CR-MTAC

Comprehensive Study Note: Cardiac Rehabilitation Medication Therapy

Adherence Clinic (CR-MTAC)

1. OBJECTIVES OF SERVICE
a) Collaborate with doctors in managing cardiac rehabilitation patients
prescribed with secondary prevention pharmacotherapy (antiplatelet agents,
beta blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor
blockers, and statins). b) Ensure continuity and enhancement of patient care
through education, monitoring, and close follow-up. c) Maximize the benefits of
secondary prevention pharmacotherapy while minimizing adverse effects and
complications. d) Provide consultative and educational services to healthcare
providers regarding secondary prevention pharmacotherapy. e) Conduct research
on secondary prevention pharmacotherapy for cardiac rehabilitation.
2. SCOPE OF SERVICE
a) A multidisciplinary approach involving doctors, pharmacists, and other
healthcare providers. b) CR-MTAC provides:
 Pharmaceutical Reviews: Medication history, OTC medicine, traditional
& complementary medicine, supplements, laboratory results monitoring,
adverse drug reaction reporting, therapy adjustment during elective
procedures.
 Medication Adherence and Knowledge Assessment.
 In-depth Medication and Disease Education.
 Prescription Screening.
 Medication Dispensing (if applicable).
 Close Follow-Up Based on Individual Patient Needs. c) Activities
conducted per standard operating procedures (SOPs).
3. PROVIDER QUALIFICATION
a) Pharmacist trained under the CR-MTAC training program approved by the
Pharmaceutical Services Program, MoH Malaysia. b) Untrained pharmacists must
work under the supervision of a trained pharmacist. c) CR-MTAC pharmacists
must:
 Identify interventions and develop pharmaceutical care plans.
 Adjust medication regimens with prescriber discussions.
 Provide counseling and improve medication adherence.
4. MANPOWER REQUIREMENT
a) Minimum of one (1) pharmacist per CR-MTAC session, with staffing adjusted
based on patient load. b) Average consultation time: 15-20 minutes per case; 30
minutes for new cases.
5. APPOINTMENT SYSTEM
a) New patients recruited via walk-in or doctor referrals. b) Follow-up patients
scheduled and reviewed by CR-MTAC pharmacists.
6. OUTCOME MEASUREMENT
To ensure optimal care, CR-MTAC assesses:
a) Medication Adherence to secondary prevention therapy. b) Medication
Knowledge (DFIT: Dose, Frequency, Indication, Time score). c) Therapeutic
Outcomes:
 Lipid profile (Total cholesterol, HDL-c, LDL-c, TG)
 Body weight, BMI, and waist circumference
 Ejection Fraction (optional)
 Clinical parameters (blood pressure, heart rate, glycemic control)
7. STANDARD OPERATING PROCEDURES (SOPs)
7.1 Patient Selection
All cardiac patients managed in MoH Malaysia hospitals or clinics are eligible,
especially those:
 Post-cardiac event (e.g., bypass surgery, percutaneous coronary
angioplasty, heart transplantation).
 Diagnosed with Acute Coronary Syndrome.
 Having uncontrolled cardiovascular risk factors.
 Demonstrating poor medication adherence.
 Managing co-morbidities related to cardiovascular disease or
polypharmacy.
7.2 Patient Registration
 Maintain an updated patient registry.
7.3 Initial Assessment (First Visit)
 Use assessment forms:
o CR-MTAC First Visit Pharmacotherapy Review Form (Appendix 1)

o CR-MTAC Follow-up Visit Pharmacotherapy Review (Appendix 2)

o Pharmacist Review and Counselling Checklist (Appendix 3)

 Assess:
o Personal information, medical history, diagnosis

o Medication list, lab results, ejection fraction, PCI status, vital signs

o Baseline DFIT score

  Identify drug-related problems.
 Counsel and educate patients on medication adherence, disease
management, and lifestyle modifications.
7.4 Subsequent Visits
 Schedule visits based on patient needs and health status.
 Review patient history, CRP notes, and lab results.
 Assess medication adherence and understanding.
 Identify drug-related problems and adjust therapy as needed.
 Counsel and educate on medication, therapy goals, and lifestyle
modifications.
 Document in:
o CR-MTAC Follow-up Visit Pharmacotherapy Review Form (Appendix
2)
o Pharmacist Review and Counselling Checklist (Appendix 3)

7.5 CR-MTAC Clinic Operation

 Conduct sessions on designated clinic days in a private setting.
 Allocate secure storage for documents and supplies.
7.6 Patient Education
 Educate on drug names, dosage, missed doses, indications, drug
interactions, side effects, compliance, and follow-up importance.
7.7 Pharmaceutical Review
 Medication Reconciliation: Interview patients to update medication
lists.
 Medication Review: Optimize therapy, monitor adherence, and follow up
on treatment outcomes.
 Identify Drug-Related Problems: Assess adverse effects, inappropriate
dosing, and interactions.
 Develop Pharmaceutical Care Plan: Propose interventions, therapeutic
alternatives, and referrals.
 Document All Recommendations and discuss with prescriber.
7.8 Monitoring and Evaluation
 Assess vital signs, lab results, and patient-reported outcomes.
7.9 Immediate Referral to Prescriber
 Signs of adverse drug reactions.
 Deranged lab results requiring intervention.
  Consistently missed appointments.
 Non-compliance requiring re-initiation of therapy.
7.10 Medication Dispensing
 Ensure the right patient, medication, dose, route, and time.
 Educate on adherence, side effects, and expected outcomes.
7.11 Missed Appointments
 Contact patient and reschedule.
 Document reasons in CR-MTAC/F2 form.
 Allow walk-ins on the next clinic day.
 Refer to prescriber if therapy needs re-initiation.
7.12 Defaulters
 Patients missing two consecutive visits.
 Contact patient and reschedule.
 Refer to prescriber for medication re-initiation.
7.13 Discharge Criteria
 Discharge if:
o Therapeutic outcomes achieved for two consecutive readings.

o Good medication knowledge (DFIT score).

o Good adherence to therapy.

o No further interventions required.

o Patient requests discharge.

o Patient transferred to another facility.

