1
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Miceli G, Daidone M, Corpora F, Gaudio FD, Tuttolomondo A. Late administration of glucarpidase in methotrexate intoxication: Do we have more time than we thought? Eur J Intern Med 2024; 119:144-145. [PMID: 37806838 DOI: 10.1016/j.ejim.2023.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 09/26/2023] [Accepted: 10/02/2023] [Indexed: 10/10/2023]
Affiliation(s)
- G Miceli
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro" (PROMISE), University of Palermo, Sicily, Italy.
| | - M Daidone
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro" (PROMISE), University of Palermo, Sicily, Italy
| | - F Corpora
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro" (PROMISE), University of Palermo, Sicily, Italy
| | - F Di Gaudio
- Dipartimento di Scienze e Tecnologie Biologiche, Chimiche e Farmaceutiche, Università degli Studi di Palermo, Via Archirafi 32, Palermo, I-90123, Italy
| | - A Tuttolomondo
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno Infantile, Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro" (PROMISE), University of Palermo, Sicily, Italy
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2
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Hosseini E, Shahbazi F. Methotrexate-induced Severe Pancytopenia in a Patient with Rheumatoid Arthritis: A Case Report and Review of Literature. Curr Drug Saf 2024; 19:224-235. [PMID: 37194235 DOI: 10.2174/1574886318666230516115737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 03/15/2023] [Accepted: 04/03/2023] [Indexed: 05/18/2023]
Abstract
Toxicity associated with low doses of methotrexate (MTX) is low, but it may be fatal. Bone marrow suppression and mucositis are among the common side effects of low dose MTX toxicity. Different risk factors have been reported for toxicities associated with low doses of MTX, including accidental use of higher doses, renal dysfunction, hypoalbuminemia, and polypharmacy. In this paper, we present a female patient who had mistakenly used 7.5 mg of MTX daily instead of the same dose of MTX on Thursday and Friday. She was presented with mucositis and diarrhea to the emergency department. Moreover, we searched the databases Scopus and PubMed for available studies and case reports on toxicities associated with MTX dosing errors. The most frequently observed toxicities included gastrointestinal lesions, nausea, vomiting, skin lesions, and bone marrow suppression. Leucovorin, hydration, and urine alkalinization were among the most frequently used treatments. Finally, we summarize the data on the toxicities of low doses of MTX in different diseases.
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Affiliation(s)
- Elham Hosseini
- Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Foroud Shahbazi
- Department of Clinical Pharmacy, School of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
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3
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Szpot P, Wachełko O, Zawadzki M. Toxicological Aspects of Methotrexate Intoxication: Concentrations in Postmortem Biological Samples and Autopsy Findings. TOXICS 2022; 10:572. [PMID: 36287852 PMCID: PMC9609116 DOI: 10.3390/toxics10100572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 09/26/2022] [Accepted: 09/27/2022] [Indexed: 06/16/2023]
Abstract
The aim of this study was the establishment of a UHPLC-QqQ-MS/MS method to determine methotrexate in postmortem biological samples and quantify the postmortem distribution of methotrexate in a case of fatal intoxication of this drug. A volume of 100 μL or 100 mg of postmortem specimens was precipitated with 400 μL of cold methanol and then analyzed using UHPLC-QqQ-MS/MS. The validation parameters of the method were as follows: limit of quantification: 0.1−1.0 ng/mL or ng/g, coefficient of determination: >0.998 (R2), matrix effect, intra- and inter-day accuracies and precisions: not greater than 13.6%, 14.8% and 17.4%, respectively. The recoveries were: 89.0−113.6%. The postmortem distribution studies revealed methotrexate concentrations as follows: blood—7.2 ng/mL, vitreous humor—0.8 ng/mL, liver—43.7 ng/g, kidney—20.6 ng/g, bone marrow—29.9 ng/g, lumbar vertebra—20.0 ng/g. The highest concentrations of methotrexate after poisoning were found in the tissues with the most rapidly dividing cells. The method described is simple, precise and selective. Methotrexate concentrations can be routinely determined in postmortem specimens. Determination of methotrexate in the postmortem biological material is possible after a few days of intensive treatment.
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Affiliation(s)
- Paweł Szpot
- Department of Forensic Medicine, Wroclaw Medical University, 4 J. Mikulicza-Radeckiego Street, 50345 Wroclaw, Poland
| | - Olga Wachełko
- Institute of Toxicology Research, 45 Kasztanowa Street, 55093 Borowa, Poland
| | - Marcin Zawadzki
- Department of Forensic Medicine, Wroclaw Medical University, 4 J. Mikulicza-Radeckiego Street, 50345 Wroclaw, Poland
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4
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Ibarra Mira ML, Gangoso Fermoso A, Herrero Domínguez-Berrueta MC. Intervención para reducir los errores en la prescripción electrónica y la monitorización del tratamiento con metotrexato a dosis bajas en Atención Primaria. REVISTA CLÍNICA DE MEDICINA DE FAMILIA 2022. [DOI: 10.55783/150213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- María Luisa Ibarra Mira
- Farmacéutica. Servicio de Farmacia de Atención Primaria. Dirección Asistencial Noroeste de Madrid. Gerencia Asistencial de Atención Primaria. Majadahonda. Madrid (España)
| | - Ana Gangoso Fermoso
- Farmacéutica. Servicio de Farmacia de Atención Primaria. Dirección Asistencial Noroeste de Madrid. Gerencia Asistencial de Atención Primaria. Majadahonda. Madrid (España)
| | - María Carmen Herrero Domínguez-Berrueta
- Farmacéutica. Servicio de Farmacia de Atención Primaria. Dirección Asistencial Noroeste de Madrid. Gerencia Asistencial de Atención Primaria. Majadahonda. Madrid (España)
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5
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Ibarra Mira ML, Gangoso Fermoso A, Herrero Domínguez-Berrueta MC. Intervención para reducir los errores en la prescripción electrónica y la monitorización del tratamiento con metotrexato a dosis bajas en Atención Primaria. REVISTA CLÍNICA DE MEDICINA DE FAMILIA 2022. [DOI: 10.55783/rcmf.150213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- María Luisa Ibarra Mira
- Farmacéutica. Servicio de Farmacia de Atención Primaria. Dirección Asistencial Noroeste de Madrid. Gerencia Asistencial de Atención Primaria. Majadahonda. Madrid (España)
| | - Ana Gangoso Fermoso
- Farmacéutica. Servicio de Farmacia de Atención Primaria. Dirección Asistencial Noroeste de Madrid. Gerencia Asistencial de Atención Primaria. Majadahonda. Madrid (España)
| | - María Carmen Herrero Domínguez-Berrueta
- Farmacéutica. Servicio de Farmacia de Atención Primaria. Dirección Asistencial Noroeste de Madrid. Gerencia Asistencial de Atención Primaria. Majadahonda. Madrid (España)
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6
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Silva MM, Ferreira CC, Garcia MA, Pereira E. Methotrexate Pneumonitis After a Low-Dose Medication Error: A Case Report. Cureus 2022; 14:e23078. [PMID: 35464521 PMCID: PMC9001873 DOI: 10.7759/cureus.23078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2022] [Indexed: 11/13/2022] Open
Abstract
Methotrexate is recommended as the first choice of standard drug therapy following the diagnosis of rheumatoid arthritis. Pneumonitis related to methotrexate is a serious, unpredictable adverse event that may become life-threatening. We reported a case of a 68-year-old woman with rheumatoid arthritis that misunderstood the directions for use and took methotrexate daily, instead of weekly, leading to hepatic, hematological, and pulmonary toxicity.Although the histological evaluation was not performed, patient’s clinical presentation, in addition to subsequent investigational findings, supported a diagnosis of pneumonitis resulting from MTX exposure. Toxic dosing over a long period of time along with the concomitant taking of pantoprazole and hypoalbuminemia could have increased the incidence of some adverse events. Concerning pneumonitis related to methotrexate, the toxic dose may have accelerated the pulmonary manifestations, but we do not know if correct dose had been taken, this adverse event would occur. This case enlightened two important issues in rheumatoid arthritis treatment: the possibility of medication errors and the rare, but potentially life-threatening, methotrexate-induced pneumonitis. Improving education and warnings when prescribing and dispensing low-dose methotrexate is essential.
