Potential drug-drug interactions in cardiothoracic intensive care unit of a pulmonary teaching hospital

An update on drug-drug interactions for care of the acutely ill in the era of COVID-19

PURPOSE

To provide key pharmacological concepts underlying drug-drug interactions (DDIs), a decision-making framework, and a list of DDIs that should be considered in the context of contemporary acutely ill patients with COVID-19.

SUMMARY

DDIs are frequently encountered in the acutely ill. The implications of DDIs include either increased risk of drug toxicity or decreased effectiveness, which may have severe consequences in the acutely ill due to lower physiological and neurocognitive reserves in these patients. In addition, an array of additional therapies and drug classes have been used for COVID-19 that were not typically used in the acute care setting. In this update on DDIs in the acutely ill, we provide key pharmacological concepts underlying DDIs, including a discussion of the gastric environment, the cytochrome P-450 (CYP) isozyme system, transporters, and pharmacodynamics in relation to DDIs. We also provide a decision-making framework that elucidates the identification of DDIs, risk assessment, selection of alternative therapies, and monitoring. Finally, important DDIs pertaining to contemporary acute care clinical practice related to COVID-19 are discussed.

CONCLUSION

Interpreting and managing DDIs should follow a pharmacologically based approach and a systematic decision-making process to optimize patient outcomes.

Prevalence of potential drug - drug interactions in the cardiothoracic intensive care unit patients in a Chinese tertiary care teaching hospital

Background

With an increasing number of reviews describing clinically significant drug–drug interactions (DDIs), the scope and severity of interactions involving commonly used drugs in cardiothoracic intensive care units (CCUs) remain unclear. This study aims to identify risk factors and determine the incidence of potential DDIs in intensive care units.

Methods

DDIs were identified based on the profile of the prescribed drug and classified according to the Micromedex drug interaction database. Potential risk factors associated with DDIs have been identified.

Results

A total of 3193 medication episodes were evaluated, and 680 DDIs (21.3%) were found. A total of 203 patients were recruited into the study, with an average of 3.4 DDIs per patient [95% confidence interval (3.2 − 3.6)]. A total of 84.2% of the patients experienced at least one DDI. Anticoagulant and antiplatelet agents were involved in 33.5% (228/680) of the potential drug − drug interactions in the CCU. Univariate analysis and multiple logistic regression analysis showed that the age of the patient and the number of medications prescribed were significantly correlated with the occurrence of DDIs. In multiple linear regression analysis, the number of DDIs had a significant correlation only with the number of prescription drugs.

Conclusions

A high prevalence of DDIs was observed, especially in intensive care units without pharmacist intervention and computerized drug monitoring systems, highlighting the need for active surveillance to prevent potential adverse events.

Comparing Important and Well-documented Potential Drug–Drug Interactions between Emergency, Medical, and Surgical ICUs of a Respiratory Referral Center

Introduction

Drug–drug interaction (DDI) is one of the major healthcare challenges in intensive care units (ICUs). The prevalence of DDIs and interacting drug pairs may vary between different types of ICUs. This study aimed to compare the frequency and nature of important and well-documented potential DDIs (pDDIs) in three types of ICUs.

Materials and methods

A prospective study was conducted in medical (M), surgical (S), and emergency (E) ICUs of a tertiary referral center for respiratory diseases. A pharmacist checked the patients’ files three days in a week for 6 months. The pDDIs were identified using the Lexi-Interact database. Interactions with a severity rating of D (modify regimen) and X (avoid combination) and with a reliability rating of good and excellent were considered important and well-documented. These pDDIs were evaluated in terms of drug combinations, mechanisms of interaction, and clinical management.

Results

One hundred eighty-nine patients admitted to MICU, SICU, and EICU were included in the study. The percentage of patients who experienced at least one important and well-documented pDDI was 18.8% in MICU, 11.1% in SICU, and 11.8% in EICU. The most common drug pairs causing important and well-documented interactions were atracurium + hydrocortisone in MICU, meropenem + valproic acid in MICU and EICU, and aspirin + warfarin in SICU.

Conclusion

The current study shows different frequency and nature of pDDIs between three types of ICUs. We recommend conducting similar studies in other settings to develop evidence-based guidance on clinically relevant pDDIs in different types of ICUs.

How to cite this article

Hosseinpoor Z, Farzanegan B, Baniasadi S. Comparing Important and Well-documented Potential Drug–Drug Interactions between Emergency, Medical, and Surgical ICUs of a Respiratory Referral Center. Indian J Crit Care Med 2022;26(5):574–578.

