up)
✓ % age mark up + minimum fee:
Cost of ingredients + (cost of ingredients x %age mark up ) + minimum fee.
✓ Profession fee:
Cost of ingredients + profession fee while the general formula for professional
fee is as follows.

Professional fee = Expected net income +lab: charges

Number of prescription dispensed

7. PREPARATION:
It is an important phase in the handling of prescription. When the prescription
requires compounding the pharmacist should take in to the consideration the large
type of mixing, order of mixing, calculation involved and the special additives or
techniques. Once he has decided on the procedure, he assembles the necessary
ingredients and container according to the dosage. The pharmacist should read and
check the label three times. Once when the container is removed from the shelf,
again when the contents are weighed and finally when the container is returned back
to the shelf. The weighing of the ingredients should be from left to right i.e. the
weighed substances on the left side.
Any information that would be necessary or useful in refilling the prescription at later
stage should be noted and if necessary should be printed on the back of the
prescription order. Additives used order of mixing, amount of each ingredient,
capsule size, type and size of the container used, name & the product number of the
manufacturer, auxiliary label used, the price charged and clarification of the illegible
words or number or any special notation should be recorded.
8. PACKAGING
Selection of a proper container is based on the particular dosage form employed,
quantity prescribed, storage requirements, dose and method of administration. The
importance of selection of the proper container should be recognized as an
important factor in properly handling a prescription.
The dispensing of a capsule or a tablet in a paste board box result in the loss of
potency from degradation due to absorbed moisture.
❖ A viscous lotion or magma dispensed in a narrow necked bottle may make the
withdrawal of the proper dose impossible, therefore should be dispensed in a
wide mouth container.
❖ A dusting powder dispensed without a shaker top may result in waste of
medication therefore should be dispensed in flexible container with perforated
or shaker top.
❖ A prescription for drops dispensed in ordinary prescription bottle will certainly
results in inconvenience to the patient and also causes the contamination of
the medication therefore should be dispensed in flexible tubes with a narrow
nozzle.
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 9. RECHECKING
The importance of this step should not be ignored. Every prescription should be
rechecked. The ingredients and the amount should be verified by the pharmacist. All
details of the label should be rechecked against the prescription order to verify the
directions, patient name, prescription number, date & prescriber
10. DELIVERING
The patient himself should receive the medication. If it is not possible then the
pharmacist should personally deliver the medication to the patient. This gives the
pharmacist an opportunity to insure himself that the patient understands how to use
the medicine properly. e.g. in case of dispensing the antihistaminic drugs, which are
mostly sedative ,The pharmacist must have to advise the patient about its use &
after use he must have to avoid operating any machine or driving etc.
11. RECORDING
Records of the prescription serve to keep the pharmacist informed as to the no: of
prescription handled. The ratio of renewal to new prescriptions & related
information. This can also serve as,
• A mean of locating prescription orders rapidly.
• Making information concerning previously dispensed prescription available to
the physician.
• Providing a family prescription record of allergies and idiosyncrasies and
Permitting complication of information needed by the patient for tax and
insurance purposes.
There are several methods by which prescription orders may be recorded. One of
which is the family record card method which is usually used. The patient name is
typed at the top of the card & as each prescription is dispensed the prescription no:
date, name and the amount of the medication, physician name and fee of medication
are placed on the card. The card contains a complete record of medication obtained
by the patient. Special information concerning the patient such as drug allergies or
particular disease such as diabetes or hypertension is also recorded. This card
enables the pharmacist to provide rapidly and completely list of
medications dispensed to the patient on the inquiry of the physician.

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 LABELLING OF THE DISPENSED MEDICINES
Label may be defined as,
“A display of written, printed or graphic matter upon the immediate container or the
outside container or wrapper of a drug package.”
While labeling means all labels & other written, printed or graphic matter
accompanying any drug.
Labels are available in printed form containing the name & address of the pharmacy
&if desired certain common directions to the patients for proper drug utilization.
Conventionally the printing is red for the labeling of external preparations.
The label contains a water activated gum on the back & is moistened with label
dampener. They are satisfactory on glass or paper board surface but they quickly
separate from plastics or metals, so in this case adhesion is achieved by using self
adhesive labels.

The label must possess following features.

 The labels should give the patient clear & complete instructions on how to
take the medicines, or use the preparation.
 They should indicate the storage conditions. In order to maintain the full
potency throughout the period of treatment.
 They should be written neatly & displayed carefully on the container in order
to enhance the patient confidence on the preparation.

INFORMATIONS GIVEN ON THE LABEL

1. NAME & STRENGTH OF THE PRESCRIBED PREPARATION.

Pharmacist give the name & strength of the prescribed preparations if there is letter
NP standing for no men proprium meaning the proper name. This letter is printed in
a box in the top left hand corner of the prescription forms. Some time the letter NP
deleted or not NP is written which indicates that patient should not know about the
nature of his treatment. however it is stated that proper name labeling is limited to
• Preparation included in the official book. B.N.F, B.P.C, B.P etc.
• Preparation described by the trade name.
• Preparation containing single drug.
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2. DIRECTIONS FOR USE.
Generally, the prescriber writes these on the prescription, otherwise the direction in
the official book from which the formula has been taken should be followed. Always
the world unless otherwise directed should be added b/c it is possible that physician
may have given the patient verbal instructions & he has not written these on the
prescription.
3. PATIENT NAME.
Conventionally it is written on the right hand side just above the line. Separating the
name &address of the pharmacy from the rest of the label.
4. THE PRESCRIPTION REFRENCE NUMBER & DATE.
Each prescription has a characteristics reference number that is written on the
prescription &on the container. This help to locate the prescription order easily when
the patient brings the container& not the prescription. The reference number is
written on the left hand side of the ‘label & it is followed by the date of dispensing.
PRESENTATION OF INFORMATION
The size of the label should be related to the size of the container. For small
container it must cover the complete depth of the container & should not project
above b/c then it may tom away leading to the loss of important information.
If the labels are hand written then black ink should be used & ball point should be
avoided b/c they don’t write clean lines & hence unsuitable. Special label writing type
writers are available having 17 characters to an inch capacity.
Numbers should be expressed in words to avoid confusion & incorrect dosage. e.g.
“two 5 ml spoonfuls”. Is free from misinterpretation that might arise with “2 5 ml
spoonful”. The passive voice is preferred to active voice. e.g. two to be taken should
be use instead of take two.

ADITIONAL LABELS.
These may be,
1. Required by law
2. Necessary for pharmaceutical reason
1. REQUIRED BY LAW.
If the preparation is a poison then law requires one of the following two labels,
o FOR EXTERNAL USE ONLY;
o NOT TO BE TAKEN;
e.g. Antiseptic &disinfectant solutions.
2. PHARMACEUTICALL REASON.
In this regard the following instructions are used.
a. Instructions restricting use of the preparation
1) For external use only.
This label although required by the law is used for all liquid, semisolid & solid
preparation intended to be applied externally.
2) Not to be taken.
This label is also not limited to the class of poisons but may be used
✓ For the liquid preparation that are not administered by the mouth.
✓ For liquid preparation having the label for external use only may
confuse the patients b/c some patient using nasal drops , nasal sprays
& enemas think that they are using the product externally.
✓ For solution tablets used to prepare disinfectant & anti septic solution,
to avoid the patient confusion . following types of alternative label may
be used. Such as,
“For nasal use only.”
“For rectal use only.”
“For vaginal use only.”

25 Hafiz Abdulrehman (2018-2023)

b. Instruction for using the preparation.
1) Shake the bottle.
This is necessary for the suspension & emulsions which are disperse systems
b/c if disperse phase separates & container is not shaken before use then
patient will take low dose at the end.
In first case he will not get the proper dose so will not be cured, while in
second case he will show some adverse effect.
2) Special instruction.
These are specific for the specific class of preparation.
i. Dusting powder.
“Not to be applied to the open wound or to raw or weeping surface.” b/c
dusting powder may irritate raw surfaces & delay healing.
ii. Gargles & mouth washes.
“Not to be swallowed in large amount.”
iii. Inhalations
“Add one teaspoonful to a pint of hot, not boiling water & inhale the
vapor.”
iv. Mixtures for adults.
Since they are concentrated so always taken in diluted form. Dilution is
done with water.
v. Mixtures for children.
Pediatric mixtures are usually given undiluted but if the ingredients cause
irritation in the G.1.T with subsequent vomiting & diarrhea then
preparation must be well diluted with water.
vi. Cachets.
Since cachets are large in size & hard to swallow so the instruction “to be
immersed in water for a few seconds placed on the tongue & swallowed
with a draught of water.” Is necessary.
vii. Tablets.
Certain type of the tablets requires special directions. e.g.,
a) “To be chewed before swallowing.” for tablets that require
mastication to ensure thorough disintegration in the gut. :
b) “To dissolve slowly in the mouth.” For drugs that are effectively
absorbed from the buccal mucosa.
c) “To be dissolved in water before taking.” for drug that are irritant to
the gastric mucosa or for effervescent tablets.

26 Hafiz Abdulrehman (2018-2023)

c. Instruction indicating the storage conditions & shelf life.
1) Storage in a cool place.
Storage in a cool place i.e. at not more than 15 degree centigrade is
necessary for many products e.g.
✓ Capsules ----------------------- loss of the moisture makes the shell brittle.
✓ Creams ------------------------- to prevent drying out. .
✓ Collodions & paints ----------they contain volatile solvent.
✓ Emulsions ----------- ----------high temperature may encourage creaming,
✓ Ointments ----------------------to prevent the loss of water when present,
loss of the volatile ingredients& structural breakdown.
✓ Molded suppositories------some melt at 37 degree centigrade. Or
slightly below.
✓ Preparation containing thermo labile medicament's to prevent the loss
of potency.
2) Protect from light.
This label is used for light sensitive preparations &unnecessary. When light
sensitive preparation is packed in a light resistant container.
3) Inflammable.
When the scalp lotions, shampoos &many other preparations containing 50%
or more of alcohol or another inflammable solvent either alone or in
combination are dispensed they should be labeled “caution.” This preparation
is inflammable do not use it or dry the hair near the fire or naked flames.
4) Expiry date.
The date stated on the label of a drug after which it is not expected to retain
its claimed efficacy, safety , quality or potency or alter which it is not
permissible to the sell drug.
d. Protection of the children.
The label “keeps out of the reach of children.” Should be used for all dispensed\
medicines.
e. warning cards.
The patient containing mono amino oxidase inhibitor should nottake foods that
contain presser amines. similarly all the patients taking coumarin anticoagulants ,
oral antibiotic drugs , should not take aspirin. Since it is very difficult for patients to
know that which food contains presser amines, or which prescribed product contain
aspirin so for those patients warning card are issued.
Two types are available
• MAO inhibitor cards
• Aspirin cards.

f. Package inserts.
It is impossible to present all the relevant information’s about the use & storage of
the product on the label.
Therefore the manufacturer introduces an information leaflet inside the box. This is
called package insert, & contain the full description of that product.
27 Hafiz Abdulrehman (2018-2023)
 EXTEMPORENOUS DISPENSING
Including:
A. SOLUTIONS
B. SUSPENSIONS
C. EMULSIONS
D. OINTMENTS
E. CREAMS
F. PASTE & GELS & JELLIES.
G. SUPPOSITORIES & PESSARIES.
H. POWDERS AND CAPSULES.
I. ORAL UNIT DOSAGE FORM

A) SOLUTIONS
A solution is a clear homogeneous mixture that is prepared by dissolving a solid
liquid or gas in another liquid. Solution may be used internally or applied externally
where as mixtures are meant for oral administration. Mixtures are mainly
prescribed for acute conditions such as cough, indigestion, diarrhea, constipation &
rheumatism.
They are prepared extemporaneously & supplied only for a few days treatment b/c
if they are stored for more than a few weeks even under normal condition they may
deteriorate e.g.

1) KAOLIN MIXTURE WITH PECTIN

Formula
Veegum 0.88gm
Sodium. Carboxy methyl cellulose 0.22gm
Purified water 79.12gm
Kaolin 17.50 gm
Pectin 0.44gm
Saccharine 0.09 gm
Glycerine 1.75 gm.
Preparation.
Add Veegum & the Sod. Carboxy methyl cellulose to the water with continuous
stirring. Then add with mixing the kaolin. Mix the pectin, saccharine &glycerine & add
to the suspension. A preservative & flavouring agent may be added to the product.
Dose
5 ml T.I.D
LABEL
Shake well before use.
USE
As anti-diarrheal.
28 Hafiz Abdulrehman (2018-2023)
2) COMPOUND NaCl MOUTH WASH.
A mouth wash is an aqueous solution with a pleasant taste & odour used for rinsing,
deodorant, refreshing or antiseptic action
FORMULA
Sodium chloride 2 gm
Sod. Bicarbonate 1 gm
Amaranth solution 2 ml
Peppermint water q.s to make 100 ml
PREPARATION
Dissolve the weighed quantities of sod. Chloride & sod. Bicarbonate in 3/4th of the
vehicle. Add amaranth solution & incorporate more of the vehicle to produce the
required volume.
Transfer to a bottle, label & dispense.
USE
It is used to cleanse & deodorize the buccal cavity.
LABEL
Dilute with an equal volume of warm water before use.
Not to be swallowed in large amount.
DOSE
Rinse the mouth 3 — 4 times daily as required.

3) EVAQUANT ENEMA.
Enemas are aqueous or oily solutions or suspensions intended for introduction in to
the rectum for their purgative, sedative, anthelmintic, anti inflammatory or nutritive
effects. They may also be used for x ray examination of the lower bowl.
FORMULA
Soft soap ---------------25 gm
Purified water ---------500 ml.
PREPARATION
Dissolve the soft soap in purified water, transfer to a container, label & dispense.
USES
It is used as evaquent enemas.
LABEL
For rectal use only
PRECAUTIONS
Large volume enemas should be warmed to body temperature before
administration.

