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Očovská Z, Procházková J, Maříková M, Vlček J. Renal drug dosage adjustments and adverse drug events in patients with chronic kidney disease admitted to the hospital: a cross-sectional study. Expert Opin Drug Saf 2024; 23:457-467. [PMID: 38332533 DOI: 10.1080/14740338.2023.2295980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 11/28/2023] [Indexed: 02/10/2024]
Abstract
BACKGROUND The study aimed to evaluate the agreement of prescribed drug dosages with renal dosing recommendations and describe adverse drug events (ADEs) contributing to hospital admissions of patients with chronic kidney disease (CKD). METHODS This cross-sectional study focused on CKD patients admitted to University Hospital Hradec Králové, with an estimated glomerular filtration rate below 60 ml/min. The necessity for renal dosage adjustments was determined using the Summary of Product Characteristics (SmPC). For medications requiring renal dosage adjustment according to SmPC, agreement between the prescribed and recommended renal dosage was assessed. ADEs were adjudicated using the OPERAM drug-related hospital admissions adjudication guide. RESULTS Of 375 CKD patients, 112 (30%, 95% CI 25-34) were prescribed drug dosages in disagreement with SmPC renal dosage recommendations. Perindopril, metformin, and ramipril were most frequently dosed in disagreement with SmPC. ADE-related hospital admissions occurred in 20% (95% CI 16-24) of CKD patients. CONCLUSION CKD patients are often prescribed medication dosages in disagreement with SmPC renal dosing recommendations. Besides explicit factors, treatment goals, feasibility of monitoring and alternative treatment must be weighed when assessing drug and dosage appropriateness. Gastrointestinal bleeding was the most frequent ADE that contributed to hospital admissions of CKD patients.
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Affiliation(s)
- Zuzana Očovská
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové, Charles University, Hradec Králové, Czech Republic
| | - Jana Procházková
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové, Charles University, Hradec Králové, Czech Republic
| | - Martina Maříková
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové, Charles University, Hradec Králové, Czech Republic
- Department of Clinical Pharmacy, Hospital Pharmacy, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Jiří Vlček
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové, Charles University, Hradec Králové, Czech Republic
- Department of Clinical Pharmacy, Hospital Pharmacy, University Hospital Hradec Králové, Hradec Králové, Czech Republic
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Maganda BA, Munishi C, Mlyuka H, Mlugu EM, Mohamedi JA, Mwamwitwa KW. Evaluation of Dose Adjustment in Patients With Renal Impairment at Muhimbili National Hospital in Tanzania. Hosp Pharm 2024; 59:86-93. [PMID: 38223861 PMCID: PMC10786056 DOI: 10.1177/00185787231188921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
Background: The burden of renal diseases is increasing in developing countries like Tanzania. Drug accumulation exposes patients with renal impairment to drug toxicity that may lead to adverse drug reactions, poor adherence to treatment, and increased healthcare costs. There is limited information on the appropriateness of dosage regimen adjustment for patients with renal impairment, particularly in developing countries such as Tanzania. This study aimed to investigate the appropriateness of drug dosing in hospitalized patients with renal impairment in Tanzania. Methods: This was a retrospective cross-sectional study. It was conducted between November 2019 and April 2020 amongst hospitalized patients at Muhimbili National Hospital. All enrolled patients had serum creatinine levels ≥1.2 mg/dL and taking at least one drug requiring dosage regimen adjustment. Creatinine clearance was calculated from patient serum creatinine using the Cockcroft-Gault equation. Drug dosing appropriateness was determined by comparing the current practice with tertiary references. The relationship between the patient's baseline characteristics and the rate of dosage regimen adjustment was determined using the X2 test. Univariate and multivariate logistic regression analysis evaluated the predictors of dosing adjustment. Results: Most of the enrolled patients, 269 (98.9%) had comorbidities. Of the medication orders included in the final analysis, 372 (27%) needed dosage regimen adjustment. Out of the 372 medication orders, not adjusted were 168 (45.2%), inappropriately adjusted 105 (28.2%), and appropriately adjusted were only 99 (26.6%). In this study, 212 (77.9%) patients received at least one drug with an incorrect dosage regimen. Females and those with level 4 renal impairment patients were more likely to have their doses appropriately adjusted compared to their counterparts. Conclusions: In this study, about three-quarters of the patients received at least one drug with an incorrect dosage regimen. Thus, appropriate measures such as the availability of national guidelines and clinical decision support systems for drug dosing adjustment in patients' renal impairment should be in place.
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Affiliation(s)
- Betty Allen Maganda
- School of Pharmacy-Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Castory Munishi
- School of Pharmacy-Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Hamu Mlyuka
- School of Pharmacy-Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Eulambius M. Mlugu
- School of Pharmacy-Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Juma Ayubu Mohamedi
- School of Pharmacy-Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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Hayat M, Ahmad N, Khan SLA, Mohkumuddin S, Siddique W, Khan A, Atif M. Pattern, frequency and factors associated with inappropriate high dosing in chronic kidney disease patients at a tertiary care hospital in Pakistan. BMC Nephrol 2023; 24:118. [PMID: 37127612 PMCID: PMC10150458 DOI: 10.1186/s12882-023-03167-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 04/13/2023] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND Patients with chronic kidney diseases (CKD) are susceptible to the toxic drug effects if given unadjusted doses. Although Pakistan harbors a high burden of CKD patients, there is limited information available on the frequency, pattern and factors associated with unadjusted drug doses among CKD patients. METHODS This cross-sectional study conducted at Sandeman Provincial Hospital, Quetta included 303 non-dialysis ambulatory CKD patients (glomerular filtration rate < 60 ml/min/1.73m2). The patients' data were collected through a purpose designed data collection form. The appropriateness of doses was checked against the renal drug handbook-2018, Kidney Disease Improving Global Outcomes guidelines, British National Formulary-2022, and manufacturer leaflets. Data were analysed by SPSS 23 and multiple binary logistic regression analysis was used to assess the factors associated with receiving inappropriate high doses. A p-value < 0.05 was considered statistically significant. RESULTS The patients received a total of 2265 prescription lines, with a median of eight different drugs per patient (interquartile range: 6-9 drugs). A total of 34.5% (783/2265) drugs required dose adjustment. Of these, doses were not adjusted for 56.1% (440) drugs in 162 (53.4%) patients. The most common pharmacological class of drugs requiring dose adjustment were antibiotics (79.1%), followed by antidiabetics (59.2%), diuretics (57.0%), angiotensin converting enzyme inhibitors (56.9%), beta blockers (56.9%), analgesics (56.0%), angiotensin receptor blockers (55.2%), domperidone (53.9%) and antihyperlipidmics (46.1%). Patient's age of 41-60 (OR = 5.76) and > 60 years (OR = 9.49), hypertension (OR = 2.68), diabetes mellitus (OR = 3.47) and cardiovascular diseases (OR = 2.82) had statistically significant association (p-value < 0.05) with inappropriate high doses. CONCLUSION The high frequency of inappropriate high doses suggests an important quality gap in medication dosing for patients with ND-CKD at the study site. Special attention should be paid to the drugs and patients with identified risk factors for receiving inappropriate high doses.
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Affiliation(s)
- Muhammad Hayat
- Department of Pharmacy Practice, Faculty of Pharmacy and Health Sciences, University of Balochistan, Quetta, Pakistan
| | - Nafees Ahmad
- Department of Pharmacy Practice, Faculty of Pharmacy and Health Sciences, University of Balochistan, Quetta, Pakistan.
