2
PROTOCOL
MEDICATION THERAPY
ADHERENCE CLINIC:
NEUROLOGY
1st Edition 2019
PHARMACY PRACTICE & DEVELOPMENT DIVISION
MINISTRY OF HEALTH MALAYSIA
First Edition, 2019
Pharmaceutical Services Programme
Ministry of Health Malaysia
Lot 36, Jalan Universiti
46350 Petaling Jaya,
Selangor, Malaysia
© ALL RIGHTS RESERVED
This is a publication of the Pharmaceutical Services Program, Ministry of Health Malaysia.
Enquiries are to be directed to the address below. Permission is hereby granted to
reproduce information contained herein provided that such reproduction be given due
acknowledgement and shall not modify the text.
Pharmaceutical Services Programme
Ministry of Health Malaysia Lot 36, Jalan Universiti, 46350 Petaling Jaya, Selangor, Malaysia
Tel: 603 – 7841 3200 Fax: 603 – 7968 2222
Website: www.pharmacy.gov.my
i
PREFACE
Medication Therapy Adherence Clinic (MTAC) was introduced in
2004 as part of clinical pharmacy services in the Ambulatory Clinic
System, which emphasized on medication management to improve
quality, safety and cost-effectiveness of patient care. Since then,
the service has been expanded and extended to various disciplines
and are available throughout Ministry of Health (MOH) Malaysia‘s
facilities where pharmacists work closely with other health care
providers in providing pharmaceutical care to the patients.
Acknowledging that long-term neurological conditions carry a significant burden
to the individual, families and carers, the government, and to society as a whole, MTAC
Stroke was initiated at Hospital Sultanah Nur Zahirah, Kuala Terengganu. With the
aim to expand the service, this First Edition MTAC Neurology Protocol is developed to
include epilepsy and Parkinson’s disease as part of MTAC Neurology. It outlines the
procedures and documentations during MTAC sessions and serve as a guide to
enable standardization of practice and establishment of MTAC Neurology service
throughout MOH’s facilities.
I would like to congratulate the Neurology Pharmacy Task Force, Pharmacy
Practice & Development Division, MOH for their contributions and commitments to the
publication of this protocol.
Thank you
DR. ROSHAYATI BINTI MOHAMAD SANI
Director
Pharmacy Practice & Development Division
Ministry Of Health Malaysia
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MEMBERS OF PANEL
ADVISORS
Dr Roshayati binti Mohamad Sani
Director of Pharmacy Practice and Development Division, Ministry of Health
EDITORS
Rozita binti Mohamad
Pharmacy Practice and Development Division, Ministry of Health
Nor Hasni binti Haron
Pharmacy Practice and Development Division, Ministry of Health
Amalina binti Amri
Pharmacy Practice and Development Division, Ministry of Health
CONTRIBUTORS
Tan Ai Leen
Hospital Kuala Lumpur
Parimala A/P Vijai Indrian
Hospital Tengku Ampuan Rahimah
Ho Chee Wah
Hospital Raja Permaisuri Bainun
Kong Lai San
Hospital Tuanku Ampuan Najihah
Siti Hajar binti Razali
Hospital Sultanah Nur Zahirah
EXTERNAL REVIEWER
Dr Santhi Datuk Puvanarajah
Senior Consultant Neurologist, Hospital Kuala Lumpur
ACKNOWLEDEGEMENTS
This Division would also like to thank those who were involved directly or indirectly in
preparing this Neurology Medication Therapy Adherence Clinic (MTAC) Protocol
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TABLE OF CONTENTS
Overview ................................................................................................................ 1
A. General Objective ............................................................................................ 1
B. Scope of Service ............................................................................................. 1
C. Types of Neurology MTAC ....................................................................................... 2
D. Location and Setting of Service ...................................................................... 2
E. Manpower Requirement .................................................................................. 2
F. Procedure ........................................................................................................ 3
1. Workflow .................................................................................................... 3
2. Patient Selection ................................................................................................... 4
3. Registration ............................................................................................................ 4
4. Appointment and Missed Visit(s) ....................................................................... 4
5. Activities during MTAC Session ......................................................................... 4
6. Documentation ...................................................................................................... 5
G. Outcome Measures .................................................................................................... 6
Section 1: Stroke ................................................................................................... 7
A. Introduction ....................................................................................................... 7
B. Patient Criteria .................................................................................................. 8
C. Specific Monitoring Parameters/Activities ......................................................... 8
D. Education Outline for Stroke Patient ................................................................. 9
E. Outcomes Measures ....................................................................................... 10
F. Discharge Criteria ........................................................................................... 10
Section 2: Epilepsy ............................................................................................. 11
A. Introduction ..................................................................................................... 11
B. Patient Criteria ................................................................................................ 11
C. Specific Monitoring Parameters/Activities ....................................................... 12
D. Education Outline for Patient with Epilepsy .................................................... 12
E. Outcomes Measures ....................................................................................... 12
F. Discharge Criteria ........................................................................................... 13
Section 3: Parkinson’s Disease ......................................................................... 14
A. Introduction ..................................................................................................... 14
B. Patient Criteria ................................................................................................ 14
C. Specific Monitoring Parameters/Activities ....................................................... 15
D. Education Outline for Patient with Epilepsy .................................................... 15
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E. Outcomes Measures ..................................................................................................15
F. Discharge Criteria ........................................................................................... 16
References ........................................................................................................... 17
Appendices ..............................................................................................................
