Electronic Supplementary Material Table S1. Categories for drug-related problems (DRPs)

Drug selection (Problems relating to the choice of drug prescribed or taken)
DRP category / Explanation / Example
D1. Duplication / When the patient is taking two brands of the same generic drug. / Patient is administered combination formulation of alendronate/vitamin D 70/70 plus a monthly vitamin D capsule.
D2. Drug interaction / When prescribed drugs could significantly interact with one another leading to an ADE. / Patient is taking digoxin, minocycline and verapamil. Verapamil may increase levels of digoxin, also minocycline can increase digoxin levels due to reduction in gastric clearance and patient’s pulse rate is regularly in the low 60's.
D3. Wrong drug / When consensus statements or guidelines do not recommend a prescribed drug foe a particular indication. / Patient prescribed prednisone for maintenance treatment of COPD. Prednisone (oral corticosteroids) are not recommended in current guidelines for the maintenance treatment of COPD
D4. Incorrect Strength / When patient presents with a prescription that has no details about a drug’s strength or incorrect details that may require clarification from the prescriber
D5. Inappropriate dosage form / When the formulation of the prescribed product is inappropriate or incorrect for the use of an indication in a patient. / Patient has ongoing reports of conjunctivitis and taking lubricant eye drops. A lubricant gel for a more sustained effect would be a better option to offset the risk of infection.
D6. Contraindications apparent / When a prescribed drug is contraindicated due to a medical condition or when a drug/drug group used previously had caused an ADE. / Pathology indicates an estimated CLCR of 30mL/min. Patient is administered alendronate. Therapy with alendronate is contraindicated when residents have a CLCR of <35mL/min.
D7. No indication apparent / When the patient is using a particular drug for which an indication could not be located. / Patient using rabeprazole long-term for which an indication could not be located.
D0. Other drug selection problem / When a more effective therapy is available and should be used instead of current therapy. / Patient has ongoing pain, which is the main concern and is prescribed with buprenorphine and morphine. Buprenorphine has mixed agonists/antagonist opioid analgesic activity and recommended not to be administered to patients receiving opioid agonist analgesics as they may reduce the analgesic effects or precipitate withdrawal symptoms. Simplifying analgesic regime by using morphine only may allow effective pain control.
Over or under-dose prescribed (Problems relating to the prescribed dose or schedule of the drug)
DRP category / Explanation / Example
O1. Prescribed dose too high / When the dose prescribed is high enough to cause an ADE. / Patient is administered 80mg atorvastatin daily. Statins are associated with muscle disorders and possible insomnia. More than 80% of the LDL lowering effect of any of the statins is achieved with 50% of the maximum dose.
O2. Prescribed dose too low / When the dose prescribed is too low to produce a desired therapeutic outcome. / Patient has ongoing knee pain, which can impact mobility. Rather than intermittent use, regular paracetamol may be worthwhile to improve mobility.
O3. Incorrect or unclear dosing instructions / When the dose, frequency or duration of use of the prescribed drug is inappropriate or unclear. / Latanoprost eye drops are given in the morning. It is recommended for latanoprost eye drops to be instilled in the evening for optimal effect.
O0. Other dose problem / Other dosing problems, which could not be classified under the above categories. / Patient being administered PRN temazepam on a regular basis. Use of benzodiazepines may increase the risk of falls. The risk may even be increased due to the previous history of falls.
Compliance (Problems relating to the way the consumer takes the medication)
DRP category / Explanation / Example
C1. Under-use by consumer / When a drug is used less or only when required. / Patient prescribed fluticasone/ salmeterol 250/50 1 bd, but has not been using them.
C2. Over-use by consumer / When a drug is used more than required.
C3. Erratic use of medication / When the patient is taking the drug on an erratic basis. / Patient charted for fluticasone/ salmeterol 500/50 1 bd and salbutamol inhaler 2 qid and PRN. However, patient is not using fluticasone/salmeterol and is using salbutamol regularly.
C4. Intentional drug misuse (incl. non-prescription medicines) / Patient is suspected of intentional over-use of a particular, potentially abused product.
C5. Difficulty using dosage form / When the patient is unable to use a drug due to physical problems. / Patient unable to swallow paracetamol SR tablet whole.
