Residential medication management reviews of antithrombotic therapy in aged care residents with atrial fibrillation: assessment of stroke and bleeding risk.

WHAT IS KNOWN AND OBJECTIVE: Antithrombotics reduce the risk of stroke in individuals with atrial fibrillation (AF). However, optimal prescribing of antithrombotics in older people remains a challenge. The objective of this study was to assess the risk of stroke for aged care home residents with AF and to examine the pharmacist-led medication reviews on the utilization of antithrombotic therapy. METHODS: This retrospective study included a random sample of de-identified residential medication management reviews (RMMRs) conducted by accredited pharmacists in aged care homes in Sydney, Australia, between August 2011 and December 2012. The study participants were 146 residents aged 65 years and older with AF living in low- and high-care residential aged care facilities. Antithrombotic therapy was examined among the residents, before and after medication review. CHADS2 , CHA2 DS2 -VASc, and HEMORR2 HAGES scoring tools were used to assess the risk of stroke and bleeding and indicate the appropriateness of antithrombotic therapy. RESULTS AND DISCUSSION: The mean age (±SD) of individuals was 88·4 (7·5) years, and 63·7% (n = 93) were female. The majority of residents (n = 99, 67·8%) were aged between 85 and 99 years. The mean (±SD) CHADS2 score was 3·1 (1·1), CHA2 DS2 -VASc was 4·6 (1·5), and HEMORR2 HAGES was 2·3 (1·0). All residents were classified as being at high risk of developing stroke. A total of 115 of 146 (78·8%) residents with AF were prescribed antithrombotics. There was a relatively low usage of anticoagulation (28·1%), and few recommendations from the medication review pharmacists to alter the thromboprophylactic therapy in AF. Application of the CHA2 DS2 -VASc risk tool indicated that 146 residents were eligible for antithrombotic treatments; of these, 74 (50·7%) were prescribed antiplatelets and 41 (28·1%) were prescribed anticoagulants. Of the 31 (21·2%) residents with AF were not prescribed antithrombotics, 21 (67·7%) had relative contraindications for anticoagulant treatments. WHAT IS NEW AND CONCLUSION: Although there was a high overall use of antithrombotic agents, the study found a reluctance to prescribe or recommend anticoagulants in eligible older people with AF, potentially due to associated contraindications and multimorbidity. The use of guideline-recommended stroke risk tools could assist medication review pharmacists in optimizing antithrombotic therapy in older adults with AF.

Renal drug dosing recommendations: evaluation of product information for brands of the same drug.

OBJECTIVES: To review the product information (PI) for various brands of the same generic drugs and investigate the extent to which information is currently available on dosing in renal impairment and the concordance between the dosing recommendations for the same generic drug. METHOD: The Monthly Index of Medical Specialities (MIMS) was examined for 28 generic drugs recommended to be used with caution in renal impairment. For each generic drug all available brands listed as having solid oral dosage form were recorded. For each identified brand, the current PI was consulted and data referring to renal impairment was collated. The dissimilarity between these PI regarding the renal dosage recommendation was determined. RESULTS: There was generally a lack of detailed information in the PI on the use of drugs in patients with renal impairment. The majority of PI documents (88 of 155 PI; 57%) provided quantitative dosage recommendations, but this was often not detailed enough to help users to make an informed decision. For 37 PI documents (24%), an altered dosage regimen was proposed without a quantifiable measure of renal function reported in the dose recommendation. The renal function severity category terms used and the associated quantitative values were also not consistent. It was observed that the recommendations varied among different brands of hydromorphone, morphine, oxycodone, tramadol, metformin and topiramate. CONCLUSION: The reporting of renal function quantification methods, and associated dosage recommendations, in PI requires standardisation to ensure optimal drug dosing. Regularly updating of PI is also necessary.

Metformin usage in type 2 diabetes mellitus: are safety guidelines adhered to?

