Impact of Adverse Drug Reactions in Patients with End Stage Renal Disease in Greece

Potential impact of underlying diseases influencing ADME in nonclinical safety assessment

Nonclinical studies involve in vitro, in silico, and in vivo experiments to assess the toxicokinetics, toxicology, and safety pharmacology of drugs according to regulatory requirements by a national or international authority. In this review, we summarize the potential effects of various underlying diseases governing the absorption, distribution, metabolism, and excretion (ADME) of drugs to consider the use of animal models of diseases in nonclinical trials. Obesity models showed alterations in hepatic metabolizing enzymes, transporters, and renal pathophysiology, which increase the risk of drug-induced toxicity. Diabetes models displayed changes in hepatic metabolizing enzymes, transporters, and glomerular filtration rates (GFR), leading to variability in drug responses and susceptibility to toxicity. Animal models of advanced age exhibited impairment of drug metabolism and kidney function, thereby reducing the drug-metabolizing capacity and clearance. Along with changes in hepatic metabolic enzymes, animal models of metabolic syndrome-related hypertension showed renal dysfunction, resulting in a reduced GFR and urinary excretion of drugs. Taken together, underlying diseases can induce dysfunction of organs involved in the ADME of drugs, ultimately affecting toxicity. Therefore, the use of animal models of representative underlying diseases in nonclinical toxicity studies can be considered to improve the predictability of drug side effects before clinical trials.

Improving Kidney Disease Care: One Giant Leap for Nephrology

Nephrology is an ever-evolving field of medicine. The importance of such a discipline is related to the high clinical impact of kidney disease. In fact, abnormalities of kidney function and/or structure are common in the general population, reaching an overall prevalence of about 10%. More importantly, the onset of kidney damage is related to a strikingly high risk of cardiovascular events, mortality, and progression to kidney failure which, in turn, compromises quality and duration of life. Attempts to comprehend the pathogenesis and molecular mechanisms involved in kidney disease occurrence have prompted the development and implementation of novel drugs in clinical practice with the aim of treating the 'specific cause' of kidney disease (including chronic kidney disease, glomerular disease, and genetic kidney disorders) and the main immunological complications following kidney transplantation. Herein, we provide an overview of the principal emerging drug classes with proved efficacy in the context of the aforementioned clinical conditions. This can represent a simplified guide for clinical nephrologists to remind them of the vast and heterogeneous armamentarium of drugs that should be used in the present and the future to improve the management of patients suffering from kidney disease.

Factors Contributing to Negative Outcomes Associated with Medications and Drug-Related Problems in Kidney Replacement Therapy-A Hospital-Based Prospective Observational Study

BACKGROUND

Negative outcomes associated with medications (NOM) and drug-related problems (DRP) significantly impact individuals with kidney replacement therapy (KRT) given the complexities of managing kidney disease and associated comorbidities. The present study aims to assess the frequency of NOMs/DRPs among KRT patients and identify contributing factors.

METHODS

A cross-sectional study was conducted at Virgen de las Nieves University Hospital (Granada, Spain), involving 117 outpatient adults with KRT. Data were collected from February 2021 to July 2023 using electronic records, semi-structured interviews (Dáder Method), and discussions with nephrology specialists. NOMs/DRPs were identified following treatment guidelines. Binary logistic regression was used to determine associated factors (p-value < 0.05).

RESULTS

Across 117 patients, 2436 NOMs and 3303 DRPs were identified, averaging 20.82 NOMs and 28.23 DRPs per patient. Prevalent NOMs included untreated conditions (58.95%), quantitative ineffectiveness (35.43%), and non-quantitative safety problems (5.13%). Dominant DRPs were undertreated conditions (37.63%), wrong dose/posology/length (33.00%), risk of adverse drug reactions (ADR) (16.14%), and non-adherence (6.87%). Patients with ADR, undertreated conditions, and anemia were associated with quantitative ineffectiveness. Risk of ADR and vitamin D deficiency/insufficiency correlated with non-quantitative safety problems.

CONCLUSIONS

KRT patients exhibited a substantial prevalence of NOMs/DRPs. Further research is needed to deepen our understanding of these complexities for improved patient care.

Evaluation of Drug Interactions in Hospitalized Patients with Respiratory Disorders in Greece

Background: Patients with respiratory disorders often have additional diseases and are usually treated with more than one medication to manage their respiratory conditions as well as additional comorbidities. Thus, they are frequently exposed to polypharmacy (≥5 drugs), which raises the risk for drug-drug interactions (DDIs) and adverse drug reactions (ADRs). In this work, we present the results regarding the prevalence of DDIs in hospitalized patients with respiratory disorders in Greece. Methods: A 6-month descriptive single-center retrospective observational study enrolled 102 patients with acute or chronic respiratory disorders. Clinical characteristics and medication regimens were recorded upon admission, hospitalization, and discharge. The prevalence of DDIs and their clinical significance was recorded and analyzed. Results: Unspecified acute lower respiratory tract infection (25%), exacerbations of chronic obstructive pulmonary disease (12%) and pneumonia (8%) were the most frequent reasons for admission. Cardiovascular disorders (46%), co-existing respiratory disorders (32%), and diabetes (25%) were the most prevalent comorbidities. Polypharmacy was noted in 61% of patients upon admission, 98% during hospitalization, and 63% upon discharge. Associated DDIs were estimated to be 55% upon admission, 96% throughout hospitalization, and 63% on discharge. Pharmacodynamic (PD) DDIs were the most prevalent cases (81%) and referred mostly to potential risk for QT-prolongation (31.4% of PD-DDIs) or modulation of coagulation process as expressed through the international normalized ratio (INR) (29.0% of DDIs). Pharmacokinetic (PK) DDIs (19% of DDIs) were due to inhibition of Cytochrome P450 mediated metabolism that could lead to elevated systemic drug concentrations. Clinically significant DDIs characterized as "serious-use alternative" related to 7% of cases while 59% of DDIs referred to combinations that could be characterized as "use with caution-monitor". Clinically significant DDIs mostly referred to medication regimens upon admission and discharge and were associated with outpatient prescriptions. Conclusions: Hospitalized patients with respiratory disorders often experience multimorbidity and polypharmacy that raise the risk of DDIs. Clinicians should be conscious especially if any occurring arrhythmias, INR modulations, and prolonged or increased drug action is associated with DDIs.

Drug-Drug Interactions among Patients Hospitalized with COVID-19 in Greece

The modulation of the pharmacological action of drugs due to drug-drug interactions (DDIs) is a critical issue in healthcare. The aim of this study was to evaluate the prevalence and the clinical significance of potential DDIs in patients admitted to the University Hospital of Heraklion in Greece with coronavirus disease 2019 (COVID-19). Cardiovascular disorders (58.4%) and diabetes (types I and II) (29.6%) were the most common comorbidities. A high occurrence of DDIs was observed, and clinically significant DDIs that may hamper response to treatment represented 40.3% of cases on admission, 21% during hospitalization, and 40.7% upon discharge. Polypharmacy and comorbidities were associated with a higher prevalence of DDIs in a statistically significant way (p < 0.05, 95% CI). Clinically significant DDIs and increased C-reactive protein values upon admission were associated with prolonged hospitalization. The results reveal that patients admitted due to COVID-19 in Greece often have an additional burden of DDIs that healthcare teams should approach and resolve.

Deprescribing Opportunities for Hospitalized Patients With End-Stage Kidney Disease on Hemodialysis: A Secondary Analysis of the MedSafer Cluster Randomized Controlled Trial

Background

End-stage kidney disease patients on dialysis have a substantial risk of polypharmacy due their propensity for comorbidity and contact with the health care system. MedSafer is an electronic decision support tool that integrates patient comorbidity and medication lists to generate personalized deprescribing reports focused on identifying potentially inappropriate medications (PIMs).

Objective

To conduct a secondary analysis of patients on regular hemodialysis included in the MedSafer randomized controlled trial to investigate the patterns of polypharmacy and evaluate the efficacy of the MedSafer deprescribing algorithms.

Design

Secondary analysis of a cluster randomized clinical trial.

Setting

Medical units in 11 acute care hospitals in Canada.

Patients

The MedSafer trial enrolled 5698 participants with an expected prognosis of >3 months, age 65 years and older, and on 5 or more daily home medications; 140 participants were receiving chronic hemodialysis.

Measurements

The primary outcome of the trial was 30-day adverse drug events (ADEs) post-hospital discharge, and a key secondary outcome was deprescribing.

Methods

Control patients received usual care (medication reconciliation), whereas clinicians caring for intervention patients received a MedSafer report that highlighted individualized opportunities for deprescribing.

Results

There were 70 patients in each of the control and intervention arms. The median number of home medications was 14 (compared with a median of 10 medications in the general trial population). The most frequent medications observed that were potentially inappropriate were proton pump inhibitors (potentially inappropriate in 55/76 users; 72.4%), diabetes medications in patients with a HBA1C <7.5% (36/65 users; 55.4%), docusate (27/27 users; 100%), gabapentinoids (27/36 users; 75%), and combination antiplatelet/anticoagulants (22/97 users; 22.7%). The proportion of PIMs deprescribed was higher during the intervention phase (28.8% vs 19.3%; absolute increase 9.4% [95% confidence interval 1.3%-17.6%]) compared with the control phase. There was no observed difference in ADEs at 30-day post-discharge between the control and the intervention groups. The most common ADE (n = 3) was gastrointestinal bleeding attributed to antiplatelet agents.

Limitations

This was a post hoc exploratory analysis, the original trial did not stratify by hemodialysis status, and the small sample size precludes drawing any definitive conclusions.

Conclusion

MedSafer facilitates deprescribing in hospitalized patients on hemodialysis. Larger-scale implementation of decision support software for deprescribing in dialysis and long-term follow-up are likely required to demonstrate an impact on ADEs.

Evaluation of Drug-Related Problems in Chronic Kidney Disease Patients

Background Chronic kidney disease (CKD) is a challenging global health problem with increasing prevalence worldwide. Concurrence of CKD and comorbidities results in the use of multiple medications and exposing patients to polypharmacy. Polypharmacy in CKD is common across all the stages of the disease and leads to poor medication adherence, higher healthcare costs, and drug-related problems, such as drug-drug interactions (DDIs) and adverse drug reactions (ADRs). DDIs and ADRs in CKD patients may lower the quality of life, increase the length of hospital stay, and augment the risks of morbidity and mortality. Methodology This was a hospital-based, prospective, cross-sectional study conducted in a secondary care hospital. The study population comprised 130 adult CKD patients admitted to the nephrology department including those on maintenance hemodialysis. Study-related data were obtained from the electronic patient case records. Medications prescribed to the patients were analyzed for potential DDIs (pDDIs) using Portable Emergency and Primary Care Information Database (PEPID 12.1) drug interaction checker. All observed and reported suspected ADRs related to the prescribed drugs were evaluated for causality, severity, preventability, and predictability. Results Out of the 130 patients, majority were males (n = 71, 54.6%), in the age group of 61-70 years (n = 45, 34.6%), and belonged to CKD stage 5 (n = 105, 80.8%). The mean number of drugs prescribed was 11.1 ± 3.8 per patient. The prevalence of pDDIs was found to be 89.2%. Upon analysis by the PEPID database, 708 pDDIs with 215 different pairs of interacting drugs were identified. Polypharmacy (odds ratio (OR): 62.34, 95% confidence interval (CI): 7.97-487.64, p < 0.001) was identified as an independent predictor of the occurrence of pDDIs. Negative binomial regression analysis revealed that dyslipidemia (incidence rate ratio (IRR): 2.7, 95% CI 2.09-3.48, p < 0.001) and diabetes (IRR: 1.2, 95% CI 1.01-1.54, p = 0.040) increased the probability of occurrence of pDDI by 2.7 and 1.2 folds, respectively. Furthermore, the likelihood of pDDI increased with every one-day increase in the length of hospital stay (IRR: 1.02, 95% CI 1.00-1.03, p = 0.015) by 1.02 times and polypharmacy (IRR: 6.30, 95% CI 3.04-13.02, p < 0.001) by 6.3 times. The incidence of ADRs was found to be 10.7%. Majority of suspected ADRs were possible (n = 7, 50.0%), of mild and moderate severity (n = 7, 50.0%), and non-preventable (n = 8, 57.1%) type. Conclusions This study investigated two important drug-related problems, pDDIs, and ADRs, in the CKD population. High proportion of CKD patients in the study had pDDIs. Comorbid conditions such as dyslipidemia and diabetes mellitus, length of hospital stay, and polypharmacy were significantly associated with increased likelihood of pDDIs. Furthermore, there was a burden of ADRs in the study population, of which most ADRs were possible and of mild to moderate severity. Prevention, identification, and resolution of these problems in CKD patients is important and can be achieved through medication optimization, which requires a proactive interdisciplinary collaboration between clinicians, clinical pharmacists, and other healthcare professionals.

