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Tamargo J, Caballero R, Delpón E. The pharmacotherapeutic management of hyperkalemia in patients with cardiovascular disease. Expert Opin Pharmacother 2021; 22:1319-1341. [PMID: 33620275 DOI: 10.1080/14656566.2021.1891223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Patients with cardiovascular diseases (CVD) are at increased risk of hyperkalemia, particularly when treated with renin-angiotensin-aldosterone inhibitors (RAASIs). Because the occurrence or fear of hyperkalemia, RAASIs are frequently down-titrated or discontinued in patients with CVD, with consequent worse outcomes than patients who remain on maximum doses.Areas covered: This article reviews potassium homeostasis, epidemiology, risk factors, and outcomes of hyperkalemia, and efficacy and safety of the drugs used for acute and chronic treatment of hyperkalemia. A literature search was carried out using the PubMed and guidelines for the management of hyperkalemia.Expert opinion: The emergency treatment of hyperkalemia is not supported by high-quality evidence and clinical trials did not report drug effects on clinical outcomes. Two potassium binders, patiromer and sodium zirconium cyclosilicate, represent a new approach in the treatment of chronic hyperkalemia as they may allow the titration and maintenance of guidelines-recommended doses of RAASIs in patients with CVD who otherwise would not tolerate them due to the risk of hyperkalemia.Further studies are needed to evaluate the safety and efficacy of drug therapy and support the development of guidelines for acute and chronic hyperkalemia.
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Affiliation(s)
- Juan Tamargo
- Department of Pharmacology, School of Medicine, Universidad Complutense, Instituto De Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Ricardo Caballero
- Department of Pharmacology, School of Medicine, Universidad Complutense, Instituto De Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Eva Delpón
- Department of Pharmacology, School of Medicine, Universidad Complutense, Instituto De Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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Kuo WH, You HL, Huang WT, Lee YT, Chiou TTY, Ng HY, Lee CT. Incidence, characteristics and outcomes among inpatient, outpatient and emergency department with reported high critical serum potassium values. Clin Chem Lab Med 2021; 59:1231-1237. [PMID: 33606926 DOI: 10.1515/cclm-2020-1476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 02/08/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Severe hyperkalemia can cause life-threatening arrhythmia, cardiac arrest, or death. This study aimed to investigate the incidence and the associated factors relevant to critical hyperkalemia (≥6 mmol/L) among inpatients, outpatients, and emergency department. Their clinical outcomes were also analyzed. METHODS All patients whose high serum potassium values had been reported as critical laboratory values in 2016 were enrolled. Their demographic data, comorbidities, clinical symptoms, biochemical data, and outcomes were reviewed and collected. The Charlson comorbidity score (CCS) and glomerular filtration rate (GFR) were computed to assess the comorbidity burden and renal function. Patients were divided into groups according to different settings, potassium and GFR levels, and their survival. RESULTS Of the 293,830 total serum potassium tests, 1,382 (0.47%) reports were listed as critical laboratory values. The average reply time was 6.3 min. Their mean age was 67.2 years, while the average GFR was 12.2 mL/min/1.73 m2. The overall mortality rate was 34%. Patients in the emergency department had the highest incidence (0.92%), while inpatients had the worst outcome (51% mortality). The leading cause of mortality was septic shock. The fatal group had higher rates of clinical symptoms, higher potassium values, CCS, and eGFR (all p<0.05). CONCLUSIONS Most of the responses for the reports were obtained within a short period of time. Patients with reported high critical serum potassium values were characterized by high rates of comorbidity, reduced eGFR, and mortality. The incidence, clinical manifestations, and outcomes varied in the different clinical settings.
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Affiliation(s)
- Wei-Hung Kuo
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Huey-Ling You
- Department of Laboratory Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wan-Ting Huang
- Department of Laboratory Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yueh-Ting Lee
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Terry Ting-Yu Chiou
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Hwee-Yeong Ng
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chien-Te Lee
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Medication as a risk factor for hospitalization due to heart failure and shock: a series of case-crossover studies in Swiss claims data. Eur J Clin Pharmacol 2020; 76:979-989. [PMID: 32270213 PMCID: PMC7306029 DOI: 10.1007/s00228-020-02835-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/20/2020] [Indexed: 01/06/2023]
Abstract
Purpose Heart failure is among the leading causes for hospitalization in Europe. In this study, we evaluate potential precipitating factors for hospitalization for heart failure and shock. Methods Using Swiss claims data (2014–2015), we evaluated the association between hospitalization for heart failure and shock, and prescription of oral potassium supplements, non-steroidal anti-inflammatory drugs (NSAIDs), and amoxicillin/clavulanic acid. We conducted case-crossover analyses, where exposure was compared for the hazard period and the primary control period (e.g., 1–30 days before hospitalization vs. 31–60 days, respectively). Conditional logistic regression was applied and subsequently adjusted for addressing potential confounding by disease progression. Sensitivity analyses were conducted and stratification for co-medication was performed. Results We identified 2185 patients hospitalized with heart failure or shock. Prescription of potassium supplements, NSAIDs, and amoxicillin/clavulanic acid was significantly associated with an increased risk for hospitalization for heart failure and shock with crude odds ratios (OR) of 2.04 for potassium (95% CI 1.24–3.36, p = 0.005, 30 days), OR 1.8 for NSAIDs (95% CI 1.39–2.33, p < 0.0001, 30 days), and OR 3.25 for amoxicillin/clavulanic acid (95% CI 2.06–5.14, p < 0.0001, 15 days), respectively. Adjustment attenuated odds ratios, while the significant positive association remained (potassium OR 1.70 (95% CI 1.01–2.86, p = 0.046), NSAIDs OR 1.50 (95% CI 1.14–1.97, p = 0.003), and amoxicillin/clavulanic acid OR 2.26 (95% CI 1.41–3.62, p = 0.001). Conclusion Prescription of potassium supplements, NSAIDs, and amoxicillin/clavulanic acid is associated with increased risk for hospitalization. Underlying conditions such as pain, electrolyte imbalances, and infections are likely contributing risk factors. Physicians may use this knowledge to better identify patients at risk and adapt patient management. Electronic supplementary material The online version of this article (10.1007/s00228-020-02835-x) contains supplementary material, which is available to authorized users.
