Original Research
Prevalence of comorbidities, polypharmacy and drug related problems among hospitalized patients with chronic kidney disease
Mustafa A. Alssageer, Manal M. Saad and Omkalthum M. Mosbah
Chronic kidney disease is a public health problem affecting people worldwide. This study was aimed to examine the characteristics of patients with chronic kidney disease and to identify prevalence of drug-related problems among Libyan patients. This is a descriptive retrospective study carried out in Southern-west part of Libya, Sebha City. Information abstraction forms were used for collection of data. The investigators reviewed the medications, medical records and laboratory data to identify drug-related problems.1 000 patients' files during 2019-2020 were examined and only 120 files were selected for this study. The majority of the participants were male (73, 61.0%) and the mean age was 56.1 years. 576 comorbidities among the selected patients were identified (73.61%) and the average number per patients was 4.8 concurrent diseases. There were 1 350 medications prescribed and the average of prescribed drugs per patient was 11.25. The majority of patients use more than 10 drugs (64, 53.3%) and the average length of staying in the hospital was 5.58 days. 502 drug-related problems were identified with an average of 4.18 per patient. Untreated conditions such as Hyponatremia and anemia were the highest rate of drug-related problems identified (199, 39.6%) followed by improper drug selection (82, 16.3%) such as cefotaxime, vancomycin and aminoglycoside for chronic kidney disease and drug use without indications such as antibiotics (68, 13.5%) and over-therapeutic dose such as metoclopramide(63, 12.5%). In conclusion, all the patients have polypharmacy and the majority have comorbid conditions and chronic kidney disease with frequent drug-related problems, thus, to lower the incidence rate of drug-related problems, therapeutic interventions are needed. Subsequently, it is a crucial to involve clinical pharmacist in hospital to improve the care of patient with chronic kidney disease.
Introduction
Chronic kidney disease (CKD) is a worldwide public health problem and affects more than 50 million people worldwide [1]. CKD is associated with end-stage renal disease (ESRD) and increases morbidity and mortality as well as the cost of the health care system [2]. CKD has resulted in almost one million deaths worldwide [3]. The significance of CKD not only lies in the burden associated with the disease but also in the burden associated with the use of medication in this chronic disease. Patients with CKD present a variety of metabolic and nutritional abnormalities [4]. Thus, patients require numerous medications and complex regimen to treat CKD and to slow progression as well as associated comorbidity. The progression of CKD may lead to increased number of medications taken by patients to manage the complication and the comorbidities, thus, subsequently increase the prevalence of drug-related problems (DRPs) [5]. Medication-related problems are implicated in 16.1% of all the hospital admissions to an internal medicine ward [6]. Of these, 58.9% of the admissions could possibly[MOU1] [ma2] be avoided. Once admitted to the hospital, greater than 18.0% of patient deaths in the internal medicine ward can be attributed to one or more drugs [7]. DRPs may increase hospital admissions, morbidity, mortality and pose a financial burden to the healthcare system [8]. Therefore, the patient who is burdened by administering many medications, it's not surprising may get mistakes in taking of these medications, intentionally or unintentionally. Understanding what characteristics of CKD patients, their comorbidities and polypharmacy would potentially effect on their health outcome and improve the overall prescribing and quality of care in CKD. DRPs can lead to increase in hospitalization rate; therefore, strategies aimed at identifying and resolving DRPs can help reduce the number of hospitalization [9]. Therefore, this study was conducted to identify characteristics of hospitalized CKD Libyan patients and to evaluate the prevalence rate of comorbidities and polypharmacy among the patients in Southern-west region of Libya.
Materials and methods
This is a descriptive retrospective study carried out in Southern-west part of Libya, Sebha city, Libya and conducted in adult patients (18 years or older) who were diagnosed with CKD at all stages and hospitalized in general medical ward at Sebha Medical Centre (SMC). The study was conducted from January to September 2021, among CKD patients admitted to SMC in 2019 and 2020. Patients were eligible for inclusion if their age is more than 18 years and pre-dialysis patients[MOU3] [ma4] . Hemodialysis patients who were reported in records he\she admitted to the medicine region were excluded[MOU5] [ma6] [ma7] [ma8] . Convenience sampling was carried out to select patients’ records to include in the study[MOU9] . Two investigators obtained and examined patient files from SMC's statistics division which serves as a repository for hospitalized patients' medical records. A standardized data extraction sheet was used to collect the relevant data from patient medical record and data were collected by trained pharmacy students by a pre-tested data collection checklist[MOU10] . Investigates reviewed the medications, comorbidities, medical records and laboratory data to identify pattern of prescribed drugs, examine the prevalence of comorbidities and identify and address DRPs.