 All discharges must be justified by the pharmacist and discussed with the
prescriber.
7.14 Documentation
 Maintain:
o CR-MTAC First Visit Pharmacotherapy Review Form (Appendix 1)

o CR-MTAC Follow-up Visit Pharmacotherapy Review Form (Appendix

2)
o Pharmacist Review & Counselling Checklist (Appendix 3)

 Document all interventions and pharmaceutical care recommendations.

ACMTAC
Study Notes on Anticoagulation Therapy Management

Introduction
 Proper anticoagulation therapy is essential to minimize the risk of
thrombotic and hemorrhagic events.
 Anticoagulation therapy with warfarin has evolved from doctor-managed
clinics to a collaborative approach with pharmacists, improving patients'
time in therapeutic range (TTR).
 Maximum benefits of warfarin therapy are evident when TTR is ≥70%.
 The availability of Direct Oral Anticoagulants (DOACs) targeting Factor
IIa/thrombin (Dabigatran) or Factor Xa (Rivaroxaban and Apixaban)
reduces the need for frequent monitoring compared to warfarin, with
fewer drug interactions and predictable pharmacokinetics.
 However, proper monitoring of DOAC patients remains crucial for
adherence and bleeding risk prevention.
 This protocol serves as a standardized guide for all Anticoagulation
Medication Therapy Adherence Clinics (ACMTAC) in the Ministry of Health
(MOH). It must be discussed with department heads and endorsed by the
Hospital Director before implementation. The protocol applies only to
drugs registered under the Malaysia Drug Formulary (FUKKM).

Selection of Patients
1. All outpatients on anticoagulation therapy in relevant disciplines.
2. For inpatients started on anticoagulation therapy, referrals should be
made before discharge for adequate case review and patient education
using the standard referral form (ACMTAC/F1 - Appendix 1).
3. All new cases from other clinics/institutions or anticoagulant initiation
must be discussed with the prescriber.
4. The pharmacist must obtain and complete the Prescriber Checklist for
DOACs (Appendix 5) and Pharmacist Checklist for DOACs (Appendix 6) for
all new DOAC patients.

Registration
1. Patients must follow general registration policies and procedures.
2. The registry of ACMTAC patients must be maintained and updated.
Blood Tests
1. For warfarin patients, INR can be determined through Point of Care Testing
(POCT) or central laboratory testing. Blood sampling for INR must be
performed by trained healthcare providers.
2. Renal and/or liver profiles should be taken before scheduled appointments
when needed.

Clinic Operation
1. A designated area with minimal interruptions to ensure patient privacy
and confidentiality.
2. A proper storage area for relevant documents and necessary items.
3. Scheduled patient case notes should be reviewed for better therapy
understanding.

Patient Education
1. Education ensures safe and effective anticoagulation therapy use.
2. Education should be individualized based on patient understanding.
3. Each patient should receive a Buku Rawatan Antikoagulasi (available
in Bahasa Malaysia, Mandarin, and Tamil) or other relevant materials.
4. Patient education should include:
o Name, strength, and description of anticoagulant tablet.

o Frequency and timing of administration.

o How to handle missed doses.

o Purpose and mechanism of anticoagulation therapy.

o Medication, supplement, and dietary interactions.

o Symptoms of bleeding/thrombosis, adverse reactions, and

necessary actions.
o Importance of compliance and clinic follow-ups.

o Special precautions for anticoagulants during pregnancy or

breastfeeding.
5. Patient education checklists:
o Warfarin Education Checklist (Appendix 7)

o Dabigatran Education Checklist (Appendix 8)

o Rivaroxaban Education Checklist (Appendix 9)

 o Apixaban Education Checklist (Appendix 10)

Monitoring and Evaluation

1. Patients' response to anticoagulation therapy should be evaluated through
INR, renal profile, and patient interviews using:
o ACMTAC/F2 (Appendix 2)

o ACMTAC/F3 (Appendix 3)

o Pharmacist Checklist for DOACs (Appendix 6)

2. Monitoring criteria:
o Signs and symptoms of hemorrhage or thromboembolism.

o Changes in condition(s) or disease state.

o Alterations in diet, medications, tobacco, or alcohol intake.

o Changes in other medical conditions.

o Compliance with therapy.

o Upcoming surgery or dental procedures.

Dosage Adjustments
A. Warfarin
1. Warfarin dose adjustments should maintain INR within range (Refer to
Warfarin Therapy Guide - Appendix 11).
2. Warfarin dose adjustment workflow (Figure 2).
3. Weekly dosing chart (Appendix 12).
4. Target INR must be precise for valve replacements and acute VTE;
extended ranges (±0.2 of target INR) can be applied otherwise.
5. Dose adjustments are required when:
o Two consecutive INR values are sub-therapeutic or supra-
therapeutic.
o Follow-up is needed after therapy initiation.

o Warfarin interactions occur (Appendix 13).

