Inappropriate Medication in Non-Hospitalized Patients With Renal Insufficiency: A Systematic Review

Prescribing Renally Inappropriate Medication to Hospitalized Geriatric Patients in Makkah, Saudi Arabia

Introduction

As a result of the physiological decline in renal function that comes with age and the common failure to recognise renal insufficiency, older adults aged 65 and above are at increased risk of receiving medications that are inappropriate for their level of renal function which in turn lead to increased risk of adverse effects. Little is known about how many older adults receive medications that are inappropriate for their level of renal function. This study aimed to determine the prevalence of renally inappropriate medications in elderly adults by reviewing patient files and evaluating the appropriateness of medication doses relative to renal function in patients aged ≥ 65 years at inpatient healthcare departments.

Methods

A retrospective cross-sectional study of patients aged ≥ 65 years was conducted, covering cases from 2015 to 2021. Patient's medical records were reviewed, their renal function and medications lists were evaluated, determined whether they had been prescribed at least one renally inappropriate medication based on drug-dosing recommendations for different degrees of renal function.

Results

A total of 317 elderly inpatients were included, 10% of whom had received inappropriate doses relative to their renal function. Glomerular filtration rate was associated with inappropriate dosing in this study. Of the patients CKD stage 5, 36.8% had at least one drug administered at an inappropriate dose, while this figure was 6.5% among the patients at CKD stage 1; this difference was statistically significant (p = 0.001).

Conclusion

A notable portion of older adults may be at risk of adverse effects due to inappropriate medication dosing related to their renal function. Further studies with large samples, drug use analyses based on comprehensive geriatric references and a prioritisation of actual outcomes over potential outcomes are needed to further determine elderly adults' exposure to inappropriate drugs.

Inappropriate prescribing in patients with kidney disease: A rapid review of prevalence, associated clinical outcomes and impact of interventions

BACKGROUND

The prevalence of patients with chronic kidney disease (CKD) and polypharmacy is increasing and has amplified the importance of examining inappropriate prescribing (IP) in CKD. This review focuses on the latest research regarding the prevalence of IP in CKD and the related adverse clinical effects and explores new interventions against IP.

METHOD

A literature search was performed using PubMed, EMBASE and the Cochrane Library searching articles published between June 2016 and March 2022.

RESULTS

Twenty-seven studies were included. An IP prevalence of 12.6% to 96% and 0.3% to 66% was reported in hospital and outpatient settings, respectively. In nonhospital settings, the prevalence of IP varied between 3.9% and 60%. IP was associated with higher risk of hospitalisation (HR 1.46, 95% CI 1.17-1.81), higher bleeding rate (HR 2.34, 95% CI 1.32 to 3.37) and higher risk of all-cause mortality (OR 1.07, 95% CI 1.02 to 1.13). Three studies reported the impact of interventions on IP.

CONCLUSION

This review highlights widespread IP in CKD patients across healthcare settings, with varying prevalence rates. IP is substantially linked to adverse outcomes in patients. While limited interventions show promise, urgent research is needed to develop effective strategies addressing IP and improving CKD patient care.

Renal drug dosage adjustments and adverse drug events in patients with chronic kidney disease admitted to the hospital: a cross-sectional study

BACKGROUND

The study aimed to evaluate the agreement of prescribed drug dosages with renal dosing recommendations and describe adverse drug events (ADEs) contributing to hospital admissions of patients with chronic kidney disease (CKD).

METHODS

This cross-sectional study focused on CKD patients admitted to University Hospital Hradec Králové, with an estimated glomerular filtration rate below 60 ml/min. The necessity for renal dosage adjustments was determined using the Summary of Product Characteristics (SmPC). For medications requiring renal dosage adjustment according to SmPC, agreement between the prescribed and recommended renal dosage was assessed. ADEs were adjudicated using the OPERAM drug-related hospital admissions adjudication guide.

RESULTS

Of 375 CKD patients, 112 (30%, 95% CI 25-34) were prescribed drug dosages in disagreement with SmPC renal dosage recommendations. Perindopril, metformin, and ramipril were most frequently dosed in disagreement with SmPC. ADE-related hospital admissions occurred in 20% (95% CI 16-24) of CKD patients.

CONCLUSION

CKD patients are often prescribed medication dosages in disagreement with SmPC renal dosing recommendations. Besides explicit factors, treatment goals, feasibility of monitoring and alternative treatment must be weighed when assessing drug and dosage appropriateness. Gastrointestinal bleeding was the most frequent ADE that contributed to hospital admissions of CKD patients.

[Polypharmacy in acute and chronic kidney diseases]

The prevalence for chronic kidney disease (CKD) has steadily increased over the past decades. It is a gradually progressive disease that is associated with several comorbidities including cardiovascular diseases, hypertension, anemia, disorders of bone and mineral metabolism, electrolyte imbalance and acid-base abnormalities. All these comorbidities require adequate medication. Therefore, patients with CKD have a high risk for polypharmacy, which is defined as five or more medications daily. Polypharmacy causes a greatly increased risk for adverse drug effects and severe drug-drug interactions, which if not closely controlled and the individual doses adapted to the decreased renal function during the progression of the CKD, can result in increased morbidity and mortality. Therefore, several aspects of the medication need to be considered and constantly addressed. This article summarizes the problems arising from inadequate polypharmacy in CKD patients, including undesired adverse drug effects, drug interactions, the complexity of medication plans, treatment burden and nonadherence to the treatment. Furthermore, the most important steps to identify patients with inadequate polypharmacy are discussed, whereby complications can also be avoided and the benefits of the medication can be increased. Finally, the polypharmacy in acute kidney injury is dealt with.

Renally Inappropriate Medications in the Old Population: Prevalence, Risk Factors, Adverse Outcomes, and Potential Interventions

Like most organs, the renal system decreases in function as we age. In the elderly, chronic kidney disease is common. When patients with chronic kidney disease take nephrotoxic medications, they are more likely to suffer adverse drug reactions, be hospitalized, and spend an extended period in the hospital. Calculating the renal clearance of a drug dose based on its glomerular filtration rate, or creatinine clearance, is necessary. Multiple tools are available for identifying renally inappropriate medications (RIMs). RIM prescriptions can be influenced by various factors, which vary according to the study. A higher number of medications means a higher likelihood of using RIMs. Numerous studies have investigated RIMs. The most contraindicated drug in renal insufficiency patients was a non-steroidal anti-inflammatory medication. A variety of interventions have been used to reduce RIM prescriptions to varying degrees of success.

