Prevalence of Potential Drug-Drug Interaction Risk among Chronic Kidney Disease Patients in a Spanish Hospital

Survey of Potential Drug Interactions, Use of Non-Medical Health Products, and Immunization Status among Patients Receiving Targeted Therapies

In recent years, several changes have occurred in the management of chronic immunological conditions with the emerging use of targeted therapies. This two-phase cross-sectional study was conducted through structured in-person interviews in 2018-2019 and 2022. Additional data sources included ambulatory medical records and the itemized reimbursement reporting interface of the National Health Insurance Fund. Drug interactions were analyzed using the UpToDate Lexicomp, Medscape drug interaction checker, and Drugs.com databases. The chi-square test was used, and odds ratios (ORs) were calculated. In total, 185 patients participated. In 53% of patients (n = 53), a serious drug-drug interaction (DDI) was identified (mean number: 1.07 ± 1.43, 0-7), whereas this value was 38% (n = 38) for potential drug-supplement interactions (mean number: 0.58 ± 0.85, 0-3) and 47% (n = 47) for potential targeted drug interactions (0.72 ± 0.97, 0-5) in 2018. In 2022, 78% of patients (n = 66) were identified as having a serious DDI (mean number: 2.27 ± 2.69, 0-19), 66% (n = 56) had a potential drug-supplement interaction (mean number: 2.33 ± 2.69, 0-13), and 79% (n = 67) had a potential targeted drug interactions (1.35 ± 1.04, 0-5). Older age (>60 years; OR: 2.062), female sex (OR: 3.387), and polypharmacy (OR: 5.276) were identified as the main risk factors. Screening methods and drug interaction databases do not keep pace with the emergence of new therapeutics.

Clinical Pertinence and Determinants of Potential Drug-Drug Interactions in Chronic Kidney Disease Patients: A Cross-sectional Study

Background: Chronic kidney disease (CKD) is one of the major health issues effecting around 15% of world population, and its further complications has raised the need of polypharmacy for management. But this polypharmacy also upsurges the risk of potential drug-drug interactions (pDDIs) in CKD patients, which may further be responsible for increased morbidity and mortality. Objective: The main objective is therefore to evaluate the distribution, severity, causes, associated drug interactions, and clinical relevance of determination of pDDIs in CKD patients. Methods: Medical files of CKD patients examined at nephrology department, Maharishi Markandeshwar Institute of Medical Sciences and Research (MMIMSR), Mullana, between December 2022 and May 2023 were cross-sectionally assessed for this study. Medscape drug interaction checker was used to study patient profiles for pDDIs, and suggestive measures to minimize those pDDIs were studied using DDInter to ensure better clinical decision-making and patient safety. IBM SPSS (version 24) was utilized for statistical analysis. Results: The data reveal that 74.5% of the 200 medical files being evaluated had 839 pDDIs in total, out of which nearly 78.3% of patients had moderate, 15.6% had minor, and 6.07% had serious interactions. The potential adverse outcomes of pDDIs included an irregular heartbeat, hypokalemia, central nervous system (CNS) adverse effects, hypoglycemia, and a decline in therapeutic efficacy. The prevalence of pDDIs was discovered to be substantially correlated with age ≥60 years, (odds ratio [OR] = 0.65; 95% CI = 0.4-0.9; P = 0.040), length of stay ≥10 days (OR = 4.0; 95% CI = 1.29-6.1; P = 0.016), and number of prescribed drugs ≥10 (OR = 5.5; 95% CI = 2.45-10.69; P = 0.004). Conclusion: Patients with CKD have a high incidence of pDDIs (mainly mild to moderate). Older age, duration of hospital stays, and polypharmacy all raise the risk of pDDIs. Healthcare professionals (physicians and clinical pharmacist) should use drug interaction checker software programs like Medscape and DDInter to acquire knowledge about different pDDIS and their alternative measures so that the associated adverse drug reactions (ADRs) can be controlled and rational drug combination can be prescribed for management of CKD ensuring better patient care.