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7
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Ghannoum M, Roberts DM, Goldfarb DS, Heldrup J, Anseeuw K, Galvao TF, Nolin TD, Hoffman RS, Lavergne V, Meyers P, Gosselin S, Botnaru T, Mardini K, Wood DM. Extracorporeal Treatment for Methotrexate Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup. Clin J Am Soc Nephrol 2022; 17:602-622. [PMID: 35236714 PMCID: PMC8993465 DOI: 10.2215/cjn.08030621] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Methotrexate is used in the treatment of many malignancies, rheumatological diseases, and inflammatory bowel disease. Toxicity from use is associated with severe morbidity and mortality. Rescue treatments include intravenous hydration, folinic acid, and, in some centers, glucarpidase. We conducted systematic reviews of the literature following published EXtracorporeal TReatments In Poisoning (EXTRIP) methods to determine the utility of extracorporeal treatments in the management of methotrexate toxicity. The quality of the evidence and the strength of recommendations (either "strong" or "weak/conditional") were graded according to the GRADE approach. A formal voting process using a modified Delphi method assessed the level of agreement between panelists on the final recommendations. A total of 92 articles met inclusion criteria. Toxicokinetic data were available on 90 patients (89 with impaired kidney function). Methotrexate was considered to be moderately dialyzable by intermittent hemodialysis. Data were available for clinical analysis on 109 patients (high-dose methotrexate [>0.5 g/m2]: 91 patients; low-dose [≤0.5 g/m2]: 18). Overall mortality in these publications was 19.5% and 26.7% in those with high-dose and low-dose methotrexate-related toxicity, respectively. Although one observational study reported lower mortality in patients treated with glucarpidase compared with those treated with hemodialysis, there were important limitations in the study. For patients with severe methotrexate toxicity receiving standard care, the EXTRIP workgroup: (1) suggested against extracorporeal treatments when glucarpidase is not administered; (2) recommended against extracorporeal treatments when glucarpidase is administered; and (3) recommended against extracorporeal treatments instead of administering glucarpidase. The quality of evidence for these recommendations was very low. Rationales for these recommendations included: (1) extracorporeal treatments mainly remove drugs in the intravascular compartment, whereas methotrexate rapidly distributes into cells; (2) extracorporeal treatments remove folinic acid; (3) in rare cases where fast removal of methotrexate is required, glucarpidase will outperform any extracorporeal treatment; and (4) extracorporeal treatments do not appear to reduce the incidence and magnitude of methotrexate toxicity.
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Affiliation(s)
- Marc Ghannoum
- Research Center, CIUSSS du Nord-de-l'île-de-Montréal, University of Montreal, Montreal, Quebec, Canada.,Department of Nephrology and Hypertension, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Darren M Roberts
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia; and St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia; and Drug Health Services, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - David S Goldfarb
- Nephrology Division, NYU Langone Health and NYU Grossman School of Medicine, New York, New York
| | - Jesper Heldrup
- Childhood Cancer and Research Unit, University Children's Hospital, Lund, Sweden
| | - Kurt Anseeuw
- Department of Emergency Medicine, ZNA Stuivenberg, Antwerp, Belgium
| | - Tais F Galvao
- School of Pharmaceutical Sciences, University of Campinas, Campinas, Sao Paulo, Brazil
| | - Thomas D Nolin
- Department of Pharmacy and Therapeutics, and Department of Medicine Renal-Electrolyte Division, University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, Pennsylvania
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, New York
| | - Valery Lavergne
- Research Center, CIUSSS du Nord-de-l'île-de-Montréal, University of Montreal, Montreal, Quebec, Canada
| | - Paul Meyers
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sophie Gosselin
- Centre Intégré de Santé et de Services Sociaux (CISSS) de la Montérégie-Centre Emergency Department, Hôpital Charles-Lemoyne, Greenfield Park, Quebec, McGill University Emergency Department, Montreal, Quebec and Centre Antipoison du Québec, Quebec, Canada
| | - Tudor Botnaru
- Emergency Department, Lakeshore General Hospital, CIUSSS de l'Ouest-de-l'lle-de-Montreal, McGill University, Montreal, Quebec, Canada
| | - Karine Mardini
- Pharmacy Department, Verdun Hospital, CIUSSS du Sud-Ouest-de-l'ïle-de-Montréal, University of Montreal, Montreal, Quebec, Canada
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, United Kingdom
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8
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Schicchi A, Scaravaggi G, Petrolini VM, Malovini A, Lonati D, Crevani M, Buscaglia E, Locatelli CA. Poisoning related to therapeutic error in prolonged low-dose methotrexate treatment. Br J Clin Pharmacol 2020; 87:2385-2391. [PMID: 33179288 DOI: 10.1111/bcp.14652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 11/30/2022] Open
Abstract
AIMS To study the predictive factors for the development of clinical manifestations in poisoning due to the erroneous taking of low-dose methotrexate (MTX). METHODS A retrospective observational study was performed. Only cases of erroneous administration in non-oncologic outpatients were included (July 2008-March 2020). RESULTS Forty-one cases were included. All patients were taking MTX for the first time. In 36 cases, patients took MTX daily instead of weekly. In the other five patients, MTX was sold instead of methylergometrine. Clinical manifestations were absent in 12/41 patients (29.3%). All 29 (70.7%) symptomatic patients recognized the medication error when they developed clinical manifestations: dermatological, haematological and gastrointestinal symptoms. Statistical results showed that symptomatic patients were older, received a higher amount of total dose and were treated for longer. Moreover, the probability of being symptomatic increases as a function of age and of total dose. Asymptomatic patients were treated with folinic acid (30 mg/m2 /day) for 5 days. Symptomatic patients were treated with folinic acid together with treatments for the specific clinical manifestations. No patients were treated with glucarpidase. All patients fully recovered. CONCLUSIONS When MTX is prescribed for the first time, it is important to clearly communicate with patients to avoid therapeutic errors. In our experience, age, total dose taken and number of days of assumption are predictive for the presence/absence of clinical manifestations. These parameters must be evaluated together to identify patients needing maximum starting treatment with folinic acid and closer monitoring.
