Social pharmacy

Extemporaneous Dispensing
• An extemporaneous preparation is a drug specially
prepared by a pharmacist because an appropriate drug is
not readily available.
• Extemporaneous dispensing is the process of
compounding ingredients to prepare a medicine for an
individual patient.
• It is also an on-demand preparation & dispensing of a
drug product according to a physician’s prescription.
• It involves mixing a powdered active ingredient with a
diluent powder & filling a given number of capsules or
other suitable dosage forms.

• Extemporaneous compounding requires
equipment's for weighing, measuring &
compounding.
• Some common equipment's are:
Balances
Forceps & Spatulas
Mortar & Pestle
Graduates & Pipettes
Master Formula Sheet

Guidelines for extemporaneous compounding:
• Pharmacist should prepare according to the
physician’s prescription to the individual patient.
• Dilutions and mixing of active ingredients with other
ingredients should be done in definite proportion
according to the master formula sheet.
• Conversion of solid dosage forms to solutions or
suspensions as per the prescription.
• All the ingredients should be within the expiry date.
• All the equipment's used for compounding should be
clean and dry.
• Product should be labelled clearly and stored in
suitable place as recommended.
• Compounding should be in accordance with Good
Manufacturing Practice.

Guidelines for Extemporaneous Dispensing:
• Pharmacist should consider extemporaneous
dispensing only if no commercial product exists and
should be according to the physician’s prescription.
• Extemporaneous preparations to be dispensed
should not exceed one month even if the shelf life is
more than 30 days.
• Proper labelling is required and storage should be
done in a suitable container as recommended.
• Provide direction to the caregiver about the
administration of medication.

Example of Extemporaneous Dispensing:
Generic name: Allopurinol
Indication: Gout or uric acid & calcium oxalate renal
stones.
Dosage form: suspension
Strength: 20mg/ml
Stability: 30 days
Storage: Refrigerate or store at room temperature.
Protect from light.
Ingredients Strength Quantity
Allopurinol 300mg 8 tablet
Vehicle QS 120ml

Procedure:
• Crush tablets in mortar to fine powder.
• Levigate the powder with small amount of
vehicle until a smooth paste is formed.
• Add more vehicle to the paste until a liquid
is formed & transfer the liquid into the
container.
• Use additional vehicle to rinse the remaining
drug from the mortar and pour into the
container.
• Make up to final volume with vehicle.
• Shake well & label.

Scope and Importance of Extemporaneous
compounding:
• Helpful for individual patient that require diluted
strengths. E.g: Pediatric Patients
• Useful if dose conversion from solid oral dose to
solution or suspension is required.
• Patients sensitive to certain compounds like dyes,
preservatives, flavours can use extemporaneous
compounding.
• Dermatological formulations with strengthened or
diluted concentration can be compounded for
commercially available products.

Labelling of Dispensed Products
A Label is an written information about the
product attached to a container with medicine to
be dispensed.
Information on label includes:
• Product Name, Strength & Quantity
• Storage condition & Shelf Life
• Information to the Patient

Types of labels:
• Patient Label
• It is a Label prepared during dispensing. It includes
name, amount, indication, dose of medicines, name
of patient. It should be easily understandable and
simple in language.
• Stock Label
• It is a label prepared by the manufacturer or
pharmaceutical company. Information related to the
medicine is mentioned in stock label

The information on the label should be:
• Accurate: label should be checked before
fixing to the container.
• Legible: label should be easily readable in
written or printed form.
• Intelligible: label should be clear &
understandable without any confusion.
• Adequate & Relevant: Proper &
important information should be mentioned
on the label avoiding too much description.

Information on labels for
Dispensed Medicines:
1. Name & Address of the patient
2. Name & Address of the supplier & date of
supply
3. Name, Strength & Quantity of Medicines
4. Storage condition & Shelf life of the
product
(e.g: Temperature, Humidity & Light)
5. Instructions to the patients
(e.g: directions, shake well, take with
water, etc)

Caution and Advice on Labels if any:

Patient Counselling
Patient counselling is defined as providing
medicine information orally or in written
form to the patient or their representatives
on direction of use, advice on side effects,
precaution, storage, diet and lifestyle
modifications.
The process provides for the exchange of
information between the patient & health
practioner.

Why patient counselling is required?
Patient counselling is important for new and
refill prescriptions. Ideally, patient counselling
will vary among individual patients according
to their needs.
• Patient receiving more than a specified
number of medications.
• Patient with visual, hearing or literacy
problems.
• Pediatric patient
• Patients on anticoagulants

Methods of patient counselling:
1. Introduction:
• Pharmacist should review the patient record before counselling
• Appropriate counselling includes information along with precaution,
contraindications and warnings.
• Inform patient on possible Food-Drug interaction and Adverse drug
reaction.
2. Counselling Contents Item:
• Discuss the name and indication of the medicine.
• Explain the dosage regimen including duration of therapy.
• Help to make plan on routine and explain about refilling information.
3. Counselling Process Items:
• Provide accurate information
• Use simple language, easy to understand
• Display non-verbal behaviours
4. Counselling Conclusion Steps:
• Verify the patient understanding getting a feedback
• Summarize the important parts
• Allow to question
• Help to make plans on follow up and next steps

Medication Counselling Tips
• Establish Relationship with Patient using Verbal &
Non-verbal Communication
• Verify patient’s name and prescriber’s name
• Demonstrate patient about method of medicine
administration
• Special care should be provided to visual and hearing
impaired, poor & illiterate patient, mentally confused
patient, children, etc.
• Regular counselling should be provided to asthmatic,
diabetic, epileptic or mentally ill patients and patients
taking many medicines at a same time.
Remind patient about:
• What to do in case of missing dose?
• Foods, alcoholic beverages or OTC that should be
avoided
• Storage of medicine and refilling

Example:
Counsel a patient with following
prescription
Tetracycline Hcl 250mg
Make capsule, dispense such 10 capsule
Label: Take one capsule every 6 hrs with milk
Type: Therapeutic incompatibility

Note:
• Tetracycline forms insoluble complex
with calcium present in the milk and other
calcium containing products.
• Hence milk and other calcium containing
products must be avoided with
tetracycline.
• The prescription is wrong.
• Refer to the prescriber.

Patient Compliance
• Patient compliance is the extent to which an
individual patient follows or obeys the
advice/instruction of Doctor or Health Care
Professional.
• Adherence is similar to patient compliance.
• Concordance is the agreement between the
patient and the doctor about the proposed
therapeutic plan.
• Non-Compliance is the failure of the patient to
comply with the medication regimen and
instructions/advice on dieting, exercise, smoking or
drinking habits.

Classification of Compliance/Adherence:
• Full compliance
The patient take the medicine as instructed by the
doctor.
• Partial compliance
The patient sometimes forget to take the medication on
time.
• Non-compliance
The patient takes medicine very irregularly causing
treatment failure.
• Over-compliance
The patient takes more medicine hoping to get faster
relief.

• Drug holiday
The patient discontinues all medicines on weekends,
holidays or during journey.
• Skewed dosing
The patient changes his dosing resulting in over or
under dosing and hence changes in therapeutic
outcome.
• Timing non-compliance
The patient takes medicines at time other than
instructed.

Types of Non-compliance:
• Patient not getting the medicine prescribed.
• Omission of doses.
• Error of doses.
• Error in time of administration.
• Self discontinuation of drugs

Factors affecting adherence/compliance:
Social & economic dimension
• Lack of knowledge in health
• Lack of support from home or state
• Higher cost of medicine
Health care system dimension
• Health care provider-patient relationship
• Lack of positive reinforcement from the health care
provider
• Changing medications

Condition related dimension
• Chronic conditions
• Depression
• Mental retardation/development disability
Therapy related dimension
• Complexity of medication regimen
• Frequent changes in medication regiimen
• Social stigma attached with medication
Patient related dimension
• Physical factors
• Visual, hearing or cognitive impairment
• Alchohol or substance abuse

Detecting non-compliance:
Interrogation
• Counselling
• Standard questionnaire
• Self administration format
Residual tablet count
Tablet counts are performed to detect the proper
administration of medication. However it may be
misleading.
Drug markers
Drug markers can be a valuable method.
Rapid drug analysis
• Analysis of body fluid samples can be used.

