RESUMEN
Liver cirrhosis, which is considered one of the leading causes of death in the world, can lead to severe complications, and is often followed by a liver transplantation. These patients take an average of nine medications daily. If not managed adequately, it can be accompanied by serious drug-related problems. To reduce this risk, a clinical pharmacist may be included as part of the healthcare team to optimize medication therapy in this population. This study aimed to systematically identify the pharmaceutical interventions which reduced drug-related problems and improved medication therapy for adult hospitalized liver cirrhotic and liver transplant patients when compared to standard care. Three databases (PubMed, Embase, and CENTRAL) were systematically searched from the inception of each database to 25 October 2023, and interventional studies in the English language were included. The risk of bias was assessed according to RoB-I for the UBA study and RoB2 for the identified RCT. The detected interventions to reduce drug-related problems in liver cirrhotic and liver transplant patients were extracted and classified according to a "Hierarchy of Controls" model. Two studies from Germany and the USA met our inclusion criteria, respectively. In these studies, we identified two interventions that included education, expert consultation, and the monitoring of the immunosuppressive medications serum level. The main objective of the two included studies was improving patients' compliance through adherence. These pharmaceutical interventions identified were classified as administrative controls, which is one of the lowest levels in the "Hierarchy of Controls" with which to address a potential risk. Pharmaceutical interventions to optimize medication therapy were found to be rare in the examined population, and were limited to "administrative controls". These interventions were limited to transplant patients' education and the monitoring of the immunosuppressive medication serum levels. No interventional studies were found to have investigated pharmaceutical interventions in patients with liver cirrhosis. Especially regarding this patient group, future studies to reduce DRPs using pharmaceutical interventions are needed. This study received no external funding and its PROSPERO registration number is CRD42022309122.
RESUMEN
Telepharmacy is used to bridge the persisting shortage of specialist ward-based pharmacists, particularly in intensive care units (ICU). During the coronavirus disease 2019 (COVID-19), pharmacotherapy was rapidly developed, which resulted in multiple changes of guidelines. This potentially led to a differing risk for drug-related problems (DRPs) in ICUs. In this study, DRPs were detected in telepharmacy consultations of a German state-wide telemedicine network for adult patients in rural ICUs. The analysis included ICUs of ten general care hospitals with a total of 514 patients and 1056 consultations. The aim of this retrospective, observational cohort study was to compare and analyze the DRPs resulting from ICU patients with or without COVID-19. Furthermore, known risk groups for severe COVID-19 progression (organ insufficiency [kidney, liver], obesity, sex, and/or older age) were investigated with their non-COVID-19 counterparts. As a result, in both groups patients with acute renal insufficiency and without renal replacement therapy showed a significantly higher risk of being affected by one or more DRPs compared to patients with normal renal function. In COVID-19 patients, the initial recommendation of therapeutic anticoagulation (ATC-code B01AB 'Heparin group') resulted in significantly more DRPs compared to non-COVID-19 patients. Therefore, COVID-19 patients with therapeutic anticoagulation and all ICU patients with renal insufficiency should be prioritized for telepharmacy consultations.
RESUMEN
Patients in intensive care units (ICUs) are at high risk of drug-drug interactions (DDIs) due to polypharmacy. Little is known about type and frequency of DDIs within German ICUs. Clinical pharmacists' interventions (PI) recorded in a national database (ADKA-DokuPIK) were filtered for ICU patients. Binary DDIs involving ≥1 anti-infective agent with >1 database entry were selected. A modified two-step Delphi process with a group of senior hospital pharmacists was employed to evaluate selected DDIs for clinical relevance by using a five-point scale and to develop guidance for clinical practice. In total, 16,173 PI were recorded, including 1836 (11%) DDIs in the ICU setting. Of the latter, 41% (756/1836) included ≥1 anti-infective agent, 32% (590/1836) were binary DDIs, and 25% (455/1836) were listed at least twice. This translates into 88 different DDIs, 74% (65/88) of which were rated as being clinically relevant by our expert panel. The majority of DDIs (76% [67/88]) included macrolides, antifungals, or fluoroquinolones. This percentage was even higher in DDIs being rated as clinically relevant by the experts (85% [55/65]). It is noted that an inter-professional discussion and approach is needed in the individual patient management of DDIs. The guidance developed might be a tool for decision support.