AIM: To (i) evaluate the prescribing patterns of metformin in patients with type 2 diabetes mellitus (T2DM) and determine the prevalence of contraindications to its use, especially renal impairment, and (ii) identify potential cases of lactic acidosis (LA) related to metformin usage. METHOD: This retrospective study reviewed all patients with a diagnosis of T2DM and taking metformin who was admitted to a major teaching hospital over an 8-month period. Data including demographics, medical conditions, medications at admission and discharge, and relevant pathology results were extracted from medical records. RESULTS: A total of 301 patients (209 medical patients, 92 surgical patients) taking metformin were included. According to guidelines, approximately 31% and 21% of patients received metformin inappropriately (in the presence of contraindications or in excessive dosage) at admission and discharge, respectively. At admission, 65 patients (n = 301, 21.6%) on metformin had at least one contraindication to its use, and 42 patients (n = 254, 16.5%) were prescribed an excessive dosage according to their renal function. At discharge, 43 patients (n = 301, 14.3%) continued on metformin with at least one contraindication and 21 patients (n = 191, 11%) received an excessive dosage according to their renal function. Four patients had evidence of LA (plasma lactate concentration > 5.0 mmol/L and pH < 7.35) without clinical diagnosis. CONCLUSION: Metformin was often used in patients with contraindications to its use, or in higher than recommended dosages. Reconsideration of the official prescribing information for metformin may be warranted as the risk of harm appears to be very low.

Dose adjustment guidelines for medications in patients with renal impairment: how consistent are drug information sources?

BACKGROUND: It is known that patients with renal disease are often administered inappropriate dosages of drugs. A lack of quantitative data in the available drug information sources and inconsistency in dosing information may augment the problem of dosing error. AIMS: To determine the concordance among five drug information sources regarding the dosing recommendations provided for drugs considered problematic in patients with renal impairment and to determine the consistency among the sources regarding the definition of renal impairment and categorisation of chronic kidney disease. METHODS: Five standard drug information sources were reviewed for 61 drugs recommended to be used with caution in renal impairment. Information on recommendations for dosage adjustment in renal impairment was extracted and analysed. Further, the definition and classification of renal impairment were recorded. The recommendation for each drug was coded into six different categories and the intersource reliability was calculated. RESULTS: Only slight agreement was observed among the sources (Fleiss Kappa: 0.3). Qualitative data were not well defined, and there was a lack of consistency in quantitative values. Some drugs marked as contraindicated in one source were not mentioned as such in others. Also, drugs considered as not requiring dosage adjustment in one source had explicit recommendations in other sources. The definition and classification of renal impairment differed among the five information sources. CONCLUSIONS: There should be an evidence-based approach to drug dosage adjustment in order to bring uniformity to the recommendations. Regular updating of the content of the drug information sources is also important.

Prevalence of medication-related problems among patients with renal compromise in an Indian hospital.

WHAT IS KNOWN AND OBJECTIVE: Patients suffering from renal dysfunction often have multiple medical conditions either as a cause or as a consequence of their renal disease. These patients receive an average of 10-12 medications daily leading to complex dosing schedules and are more likely to develop medication-related problems (MRPs). The objectives of this study were to determine the nature and extent of MRPs in renally compromised patients and to explore the potential clinical significance of the MRPs. The potential for a clinical pharmacist to contribute towards resolving or preventing some of these MRPs was also explored. METHODS: A prospective study was conducted for a period of 9 months in the renal unit of Jagadguru Shri Shivaratheeshwara (JSS) Medical College Hospital, Mysore, India. Patients undergoing dialysis on outpatient basis and patients who were admitted under the care of or referred to the nephrologists for renal dysfunction from other specialties were reviewed. Patterns of the MRPs were identified using an adapted Hepler and Strand criteria. The potential clinical significance of the MRPs and the contribution of the clinical pharmacist in resolving or minimizing some of the MRPs were also explored. RESULTS AND DISCUSSION: Three hundred and twenty-seven MRPs were identified with 308 patients reviewed. The incidence of MRPs was found to be 1·06 ± 0·85 per patient reviewed. The most common MRP identified in our study was overdose (19·3%) followed by adverse drug reactions (19·0%). Cardiovascular agents (33·6%) followed by anti-infective agents (26·3%) were the most common therapeutic classes of medication implicated in causing MRPs. Twenty-six per cent of the MRPs identified were explored to be potentially moderate or major in clinical significance. The clinical pharmacists' recommendations were accepted in 97% of the cases, which resulted in a change in therapy in 83% of the cases. WHAT IS NEW AND CONCLUSION: Medication-related problems are frequent in renally compromised patients in our patient population. The high level of acceptance of clinical pharmacist's recommendations by the nephrologists demonstrates that clinical pharmacists may help improve overall patient care in this setting.