B) SUSPENSIONS
It may be defined as,
"A coarse dispersion containing finely divided insoluble materials suspended in a
liquid medium or available in dry form to be distributed in the liquid when desired"
Suspensions are of two types,
1. Flocculated suspensions
2. Deflocculated suspensions.
Suspension may contain diffusible solids, in diffusible solids & may be produced due
to chemical reaction.
Diffusible solids are those substances which do not dissolve in water but on shaking
they can be mixed with it & remain evenly distributed throughout the liquid ensuring
uniform distribution of the drug in each dose, e.g. Chalk powder, light kaolin, MgO,
Mg trisilicate etc. While in diffusible solids are those substances which do not
dissolve in water & do not remain evenly distributed in the vehicle for sufficiently long
time to ensure uniformity of the measured dose.
e.g. aspirin, phenobarbitone , sulphur or ZnO etc.

29 Hafiz Abdulrehman (2018-2023)

TRI SULFA PYRIMIDINE ORAL SUSPENSION
FORMULA.
Veegam --------------------------1 gm
Syrup USP-----------------------90.60 gm
Sod. Citrate----------------------0.78gm
Sulfadiazine----------------------2.54 gm
Sulfamerazine-------------------2.54 gm
Sulfamethazine------------------2.54 gm
PREPARATION
Add Veegum slowly with continuous stirring to the syrup. Incorporate the sod. Citrate
into the Veegum - syrup mixture premix the sulfa drugs, add to the syrup stir &
homogenize. Add sufficient 5% citric acid to adjust the PH of the product to 5.6. A
preservative & a flavouring agent may be added to the product.
DOSE
5 ml B.I.D
LABELS
Oral suspension.
USE
Used in the treatment of intestinal infection, ulcerative colitis etc.

C) EMULSIONS
An emulsion is a mixture of two or more liquids that are normally immiscible
(unmixable or unblendable) owing to liquid-liquid phase separation. Emulsions are
part of a more general class of two-phase systems of matter called colloids. ... Two
liquids can form different types of emulsions.
As an example, oil and water can form, first, an oil-in-water emulsion, in which the
oil is the dispersed phase, and water is the continuous phase. Second, they can form
a water-in-oil emulsion, in which water is the dispersed phase and oil is the
continuous phase. Multiple emulsions are also possible, including a "water-in-oil-in-
water" emulsion and an "oil-in-water-in-oil" emulsion. EXAMPLE:

30 Hafiz Abdulrehman (2018-2023)

LIQUID PARRAFIN EMULSION
FORMULA.
Liquid paraffin 500 ml
Vanillin 0.5 gm
Chloroform 2.5 ml
Saccharine sodium 0.05 gm
Benzoic acid solution 20 ml
Methyl cellulose 20 gm
Distilled water Q.s to make 1000 ml.
PREPARATION.
Mix the methyl cellulose with 200ml boiling water. Allow to stand for two hours
with constant stirring. Dissolve vanillin in a mixture or chloroform & benzoic
acid solution with vigorous stirring. Then add saccharine sodium already
dissolved in sufficient quantity of distilled water.
Add methyl cellulose to this mixture & mix sufficient quantity of D/W to make the
volume up to 1000ml.
USE
As laxative.
DOSE
30 ml to be taken at bed time.
LABEL
Shake well before use’

D) OINTMENTS
Ointments are soft semisolid preparations meant for external application to the
skin or mucous membrane. They usually contains a medicament's dissolved
suspended or emulsified in the base. Ointments are used for their emollient &
protective action to the skin. They may also be used as vehicle or bases for the
topical applications of the medicinal substances.
Ointments are prepared by the following two methods,
✓ Trituration method
✓ Fusion method

1.CALAMINE OINTMENT
FORMULA
Calamine, finely sifted 15 gm
White soft paraffin 85 gm
PREPARATION
Pass the calamine through a very fine sieve to get a fine powder. Triturate the
calamine with a portion of white soft paraffin on an ointment slab with ointment
spatula, until smooth.
Gradually add the remaining portion of white soft paraffin with continuous trituration
until a uniform ointment is obtained.
PACKING
Pack the ointment in a wide mouth container or in an ointment jar.
LABEL
For external use only.
USE
Calamine has a mild astringent action on the skin & is used in ointments to
relieve discomfort of the dermatitis.
31 Hafiz Abdulrehman (2018-2023)
2. NON -STAINING IODINE OINTMENT B.P.C
FORMULA.
Iodine 50 gm
Arachis oil 150
Yellow soft paraffin ---------Q S
PREPARATION
Make a fine powder of iodine in glass mortar & add the required amount of arachis
oil contained in a glass stoppered conical flask & stir well.
Heat the flask at 50degree centigrade until the brown colour changes to greenish
black.Warm the required amounts of yellow soft paraffin to 40 degree centigrade & to
this add the dissolved iodine with continues stirring. Pour the mixed mass in to a
warm container & allow to cool with out stirring. Other wise air will be entrapped &
the product will become opaque.
LABEL
For external use only
USE
Antiseptic, anti fungal agent.

E) CREAMS
Creams are viscous liquids or semi-solids emulsions of either the o/w or w/o types.
Creams of the o/w types include shaving creams, hand creams & foundation
creams. w/o creams include cold creams & emollient creams

EXAMPLES
ANTISEPTIC CREAM
FORMULA
Cetrimide------------------------1 gm
Cetostearyl alcohol-----------10gm
White soft paraffin ----------10 gm
Liquid paraffin ----------------29 gm
Purified water -----------------50 gm
PREPARATION
Melt cetostearyl alcohol, white soft paraffin, & liquid paraffin together at 60degree
centigrade. Separately dissolve cetrimide in purified water & warm it at about
60degree centigrade. Add the warmed aqueous liquid to the melted mixture & stir
thoroughly until cold. Pack in suitable container & dispense.
LABEL
For external use only
USE
It is used as an antiseptic cream for the treatment of wound & burn.

32 Hafiz Abdulrehman (2018-2023)

F) PASTE & GELS & JELLIES.
Pastes are semisolid preparations like ointments meant for external applications
to the skin. They differ from ointment that they generally contain a large amount
of finely powdered solids. Due to which they are quite thick & stiff than the
ointment.While jellies are thin transparent or translucent non greasy semisolid
preparations meant for external applications to the skin or mucous membrane.
They are chiefly used on mucous membranes for their lubricating antiseptic or
spermicidal purposes.

EXAMPLES
1.COMPOUND ZINC PASTE.
FORMULA
Zinc oxide ---------------25 gm
Starch ------------------- 25 gm
White soft paraffin------50 gm
PREPARATION
Separately pass the zinc oxide & starch through sieves no 120, melt the white
soft paraffin on water bath mix the required weight of powder in a warm mortar. Add
small amount of melted base with continuous trituration until smooth. Gradually add
remaining amount of the base & mix until cold & uniform paste is obtained.
USE
It is used as an antiseptic paste.
LABEL
For external use only.
2. Zinc - GELATIN JELLY
FORMULA
Zinc oxide -------------------- 15 gm
Gelatin--------------------------15 gm
Glycerine ----------------------35 gm
Water----------------------------35gm
PREPARATION
Soak the gelatin in water until thoroughly softened, add glycerin& heat over water
bath until gelatin is dissolved. Add the required amount of zinc oxide in small
increments to the melted base with gentle stirring. Continue the stirring until a
uniform viscous product is obtained.
Uses
It is used as antiseptic jel.
Label
For external use only
Dose
Apply to the effected parts as directed

G) SUPPOSITORIES & PESSARIES.

Suppositories are solid or semisolid dosage forms generally intended for use in the
rectum, vagina, & to a lesser extent urethra.
Rectal & urethral suppositories generally employ vehicle that melt in the rectum or
urethra while vaginal suppositories are also known as pessaries. These are made as
compressed tablets that disintegrate into the body fluids.
33 Hafiz Abdulrehman (2018-2023)
EXAMPLES
ALUM SUPPOSITORIES
FORMULA.
Alum----------------300mg
Theobroma oil --Q.s
PREPARATION
Melt the theobroma oil in a dish over water bath. Pour about half of the melted
theobroma oil on powdered alum already placed on a tile & mix thoroughly.
Transfer the mixed mass to the dish & warm to make the mass pour able. Lubricate
the mould cavities & pour the melted mass the cavities. Allow the mass to solidify,
when it is solidified, open the mould & remove the suppositories.
Uses.
Used as an astringent.
Label
Stored in a cool place.
For rectal use only.

H) POWDERS AND CAPSULES.

Powders are the solid dosage forms of medicaments which are meant for
internal & external use. They are available in crystalline or amorphous form.
A powder may be a finely sub divided preparation, coarsely comminute product or a
product of intermediate particle size.Granules may be defined as,"Irregular
agglomerates of small particles which behave as single larger particles" They are
often prepared by blending powdered with a liquid that serve as adhesive. The wet
cohesive mass is then passed through a screen & the wet granules are then dried,

34 Hafiz Abdulrehman (2018-2023)

EXAMPLES
1. DUSTING POWDER
FORMULA.
Purified talc, sterilized ------50gm
Starch --------------------------25 gm
Zinc oxide ---------------------25 gm
PREPARATION
Weigh the required quantity of the talc, starch & ZnO. Mix Zno with starch then
incorporate purified talc & mix thoroughly. Pass the mixed powder through a sieve no
120 to remove the gritty particles.
PACKEGING
Pack the powder in the sifter top container to protect it from air, moisture,&
contamination as well convenience of application.
USES
It is used as antiseptic, anti pruritic agent.
DOSE.
Apply as directed.
LABEL
For external use only

I) ORAL UNIT DOSAGE FORM

Oral unit dosage form Includes tablets & capsules.
Tablets may be defined as,
"Solid unit dosage form of medicaments or medicaments with or without suitable
diluent& prepared either by mould or compression. These are made by the
following methods,

a) Wet granulation method.

b) Dry granulation method.
c) Direct compression method.
Capsules are solid unit dosage forms in which the medication is contained within
hard or soft gelatin shells. Hard gelatin capsules are used for filling the solids
substances, where as soft gelatin capsules are used for filling the liquid &semi-
solids.
EXAMPLES.
Phenolphthalein pills. See in classical dosage form.

35 Hafiz Abdulrehman (2018-2023)

 PHARMACEUTICAL INCOMPATIBILITIES

PRESCRIPTION INCOMPATIBILITIES:
Definition:
It is the result of mixing two or more antagonistic substances & is detected by
the change in physical, chemical, & therapeutic qualities.
OR
The interaction b/w two or more components of a prescription to produce,
physical, chemical& therapeutic changes in the preparation.” It may affect the safety,
efficacy & appearance of the medicine & so pharmacists must use their knowledge
of chemistry & pharmacology to detect & then to prevent such types of
incompatibilities.
TYPES OF INCOMPATIBILITIES:
Generally, incompatibilities are classified on the basis of different types of reactions,
which actually lead to unwanted effects. Following three types are well known.
1. PHYSICAL INCOMPATIBILITY
2. CHEMICAL INCOMPATIBILITY
3. THERAPEUTIC INCOMPATIBILITY.
These may occur singly or a combination of two or more at a time.

1. PHYSICAL INCOMPATIBILITY:
The interaction b/w two or more components of a prescription - order, leading to
change in the physical properties of the preparation is called physical incompatibility.
Since it is due to the physical change hence it is visible & recognizable change &
may appear in the form of ppt or a color change.
Physical incompatibility is usually the result of,
a) Insolubility
b) Immiscibility
c) Liquefaction
a) INSOLUBILITY:
It is the inability of the material to dissolve in a particular solvent system. Polar
solvent such as water can dissolve the polar solute b/c of high dielectric constant &
salvation of the ions through dipole interaction, while on the other hand the non polar
solvents can dissolve the non polar solutes. So when dissimilar compounds are
mixed together, this leads to the insolubility of the materials & hence physical
incompatibility occurs.
PREVENTION:
The physical incompatibility due to insolubility can be treated by the following
methods.
• Adjust the solvent system to permit dissolution.
• Changing the order of mixing.
• Addition of the suspending or emulsifying agent to the system.
EXAMPLES:
➢ If we mix diffusible preparations like chalk powder, calamine, zinc oxide, & kaolin
with water insolubility will occur b/c of the sedimentation of these compounds. So

36 Hafiz Abdulrehman (2018-2023)

 in these preparations suspending & thickening agents are added to obtain an
elegant product.
➢ Powders such as sulphur & certain corticosteroids are difficult to wet with water.
To overcome this problem wetting agents are used. Saponin for sulphur
containing lotions & poly sorbates for parenteral solutions of corticosteroids.
➢ The deflocculating action of excess surface-active agents may cause claying. So
this may controlled by reducing surfactant concentration.

b) IMMISCIBILITY:
It is the inability of one liquid to mix with another liquid. As we know that
similar liquids are miscible with similar liquids so if two dissimilar liquids are mixed
together, then two separate layers are formed. &two phase system is obtained. This
type of incompatibility is called physical incompatibility due to immiscibility.
PREVENTION:
It can be prevented by considering the same factor as used for insolubility.
• Adjusting the solvent system to permit dissolution.
• Changing the order of mixing.
• Addition of suspending or emulsifying agents to the system.
EXAMPLES:
• Oils are immiscible with water. This problem may overcome by
emulsification process.
• When the spirit & conc. Water is used as flavoring agents in aqueous
solutions oil separate as large globules. To prevent this spirit is gradually
diluted with vehicle before admixture with the remaining ingredients.
• During the preparation of potassium citrate mixture B.P.C when the lemon
syrup is added to the solution then lemon oil separates from the
preparation. This problem can be solved by the addition of quill tincture
that is added as an emulsifying agent.

c) LIQUEFACTION:
When certain low m.pt solids are powdered together, a liquid or soft mass is
produced. This phenomenon is called liquefaction. Liquefaction of dry material may
result from eutexia, release of water of hydration or absorption of water. A
depression in the m.pt of a solid in contact with the other components, resulting in
liquefaction at room temp: is known as eutexia' & the mixture is called eutectic
mixture.
The substances having this property are the pairs of any two of the following
compounds.
Camphor, ------------- menthol
Thymol, --------------- phenol.
Aspirin -----------------phenazone etc.
EXAMPLES:
When camphor & menthol are powdered together, we get a wet mass, which is
undesirable & thus shows physical incompatibility. To prevent these difficulty inert
diluents such as mgco3, light mgo, starch & talc may be added.
In the above examples, first triturate camphor with talc & then mix menthol, triturate
again. In this way a solid mass is obtained b/c talc has high m.pt.