Medication-Related Problems and Their Intervention in the Geriatric Population: A Review of the Literature

In order to implement the principles of providing clinically and economically effective care, the current state of healthcare must be evaluated, and challenges must be addressed. As part of a physician's role in such a context, one tool consists of identifying medication-related problems (MRPs) and accordingly implementing best practices and innovative strategies to improve patient healthcare outcomes. The geriatric population is expected to have passed through the natural ageing process and experienced several physiological and biological changes that impact their bodies and lives. In the presence of geriatric syndromes and the increased number of medications consumed, the risk of MRPs such as polypharmacy, potentially inappropriate medication (PIM), adverse events, drug-drug interactions, and risk of non-adherence increases. Different interventions that focus on practical and perceptual barriers have been studied, and different tools to define clinically important prescribing problems relating to PIM have been established. The Beers Criteria and STOPP (Screening Tool of Older Persons' Prescriptions)/START (Screening Tool to Alert to Right Treatment) criteria are the most widely used sets of explicit PIM criteria; however, they are still limited in Saudi Arabia. These tools should be considered in clinical settings to improve healthcare outcomes in the geriatric population, and the clinical relevance of enhancing medication should also be explored from the point of view of both the patient and healthcare practitioners.

Hypoglycemia risk with inappropriate dosing of glucose-lowering drugs in patients with chronic kidney disease: a retrospective cohort study

The incidence rates and consequences of inappropriate dosing of glucose-lowering drugs remain limited in patients with chronic kidney disease (CKD). A retrospective cohort study was conducted to estimate the frequency of inappropriate dosing of glucose-lowering drugs and to evaluate the subsequent risk of hypoglycemia in outpatients with an estimated glomerular filtration rate (eGFR) of < 50 mL/min/1.73 m². Outpatient visits were divided according to whether the prescription of glucose-lowering drugs included dose adjustment according to eGFR or not. A total of 89,628 outpatient visits were included, 29.3% of which received inappropriate dosing. The incidence rates of the composite of all hypoglycemia were 76.71 and 48.51 events per 10,000 person-months in the inappropriate dosing group and in appropriate dosing group, respectively. After multivariate adjustment, inappropriate dosing was found to lead to an increased risk of composite of all hypoglycemia (hazard ratio 1.52, 95% confidence interval 1.34, 1.73). In the subgroup analysis, there were no significant changes in the risk of hypoglycemia regardless of renal function (eGFR < 30 vs. 30-50 mL/min/1.73 m²). In conclusion, inappropriate dosing of glucose-lowering drugs in patients with CKD is common and associated with a higher risk of hypoglycemia.

Renally inappropriate medications in elderly outpatients and inpatients with an impaired renal function

BACKGROUND AND AIMS

The purpose of this study was to investigate differences in the frequency of renally inappropriate medications (RIMs) in outpatient and inpatient among three institutions.

METHODS

We collected prescription and renal function data for patients over 65 years of age from the drug department system. We selected 50 kinds of the most frequently used medicines which require dose adjustment according to a patient's renal function.

RESULTS

Outpatient RIM was seen in 611 cases (6.17%), and inpatient prescription RIM was seen in 317 cases (5.29%), showing a significant difference between the groups (odds ratio [OR] 1.18, 95% confidence interval [CI] 1.02-1.35). However, in a multivariate analysis, when the renal function was included, that difference between outpatients and inpatients became insignificant (OR 1.16, 95% CI 0.98-1.37). The distribution of prescription with or without RIM in outpatient and inpatient settings depended on the CKD stage. Outpatients with a better CKD stage (stage 1-3) had a higher rate of RIM than inpatients, while patients with a worse CKD stage (stage 4 or 5) had a higher rate of RIM than outpatients.

CONCLUSION

The rate of RIM in outpatients tends to be high, and attention should be paid to RIM in inpatients with a severe CKD stage.

Prevalence of inappropriate drug dose adjustment and associated factors among inpatients with renal impairment in Africa: A systematic review and meta-analysis

Objective

There is a high prevalence of inadequate dose adjustment among inpatients with renal insufficiency worldwide. There is, however, a paucity of studies that summarizes the topic in the African context. Therefore, this study aims to summarize the prevalence of inappropriate drug dose adjustment (IDDA) and associated factors among inpatients with renal impairment in Africa.

Methods

A literature search for English-language articles was conducted using reputable databases such as PubMed/MEDLINE, Google Scholar, and Science Direct. The search was carried out between 3 February and 3 March of 2022. All published articles that were online at the time of data collection were considered. Observational studies that examined the prevalence of IDDA for any type of drug in renal impairment as a primary or secondary outcome were included in our analysis. Statistical software such as Open Meta Analyst and Review Manager were used to examine outcome measures. I² statistics, Logit event rate, and Der Simonian and Laird's random effect models were also used.

Results

Seven articles were qualified for the systematic review and meta-analysis. All included studies comprised a total of 1918 patients. A total of 5072 prescriptions were assessed, and 1879 (37%) of them had at least one drug that required a dose adjustment. The pooled prevalence of IDDA among adult patients with renal impairment was 13.7% (95% confidence interval (CI) = 7.9%-19.5%) in Africa. Based on the number of prescriptions containing medications that required dose adjustment, the pooled prevalence accounts for 39.3% (95% CI = 24.1%-54.4%) (932/1879). Factors associated with inappropriate drug prescribing and usage concerning renal function were the number/types of prescribed medicines (most common), age, stage of renal impairment, comorbidity, and unemployment.

Conclusions

In this study, IDDA practice appears to be a common challenge among inpatients with renal insufficiency in Africa. The number and type of medications prescribed, age, stage of renal impairment, comorbidity, and unemployment were factors associated with inappropriate drug prescribing and use. In addition to expanding such studies, hospitals across Africa must conduct research on the clinical outcomes of IDDA practices in patients with renal impairment.

Development of a list with renally relevant drugs as a tool to increase medicines optimisation in patients with chronic kidney disease

OBJECTIVES

Chronic kidney disease (CKD) is a common disorder all over the world. Therapeutic goals are early detection of declining renal function and implementation of adequate pharmacological treatments regarding underlying and secondary diseases. As therapy becomes more complex with increasing stages of CKD, a decision-making tool for healthcare professionals could help to ensure safe drug treatment in patients with CKD in the outpatient setting. Therefore, a list of renally relevant drugs as a decision-making tool was developed to improve medicines optimisation for CKD patients in the outpatient setting long term.