| | | | - Syed Mohkumuddin
- Department of Nephrology, Bolan Medical College, Quetta, Pakistan
| | - Wajeeha Siddique
- Department of Pharmacy Practice, Faculty of Pharmacy and Health Sciences, University of Balochistan, Quetta, Pakistan
| | - Amjad Khan
- Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
| | - Muhammad Atif
- Department of Pharmacy Practice, Faculty of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, Pakistan
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Dale D, Asmamaw G, Etiso T, Bussa Z. Prevalence of inappropriate drug dose adjustment and associated factors among inpatients with renal impairment in Africa: A systematic review and meta-analysis. SAGE Open Med 2023; 11:20503121221150104. [PMID: 36741935 PMCID: PMC9893064 DOI: 10.1177/20503121221150104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 12/21/2022] [Indexed: 01/22/2023] Open
Abstract
Objective There is a high prevalence of inadequate dose adjustment among inpatients with renal insufficiency worldwide. There is, however, a paucity of studies that summarizes the topic in the African context. Therefore, this study aims to summarize the prevalence of inappropriate drug dose adjustment (IDDA) and associated factors among inpatients with renal impairment in Africa. Methods A literature search for English-language articles was conducted using reputable databases such as PubMed/MEDLINE, Google Scholar, and Science Direct. The search was carried out between 3 February and 3 March of 2022. All published articles that were online at the time of data collection were considered. Observational studies that examined the prevalence of IDDA for any type of drug in renal impairment as a primary or secondary outcome were included in our analysis. Statistical software such as Open Meta Analyst and Review Manager were used to examine outcome measures. I2 statistics, Logit event rate, and Der Simonian and Laird's random effect models were also used. Results Seven articles were qualified for the systematic review and meta-analysis. All included studies comprised a total of 1918 patients. A total of 5072 prescriptions were assessed, and 1879 (37%) of them had at least one drug that required a dose adjustment. The pooled prevalence of IDDA among adult patients with renal impairment was 13.7% (95% confidence interval (CI) = 7.9%-19.5%) in Africa. Based on the number of prescriptions containing medications that required dose adjustment, the pooled prevalence accounts for 39.3% (95% CI = 24.1%-54.4%) (932/1879). Factors associated with inappropriate drug prescribing and usage concerning renal function were the number/types of prescribed medicines (most common), age, stage of renal impairment, comorbidity, and unemployment. Conclusions In this study, IDDA practice appears to be a common challenge among inpatients with renal insufficiency in Africa. The number and type of medications prescribed, age, stage of renal impairment, comorbidity, and unemployment were factors associated with inappropriate drug prescribing and use. In addition to expanding such studies, hospitals across Africa must conduct research on the clinical outcomes of IDDA practices in patients with renal impairment.
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Affiliation(s)
| | - Getahun Asmamaw
- Getahun Asmamaw, Department of Pharmacy, Arba Minch University, Arba Minch 4400, Ethiopia.
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Kassa Birarra M, Mekonnen GB, Gelayee DA, Assimamaw NT, Kifle ZD. Drug dose adjustment in patients with renal impairment attending a specialized referral hospital, Northwest Ethiopia. Metabol Open 2022; 16:100211. [PMID: 36177456 PMCID: PMC9513174 DOI: 10.1016/j.metop.2022.100211] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 09/14/2022] [Accepted: 09/14/2022] [Indexed: 10/29/2022] Open
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Sonoda A, Kondo Y, Iwashita Y, Nakao S, Ishida K, Irie T, Ishitsuka Y. In-Hospital Prescription Checking System for Hospitalized Patients with Decreased Glomerular Filtration Rate. Kidney360 2022; 3:1730-1737. [PMID: 36514725 PMCID: PMC9717669 DOI: 10.34067/kid.0001552022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 07/08/2022] [Indexed: 01/12/2023]
Abstract
Background Clinical decision support systems (CDSS) are reported to be useful in preventing dosage errors in renally excreted drugs by alerting hospital pharmacists to inadequate dosages for hospitalized patients with decreased GFR. However, it is unclear whether CDSS can reduce dosage errors in renally excreted drugs in hospitalized patients. To prevent dosage errors in renally excreted drugs, we introduced a prescription checking system (PCS) for in-hospital prescriptions. This retrospective study aimed to evaluate whether a prescription audit by hospital pharmacists using the PCS reduced the rate of dosage errors in renally excreted drugs. Methods The target drugs were allopurinol, cibenzoline, famotidine, and pilsicainide. Interrupted time series analysis was used to evaluate trends in the 4-weekly dosage error rates over 52 weeks before PCS implementation and 52 weeks after PCS implementation. Results Before and after PCS implementation, 474 and 331 prescriptions containing one of the targeted drugs, respectively, were generated. The estimated baseline level of the 4-weekly dosage error rates was 34%. The trend before the PCS implementation was stable with no observable trend. The estimated level change from the last point in the pre-PCS implementation to the first point in the PCS implementation was -20% (P<0.001). There was no change in the trend after PCS implementation. Conclusions We demonstrated that a prescription audit by hospital pharmacists using the PCS reduced the rate of dosage errors in the target renally excreted drugs in hospitalized patients. Although further studies are needed to confirm whether our results can be generalized to other health facilities, our findings highlight the need for a PCS to prevent the overdose of renally excreted drugs.
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Affiliation(s)
- Akihiro Sonoda
- Department of Pharmacy, Izumi Regional Medical Center, Akune, Japan
| | - Yuki Kondo
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | | | - Shoji Nakao
- Department of Pharmacy, Izumi Regional Medical Center, Akune, Japan
| | - Kazuhisa Ishida
- Department of Pharmacy, Izumi Regional Medical Center, Akune, Japan
| | - Tetsumi Irie
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan,Department of Pharmaceutical Packaging Technology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Yoichi Ishitsuka
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
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Alruqayb WS, Price MJ, Paudyal V, Cox AR. Drug-Related Problems in Hospitalised Patients with Chronic Kidney Disease: A Systematic Review. Drug Saf 2021; 44:1041-1058. [PMID: 34510389 DOI: 10.1007/s40264-021-01099-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Globally, chronic kidney disease (CKD) is one of the leading causes of mortality. Impaired renal function makes CKD patients vulnerable to drug-related problems (DRPs). AIM The aim of this systematic review was to investigate the prevalence and nature of DRPs among hospital in-patients with CKD. METHODS A systematic review of the literature was conducted using Medline, EMBASE, PsycINFO, Web of Science (Core Collection), CINAHL plus (EBSCO), Cochrane Library (Wiley), Scopus (ELSEVIER) and PubMed (U.S.NLM) from index inception to January 2020. Studies investigating DRPs in hospitalised CKD patients published in the English language were included. Two independent reviewers extracted the data and undertook quality assessment using the Joanna Briggs Institute (JBI) tool. RESULTS A total of 2895 unique titles were identified; with 20 meeting the inclusion criteria. DRPs prevalence in CKD was reported between 12 and 87%. The most common DRPs included ineffective treatment, inappropriate drug choice and dosing problems. Antibiotics, H2-antihistamines and oral antidiabetics (metformin) were common drug classes involved in DRPs. Factors associated with DRPs included severity of CKD, the number of medications taken, age, length of hospital stay, and gender. CONCLUSION This systematic review provides evidence that DRPs are a frequent occurrence and burden for hospitalised patients with stage 1-4 CKD. Heterogeneity in study design, case detection and definitions are common, and future studies should use clearer definitions and study designs. Protocol Registration: PROSPERO: CRD42018096364.
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Affiliation(s)
- Wadia S Alruqayb
- School of Pharmacy, Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
- College of Pharmacy, Taif University, Taif, Kingdom of Saudi Arabia
| | - Malcolm J Price
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Vibhu Paudyal
- School of Pharmacy, Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Anthony R Cox
- School of Pharmacy, Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
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Chahine B. Antibiotic dosing adjustments in hospitalized patients with chronic kidney disease: a retrospective chart review. Int Urol Nephrol 2021. [PMID: 33738646 DOI: 10.1007/s11255-021-02834-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/06/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Infections in patients with chronic kidney disease (CKD) are a major cause of hospitalization. The pharmacokinetics of renally eliminated antibiotics may lead to drug accumulation, resulting in potential toxicity. The renal dosing adjustment of antibiotics is crucial to avoid toxicity and decrease mortality. In Lebanon, limited data are available on antibiotic dose adequacy in CKD. OBJECTIVES To estimate the prevalence of inappropriately dosed antibiotics in non-dialysis CKD patients and to identify possible risk factors that may be associated with unadjusted renal dosing. METHODS A retrospective chart review was conducted at two tertiary-care hospitals in Lebanon. International Statistical Classification of Diseases (ICD-10) code for CKD was used to search the databases. Demographic and clinical data were collected for patients who received antibiotics that requires renal dosing adjustment. Lexi-Comp online Drug Information database was the guideline used to evaluate the appropriateness of dosing. RESULTS A total of 495 antibiotic orders were dispensed to 190 patients. 51.6% of patients received antibiotics without renal dose adjustments. The most inappropriately dosed class was penicillins (39.8%), while fluoroquinolones were the most adequately adjusted. Piperacillin/tazobactam was the most frequently prescribed drug (30.6%) without renal dose adjustment. Respiratory infections (OR 1.301, CI 95% 1.327-1.915) and multimorbidity (OR 1.183, CI 95% 1.358-2.081) were statistically highly significant associations for unadjusted antibiotic dosing from the fitted multivariable-adjusted logistic models. CONCLUSION Our study revealed a high frequency of guideline-discordant antibiotic dosing in patients with CKD. This dosing error is preventable by increasing awareness of prescribing physicians and collaborating with clinical pharmacists.