37 Hafiz Abdulrehman (2018-2023)

2. CHEMICAL INCOMPATIBILITY:
It is defined as, “The interaction b/w two or more components of prescription
order, leading to the formation of a new undesirable compound is called chemical
incompatibility.” Chemical incompatibility may be due to
a) PH CHANGE
b) CHEMICAL REACTION.
a) PH CHANGE:
Modern medicaments are often salts of weak acids & bases. These salts are
soluble in water while most unionized acids & bases are practically insoluble. So if a
solution of weak basic salt is made alkaline, free base may be precipitated & vice
versa. Whether precipitation occurs or not depends upon
• Solubility of the unionized acids / bases
• PH & Pka
EXAMPLES:
• Alkaloids are insoluble in water so salt should be prescribed b/c salts are
soluble in water.
• Barbiturates like phenobarbitone are insoluble in water but their salt
i.ephenobarbitone sodium can be dispensed for getting the desired
products & preventing incompatibilities.
b) CHEMICAL REACTIONS:
These includes
I. Redox reactions.
II. Acid base reactions.
III. Hydrolysis.
IV. Combination reactions.
I. REDOX REACTION: The loss of electrons & the gain of electrons are collectively
termed as oxidation reduction. It is important that a compound donating a proton &
the other accepting it must occur together.
Almost all of the cations used in pharmacy that exist in more than one valence
state will be oxidized from their lower to higher valence states by strong oxidizing
agents such as permanganates, chlorides, & per oxides.
PREVENTION:
The chemical incompatibility due to redox reaction can only be removed by
the removal of one of the species i.e. either oxidants or reductants. But this requires
the permission of the prescriber.
However light catalyzed reaction can be minimized by storage in light
resistant completely filled containers.
EXAMPLES:
➢ Prescription.
Sod. Salicylate------------------ 8gm
Sod. Bicarbonate --------------16 gm
Peppermint water Q.S --------180 ml.
This solution become darken due to the alkaline catalyzed oxidation of the salicylate
to a quinoid form. To prevent this, 0.1 % bisulfate (anti oxidant) is added which
retarded the color development
➢ Oils & fats develop rancidity as a result of auto oxidation, generally catalyzed by
the light. To prevent this light resistant container is used.
38 Hafiz Abdulrehman (2018-2023)
II. ACID BASE REACTION:
These reactions are also termed as neutralization reactions. Most incompatibilities
due to acid base reactions manifest themselves by the precipitation, gas formation or
change in color.
a. Precipitation:
Rx
Cocaine HCl -----------------0.3gm
Sod, borate ------------------1.2 gm
Purified water---- Q.S ----- 60 ml
If the prescription is dispensed as such then due to alkalinity of sodium. Borate
cocaine will be precipitated. To prevent this incompatibility sodium. Borate replaced
by boric acid.
b. Evolution of gases:
Rx
Sod. Bicarbonate-----------4 gm
Bismuth sub nitrate------- 90 ml
Water ------ Q.S ---------- 100 ml
In this prescription, hydrolysis of the bismuth sub nitrate yields nitric acid which
reacts with sod. Bicarbonate to evolve carbon dioxide. To prevent this, bismuth sub
nitrate is replaced by bismuth sub carbonate/
c) Change of color:
Phenolphthalein is a color-less acidic compound. On the addition of an
aqueous solution of a base such as sod. Hydroxide, a red ionized disodium salt with
a quinoid structure is formed.
PREVENTION:
Chemical incompatibility due to neutralization reaction can be prevented by
one of the following ways.
• Addition of buffer.
• Change of vehicle to prevent the formation of free acids or bases from the
salt.
• The sensitive coloring agents can be replaced by the others.
III. HYDROLYSIS:
The reaction of the medicinal components of the prescription with water is
called hydrolysis. Which leads to the special type of chemical incompatibility, such
types of the reactions can be categorized into two classes.
✓ IONIC HYDROLYSIS
✓ MOLECULAR HYDROLYSIS
✓ IONIC HYDROLYSIS:
It involves the reaction of an ionized species with either H+ or OH- of water to
form an unionized insoluble product. This will result in the change in PH of the
solution & occurs as ppt of basic salts or hydroxides. e.g.
ZnCl2 + 2H20 →Zn (OH)2 + 2HCI
✓ MOLECULAR HYDROLYSIS:
This term is applied to the reaction of water with organic compounds such as
amides, casters, etc. E.g. when esters are subjected to hydrolysis then we get
alcohols & acids. Similarly, aspirin is readily hydrolyzed to acetic acid &
salicylic acid in moisture.

39 Hafiz Abdulrehman (2018-2023)

PREVENTION;
Hydrolysis can be prevented or reversed by the addition of any of the species formed
as a result of hydrolysis. This also requires knowledge of conditions that affects the
stability of the drug involved.

IV. COMBINATION REACTIONS:

During this ionic reaction, a pair of ions is removed from the sphere of activity
by precipitation or by the formation of a very slightly ionized species.
EXAMPLE:
Butynsulfate ----------------- 0.65 gin
Silver nitrate------------------- 0.06gın
Distilled water --- Q.S ------ 30 ml The silver &sulfate ions will combine to form
insoluble silver sulfate. To prevent this incompatibility, elimination of one of the
compounds is necessary.
PREVENTION:
It can be prevented by the following methods.
• Elimination of one of the ionic species.
• Reduction in the conc. Of one of the species.
• Diluting the solution
• Adjusting the solvent system to keep the new species in the solution.

3. THERAPEUTIC INCOMPATIBILITY:
It is undesirable interaction b/w two or more ingredients which leads to
potentiation of therapy, destruction of effectiveness of one or more of the ingredients.
Or occurrence of the toxic effects.
Therapeutic incompatibility exists when the response of one or more drugs in
the patient is of different nature or intensity than that intended by the prescriber .
Adverse reaction might be therapeutic incompatibility. The different forin of physical
& chemical incompatibilities also leads to the decrease in the activity & efficacy of
the drug. So we can say that therapeutic incompatibility is the result. But mainly the
therapeutic incompatibility is resulted from error on writing or interpreting the
prescription order.
It may occur due to one of the following reason,
i. DOSAGE ERROR
ii. CONTRAINDICATED DRUGS
iii. WRONG DOSAGE FORM OR DRUG
iv. SYNERGISTIC EFFECTS
v. ANTAGONISTIC EFFECTS
vi. DRUG INTERACTION

i. DOSAGE ERROR:
The over dose of the medication is the most important & serious type of dosage error
which Icads to therapeutic incompatibility. It can result from the administration of
excessive single dose or the loo frequent administrations of usual doses.
It is important that pharmacists in rust check such crrors as it is foundoftenly in case
of children.

40 Hafiz Abdulrehman (2018-2023)

EXAMPLE:
Prescription for one capsule.
Atropine sulfate ------ 0.006gm
Phenobarbitone ------ 0.015 gm.
Aspirin -- 0.300 gm. Dispense 10 capsules
The quantity of phenobarbitone& aspirin represents a reasonable single disc
however; the quality of atropine sulfate is high as compared to thc recommended
doses. So this leads to 10 therapeutic incompatibilities.
PREVENTION.
Pharmacists should contact the prescriber to clarify the matter.
ii.CONTRAINDICATED DRUGS:
The use of certain drugs may be contraindicated in a particular disease or in a
situation where an individual has previously shown an allergic response to it.
• Adrenaline is contraindicated in patients having an acute peptic ulcer.
• Phenylbutazoneis contraindicated in jaundice.
• Iron & calcium is contraindicated to the kidney patient.
• Sugar is contraindicated to the diabetes patient.
PREVENTION;
Same as mentioned above
iii. WRONG DOSAGE FORM:
There are many drugs having names similar to the other drugs, but both are
totally different in nature. When the drug prescribed is miswritten for its actual
(desired drug, incompatibility will occur due to the wrong drug) e.g. valium&kalium. If
kaliumis administered instead of valium, incompatibility will occur. Similarly, the
supply of medications in wrong dosage forin can result in overdose or underdose of
drug. This may leads to various problems especially for those drugs whose safety
margin is very narrow.
EXAMPLE
• If polyfax ointment is prescribed. Then it must be considered that whether it is cyc*
ointment or skin ointment. So incompatibility due to wrong dosage form occurs. If the
prescriber writes only betnovate lubes it is not clear whether it is betnovate cream or
ointment. So prescriber must be consulted in this regard.
PREVENTION;
Pharmacist should contact the prescriber to overcome such type of therapeutic
incompatibility.
iv. SYNERGISTIC EFFECT:
When one drug enhances the effect of the other drug, this is called
synergism. In synergising, the combined action of two or more drugs is greater than
that which would be expected from the sum of their individual actions.
EXAMPLE:
Alcohol when administered with antihistamine, barbiturates, & hypnotics, enhances
the depression of CNS. Thiazide diuretics increases the rate of metabolism of
coumarin anti-coagulants such as warfarin.
PREVENTION;
To prevent such type of therapeutic incompatibility a sound basic background of
pharmaceutical sciences is required b/c some time the prescriber does so
intentionally.

41 Hafiz Abdulrehman (2018-2023)

v. ANTAGONISTIC EFFECT:
When one drug blocks the effect of another drug then this is called
antagonism. This opposing action is the basis for the use of antidotes.
EXAMPLE:
• Antacids may delay the absorption of Phenobarbital.
• An antacid decreases the absorption of aspirin.
• Diazepam & caffeine when administered together, they cancel the effect of
each other b/c caffeine is CNS stimulant while diazepam is CNS depressant.
PREVENTION;
Same as above for synergism.
vi. DRUG -INTER ACTION:
This term is applied to those situations in which the effects of one drug are
altered by prior or concurrent administration of another drug.
It may be,
❖ Drug - drug interaction.
❖ Drug – food interaction.
EXAMPLES:
Penicillin prolongs the action of probenecid. Castor oil decreases the absorption of
fat soluble vitamins. Tetracycline combines with the metal ion in GIT or present in the
milk 10 form complex that are poorly absorbed.
PREVENTION:
This type of incompatibility can be prevented by the ability of the pharmacist to
detect such interactions & to contact the prescriber in this regard. Since in drug
interaction the effect of one drug may be modified by the other drug or dietary
constituents, these effects may either be in increased form or decreased form. So we
can say that synergism (case of increased effect) & antagonism (case of decreased
effect) are the form of drug interaction.

42 Hafiz Abdulrehman (2018-2023)

 PART-B
DEFINITION & BACKGROUND
Definition:
Community pharmacy can be defined as, “An establishment that is privately owned &
whose function is to serve the society's need for both drug products &
pharmaceutical services”.
Community pharmacy supplies the pharmacist with a diversified source of
income. It is the most attractive & profitable establishment meeting the needs of the
community. A community pharmacist is the hybrid of professional & business man.
He is the best educated person in the community which is available for general
public to guide them about their health.
TYPES
It has two types.
1. Independent pharmacy.
2. Chain pharmacy.
1. INDEPENDENT PHARMACY.
It is a pharmaceutical canter owned by an independent person.
It provides
• Prescription service.
• Health related products.
ADVANTAGES:
o Requires less investment.
o No profit sharing
o Freedom in control & from restrictions.

2. CHAIN PHARMACY.
Chain pharmacy stores are branched stores existing at various locations but
operating under a common ownership. Chain pharmacy concept was first initiated a
decade ago by Pharmacia, a subsidiary of ferozsons, Nowshera.
This concept is gaining success & there is an increasing trend, particularly in big
cities such as Karachi, Lahore & Rawalpindi, Islamabad.
Various chain stores at city level include,
❖ Fazal din's pharma plus.
❖ Shazoo,s zaka pharmacy.
❖ Clinix pharmacy
❖ Pharmax etc.
Chain pharmacy differs from independent pharmacy in following respects.
o Variety of goods available.
o Kinds of goods are limitless.
o Complex organization as compared to the independent pharmacies
43 Hafiz Abdulrehman (2018-2023)
ADVANTAGES:
• Wide geographical coverage.
• Economical buying due to bulk purchase.
• Attracts qualified persons.
• Better service.
• Use of employees.
• Promotional activities can be initiated.

ESTABLISHMENT OF COMMUNITY PHARMACY:

The establishment of a community pharmacy consists of the following factors.
1. ORGANIZATION
2. SITE SELECTION
3. CAPITAL
1. ORGANIZATION:
We can define organization as, “The mechanism for determining & assigning the
duties to the people so that they can work together effectively."
There are three types of organizations.
a) SOLE PROPRIETORSHIP
It is the simplest form of setup & is owned & operated by one person. It is
geographically local & there is no legal formality except licenses. The
pharmacist is free of conducting the enterprise in any manner & the owner
receives all the profits.
b) PARTNERSHIP.
Partnership is an intended association of two or more individuals to carry on a
retail business to gather & to share in its profits or losses. It is applicable
when,
❖ Resources of one individual are insufficient.
❖ One does not wish to take the entire risk.
Partnership b/w two or more individuals considers the following matters.
❖ Investment
❖ Division of profits & losses.
❖ Duties
❖ Responsibilities.
c) CORPORATION
“It is a separate entity created by the authority of the state.” Corporation is
composed of various stock holders & capital is provided by several
individuals. It provides an opportunity to individuals to invest without
endangering their personal assets,
44 Hafiz Abdulrehman (2018-2023)
2. SITE SELECTION
The location of a community pharmacy may be a critical factor in its survival.
Traditionally community pharmacies must have been located in close proximity to
physicians. So they must be located within large medical complexes & clinics etc.
Socioeconomic qualities of the population in the immediate area of the proposed
location must be determined. He should determine if the economy of the community
is viable & is the supply of health professionals is adequate, then these
socioeconomic variables will determine the economic suture of the pharmacy.
Similarly, traffic flow, parking facilities, & access to means of transportation are also
the factors which must be considered.
3. CAPITAL:
The amount of capital required for the operation of a successful pharmacy depends
upon,
❖ Sales volume.
❖ Inventory requirements.
❖ Estimated operating expenses.
While estimating the capital needed, projected sales volume should be considered
as minimum & operating expenses at maximum level.
There are following types of capital.
a) CASH:
It is required in sufficient amount for,
✓ Pre operating expenses: such as.
• License fee
• Legal fees.
• Utility deposits.
• Advertising etc.
✓ Operating expenses:
Sufficient cash is required to pay the first two to three months operating
expenses, b/c operations are extremely slow.
b) FIXTURES & EQUIPMENTS:
These depend upon the volume of the pharmacy. Larger the pharmacy, more
fixtures & equipment should be required & vice versa.
SOURCE OF CAPITAL
i. Equity capital: comes from owners own sources.
ii. Borrowed capital: comes from a bank or loan association etc.
iii. Credit.

