Clinical pharmacy is the branch of pharmacy in which clinical pharmacists provide direct patient care that optimizes the use of medication and promotes health, wellness, and disease prevention. Clinical pharmacists care for patients in all health care settings but the clinical pharmacy movement initially began inside hospitals and clinics. Clinical pharmacists often work in collaboration with physicians, physician assistants, nurse practitioners, and other healthcare professionals. Clinical pharmacists can enter into a formal collaborative practice agreement with another healthcare provider, generally one or more physicians, that allows pharmacists to prescribe medications and order laboratory tests

What does a pharmacist do?

  • Assess the status of the patient’s health problems and determine whether the prescribed medications are optimally meeting the patient’s needs and goals of care.
  • Evaluate the appropriateness and effectiveness of the patient’s medications.
  • Recognize untreated health problems that could be improved or resolved with appropriate medication therapy.
  • Follow the patient’s progress to determine the effects of the patient’s medications on his or her health.
  • Consult with the patient’s physicians and other health care providers in selecting the medication therapy that best meets the patient’s needs and contributes effectively to the overall therapy goals.
  • Advise the patient on how to best take his or her medications.
  • Support the health care team’s efforts to educate the patient on other important steps to improve or maintain health, such as exercise, diet, and preventive steps like immunization.
  • Refer the patient to his or her physician or other health professionals to address specific health, wellness, or social services concerns as they arise.

Standards of Clinical Practice for Renal Pharmacists

The prevalence of chronic kidney disease (CKD) continues to increase.1 Patients with stage 1 to 5 CKD and those undergoing dialysis are at extremely high risk for drug therapy problems (DTPs).2,3 In controlled trials involving general patient populations, clinical pharmacist interventions have reduced hospital admissions, length of hospital stay, readmissions, and emergency department visits.47 The activities of pharmacists most strongly associated with improved patient outcomes include participating on rounds, interviewing patients, performing medication reconciliation, counselling patients on discharge, and conducting postdischarge follow-up. A systematic review of 8 controlled trials involving patients with CKD showed that clinical pharmacist interventions improved management of anemia, blood pressure, and lipids, as well as calcium and phosphate parameters. In this patient population, clinical pharmacists’ interventions reduced hospital admissions, length of hospital stay, and incidence of end-stage renal disease or death.

The pharmacist must perform these core clinical activities on fully staffed weekdays*(in order of priority):
1. Attend all MRP clinics (includes PD, home and rural HD, and CKD stages 1–5 clinics; total of 24 half-day clinics per week): ○ Review laboratory test results and medications for all patients. ○ Document in health record any recommendations, suggestions, or further patient information required for patients not seen by a pharmacist. ○ For patients seen by a pharmacist, generate best possible medication history and perform medication reconciliation and detailed medication review.
2. Attend multidisciplinary patient care rounds (twice weekly for HD and PD patients): ○ Contribute to interprofessional discussion about patients. ○ Identify admitted patients for discharge medication reconciliation. ○ Identify patients for medication review by a pharmacist.
3. Perform discharge (and transfer) medication reconciliation for admitted patients receiving dialysis before discharge or at first subsequent dialysis session (HD patients only). ○ Reconcile inpatient medications with home and in-centre HD medications. ○ Perform detailed medication review and document recommendations in the patient’s medical record. ○ Write discharge prescription for medications, including appropriate medications for in-centre HD and new medications started in hospital. Contact prescribing nephrologist to make recommendations and confirm prescription. ○ Provide patient with medication card and counselling.
4. Review monthly laboratory test results for HD patients.
5. Perform detailed medication review for new starts to HD or PD within 2 weeks.
6. Perform detailed medication review for other patients.
The pharmacist will perform the following “must do” activities (prioritized according to pharmacist’s professional judgment): Ensure follow-up laboratory tests are ordered, according to pharmacist’s recommendations. Ensure patients have adequate prescriptions and refills. Liaise with community pharmacy as appropriate (e.g., to facilitate prescription delivery, compliance aid, drug coverage). Liaise with patient, caregivers, family members, and other health care professionals as appropriate to provide medication-related information to or for patients. Provide drug information for immediate patient care that day. Provide education to pharmacy students and residents. Provide monitoring and follow-up for recommendations. Provide communication between MRP and other pharmacists within the facility.
The pharmacist shall perform the following desirable activities as appropriate and as pharmacist is available: Participate in MRP and pharmacy program initiatives (e.g., development of drug protocols, review of preprinted orders, participation on committees, development of policy and procedures, responses to drug shortages). Provide education-related activities to health care professionals. Provide communication between MRP and other pharmacists at other facilities. Provide drug information not needed immediately. Perform drug-use management activities, including prospective audits. Participate in projects or research. Investigate medication incidents or errors. Review or triage medication orders to identify drug therapy problems related to appropriateness, duration, and dosing of each medication, as well as drug interactions (as an activity separate from medication review, medication reconciliation, or MRP clinic visit).