For each patient, the following data were
collected: age, gender, body weight, family and social histories, history of
drug allergies, relevant medical and medication history, vital signs, drugs
used at admission, drugs started during the hospital stay and at discharge, results
of routine laboratory tests and the diagnosed diseases which are important for
identification of drug therapy problems. All personal data including name,
contact details and diagnosis remained confidential. Each documented drug
therapy was evaluated for the presence of DRPs based on using[MOU11] standard guideline as a pathophysiologic
approach and the clinical use of drugs. Medscape website was used which
provides an access to medical information for clinicians. The reliability and
accuracy of each drug therapy problem were assessed by clinical pharmacist.
Data about weight was not always available for all the patients’ records. Based
on the literature, the modification of diet in renal disease (MDRD) equation[MOU12] was applied to calculate the GFR since the
MDRD formula is simpler and does not require body weight information.
Ethical
consideration: A letter of ethical clearance was obtained
from the ethical review committee of Sebha University[MOU13] , Sebha, Libya (02/2021). The investigators
obtained official permission from the Faculty of Pharmacy and SMC
administration. Investigators evaluated all the prescribed drugs
included in individuals' medical records to find any potential DRPs and
recorded their findings on a report form. The investigators were trained by
professional clinical pharmacist (principal investigator).
Statistical
analysis: Data were analyzed
by Microsoft Excel and IBM Statistical Package for the Social Sciences (SPSS-20)
software[MOU13] . The categorical and nominal variables were expressed as
number and percentage and data presented as frequency, average and percentage
for descriptive presentation. For the comparative analysis, Chi-square test was used for
qualitative data and Kendall
rank correlation coefficient for ordinal-ordinal correlation. A p-value of < 0.05 was
considered as a significant.
Results
Demographic data: The demographic characteristics of the patients with CKD are summarized
in Table 1 and Figure 1. The majority of respondents were in the middle
age (30 - 60 years) which was accounted for 56.0% compared with the elderly group
(> 60 years) which was accounted for 37.0%. The average of age is 56.10 years
old. The majority of the patients were male (61.0%) compared to females. The
CKD patients were from stage V which accounted for 61.0% and from this stage, 61.0%
belong to the age group of 31 - 60 years. The next highest stage was IV which
accounted for 25.0%, whereas, over the half of them were from elderly (over 65 years, 53.0%). However, a minority of the patients
are from stage III (12.5%) and stage II (01.6%).
Table
1: Frequency and gender of Libyan patients according to
the stage of renal failure |
||||||||||
Total |
% |
< 60 |
% |
31 - 60 |
% |
18 - 30 |
|
|||
Female |
Male |
Female |
Male |
Female |
Male |
Stage |
||||
00 |
00 |
00 |
00 |
00 |
00 |
00 |
00 |
00 |
00 |
I |
02 (01.6%) |
00 |
00 |
00 |
01.6 |
00 |
02 |
00 |
00 |
00 |
II |
15 (12.5%) |
05.8 |
01 |
06 |
06.6 |
03 |
05 |
00 |
00 |
00 |
III |
30 (25.0%) |
13.3 |
04 |
12 |
09.1 |
04 |
07 |
02.5 |
01 |
02 |
IV |
73 (61.0%) |
18.3 |
10 |
12 |
37.5 |
22 |
23 |
05.0 |
02 |
04 |
V |
120 (100%) |
37.5 |
15 |
30 |
55.0 |
29 |
37 |
07.5 |
03 |
06 |
Total |
Comorbidities: As showed in Table 2, all of the patients were found to have at least one comorbidity. Nearly, two-third of the patients had three to five comorbidities which accounted for 65.0% whereas 34.2% had one or two comorbidities. The average of comorbidities for each patient was 4.8. In Table 3, the majority of patients have anemia and electrolyte imbalance which was reported by 90.8% and 86.7%, respectively, followed by over two-third of the patients have hypertension and diabetes mellitus which accounted with 70.8% and 60.8%, respectively, and those patients who have hypertension accompanied with diabetes mellitus were 46.6[MOU14] %. In this study, the infection was recorded in 42.5% and mineral and bone disorder for 40.8% and cardiovascular diseases for 35.8[MOU15] % as ischemic heart disease. The minority of the patients have dyslipidemia (06.7%) (Table 3). Regarding to electrolyte imbalance[MOU16] , the present results showed that hyponatremia is the highest prevalence rate (58.3%) followed hypocalcemia (39.1%) and to a less extent, hypokalemia (21.6%) and hyperkalemia (16.6%) while minority of patients have hypernatremia (08.3%) and hypercalcemia (00.8%), as shown in Table 4.