MANAGEMENT OF COMMUNITY PHARMACY:

The word management may be defined as, “Set of activities directed at the effective
utilization of resources in search of one or more goals."
OR
“It is an art & science of planning, organization, directory & controlling human effort
with in the organizational framework & economic environment of the firm to achieve
its objectives”.
For an effective running of a community pharmacy there must be proper co –
ordination among money, material equipment, & people. Managements of a
community pharmacy concerns following aspects.
45 Hafiz Abdulrehman (2018-2023)
1. MANAGEMENT OF MONEY
➢ Includes the ability to obtain money from a variety of sources in sufficient
quality to support the necessary operation.
➢ It is the management function to employ the most appropriate way or money
management so as to get maximum return over minimum investment.
➢ Only those owners can succeed who can manage the money effectively.

2. MANAGEMENT OF INVENTORY:
“Inventory is an itemized list of goods with their estimated worth.”
Major portion of the inventory consists of the prescribed drugs. Management of
inventory includes;
➢ Items to be included in inventory.
➢ Quantity of each item required.
➢ Source of supply.
A good inventory management should have an implementation of well organized
stock control systems.

3. MANAGEMENT OF FACILITIES
It includes the capital required for the fixture & equipments. It represents the
sufficient portion of the capital. It is the management role to make an economical use
of the facilities.

4. MANAGEMENT OF PERSONNELS:
The management of personals requires
i. Proper selection.
ii. Proper training.
iii. Maintenance of employees.
➢ A properly selected & well trained employee can assume many duties which
otherwise may be the responsibility of the manager.
➢ It is stated that the employee should be compatible with the job & must meet
minimum qualification standards. Some tests may be developed for the
selection process & over hiring should be avoided.
➢ After selection, the employee is put to work under observation to pick up
knowledge about the job.
➢ Compensation is an important factor responsible for retaining good
employees.
“The direct return or reward in cashable forms given to an individual per
month for time worked is called compensation.”
➢ However personnel with strong capabilities are in a position to demand their
own compensation.
➢ It is necessary to encourage the employee to achieve goals & objectives of
pharmacy.

46 Hafiz Abdulrehman (2018-2023)

Pharmaceutical supply chain template:

47 Hafiz Abdulrehman (2018-2023)

GENERAL AND SOCIO ECONOMIC ASPECTS OF MEDICAL

COMPLICATION OF DRUG TAKING:

The various means by which drugs may induce diseases are over dosage drug
interactions, secondary effects, idiosyncrasy and hypersensitivity. Generally a drug
reaction appears when the conc. or a given drug exceeds a certain threshold in the
body. However drug interactions or idiosyncratic reactions may turn a normal dose
into an overdose leading to toxicity.
Therefore it is not usual for one to find that disease is not of pathological origin but
instead is due to a secondary drug effect.
Drugs are used for one or a number of their beneficial effects, while those
undesirable effects that cannot be avoided are often considered to be side effects. It
is these unavailable effects that will be considered as secondary effects or
complications of drug taking.
e.g.
❖ Narcotic analgesics cause significant respiratory depression in patients even
at low doses due to decreased responsiveness of the brain stem to increases
in carbon dioxide. They also cause nausea & vomiting due to direct
stimulation of the chemoreceptor trigger zone center.
❖ Thiazide diuretics therapy can lead to hyper uricemia and / or changes in
carbohydrate metabolism in certain patients. Actually thiazide diuretics show
biphasic effect on uric acid. When used intravenously causes uricosuria
whereas chronic oral administration causes hyper uricemia.
❖ The therapeutic doses of salicylates can reduce blood glucose level in both
diabetics & non diabetics. It is due to increased utilization of glucose by
peripheral tissues and a decrease in carbohydrate synthesis.
❖ A medical complication of the amino glycosides and polymyxins is respiratory
depression due to neuromuscular blockade. This problem occurs in patients
either with renal impairment or in patients receiving concomitant muscle
relaxants.
❖ Another example of medical complication of drug taking is diphenyl hydration -
induced folic acid deficiency leading to metabolic anemia.
❖ The unusual drug reactions that cannot be explained by the inherent
properties of
❖ Drugs themselves but instead by some altered characteristics within the
patient taking the drugs are called idiosyncratic reactions and this
phenomenon is termed as idiosyncrasy. The best example in this regard is
induction of haemolytic anemia by drug in patients having a deficiency of
glucose - 6 phosphate dehydrogenase.
❖ Drugs that are metabolized or concentrated in the liver have prolonged levels
in patients with impaired hepatic functions. For example neonates exhibit low
levels of glucuronyl transferee in the liver. So when the chloramphenicol is
used in these neonates the accumulation of chloramphenicol 10 toxic levels
occurs on about the 4th day of treatment leading to the inhibition of protein
synthesis and increased levels of amino acids. This way leads to a gray baby
syndrome.

48 Hafiz Abdulrehman (2018-2023)

 ❖ However, due to the deficiency of same glucuronyl transferase enzyme ,
kernicterus (hyperbilirubinemia) may occur in neonates following sulfonamide
- therapy
❖ Due to the penicillin hypersensitivity the anaphylactic shock occurs. Similarly
the penicillin antibiotics may also cause diarrhoea due to wash out of normal
Nora.
❖ Finally the most classic drug induced disease is systemic lupus
erythematosus (SLE). This disorder has been initiated by more than 30 drugs.
Fever, arthralgias, skin lesions, pulmonary infiltrates, pericarditis,
glomerulonephritis & CNS abnormalities have all been frequently
documented.
As for as socioeconomic aspects are concerned, it is clear that if the drug cause any
complication then the patient may lack motivation which not only require extra money
to treat the condition thus becoming burden on the economy of the family but also
face problems for adjustment into society. The people of our country are very much
poor and even some are fail to pay the high consultation fee of the physician. Such
people are thus reluctant to visit the physician due to poor economic background &
so started their treatment by uneven prescription which gives them nothing but the
waste of money. So money is spent but patient is getting worse. Such patients are
then subjected to social isolation b/c their friends and relatives possess no time for
the patients. As a result the patient may develop mental problems so such patients
are then considered to be misfit for the society.
On the other hand, many alcoholics also create problems in the form of road
accidents. The establishment of various rehabilitation centers for addicted patients
require greater proportion of investment thus it is also a burden on the government
assets.
If the country is free from addicted persons then the money which is spent for the
construction of rehabilitation centers can be utilized for the various welfare
programmes. In the end it is concluded that drugs must be used according to the
recommended schedule for specific duration of time and in this way one can protect
himself /herself from various hazards and life may become quite easy.

49 Hafiz Abdulrehman (2018-2023)

 PATIENT EDUCATION AND COUNSELLING
COUNSELLING:
The counselling is the basic & important component of community
pharmacy practice. It may be defined as,
“Provision of advice on therapeutic matters to patients or member of health care
team”Both institutional & community settings provide an opportunity for the
pharmacist to advise patients regarding their prescriptions. However, community
pharmacists are in a better position to provide counselling to the discharged patients
& clinic outpatients about the prescription as well as OTC drugs.
During counselling following information should be provided to the patients.

1. INFORMATION ABOUT THE USE OF THE DRUG:

Community pharmacist is the member of the healthcare team. He is the most
accessible person to the general public. He is consulted by the patient or consumer
on the purchase of OTC drugs & also on the administration of prescribed drugs. He
should provide the patient with information such as,
a) Side effects & contraindications.
b) How, when & how long to take the medication?
c) Proper storage of drugs dispensed to the patient.
Due to pharmacists the lack of communication b/w physician & patient is covered.
a) SIDE EFFECTS:
Patient must be informed about the side effects of the drugs to remove their fear
Side effects may be
✓ Those which will disappear.
✓ Those which must be tolerated
✓ Those which warrant the attention of a doctor or pharmacist.
b) FOOD AND DRUGS TO AVOID:
Patient should be cautioned about the use of certain foods & drug while taking
their prescription. e.g.
✓ MAO inhibitors are contraindicated with food containing tyramine,
tryptamine liver extract, beer etc.
✓ Tetracyclines are contraindicated with milk. An essential component of
counselling is the maintenance of a patient's medication profile.
Patient medication profile helps to monitor the following.
➢ Drug abuse.
➢ Drug misuse (over dose & under dose)
➢ Abnormal prescribing pattern.
➢ Duplicated prescription
➢ Drug - drug interactions.
➢ Drug - food interactions.
➢ Drug laboratory test interaction.
➢ Adverse drug reactions.
➢ I/v admixtures compatibility.
➢ Pathological condition of the patients which might predispose them to
adverse effects from prescribed drug therapy.

50 Hafiz Abdulrehman (2018-2023)

2. PATIENT EDUCATION:
Patient education is the most important factor in improving compliance.
“Taking medications according to the instructions of the physician by the patient for
the treatment of some illness is called compliance.”
While “Failure to obey the instructions of the physician by the patient for the
management of some illness is called non compliance.” Several methods can be
used to improve patient education. They may be,
i. VERBAL COUNSELLING:
Routine counseling of all patients is undesirable & impractical. However priority
should be given to case where
a) Prophylactic treatment is required in the absence of symptoms e.g
tuberculosis.
b) The drug in use leaves a low margin of safety e.g. warfarin.
c) Premature withdrawal from treatment has serious consequences e.g
corticosteroids.
d) Long term therapy is indicated for chronic condition e.g. epilepsy.
In counseling it is required to use common language& familiar term. The answer of
every question from the patient should be given in a polite manner & it should be
clear & comprehensive.
ii. PRINTED DRUG INFORMATION:
Printed information may be of value since oral instructions may be quickly forgotten.
Printed information may be in the form of,
i. Warning cards
ii. Individualized medication instruction cards.
iii. Booklet from patient welfare associations.
iv. Leaflet from pharmaceutical industry
v. Patient package inserts.
Printed information may be useful to supplement but not replace verbal
communication b/w the pharmacist & the patient.
iii. COMPLIANCE CLINICS:
Compliance clinic is an assumed future programme. This doctor will refer a patient to
its clinic pharmacist for an identified compliance problem. The pharmacist will work
for individual patient problems & will try to enhance compliance with various suitable
compliance aids. Due to professional knowledge & training of the pharmacist he is in
the first line team to maintain the health of the people of his community by serving as
health educator.

51 Hafiz Abdulrehman (2018-2023)

 CONTROL OF DRUG ABUSE & DRUG MISUSE
DRUG ABUSE:
The consumption of the drug without medical authorization that has the capacity to
alter the mood or behavior is called drug abuse." It is drug induced illness.
Major examples are
1. ALCOHOLISM
2. DRUGADDICTION

1. ALCOHOLISM.
Alcoholics are defined as,
“'Those excessive drinkers whose dependence upon alcohol has attained such a
degree that it shows a noticeable mental disturbance or an interference with their
bodily & mental health, their interpersonal relations & their smooth social & economic
functioning or who show the prodrawal signs of such developments."
Chronic form of alcoholism causes disturbances of the nervous & digestive systems.

Causes of alcoholism.
i. Drinking companions.
ii. Use of drink at social gathering.
iii. Failure of ambition.
iv. Domestic disharmony.
v. Disappointments in love.
In the body the alcohol is hydrolyzed by alcohol dehydrogenase into acetaldehyde &
then to acetic acid which is incorporated in TCA cycle which compensates the caloric
demand of the body & causes deficiency of other elements such as carbohydrates,
proteins, fats, & minerals etc.
The alcoholic person may face
i. Dehydration
ii. Deficiency of magnesium
iii. Alcohol causes peripheral vasodilation leading to redness of skin.
iv. Speech is slurred.
v. Delirium tremens that results from alcoholic intoxication & is represented
by a picture of confusion, terror, restlessness & hallucinations. It is
withdrawal symptom.
52 Hafiz Abdulrehman (2018-2023)
TREATMENT:
1) In delirium tremens further progression can be abolished by the
administration of alcohol, barbiturates & chlordiazepoxide. Once the
delirium tremens is controlled then the alcohol is reduced & withdraws.
2) Emetine, apomorphine along with pilocarpine is administered followed
by alcohol intake. The person will develop nausea & vomiting & leading to
the development of conditional reflexes in such a way the person thinks
that only alcohol can initiate the nausea & vomiting & hence should be
stopped it.
CONTROL:
Among the legislative measure that has proved effective include.
➢ Regulation of alcohol production.
➢ The control of imports.
➢ The limiting of sales outlets.

2. DRUG ADDICTION:
Today drug addiction has become a world problem. Addiction has three separate
phases.
a) Tolerance.
b) Habituation.
c) Physical dependence.
a. Tolerance is the need to increase the size of the dose to get an effect
similar to the earliest ones.
b. Habituation is the emotional or psychological need salt for a drug.
c. Dependence is the body's need to get the drug.
Addicts use different drugs for different purposes depending upon the characteristics
of the drugs, some drug have sedative effects, some arc stimulants, some causes
depression and other brings sleep.
Heroin abuse has taken an epidemic form due to its light purity, availability at low
prices i strong dependence quality. Similarly, opium & cannabis are also abused.