B. DOACs
1. DOAC dosing should follow the Dosing Guide:
o Dabigatran (Appendix 14)

o Rivaroxaban (Appendix 15)

 o Apixaban (Appendix 16)

2. Dose adjustments are required if:

o Creatinine clearance ≤30ml/min.

o Older age.

o High bleeding risk.

C. Triple Therapy
1. Triple antithrombotic therapy post-ACS/PCI increases bleeding risk.
2. Triple therapy beyond six months post-PCI is not recommended (Triple
Therapy Guideline - Appendix 17).
D. Anticoagulant Conversion
Conversion between warfarin, LMWH, UFH, and DOACs should follow the
Anticoagulant Conversion Guide (Appendix 18).

Managing Bleeding in Anticoagulation Patients

1. Anticoagulation reversal for Warfarin or DOACs should follow guidelines
based on bleeding severity and INR value (Appendix 19).

Pharmacist Responsibilities
1. Educate patients during initial and follow-up visits.
2. Monitor:
o INR values (Appendix 11)

o Bleeding risk

o Antiplatelet discontinuation (Appendix 11)

o Renal/liver profile (Appendices 14-16)

3. Transcribe warfarin prescriptions (signed by an appointed doctor for

medico-legal purposes based on local policy).
4. Refer patients to a doctor when:
o Severe hemorrhage is suspected.

o Thromboembolism symptoms occur.

o INR >4.0 or at hospital discretion.

o LMWH bridging is needed.

o Therapy duration is complete.

o Non-compliance is an issue.
 o Warfarin re-initiation or anticoagulant conversion is necessary.

o DOAC dose reduction is required.

Dispensing
1. Pharmacists must ensure the correct dose and quantity are dispensed.
2. Emphasize correct dose, frequency, and timing upon dispensing.
3. Use standardized labels (Appendix 19) for warfarin.
4. Provide patients with an information summary at the end of ACMTAC
sessions.
5. Reassess patients' understanding when necessary.

Missed Appointments
1. Contact the patient promptly and reschedule (for clinics operating once
weekly).
2. Allow walk-ins on the next ACMTAC day (for clinics operating twice
weekly).
3. Document missed appointments (Appendix 4).
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Neurology MTAC Study Notes

A. General Objectives
1. Empower patients with knowledge on medications and disease.
2. Improve and sustain adherence to medications.
3. Optimize pharmacotherapy in terms of quality, safety, and cost-
effectiveness.
4. Minimize the risk of adverse drug reactions and medication side effects.
B. Scope of Service
Neurology MTAC services will be provided to patients managed in the Neurology
Clinic, MOPD Clinic, Stroke Clinic, Rehabilitation Clinic, or other relevant clinics.
Eligibility is based on the enrolment criteria.
C. Patient Selection Criteria
Patients are selected based on specific neurologic conditions, including:
 Non-adherence to medications.
 Drug-related problems (e.g., sub-optimal therapy, overdose, inappropriate
therapy).
  Referral via CP4 form (pharmacists) or standard facility forms (other
healthcare providers).
D. Registration
A registry of all MTAC patients must be maintained.
E. Appointment & Missed Visits
1. Appointment Scheduling: Managed by MTAC pharmacist via tools like
calendar, planner, or PhIS system.
2. Missed Visits: Patients will be contacted by the pharmacist or clinic staff
for rescheduling.
F. Activities During MTAC Sessions
1. Initial Visit:
o Introduction to Neurology MTAC objectives and benefits.

o Discussion on patient’s specific drug therapy needs and

responsibilities.
o Baseline assessment (demographics, medical/medication history,
family history, medication knowledge, adherence).
o Patient education and counseling at an appropriate pace.

o Identification of pharmaceutical care issues and communication

with the physician.
2. Second & Subsequent Visits:
o Management of pharmaceutical care issues.

o Continued patient education.

o Scheduling visits based on health status, clinic visits, and

medication refills.
o Caregiver involvement for bedridden patients.

G. Documentation
 1. Update all MTAC forms during sessions and store records in the pharmacy
department.
2. Attach relevant forms to patient case notes.
3. Use standardized assessment forms for all neurologic conditions, with
additional forms for specific diseases.
H. Outcome Measures
1. Medication adherence status.
2. Medication knowledge assessment.
3. Laboratory investigations and treatment responses.

SECTION 1: STROKE
Definition
A major health issue, ranking among the top causes of hospitalization and death.
Stroke can lead to long-term physical and cognitive disabilities.
Risk Factors in Malaysia
 Hypertension (67.0%)
 Diabetes (39.6%)
 Smoking (25.2%)
 Hyperlipidemia (23.0%)
Patient Selection Criteria
1. Recent first or recurrent stroke with risk factors.
2. Suspected non-adherence to medication.
3. Drug-related problems or adverse drug reactions.
4. Referral from healthcare providers.
Monitoring Parameters/Activities
1. Recent Stroke Recovery:
o Assess swallowing function and medication suitability.

o Review medication handling by patients/caregivers.

2. Recurrent Stroke Prevention:

o Ensure medications for secondary prevention.

o Monitor risk factors (BP, glucose, lipids, INR).

o Promote smoking cessation.

Outcome Measures
 1. Risk factor management.
2. Medication adherence.
3. Medication knowledge (DFIT score).
4. Laboratory parameters (renal, liver function tests, etc.).