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Affiliation(s)
- Azzurra Schicchi
- Pavia Poison Control Centre - National Toxicology Information Centre - Clinical and Experimental Lab, Toxicology Unit - Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Giulia Scaravaggi
- Pavia Poison Control Centre - National Toxicology Information Centre - Clinical and Experimental Lab, Toxicology Unit - Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Valeria M Petrolini
- Pavia Poison Control Centre - National Toxicology Information Centre - Clinical and Experimental Lab, Toxicology Unit - Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Alberto Malovini
- Laboratory of Informatics and Systems Engineering for Clinical Research, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Davide Lonati
- Pavia Poison Control Centre - National Toxicology Information Centre - Clinical and Experimental Lab, Toxicology Unit - Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Marta Crevani
- Pavia Poison Control Centre - National Toxicology Information Centre - Clinical and Experimental Lab, Toxicology Unit - Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Eleonora Buscaglia
- Pavia Poison Control Centre - National Toxicology Information Centre - Clinical and Experimental Lab, Toxicology Unit - Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Carlo A Locatelli
- Pavia Poison Control Centre - National Toxicology Information Centre - Clinical and Experimental Lab, Toxicology Unit - Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
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9
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Wurmbach VS, Schmidt SJ, Lampert A, Frick E, Metzner M, Bernard S, Thürmann PA, Wilm S, Mortsiefer A, Altiner A, Sparenberg L, Szecsenyi J, Peters-Klimm F, Kaufmann-Kolle P, Haefeli WE, Seidling HM. Development of an algorithm to detect and reduce complexity of drug treatment and its technical realisation. BMC Med Inform Decis Mak 2020; 20:154. [PMID: 32641027 PMCID: PMC7346621 DOI: 10.1186/s12911-020-01162-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 06/24/2020] [Indexed: 11/22/2022] Open
Abstract
Background The increasing complexity of current drug therapies jeopardizes patient adherence. While individual needs to simplify a medication regimen vary from patient to patient, a straightforward approach to integrate the patients’ perspective into decision making for complexity reduction is still lacking. We therefore aimed to develop an electronic, algorithm-based tool that analyses complexity of drug treatment and supports the assessment and consideration of patient preferences and needs regarding the reduction of complexity of drug treatment. Methods Complexity factors were selected based on literature and expert rating and specified for integration in the automated assessment. Subsequently, distinct key questions were phrased and allocated to each complexity factor to guide conversation with the patient and personalize the results of the automated assessment. Furthermore, each complexity factor was complemented with a potential optimisation measure to facilitate drug treatment (e.g. a patient leaflet). Complexity factors, key questions, and optimisation strategies were technically realized as tablet computer-based application, tested, and adapted iteratively until no further technical or content-related errors occurred. Results In total, 61 complexity factors referring to the dosage form, the dosage scheme, additional instructions, the patient, the product, and the process were considered relevant for inclusion in the tool; 38 of them allowed for automated detection. In total, 52 complexity factors were complemented with at least one key question for preference assessment and at least one optimisation measure. These measures included 29 recommendations for action for the health care provider (e.g. to suggest a dosage aid), 27 training videos, 44 patient leaflets, and 5 algorithms to select and suggest alternative drugs. Conclusions Both the set-up of an algorithm and its technical realisation as computer-based app was successful. The electronic tool covers a wide range of different factors that potentially increase the complexity of drug treatment. For the majority of factors, simple key questions could be phrased to include the patients’ perspective, and, even more important, for each complexity factor, specific measures to mitigate or reduce complexity could be defined.
