Potential drug-drug interactions associated with adverse clinical outcomes and abnormal laboratory findings in patients with malaria

A Prospective Study of Medication Surveillance of a Pediatric Tertiary Care Hospital in Lahore, Pakistan

PURPOSE

Several studies have shown that polypharmacy is the main cause of drug interactions, and the prevalence and the level of the severity varied with the duration of stay in the hospital, sex and race of the patients. The aims of this investigation were to identify the drug-drug interactions in hospitalized pediatric patients associated with polypharmacy, and to categorize the drug interactions in pharmacokinetic or pharmacodynamic interactions according to their level of severity.

METHODS

A cross-sectional, prospective analytical study was performed at a pediatric tertiary care hospital in Lahore, Pakistan for the duration of 4 months, which included prescription orders for 300 patients. Data were collected from patient medical files about previous and current medication history. Drug interactions were analyzed using interaction checker on Medscape and categorized according to the severity levels.

RESULTS

Out of 300 patients, the occurrence of drug interactions was found in 157 (52.3%) patients, while in 143 (47.7%), no interaction was found. Among these interactions, 50.7% were pharmacodynamic interactions, and 49.30% were pharmacokinetic interactions. Eighty-one percent of prescription orders with drug interactions contained more than three drugs, and 11.9% of interactions were severe. The majority of interactions were of amikacin-vancomycin, piroxicam-captopril and captopril-ciprofloxacin.

CONCLUSION

Most of the interactions were moderate among patients with multiple drug prescriptions. The drug interactions can be minimized by providing special patient monitoring and adequate management with prior knowledge of these drug interaction.

A Literature Review of Liver Function Test Elevations in Rifampin Drug-Drug Interaction Studies

Although rifampin drug–drug interaction (DDI) studies are routinely conducted, there have been instances of liver function test (LFT) elevations, warranting further evaluation. A literature review was conducted to identify studies in which combination with rifampin resulted in hepatic events and evaluate any similarities. Over 600 abstracts and manuscripts describing rifampin DDI studies were first evaluated, of which 30 clinical studies reported LFT elevations. Out of these, 11 studies included ritonavir in combination with other drug(s) in the rifampin DDI study. The number of subjects that were discontinued from treatment on these studies ranged from 0 to 71 (0–100% of subjects in each study). The number of subjects hospitalized for adverse events in these studies ranged from 0 to 41 (0–83.67% of subjects in each study). LFT elevations in greater than 50% of subjects were noted during the concomitant administration of rifampin with ritonavir‐boosted protease inhibitors and with lorlatinib; with labeled contraindication due to observed hepatotoxicity related safety findings only for saquinavir/ritonavir and lorlatinib. In the lorlatinib and ritonavir DDI studies, considerable LFT elevations were observed rapidly, typically within 24–72 h following co‐administration. A possible sequence effect has been speculated, where rifampin induction prior to administration of the combination may be associated with increased severity of the LFT elevations. The potential role of rifampin in the metabolic activation of certain drugs into metabolites with hepatic effects needs to be taken into consideration when conducting rifampin DDI studies, particularly those for which the metabolic profiles are not fully elucidated.

Identification of drug-related problems followed by clinical pharmacist interventions in an outpatient pharmacotherapy clinic

WHAT IS KNOWN AND OBJECTIVE

Pharmacotherapy is an essential strategy for the treatment of many medical conditions especially chronic disease and often involves multiple medications being used simultaneously. Increasing the use of medications may pose some challenges to safe and effective drug therapy and if not identified and prevented by the pharmacists eventually can lead to drug-related problems (DRPs). The present study aimed to examine the incidence of DRPs in Iranian patients and to evaluate patients' adherence to the clinical pharmacist interventions as well as the physicians' acceptance of these recommendations.