Heterogeneity in the identification of potential drug-drug interactions in the intensive care unit: A systematic review, critical appraisal, and reporting recommendations

Patients admitted to the intensive care unit (ICU) are frequently exposed to potential drug‐drug interactions (pDDIs). However, reported frequencies of pDDIs in the ICU vary widely between studies. This can be partly explained by significant variation in their methodological approach. Insight into methodological choices affecting pDDI frequency would allow for improved comparison and synthesis of reported pDDI frequencies. This study aimed to evaluate the association between methodological choices and pDDI frequency and formulate reporting recommendations for pDDI frequency studies in the ICU. The MEDLINE database was searched to identify papers reporting pDDI frequency in ICU patients. For each paper, the pDDI frequency and methodological choices such as pDDI definition and pDDI knowledge base were extracted, and the risk of bias was assessed. Each paper was categorized as reporting a low, medium, or high pDDI frequency. We sought associations between methodological choices and pDDI frequency group. Based on this comparison, reporting recommendations were formulated. Analysis of methodological choices showed significant heterogeneity between studies, and 65% of the studies had a medium to high risk of bias. High risk of bias, small sample size, and use of drug prescriptions instead of administrations were related to a higher pDDI frequency. The findings of this review may support researchers in designing a reliable methodology assessing pDDI frequency in ICU patients. The reporting recommendations may contribute to standardization, comparison, and synthesis of pDDI frequency studies, ultimately improving knowledge about pDDIs in and outside the ICU setting.

Clinical significance of potential drug-drug interactions in a pediatric intensive care unit: A single-center retrospective study

Despite the high prevalence of potential drug-drug interactions in pediatric intensive care units, their clinical relevance and significance are unclear. We assessed the characteristics and risk factors of clinically relevant potential drug-drug interactions to facilitate their efficient monitoring in pediatric intensive care units. This retrospective cohort study reviewed the medical records of 159 patients aged <19 years who were hospitalized in the pediatric intensive care unit at Seoul National University Hospital (Seoul, Korea) for ≥3 days between August 2019 and February 2020. Potential drug-drug interactions were screened using the Micromedex Drug-Reax® system. Clinical relevance of each potential drug-drug interaction was reported with official terminology, magnitude of severity, and causality, and the association with the patient's clinical characteristics was assessed. In total, 115 patients (72.3%) were exposed to 592 potential interactions of 258 drug pairs. In 16 patients (10.1%), 22 clinically relevant potential drug-drug interactions were identified for 19 drug pairs. Approximately 70% of the clinically relevant potential drug-drug interactions had a severity grade of ≥3. Exposure to potential drug-drug interactions was significantly associated with an increase in the number of administrated medications (6-7 medications, p = 0.006; ≥8, p<0.001) and prolonged hospital stays (1-2 weeks, p = 0.035; ≥2, p = 0.049). Moreover, clinically relevant potential drug-drug interactions were significantly associated with ≥8 prescribed drugs (p = 0.019), hospitalization for ≥2 weeks (p = 0.048), and ≥4 complex chronic conditions (p = 0.015). Most potential drug-drug interactions do not cause clinically relevant adverse outcomes in pediatric intensive care units. However, because the reactions that patients experience from clinically relevant potential drug-drug interactions are often very severe, there is a medical need to implement an appropriate monitoring system for potential drug-drug interactions according to the pediatric intensive care unit characteristics.

The effect of different intensivist staffing patterns on the rate of potential drug-drug interactions in adult trauma intensive care units

BACKGROUND

Drug-drug interactions (DDIs) have created alarming challenges for public health, especially in those admitted to intensive care units (ICUs). Many studies have shown that involvement of intensivists in the ICUs improves the outcome and decreases the treatment costs. The effect of academic versus non-academic (therapeutic) intensivist as well as hours of coverage and attendance of intensivist on potential DDIs (pDDIs) was evaluated in six adult trauma ICUs of a level one trauma center.

METHODS

In this 6-month cross-sectional study, 200 patients were included. The DDIs were classified into five groups, including type A, B, C, D, and X. pDDIs were defined as interactions belonged to C, D and X categories. Patients in six adult ICUs with three different patterns of intensivist staffing models including type A (once-daily therapeutic intensivist visit followed by 24 h on-call), B (twice-daily academic intensivist visit, 8 h of attendance in ICU and 16 h on-call) and C (all criteria just like ICU type B, except for the presence of therapeutic instead of academic intensivist) were screened for pDDIs.