C0. Other compliance problem / Behavioural issues in a patient, which interferes with the compliance of a drug in that patient. / Patient has been known to refuse and spit out medication and therefore, prescribed medications need to be crushed.
Undertreated (Problems relating to actual or potential conditions that require management or prevention)
DRP category / Explanation / Example
U1. Condition undertreated / When the patient is not being treated adequately for an existing medical condition or symptoms. / Patient has relatively high BP and needs further review of antihypertensive therapy
U2. Condition untreated / When existing medical condition or symptoms remain untreated. / Recent pathology reports of the patient indicated significant vitamin D deficiency and therapy with vitamin D should be initiated.
U3. Preventive therapy required / When an additive therapy is required in a patient to prevent an ADE that could occur as a result of the current drug therapy, medical condition or risk factors. / In view of patient’s independent mobility, a vitamin D supplement may be warranted, which is recommended for all residents of aged care facilities according to the new guidelines and has shown to increase muscle strength and reduce the risk of fractures.
U4. Condition resolved / When the medical condition or symptom for which the patient is currently being treated is significantly managed. / Vitamin D level monitored recently was within recommended range. The patient is still being administered vitamin D 2 daily. Reducing vitamin D to 1 daily may be warranted.
U0. Other untreated indication problem / Other medical condition or symptom related management issues which could not be classified under the above three categories. / Patient has continuous pain despite of therapy with opioids and paracetamol. If pain is thought to be of neuropathic origin, the use of amitriptyline may be considered. This may also be of benefit with urinary incontinence.
Monitoring (Problems relating to monitoring the efficacy or adverse effects of a drug)
DRP category / Explanation / Example
M1. Laboratory monitoring / When a laboratory test is required to monitor the efficacy/adverse effects of a drug. / Long-term use of pantoprazole and metformin may contribute to vitamin B12 deficiency, which may precipitate confusion. An investigation into current B12 levels may be required to exclude deficiencies and need for supplementation.
M2. Non-laboratory monitoring / When a non – laboratory test is required to monitor the efficacy/adverse effects of a drug. / Recent systolic BP readings of the patient were in the lower range, consider the need to assess for orthostatic hypotension by measuring sitting and standing BP.
M0. Other monitoring problem / Patient has another problem related to the monitoring of their medicines or medical conditions for either efficacy or adverse effects. Patient has problems attending laboratory or paying for the test or equipment needed.
Education or information (Consumer requires/requests further information about a drug or disease state)
DRP category / Explanation / Example
E1. Consumer requires/requests drug information / Patient needs/requests more information regarding the current drug therapy with which they are being treated. / Patient suffers from chest pain at times and presented with an opened bottle of glyceryl trinitrate sublingual tablets dispensed >3 months ago. Patient was advised that glyceryl trinitrate sublingual tablets due to instability have an expiry date of 3 months after the bottle is opened and was asked to keep a record of the opening and expiry date whenever a new bottle was opened.
E2. Consumer requires/requests disease management advice / Patient needs/requests more information and advice regarding their medical condition management. / Current treatment is appropriate for optimal management of patient’s COPD and although patient is reluctant to quit smoking, it is the only intervention likely to help at the advanced stage of disease. Suggest ensuring patient is fully aware of the benefits of quitting which include an improvement in exercise tolerance, reduced cough, and regrowth of cilia in the lungs, which increases the ability to clear airways and reduce the risk of infection.
E0. Other education or information problem / Any other education or information related problem
Not classifiable (Problems that cannot be classified under another category)
DRP category / Explanation / Example
N0. Clinical interventions that cannot be classified under another category / A clinical intervention
carried out by a pharmacist,
which could not be classified
in the categories mentioned
above / Patient is currently administered with pantoprazole 40mg per day. Proton pump inhibitors can increase the risk of community-acquired pneumonia, particularly at higher dosage.
Toxicity or adverse reaction (Problems relating to the presence of signs or symptoms that may be attributed to a drug)
DRP category / Explanation / Example
T1. Toxicity, allergic reaction or adverse effect present / When patient shows signs and symptoms of drug associated adverse effects or toxicity. / Patient has marked confusion and according to the weight charts has lost 8kg in the last 8 months. Galantamine may cause reduced appetite and GI irritation, while it may also contribute to agitation in some patients. Perhaps a further review of dementia may be considered in view of therapy with galantamine to ascertain whether it is providing any benefit.