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Hassan Z, Ali I, Ullah AR, Ahmed R, Zar A, Ullah I, Rehman S, Khan AU, Ullah R, Hanif M. Assessment of Medication Dosage Adjustment in Hospitalized Patients With Chronic Kidney Disease. Cureus 2021; 13:e13449. [PMID: 33767933 PMCID: PMC7982869 DOI: 10.7759/cureus.13449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Inappropriate medication dosing can cause adverse drug reactions or ineffective therapy due to declined renal function in patients with renal insufficiency. This necessitates proper renal dose adjustment. This study was proposed to evaluate medication dosage adjustment in hospitalized chronic kidney disease (CKD) patients. Methods This study included all CKD patients hospitalized between May 1, 2019, and April 25, 2020, at the Institute of Kidney Disease, Peshawar, Pakistan. The estimated glomerular filtration rate was calculated using the Modification of Diet in Renal Disease formula, and dose appropriateness was established by evaluating practice with relevant reference books. Results Of the total 1,537 CKD patients, 231 (15.03%) had evidence of dosing error, which was considered for final analysis. Overall, 1,549 drugs were prescribed; 480 (30.99%) drugs required dose adjustment, of which 196 (40.42%) were adjusted properly and the remaining 286 (59.58%) were unadjusted. The most common unadjusted drugs were meropenem, cefepime, ciprofloxacin, and rosuvastatin, whereas captopril, aspirin, bisoprolol, pregabalin, and levofloxacin had the highest percentage of adjusted drugs. On multivariate logistic regression, the number of drugs requiring dosing adjustments and obstructive nephropathy were found to be statistically significant factors that increased the likelihood of the medication dosing errors: a unit increase in the number of drugs requiring dose adjustment increases 5.241 times the likelihood of dosing error. Similarly, the presence of obstructive nephropathy (OR: 0.383; 95% Cl: 0.153-0.960; p = 0.041) was found to be significantly associated with dosing error after adjustment for potential confounding factors. Conclusion The dosing of more than half of the prescribed drugs that required adjustment in CKD patients was not adjusted, which showed that medication dosing errors were high. This highlights the importance of medication prescription according to guidelines in these patients to improve the outcomes of pharmacotherapy.
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Affiliation(s)
- Zair Hassan
- Cardiology, Lady Reading Hospital, Peshawar, PAK
| | | | - Arslan R Ullah
- Internal Medicine, Northwest General Hospital & Research Centre, Peshawar, PAK
| | - Raheel Ahmed
- Nephrology, Institute of Kidney Diseases, Peshawar, PAK
| | - Adnan Zar
- Internal Medicine, Lady Reading Hospital, Peshawar, PAK
| | - Irfan Ullah
- Internal Medicine, Kabir Medical College, Peshawar, PAK
| | - Shakeel Rehman
- Pharmacy, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Peshawar, PAK
| | | | - Rizwan Ullah
- Cardiology, Lady Reading Hospital, Peshawar, PAK
| | - Muhammad Hanif
- Internal Medicine, Khyber Medical College Peshawar, Hayatabad Medical Complex, Peshawar, PAK
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Sheikh AM, Rwegerera GM, Godman B, Habte D. Adjustments of medication dosages in patients with renal impairment in Botswana; findings and implications to improve patient care. Hosp Pract (1995) 2019; 47:231-240. [PMID: 31662005 DOI: 10.1080/21548331.2019.1685800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background and aims: Medication dosage adjustments for renally impaired patients have not been studied in Botswana. This study was conducted to determine prescribing practices among patients with renal impairment in medical wards to improve future patient care.Methods: We conducted a retrospective study involving medical charts of patients admitted at a tertiary level hospital in Gaborone Botswana. Study participants included all patients admitted between August and October 2016 who were hospitalized for ≥24 h. 'Drug prescribing in renal failure: dosing guidelines for adults and children'. was used to determine the extent of dosage adjustments. A logistic regression model was used to assess which patient factors were associated with inappropriate dosage adjustment.Results: Twenty-nine percent (233/804) of patients had renal impairment. Of these, 184 patients with renal impairment were included in the final analysis. There were 1143 prescription entries, of which 20.5% (n = 234) required dosage adjustment for renal function but only 45.7% (n = 107) were adjusted correctly. Of note, 112 patients were prescribed at least one drug that required dosage adjustment and only 30.4% (n = 34) patients had all of their medications appropriately adjusted. Patient factors associated with inappropriate dosage adjustment included a higher number of medicines being prescribed. Mortality among patients with renal impairment was independently associated with higher scores of the Charlson comorbidity index and hospital stay duration of 1-7 days.Conclusion: The renal function status of patients was not sufficiently taken into account when prescribing medicines especially in patients with severely impaired kidney function in Botswana. Continuous medical education needs to be encouraged to address this, which is being implemented. We will be following this up in future studies.
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Affiliation(s)
| | - Godfrey Mutashambara Rwegerera
- Department of Internal Medicine, University of Botswana, Gaborone, Botswana AND Department of Medicine, Princess Marina Hospital, Gaborone, Botswana
| | - Brian Godman
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden.,Department of Pharmacoepidemiology, Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK.,Health Economics Centre, Liverpool University Management School, Liverpool, UK.,Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Garankuwa, South Africa
| | - Dereje Habte
- Consultant Public Health Specialist, Addis Ababa, Ethiopia
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Saad R, Hallit S, Chahine B. Evaluation of renal drug dosing adjustment in chronic kidney disease patients at two university hospitals in Lebanon. Pharm Pract (Granada) 2019; 17:1304. [PMID: 31015868 PMCID: PMC6463404 DOI: 10.18549/pharmpract.2019.1.1304] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 01/20/2019] [Indexed: 11/27/2022] Open
Abstract
Background: Inappropriate medication dosing in patients with chronic kidney disease can cause toxicity or ineffective therapy. Patients are at a high risk of developing related adverse events caused by the altered effect of drugs in conjunction with the use of polypharmacy to treat comorbid conditions. This necessitates adequate renal dosing adjustments. Objective: The current study aims at assessing whether appropriate dosing adjustments were made in hospitalized patients with chronic kidney disease. Methods: A retrospective descriptive study was conducted at two university hospitals in Beirut between January and December 2016. All adult CKD patients with creatinine clearance less than 60 ml/min and receiving at least one medication that require renal dosing adjustment were included. Kidney function was estimated from serum creatinine using Cockcroft-Gault equation, and dose appropriateness was determined by comparing practice with specific guidelines. The rates of renal drug dosing adjustment were investigated, in addition to the influence of possible determinants, such as the severity of renal impairment, reason of hospital admission, and other patient characteristics. Results: 2138 patients admitted in 2016 were screened. 223 adults receiving 578 drug orders that require adjustment were included. Among the 578 orders, 215 (37%) were adjusted adequately, 284 (49%) were adjusted inadequately, and 79 (14%) were not adjusted at all. Beta-blockers were the most inadequately dosed (83.6%) class of medication, whereas lipid-lowering agents had the highest percentage of adequate dosing (65.1%). As per patient, 84.3% of patients appeared to be receiving at least one inappropriate drug dose. Conclusions: Our study confirms that physicians are not prescribing appropriate dosing adjustments in chronic kidney disease inpatients, which may have deleterious effects. This highlights the need for more nephrology consultation and the implementation of physician education programs.
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Affiliation(s)
- Rayane Saad
- School of Pharmacy, Lebanese International University. Beirut, (Lebanon).
| | - Souheil Hallit
- INSPECT-LB: Institut National de Sante Publique, Epidemiologie Clinique et Toxicologie; Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik, Jounieh (Lebanon).
| | - Bahia Chahine
- School of Pharmacy, Lebanese International University. Beirut, (Lebanon).