Pattern of drug use: In this study, 1350 medications were prescribed[MOU17] for patients with CKD during their stay in
SMC. As outlined in Table 5, the most frequently prescribed medications
were supplements followed by anti-hypertension drugs which were accounted for
33.9% and 18.6%, respectively. To a less extent, antibiotic and GIT drugs were
represented by 18.6% and 14.0%, correspondingly. Among all the prescribed
drugs, anti-thrombotic, anti-diabetic, analgesic, anti-lipidemic and CNS agents
were accounted for 03.7%, 03.6%, 03.0%, 02.9% and 02.1%, respectively. However,
corticosteroids were the lowest prescribed drugs which accounted for 00.3%.
Other medications were represented by 05.9%. The pattern of prescribed
drugs based on patients is showed in Table 5. Supplements were the
highest category prescribed drugs to the patients which reported by 93.3% of
the patients and followed by antibiotics which accounted with 84.1% of the patients.
Patients who received antihypertensive medications and diuretics concurrently
made up 80.0% of the patient population while those who solely received
diuretic made up 58.3% of the patient population. The majority of the patients have
received GIT medications (76.7%) and to a less extent, the antibiotic and anti-thrombotic,
analgesic agents and anti-hyperlipidemic drugs were taken (32.5%, 30.0%, 29.2%
and 28.3%, respectively). A minority of the patients have been given
corticosteroids (03.3%).
Polypharmacy: In Figure 2, poly-pharmacy (the concurrent use of more than five
different medications by patient) was observed among all the participants in
this study. The majority of the patients (53.3%) were used more than 10
medications in this study compared with those who had 5 to 10 medications (46.7%)
as showed in Figure 2. The average of drugs per each CKD patient was found
to be 11.25.
Table 2: Prevalence rate of comorbidities |
||
Rate |
Frequency |
Percentage |
1 - 2 |
41 |
34.2 |
3 - 5 |
78 |
65.0 |
> 5 |
1 |
00.8 |
Total |
120 |
100 |
Average rate is 4.8 per patient |
Table 3: Type of comorbidities |
||
Comorbidity |
Frequency |
Percentage |
Anemia |
109 |
90.8 |
Electrolyte imbalance |
104 |
86.7 |
Hypertension |
85 |
70.8 |
Diabetes mellitus |
71 |
59.1 |
Hypertension & Diabetes |
56 |
46.6 |
Infection |
51 |
42.5 |
Mineral and bone disorder |
49 |
40.8 |
Cardiovascular disease |
43 |
35.8 |
Dyslipidemia |
08 |
06.7 |
Total |
576 |
|
Mean comorbidity per patient is 4.8 |
Table 4: Electrolyte imbalance |
||
58.33% |
70 |
Hyponatremia |
08.33% |
10 |
Hypernatremia |
21.66% |
26 |
Hypokalemia |
16.66% |
20 |
Hyperkalemia |
39.16% |
47 |
Hypocalcaemia |
00.83% |
01 |
Hypercalcemia |
Drug-related
problems: As showed in Tables 6 and 7,
the total number of identified DRPs was 502 events with an average of 4.18 per patient[MOU18] . The rate of overall DRPs was 37.18 per
100 medication orders. The identified DRPs were in decreasing order, the
highest rate of DRPs reported were untreated conditions which accounted by
39.6% followed by improper drug selection (16.3%). To a less extent, drug use
without indication, over-therapeutic dose which were reported by 13.5% and
12.5%, respectively. A minority of DRPs were reported in ADRs and
sub-therapeutic dose which accounted for 08.2% and 06.8%, respectively. The
lowest rate was reported in drug-drug interaction (03.1%). 98.4% of the
patients have at least one DRP. The common rate of prevalence (3 - 4) of DRPs
among the patients was represented by 41.7%, then followed by (5 - 6) for over
one-quarter of the patients (27.5%) whereas the (1 - 2) and (> 6) were represented
by 16.7% and 12.5%, respectively. Lastly, only two patients had no DRPs which
accounted for only 01.6%. Patient with progression of renal failure
stage is more likely related with increased number of DRPs with highly
significant (p < 0.001). Patients with stage V have 60.0% of DRP events
compared with stages IV and III which accounted with 26.0% and 12.0%,
respectively. There is a significant relationship between number of comorbidities
and prevalence of DRPs in this study with a p of < 0.001. Patients with
higher rate of comorbidities have more risk to incidence of DRPs. For example,
patient with 3 - 5 comorbidities have 65.0% of the total of patients have DRPs
compared with just 34.2% accounted with those having 1 - 2 comorbidities[MOU19] .