HARMFUL EFFECTS OF DRUG ADDICTION:

❖ The physical health & sexual energy of the addicts weaken so rapidly that a
young man of thirties looks like an old man of over sixties.
❖ Addicts bring a ruin to the economic structure of the families.
❖ Addicts loose self confidence & the will to work so they become a burden for
their family.
❖ The male addicts indulge in obtain money for their drug supplies. crime &
women take to prostitution to
❖ Drug addicts are responsible for most of the accidents on road.
53 Hafiz Abdulrehman (2018-2023)
TREATMENT OF ADDICTION
Its treatment is of two types.
a) HOSPITAL TREATMENT
Any therapeutic treatment is effective only if the addict voluntarily submits to
treatment, his family cooperates with the doctor & there is fool proof system of
vigilance over the patient that he is not supplied with the drug during
treatment.
b) PSYCHIATRIC TREATMENT.
Effort should be made to remove the causes responsible for addiction, e.g.
mental worries, family differences, economic problems. The contact of the
addict with his anti social associates should be stopped.
Introduction of children to religious education & its continuation in school life
he should be informed about the harmful effects of addiction on his health &
family.
CONTROL:
Cultivation of drug plants should be licensed. The use of mass media of
communication like films, radio, TV, newspaper etc should be carefully considered
for a possible role in prevention. Smuggling & illicit traffic king of drugs & plants
should be effectively checked Unemployment problem should be solved by
increasing job opportunities b/c economic worries provides a fertile ground for drug
addiction.
MISUSE OF MEDICATION:
It is known that this misuse of medication is observed mainly in ambulatory patients.
Ambulatory patients are defined as, “non institutionalized patients who have the
responsibility for obtaining their medication storing it & taking It." the misuse of
medication is defined by berry in the following ways.
1. OVER DOSAGE:
a) Taking more than the prescribed dose at any one administration.
b) Taking more than the prescribed number of dose in any one day.
c) Taking the same medication from two or more different bottles
simultaneously

2. UNDER DOSAGE:
❖ taking less than the prescribed dose at any one administration. '
❖ Omitting one or more doses.
❖ Discontinuing the drug before the prescribed duration of time.
❖ Taking a dose at different time if a time has been specified in the
directions.
❖ Using the wrong route of administration.
❖ Taking medications that have been discontinued.
❖ Taking out dated medications.
❖ Taking someone else's medications.

54 Hafiz Abdulrehman (2018-2023)

 ❖ Taking two or more medications that are contraindicated
therapeutically.
❖ Failing to get the prescription filled.
❖ Failing to understand how to use the administration unit properly e.g.
inhaler.
The misuse of medication is very harmful & their %age ranges from 20 to 82%.
Sometimes medication misuse occurs due to patient misconception e.g. the patient
may think that, “ if one tablet is good , then two will be even better.”
However misuse of medication may also occur due to following reasons.
❖ Medication was not working ;
❖ Medication was causing side effects.
❖ Conditioned improved.
❖ Patient received negative information about the medication.
❖ Cost of medication was too high.
❖ Patient was confused about how to take the medication.
Due to the above reasons patient frequently discontinue medicines & as a result
misuse of medication occurs.
Control of Misuse of Medication.
It is the responsibility of the pharmacist to dispense prescriptions accurately,
to provide medication counseling & to answer questions of concern to the patient.
The pharmacist should guide the patient about the dose of the drug, correct route of
administration & undesirable effects of drugs if taken in high doses. For the
correction of misuse of medication following parameter must be considered.
❖ Pharmacist should counsel the patient about safe & appropriate utilization of
his medicine.
❖ Pharmacist must play the role of health advisor to provide advice to the
patients on non prescription products.
❖ He must serve as a health educator to the community.
❖ He must serve as a source of drug information for the physician.

55 Hafiz Abdulrehman (2018-2023)

 ROLE OF PHARMACIST
According to pharmacy Act 1948 “Registered Pharmacist is person whose name for
time being is entered in the register of pharmacist of the state, in which he is for the
time being residing or carrying on his profession or business of pharmacy”. The word
PHARMACIST stands for
P- Patience
H- Honesty
A-Alertness
R-Research
M- Motivator
A-Administrator
C- Courageous
I-Intelligent
S- Studious
T- Thinker
Mission:
“Right drug to the patient at right time in right dose through right route in right way”.
From ancient days the it is cleared that medicine was prepared by the specialize
person, that today we refer as Pharmacist. Till to days date medicine save life of
human beings. Food, cloth and shelter are basic need of human being but now day’s
medicine is major basic need of human being.
“Without medicine there no life, it act as sanjivani for human being’’, such medicine
are manufactured by only pharmacist is the first person of health care system as per
the discussion held at British pharmaceutical conference in 1963 a pharmacist is
regarded as an expert on drugs.
Roles of Pharmacist

1. Academic Pharmacist:
In academic pharmacist focus on teaching, research and training of the upcoming
pharmacist. Academic institute are major source of pharmacist, who adds
professional into health care system. By arranging seminar, project, or system
academics, pharmacist plays valuable role in health care system. Education
motivates the professionals in the health care system.
From their basic education training and pre-registration training, students acquire a
broad understanding of the scientific principles and techniques of the pharmaceutical
sciences and the ability to keep pace throughout their careers with developments in
medicine and pharmacy. Their knowledge and expertise extent to all aspects of the
preparation, distribution, action and uses of drugs and medicines as well as to
enable those who wish to continue their studies to undertake postgraduate training
and research.

56 Hafiz Abdulrehman (2018-2023)

2. Community pharmacists:
Pharmacist work at the frontline of healthcare in cities, towns and villages across
nation. They work from their own pharmacies or out of local healthcare center and
doctors surgeries.
As community pharmacist job would be all about helping the public, assessing their
condition and making decision about which medicines they should take. They will be
involved in dispensing medicine and offering patient advice and practical help on
keeping health.
It is very responsible job and community pharmacist tends to be highly respect
members of their communities. Community pharmacist are also taking on more of
the clinical roles that have traditionally been undertaken by doctors, such as the
management of asthma and diabetes as well as blood pressure testing .they also
help people give up smoking ,alter their diets to make them healthier and advise on
sexual health matters.

3. Hospital pharmacist:
Hospital pharmacists are a vital part of the healthcare term. Working in either the
PHC or private hospitals, being a hospital pharmacist means you’re part of a team
where the focus is firmly on patients.
In a hospital pharmacy department there are many areas we can get involved in.
Like doctors, pharmacist regularly attends ward rounds and more involved in
selecting treatments for patients than ever before. Aside from working on the wards,
there is the manufacturing of sterile medicines, managing the care of patients with all
types of condition, working in the dispensary, providing information on medicines for
the whole hospital. You can also get involved in general management of hospital
itself. Some pharmacists specialize as consultant (or as pharmacists with specialist
interests) in many areas as Hematology (blood), Nephrology (kidneys), Respiratory
medicine, Cardiology (heart), Urology (urinary), Diabetes, Gastroenterology
(stomach and intestine), Infection diseases, pediatrics (children) and care of the
elderly.

4. Industrial Pharmacist Research and development:

Pharmacist contributes to research, and their expertise in formulation development is
of particular relevance to the biological availability of active ingredients.

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 a) Manufacture and quality assurance:
The pharmacist’s broad knowledge of the pharmaceutical sciences ensures
an integrated approach to quality assurance (including good manufacturing
practice) through the validation of the various stages of production and the
testing of products before release.
b) Drug Information:
The pharmacist has the knowledge and expertise to provide detailed
information on medicines to members of the health profession and the public.
Also, pharmacists provide an information service within the company.
c) Parent application and drug registration:
The pharmacist is ideally qualified to understand and collate the diverse
Information required for potent and authorization submissions.
d) Clinical trials and post–marketing surveillance:
The pharmacist has the knowledge of drug and health care provision required
to facilitate collaboration between companies, health professionals and
governments in relation to clinical trials and surveillance.
e) Sales and marketing:
The pharmacist, whose professional ethics demand a concern for the interest
of Patients can make a contribution to proper marketing practices related to
health care and to the provision of appropriate information to health
professionals and the public.
f) Management:
The inclusion of pharmacist in all levels of management promotes an ethical
approach within management policies.
g) Primary care pharmacist/ prescribing advisors:
These are people work for NHS organizations that are in charge of a range of
local. Health services - such as doctor’s surgeries and community
pharmacies. Their job is to ensure the best use of medicines and resources
across the area. In Some places practice pharmacist or primary care
pharmacist also run medication review Clinics and have lots of patient
contact.
Pharmacist with special interest:
Pharmacists with special interests are involved with developing their skill and
expertise in specialist areas such as cancer or diabetes. Almost half of all
pharmacists (42%) offered.
Pharmacy a complete profession:
Pharmacists reflect on every sector of society in the form of Artists – designing a
drug dosage form, Lawyer – having fair knowledge of laws and legislation about the
drug Engineer - having sound technical knowledge Entrepreneur - with sound
knowledge of management, accounting, marketing, Counseling Health professional -
having fair knowledge regarding health. As pharmacists deals with the every issue
regarding health of the society and built superior health care system, constantly
endeavor and elaborate his knowledge with ethics. Thus, pharmacists are the one
and only well qualified and practitioner that provides backbone that strengthens the
health care of the nation.

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Conclusion:
Pharmacists is the first person of health care system by playing various roles like
academic pharmacists, industrial pharmacist, community pharmacists, clinical
pharmacists, hospital pharmacists, veterinary pharma-cists etc. All pharmacists
working in different fields of the profession are directly or indirectly related to nation’s
health. Finally pharmacists are responsible for insuring that “Right drug to right
patient at right time in right dose through right route in right way.” So that
pharmacists is an integral part of health care system.
Top Pharmacist Duties and Responsibilities
No single job description covers all the 274,000-plus pharmacist positions in the
United States. Practice settings for pharmacists vary widely from independently
owned drugstores to nationwide grocery store chains, medical centers, military
bases and marijuana dispensaries. These are following;
1. Dispense Prescriptions
This is the "filling, licking and sticking" most people imagine when they conjure a
mental image of a pharmacist counting out tablets, preparing a bottle label and
handling medications to patients.
2. Communicate With Prescribers
Any time a prescription order is unclear or potentially harmful for a patient, you need
to confirm the dosage and formulation (e.g., liquid or tablet), as well as whether
brand name product is required or if you can substitute a generic equivalent.
3. Ensure Patients' Safety
Check each patient’s medication record every time he or she gets a new or refill
prescription filled. This is the best way for a pharmacist to prevent potentially
dangerous interactions between drugs.
4. Counsel Patients
This involves more than informing about adverse reactions and interactions with
other medications, food, alcohol and other beverages like grapefruit juice.
Counseling includes training patients how and when to take doses, following up with
patients to see if medications are working, sharing tips on how to minimize side
effects while maximizing benefits and listening to all of a patient's concerns.
5. Work with Patients on General Health
Maintaining health requires more than taking prescription medications, Pharmacists
can help patients heal and avoid getting sick by sharing advice on using
nonprescription remedies, taking health supplements such as vitamins, using herbal
and natural health products, exercising and maintaining a good diet.
6. Deal with Insurance Companies
Pharmacists working in a chain and independent pharmacies, especially, have to
submit insurance claims and work with private insurance companies, Medicare and
Medicaid to ensure payment, and resolve coverage denials so patients do not go
with medications.
7. Manage Staff
Pharmacists have the ultimate responsibility for ensuring the “three Rs” of right drug,
right patient and right dose. Meeting this responsibility requires overseeing the work
of and mentoring pharmacy technicians, student interns and residents. Pharmacy
owners and supervisors also have responsibilities for making hiring decisions and
setting and enforcing workplace policies.
8. Perform Administrative Tasks
Everyone in a pharmacy has some responsibilities for keeping patient files up to
date, making sure needed products are stocked and required reports get generated
and filed. If you hold a supervisor or management position, you can spend as much
or more time on administrative duties as on patient care.

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 HEALTH SYSTEM RESEARCH
Introduction:
Health services research (HSR) became a burgeoning field in North America in the
1960s, when scientific information and policy deliberation began to coalesce. Also
known as health systems research or health policy and systems research (HPSR), is
a multidisciplinary scientific field that examines how people get access to health care
practitioners and health care services, how much care costs, and what happens
to patients as a result of this care. Health Services Research utilizes all qualitative
and quantitative methods across the board to ask questions of the healthcare
system. It focuses on performance, quality, effectiveness and efficiency of health
care services as they relate to health problems of individuals and populations, as
well as health care systems. Health Services Research addresses wide-ranging
topics of structure, processes, and organization of health care services; their use and
people's access to services; efficiency and effectiveness of health care services; the
quality of healthcare services and its relationship to health status, and; the uses of
medical knowledge. Studies in HSR investigate how social factors, health policy,
financing systems, organizational structures and processes, medical technology, and
personal behaviors affect access to health care, the quality and cost of health care,
and quantity and quality of life. Compared with medical research, HSR is a relatively
young science that developed through the bringing together of social
science perspectives with the contributions of individuals and institutions engaged in
delivering health services.

Goals:
The primary goals of health services research are to identify the most effective ways
to organize, manage, finance, and deliver high quality care; reduce medical errors;
and improve patient safety. HSR is more concerned with delivery and high quality
access to care, in contrast to medical research, which focuses on the development
and evaluation of clinical treatments. Health services researchers come from a
variety of specializations, including geography, nursing, economics, political
science, epidemiology, public
health, medicine, biostatistics, operations, management, engineering, pharmacy, psy
chology, usability and user experience design. While health services research is
grounded in theory, its underlying aim is to perform research that can be applied
by physicians, nurses, health managers and administrators, and other people who
make decisions or deliver care in the health care system. For example, the
application of epidemiological methods to the study of health services by managers
is a type of health services research that can be described as Managerial
epidemiology.

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Approaches
Approaches to HSR include, Implementation research: research focusing on
public policy analysis, or the concerns of program managers regarding the
effectiveness of specific health interventions; Impact evaluation: research with
emphasis on effectiveness of health care practices and organization of care, using a
more narrow range of study methods such as systematic reviews of health system
interventions.

Data Sources
Many data and information sources are used to conduct health services research,
such as population and health surveys, clinical administrative records, health care
program and financial administrative records, vital statistics records (births and
deaths), and other special studies.