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Bouadma L, Mankikian S, Darmon M, Argaud L, Vinclair C, Siami S, Garrouste-Orgeas M, Papazian L, Cohen Y, Marcotte G, Styfalova L, Reignier J, Lautrette A, Schwebel C, Timsit JF. Influence of dyskalemia at admission and early dyskalemia correction on survival and cardiac events of critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:415. [PMID: 31856891 PMCID: PMC6921444 DOI: 10.1186/s13054-019-2679-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 11/20/2019] [Indexed: 12/24/2022]
Abstract
Objectives Our objectives were (1) to characterize the distribution of serum potassium levels at ICU admission, (2) to examine the relationship between dyskalemia at ICU admission and occurrence of cardiac events, and (3) to study both the association between dyskalemia at ICU admission and dyskalemia correction by day 2 on 28-day mortality. Design Inception cohort study from the longitudinal prospective French multicenter OUTCOMEREA database (1999–2014) Setting 22 French OUTCOMEREA network ICUs Patients Patients were classified into six groups according to their serum potassium level at admission: three groups of hypokalemia and three groups of hyperkalemia defined as serious hypokalemia [K+] < 2.5 and serious hyperkalemia [K+] > 7 mmol/L, moderate hypokalemia 2.5 ≤ [K+] < 3 mmol/L and moderate hyperkalemia 6 < [K+] ≤ 7 mmol/L, and mild hypokalemia 3 ≤ [K+] < 3.5 mmol/L and mild hyperkalemia 5 < [K+] ≤ 6 mmol/L. We sorted evolution at day 2 of dyskalemia into three categories: balanced, not-balanced, and overbalanced. Intervention None Measurements and main results Of 12,090 patients, 2108 (17.4%) had hypokalemia and 1445 (12%) had hyperkalemia. Prognostic impact of dyskalemia and its correction was assessed using multivariate Cox models. After adjustment, hypokalemia and hyperkalemia were independently associated with a greater risk of 28-day mortality. Mild hyperkalemic patients had the highest mortality (hazard ratio (HR) 1.29, 95% confidence interval (CI) [1.13–1.47], p < 0.001). Adjusted 28-day mortality was higher if serum potassium level was not-balanced at day 2 (aHR = 1.51, 95% CI [1.30–1.76], p < 0.0001) and numerically higher but not significantly different if serum potassium level was overbalanced at day 2 (aHR = 1.157, 95% CI [0.84–1.60], p = 0.38). Occurrence of cardiac events was evaluated by logistic regression. Except for patients with serious hypokalemia at admission, the depth of dyskalemia was associated with increased risk of cardiac events. Conclusions Dyskalemia is common at ICU admission and associated with increased mortality. Occurrence of cardiac events increased with dyskalemia depth. A correction of serum potassium level by day 2 was associated with improved prognosis.
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Affiliation(s)
- Lila Bouadma
- UMR 1137, IAME, Université Paris Diderot, F75018, Paris, France. .,Medical and Infectious Diseases Care Unit, AP-HP, Bichat University Hospital, F75018, Paris, France. .,Service de Réanimation Médicale et des Maladies Infectieuses, Hôpital Bichat-Claude-Bernard, 46 rue Henri-Huchard, 75877, Paris Cedex 18, France.
