Effect of high-intensity exercise on cardiorespiratory fitness, cardiovascular disease risk and disease activity in patients with inflammatory joint disease: protocol for the ExeHeart randomised controlled trial

INTRODUCTION

Inflammatory joint disease (IJD) is associated with increased risk of cardiovascular disease (CVD) fostered by systemic inflammation and a high prevalence of CVD risk factors. Cardiorespiratory fitness (CRF) is an important health parameter and CRF-measures are advocated in routine health evaluations. CRF associates with CVD risk, and exercise modalities such as high intensity interval training (HIIT) can increase CRF and mitigate CVD risk factors. In IJD, exercise is rarely used in CVD risk management and the cardioprotective effect of HIIT is unclear. Furthermore, the clinical applicability of HIIT to primary care settings is largely unknown and warrants investigation. The primary aim is to assess the effect of a HIIT programme on CRF in patients with IJD. Second, we will evaluate the effect of HIIT on CVD risk and disease activity in patients with IJD, feasibility of HIIT in primary care and validity of non-exercise algorithms to detect change in CRF.

METHODS AND ANALYSIS

ExeHeart is a single-blinded, randomised controlled trial. Sixty patients with IJD will be recruited from the Preventive Cardio-Rheuma clinic at Diakonhjemmet Hospital, Norway. Patients will be assigned to receive standard care (relevant lifestyle advice and cardio-preventive medication) or standard care plus a 12-week HIIT intervention by physiotherapists in primary care. HIIT sessions will be prescribed at 90%-95% of peak heart rate. Outcomes include CRF (primary outcome), CVD risk factors, anthropometric measures, disease activity and patient-reported outcomes related to pain, fatigue, disease, physical activity and exercise and will be assessed at baseline, 3 months (primary endpoint) and 6 months postbaseline.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Regional Committee for Medical and Health Research Ethics (201227). Participants are required to sign a written informed consent form. Results will be discussed with patient representatives, submitted to peer-reviewed journals and presented at relevant platforms.

TRIAL REGISTRATION NUMBER

NCT04922840.

Serum Concentrations and Elimination Rates of Direct-Acting Oral Anticoagulants (DOACs) in Older Hip Fracture Patients Hospitalized for Surgery: A Pilot Study

BACKGROUND

Use of direct-acting oral anticoagulants (DOACs) is increasing, but knowledge about pharmacokinetics and safety in frail patients is lacking.

OBJECTIVE

The aim was to determine serum concentrations and elimination rates of DOACs in older hip fracture patients hospitalized for surgery.

METHODS

The study included patients ≥ 65 years of age hospitalized for acute hip fracture surgery over a period of 6 months. Use of antithrombotic drugs was registered and serum samples collected for analysis of DOACs (apixaban, dabigatran and rivaroxaban) at admission and surgery. Measured concentrations were assessed in relation to reference (therapeutic) ranges of the respective drugs and applied for half-life calculations. Furthermore, waiting time for surgery was compared between DOAC and warfarin users.

RESULTS

Of 167 patients included (median age 84 years), 11 and 14 used DOACs and warfarin, respectively. Seven of the DOAC-treated patients had concentrations above the upper reference range (> 300 nM) at admission, and concentrations were still in the reference range for five of these at surgery. Elimination half-lives could be estimated in eight patients and ranged between 14.6 and 59.7 h (median 21.6). The observed waiting time for surgery was longer for patients using DOACs than warfarin (median 44 vs. 25 h).

CONCLUSION

This pilot study indicates that older patients prone to hip fracture are at risk of being exposed to therapeutic serum concentrations of DOACs during surgery due to reduced drug elimination rates. The observation that almost 50% of the patients had therapeutic concentrations at surgery should be investigated further regarding safety of DOAC use in this frail elderly population.

Interdisciplinary collaboration across secondary and primary care to improve medication safety in the elderly (IMMENSE study): study protocol for a randomised controlled trial

INTRODUCTION

Drug-related problems (DRPs) are common in the elderly, leading to suboptimal therapy, hospitalisations and increased mortality. The integrated medicines management (IMM) model is a multifactorial interdisciplinary methodology aiming to optimise individual medication therapy throughout the hospital stay. IMM has been shown to reduce readmissions and drug-related hospital readmissions. Using the IMM model as a template, we have designed an intervention aiming both to improve medication safety in hospitals, and communication across the secondary and primary care interface. This paper presents the study protocol to explore the effects of the intervention with regard to healthcare use, health-related quality of life (HRQoL) and medication appropriateness in elderly patients.

