Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 20  |  Issue : 3  |  Page : 221-224

Detection and solving of drug therapy problems: a clinical pharmacist experience from a specialized nephrology clinic in Egypt


1 Clinical Pharmacist, Gawad Nephrology Clinic, Alexandria, Egypt
2 Nephrology Consultant, Gawad Nephrology Clinic, Alexandria, Egypt
3 Nephrology Specialist, Davita Kidney Care, Khobar, Saudi Arabia

Date of Submission21-Mar-2021
Date of Decision25-May-2021
Date of Acceptance06-Jun-2021
Date of Web Publication08-Sep-2021

Correspondence Address:
MD Mohammed A Abdel Gawad
Gawad Nephrology Clinic, 237, Port Said Street, Cleopatra, Alexandria
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/epj.epj_17_21

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  Abstract 


Background Clinical pharmacists (CPs) play a vital role in detecting and solving drug therapy problems (DTPs). This is a common practice in hospitals; however, it can be applicable for outpatient settings as well. Patients with chronic kidney disease (CKD) usually have multiple medication prescriptions and are at greater risk of medication errors (MEs) and/or DTPs.
Objectives The aim of this work is to assess the prevalence of DTPs among prescriptions for patients with CKD attending for outpatient nephrology consultation and to highlight the role of CPs team in outpatient settings.
Patients and methods This is a chart review study conducted at a private specialized nephrology clinic in Alexandria, Egypt. After taking informed consent from participants to use their medical data, CPs collected and evaluated 550 prescriptions for possible DTPs. Prescriptions were ordered by different health care providers for 49 adult patients with CKD who attended the clinic from April to November 2019. Data were classified and subcategorized accordingly. Statistical analysis was done, and results were expressed in numbers and percentages.
Results and conclusion Of 550 reviewed prescriptions, 122 (22.2%) DTPs were detected and solved. Dosage regimen ranked the top DTP 40 (32.8%), and it was mainly related to: (a) vitamins, minerals, and dietary supplements’ prescriptions [23 (18.9%)], (b) antihypertensive medications [20 (16.40%)], and (c) circulatory enhancers [11 (9.02%)]. To conclude: suboptimal dosing regimens are common problems encountered by the CPs team during routine patient care. CPs provided direct outpatient patient care, solved DTPs, and prevented possible MEs.

Keywords: errors, medication, nephrology, pharmacist, problems, therapeutic


How to cite this article:
Zaki DA, Morsi AM, Abdel Gawad MA, Ahmed MA. Detection and solving of drug therapy problems: a clinical pharmacist experience from a specialized nephrology clinic in Egypt. Egypt Pharmaceut J 2021;20:221-4

How to cite this URL:
Zaki DA, Morsi AM, Abdel Gawad MA, Ahmed MA. Detection and solving of drug therapy problems: a clinical pharmacist experience from a specialized nephrology clinic in Egypt. Egypt Pharmaceut J [serial online] 2021 [cited 2022 Nov 26];20:221-4. Available from: http://www.epj.eg.net/text.asp?2021/20/3/221/325716




  Introduction Top


Medication errors (MEs) are defined as ‘failure in the treatment process that leads to (or has the potential to lead to) harm to the patient’ [1]. Reviewing medication orders by the clinical pharmacist (CP) − in both inpatient and outpatient settings − helps identifying, solving, and preventing any unwanted incident related to medication therapy [i.e., drug therapeutic problems (DTPs)]. Patients with chronic kidney disease (CKD) require multiple medications and have complex medical problems; therefore, they might be at greater risk of MEs and/or DTPs [2],[3],[4].


  Patients and methods Top


This is a chart review study of clinical pharmacist interventions (CPI) to assess the prevalence of DTPs among external prescriptions (ordered by other health care providers) for patients with CKD attending a private specialized outpatient nephrology clinic in Alexandria, Egypt. The clinic team consists of nephrology consultant, CPs, dietitian, and admin who work together to provide multidisciplinary care. Each nephrology consultation process includes an interview with the CP, who detects, records, and solves any DTPs.