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Affiliation(s)
- Viktoria S Wurmbach
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,Cooperation Unit Clinical Pharmacy, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Steffen J Schmidt
- Chair of Clinical Pharmacology, Faculty of Health, University Witten/Herdecke, Alfred-Herrhausen-Straße 50, 58448, Witten, Germany
| | - Anette Lampert
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,Cooperation Unit Clinical Pharmacy, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Eduard Frick
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Michael Metzner
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Simone Bernard
- Chair of Clinical Pharmacology, Faculty of Health, University Witten/Herdecke, Alfred-Herrhausen-Straße 50, 58448, Witten, Germany
| | - Petra A Thürmann
- Chair of Clinical Pharmacology, Faculty of Health, University Witten/Herdecke, Alfred-Herrhausen-Straße 50, 58448, Witten, Germany.,Philipp Klee-Institute of Clinical Pharmacology, HELIOS University Clinic Wuppertal, Heusnerstraße 40, 42283, Wuppertal, Germany
| | - Stefan Wilm
- Institute of General Practice, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Achim Mortsiefer
- Institute of General Practice, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Attila Altiner
- Institute of General Practice, Rostock University Medical Center, Doberaner Str. 142, 18057, Rostock, Germany
| | - Lisa Sparenberg
- Institute of General Practice, Rostock University Medical Center, Doberaner Str. 142, 18057, Rostock, Germany
| | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, Heidelberg University Hospital, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Frank Peters-Klimm
- Department of General Practice and Health Services Research, Heidelberg University Hospital, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Petra Kaufmann-Kolle
- AQUA-Institute for Applied Quality Improvement and Research in Health Care, Maschmühlenweg 8-10, 37073, Göttingen, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,Cooperation Unit Clinical Pharmacy, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Hanna M Seidling
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany. .,Cooperation Unit Clinical Pharmacy, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
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10
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Schmidt SJ, Wurmbach VS, Lampert A, Bernard S, Haefeli WE, Seidling HM, Thürmann PA. Individual factors increasing complexity of drug treatment-a narrative review. Eur J Clin Pharmacol 2020; 76:745-754. [PMID: 32239242 PMCID: PMC7239823 DOI: 10.1007/s00228-019-02818-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 12/08/2019] [Indexed: 12/11/2022]
Abstract
Purpose Complexity of drug treatment is known to be a risk factor for administration errors and nonadherence promoting higher healthcare costs, hospital admissions and increased mortality. Number of drugs and dose frequency are parameters often used to assess complexity related to the medication regimen. However, factors resulting from complex processes of care or arising from patient characteristics are only sporadically analyzed. Hence, the objective of this review is to give a comprehensive overview of relevant, patient-centered factors influencing complexity of drug treatment. Methods A purposeful literature search was performed in MEDLINE to identify potential complexity factors relating to the prescribed drug (i.e. dosage forms or other product characteristics), the specific medication regimen (i.e. dosage schemes or additional instructions), specific patient characteristics and process characteristics. Factors were included if they were associated to administration errors, nonadherence and related adverse drug events detected in community dwelling adult patients. Results Ninety-one influencing factors were identified: fourteen in “dosage forms”, five in “product characteristics”, twelve in “dosage schemes”, nine in “additional instructions”, thirty-one in “patient characteristics” and twenty in “process characteristics”. Conclusions Although the findings are limited by the non-systematic search process and the heterogeneous results, the search shows the influence of many factors on the complexity of drug treatment. However, to evaluate their relevance for individual patients, prospective studies are necessary. Electronic supplementary material The online version of this article (10.1007/s00228-019-02818-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Steffen J Schmidt
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448, Witten, Germany
| | - Viktoria S Wurmbach
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,Cooperation Unit Clinical Pharmacy, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Anette Lampert
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,Cooperation Unit Clinical Pharmacy, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Simone Bernard
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448, Witten, Germany
| | | | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,Cooperation Unit Clinical Pharmacy, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Hanna M Seidling
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany. .,Cooperation Unit Clinical Pharmacy, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
| | - Petra A Thürmann
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448, Witten, Germany.,Philipp Klee-Institute for Clinical Pharmacology, HELIOS Clinic Wuppertal, Heusnerstraße 40, 42283, Wuppertal, Germany
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11
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Lalevée S, Lebrun-Vignes B, Simon C, Laugier D, Fardet L. Cytopenia induced by low-dose methotrexate: An analysis of 433 cases from the French pharmacovigilance database. Eur J Intern Med 2019; 67:97-101. [PMID: 31350129 DOI: 10.1016/j.ejim.2019.07.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 07/15/2019] [Accepted: 07/17/2019] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Up to 5% of individuals exposed to low-dose methotrexate (MTX) (i.e., ≤30 mg/week) may develop cytopenia. However, MTX-induced cytopenia have been poorly described. MATERIAL AND METHODS All cases of cytopenia (i.e., anaemia, leukopenia, thrombocytopenia, bi- or pancytopenia) in patients receiving low-dose MTX reported to the French pharmacovigilance database during 2006-2016 were analysed. Three groups were defined: cytopenia due to MTX medication errors (e.g., daily rather than weekly administration), cytopenia in people receiving several medications including MTX, cytopenia in people receiving only MTX. RESULTS 433 cases were analysed. Eighty-four cases (19.4%) were due to medication errors, 180 (41.6%) occurred in individuals exposed both to MTX and other drugs, and 169 (39.0%) occurred in individuals only exposed to MTX. By comparison to other patients, those with cytopenia due to medication errors were older (74 ± 13 vs 69 ± 15 years, p = 0.002), received more frequently MTX orally (92.9% vs 65.3%, p<0.001) and had more frequently pancytopenia (71.4% vs 54.4%, p = 0.005). By comparison to individuals exposed to multiple drugs (n = 180), those exposed only to MTX (n = 169) were older (71 ± 15 vs 67 ± 14, p = 0.02), and had more often pancytopenia (62.7% vs 46.7%, p = 0.001). Among those only exposed to MTX, most cases (n = 140, 82.8%) were considered as toxic rather than idiosyncratic reactions and a trigger (e.g. diarrhoea) was found in 59.3% of those cases. Overall 30 (6.9%) deaths occurred, including 8 in the "medication error" group and 8 in the "MTX only" group. CONCLUSION These data may be useful for defining optimal biological monitoring of patients prescribed low-dose MTX.
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Affiliation(s)
- Sophie Lalevée
- Department of Dermatology, Hôpital Henri-Mondor, AP-HP, 94000 Créteil, France
| | - Bénédicte Lebrun-Vignes
- Regional Pharmacovigilance Centre, Hôpital Pitié-Salpêtrière, AP-HP, 75013 Paris, France; EA 7379 EpiDermE, Université Paris Est Créteil, 94000 Créteil, France
| | - Corinne Simon
- Regional Pharmacovigilance Center Centre Val de Loire, CHRU Tours, 37000 Tours, France
| | - Delphine Laugier
- Regional Pharmacovigilance Centre of Marseille Provence Corse, Departement of clinical Pharmacology and Pharmacovigilance, AP-HM, 13000 Marseille, France
| | - Laurence Fardet
- Department of Dermatology, Hôpital Henri-Mondor, AP-HP, 94000 Créteil, France; EA 7379 EpiDermE, Université Paris Est Créteil, 94000 Créteil, France.