Appendix 1(a-d): Medication Therapy Adherence Clinic Neurology (Stroke)
Forms .................................................................................................................. 19
Appendix 2(a-e): Medication Therapy Adherence Clinic Neurology (Epilepsy)
Forms ................................................................................................................. 24
Appendix 3(a-e): Medication Therapy Adherence Clinic Neurology (Parkinson’s
disease) Forms .......................................................................................................... 30
1
OVERVIEW
Medication management of neurologic disorders can be challenging in an
ambulatory care setting, which require close monitoring due to multiple medication
related issues such as complex titration and tapering schedule, use of multiple agents,
unique monitoring parameters and broad range of potential side effects that may be
harmful to the patients. Neurologic conditions are often chronic in nature, thus regular
assessment and review of medication regimen are required.
Clinical pharmacists may be uniquely positioned to assist with the medication
adjustments and monitoring that are often necessary for these conditions. Pharmacist‐
led Medication Therapy Adherence clinics (MTAC) are well established in some areas
of ambulatory care and have been beneficial in treatment aspect of the patient by
improving drug compliance, decreasing inappropriate prescribing and providing
positive therapeutic outcomes by monitoring patients' treatment plans1,2,3,4.
Expansion of clinical pharmacy services in the ambulatory neurology clinic via
Neurology MTAC is a good platform for pharmacist to play their role in extending the
provision of pharmaceutical care to the target group. This protocol will describe MTAC
Neurology, which is currently offered for patients with stroke, epilepsy and Parkinson’s
disease at an ambulatory setting.
A. General Objectives
• To empower patients with knowledge on medications and disease.
• To improve and sustain adherence towards medications.
• To optimize pharmacotherapy in terms of quality, safety and cost-effectiveness.
• To minimize risk of adverse drug reactions and side effects of medications.
B. Scope of Service
Neurology MTAC service will be provided to the patients who are managed in the
Neurology clinic, MOPD clinic or clinic focusing on specific conditions (e.g. Stroke
Clinic, Rehabilitation Clinic, etc.) and patients who fulfil the enrolment criteria.
2
Patients can either be referred by health care professionals or selected by
Neurology MTAC pharmacists.
C. Types of Neurology MTAC
Currently, there are three (3) types of Neurology MTAC:
a) Stroke,
b) Epilepsy, and
c) Parkinson’s Disease
Each Neurology MTAC protocol comprises of topics, counselling points and
monitoring parameters for specific disorders. It is important to note that the
selection of topics and the number of MTAC sessions should be tailored to
individual patient’s needs.
D. Location and Setting of Service
The Neurology MTAC service will operate in the clinic area during clinic day.
Subsequent visits can be carried out in either the pharmacy or clinic area
whichever deemed suitable depending on local setting.
E. Manpower Requirement
• Neurology MTAC service shall be provided by trained pharmacist(s).
• A minimum of one pharmacist will be required during MTAC session. However,
the number of pharmacists shall depend on the number of patients scheduled
per day.
• A coordinator should be appointed to facilitate the continuity of the service.
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F. Procedure
1. Workflow
a. Initial Visit
b. Second and Subsequent Visits
No
Yes
Identify Patient
Medication education &
counselling
Communicate
with physician Intervention
Initial assessment
Registration
Documentation
Provide next
appointment date
No
Yes
Patient comes for
MTAC follow-up
Medication education &
counselling
Communicate
with physician Intervention
Follow-up assessment
Documentation
Provide next
appointment date
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2. Patient Selection
Criteria for patient selection will depend on specific neurologic conditions.
Generally, patient with the following criteria will be selected:
a) Patients who is not adhering to their medications
b) Patients with drug-related problem, e.g. sub-optimal drug therapy,
medication overdose, inappropriate drug therapy etc.
Referral for MTAC between pharmacists will use CP4 form while referral for
MTAC from other health care providers will use standard forms in the facility.
3. Registration
A registry of all MTAC patients must be maintained.
4. Appointment & Missed Visit(s)
a) Appointment
All MTAC appointments shall be scheduled by the MTAC pharmacist using
a suitable tool e.g. calendar, planner, PhIS system etc.
b) Missed visits
Patients shall be contacted by pharmacist or clinic staff if he/she missed
any visit to reschedule the appointment.
