Assessment of Drug-Related Problems in Chronic Disease Patients in a TertiaryCare Teaching Hospital

Introduction

Drug-related problems (DRP) are the adverse events that patients experience in connection with drug therapy, preventing them from achieving their desired therapeutic goals. DRP are usually categorized as additional medication, unnecessary medication, ineffective medication, under dose, overdose, side effects, and noncompliance. These problems usually occur in patients with chronic illnesses consuming more medications as part of their treatment. However, these issues are often not reported. The reasons for this could be that the patient may have been taking the drug for years without problems and the same provider has not prescribed all the medications the patient is taking both the patient and prescriber thinking more about the possible risks of discontinuing the medication than its benefits, the patient often does not want to change his medication.

For all these reasons, drug-related problems are rarely reported.¹

Drug-related problems are the result of a patient’s unmet drug-related needs. Pharmacists have the expertise to identify, correct, and prevent medication errors and medication problems. These practices have shown a positive impact on patient safety. DRP can occur at all stages of the treatment process, primarily during prescribing, transcription, delivery, and application of drug therapy to patients.²

This study will give the knowledge that chronic disease patients are more susceptible to drug-related problems as they are on multiple medications. It has been attributed to unnecessary over-prescription of medicine, substantial worsening of diseases, avoidable increase in hospital admission rates, and longer hospital stay resulting in a big medical burden. The above facts pinpoint the necessity for a study on drug-related problems to supply optimal drug therapy to the patients. This study aimed to supply updated information on drug-related problems in a tertiary care teaching hospital in India for optimizing the therapy supported with current knowledge.³

Materials and Methods

A prospective observational study was carried out for six months in Navodaya Medical College Hospital & Research Centre, Raichur. Information was collected from 160 participants. Data was pooled and analysed. Ethical permission to conduct the study was granted by the institutional ethics committee.

Study population

Data were collected from the case sheets using a specially designed data entry form from all the hospitalized patients diagnosed with chronic disease during the study period. Subjects willing to participate were included in the study.

Analysis of data

Prospective data was gathered from all the study participants during the study period. The data were analysed and monitored for the following variables:

• Age

• Patient diagnosis

• Drugs involved in the DRP

• Drug-related problems

• Causes for the DRP

Results

Distribution of participants according to age group:

The sample size was calculated based on the prevalence of drug-related problems. A total of 160 patients who met the inclusion criteria were recruited for the study. Majority of the study participants were in the age group of >60 years (31%) followed by 40-50 years (27%) (Table 1).

Distribution of participants according to diagnosis:

In our study, among 160 participants included, presence of 226 chronic diseases was observed. The most common disease condition observed among the participants was endocrine disease (27%) followed by cardiovascular diseases (22%) and the least observed disease condition was hematologic disorder. This is depicted in table 2.

Distribution according to the drugs involved in drugrelated problems:

Among 160 participants included in our study, it was observed that 116 drugs were involved in drug-related problems. The most common drug class involved in the DRP was anti-hypertensive agents which caused problems in 31% of the total study population. NSAIDs caused 27% of the total drug-related problems. Antibiotics accounted for 20% of problems of the total study population. This is depicted in table 3.

Distribution according to drug-related problems:

In our study, a total of 177 drug-related problems were observed during the study period. The most common DRP observed were untreated symptoms or indication (36%) followed by unnecessary drug treatment (29%) and unclear problems or complaints respectively. Absence of effect of drug treatment despite correct use was not reported in any of the study participants. This is depicted in table 4.

Distribution according to cause for drug-related problems:

In our study, various causes have been observed for the drug-related problems that have been assessed from the study participants. The most common possible cause for DRP were ‘No or incomplete drug treatment’ despite existing indications (38%) of the participants. 24% of the study population experienced DRP because of the use of drugs for no indication. The least observed cause for DRP was prescription of lower dose of a drug and also due to other causes which were unclear in 0.5% of the participants. This is depicted in table 5.