METHODS AND ANALYSIS

A total of 500 patients aged ≥70 years will be included and randomised to control (standard care) or intervention group (1:1). The intervention comprises five steps mainly performed by pharmacists: (1) medication reconciliation at admission, (2) medication review during hospital stay, (3) patient counselling about the use of medicines, (4) a comprehensible and patient-friendly medication list with explanations in discharge summary and (5) postdischarge phone calls to the primary care level. The primary outcome is the difference between intervention and control patients in the rate of emergency medical visits (acute readmissions and visits to emergency department) 12 months after discharge. Secondary outcomes include length of index hospital stay, time to first readmission, mortality, hip fractures, strokes, medication changes, HRQoL and medication appropriateness. Patient inclusion started in September 2016.

ETHICS AND DISSEMINATION

The trial was approved by the Norwegian Centre for Research Data and the Norwegian Data Protection Authority. We aim to publish the results in international peer-reviewed open access journals, at national and international conferences, and as part of two PhD theses.

TRIAL REGISTRATION NUMBER

NCT02816086.

Use of antibiotics in nursing homes--surveillance with different methods

BACKGROUND

Residents in nursing homes have a heightened risk of developing infections that should be treated with antibiotics. Inappropriate use of antibiotics may generate drug-related problems and increase resistance. In this study, we describe the use of antibiotics in nursing homes on the basis of prevalence surveys and drug sales statistics.

MATERIAL AND METHODS

Five nursing homes in Oslo participated in two one-day surveys in 2009. All use of systemic antibiotics was registered. The data collection was undertaken according to a protocol developed by the European Surveillance of Antimicrobial Consumption (ESAC) Network and was part of a European study. The nursing homes' drug sales statistics for systemic antibiotics during 2009, distributed by the number of bed days for each nursing home, were estimated. Information on indications for each antibiotic from the prevalence surveys was collated with sales data to achieve an estimate of how the purchased antibiotics were used.

RESULTS

The prevalence surveys showed that more than 8% of the residents received antibiotics. Prophylactic treatment accounted for 33% of the prescriptions. A prevalence of antibiotic use of 10% was estimated from the drug sales statistics. Urinary tract infection was the most frequently registered indication. Pivmecillinam and methenamine were most frequently prescribed and most frequently purchased. Most courses of treatment were prescribed in accordance with the national guidelines for antibiotic use.

INTERPRETATION

The results from the drug sales statistics concurred well with the prevalence surveys, and the methods can thus be relevant for purposes of monitoring the use of antibiotics.

Beliefs about medicines among Norwegian outpatients with chronic cardiovascular disease

Objective

To investigate the beliefs of Norwegian outpatients about medicines, and to explore if some patient-specific factors and drug use are associated with the beliefs.

Methods

Patients from an outpatient clinic for chronic cardiovascular diseases were referred by physicians to a pharmacist-led medication outpatient clinic. Here the patients were asked to complete the Beliefs about Medicines Questionnaire.

Results

150 patients were included (mean age 70.0 years (range 31–91), 50 (33.3%) women), using a total of 1061 drugs. 91.2% strongly believed in the necessity of their medicines and 29.7% had strong concerns. Multivariate regression analyses showed that with an increasing number of drugs, the score for necessity was significantly increased (p<0.01). Women were significantly more concerned than men (p=0.03). The older the patient, the higher the score for general harm of medicines (p=0.01).

Conclusions

Although the majority of the patients in this study believed in the necessity of their medication, one-third had strong concerns.

How are drug regimen changes during hospitalisation handled after discharge: a cohort study

OBJECTIVES

To investigate drug regimen changes during hospitalisation and explore how these changes are handled after patients are transferred back into the care of their general practitioners (GPs).

DESIGN

Cohort study.