5. Activities During MTAC sessions
The following activities will be performed by MTAC Pharmacist during MTAC
session:
a) Initial Visit
• Discussion with patient on:
o Introduction to Neurology MTAC & its objectives
o Anticipated benefits to the patients or caregivers
o Goals for patient
o Patient’s specific drug therapy-related needs
o Patient’s rights and responsibilities in the programme
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• Initial assessment of patient’s baseline on:
o Demographic data
o Medical / medication history
o Social / family history
o Medication knowledge
o Patient’s understanding of medication & adherence
• Counselling and patient education on the topics listed for respective
neurologic conditions (refer to respective modules).
The topics should be delivered at a pace suitable to patient’s knowledge
and understanding.
• Identification of pharmaceutical care issues and communication of
pharmaceutical care plan to the physician.
b) Second & Subsequent Visits
Activities during subsequent visits include managing pharmaceutical care
issues and providing patient education. Subsequent visits shall be
scheduled based on patients’ needs, current health status, other clinic visits
and medication refill appointments.
In cases whereby patients having difficulties or it is impossible for them to
attend the visit (e.g. bedridden due to stroke), the subsequent visits can be
done to the identified caregiver provided the patient medications are fully
managed by them.
6. Documentation
a) All relevant MTAC Forms must be updated during the MTAC sessions and
the record should be kept in the pharmacy department.
b) A copy of relevant forms will then be attached together with the patient’s
case notes.
c) All type of neurologic conditions (strokes / epilepsy / Parkinson’s disease)
will be using the similar assessment forms with additional form for specific
activities for respective disease.
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G. Outcome Measures
The following measures shall be monitored
a) Medications adherence status
b) Medication knowledge
c) Relevant laboratory investigations/ responses to treatment
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SECTION 1: STROKE
A. Introduction
Cerebrovascular accidents (stroke) are the second leading cause of death
worldwide and the third leading cause of disability5. In Malaysia, stroke represents
a major health concern ranking as one of the top 10 reasons for hospitalization and
the third largest cause of death6,7. The National Health and Morbidity Survey
(NHMS) in 2011 reported that the prevalence of stroke in Malaysia is 0.7%
compared to 0.3% in 20068. The number of patients suffering from stroke is
increasing rapidly due to expanding population numbers and aging as well as the
increased prevalence of modifiable stroke risk factors where most of the cases were
preventable9.
The mobility burden for patients, families, and society is considerable. About
thirty-five percent of stroke patients recovered independently at discharge while
54% of survivors suffer due to various degree of physical or cognitive disability,
which may inflict additional social issues affecting the family members in coping
with their daily activities10.
Hypertension (67.0%), diabetes (39.6%), cigarette smoking (25.2%), and
hyperlipidaemia (23.0%) were the commonest risk factors in the Malaysian
population11. Most strokes are preventable where 90% of strokes are linked with 10
modifiable risk factors11. Thus, early awareness of risk factors and modification of
certain behaviours could decrease stroke incidence and prevent stroke
recurrence12. Awareness on recognizing the signs and symptoms of strokes are a
necessity for prompt emergency stroke care can also minimize the chance of getting
stroke, limit the brain damage as well as the level of disabilities it cause13.
The pharmacist as an integral part of health care team can play a significant
role in improving patients’ awareness and knowledge and are in a key position to
tract adherence to drug therapy. A pharmacist involvement can improve disease
and disability prevention, leading to fewer physician visits, decrease the need for
medical treatment, lower health care costs and most important, improve patient’s
quality of life.
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B. Patient Criteria
Patient who has been diagnosed with stroke with the following criteria:
i. Recent first or recurrent stroke event with risk factors.
ii. Patient suspected of having non-adherence towards medication.
iii. Patient who has drug-related problems and suspected adverse drug reactions.
iv. Patient referred by healthcare providers, i.e. specialist, medical officers,
pharmacist, speech therapist.
C. Specific Monitoring Parameter / Activities
i. Patient recovering from recent stroke
Swallowing function
o Review suitability and appropriateness of medication (types, dosage
design, etc.)
o Review handling of medication by patient / caregivers (method and time
of administration time, etc.)
ii. Recurrent stroke prevention
Risk factors of recurrent stroke
o Ensure medications for secondary stroke prevention are given (if not
contraindicated)
o Monitor and optimize risk factor parameters (blood pressure, blood
glucose level, lipid profile, INR).
o Smoking reduction and cessation.
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D. Education Outline for Stroke Patient
No. Visit Education
1. First Visit Brief overview about stroke and stroke subtypes
Stroke risk factors
Stroke symptoms
Specific discussion on drugs as secondary prevention of
stroke (indication, role of each drug and adverse effects
o Antiplatelet (for ischemic stroke and transient
ischemic attack (TIA))
o Lipid lowering therapy
o Antihypertensive drug
o Anticoagulant for cardio-embolic stroke
Therapeutic goal for main parameters: blood pressure,
glucose level, LDL and INR.