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.

Association between CYP4A11 and EPHX2 genetic polymorphisms and chronic kidney disease progression in hypertensive patients

BACKGROUND

There are evidence indicating that some metabolites of arachidonic acid produced by cytochromes P450 (CYP) and epoxide hydroxylase (EPHX2), such as hydroxyeicosatetraenoic acids (HETEs), epoxyeicosatrienoic acids (EETs) or dihydroxyeicosatrienoic acids (DHETEs), play an important role in blood pressure regulation and they could contribute to the development of hypertension (HT) and kidney damage. Therefore, the main aim of the study was to evaluate whether the genetic polymorphisms of CYP2C8, CYP2C9, CYP2J2, CYP4F2, CYP4F11 and EPHX2, responsible for the formation of HETEs, EETs and DHETEs, are related to the progression of impaired renal function in a group of patients with hypertension.

METHODS

151HT patients from a hospital nephrology service were included in the study. Additionally, a group of 87 normotensive subjects were involved in the study as control group. For HT patients, a general biochemistry analysis, estimated glomerular filtration rate and genotyping for different CYPs and EPHX2 variant alleles was performed.

RESULTS

CYP4A11 rs3890011, rs9332982 and EPHX2 rs41507953 polymorphisms, according to the dominant model, presented a high risk of impaired kidney function, with odds ratios (OR) of 2.07 (1.00-4.32; P=0.049) 3.02 (1.11-8.23; P=0.030) and 3.59 (1.37-9.41; P=0.009), respectively, and the EPHX2 rs1042032 polymorphism a greater risk according to the recessive model (OR=6.23; 95% CI=1.50-25.95; P=0.007). However, no significant differences in allele frequencies between HT patients and in normotensive subjects for any of the SNP analysed. In addition, the patients with diagnosis of dyslipidemia (n=90) presented higher frequencies of EPHX2 K55R (rs41507953) and *35A>G (rs1042032) variants than patients without dyslipidemia, 4% vs. 14% (P=0.005) and 16 vs. 27% (P=0.02), respectively.

CONCLUSIONS

In this study has been found higher odds of impaired renal function progression associated with rs3890011 and rs9332982 (CYP4A11) and rs41507953 and rs1042032 (EPHX2) polymorphisms, which may serve as biomarkers for improve clinical interventions aimed at avoiding or delaying, in chronic kidney disease patients, progress to end-stage kidney disease needing dialysis or kidney transplant.

An Assessment of Different Decision Support Software from the Perspective of Potential Drug-Drug Interactions in Patients with Chronic Kidney Diseases

Chronic kidney disease (CKD) is a multifaceted disorder influenced by various factors. Drug-drug interactions (DDIs) present a notable risk factor for hospitalization among patients with CKD. This study aimed to assess the frequency and attributes of potential DDIs (pDDIs) in patients with CKD and to ascertain the concordance among different Clinical Decision Support Software (CDSS). A cross-sectional study was conducted in a nephrology outpatient clinic at a university hospital. The pDDIs were identified and evaluated using Lexicomp® and Medscape®. The patients' characteristics, comorbidities, and medicines used were recorded. The concordance of different CDSS were evaluated using the Kendall W coefficient. An evaluation of 1121 prescribed medications for 137 patients was carried out. The mean age of the patients was 64.80 ± 14.59 years, and 41.60% of them were male. The average year with CKD was 6.48 ± 5.66. The mean number of comorbidities was 2.28 ± 1.14. The most common comorbidities were hypertension, diabetes, and coronary artery disease. According to Medscape, 679 pDDIs were identified; 1 of them was contraindicated (0.14%), 28 (4.12%) were serious-use alternative, and 650 (9.72%) were interventions that required closely monitoring. According to Lexicomp, there were 604 drug-drug interactions. Of these interactions, 9 (1.49%) were in the X category, 60 (9.93%) were in the D category, and 535 (88.57%) were in the C category. Two different CDSS systems exhibited statistically significant concordance with poor agreement (W = 0.073, p < 0.001). Different CDSS systems are commonly used in clinical practice to detect pDDIs. However, various factors such as the operating principles of these programs and patient characteristics can lead to incorrect guidance in clinical decision making. Therefore, instead of solely relying on programs with lower reliability and consistency scores, multidisciplinary healthcare teams, including clinical pharmacists, should take an active role in identifying and preventing pDDIs.