METHODS

A renally relevant drug list (RRD-list) with renally relevant drugs, based on data from a study on medicines optimisation in patients with CKD from June 2015 to March 2018, was developed at the nephrological outpatient clinic at the Klinikum Fulda, Germany. The whole study is published elsewhere. A clinical pharmacist reviewed the patients' medications, current drug-related problems and all nephrologists' recommendations, and categorised all detected drugs into renally relevant and non-renally relevant groups. The 10 most frequently detected renally relevant drug groups were summarised in the RRD-list and extended by treatment alternatives and advice.

RESULTS

The medication of 160 patients, who were receiving overall 1376 drugs, was analysed; 831 drugs were defined as renally relevant. Drug-related problems were caused by 543 renally relevant drugs. The nephrologists made 292 recommendations regarding 28 drug classes. Considering the 10 most frequent drug groups, in total 16 renally relevant drug groups with 36 drug classes were added to the RRD-list.

CONCLUSIONS

The RRD-list could be an essential tool for all healthcare professionals in their daily work, such as general practitioners and community pharmacists, for the treatment of patients with renal insufficiency.

Medicine-Induced Acute Kidney Injury Findings from Spontaneous Reporting Systems, Sequence Symmetry Analysis and a Case-Control Study with a Focus on Medicines Used in Primary Care

INTRODUCTION

Primary care provides an opportunity to prevent community acquired, medicine or drug-induced acute kidney injury. One of the barriers to proactive prevention of medicine-induced kidney injury in primary care is the lack of a list of nephrotoxic medicines that are most problematic in primary care, particularly one that provides a comparison of risks across medicines.

OBJECTIVE

The aim of this study was to consolidate evidence on the risks associated with medicines and acute kidney injury, with a focus on medicines used in primary care.

METHOD

We searched the MEDLINE and EMBASE databases to identify published studies of all medicines associated with acute kidney injury identified from spontaneous report data. For each medicine positively associated with acute kidney injury, as identified from spontaneous reports, we implemented a sequence symmetry analysis (SSA) and a case-control design to determine the association between the medicine and hospital admission with a primary diagnosis of acute kidney injury (representing community-acquired acute kidney injury). Administrative claims data held by the Australian Government Department of Veterans' Affairs for the study period 2005-2019 were used.

RESULTS

We identified 89 medicines suspected of causing acute kidney injury based on spontaneous report data and a reporting odds ratio above 2, from Japan, France and the US. Spironolactone had risk estimates of 3 or more based on spontaneous reports, SSA and case-control methods, while furosemide and trimethoprim with sulfamethoxazole had risk estimates of 1.5 or more. Positive association with SSA and spontaneous reports, but not case control, showed zoledronic acid had risk estimates above 2, while candesartan telmisartan, simvastatin, naproxen and ibuprofen all had risk estimates in SSA between 1.5 and 2. Positive associations with case-control and spontaneous reports, but not SSA, were found for amphotericin B, omeprazole, metformin, amlodipine, ramipril, olmesartan, ciprofloxacin, valaciclovir, mycophenolate and diclofenac. All with the exception of metformin and omeprazole had risk estimates above 2.

CONCLUSION

This research highlights a number of medicines that may contribute to acute injury; however, we had an insufficient sample to confirm associations of some medicines. Spironolactone, furosemide, and trimethoprim with sulfamethoxazole are medicines that, in particular, need to be used carefully and monitored closely in patients in the community at risk of acute kidney injury.

Pharmacist-driven renal dose optimization practice—outcomes of a retrospective study in ambulatory care settings

Objectives

Previous studies indicate a higher prevalence of inappropriate drug usage in patients with renal disease in ambulatory care settings and a higher rate of non-compliance with the renal dose adjustment protocol. This study aimed to investigate the number of renal dose adjustments recommended by pharmacists in ambulatory care settings, acceptance rate by the physicians and medications involved.

Methods

This two-year retrospective study was conducted in an ambulatory care pharmacy in a Saudi Arabian tertiary care hospital. Based on the renal protocol at the study site, the pharmacists recommended dose adjustments for inappropriate medication orders, and the outcomes were documented electronically. A quantitative descriptive analysis of this practice was performed by retrieving the pharmacists’ documentation from electronic health records. Only protocol-compliant recommendations with proper documentation were included in the study.

Key findings

A total of 302 renal dose adjustments were recommended by pharmacists for 269 patients involving 47 medications, with an average of 1.12 recommendations per patient. The average monthly recommendation was 12.58 (median: 11; SD: 5.174; 95% Confidence Interval (CI), 12 to 13.16). Of the 302 recommendations, 219 (72.52%) were accepted by the physician, and 71 (23.51%) were not. The most common medications accepted for renal dosage adjustment included levofloxacin (8.94%), metformin (5.29%), amoxicillin-clavulanate (5.29%), cetirizine (4.97%), diclofenac (4.64%), ciprofloxacin (3.97%) and nitrofurantoin (3.31%).

Conclusions

The pharmacist’s renal dose recommendations have a high acceptance rate in ambulatory care. This study demonstrated that ambulatory care pharmacists play a substantial clinical role in reducing inappropriate drug use in patients with renal disease.

Using Machine Learning to Identify Patients at High Risk of Inappropriate Drug Dosing in Periods with Renal Dysfunction

Purpose

Dosing of renally cleared drugs in patients with kidney failure often deviates from clinical guidelines, so we sought to elicit predictors of receiving inappropriate doses of renal risk drugs.

Patients and methods

We combined data from the Danish National Patient Register and in-hospital data on drug administrations and estimated glomerular filtration rates for admissions between 1 October 2009 and 1 June 2016, from a pool of about 2.6 million persons. We trained artificial neural network and linear logistic ridge regression models to predict the risk of five outcomes (>0, ≥1, ≥2, ≥3 and ≥5 inappropriate doses daily) with index set 24 hours after admission. We used time-series validation for evaluating discrimination, calibration, clinical utility and explanations.

Results

Of 52,451 admissions included, 42,250 (81%) were used for model development. The median age was 77 years; 50% of admissions were of women. ≥5 drugs were used between admission start and index in 23,124 admissions (44%); the most common drug classes were analgesics, systemic antibacterials, diuretics, antithrombotics, and antacids. The neural network models had better discriminative power (all AUROCs between 0.77 and 0.81) and were better calibrated than their linear counterparts. The main prediction drivers were use of anti-inflammatory, antidiabetic and anti-Parkinson's drugs as well as having a diagnosis of chronic kidney failure. Sex and age affected predictions but slightly.