2. Second Visit Education on risk factors (hypertension, diabetes
mellitus, atrial fibrillation, ischemic heart disease,
hyperlipidaemia, smoking cessation (if applicable),
alcohol consumption (if applicable), etc.)
3. Third Visit Stroke complication and prevention
4. Forth Visit Benefit of exercise
Basic nutrition and diet control
5. Subsequent
Visit
How to maintain therapeutic goals and long term plan
Revision of treatment goals
Specific drug counselling
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E. Outcome Measures
The following shall be monitored and assessed during MTAC visits:
i. Risk factors of recurrent stroke (blood pressure, blood sugar profile, lipid
profile).
ii. Adherence towards medications for chronic illnesses.
iii. Medication knowledge (DFIT score).
iv. Other laboratory parameters e.g. renal profile, liver function test etc.
F. Discharge Criteria
Patient who fulfilled two (2) of the following criteria can be discharged from MTAC
service:
i. Medication knowledge evaluation is satisfactory (DFIT > 80%) and no changes
in treatment regime for at least two (2) visits.
ii. Therapeutic goals have been achieved, all pharmaceutical issues have been
resolved and no further monitoring is needed.
iii. Discharged or transferred out to other facilities.
iv. Default two (2) consecutive appointments despite being contacted (effort must
be made to contact patient / caregiver by telephone call) or patient requests to
exit MTAC service.
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SECTION 2: EPILEPSY
A. Introduction
An epileptic seizure is defined as a transient occurrence of signs and / or
symptoms due to abnormal excessive or synchronous neuronal activity in the brain
while epilepsy is a disorder of the brain characterised by an enduring predisposition
to generate epileptic seizures that is, a seizure is an event and epilepsy is the
disease involving recurrent unprovoked seizures14,15. Epilepsy is responsible for an
enormous amount of suffering, affecting some 50 million people of all ages16. The
estimated proportion of the general population with active epilepsy at a given time
is between 4 and 10 per 1000 people and about 5 million new cases occur each
year16. Epilepsy is universal and the most common serious neurological disorder,
which accounts for 0.5% of the global burden of disease16.
Epilepsy can be associated with profound physical, psychological and social
consequences, and its impact on a person’s quality of life can be greater than that
of some other chronic conditions16. In many parts of the world, people with epilepsy
and their families suffer from stigma and discrimination and the risk of premature
death in people with epilepsy is up to three times higher than for the general
population16.
Epilepsy is treatable where 70% of patients could respond to treatment with
appropriate use of cost-effective anti-seizure medicines16. Failure to comply with
drug regimens is prevalent amongst patients with epilepsy and the consequence of
this, is often an increased risk of further seizures17. Further implementation of
educational programs for people with epilepsy would help to improve levels of
compliance thereby reducing the risk of unnecessary and preventable seizures.
B. Patient Criteria
Patient who has been diagnosed with epilepsy with the following criteria:
i. Newly diagnosed / newly initiated with antiepileptic medications.
ii. Requires changes in antiepileptic medications.
iii. Patient with drug-related problems and suspected adverse drug reactions.
iv. Patient with adherence problems towards antiepileptic medications.
v. Patient with uncontrolled seizure.
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C. Specific Monitoring Parameters/ Activities
i. Seizure Control: Seizure Diary (seizure profile, fit frequency and trigger of
seizures)
ii. Therapeutic Drug Monitoring (Phenytoin, Carbamazepine, Sodium Valproate,
Phenobarbitone)
D. Education Outline for Patient with Epilepsy
No. Visit Education
1. First Visit Brief overview on epilepsy and types of epilepsy
Treatment of epilepsy
Side effects of medications
Importance of adherence to antiepileptic
Management during and after seizure
Seizure diary
2. Second and
subsequent
visits
Review seizure diary & adherence
Other suggested additional info:
o Further explanation on medications (according to
types of medications)
o Complications of seizure attack
o Antiepileptics in pregnancy (if relevant)
E. Outcome Measures
The following measures shall be monitored and assessed during MTAC visits:
i. Adherence towards antiepileptic medications.
ii. Frequency and duration of seizure.
iii. Medication knowledge (DFIT score).
iv. Therapeutic Drug Monitoring of antiepileptic medications.
v. Other laboratory parameters e.g. renal profile, liver function test etc.
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F. Discharge criteria
Patient who fulfilled two (2) of the following criteria can be discharged from MTAC
service:
i. Medication knowledge evaluation is satisfactory (DFIT > 80%) and no changes
in treatment regime for at least two (2) visits.
ii. Therapeutic goals have been achieved, all pharmaceutical issues have been
resolved and no further monitoring is needed.
iii. No seizure attack after stopping antiepileptic for at least two (2) visits.
iv. Discharged or transferred out to other facilities.
v. Defaults two (2) consecutive appointments despite being contacted (effort must
be made to contact patient / caregiver by telephone call) or patient requests to
exit MTAC service.
