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When I viewed the PK parameters of both warfarin and candesartan, I found that both medications have 99% plasma protein binding. I then went to check and confirm there will be PK interaction through resources and I was surprised when I found no interaction! So can it be? Any explanation?
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Hi
Conclusion about no interactions probably cover lack of meaningful PD observations see:
" Candesartan cilexetil produced a 7% decrease in trough plasma warfarin concentration but this had no effect on prothrombin time. "
So in some cases pharmacokinetic interaction can exist but have no impact on clinical findings. Probably this is why you find conclusions about lack of interaction. Finally protein binding in blood plasma not must be most important aspect of interactions between both drugs
from another hand:
" Candesartan had no effect on S-warfarin 7-hydroxylation. In contrast, S-warfarin inhibited candesartan metabolism by the wild-type (K = 17microM) greater than by the Leu359 variant (Ki = 36 microM). These findings suggest that CYP2C9*3 may change not only the metabolic activity but also the inhibitory susceptibility compared with CYP2C9*1. "
Best regards
Tomasz
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Is there any reference/Book/Software that shows only the pharmacokinetic parameters of all medications available? For example, if I want to know the absorption, metabolism of acetaminophen, I should open the monograph in this reference and see all the information I need, the same goes for omeprazole, cetirizine, any medication. Is there such a resource/reference?
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Hi
To be onest from my point of view best are FDA documents related to specific drug submission its better than any database (for example drugbank https://go.drugbank.com/drugs/DB00341) ....
for example
google, key words: fda cetirizine pharmacokinetics accedata
Or maybe such books will be better
Best regards
Tomasz
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  • What is the time taken for steady state to be established in adults for ( Mycophenolate mofetil ) ?
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Please bear in mind that there is a large interindividual variability in the bioavailability and therefore the plasma concentration of parent mycophenolate and active metabolite. The variation can b as large as 30%. You may consider checking the plasma concentration in critical cases.
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During this pandemic we have changed our complete ways of practicing of normal way, similarly pharmacist are also shifting toward a new concept of telepharmacy. How does it impact the society in long run. Both the positive and negative effects?
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Hello, On the Long run telepharmacy is the advanced way of Pharmacy in dealing with patients.
For its Positive effects: -Dealing with patients remotely
-Tracing the compliance of Patients
-easier way of communication
For its negative effects: -Elderly are the bigger population among patients thus they have low skills in using technology
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In my country, general practitioners also provide (sell) the medicine. What do you think of this practice? Please share your views concerning the advantages or disadvantages of this practice.
Do you know of places where it started like this; and then changed so that only pharmacists can dispense medicine? Thanks.
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In the first place they are most trusted by locals. The medicine is usually effective but d problem is often with the posology. Every practitioner gives as per their knowledge which limits sustainability.
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Is it possible for a person to crush a sustained release tablet for fast action?
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What a lot of parrots in here. Not one person has given a detailed explanation of what happens to the dose on crushing for the purpose of rapid release.
What would be the effective dose then, and why would it necessarily be dangerous?
Mostly the responses on here could have just as easily have been read off the packet.
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There are 600 pharmacies distributed to 6 neighborhoods how to calculate the sample required to make a survey and what is sampling technique as the unit for thhe survey is a pharmay
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If the pharmacies are not equitably distributed in the 6 neighborhoods, I propose you to take at random 30 or 40% of the pharmacies of each neighborhood.
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4.5 half life are required in order for the medication to be eliminated from the body right? Thus in order for the cefipime to be eliminated from the body 2 days (t1/2= 12 hour)? I'm asking because if someone stopped taking the medication for one day, can he continue the medication afterward?
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basically their is no any clinical evidence of accumulation of the drug when injected tid mean while the total elimination of cefepime in the body is 2hrs independent of the dose administered to the patient or the volunteers during the clinical trials of the drug
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If someone was taking Cefipime IM 1 gm/ 12 hours for 10 days (The course is supposed to be 14 days) for complicated urinary tract infection (Cystitis) then he suddenly stopped taking the medication for one day. Can he continue the medication afterwards or he needs to adjust the dose?