| | - Stefan Mankikian
- AP-HP, Pitié-Salpêtrière University Hospital, Cardiology, Paris, France
| | - Michael Darmon
- APHP, Saint-Louis University Hospital, Medical Intensive Care Unit, Paris, France.,Paris-7 Paris Diderot University, Paris, France
| | - Laurent Argaud
- Medical ICU, Edouard Herriot University Hospital, Lyon, France
| | | | - Shidasp Siami
- Critical Care Medicine Unit CH Etampes-Dourdan, Etampes, France
| | | | - Laurent Papazian
- Respiratory and Infectious Diseases ICU, APHM Hôpital Nord, Aix Marseille University, Marseille, France
| | - Yves Cohen
- AP-HP, Avicenne Hospital, Intensive Care Unit, Paris, France.,Medicine University, Paris 13 University, Bobigny, France
| | | | | | - Jean Reignier
- Medical Intensive Care Unit and University Hospital Centre, Nantes, France
| | - Alexandre Lautrette
- Medical Intensive Care Unit, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | - Carole Schwebel
- Medical Intensive Care Unit, Grenoble University Hospital, Grenoble 1 University, U823, La Tronche, France
| | - Jean-Francois Timsit
- UMR 1137, IAME, Université Paris Diderot, F75018, Paris, France.,Medical and Infectious Diseases Care Unit, AP-HP, Bichat University Hospital, F75018, Paris, France
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Muylle KM, Gentens K, Dupont AG, Cornu P. Evaluation of context-specific alerts for potassium-increasing drug-drug interactions: A pre-post study. Int J Med Inform 2019; 133:104013. [PMID: 31698230 DOI: 10.1016/j.ijmedinf.2019.104013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 10/04/2019] [Accepted: 10/14/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To investigate whether context-specific alerts for potassium-increasing drug-drug interactions (DDIs) in a clinical decision support system reduced the alert burden, increased alert acceptance, and had an effect on the occurrence of hyperkalemia. MATERIALS AND METHODS In the pre-intervention period all alerts for potassium-increasing DDIs were level 1 alerts advising absolute contraindication, while in the post-intervention period the same drug combinations could trigger a level 1 (absolute contraindication), a level 2 (monitor potassium values), or a level 3 alert (informative, not shown to physicians) based on the patient's recent laboratory value of potassium. Alert acceptance was defined as non-prescription or non-administration of the interacting drug combination for level 1 alerts and as monitoring of the potassium levels for level 2 alerts. RESULTS The alert burden decreased by 92.8%. The relative risk (RR) for alert acceptance based on prescription rates for level 1 alerts and monitoring rates for level 2 alerts was 15.048 (86.5% vs 5.7%; 95% CI 12.037-18.811; P < 0.001). With alert acceptance for level 1 alerts based on actual administration and for level 2 alerts on monitoring rates, the RR was 3.597 (87.6% vs 24.4%; 95% CI 3.192-4.053; P < 0.001). In the generalized linear mixed model the effect of the intervention on the occurrence of hyperkalemia was not significant (OR 1.091, 95% CI 0.172-6.919). CONCLUSION The proposed strategy seems effective to get a grip on the delicate balance between over- and under alerting.
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Affiliation(s)
- Katoo M Muylle
- Research Group Clinical Pharmacology & Clinical Pharmacy (KFAR), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Laarbeeklaan 103, 1090, Brussels, Belgium.
| | - Kristof Gentens
- Department of Medical Informatics, UZ Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Alain G Dupont
- Research Group Clinical Pharmacology & Clinical Pharmacy (KFAR), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Laarbeeklaan 103, 1090, Brussels, Belgium.
| | - Pieter Cornu
- Research Group Clinical Pharmacology & Clinical Pharmacy (KFAR), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Laarbeeklaan 103, 1090, Brussels, Belgium; Department of Medical Informatics, UZ Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
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Robert L, Ficheur G, Décaudin B, Gellens J, Luyckx M, Perichon R, Gautier S, Puisieux F, Chazard E, Beuscart J. Hospital‐Acquired Hyperkalemia Events in Older Patients Are Mostly Due to Avoidable, Multifactorial, Adverse Drug Reactions. Clin Pharmacol Ther 2018; 105:754-760. [DOI: 10.1002/cpt.1239] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 09/10/2018] [Indexed: 01/31/2023]
Affiliation(s)
- Laurine Robert
- Univ. Lille EA 2694 ‐ Santé publique: épidémiologie et qualité des soins F‐59000 Lille France
| | - Grégoire Ficheur
- Univ. Lille EA 2694 ‐ Santé publique: épidémiologie et qualité des soins F‐59000 Lille France
- Department of Public health CHU Lille F‐59000 Lille France
| | - Bertrand Décaudin
- Univ. Lille EA 7365 ‐ GRITA ‐ Groupe de Recherche sur les Injectables et les Technologies Associées F‐59000 Lille France
- Department of Pharmacy CHU Lille F‐59000 Lille France
| | - Juliette Gellens
- Univ. Lille EA 2694 ‐ Santé publique: épidémiologie et qualité des soins F‐59000 Lille France
| | - Michel Luyckx
- Univ. Lille EA 7365 ‐ GRITA ‐ Groupe de Recherche sur les Injectables et les Technologies Associées F‐59000 Lille France
- Department of Pharmacy CH Denain F‐59220 Denain France
| | - Renaud Perichon
- Univ. Lille EA 2694 ‐ Santé publique: épidémiologie et qualité des soins F‐59000 Lille France
| | - Sophie Gautier
- Department of Pharmacology CHU Lille F‐59000 Lille France