Discharge Criteria
Patients can be discharged if they meet two or more of the following:
1. DFIT > 80% with no treatment changes for 2 visits.
2. Therapeutic goals achieved, no further monitoring needed.
 3. Transfer to another facility.
4. Defaults 2 consecutive visits despite follow-up calls or requests to exit
MTAC.

SECTION 2: EPILEPSY
Definition
 Seizure: A brief occurrence of signs/symptoms due to excessive brain
activity.
 Epilepsy: A disorder causing recurrent, unprovoked seizures.
Patient Selection Criteria
1. Newly diagnosed/initiation of antiepileptic drugs (AEDs).
2. Medication changes required.
3. Drug-related problems or adverse reactions.
4. Adherence issues.
5. Uncontrolled seizures.
Monitoring Parameters/Activities
1. Seizure Control: Maintain seizure diary (profile, frequency, triggers).
2. Therapeutic Drug Monitoring: Phenytoin, Carbamazepine, Sodium
Valproate, Phenobarbitone.
Outcome Measures
1. Medication adherence.
2. Seizure frequency and duration.
3. Medication knowledge (DFIT score).
4. AED therapeutic drug levels.
5. Laboratory tests (renal, liver function, etc.).
Discharge Criteria
Patients can be discharged if they meet two or more of the following:
1. DFIT > 80% with no treatment changes for 2 visits.
2. Therapeutic goals achieved, no further monitoring needed.
3. No seizures after stopping AEDs for 2 visits.
4. Transfer to another facility.
5. Defaults 2 consecutive visits despite follow-up calls or requests to exit
MTAC.
SECTION 3: PARKINSON’S DISEASE (PD)
Definition
A neurodegenerative disease involving the loss of dopaminergic neurons in the
basal ganglia, leading to movement disorders.
Motor Complications of Levodopa Therapy
 40% of levodopa-treated patients develop motor fluctuations/dyskinesia
after 4-6 years.
 10% yearly increase in motor fluctuations after levodopa initiation.
 80% develop motor fluctuations/dyskinesia after 10 years of treatment.
Patient Selection Criteria
1. Newly diagnosed and started on medication.
2. Suspected non-adherence.
3. Drug-related problems or adverse reactions.
4. Motor fluctuations and dyskinesia with levodopa therapy.
5. Referred by healthcare providers.
Monitoring Parameters/Activities
 1. Patient Education: For all recruited patients.
2. Individualized Dose Adjustment of Levodopa:
o Required for uncontrolled movements.

o Based on a 24-hour motor diary (ON/OFF periods, dyskinesia

timing).
o Physical assessment.

o Patients with cognitive impairment are referred to physicians for

accuracy.

Discharge Criteria
Patients can be discharged if they meet two or more of the following:
1. DFIT > 80% with no treatment changes for 2 visits.
2. Therapeutic goals achieved, no further monitoring needed.
3. Transfer to another facility.
4. Defaults 2 consecutive visits despite follow-up calls or requests to exit
MTAC.

This study note consolidates all the key information while maintaining accuracy
and clarity.

GERIATRIC PROTOCOL
Geriatric Pharmacy Services Study Note
GENERAL OBJECTIVES
Geriatric Pharmacy Services aim to establish a collaborative relationship with
healthcare team members, patients, and caregivers. This is achieved by
collecting, analyzing, and communicating patient assessments as part of the
Comprehensive Geriatric Assessment (CGA) to develop a holistic treatment
plan that ensures efficacy, safety, and continuity of care.
Key Objectives:
1. Optimize Pharmacotherapy Plans: Design individualized care plans
tailored to psychosocial and economic needs, implement evidence-based
regimens, and monitor therapeutic outcomes.
2. Enhance Medication Understanding: Educate and empower patients
and caregivers to promote medication adherence.
3. Minimize Potentially Inappropriate Medications (PIMs): Reduce
adverse drug reactions by implementing personalized pharmaceutical
care plans focused on quality, safety, and cost-effectiveness.
4. Ensure Seamless Continuity of Care: Conduct comprehensive
medication reviews during hospitalization and follow-ups.

SCOPE OF SERVICE
Geriatric Pharmacy Services consist of three main components:
1. Geriatric Medication Therapy Adherence Clinic (GMTAC)
2. Geriatric Ward Pharmacy Services
3. Geriatric Home Medication Review (G-HMR)

1. Geriatric Medication Therapy Adherence Clinic (GMTAC)

Objectives:
1. Improve Adherence: Develop personalized medication plans based
on psychosocial and economic factors, ensuring adherence to therapy.
2. Educate Patients & Caregivers: Empower them with medication
knowledge.
3. Enhance Medication Safety: Reduce adverse effects and
complications.
4. Collaborate with Healthcare Providers: Work with physicians and
other professionals for optimal patient care.
Scope of Services:
 1. Conducted on Clinic Days: Pharmacists work in collaboration with
physicians.
2. Pharmacist Roles:
o Perform medication reviews and monitor efficacy and adverse
effects.
o Conduct medication reconciliation to optimize therapy.

o Address drug-related problems.

o Design a medication management plan with input from patients,

caregivers, and healthcare providers.
o Educate patients/caregivers on medication use and monitoring.