Table 5: Pattern of the
drug prescribed in CKD patients |
||||||
Number and percentage of drugs prescribed based on total
of drugs |
|
Number and percentage of patients used different
categories of drugs |
||||
Drugs |
Frequency |
Percentage |
|
Drug category |
Frequency |
Percentage |
Supplements |
458 |
33.9 |
|
Antibiotic |
101 |
84.17 |
Anti-hypertensive |
251 |
18.6 |
|
GIT drugs |
92 |
76.67 |
Antibiotics |
189 |
14.0 |
|
Anti-lipidemic |
34 |
28.33 |
GIT Drugs |
163 |
12.0 |
|
Anti-diabetic |
39 |
32.50 |
Other drugs |
79 |
05.9 |
|
Anti-hypertensive |
96 |
80.00 |
Anti-thrombotic |
50 |
03.7 |
|
Diuretic |
70 |
58.33 |
Anti-diabetic |
48 |
03.6 |
|
Anti-hypertensive without diuretics |
81 |
67.50 |
Analgesics |
40 |
03.0 |
|
Analgesic |
35 |
29.17 |
Anti-lipidemic |
39 |
02.9 |
|
Corticosteroid |
04 |
03.33 |
CNS drugs |
28 |
02.1 |
|
Anti-thrombotic |
36 |
30.00 |
Corticosteroids |
05 |
00.3 |
|
CNS drugs |
21 |
17.50 |
Total |
1350 |
|
Supplements |
112 |
93.33 |
|
|
|
|
|
Others |
58 |
48.33 |
Table 6: Type of drug related problems |
||
DRP |
Frequency |
Percentage |
Untreated condition |
199 |
39.6 |
Drug without indications |
68 |
13.5 |
Over-therapeutic dose |
63 |
12.5 |
Sub-therapeutic dose |
34 |
06.8 |
Improper drug selection |
82 |
16.3 |
Adverse drug reaction |
41 |
08.2 |
Drug-drug interaction |
15 |
03.1 |
Total |
502 |
100 |
Table 7: Categorized drug related problems
with their examples |
|||
Drug related problems |
Examples |
Frequency |
Details |
Untreated diseases |
Hyponatremia |
52 |
|
Anemia |
48 |
|
|
Hypokalemia |
18 |
|
|
Thrombocytopenia |
12 |
|
|
Hypocalcemia |
10 |
|
|
Diabetes mullitus |
09 |
|
|
Hyperkalemia |
07 |
|
|
Diarrhea |
05 |
|
|
Infection |
05 |
|
|
Dyslipidemia |
05 |
|
|
Others |
28 |
IHD,
pleural effusion, constipation |
|
Total |
199 |
|
|
Drug without indication |
Antibiotics |
50 |
|
Diuretics |
06 |
|
|
Others |
12 |
diazepam,
haloperidol and propranolol |
|
Total |
68 |
|
|
Inappropriate
drug Selection |
ACE and ARBs |
22 |
|
Metformin |
07 |
|
|
Antibiotics |
14 |
cefotaxime,
vancomycin, aminoglycosides
for CKD |
|
Hematinic agents |
14 |
Not based on type of anemia |
|
Others |
25 |
H-2
blocker instead PPIs |
|
Total |
82 |
|
|
Over
therapeutic dose |
Metoclopramide |
33 |
need
dose adjustment based GFR |
Antibiotic |
22 |
need dose adjustment based GFR |
|
Others |
08 |
allopurinol,
aspirin, lisinopril |
|
|
63 |
|
|
Sub-therapeutic
dose |
Furosemide |
27 |
advanced
stage need higher dose |
Others |
07 |
antibiotics and insulin |
|
total |
34 |
|
|
Possible adverse effects |
ACEI |
23 |
cause hyponatremia or dry cough |
diuretics |
09 |
cause
hyperkalemia or hypokalemia |
|
Others |
09 |
diarrhea from metformin and hypotensive effects from ACEIs, ARBs |
|
|
41 |
|
|
Potential drug-drug interaction |
Risk of bleeding |
10 |
due to more than antiplatelet |
Others: nephrotoxicity, hypotension |
05 |
due to combination of antihypertensive agents and antibiotics |
|
Total |
15 |
|
Discussion
This study reveals older patients are more
likely increasing in renal failure stage. The progression of CKD rises
dramatically with age as supported by the significant finding of
