Primary Care Providers' Acceptance of Pharmacists' Recommendations to Support Optimal Medication Management for Patients with Diabetic Kidney Disease

Potentially inappropriate medication among older patients with diabetic kidney disease

Objective: Potentially inappropriate medications (PIM) contribute to poor outcomes in older patients, making it a widespread health problem. The study explored the occurrence and risk factors of PIM in older diabetic kidney disease (DKD) patients during hospitalization and investigated whether polypharmacy was associated with it. Methods: Retrospective analysis of the patients ≥ 65 years old diagnosed with DKD from July to December 2020; the PIM was evaluated according to the American Beers Criteria (2019). Factors with statistical significance in univariate analysis were included in Logistic multivariate analysis to explore the potential risk factors related to PIM. Results: Included 186 patients, 65.6% of patients had PIM, and 300 items were confirmed. The highest incidence of PIM was 41.7% for drugs that should be carefully used by the older, followed by 35.3% that should be avoided during hospitalization. The incidence of PIM related to diseases or symptoms, drug interactions to avoid, and drugs to avoid or reduce dose for renal insufficiency patients were 6.3%, 4.0% and 12.7%, respectively. The medications with a high incidence of PIM were diuretics (35.0%), benzodiazepines (10.7%) and peripheral ɑ1 blockers (8.7%). Compared with hospitalization, there were 26% of patients had increased PIM at discharge. Multivariate Logistic regression analysis showed that polypharmacy during hospitalization was an independent risk factor for PIM, OR = 4.471 (95% CI: 2.378, 8.406). Conclusion: The incidence of PIM in hospitalized older DKD patients is high; we should pay more attention to the problem of polypharmacy in these patients. Pharmacists identifying the subtypes and risk factors for PIM may facilitate risk reduction for older DKD patients.

Lessons learned from two randomized controlled trials: CITIES and STOP-DKD

Background

Even well-designed, theoretically driven clinical trials can fall short of achieving the desired clinical outcomes. Our research team had an opportunity to conduct two randomized controlled trials that were enrolling patients in parallel. While both studies were targeting chronic disease management among patients with multiple comorbid conditions, the patient population and settings varied. The studies were the Cardiovascular Intervention Improvement Telemedicine Study (CITIES) and Simultaneous Risk Factor Control Using Telehealth to slow Progression of Diabetic Kidney Disease (STOP-DKD) studies. Both studies had null findings.

Objectives

Our goal is to discuss common design considerations across CITIES and STOP-DKD and potential implications for the design of future randomized controlled trials.

Methods

These were two 1:1 randomized controlled trials with attention control groups that recruited patients from various clinical practices in the Research Triangle area of North Carolina.

Conclusions

We make three recommendations for future studies. First, we assert that it is important to allow for piloting the enrollment process to ensure that it is possible to identify and recruit a patient population that is well aligned with the clinical outcomes of the intervention. Second, analysis plans should be more targeted in their approach and should consider heterogeneity of treatment effects. Third, in order to support the transition of evidence generated from randomized controlled trials into clinical practice, it is important to consider even early stage randomized controlled trials through an implementation science lens.

Trial registration

Simultaneous Risk Factor Control Using Telehealth to slow Progression of Diabetic Kidney Disease (STOP-DKD) NCT01829256; Cardiovascular Intervention Improvement Telemedicine Study NCT01142908.