Steps in Review of Patients with Chronic Kidney Disease for Drug Therapy Problems (DTPs)

General medication review: – For new dialysis patients, before nephrologist review or clinic visit (every 6 months to 1 year) or at the request of another health care professional – Interview patient, caregivers, family members, and other health care professionals – Generate best possible medication history and perform medication reconciliation – Review laboratory test results, investigations, physical findings, and medications to identify DTPs – Document medication review, DTPs, and recommendations in the medical record – Identify and resolve actual/potential DTPs during discharges, medication reviews, clinic visits, between clinic visits (after review of laboratory test results), on medication order review, or detailed medication review
Assess patient for general DTP: – allergies and intolerances – drug–drug interactions – adverse drug reactions – medication causing or exacerbating a symptom – duplication of pharmacologically or therapeutically similar medications – appropriate dosage form and route of administration – medication therapy not indicated – medication indicated but not utilized – medication adherence – problems related to IV administration – medications that require renal dose adjustments – medications that are contraindicated in CKD or that should be minimized – medications that are no longer required in dialysis
Assess patient for DTPs specific to CKD by assessing the following: – Anemia: Assess hemoglobin, transferrin saturation, ferritin, use of erythropoietic-stimulating agent, iron, and renal multivitamin. Consider erythropoietin hyporesponsiveness. – Mineral and bone disease: Assess corrected calcium, serum phosphate, parathyroid hormone, alkaline phosphatase, albumin, calcium bath concentration, phosphate and calcium additives to the dialysate, surgical history (for parathyroidectomy), use of phosphate binders, vitamin D analogue, or cinacalcet. Liaise with dietitian about diet. – Cardiovascular risk: Assess for presence of cardiovascular disease and risk factors, and therapies to reduce this risk (antiplatelets, anticoagulants, antihypertensives, statins, antianginal therapies, and antiarrhythmics). – Hypertension and proteinuria: Assess blood pressure before, during, and after dialysis, in clinic and at home; assess dry weight, proteinuria, antihypertensives, and antiproteinuric therapies. – Diabetes mellitus: Assess glucose monitoring before and after dialysis, in clinic and at home, as well as glycated hemoglobin and use of hypoglycemic agents. – Pain: Assess source of pain, its quantity and quality, and use of opioids, NSAIDs, and adjunctive therapies. – Peripheral neuropathy: Assess source of pain, its quantity and quality, and use of antidepressants, anticonvulsants, and opioids.- Restless leg syndrome: Assess symptom severity and frequency, sleep disturbance, daytime fatigue, and use of dopamineagonists, gabapentin, levodopa, benzodiazepines, and opioids. – Smoking status: Assess readiness to quit and use of nicotine replacement therapy, bupropion, or varenicline; provide education – Cramps: Assess symptom severity and frequency, as well as use of quinine or vitamin E. – Pruritus: Assess symptom severity and use of topical or systemic agents. – Gastrointestinal issues (e.g., reflux, history of bleeding, ulcer, dyspepsia, constipation, diarrhea): Assess signs and symptoms, as well as use of antacids, laxatives, stool softeners, agents to treat diarrhea, NSAIDs, or corticosteroids. – Infectious diseases (e.g., IV catheter-related infections, skin infections, peritonitis) requiring treatment or prophylaxis, including antibiotic locks and intraperitoneal antibiotics: Assess signs and symptoms, as well as culture and sensitivity results. – Hyperkalemia (for stage 1–5 CKD patients): Assess serum potassium, presence of hemolysed sample, and use of potassium supplements, ACE inhibitors, ARBs, potassium-sparing diuretics, and other agents known to increase serum potassium. Assess use of potassium-binding resins and diuretics. Liaise with dietitian regarding diet. – Metabolic acidosis (for stage 1–5 CKD patients): Assess serum bicarbonate concentrations and use of supplementation. – Depression, anxiety, insomnia: Assess consultations with other health care professionals and use of antidepressants, antipsychotics, benzodiazepines, and sedatives. – Gout (for patients with stage 1–5 CKD): Assess serum uric acid level, frequency and severity of gout attacks, and use of colchicine, NSAIDs or corticosteroids, allopurinol, and febuxostat – Review patient for the use of the following high-alert medications: digoxin, lithium, phenytoin, immunosuppressive therapy. – Assess serology and vaccination status for hepatitis B, pneumonia, and influenza.