Conclusion

Our models can flag patients at high risk of receiving at least one inappropriate dose daily in a controlled in-silico setting. A prospective clinical study may confirm that this holds in real-life settings and translates into benefits in hard endpoints.

Drug-Related Problems in Hospitalised Patients with Chronic Kidney Disease: A Systematic Review

INTRODUCTION

Globally, chronic kidney disease (CKD) is one of the leading causes of mortality. Impaired renal function makes CKD patients vulnerable to drug-related problems (DRPs).

AIM

The aim of this systematic review was to investigate the prevalence and nature of DRPs among hospital in-patients with CKD.

METHODS

A systematic review of the literature was conducted using Medline, EMBASE, PsycINFO, Web of Science (Core Collection), CINAHL plus (EBSCO), Cochrane Library (Wiley), Scopus (ELSEVIER) and PubMed (U.S.NLM) from index inception to January 2020. Studies investigating DRPs in hospitalised CKD patients published in the English language were included. Two independent reviewers extracted the data and undertook quality assessment using the Joanna Briggs Institute (JBI) tool.

RESULTS

A total of 2895 unique titles were identified; with 20 meeting the inclusion criteria. DRPs prevalence in CKD was reported between 12 and 87%. The most common DRPs included ineffective treatment, inappropriate drug choice and dosing problems. Antibiotics, H2-antihistamines and oral antidiabetics (metformin) were common drug classes involved in DRPs. Factors associated with DRPs included severity of CKD, the number of medications taken, age, length of hospital stay, and gender.

CONCLUSION

This systematic review provides evidence that DRPs are a frequent occurrence and burden for hospitalised patients with stage 1-4 CKD. Heterogeneity in study design, case detection and definitions are common, and future studies should use clearer definitions and study designs. Protocol Registration: PROSPERO: CRD42018096364.

Potentially Inappropriately Prescribed Medications Among Medicare Medication Therapy Management Eligible Patients with Chronic Kidney Disease: an Observational Analysis

BACKGROUND

Potentially inappropriately prescribed medications (PIPMs) among patients with chronic kidney disease (CKD) may vary among clinical settings. Rates of PIPM are unknown among Medicare-enrolled Medication Therapy Management (MTM) eligible patients.

OBJECTIVES

Determine prevalence of PIPM among patients with CKD and evaluate characteristics of patients and providers associated with PIPM.

DESIGN

An observational cross-sectional investigation of a Medicare insurance plan for the year 2018.

PATIENTS

Medicare-enrolled MTM eligible patients with stage 3-5 CKD.

MAIN MEASURES

PIPM was identified utilizing a tertiary database. Logistic regression assessed relationship between patient characteristics and PIPM.

KEY RESULTS

Investigation included 3624 CKD patients: 2856 (79%), 548 (15%), and 220 (6%) patients with stage 3, 4, and 5 CKD, respectively. Among patients with stage 3, stage 4, and stage 5 CKD, 618, 430, and 151 were with at least one PIPM, respectively. Logistic regression revealed patients with stage 4 or 5 CKD had 7-14 times the odds of having a PIPM in comparison to patients with stage 3 disease (p < 0.001). Regression also found PIPM was associated with increasing number of years qualified for MTM (odds ratio (OR) 1.46-1.74, p ≤ 0.005), female gender (OR 1.25, p = 0.008), and increasing polypharmacy (OR 1.30-1.57, p ≤ 0.01). Approximately 14% of all medications (2879/21093) were considered PIPM. Majority of PIPMs (62%) were prescribed by physician primary care providers (PCPs). Medications with the greatest percentage of PIPM were spironolactone, canagliflozin, sitagliptin, levetiracetam, alendronate, pregabalin, pravastatin, fenofibrate, metformin, gabapentin, famotidine, celecoxib, naproxen, meloxicam, rosuvastatin, diclofenac, and ibuprofen.

CONCLUSION

Over one-third of Medicare MTM eligible patients with CKD presented with at least one PIPM. Worsening renal function, length of MTM eligibility, female gender, and polypharmacy were associated with having PIPM. Majority of PIPMs were prescribed by PCPs. Clinical decision support tools may be considered to potentially reduce PIPM among Medicare MTM-enrolled patients with CKD.

Medicines optimization for patients with chronic kidney disease in the outpatient setting: the role of the clinical pharmacist

OBJECTIVES

Medicines optimization (MO) in patients with chronic kidney disease (CKD) is at high risk at transition points of different ambulatory care levels such as nephrologists in outpatient clinics and general practitioners (GPs). We examined if adding a clinical pharmacist to the therapeutic team promotes implementation of nephrologists' drug therapy recommendations by GPs' and reduces drug-related problems (DRPs).

METHODS

A prospective, controlled intervention study was conducted in the nephrology outpatient clinic of the Klinikum Fulda, Germany. The control and intervention phases took place successively. Patients with CKD stage 3-5 and at least one concomitant disease, for example, arterial hypertension or type-2 diabetes were recruited consecutively in three subgroups (naive, 1 contact, ≥2 contacts with nephrologist) from June 2015 to May 2019. GPs' acceptance and frequency of DRPs without (control group [CG]) and with (intervention group [IG]) pharmacist's interventions were compared after 6 months. Interventions include educational training events for GPs between control- and intervention phase, medication therapy management and pharmaceutical patient counselling.

KEY FINDINGS

In total, 256 patients (CG = 160, IG = 96) were recruited into the study. GPs' acceptance of nephrologists' medication recommendations increased significantly among naive patients and those with one prior contact with the nephrologist (CG/IG: naive = 72.8%/95.5%, 1 contact = 81.1%/94.4%; P < 0.001). DRPs per patient were significantly reduced in all subgroups (P < 0.001).

CONCLUSIONS

Interdisciplinary collaboration between the nephrologist, GPs and clinical pharmacist resulted in better MO for patients with CKD.