RESULTS

In total, 3735 drug orders and 3869 drugs (193 different types) were screened and 1826 pDDIs were identified. Type C, D and X interactions accounted for 60.6%, 35.5%, and 3.9% of all pDDIs, respectively. The mean of pDDI per patient was significantly higher (p-value < 0.001) in the ICU type A than ICU types C and B. The frequency of pDDIs was the highest in the type A ICUs. A statistically significant relationship was observed between the number of prescribed drugs and ICU length of stay (p-value < 0.001 and p = 0.009, respectively).

CONCLUSION

Different patterns of intensivist staffing affect pDDIs to varying degrees. In the studied ICUs academic versus therapeutic intensivist, twice versus once-daily visit, and 8 h attendance with16 h on-call versus 24 h on-call were associated with more reductions in pDDIs.

PLAIN LANGUAGE SUMMARY

The impact of different intensivist staffing patterns in ICUs on the rate of potential drug-drug interactionsDrug-drug interactions (DDIs) have created alarming challenges for public health, especially in patients admitted to intensive care units (ICUs). Many studies have shown that involvement of intensivists in the ICUs improves the outcome and limits the costs. Considering the high incidence of potential DDIs (pDDIs) occurring for critically ill patients and the importance of ADRs caused by pDDIs in ICUs, the effect of the presence of an academic versus therapeutic intensivist, as well as the hour of coverage of intensivist on prevalence of pDDIs was evaluated in six adult trauma ICUs of a level one trauma center in Shiraz, Iran. We also determined the prevalence of pDDIs and their associated risk factors. To the best of our knowledge, this is the first study that has assessed the effect of various ICU physician staffing models on the incidence and pattern of pDDIs.

Potential drug-drug interactions in hospitalized pediatric patients with respiratory disorders: a retrospective review of clinically important interactions

Background Hospitalized pediatric patients are at an increased risk of experiencing potential drug-drug interactions (pDDIs) due to polypharmacy and the unlicensed and off-label administration of drugs. The aim of this study is to characterize clinically significant pDDIs in pediatric patients hospitalized in a tertiary respiratory center. Methods A retrospective analysis of medications prescribed to pediatric patients admitted to the pediatric ward (PW) and pediatric intensive care unit (PICU) of a respiratory referral center was carried out over a six-month period. The pDDIs were identified using the Lexi-Interact database and considered as clinically relevant according to the severity rating as defined in the database. Frequency, drug classes, mechanisms, clinical managements, and risk factors were recorded for these potential interactions. Results Eight hundred and forty-five pDDIs were identified from the analysis of 176 prescriptions. Of the total pDDIs, 10.2% in PW and 14.6% in PICU were classified as clinically significant. Anti-infective agents and central nervous system drugs were the main drug classes involved in clinically significant pDDIs as object and/or precipitant drugs. A higher number of medications [odds ratio (OR): 4.8; 95% confidence interval (CI): 2.0-11.4; p < 0.001] and the existence of a nonrespiratory disease, which led to a respiratory disorder (OR: 3.8; 95% CI: 1.40-10.4; p < 0.05), were the main risk factors associated with an increased incidence of pDDIs. Conclusions A high and similar risk of pDDIs exists in pediatric patients with respiratory disorders hospitalized in PW and PICU. The patients prescribed a higher number of medications and presenting respiratory symptoms induced by a nonrespiratory disease require extra care and monitoring. Pediatricians should be educated about clinically significant DDIs for highly prescribed medications in their settings in order to take preventive measures and safeguard patient safety.

Drug interactions in maternal intensive care: prevalence, risk factors, and potential risk medications

Objective:

To characterize severe potential drug interactions in maternal intensive care, and to determine their frequency, risk factors and potential risk medications.

Methods:

An observational and longitudinal study conducted between December 2014 and December 2015 in a maternal intensive care unit. Clinical data were collected and severe potential drug interactions were identified on pregnant inpatients. The drug interactions were classified by type, prevalence and exposure rate. A multivariate logistic regression model was used to identify the severe potential drug interactions and the related drugs (p<0.05).

Results:

A total of 95.1% of patients were exposed to, at least, one potential drug interaction; in that, 91.7% 33.9% were related to, respectively, moderate and severe potential drug interactions. The patients were exposed, on average, on 69.2% of days they were in the intensive care unit. The main drugs involved in more severe drug interactions were magnesium sulfate, metoclopramide, propranolol and diazepam.

Conclusion:

The severe potential drug interactions were observed in almost all patients of the study, and, approximately one third of those interactions were related to greater severity and resulted in exposure during long hospital stay. The higher number of prescribed drugs and its previous use of medications at home increase the occurrence of severe potential drug interactions.