SETTING

Patients in this multicentre study had undergone at least one change in their drug regimens at discharge from the general medicine departments at six hospitals in Norway. These changes were altered doses, discontinuation of drugs or start of new drugs. Clinical pharmacists visited the patients' GPs 4-5 months after patient discharge and recorded any additional drug regimen changes.

RESULTS

In total, 105 patients (mean age 76.1 years, 54.3% women) completed the study. On average, they used 5.6 drugs at admission (range 0-16) and 7.6 drugs at discharge (range 1-17). On average, 4.4 drug changes per patient (SD 2.7, range 1-16) were made at the hospital, and 3.4 drug changes per patient (SD 2.9, range 0-14) within 4-5 months of discharge. Of the 465 drug changes made in hospital, 153 were changed again after discharge (mean 1.5 per patient, SD 1.8, range 0-13). The drug regimens of 90 of these 105 patients were changed after discharge. The OR for extensive drug changes after discharge (≥ 4 changes) increased significantly with the number of drugs used at discharge from hospital (OR=1.29, 95% CI 1.04 to 1.59). Only 68 of 105 discharge notes contained complete drug lists, and only 24 of the discharge notes were received by the GPs within 7 days.

CONCLUSIONS

In addition to the extensive changes in drug regimens during hospitalisation, almost equally extensive changes were made in the initial months after discharge. Surveillance of drug regimens is particularly necessary in the period immediately after hospital discharge.

Multidisciplinary intervention to identify and resolve drug-related problems in Norwegian nursing homes

OBJECTIVE

To describe an innovative team intervention to identify and resolve DRPs (drug-related problems) in Norwegian nursing homes.

DESIGN

Descriptive intervention study. Setting. Three nursing homes in Bergen, Norway.

SUBJECTS

A total of 142 long-term care patients (106 women, mean age 86.9 years).

RESULTS

Systematic medication reviews performed by pharmacists in 142 patients revealed altogether 719 DRPs, of which 504 were acknowledged by the patients' physician and nurses, and 476 interventions were completed. "Unnecessary drug" and "Monitoring required" were the most frequently identified DRPs. Drugs for treating the nervous system and the alimentary tract and metabolism were most commonly questioned.

CONCLUSIONS

The multidisciplinary team intervention was suitable to identify and resolve drug-related problems in nursing home settings. Systematic medication reviews and involvement of pharmacists in clinical teams should therefore be implemented on a regular basis to achieve and maintain high-quality drug therapy.

Drugs with narrow therapeutic index as indicators in the risk management of hospitalised patients

Drugs with narrow therapeutic index (NTI-drugs) are drugs with small differences between therapeutic and toxic doses. The pattern of drug-related problems (DRPs) associated with these drugs has not been explored.

The Janus face of polypharmacy – overuse versus underuse of medication

As modern guidelines may recommend several drugs for a single medical condition, it follows that many patients, especially if co-morbidity is present, use a number of medications. Also, an aging population implies more morbidity and consequently will have the result that many patients use many drugs – a situation often referred to as polypharmacy. Polypharmacy has been linked to negative health outcomes such as adverse drug reactions, interaction problems, poor patient adherence, and hospitalisations. Such experiences have led to the attitude that efforts should be made to reduce polypharmacy. However, this approach might prevent patients from obtaining optimal treatment. There is no universal definition of polypharmacy and measuring of a reduction in polypharmacy becomes problematic. Because polypharmacy is an imprecise term it should be used with caution in research as well as in patient management. Moreover, studies have shown that undertreatment occurs frequently also among patients using many drugs. This is the Janus face of polypharmacy: too many drugs should be avoided, but the individual patient should receive the appropriate drugs that have the potential to reduce morbidity and improve quality of life. It is the individual drugs themselves, along with patient specific factors, and not a fixed number of drugs, that we should pay attention to.