| | - François Puisieux
- Univ. Lille EA 2694 ‐ Santé publique: épidémiologie et qualité des soins F‐59000 Lille France
- Department of Geriatrics CHU Lille F‐59000 Lille France
| | - Emmanuel Chazard
- Univ. Lille EA 2694 ‐ Santé publique: épidémiologie et qualité des soins F‐59000 Lille France
- Department of Public health CHU Lille F‐59000 Lille France
| | - Jean‐Baptiste Beuscart
- Univ. Lille EA 2694 ‐ Santé publique: épidémiologie et qualité des soins F‐59000 Lille France
- Department of Geriatrics CHU Lille F‐59000 Lille France
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New Therapeutic Approaches for the Treatment of Hyperkalemia in Patients Treated with Renin-Angiotensin-Aldosterone System Inhibitors. Cardiovasc Drugs Ther 2018; 32:99-119. [DOI: 10.1007/s10557-017-6767-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Linder KE, Krawczynski MA, Laskey D. Sodium Zirconium Cyclosilicate (ZS-9): A Novel Agent for the Treatment of Hyperkalemia. Pharmacotherapy 2016; 36:923-33. [PMID: 27393581 DOI: 10.1002/phar.1797] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Hyperkalemia is a potentially life-threatening electrolyte abnormality that may be caused by select medications, underlying organ dysfunction, or alterations in potassium homeostasis. Treatment for this condition has remained largely unchanged since the release of sodium polystyrene sulfonate (SPS) in 1958. Despite its widespread use, the safety and efficacy of SPS remains controversial. Two novel potassium-binding resins have emerged in recent years. Patiromer was the first of these to receive U.S. Food and Drug Administration approval for the treatment of hyperkalemia in October 2015. A second potassium-binding resin, a zirconium cyclosilicate currently known as ZS-9, may provide yet another alternative to the archetypal treatment with SPS. ZS-9 is an orally administered nonabsorbed inorganic compound that selectively binds potassium ions in vivo. Two phase III multicenter, randomized, placebo-controlled, double-blind trials have evaluated ZS-9 for the treatment of acute hyperkalemia. In this review, we discuss the pharmacology, clinical efficacy, safety, and potential place in therapy of ZS-9 for the enhanced elimination of potassium in the setting of hyperkalemia.
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Affiliation(s)
- Kristin E Linder
- Department of Pharmacy Services, Hartford Hospital, Hartford, Connecticut.,School of Pharmacy, University of Connecticut, Storrs, Connecticut
| | - Michelle A Krawczynski
- Department of Pharmacy Services, Hartford Hospital, Hartford, Connecticut.,School of Pharmacy, University of Connecticut, Storrs, Connecticut
| | - Dayne Laskey
- Department of Pharmacy Services, Hartford Hospital, Hartford, Connecticut.,University of Saint Joseph School of Pharmacy, Hartford, Connecticut
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Robert T, Algalarrondo V, Mesnard L. Hyperkaliémie sévère ou menaçante : le diable est dans les détails. ACTA ACUST UNITED AC 2015. [DOI: 10.1007/s13546-015-1125-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Leonard CE, Razzaghi H, Freeman CP, Roy JA, Newcomb CW, Hennessy S. Empiric potassium supplementation and increased survival in users of loop diuretics. PLoS One 2014; 9:e102279. [PMID: 25029519 PMCID: PMC4100893 DOI: 10.1371/journal.pone.0102279] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 06/17/2014] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The effectiveness of the clinical strategy of empiric potassium supplementation in reducing the frequency of adverse clinical outcomes in patients receiving loop diuretics is unknown. We sought to examine the association between empiric potassium supplementation and 1) all-cause death and 2) outpatient-originating sudden cardiac death (SD) and ventricular arrhythmia (VA) among new starters of loop diuretics, stratified on initial loop diuretic dose. METHODS We conducted a one-to-one propensity score-matched cohort study using 1999-2007 US Medicaid claims from five states. Empiric potassium supplementation was defined as a potassium prescription on the day of or the day after the initial loop diuretic prescription. Death, the primary outcome, was ascertained from the Social Security Administration Death Master File; SD/VA, the secondary outcome, from incident, first-listed emergency department or principal inpatient SD/VA discharge diagnoses (positive predictive value = 85%). RESULTS We identified 654,060 persons who met eligibility criteria and initiated therapy with a loop diuretic, 27% of whom received empiric potassium supplementation (N = 179,436) and 73% of whom did not (N = 474,624). The matched hazard ratio for empiric potassium supplementation was 0.93 (95% confidence interval, 0.89-0.98, p = 0.003) for all-cause death. Stratifying on initial furosemide dose, hazard ratios for empiric potassium supplementation with furosemide < 40 and ≥ 40 milligrams/day were 0.93 (0.86-1.00, p = 0.050) and 0.84 (0.79-0.89, p < 0.0001). The matched hazard ratio for empiric potassium supplementation was 1.02 (0.83-1.24, p = 0.879) for SD/VA. CONCLUSIONS Empiric potassium supplementation upon initiation of a loop diuretic appears to be associated with improved survival, with a greater apparent benefit seen with higher diuretic dose. If confirmed, these findings support the use of empiric potassium supplementation upon initiation of a loop diuretic.