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Patient should containue dose as prescribed
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This screenshot is from "Community Pharmacy Symptoms, Diagnosis, and Treatment". I wonder How Postnasal drip is experienced by Adults only as shown in the image, and Allergy which is the cause of PND is experienced by any age ? Shouldn't this be the other way around ? Because unless there is a PND, there would be no cough in this scenario ? And allergy is one of the causes of PND
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In adults main cause is DNS or Turbinate pathology
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Is there any website that can tell me when this adverse reaction will occur? For example, will this adverse reaction occur after repeated exposure? Or can occur after first dose? Or can be delayed?
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Which resource or what is the most reliable reference/website/textbook to check when looking for the safety of medications during pregnancy?
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Food Drug Administration USA ( USA), Harrison's principles of internal medicine
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Is there any reference/resource that can explain the reason behind the contraindications? I'd like to know so I can be sure that if the patient can take the medication (no alternatives available) safely despite the presence of one of the contraindications.
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Mostafa: Within the contraindications there are different types . Depending on what you look for you can find information in one way or another: Contraindications for side effects: that refer to an unintended consequence that is part of the pharmacological action of a medication; for example, dry mouth in the course of a treatment with anticholinergics. Think of, a patient with s. Sjogren, who sees his symptoms worsened by taking anticholinergics. It could also be a non-selective beta-blocker and an asthmatic patient. The physiological mechanism of bronchial relaxation is through beta2 agonism, if you block it you can trigger asthma attacks. You can usually find the cause by looking at the physiology of the mechanism of action and physiology of the side effect.Also books of clinical pharmacolgy usually explain this.
Secondary effect, on the other hand, is an unintended manifestation that arises as a consequence of the fundamental action of a medicine, but that is not an inherent part of it. By way of example, hypokalemia may occur that occurs in the course of treatment with thiazide diuretics. You can also evaluate it depending on the mechanism of action of the drug. Adverse reaction or undesirable effect, finally, refer to the unwanted effects that, in addition, are harmful. In these the cause of the adverse reaction is not usually known . You know the frequency of appearance, the characteristics of the population that it affects ... in these cases the information can be found in pivotal trials, or in safety drug monitoring agencies, and drug technical data sheets. Physiologically justify why they appear is difficult, if a patient taking ibuprofen suffers a syndrome of Steve Johnson, you may say that it is a very rare adverse reaction, but not why this patient, its idiosyncrasic.
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What will happen if the patient used carbamide peroxide to remove earwax when there is dizziness? I know dizziness could indicate inner ear problem, but what if the patient used carbamide peroxide while he is complaining of dizziness? Will there be adverse reactions like hydrogen peroxide could affect the inner ear?
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Donna, I have two Qs. Firstly, how can I know the rationale behind the contraindications? Is there any draft that explains so? Because I'd like to know if the contraindication in Q can be managed or it is absolutely not. Secondly, can I rephrase what you said with regard to dizziness? You mean that if the patient used carbamide peroxide while he is suffering tymanic membrane perforation, will suffer vertigo? Is that the rationale behind the contraindication?
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Do you use German comission E , USP, other resources? To check interactions, adverse reactions, etc..
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Hi all.. was wondering if anyone is aware of any online sources or books which gives an overview of social pharmacy methods. I am thinking of an overview of anything stretching from:
1) Which methods are available (quan or qual)
-2) How to determine which quality appraisal tools to use (dependent on methods)
3) Internal and external validity (again dependent on methods)
4) How to analyse findings (economic calculations, statistic etc)
// Sara
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This is a good book on Social Pharmacy. I learned Social Pharmacy from this book. https://www.crcpress.com/Social-and-Behavioral-Aspects-of-Pharmaceutical-Care/Wertheimer/p/book/9781560249528
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I see some Healthcare Professionals recommend Coenzyme Q10 supplementation because Beta Blockers deplete it. I tried to find evidence for this, and I didn't find except this paper.
So my Q, as a Pharmacist, do I have to supplement someone who is taking Bisoprolol or not? Because I didn't find also Bisoprolol mentioned in this paper.
