Clinical pharmacy practice in the care of Chronic Kidney Disease patients: a systematic review

Interventions and impact of pharmacist-delivered services in perioperative setting on clinically important outcomes: a systematic review and meta-analysis

Background

The perioperative arena is a unique and challenging environment that requires coordination of the complex processes and involvement of the entire care team. Pharmacists' scope of practice has been evolving to be patient-centered and to expand to variety of settings including perioperative settings.

Objectives

To critically appraise, synthesize, and present the available evidence of the characteristics and impact of pharmacist-led interventions on clinically important outcomes in the perioperative settings.

Design

A systematic review and meta-analysis.

Methods

We searched PubMed, Embase, and CINAHL from index inception to September 2023. Included studies compared the effectiveness of pharmacist-led interventions on clinically important outcomes (e.g. length of stay, readmission) compared to usual care in perioperative settings. Two independent reviewers extracted the data using the DEPICT-2 (Descriptive Elements of Pharmacist Intervention Characterization Tool) and undertook quality assessment using the Crowe Critical Appraisal (CCAT). A random-effect model was used to estimate the overall effect [odds ratio (OR) for dichotomous and standard mean difference (SMD) for continuous data] with 95% confidence intervals (CIs).

Results

Twenty-five studies were eligible, 20 (80%) had uncontrolled study design. Most interventions were multicomponent and continuous over the perioperative period. The intervention components included clinical pharmacy services (e.g. medication management/optimization, medication reconciliation, discharge counseling) and education of healthcare professionals. While some studies provided a minor description in regards to the intervention development and processes, only one study reported a theoretical underpinning to intervention development. Pooled analyses showed a significant impact of pharmacist care compared to usual care on length of stay (11 studies; SMD -0.09; 95% CI -0.49 to -0.15) and all-cause readmissions (8 studies; OR 0.60; 95% CI 0.39-0.91). The majority of included studies (n = 21; 84%) were of moderate quality.

Conclusion

Pharmacist-led interventions are effective at improving clinically important outcomes in the perioperative setting; however, most studies were of moderate quality. Studies lacked the utilization of theory to develop interventions; therefore, it is not clear whether theory-derived interventions are more effective than those without a theoretical element. Future research should prioritize the development and evaluation of multifaceted theory-informed pharmacist interventions that target the whole surgical care pathway.

The effect of pharmacist-led medication therapy management in the multidisciplinary care of acute kidney injury survivors

BACKGROUND

The Acute Disease Quality Initiative advocates multidisciplinary care for the survivors of acute kidney injury (AKI). The bundled care strategy recognizes the role of pharmacists. However, their specific contributions in this context remain underexplored.

METHODS

This retrospective study examined the efficacy of pharmacist-led post-AKI pharmaceutical care in outpatient settings at a single center. Adults with recent AKI during hospitalization, maintaining an estimated glomerular filtration rate <45 mL/min/1.73 m2 postdischarge, were enrolled in a multidisciplinary team care program from March 2022 to January 2023, with a 6-month follow-up period. Pharmacist-delivered care adhered to international multidisciplinary consensus guidelines. Efficacy was evaluated by analyzing medication-related recommendations, medication adherence, nephrotoxic drug utilization, and renoprotective medication usage before and after the intervention.

RESULTS

A total of 40 patients were referred to the pharmacist-managed clinic. Of these, 33 patients (mean age, 63 ± 15 years; 60.6% male) attended the clinic. Nineteen patients completed follow-up visits. The pharmacist provided 14 medication-related recommendations to relevant physicians, with 10 of these recommendations (71.4%) being accepted. There was a significant decrease in the use of modifiable nephrotoxic drugs (p = 0.03). However, no significant improvements were noted in medication adherence or the utilization of renoprotective medications.

CONCLUSION

Our study underscores the potential benefits of pharmacist-led post-AKI bundled care strategy in outpatient settings. We observed a significant reduction in the utilization of modifiable nephrotoxic drugs, indicating the effectiveness of pharmacist interventions in optimizing medication regimens to mitigate renal harm.

Drug stewardship in chronic kidney disease to achieve effective and safe medication use

People living with chronic kidney disease (CKD) often experience multimorbidity and require polypharmacy. Kidney dysfunction can also alter the pharmacokinetics and pharmacodynamics of medications, which can modify their risks and benefits; the extent of these changes is not well understood for all situations or medications. The principle of drug stewardship is aimed at maximizing medication safety and effectiveness in a population of patients through a variety of processes including medication reconciliation, medication selection, dose adjustment, monitoring for effectiveness and safety, and discontinuation (deprescribing) when no longer necessary. This Review is aimed at serving as a resource for achieving optimal drug stewardship for patients with CKD. We describe special considerations for medication use during pregnancy and lactation, during acute illness and in patients with cancer, as well as guidance for the responsible use of over-the-counter drugs, herbal remedies, supplements and sick-day rules. We also highlight inequities in medication access worldwide and suggest policies to improve access to quality and essential medications for all persons with CKD. Further strategies to promote drug stewardship include patient education and engagement, the use of digital health tools, shared decision-making and collaboration within interdisciplinary teams. Throughout, we position the person with CKD at the centre of all drug stewardship efforts.

Pharmacists' perspectives and perceived barriers to counselling patients with kidney stones

BACKGROUND

The global increase in kidney stone incidence and its complications emphasise the need for effective management. While pharmacists can play a significant role in counselling and guiding patients, their practices in managing patients with kidney stones remain unclear.

OBJECTIVE(S)

To explore counselling practices and experiences of pharmacists when dealing with patients with kidney stones and to identify the barriers they face while providing counselling.

METHODS

A qualitative study was performed using semi-structured phone interviews with pharmacists practising in Jordan. Pharmacists were selected using quota sampling from those who took part in a previous study focused on pharmacists' knowledge of kidney stone aetiology and treatment. The COM-B Model of Behaviour Change was used to develop the interview guide and the analytical framework. Interviews were transcribed verbatim and analysed using a deductive thematic approach based on the pre-specified analytical framework.

RESULTS

Seven pharmacists (85.7% female; 57.1% working in community pharmacies) were interviewed. Counselling practices of patients with kidney stones were categorised into five themes: (1) Pharmacists' beliefs about patient counselling: perceived importance and desire to improve health through counselling; (2) Most priority patients: Types of patients mostly counselled; (3) Content of kidney stones-specific counselling: patient assessment and recommendations about kidney stones management; (4) Duration of the counselling sessions: time offered and influencing factors; (5) Barriers to patient counselling: patient-related, and pharmacist- and doctor-related challenges.

CONCLUSIONS

Pharmacists recognise the crucial role of kidney stones counselling but face gaps in their practices, including incomplete dietary education, limited knowledge of medication prescriptions, inconsistent patient-specific approaches, and potential communication challenges. These gaps can be overcome by enhancing training, standardising protocols of kidney stone treatment, promoting interprofessional communication, and improving communication strategies. Future research, including quantitative assessments, is needed to inform strategies that optimise patient counselling practices and facilitate improved outcomes.

Navigating nephrology: unveiling pharmacist perspectives on renal dose adjustment in Saudi Arabia - a comprehensive cross-sectional analysis

Introduction

Chronic kidney disease (CKD) is a major public health concern in Saudi Arabia. it is pertinent to mention that in the Southwestern region of Saudi Arabia. Hypertension and diabetes mellites are considered the major drivers of CKD. Research has documented worldwide the inappropriate dose adjustments in patients, ranging from 25% to 77%, of drugs requiring dose modifications. Pharmacists are pivotal members of the healthcare team, tasked with addressing issues pertaining to medications. This study aims to unveil pharmacist perspectives on renal dose adjustment in Saudi Arabia an important step in gauging their involvement in promoting healthy behaviours.

Method

A cross-sectional study design was conducted from December 2023 to January 2024 among pharmacists working in diverse healthcare settings, including clinical and hospital pharmacies, retail, and community pharmacies who had direct encounters with patients diagnosed with CKD. A validated questionnaire, the Renal Dose Adjustment-13 (RDQ-13) was used for this study. For comparing the knowledge, attitude, and perception scores of pharmacists statistical tests like One-Way ANOVA, and independent t-test; while for factors influencing the knowledge, attitude, and perception scores a multivariate linear regression was performed. The statistical significance level was set at 0.05.

Results

A total of 379 pharmacists completed the questionnaire, the knowledge score of pharmacists was 22.06 ± 2.81, while the attitude score was 8.56 ± 2.62 and the practice score was 5.75 ± 2.25. The findings of multivariate linear regression analysis indicated a statistically significant positive association between knowledge score and pharmacist's age while for practice score the findings revealed a statistically negative association between working setting and designation of pharmacists.

Conclusion

The pharmacist in Saudi Arabia exhibited a proficient knowledge score of drug dosage adjustment pertinent to renal function while the attitude and practice score was less as compared to the knowledge score.