ordinal-ordinal correlation by suing Kendall rank correlation coefficient test.
The kidneys are affected by the aging process which results in numerous effects
on the renal system [10]. The majority of the current participants were male
compared females. This is consistence with a previous study that revealed the
incidence rate to end stage kidney disease (ESKD) in[MOU20] Libya was higher in males than females
[11] predicting that renal impairment in female start in older age compared with
male. The majority of patients were from stage V. The reasons for this finding could
be related to that most of the participants live in the South Libya areas and
may have a history of many medical conditions and came to hospital after
developing ESRD. This is slightly lower than the finding obtained in Ethiopia [12]. The high prevalence rate of ESKD might
associated with a limited access to renal transplantation in the Libya [11]. All
the patients with CKD have at least one comorbidity. Evidence showed that
people with CKD have high mean number of comorbidities than people without CKD
[13]. Majority of the patients of this study have anemia similar to Ethiopia patients
[12]. However, in Nigeria’s study, only few patients had anemia [14]. Reasons for
this difference could be explained that patients were in stage IV and V renal
failure. In advanced stages of CKD, anemia is existing in high number of patients
[15, 16]. Appropriate and timely intervention using erthyropoiesis-stimulating
agent is needed to improve clinical indices and to retard the progression of
renal failure [17]. Interestingly, there was no prescribing of erythropoietin
for our patients. The absence of erythropoietin-stimulating agents from the
treatment regimen might be due to shortage of medication in hospital.
The majority of CKD patients have electrolytes
imbalance. This trend is higher than the published study conducted in Ethiopia
which represented the electrolyte abnormality prevalence was among CKD inpatients,
the most serious electrolyte disturbances involve abnormalities in the levels
of sodium, potassium or calcium. Hyponatremia is highly prevalent in patients
with CKD [18]. The majority of the patients have hyponatremia represented highest
rate of electrolyte imbalances. Hypernatremia is much less common than
Hyponatremia among patients admitted to the hospital and 10.0% in critical care
unit [19]. This trend is in consistence with present findings, since most of
the patients in advanced stages of CKD. It has been documented that the
intestinal[MOU20] calcium absorption was decreased [20]. Reduced
production of active vitamin D will result in reduced absorption of calcium
from the gut [21].
Hypocalcemia was observed in patients of this study as the eGFR falls, the
renal excretion of potassium is reduced and prevalence of hyperkalemia
increases from 02.0% in patients with eGFR > 60 ml/min/1.73 m2 to
42% in patients with eGFR < 20 ml/min/1.73 m2 [22, 23]. Patients
with CKD may be predisposed to hyperkalemia for a variety of reasons. Interestingly,
hypokalemia was higher in current study than hyperkalemia.