3. Follow-Ups: Regular check-ups based on patient selection criteria.

4. Patient Recruitment: Based on defined selection criteria.
Manpower Requirement:
 At least one registered pharmacist should be present during each MTAC
session.
Appointment & Missed Visits:
1. Scheduled Appointments: Based on geriatric clinic schedules; virtual
sessions may be arranged.
2. Missed Appointments: Patients will be rescheduled for the next
geriatric clinic visit or a virtual session.
Procedures:
1. Location:
 Geriatric clinic or an area ensuring patient privacy during pharmacist-
patient interactions.
2. Operation Hours:
 Conducted on geriatric clinic days or as per schedule.
3. Patient Selection Criteria:
 Geriatric patients receiving treatment in geriatric clinics.
 Patients with multiple medications or pharmaceutical care issues.
 Patients suspected of having 5 I’s Geriatric Giant Syndrome:
1. Iatrogenic (drug-related issues)
2. Instability
3. Immobility
4. Incontinence
 5. Impaired cognition
 Patients referred by doctors or other healthcare providers.
 Virtual session inclusion criteria:
o Bedridden patients

o Logistic difficulties

o Availability of IT infrastructure

Key Activities:
1. Patient Screening:
o Review patient case notes and medical history.

o Select eligible patients for GMTAC enrollment.

2. First Visit – Enrollment:

o Registration: Follow standard procedures.

o Introduction: Explain objectives, activities, rights, and expected

benefits.
o Initial Assessment:

 Medical history, social history, allergies, and lab results.

 Medication reconciliation (using EMMAS form).
3. Medication Knowledge & Adherence Evaluation:
o Conduct medication assessment using DFIT score, pill count,
MyMAAT, or other validated tools.
o Document findings.

4. Pharmacotherapy Review:
o Identify pharmaceutical care issues.

o Use screening tools (MeSATE, MAI, START, STOPP, Beer’s

Criteria, FRIDs, MALPIP).
o Develop and implement a care plan.

o Collaborate with geriatricians and physicians to make necessary

therapy adjustments.
o Monitor progress and modify care plans as needed.

5. Medication Counseling:
o Educate patients/caregivers on proper medication use.

o Remind patients to bring medication records to each visit.

Discharge Criteria:
  Default follow-up for 1 year.
 Deceased patient.
 Patient refusal.
 Transfer to another facility.
 No pharmaceutical care issues for 2 consecutive visits.
Documentation:
 Maintain GMTAC-1 and EMMAS forms.
 Record all relevant patient data.

2. Geriatric Ward Pharmacy Services

Objectives:
1. Conduct medication review and reconciliation.
2. Identify and resolve pharmaceutical care issues.
3. Collaborate with healthcare teams to optimize pharmacotherapy.
4. Develop and implement pharmaceutical care plans.
5. Provide disease and medication counseling.
6. Report adverse drug reactions and medication errors.
7. Ensure accurate medication lists for transition of care.
8. Document clinical data for multidisciplinary team communication.
9. Provide continuous pharmacotherapy education for healthcare
providers.
Scope of Services:
 Pharmacists ensure safe and responsible medication use by assisting
physicians in prescribing and monitoring therapy.
 Services include medication reconciliation, therapeutic drug
monitoring, and patient counseling.

3. Geriatric Home Medication Review (G-HMR)

Objectives:
1. Reconcile medications to prevent inappropriate drug use.
2. Identify and manage medication-related issues.
3. Educate patients and caregivers on medication use.
4. Improve adherence to prescribed therapy.
 5. Monitor and ensure proper medication storage at home.
6. Address psycho-socioeconomic factors affecting medication
adherence.
Patient Selection Criteria:
 Aged ≥60 years.
 Poor adherence or difficulty managing medications.
 Polypharmacy (≥5 medications) or multiple clinic follow-ups.
 Patients on enteral feeding tubes.
 Recurrent hospital admissions or falls.
 Referrals from geriatric teams (doctors, pharmacists, MDT
members).
Scope of Services:
 Pharmacists perform home visits to evaluate the patient’s living
environment, assess physical/mental health, and educate caregivers.
 Address medication discrepancies after hospital discharge.
 Collaborate with doctors, therapists, and nurses for seamless
patient care.

***SIMPLIFIED***

Geriatric Pharmacy Services Overview

Geriatric pharmacy services focus on optimizing pharmacotherapy for elderly
patients by improving adherence, reducing adverse drug reactions (ADRs), and
ensuring medication safety. The services include:
1. Geriatric Medication Therapy Adherence Clinic (GMTAC) –
Enhancing adherence through structured pharmaceutical care.
2. Geriatric Ward Pharmacy – Medication review and reconciliation during
hospitalization.
3. Geriatric Home Medication Review (G-HMR) – Continuity of care
through home visits.

STOPP & START Criteria for Medication Review

The STOPP (Screening Tool of Older People’s potentially inappropriate
Prescriptions) and START (Screening Tool to Alert doctors to Right
Treatment) criteria help identify inappropriate prescriptions and ensure
necessary medications are prescribed.
  STOPP Examples:
o Benzodiazepines for insomnia >2 weeks (risk of dependence,
falls).
o Antipsychotics in dementia patients beyond 12 weeks (increased
stroke risk).
o Anticholinergic drugs in dementia or delirium (worsens cognitive
impairment).
 START Examples:
o Acetylcholinesterase inhibitors for Alzheimer’s (if indicated).

o Antihypertensives for uncontrolled hypertension.

o Antiplatelets for secondary stroke prevention.