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Canada
Several government, academic and non-government agencies conduct or sponsor
health services research, notably the Canadian Institute for Health Information and
the Canadian Institutes of Health Research (i.e. the third pillar: "research respecting
health systems and services"). Others include the Institute for Clinical Evaluative
Sciences (ICES) in Toronto, and the Canadian Collaborative Study of Hip Fractures.
There are some universities which train in health services research. Atlantic
Regional Training Centre
Denmark
Data availability;
Several registries are available for research use, such as Danish Twin Register or
Danish Cancer Reg.
United Kingdom of Great Britain and Northern Ireland (UK)
Several governmental agencies exist that sponsor or support HSR, with their remits
set by central and devolved governments. These include the National Institute for
Health Research (NIHR) and its constituent infrastructure (including the CLAHRC
programme); Healthcare Improvement Scotland; Health and Care Research
Wales; and Health and Social Care Research and Development Many universities
have HSR units, a web search can find these with relative ease.
United States
Data availability;
Claims data on US Medicare and Medicaid beneficiaries are available for analysis.
Data is divided into public data available to any entity and research data available
only to qualified researchers. The US's Centers for Medicare and Medicaid
Services (CMS) delegates some data export functions to a Research Data
Assistance Center.
23 Claims data from various states that are not limited to any particular insurer are
also available for analysis via AHRQ's HCUP project.
Centers
Colloquially, health services research departments are often referred to as "shops";
in contrast to basic science research "labs". Broadly, these shops are hosted by
three general types of institutions—government, academic, or non-governmental
think tanks or professional societies.
1. Government Sponsored:
U.S. Department of Veterans Affairs Award in Health Services Research
Institute of Medicine, U.S.-based policy research organization
2. University Sponsored:
Center for Surgery and Public Health, U.S. -based research institute at the
Brigham and Women's Hospital (Harvard University Affiliate) Regenstrief
Institute. Institute for Healthcare Policy and Innovation, U.S. -based research
institute at the University of Michigan (Founded in 2011, IHPI includes smaller
centers focused on specific healthcare topics).
Leonard Davis Institute of Health Economics, U.S.-based center for HSR at
the University of Pennsylvania
3. Think Tank or Professional Society Sponsored:
• Society of General Internal Medicine, U.S.-based professional
organization in internal medicine research.
• Commonwealth Fund, U.S.-based center for HSR.
• Rand Corporation Health Division, U.S.-based center for HSR.

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 PHARMACOECONOMICS
INTRODUCTION
➢ Term coined by Townsend in 1986.
➢ Branch of health economics.
➢ Making choices between options, when there is scarcity of resources
➢ Fundamentally comparative, weighing the costs and benefits of 2
options- Most efficient.
➢ The description & analysis of the costs of drug therapy to health
care system & society.
➢ Pharmacoeconomics research identifies measures & compares the
costs (i.e. resources consumed) & consequences (i.e. clinical,
economic, and humanistic) of pharmaceutical products & services.
➢ PE analysis.
➢ Efficient allocation of limited resources among competing alternative
medications and services.
➢ Biggest bang for your buck, using a quantitative measure.
➢ To make the best use of limited resources.

WHY STUDY PHARMACOECONOMICS?

• Helps to decide which drug to develop.
• To estimate and understand the full impact of new therapy.
• To make an informed decision regarding appropriate use of drug which
have been developed.
• To make the best use of limited resources.
GOALS:
• To determine which healthcare alternatives provide the best healthcare
outcome in terms of money spent
• To improve the allocation of resources for pharmaceutical products and
services

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COSTS
➢ Cost vs. Price?
➢ Cost involves all the resources that are used to produce and deliver a
particular drug therapy
Types of Costs
1. Direct costs (Medical vs Nonmedical)
2. Indirect costs
3. Intangible costs
4. Opportunity costs
1. Direct costs
a) Direct Medical Costs:
Costs of medical service .These include:
➢ Fixed costs or costs that do not vary immediately with the number of
patients treated. E.g. capital costs of hospital building or equipment etc.
➢ Variable costs or costs that vary immediately with number of patients
treated. E.g. costs of drugs, syringes, needles etc.
b) Direct non-medical costs:
Costs incurred by the patient in receiving medical care. E.g. transportation to
and from hospital.
2. Indirect cost:
e.g. income lost because of absenteeism, loss of productivity
3. Intangible costs
Costs of pain, worry and other suffering which a patient or his family might
suffer
4. Opportunity costs:
The amount lost by not using economic resources in its best alternative use
(labour, capital, building, management etc.)
Resources invested in one area will be at expense of loss of another
opportunity.
PERSPECTIVES OF PHARMACOECONOMICS
1. Patient perspective
2. Provider perspective
3. Payer perspective
4. Societal perspective
1. PATIENT PERSPECTIVE
All the relevant cost and consequences experienced by the patient. Included costs:
Direct, Indirect, Intangible
2. PROVIDER PERSPECTIVE
Concerned with the expenses of providing products or services. Included costs:
Direct costs only.
3. PAYER PERSPECTIVE
Social Security/Government, third party payers eg. Private insurance companies and
employers
Included costs:
➢ Direct costs
➢ Indirect costs
• Relevant to employers lost workdays.
• Lost productivity at work.
4. SOCIETAL PERSPECTIVE
The broadest of all perspectives that comprehensively evaluates all costs and
consequences considers the benefits to society as a whole Included costs:
➢ Direct; overall cost of providing care.
➢ Indirect; loss of productivity.
ECHO MODEL
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OUTCOME PARAMETERS
a. Clinical- As a result of disease or treatment
Survival / mortality
Morbidity
b. Economic- Direct, indirect and intangible costs
c. Humanistic
Patient preferences / Utilities
Quality of life
Types of pharmacoeconomic studies
1. Cost Minimization Analysis (CMA)
2. Cost Effectiveness Analysis (CEA)
3. Cost Benefit Analysis (CBA)
4. Cost Utility Analysis
1. COST MINIMIZATION ANALYSIS (CMA)
❖ Compares the costs of two or more alternatives that have
a demonstrated equivalence in therapeutic outcome.
❖ Relatively straight forward and simple method.
❖ Least cost alternative is chosen.
Examples:
Brand vs. Generic products, Different antibiotic therapies, and Different route of
administration of the same drug
COST-MINIMIZATION ANALYSIS (CMA): IN DRUG THERAPY

COSTS Drug A Drug B

Acquisition cost 250 350
Administration 75 0
Monitoring 75 25
Adverse effects 100 25
Subtotal 500 400
OUTCOMES
Antibiotic effectiveness 90% 90%

2. COST-EFFECTIVENESS ANALYSIS (CEA)

➢ Form of economic evaluation whose goal is to identify, examine, and
compare the relevant costs and consequences of competing drug regimens
and interventions
➢ Costs are expressed in monetary terms
➢ Consequences are measure in their natural units, such as:
• Cases cured
• Lives saved
• Hospitalization prevented
➢ Decision maker in identifying a preferred choice among possible alternatives
CEA in drug therapy;

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 COSTS Drug A Drug B

Acquisition cost 300 400

Administration 50 0

Monitoring 50 0

Adverse effects 100 0

Subtotal 500 400

OUTPUTS

Extra years of life 2.22 1.6

Cost-effectiveness ratio 500/2.2 = ₹ 225 400/1.6 = ₹ 250

Per extra year of life

3. COST-BENEFIT ANALYSIS (CBA)

➢ All costs (inputs) and benefits (consequences) of alternatives expressed in
monetary terms
➢ Results are often expressed as:
• Ratio of benefit to cost
• Net cost or benefit = benefit – cost
➢ CBA allows uniform comparison of programs or interventions
with entirely different outcomes
➢ Useful when resources are limited and only one program can be
implemented
COSTS Drug A Drug B

Acquisition cost 300 400

Administration 50 0

Monitoring 50 0

Adverse effects 100 0

Subtotal 500 400

BENEFITS(₹)

Days at work (₹) 1000 1000

Extra months of life (₹) 2000 3000

Subtotal (₹) 3000 4000

Benefit to cost ratio 3000/500=6:1 4000/400=10:1

Net benefit (₹) 3000-500 =2500 4000-400

=3600
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4. COST-UTILITY ANALYSIS (CUA)
➢ Method to compare treatment alternatives or programs where costs are
measured in monetary terms and outcomes is expressed in terms of patient
preferences or quality of life.
➢ CUR = Cost / QALY
➢ Least cost preferred
Example: Evaluating arthritis treatment. Chemotherapy that increases survival but
decreases patient well-being
COSTS Drug A Drug B
Acquisition cost 300 400
Administration 50 0
Monitoring 50 0
Adverse effects 100 0
Subtotal 500 400
UTILITIES
Extra years of life (yrs) 2.22 1.6
Quality of life index 0.33 0.41
QALYs 0.73 0.66
Cost-to-utility ratio 500/0.73=₹ 685 Per 400/0.66= ₹
606
Extra quality of life Per extra
year quality of life
year

PHARMACOECONOMIC METHODS
❑ Cost minimization analysis (CMA)
Assumes equal outcomes
❑ Cost effectiveness analysis (CEA)
Measures outcome in natural or physical units
❑ Cost Benefit analysis (CBA)
Measures both benefit and cost in monetary terms
❑ Cost Utility analysis (CUA)
Measures outcomes in QALY

APPLICATIONS
❖ Assist in decision making and allocating scarce resources
❖ Assessing the value of a new agent
❖ Formulary decision making
❖ Drug policy decisions, treatment guidelines & Justify the addition of new
clinical service
❖ Pricing in pharmaceutical industry
❖ Decision on reimbursement
Third-party; payers use such information to decide whether to pay for a particular
treatment, or to determine what price they are willing to pay.

CONCLUSION
❖ Time and money can only be spent once- choice is inevitable
❖ Pharmacoeconomics can enhance the quality of practice by strengthening
evaluation process and increasing the probability that deliver better value in
patient care.

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 Public Health
Definition:
Public health is the science of protecting and improving the health of people
and their communities. This work is achieved by promoting healthy lifestyles,
researching disease and injury prevention, and detecting, preventing and responding
to infectious diseases
Goals of Public health:
People who work in public health hold the common goal of improving the
health of individuals and society by promoting healthy lifestyles, preventing injuries
and disease, and controlling infectious diseases. They may be concerned with
protecting and improving the health of a small community, or the entire planet.

It covers three key areas:

❖ Health Protection:
Protection against infectious diseases and environmental threats .
❖ Health Improvement:
Target individual behavior or promote healthy education.
❖ Health-Care service:
Provide analysis and improve health-care services.
Public health services:
The strength of a public health system rests on its capacity to effectively
deliver the 10 Essential Public Health Services.

1. Assess and monitor population health.

2. Investigate, diagnose and address health hazards and root causes.
3. Communicate effectively to inform and educate.
4. Strengthen, support and mobilize communities and partnerships.
5. Create, champion and implement policies, plans and laws.
6. Utilize legal and regulatory actions.
7. Enable equitable access.
8. Build a diverse and skilled workforce.
9. Improve and innovate through evaluation, research and quality improvement.
10. Build and maintain a strong organizational infrastructure for public health.

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Examples:
Examples of public health efforts include educating the public about healthier
choices, promoting physical activity and fitness, preventing disease outbreaks and
the spread of infectious diseases, ensuring safe food and water in communities,
preparing for emergency and preventing injury.

Epidemiology
Definition:

Epidemiology is the branch of medical science that investigates all the factors
that determine the presence or absence of diseases and disorders. Epidemiological
research helps us to understand how many people have a disease or disorder, if
those numbers are changing, and how the disorder affects our society and our
economy.

Relationship of epidemiology with public health:

Whereas epidemiology is the study of disease occurrence and transmission in
a human population, epidemiological studies focus on the distribution and
determinants of disease. Epidemiology may also be considered the method of public
health a scientific approach to studying disease and health problems.
The epidemiology of human communication is a rewarding and challenging
field. Much of the data that epidemiologists collect comes from self-report from
answers provided by people participating in a study. For instance, an epidemiological
study may collect data on the number of people who answer, “Yes” when asked if
69 Hafiz Abdulrehman (2018-2023)
someone in their household has trouble hearing. Each person providing such an
answer may interpret “trouble hearing” differently. This means that the results of
such a study may be quite different from a study in which actual hearing
(audiometric) tests are administered to each person in a household.Also, many
epidemiological estimates try to determine how the number of people affected by a
disorder changes over time. The definition of a disorder also tends to change over
time, however, making estimates more difficult. Even scientists working in the same
field at the same time may not agree on the best way to measure or define a
particular disorder.

Key terms to know in this field are:

➢ Incidence:
The number of new cases of a disease or disorder in a population over a
period of time.
➢ Prevalence:
The number of existing cases of a disease in a population at a given time.
➢ Cost of illness:
Many reports use expenditures on medical care (i.e., actual money spent) as
the cost of illness. Ideally, the cost of illness would also take into account
factors that are more difficult to measure, such as work-related costs,
educational costs, the cost of support services required by the medical
condition, and the amount individuals would pay to avoid health risks.
(Adapted from the Environmental Protection Agency’s Cost of Illness
Handbook)

Types of epidemiology:
These are the following types of epidemiology;

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The fivemain objectives of epidemiology:
In the mid-1980s, five major tasks of epidemiology in public health practice were
identified:
(1) Public health surveillance.
(2) Field investigation.
(3) Analytic studies.
(4) Evaluation.
(5) Linkages.

Goals of epidemiology:
The objectives of epidemiology include the following: to identify the etiology or
cause of disease.Todetermine the extent of disease. To study the progression
of disease

Epidemiological studies generally fall into four broad categories:

1) Cross-sectional studies.
2) Case-control studies.
3) Cohort studies.
4) Intervention studies.

Cross-sectional studies

A cross-sectional study is defined as a type of observational research that

analyzes data of variables collected at one given point in time across a sample
population or a pre-defined subset. This study type is also known as cross-sectional
analysis, transverse study, or prevalence study.

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Case-control studies

A case–control study is a type of observational study in which two existing

groups differing in outcome are identified and compared on the basis of some
supposed causal attribute.

Cohort studies

A cohort study is a particular form of longitudinal study that samples a cohort

(a group of people who share a defining characteristic, typically those who
experienced a common event in a selected period, such as birth or graduation),
performing a cross-section at intervals through time.