Assessing the applicability and appropriateness of ChatGPT in answering clinical pharmacy questions

OBJECTIVES

Clinical pharmacists rely on different scientific references to ensure appropriate, safe, and cost-effective drug use. Tools based on artificial intelligence (AI) such as ChatGPT (Generative Pre-trained Transformer) could offer valuable support. The objective of this study was to assess ChatGPT's capacity to correctly respond to clinical pharmacy questions asked by healthcare professionals in our university hospital.

MATERIAL AND METHODS

ChatGPT's capacity to respond correctly to the last 100 consecutive questions recorded in our clinical pharmacy database was assessed. Questions were copied from our FileMaker Pro database and pasted into ChatGPT March 14 version online platform. The generated answers were then copied verbatim into an Excel file. Two blinded clinical pharmacists reviewed all the questions and the answers given by the software. In case of disagreements, a third blinded pharmacist intervened to decide.

RESULTS

Documentation-related issues (n=36) and drug administration mode (n=30) were preponderantly recorded. Among 69 applicable questions, the rate of correct answers varied from 30 to 57.1% depending on questions type with a global rate of 44.9%. Regarding inappropriate answers (n=38), 20 were incorrect, 18 gave no answers and 8 were incomplete with 8 answers belonging to 2 different categories. No better answers than the pharmacists were observed.

CONCLUSIONS

ChatGPT demonstrated a mitigated performance in answering clinical pharmacy questions. It should not replace human expertise as a high rate of inappropriate answers was highlighted. Future studies should focus on the optimization of ChatGPT for specific clinical pharmacy questions and explore the potential benefits and limitations of integrating this technology into clinical practice.

Peter WL, Shubrook JH. Type 2 Diabetes and Chronic Kidney Disease: An Opportunity for Pharmacists to Improve Outcomes

Chronic kidney disease (CKD) is an important contributor to end-stage kidney disease, cardiovascular disease, and death in people with type 2 diabetes (T2D), but current evidence suggests that diagnosis and treatment are often not optimized. This review examines gaps in care for patients with CKD and how pharmacist interventions can mitigate these gaps. We conducted a PubMed search for published articles reporting on real-world CKD management practice and compared the findings with current recommendations. We find that adherence to guidelines on screening for CKD in patients with T2D is poor with particularly low rates of testing for albuminuria. When CKD is diagnosed, the prescription of recommended heart-kidney protective therapies is underutilized, possibly due to issues around treatment complexity and safety concerns. Cost and access are barriers to the prescription of newer therapies and treatment is dependent on racial, ethnic, and socioeconomic factors. Rates of nephrologist referrals for difficult cases are low in part due to limitations of information and communication between specialties. We believe that pharmacists can play a vital role in improving outcomes for patients with CKD and T2D and support the cost-effective use of healthcare resources through the provision of comprehensive medication management as part of a multidisciplinary team. The Advancing Kidney Health through Optimal Medication Management initiative supports the involvement of pharmacists across healthcare systems to ensure that comprehensive medication management can be optimally implemented.

The Effects of Pharmacist-Led Medication Therapy Management on Medication Adherence and Use of Non-Steroidal Anti-Inflammatory Drug in Patients with Pre-End Stage Renal Disease

Purpose

Patients with chronic kidney disease (CKD) are particularly vulnerable to the risks of polypharmacy, largely owing to various comorbid conditions. This vulnerability is further compounded by an escalated risk of renal function deterioration when exposed to nephrotoxic medications. As part of the national health insurance program in Taiwan, the pre-end-stage kidney disease patient care and education plan has included pharmaceutical care since October 2021. This study aims to explore the effect of pharmacist involvement in a multidisciplinary care team for patients with kidney disease in outpatient settings.

Patients and Methods

This retrospective observational study was conducted at a single center. It analyzed data from May 2022 to May 2023, focusing on patients who received medication therapy management in the kidney disease pharmacist-managed clinic. The study assessed changes in patient medication adherence, non-steroidal anti-inflammatory drugs (NSAIDs) usage, CKD stage, and urine protein-to-creatinine ratio (UPCR) after pharmacist intervention. It also documented pharmacists' medication recommendations and the rate of acceptance by physicians.

Results

A total of 202 patients who had at least two clinic visits were included in the study. After pharmacist intervention, the proportion of poor medication adherence reduced significantly from 67.8% to 43.1% (p<0.001). The proportion of NSAID users also decreased significantly from 19.8% to 8.4% (p=0.001). CKD stage showed a significant reduction (p=0.007), and the average UPCR improved from 2828.4 to 2111.0 mg/g (p<0.001). The pharmacists provided a total of 56 medication recommendations, with an acceptance rate of 86%.

Conclusion

The involvement of pharmacists in the multidisciplinary care team can effectively provide medication-related recommendations, ensuring the effectiveness and safety of patients' medication use, and lead to better kidney function and lower proteinuria.

Evaluation of Dose Adjustment in Patients With Renal Impairment at Muhimbili National Hospital in Tanzania

Background: The burden of renal diseases is increasing in developing countries like Tanzania. Drug accumulation exposes patients with renal impairment to drug toxicity that may lead to adverse drug reactions, poor adherence to treatment, and increased healthcare costs. There is limited information on the appropriateness of dosage regimen adjustment for patients with renal impairment, particularly in developing countries such as Tanzania. This study aimed to investigate the appropriateness of drug dosing in hospitalized patients with renal impairment in Tanzania. Methods: This was a retrospective cross-sectional study. It was conducted between November 2019 and April 2020 amongst hospitalized patients at Muhimbili National Hospital. All enrolled patients had serum creatinine levels ≥1.2 mg/dL and taking at least one drug requiring dosage regimen adjustment. Creatinine clearance was calculated from patient serum creatinine using the Cockcroft-Gault equation. Drug dosing appropriateness was determined by comparing the current practice with tertiary references. The relationship between the patient's baseline characteristics and the rate of dosage regimen adjustment was determined using the X2 test. Univariate and multivariate logistic regression analysis evaluated the predictors of dosing adjustment. Results: Most of the enrolled patients, 269 (98.9%) had comorbidities. Of the medication orders included in the final analysis, 372 (27%) needed dosage regimen adjustment. Out of the 372 medication orders, not adjusted were 168 (45.2%), inappropriately adjusted 105 (28.2%), and appropriately adjusted were only 99 (26.6%). In this study, 212 (77.9%) patients received at least one drug with an incorrect dosage regimen. Females and those with level 4 renal impairment patients were more likely to have their doses appropriately adjusted compared to their counterparts. Conclusions: In this study, about three-quarters of the patients received at least one drug with an incorrect dosage regimen. Thus, appropriate measures such as the availability of national guidelines and clinical decision support systems for drug dosing adjustment in patients' renal impairment should be in place.

Council of Europe Resolution on the Implementation of Pharmaceutical Care-A Step Forward in Enhancing the Appropriate Use of Medicines and Patient-Centred Care

Pharmaceutical care was proposed to address morbidity and mortality associated with medicine-related problems. It utilises the pharmacist's expertise in medicines, their relationship with the patient and cooperation with other healthcare professionals to optimise the use of medicines. The European Directorate for the Quality of Medicines & HealthCare (EDQM), part of the Council of Europe, found significant variation in the acceptance of pharmaceutical care and in the implementation of pharmaceutical care in Europe. A multidisciplinary group was established to draft a statement of principles and recommendations concerning pharmaceutical care. Through face-to-face meetings, circulation of draft texts and informal consultation with stakeholders, the group produced a resolution. On 11 March 2020, the resolution was adopted by the Committee of Ministers of the Council of Europe. It explains pharmaceutical care and illustrates pharmacists' contribution to medicine optimisation in different care settings. Pharmaceutical care's value to health services and its place in health policy were emphasised by addressing the risks and harms from suboptimal use of medicines. Pharmaceutical care can improve medicine use, promote rational use of healthcare resources and reduce inequalities in healthcare by realigning the roles and responsibilities of pharmacists and healthcare professionals. EDQM will promote and advocate for the implementation of pharmaceutical care by enacting practice Resolution CM/Res(2020)3.