Legemiddel­interaksjoner hos sykehuspasienter – forekomst og klinisk betydning

Introduction: Little is known about the occurrence of drug interactions of hospitalised patients. We aimed to identify the frequency of potential drug interactions among hospitalised patients and, furthermore, to evaluate how many of these were problematic and clinically significant. Methods: We investigated drug interactions by two methods: by applying a computerised drug-drug interaction programme and by prospective clinical evaluation. The study was carried out at departments of internal medicine and rheumatology in five Norwegian hospitals in 2002. Patient characteristics and information on drug use were recorded for 827 patients consecutively included. Medication reviews were carried out by clinical pharmacists and drug-related problems (DRPs), among which drug interactions is one category, were identified and discussed in the hospital multidisciplinary team, chaired by a physician. Retrospectively, the patients’ drug regimens were screened by using a computer programme for drug-drug interactions, DRUID. This programme is universally used in Norway and classifies DDIs into four categories according to assumed severity: A, avoid; B, avoid/take precautions; C, take precautions; D, no action needed. Results: A total of 1513 DDIs were found in 544 patients (66% of the total sample of 827 patients) by computer screening. Many of these were related to drugs started in the hospital, that is they were new drug interactions. By bedside evaluation, 99 DDIs were found in 73 patients (9%). Of these, 89 were also identified by computer screening. Thus, only 6% of the computer identified drug interactions were assessed to be clinically problematic. Interactions of all degrees of severity, according to the computer programme, were identified as problematic by bedside screening. Drugs most often causing new drug interactions were warfarin, acetylsalicylic acid, digitoxin and combinations of codeine and paracetamol. Conclusions: The majority of hospitalised patients have potential drug interactions, however, less than one in ten have interactions of clinical importance. Computer graded severity has limitations when intended to be used as an indicator for clinical importance. Another way of picking up new, possibly serious drug interactions would be to select indicator drugs, which are drugs frequently known to be involved in interactions, and then undertake the main interaction search on these drugs.

Identification of drug interactions in hospitals--computerized screening vs. bedside recording

BACKGROUND AND OBJECTIVE

Managing drug interactions in hospitalized patients is important and challenging. The objective of the study was to compare two methods for identification of drug interactions (DDIs)--computerized screening and prospective bedside recording--with regard to capability of identifying DDIs.

METHODS

Patient characteristics were recorded for patients admitted to five hospitals. By bedside evaluation drug-related problems, including DDIs, were prospectively recorded by pharmacists and discussed in multidisciplinary teams. A computer screening programme was used to identify DDIs retrospectively--dividing DDIs into four classes: A, avoid; B, avoid/take precautions; C, take precautions; D, no action needed.

RESULTS

Among 827 patients, computer screening identified DDIs in 544 patients (66%); 351 had DDIs introduced in hospital. The 1513 computer-identified DDIs had the following distribution: type A 78; type B 915; type C 38; type D 482. By bedside evaluation, 99 DDIs were identified in 73 patients (9%). The proportions of computer recorded DDIs which were also identified at the bedside were: 5%, 8%, 8%, 2% DDIs of types A, B, C and D respectively. In 10 patients, DDIs not registered by computer screening were identified by bedside evaluation. The drugs most frequently involved in DDIs, identified by computerized screening were acetylsalicylic acid, warfarin, furosemide and digitoxin compared with warfarin, simvastatin, theophylline and carbamazepine, by bedside evaluation.

CONCLUSION

Despite an active prospective bedside search for DDIs, this approach identified less than one in 10 of the DDIs recorded by computer screening, including those regarded as hazardous. However, computer screening overestimates considerably when the objective is to identify clinically relevant DDIs.

The impact of clinical pharmacists on drug-related problems and clinical outcomes

Drug-related problems are frequent and may result in reduced quality of life, and even morbidity and mortality. Many studies have shown that clinical pharmacists can effectively identify and prevent clinically significant drug-related problems and that physicians acknowledge and act on the clinical pharmacist's suggestions for interventions to the drug-related problems. A pro-active rather than a reactive approach on the part of the pharmacists seems prudent for obtaining most benefit. This includes participation of pharmacists in the multidisciplinary team discussions - at the stage of ordering and prescribing - where all types of drug-related problems, including also potential problems, should be discussed. In addition, counselling by pharmacists about medication on discharge and follow-up after discharge resulted in better outcomes. Furthermore, clinical pharmacists can positively influence other outcomes, such as improvement of levels of markers for drug use (e.g. optimization of lipid levels, anticoagulation levels and blood pressure). Some studies have reported positive effects on hard clinical outcomes, such as reduced length of stay, fewer re-admissions and fewer disease events (e.g. heart failure events and thromboembolism). However, more studies should be undertaken with larger patient populations, including patients from multiple sites. More knowledge about patient-specific factors that predict improved care is also needed. In conclusion, there is increasing evidence that participation and interventions of clinical pharmacists in health care positively influence clinical practice.