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Herrinton LJ, Woodworth TS, Eworuke E, Amsden LB, Liu L, Wyeth J, Petrone A, Menzin TJ, Williams J, Goldfien R, Nguyen M. Development of an algorithm to detect methotrexate wrong frequency error using computerized health care data. Pharmacoepidemiol Drug Saf 2019; 28:1361-1368. [PMID: 31410932 DOI: 10.1002/pds.4858] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 05/07/2019] [Accepted: 06/12/2019] [Indexed: 11/07/2022]
Abstract
PURPOSE We validated an algorithm to detect frequency errors in computerized healthcare data and estimated the incidence of these errors in an integrated healthcare system. METHODS We applied Sentinel System analytic tools on the electronic health records of Kaiser Permanente, Northern California, January 1, 2010, through May 30, 2015,to identify rheumatoid arthritis (RA) patients with new use of methotrexate (365-day baseline period). We identified potential methotrexate frequency errors using ICD-9 code 995.20 (adverse drug event), Current Procedural Terminology (CPT) code 96409 for injection of leucovorin and prescription refill patterns. We performed chart review to confirm the frequency errors, assessed performance for detecting frequency errors, and estimated the incidence of chart-confirmed errors. RESULTS The study included 24,529 methotrexate dispensings among 3,668 RA patients. Among these, 722 (3%) had one dispensing and 23,807 (97.1%) had ≥2 dispensings during 1-year follow-up period. We flagged 653 (2.7%) with a potential medication error (46 with one dispensing and 607 with ≥2 dispensings). We sampled 94 for chart review, and confirmed three methotrexate errors. All three confirmed frequency errors involved a first methotrexate dispensing followed by injected rescue therapy, leucovorin, (positive predictive value, 60%; 95% confidence interval [CI], 15-95%). No potential errors were found among patients with ≥2 dispensings. We estimated the frequency error incidence among one methotrexate dispensing to be 0.4% (95%CI, 0.1% to 1.2%). CONCLUSION Rescue therapy is a specific indicator of methotrexate overdose among first methotrexate dispensings. This method is generalizable to other medications with serious adverse events treated with antidotes.
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Affiliation(s)
- Lisa J Herrinton
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Tiffany S Woodworth
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Efe Eworuke
- Office of Surveillance and Epidemiology, U.S. Food and Drug Administration, Silver Spring, MD
| | - Laura B Amsden
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Liyan Liu
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Jo Wyeth
- Office of Surveillance and Epidemiology, U.S. Food and Drug Administration, Silver Spring, MD
| | - Andrew Petrone
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Talia J Menzin
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - James Williams
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Robert Goldfien
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Michael Nguyen
- Office of Surveillance and Epidemiology, U.S. Food and Drug Administration, Silver Spring, MD
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Vial T, Patat AM, Boels D, Castellan D, Villa A, Theophile H, Torrents R, Kassai B. Adverse consequences of low-dose methotrexate medication errors: data from French poison control and pharmacovigilance centers. Joint Bone Spine 2018; 86:351-355. [PMID: 30243781 DOI: 10.1016/j.jbspin.2018.09.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 09/06/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The objectives of this study are to carefully describe the context of methotrexate medication errors, to details medical consequences and management approaches, and to determine the rate of fatal outcome. METHODS Data on methotrexate medication errors were obtained from the French network of poison control and pharmacovigilance centres, which collected and documented reported drug-induced adverse effects. Cases were included if the intake was more than 2-fold the intended weekly dose or a weekly cumulative dose ≥ 30 mg and a follow-up of at least 4 days after the last dose. Data were analysed for demographics, treatment indication, prescribed dose, drug interactions, clinical complications and medical outcomes. RESULTS Seventy four patients were included. The causes of methotrexate errors resulted from an erroneous prescription renewal (23.3%), incomprehensiveness of the weekly schedule by patients or at-home caregivers (56.2%) and administration of a wrong dose by a health care professional (20.5%). Of the 70 patients who took methotrexate daily, the mean daily dose received over the whole duration of the error was 9.6 ± 4.1 mg (range 2.5-22.5) with a mean duration of the error of 11.7 ± 12.2 days (range 2 to 90). Thirteen (18%) patients remained asymptomatic and 61 (82%) developed complications of which 46 (62.2%) were severe. Nine (14.8%) patients died within 11 to 45 days after the first dosing error. Compared to patients with no or mild symptoms, those with severe symptoms were more likely to be older (75.6 ± 10.8 vs. 69.5 ± 12.9 years) and to be exposed to a higher cumulative dose (94.8 ± 46.2 vs. 68.0 ± 45.7 mg). CONCLUSIONS This study confirms that dosing errors with methotrexate can be lethal and persisted despite several warnings from drug agencies. Further measures are awaited from the European Medicine Agency.
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Affiliation(s)
- Thierry Vial
- Department of pharmacotoxicology, poison control and regional pharmacovigilance centres, hospices civils de Lyon, 69424 Lyon, France.
| | - Anne Marie Patat
- Department of pharmacotoxicology, poison control and regional pharmacovigilance centres, hospices civils de Lyon, 69424 Lyon, France
| | - David Boels
- Poison control centre, university hospitals, 49033 Angers, France
| | - Delphine Castellan
- Regional pharmacovigilance centre, university hospitals, 13009 Marseille, France
| | - Antoine Villa
- Poison control centre, GH-Fernand Widal, Lariboisière, Saint-Louis, university hospitals, 75475 Paris, France
| | - Hélène Theophile
- Regional pharmacovigilance centre, university hospitals, 33076 Bordeaux, France
| | - Romain Torrents
- Poison control centre, university hospitals and Aix-Marseille university, Inserm, SESSTIM UMR 912, 13274 Marseille, France
| | - Behrouz Kassai
- Department of pharmacotoxicology, poison control and regional pharmacovigilance centres, hospices civils de Lyon, 69424 Lyon, France
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Shastay A. Severe Harm and Death Associated With Errors and Drug Interactions Involving Low-Dose Methotrexate. Home Healthc Now 2017; 35:519-522. [PMID: 28953545 DOI: 10.1097/nhh.0000000000000582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Ann Shastay
- Ann Shastay, MSN, RN, AOCN, is the Managing Editor, Institute for Safe Medication Practices, Horsham, Pennsylvania
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Errores de medicación asociados a la administración oral de metotrexato. Datos de notificación espontánea y revisión de la bibliografía médica. Med Clin (Barc) 2017; 148:330-332. [DOI: 10.1016/j.medcli.2016.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 11/25/2016] [Accepted: 12/01/2016] [Indexed: 11/24/2022]
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Cairns R, Brown JA, Lynch AM, Robinson J, Wylie C, Buckley NA. A decade of Australian methotrexate dosing errors. Med J Aust 2017; 204:384. [PMID: 27256650 DOI: 10.5694/mja15.01242] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 02/29/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Accidental daily dosing of methotrexate can result in life-threatening toxicity. We investigated methotrexate dosing errors reported to the National Coronial Information System (NCIS), the Therapeutic Goods Administration Database of Adverse Event Notifications (TGA DAEN) and Australian Poisons Information Centres (PICs). DESIGN AND SETTING A retrospective review of coronial cases in the NCIS (2000-2014), and of reports to the TGA DAEN (2004-2014) and Australian PICs (2004-2015). Cases were included if dosing errors were accidental, with evidence of daily dosing on at least 3 consecutive days. MAIN OUTCOME MEASURES Events per year, dose, consecutive days of methotrexate administration, reasons for the error, clinical features. RESULTS Twenty-two deaths linked with methotrexate were identified in the NCIS, including seven cases in which erroneous daily dosing was documented. Methotrexate medication error was listed in ten cases in the DAEN, including two deaths. Australian PIC databases contained 92 cases, with a worrying increase seen during 2014-2015. Reasons for the errors included patient misunderstanding and incorrect packaging of dosette packs by pharmacists. The recorded clinical effects of daily dosage were consistent with those previously reported for methotrexate toxicity. CONCLUSION Dosing errors with methotrexate can be lethal and continue to occur despite a number of safety initiatives in the past decade. Further strategies to reduce these preventable harms need to be implemented and evaluated. Recent suggestions include further changes in packet size, mandatory weekly dosing labelling on packaging, improving education, and including alerts in prescribing and dispensing software.