Medication Adherence Among Patients With Kidney Disease: An Umbrella Review

Chronic kidney disease (CKD) imposes a significant medication burden on patients due to the necessity of multiple treatments to slow disease progression, manage coexisting conditions, and address complications. The complex medication regimen, in turn, has implications for clinical and patient-centered outcomes. This umbrella review provides comprehensive evidence on extent of medication nonadherence among adults with CKD, as well as associated risk factors, outcomes, and the effectiveness of interventions by synthesizing evidence from published systematic reviews and/or meta-analyses. We identified 37 works that met our inclusion criteria. These reviews covered various aspects of treatment adherence in people with CKD, which can be categorized into four main themes: (i) prevalence of treatment nonadherence; (ii) factors associated with (non)adherent behaviors; (iii) outcomes associated with treatment (non)adherence; and (iv) interventions to improve treatment adherence or overall self-management practices. Approximately half of the included studies (15/34) focused on interventions aimed at improving medication adherence or overall CKD management, while outcomes associated with medication (non)adherence were relatively underexplored in the literature. The reported prevalence rates of medication nonadherence varied widely among reviews and stages of CKD. The determinants of adherence identified included socioeconomic variables, disease or clinical conditions, and psychosocial factors. Common interventions to improve adherence included nurse-led interventions, pharmaceutical services, and eHealth technologies, which had varying effects on medication adherence or dialysis sessions.

Polypharmacy in chronic kidney disease: Health outcomes & pharmacy-based strategies to mitigate inappropriate polypharmacy

The rising prevalence of comorbidities in an increasingly aging population has sparked a reciprocal rise in polypharmacy. Patients with chronic kidney disease (CKD) have a greater burden of polypharmacy due to the comorbidities and complications associated with their disease. Polypharmacy in CKD patients has been linked to myriad direct and indirect costs for patients and the society at large. Pharmacists are uniquely positioned within the healthcare team to streamline polypharmacy management in the setting of CKD. In this article, we review the landscape of polypharmacy and examine its impacts through the lens of the ECHO model of Economic, Clinical, and Humanistic Outcomes. We also present strategies for healthcare teams to improve polypharmacy care through comprehensive medication management process that includes medication reconciliation during transitions of care, medication therapy management, and deprescribing. These pharmacist-led interventions have the potential to mitigate adverse outcomes associated with polypharmacy in CKD.

Drug-related problems in hospitalized patients with chronic kidney diseases and clinical pharmacist interventions

BACKGROUND

Patients with chronic kidney disease (CKD) are at high risk of drug-related problems (DRPs) because of extensive comorbidities and pharmacokinetic changes. This study aimed to identify DRPs and possible contributing factors in hospitalized patients with CKD, and evaluate the efficacy of the clinical pharmacist services in detection and intervention of DRPs in a large general hospital in Zhejiang Province, eastern China.

METHODS

With the approval of the Ethics Committee, patients with CKD admitted to the nephrology ward from January to December 2020 were enrolled in this prospective study. The clinical pharmacist identified and intervened the DRPs during hospitalization. The DRPs were classified using the Pharmaceutical Care Network Europe (PCNE) DRP classification system, and all data were statistically analyzed using Statistical Package for Social Science (SPSS) version 26.0.

RESULTS

A total of 914 patients with CKD were included, with 463 DRPs observed among 420 (45.95%) participants; the average DRP per patient was 0.51 (standard deviation [SD], 0.60) before pharmacist intervention. Treatment safety accounted for the highest proportion of problems (43.84%), followed by treatment efficacy, accounting for 43.20%. Drug selection was the most common cause of DRPs (60.26%), and antibiotics and cardiovascular agents were the most common drugs associated with DRPs (32.84% and 28.66%, respectively). A total of 85.53% of pharmaceutical intervention recommendations were followed, and 84.23% of DRPs were completely resolved after intervention by the clinical pharmacist. The proportion of patients who experienced DRPs decreased to 7.77%, with an average of 0.08 (SD 0.28) DRPs during hospitalization after pharmacist's intervention. Significant contributing factors for DRPs were CKD stage 4, number of comorbid diseases, number of prescribed medications, and hospitalization days in both the univariate and multivariate logistic regression models.

CONCLUSION

DRPs are common among hospitalized patients with CKD in China. CKD stage 4, the number of comorbidities, use of multiple prescription drugs, and extended length of hospital stay are contributing factors for DRPs. Even only one clinical nephrology pharmacist in the nephrology ward, clinical pharmacist can play an important role in facilitating the identification of DRPs in patients with CKD and assisting physicians resolve DRPs in this single center study in China.

Pharmacist-Led Interventions for Medication Adherence in Patients with Chronic Kidney Disease: A Scoping Review

BACKGROUND

Patients with chronic kidney disease (CKD) are routinely prescribed complex medication regimes. Medication reconciliation, medicine reviews, patient counselling and disease state and medication education are all key pharmacist-led interventions, which can improve medication adherence in patients with CKD.

AIM

To characterize peer reviewed literature on the role of pharmacists in supporting medication adherence of patients with chronic kidney disease and highlight the impact they might have in the health outcomes for patients.

METHOD

This review was performed in accordance with the Scoping Review Framework outlined in the Joanna Briggs Institute Reviewer's Guide. Four electronic databases were searched (Medline (Ovid), Emcare, Scopus and Web of Science) for all relevant literature published up until November 2022. A total of 32 studies were reviewed against an exclusion and inclusion criteria, with findings from each study categorized into barriers, interventions, perceptions, financial implications and outcomes.

RESULTS

Eight eligible studies were identified, where pharmacists' interventions including medication reconciliation, medicine reviews, patient counselling and disease state and medication education, were all reported to have a positive effect on medication adherence. Although pharmacy services in chronic kidney disease were acceptable to patients and pharmacists, these services were under-utilized and limited by logistical constraints, including staffing shortages and time limitations. Patient education supplemented with education tools describing disease states and medications was reported to increase patient adherence to medication regimes.

CONCLUSIONS

Pharmacist-led interventions play an integral role in improving medication adherence in patients with chronic kidney disease, with their inclusion in renal care settings having the potential to improve outcomes for patients.

Pharmacotherapy considerations with finerenone in the treatment of chronic kidney disease associated with type 2 diabetes

PURPOSE

This review provides an overview of the management of chronic kidney disease (CKD) associated with type 2 diabetes (T2D), how the novel treatment class of nonsteroidal mineralocorticoid receptor antagonists (MRAs) fits within the treatment landscape, and how pharmacists can contribute to the multidisciplinary care of patients with CKD associated with T2D.

SUMMARY

Optimizing pharmacotherapy for patients with CKD associated with T2D is critical to prevent or slow progression to end-stage kidney disease and reduce the incidence of cardiovascular events. However, many patients with CKD receive suboptimal treatment, in part because of the high complexity of care required, a lack of disease recognition among providers and patients, and a failure to utilize new kidney-protective therapies. Finerenone is the first nonsteroidal, selective MRA to be approved by the US Food and Drug Administration and the European Medicines Agency for the treatment of adult patients with CKD associated with T2D. Clinical trials have demonstrated that finerenone significantly reduces the risk of cardiorenal disease progression vs placebo and has a reduced risk of hyperkalemia compared to traditional steroidal MRAs. Initiation of finerenone should follow evaluation of baseline estimated glomerular filtration rate and serum potassium levels. Consideration of potential drug-drug interactions, follow-up monitoring of potassium levels, and coordination of changes in pharmacotherapy across the patient care team are also important.

CONCLUSION

Finerenone is a valuable addition to the treatment landscape for CKD associated with T2D. Through their expertise in -medication -management, transitions of care, and patient education, clinical pharmacists are well positioned to ensure patients receive safe and effective -treatment.

Improving the accuracy of discharge medication documentation in people with kidney disease through pharmacist-led partnered prescribing

BACKGROUND

Inaccurate medication documentation in prescriptions and discharge summaries produce poorer patient outcomes, are costly to healthcare systems and result in more readmissions to hospital. Errors in medication documentation are common in Australian hospitals.

AIM

To determine whether pharmacist-led partnered prescribing (PPP) on discharge reduced errors and improved accuracy in documentation of medications in the discharge prescription and the discharge summary of people with kidney disease compared with medical prescribing (MP).

METHODS

This interventional two-phase study compared current workflow (MP) with the subsequent implementation of the interventional workflow (PPP) in the renal unit of a tertiary referral hospital. Patients were included if they were discharged within pharmacy working hours and had a discharge prescription and discharge summary. The primary outcome was the percentage of discharge prescriptions with at least one error. The secondary outcome was the percentage of discharge summaries with at least one error.

RESULTS

Data were collected from 185 discharged patients (95 in MP phase then 90 in PPP phase). Discharge prescriptions with at least one error reduced from 75.8% in the MP phase to 6.7% in PPP phase (P < 0.001). Discharge summaries with at least one error reduced from 53% in MP phase to 24% in the PPP phase (P < 0.001).

CONCLUSION

PPP improves the accuracy of the documentation of medications in both the discharge prescription and the discharge summary of patients with kidney disease.

Clinical Effectiveness of Renal Transplant Outpatient Pharmaceutical Care Services in Korea

BACKGROUND

The necessity and importance of pharmaceutical care services (PCS) are well recognized, yet the concept and scope of PCS have not yet been clearly defined in Korea, particularly in kidney transplantation outpatient clinics.