The impact of clinical pharmacists on drug-related problems and clinical outcomes

Drug-related problems are frequent and may result in reduced quality of life, and even morbidity and mortality. Many studies have shown that clinical pharmacists can effectively identify and prevent clinically significant drug-related problems and that physicians acknowledge and act on the clinical pharmacist's suggestions for interventions to the drug-related problems. A pro-active rather than a reactive approach on the part of the pharmacists seems prudent for obtaining most benefit. This includes participation of pharmacists in the multidisciplinary team discussions - at the stage of ordering and prescribing - where all types of drug-related problems, including also potential problems, should be discussed. In addition, counselling by pharmacists about medication on discharge and follow-up after discharge resulted in better outcomes. Furthermore, clinical pharmacists can positively influence other outcomes, such as improvement of levels of markers for drug use (e.g. optimization of lipid levels, anticoagulation levels and blood pressure). Some studies have reported positive effects on hard clinical outcomes, such as reduced length of stay, fewer re-admissions and fewer disease events (e.g. heart failure events and thromboembolism). However, more studies should be undertaken with larger patient populations, including patients from multiple sites. More knowledge about patient-specific factors that predict improved care is also needed. In conclusion, there is increasing evidence that participation and interventions of clinical pharmacists in health care positively influence clinical practice.

[Classification of drug-related problems]

BACKGROUND

Drug-related problems are prevalent and cause considerable patient morbidity and in some cases death, as well as increased health care expenditures. A classification system may contribute to identify such problems, and further to resolve and prevent them.

MATERIAL AND METHODS

A draft classification was circulated to a panel of physicians and pharmacists and comments were requested. Consensus was achieved after two subsequent hearing rounds where the structure, content and relevance of the draft were discussed. By means of mini cases the classification was validated concerning various professionals' understanding and interpretation of the problem categories.

RESULTS

The classification has a hierarchical structure with 6 main categories (drug choice, dosing, adverse reaction, interaction, wrong use and other) and 12 subcategories. The system is relevant for hospitals, general practices, nursing homes and pharmacies. Validation of the system revealed that a majority would assign identical categories to 9/10 cases.

INTERPRETATION

We propose a validated Norwegian classification system for drug-related problems. The systems may facilitate better and more systematic documentation and communication on such problems.

Characteristics of drug-related problems discussed by hospital pharmacists in multidisciplinary teams

OBJECTIVE

To investigate pharmacist contribution in the therapeutic hospital team by studying drug-related problems (DRPs), pharmacist therapy advice and consequences of the advice.

METHODS

From May to December 2002, 827 patients in five Norwegian hospitals were included in the study. Demographic data, drugs used, relevant medical history, laboratory data and clinical/pharmacological risk factors were recorded prospectively at the wards.

MAIN OUTCOME MEASURE

DRPs, patients characteristics, pharmacist advice to physicians, nurses or patients, response to the pharmacist advice, and reasons (stated by the pharmacist) for not discussing an identified DRP, were reported. An independent quality assessment team retrospectively assessed the DRPs for a randomly selected number of the study population.

RESULTS

On average 2.6 DRPs per patient were found. A total of 2128 DRPs were registered and of these 1583 (74%) DRPs were brought up for discussion. Physician immediate acceptance rates varied from 80% (for extremely important clinically significant DRPs) to 50% (for DRPs of minor clinical significance). High age, use of many drugs at admission, existence of many DRPs and many clinical/pharmacological risk factors for DRPs were associated with low immediate acceptance rate. Type of DRP influenced how the DRP was discussed; adverse drug reaction (ADR) and unnecessary drug were discussed with physicians while e.g. medical chart error and need for patient education were discussed with nurses/patients. Reasons for not discussing DRPs in the team were: not given priority (37%), no longer relevant (31%) and others (31%). DRPs of minor clinical significance were most often excluded from discussion (37%) as opposed to 14% and 22% of those of moderate and major clinical significance.