ADE Adverse drug event, COPD Chronic Obstructive Pulmonary Disease, eCLCR estimated Creatinine clearance, LDL Low-density lipoprotein, PRN Pro re nata (as needed), bd bis in die (twice daily), qid quarter in die (four times a day), SR Slow release, BP Blood pressure and GI gastrointestinal.

Electronic Supplementary Material Table S2. Categories for recommendations

Change of therapy
Recommendation category / Explanation / Example
R1. Dose increase / When pharmacist makes a recommendation to increase the total daily dose of the drug for a desired therapeutic outcome. / Patient experienced some episodes of uncontrollable laughter, which may be related to manic episodes. Patient is currently administered a low dose of valproate for mood stabilisation and as the recent valproate level is noted to be low; there may be room for up titration of dosage.
R2. Dose decrease / When pharmacist makes a recommendation to decrease the total daily dose of the drug to resolve actual or potential DRP. / Patient is reported to be more settled and to have been feeling more depressed. Patient is prescribed risperidone and dose reduction may be tried to see any changes with ongoing behavioural monitoring and assessment of mood.
R3. Drug change / When pharmacist makes a recommendation to change the drug of therapy prescribed for a current indication. / Recent MSU indicated resistance to trimethoprim, sensitive to amoxicillin and nitrofurantoin. Suggest change of treatment with the possibility of 10-14 days treatment in view of recurrent urinary tract infections.
R3a. Add drug to therapy / When pharmacist recommends adding another drug to the current therapy for optimal therapeutic outcome. / Patient is currently prescribed carvedilol and BP is noted to be well controlled at 140/78mmHg, however as patient also has CCF and diabetes, commencement of an ACE Inhibitor may be of benefit, which is recommended for all patients with heart failure and may provide renal protection in patients with diabetes.
R3b. Cease/Withdraw therapy / When a pharmacist recommends withdrawing a therapy as the condition is under control or when the drug is contraindicated or causing an ADE. / Patient is administered cholecalciferol tablets as well as calcitriol on Mondays and Fridays. Please note patients with severe renal impairment are unable to convert cholecalciferol to the active form of vitamin D. Given patient is receiving treatment with calcitriol (active vitamin D) query the ongoing requirement for cholecalciferol with the view to cease.
R4. Drug formulation change / When the active ingredient and dose is not changed but the formulation is changed. / Medications need to be crushed for administration due to swallowing issues. antoprazole - the active drug is unstable in gastric acid when the tablet is crushed. Suggest giving the pantoprazole granules as an alternative formulation.
R5. Drug brand change / The pharmacist suggests a change in brand of the drug usually due to difficulty using a particular brand.
R6. Dose frequency/schedule change / The total daily dose of the drug remains the same but the pharmacist suggests a change in the number of times a day or a change in the timing of the drug to be taken. / The bioavailability of strontium ranelate is reduced significantly (60-70%) with co-administration of calcium. Consider separating strontium ranelate and calcium therapy. Strontium ranelate should be taken late in the evening if possible 2 hours post meal as well as separate from calcium.
R7. Prescription not dispensed / When the prescription for the patient has not been dispensed.
R8. Other changes to therapy / Changes recommended which could not be categorised under the ones mentioned above. / According to patient’s BSL records, occasionally low BSL <4mmol/L in early morning before breakfast was noted. To minimise risk of hypoglycaemia, consider reducing long acting insulin dose and increasing short acting insulin dose at mealtimes adjusted to BSLs during the day.
Referral required
Recommendation category / Explanation / Example
R9. Refer to prescriber / When the problem is sufficient enough to see the prescriber again for its resolution. / Patient has considerable problems with salivation and may be a candidate for botox injection into salivary glands. This may give some symptomatic relief.
R9a. Start drug/supplement / When a drug/supplement needs to be initiated to treat a medical condition. / In view of patient's age and history of fracture, while on calcium supplements, adding vitamin D for reducing risk of falls and fractures is suggested.