[Medical specialist undertreatment in nursing home residents-Prevalence and extrapolation]

Hintergrund

Bisherige Studien deuten darauf hin, dass Pflegebedürftige eine geringere fachärztliche Versorgung aufweisen als Nichtpflegebedürftige. Insbesondere im stationären Setting ist die fachärztliche Versorgungsintensität gering. Aus den bestehenden quantitativen Versorgungsunterschieden lässt sich bislang jedoch nicht ableiten, inwieweit von einer Unterversorgung bei Pflegebedürftigen ausgegangen werden muss. Für die Versorgungsbereiche Sehfähigkeit, Hörfähigkeit, Mundgesundheit und Parkinson-Syndrom wird geprüft, inwieweit Heimbewohner fachärztlich unterversorgt sind.

Material und Methoden

In 44 Pflegeheimen in Bremen und Niedersachsen wurde der Gesundheitszustand von 409 Pflegebedürftigen mittels standardisierter Assessments und Befragungen erhoben; zusätzlich wurden Diagnosen und die medizinische Versorgung aus der Pflegedokumentation ausgewertet. Ärzteteams beurteilten auf dieser Grundlage für jeden Pflegebedürftigen, inwieweit eine bedarfsgerechte fachärztliche Versorgung vorlag oder nicht.

Ergebnisse

Gemäß ärztlichem Urteil zeigt sich bei 45 % (Sehfähigkeit), 19 % (Parkinson-Syndrom), 16 % (Mundgesundheit) und 15 % (Hörfähigkeit) der Bewohner mit entsprechendem Versorgungsbedarf eine fachärztliche Unterversorgung. Bei 27 % aller Bewohner zeigt sich in mindestens einem der 4 Versorgungsbereiche eine fachärztliche Unterversorgung. Hochgerechnet entspricht dies bis zu 205.000 fachärztlich unterversorgten Pflegeheimbewohnern in Deutschland.

Diskussion

Die Studie liefert für ausgewählte Versorgungsbereiche die ersten empirischen Belege über das Ausmaß fachärztlicher Unterversorgung von Pflegeheimbewohnern. Daher erscheint es notwendig, entsprechende Interventionen zur Reduktion der Unterversorgung zu entwickeln und zu erproben.

Zusatzmaterial online

Die Online-Version dieses Beitrags (10.1007/s00391-021-01865-z) enthält eine detaillierte Erklärung zur Methodik der Datenerhebung sowie 6 Tabellen mit weiterführenden Analysen. Beitrag und Zusatzmaterial stehen Ihnen im elektronischen Volltextarchiv auf https://www.springermedizin.de/link/10.1007/10.1007/s0391-021-01865-z zur Verfügung. Sie finden das Video am Beitragsende unter „Supplementary Material“.

Implementation of a renal pharmacist consultant service - Information sharing in paper versus digital form

WHAT IS KNOWN AND OBJECTIVE

Renal impairment (RI) and renal drug-related problems (rDRP) often remain unrecognized in the community setting. A "renal pharmacist consultant service" (RPCS) at hospital admission can support patient safety by detecting rDRP. However, the efficient information sharing from pharmacists to physicians is still discussed. The aim of the study was to test the implementation of a RPCS and its effectiveness on prescription changes and to evaluate two ways of written information sharing with physicians.

METHODS

Urological patients with eGFR_non-indexed of 15-59 ml/min and ≥1 drug were reviewed for manifest and potential rDRP at admission by a pharmacist. Written recommendations for dose or drug adaptation were forwarded to physicians comparing two routes: July-September 2017 paper form in handwritten chart; November 2017-January 2018 digital PDF document in the electronic patient information system and e-mail alert. Prescription changes regarding manifest rDRP were evaluated and compared with a previous retrospective study without RPCS.

RESULTS AND DISCUSSION

The RPCS detected rDRP in 63 of 234 (26.9%) patients and prepared written recommendations (median 1 rDRP (1-5) per patient) concerning 110 of 538 (20.5%) drugs at admission. For manifest rDRP, acceptance rates of recommendations were 62.5% (paper) vs 42.9% (digital) (P = 0.16). Compared with the retrospective study without RPCS (prescription changes in 21/76 rDRP; 27.6%), correct prescribing concerning manifest rDRP significantly increased by 27.1%.

WHAT IS NEW AND CONCLUSION

A RPCS identifies patients at risk for rDRP and significantly increases appropriate prescribing by physicians. In our hospital (no electronic order entry, electronic chart or ward pharmacists), consultations in paper form seem to be superior to a digital PDF document.

Correct use of non-indexed eGFR for drug dosing and renal drug-related problems at hospital admission

Purpose

Two to seven percent of the German adult population has a renal impairment (RI) with an estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73m². This often remains unrecognized and adjustment of drug therapy is lacking. To determine renal function in clinical routine, the CKD-EPI equation is used to calculate an indexed eGFR (ml/min/1.73m²). For drug dosing, it has to be individualized to a non-indexed eGFR (ml/min) by the patient’s body surface area. Here, we investigated the number of patients admitted to urological wards of a teaching hospital with RI between July and December 2016. Additionally, we correctly used the eGFR_non-indexed for drug and dosage adjustments and to analyse the use of renal risk drugs (RRD) and renal drug-related problems (rDRP).

Methods

In a retrospective observational study, urological patients with pharmacist-led medication reconciliation at hospital admission and eGFR_indexed (CKD-EPI) of 15–59 ml/min/1.73m² were identified. Indexed eGFR (ml/min/1.73m²) was recalculated with body surface area to non-indexed eGFR (ml/min) for correct drug dosing. Medication at admission was reviewed for RRD and based on the eGFR_non-indexed for rDRP, e.g. inappropriate dose or contraindication.

Results

Of 1320 screened patients, 270 (20.5%) presented with an eGFR_indexed of 15–59 ml/min/1.73m². After readjustment, 203 (15.4%) patients had an eGFR_non-indexed of 15–59 ml/min. Of these, 190 (93.6%) used ≥ 1 drugs at admission with 660 of 1209 (54.7%) drugs classified as RRD. At least one rDRP was identified in 115 (60.5%) patients concerning 264 (21.8%) drugs.

Conclusion

Renal impairment is a common risk factor for medication safety in urologic patients admitted to a hospital. Considerable shifts were seen in eGFR-categories when correctly calculating eGFR_non-indexed for drug dosing purposes. The fact that more than half of the study patients showed rDRP at hospital admission underlines the need to consider this risk factor appropriately.

Electronic supplementary material

The online version of this article (10.1007/s00228-020-02953-6) contains supplementary material, which is available to authorized users.