Effect of Online Home-Based Training on Functional Capacity and Strength in Two CKD Patients: A Case Study

Chronic kidney disease (CKD) is a clinical condition characterized by the loss of kidney function over time, as well as several complications affecting gastrointestinal, cardiovascular, and musculoskeletal systems. Physical exercise seems to induce positive adaptations in CKD patients, without side effects. Usually, these patients show a reduced physical activity and physical performance. The aim of this case-report was to evaluate the effects of an online training protocol on functional capacity and on muscle mass, in CKD stage III patients. Methods: Two CKD (stage III according to KDIGO guidelines) participants (1 female, Patient A; 1 male, Patient B) were enrolled and they performed an online tailored-supervised combined training lasting 12 weeks, including multi-joint strength exercises using TheraBand and an aerobic session at 65–70% of the patients' heart rate reserve. Results: Both patients showed an improving trend on functional capacity (6 minutes walking test: Patient A = +3%; Patient B = +5.3%) and on strength of the upper arms (handgrip strength test-right: Patient A = +13.4%; Patient B = +19.1%; handgrip strength test-left: Patient A = +42.8%; Patient B= +12.9%), as well as a reduction in inflammation and oxidative stress biomarkers. The protocol was feasible, and no side effects were evidenced. These case studies suggest that the online combined training can produce beneficial effects in CKD patients under conservative therapy, by reducing the CKD-related complications and improving the adherence to exercise of this population of patients, overcoming logistic barriers such as transportation, availability of facilities, and working and personal-life schedule.

Drug Interactions for Patients with Respiratory Diseases Receiving COVID-19 Emerged Treatments

Pandemic of coronavirus disease (COVID-19) is still pressing the healthcare systems worldwide. Thus far, the lack of available COVID-19-targeted treatments has led scientists to look through drug repositioning practices and exploitation of available scientific evidence for potential efficient drugs that may block biological pathways of SARS-CoV-2. Till today, several molecules have emerged as promising pharmacological agents, and more than a few medication protocols are applied during hospitalization. On the other hand, given the criticality of the disease, it is important for healthcare providers, especially those in COVID-19 clinics (i.e., nursing personnel and treating physicians), to recognize potential drug interactions that may lead to adverse drug reactions that may negatively impact the therapeutic outcome. In this review, focusing on patients with respiratory diseases (i.e., asthma or chronic obstructive pulmonary disease) that are treated also for COVID-19, we discuss possible drug interactions, their underlying pharmacological mechanisms, and possible clinical signs that healthcare providers in COVID-19 clinics may need to acknowledge as adverse drug reactions due to drug-drug interactions.

Prevalence and Clinical Significance of Drug-Drug and Drug-Dietary Supplement Interactions among Patients Admitted for Cardiothoracic Surgery in Greece

Background: Drug interactions represent a major issue in clinical settings, especially for critically ill patients such as those with cardiovascular disease (CVD) who require cardiothoracic surgery (CTS) and receive a high number of different medications. Methods: A cross-sectional study aimed at evaluating the exposure and clinical significance of drug–drug (DDIs) and drug–dietary supplement interactions (DDSIs) in patients admitted for CTS in the University Hospital of Crete Greece. DDIs were evaluated regarding underlying pharmacological mechanisms upon admission, preoperation, postoperation, and discharge from CTS clinic. Additionally, upon admission, the use of dietary supplements (DSs) and if patients had informed their treating physician that they were using these were recorded with subsequent analysis of potential DDSIs with prescribed medications. Results: The study employed 76 patients who were admitted for CTS and accepted to participate. Overall, 166 unique DDIs were identified, with 32% of them being related to pharmacokinetic (PK) processes and the rest (68%) were related to possible alterations of pharmacodynamic (PD) action. CVD medications and drugs for central nervous system disorders were the most frequently interacting medications. In total, 12% of the identified DDIs were of serious clinical significance. The frequency of PK-DDIs was higher during admission and discharge, whereas PD-DDIs were mainly recorded during pre- and postoperation periods. Regarding DS usage, 60% of patients were using DSs and perceived them as safe, and the majority had not informed their treating physician of this or sought out medical advice. Analysis of medical records showed 30 potential combinations with prescribed medications that could lead in DDSIs due to modulation of PK or PD processes, and grapefruit juice consumption was involved in 38% of them. Conclusions: An increased burden of DDIs and DDSIs was identified mostly upon admission for patients in CTS clinics in Greece. Healthcare providers, especially prescribing physicians in Greece, should always take into consideration the possibility of DDIs and the likely use of DS products by patients to promote their well-being; this should only be undertaken after receiving medical advice and an evidenced-based evaluation.