The study included 49 adult patients with CKD who visited the clinic for outpatient nephrology consultation from April to November 2019. After taking informed consent from participants to use their medical data, CPs collected and evaluated prescriptions for possible DTPs. During this period, CPs collected and reviewed 550 prescriptions (a single patient could have more than one prescription and/or outpatient visit). Informed consent was taken from all participants to use their anonymous outpatient medical data for research purposes. The CPs’ team designed a special electronic sheet to collect and record both clinical data and medications. The clinical data included the medical record number, demographic data, and medical history. The medication record included the number of medications, generic names, category, DTPs, and CPI. Detected DTPs were classified into seven categories: (a) indication, (b) selection, (c) dosing regimen, (d) drug interaction, (e) instructions for preparation and administration, (f) monitoring, and (g) adherence. Estimated glomerular filtration rate was calculated using Cockcroft–Gault and Salazar equations to adjust the renal doses [5]. All detected DTPs were adjusted, and medication reconciliation was provided to the patient or the caregiver.

Data were then analyzed, and the results were expressed in numbers and percentages. The statistical analysis was performed using IBM SPSS Statistics, version 25 (2017; SPSS Inc., Chicago, Illinois, USA).


  Results Top


In this study, we assessed 49 adult patients with CKD, comprising 25 (51%) males and 24 (49%) females, aged between 19 and 82, with a mean age of 64.6±10.7 years. Hypertension (83.7%) and diabetes mellitus (59.2%) were the two most common comorbidities among participants ([Table 1]).
Table 1 Demographic characteristics and comorbidities of the study participants

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Of 550 reviewed prescriptions, 122 (22.2%) DTPs were recorded. Among those DTPs, 23 (18.9%) errors were related to vitamins, minerals, and dietary supplements (DS), 20 (16.4%) DTPs were related to antihypertensive medications, and 11 (9%) DTPs were found related to circulatory enhancers. DTPs related to both antidiabetic and lipid-lowering agents ranked the sixth (6.6%) for each, followed by DTPs related to antibiotics (5.7%) ([Table 2]).
Table 2 Prevalence of drug therapy problems among drug groups prescribed to the study population

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Main DTPs were classified into seven categories listed in [Table 3]. The most prevalent one was ‘wrong dosing regimen’ found in 40 (32.8%) prescriptions, whereas the least was due to drug monitoring issue, counted as only one observation (0.82%). Drug interaction DTPs were reported in 13 (10.7%) prescriptions.
Table 3 Categories of drug therapy problems detected by clinical pharmacists during the study duration

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[Figure 1] shows the distribution of DTPs reported among the different classes of medications.Antihypertensive medications expressed all types of DTPs, and the highest percentage was due to wrong dosing regimen followed by problems in instructions for preparation and administration (45 and 15%, respectively). Inappropriate dosing regimen and inappropriate indication were the most common types of DTPs reported among prescriptions of vitamins, minerals, and DS (52%), whereas, drug interactions were mostly observed in prescriptions including antiplatelets, anticoagulants (100%), antidysrhythmic/antianginal (50%), antihyperuricemia (44.4%), and antibiotics (14.1%). Wrong indication and dosing regimen also contributed the most common DTPs among antibiotic prescriptions (57%). The wrong indication was the only DTP found in antioxidants, corticosteroids, and phosphate-binder medications. Inappropriate selection of both proton pump inhibitors (PPIs) and NSAIDs was the only DTP encountered for these medication class.
Figure 1 Detected drug therapy problems among different classes of medications.

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  Discussion Top


Physician ordering is a relatively common reported source of MEs and adverse drug reactions owing to inappropriate medication history taking at the time of the first visit [4]. In this work, we tried to overcome this by involving the CPs’ team in the consultation process. Our study showed that an average of 11 medications per order were prescribed for each patient with CKD. This indicates a high prevalence of polypharmacy in this group of patients. Several studies have shown that monitoring pharmacotherapy regimens can reduce the rates of MEs by up to 78%. Most of the DTPs occur during medication prescription and use processes. CPs involvement could greatly improve the quality of medication prescription and administration processes. Reviewing the prescription orders for all patients with CKD is an essential practice to detect and resolve MEs and improve the quality of care [6],[7],[8].

