The impact of inpatient collaborative clinical pharmacy renal dosing service on dosage adjustment in patients with chronic kidney disease
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Date
2009
Authors
Khatib (Al-Ramahi), Rowa Jamal Abdulhafez
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Abstract
Patients with chronic kidney disease often have alterations in their pharmacokinetic
and pharmacodynamic response. They constitute a population at high-risk for
adverse drug reactions and drug-drug interactions. Drug dosing in these patients is a
very challenging task. The objectives of this study were to evaluate the impact of an
inpatient collaborative renal dosing service by pharmacist’s participating in clinical
rounds on dosage adjustment according to renal function, adverse drug events, and
drug costs. It aimed also to describe prescribing patterns for hospitalized chronic
kidney disease patients and to assess the frequency of inappropriate dosing. The
study was an interventional prospective comparative study. A total of 600 patients
were randomly selected with 300 patients in each groups. Patients who had an
estimated creatinine clearance of ≤ 50 ml/min on admission were included. A
collection of reliable and up-to-date references became the basis of applied pocket
sized handbook that was used by the clinical pharmacist during medical rounds. Data
before and during the intervention were compared. The percentages of male patients
in the pre-intervention and intervention groups were 56.0% and 51.0% respectively.
In the pre-intervention group 51.0% were Chinese, 32.3% were Malay, and 16.0%
were Indian. The mean age was 55.56 ± 14.15 years. Most patients 88.7% had end
stage renal disease (stage 5). The most common co-morbidities were hypertension in
80.0% of the patients, diabetes mellitus in 62.3%, and ischemic heart disease 25.7%.
In the intervention group, 40.0% were Chinese, 44.7% were Malay, and 15% were
Indian. The mean age was 55.30 ± 14.37 years. Most patients 93.7% had end stage
renal disease (stage 5). The most common co-morbidities were hypertension in
84.0% of the patients, diabetes mellitus in 56.0%, and ischemic heart disease 20.7%.
In the pre-intervention group, the mean ± SD number of medications used in ward
during hospitalization was 9.38 ± 3.63 per patient, whereas in the intervention group,
the mean ± SD number of medications used in ward during hospitalization was 9.94
± 3.78 per patient. The most commonly used medication classes were mineral
supplements, vitamins, anti-anemic preparations, anti-bacterials, beta blockers,
calcium channel blockers, diuretics, serum lipid reducing agents, drugs used in
diabetes, drugs for acid-related disorders, anti-thrombotic agents, analgesics, and
agents acting on the renin angiotensin system. The intervention was performed by a
clinical pharmacist from March to July 2008. Out of 388 dosing recommendations
given by the pharmacist, the prescribers accepted a total of 212 recommendations
(54.6%). The most commonly accepted interventions were with ranitidine,
ceftazidime, ampicillin/sulbactam, amoxicillin/clavulanate, metoclopramide,
digoxin, atenolol, chlorothiazide, and amikacin. In the pre-intervention group, drug
dosage adjustments or avoidance based on renal function was necessary in 607 of
2814 (21.6%) of prescriptions. Out of these, 322 (53.0%) did not comply with
guidelines. In the intervention group, dosage adjustment or avoidance based on renal
function was necessary in 640 of 2981 (21.5%) of prescriptions. During the
collaborative dosing service, noncompliance significantly decreased to 176 (27.5%)
(p-value < 0.0001). In the pre-intervention group, 64 (21.3%) patients had a
suspected adverse drug event with a total of 73 events. The number significantly
decreased in the intervention group to 49 events in 48 ( 16.0%) patients (p-value <
0.05). The intervention caused savings in drug cost of RM 7760. There was no
significant difference in length of hospital stay and outcomes of hospitalization
between the pre-intervention and the intervention group. We concluded that the
inpatient collaborative clinical pharmacy dosing service can increase the proportion
of drugs adjusted to renal function. This can save drug costs and has the potential to
prevent adverse drug events.
Description
PhD
Keywords
Pharmaceutical science , Renal dosing service , Chronic kidney disease