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SECTION 3: PARKINSON’S DISEASES (PD)
A. Introduction
Parkinson’s disease (PD) was described by James Parkinson in his monograph
1817, “An Essay on the Shaking Palsy”. PD is a neurodegenerative disease, which
involves degeneration of dopaminergic neurons at basal ganglia and causes
movement disorder symptoms.
PD has a worldwide prevalence of approximately 0.3% in general population
over age of 40. This also suggests that there are about 7.5 million people who suffer
from PD worldwide18,19. The prevalence of PD is increasing over age whereby ratio
is 41:100,000 for 40-49 years old to 1900:100,000 for 80 years old and above18.
When PD progress or in advanced PD, motor fluctuation and dyskinesia are the
main complications especially in those who are treated with levodopa. There are as
many as 40% of levodopa-treated PD patients who experience motor fluctuation
and dyskinesia after being treated for 4-6 years20. The incidence of motor fluctuation
and dyskinesia is estimated to be about 10% per year after initiating levodopa21.
More than 80% of patients will experience motor fluctuation and dyskinesia, 10
years after initiating levodopa20.
Pharmacist in Neurology MTAC may help PD patients who suffer from motor
fluctuation complications through better management of medications and
subsequently improve their quality of life.
B. Patient Criteria
Patient who has been diagnosed with Parkinson’s disease with the following criteria:
i. Newly diagnosed and initiated with medication.
ii. Patient suspected of having non-adherence towards medication.
iii. Patient who has drug-related problems and suspected adverse drug reactions.
iv. Patient on levodopa therapy with motor fluctuation and dyskinesia.
v. Patient referred by healthcare providers, i.e. specialist, medical officers,
pharmacist.
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C. Specific Monitoring Parameter / Activities
i. Patient Education
For all recruited patients.
ii. Individualized dose adjustment of levodopa therapy
For patient who has potential for uncontrolled movement, or
For patient on levodopa with motor fluctuation and dyskinesia.
Based on patient’s motor diary (24 hours chart describing time at which ON,
OFF and dyskinesia occur) and basic physical test.
Patient with poor cognitive impairment will be referred to physician due to
possible inaccuracy of information on the ON, OFF and dyskinesia.
D. Education Outline for Patient with Parkinson’s Disease
No. Visit Education
1. First Visit Brief overview on Parkinson’s disease and signs and
symptoms
Treatment goal for Parkinson’s disease
Medication used for treatment of Parkinson’s disease
and their mechanism
Side effects of medication
Food interaction with levodopa therapy
2. Second and
subsequent
visits
Review patient’s response on treatment
Management of motor fluctuation, dyskinesia and
wearing off in levodopa therapy
E. Outcome Measures
The following shall be monitored and assessed during each MTAC visit:
i. Signs and symptoms of progressiveness of Parkinson symptoms (bradykinesia,
tremor and rigidity, swallowing function)
ii. History of falls
iii. Patient’s response after initiation / adjustment of a particular medication regime
iv. Recent alteration in diet (protein intake) and time of medication intake (before
or after meal)
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v. Medication knowledge (DFIT score) and adherence towards medications for
Parkinson’s disease.
F. Discharge Criteria
Patient who fulfilled two (2) of the following criteria can be discharged from MTAC
service:
i. Medication knowledge evaluation is satisfactory (DFIT > 80%) and no changes
in treatment regime for at least two (2) visits.
ii. Therapeutic goals have been achieved, all pharmaceutical issues have been
resolved and no further monitoring is needed.
iii. Discharged or transferred out to other facilities.
iv. Default two (2) consecutive appointments despite being contacted (effort must
be made to contact patient / caregiver by telephone call) or patient requests to
exit MTAC service.
In cases where discharged patient require continuation of MTAC service due to
progression of the Parkinson’s disease, patient may continue MTAC follow-up by
using previous registration.
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REFERENCES
1. You L.X., et al. (2015). Impact of pharmacist-managed Diabetes Medication
Therapy Adherence Clinic (DMTAC) in government health clinics. Malaysian
Journal of Pharmaceutical Sciences, Vol. 13, No. 1, 43–51.
2. Thanimalai S., Shafie A. A., Hassali M. A., & Sinnadurai J. (2013). Comparing
effectiveness of two anticoagulation management models in a Malaysian tertiary
hospital. International Journal of Clinical Pharmacy, 35(5), 736–743.
doi:10.1007/s11096-013-9796-6.
3. Mubashra B., Adliah M.A., Mohd M.B., & Norlaila M. (2016). Impact of a
pharmacist-led diabetes mellitus intervention on HbA1c, medication adherence
and quality of life: A randomised controlled study. Saudi Pharmaceutical Journal
Volume 24, Issue 1, January 2016, Pages 40-48.
4. Alrasheedy A.A., Hassali M.A., Wong Z.Y., & Saleem F. (2017). Pharmacist-
managed medication therapy adherence clinics: The Malaysian experience. Res
Social Adm Pharm. 2017 Jul - Aug;13(4):885-886.