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Hi Mostafa,, I totally agreed with answar of Dr Koshy. There are some suggestions that propranolol may reduce level of Co enzyme Q. But supplementation is not required. Bisoprolol is very unlikely to cause Co enzyme Q depletion. Following article might help you... Thanks
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As a Pharmacist, which resource do you use to check whether the Excipients are safe for your patients or not? I have read in some references that Saccharin is hepatotoxic, and when I checked "Handbook of Pharmaceutical Excipients, Sixth Edition", I found nothing about that! So, can you help me with this dilemma?
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For excipients used in pediatrics see the Safety and Toxicity of Excipients for Paediatrics (STEP) database provided by the European Pediatric Formulation Initiative (EUPFI)
Best regards
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As a community Pharmacist, which guideline or resource do you follow for differential diagnosis of common ailments like common cold, allergic rhinitis, and other mild cases ? As well as the established pathway for OTC products to recommend in each of the above mentioned cases ? Do you follow "handbook of nonprescription drugs" or " community pharmacy symptoms diagnosis and treatment" or both combined or something else ?
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There are no guidelines or standards widely accepted for OTC medicines used in community pharmacies, as minor illnesses vary from one region to another. However, you may follow the WHO's brief guidance as you wish. In the UK, three reference books have been used by most pharmacy students and pharmacists:
1. Symptoms in the pharmacy: a guide to the management of common illness. 7th ed. Blenkinsopp A, Paxton P, Blenkinsopp J. Oxford: Wiley-Blackwell; 2014.
*** This book is recommended for pharmacy students and pharmacists, as it provides many good disease and medication points, esp. when to refer patients.
2. Community pharmacy: symptoms, diagnosis and treatment. 4th ed. Rutter P. Edinburgh: Elsevier; 2017.
*** Professor Rutter is an experienced community pharmacist himself and he spent many years writing this book to meet all purposes.
3. Minor illness or major disease. 6th ed. Addison B, Brown A, Edwards R, Gray G. London: Pharmaceutical Press; 2016.
*** It is interesting to see some OTC and P medicines used for both minor and major diseases.
Hope this helps.
Dr Win
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Will they have the same magnitude of therapeutic effect ? Or do I have to check for bioequivalence studies before choosing the brand name ?
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I think we need to remember we are treating a patient. If the person really needs a treatment we should not deny them simply because we can't find the same brand. Most of the time the differences between brands are smaller than the differences between individuals, so It is entirely logical to give the patient a trial of a different brand and to watch what happens. So, my recommendation is to switch brands ( my own GP does it all the time) but ensure that the patient knows and is on the lookout for any differences that could be due to a change in pharmacokinetics such as an initially more intense effect (eg: Higher Cmax in an antihypertensive) or delayed effect (Later Tmax).
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I have researched, and there are many available ways to manage cough in community pharmacy setting, so which resource or reference do you use ?
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I was wondering How do you utilize medicinal chemistry in your daily practice as a community Pharmacist ? or you are no longer utilizing it in any form in your daily practice ?
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If you know one drug is a free acid or free base you can predict what it will react with/precipitate out with in IV solution. Since some community pharmacy practices interface with home infusion, this can be a possible circumstance in which medchem would come into play.
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Does medicinal chemistry in general or knowing the Pharmacophore to be specific will help in the practice of Pharmacists in community Pharmacy ? If so, may you give examples to illustrate this point ? Because I think medicinal chemistry is all related to scientific research and Pharmaceutical companies, not related to the practice of Pharmacists.
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In my opinion it is helpful to know the general structure of the compound classes to understand interactions, side effects etc. For example, if you understand, that the antibiotic tetracyclines are good chelatic binders because of their structure, you will remember more easily to warn the patient to not take it together with 2+ charged ions like Ca2+ and Mg2+. Another example are antihistaminic drugs: If you are familiar with the structure, you will realize the similarity to cholin, meaning these drugs, especially the first generation, show cholinergic action, which explains a lot of the side reactions.
So in my opinion it is important and useful to know the pharmacophore, or at least to be able to recognize and know important key elements of the structure. But of course in the time of databases and computers, which are of course used in the community pharmacy, one could argue that you don't need to know anymore. But honestly I prefer a pharmacist who is not just selling you drugs but also understands their action and side effects.
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What parameters do you check before recommending botanical products? Interactions, adverse reactions, contraindications, and dose only, or there are other essential parameters?