Hypertension and diabetes mellitus are the
most common comorbid conditions present in CKD while those have these two
comorbidities are almost half of the patients. Published data indicated that
patients with diabetes mellitus and hypertension have seven-fold greater risk
for progression to end-stage renal failure [24]. When CKD and hypertension
exist together, the risk of CVD morbidity and mortality are substantially
increased [25, 26]. Patients presenting with CKD are particularly vulnerable to
infections as the quality of their humoral and cellular immune response is
impaired [27] and overwhelming uremia, which is associated with alterations in
primary host defense mechanisms [28]. In current study, half of the patients
have bacterial infection while[MOU21] about double of patients have prescribed
antibiotics during staying in hospital. Basically, medical professionals
believe patient has an infection based on their symptoms, physical examination,
laboratory results and risk factors. However, at SMC, the poor and incomplete
documenting practice among physicians was noticed in patients' records about
infection, the measurement used for diagnosing bacterial infections and
frequent missing antibiotic prescribing for it. Bone abnormalities are found in
the majority of patients with CKD stages III - V [29]. About half of patients
have chronic renal disease - mineral and bone disorder. Numerous cohort studies
have shown association between disorders of mineral metabolism or deranged
markers of CKD-MBD and poor clinical outcomes as fracture, cardiovascular
disease and mortality in patients with CKD [30 - 32]. Dyslipidemia is often present
in patients with renal failure, long before they reach ESRD [33, 34]. Out of
total, about third of the patients have been given statins, only eight patients
have dyslipidemia. This shows that the majority of patients who treated by
statins have successful management of their dyslipidemia. Patients with CKD
suffer from high comorbidities. In German CKD cohort, the prevalence of
polypharmacy was 81.8%, which was increased with the increase of CKD stages [35].
Polypharmacy was observed among all the patients and the majority of patients using
more than 10 medications. Additionally, it is noticed a substantial correlation
between rising drug usage per patient and deteriorating renal function. The
interpretation of the rising drug use may point to increase comorbidities among
renal patients, which contributes to advancement of renal impediments in stages
[36]. Polypharmacy has the potential to DRPs. Australian general practices
found that the mean number of medications prescribed to people with CKD was 8.2
with third of the patients prescribed at least one potentially inappropriate
medication [37]. Currently, almost all the patients have at least one DRPs.
Inappropriate polypharmacy can lead to significant morbidities and mortality [38].
Of total medication orders for CKD patients, supplements were the highest
category of drugs which was prescribed during patients staying in hospital.
Dietary prescription may limit foods which are high in vitamins, particularly
water-soluble vitamins, because of their high potassium or phosphorus content
[39]. The majority of patients have anemia and nearly half of the cases have mineral
and bone disorder who need supplements to correct these deficiencies. The
second major drugs prescribed for CKD patients was anti-hypertension. Blood
pressure becomes more difficult to control with advancing CKD stages [40].
ACEIs were more prescribed orders compared with calcium channel blockers [28].
The effects of antihypertensive therapy on kidney function need to be carefully
considered. According to the current KDIGO guideline [1] that recommends RAAS
blockade as the first-line therapy in non-diabetic and proteinuric patients
with CKD. RAAS inhibitor therapy compared with CCBs may provide kidney some
benefits among patients with advanced CKD and cardiovascular protection [41]. However,
currently, the percentage of patients prescribed ACEIs and ARBs was less than
prescribing CCBs. Infectious diseases are the second leading cause of
death in end-stage CKD patients [42]. Thus, antibiotic treatment is common in
these patients and requires special attention. All antibiotic use, whether
appropriate or not, carries a risk of contributing to the development of
antibiotic resistance. High antibiotic use is unnecessary or inappropriate. Patients
have infection while double of patients have prescribed antibiotics without
documented their indications in medical records[MOU22] [ma23] . Appropriateness of antibiotic use
determined by presence documented indications in medical records. However, this
documentation may miss indication data which lead to underestimation the risk
of inappropriate antibiotic use.