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Intervention studies

Intervention (or Experimental) studies differ from observational studies in that

the investigator assigns the exposure. They are used to determine the effectiveness
of an intervention or the effectiveness of a health service delivery.

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 Pharmacoepidemiology
Definition:
Pharmacoepidemiology is the study of the uses and effects of drugs in well-
defined populations. To accomplish this study, pharmacoepidemiology borrows from
both pharmacology and epidemiology. Thus, pharmacoepidemiology is the bridge
between both pharmacology and epidemiology.

Pharmacoepidemiology is also defined as it is the the study of interactions

between drugs and human populations, investigating, in real conditions of life,
benefits, risks and use of drugs. Pharmacoepidemiology applies to drugs the
methods and/or reasoning of both pharmacology and epidemiology .

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 Vaccination and EPI (a public health concern)
EPI stands for Expanded Program on Immunization which is a World
Health Organization program with the goal to make vaccines available to all children
of a community.

Brief History
The World Health Organization (WHO) initiated the Expanded Program on
Immunization (EPI) in May 1974 with the objective to vaccinate children throughout
the world.
Ten years later, in 1984, the WHO established a standardized vaccination
schedule for the original EPI vaccines: Bacillus Calmette-Guérin (BCG), diphtheria-
tetanus-pertussis (DTP), oral polio, and measles. Increased knowledge of the
immunologic factors of disease led to new vaccines being developed and added to
the EPI’s list of recommended vaccines: Hepatitis B (HepB), yellow fever in countries
endemic for the disease, and Haemophilusinfluenzae meningitis (Hib) conjugate
vaccine in countries with high burden of disease.
In 1999, the Global Alliance for Vaccines and Immunization (GAVI) was
created with the sole purpose of improving child health in the poorest countries by
extending the reach of the EPI.

Goals of EPI

The current goals of the EPI are,

✓ To ensure full immunization of children under one year of age in every district,
✓ To globally eradicate poliomyelitis,
✓ To reduce maternal and neonatal tetanus to an incidence rate of less than
one case per 1,000 births by 2005,
✓ To cut in half the number of measles-related deaths that occurred in 1999,
and
✓ To extend all new vaccine and preventative health interventions to children in
all districts in the world.

Table 2 (urdu). Pakistan's EPI vaccination schedule (based on age)

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 Table 1. Pakistan's EPI vaccination schedule (based on infection)

Disease Causative Vaccine Doses Age of

agent administration
Childhood TB Bacteria BCG 1 Soon after birth

Poliomyelitis Virus OPV 4 OPV0: soon after birth

OPV1: 6 weeks

OPV2: 10 weeks

OPV3: 14 weeks
IPV 1 IPV-I: 14 weeks

Diphtheria Bacteria Pentavalent vaccine 3 Penta1: 6 weeks

Tetanus Bacteria
(DTP+Hep B + Hib) Penta2: 10 weeks
Pertussis Bacteria
Penta3: 14 weeks
Hepatitis B Virus
Hib pneumonia and Bacteria
meningitis
Measles Virus Measles 2 Measles1: 9 months

Measles2: 15months
Diarrhoea due to Virus *Rotavirus 2 Rota 1: 6 weeks
rotavirus
Rota 2: 10 weeks

Family planning
Introduction:

Family planning is the term given for pre-pregnancy planning and action to delay,
prevent or actualize a pregnancy.

DEFINITION:

Family planning is a way of thinking and living that is adopted voluntarily, upon the
bases of knowledge, attitude and responsible decision by individuals and couples in order to
promote the health and welfare of family group and thus contribute effectively to the social
development of country.

Objectives:
( WHO ) “the use of a range of methods of a fertility regulation to help individuals or
couples attain certain objectives:

❖ avoid unwanted birth.

❖ bring about wanted birth.
❖ Produce a change in the no. of children born.
❖ Regulate the intervals between pregnancies.
❖ Control time at which birth occur.”
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Elements of family planning:

3 important elements in family planning:

Benefits:
Benefits to Mother :

➢ Reduce the health risk.

➢ Below 20years, And above 35 years. At risk of developing complications
during pregnancy.
➢ physical strain of child bearing.
➢ reduce number of maternal death.
➢ reduce the risk of ovarian cysts.

Health Benefits to Children:

➢ Ensures better chance of survival at birth.

➢ Promote better childhood nutrition.
➢ Promote physical growth and development.
➢ Prevent birth defects.

Health Benefits to Father:

➢ Allows father to keep a constant balance between their physical, mental,

social well –being.
➢ Increase father sense of respect because he is able to provide the type of
education and home environment.

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Benefits to Whole Family Health:

Benefits to Whole Family Health - help the family enjoy the better kind of life.

TYPES OF FAMILY PLANNING

INTRODUCTION OF NATURAL FAMILY PLANNING

❖ No introduction of chemical of foreign material into the body.

❖ Practice may be due to religious belief, “natural” way is best for them.
❖ Effectiveness varies greatly, depends on couples ability to refrain from having
intercourse on fertile days.
❖ Failure Rates: about 25% Poses no risk to fetus

NATURAL FAMILY PLANNING

a) Rhythm (Calendar) method

b) Basal Body Temperature (BBT)
c) Ovulation or Cervical Mucus Method
d) Symptothermal method
e) Coitus Interruptus
f) Lactation amennorhea

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a)Rhythm (Calendar) method

➢ The rhythm method, also called the fertility awareness method, is a form of
pregnancy prevention where couples calculate a woman's fertile time using a
calendar .
➢ Abstaining from coitus on the days of menstrual cycle when a woman is most
likely to conceive (3 or 4 days before until 3 or 4 days after ovulation). Woman
keeps a diary of 6 menstrual cycles.
➢ This method may be used by women whose menstrual cycles are always
between 26 and 32 days in length.
➢ To calculate: 18 from shortest cycle documented –11 from longest cycle =
represents her last fertile day.
➢ Example: If she has 6 menstrual cycles ranging from 25 to 29 days, fertile
period would be from 7th day (25- 18) to the 18th day (29-11). To avoid
pregnancy, avoid coitus/use contraceptive during those days.

Disadvantages:

b)Basal Body Temperature (BBT):

❖ Identifying fertile and infertile period of a woman’s cycle by daily taking and
recording of the rise in body temperature during and after ovulation.
❖ Just before ovulation, a woman’s BBT falls about 0.5ºF At time of ovulation,
her BBT rises a full degree (influence of progesterone). This higher level is
maintained the rest of menstrual cycle.

Disadvantages:

NOT reliable method: of birth control, especially for women with irregular
cycles. Plus, outside factors, such as a lack of sleep, can cause a woman’s
temperature to vary.

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c)Cervical Mucus/Ovulation
➢ Cervical mucus is a fluid produced by small glands near the cervix
➢ This fluid changes throughout her cycle, from scant and sticky, to cloudy and
thick, to slick and stringy.
➢ Each of these types of mucus is related to the hormonal shifts that naturally
occur during the menstrual cycle as her body prepares for and achieves
ovulation.
➢ Right before ovulation, the mucus from the cervix changes from being cloudy
and scanty to being clear and slippery.
➢ The consistency of ovulation mucus is like that of an egg white and it can be
stretched between the fingers. It is the peak of her fertility.
➢ After the ovulation, the mucus tends to dry up again. These are also safe
days.
➢ Ideal Failure rate: 3%

Disadvantages:

➢ It is not a particularly reliable method of birth control, especially for women

with irregular cycles.
➢ Remember that cervical mucus does not let you know when you will soon be
ovulating, but sperm can live up to seven days inside the vagina. Any sperm
deposited ahead of time can still impregnate the woman.

d)Symptothermal Method:

➢ Combines the cervical mucus and BBT methods Watches temp. Daily and
analyzes cervical mucus daily.
➢ Watch for midcycle abdominal pain Couple must abstain from intercourse until
3 days after rise in temp. or 4th day after peak of mucus change.
➢ More effective than BBT or CM method alone Ideal Failure rate: 2%

e) COITUS INTERRUPTUS:

One of oldest known methods of contraception Couple proceeds with coitus

until the moment of ejaculation which Offers little protection

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f)Lactation amenorrhea:

The lactation amenorrhea method (LAM) is a natural birth control technique

based on the fact that lactation (breast milk production) causes amenorrhea
(lack of menstruation).

How it works:

Breastfeeding interferes with the release of the hormones needed to trigger

ovulation.

ADVANTAGES:

➢ Breastfeeding on demand improves health for mother and baby.

➢ Nothing to buy or use.

DISADVANTAGES

▪ An use this method only for the first six months after birth or until the first
menstrual period.
▪ LAM does not provide protection against SEXUALLY TRANSMITTED
INFECTIONS.

CLASSIFICATION OF CONTRACEPTIVE METHOD

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(A) BARRIER METHODS:

(1) Condoms (male and female)

(2) Diaphragm
(3) Spermicidal
(4) Sponge
(5) Cervical cap

(1) CONDOMS:
Male condoms

▪ These are made up of polyurethane or latex.

▪ Silicon used now days to produce semi dry pre- lubricated forms.
▪ In India one particularly brand is widely marketed as ‘Nirodh’.
▪ Spermicidal – coated with nonoxynol on inner and outer surfaces.

ADVANTAGES:

➢ Simple spacing method

➢ No side effects
➢ Easily available, safe & inexpensive
➢ Protects against STDs
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DISADVANTAGES

➢ Chances of slip off and tear off

➢ Allergic reaction to latex
➢ Failure rate: 16%

Female condoms

It is a pouch made up of polyurethane which lines the vagina and also external
genitalia.It is 17cm in l;oenth with one flexible polyurethane ring at each end.

ADVANTAGES:

➢ Prevents STDs including HIV/AIDs

➢ Not damaged by oils and other chemicals.

DISADVANTAGES:

➢ High motivation
➢ Only women who can use diaphragms can use female condom
➢ Slippage occurs
➢ Expensive
➢ Failure rate 21% with typical use and 5% with correct and consistent use.

(2)Diaphragm

▪ Most common and easiest to fit and use.

▪ Thin, nearly hemispherical dome made of rubber or latex material, with
circular, covered metal spring at periphery (flat type and coil type)
▪ External diameter of rim is size of diaphragm – 45 mm diameter rising in
steps of 5 mm to 105mm (most common 60,65,70,75,80)
▪ The device is introduced up to 3 hrs. before intercourse and is to be kept for
at least 6 hrs after intercourse.

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ADVANTAGES:

✓ Cheap
✓ No gross medical side effects
✓ Control of pregnancy in hands of woman
✓ Reasonably safe when properly used
✓ Prevent spread of STDs though less effective than condom

DISADVANTAGES:

✓ Requires help of doctor to measure the size required.

✓ Need high motivation
✓ Allergic reaction to rubber
✓ Erosion
✓ UTI’s

(3)SPERMICIDES

➢ Available as vaginal foams, gels, creams, tablets and suppositories.

➢ Contain surfactant like nonoxynol-9, benzalkonium chloride.
➢ Alter the sperm surface membrane permeability resulting in killing of
sperm.

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ADVANTAGES:

➢ No instructions by doctors or nurses

➢ Easily available and easy to use
➢ No gross medical side effects

DISADVANTAGES

➢ Failure rate high when used alone

➢ Can increase spread of HIV infection by irritating vaginal and cervical
mucosa
➢ Failure rate – 21% with typical use and 6%

(4)Sponges (Vaginal contraceptive (TODAY)

❖ The sponge is a doughnut-shaped device made of soft foam coated

with spermicide.
❖ Made up of polyurethane with 1gm of nonoxynol-9 as a spermicide.
❖ It releases spermicide during coitus, absorbs ejaculate and blocks the
entrance of cervical canal.
❖ To use the sponge, it must be moistened with water. Once inserted in
the vagina, it covers the cervix and blocks sperm from entering the
uterus.

DISADVANTADES:

➢ May get broken

➢ difficult removal
➢ High pregnancy rate
➢ Allergic reactions
➢ Vaginal dryness, soreness
➢ May damage vaginal epithelium
➢ increase risk of HIV transmission

(5)Cervical Cape:

❖ The cervical cap is a birth control (contraceptive) device that prevents sperm
from entering the uterus. The cervical cap is a reusable, deep silicone cup
that is inserted into the vagina and fits tightly over the cervix. The cervical cap
is held in place by suction and has a strap to help with removal. The cervical
cap is effective at preventing pregnancy only when used with spermicide.

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 ❖ Only one cervical cap — FemCap — has Food and Drug Administration
(FDA) approval in the U.S. It must be fitted and prescribed by a doctor, but
can be purchased online if you have a current prescription.

(B) INTRAUTERINEDEVICES:
Intrauterine Device The IUD is a small, T-shaped, plastic device that is
inserted and left inside the uterus to prevent pregnancy.

CLASSIFICATION OF IUDs:

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NON MEDICATED (First generation):

✓ Non-medicated made up of polyethylene.

✓ Different shapes and sizes
✓ LIPPE’S LOOP
✓ Double ‘S’ shaped device, made up of polyethylene material.
✓ Non- toxic, non-tissue reactive and extremely durable.
✓ Small amount of barium sulphate is also added for radiological
examination
✓ Available in 4 sizes A,B,C,D

MEDICATED (Second generation):

✓ Made up of metal Cu
✓ Earlier devices Cu-7 , Cu-T 200
✓ Newer devices T copper 220 C ,T copper 380 C ,nova T
✓ multiload devices:
✓ ML-Cu 250
✓ ML-Cu 375

Third generation:

✓ Hormones releasing IUD

✓ PROGESTASTERT:
✓ Most commonly used T shaped device filled with 38 mg progesterone
✓ Effective for 1 year
✓ LNG- mirena
✓ Mirena (levonorgestrel-releasing intrauterine device) is a form of birth
control that is indicated for intrauterine contraception for up to 5 years
and Releases 20 µg of levonorgestrol.
✓ Effective for 5 years.

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SIDE EFFECTS

➢ Amenorrhea
➢ Intermenstrual bleeding and spotting
➢ Abdominal/pelvic pain
➢ Ovarian cysts
➢ Headache/migraine
➢ Acne
➢ depressed/altered mood.