5. Walter J., Oyere O., Mayowa O., & Sonal S. (2016). Stroke: A global response is
needed. Bull World Health Organ. 2016 Sep 1;94(9):634-634A.
6. Statistics on Causes of Death, Malaysia, 2018, Department Of Statistics Malaysia.
7. Health Facts 2018, Planning Division Health Informatics Centre, Ministry of Health
Malaysia.
8. MOH Malaysia. National Health and Morbidity Survey 2011 Report: Institute of
Public Health.
9. Katan, M., & Luft, A. (2018). Global burden of stroke. Seminars in Neurology,
38(02), 208–211.
10. Annual Report of the Malaysian Stroke Registry 2009-2016.
11. Dr Martin J O’Donnell, et al. “Global and regional effects of potentially modifiable
risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-
control study,” The Lancet, 2017; 388: 761-775.
12. Chin Y.Y., Sakinah H., Aryati A., & Hassan B.M. (2018). Prevalence, risk factors
and secondary prevention of stroke recurrence in eight countries from South, East
and Southeast Asia: a scoping review. MMed2, Med J Malaysia Vol 73 No 2 April
2018.
18
13. Díez-Tejedor E. & Fuentes B. (2004). Acute care in stroke: the importance of early
intervention to achieve better brain protection. Cerebrovasc Dis. 2004;17 Suppl
1:130-7.
14. International Leagues Against Epilepsy
15. Consensus Guidelines on Management of Epilepsy 2017, Malaysian Society of
Neuroscience.
16. WHO https://www.who.int/news-room/fact-sheets/detail/epilepsy
17. Malek N., Heath C. A., & Greene J. (2016). A review of medication adherence in
people with epilepsy. Acta Neurologica Scandinavica, 135(5), 507–515.
18. Pringsheim T., Jette N., Frolkis A., & Steeves T.D. (Nov 2014). The prevalence of
Parkinson’s disease: A systematic review and meta-analysis. Mov Disord. 29 (13):
1583-90.
19. Ross GW, Abbot RD (Nov 2014). Living and dying with Parkinson’s disease. Mov
Disord 29 (13):1571-3
20. Ahlskog J.E. & Muenter M.D. (2001). Frequency of Levodopa-related dyskinesia
and motor fluctuations as estimated from the cumulative literature. Movement
disorder: official journal of movement disorder society 16 (3), 448-458, 2001.
21. Marsden C.D. & Parkes J.D. (1977) Success and problems of long-term levodopa
therapy in Parkinson’s disease. Lancet 1977;1:345-9.
19
Appendix 1a
MEDICATION THERAPY ADHERENCE CLINIC
NEUROLOGY (STROKE)
Patient Name: MRN:
Stroke Subtype:
ADL:
Dependent / Independent
Caregiver’s Name & Contact No:
Address:
Risk Factor □ Hypertension
□ Diabetes Mellitus
□ Hyperlipidemia
□ Atrial Fibrillation
□ Smoking
□ Others:
Date of MTAC Recruitment
Date of MTAC Visit 1.
2.
3.
4.
5.
6.
7.
8.
Date of Discharge
20
Appendix 1b
MEDICATION THERAPY ADHERENCE CLINIC
NEUROLOGY (STROKE)
Patient Name : Gender : M / F
MRN / ID NO : Race : M / C / I / Other _____
Age : Allergy :
Diagnosis :
Assessment
Social History Family History
Smoking :
Alcohol Intake :
Pregnancy :
Drug Abuse :
Education Level:
Diet & Lifestyle :
Yes (___Sticks/day) /
No / Ex-smoker / Passive
smoking
Yes ( amount ______) /
No / Ex-alcoholic
Yes (______ trimester) /
No / Planning to get
pregnant
Yes (_________) / No
Primary / Secondary /
Tertiary
Marital status :
Family history of
illness :
No. of Children :
Lives with :
Single / Married /
Divorced / Widowed
Alone / Family
Members / Nursing
Homes / Others
Medical History
Comorbidities:
Surgical History:
Diagnostic Test:
Medication History
Past Medication History (and indication):
Non-Prescription Medication
(includes herb/ vitamin/ supplement &
reasons of taking):
21
Current Medication
DFIT Score: Level of adherence:
22
Appendix 1c
STROKE RISK FACTOR EVALUATION & MEDICATION REVIEW
Date: Visit No:
Medication D F I T Remark
Score (%) D = Dose, F = Frequency, I = Indication, T = Method of Administration
Control of Risk Factor
Risk Factors Status Comment
i. Hypertension Control/Uncontrolled,
ii. Diabetes Mellitus Control/Uncontrolled
