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

Potential drug-drug interactions analysis in Polish pediatric pneumonology units, including cystic fibrosis patients

The lack of data on drug-drug interactions in pediatrics represents a relevant problem in making appropriate therapeutic decisions. Our study aimed to investigate the incidence and risk factors for potential drug-drug interactions (pDDIs) in pediatric pneumonology units, including cystic fibrosis patients. We performed a 6-month prospective observational study during which clinical pharmacists, using the Lexicomp Drug Interactions checker, screened medical records to identify pDDIs. Spearman's rank coefficient, logistic regression, and the Mann-Whitney U test were used to identify correlations, analyze risk factors for pDDIs, and compare cystic fibrosis patients with the rest, respectively. Recommendations were provided for the D and X pDDIs categories. Within the 218 patients, 428 pDDIs were identified, out of which 237 were classified as clinically significant. Almost 60% of patients were exposed to at least one relevant interaction. The number of pDDIs correlated with the number of; drugs (rs = 0.53, P <  .001), hospitalization length (rs = 0.20, P <  .01), and off-label medicines (rs = 0.25, P <  .001). According to the multivariate analysis, at least 6 administered medications (OR = 4.15; 95% CI = 2.21-7.78), 4 days of hospitalization (OR = 6.41; 95% CI = 2.29-17.97), and off-label therapy (OR = 3.37; 95% CI = 1.69-6.70) were the risk factor for pDDIs. Despite significant differences in the number of medications taken, comorbidities, and off-label drugs, cystic fibrosis patients were not more exposed to pDDI. Given the lack of data on pDDIs in the pediatric population, the need for close cooperation between clinicians and clinical pharmacists to improve the safety and efficacy of pharmacotherapy is highlighted.

Drug-Drug Interactions Involving High-Alert Medications that Lead to Interaction-Associated Symptoms in Pediatric Intensive Care Patients: A Retrospective Study

BACKGROUND

Children treated in a pediatric intensive care unit (PICU) often receive several drugs together, among them drugs defined as high-alert medications (HAMs). Those drugs carry a high risk of causing patient harm, for example, due to a higher potential for interactions. HAMs should therefore be administered with caution, especially in a PICU.

OBJECTIVES

The objective of the current study was to identify drug-drug interactions involving HAMs that increase the risk of interaction-associated symptoms in pediatric intensive care.

METHODS

In a retrospective study, we analyzed the electronic documentation of patients hospitalized for at least 48 h in a general PICU who received at least two different drugs within a 24-h interval. We assessed potential drug-drug interactions involving HAM on the basis of the two drug information databases UpToDate and drugs.com. Furthermore, we analyzed whether symptoms were observed after the administration of drug pairs that could lead to interaction-associated symptoms. For drug pairs involving HAM administered on at least 2% of patient days, and symptoms observed at least ten times after a respective drug pair, we calculated odds ratios, 95% confidence intervals, and p-values by using a univariate binary logistic regression.

RESULTS

Among 315 analyzed patients, 81.3% (256/315) received drugs defined as high-alert medication for pediatric patients. Those high-alert medications were involved in 20,150 potential drug-drug interactions. In 14.0% (2830/20,150) of these, one or more symptoms were observed that could be a possible consequence of the interaction, resulting in 3203 observed symptoms affecting 56.3% (144/256) of patients receiving high-alert medication. The odds ratios for symptoms observed after a drug-drug interaction were increased for eight specific symptoms (each p ≤ 0.05), especially hemodynamic alterations and disturbances of electrolyte and fluid balance. The odds ratio was highest for decreased blood pressure observed after the administration of the drug pair fentanyl and furosemide (OR 5.06; 95% confidence interval 3.5-7.4; p < 0.001). Increased odds ratios for specific symptoms observed after drug-drug interactions resulted from eight combinations composed of eight different drugs: digoxin, fentanyl, midazolam, phenobarbital, potassium salts and vancomycin (high-alert medications), and the diuretics furosemide and hydrochlorothiazide (non-high-alert medications). The resulting drug pairs were: potassium salts-furosemide, fentanyl-furosemide, vancomycin-furosemide, digoxin-furosemide, digoxin-hydrochlorothiazide, fentanyl-phenobarbital, potassium salts-hydrochlorothiazide, and midazolam-hydrochlorothiazide.