Medical Students' and Internal Medicine Trainees' Knowledge of Drug Prescribing Recommendations in Older Patients with Impaired Kidney Function

Background

Numerous medications used in older adults require dose modification or should be avoided in individuals with impaired kidney function.

Purpose

To assess medical students’ and physicians’ knowledge of drug prescribing recommendations in older patients with estimated glomerular filtration rate (eGFR) < 30 mL/min/1.73m².

Patients and Methods

A survey comprising a list of 64 drugs conducted in 183 medical students (Students), and 138 post-graduate trainees in internal medicine (Physicians). The respondents were asked to classify each drug into one of three categories: 1) no renal precautions; 2) dose should be reduced; and 3) medication should be avoided.

Results

A range of 16.9–68.3% students and 14.5–81.2% physicians correctly classified drugs in the category “No renal precautions.” Drugs requiring dose reduction were correctly classified by 6–67.2% students, and 24.6–85.5% physicians. For drugs that should be avoided in subjects with eGFR < 30 mL/min/1.73m², the range was 6–44.8% in the Students, and 8.7–76.1% in the Physicians. The Physicians did better than the Students by classifying five drugs that do not require renal precautions, 12 drugs requiring dose reduction, and six medications that should be avoided. The Students had a higher percentage of correct answers for seven drugs in the category “no renal precautions,” and one drug requiring dose reduction.

Conclusion

Medical students and post-graduate trainees in internal medicine have poor knowledge of drug prescribing recommendations in older patients with renal impairment.

Outcomes for Inappropriate Renal Dose Adjustment of Dipeptidyl Peptidase-4 Inhibitors in Patients With Type 2 Diabetes Mellitus: Population-Based Study

OBJECTIVES

To estimate inappropriate dosing of dipeptidyl peptidase-4 (DPP-4) inhibitors and to assess the risk of emergency department visits, hypoglycemia, and mortality in patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD) prescribed inappropriate DPP-4 inhibitor doses because limited real-world information is available regarding rates of DPP-4 inhibitor dose adjustment and its safety in patients with T2DM and CKD.

PATIENTS AND METHODS

We performed a retrospective observational cohort study of 82,332 patients aged 30 to 75 years with T2DM and CKD being treated with DPP-4 inhibitors from January 1, 2012, through December 31, 2014, using the Korean National Health Information Database. We divided the patients according to the prescription of DPP-4 inhibitor with or without dose adjustment according to estimated glomerular filtration rate. The incidences of emergency department visits, hypoglycemia, and mortality were assessed using hazard ratios estimated using Cox proportional hazards regression modeling.

RESULTS

Approximately 40% of patients with T2DM and CKD were prescribed an inappropriate dose of DPP-4 inhibitor from 2009 through 2011; this proportion decreased to 24.4% in 2015. Hazard ratios (95% CIs) for inappropriate vs appropriate dosing of DPP-4 inhibitors were 1.115 (1.005-1.237) for mortality, 1.074 (1.018-1.133) for emergency department visits, and 1.192 (1.054-1.349) for severe hypoglycemia after multivariable adjustment for confounding factors.

CONCLUSION

One of every 3 patients with T2DM and CKD received inappropriate dosing of DPP-4 inhibitor, which was associated with high risk of emergency department visits, severe hypoglycemia, and mortality.

Adjustments of medication dosages in patients with renal impairment in Botswana; findings and implications to improve patient care

Background and aims: Medication dosage adjustments for renally impaired patients have not been studied in Botswana. This study was conducted to determine prescribing practices among patients with renal impairment in medical wards to improve future patient care.Methods: We conducted a retrospective study involving medical charts of patients admitted at a tertiary level hospital in Gaborone Botswana. Study participants included all patients admitted between August and October 2016 who were hospitalized for ≥24 h. 'Drug prescribing in renal failure: dosing guidelines for adults and children'. was used to determine the extent of dosage adjustments. A logistic regression model was used to assess which patient factors were associated with inappropriate dosage adjustment.Results: Twenty-nine percent (233/804) of patients had renal impairment. Of these, 184 patients with renal impairment were included in the final analysis. There were 1143 prescription entries, of which 20.5% (n = 234) required dosage adjustment for renal function but only 45.7% (n = 107) were adjusted correctly. Of note, 112 patients were prescribed at least one drug that required dosage adjustment and only 30.4% (n = 34) patients had all of their medications appropriately adjusted. Patient factors associated with inappropriate dosage adjustment included a higher number of medicines being prescribed. Mortality among patients with renal impairment was independently associated with higher scores of the Charlson comorbidity index and hospital stay duration of 1-7 days.Conclusion: The renal function status of patients was not sufficiently taken into account when prescribing medicines especially in patients with severely impaired kidney function in Botswana. Continuous medical education needs to be encouraged to address this, which is being implemented. We will be following this up in future studies.

The Finnish Interprofessional Medication Assessment (FIMA): baseline findings from home care setting

PURPOSE

Medication-related problems and declined functional capacity are closely associated factors among older people. The purpose of this study is to describe the procedure of interprofessional medication assessment in home care context and the baseline characteristics of the study population.

METHODS

The FIMA study was a randomized, controlled intervention study comparing general practitioner-led interprofessional medication assessment and usual care. Patients' chronic diagnoses and medication use as well as physical and cognitive functions were investigated. Performance in daily activities, use of care services and help from family and relatives, self-rated health and health-related quality of life, and adverse effects commonly related to medication were assessed.

RESULTS

The home care patients (n = 512) had significant disease burden and functional limitations. The mean number of all medicines was 15 and that of regularly taken medicines 10. The majority of patients (87%) had excessive polypharmacy. The most commonly used (97%) ATC medicine class was nervous system medicines. Clinically relevant (class C or D SFINX record) drug-drug interactions were seen in 74% of the patients. The most frequent risks of adverse effects were risk of bleeding (66%), constipation (58%) and orthostatism (54%) occurring in over half of the patients. Medicines affecting renal function were used by 85% of the patients.

CONCLUSIONS

There is an evident need and justification for medication assessments in home care. In most cases, home care patients fulfill the criteria for regular medication assessments.

Needs-based provision of medical care to nursing home residents: protocol for a mixed-methods study

INTRODUCTION

Nursing home residents typically have greater needs for medical care than community-dwelling elderly. However, restricted cognitive abilities and limited mobility may impede their access to general practitioners and medical specialists. The provision of medical care in nursing homes may therefore be inappropriate in some areas of medical care. The purpose of this mixed-methods study is to systematically assess, evaluate and explain met and unmet medical care needs in German nursing homes and to develop solutions where medical care is found to be inappropriate.