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The three main parameters and under them many sub parameters are important for Herbal Products. The suggested by JA Brinckmann are quite sufficient and suitable.
Quality, Safety and Efficacy are the main parameters
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The maximum dose is 10 mg/day, so why let it available while having such narrow therapeutic window?
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The therapeutic index of cetirizine is not indicated by the recommended maximum dose of 10 mg/day. I belive the recommended dose was chosen to be 10 mg/day since it had the same efficacy as 20 mg/day in several randomized controlled trials. Not due to any toxicity.
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I'm not sure why d they mention rare adverse reactions? Any idea, of what purpose does this serve? Like here in the case of Cetirizine
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When a side effect is listed as “common,” what does that mean? What are the odds of a “rare” side effect happening to me? It was news to me that these terms are actually very specific. The World Health Organization (WHO) defines categories as:
  • Very common means 1 in 10 — 1 out of every 10 people (or more) taking that medicine will experience that side effect.
  • Common means more than 1 in 100 — between one in 10 and one in 100 people are affected
  • Uncommon means more than 1 in 1,000 — between one in 100 and one in 1,000 people are affected
  • Rare means more than 1 in 10,000 — between one in 1,000 and one in 10,000 people are affected
  • Very Rare means more than 1 in 10,000+ — fewer than one in 10,000 people are affected
I found these definitions to be comforting. After all, a rare effect that happens to 1 in 1,000 to 10,000 seems safe. Then I pulled out my calculator. As an example, Crestor is one of the most prescribed drugs in America, through June 2015. It “rarely” causes liver damage (among other things). 21 million prescriptions for Crestor were written from July 2014-June 2015. Doing the math reveals that it’s possible that between 2,100 and 21,000 people in the US suffered new onsets of liver damage from taking Crestor each year.
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We know that natural products aren't regulated by the FDA, so when checking the safety of natural products/Herbs, should I check for adverse reactions and toxic dose only? Or should I also check for carcinogenic capability? Or carcinogenic capability will be listed as a default under adverse reactions? (I mean whether this product is carcinogenic or not)
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Natural products are a very important class of medicinal drugs. Roughly 25% of all drugs are derived from natural sources. For your particular product, a good starting point would be the products history. If people have been taking this product for many centuries (eons?), then the risk of adverse effects is very low. However, standard toxicity tests and carcinogen tests should be performed. Beyond this, I would recommend testing for heavy metals and persistent environmental toxins (pcbs, etc.). Also, there are requirements in the US for vitamins (not sure how much supplements apply). These are listed in the DSHEA standards.
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So like the attached image. There should be a purpose behind mentioning rare adverse reactions, otherwise why they would mention it.
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The frequency (whether rare or very rare) speaks to how likely the adverse effect is to be a problem. If an adverse event is rare/very rare, then the benefits of the drug is likely going to outweigh the risk. This is especially when the disease condition is serious.
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In other words, which websites list the adverse reactions of the drugs instead of listing the adverse events (no causality established)? I know of https://www.medicines.org.uk/emc/ which lists SmPC, any other websites?
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LexiComp is the as it give an up to date information and I find very handy and user friendly.
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Why most websites report frequency of adverse reactions of drugs(In terms of common, rare, etc..)? Does this indicate causal relationship? Like common adverse reactions is established to be induced by the drug and not as an adverse event? Like here in the case of cetirizine or reporting the frequency serves another purpose?
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CIOMS generally gives this classification :
  • Very common ADR occurs in more than 1/10 patients who take the drug
  • Common (frequent) > = 1/100 and < 1/10
  • Uncommon (infrequent) >= 1/1000 and < 1/100
  • Rare >= 1/10000 and < 1/1000
  • Very rare < 1/10000
The frequency of ADR is often determined during the clinical trials, although clinical trials are more designed to assess efficiency than to detect side effects (as clinical trials do not include more than 3000, it is for example impossible to see very rare ADR).
During those clinical trials ADR are assessed with an imputability method, as it is done in real life with pharmacovigilance.
When a patient has a symptom, those data helps health professionals to see if it could be or not an ADR, and if so stop or not the drugs if needed (and ask an expertise).