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Affiliation(s)
- Charles E. Leonard
- Center for Clinical Epidemiology & Biostatistics, Department of Biostatistics & Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Hanieh Razzaghi
- Center for Clinical Epidemiology & Biostatistics, Department of Biostatistics & Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Cristin P. Freeman
- Center for Clinical Epidemiology & Biostatistics, Department of Biostatistics & Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Jason A. Roy
- Center for Clinical Epidemiology & Biostatistics, Department of Biostatistics & Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Craig W. Newcomb
- Center for Clinical Epidemiology & Biostatistics, Department of Biostatistics & Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Sean Hennessy
- Center for Clinical Epidemiology & Biostatistics, Department of Biostatistics & Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Department of Pharmacology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
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Khanagavi J, Gupta T, Aronow WS, Shah T, Garg J, Ahn C, Sule S, Peterson S. Hyperkalemia among hospitalized patients and association between duration of hyperkalemia and outcomes. Arch Med Sci 2014; 10:251-7. [PMID: 24904657 PMCID: PMC4042045 DOI: 10.5114/aoms.2014.42577] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Revised: 06/22/2013] [Accepted: 06/24/2013] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION The aim of the study was to investigate predictors of mortality in patients hospitalized with hyperkalemia. MATERIAL AND METHODS Data among hospitalized patients with hyperkalemia (serum potassium ≥ 5.1 mEq/l) were collected. Patients with end-stage renal disease on dialysis were excluded. RESULTS Of 15,608 hospitalizations, 451 (2.9%) episodes of hyperkalemia occurred in 408 patients. In patients with hyperkalemia, chronic kidney disease, hypertension, diabetes, coronary artery disease and heart failure were common comorbidities. Acute kidney injury (AKI) and metabolic acidosis were common metabolic abnormalities, and 359 patients (88%) were on at least one drug associated with hyperkalemia. Mean duration to resolution of hyperkalemia was 12 ±9.9 h. Nonsteroidal anti-inflammatory drugs (HR = 1.59), highest potassium level (HR = 0.61), tissue necrosis (HR = 0.61), metabolic acidosis (HR = 0.77), and AKI (HR = 0.77) were significant independent determinants of duration prior to hyperkalemia resolution. Tissue necrosis (OR = 4.55), potassium supplementation (OR = 5.46), metabolic acidosis (OR = 4.84), use of calcium gluconate for treatment of hyperkalemia (OR = 4.62), AKI (OR = 3.89), and prolonged duration of hyperkalemia (OR = 1.06) were significant independent predictors of in-hospital mortality. CONCLUSIONS Tissue necrosis, potassium supplementation, metabolic acidosis, calcium gluconate for treatment of hyperkalemia, AKI and prolonged duration of hyperkalemia are independent predictors of in-hospital mortality.
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Affiliation(s)
- Jagadish Khanagavi
- Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Tanush Gupta
- Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Wilbert S. Aronow
- Division of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Tushar Shah
- Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Jalaj Garg
- Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Chul Ahn
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sachin Sule
- Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Stephen Peterson
- Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
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Bucher C, Tapernoux D, Diethelm M, Büscher C, Noser A, Fehr T, Henz S. Influence of weather conditions, drugs and comorbidities on serum Na and Cl in 13000 hospital admissions: evidence for a subpopulation susceptible for SIADH. Clin Biochem 2014; 47:618-24. [PMID: 24389078 DOI: 10.1016/j.clinbiochem.2013.12.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Revised: 12/06/2013] [Accepted: 12/17/2013] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Considerable variation in serum sodium (Na) and chloride (Cl) is found in patients at hospital admission. Our goal was to quantify the respective impact of drugs, comorbidities, demographic factors and weather conditions on serum Na and Cl. DESIGN AND METHODS For 13277 consecutive patients without terminal kidney disease admitted to the Department of Internal Medicine of the Kantonsspital St. Gallen drug history on admission, age, sex, body weight, ICD-10 diagnoses, and laboratory data were extracted from electronic medical records. Weather parameters prior to hospital admission were also integrated in a multivariate regression analysis. RESULTS Both serum Na and Cl showed an asymmetric left-tailed distribution. Median (interquartile range) Na was 138 (136/140) and Cl 104 (101/106). The distribution of sodium in patients with one or more risk factors for SIADH was best explained by the presence of two populations: one population with a similar distribution as the unexposed patients and a smaller population (about 25%) shifted to lower sodium levels. Lower weight, lower blood pressure, kidney dysfunction, fever, and diabetes were associated with both lower Na and Cl. Higher ambient temperature and higher air humidity preceding admission were associated with both higher Na and Cl values. CONCLUSIONS Na and Cl at hospital admission are highly influenced by ambient weather conditions, comorbidities and medication. The bimodal distribution of Na and Cl in persons exposed to risk factors for SIADH suggests that SIADH may only affect a genetically distinct vulnerable subpopulation.
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Affiliation(s)
- Christian Bucher
- Department of Internal Medicine, Kantonsspital, St. Gallen, Switzerland
| | - Daniel Tapernoux
- Department of Internal Medicine, Kantonsspital, St. Gallen, Switzerland
| | - Markus Diethelm
- Department of Internal Medicine, Kantonsspital, St. Gallen, Switzerland
| | - Christine Büscher
- Department of Internal Medicine, Kantonsspital, St. Gallen, Switzerland
| | - Anja Noser
- University of Applied Sciences, St. Gallen, Switzerland
| | - Thomas Fehr
- Division of Nephrology, University Hospital, Zürich, Switzerland
| | - Samuel Henz
- Department of Internal Medicine, Kantonsspital, St. Gallen, Switzerland.