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O'Shaughnessy M, Allen N, O'Regan J, Payne-Danson E, Mentre L, Davin D, Lavin P, Grimes T. Agreement between renal prescribing references and determination of prescribing appropriateness in hospitalized patients with chronic kidney disease. QJM 2017; 110:623-628. [PMID: 28431157 PMCID: PMC6256938 DOI: 10.1093/qjmed/hcx086] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is a risk factor for adverse drug events. The clinical significance of discordance between renal prescribing references is unknown. AIM We determined the prevalence of potentially inappropriate prescribing (PIP) in CKD, measured agreement between two prescribing references, and assessed potential for harm consequent to PIP. DESIGN Single-centre observational study. METHODS A random sample of hospitalized patients with CKD were grouped according to baseline CKD stage (3, 4, or 5). Prescriptions requiring caution in CKD were referenced against the Renal Drug Handbook (RDH) and British National Formulary (BNF) to identify PIP (non-compliance with recommendations). Inter-reference agreement was measured using percentage agreement and Kappa coefficient. Potential for harm consequent to PIP was assessed by physicians and pharmacists using a validated scale. One-year mortality was compared between patients with or without PIP during admission. RESULTS Among 119 patients (median age 73 years, 50% male), 136 cases of PIP were identified in 78 (65.5%) patients. PIP prevalence, per patient, was 64.7% using the BNF and 28.6% using the RDH (fair agreement, Kappa 0.33, P < 0.001). The majority (63.2%) of PIP cases detected exclusively by the BNF carried minimal or no potential for harm. PIP was not significantly associated with one-year mortality (34.7% vs. 21.1%, P = 0.14). CONCLUSIONS PIP was common in hospitalized patients with CKD. Substantial discordance between renal prescribing references was apparent. The development of universally-adopted, evidence-based, prescribing guidelines for CKD might optimize medications safety in this vulnerable group.
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Affiliation(s)
- M O'Shaughnessy
- Department of Pharmacy, Adelaide and Meath Hospital, Trinity Health Kidney Centre, Tallaght, Dublin D24 NROA, Ireland
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA 94305, USA
| | - N Allen
- Department of Pharmacy, Adelaide and Meath Hospital, Trinity Health Kidney Centre, Tallaght, Dublin D24 NROA, Ireland
| | - J O'Regan
- Department of Pharmacy, Adelaide and Meath Hospital, Trinity Health Kidney Centre, Tallaght, Dublin D24 NROA, Ireland
| | - E Payne-Danson
- Department of Pharmacy, Adelaide and Meath Hospital, Trinity Health Kidney Centre, Tallaght, Dublin D24 NROA, Ireland
- School of Pharmacy and Pharmaceutical Sciences, University of Dublin Trinity College, Dublin D02 W272, Ireland
| | - L Mentre
- Department of Pharmacy, Adelaide and Meath Hospital, Trinity Health Kidney Centre, Tallaght, Dublin D24 NROA, Ireland
- School of Pharmacy and Pharmaceutical Sciences, University of Dublin Trinity College, Dublin D02 W272, Ireland
| | - D Davin
- Department of Pharmacy, Adelaide and Meath Hospital, Trinity Health Kidney Centre, Tallaght, Dublin D24 NROA, Ireland
| | - P Lavin
- Department of Pharmacy, Adelaide and Meath Hospital, Trinity Health Kidney Centre, Tallaght, Dublin D24 NROA, Ireland
| | - T Grimes
- Department of Pharmacy, Adelaide and Meath Hospital, Trinity Health Kidney Centre, Tallaght, Dublin D24 NROA, Ireland
- School of Pharmacy and Pharmaceutical Sciences, University of Dublin Trinity College, Dublin D02 W272, Ireland
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Tesfaye WH, Castelino RL, Wimmer BC, Zaidi STR. Inappropriate prescribing in chronic kidney disease: A systematic review of prevalence, associated clinical outcomes and impact of interventions. Int J Clin Pract 2017; 71. [PMID: 28544106 DOI: 10.1111/ijcp.12960] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 04/10/2017] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Adjusting doses of renally cleared medications and/or avoidance of nephrotoxic medications are standard clinical practices in chronic kidney disease (CKD), albeit the prevalence of inappropriate prescribing (IP) in these patients remains high. Therefore, this work sought to systematically review the prevalence of IP and compare the relative effectiveness of available interventions in reducing IP in CKD. METHODS Studies were identified searching PubMed/Medline, EMBASE, Cochrane Library, IPA, Web of Science, Ovid/Medline, CINAHL, and PsychINFO databases. Studies defining CKD based on laboratory markers and quantifying prevalence of IP were included. RESULTS Forty-nine studies from 23 countries met the inclusion criteria. An IP prevalence of 9.4%-81.1% and 13%-80.50% was reported in hospital and ambulatory settings, respectively; whereas, in long-term care facilities the prevalence ranged between 16% and 37.9%. Unsurprisingly, IP was associated with adverse drug events like increased hospital stay (Mean [SD] of 4.5 [4.8] vs 4.3 [4.5]) and high risk of mortality [40%]. Twenty-one studies reported the impact of interventions on IP; manual and computerised alerts were the main forms of interventions (n=19). The most significant reduction in IP was observed when physicians received immediate concurrent feedback from a clinical pharmacist (P<.001). Polypharmacy, comorbidities, and age were identified as predictors of IP. CONCLUSION IP has led to poor patient outcomes. Although pharmacist-based and computer-aided approaches have shown promising results, there is still room for improvement. Future studies should focus on developing a multifaceted intervention to address the widespread prevalence of IP and associated clinical outcomes in CKD patients.
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Affiliation(s)
| | - Ronald L Castelino
- Sydney Nursing School, The University of Sydney, Lidcombe, New South Wales, Australia
| | - Barbara C Wimmer
- Pharmacy, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Syed Tabish R Zaidi
- Pharmacy, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
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Li Z, Su W, Zhu Y, Tao T, Li D, Peng X, Qin J. Drug absorption related nephrotoxicity assessment on an intestine-kidney chip. Biomicrofluidics 2017; 11:034114. [PMID: 28652884 PMCID: PMC5453794 DOI: 10.1063/1.4984768] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 05/18/2017] [Indexed: 05/04/2023]
Abstract
Drug absorption in the intestine is tightly related to drug-induced nephrotoxicity, which is a relatively common side effect in clinical practice. It highlights a great need to develop predictive models with high accuracy in the early stage during new drug discovery and development. Herein, we presented a novel intestine-kidney chip, which recapitulated drug absorption in the intestine and its resultant drug toxicity on the kidney. This work aims to provide an integrated tool for accurate assessment of drug absorption-related nephrotoxicity in vitro. A microfluidic device with multi-interfaces was designed, which facilitated the co-culture of the intestinal and glomerular endothelial cells in compartmentalized micro-chambers. Thus, drug absorption and following nephrotoxicity could be explored in a single assay based on the formation of the intact intestine function on the chip. Specifically, we adopt digoxin (DIG) as a model drug combined with colestyramine (COL) or Verapamil (VER), which significantly influence DIG absorption in the intestine. Different degrees of nephrotoxicity under drug combinations were further observed on the chip, including cell apoptosis, cell viability, and lactate dehydrogenase leakage. These features were consistent with the variance of DIG absorption by the intestinal cells. In agreement with clinical observations, our data demonstrated that DIG-induced nephrotoxicity was enhanced combined with VER but weakened with COL. All of these findings suggest that the established microdevice might provide a useful and cost-effective platform in vitro for testing drug absorption and nephrotoxicity in preclinical trials during new drug development.
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Affiliation(s)
| | - Wentao Su
- Division of Biotechnology, Dalian Institute of Chemical Physics, Chinese Academy of Sciences, Dalian 116023, China
| | | | - Tingting Tao
- Division of Biotechnology, Dalian Institute of Chemical Physics, Chinese Academy of Sciences, Dalian 116023, China
| | - Dong Li
- Dalian Municipal Women and Children's Medical Center, Dalian 116024, China
| | - Xiaojun Peng
- College of Chemistry, Dalian University of Technology, Dalian 116024, China
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Dörks M, Allers K, Schmiemann G, Herget-Rosenthal S, Hoffmann F. Inappropriate Medication in Non-Hospitalized Patients With Renal Insufficiency: A Systematic Review. J Am Geriatr Soc 2017; 65:853-862. [PMID: 28240771 DOI: 10.1111/jgs.14809] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Renal insufficiency is common among older patients and, accordingly, renally excreted drugs may require an adjustment in dosage for them. Rates of non-adherence to renal dosing guidelines range from 19% to 70% across all settings, with the highest rate occurring in outpatient care. However, there is a paucity of research in this field. The main objective of this systematic review is to assess how often drugs are inappropriately prescribed in non-hospitalized patients with renal insufficiency. DESIGN A systematic literature search was performed. Data were identified from three electronic databases: PubMed, CINAHL, and Scopus. Studies were included if they reported quantitative data on inappropriate drug use with respect to renal function in non-hospitalized patients. RESULTS Our search strategy resulted in 2,403 hits, of which 18 articles satisfied the criteria for inclusion. Mean estimated glomerular filtration rate ranged from 36.0 to 60.4 mL/min. Prevalence of renally inappropriate drug use ranged from 1% to 37% in outpatient settings other than nursing homes, and from 6% to 43% in nursing homes. Eight of the studies we included identified predictors for use of drugs inappropriate for kidney function. Most frequently determined risk factors were increasing age and a high number of prescribed drugs. CONCLUSION Lack of dose adjustment for renal impairment seems to be a common problem, even in outpatients. However, the differences in methodologies used in these studies hampered any direct comparison. Accepted and comparable standards regarding the drugs included in the studies as well as estimation of renal function would be beneficial.
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Affiliation(s)
- Michael Dörks
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Katharina Allers
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Guido Schmiemann
- Institute for Public Health and Nursing Science, Department for Health Services Research, University of Bremen, Bremen, Germany.,Health Sciences, University of Bremen, Bremen, Germany
| | | | - Falk Hoffmann
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
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Yang P, Chen N, Wang RR, Li L, Jiang SP. Inappropriateness of medication prescriptions about chronic kidney disease patients without dialysis therapy in a Chinese tertiary teaching hospital. Ther Clin Risk Manag 2016; 12:1517-1524. [PMID: 27785039 PMCID: PMC5066999 DOI: 10.2147/tcrm.s116789] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background With the increasing incidence rate of chronic kidney disease (CKD), inappropriate use of medicine in CKD patients is an important issue, as it may cause adverse effects in patients and progression to chronic renal failure. Objective The aim of this study is to assess the frequency of inappropriate medicine use among CKD patients. Methods A cross-sectional study was conducted from November 1 to December 1, 2014 in a Chinese teaching tertiary hospital. All medication prescriptions for CKD patients with serum creatinine level above normal value were enrolled. The prescriptions, including unreasonable dosage, contraindicated, and cautiously used medicines in CKD patients, were evaluated and the related medications were also analyzed and classified. Results Two hundred and two patients were included, and a total of 1,733 lines of medication prescriptions were evaluated. The prevalence of inappropriate medication prescriptions in CKD patients was 15.18%, of which, unreasonable dosage (n=56), contraindicated (n=46), and cautiously used medicines (n=161) accounted for 3.23%, 2.65%, and 9.29%, respectively. Spearman’s rank correlation coefficient implied that there was a significant correlation between the severity of renal insufficiency and frequency of inappropriate medication prescriptions (P=0.02, r=0.056). Among the inappropriate medication prescriptions, nutraceutical and electrolytes (n=65, 24.71%), cardiovascular drugs (n=61, 23.19%), and antimicrobial drugs (n=55, 20.91%) represented the top three medicine categories in CKD patients. Conclusion The study confirmed that inappropriate medication prescriptions were prevalent in CKD patients. Improving the quality of medication prescriptions in CKD patients is necessary.
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Affiliation(s)
- Ping Yang
- Department of Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Na Chen
- Department of Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Rong-Rong Wang
- Department of Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Lu Li
- Department of Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Sai-Ping Jiang
- Department of Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
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Saleem A, Masood I. Pattern and Predictors of Medication Dosing Errors in Chronic Kidney Disease Patients in Pakistan: A Single Center Retrospective Analysis. PLoS One 2016; 11:e0158677. [PMID: 27367594 DOI: 10.1371/journal.pone.0158677] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Accepted: 06/20/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) alters the pharmacokinetic and pharmacodynamic response of various drugs and increases the risk of toxicity. The data regarding the pattern and predictors of medication dosing errors is scare from the developing countries. Therefore, the present study was conducted to assess the pattern and predictors of medication dosing errors in CKD patients in a tertiary care setting in Pakistan. METHODS A retrospective study design was employed and medical charts of all those CKD patients who had an eGFR ≤60ml/min/1.73m2, hospitalization ≥24 hours, and admitted in the nephrology unit during January 2013 to December 2014 were assessed. Descriptive statistics and the logistic regression analysis were done using IBM SPSS version 20. RESULTS In total, 205 medical charts were assessed. The mean age of patients was 38.64 (±16.82) years. Overall, 1534 drugs were prescribed to CKD patients, of which, nearly 34.0% drugs required dose adjustment. Among those drugs, only 41.8% were properly adjusted, and the remaining 58.2% were unadjusted. The logistic regression analysis revealed that the medication dosing errors were significantly associated with the CKD stages, i.e. stage 4 (OR 0.054; 95% CI [0.017-0.177]; p <0.001) and stage 5 (OR 0.098; 95% CI [0.040-0.241]; p <0.001), the number of prescribed medicines ≥ 5 (OR 0.306; 95% CI [0.133-0.704]; p 0.005), and the presence of a comorbidity (OR 0.455; 95% CI [0.226-0.916]; p 0.027) such as the hypertension (OR 0.453; 95% CI [0.231-0.887]; p 0.021). CONCLUSIONS It is concluded that more than half drugs prescribed to CKD patients requiring dose adjustment were unadjusted. The predictors of medication dosing errors were the severe-to-end stages of chronic kidney disease, the presence of a comorbidity such as hypertension, and a higher number of prescribed medicines. Therefore, attention should be paid to these risk factors.
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Khanal A, Peterson GM, Castelino RL, Jose MD. Potentially inappropriate prescribing of renally cleared drugs in elderly patients in community and aged care settings. Drugs Aging 2016; 32:391-400. [PMID: 25925940 DOI: 10.1007/s40266-015-0261-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Limited data are available on the prevalence of inappropriate prescribing of renally cleared drugs in elderly patients in Australia. OBJECTIVES To quantify and compare the extent of inappropriate prescribing (defined as at least one drug prescribed in an excessive dose or when contraindicated with respect to renal function) of renally cleared drugs in elderly patients across the community and aged care settings, and to determine factors associated with patients being prescribed one or more potentially inappropriate renally cleared drugs. METHODS This retrospective study examined de-identified Home Medicines Review (HMR) and Residential Medication Management Review (RMMR) cases pertaining to 30,898 patients aged 65 years and over. Only 25 % (n = 7625) of these patients had documented information on their renal function. Among them, 4035 patients were prescribed at least one of the 31 renally cleared drugs examined in this study. For these patients, details including demographics, medications, medical conditions and pathology test results were extracted. Creatinine clearance was estimated using the Cockcroft-Gault formula, and the prevalence of inappropriate prescribing of the 31 drugs was examined on the basis of conformity with the recommendations in the Australian Medicines Handbook. Multivariate logistic regression was performed to determine the factors associated with patients being prescribed one or more potentially inappropriate renally cleared drugs. RESULTS The mean (± standard deviation) ages of the HMR patients (n = 3315; 59 % female) and RMMR patients (n = 720; 68 % female) were 78.3 ± 7.2 and 86 ± 7.3 years, respectively. Over one quarter of the patients (n = 1135 out of 4035; 28.1 %) prescribed the renally cleared drugs examined in this study had evidence of inappropriate prescribing of at least one of the drugs, with respect to their renal function. The drugs/drug classes most commonly prescribed inappropriately were perindopril, fenofibrate, glibenclamide, gliptins, metformin, olmesartan, bisphosphonates and strontium. The factors independently associated with patients being prescribed one or more potentially inappropriate renally cleared drugs were advancing age [odds ratio (OR) 1.06 per year increase, 95 % confidence interval (CI) 1.05-1.07; P < 0.001], the total number of renally cleared drugs prescribed (OR 1.44 per unit increase, 95 % CI 1.29-1.61; P < 0.001), presence of diabetes (OR 1.51, 95 % CI 1.30-1.76; P < 0.001), presence of heart failure (OR 1.38, 95 % CI 1.13-1.69; P < 0.005) and living in aged care facilities (OR 1.28, 95 % CI 1.06-1.5; P < 0.05). CONCLUSION Inappropriate prescribing of renally cleared drugs is common in older Australians. Intervention studies to improve prescribing of renally cleared drugs in the elderly appear to be warranted.
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Affiliation(s)
- Aarati Khanal
- Unit for Medication Outcomes Research and Education, University of Tasmania, Hobart, TAS, Australia,
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Getachew H, Tadesse Y, Shibeshi W. Drug dosage adjustment in hospitalized patients with renal impairment at Tikur Anbessa specialized hospital, Addis Ababa, Ethiopia. BMC Nephrol 2015; 16:158. [PMID: 26446847 PMCID: PMC4597768 DOI: 10.1186/s12882-015-0155-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 09/30/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Dose adjustment for certain drugs is required in patients with reduced renal function to avoid toxicity as many drugs are eliminated by the kidneys. The aim of this study was to assess whether appropriate dosage adjustments were made in hospitalized patients with renal impairment. METHODS A prospective cross-sectional study was carried out in the internal medicine wards of Tikur Anbessa Specialized Hospital. All patients with creatinine clearance ≤ 59 ml/min admitted to hospital between April and July, 2013 were included in the analysis. Data regarding serum creatinine level, age, sex and prescribed drugs and their dosage was collected from the patients' medical records. Serum creatinine level ≥ 1.2 mg/dL was used as a cutoff point in pre-selection of patients. The estimated creatinine clearance was calculated using the Cockcroft- Gault (CG) equation. Guideline for Drug prescribing in renal failure provided by the American College of Physicians was used as the standard for dose adjustment. RESULTS Nine percent (73/810) of medical admissions were found to have renal impairment (CrCl ≤ 59 ml/min). There were 372 prescription entries for 73 patients with renal impairment. Dose adjustment was required in 31 % (115/372) of prescription entries and fifty eight (51 %) prescription entries requiring dose adjustment were found to be inappropriate. Of 73 patients, 54 patient received ≥ 1 drug that required dose adjustment (median 2; range 1-6). Fifteen (28 %) patients had all of their drugs appropriately adjusted while twenty two (41 %) patients had some drugs appropriately adjusted, and seventeen (31 %) of patients had no drugs appropriately adjusted. No patients were documented to have received dialysis. CONCLUSION The findings indicate that dosing errors were common among hospitalized patients with renal impairment. Improving the quality of drug prescription in patients with renal impairment could be of importance for improving the quality of care.
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Affiliation(s)
- Henok Getachew
- Department of Clinical Pharmacy, School of Pharmacy, College of Medical and Health Science, University of Gondar, Gondar, Ethiopia.
| | - Yewondwossen Tadesse
- Department of Internal Medicine, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Workineh Shibeshi
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, P.O. Box 9086, Addis Ababa, Ethiopia.
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Drenth-van Maanen AC, van Marum RJ, Jansen PAF, Zwart JEF, van Solinge WW, Egberts TCG. Adherence with Dosing Guideline in Patients with Impaired Renal Function at Hospital Discharge. PLoS One 2015; 10:e0128237. [PMID: 26053481 PMCID: PMC4459981 DOI: 10.1371/journal.pone.0128237] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 04/24/2015] [Indexed: 01/23/2023] Open
Abstract
Objectives To determine the prevalence, determinants, and potential clinical relevance of adherence with the Dutch dosing guideline in patients with impaired renal function at hospital discharge. Design Retrospective cohort study between January 2007 and July 2011. Setting Academic teaching hospital in the Netherlands. Subjects Patients with an estimated glomerular filtration rate (eGFR) between 10-50 ml/min/1.73m2 at discharge and prescribed one or more medicines of which the dose is renal function dependent. Main Outcome Measures The prevalence of adherence with the Dutch renal dosing guideline was investigated, and the influence of possible determinants, such as reporting the eGFR and severity of renal impairment (severe: eGFR<30 and moderate: eGFR 30-50 ml/min/1.73m2). Furthermore, the potential clinical relevance of non-adherence was assessed. Results 1327 patients were included, mean age 67 years, mean eGFR 38 ml/min/1.73m2. Adherence with the guideline was present in 53.9% (n=715) of patients. Reporting the eGFR, which was incorporated since April 2009, resulted in more adherence with the guideline: 50.7% vs. 57.0%, RR 1.12 (95% CI 1.02-1.25). Adherence was less in patients with severe renal impairment (46.0%), compared to patients with moderate renal impairment (58.1%, RR 0.79; 95% CI 0.70-0.89). 71.4% of the cases of non-adherence had the potential to cause moderate to severe harm. Conclusion Required dosage adjustments in case of impaired renal function are often not performed at hospital discharge, which may cause harm to the majority of patients. Reporting the eGFR can be a small and simple first step to improve adherence with dosing guidelines.
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Affiliation(s)
- A. Clara Drenth-van Maanen
- University Medical Center Utrecht, Department of Geriatrics, Utrecht, The Netherlands
- Expertise Centre Pharmacotherapy for Old persons (Ephor), Utrecht, The Netherlands
- * E-mail: (ACM); (PAFJ)
| | - Rob J. van Marum
- Expertise Centre Pharmacotherapy for Old persons (Ephor), Utrecht, The Netherlands
- Jeroen Bosch Hospital, Department of Geriatrics, ‘s-Hertogenbosch, The Netherlands
- VUmc, Department of General Practice & Elderly Care Medicine, EMGO+ Institute for Health and Care Research, Amsterdam, The Netherlands
| | - Paul A. F. Jansen
- University Medical Center Utrecht, Department of Geriatrics, Utrecht, The Netherlands
- Expertise Centre Pharmacotherapy for Old persons (Ephor), Utrecht, The Netherlands
- * E-mail: (ACM); (PAFJ)
| | - Jeannette E. F. Zwart
- University Medical Center Utrecht, Department of Clinical Pharmacy, Utrecht, The Netherlands
| | - Wouter W. van Solinge
- University Medical Center Utrecht, Department of Clinical Chemistry and Haematology, Utrecht, The Netherlands
| | - Toine C. G. Egberts
- Expertise Centre Pharmacotherapy for Old persons (Ephor), Utrecht, The Netherlands
- University Medical Center Utrecht, Department of Clinical Pharmacy, Utrecht, The Netherlands
- Utrecht Institute for Pharmaceutical Sciences (UIPS), Department of Pharmacoepidemiology and Pharmacotherapy, Faculty of Science, Utrecht University, Utrecht, the Netherlands
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Abstract
BACKGROUND/AIMS Patients with chronic kidney disease require appropriate adjustment of nephrotoxic and renally cleared medications to ensure safe and effective pharmacotherapy. It is currently unclear how often appropriate medication selection and dosage adjustment occurs in practice. Therefore, this study aimed to evaluate the extent of potentially inappropriate prescribing (PIP) (the use of a contraindicated medication or inappropriately high dose according to the renal function) in patients with renal impairment from admission through to discharge from the Royal Hobart Hospital (RHH), Tasmania, Australia; to evaluate the medications most commonly implicated in PIP; and the factors associated with PIP in renal impairment. METHODS Medical records of 251 patients consecutively admitted to the RHH aged 40 years and above, with a creatinine clearance of ≤60 mL/min, and hypertension and/or diabetes mellitus in their medical history, were reviewed. PIP was assessed using the Australian Medicines Handbook and/or product information. RESULTS Of the 251 patients, 81 (32.3%) were receiving a total of 116 potentially inappropriate medications (PIMs) at the time of admission. The number of patients receiving PIMs (81 vs. 44, p<0.001 chi-square test) as well as the total number of PIMs (116 vs. 63, p<0.001 Wilcoxon signed rank test) were significantly decreased at discharge. Metformin was the most common PIM at admission. However, PIP of metformin was reduced by approximately 50% by discharge. Logistic regression analysis revealed two significant independent risk factors for PIP: a higher number of medications at admission increased risk of PIP (OR 1.1, 95% CI 1.02-1.18, p=0.010), and higher initial estimated glomerular filtration rate (eGFR) decreased the risk of PIP (OR 0.9, 95% CI 0.96-0.99, p=0.011). CONCLUSIONS Despite the limitations of lack of body weight documentation and lack of clear guidelines for dosage adjustment based on the eGFR, PIP in patients with renal impairment is common and admission to the hospital was associated with a significant reduction in PIP. More recognition of chronic kidney disease in the community and strategies to alert clinicians of the need for dosage adjustment in renal impairment are warranted.
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Khanal A, Castelino RL, Peterson GM, Jose MD. Dose adjustment guidelines for medications in patients with renal impairment: how consistent are drug information sources? Intern Med J 2014; 44:77-85. [PMID: 24112311 DOI: 10.1111/imj.12291] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 09/09/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND It is known that patients with renal disease are often administered inappropriate dosages of drugs. A lack of quantitative data in the available drug information sources and inconsistency in dosing information may augment the problem of dosing error. AIMS To determine the concordance among five drug information sources regarding the dosing recommendations provided for drugs considered problematic in patients with renal impairment and to determine the consistency among the sources regarding the definition of renal impairment and categorisation of chronic kidney disease. METHODS Five standard drug information sources were reviewed for 61 drugs recommended to be used with caution in renal impairment. Information on recommendations for dosage adjustment in renal impairment was extracted and analysed. Further, the definition and classification of renal impairment were recorded. The recommendation for each drug was coded into six different categories and the intersource reliability was calculated. RESULTS Only slight agreement was observed among the sources (Fleiss Kappa: 0.3). Qualitative data were not well defined, and there was a lack of consistency in quantitative values. Some drugs marked as contraindicated in one source were not mentioned as such in others. Also, drugs considered as not requiring dosage adjustment in one source had explicit recommendations in other sources. The definition and classification of renal impairment differed among the five information sources. CONCLUSIONS There should be an evidence-based approach to drug dosage adjustment in order to bring uniformity to the recommendations. Regular updating of the content of the drug information sources is also important.
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Affiliation(s)
- A Khanal
- School of Pharmacy, University of Tasmania, Hobart, Tasmania, Australia
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Gheewala PA, Peterson GM, Curtain CM, Nishtala PS, Hannan PJ, Castelino RL. Impact of the Pharmacist Medication Review Services on Drug-Related Problems and Potentially Inappropriate Prescribing of Renally Cleared Medications in Residents of Aged Care Facilities. Drugs Aging 2014; 31:825-35. [DOI: 10.1007/s40266-014-0208-y] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Cabello-Muriel A, Gascón-Cánovas JJ, Urbieta-Sanz E, Iniesta-Navalón C. Effectiveness of pharmacist intervention in patients with chronic kidney disease. Int J Clin Pharm 2014; 36:896-903. [PMID: 25135803 DOI: 10.1007/s11096-014-0001-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Accepted: 08/05/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Collaboration between pharmacists and physicians in the care of patients with chronic kidney disease (CKD) may improve the quality of drug dosage regimens that require adjustment according to the renal function. OBJECTIVE To demonstrate that the intervention of a pharmacist in a monitoring program for patients with CKD improves the outcome of renal function in these patients. Setting A 330-bed regional referral hospital in the city of Murcia (Spain). METHOD All patients with CKD and taking nephrotoxic medication admitted to the internal medicine service were included in the study. Depending on the department of the hospital to which the patients were admitted, they were assigned to an intervention or control group. In the control group, the renal function at the time of admission and discharge was measured. In the intervention group, in addition to measuring kidney function at the time of admission and at discharge, the patients were followed daily and recommendation for dose adjustment were made when nephrotoxic drugs were not properly dosed. MAIN OUTCOME MEASURE Glomerular filtration rate on admission and at discharge. RESULTS A total of 249 patients were included in the study, 124 in the control group and 125 in the intervention group. Significant differences were noted when comparing creatinine clearance (CrCl) between discharge and admission in both the control and intervention groups (5.1 ± 0.9 vs. 6.4 ± 1.0 p < 0.01). In a comparison of the observed improvement in the two groups, we found significant differences in adjusted relative CrCl according to sex, age and stage (19.9 [1.2-38.5] p < 0.05). When the disease was analyzed by stage, we observed significant differences that favored the intervention group in regards CrCl (3.1 ± 2.1 vs. 7.9 ± 3.8 p < 0.05) and relative CrCl (16.1 ± 10.3 vs. 36.6 ± 16.7) in stages 4-5. The rate of acceptance of the pharmacists' recommendations was 74 %. CONCLUSION The implementation of a monitoring program for CKD patients was effective in the group in which monitoring was conducted, especially in patients with more advanced stage of CKD.
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Affiliation(s)
- Aurelio Cabello-Muriel
- Pharmacy department, Hospital General Universitario Reina Sofía of Murcia, Av/Intendente Jorge Palacios 1, 30003, Murcia, Spain,
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Zyoud S, Abd-Alhafez A, Hussein A, Abu-Shehab I, Al-Jabi S, Sweileh W. Patterns of use of medications, herbal products and nutritional supplements and polypharmacy associating factors in Palestinian geriatric patients. Eur Geriatr Med 2014. [DOI: 10.1016/j.eurger.2013.11.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Via-Sosa MA, Lopes N, March M. Effectiveness of a drug dosing service provided by community pharmacists in polymedicated elderly patients with renal impairment--a comparative study. BMC Fam Pract 2013; 14:96. [PMID: 23849005 PMCID: PMC3723832 DOI: 10.1186/1471-2296-14-96] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Accepted: 06/12/2013] [Indexed: 01/06/2024]
Abstract
BACKGROUND Drug dosing errors are common in renal-impaired patients. Appropriate dosing adjustment and drug selection is important to ensure patients' safety and to avoid adverse drug effects and poor outcomes. There are few studies on this issue in community pharmacies. The aims of this study were, firstly, to determine the prevalence of dosing inadequacy as a consequence of renal impairment in patients over 65 taking 3 or more drug products who were being attended in community pharmacies and, secondly, to evaluate the effectiveness of the community pharmacist's intervention in improving dosing inadequacy in these patients when compared with usual care. METHODS The study was carried out in 40 Spanish community pharmacies. The study had two phases: the first, with an observational, multicentre, cross sectional design, served to determine the dosing inadequacy, the drug-related problems per patient and to obtain the control group. The second phase, with a controlled study with historical control group, was the intervention phase. When dosing adjustments were needed, the pharmacists made recommendations to the physicians. A comparison was made between the control and the intervention group regarding the prevalence of drug dosing inadequacy and the mean number of drug-related problems per patient. RESULTS The mean of the prevalence of drug dosing inadequacy was 17.5% [95% CI 14.6-21.5] in phase 1 and 15.5% [95% CI 14.5-16.6] in phase 2. The mean number of drug-related problems per patient was 0.7 [95% CI 0.5-0.8] in phase 1 and 0.50 [95% CI 0.4-0.6] in phase 2. The difference in the prevalence of dosing inadequacy between the control and intervention group before the pharmacists' intervention was 0.73% [95% CI (-6.0) - 7.5] and after the pharmacists' intervention it was 13.5% [95% CI 8.0 - 19.5] (p < 0.001) while the difference in the mean of drug-related problems per patient before the pharmacists' intervention was 0.05 [95% CI( -0.2) - 0.3] and following the intervention it was 0.5 [95% CI 0.3 - 0.7] (p < 0.001). CONCLUSION A drug dosing adjustment service for elderly patients with renal impairment in community pharmacies can increase the proportion of adequate drug dosing, and improve the drug-related problems per patient. Collaborative practice with physicians can improve these results.
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Affiliation(s)
- M Angeles Via-Sosa
- Pharmacy Practice, Unidad de Prácticas Tuteladas, Faculty of Pharmacy, University of Barcelone, Spain.
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Prajapati A, Ganguly B. Appropriateness of drug dose and frequency in patients with renal dysfunction in a tertiary care hospital: A cross-sectional study. J Pharm Bioallied Sci 2013; 5:136-40. [PMID: 23833519 PMCID: PMC3697192 DOI: 10.4103/0975-7406.111829] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 04/28/2012] [Accepted: 10/24/2012] [Indexed: 11/04/2022] Open
Abstract
AIM Study was aimed to assess the accuracy of drug dose and its frequency in patients with renal dysfunction in a tertiary care hospital. MATERIALS AND METHODS This was a retrospective observational study. Patients > 18 years old, with the serum creatinine (SCr) level > 1.4 mg/dl were included. Drugs prescribed to these patients were recorded in case record form. Drugs for which the dose was adjusted according to the clinical response to therapy, not according to SCr level (i.e., angiotensin converting enzyme inhibitors, diuretics, B blockers, anti-diabetics, etc.) were not taken into consideration. Based on the creatinine clearance which was calculated by Cockroft-Gault formula, dose and frequency of prescribed drugs were assessed using "Drug prescribing in renal failure - dosing guidelines for adults, 4(th) edition" and by another literature. Data was analyzed using Statistical Product and Service Solutions by IBM corporation version 17.0 software. RESULTS Total 278 indoor patients were screened, out of which 205 patients included. Total drugs prescribed to the patients were 1338 with the average of 6.53 drugs per patient. Out of these 180 (13.45%) drugs needed dose adjustment. Among them only 34 (18.89%) drugs were adjusted appropriately, and rest 146 (81.11%) were not adjusted. The most common group of drug that need dose adjustment was anti-microbials (144, 80%) with levofloxacin as individual drug. CONCLUSION This study emphasizes the importance of patients with renal dysfunction and implementing appropriate dose adjustments. This study also suggests intervention such as on-line information to assist dose guidelines and participation of clinical pharmacologist could improve patient outcome.
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Affiliation(s)
- Arpit Prajapati
- Medical and Scientific Affairs, Lambda Therapeutic Research Ltd., Ahmedabad, Gujarat, India
| | - Barna Ganguly
- Department of Pharmacology, Pramukh Swami Medical College, Karamsad, Anand, Gujarat, India
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Alsulami Z, Conroy S, Choonara I. Medication errors in the Middle East countries: a systematic review of the literature. Eur J Clin Pharmacol 2012; 69:995-1008. [PMID: 23090705 PMCID: PMC3621991 DOI: 10.1007/s00228-012-1435-y] [Citation(s) in RCA: 124] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2012] [Accepted: 10/09/2012] [Indexed: 11/30/2022]
Abstract
Background Medication errors are a significant global concern and can cause serious medical consequences for patients. Little is known about medication errors in Middle Eastern countries. The objectives of this systematic review were to review studies of the incidence and types of medication errors in Middle Eastern countries and to identify the main contributory factors involved. Methods A systematic review of the literature related to medication errors in Middle Eastern countries was conducted in October 2011 using the following databases: Embase, Medline, Pubmed, the British Nursing Index and the Cumulative Index to Nursing & Allied Health Literature. The search strategy included all ages and languages. Inclusion criteria were that the studies assessed or discussed the incidence of medication errors and contributory factors to medication errors during the medication treatment process in adults or in children. Results Forty-five studies from 10 of the 15 Middle Eastern countries met the inclusion criteria. Nine (20 %) studies focused on medication errors in paediatric patients. Twenty-one focused on prescribing errors, 11 measured administration errors, 12 were interventional studies and one assessed transcribing errors. Dispensing and documentation errors were inadequately evaluated. Error rates varied from 7.1 % to 90.5 % for prescribing and from 9.4 % to 80 % for administration. The most common types of prescribing errors reported were incorrect dose (with an incidence rate from 0.15 % to 34.8 % of prescriptions), wrong frequency and wrong strength. Computerised physician rder entry and clinical pharmacist input were the main interventions evaluated. Poor knowledge of medicines was identified as a contributory factor for errors by both doctors (prescribers) and nurses (when administering drugs). Most studies did not assess the clinical severity of the medication errors. Conclusion Studies related to medication errors in the Middle Eastern countries were relatively few in number and of poor quality. Educational programmes on drug therapy for doctors and nurses are urgently needed.
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Affiliation(s)
- Zayed Alsulami
- Academic Division of Child Health, School of Graduate Entry Medicine and Health, University of Nottingham, Derbyshire Children's at the Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3DT, UK.
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Modig S, Lannering C, Ostgren CJ, Mölstad S, Midlöv P. The assessment of renal function in relation to the use of drugs in elderly in nursing homes; a cohort study. BMC Geriatr 2011; 11:1. [PMID: 21223578 DOI: 10.1186/1471-2318-11-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Accepted: 01/11/2011] [Indexed: 12/01/2022] Open
Abstract
Background Renal function decreases with age. Dosage adjustment according to renal function is indicated for many drugs, in order to avoid adverse reactions of medications and/or aggravation of renal impairment. There are several ways to assess renal function in the elderly, but no way is ideal. The aim of the study was to explore renal function in elderly subjects in nursing homes and the use of pharmaceuticals that may be harmful to patients with renal impairment. Methods 243 elderly subjects living in nursing homes were included. S-creatinine and s-cystatin c were analysed. Renal function was estimated using Cockcroft-Gault formula, Modification of Diet in Renal Disease (MDRD) and cystatin C-estimated glomerular filtration rate (GFR). Concomitant medication was registered and four groups of renal risk drugs were identified: metformin, nonsteroidal anti-inflammatory drugs (NSAID), angiotensin-converting enzyme -inhibitors/angiotensin receptor blockers and digoxin. Descriptive statistics and the Kappa test for concordance were used. Results Reduced renal function (cystatin C-estimated GFR < 60 ml/min) was seen in 53%. Normal s-creatinine was seen in 41% of those with renal impairment. Renal risk drugs were rather rarely prescribed, with exception for ACE-inhibitors. Poor concordance was seen between the GFR estimates as concluded by other studies. Conclusions The physician has to be observant on renal function when prescribing medications to the elderly patient and not only rely on s-creatinine level. GFR has to be estimated before prescribing renal risk drugs, but using different estimates may give divergence in the results.
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Hassan Y, Al-Ramahi RJ, Aziz NA, Ghazali R. Impact of a Renal Drug Dosing Service on Dose Adjustment in Hospitalized Patients with Chronic Kidney Disease. Ann Pharmacother 2009; 43:1598-605. [DOI: 10.1345/aph.1m187] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: Appropriate drug selection and dosing for patients with chronic kidney disease (CKD) is important to avoid unwanted drug effects and ensure optimal patient outcomes. Objective: To assess the rate of inappropriate dosing in patients with CKD in a nephrology unit and to evaluate the impact on dose adjustment, adverse drug events (ADEs), and drug cost of having a pharmacist accompany a team of physicians on their rounds. Methods: This was a comparative study with a preintervention and postintervention design. The preintervention phase served as the control; it was prospective and observational only and was conducted from the beginning of February to the end of May 2007. The second phase (intervention phase) was conducted from the beginning of March to the end of June 2008. Two random samples of 300 patients with an estimated creatinine clearance less than or equal to 50 mL/min were included. During the intervention phase, a clinical pharmacist made rounds with the nephrology unit team and gave dosing adjustment recommendations when needed. A collection of reliable and up-to-date drug information references that are commonly used globally were used during the intervention. Results: In the preintervention group, drug dosage adjustment or avoidance, based on renal function, was necessary in 607 of 2814 (21.6%) prescriptions. Of these, 322 (53.0%) did not comply with guidelines. In the intervention group, adjustment was necessary for 640 of 2981 (21.5%) prescriptions. The pharmacist made 388 recommendations related to dosing adjustment, 212 (54.6%) of which were accepted by physicians. Clinicians' noncompliance with dosing guidelines decreased to 176 (27.5%) (p < 0.001). In the preintervention group, 64 (21.3%) patients had a suspected ADE, with a total of 73 events. In the intervention group, this number was significantly lower with 49 events in 48 (16.0%) patients (p < 0.05). The intervention resulted in drug cost savings of $2250 US. Conclusions: A renal drug dosing service for patients hospitalized with CKD can increase the proportion of drug dosing that is adjusted to take into account renal function. This can save drug costs and may prevent ADEs.
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Affiliation(s)
- Yahaya Hassan
- Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
| | | | - Noorizan Abd Aziz
- Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia
| | - Rozina Ghazali
- Internal Medicine Department, Penang Hospital, Penang, Malaysia
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Álvarez Arroyo L, Climent Grana E, Bosacoma Ros N, Roca Meroño S, Perdiguero Gil M, Ordovás Baines J, Sánchez Payá J. Evaluación de un programa de intervención farmacéutica en pacientes con medicamentos de riesgo renal. Farmacia Hospitalaria 2009; 33:147-154. [DOI: 10.1016/s1130-6343(09)71156-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Field TS, Rochon P, Lee M, Gavendo L, Baril JL, Gurwitz JH. Computerized clinical decision support during medication ordering for long-term care residents with renal insufficiency. J Am Med Inform Assoc 2009; 16:480-5. [PMID: 19390107 DOI: 10.1197/jamia.m2981] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
UNLABELLED OBJECTIVE To determine whether a computerized clinical decision support system providing patient-specific recommendations in real-time improves the quality of prescribing for long-term care residents with renal insufficiency. DESIGN Randomized trial within the long-stay units of a large long-term care facility. Randomization was within blocks by unit type. Alerts related to medication prescribing for residents with renal insufficiency were displayed to prescribers in the intervention units and hidden but tracked in control units. Measurement The proportions of final drug orders that were appropriate were compared between intervention and control units within alert categories: (1) recommended medication doses; (2) recommended administration frequencies; (3) recommendations to avoid the drug; (4) warnings of missing information. RESULTS The rates of alerts were nearly equal in the intervention and control units: 2.5 per 1,000 resident days in the intervention units and 2.4 in the control units. The proportions of dose alerts for which the final drug orders were appropriate were similar between the intervention and control units (relative risk 0.95, 95% confidence interval 0.83, 1.1) for the remaining alert categories significantly higher proportions of final drug orders were appropriate in the intervention units: relative risk 2.4 for maximum frequency (1.4, 4.4); 2.6 for drugs that should be avoided (1.4, 5.0); and 1.8 for alerts to acquire missing information (1.1, 3.4). Overall, final drug orders were appropriate significantly more often in the intervention units-relative risk 1.2 (1.0, 1.4). CONCLUSIONS Clinical decision support for physicians prescribing medications for long-term care residents with renal insufficiency can improve the quality of prescribing decisions. TRIAL REGISTRATION http://clinicaltrials.gov Identifier: NCT00599209.
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Affiliation(s)
- Terry S Field
- Meyers Primary Care Institute, Worcester, MA 01605, USA.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2007. [DOI: 10.1002/pds.1380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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