What is Polypharmacy in Patients with Chronic Kidney Disease? A Systematic Review

PURPOSE

Polypharmacy presents an increasing therapeutic challenge for physicians managing patients with chronic kidney disease (CKD). However, there is a lack of consensus regarding the specific medication count threshold that defines polypharmacy in this population. The objective of this review is to establish a unified definition of polypharmacy in the CKD population by examining the diverse definitions used in previously published studies.

METHODS

A comprehensive search was conducted in relevant databases (PubMed, SCOPUS, Cochrane, and disease-specific databases) from 2000 to May 2022 to identify studies with polypharmacy threshold definitions in patients with CKD. Studies meeting the inclusion criteria were included in this review, and their methodologic quality was assessed.

FINDINGS

Following the screening of the search results, duplicate records and studies that did not meet the inclusion criteria were removed, resulting in a total of 18 studies included in this review. Among these, 61.1% specified the polypharmacy definition to be a threshold of ≥5 medications. In addition, 22.2% specified a high polypharmacy definition at a threshold of ≥10 medications. However, none of the studies reported on the dichotomy between kidney-related and non-kidney-related polypharmacy.

IMPLICATIONS

This review indicates that a numerical threshold of ≥5 medications is commonly used to define polypharmacy in patients with CKD. Nevertheless, it remains uncertain whether a kidney-related polypharmacy definition or a high polypharmacy definition would better identify patients with CKD at risk for polypharmacy-related complications.

Comparative analysis of potential drug-drug interactions in a public and private hospital among chronic kidney disease patients in Khyber Pakhtunkhwa: A retrospective cross-sectional study

INTRODUCTION

Chronic kidney disease (CKD) is a significant public health challenge due to its rising incidence, mortality, and morbidity. Patients with kidney diseases often suffer from various comorbid conditions, making them susceptible to potential drug-drug interactions (pDDIs) due to polypharmacy and multiple prescribers. Inappropriate prescriptions for CKD patients and their consequences in the form of pDDIs are a major challenge in Pakistan.

AIM

This study aimed to compare the incidence and associated risk factors of pDDIs among a public and private sector hospital in Khyber Pakhtunkhwa, Pakistan.

METHOD

A retrospective cross-sectional study design was conducted to compare pDDIs among public and private sector hospitals from January 2023 to February 2023. Patients profile data for the full year starting from January 1 2022 to December 302022, was accessed All adult patients aged 18 years and above, of both genders, who currently have or have previously been diagnosed with end-stage renal disease (ESRD) were included. For assessing pDDIs, patient data was retrieved and checked using Lexicomp UpToDate® for severity and documentation of potential drug-drug interactions.

RESULTS

A total of 358 patients' data was retrieved (with n = 179 in each hospital); however, due to incomplete data, n = 4 patients were excluded from the final analysis. The prevalence of pDDIs was found to be significantly higher in private hospitals (84.7%) than in public hospitals (26.6%), with a p-value <0.001. Patients in the age category of 41-60 years (AOR = 6.2; p = 0.008) and those prescribed a higher number of drugs (AOR = 1.2; p = 0.027) were independently associated with pDDIs in private hospitals, while the higher number of prescribed drugs (AOR = 2.9; p = <0.001) was an independent risk factor for pDDIs in public hospitals. The majority of pDDIs (79.0%) were of moderate severity, and a significant number of patients (15.1%) also experienced major pDDIs, with a p-value <0.001. The majority of pDDIs had fair documentation for reliability rating in both public and private hospitals.