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Eschmann E, Beeler PE, Kaplan V, Schneemann M, Zünd G, Blaser J. Patient- and physician-related risk factors for hyperkalaemia in potassium-increasing drug-drug interactions. Eur J Clin Pharmacol 2013; 70:215-23. [PMID: 24150532 DOI: 10.1007/s00228-013-1597-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 09/30/2013] [Indexed: 12/13/2022]
Abstract
PURPOSE Hyperkalaemia due to potassium-increasing drug-drug interactions (DDIs) is a clinically important adverse drug event. The purpose of this study was to identify patient- and physician-related risk factors for the development of hyperkalaemia. METHODS The risk for adult patients hospitalised in the University Hospital Zurich between 1 December 2009 and 31 December 2011 of developing hyperkalaemia was correlated with patient characteristics, number, type and duration of potassium-increasing DDIs and frequency of serum potassium monitoring. RESULTS The 76,467 patients included in this study were prescribed 8,413 potentially severe potassium-increasing DDIs. Patient-related characteristics associated with the development of hyperkalaemia were pulmonary allograft [relative risk (RR) 5.1; p < 0.0001), impaired renal function (RR 2.7; p < 0.0001), diabetes mellitus (RR 1.6; p = 0.002) and female gender (RR 1.5; p = 0.007). Risk factors associated with medication were number of concurrently administered potassium-increasing drugs (RR 3.3 per additional drug; p < 0.0001) and longer duration of the DDI (RR 4.9 for duration ≥6 days; p < 0.0001). Physician-related factors associated with the development of hyperkalaemia were undetermined or elevated serum potassium level before treatment initiation (RR 2.2; p < 0.001) and infrequent monitoring of serum potassium during a DDI (interval >48 h: RR 1.6; p < 0.01). CONCLUSION Strategies for reducing the risk of hyperkalaemia during potassium-increasing DDIs should consider both patient- and physician-related risk factors.
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Affiliation(s)
- Emmanuel Eschmann
- Research Centre for Medical Informatics, Directorate of Research and Education, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland,
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14
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An JN, Lee JP, Jeon HJ, Kim DH, Oh YK, Kim YS, Lim CS. Severe hyperkalemia requiring hospitalization: predictors of mortality. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R225. [PMID: 23171442 PMCID: PMC3672605 DOI: 10.1186/cc11872] [Citation(s) in RCA: 173] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2012] [Accepted: 11/19/2012] [Indexed: 11/29/2022]
Abstract
Introduction Severe hyperkalemia, with potassium (K+) levels ≥ 6.5 mEq/L, is a potentially life-threatening electrolyte imbalance. For prompt and effective treatment, it is important to know its risk factors, clinical manifestations, and predictors of mortality. Methods An observational cohort study was performed at 2 medical centers. A total of 923 consecutive Korean patients were analyzed. All were 19 years of age or older and were hospitalized with severe hyperkalemia between August 2007 and July 2010; the diagnosis of severe hyperkalemia was made either at the time of admission to the hospital or during the period of hospitalization. Demographic and baseline clinical characteristics at the time of hyperkalemia diagnosis were assessed, and clinical outcomes such as in-hospital mortality were reviewed, using the institutions' electronic medical record systems. Results Chronic kidney disease (CKD) was the most common underlying medical condition, and the most common precipitating factor of hyperkalemia was metabolic acidosis. Emergent admission was indicated in 68.6% of patients, 36.7% had electrocardiogram findings typical of hyperkalemia, 24.5% had multi-organ failure (MOF) at the time of hyperkalemia diagnosis, and 20.3% were diagnosed with severe hyperkalemia at the time of cardiac arrest. The in-hospital mortality rate was 30.7%; the rate was strongly correlated with the difference between serum K+ levels at admission and at their highest point, and with severe medical conditions such as malignancy, infection, and bleeding. Furthermore, a higher in-hospital mortality rate was significantly associated with the presence of cardiac arrest and/or MOF at the time of diagnosis, emergent admission, and intensive care unit treatment during hospitalization. More importantly, acute kidney injury (AKI) in patients with normal baseline renal function was a strong predictor of mortality, compared with AKI superimposed on CKD. Conclusions Severe hyperkalemia occurs in various medical conditions; the precipitating factors are similarly diverse. The mortality rate is especially high in patients with severe underlying disease, coexisting medical conditions, and those with normal baseline renal function.