CONCLUSIONS

The majority of patients had one or more DRPs. The problems identified as DRPs by the pharmacists were accepted as such by the physicians and to a high degree acted upon. Both clinical significance of the DRP and patient characteristics influenced physician immediate acceptance rate. Some DRPs could be solved by direct contact with nurses or the patients. Awareness of DRPs increases through participation of pharmacists in the multidisciplinary therapeutic hospital team.

Polypharmacy as commonly defined is an indicator of limited value in the assessment of drug-related problems

AIM

To investigate whether polypharmacy defined as a definite number of drugs is a suitable indicator for describing the risk of occurrence of drug-related problems (DRPs) in a hospital setting.

METHODS

Patients admitted to six internal medicine and two rheumatology departments in five hospitals were consecutively included and followed during the hospital stay, with particular attention to medication and DRPs. Comparisons were made between patients admitted with five or more drugs and with less than five drugs. Clinical pharmacists assessed DRPs by reviewing medical records and by participating in multidisciplinary team discussions.

RESULTS

Of a total of 827 patients, 391 (47%) used five or more drugs on admission. Patients admitted with five or more and less than five drugs were prescribed the same number of drugs after admission: 4.1 vs. 3.9 drugs [P = 0.4, 95% confidence interval (CI) - 0.57, 0.23], respectively. The proportion of drugs used on admission which was associated with DRPs was similar in the patient group admitted with five or more drugs and in those admitted with less than five drugs. The number of DRPs per patient increased approximately linearly with the increase in number of drugs used; one unit increase in number of drugs yielded a 8.6% increase in the number of DRPs (95% CI 1.07, 1.10).

CONCLUSION

The number of DRPs per patient was linearly related to the number of drugs used on admission. To set a strict cut-off to identify polypharmacy and declare that using more than this number of drugs represents a potential risk for occurrence of DRPs, is of limited value when assessing DRPs in a clinical setting.

Interview of patients by pharmacists contributes significantly to the identification of drug-related problems (DRPs)

PURPOSE

To investigate whether pharmacist interviews of hospitalised patients about their medication would result in identification of more drug-related problems (DRPs) than those found by usual care procedures and further to characterise the DRPs revealed at the interviews.

METHODS

Patients from five internal medicine and two rheumatology departments in four hospitals in Norway were prospectively included in the study. Clinical pharmacists assessed DRPs by reviewing medical records and by participating in multidisciplinary team discussions. Drugs used, medical history, laboratory data and clinical/pharmacological risk factors were recorded (usual care procedure). A proportion of patients were randomly selected for interview with pharmacists. A quality team assessed the clinical significance of the DRPs.

RESULTS

Seven hundred and twenty seven patients were included. Significantly more DRPs were found in the interview group (96 patients), an average of 4.4 DRPs per patient as compared to 2.4 DRPs in the non-interview group (631 patients) (p < 0.01). Of a total of 431 DRPs recorded in the interview group, 168 DRPs (39.9%) were disclosed through interviews. 'Need for additional drug', 'medical chart error', 'patient adherence' and 'need for patient education' were significantly more often recorded in this group. The quality team assessed 63% of the DRPs revealed in the interviews to be of major clinical significance.

CONCLUSION

Significantly more DRPs were identified among the patients who were interviewed compared to those patients having only usual care examination. A high proportion of the DRPs identified in the interviews were of major clinical significance. The clinical pharmacists, with their way of interviewing, seem to fill a gap, ensuring that significant DRPs do not escape detection.

The majority of hospitalised patients have drug-related problems: results from a prospective study in general hospitals

OBJECTIVE

To describe the frequency and types of drug-related problems (DRPs) in hospitalised patients, and to identify risk factors for DRPs and the drugs most frequently causing them.

METHODS

From May to December 2002, 827 patients from six internal medicine and two rheumatology departments in five hospitals in Norway were included in this study. We recorded demographic data, drugs used, relevant medical history, laboratory data and clinical/pharmacological risk factors, i.e. reduced renal function, reduced liver function, heart failure, diabetes, compliance problems, drugs with a narrow therapeutic index and drug allergy. DRPs were documented after reviewing medical records and participation in multidisciplinary team discussions. An independent quality assessment team retrospectively assessed the DRPs in a randomly selected number of the study population.