AIM

The main purpose of this study is to evaluate whether PCS is effective in the outpatient setting for kidney transplant patients.

METHODS

For three years, a clinical pharmacist provided PCS to kidney transplant patients in an outpatient setting to evaluate the clinical effectiveness of PCS.

RESULTS

A total of 302 patients were matched in a 1:1 ratio, with 151 in the PCS group and 151 in the control group. These patients were followed, and a total of 476 interventions were provided to them, including medication reconciliation (n = 113, 23.7%), medication evaluation and management (n = 186, 39.1%), and pharmaceutical care transition (n = 177, 37.2%) services. The estimated glomerular filtration rate (eGFR) exhibited a notable difference between the control and PCS groups when comparing the pre- and post-study periods measurements. In the control group, there was a decline of 7.0 mL/min/1.73 m2 in eGFR. In contrast, the PCS group showed a smaller decline of 2.5 mL/min/1.73 m2 (p = 0.03). The adjusted odds ratio for end stage renal disease development in the PCS group was 0.51 (95% confidence interval: 0.26-0.96), indicating a significantly lower risk compared to the control group.

CONCLUSION

Our study highlights the promising potential of PCS implementation in kidney transplantation outpatient clinics. Further research is needed to validate and expand upon these findings, especially in diverse clinical settings.

Effect of medication therapy management services on medication-burden quality of life in hemodialysis patients

BACKGROUND

Hemodialysis (HD) patients commonly receive polypharmacy leading to increased likelihood of drug related problems (DRPs) and poor quality of life. Medication Therapy Management (MTM) services discover and resolve DRPs and may specifically improve Medication-burden Quality of life (MBQoL) in HD patients. We aimed to assess the effect of MTM services on DRPs and MBQoL among HD patients.

METHODS

A prospective pre-post study was conducted on 104 patients in an HD unit in Alexandria, Egypt. MBQoL was assessed at baseline and after three months of MTM sessions, using the Arabic, validated version of the Patient Reported Outcomes Measure of Pharmaceutical Therapy (PROMPT) questionnaire. Cohen's d test and multiple linear regression were used to assess the effect size of MTM and the factors affecting MBQoL, respectively. DRPs, adverse events and adherence were also monitored.

RESULTS

MBQoL improved significantly after the implementation of MTM (Cohen's d=0.88, p < 0.01) with the largest effect size in the "medicine information and relation with healthcare providers" domain. DRPs decreased significantly after MTM implementation (11.97 ± 4.65 versus 7.63 ± 3.85 per patient, p<0.001). The mean adverse events per patient were also reduced (9.69 ± 4.12 versus 6.56 ± 3.77, p < 0.001).

CONCLUSION

Applying MTM services presents an opportunity to improve care for HD patients by improving MBQoL, decreasing DRPs and adverse events.

Iron-Deficiency Anemia in CKD: A Narrative Review for the Kidney Care Team

Anemia is a common complication of chronic kidney disease (CKD) and is associated with increased mortality and reduced health-related quality of life. Anemia is characterized by a decrease in hemoglobin, the iron-rich protein that the body uses for oxygen transport. Iron is required to produce hemoglobin, and disruptions in the iron homeostasis can lead to iron-deficiency anemia. Management of anemia in individuals with CKD is typically performed by a team of physicians, nurse practitioners, physician assistants, or registered nurses. Throughout the care continuum, the management can be enhanced by multidisciplinary care, and individuals with CKD can benefit from the involvement of other specialties, with dietitians/nutritionists playing an important role. However, a key area of unmet clinical need is how to assess and address iron-deficiency anemia. This review aims to provide an overview of iron-deficiency anemia in CKD and how this may be diagnosed and managed by the entire kidney care team, such as describing the mechanisms underlying iron homeostasis, the complications of iron-deficiency anemia, and the current challenges associated with its diagnosis and treatment in CKD. Opportunities for each multidisciplinary team member to add value to the care of individuals with CKD and iron-deficiency anemia are also described.

Impact of a multidisciplinary approach involving clinical pharmacist on resolving drug related problems in chronic kidney patients: a prospective interventional study

BACKGROUND

Chronic kidney disease (CKD) is a major public health concern due to its high mortality risk, high hospitalization rates and cost, and low life expectancy. Thus, CKD patients are among patient group that may benefit from clinical pharmacy services the most.

METHODS

This was a prospective interventional study conducted between October 1, 2019, and March 18, 2020, in the nephrology ward of Ankara University School of the Medicine, Ibn-i Sina Hospital. DRPs were classified according to PCNE v8.03. The main outcomes were interventions proposed and the rate of acceptance by the physicians.

RESULTS

269 pre-dialysis patients were included to determine DRPs during the treatment process of the patients. 205 DRPs were found in 131 (48.7%) patients. Treatment efficacy was found to be the main type of DRPs (56.2%) followed by treatment safety (39.6%). When patients with and without DRPs were compared, it was found that the number of female patients (55.0%) was higher in the group with DRPs (p < 0.05). The length of hospital stays (11.3 ± 7.7) and the mean number of drugs used (9.6 ± 3.6) in the group with DRPs were significantly higher than those without DRPs (9.3 ± 5.9; 8.1 ± 3.5, respectively) (p < 0.05). 91.7% of the interventions were accepted by the physicians, and patients and found clinically beneficial. 71.7% of DRPs were fully resolved, 1.9% partially resolved and 23.4% could not be resolved.

CONCLUSIONS

A high prevalence of DRPs in patients with chronic kidney disease was determined during therapy. Clinical pharmacist interventions were highly accepted by the physicians and patients. This may indicate implementation of clinical pharmacy services in the nephrology ward has a great impact on optimized therapy and prevention DRPs.

Optimizing Multidisciplinary Care of Patients with Chronic Kidney Disease and Type 2 Diabetes Mellitus

Diabetes is the leading cause of chronic kidney disease (CKD), a condition associated with significant morbidity and mortality. As these patients have a high risk of developing cardiovascular disease and end-stage kidney disease, there is a need for early detection and early initiation of appropriate therapeutic interventions that slow disease progression and prevent adverse outcomes. Due to the complex nature of diabetes and CKD management, a holistic, patient-centered, collaborative care approach delivered by a coordinated multidisciplinary team (ideally including a clinical pharmacist as part of a comprehensive medication management program) is needed. In this review, we discuss the barriers to effective care, the current multidisciplinary approach used for CKD prevention and treatment, and the potential ways that the multidisciplinary management of CKD associated with type 2 diabetes mellitus can be refined to improve patient outcomes.

Evaluation of interactive teaching strategies and learning outcomes on the topic of kidney pharmacotherapy

BACKGROUND AND PURPOSE

Students' knowledge retention decreases overtime when experiencing large-group teaching. Engaging class activities improve student learning. We report the rapid changes in teaching methods and measurable learning outcomes on the topic of kidney pharmacotherapy (KP) in a doctor of pharmacy program.

EDUCATIONAL ACTIVITIES AND SETTING

The KP modules were delivered using two different methods, traditional lecture (TL) (in-person class) and interactive strategies of online learning (ISOL), to fourth-year pharmacy students during the academic years 2019 and 2020, respectively. This study aimed to compare the learning outcomes from TL and ISOL examinations. Students' perceptions regarding their new learning experiences were also explored.

FINDINGS

A total of 226 students were included in the study (TL, n = 118; ISOL, n = 108). The median percentage of the overall score from the ISOL examinations was higher than that achieved by the TL class (73% vs. 67%, P = .003). Further analyses revealed similar improvements in most learning outcomes and cognitive domains. A higher proportion of students taught through ISOL achieved scores >80% than those in the TL group (39% vs. 16%, P < .001). The student respondents provided positive feedback regarding activities in the ISOL cohort.

SUMMARY

The delivery of online KP when integrated with interactive strategies can maintain the outcome-based learning in Faculty of Pharmacy, Mahidol University. Approaches that aid student engagement during teaching and learning become opportunities for the improvement of education adaptability.

The effect of pharmacist-led interventions on the management and outcomes in chronic kidney disease (CKD): A systematic review and meta-analysis protocol

Background and Aims

Chronic kidney disease (CKD) is a progressive condition that results in a decline in kidney function over time. There are several conditions that increase the likelihood of developing CKD, particularly diabetes and hypertension. CKD increases the risk of mortality and has a detrimental impact on quality of life (QoL). Strategies for managing CKD include controlling cardiovascular risk factors and treating complications of CKD. There is an ever-increasing role of pharmacists in managing CKD, from the optimization of risk factors to patient education. However, currently, there is a lack of data on the effect pharmacist-led interventions have on the clinical, economic, and humanistic outcomes.