CONCLUSIONS

In a cohort of PICU patients, this study identified eight specific drug pairs involving high-alert medications that may increase the risk of interaction-associated symptoms, mainly hemodynamic alterations and electrolyte/fluid balance disturbances. If the administration of those drug pairs is unavoidable, patients should be closely monitored.

The impact of antimicrobial use on potential major drug-drug interactions in the pediatric Intensive Care Unit patients at University Hospital in Türkiye

BACKGROUND

Antimicrobials, especially antibiotics, are among the most widely used drugs in the pediatric intensive care unit. Pediatrics patients in intensive care unit are exposed to potential drug-drug interactions (PDDIs) and suffered from their adverse and side effects. The aim of this study is to evaluate the impact of antimicrobial use on PDDIs, as well as to examine the rate and the risk factors PDDIs, furthermore the management of PDDIs.

METHODS

The present retrospective cohort study included 179 patients under 18 years of age who were hospitalized in Pediatric Intensive Care Unit in Türkiye. Drug interactions were evaluated using the Lexicomp® (Macedonia, OH, USA) drug interaction tool which provides evidence-based drug information.

RESULTS

Our study results showed that the frequency of the use of antimicrobial drugs (antibiotic, antifungal, antiviral) was found to be statistically significantly higher (P<0.05) in the group with PDDIs compared to the group without PDDIs. Especially, the use of carbapenem, cephalosporin among the antibiotic groups significantly increased the frequency of PDDIs (P<0.05). While the probability PDDIs statistically significantly increased 3.73 times (OR [odds ratio] = 3.73; 95% CI=1.47-9.50) in patients who used a single antibiotic compared to patients who did not use antibiotics (P=0.006), the probability of the occurrence of PDDIs by using more than one antibiotic was statistically significantly 8.5 times (95% CI=3.30-21.89) (P<0.001).

CONCLUSIONS

Our study results showed that the use of antimicrobial drugs (antibiotic, antifungal, antiviral) was found to be statistically significantly higher (P<0.05) in the group with PDDIs.

Prevalence and differences in the co-administration of drugs known to interact: an analysis of three distinct and large populations

BACKGROUND

The co-administration of drugs known to interact greatly impacts morbidity, mortality, and health economics. This study aims to examine the drug-drug interaction (DDI) phenomenon with a large-scale longitudinal analysis of age and gender differences found in drug administration data from three distinct healthcare systems.

METHODS

This study analyzes drug administrations from population-wide electronic health records in Blumenau (Brazil; 133 K individuals), Catalonia (Spain; 5.5 M individuals), and Indianapolis (USA; 264 K individuals). The stratified prevalences of DDI for multiple severity levels per patient gender and age at the time of administration are computed, and null models are used to estimate the expected impact of polypharmacy on DDI prevalence. Finally, to study actionable strategies to reduce DDI prevalence, alternative polypharmacy regimens using drugs with fewer known interactions are simulated.

RESULTS

A large prevalence of co-administration of drugs known to interact is found in all populations, affecting 12.51%, 12.12%, and 10.06% of individuals in Blumenau, Indianapolis, and Catalonia, respectively. Despite very different healthcare systems and drug availability, the increasing prevalence of DDI as patients age is very similar across all three populations and is not explained solely by higher co-administration rates in the elderly. In general, the prevalence of DDI is significantly higher in women - with the exception of men over 50 years old in Indianapolis. Finally, we show that using proton pump inhibitor alternatives to omeprazole (the drug involved in more co-administrations in Catalonia and Blumenau), the proportion of patients that are administered known DDI can be reduced by up to 21% in both Blumenau and Catalonia and 2% in Indianapolis.

CONCLUSIONS

DDI administration has a high incidence in society, regardless of geographic, population, and healthcare management differences. Although DDI prevalence increases with age, our analysis points to a complex phenomenon that is much more prevalent than expected, suggesting comorbidities as key drivers of the increase. Furthermore, the gender differences observed in most age groups across populations are concerning in regard to gender equity in healthcare. Finally, our study exemplifies how electronic health records' analysis can lead to actionable interventions that significantly reduce the administration of known DDI and its associated human and economic costs.

Intensive care drug therapy and its potential adverse effects on blood pressure and heart rate in critically ill children

BACKGROUND

Owing to complex treatment, critically ill children may experience alterations in their vital parameters. We investigated whether such hemodynamic alterations were temporally and causally related to drug therapy.