Deprescribing Guidelines
Deprescribing algorithms assist in discontinuing inappropriate medications safely.
Algorithms exist for:
 Benzodiazepines & Z-drugs (reduce risk of dependence, falls).
 Proton Pump Inhibitors (PPIs) (reduce long-term adverse effects).
 Antipsychotics (prevent unnecessary use in dementia).
 Cholinesterase Inhibitors & Memantine (discontinuation criteria for
Alzheimer’s patients).
 Antihyperglycemics (prevent overtreatment in frail elderly).

Geriatric Home Medication Review (G-HMR)

This service ensures proper medication use after hospital discharge and prevents
drug-related problems.
Patient Eligibility for G-HMR
 Aged ≥60 years.
 Polypharmacy (≥5 medications).
 Poor adherence or medication management issues.
 Recurrent hospital admissions or falls.
 Enteral feeding (NG tube, PEG tube).
 Referred by geriatricians or healthcare providers.
Key Activities in G-HMR
 1. Medication reconciliation – Identifying discrepancies between
prescribed and taken medications.
2. Pharmaceutical care plan – Identifying and resolving drug-related
issues.
3. Patient & caregiver education – Optimizing medication adherence and
understanding.
4. Storage assessment – Ensuring safe medication storage.

Geriatric Ward Pharmacy Services

Geriatric pharmacists work with multidisciplinary teams (MDT) in hospitals to
ensure:
 Safe and effective medication therapy.
 Medication reconciliation at admission, transfer, and discharge.
 Monitoring adverse drug reactions and medication errors.
 Pharmacotherapy review for optimal drug selection.

Geriatric Medication Therapy Adherence Clinic (GMTAC)

Pharmacists conduct structured interventions to improve adherence and optimize
medication use.
Patient Selection
 Geriatric patients with polypharmacy or medication-related issues.
 Suspected 5 I’s Geriatric Giant Syndrome:
o Iatrogenic (drug-related problems)

o Instability (falls)

o Immobility

o Incontinence

o Impaired cognition

Key Activities
1. Medication reconciliation – Reviewing medication lists for
discrepancies.
2. Adherence assessment – Using tools like DFIT score and MyMAAT.
3. Medication review – Using screening tools like MeSATE, MAI,
STOPP/START.
4. Education & counseling – Enhancing patient understanding and
compliance.
Discharge Criteria
 No pharmaceutical issues in 2 consecutive visits.
 DFIT score >80%, stable therapeutic goals.
 Transferred to another facility or patient refusal.

Key Screening Tools for Medication Review

Pharmacists use structured tools to assess medication safety in older adults:
1. MeSATE – Medication Safety Alert Tool for Elderly.
2. MAI – Medication Appropriateness Index.
3. STOPP/START – Identifying inappropriate prescribing.
4. Beer’s Criteria – U.S.-based list of potentially inappropriate medications.
5. FRIDs – Identifies Fall Risk Increasing Drugs.
6. MALPIP – Malaysian Potentially Inappropriate Prescribing Screening Tool.

RESPIRATORY MTAC
Respiratory Medication Therapy Adherence Clinic (RMTAC) Study Note
OBJECTIVES
1. Maximize the benefits of medication therapy in Asthma/COPD patients.
2. Increase patient adherence to Asthma/COPD medications.
3. Educate and encourage patients/caregivers on the proper use of
medications and inhalers/devices.
4. Minimize adverse effects or complications from medications or
multiple drug regimens.
5. Reduce emergency room visits, lowering total healthcare costs.
6. Collaborate with physicians and healthcare professionals on
medication-related issues.

SCOPE OF SERVICE
1. The RMTAC service operates during clinic days, with follow-up sessions
in the Pharmacy/Clinic area.
2. RMTAC pharmacists assess pharmaceutical care issues, educate
patients/caregivers, conduct follow-up sessions, and document actions in
RMTAC forms.
MANPOWER REQUIREMENT
 A minimum of one trained pharmacist must be present at the clinic
during RMTAC sessions.

APPOINTMENTS
1. Appointments are scheduled by the pharmacist using the Respiratory
MTAC Appointment Book (Appendix 1).
2. Minimum follow-up sessions: Each patient must complete at least
three (3) follow-ups (Pre:Post = 1:3), with additional sessions as
needed.
3. Definitions:
o Pre-visit: First visit with patient’s consent for enrollment.

o Post-visit: Follow-up sessions (visit 2, 3, 4, etc.). At least three

(3) follow-ups are required.

PROCEDURES
1. Patient Selection Criteria
Patients diagnosed with Asthma/COPD meeting at least ONE of the following:
1. Asthma Control Test (ACT) score ≤19 (or Childhood Asthma Control
Test (C-ACT) score ≤19).
2. Uncontrolled Asthma based on the latest GINA Guidelines.
3. Frequent exacerbations per GINA/GOLD Guidelines.
4. Poor inhaler technique.
5. Low medication adherence.
2. Enrollment (Pre-visit)
1. Pharmacist introduction and patient consent (Appendix 4).
2. Initial visit activities:
o Explain RMTAC objectives.

o Educate on disease overview (via Asthma/COPD Flipchart).

o Conduct baseline assessment using RMTAC Pharmacy

Assessment Form (Adult) (Appendix 5a) or (Paediatric)
(Appendix 5b):
 Past medical history
 Exacerbation history
 Peak Expiratory Flow Rate (PEFR)
  Spirometry results (if applicable)
 Asthma symptom assessment (ACT, C-ACT, GINA)
 COPD symptom assessment (CAT, mMRC Dyspnea
Scale)
 Medication history & adherence
 Inhaler/device technique
3. Provide medication counseling and patient education as needed.
3. Follow-Up (Post-visit)
1. Scheduled based on clinic/pharmacist availability.
2. Counseling & education topics:
o Therapeutic goals:

 Asthma patients:
 ACT or C-ACT ≥20 OR GINA classification:
Controlled.
 Inform expected PEFR (using Appendix 6a/b for
age-specific values).
o Specific drug therapy: Align with patient’s treatment goals.

o Medication information: Benefits, side effects, and proper use.

o Inhaler/device technique training.

o Medication adherence importance.