Consequences of Non-compliance:
• Therapeutic failure
• Worsening of condition
• Recurrence of infection
• Unwanted/Adverse effects
• May require hospitalization
• Drug abuse and accidental poisoning

Methods to improve/promote compliance:
The patient
• The physician and the pharmacist must talk to the patient
about the illness, types of drugs prescribed and effectiveness
of the therapy.
• The patient should be encouraged to ask questions for proper
understanding.
• Patient leaflet, medication charts helps to aid compliance.
The prescription
• Proper prescription of drugs
• Use fewer drugs as possible for short period of time
• Regularly review drug therapy
• Use consistent drugs
Medication details
• Provide medication details to the patient
• Explain the administration & duration of therapy
• Notify any possible side effects
• Suggest food/drinks with drugs to avoid

Patient profile
• Patient profile is a simple form containing
patient information, medication list, illness,
immunization and other information.
• Patient profile is a record of all the information
associated with the patients that allows health
care providers to keep track of important health
information.

Patient Information:
Name:
Date of Birth:
Address
Phone:
History of present illness
Social History
Family History
Past medical History
Medication List
Medication/
Strength
sig qty Day
supply
Original
rx date
Date
picked up
Refills
1.
2.
3.
Immunization
Model Patient Profile

Drug Profile
• Drug Profile is a brief description of drugs
about the chemistry, pharmacology, synthesis,
analysis, physical form and mode of use of
drugs.
• Drug Profile provides brief information about
the medicine for the health care providers.

Drug Profile of Panorma
Generic Name Pantoprazole
Class Proton Pump Inhibitor
Chemistry
Mechanism of action
Indication/Uses
Contraindication
Adverse Reactions
Drug Interactions
Dose for adult and Child
Route of administration
Onset of action
Duration of action
Special Note

PANORMA
Pantoprazole Sodium Sesquihydrate 40 mg Tablets
GENERIC NAME: Pantoprazole
PHARMACOLOGICAL CLASS: Proton pump inhibitors
(PPI)
THERAPEUTIC CLASS: GI agents
COMPOSITION & PRESENTATION:
Composition
Each tablet contains Pantoprazole Sodium Sesquihydrate
equivalent to Pantoprazole 40
mg.
Presentation
10 Tablets x 20 Blisters

MECHANISM OF ACTION:
Pantoprazole is a proton pump inhibitor that suppresses the final step in
gastric acid production by forming a covalent bond to two sites of the (H+,
K+)-ATPase enzyme system at the secretory surface of the gastric parietal
cell. This effect is dose-related and leads to the inhibition of both basal and
stimulated gastric acid secretion irrespective of the stimulus. The binding to
the (H+, K+)-ATPase results in a duration of antisecretory effect that
persists longer than 24 hours.

INDICATIONS:
Reflux Esophagitis
GERD or heartburn
Duodenal and Gastric ulcers
H.pylori infection
Zollinger-Ellison syndrome
Stomach ulcers associated with NSAID use.
DOSAGE:
Reflux Esophagitis: 40mg OD for 4-8wks
GERD or heartburn: 40mg OD for 4wks
Duodenal (intestinal) ulcers:40mg OD 2-4wks
Gastric (stomach) ulcers: 40mg OD for 4-8wks
H.pylori infection: 40mg BD for 7 days
Zollinger-Ellison syndrome: 40mg BD
PHARMACOKINETICS:
Bioavailability: 77%
Half life: 1hr.
Onset of action: 2-4hrs.
Duration of action: About 24hrs.
Metabolism: In the liver by the cytochrome P450 system.
Excreation: Renal

ADVERSE EFFECTS:
Headache
Diarrhea or constipation
Gas
Nausea or vomiting
Dizziness
Mild rash

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