Methods

This protocol, in adherence to PRISMA-P (Preferred Reporting Items for Systematic review and Meta-Analysis Protocols) standards, describes a prospective systematic review and meta-analysis of randomized controlled trials, where any intervention led by a pharmacist in CKD is used. Comparison groups will consist of usual care or non-pharmacist-led interventions. Literature searches will be conducted in the following databases: MEDLINE, Scopus, and Web of Science. Data pertaining to clinical (e.g., mortality), economic (e.g., healthcare-associated costs), and humanistic (e.g., QoL) outcomes will be extracted. Risk of bias will be assessed using the United States National Heart Lung and Blood Institute quality assessment tool for controlled intervention studies. A meta-analysis will be conducted to synthesize appropriate comparable outcomes.

Results

The findings of this review will be published in a peer-reviewed journal, where the results will be presented in lay language with appropriate infographics online and via social media.

Conclusion

The findings of this review can identify gaps in the literature concerning optimizing pharmacist-led interventions in improving outcomes. In addition, this review will establish the importance of pharmacists in managing CKD patients, and whether this may result in their increased incorporation in multidisciplinary teams.

Geriatric Medicine Principles in Conservative Kidney Management: Frailty, Functional Assessments, and Selective Deprescribing

Conservative kidney management is a nondialytic treatment option for advanced chronic kidney disease that involves interventions to delay kidney function loss, medications to treat symptoms, and psychosocial support for patients and their loved ones. Several geriatric medicine principles are applicable to patients who are considering or receiving conservative kidney management, including the integration of physical, psychological, and social factors into medical care and medical decisions; careful review of medication lists with selective deprescribing; and screening for geriatric syndromes such as frailty and functional impairment. In this review, we discuss how functional and frailty assessments as well as selective deprescribing can be useful for patients considering or receiving conservative kidney management.

Chronic kidney disease and NLRP3 inflammasome: Pathogenesis, development and targeted therapeutic strategies

Chronic kidney disease (CKD) is a global health concern and public health priority. The condition often involves inflammation due to the accumulation of toxins and the reduced clearance of inflammatory cytokines, leading to gradual loss of kidney function. Because of the tremendous burden of CKD, finding effective treatment strategies against inflammation is crucial. Substantial evidence suggests an association between kidney disease and the inflammasome. As a well-known multiprotein signaling complex, the NLR family pyrin domain containing 3 (NLRP3) inflammasome plays an important role in inducing renal inflammation and fibrosis. Small molecule inhibitors targeting the NLRP3 inflammasome are potential agents for the treatment of CKD.The NLRP3 inflammasome activation amplifies the inflammation response, promoting pyroptotic cell death. Thus, it may contribute to the onset and progression of CKD, but the mechanism behind inflammasome activation in CKD remains obscure.In this review, we summarized recent findings on the role of the NLRP3 inflammasome in CKD and new strategies targeting the NLRP3 inflammasome.

Telephone versus In-Person Pharmacist-Led Medication Reviews in Home Dialysis Patients: Evaluating Quality of Care and Patient Satisfaction

The COVID-19 pandemic required pharmacists in a provincial Home Dialysis Clinic to adapt from in-person to telephone-based medication reviews. Studies have shown that in-person pharmacist interventions in patients with chronic kidney disease (CKD) lead to a reduction of drug therapy problems (DTPs), however, it's unknown if telephone interventions provide similar outcomes. The purpose of this study was to evaluate whether differences in quality of care exist between in-person vs. telephone medication reviews in home dialysis patients and to evaluate patient satisfaction with telephone medication reviews. Data from the two most recent in-person medication reviews was compared with the two most recent telephone medication reviews for each patient (n = 46). There were no statistically significant differences in DTPs identified between in-person and telephone medication reviews (p = 0.431). Physician acceptance of pharmacist recommendations was higher for in-person medication reviews (p = 0.009). Patients were satisfied with the care they received with pharmacist-led telephone medication reviews, however, 29% (n = 7) would prefer an in-person medication review once per year with telephone medication reviews the rest of the time. Overall, patients were satisfied with the care they received from telephone medication reviews.

"Positive Kidney Health": Implementation and design of a pharmacist-led intervention for patients at risk for development or progression of chronic kidney disease

BACKGROUND

Patients with early chronic kidney disease (CKD) or underlying risk factors are often unaware of their kidney test results, common causes of CKD, and ways to lower risk of disease onset/progression.

OBJECTIVE

To test feasibility of a pharmacist-led intervention targeting patient education and risk factors in patients with early CKD and those at risk for CKD.

PRACTICE DESCRIPTION

Ambulatory care pharmacists in community-based primary care clinics delivered kidney health education, ordered labs, and recommended medication adjustments.

PRACTICE INNOVATION

We identified patients with a moderate rate of decline (≥2 mL/min/1.73 m² per year) in estimated glomerular filtration (eGFR) at-risk for CKD or early stage CKD. An interactive workbook was designed to teach patients about kidney test results and self-management of risk factors including hypertension, type 2 diabetes, cigarette smoking, and chronic oral nonsteroidal anti-inflammatory drug use.

EVALUATION METHODS

Outcomes included visit uptake, completion of annual albuminuria screening, and initiation of guideline-directed medications for CKD. Patients were surveyed pre- and post-intervention for kidney health knowledge and perceptions regarding pharmacist-provided information.

RESULTS

Our sample of 20 participants had a mean eGFR of 59 mL/min/1.73 m² and the mean eGFR decline was -4.6 mL/min/1.73 m² per year. There were 47 visits during the pilot period from February 2021 to October 2021. Thirteen patients were missing albuminuria screening within 12 months; 2 of 9 patients with resulting labs had new microalbuminuria and were started on renoprotective medications. Patients had improved understanding of their kidney function test results and most did not consider the information scary or confusing.

CONCLUSION

Barriers to enrollment included fewer participants with multiple risk factors for CKD. The pharmacists were able to engage patients in learning the importance of monitoring and self-management of kidney health. A collaborative practice agreement may enhance a similar intervention that includes initiation of renoprotective medications.

The Effectiveness of Pharmacist Interventions in the Management of Patient with Renal Failure: A Systematic Review and Meta-Analysis

The existing trials have focused on a variety of interventions to improve outcomes in renal failure; however, quantitative evidence comparing the effect of performing multidimensional interventions is scarce. The present paper reviews data from previous randomized controlled trials (RCTs), examining interventions performed for patients with chronic kidney disease (CKD) and transplants by multidisciplinary teams, including pharmacists. Methods: A systematic search with quality assessment was performed using the revised Cochrane Collaboration's 'Risk of Bias' tool. Results and Conclusion: Thirty-three RCTs were included in the review, and the data from nineteen protocols were included in further quantitative analyses. A wide range of outcomes was considered, including those associated with progression of CKD, cardiovascular risk factors, patient adherence, quality of life, prescription of relevant medications, drug-related problems (DRPs), rate of hospitalizations, and death. The heterogeneity between studies was high. Despite low-to-moderate quality of evidence and relatively short follow-up, the findings suggest that multidimensional interventions, taken by pharmacists within multidisciplinary teams, are important for improving some clinical outcomes, such as blood pressure, risk of cardiovascular diseases and renal progression, and they improve non-adherence to medication among individuals with renal failure.

Evaluation of medication dose adjustments in patients with impaired renal function using different online drug information databases

OBJECTIVES

Clinical pharmacist-led medication dose adjustment is required to provide safe and effective pharmacotherapy in patients with impaired renal function. This study aimed to assess clinical pharmacist-led medication dose adjustments in hospitalised patients with impaired renal function by comparing three online drug information databases.

METHODS

This retrospective observational study was conducted in an internal medicine ward between November 2016 and February 2017 among hospitalised patients with at least one estimated glomerular filtration rate (eGFR) value <60 mL/min/1.73 m2. Clinical pharmacist-led medication dose adjustments according to eGFR were performed by comparing three online drug information databases: Micromedex, Medscape and Lexicomp. The number of items related to dose adjustments detected during the study period and the concordance between databases were evaluated.

RESULTS

This study was conducted among 100 hospitalised patients (mean age 74.6±13.2 years) with impaired renal function. Clinical pharmacists detected at least one medication dose adjustment in 71.0% of patients. Among these patients, it was found that physician-led medication dose adjustments were made in only 15.5% of them. Of 1053 medications, the number of medications that required dose adjustments were 149 (14.2%), 151 (14.3%) and 163 (15.5%) according to Micromedex, Medscape and Lexicomp, respectively. The Fleiss kappa coefficient was 0.875 and the agreement of the three clinical decision support systems were almost perfect.

CONCLUSIONS

In renal dose adjustments, Micromedex, Lexicomp and Medscape are concordant as online drug information databases. Clinical pharmacists could detect medication dose adjustment requirements in hospital patients with impaired renal function. The potential positive impact of clinical pharmacist-led medication dose adjustment should be investigated in further studies.