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Uijtendaal EV, Zwart-van Rijkom JEF, van Solinge WW, Egberts TCG. Frequency of laboratory measurement and hyperkalaemia in hospitalised patients using serum potassium concentration increasing drugs. Eur J Clin Pharmacol 2011; 67:933-40. [PMID: 21424384 PMCID: PMC3154285 DOI: 10.1007/s00228-011-1028-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Accepted: 02/27/2011] [Indexed: 10/28/2022]
Abstract
PURPOSE Although, drug-drug interactions (DDIs) between potassium-increasing drugs (PIDs) are known risk factors for developing hyperkalaemia, not much is known about their risk and management strategies during hospitalisation. This study examines the frequency of serum potassium measurements and hyperkalaemia in hospitalised patients, based on the use of one or more PIDs, and the determinants thereof. METHODS Adult patients hospitalised in the University Medical Centre Utrecht between 2006 and 2008 were included in this cross-sectional study. The frequency of serum potassium measurements and of hyperkalaemia were compared between patients using only one PID at a time (monotherapy group) and patients using two or more PIDs concomitantly (interaction group). The determinants studied were renal failure, diabetes mellitus, use of diuretics, type of DDI, start of the PIDs within the hospital versus continued home medication and medical speciality. RESULTS Serum potassium was measured more frequently in the interaction group than in the monotherapy group [67 vs. 56%; relative risk (RR) 1.19, 95% confidence interval (CI) 1.14-1.24] and the risk of hyperkalaemia was also increased in the interaction group (9.9 vs. 5.9%, RR 1.7, 95% CI 1.3-2.1). The combination of potassium-sparing diuretics plus a potassium supplement, start of the PID within the hospital and hospitalisation in non-internal medicine departments was associated with higher relative risk estimates for hyperkalaemia. CONCLUSIONS Among our patient cohort, even when physicians received a direct pop-up to monitor serum potassium levels when prescribing two PIDs concomitantly, serum potassium levels were not measured in 33% of patients, and 10% of patients developed hyperkalaemia. Improved management strategies and/or clinical decision-support systems are needed to decrease the frequency of hyperkalaemia following DDIs.
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Affiliation(s)
- Esther V Uijtendaal
- Department of Clinical Pharmacy, University Medical Centre Utrecht, P.O. Box 85500, 3508 GA, Utrecht, the Netherlands.
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16
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Noize P, Bagheri H, Durrieu G, Haramburu F, Moore N, Giraud P, Galinier M, Pourrat J, Montastruc JL. Life-threatening drug-associated hyperkalemia: a retrospective study from laboratory signals. Pharmacoepidemiol Drug Saf 2011; 20:747-53. [PMID: 21438068 DOI: 10.1002/pds.2128] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Revised: 02/07/2011] [Accepted: 02/09/2011] [Indexed: 11/10/2022]
Abstract
PURPOSE Life-threatening hyperkalemia may be induced by drugs and preventable in at-risk patients. This study was designed to describe cases of 'serious' drug-associated hyperkalemia. METHODS Adult subjects with a serum potassium concentration above 6.5 mmol/L detected at admission or during hospital stay in nephrology, cardiology, geriatric, emergency or intensive care units were identified by biology laboratories of hospitals and clinics located in Midi-Pyrenees (southwest France). Patients dialyzed for end-stage kidney disease were excluded. Data were collected from medical files. Hyperkalemia was defined as drug-associated if at least one drug known to increase serum potassium concentration was taken when hyperkalemia occurred (among drugs taken in outpatient care for hyperkalemia detected at admission and among drugs taken in outpatient care and continued at hospital and drugs introduced from admission for hyperkalemia detected during hospital stay). RESULTS Of 168 hyperkalemia cases, 102 (60.7%) were classified as drug-associated. They concerned elderly patients (mean age: 76.1 years) often having arterial hypertension and/or cardiac diseases (88.2%). Risk factors, mainly acute kidney failure, were observed in almost all cases (98.0%). Drugs predominantly involved were angiotensin-converting enzyme inhibitors (47.1%), spironolactone (41.2%), angiotensin II receptor antagonists (23.5%) and potassium supplements (23.5%). In 10% of cases, death could be attributed to hyperkalemia. CONCLUSIONS Laboratory databases allowed an exhaustive identification of hyperkalemia cases. The frequency of drug-related hyperkalemia and their characteristics suggest that treatment with drugs known to increase serum potassium concentration can be inappropriate, especially regarding associations or indications, and is highly risky for predisposed patients.