METHODS

This study was conducted in a university-affiliated outpatient pharmacotherapy clinic over a 22-month period. Patients aged 18 years and older with at least one chronic disease receiving at least four medications were included in the study. The patients were interviewed by a clinical pharmacist for comprehensive medication review. DRPs were identified using the DOCUMENT classification system. Recommendations were provided by the clinical pharmacist including interventions involving patient and/or physician to resolve DRPs. The patients were followed up after 2 weeks to evaluate their compliance and physician acceptance of clinical pharmacist recommendations.

RESULTS AND DISCUSSION

Two hundred patients were included in this study. Overall, 875 DRPs were identified with an average of 4.37 per patient. The most prevalent DRPs were related to patient education or information (22.8%), undertreated indications (17.4%) and patient compliance (17.2%). The most common drugs associated with DRPs were alimentary and metabolism (22.2% of DRPs) followed by the cardiovascular system (19.2%) and nervous system (9.6%) medications. The DRP incidence correlated with gender only and was higher in females (p = 0.019). The clinical pharmacist provided 912 interventions with an average of 4.56 and 1.04 interventions per patient and per DRPs respectively. Patient education (41.3%), medication initiation or discontinuation (24.5%), and non-pharmacological interventions (12.9%) were the most common clinical pharmacist interventions. Out of 912 interventions, 665 were followed up, out of which 427 were patient dependent and 228 involved physicians. The patient's compliance with clinical pharmacist recommendations was 81.2%. The physician acceptance rate of the recommendations was 44.1%.

WHAT IS NEW AND CONCLUSION

The study shows that especially designed services such as pharmacotherapy clinics running by clinical pharmacists are necessary to detect and resolve DRPs in an effective way. The high compliance rate of the patients indicates patients' confidence in the clinical pharmacist services provided in the pharmacotherapy clinic. The low acceptance rate of the physicians highlights the need to improve interprofessional collaboration between clinical pharmacists and physicians in an outpatient setting.

Spontaneous Splenic Rupture as a Complication of Malaria and Incidental Acute Appendicitis: A Case Report

Malaria presents a challenge to healthcare systems globally. It is associated with severe complications, notably splenic rupture. The prognosis of malaria complicated by splenic rupture is poor and sometimes leads to death even with timely intervention. Here, we report the case of a patient who presented with complicated malaria with spontaneous splenic rupture and coincidental acute appendicitis. A 34-year-old man was successfully treated for a grade IV ruptured spleen and acute appendicitis with splenectomy and appendectomy. Postoperative care took place in the intensive care unit and the patient was shifted to the general floor on the fifth day. Upon discharge the next day, he was prescribed amoxicillin twice daily for one year. Malaria can present with life-threatening complications requiring prompt surgical intervention.

Drug related problems in clinical practice: a cross-sectional study on their prevalence, risk factors and associated pharmaceutical interventions

Drug-related problems (DRP) cause preventable negative health outcomes, especially during hospital admissions. The aim of our study was to examine the prevalence and characteristics of DRP in regular clinical pharmacy, as well as to determine those factors associated with a higher risk of DRP in the hospital setting. We analyzed data from a standardized registry database of regular pharmacy practice (2015- 2016). DRP were classified according to the Pharmaceutical Care Network Europe v6.2 classification. Cross-sectional data were obtained from 1602 adults admitted to medical wards. Crude and adjusted binary logistic regressions were performed to identify associations between potential risk factors and DRP. Overall DRP prevalence was high across medical specialties (45,1%), in a population characterized by advanced age, polypharmacy and multimorbidity. Problems leading to DRP were mainly classified into two domains (effectiveness and adverse reactions), being drug and dose selection the most frequent causes. Interventions were accepted and DRP were totally or partially solved in 74.1% and 4.81% of cases, respectively. In the adjusted model polypharmacy, allergies, BMI > 25 kg/m2 and clearance < 30 mL/min were associated with a higher risk of DRP. The participation of clinical pharmacists into multidisciplinary teams promotes the detection and solution of DRP. Polypharmacy, obesity, renal impairment and allergy are associated with a higher risk of DRP during admission.