The role of clinical pharmacist in enhancing hemodialysis patients' adherence and clinical outcomes: a randomized-controlled study

BACKGROUND

Adherence to treatment recommendations is challenging in hemodialysis (HD) patients, yet it has been found to be extremely crucial in obtaining positive clinical and health outcomes.

AIM

To evaluate the influence of implementing an educational process provided by the clinical pharmacist on HD patients' adherence to treatment recommendations and clinical outcomes.

METHOD

A randomized controlled trial was conducted in which patients from three HD units in Jordan were randomly allocated to either an intervention (n = 60) or a control group (n = 60). During a three-month period, the intervention group received a monthly educational approach from a clinical pharmacist with recommendations for improving medication, nutrition, and fluid adherence, whereas the control received standard medical care. The primary outcome was patient adherence to HD-related recommendations. Quality of life (QOL), disease awareness, hospitalization, and changes in biochemicals were secondary outcomes.

RESULTS

The final analysis included 114 patients (n = 57/group). In the intervention group, there was a significant improvement in total adherence score versus control (1170.6 ± 44.1 vs. 665.8 ± 220.7, p < 0.001), and adherence to various aspects including episodes/duration of shortening HD, dietary guidelines, fluid restriction, and prescription medications. The clinical pharmacist intervention enhanced patients' QOL and improved awareness and perspective of the disease. Following the intervention, laboratory values for urea, creatinine, phosphorus, and hemoglobin were considerably improved. Additionally, the intervention group had fewer hospitalizations than the control group (0.54 ± 0.07 vs. 0.78 ± 0.26, p < 0.001).

CONCLUSION

Providing clinical pharmacy education to HD patients improved adherence behavior and clinical outcomes. This illustrates the importance of clinical pharmacists as interdisciplinary team members in dialysis care. Trial registration This trial has been registered in ISRCTN Register (ISRCTN75517095). https://clinicaltrials.gov/ct2/show/ISRCTN75517095.

Impact of medical and pharmaceutical interventions on anti-infective prescriptions: an observational study

Appropriate prescribing of anti-infectives is a public health challenge. In our hospital, clinical microbiologists (clinical microbiology mobile unit, UMMc) and clinical pharmacists (clinical pharmacy, PHAc) carry out interventions on anti-infective prescriptions to improve practices. Our main objective was to evaluate the acceptance of UMMc and PHAc interventions on anti-infective prescriptions by quantifying the rate of prescription change 24 h after intervention. The secondary objective was to characterize the type of intervention and associate the rate of change for each. All prescriptions are computerized, and interventions traced via DxCare® software, which feeds a local data warehouse (HEGP-CDW). This descriptive, retrospective, single-center, uncontrolled study was conducted from January 2015 to December 2018. The data were extracted over this period from the data warehouse and analyzed using R software. UMMc interventions were accepted 72.2% of the time and PHA interventions 87.3%. The types of interventions found were mostly dose adjustments (61.1% for the UMMc and 54.2% for the PHAc) and proposals to change or stop a drug. Interventions have an impact on anti-infective prescriptions and are generally followed by clinicians. For the category "discontinuation of a molecule", almost half of the advice from the UMMc was refused. The collaboration between the UMMc and PHAc should be reinforced to improve acceptance.

Pharmacist-driven renal dose optimization practice—outcomes of a retrospective study in ambulatory care settings

Objectives

Previous studies indicate a higher prevalence of inappropriate drug usage in patients with renal disease in ambulatory care settings and a higher rate of non-compliance with the renal dose adjustment protocol. This study aimed to investigate the number of renal dose adjustments recommended by pharmacists in ambulatory care settings, acceptance rate by the physicians and medications involved.

Methods

This two-year retrospective study was conducted in an ambulatory care pharmacy in a Saudi Arabian tertiary care hospital. Based on the renal protocol at the study site, the pharmacists recommended dose adjustments for inappropriate medication orders, and the outcomes were documented electronically. A quantitative descriptive analysis of this practice was performed by retrieving the pharmacists’ documentation from electronic health records. Only protocol-compliant recommendations with proper documentation were included in the study.

Key findings

A total of 302 renal dose adjustments were recommended by pharmacists for 269 patients involving 47 medications, with an average of 1.12 recommendations per patient. The average monthly recommendation was 12.58 (median: 11; SD: 5.174; 95% Confidence Interval (CI), 12 to 13.16). Of the 302 recommendations, 219 (72.52%) were accepted by the physician, and 71 (23.51%) were not. The most common medications accepted for renal dosage adjustment included levofloxacin (8.94%), metformin (5.29%), amoxicillin-clavulanate (5.29%), cetirizine (4.97%), diclofenac (4.64%), ciprofloxacin (3.97%) and nitrofurantoin (3.31%).

Conclusions

The pharmacist’s renal dose recommendations have a high acceptance rate in ambulatory care. This study demonstrated that ambulatory care pharmacists play a substantial clinical role in reducing inappropriate drug use in patients with renal disease.

Impact of pharmacist services on economic, clinical, and humanistic outcome (ECHO) of South Asian patients: a systematic review

Background

Pharmacists in high-income countries routinely provide efficient pharmacy or pharmaceutical care services that are known to improve clinical, economic, and humanistic outcomes (ECHO) of patients. However, pharmacy services in low- and middle-income countries, mainly South Asia, are still evolving and limited to providing traditional pharmacy services such as dispensing prescription medicines. This systematic review aims to assess and evaluate the impact of pharmacists’ services on the ECHO of patients in South Asian countries.

Methods

We searched PubMed/Medline, Scopus, EMBASE, CINAHL, and Cochrane Library for relevant articles published from inception to 20th September 2021. Original studies (only randomised controlled trials) conducted in South Asian countries (published only in the English language) and investigating the economic, clinical (therapeutic and medication safety), and humanistic impact (health-related quality of life) of pharmacists’ services, from both hospital and community settings, were included.

Results

The electronic search yielded 430 studies, of which 20 relevant ones were included in this review. Most studies were conducted in India (9/20), followed by Pakistan (6/20), Nepal (4/20) and Sri Lanka (1/20). One study showed a low risk of bias (RoB), 12 studies showed some concern, and seven studies showed a high RoB. Follow-up duration ranged from 2 to 36 months. Therapeutic outcomes such as HbA1c value and blood pressure (systolic blood pressure and diastolic blood pressure) studied in fourteen studies were found to be reduced. Seventeen studies reported humanistic outcomes such as medication adherence, knowledge and health-related quality of life, which were found to be improved. One study reported safety and economic outcomes each. Most interventions delivered by the pharmacists were related to education and counselling of patients including disease monitoring, treatment optimisation, medication adherence, diet, nutrition, and lifestyle.

Conclusion

This systematic review suggests that pharmacists have essential roles in improving patients’ ECHO in South Asian countries via patient education and counselling; however, further rigorous studies with appropriate study design with proper randomisation of intervention and control groups are anticipated.

Potential drug-drug interactions of immunosuppressants in kidney transplant recipients: comparison of drug interaction resources

Background Drug-drug interactions are frequently observed in kidney transplant recipients due to polypharmacy and use of immunosuppressants. However, there is only one study evaluating clinically relevant potential drug-drug interactions of immunosuppressants specially in kidney transplant recipients by means of online databases and Stockleys Drug Interactions, as a gold standard. Aim This study aimed to compare four online databases used frequently to determined clinically relevant potential drug-drug interactions of immunosuppressants in kidney transplant recipients according to the Renal Drug Handbook. Method This was a descriptive cross-sectional study conducted between October 1, 2019, and March 18, 2020, in the nephrology ward of Ankara University School of the Medicine, Ibn-i Sina Hospital. In total, 52 adult patients' discharge prescriptions were retrieved from their medical records and analyzed retrospectively. Micromedex®, Lexicomp®, Medscape, and Drugs.com databases were used to evaluate drug interactions. The Renal Drug Handbook was used as a gold standard to do specificity and sensitivity analysis. Results A total of 127 potential drug-drug interactions between the immunosuppressants and co-medications were detected by at least one online database. 32 (25.2%) of these were approved as clinically relevant potential drug-drug interactions by the Renal Drug Handbook. Lexicomp® and Drugs.com have exhibited the highest sensitivity (0.72 and 0.75) while Micromedex® has shown the highest specifity (0.83). Furthermore, the highest positive predictive value has been observed in Micromedex® (0.53). Micromedex® and Medscape had the highest negative predictive value (0.83 and 0.82). However, the kappa value of all was low. The values of inter-rater agreement (Kappa index) between online databases and the Renal Drug Handbook were weak (range 0.05-0.36). In addition, only 11 (8.7%) of potential drug-drug interactions were identified by all online databases. Conclusion This study showed that there was a weak compatibility between each database examined and the Renal Drug Handbook to detect clinically relevant potential drug-drug interactions for immunosuppressants in kidney transplant recipients. Therefore, we suggest that although databases might be practical to take a quick glance in detection of potential drug-drug interactions between immunosuppressants and co-medications, the data should be evaluated in detail and interpreted with caution in combination with a reference book like Renal Drug Handbook.