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Affiliation(s)
- Rose Cairns
- NSW Poisons Information Centre, The Children's Hospital at Westmead, Sydney, NSW
| | - Jared A Brown
- NSW Poisons Information Centre, The Children's Hospital at Westmead, Sydney, NSW
| | - Ann-Maree Lynch
- Western Australian Poisons Information Centre, Sir Charles Gairdner Hospital, Perth, WA
| | - Jeff Robinson
- Victorian Poisons Information Centre, Austin Health, Melbourne, VIC
| | - Carol Wylie
- Queensland Poisons Information Centre, Lady Cilento Children's Hospital, Brisbane, QLD
| | - Nicholas A Buckley
- NSW Poisons Information Centre, The Children's Hospital at Westmead, Sydney, NSW
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Mortensen KL, Krogh TP, Jensen-Fangel S, Hauge EM. Severe acute pancytopaenia in a patient with rheumatoid arthritis complicated by fatal invasive pulmonary aspergillosis. Scand J Rheumatol 2016; 46:249-250. [PMID: 27575284 DOI: 10.1080/03009742.2016.1209553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- K L Mortensen
- a Department of Infectious Diseases , Aarhus University Hospital Skejby , Aarhus , Denmark.,b Department of Medicine , Randers Regional Hospital , Randers , Denmark
| | - T P Krogh
- c Department of Rheumatology , Aarhus University Hospital , Aarhus , Denmark
| | - S Jensen-Fangel
- a Department of Infectious Diseases , Aarhus University Hospital Skejby , Aarhus , Denmark
| | - E M Hauge
- c Department of Rheumatology , Aarhus University Hospital , Aarhus , Denmark.,d Department of Clinical Medicine , Aarhus University , Aarhus , Denmark
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Cohen MR, Smetzer JL. Methylene Blue is a Monoamine Oxidase Inhibitor; Severe Harm and Death Associated with Low-Dose Methotrexate; Potentially Dangerous Mix-up between Cancer Drugs. Hosp Pharm 2016. [DOI: 10.1310/hpj5102-110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program. Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported directly to ISMP through the ISMP Web site ( www.ismp.org ), by calling 800-FAIL-SAFE, or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.
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Affiliation(s)
- Michael R. Cohen
- Institute for Safe Medication Practices, 200 Lakeside Drive, Suite 200, Horsham, PA 19044
| | - Judy L. Smetzer
- Institute for Safe Medication Practices, Horsham, Pennsylvania
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Butt F, Ream E. Implementing oral chemotherapy services in community pharmacies: a qualitative study of chemotherapy nurses' and pharmacists' views. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2015; 24:149-59. [DOI: 10.1111/ijpp.12237] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 09/25/2015] [Indexed: 11/29/2022]
Abstract
Abstract
Objectives
Changes in health-care provision have led to cancer patients being offered oral chemotherapy in the community. Three levels of oral chemotherapy services have been proposed (levels 1, 2 and 3) with community pharmacies playing differing roles within them. This study aims to explore health-care professionals' views on oral chemotherapy services being delivered by community pharmacies and to gain insights into the barriers, facilitators and training/knowledge needs of community pharmacists with respect to providing them.
Methods
Qualitative semi-structured interviews were conducted with a purposive sample of three chemotherapy nurses, five oncology pharmacists and five community pharmacists. Data were analysed thematically using Framework Analysis.
Key findings
Findings for level 1 and 2 services included uncertainty on community pharmacists' professional responsibilities, the expertise of GPs in prescribing oral chemotherapy and the training and competency of community pharmacists. The lack of patient information, care and support provision was emphasised for all the models. Although level 1 was achievable in current practice, level 2 was considered the safest option, while level 3 was ideal but risky option.
For all levels, training and education for community pharmacists and inter-professional issues were facilitators to oral chemotherapy services. The service environment, dispensing process-related constraints (access to blood test results and protocols) were significant barriers for levels 2 and 3.
Advanced communication skills, patient education and counselling were identified as key areas for education and training for community pharmacists.
Conclusion
The study suggests there are significant concerns and challenges associated with community pharmacies implementing any of the proposed levels of oral chemotherapy services. Educational and training opportunities for community pharmacists and the careful development of safe infrastructures will be essential in the future planning and implementation of any community pharmacy oral chemotherapy service.
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Affiliation(s)
- Farida Butt
- Pharmacy Department, Kingston University, Kingston upon Thames, UK
| | - Emma Ream
- Florence Nightingale Faculty of Nursing and Midwifery, Kings College London, London, UK
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Medication errors detected in non-traditional databases: types of errors in methotrexate dosing as listed in four different Danish registers. Eur J Clin Pharmacol 2015; 71:1375-9. [DOI: 10.1007/s00228-015-1910-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Accepted: 07/14/2015] [Indexed: 10/23/2022]
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Freigofas J, Seidling HM, Quinzler R, Schöttker B, Saum KU, Brenner H, Haefeli WE. Characteristics of medication schedules used by elderly ambulatory patients. Eur J Clin Pharmacol 2015; 71:1109-20. [PMID: 26105963 DOI: 10.1007/s00228-015-1888-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 06/09/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE We investigated the prevalence and quality of medication schedules of elderly ambulatory patients and assessed factors associated with the availability of a medication schedule. In particular, we evaluated whether sending out a blank medication schedule template would increase the chances to use such a document. METHODS Data originate from the ESTHER study, a cohort study conducted in Saarland, Germany, in which trained study physicians performed home visits. They scanned all medication schedules, recorded the participants' medication, and performed thorough geriatric assessments. As part of the intervention, a blank medication schedule template along with a brochure was mailed to half of the participants (intervention group) 4 weeks prior to the home visits. RESULTS In total, 553 of 2470 participants (22.4 %) had a medication schedule. Almost two thirds of the schedules were issued by health care professionals (n = 353, 63.8 %). These schedules offered a higher quality, although important information such as over-the-counter (OTC) medication was regularly missing. Self-reported adherence was higher in participants who used self-issued medication schedules; however, self-reported medication adherence in patients with any medication schedule was poorer compared to those patients not using a schedule. Factors associated with the availability of a medication schedule were male sex, a higher number of medicines to take, and a more complex drug regimen. The intervention did not increase the number of patients having a medication schedule. CONCLUSION Only a minority of elderly ambulatory patients had a medication schedule at home. Sending out a brochure along with a blank medication schedule template did not increase the prevalence of medication schedules.