ACE/ARB = angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker, A.Fib = atrial fibrillation, ALKPhos = alkaline phosphatase, ASA = acetylsalicylic acid, BB = beta-blocker, BP = blood pressure, B.S. = blood sugar, Ca2++ = calcium, CCB = calcium channel blocker, CHF = congestive heart failure, CorCa = calcium corrected for albumin, CVA = cerebrovascular accident, ESA = erythropoiesis-stimulating agent, ESRD = end-stage renal disease, GGT = gamma-glutamyl transferase, HbA1c = glycosylated hemoglobin, HD = hemodialysis, HDL = high-density lipoprotein, Hgb = hemoglobin, HR = heart rate, HTN = hypertension, INR = international normalized ratio, IV = intravenous, LDL = low-density lipoprotein, MI = myocardial infarction, NTG = nitroglycerin, OHA = oral hypoglycemic agent, OTC = over-the-counter, PO4 = phosphate, PTH = parathyroid hormone, RLS = restless leg syndrome, Rx = prescription, TC = total cholesterol, TG = triglycerides, TIA = transient ischemic attack, TSAT = transferrin saturation.

Date: _______________________ Seen:  In Unit    Clinic    Site Visit

Compliance Tools:    Bubble Pack    Dosette    Other: _______________________

Community Pharmacy: ____________________ Potassium binding resin at home  Yes  No

Medications verified with:    Patient/Caregiver  Rx Label  Pharmacy

          Electronic prescription record  Chart reviewed

Herbal Products:  No  Yes ____________________________________________________________________

OTC (other than as Rx):  No  Yes _____________________________________________________________

Allergies/Intolerances: _______________________________________________________________________

ESRD Secondary to: _____________________________ HD initiated on: _____________________________

Comments: ________________________________________________________________________________


Hgb ____________________ESA _______________________________
TSAT ____________________IV iron _____________________________
Ferritin __________________Replavite  Yes  No

Mineral Metabolism:

CorCa ___________________PO4 binders_________________________
PO4 ____________________PTH ________________________________
ALKPhos/GGT ____________Vitamin D ___________________________
Ca2++ bath ______________Parathyroidectomy  No  Yes __________

Cardiovascular disease:

History of:  HTN  Diabetes  CVA/TIA  MI  A.fib  CHF

Smoking Angina _______________________________

Pre HD BP: _______ Post HD BP: _______ HR ______

Lipid profile: _______ (date)TC ____ HDL ____ LDL ____ TG ____ TC/HDL ___

BB ___________ ACE/ARB ___________ ASA Clopidogrel

Statin _________ CCB ___________ Warfarin Diuretic

              (INR target_____________)

NTG Spray ________________________________


1  2HbA1c: ____(date) Ophthalmologist Endocrinologist __________________
NoPre/Post HD glucose: ______/______ Home glucose: ____________________
B.S.<4:  No  Yes _____ Insulin_______________________________________
OHA: _____________________________________________________________

Gastrointestinal Issues:

RLS/Leg Cramps:


Sleep Disturbances:

Pain Issues:

Therapeutic Drug Monitoring:

Other Issues: