Drug-induced life-threatening potassium disturbances detected by a pharmacovigilance program from laboratory signals

An Awareness of Pharmacovigilance Among Healthcare Professionals Due to an Underreporting of Adverse Drug Reactions Issue: A Systematic Review of the Current State, Obstacles, and Strategy

BACKGROUND

Healthcare professionals play an essential role in reporting adverse drug reactions as part of pharmacovigilance activities. However, adverse drug reactions reported by healthcare professionals remain low.

OBJECTIVE

The aim of this systematic review was to investigate healthcare professionals' knowledge, awareness, attitude, and practice on pharmacovigilance and adverse drug reaction reporting, explore the causes of the underreporting issue, and provide improvement strategies.

METHODS

This systematic review was conducted using four electronic databases for original papers, including PubMed, Scopus, Google Scholar, and Scholar ID. Recent publications from 1st January 2012 to 31st December 2022 were selected. The following terms were used in the search: "awareness", "knowledge", "adverse drug reaction", "pharmacovigilance", "healthcare professional", and "underreporting factor". Articles were chosen, extracted, and reviewed by the two authors.

RESULTS

Twenty-five studies were selected for systematic review. This review found that 24.8%-73.33% of healthcare professionals were unaware of the National Pharmacovigilance Center. Around 20%-95.7% of healthcare professionals have a positive attitude toward pharmacovigilance and adverse drug reaction reporting, while 12%-60.8% of healthcare professionals have experience reporting any adverse drug reaction in their practice. The most frequently highlighted barriers to pharmacovigilance were a lack of awareness and knowledge regarding what, when, and to whom to report.

CONCLUSION

Underreporting issues require immediate attention among healthcare professionals due to a lack of awareness and knowledge of pharmacovigilance and adverse drug reaction reporting. Educational and training program interventions have been suggested by most studies to address these issues.

What is Polypharmacy in Patients with Chronic Kidney Disease? A Systematic Review

PURPOSE

Polypharmacy presents an increasing therapeutic challenge for physicians managing patients with chronic kidney disease (CKD). However, there is a lack of consensus regarding the specific medication count threshold that defines polypharmacy in this population. The objective of this review is to establish a unified definition of polypharmacy in the CKD population by examining the diverse definitions used in previously published studies.

METHODS

A comprehensive search was conducted in relevant databases (PubMed, SCOPUS, Cochrane, and disease-specific databases) from 2000 to May 2022 to identify studies with polypharmacy threshold definitions in patients with CKD. Studies meeting the inclusion criteria were included in this review, and their methodologic quality was assessed.

FINDINGS

Following the screening of the search results, duplicate records and studies that did not meet the inclusion criteria were removed, resulting in a total of 18 studies included in this review. Among these, 61.1% specified the polypharmacy definition to be a threshold of ≥5 medications. In addition, 22.2% specified a high polypharmacy definition at a threshold of ≥10 medications. However, none of the studies reported on the dichotomy between kidney-related and non-kidney-related polypharmacy.

IMPLICATIONS

This review indicates that a numerical threshold of ≥5 medications is commonly used to define polypharmacy in patients with CKD. Nevertheless, it remains uncertain whether a kidney-related polypharmacy definition or a high polypharmacy definition would better identify patients with CKD at risk for polypharmacy-related complications.

Daptomycin-Induced Severe Hyperkalemia With Normal Creatine Kinase in a Patient With Methicillin-Resistant Staphylococcus aureus Osteomyelitis

We report a case of an asymptomatic 60-year-old female who presented to the emergency department due to a home health measured serum potassium of 7.7 mmol/L (normal range: 3.6-5.0 mmol/L) and was admitted for severe hyperkalemia. She was recently started on a low dose of daily intravenous daptomycin to treat methicillin-resistant Staphylococcus aureus (MRSA) osteomyelitis of her sacral decubitus ulcers. Laboratory results showed normal creatine kinase (CK). Her elevated serum potassium levels reversed throughout her hospital stay and remained within normal range after daptomycin discontinuation, establishing a temporal relationship between daptomycin and hyperkalemia. To our knowledge, no other cases report daptomycin-induced severe hyperkalemia in the absence of rhabdomyolysis. Our case emphasizes the importance of considering hyperkalemia as an adverse effect of daptomycin, especially in elderly hospitalized patients.

Cotrimoxazole-induced hyperkalemia in renal transplant patient-Case report

We present the case of a 55-year-old male patient who developed hyperkalemia after using Cotrimoxazole (TMP-SMX). There was a marked increase in potassium levels from 3.3 mEq/L on Day 5 when cotrimoxazole was started to 6.2 mEq/L on Day 11 when the drug was withheld.

Association of Hyper-Polypharmacy With Clinical Outcomes in Heart Failure With Preserved Ejection Fraction

BACKGROUND

Polypharmacy is associated with a poor prognosis in the elderly, however, information on the association of polypharmacy with cardiovascular outcomes in heart failure with preserved ejection fraction is sparse. This study sought to investigate the relationship between polypharmacy and adverse cardiovascular events in patients with heart failure with preserved ejection fraction.

METHODS

Baseline total number of medications was determined in 1758 patients with heart failure with preserved ejection fraction enrolled in the Americas regions of the TOPCAT trial (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist), by 3 categories: nonpolypharmacy (<5 medications), polypharmacy (5-9), and hyper-polypharmacy (≥10). We examined the relationship of polypharmacy status with the primary outcome (cardiovascular death, HF hospitalization, or aborted cardiac arrest), hospitalizations for any reason, and serious adverse events.

RESULTS

The proportion of patients taking 5 or more medications was 92.5% (inclusive of polypharmacy [38.7%] and hyper-polypharmacy [53.8%]). Over a 2.9-year median follow-up, compared with patients with polypharmacy, hyper-polypharmacy was associated with an increased risk for the primary outcome, hospitalization for any reason and any serious adverse events in the univariable analysis, but not significantly associated with mortality. After multivariable adjustment for demographic and comorbidities, hyper-polypharmacy remained significantly associated with an increased risk for hospitalization for any reason (hazard ratio, 1.22 [95% CI, 1.05-1.41]; P=0.009) and any serious adverse events (hazard ratio, 1.23 [95% CI, 1.07-1.42]; P=0.005), whereas the primary outcome was no longer statistically significant.

CONCLUSIONS

Hyper-polypharmacy was common and associated with an elevated risk of hospitalization for any reason and any serious adverse events in patients with heart failure with preserved ejection fraction. There were no significant associations between polypharmacy status and mortality.

Serum potassium and outcomes in heart failure with preserved ejection fraction: a post-hoc analysis of the PARAGON-HF trial

AIMS

The relationship between serum potassium concentration and outcomes in patients with heart failure and preserved ejection fraction (HFpEF) is not well-established. The aim of this study was to explore the association between serum potassium and clinical outcomes in the PARAGON-HF trial in which 4822 patients with HFpEF were randomised to treatment with sacubitril/valsartan or valsartan.

METHODS AND RESULTS

The relationship between serum potassium concentrations and the primary study composite outcome of total (first and recurrent) heart failure hospitalisations and cardiovascular death was analysed. Hypo-, normo-, and hyperkalaemia were defined as serum potassium <4 mmol/L, 4-5 mmol/L and >5 mmol/L, respectively. Both screening and time-updated potassium (categorical and continuous spline-transformed) were studied. Patient mean age was 73 years and 52% were women. Patients with higher baseline potassium more often had an ischaemic aetiology and diabetes and mineralocorticoid receptor antagonist treatment. Compared with normokalaemia, both time-updated (but not screening) hypo- and hyperkalaemia were associated with a higher risk of the primary outcome [adjusted hazard ratio (HR) for hypokalaemia 1.55, 95% confidence interval (CI) 1.30-1.85; P < 0.001, and for hyperkalaemia HR 1.21, 95% CI 1.02-1.44; P = 0.025]. Hypokalaemia had a stronger association with a higher risk of all-cause, cardiovascular and non-cardiovascular death than hyperkalaemia. The association of hypokalaemia with increased risk of all-cause and cardiovascular death was most marked in participants with impaired kidney function (interaction P < 0.05). Serum potassium did not significantly differ between sacubitril/valsartan and valsartan throughout the follow-up.

CONCLUSIONS

Both hypo- and hyperkalaemia were associated with heart failure hospitalisation but only hypokalaemia was associated with mortality, especially in the context of renal impairment. Hypokalaemia was as strongly associated with death from non-cardiovascular causes as with cardiovascular death. Collectively, these findings suggest that potassium disturbances are a more of a marker of HFpEF severity rather than a direct cause of death.

Understanding Patient Needs Regarding Adverse Drug Reaction Reporting Smartphone Applications: A Qualitative Insight from Saudi Arabia

BACKGROUND

A pragmatic shift in the healthcare sector characterized by moving from curative to preventive approaches highlights the role of pharmacovigilance in patient safety. There have been few published studies on patient reporting of adverse drug reactions (ADRs) in Saudi Arabia. This qualitative study aims to explore the community opinions and the need for patient-friendly smartphone applications (SPAs) to enhance their participation in ADR reporting.

METHODS

Purposeful sampling was followed to recruit study participants, a semi-structured interview guide was used to conduct interviews, and the saturation was reached after the 13th interviewer; no new information was obtained after two subsequent interviews. All the interviews were audio-recorded, transcribed verbatim, and analyzed by means of a standard content analysis framework.

RESULTS

As per the WHO guidelines, eleven participants were aware of the term "ADR". All the participants denied receiving any prior education and attending events about ADRs and were unaware of the Saudi FDA-ADR reporting systems. The use of technologies such as SPAs has been widely accepted with a high level of concern for data confidentiality and privacy.

CONCLUSIONS

These findings point out the need to build patient-oriented educational programs to increase their awareness of ADR reporting and to prioritize the use of artificial intelligence (AI) to be integrated in the Saudi healthcare system to develop future SPAs for improving both patient safety and signal detection of ADRs.

Drug Induced Liver Injury in Geriatric Patients Detected by a Two-Hospital Prospective Pharmacovigilance Program: A Comprehensive Analysis Using the Roussel Uclaf Causality Assessment Method

Background/aim: A prospective evaluation of drug-induced liver injury (DILI) in two tertiary hospitals was conducted through a pharmacovigilance program from laboratory signals at hospital (PPLSH) to determine the principal characteristics of DILI in patients older than 65 years, a growing age group worldwide, which is underrepresented in the literature on DILI.

Methods: All DILI in patients older than 65 years detected by PPLSH in two hospitals were followed up for 8 years in the La Paz Hospital and 2 years in the Getafe Hospital. A descriptive analysis was conducted that determined the causality of DILI and suspected drugs, the incidence of DILI morbidities, DILI characteristics, laboratory patterns, evolution and outcomes.

Results: 458 DILI cases in 441 patients were identified, 31.0% resulting in hospitalisation and 69.0% developing during hospitalisation. The mean age was 76.61 years old (SD, 7.9), and 54.4% were women. The DILI incidence was 76.33/10,000 admissions (95%CI 60.78–95.13). Polypharmacy (taking >4 drugs) was present in 86.84% of patients, 39.68% of whom took >10 drugs. The hepatocellular phenotype was the most frequent type of DILI (53.29%), a higher proportion (65%) had a mild severity index, and, in 55.2% of the evaluated drugs the RUCAM indicated that the causal relationship was highly probable. The most frequently employed drugs were paracetamol (50-cases), amoxicillin-clavulanate (42-cases) and atorvastatin (37-cases). The incidence rate of in-hospital DILI per 10,000 DDDs was highest for piperacillin-tazobactam (66.96/10,000 DDDs). A higher risk of in-hospital DILI was associated with the therapeutic chemical group-J (antiinfectives for systemic use) (OR, 2.65; 95%CI 1.58–4.46) and group-N (central nervous system drugs) (OR, 2.33; 95%CI 1.26–4.31). The patients taking >4 medications presented higher maximum creatinine level (OR, 2.01; 95%CI 1.28–3.15), and the patients taking >10 medications had a higher use of group J drugs (OR, 2.08; 95%IC 1.31–3.32).

Conclusion: The incidence rate of DILI in the patients older than 65 years was higher than expected. DILI in elderly patients is mild, has a good outcome, has a hepatocellular pattern, develops during hospitalisation, and prolongs the hospital stay. Knowing the DILI incidence and explanatory factors will help improve the therapy of the elderly population.

Oral acyclovir induced hypokalemia and acute tubular necrosis a case report

Background

Acyclovir is one of the most common prescribed antiviral drugs. Acyclovir nephrotoxicity occurs in approximately 12–48% of cases. It can present in clinical practice as acute kidney injury (AKI), crystal-induced nephropathy, acute tubulointerstitial nephritis, and rarely, as tubular dysfunction. Electrolytes abnormalities like hypokalemia, were previously described only when given intravenously.

Case presentation

A 54 year-old female presented with weakness and lower extremities paresis, nausea and vomiting after receiving oral acyclovir. Physical examination disclosed a decrease in the patellar osteotendinous reflexes (++ / ++++). Laboratory data showed a serum creatinine level of 2.1 mg/dL; serum potassium 2.1 mmol/L. Kidney biopsy was obtained; histological findings were consistent with acute tubular necrosis and acute tubulointerstitial nephritis. The patient was advised to stop the medications and to start with oral and intravenous potassium supplement, symptoms improved and continued until serum potassium levels were > 3.5 meq/L.

Conclusions

The case reported in this vignette is unique since it is the first one to describe hypokalemia associated to acute tubular necrosis induced by oral acyclovir.

An in vitro investigation of genotoxic effects of dexketoprofen trometamol on healthy human lymphocytes

Non-steroidal anti-inflammatory drugs are drugs with analgesic, antipyretic, and anti-inflammatory effects. This study uses in vitro methods to investigate the potential and unknown genotoxic effects of dexketoprofen trometamol, an active substance in painkillers, on healthy human lymphocytes. In this study, a cytokinesis-block micronucleus cytome assay is used to investigate potential clastogenic, aneugenic activity and to identify chromosome breakages caused by the active drug substance dexketoprofen trometamol; a comet assay is performed to identify the genotoxic damage resulting from DNA single-strand breaks; a real-time reverse transcription polymerase chain reaction panel system is used to evaluate the potential negative effects on the expression of the genes responsible for DNA damage assessment. Dexketoprofen trometamol induces toxic effects in healthy human lymphocytes at concentrations of 750-1000 µg/mL and above, and shows clastogenic, aneugenic activity by inducing micronucleus formations at exposures of 750-500 µg/mL. At concentration intervals of 1000, 500, 250, 100 µg/mL, dexketoprofen trometamol also resulted in DNA damage in the form of strand breaks, as demonstrated by highly significant increases in DNA tail length and density comet parameters when compared to spontaneous values. Human lymphocytes exposed to 750-100 µg/mL dexketoprofen trometamol were found to have significantly increased levels of expression of the XPC, XRCC6, PNKP genes in the DNA damage signaling pathway. It can be concluded that dexketoprofen trometamol may have cytotoxic, cytostatic, genotoxic effects on healthy human lymphocytes in vitro, depending on the concentration and duration of exposure. It is anticipated that this outcome will be supported by advanced studies.

Hypokalemia during antibiotic treatment for bone and joint infections

PURPOSE

During treatment of bone and joint infections (BJIs) with multiple antibiotic therapy, hypokalemia has been reported as a rare side effect. The aim of this study was to evaluate incidence and risk factors for hypokalemia in a cohort of patients treated with multidrug therapy for BJIs, in a single center.

METHODS

We retrospectively reviewed 331 clinical files of 150 consecutive patients (65% males; median age 59 years, 95% CI 55-62) admitted repeatedly to our Osteomyelitis Department for treatment of chronic BJIs. Besides surgical debridement, patients received a combination of oral and intravenous antibiotics. Routine laboratory tests were performed at admittance and repeated at least weekly. Possible hypokalemia risk factors were recorded and analyzed.

RESULTS

Progressive kalemia reduction occurred in > 39% of patients during hospitalization; prevalence of marked hypokalemia (K ⁺ < 3.5 mEq/l) increased from 5% at admission to 11% (up to 22%) at day 14. Correlated factors were: age ≥ 68 years (p = 0.033), low serum albumin (p = 0.034), treatment with vancomycin (p < 0.001), rifampicin (p = 0.017) and ciprofloxacin (p < 0.001) and use of thiazide (p = 0.007) or loop diuretics (p = 0.029 for K ⁺ < 3.5 mEq/l). At multivariate regression analysis, the main determinants of hypokalemia were simultaneous use of diuretics (p = 0.007) and older age (p < 0.049).

CONCLUSIONS

Appearance of severe hypokalemia is a frequent event among patients treated for BJIs with multiple antibiotic therapy, when this is prescribed in older age patients and associated with simultaneous use of diuretics. Due to possible increase in mortality risk in the short term, particular caution should be paid during intensive antibiotic treatment in these groups of patients.

Safety of potassium-bearing citrate in patients with renal transplantation: A case report

RATIONALE

Urinary lithiasis is one of severe postoperative complications in patients undergoing renal transplantation, possibly leading to anuria, urinary infection, or even acute renal failure. Potassium sodium hydrogen citrate (PSHC), a potassium-bearing citrate, is commonly prescribed to prevent stone formation.

PATIENT CONCERNS

A 25-year-old man (patient 1) and a 31-year-old man (patient 2) receiving renal transplantation for end-stage renal disease (ESRD) were enrolled in this study. They were given 10 g/day of PSHC granules from the ninth day to the 17th day after surgery. Patient 1 presented chest tightness, nausea, muscle weakness, and ascending paralysis on the 10th day. Patient 2 presented weak waves on EGG on the 17th day. Moreover, their serum potassium concentrations (SPCs) were 7.67 and 6.05 mmol/L, respectively.

DIAGNOSIS

Acute hyperkalemia.

INTERVENTIONS

Hemo-filtration was performed for patient 1, while patient 2 received 10% calcium gluconate 10 mL, 5% NaHCO3 125 mL, and 10% glucose 500 mL with the addition of 10 units of insulin through intravenous drip.

OUTCOMES

Their SPCs dropped to the normal range.

LESSONS

Physicians should pay close attentions to potential risks caused by PSHC, and monitor the SPCs to minimize the occurrence of hyperkalemia.

How to Improve Adherence to Life-saving Heart Failure Treatments with Potassium Binders

Medications that affect the renin-angiotensin-aldosterone system (RAAS) form the mainstay of current heart failure (HF) therapy in patients with reduced ejection fraction. Concerns about the risk of hyperkalaemia have created a significant barrier to optimal RAAS inhibitor therapy in patients with HF, however, and many patients are discontinuing or receiving suboptimal doses of these lifesaving therapies. This has serious health and economic implications due to adverse renal and cardiovascular events. There is therefore an important unmet need for novel therapeutic options for the long-term management of patients with, and at risk for, hyperkalaemia. Two new potassium-binding agents, patiromer and ZS-9, have been shown to be effective and safe for the treatment of hyperkalaemia, as well as the maintenance of normokalaemia, without dose reduction or discontinuation of RAAS inhibitors. In addition, the fast onset of ZS-9 action suggests that it may be useful in the treatment of acute hyperkalaemia. These agents may allow for dose optimisation of RAAS inhibitors for the long-term maintenance and protection of the renal and cardiovascular system.

Optimising the use of medicines to reduce acute kidney injury in children and babies

The majority of medications in children are administered in an unlicensed or off-label manner. Paediatricians are obliged to prescribe using the limited evidence available. The 2007 EU regulation on the use of paediatric drugs means pharmaceutical companies are now obliged to (and receive incentives for) contributing to paediatric drug data and carrying out paediatric clinical trials. This is important, as the efficacy and adverse effect profiles of medicines vary across childhood. Additionally, there are significant age-related changes in the pharmacodynamic and pharmacokinetic activity of many drugs. This may be related to physiological (differential expressions of cytochrome P450 enzymes or variable glomerular filtration rates at different ages for example) and psychological (increasing autonomy and risk perception in teenage years) changes. Increasing numbers of children are surviving life-threatening childhood conditions due to medical advances. This means there is an increasing population who are at risk of the consequences of the long-term, early exposure to nephrotoxic agents. The kidney is an organ that is particularly vulnerable to damage as a consequence of drugs. Drug-induced acute kidney injury (AKI) episodes in children and babies are principally due to non-steroidal anti-inflammatory drugs, antibiotics or chemotherapeutic agents. The renal tubules are vulnerable to injury because of their concentrating ability and high-energy hypoxic environment. This review focuses on drug-induced AKI and the methods to minimise its effect, including general management plus the role of child-specific pharmacokinetic data, the use of pharmacogenomics and early detection of AKI using urinary biomarkers and electronic triggers.

Hyporeninemic hypoaldosteronism and diabetes mellitus: Pathophysiology assumptions, clinical aspects and implications for management

Patients with diabetes mellitus (DM) frequently develop electrolyte disorders, including hyperkalemia. The most important causal factor of chronic hyperkalemia in patients with diabetes is the syndrome of hyporeninemic hypoaldosteronism (HH), but other conditions may also contribute. Moreover, as hyperkalemia is related to the blockage of the renin-angiotensin-aldosterone system (RAAS) and HH is most common among patients with mild to moderate renal insufficiency due to diabetic nephropathy (DN), the proper evaluation and management of these patients is quite complex. Despite its obvious relationship with diabetic nephropathy, HH is also related to other microvascular complications, such as DN, particularly the autonomic type. To confirm the diagnosis, plasma aldosterone concentration and the levels of renin and cortisol are measured when the RAAS is activated. In addition, synthetic mineralocorticoid and/or diuretics are used for the treatment of this syndrome. However, few studies on the implications of HH in the treatment of patients with DM have been conducted in recent years, and therefore little, if any, progress has been made. This comprehensive review highlights the findings regarding the epidemiology, diagnosis, and management recommendations for HH in patients with DM to clarify the diagnosis of this clinical condition, which is often neglected, and to assist in the improvement of patient care.

Patient- and physician-related risk factors for hyperkalaemia in potassium-increasing drug-drug interactions

PURPOSE

Hyperkalaemia due to potassium-increasing drug-drug interactions (DDIs) is a clinically important adverse drug event. The purpose of this study was to identify patient- and physician-related risk factors for the development of hyperkalaemia.

METHODS

The risk for adult patients hospitalised in the University Hospital Zurich between 1 December 2009 and 31 December 2011 of developing hyperkalaemia was correlated with patient characteristics, number, type and duration of potassium-increasing DDIs and frequency of serum potassium monitoring.

RESULTS

The 76,467 patients included in this study were prescribed 8,413 potentially severe potassium-increasing DDIs. Patient-related characteristics associated with the development of hyperkalaemia were pulmonary allograft [relative risk (RR) 5.1; p < 0.0001), impaired renal function (RR 2.7; p < 0.0001), diabetes mellitus (RR 1.6; p = 0.002) and female gender (RR 1.5; p = 0.007). Risk factors associated with medication were number of concurrently administered potassium-increasing drugs (RR 3.3 per additional drug; p < 0.0001) and longer duration of the DDI (RR 4.9 for duration ≥6 days; p < 0.0001). Physician-related factors associated with the development of hyperkalaemia were undetermined or elevated serum potassium level before treatment initiation (RR 2.2; p < 0.001) and infrequent monitoring of serum potassium during a DDI (interval >48 h: RR 1.6; p < 0.01).

CONCLUSION

Strategies for reducing the risk of hyperkalaemia during potassium-increasing DDIs should consider both patient- and physician-related risk factors.