CONCLUSION

The prevalence of pDDIs was higher among CKD patients at private hospitals, and most of the pDDIs were of moderate severity. A considerable number of patients also experienced major pDDIs. The risk of experiencing pDDIs was found to be higher in older patients and among those prescribed a higher number of drugs.

Knowledge, attitude and perceptions of pharmacists regarding renal dose adjustment among chronic kidney disease patients in Pakistan

BACKGROUND

Chronic kidney disease (CKD) poses a significant public health challenge. CKD patients have compromised renal function, which not only alters the pharmacokinetics of drugs but also their pharmacodynamics. Adjusting drug doses for these patients is essential to achieve the intended clinical outcomes, prevent adverse drug events, and halt further progression of the disease. Pharmacists play a pivotal role in ensuring safe and appropriate therapy for CKD patients. However, there is a noticeable absence of national dosing guidelines for CKD in Pakistan, coupled with a scarcity of studies exploring the knowledge, attitude, and perception of renal dose adjustments in the country. This study aimed to evaluate the knowledge, attitudes, and perceptions of pharmacists in the Khyber Pakhtunkhwa province and Islamabad regarding renal dose adjustments.

METHODOLOGY

A cross-sectional study was conducted to gauge the knowledge, attitude, and perception of pharmacists working in various cities of Khyber Pakhtunkhwa and the capital city, Islamabad, from February to May 2023. The Renal Dosing Questionnaire-13 (RDQ-13) scale was employed for this purpose. The survey link was disseminated through emails, and the RDQ-13 scale was also completed in person by pharmacists from hospitals, clinics, community, and retail settings who interact with CKD patients. Univariate linear regression was employed, and factors with a p value < 0.25 were subjected to multivariate linear regression. For comparing knowledge, attitude, and perception scores of pharmacists, the independent t test and one-way ANOVA were utilized as appropriate. A p value < 0.05 was deemed statistically significant.

RESULTS

Of the 384 pharmacists approached, 270 completed the RDQ-13 scale, resulting in a response rate of 70.3%. The overall knowledge score regarding renal dose adjustment was 21.24 ± 2.18 (mean ± SD). Attitude scores averaged at 10.04 ± 1.81, and perception scores at 7.19 ± 2.15. Multivariate analysis indicated a positive correlation between the pharmacists' perception scores and gender, with male pharmacists scoring higher than their female counterparts.

CONCLUSIONS

The study underscores the importance of instituting targeted training programs for pharmacists, ensuring access to dependable resources, and promoting research and results dissemination in the realm of renal pharmacotherapy to enhance public health outcomes.

Identification of Prescribing Patterns in Hemodialysis Outpatients Taking Multiple Medications

We investigated the relationship between multidrug administration and the characteristics, pathophysiology, and drug class in outpatients with hemodialysis. A retrospective cross-sectional study was conducted at Saitama Medical University Hospital in October 2018. Multidrug administration was defined as receiving either more than six drugs or more than the median number of drugs. The drugs used were represented by their anatomical classification codes in the Anatomical Therapeutic Chemistry Classification System (ATC classification). A latent class analysis (LCA) was used to identify clusters at risk of receiving multiple medications. A stepwise logistic regression analysis was performed to select ATC classifications prone to being involved in multidrug administration. As of October 2018, 98 outpatients with hemodialysis were enrolled in the study. In the LCA, when diabetes was the main primary disease, oral hypoglycemic agents available to dialysis patients were limited, but the number of drugs administered was large. Old age, poor nourishment, a long history of dialysis, and chronic nephritis were associated with multidrug administration among nondiabetic patients. In the second level of the ATC classification, the drugs frequently used were coded A02 (drugs for acid-related disorders), A07 (antidiarrheal agents, intestinal anti-inflammatory/anti-infective agents), B01 (antithrombotic agents), and N05 (psycholeptics). The prescribing patterns for either diabetic patients or nondiabetic elderly patients were identified in outpatients with hemodialysis taking multiple medications, and drugs for acid-related disorders, antidiarrheal agents, intestinal anti-inflammatory/anti-infective agents, antithrombotic agents, and psycholeptics are frequently used in those patients.

Evaluation of Renal Impairment Influence on Metabolic Drug Clearance using a Modelling Approach

BACKGROUND AND OBJECTIVE

Chronic kidney disease (CKD) may alter drug renal elimination but is also known for interacting with hepatic metabolism via multiple uremic components. However, few global models, considering the five major cytochromes, have been published, and none specifically address the decrease in cytochrome P450 (CYP450) activity. The aim of our study was to estimate the possibility of quantifying residual cytochrome activity as a function of filtration rate, according to the data available in the literature.

METHODS

For each drug in the DDI-predictor database, we collected available pharmacokinetic data comparing drug exposition in the healthy patient and in various stages of CKD, before building a model capable of predicting the variation of exposure according to the degree of renal damage. We followed an In vivo Mechanistic Static Model (IMSM) approach, previously validated for predicting change in liver clearance. We estimated the remaining fraction parameters at glomerular filtration rate (GFR) = 0 and the alpha value of GFR to 50% impairment for the 5 major cytochromes using a non-linear constrained regression using Matlab software.

RESULTS

Thirty-one compounds had usable pharmacokinetic data, with 51 AUC ratios between healthy and renal impaired patients. The remaining CYP3A4 activity was estimated to be 0.4 when CYP2D6, 2C9, 2C19 and 1A2 activity was estimated to be 0.43; 1; 0.73 and 0.7, respectively. The alpha value was estimated to be at 6.62; 25; 9.8; 1.38 and 11.04 for each cytochrome. In comparison with published data, all estimates but one were correctly predicted in the range of 0.5-2.

CONCLUSION

Our approach was able to describe the impact of CKD on metabolic elimination. Modelling this process makes it possible to anticipate changes in clearance and drug exposure in CKD patients, with the advantage of greater simplicity than approaches based on physiologically-based pharmacokinetic modelling. However, a precise estimation of the impact of renal failure is not possible with an IMSM approach due to the large variability of the published data, and thus should rely on specific pharmacokinetic modelling for narrow therapeutic margin drugs.

Assessment of risk factors associated with potential drug-drug interactions among patients suffering from chronic disorders

Patients suffering from chronic diseases are more likely to experience pDDIs due to older age, prolonged treatment, severe illness and greater number of prescribed drugs. The objective of the current study was to assess the prevalence of pDDIs and risk factors associated with occurrence of pDDIs in chronic disease patients attending outpatient clinics for regular check-ups. Patients suffering from diabetes, chronic obstructive pulmonary disease (COPD), stroke and osteoporosis were included in the study. This study was a cross sectional, observational, prospective study that included 337 patients from outpatient clinics of respiratory ward, cardiac ward and orthopedic ward of Nishter Hospital Multan, Pakistan. The mean number of interactions per patient was 1.68. A greater risk for occurrence of pDDI was associated with older age ≥ 60 years (OR = 1.95, 95% CI = 1.44-2.37, p<0.001); polypharmacy (≥ 5 drugs) (OR = 3.74, 95% CI 2.32-4.54, p<0.001); overburden (OR = 2.23, 95% CI = 1.64-3.16, p<0.01); CCI score (OR = 1.28, 95% CI = 1.04-1.84, p<0.001); multiple prescribers to one patient (OR = 1.18, 95% CI = 1.06-1.41, p<0.01); and trainee practitioner (OR = 1.09, 95% CI = 1.01-1.28, p<0.01). Old age, polypharmacy, overburden healthcare system, higher comorbidity index, multiple prescribers to one patient and trainee practitioner were associated with increased risk of occurrence of pDDIs in chronic disease patients.

Polypharmacy, chronic kidney disease, and mortality among older adults: A prospective study of National Health and nutrition examination survey, 1999-2018

Introduction

Polypharmacy might contribute to a range of adverse outcomes, which could get worse in the elderly with chronic kidney disease (CKD). Evidence on polypharmacy, CKD, and mortality is scarce. We aimed to investigate the prospective association between polypharmacy, CKD and all-cause and cause-specific mortality in adults aged ≥65 years.

Methods

A total of 13,513 adults from the National Health and Nutrition Examination Surveys were included, following up from 1999 to 2018 until December 31, 2019. The simultaneous use of ≥5 medications by one individual was defined as polypharmacy. Survey-weighted Cox proportional hazard models were used to estimate the hazard ratio (HRs) for mortality from all-cause, cardiovascular diseases (CVD), and cancer after adjusting for potential confounding factors.

Results

Among the elderly with CKD, we identified 3,825 total deaths (1,325 CVD and 714 cancer) during a median follow-up of 7.7 years. Participants with polypharmacy had a 27% (HR = 1.27 [1.15, 1.39]) and 39% (HR = 1.39 [1.19, 1.62]) higher risk of all-cause and CVD mortality, respectively, but not for cancer mortality. Compared with the elderly with no polypharmacy and no CKD, the corresponding HRs (95%CIs) for all-cause mortality were 1.04 (0.96, 1.14) for those with no polypharmacy but CKD, 1.24 (1.11, 1.39) for with polypharmacy but no CKD, and 1.34 (1.21, 1.49) for those with both polypharmacy and CKD. A similar pattern was detected for CVD mortality.

Discussion

Polypharmacy was associated with elevated risks of all-cause and CVD mortality among the elderly CKD patients. More evidence-based approaches should be promoted for the appropriate deprescribing in the older adults with CKD.

Prevalence and predictors of clinically significant statin-drug interactions among Yemeni patients taking statins for primary and secondary prevention of cardiovascular disease

BACKGROUND

Statins are extensively used in clinical practice for the primary and secondary prevention of cardiovascular diseases. Statins are usually taken in combination with other medications. This may increase the risk of statin-drug interactions. The study aimed to evaluate the prevalence, patterns, and predictors of clinically significant statin-drug interactions among patients on statin therapy.

MATERIAL AND METHODS

A cross-sectional study was conducted at the cardiology, endocrine, and internal medicine outpatient clinics in four tertiary care hospitals in Sana'a, Yemen. Lexicomp Drug Interaction database was used to analyze the prescriptions for potential statin-drug interactions. Binary and multivariable logistic regression were utilized for analysis.

RESULTS

Of the total number of patients (634), 114 individuals (18%) had a total of 122 statin-drug interactions. According to Lexicomp risk classification, 102 (83.6%) DDIs were class C (monitor therapy), 19 (15.6%) were class D (therapy modification), and only one (0.8%) class X (avoid combination). Simvastatin use was significantly associated with the presence of category D and X DDIs (15.9% vs. 1.6%, p < .001). Polypharmacy (OR = 2.571, p < .001) and having ≥3 comorbidities (OR = 2.512, p < .001) were the only variables associated with the presence of statin-drug interactions (C, D, and/or X).

CONCLUSION

Patients with polypharmacy and those with three or more comorbidities had a higher risk for statin-drug interactions. Therefore, routine screening by physicians and pharmacists for potential interactions should occur before prescribing or dispensing any medication to avoid clinically significant statin-drug interactions.

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.

Assessing the binding interaction of polystyrene sulfonate with amitriptyline in healthy volunteers: a cross-over design - The BIND study

PURPOSE

Polystyrene sulfonate is used for binding potassium in patients with chronic kidney disease (CKD). Because of its binding properties, it can potentially bind other medications and thereby decrease their bioavailability and effectiveness. Amitriptyline, often used by CKD patients for neuropathic pain, shows significant binding to polystyrene sulfonate in vitro. The purpose of this study was to determine the effect of polystyrene sulfonate on the exposure of amitriptyline in vivo when taken concomitantly in healthy volunteers.

METHODS

We performed a prospective cross-over study in nine healthy volunteers. Participants were 18 years of age or older, did not use any medication, and had no known allergy to amitriptyline or polystyrene sulfonate. Participants visited Deventer Teaching Hospital twice. Once they received a single dose of amitriptyline 50 mg and once they received a single dose of both polystyrene sulfonate 15 g and amitriptyline 50 mg taken concomitantly, with a wash out period of at least 1 week. After intake of the medication, six blood samples were collected, at 2, 3, 4, 5, 6, and 8 h. Blood samples were analysed to determine maximum concentration (Cmax) and area under the curve 0-8 h after intake (AUC_0-8 h). Difference in Cmax and AUC_0-8 h was analysed with a paired T-test or Wilcoxon signed rank test, depending on normality of the data. A p-value < 0.05 was considered statistically significant.

RESULTS

Of the nine participants included, eight participants completed both visits to the hospital. Mean maximum concentration (Cmax) of amitriptyline was 35.61 µg l^-1 (95% CI 27.90-43.33 µg l^-1) when taken alone, compared to 9.25 µg l^-1 (95% CI 6.59-11.92 µg l^-1) when taken with polystyrene sulfonate (p < 0.001). Mean AUC_0-8 h of amitriptyline was 168.20 µg × h l^-1 (95% CI 139.95-196.45 µg × h l^-1) when taken alone and 45.78 µg × h l^-1 (95% CI 30.20-61.36 µg × h l^-1) when taken with polystyrene sulfonate (p < 0.0001).

CONCLUSION

These results show a significant decrease in exposure of amitriptyline of approximately 75% when taken concomitantly with polystyrene sulfonate, thereby probably compromising therapy efficacy. Patients using both amitriptyline and polystyrene sulfonate should be informed to separate intake of these medications.

TRIAL REGISTRATION

NL8539 (17 April 2020).

The Prevalence of Potential Drug-Drug Interactions in CKD-A Retrospective Observational Study of Cerrahpasa Nephrology Unit

Background and Objectives: Chronic kidney disease (CKD) is usually linked with polypharmacy and patients are invariably at risk of complex medication regimens. The present study was designed to estimate the potential drug-drug interactions (pDDIs) through the prescription patterns provided to patients of the Nephrology Transplant Unit of Cerrahpasa Medical Faculty patients. Materials and Methods: 96 patients were included in the study. pDDIs among every combination of the prescribed drug were analyzed using the Thomson Reuters Micromedex. Results: We found 149 pDDIs making 2.16 interactions per prescription with incidence rates of 69.7%. Approximately 4.1% of interactions were of significant severity, 75.1% moderate severity, and 20.8% were classified as minor pDDIs. The most frequent interactions were found between iron and aluminum, calcium or magnesium-containing products (21.37%), calcium channel blockers and beta-blockers (8.96%); and aspirin and aluminum, calcium, or magnesium-containing products (7.58%). We identified 42 drug pairs with probability of clinical significance. The most commonly reported clinical outcomes of the pDDIs were hypo- or hypertension (39.24%), decreased drug efficacy (24.05%), and arrhythmia (9.49%). Aluminum, calcium, or magnesium-containing drug products (33.10%) constituted the primary class of drugs involved in interactions. Conclusions: This study showed pharmacodynamics (49%), pharmacokinetics (42.94%) interactions, polypharmacy and gender as determinant of pDDIs. A comprehensive multicenter research is required to decrease the morbidity and ease the state burden.