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looking to obtain materials on research for community pharmacy over the counter recommendations
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Hi Lawrence!
We are rightly working on similar research project. As we proceed further,  dataset may be shared with you for your guidance.
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I am going to explore general population' s KAP about OTC usage.
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Dear Kazem
Yes you can use our questionnaire attached here but keep in mind to make citation for us once you published your work.
Good luck
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Community pharmacies are spread over wide area in each city. Each pharmacy serve the surrounding neighborhood which can have some distinctive characteristics regarding prevalence of diseases and socioeconomic factors affecting choice of medications. How can a pharmacist describe the socioeconomic class of his neighborhood?
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As previous answers in the UK you can use LSOA (Lower Layer Super Output Areas) classification to guide the deprivation index of the location of the community pharmacy. You can see my research team has already done that in the UK using ArcMap, this was published in BMJ Open at http://bmjopen.bmj.com/content/4/8/e005764.abstract the paper shows how do map pharmacy post codes against deprivation indices obtained from LSOA data. Of course the confounding factor in all of this is that one can't be sure that the patients using the pharmacy are actually from the same areas and thus this could affect certain aspects of health inequality if these studies are used for commissioning purposes. We are working further on this now 
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I am conducting a systematic review of intervention studies and am interested in finding all relevant publications. If you would like more information, the review protocol is registered on Prospero:
I can be contacted via this ResearchGate portal 
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Dear Ibrahim,
Thank you for spending the time to respond to my question - it adds to the completeness of the review.
Kind regards,
Liza
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published articles
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Law and policy of pharmacy 2015
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In general sense, all the drugs have an expiry date (shelf life). After the expiry date the drug is recommended not to use as it may produce toxic effects in biological system and/or lose its potency in lesser or greater extent i.e. deviation from the optimum specification is seen. My question is what will be happened in case of a toxicant (toxin)? Is there any recommendation for toxiants' using? What will be there toxicological efficacy after expiry?
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The expire date for any compound is the beginning of the degradation of the active ingredient i the compound. Sometimes the degradation lead to break down  into different compounds, which may act as more toxic compared to the parent compound or may loss it toxicity. On the other hand, the active ingredient changed to another for by oxidation lead to produce more toxic compound or loss it toxicity. So it is recommended to avoid the using these compounds after expiration date.
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I would like to know if anybody has any experiences with diabetes prevention programs in Community Pharmacies, something like Findrisc or similar. I would be most grateful for any information you have.
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Look for the GLICEMIA Study in Germany from Prof. Kristina Leuner.
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Although community pharmacy and dispensing pharmacy are basic role of pharmacists but the training and implementation of community pharmacy at institutional level is not well considered. I would like to know what may be the reasons behind for not having such things in the college, students often referred to local community pharmacies to get trained, but a institution has their own community pharmacy shop this can help the students to train and also can generate a trustful revenue to the institution.
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the role of a pharmacist in India is not very clear. Dispensing any drug was done at a time when there was formulations but not now.
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I work as a pharmacist in a community pharmacy in Croatia. Does in your country a clinical pharmacist work in a communitiy pharmacy?
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hi Dahna,
Yes ofcourse. Community pharmacy practice is an important part of clinical pharmacist role. Pharm Ds in USA work in community pharmacies as well as other pharmacy locations like hospitals. I strongly recommend that all community pharmacists be clinical pharmacists because they are the first to face the patient and must be better qualified to deliver the needed pharmaceutical care. I think traditional pharmacists need to phased out entirely in favor of clinical pharmacists/ Pharm Ds in all pharmacy aspects.
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It is quite different to differentiate between chemical sellers and community pharmacy aside the wider range of drugs in the community pharmacy. However, the practice of pharmaceutical care in Ghana is prominent only in some private sectors and most of the public hospitals and other health facilities do little more to dispensing of medications and that still puts the medicines at the centre of the pharmacists instead of the patient as it is supposed to be the case. It is my desire to find out the reasons of this problem and make room for the delivery of effective pharmaceutical care to society.
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Make your study purely descriptive, Select a represent sample of community pharmacies and observe key elements in the process of dispensing and patients communication and record that as a descriptive and narrative manner