Drug-drug interactions in polypharmacy patients: The impact of renal impairment

Chronic kidney disease (CKD) is a long-term condition characterized by a gradual loss of kidney functions, usually accompanied by other comorbidities including cardiovascular diseases (hypertension, heart failure and stroke) and diabetes mellitus. Therefore, multiple pharmacological prescriptions are very common in these patients. Epidemiological and clinical observations have shown that polypharmacy may increase the probability of adverse drug reactions (ADRs), possibly through a higher risk of drug-drug interactions (DDIs). Renal impairment may further worsen this scenario by affecting the physiological and biochemical pathways underlying pharmacokinetics and ultimately modifying the pharmacodynamic responses. It has been estimated that the prevalence of DDIs in CKD patients ranged between 56.9% and 89.1%, accounting for a significant increase in healthcare costs, length and frequency of hospitalization, with a detrimental impact on health and quality of life of these patients. Despite these recognized high-risk conditions, scientific literature released on this topic is still limited. Basing on the most commonly prescribed therapies in patients with CKD, the present short review summarizes the current state of knowledge of the putative DDIs occurring in CKD patients undergoing polytherapy. The most relevant underlying mechanisms and their clinical significance are also debated.

Management of Drug-Drug Interactions among Critically Ill Patients with Chronic Kidney Disease: Impact of Clinical Pharmacist's Interventions

BACKGROUND AND OBJECTIVES

Drug-drug interactions (DDIs) can create a burden on prescribers to preserve patient safety. This study aimed to identify common DDIs in critically ill patients with chronic kidney disease (CKD) and to evaluate clinical pharmacist's interventions in managing DDIs among these patients.

METHODS

A prospective observational study was conducted from October 2018 to March 2019. The clinical pharmacist performed a medication chart review; DDIs were identified by using Lexicomp® drug interaction. Based on the occurrence of DDIs, patients were divided into group A: patients with DDI (n = 76) and group B: patients without DDI (n = 15). Clinical pharmacist's interventions were classified according to Pharmaceutical Care Network Europe. The National Coordinating Council for Medication Error Reporting and Prevention was used to categorize the severity outcomes of DDIs and the degree of patient harm.

RESULTS

A total of 273 DDIs were identified. The majority of DDIs (63.7%) required close monitoring of the therapeutic outcome to ensure maintaining patient safety. DDIs that needed to be managed by considering therapy modification and avoiding drug combination were accounted for 17.2 and 12.8% of the most common detected interactions, respectively. Seventy-eight percent of DDIs induced no harm to patient. Clinical pharmacist provided different types of recommendations to manage detected interactions, which ranged from therapy outcome monitoring to stop DDIs. A great proportion of pharmacist's interventions (92%) were accepted by prescribers. Compared to patients with stage 3 and 4 CKD, patients with stage 5 had a significantly higher number of DDIs (stage 3 vs 5: p = 0.0019, stage 4 vs 5: p = 0.0456). The number of comorbidities (p = 0.0003) and (p <0.0001) medications were found to be significantly greater in group A.

CONCLUSION

Clinical pharmacist performed important interventions in timely identifying, managing DDIs, and prevention of associated patient harms.

HOW TO CITE THIS ARTICLE

Aghili M, Kasturirangan MN. Management of Drug-Drug Interactions among Critically Ill Patients with Chronic Kidney Disease: Impact of Clinical Pharmacist's Interventions. Indian J Crit Care Med 2021;25(11):1226-1231.

Drug-related problems in older patients with advanced chronic kidney disease identified during pretransplant comprehensive geriatric assessment

BACKGROUND

Older patients with advanced chronic kidney disease may be exposed to a higher risk of adverse drug events due to chronic kidney disease and aging. The integration of clinical pharmacist into pretransplant comprehensive geriatric assessment is an opportunity to perform medication optimization.

OBJECTIVE

The aim was to describe drug-related problems in older patients with advanced chronic kidney disease.

METHODS

Observational study was conducted with retrospective data from July 2017 to April 2019. Patients≥65 years with advanced chronic kidney disease, referred by nephrologists for pretransplant comprehensive geriatric assessment were included. During medication optimization, the pharmacist evaluated the appropriateness of each medication prescribed and identified drug-related problems. Any drug-related problem identified lead to a pharmaceutical intervention.

RESULTS

In total, 103 patients were included (74.5±2.9 years, 26.2% female, 47.6% on dialysis). Overall, 394 drug-related problems were identified in 93.2% of patients (3.8±2.4 drug-related problems per patient) during the medication optimization. Cardiovascular medications (25.1%), antithrombotics (13.5%) and drugs for peptic ulcer and reflux disease (10.2%) were the most involved drugs in drug-related problems. Drug-related problems mainly concerned drugs without indication (27.1%), inappropriate method of administration (24.4%) and non-conformity to guidelines (20.1%).

CONCLUSION

A high prevalence of drug-related problems in older patients with advanced chronic kidney disease was identified during medication optimization. The systematic integration of a clinical pharmacist in the multidisciplinary team performing pretransplant comprehensive geriatric assessment may be relevant to detect inappropriate prescriptions and to prevent from adverse drug events.

Kidney Disease Management in the Hospital Setting: A Focus on Inappropriate Drug Prescriptions in Older Patients

Aging with multimorbidity and polytherapy are the most significant factors that could led to inappropriate prescribing of contraindicated medications in patients with chronic kidney disease (CKD). The aim of this study was to evaluate the prescriptions of contraindicated drugs in older adults in CKD and to identify their associated factors in a hospital context. An observational retrospective study was carried out considering all patients ≥65 years with at least one serum creatinine value recorded into the REPOSI register into 2010-2016 period. The estimated glomerular filtration rate (eGFR) was applied to identify CKD. A descriptive analysis was performed to compare demographic and clinical characteristics; logistic regression models were used to estimate factors of inappropriate and percentage changes of drug use during hospitalization. A total of 4,713 hospitalized patients were recorded, of which 49.8% had an eGFR <60 ml/min/1.73 m²; the 21.9% were in treatment with at least one inappropriate drug at the time of hospital admission with a decrease of 3.0% at discharge (p = 0.010). The probability of using at least one contraindicated drug was significantly higher in patients treated with more several drugs (OR 1.21, 95% CI 1.16-1.25, p <0.001) and with CKD end-stages (G4: 16.90, 11.38-25.12, p < 0.001; G5: 19.38, 11.51-32.64, p < 0.001). Low-dose acetylsalicylic acid was the contraindicated drug mainly used at the time of admission, reducing 1.2% at discharge. An overall increase in therapeutic appropriateness in hospitalized older patients with CKD was observed, despite a small percentage of therapeutic inappropriateness at discharge that underlines the need for a closer collaboration with the pharmacologist to improve the drug management.

Assessment of Pharmacists' Knowledge and Practices towards Prescribed Medications for Dialysis Patients at a Tertiary Hospital in Riyadh Saudi Arabia

Objective: The present study examined pharmacists’ knowledge and practices towards prescribed medications for hemodialysis patients. The impact of a pharmacist’s current positions and years of experience on practices and knowledge was also assessed. Methods: A cross-sectional survey was distributed to pharmacists working at King Abdul-Aziz Medical City-Central Region over a period of 4 months from July to October in 2015. Results: Of the 85 approached pharmacists, 66 pharmacists completed the questionnaire, among which 45 (68.2%), 9 (13.6%), and 12 (18.2%) of them were outpatient hospital pharmacists, discharge counselling pharmacists, and pharmacy practice residents, respectively. In total, 47 (55.3%) of the pharmacists sought drug information resources for newly prescribed medications to hemodialysis patients. Among the surveyed pharmacists, around two-thirds of them (63.6%) were completely confident during counselling hemodialysis patients, while 32% were moderately confident, and only 4.5% were not confident. All of the participating pharmacists checked each patient’s allergic status before dispensing hemodialysis medications. The majority of the outpatient hospital pharmacists (35; 77.8%), discharge pharmacists (8; 88.9%), and the pharmacy practice residents (11; 91.7%) agreed that oral ciprofloxacin should be given after dialysis session on the same dialysis days, while 18 (40%), 5 (55.6%), and 9 (75%) of the outpatient hospital pharmacists, discharge pharmacists, and pharmacy practice residents agreed that IV route is preferred for hemodialysis patients to administer epoetin alfa, respectively. Sixty-six percent of discharge pharmacists (n = 6), 91.7% (n = 11) of the pharmacy practice residents, and 55.6% (n = 25) of the outpatient hospital pharmacists checked patient laboratory results prior to dispensing medications (p = 0.001). Conclusions: Despite the limited knowledge regarding some prescribed medications, most of the hospital pharmacists showed good practices toward dialysis patients.