Discussion

Distribution of participants according to age group:

The age of the participants is an important factor for drug-related problems as aging increases the chances of getting multiple chronic diseases that will lead to multiple drug therapies and thus causing drug-related problems. In the present study, most of the problems were observed in aged participants with the least number of problems observed in younger participants. These results were almost similar to the study conducted by Yaschilal Muche Belayneh et al., who stated that most of the DRPs were reported in the age group <50 years.⁴

Distribution of participants according to patient diagnosis:

Most of the patients were having multiple chronic conditions and were on drug therapy for these conditions. Endocrine disorders experienced by most of the participants included diabetes mellitus, diabetic ketoacidosis, and chronic pancreatitis. Cardiovascular disease was also one of the important disease conditions where patients experienced problems that included hypertension, and ischemic heart disease. Respiratory diseases like COPD, pulmonary TB, and asthma were experienced by the patients. The hematologic disorders such as Beta- Thalassemia major were least reported. This can be compared with the findings reported by Discussion Distribution of participants according to age group: The age of the participants is an important factor for drug-related problems as aging increases the chances of getting multiple chronic diseases that will lead to multiple drug therapies and thus causing drug-related problems. In the present study, most of the problems were observed in aged participants with the least number of problems observed in younger participants. These results were almost similar to the study conducted by Yaschilal Muche Belayneh et al., who stated that most of the DRPs were reported in the age group <50 years.4 Distribution of participants according to patient diagnosis: Most of the patients were having multiple chronic conditions and were on drug therapy for these conditions. Endocrine disorders experienced by most of the participants included diabetes mellitus, diabetic ketoacidosis, and chronic pancreatitis. Cardiovascular disease was also one of the important disease conditions where patients experienced problems that included hypertension, and ischemic heart disease. Respiratory diseases like COPD, pulmonary TB, and asthma were experienced by the patients. The hematologic disorders such as Beta- Thalassemia major were least reported. This can be compared with the findings reported by Sarah M Westberg et al. It was reported in their study that drug therapy problems were most commonly associated with cardiovascular disease. From this study, it can be understood that patients having multiple chronic conditions were more prone to develop drug therapy problems.⁵

Distribution according to drugs involved in drug-related problems:

Patients were on multiple drug therapies for their conditions which lead to many drug-related problems. Anti-hypertensive agents developed most of the problems which include beta-blockers, calcium channel blockers, diuretics, and angiotensin receptor blockers. NSAIDs that caused DRP were paracetamol and diclofenac. Antibiotics were also involved in certain problems including ceftriaxone, and cefotaxime. This can be compared with the study conducted by Yaschilal Muche Belayneh et al., who demonstrated that the most common drug class involved in the drug therapy problems were antibiotics (29%) followed by antihypertensive agents (20%) and the least were observed with antiplatelet agents.⁴

Distribution according to drug therapy problems:

Patients with multiple chronic diseases may experience more than one drug therapy problem. In untreated symptoms or indications, drug therapy was not provided for an expressed condition that may lead to drug therapy problems. Unnecessary drug treatment was observed in certain patients where the unwanted drug therapy may result from the patient not achieving desired effects of the therapy. The problem, the effect of drug treatment is not optimal which requires an alternative drug therapy to achieve optimal drug effect. Adverse drug events possibly occurred in conditions when using multiple drugs belonging to the same drug class resulting in a synergistic effect that further worsens the situation. This can be compared with the study conducted by Sarah M Westberg et al. In this study, the most commonly observed drug therapy problem was the need for additional drug therapy (36%) followed by unnecessary drug therapy (30%) and low dose (13%) respectively.⁵

Causes for drug therapy problems:

Among majority of the patients with drug-related problems observed in this study, no or incomplete drug treatment was provided to the patient even though the patient had an existing indication. This may result in worsening of the condition. The treatment was also provided in certain cases where the patient had no disease indication. This unwanted treatment can also lead to many problems. In some conditions, too many drugs prescribed for the treatment may interact with each other resulting in drug related problems.

Conclusion

Drug therapy problems were mostly seen in elderly people who were on multiple medications as a part of their therapy which could prevent them from attaining desired goals of therapy. Improved practices in appropriate prescription of drugs are required and both the physician and health care workers should get awareness on drug therapy problems. The health care workers must remember that the DRP occurs in chronic disease patients and therefore the prescribing practices must be improved. The findings of the present study can help in minimising the DRPs in chronic disease patients.

Acknowledgments

Authors take it as a privilege to acknowledge Sri S R Reddy, Chairman Navodaya Education Trust; Medical Superintendent, Navodaya Medical College Hospital and Research Centre; Principal, NET Pharmacy College; HOD of Medicine department, and the staff for their support during the study. Special thanks to Mr. Bhaskar, Biostatician, and Dr. Tanveer Ahmed, Assistant professor of Medicine for their valuable inputs.

Conflicts of Interest

None.