Potential drug-drug interactions and nephrotoxicity in hematopoietic stem cell transplant adult recipients during bone marrow transplantation unit stay

PURPOSE

Studies have documented potential drug-drug interactions (pDDIs) occurring in cancer patients mainly with solid malignancies, either in the ambulatory or hospital settings. While hematopoietic stem cell transplant (HSCT) patients during their bone marrow transplantation unit (BMTU) stay have rather complex medical regimens combining chemotherapy, anti-infectious agents, immunosuppressive agents, and supportive-care drugs, studies on potential DDIs are lacking. Our objective was to evaluate the prevalence and the density of pharmacokinetic and pharmacodynamic potential DDIs, and the evolution of the renal function in hematopoietic stem cell transplant (HSCT) adult recipients during their BMTU stay.

METHODS

Retrospective study in 31 adult patients consecutively admitted to the BMTU.

RESULTS

Prevalence of pharmacokinetic interactions was ten times lower than the pharmacodynamic interactions. The contraindications were rare, and only of pharmacokinetic origin. The main drugs involved in pharmacokinetic DDIs were ciclosporine, methotrexate, esomeprazole, tramadol, and vincristine. The median number of potential nephrotoxicity-related DDIs per patient was 7 and the median number of days during which nephrotoxicity-related DDIs potentially occurred was 77 days per patient. The decrease in glomerular filtration rate (GFR) throughout the BMTU stay (mean decrease of 13 ml/min) was correlated with the number of days of potential nephrotoxic drug interactions.

CONCLUSIONS

Potential DDIs in HCST patients in BMTU were quite common. The DDIs from pharmacokinetic origin were less frequent, but of higher grade, than those of pharmacodynamic origin. The decrease in GFR suggests that the density of potential nephrotoxic drug interactions may be an issue to be considered in these patients.

Potential Drug-Drug Interactions Among Critically Ill Pediatric Patients in a Tertiary Pulmonary Center

Patients in the pediatric intensive care unit (PICU) are at increased risk of potential drug-drug interactions (pDDIs) because of the complexity of pharmacotherapy. The current study aimed to assess the rate, pattern, risk factors, and management of pDDIs in the PICU of an academic pulmonary hospital. A prospective observational study was conducted for 6 months. Pharmacotherapy data of PICU-admitted patients were evaluated by a clinical pharmacologist. Interacting drugs, reliability, mechanism, potential outcome, and clinical management of pDDIs were identified using the Lexi-Interact database. Logistic regression was applied to analyze the risk factors that could be associated with the interactions. One hundred and twenty-three medication profiles were evaluated during the study period. Diseases of the respiratory system were the main diagnoses among intensive care unit (ICU)-admitted patients (56.1%). A total of 38.6% of the patients exposed to at least 1 major and/or contraindicated interaction during ICU admission. Most pDDIs occurred through metabolic (35.4%) and additive (34.8%) mechanisms. The existence of pDDIs was significantly associated with the number of prescribed medications. Exposure to pDDIs is frequent in critically ill pediatric patients and related to the number of medications. Daily and close cooperation between clinicians and clinical pharmacologists is recommended to prevent harmful outcomes of DDIs.

Drug-drug interactions in the intensive care unit: Do they really matter?

PURPOSE

To describe prevalence and patterns of potential drug-drug interactions (pDDIs) in the intensive care unit (ICU), occurrence of adverse drug events (ADEs), and agreement between different compendia and intensivists' perceptions.

METHODS

A cross-sectional study. Drug profiles of all adult patients from 2 academic ICUs were screened on day 3 upon admission. We identified pDDIs using 3 compendia (Stockley's, Micromedex, and Epocrates) and documented their mechanism of action, clinical consequences, severity, level of evidence, and management. Medical records were searched to identify ADEs potentially related to major pDDIs. Agreement between information sources (compendia, intensivists) was evaluated.

RESULTS

We identified 1120 pDDIs among 275 patients. Median number of pDDIs per patient was 3.0 (interquartile range, 1-6), with 79% of patients presenting with at least 1 pDDI. Major pDDIs were detected in 18% of patients, with potentially related to ADEs in 4% of patients. Only 13% of all pDDIs were documented simultaneously in all 3 compendia. Different information sources (compendia, clinicians) showed "no" to "fair" agreement.

CONCLUSIONS

Potential drug-drug interactions occurred in most ICU patients, contrasting with low rates of potentially related ADEs, which may have been underestimated. Sources of information are inconsistent, challenging the identification of pDDIs.