4. Discharge Criteria
Patients can be discharged when:
1. Asthma patients: Achieve PEFR ≥80% of personal best (Adults only).
2. Patients meeting ANY of the following:
o Defaulted two consecutive appointments despite contact
attempts.
o Patient requests discharge.

o Transferred to another facility.

3. Re-enrollment: Discharged patients may be re-enrolled as new

RMTAC patients.
4. Discharged patient records will be considered as outpatient
counseling data.

MISSED APPOINTMENTS
  Follow-up within 14 working days for rescheduling.
 Record new appointment in the Respiratory MTAC Appointment Book
(Appendix 1).

DOCUMENTATION
1. Assessment, interventions, and drug-related issues must be
documented in the patient’s case notes:
o Directly written in case notes (Appendix 7a) OR

o Fill and attach:

 RMTAC Patient’s Progress Note (Adult) (Appendix 7b)

OR
 RMTAC Patient’s Progress Note (Paediatric) (Appendix
7c).
2. Additional Documentation:
o RMTAC Pharmacy Assessment Form (Adult) (Appendix 5a) OR

o RMTAC Pharmacy Assessment Form (Paediatric) (Appendix

5b)
o Store in pharmacy department patient file.

3. Reference for future MTAC follow-ups:

o RMTAC Pharmacy Assessment Form (Appendix 5a/b).

4. Patient details recorded in:

o Respiratory MTAC Record Book (Appendix 8).

RETROVIRAL MTAC
Comprehensive Study Notes: Retroviral Disease Medication Therapy
Adherence Clinic (RVD MTAC)
1. Introduction
 HIV Infection: A progressive immune system disease caused by
persistent viral replication, leading to immune destruction.
 Antiretroviral Therapy (ART): A treatment approach that improves CD4
count, reduces viral load, and prevents opportunistic infections.
 Pharmacist’s Role: Ensuring adherence, monitoring therapy, and
collaborating with healthcare professionals.
2. Objectives of RVD MTAC
1. Optimize benefits of Highly Active Antiretroviral Therapy (HAART).
2. Assist in managing drug-related side effects.
3. Provide patient and caregiver education.
4. Collaborate with healthcare professionals for HIV pharmacotherapy
management.

3. HIV Infection in Paediatrics

 Unique Considerations:
o Perinatal transmission is common.

o Requires specialized HIV virologic tests for diagnosis under 18

months.
o CD4 count varies with age.

o Drug metabolism changes with organ development.

 Challenges: Medication adherence, drug resistance, and multi-drug

management in growing children.

4. Disease Disclosure Status

 Partial Disclosure (≥7 years old): Use general terms like “germs” and
“germ fighters” (CD4).
 Full Disclosure (≥12 years old): Introduce the term “HIV” when child is
cognitively and emotionally ready.
 Impact: Disclosure may lead to stigma; pharmacists must maintain
confidentiality and assess readiness.

5. Pharmacist’s Responsibilities
 Educate on HAART initiation and regimen changes.
 Assess medication adherence and social stressors.
 Interpret laboratory results for therapy monitoring.
 Identify and prevent drug-drug interactions.
 Document interventions and ensure patient confidentiality.

6. Clinic Operations
  Setting: Conducted in medical, infectious disease, or paediatric
outpatient clinics.
 Manpower: Minimum one pharmacist per clinic, with 10–30 minutes per
session.
 Counselling Tools: Pamphlets, flipcharts, medication charts.
 Appointments: Scheduled by pharmacists or healthcare providers.
 Discharge Criteria: Patients discharged when transferred to another
MOH facility.

7. HAART Therapy & Counselling

 Pre-HAART Counselling:
o Educate on HIV, CD4, and viral load.

o Assess readiness and beliefs about HAART.

o Explain HAART regimen and adherence importance.

 Initiating HAART:
o Reinforce adherence and provide medication guides.

o Explain drug interactions and side effects.

o Address immune reconstitution inflammatory syndrome (IRIS).

 Follow-up HAART:
o Regular monitoring via pill counts and patient feedback.

o Address side effects and reinforce adherence importance.

o Encourage healthy lifestyle and hygiene practices.

8. Additional Counselling Notes

 Avoid mixing HAART drugs with milk.
 Consume only well-cooked meat and boiled water.
 Maintain proper hygiene and avoid exposure to animal feces.
 Store HAART medications properly.
 Educate on adherence challenges during fasting and travel.

9. RVD Ward Pharmacy Protocol

 Purpose: Manage hospital-admitted HIV patients, primarily due to
opportunistic infections or HAART side effects.
  Pharmacist’s Duties:
o Review medication history and case progression.

o Participate in ward rounds and recommend therapy adjustments.

o Provide bedside and discharge counselling.

o Monitor and report adverse drug reactions (ADRs).