METHODS AND ANALYSIS

First, statutory health insurance claims data are analysed to identify differences in the utilisation of medical care between nursing home residents and community-dwelling elderly with and without need for long-term care. Second, the health status and medical care of 500 nursing home residents are assessed and evaluated to quantify met and unmet medical care needs. Third, qualitative expert interviews and case conferences and, fourth, quantitative analyses of linked data are used to provide structural, case-specific and generalisable explanations of inappropriate medical care among nursing home residents. Fifth, a modified Delphi study is employed to develop pilot projects aiming to improve medical care in nursing homes.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee of the University of Bremen on 23 November 2017. Research findings are disseminated through presentations at national and international conferences and publications in peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

DRKS00012383.

Shared Decision-Making in Chronic Patients with Polypharmacy: An Interventional Study for Assessing Medication Appropriateness

Potentially inappropriate medications are associated with polypharmacy and polypathology. Some interventions such as pharmacotherapy reviews have been designed to reduce the prescribing of inappropriate medications. The objective of this study is to evaluate how effective a decision-making support tool is for determining medication appropriateness in patients with one or more chronic diseases (hypertension, dyslipidaemia, and/or diabetes) and polypharmacy in the primary care setting. For this, a quasi-experimental study (randomised, controlled and multicentre) has been developed. The study compares an intervention group, which assesses medication appropriateness by applying a decision support tool, with a control group that follows the usual clinical practice. The intervention included a decision support tool in paper format, where participants were informed about polypharmacy, inappropriate medications, associated problems and available alternatives, as well as shared decision-making. This is an informative guide aimed at helping patients with decision-making by providing them with information about the secondary risks associated with inappropriate medications in their treatment, according to the Beers and START/STOPP criteria. The outcome measure was the proportion of medication appropriateness. The proportion of patients who confirmed medication appropriateness after six months of follow-up is greater in the intervention group (32.5%) than in the control group (27.9%) p = 0.008. The probability of medication appropriateness, which was calculated by the proportion of drugs withdrawn or replaced according to the STOPP/Beers criteria and those initiated according to the START criteria, was 2.8 times higher in the intervention group than in the control group (OR = 2.8; 95% CI 1.3–6.1) p = 0.008. In patients with good adherence to the treatment, the percentage of appropriateness was 62.1% in the shared decision-making group versus 37.9% in the control group (p = 0.005). The use of a decision-making support tool in patients with potentially inappropriate medications increases the percentage of medication appropriateness when compared to the usual clinical practice.

Impact of pharmacists' interventions on physicians' decision of a knowledge-based renal dosage adjustment system

Background Early interventions with clinical decision support system (CDSS) guidance have ensured appropriate drug dosing for patients with renal impairment. However, the low rates of physician compliance with CDSS alerts have been reported. Objective We investigated whether designated pharmacist interventions were associated with physician' acceptance of the knowledge-based renal dosage adjustment system (K-RDS) for patients with reduced renal function. Setting A retrospective, single-center study was conducted using a healthcare information system at a tertiary teaching hospital. Methods This study compared physicians' acceptance of the K-RDS with and without designated pharmacists. The severity of prescription errors and the impact of service provided by the pharmacist were evaluated using the validated method developed by Overhage and Lukes. From April to June 2017, we enrolled patients who were ≥ 20 years of age and admitted with an estimated glomerular filtration rate under 50 ml/min on medications that required dose adjustments. Main outcomes measure The number of dosing alerts of the K-RDS and physicians' acceptance rates were compared between a control group guided by the central pharmacy only and a group with assigned designated pharmacists. The factors associated with the physicians' acceptance rate were also analyzed using a multivariate logistic regression method. The impact of service provided by the pharmacist were considered as 'highly significant' (categories: 1-2). Severity of prescription errors were defined as 'serious' if they corresponded to categories 1-2 of the Overhage and Lukes scale for severity, and interventions were relevant if they corresponded to categories 1-3 in the impact of  service provided by the pharmacist scale. Results Among 1363 prescription interventions, 491 (36.0%) were performed by designated pharmacists. The K-RDS alert acceptance rate by the physicians was 54.4% in the designated pharmacist group and 47.0% in the control group (p = 0.0233). The statistically significant association was found in the designated pharmacists group in 'highly significant' service provided by the pharmacist (p < 0.001, OR 1.772; 95% CI 1.362-2.305) and 'serious' severity of prescription errors (p = 0.012, OR 1.657; 95% CI 1.116-2.460). The presence of designated pharmacists (OR 1.353, p = 0.0272), patient's gender (OR 0.758, p = 0.0016), department specialty (OR 0.659, p < 0.0001), eGFR (OR 1.538 if < 10 ml/min; OR 1.519 if 10-40 ml/min, p < 0.0001), and medications (OR 6.058-43.992 depending on the medication category, p < 0.0001) were significant factors affecting physicians' acceptance. Conclusion Pharmacists' interventions effectively improved physicians' acceptance of the K-RDS alerts.

Use of renal risk drugs in a nation-wide Polish older adult population: an analysis of PolSenior database

BACKGROUND

Numerous medications should be avoided, or require dose adjustment in subjects with impaired kidney function. We aimed to assess the prevalence of potentially inappropriate use of renal risk drugs in a nation-wide, community-dwelling Polish older adult population.

METHODS

We analysed regular intake of 38 medications that should be avoided, requiring dose modification, increase the risk of pre-renal kidney injury, or may cause potassium retention in subjects with moderately to severely impaired renal function in the PolSenior data base (N = 4514, mean age 76 ± 11 yrs). Kidney function was assessed with short Modification of Diet in Renal Disease formula estimated glomerular filtration rate (sMDRD) and Cockcroft-Gault creatinine clearance (CC).