Medicines optimization for patients with chronic kidney disease in the outpatient setting: the role of the clinical pharmacist

OBJECTIVES

Medicines optimization (MO) in patients with chronic kidney disease (CKD) is at high risk at transition points of different ambulatory care levels such as nephrologists in outpatient clinics and general practitioners (GPs). We examined if adding a clinical pharmacist to the therapeutic team promotes implementation of nephrologists' drug therapy recommendations by GPs' and reduces drug-related problems (DRPs).

METHODS

A prospective, controlled intervention study was conducted in the nephrology outpatient clinic of the Klinikum Fulda, Germany. The control and intervention phases took place successively. Patients with CKD stage 3-5 and at least one concomitant disease, for example, arterial hypertension or type-2 diabetes were recruited consecutively in three subgroups (naive, 1 contact, ≥2 contacts with nephrologist) from June 2015 to May 2019. GPs' acceptance and frequency of DRPs without (control group [CG]) and with (intervention group [IG]) pharmacist's interventions were compared after 6 months. Interventions include educational training events for GPs between control- and intervention phase, medication therapy management and pharmaceutical patient counselling.

KEY FINDINGS

In total, 256 patients (CG = 160, IG = 96) were recruited into the study. GPs' acceptance of nephrologists' medication recommendations increased significantly among naive patients and those with one prior contact with the nephrologist (CG/IG: naive = 72.8%/95.5%, 1 contact = 81.1%/94.4%; P < 0.001). DRPs per patient were significantly reduced in all subgroups (P < 0.001).

CONCLUSIONS

Interdisciplinary collaboration between the nephrologist, GPs and clinical pharmacist resulted in better MO for patients with CKD.

Ghent Older People's Prescriptions Community Pharmacy Screening (GheOP3S)-Tool Version 2: Update of a Tool to Detect Drug-Related Problems in Older People in Primary Care

Background

The Ghent Older People’s Prescriptions community Pharmacy Screening (GheOP³S)-tool was developed in 2016 as a screening tool to detect drug-related problems (DRPs) and to help in performing medication reviews in older people (≥ 65 years).

Objective

This study aimed to revise and update the GheOP³S-tool.

Methods

Users’ comments were collected to improve the usability and appropriateness of the original GheOP³S-tool, followed by a two-round modified Delphi process according to the RAND/UCLA appropriateness method. This included a literature review, a round zero meeting, a first written round (with 15 international and multidisciplinary experts) and a second face-to-face round (with 11 experts) to change, delete or add GheOP³S-criteria. An additional third round with 14 community pharmacists was organised to preserve criteria applicable in the current community pharmacy practice.

Results

The updated GheOP³S-tool consists of five lists of DRPs and a new addendum containing medications that should be avoided or used with caution in older people with reduced renal function. During the first two rounds, related criteria were grouped, 14 criteria were added and 17 criteria were deleted from the original tool. All criteria were deemed applicable in round 3. This led to a final tool (version 2) with 64 GheOP³S-criteria.

Conclusion

GheOP³S-criteria were revised and updated according to experts’ agreement on their clinical relevance and recent scientific evidence. Future studies should investigate the impact of pharmacist-led medication reviews with GheOP³S-tool version 2 on clinical, humanistic and economic outcomes in primary care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40266-021-00862-6.

Effectiveness of Clinical Pharmacist Service on Drug-Related Problems and Patient Outcomes for Hospitalized Patients with Chronic Kidney Disease: A Randomized Controlled Trial

(1) Background: The study aimed to analyze the effectiveness of clinical pharmacist services on drug-related problems (DRPs) and patient outcomes in inpatients with chronic kidney disease (CKD). (2) Methods: In a randomized controlled trial, the participants in the intervention group received pharmacist services, including medication reconciliation, medication evaluation and management, and discharge pharmaceutical care transition services. Participants in the control group received usual care. The primary outcome was the number of DRPs per patient at discharge. (3) Results: The baseline characteristics of 100 participants included the following: mean age, 52.5 years; median eGFR, 9.2 mL/min/1.73 m². The number of DRPs in the intervention group during hospitalization increased significantly with decreasing eGFR (PR, 0.970; 95% CI, 0.951–0.989) and an increasing number of unintentional medication discrepancies at admission (PR, 1.294; 95% CI, 1.034–1.620). At discharge, the number of DRPs per patient was 0.94 ± 1.03 and 1.96 ± 1.25 in the intervention and control groups, respectively (p < 0.001). The service had a significant effect on the reduction of the unintentional discrepancies at discharge (p < 0.001). (4) Conclusion: Hospital pharmacists play an important role in the prevention of DRPs at discharge and unintentional medication discrepancies in inpatients with CKD.

Pharmacist-Led Collaborative Medication Management for the Elderly with Chronic Kidney Disease and Polypharmacy

Inappropriate polypharmacy is likely in older adults with chronic kidney disease (CKD) owing to the considerable burden of comorbidities. We aimed to describe the impact of pharmacist-led geriatric medication management service (MMS) on the quality of medication use. This retrospective descriptive study included 95 patients who received geriatric MMS in an ambulatory care clinic in a single tertiary-care teaching hospital from May 2019 to December 2019. The average age of the patients was 74.9 ± 7.3 years; 40% of them had CKD Stage 4 or 5. Medication use quality was assessed in 87 patients. After providing MMS, the total number of medications and potentially inappropriate medications (PIMs) decreased from 13.5 ± 4.3 to 10.9 ± 3.8 and 1.6 ± 1.4 to 1.0 ± 1.2 (both p < 0.001), respectively. Furthermore, the number of patients who received three or more central nervous system-active drugs and strong anticholinergic drugs decreased. Among the 354 drug-related problems identified, “missing patient documentation” was the most common, followed by “adverse effect” and “drug not indicated.” The most frequent intervention was “therapy stopped”. In conclusion, polypharmacy and PIMs were prevalent in older adults with CKD; pharmacist-led geriatric MMS improved the quality of medication use in this population.

Opportunities of information communication technologies for providing pharmaceutical care in the COVID-19 pandemic

This article discusses the opportunities of information and communication technologies for providing pharmaceutical care in the context of the COVID-19 pandemic.

The global COVID-19 pandemic has necessitated a reorientation of the concept of providing health care to large-scale implementation of information technologies to improve the quality of medical and pharmaceutical services for the population. It had a significant impact on pharmacy, which necessitated changes in the management of pharmaceutical care for patients. Rapid and urgent measures were taken by the pharmacists, who found themselves at the forefront. Telepharmacy has proven to be a successful solution in the fight against the virus in the conditions of physical distance. The introduction of modern information and communication technologies worldwide will create significant advantages for more efficient use of resources and management of pharmaceutical care.

Pharmacist impact on medication dosing and billable coding accuracy in outpatients with chronic kidney disease

BACKGROUND

Ambulatory care pharmacists can enhance economic and clinical outcomes as part of interdisciplinary health care teams. Patients with chronic kidney disease (CKD) often have complex medication regimens, potentially resulting in dosing errors and drug interactions.

OBJECTIVE

To demonstrate the impact that clinic-based pharmacists may have in populations comprising ambulatory patients with CKD.

PRACTICE DESCRIPTION

Community-owned, not-for-profit health system with outpatient, primary, and specialty care clinics.

PRACTICE INNOVATION

This quality-assurance, cohort, interventional study included patients aged at least 18 years with a CKD- or end-stage renal disease-associated diagnosis code seen by a clinic primary care provider at least once between January and June 2019. Primary outcomes included the number of medications requiring pharmacist intervention, pharmacist-initiated recommendations, and associated outcomes.

EVALUATION METHODS

Patients were randomly assigned to 2 cohorts. Providers of patients in the proactive pharmacist intervention group were notified of pharmacist recommendations immediately after initial data collection. Providers of patients in the group undergoing usual care (control group) were notified of identified medication recommendations after a 3-month period of usual care. Demographics were assessed using descriptive statistics. Differences in CKD staging, number of recommendations made, and provider responses were assessed using the chi-square, Fisher exact, and Mann-Whitney U tests.

RESULTS

A total of 182 patients were eligible for inclusion. In the intervention group, 22.1% of patients were identified as having inappropriately dosed medications versus 19.5% in the control group. In the intervention group, 46 of the 95 patients (48.4%) had an inaccurate CKD stage documented compared with 48 of the 87 patients (55.2%) in the control group (P = 0.772). The rate of pharmacist recommendation rejection substantially decreased between the intervention and control groups' provider responses (24% to 11.8%).

CONCLUSION

Pharmacist-initiated recommendations resulted in the identification and resolution of medication-dosing errors and improved collaboration between providers and pharmacists.