Clinically Significant Cytochrome P450-Mediated Drug-Drug Interactions in Children Admitted to Intensive Care Units

OBJECTIVES

Children admitted to intensive care units (ICUs) often require multiple medications due to the complexity and severity of their disease, which put them at an increased risk for drug interactions. This study examined cytochrome P450-mediated drug-drug interactions (DDIs) based on the Pediatric Intensive Care (PIC) database, with the aim of analyzing the incidence of clinically significant potential drug-drug interactions (pDDIs) and exploring the occurrence of actual adverse reactions.

METHODS

The Lexicomp database was used to screen cytochrome P450-mediated DDI pairings with good levels of reliability and clear clinical phenotypes. Patients exposed to the above drug pairs during the same period were screened in the PIC database. The incidence of clinically significant pDDIs was calculated, and the occurrence of adverse reactions was explored based on laboratory measurements.

RESULTS

In total, 84 (1.21%) of 6920 children who used two or more drugs were exposed to at least one clinically significant pDDI. All pDDIs were based on CYP3A4, with nifedipine + voriconazole (39.60%) being the most common drug pair, and the most frequent being the J02 class of drugs. Based on laboratory measurements, 15 adverse reactions were identified in 12 patients.

CONCLUSIONS

Clinically significant cytochrome P450-mediated pDDIs existed in the children admitted to ICUs, and some of the pDDIs led to adverse clinical outcomes. The use of clinical decision support systems can guide clinical medication use, and clinical monitoring of patients' needs has to be enhanced.

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.

Exploring co-dispensed drug use in patients on sevelamer or polystyrene sulfonate to identify potential novel binding interactions: a cross sectional in silico study : Potential novel binding interactions with resins

Background Sevelamer and polystyrene sulfonate are used for treating hyperphosphatemia and hyperkalaemia in chronic kidney disease patients. Because of their binding properties, these resins potentially bind other drugs in the gastrointestinal tract, thereby decreasing their bioavailability and clinical effectiveness. Aim The aim of this study was to explore co-dispensed drug use in patients on sevelamer or polystyrene sulfonate to identify potential novel binding interactions. Method In this in silico study, the 100 drugs most frequently co-dispensed with sevelamer/polystyrene sulfonate in the period 2000-2018 were extracted from the University Groningen IADB.nl database. Drugs dispensed to < 5% of patients, drugs not orally administered, drugs administered once daily before bedtime and drugs for which information on binding interactions with sevelamer or polystyrene was already available were excluded. The likelihood of an interaction (yes or no) of the included drugs was assessed based on pKa- and Log P values. For sevelamer, drugs with a pKa (acid) between 1.5 and 7.4 and or a Log P value > 2.0 were identified as potential interacting drug. For polystyrene sulfonate, drugs with a pKa (base) > 1.5 were identified as potential interacting drug. Results Of the top 100 drugs most frequently co-dispensed with sevelamer/polystyrene sulfonate, 22 and 27 potentially clinically relevant new interacting drugs were identified for sevelamer and polystyrene sulfonate respectively. Conclusion Several potentially relevant novel binding interactions for sevelamer and polystyrene sulfonate were identified based on dispensing data and assessment of chemical properties for which further interaction research is warranted.

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.

Binding interactions with sevelamer and polystyrene sulfonate in vitro

This study explored the binding of 28 drugs, which were selected based on frequency of concomitant use and chemical properties, to sevelamer and polystyrene sulfonate in vitro. The relative binding was determined by dissolving the investigated drugs alone (=control), together with 800 mg of sevelamer and 15 g of polystyrene sulfonate at different pH levels (1.5, 5.5, and 7.4), respectively. After incubation at 37℃ and shaking for 60 min, the solutions were diluted and centrifuged, and the drug concentrations were quantified with validated analytical assays. The binding assays were performed in threefold. The mean relative binding (MRB) at each pH level was calculated, with a MRB >20% for at least one pH level to be considered as relevant binding. Fourteen and 23 potentially new binding interactions were identified with sevelamer and polystyrene sulfonate, respectively. These potentially new binding interactions have to be studied in vivo to assess their clinical relevance.