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Affiliation(s)
- Julia Freigofas
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
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Elsaid KA, Garguilo S, Collins CM. Chemotherapy e-prescribing: opportunities and challenges. INTEGRATED PHARMACY RESEARCH AND PRACTICE 2015; 4:39-48. [PMID: 29354518 PMCID: PMC5741026 DOI: 10.2147/iprp.s84232] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Chemotherapy drugs are characterized by low therapeutic indices and significant toxicities at clinically prescribed doses, raising serious issues of drug safety. The safety of the chemotherapy medication use process is further challenged by regimen complexity and need to tailor treatment to patient status. Errors that occur during chemotherapy prescribing are associated with serious and life-threatening outcomes. Computerized provider order entry (CPOE) systems were shown to reduce overall medication errors in ambulatory and inpatient settings. The adoption of chemotherapy CPOE is lagging due to financial cost and cultural and technological challenges. Institutions that adopted infusional or oral chemotherapy electronic prescribing modified existing CPOE systems to allow chemotherapy prescribing, implemented chemotherapy-specific CPOE systems, or developed home-grown chemotherapy electronic prescribing programs. Implementation of chemotherapy electronic prescribing was associated with a significant reduction in the risk of prescribing errors, most significantly dose calculation and adjustment errors. In certain cases, implementation of chemotherapy CPOE was shown to improve the chemotherapy use process. The implementation of chemotherapy CPOE may increase the risk of new types of errors, especially if processes are not redesigned and adapted to CPOE. Organizations aiming to implement chemotherapy CPOE should pursue a multidisciplinary approach engaging all stakeholders to guide system selection and implementation. Following implementation, organizations should develop and use a risk assessment process to identify and evaluate unanticipated consequences and CPOE-generated errors. The results of these analyses should serve to further enhance the chemotherapy electronic prescribing process and improve the quality and safety of cancer care.
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Affiliation(s)
- Khaled A Elsaid
- Department of Pharmaceutical Sciences, School of Pharmacy, MCPHS University, Boston, MA.,Pharmacy Services, Rhode Island Hospital, Providence, RI, USA
| | - Steven Garguilo
- Department of Pharmaceutical Sciences, School of Pharmacy, MCPHS University, Boston, MA
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Mitchell G, Porter S, Manias E. A critical ethnography of communication processes involving the management of oral chemotherapeutic agents by patients with a primary diagnosis of colorectal cancer: study protocol. J Adv Nurs 2014; 71:922-32. [DOI: 10.1111/jan.12565] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Gary Mitchell
- Department of Employment and Learning; School of Nursing and Midwifery; Queen's University Belfast; UK
| | - Sam Porter
- School of Nursing and Midwifery; Queen's University Belfast; UK
| | - Elizabeth Manias
- School of Nursing and Midwifery; Deakin University; Melbourne Victoria Australia
- Department of Medicine; Royal Melbourne Hospital; University of Melbourne Victoria Australia
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Saedder EA, Brock B, Nielsen LP, Bonnerup DK, Lisby M. Identifying high-risk medication: a systematic literature review. Eur J Clin Pharmacol 2014; 70:637-45. [DOI: 10.1007/s00228-014-1668-z] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 03/04/2014] [Indexed: 10/25/2022]
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Improving treatment with methotrexate in rheumatoid arthritis—Development of a multimedia patient education program and the MiRAK, a new instrument to evaluate methotrexate-related knowledge. Semin Arthritis Rheum 2014; 43:437-46. [DOI: 10.1016/j.semarthrit.2013.07.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Revised: 05/28/2013] [Accepted: 07/08/2013] [Indexed: 11/22/2022]
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Holsappel IGA, Koster ES, Winters NA, Bouvy ML. Prescribing with indication: uptake of regulations in current practice and patients opinions in the Netherlands. Int J Clin Pharm 2013; 36:282-6. [DOI: 10.1007/s11096-013-9903-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Accepted: 11/30/2013] [Indexed: 10/25/2022]
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Cohen MR, Smetzer JL, Westphal JE, Comden SC, Horn DM. Risk models to improve safety of dispensing high-alert medications in community pharmacies. J Am Pharm Assoc (2003) 2013; 52:584-602. [PMID: 23023839 DOI: 10.1331/japha.2012.10145] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To determine whether sociotechnical probabilistic risk assessment can create accurate approximations of detailed risk models that describe error pathways, estimate the incidence of preventable adverse drug events (PADEs) with high-alert medications, rank the effectiveness of interventions, and provide a more informative picture of risk in the community pharmacy setting than is available currently. DESIGN Developmental study. SETTING 22 community pharmacies representing three U.S. regions. PARTICIPANTS Model-building group: six pharmacists and three technicians. Model validation group: 11 pharmacists; staff at two pharmacies observed. INTERVENTION A model-building team built 10 event trees that estimated the incidence of PADEs for four high-alert medications: warfarin, fentanyl transdermal systems, oral methotrexate, and insulin analogs. MAIN OUTCOME MEASURES Validation of event tree structure and incidence of defined PADEs with targeted medications. RESULTS PADEs with the highest incidence included dispensing the wrong dose/strength of warfarin as a result of data entry error (1.83/1,000 prescriptions), dispensing warfarin to the wrong patient (1.22/1,000 prescriptions), and dispensing an inappropriate fentanyl system dose due to a prescribing error (7.30/10,000 prescriptions). PADEs with the lowest incidence included dispensing the wrong drug when filling a warfarin prescription (9.43/1 billion prescriptions). The largest quantifiable reductions in risk were provided by increasing patient counseling (27-68% reduction), conducting a second data entry verification process during product verification (50-87% reduction), computer alerts that can't be bypassed easily (up to 100% reduction), opening the bag at the point of sale (56% reduction), and use of barcoding technology (almost a 100,000% increase in risk if technology not used). Combining two or more interventions resulted in further overall reduction in risk. CONCLUSION The risk models define thousands of ways process failures and behavioral elements combine to lead to PADEs. This level of detail is unavailable from any other source.