iii. Hyperlidemia Control/Uncontrolled
iv. Smoking Yes / No
v. INR (if applicable) ____ (Target:_____)
Complications
□ Aspiration Pneumonia
□ Urinary Tract Infection
□ Bedsore
□ Seizure
□ Upper GI Bleeding
□ Depression
□ Recurrent stroke
□ Others: ___________
Pharmaceutical Care Issue
Pharmacist Intervention
Outcome/Plan
Pharmacist Name & Signature
23
Appendix 1d
Laboratory Values
Visit
Date
BP (mmHg)
PR (bpm) 60-100
RR (bpm) 12-18
Lipid Profile
T. Chol (mmol/l) <5.2
TG (mmol/l) 0.6-2.3
LDL (mmol/l) <1.8
HDL (mmol/l) >1.7
Renal Profile
Urea (mmol/l) 2.8-7.2
Na (mmol/l) 133-145
K (mmol/l) 3.3-5.1
SrCreatinine (umol/l) 45-84
CrCl (ml/min)
Liver Profile
T. Protein (g/L) 55-82
Albumin (mg/dl) 35-50
ALP (u/l) 30-120
ALT(u/l) <34
AST (u/l) <37
T. Bilirubin (umol/l) <21
Full Blood Count
WBC (x103/uL) 4-11
Hb (g/dL) 13.5-18
Platelet (x103/uL) 150 - 450
Cardiac Enzymes
CK (u/l) 24-195
LDH (u/l) <247
AST (u/l) <45
Coagulation Profile
PT 10.6-15.0 sec
APTT 26-42 sec
INR
Blood Sugar Profile
FBS (mmol/l) 4-6
RBS (mmol/l) 6-8
HbA1c <6.5%
Others
Weight (kg)
24
Appendix 2a
MEDICATION THERAPY ADHERENCE CLINIC
NEUROLOGY (EPILEPSY)
Patient Name: MRN:
Diagnosis:
ADL:
Dependent / Independent
Caregiver’s Name & Contact No:
Address:
Date of MTAC Recruitment
Date of MTAC Visit 1.
2.
3.
4.
5.
6.
7.
8.
Date of Discharge
25
Appendix 2b
MEDICATION THERAPY ADHERENCE CLINIC
NEUROLOGY (EPILEPSY)
Patient Name : Gender : M / F
MRN / ID NO : Race : M / C / I / Other _____
Age : Allergy :
Diagnosis :
Assessment
Social History Family History
Smoking :
Alcohol Intake :
Pregnancy :
Drug Abuse :
Education Level:
Diet & Lifestyle :
Yes (___Sticks/day) /
No / Ex-smoker / Passive
smoking
Yes ( amount ______) /
No / Ex-alcoholic
Yes (______ trimester) /
No / Planning to get
pregnant
Yes (_________) / No
Primary / Secondary /
Tertiary
Marital status :
Family history of
illness :
No. of Children :
Lives with :
Single / Married /
Divorced / Widowed
Alone / Family
Members / Nursing
Homes / Others
Medical History
Comorbidities:
Surgical History:
Diagnostic Test:
Medication History
Past Medication History (and indication):
Non-Prescription Medication
(includes herb/ vitamin/ supplement &
reasons of taking):
26
Current Medication
DFIT Score: Level of adherence:
27
Appendix 2c
EPILESY EVALUATION & MEDICATION REVIEW
Date Visit No
Medication D F I T Remark
Score (%) D = Dose, F = Frequency, I = Indication, T = Method of Administration
Seizure Control (since last visit)
Description of seizure
Trigger Factor
Latest TDM result
Adherence status
Any adverse
effect(s) of AED?
Pharmaceutical Care Issue
Pharmacist Intervention
Outcome/Plan:
Pharmacist Name & Signature
28
Appendix 2d
Laboratory Values
Visit
Date
BP (mmHg)
PR (bpm) 60-100
RR (bpm) 12-18
Lipid Profile
T. Chol (mmol/l) <5.2
TG (mmol/l) 0.6-2.3
LDL (mmol/l) <1.8
HDL (mmol/l) >1.7
Renal Profile
Urea (mmol/l) 2.8-7.2
Na (mmol/l) 133-145
K (mmol/l) 3.3-5.1
SrCreatinine (umol/l) 45-84
CrCl (ml/min)
Liver Profile
T. Protein (g/L) 55-82
Albumin (mg/dl) 35-50
ALP (u/l) 30-120
ALT(u/l) <34
AST (u/l) <37
T. Bilirubin (umol/l) <21
Full Blood Count
WBC (x103/uL) 4-11
Hb (g/dL) 13.5-18
Platelet (x103/uL) 150 - 450
Cardiac Enzymes
CK (u/l) 24-195
LDH (u/l) <247
AST (u/l) <45
Coagulation Profile
PT 10.6-15.0 sec
APTT 26-42 sec
INR
Blood Sugar Profile
FBS (mmol/l) 4-6
RBS (mmol/l) 6-8
HbA1c <6.5%
Others
Weight (kg)
29
Appendix 2e
Therapeutic Drug Monitoring Assay Result
Date & Time of
sampling Medication Therapeutic Range
Expected Range
(based on calculation) Measured Level TDM Recommendation
30
Appendix 3a
MEDICATION THERAPY ADHERENCE CLINIC
NEUROLOGY (PARKINSON’S DISEASE)
Patient Name: MRN:
Diagnosis:
ADL:
Dependent / Independent
Caregiver’s Name & Contact No:
Address:
Diet Normal / Vegetarian
Date of MTAC Recruitment
Date of MTAC Visit 1.