METHODS

In a university pediatric intensive care unit, we retrospectively analyzed hemodynamic alterations defined as values exceeding the limits set for heart rate (HR) and blood pressure (BP). For causality assessment, we used the World Health Organization-Uppsala Monitoring Center (WHO-UMC) system, which categorizes the probability of causality as "certain," "probable," "possible," and "unlikely."

RESULTS

Of 315 analyzed patients with 43,200 drug prescriptions, 59.7% experienced at least one hemodynamic alteration; 39.0% were affected by increased HR, 19.0% by decreased HR, 18.1% by increased BP, and 16.2% by decreased BP. According to drug information databases, 83.9% of administered drugs potentially lead to hemodynamic alterations. Overall, 88.3% of the observed hemodynamic alterations had a temporal relation to the administration of drugs; in 80.2%, more than one drug was involved. Based on the WHO-UMC system, a drug was rated as a "probable" causing factor for only 1.4% of hemodynamic alterations. For the remaining alterations, the probability ratings were lower because of multiple potential causes, e.g., several drugs.

CONCLUSIONS

Critically ill children were frequently affected by hemodynamic alterations. The administration of drugs with potentially adverse effects on hemodynamic parameters is often temporally related to hemodynamic alterations. Hemodynamic alterations are often multifactorial, e.g., due to administering multiple drugs in rapid succession; thus, the influence of individual drugs cannot easily be captured with the WHO-UMC system.

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.

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.

Evaluation of potential drug-drug interactions in a pediatric population

Aim:

A large number of medications are prescribed in pediatric clinics and this leads to the development of drug–drug interactions (DDI) that may complicate the course of the disease. The aim of the study was to identify the prevalence of potential drug–drug interactions, to categorize main drug classes involved in severe drug–drug interactions and to highlight clinically relevant DDIs in a pediatric population.

Material and Methods:

A total of 1500 prescriptions during the 12-month study period were retrospectively reviewed; 510 prescriptions that comprised two or more drugs were included in study. The presence of potential drug–drug interactions was identified by using the Lexi-Interact database and categorized according to severity A (unknown), B (minor), C (moderate), D (major), and X (contraindicated).

Results:

There were 1498 drugs in 510 prescriptions; 253 of these (49.6%) included 2 drugs, 228 (44.7%) included 3–4 drugs, and 29 (5.6%) included ≥5 drugs. A total of 634 (42%) potential drug–drug interactions were idenfied. Among those, 271 (42.7%) were categorized as A, 284 (44.8%) as B, 53 (8.4%) as C, and 26 (4.1%) as D. There was no potential risk for X interaction. Anti-infectives (36%) were the most commonly prescribed drug classes involved in C and/or D categories. Clarithromycin was the most commonly interacting agent that interfered with budesonide.

Conclusion:

It is noteworthy that a significant number of drugs causing potential drug–drug interactions are prescribed together in pediatric clinics. Increasing the awareness of physicians on this issue will prevent potential complications and ensure patient safety.

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.

The prevalence of potentially beneficial and harmful drug-drug interactions in intensive care units

Background The present study was conducted with the aim of investigating the prevalence of potentially beneficial and harmful drug-drug interactions (DDIs) in intensive care units (ICUs). Methods The present cross-sectional prospective study was conducted in two ICUs in Shahr-e Kord city, Iran. The study sample was consisted of 300 patients. The Drug Interaction Facts reference text book [Tatro DS. Drug interaction facts. St Louis, MO: Walters Kluwer Health, 2010.] was used to determine the type and the frequency of the DDIs. Results The participants consisted of 189 patients men and 111 women. The mean age of patients was 44.2 ± 24.6 years. Totally, 60.5% of patients had at least one drug-drug interaction in their profile. The total number of DDIs found was 663 (the mean of the total number of drug-drug interactions was 2.4 interactions per patient). Of all the 663 interactions, 574 were harmful and others were beneficial. In terms of starting time, 98 of the potential interactions were rapid and 565 of them were delayed. In terms of severity, 511 of the potential interactions were moderate. Some of the drugs in the patients' medical records including phenytoin, dopamine, ranitidine, corticosteroid, dopamine, heparin, midazolam, aspirin, magnesium, calcium gluconate, and antibiotics, the type of ventilation, the type of nutrition and the duration of hospital stay were among the factors that were associated with high risk of potential DDIs (p < 0.05). Conclusions The prevalence of potentially beneficial and harmful DDIs, especially harmful drug-drug interactions, is high in ICUs and it is necessary to reduce these interactions by implementing appropriate programs and interventions.