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Affiliation(s)
- Pernelle Noize
- CHU de Toulouse, Service de Pharmacologie Clinique, Centre Midi-Pyrénées de Pharmacovigilance, de Pharmacoépidémiologie et d'Informations sur le Médicament, F-31000 Toulouse, France
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17
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Goswami SK, Jain S, Chudasama H, Santani D. Potential pharmacodynamic drug-drug interaction between concomitantly administered lisinopril and diclofenac sodium: a call for appropriate management in hypertensive osteoarthritic patients. DRUG METABOLISM AND DRUG INTERACTIONS 2011; 26:127-137. [PMID: 21980964 DOI: 10.1515/dmdi.2011.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND The present study was designed as an open label, multiple-dose, randomized, parallel trial to evaluate the pharmacodynamic drug-drug interaction of lisinopril and concomitantly administered diclofenac sodium in non-diabetic and diabetic, mild to moderate hypertensive, osteoarthritic patients. METHODS Post-screening and on inclusion, patients were put on a 2-week washout period and then randomly assigned to either only lisinopril 10 mg or combination of lisinopril 10 mg and diclofenac sodium 100 mg treatments for 8-12 weeks in diseased states of hypertension and osteoarthritis with or without type 2 diabetes mellitus. RESULTS The blood pressure (BP) control with lisinopril was reduced by concomitantly administered diclofenac sodium in non-diabetic (SBP: p=0.00002; DBP: p=0.000008) and diabetic (SBP: p=0.002; DBP: p=0.001) patients when compared with the patients receiving lisinopril alone. Insulin sensitivity was improved (p=0.00002) and urinary albumin excretion rate was better controlled (p=0.0096) in lisinopril-treated patients when compared with the combination treatment in diabetic pool. Serum creatinine levels increased significantly in non-diabetic patients (p=0.00004) receiving combination treatment. In addition, creatinine clearance (CLCR) and blood urea nitrogen (BUN) were significantly higher in diabetic (CLCR: p<0.00001; BUN: p=0.0098) as well as in non-diabetic (CLCR: p<0.00001; BUN: p=0.03) patients treated with combination treatment. The alterations in serum electrolytes, reduction in % platelet aggregation activity and improvement in lipid profile was more profound with combination treatment in comparison to lisinopril alone. CONCLUSIONS The antihypertensive efficacy and insulin sensitivity improving property of lisinopril along with the renal function might get worse in hypertensive osteoarthritic patients receiving concomitant treatment of oral diclofenac sodium with lisinopril. In addition to this, close monitoring of serum electrolytes is also suggested to rule out any long-term detrimental effect.
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Reis AMM, Cassiani SHDB. Prevalence of potential drug interactions in patients in an intensive care unit of a university hospital in Brazil. Clinics (Sao Paulo) 2011; 66:9-15. [PMID: 21437429 PMCID: PMC3044563 DOI: 10.1590/s1807-59322011000100003] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2010] [Revised: 04/12/2010] [Accepted: 05/03/2010] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES To investigate the prevalence of potential drug interactions at the intensive care unit of a university hospital in Brazil and to analyze their clinical significance. METHODS This cross-sectional retrospective study included 299 patients who had been hospitalized in the intensive care unit of the hospital. The drugs administered during the first 24 hours of hospitalization, in the 50th length-ofstay percentile and at the time of discharge were analyzed to identify potential drug-drug and drug-enteral nutrition interactions using DRUG-REAXH software. The drugs were classified according to the anatomical therapeutic chemical classification. RESULTS The median number of medications per patient was smaller at the time of discharge than in the 50th length-of-stay percentile and in the first 24 hours of hospitalization. There was a 70% prevalence of potential drug interactions at the intensive care unit at the studied time points of hospitalization. Most of the drug interactions were either severe or moderate, and the scientific evidence for the interactions was, in general, either good or excellent. Pharmacodynamic interactions presented a subtle predominance in relation to pharmacokinetic interactions. The occurrence of potential drug interactions was associated with the number of medications administered and the length of stay. Medications that induced cytochrome P450, drugs that prolong the QT interval and cardiovascular drugs were pharmacotherapy factors associated with potential drug interactions. CONCLUSION The study showed that potential drug interactions were prevalent in the intensive care unit due to the complexity of the pharmacotherapies administered. The interactions were associated with the number of drugs, the length of stay and the characteristics of the administered medications.
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Deaths involving contraindicated and inappropriate combinations of serotonergic drugs. Int J Legal Med 2010; 125:803-15. [PMID: 21120513 DOI: 10.1007/s00414-010-0536-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Accepted: 11/18/2010] [Indexed: 12/23/2022]
Abstract
In the Australian state of Victoria, all fatalities that were recorded from 2002 through to 2008 involving the use of certain serotonin active drugs (tramadol, venlafaxine, fluoxetine, sertraline, citalopram and paroxetine), were reviewed to assess the incidence of contraindicated or ill advised drug combinations. More than 1,000 were identified of which 326 cases formed the basis of this study. These cases involved contraindicated or inappropriate drug combinations that can lead to adverse drug reactions (ADRs) and subsequent fatal toxicity. Of these, 46% were drug-related, 35% were a result of natural disease and 13% were classified as external injury cases. The remaining cases were those where the cause of death (COD) was unascertained. Tramadol was the most common drug, usually detected alongside a serotonergic antidepressant (in 20% of cases). Twenty-five (8%) cases involved contraindicated drug combinations while the remainder (301 cases, 92%) involved drug combinations that are associated with adverse interactions ranging from minor to major severity. Of these 326 cases, the Coroner determined 166 cases (51%) to be acts of intentional self-harm or drug misuse, with the remainder unascertained or attributed to natural disease. Very few post-mortem reports and Coroners' findings made mention of possible ADRs when such combinations were actually present. The majority of cases comprising contraindicated drug combinations involved the combined use of five drugs (24%) at the time of death. A combination of three to five drugs was most common in cases involving inadvisable drug combinations. Combined drug toxicity was the most common COD, with heart disease the most common co-morbidity.
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Torres OH, Hernandez N, Francia E, Barcelo M, Mateo J, Ruiz D. Effect of Prophylactic Treatment with Low-Molecular-Weight Heparin Bemiparin Sodium on Serum Potassium Levels. Drugs Aging 2010; 27:399-406. [DOI: 10.2165/11535440-000000000-00000] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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