2.
3.
4.
5.
6.
7.
8.
Date of Discharge
31
Appendix 3b
MEDICATION THERAPY ADHERENCE CLINIC
NEUROLOGY (PARKINSON’S DISEASE)
Patient Name : Gender : M / F
MRN / ID NO : Race : M / C / I / Other _____
Age : Allergy :
Diagnosis :
Assessment
Social History Family History
Smoking :
Alcohol Intake :
Pregnancy :
Drug Abuse :
Education Level:
Diet & Lifestyle :
Yes (___Sticks/day) /
No / Ex-smoker / Passive
smoking
Yes ( amount ______) /
No / Ex-alcoholic
Yes (______ trimester) /
No / Planning to get
pregnant
Yes (_________) / No
Primary / Secondary /
Tertiary
Marital status :
Family history of
illness :
No. of Children :
Lives with :
Single / Married /
Divorced / Widowed
Alone / Family
Members / Nursing
Homes / Others
Medical History
Comorbidities:
Surgical History:
Diagnostic Test:
Medication History
Past Medication History (and indication):
Non-Prescription Medication
(includes herb/ vitamin/ supplement &
reasons of taking):
32
Current Medication
DFIT Score: Level of adherence:
33
Appendix 3c
PARKINSON’S DISEASE EVALUATION & MEDICATION REVIEW
Date: Visit No
Disease Control
Motor
symptoms
□ Bradykinesia
□ Tremor
□ Fall (time: ___)
□ Swallowing difficulty
□ OFF
□ ON
□ Others: ______
Non-Motor
symptoms
Medication
Adverse Effect
Levodopa
□ Dyskinesia
□ Hallucination
□ GI symptoms
□ Delayed-ON
(___ minutes)
□ OFF
□ Others: ______
Dopamine
Agonist
□ Hallucination
□ Obsessive behaviour
□ Insomnia
□ Orthostatic
hypotension
Headache
□ Others:_____
Anti-
cholinergic
□ Tremor
□ Dry mouth
□ Urinary retention
□ Hallucination
□ Blurred vision
□ Others:_____
Pharmaceutical
Care Issue
Pharmacist
Intervention
Outcome/Plan
Pharmacist Name
& Signature
34
Appendix 3d
D = Dose, F = Frequency, I = Indication, T = Method of Administration * 2012 consensus Guidelines for the treatment of Parkinson's disease
Date: PATIENT’S ‘ON & OFF’ CHART
MEDICATION D F I T Morning (AM) Afternoon (PM) Evening (PM)
00-01
01-02
02-03
03-04
04-05
05-06
06-07
07-08
08-09
09-10
10-11
11-12
12-13
13-14
14-15
15-16
16-17
17-18
18-19
19-20
20-21
21-22
22-23
23-00
Score (%)
STATUS Morning (AM) Afternoon (PM) Evening (PM)
Date of recording: _________ 00-01
01-02
02-03
03-04
04-05
05-06
06-07
07-08
08-09
09-10
10-11
11-12
12-13
13-14
14-15
15-16
16-17
17-18
18-19
19-20
20-21
21-22
22-23
23-00
ASLEEP
OFF
ON without dyskinesia
ON with non-troublesome dyskinesia
ON with troublesome dyskinesia
Pharmacist’s note:
35
Appendix 3e
Laboratory Values
Visit
Date
BP (mmHg)
PR (bpm) 60-100
RR (bpm) 12-18
Lipid Profile
T. Chol (mmol/l) <5.2
TG (mmol/l) 0.6-2.3
LDL (mmol/l) <1.8
HDL (mmol/l) >1.7
Renal Profile
Urea (mmol/l) 2.8-7.2
Na (mmol/l) 133-145
K (mmol/l) 3.3-5.1
SrCreatinine (umol/l) 45-84
CrCl (ml/min)
Liver Profile
T. Protein (g/L) 55-82
Albumin (mg/dl) 35-50
ALP (u/l) 30-120
ALT(u/l) <34
AST (u/l) <37
T. Bilirubin (umol/l) <21
Full Blood Count
WBC (x103/uL) 4-11
Hb (g/dL) 13.5-18
Platelet (x103/uL) 150 - 450
Cardiac Enzymes
CK (u/l) 24-195
LDH (u/l) <247
AST (u/l) <45
Coagulation Profile
PT 10.6-15.0 sec
APTT 26-42 sec
INR
Blood Sugar Profile
FBS (mmol/l) 4-6
RBS (mmol/l) 6-8
HbA1c <6.5%
Others
Weight (kg)