ADVANTAGES OF IUD :

✓ Safe
✓ effective , Reversible
✓ Long action ,Inexpensive

DISADVANTAGESOF IUD:

✓ Heavy bleeding and pain

✓ Pelvic inflammatory diseases
✓ Ectopic pregnancy
✓ May come out accidently if not properly inserted.

CONTRAINDICATION:

❖ History of PID
❖ Abnormal shaped uterus
❖ Ectopic pregnancy
❖ Menorrhagia

(C)HORMONAL CONTRACEPTIVES
✓ Hormonal contraceptives (the pill, the patch, and the vaginal ring) all
contain a small amount of human-made estrogen and
progestin hormones.
✓ These hormones inhibit your body's natural hormones to prevent
pregnancy in a few ways. The hormonal contraceptive usually stops
the body from ovulating.

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 (1)Oral contraceptives:

—
—
—
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— Combined oral contraceptive pills
— Commonly used progestin are either levonorgestrol or norethisterone and
estrogens are ethiyl estradiol or menstranol.
—

Contraindications:

ABSOLUTE:

✓ Circulatory diseases
✓ Severe HTN
✓ Angina,ischemic heart dis.
✓ Liver disease
✓ Tumors
✓ Pregnancy
✓ Breast cancer,breast feeding.

RELATIVE:

✓ Age>40 years.
✓ Smoker, history of jaundice
✓ Diabetes

Benefits:

Contraceptive benefits:

✓ Protection against unwanted pregnancy

✓ Convenient to use.

Non-contraceptives benefits:

✓ Regulation of menstrual cycle

✓ Reduction of dysmenorrhea
✓ Protection against PID, fibroids, ovarian cysts, chances of cancer.

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 Side effects:

➢ Dizziness
➢ Nausea
➢ Weight gain
➢ Headache
➢ Breast tenderness
➢ vaginal infection
➢ Mild HPN
➢ Depression
➢ increase blood clotting

Progesterone only pills

❖ Also known as “Minipill”.

❖ Contains just progesterone or progesterone hormone.
❖ Causing plug of mucus in the neck of cervix

block the entry of the sperm.

Example: levonorgesrol 75 µg, desogestrel 75 µg

Advantages:

➢ No side effect on breast feeding or lactation

➢ May be prescribed in patient having diabetes, HTN, smoking etc.
➢ Reduce risk of PID

Disadvantages:

➢ Acne
➢ mastalgia
➢ headache

Long acting contraceptives

These are more suitable for women who do not want to pregnant again or for few
years .

THESE ARE:

➢ CONTRACEPTIVE INJECTIONS
➢ IMPLANTS
➢ PATCHES

CONTRACEPTIVE INJECTIONS ( DEPOPROVERA & NORISTERET):

❖ Contain progesterone hormone.

❖ Prevents ovulation.
❖ Commonly used as Depomedroxyl progesterone acetate
(DMPA) administered on deltoid muscle within 5 days of cycle.
❖ DOSE: 150 mg
❖ Provide protection for 3 months.

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Contraceptive implants:

✓ It is a small device placed under the skin

✓ Contains progesterone hormone.
✓ Works in a similar way to injection
✓ Contains 3 ketodesogestrel
✓ Releases hormone about 60 mcg, gradually reduced to 30 mcg
per day over year.
✓ Inhibits ovulation.
✓ Lasts for 3 years.
✓ NORPLANT – II
✓ Two rods of 4cm long. Each rod containing 75 mg of
levonorgestrel releases 50 mcg per day.

Emergency contraceptives
✓ Emergency contraception refers to methods of contraception that can be used to
prevent pregnancy after sexual intercourse. ...
✓ Emergency contraceptive pills prevent pregnancy by preventing or delaying
ovulation and they do not induce an abortion.

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INDICATIONS

✓ Unprotected intercourse
✓ Condom rupture
✓ Sexual assault

HORMONES:

✓ MORNING AFTER PILLS:

✓ It preventing conception in case of accidental intercourse.
✓ Drugs used ethinyl oestradiol 2.5mg, premarin(conjugated
oestrogen) 15 mg.
✓ Drug is taken orally twice daily for 5 days

DRUG DOSE

Levonorgesterel 0.75 mg stat and after 12 hrs.

Ethinyl oestradiol 50 µg + 2 tab stat and 2 after 12 hours
norgesterel

0.25 mg
Conjugated oestrogen 15 mg BD× 5 days

Thinyl oestradiol 2.5 mg BD 5 days

Mifepristone 10 mg single dose
Copper IUDs Insertion within 5 days

PERMANENT STERLIZATION

Sterilization is a permanent form of birth control that is extremely effective at preventing

pregnancy. But it is difficult to reverse if you change your mind, and it does not protect
against STDs. Both men and women can be sterilized. For women, a Tubectomy is
performed; for men, a vasectomy is performed.

❖ Tubectomy
❖ vasectomy

Tubectomy:
Tubectomy, also known as tubal sterilization, is a permanent method of
contraception in women. It is a surgical process that blocks the fallopian tubes,
thereby preventing the egg released by the ovary from reaching the uterus

DISADVANTAGES:

➢ Slightly uncomfortable due slightly pain and swelling after 2-3 days of the
procedure .
➢ Bleeding may result in the hematoma in scrotum

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The approach of tubectomy may be;
a) Abdominal
b) Vaginally

Abdominal:
There are two types of abdominal tubectomy;
1) Conventinal
2) Minilaprotomy

Conventinal
Tubectomy, also known as tubal sterilization, is a permanent method of
contraception in women. It is a surgical process that blocks the fallopian
tubes, thereby preventing the egg released by the ovary from reaching the
uterus.

Minilaprotomy
Minilaparotomy, generally referred to as “minilap,” is an abdominal surgical
approach to the fallopian tubes by means of an incision less than 5 cm in length.As
a sterilization procedure for permanently occluding the fallopian
tubes, minilaparotomy has been performed safely and frequently in a wide range of
countries.

Vaginally
Each step of this procedure takes place under naked-eye visualization and
digital penetration. It has the advantages of not leaving a scar and protecting the
integrity of the anterior abdominal wall. The fimbrial is tied with catgut and
fimbriectomy is performed on each side.

COMPLICATION:

❖ Ectopic pregnancy
❖ Menstrual irregularities
❖ Loss of libido
❖ Infection

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Vasecotomy:
Vasectomy is minor surgery to block sperm from reaching the semen that is
ejaculated from the penis. Semen still exists, but it has no sperm in it. After a
vasectomy the testes still make sperm, but they are soaked up by the body. Each
year, more than 500,000 men in the U.S. choose vasectomy for birth control. A
vasectomy prevents pregnancy better than any other method of birth control, except
abstinence.
Sperm and male sex hormones are made in the testicles. Sperm is the male
reproductive cells made in the testicles that can fertilize a female partner’s eggs, which
may result in a child. The testes are in the scrotum at the base of the penis. Sperm
leave the testes through a coiled tube (the "epididymis"), where they stay until they're
ready for use. Each epididymis is linked to the ejaculatory duct by a long tube called
the vas deferens (or "vas"). The vas runs from the lower part of the scrotum into the
inguinal canal (groin area). It then goes into the pelvis and behind the bladder. This is
where the vas deferens joins with the seminal vesicle and forms the ejaculatory duct.
When you ejaculate, seminal fluid from the seminal vesicles mix with sperm to form
semen. The semen flows through the urethra and comes out the end of your penis.
Ejaculate with sperm may cause a pregnancy.

Disadvantages
➢ The main disadvantage of vasectomy is that it doesn't protect against sexually
transmitted infections.
➢ Reversal may be possible in some circumstances, but it's not always an
option.
➢ Reversal is more complicated than the initial procedure.
➢ Your semen quality, amount, and texture won't change
noticeably after a vasectomy. The sensation of ejaculation during an orgasm
shouldn't feel any different at all. You may find that your first few ejaculations
after the procedure are uncomfortable. This discomfort will diminish over time.

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 ALTERNATIVE THERAPIES
Definitions:
Complementary and alternative medicine (CAM) is the term commonly used
to describe a broad range of healing philosophies, approaches and therapies that
focus on the whole person including biopsychosocial and spiritual aspect.

COMPLEMENTARY THERAPIES:
CAM therapies when used alone referred as alternative therapies.When CAM
therapies are used in combination with other conventional therapies referred as
complementary therapies.

Types of Complementary / Alternative Medicine:

1. Alternative Medical Systems
2. Mind-Body Interventions
3. Biologically-Based Therapies
4. Manipulative and Body-Based Methods
5. Energy Therapies

1. Alternative Medical Systems

Alternative medical systems are built upon complete systems of theory and
practice. Often, these systems have evolved apart from an earlier than the
conventional medical approach used.
Types of Alternative Medical Systems
a) Acupuncture
b) Ayurveda
c) Homeopathy
d) Naturopathic medicine
Acupuncture
Acupuncture is a component of traditional Chinese medicine that originated in
China over 5,000 years ago. It is based on the belief that living beings have a vital
energy, called "qi” that circulates through twelve invisible energy lines known as
meridians on the body.

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CONTD...
Acupuncturists insert needles into specified points along meridian lines to
influence the restore balance to the flow of qi. There are over 1,000 acupuncture
points on the body.
Conditions Treated By Acupuncture
➢ migraines and tension headaches
➢ Sinusitis
➢ Common cold
➢ Addictions
➢ Quit smoking
➢ Meniere's disease
➢ Arthritis
➢ Menstrual cramps
➢ Asthma
➢ Weight loss
➢ Infertility

LIMITATIONS OF ACUPUNCTURE:
Acupuncture is considered a safe therapy when the practitioner has been
trained and uses sterilized needles.
The complications includes...
❖ Infection
❖ Broken needle puncture of an internal organ
❖ Bleeding
❖ Fainting
❖ Seizure

Ayurveda
Definition; The term “ Ayurveda” is derived from two Sanskrit words , Ayur and
Veda. Ayur means life and Veda means knowledge or science. • Therefore Ayurveda
means science of life or way of life.
Ayurveda is the traditional medicine of India, which originated there over
5,000 years ago. Ayurveda emphasizes reestablishing balance in the body through
diet, lifestyle, exercise, and body cleansing, and on the health of the mind, body, and
spirit.
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CONTD...
According to Ayurveda, everything is composed of five elements:
a) Air,
b) Water
c) Fire
d) Earth
e) Space.

These elements combine to form the three doshas i.e.

1. Vata
2. Pitta
3. kapha

1. The vata doshas:

➢ The vata dosha is a combination of space and air.
➢ It controls movement and is responsible for basic body processes such as
breathing, cell division and circulation.
➢ Vata body areas are the large intestine, pelvis, bones, skin, ears, and thighs.
People with vata as their main dosha are believed to be quick-thinking, thin,
and fast, and are susceptible to anxiety, dry skin, and constipation.

2. The kapha doshas:

➢ The kapha doshas represents the elements of water and earth.
➢ Kapha is believed to be responsible for strength, immunity, and growth.
➢ Kapha body areas are the chest, lungs, and spinal fluid. People with kapha as
their main doshas are thought to be calm, have a solid body frame, and are
susceptible to diabetes, obesity, sinus congestion, and gallbladder problems.

3. The pitta doshas:

➢ The pitta doshas combines fire and water.
➢ It is thought to control hormones and the digestivesystem.
➢ Pitta body areas are the small intestines, stomach, sweat glands, skin, blood,
and eyes. People with pitta as their primary doshas are thought to have a fiery
personality, oily skin, and are susceptible to heart disease, stomach ulcers,
inflammation, heartburn, and arthritis.

Homeopethy:
Homeopathy is relatively a recent system of medicine. The word “Homeopathy" is
derived from two Greek words, Homois meaning similar and pathos meaning
suffering.
Homeopathic remedies are typically derived from plants, herbs, minerals, or
animal products. After being crushed and dissolved in alcohol and/or water, the
selected substance undergoes a long process of dilution and succession (a process
that involves vigorous shaking of the solution). The solution is then stored.

CLINICAL APPLICATION OF HOMEOPATHY

❖ Diarrhea
❖ Migraines
❖ Motion
❖ Sickness
❖ The flu
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LIMITATIONS OF HOMEOPAHY
➢ A surgical problem which has progressed far beyond its initial stages might
not respond to homoeopathy.
➢ Some sudden life threatening situations like heart attacks, paralytic strokes,
diabetic comas etc. might have to be initially treated with allopathy, till the
patient is out of danger.
➢ It is relatively slow acting as compared to the steroids.
➢ The success rate is not 100%.
UNANI MEDICINE
• The Unani System of Medicine has a long and impressive record in India.
• It was introduced in India by the Arabs and Persians sometime around the
eleventh century.
• Today, India is one of the leading countries in so for as the practice of Unani
medicine is concerned.
• It has the largest number of Unani educational, research and health care
institutions.
Origin & Development of Unani System:
•Unani system originated in Greece
•Hakim Ajmal Khan is UNANI physician but also one of the foremost freedom
fighters in the country. He established an Ayurvedic and Unani Tibbia College
and Hindustani Dawakhana - a pharmaceutical company - for Ayurvedic and
Unani medicine in Delhi in 1916.
Principles & Concepts:
According to the basic principles of Unani the body is made up of the four
basic elements i.e earth, air, water, fire which have different temperaments i.e. cold,
hot, wet, dry. After mixing and interaction of four elements a new compound having
new temperament existence. i.e Hot wet, hot dry, cold wet, and cold and dry.
The body has the simple and compound organs which got their nourishment
(The substances necessary for growth, health, and good condition) through four
humors i.e. blood, phlegm, yellow bile and black bile.
Unani medicine believes in promotion of health, prevention of diseases and
cure. Health of human is based on the six essentials…
1. Atmospheric air
2. Physical activity
3. Rest Drinks and foods
4. Sleep and wakefulness
5. Excretion and retention
6. Mental activity and rest

The human body is considered to be made up of the following seven components

are:
i. Elements (Arkan)
ii. Temperament (Mizaj)
iii. Humors (Akhlat)
iv. Organs (Aaza)
v. Spirits (Arwah)
vi. Faculties (Quwa)
vii. Functions (Afaal)

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