Evidence indicates that as CKD progresses and
medication usage increases, the prevalence of DRPs increases [43]. A
significant relationship between stages of CKD and the prevalence of DRPs was
found. In the same way, the result shows a significant relationship between
rate of comorbidities and DRPs. So, DRPs were reported among patients with
stage V and just over the quarter accounted with those having stage IV. But, polypharmacy
has insignificant relationship with prevalence DRPs. This finding has a lower
rate compared with Indonesian study that the average of DRPs about ten DRPs for
each patient [44]. In contrast, higher than similar study was conducted in
Ethiopia which reported the average of DRPs was 1.9 per patient [12]. This
variation could relate to differences in the characteristics the population and
duration of study. Nearly, two thirds of patients with CKD stage V patients are
likely to have multiple comorbidities and complications and their treatment
need a variety of drugs which are potential risk of DRPs [45]. The poor
collaboration between physicians and pharmacists was recognized as a
significant factor responsible for an inappropriate prescription [46]. DRPs
data analysis showed the most common type of DRPs was need additional drug
therapy or untreated conditions. This explained by the high burden of
comorbidities among the study population and higher rate of untreated condition
could be illustrated that physicians are more likely focusing on major
conditions and paying less attention on minor disease conditions as anemia. Physician
prescribing errors can arise from the choice of the wrong drug or improper drug
selection. Thus, about 15.0% of the prescribed drugs were under improper drug
selection. It is worth noting that anti-diabetic drugs (metformin) is
prescribed to nine patients which is the most common contraindicated used
medicines in CKD patients because it may cause life-threatening lactic acidosis
[47]. However, the use of metformin in patients with mild renal impairment was
subject to debate. The poor quality of data about prescribing decisions in
medical notes have been identified as contributing to prescribing errors [48]. Medication
indications are not routinely documented by prescribers, in inpatient and
outpatient settings [49]. Currently, drug use without indication were reported
by 13.5% of patients and 84.1% of patients have received antibiotics, 50.0% of have
recoded for infection indication. In line with treatment guidelines and
recommendations, only patients who have confirmed infectious diagnosis are
expected to be given an antibiotic prescription [50, 51].
One of the most important DRPs in patients
with renal impairment is medication dosing errors. Hence, many medications
require dosage adjustments in CKD in order to ensure efficacy and prevent
toxicity. Currently, 12.5% prescribed drugs have over-therapeutic dose of all DRPs
identified. As, metoclopramide need adjusting dose according to patient GFR as
a similar trend in Ethiopia and Canada [12, 52]. Unnecessary decreases in
dosage may result in under-treatment, or changing to an alternate drug with a
narrower therapeutic index, lower efficacy or both. A major reason for
inappropriate dosage adjustment is the underestimation of potential adverse
consequences [53]. One of the strategies were suggested to assist practitioners
in monitoring and adjusting drug therapy in patients is clinical pharmacist
dosing services [54]. CKD is a major health burden that amplifies the risk for
adverse events [55], the mild interaction experienced by renal competent
patients may be life threatening in patients with impaired renal disease since
their pharmacokinetic responses to the drugs are altered [56]. The potential
drug-drug interactions was reported for few patients of all the prescribed
drugs. A similar trend was reported in Ethiopia for of DRPs [12]. Early
diagnosis, optimal use of medications, treatment of comorbid conditions which they
have all been associated with better outcomes in patients with CKD [29]. Given
the nature of clinical pharmacist major responsibilities and tasks, they can
directly be engaged[MOU24] in the care of CKD and ESRD patients in
different settings by identifying and addressing the DRPs in hospitals,
introduce their recommendations regarding prevention and treatment of these
problems and collaboration between all healthcare providers [57]. Clinical
pharmacist-led programs showed higher proportions of CKD patients achieving
hemoglobin target [58] increased medication knowledge [59] decreased
hospitalization rate [28] and an overall improvement in the quality of life of
CKD patient [60]. Based on the above, enhancing the involvement of clinical
pharmacist may be one potential strategy to improvement patient healthcare
outcome.
Conclusion: The majority of the CKD patients in Libya are middle-aged with advanced
stages. High rate of Libyan patients have comorbidities and polypharmacy with
DRPs. To lower the incidence rate of DRPs among CKD patients, therapeutic
intervention is necessary. Since their intervention involve patient follow-up,
medication review and dose adjustments according to the functions of the
kidneys, the clinical pharmacist's presence at hospital is a crucial for
enhancing the care of CKD patients. To achieve this goal, physician and
clinical pharmacist in the renal field must improve their communication,
collaboration and teamwork.
Citation :
Alssageer et al. (2023) Prevalence of comorbidities, polypharmacy and drug related problems among hospitalized patients with chronic kidney disease. Mediterr J Pharm Pharm Sci. 3 (1): 50 - 62. https://doi.org/10.5281/zenodo.7771698.