RESULTS

Of the patients, 81% had DRPs, and an average of 2.1 clinically relevant DRPs was recorded per patient. The DRPs most frequently recorded were dose-related problems (35.1% of the patients) followed by need for laboratory tests (21.6%), non-optimal drugs (21.4%), need for additional drugs (19.7%), unnecessary drugs (16.7%) and medical chart errors (16.3%). The patients used an average of 4.6 drugs at admission. A multivariate analysis showed that the number of drugs at admission and the number of clinical/pharmacological risk factors were both independent risk factors for the occurrence of DRPs, whereas age and gender were not. The drugs most frequently causing a DRP were warfarin, digitoxin and prednisolone, with calculated risk ratios 0.48, 0.42 and 0.26, respectively. The drug groups causing most DRPs were B01A-antithrombotic agents, M01A-non-steroidal anti-inflammatory agents, N02A-opioids and C09A-angiotensin converting enzyme inhibitors, with risk ratios of 0.22, 0.49, 0.21 and 0.35, respectively.

CONCLUSIONS

The majority of hospitalised patients in our study had DRPs. The number of drugs used and the number of clinical/pharmacological risk factors significantly and independently influenced the risk for DRPs. Procedures for identification of, and intervention on, actual and potential DRPs, along with awareness of drugs carrying a high risk for DRPs, are important elements of drug therapy and may contribute to diminishing drug-related morbidity and mortality.

Comparison of Drug-Related Problems in Different Patient Groups

BACKGROUND:

There is a lack of knowledge concerning how drug-related problems (DRPs) vary in different patient groups. Possible dissimilarities need to be taken into consideration when guidelines for detecting and preventing DRPs are compiled.

OBJECTIVE:

To characterize and compare the frequency and categories of DRPs in different groups of hospitalized patients.

METHODS:

Patients admitted to 4 different types of departments at 5 hospitals in Norway were included consecutively. Medical records and information acquired at multidisciplinary morning meetings were sources for assessing the patients' DRPs.

RESULTS:

A total of 827 patients were included. Mean age was 70.8 years, 58.6% were female, and 81% had at least one DRP. An average of 1.9, 2.0, 2.1, and 2.3 DRPs per patient were found in the departments of cardiology, geriatrics, respiratory medicine, and rheumatology, respectively. Significant differences in the type of DRPs between the patient groups were found. The most frequent DRPs and the patient group in which they most often occurred were nonoptimal dose (cardiology, respiratory, geriatric) and need for additional drug (rheumatology).

CONCLUSIONS:

DRPs occurred in the majority of the patients in all departments. The type of DRP differed markedly between the patient groups. Knowledge of these differences is clinically valuable by enabling us to guide efforts toward prevention of DRPs. Antithrombotic agents, loop diuretics, angiotensin-converting enzyme inhibitors, penicillins, antiinflammatory drugs, and opioid analgesics commonly caused DRPs, even in departments where knowledge of these drugs is assumed to be extensive.

Polypharmacy among patients admitted to hospital with rheumatic diseases

AIM

This study describes polypharmacy among patients admitted to hospital with rheumatic diseases.

METHODS

The study was performed in departments of rheumatology at nine Norwegian hospitals during five weeks in 1998. Pharmacists recorded all drugs on admittance among patients 18 years or older with rheumatic diseases.

RESULTS

Sixty percent of 313 patients had polypharmacy defined as the concurrent use of five or more drugs, and this was most frequent among the older patients. However, they used fewer antirheumatic drugs compared to the younger patients. With regard to the three most common drug groups, older patients used more corticosteroids, and less nonsteroidal antiinflammatory drugs (NSAIDs) and disease modifying antirheumatic drugs (DMARDs), compared to the younger. Eighty-four percent of patients on methotrexate used folic acid, but only 52% of the patients who used corticosteroids used calcium supplements.

CONCLUSION

Polypharmacy among patients with rheumatic diseases is common, and the present description could be useful for drug-related interventions.