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Affiliation(s)
- Michael R Cohen
- Institute for Safe Medication Practices, 200 Lakeside Dr., Horsham, PA 19044, USA
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Claus BOM, Vandeputte FMR, Robays H. Epidemiology and cost analysis of pharmacist interventions at Ghent University Hospital. Int J Clin Pharm 2012; 34:773-8. [DOI: 10.1007/s11096-012-9676-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 07/10/2012] [Indexed: 11/30/2022]
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Methotrexate safety improvement in nursing home residents. J Am Med Dir Assoc 2010; 13:69-74. [PMID: 21450205 DOI: 10.1016/j.jamda.2010.08.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2010] [Revised: 08/15/2010] [Accepted: 08/16/2010] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Improve the safety of methotrexate use in nursing home residents by reducing methotrexate errors. DESIGN Concurrent cohort analysis. SETTING Long term care facilities. PARTICIPANTS Residents who received methotrexate from January 1, 2007, to December 31, 2009. INTERVENTION A 3-pronged approach involving modification to dispensing systems and practices, mandatory staff training, and measurement was implemented in June 2008 and monitored through December 2009. Software programming to the pharmacy operating systems occurred forcing a mandatory second clinical review of all methotrexate orders during the pharmacist verification process, before dispensing. Pharmacists were required to call and clarify orders that failed to fulfill prespecified safety criteria before approving the prescription for dispensing. All pharmacists were required to complete a brief, concise, focused, mandatory training program that emphasized the proper use, adverse effects, boxed warnings, appropriate dosing schedules, and new dispensing requirements for methotrexate. MEASUREMENTS On a daily basis, methotrexate orders from the previous day were summarized and forwarded to a Clinical Intervention Center for analysis and measurement. Prescriptions that triggered preestablished safety concerns were triaged back to their respective pharmacies for verification or modification. The results of the Methotrexate Safety Program were measured by tracking the number of prescriptions filled, number of patients treated, number of sentinel events, and number of safety variances identified. RESULTS All assigned pharmacists (n = 2293) completed the mandatory training between June and December 2008. In 2009, a total of 369 new employees completed the training. The prescriptions per year and patients treated per year remained comparable, whereas the number of sentinel events decreased from 3 in 2007 and 4 in 2008 to 0 following program implementation. The most prevalent variance was daily dosing of methotrexate when weekly was intended. The measurement process detected and averted 497 variances in 2008 and 693 variances in 2009 that could have resulted in sentinel events. CONCLUSION Implementation of intensification of dispensing practices, mandatory training, and measurement eradicated sentinel events associated with methotrexate in nursing homes.
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Lisby M, Nielsen LP, Brock B, Mainz J. How are medication errors defined? A systematic literature review of definitions and characteristics. Int J Qual Health Care 2010; 22:507-18. [DOI: 10.1093/intqhc/mzq059] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Zarowitz BJ. Reducing methotrexate errors. Geriatr Nurs 2010; 31:361-4. [PMID: 20832909 DOI: 10.1016/j.gerinurse.2010.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Barbara J Zarowitz
- College of Pharmacyand Allied Health Sciences, Wayne State University, Detroit, MI, USA
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Cohen MR, Smetzer JL. Oral Syringes: A Crucial and Economical Risk-Reduction Strategy that has Not Been Fully Utilized; Caution regarding Once-Weekly Levothyroxine; When Drug Strengths Differ by 10-Fold; Lower Colchicine Dose Effective and Safer. Hosp Pharm 2010. [DOI: 10.1310/hpj4501-13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program. Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported directly to ISMP through the ISMP Web site ( www.ismp.org ), by calling 800-FAIL-SAFE, or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.
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Affiliation(s)
| | - Judy L. Smetzer
- Institute for Safe Medication Practices, Horsham, Pennsylvania
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Electronic screening of medical records to detect inpatients at risk of drug-related problems. ACTA ACUST UNITED AC 2009; 32:103-7. [DOI: 10.1007/s11096-009-9352-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2009] [Accepted: 11/25/2009] [Indexed: 11/25/2022]
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Sécurisation de l’emploi des chimiothérapies anticancéreuses administrables par voie orale. ACTA ACUST UNITED AC 2009. [DOI: 10.1016/j.phhp.2008.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Bookstaver PB, Norris L, Rudisill C, DeWitt T, Aziz S, Fant J. Multiple toxic effects of low-dose methotrexate in a patient treated for psoriasis. Am J Health Syst Pharm 2008; 65:2117-21. [DOI: 10.2146/ajhp070676] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | - LeAnn Norris
- South Carolina College of Pharmacy, University of South Carolina, Columbia
| | - Celeste Rudisill
- South Carolina College of Pharmacy, University of South Carolina, Columbia
| | - Tammy DeWitt
- University of Virginia Health System, Charlottesville. At the time of writing, she was Post Graduate Year One Resident, Palmetto Health Richland, Columbia
| | | | - James Fant
- Division of Rheumatology, School of Medicine, University of South Carolina
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Abstract
The treatment of chronic inflammatory conditions often involves a difficult balance between the benefits of disease modification and the risks attendant with the use of disease-modifying agents. Methotrexate is a useful and commonly used disease-modifying agent but has a particularly notable reputation for causing morbidity and mortality. We explore ways in which the safety of methotrexate prescribing may be improved. There has been considerable debate as to the whether some of the side-effects can be mitigated by co-prescription of folate with methotrexate. Whereas no definitive conclusion can yet be reached, evidence suggests that the improvement in side-effect profile is limited to fewer elevations of liver enzymes, but that this may be at the expense of decreased methotrexate efficacy. The question remains as to whether the improved tolerability more than compensates for the decreased efficacy or whether folic acid should be used in a more circumspect way. However, a very specific danger arises from the fact that methotrexate is prescribed once weekly for inflammatory conditions, leading to errors at both the prescription and patient level. We highlight simple ways of improving safety to decrease such errors.
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Affiliation(s)
- P Goldsmith
- Department of Neurology, Addenbrooke's Hospital, Cambridge, and DanioLads Ltd, Cambridge, UK.
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Affiliation(s)
- Robert M Kalus
- Division of General Internal Medicine, Department of Internal Medicine, University of Washington, Seattle 98104, USA.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2004. [DOI: 10.1002/pds.925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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