RESULTS

There were 855 (19%) individuals with sMDRD < 60 ml/min/1.73m2, and 1734 (38%) with CC <  60 ml/min. Among drugs that should be avoided, spironolactone (20.4% of patients as classified by sMDRD and 17.5% by CC), non-steroidal anti-inflammatory drugs (13.4 and 11.3%), hydrochlorothiazide (11.1 and 11.0%), and metformin (6.9 and 8.2%) were most frequently used. The most frequently used drugs requiring dose modification were piracetam (13.9% by sMDRD, and 11.9% by CC), digoxin (8.3 and 8.8%), and gliclazide (6.8 and 5.9%). Classification of a drug use as 'appropriate' or 'inappropriate' was discordant depending on the method of kidney function assessment (sMDRD or CC) in up to 30%. Subgroups with sMDRD < 60 ml/min/1.73m2 and with CC <  60 ml/min were taking ≥2 drugs increasing the risk of pre-renal kidney injury more frequently than individuals with better kidney function (46.6 vs. 23.1 and 33.0% vs. 24.4%, respectively). There were 24.7% of individuals with sMDRD < 60 ml/min/1.73m2 and 18.0% with CC <  60 ml/min taking 2 or more drugs increasing serum potassium level. The proportion of subjects with hyperkalaemia increased with the number of such drugs.

CONCLUSIONS

Use of drugs that should be avoided or require dose adjustment due to renal impairment, and potentially inappropriate drug combinations is a common problem in older adults in Poland. Assessment of kidney function with sMDRD may result in overlooking of requirements for dose adjustment formulated based on creatinine clearance.

TRIAL REGISTRATION

Not applicable.

Differences in Kidney Function Estimates Based on Creatinine and/or Cystatin C in Non-Traumatic Amputation Patients and Their Impact on Drug Prescribing

Accurate kidney function estimates are necessary when prescribing renally-eliminated medications. Our objectives were to investigate how amputation affects estimated glomerular filtration rate (eGFR) and to determine if dosing recommendations differ among different eGFR equations. In a cohort study of non-traumatic amputation patients, eGFR based on creatinine and/or cystatin C were measured before and after amputation. Prescribed, renally-eliminated medications were compared with dosing guidelines in Renbase^®. Data from 38 patients with a median age of 75 years were analyzed. The median (range) eGFR was 65 (15⁻103), 38 (13⁻79), and 48 (13⁻86) mL/min/1.73 m² before amputation and 80 (22⁻107), 51 (13⁻95), and 62 (16⁻100) mL/min/1.73 m² after amputation for eGFR_Creatinine, eGFR_CystatinC, and eGFR_Combined, respectively (p < 0.01). From before to after amputation, eGFR increased on average by 8.5, 6.1, and 7.4 mL/min/1.73 m² for eGFR_Creatinine, eGFR_CystatinC, and eGFR_Combined (all p < 0.01), respectively. At least one renally-eliminated medication was prescribed at a higher dose than recommended in 37.8% of patients using eGFR_CystatinC, 17.6% using eGFR_Combined and 10.8% using eGFR_Creatinine. In conclusion, amputation affects eGFR regardless of the eGFR equations. The differences among equations would impact prescribing of renally-eliminated medications, particularly when switching from creatinine to cystatin C.

Pharmacotherapy in Older Adults with Cardiovascular Disease: Report from an American College of Cardiology, American Geriatrics Society, and National Institute on Aging Workshop

OBJECTIVES

To identify the top priority areas for research to optimize pharmacotherapy in older adults with cardiovascular disease (CVD).

DESIGN

Consensus meeting.

SETTING

Multidisciplinary workshop supported by the National Institute on Aging, the American College of Cardiology, and the American Geriatrics Society, February 6-7, 2017.

PARTICIPANTS

Leaders in the Cardiology and Geriatrics communities, (officers in professional societies, journal editors, clinical trialists, Division chiefs), representatives from the NIA; National Heart, Lung, and Blood Institute; Food and Drug Administration; Centers for Medicare and Medicaid Services, Alliance for Academic Internal Medicine, Patient-Centered Outcomes Research Institute, Agency for Healthcare Research and Quality, pharmaceutical industry, and trainees and early career faculty with interests in geriatric cardiology.

MEASUREMENTS

Summary of workshop proceedings and recommendations.

RESULTS

To better align older adults' healthcare preferences with their care, research is needed to improve skills in patient engagement and communication. Similarly, to coordinate and meet the needs of older adults with multiple comorbidities encountering multiple healthcare providers and systems, systems and disciplines must be integrated. The lack of data from efficacy trials of CVD medications relevant to the majority of older adults creates uncertainty in determining the risks and benefits of many CVD therapies; thus, developing evidence-based guidelines for older adults with CVD is a top research priority. Polypharmacy and medication nonadherence lead to poor outcomes in older people, making research on appropriate prescribing and deprescribing to reduce polypharmacy and methods to improve adherence to beneficial therapies a priority.

CONCLUSION

The needs and circumstances of older adults with CVD differ from those that the current medical system has been designed to meet. Optimizing pharmacotherapy in older adults will require new data from traditional and pragmatic research to determine optimal CVD therapy, reduce polypharmacy, increase adherence, and meet person-centered goals. Better integration of the multiple systems and disciplines involved in the care of older adults will be essential to implement and disseminate best practices. J Am Geriatr Soc 67:371-380, 2019.

Prevalence of renally inappropriate medicines in older people with renal impairment - A cross-sectional register-based study in a large primary care population

The aim of this population-based, cross-sectional study was to analyse the prevalence of renally inappropriate medicines (RIMs) in older people with renal impairment. We included 30 372 people aged ≥65 years with chronic kidney disease (CKD) stage 3, and 2161 with stage 4 attending primary care in Stockholm, Sweden. We used data derived from SCREAM, a database linking patient-specific data on demography, morbidity, healthcare consumption and dispensed drugs to creatinine measurements. Estimated glomerular filtration rate was calculated with CKD-EPI based on the first non-hospital serum creatinine in 2010. RIMs were defined as medicines needing dose adjustment or being contra-indicated in CKD stage 3 or 4 with reference to Swedish "Janusmed Drugs and Renal function." Dispensed prescription drugs were analysed during 1 year after creatinine assessment. Drug doses were considered as excessive if their mean volume dispensed per day exceeded the recommended dose. Contra-indicated medicines were regarded as inappropriate if dispensed at least once during 1 year. Excessive dosing was present in 42.5% of older people with CKD stage 3 and in 58.1% with stage 4. The prevalence of contra-indicated medicines was 9.4% and 38.0%, respectively. A limited number of RIMs accounted for the majority of excessive dosing, such as drugs acting on the renin-angiotensin-aldosterone system, betablockers and opioids. Commonly dispensed contra-indicated substances were NSAIDs and antidiabetics. We conclude that the prevalence of RIMs in older people with renal impairment is considerably high. Still, RIM use may be manageable as only a limited number of RIMs are frequently used.