10. Key HAART Medications

 Nucleoside Reverse Transcriptase Inhibitors (NRTIs):
o Lamivudine (3TC): Well-tolerated; causes peripheral neuropathy
and nausea.
o Zidovudine (AZT): Can cause anemia and hepatotoxicity.

 Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs):

o Nevirapine (NVP): High risk of hepatotoxicity.

o Efavirenz (EFV): Can cause neuropsychiatric side effects.

 Protease Inhibitors (PIs):

o Lopinavir/Ritonavir (LPV/r): Causes hyperlipidemia and
gastrointestinal issues.
 Integrase Inhibitors (INSTIs):
o Dolutegravir (DTG): Generally well-tolerated with minimal side
effects.

Diabetes Medication Therapy Adherence Clinic (DMTAC) Study Note

OBJECTIVES
1. Improve patient knowledge of medications and disease management.
2. Increase medication adherence among diabetes patients.
3. Reduce adverse effects and complications from multiple treatments.
4. Educate patients on diabetes complications, self-management,
medication use, and self-care devices.
5. Monitor pharmacotherapy responses between doctor’s visits.
6. Identify pharmaceutical care issues and recommend interventions.
7. Improve patient quality of life through structured diabetes care.

SCOPE OF SERVICE
 1. Clinic Operations:
o DMTAC services are provided in clinic areas during clinic days, with
follow-ups in pharmacy/clinic areas.
2. Pharmacist Responsibilities:
o Assess pharmaceutical care issues.

o Document actions and plans.

o Provide patient education.

o Complete follow-up sessions.

3. Workflow Adherence:
o Follow procedures outlined in Appendices 1, 2, and 3.

MANPOWER REQUIREMENT
 Only trained pharmacists may provide DMTAC services.

APPOINTMENTS
 Scheduled by pharmacists according to patient needs.

OUTCOME MEASUREMENTS
Patients are assessed at each DMTAC visit based on:
1. Medication adherence (Refer to Appendix).
2. Glycemic control:
o HbA1c, fasting plasma glucose (FPG), 2-hour postprandial
glucose (PPG).
3. Medication knowledge (DFIT score).
4. Other monitoring parameters:
o Lipid profile, blood pressure, etc.

WORKFLOW
1. Patient Selection Criteria
Eligible patients include those managed under MOH hospitals/clinics who:
1. Have uncontrolled diabetes despite medication optimization.
2. Are non-adherent to medications (Refer to Appendix 5).
3. Fail to achieve individualized HbA1c targets (Refer to Table 1).
 4. Have co-morbidities or multiple medications.
5. Experience microvascular or macrovascular complications.
6. Have frequent hypoglycemia episodes.
7. Were discharged from DMTAC for at least six months (eligible for re-
recruitment).

2. Initial Assessment by DMTAC Pharmacist

1. Review:
o Medical and medication history.

o Social/family history.

o Occupational history.

o Knowledge of disease and medications.

o Insulin/glucometer device technique.

o Medication adherence.

o Lifestyle factors (diet, physical activity).

o Allergies (drug, food, etc.).

2. Review vital signs and laboratory parameters.

3. Identify medication-related issues.
4. Patient Interview:
o Explain DMTAC objectives.

o Discuss treatment goals (HbA1c, weight, etc.).

o Assess drug therapy needs.

o Educate on rights and responsibilities in DMTAC.

5. Education Modules:
o Delivered at a pace suited to the patient’s understanding (Appendix
4).

3. Subsequent Visits
1. Scheduled every 1-3 months based on patient needs and clinic
schedules.
2. Longer intervals (>3 months) may be considered at the pharmacist’s
discretion.
 3. Virtual/phone consultations allowed, but patients require face-to-face
pharmacist review during doctor visits.
4. Each visit includes:
o Medication adherence assessment.

o Glycemic control review.

o Monitoring of relevant health parameters.

o Device technique assessment.

o Disease progression discussion.

o Medication knowledge assessment.

o Identification of side effects.

o SMBG (Self-Monitoring Blood Glucose) review.

o Lifestyle assessment.

o Education using Diabetes Modules (Appendix 4).

o Medication counseling.

o Adjusting insulin doses (with patient self-adjustment

guidance).
o Referrals to other healthcare providers if needed.

o Continuation of appointments until targets are achieved.

4. DMTAC Patient Registry

 A registry of all enrolled patients must be maintained.

5. Missed Visits
 Patients missing a visit must be rescheduled for a new appointment.

6. Pharmaceutical Review
1. Issue Identification:
o Assess patient for medication-related problems.

2. Recommendations:
o Suggest optimized pharmacological and non-pharmacological
interventions.
o Develop a patient-specific care plan.

o Consider medical, social, and financial factors.

 3. Evaluation:
o Monitor adherence to care plans.

o Track progress and adjust therapy as needed.

7. Medication Dispensing & Counseling

 Pharmacists dispense medications where feasible.
 Provide detailed counseling on medications.

8. Documentation
1. All assessments and recommendations must be recorded electronically
or manually.
2. Accessible to doctors, pharmacists, and healthcare teams.
3. Records must be retained for at least two years.

9. Discharge Criteria
Patients are discharged when:
1. HbA1c targets achieved for two consecutive readings.
2. Minimum of four visits completed with a DFIT score of 100% and
good adherence.
3. Defaulted for six months or missed three consecutive visits.
4. Transferred or discharged to another facility.

This structured study note ensures clarity in DMTAC objectives, patient

selection, assessments, workflow, pharmaceutical care, and discharge
protocols.