NSAIDs and PPIs were ordered to more than one-third of adult patients with CKD according to the Center for Kidney Disease Research, Education, and Hope (CURE-CKD) registry published in 2019 [9]. The present study revealed that most of the DTPs were observed among vitamins, minerals, and DS (18.9%); antihypertensive medications (16.4%); antibiotics (5.8%); NSAIDs (1.6%); and PPIs (7.4%). It is worth noting that the recent Joint Commission’s National Patient Safety Goals require documenting the patient’s DS usage and over-the-counter drugs, just like any other medication. Failure to document these supplements creates opportunities for potential complications owing to either DS per se or its interactions with other prescribed medications [10]. Looking at our data from a different perspective, we found that 6.6% of the reviewed medications had no real indication. The National Health and Nutrition Examination Study of the Centers for Disease Control and Prevention in the United States revealed that 34% of participants − representing 72 million people in the United States − were taking some kind of DS in addition to a prescription medication. Although many people consume supplements to ensure an adequate intake of essential nutrients, DS should not replace good food choices and healthy diet [11]. Overall, 22% of the reviewed prescriptions in the current work were found to have one or more DTP that requires CPI. Dosage regimen issues were the most common DTP (32.8%). This result is supported by a retrospective analysis conducted by Saleem and Masood [12] to predict dosing errors in patients with CKD that showed that dosage adjustments were required in 34% of the drugs prescribed. An additional study stated that drug–drug interaction was the most frequent DTP observed among medication orders to patients with CKD (46%) [13]. Incorrect dosing was the most detected DTP among antibiotics prescriptions in our research (10%). Similar findings were reported in alternative studies conducted in Indonesia and Palestine [14],[15].


  Conclusion Top


DTPs are relatively common among patients with CKD attending outpatient settings, especially inappropriate dosage. Close monitoring and early detection of DTPs may help improve therapeutic outcomes and decrease unnecessary health care-related morbidity. CPs, working in close liaison with other health care teams, can promote sustained patient safety.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Aronson JK. Medication errors: definitions and classification. Br J Clin Pharmacol 2009; 67:599–604.  Back to cited text no. 1
    
2.
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Mason NA. Polypharmacy and medication-related complications in the chronic kidney disease patient. Curr Opin Nephrol Hypertens 2011; 20:492–497.  Back to cited text no. 3
    
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Kucukarslan SN, Peters M, Mlynarek M, Nafziger DA. Pharmacists on rounding teams reduce preventable adverse drug events in hospital general medicine units. Arch Intern Med 2003; 163:2014–2018.  Back to cited text no. 8
    
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Tuttle KR, Alicic RZ, Duru OK, Jones CR, Daratha KB, Nicholas SB et al. Clinical characteristics of and risk factors for chronic kidney disease among adults and children: an analysis of the CURE-CKD Registry. JAMA Netw Open 2019; 2:e1918169.  Back to cited text no. 9
    
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The Joint Commission international (JCI). National Patient Safety Goals Effective January 2021 for the Ambulatory Health Care Program. Report Generated by DSSM, Wednesday, Mar 31, 2021.  Back to cited text no. 10
    
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U.S. Food and Drug Administration (FDA). Website Policies/FDA, 2019. Tips for Dietary Supplement Users. Available at: https://www.fda.gov/food/information-consumers-using-dietary-supplements/tips-dietary-supplement-users. [Accessed June 2021].  Back to cited text no. 11
    
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Saleem A, Masood I. Pattern and predictors of medication dosing errors in chronic kidney disease patients in Pakistan: a single center retrospective analysis. PLoS ONE 2016; 11:e0158677.  Back to cited text no. 12
    
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Rashid H, Ahmad T, Ahmad S, Rehman HU, Haleem S. Reporting of medication errors by pharmacist in the treatment of chronic kidney failure in Tertiary Hospital Peshawar. J Chem Pharma Rese 2017; 9:11–18.  Back to cited text no. 13
    
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Soetikno V, Effendi I, Nafrialdi XX, Setiabudy R. A survey on the appropriateness of drug therapy in patients with renal dysfunction at the internal medicine ward FMUI/Dr. Cipto Mangunkusumo hospital. Med J Indonesia 2009; 18:108–113.  Back to cited text no. 14
    
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Sweileh WM, Janem SA, Sawalha AF, Abu-Taha AS, Zyoud SH, Sabri IA et al. Medication dosing errors in hospitalized patients with renal impairment: a study in Palestine. Pharmacoepidemiol Drug Saf 2007; 16:908–912.  Back to cited text no. 15
    


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  [Table 1], [Table 2], [Table 3]



 

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