Evaluation of Drug-Related Problems among Chronic Kidney Disease Patients by Clinical Pharmacist

Introduction

Chronic kidney disease (CKD) is defined by the Kidney Disease Outcomes Quality Initiatives (KDOQI) of the National Kidney Foundation as either kidney damage or a decreased glomerular filtration rate of 60 mL/ min/1.73m² for three months or longer.¹ The steady, lengthy, and persistent decline in renal function is a hallmark of chronic renal failure. The undamaged nephrons can make up for the malfunctioning of certain nephrons. However, the compensatory process fails when more nephrons start to lose function over months or years, and chronic renal failure emerges.² An ongoing decline in kidney function is referred to as chronic kidney disease (CKD). Reduced kidney function has a number of negative effects, such as endocrine problems, metabolic abnormalities, and an elevated risk of cardiovascular disease. If these implications are not effectively managed, it can result in a lengthier hospital stay and a higher death risk. Additionally, CKD causes modifications in the pharmacokinetics of a number of medications, particularly those excreted by the kidney. Pharmacokinetic alterations may have an impact on medication distribution, excretion, protein binding level, drug bioavailability, and more. Sadly, this illness renders patients more vulnerable to drug-related problems (DRPs). Additionally, as CKD progresses, patients may require additional medications to manage their problems and comorbidities, which would increase the prevalence of DRPs.³

Data from the World Health Organization (WHO) shows that renal disease and other genitourinary diseases resulted in close to 800,000 deaths annually all over the world and led to more than 26 million years of life with a handicap.³

Diabetes and hypertension account for 40-60% of CKD cases in India.4 According to a recently published systematic review & meta-analysis, India has a recurrence of CKD of up to 17.2%.⁵ The rising prevalence of diabetes and hypertension can be related to India’s rise as a main reservoir of CKD.¹

Drug-related problems

An event or circumstance concerning drug therapy that affects either directly or indirectly the anticipated health results is referred to as a drug-related problem. These could prevent or make it more difficult for patients to achieve their therapeutic goals.¹

A haemodialysis patient can often receive ten prescription and two non-prescription items every day. This makes it difficult for a single medical staff to manage the usage of various drugs. Expensive dialysis medications, like erythropoietin, require regular laboratory tests monitoring, drug dose adjustments, review of both the efficacy and side effects of the medication, and patient counselling. The availability of new medications with potential nephrotoxic effects may call for a pharmacist’s participation. For the patient to receive the most benefits, these parameters must be controlled by a drug expert such as a pharmacist.⁶

A well-known and regularly updated categorization system for drug-related problems is used by the Pharmaceutical Care Network Europe (PCNE). Six basic themes for issues and six key categories for causes now make up the basic categorization.

Materials and Methods

A six-month prospective observational study was conducted at HKES’s Basaveshwar Teaching and General Hospital in Kalaburagi. According to the research criteria, individuals with chronic renal disease admitted to the hospital were included in the study. The inclusion criteria was in-patients of either sex with CKD and the exclusion criteria were CKD patients under the age of 18 years, and pregnant or lactating women.

Prior to the study, ethical clearance was obtained from the HKES’s MTRIPS Institutional review board.

At the time of enrolment in the study, each patient provided written informed consent. Demography, medicine, and other relevant data were gathered from the case sheets and recorded in the appropriate design of patient data collecting form by clinical pharmacist. To identify drug-related problems, the obtained data were analysed using the PCNE Classification Scheme V5.01.

Results

During the study, 60 patients were enrolled based on inclusion and exclusion criteria. Among them, 41 (68.33%) patients were males and 19 (31.66%) patients were females. The average age of the study population was 46 years. Around 26.7% of patients were between the ages of 31 and 40 years. Approximately 46.55% of patients were hospitalized for 6-10 days. When concomitant conditions were examined, 21 (35%) had hypertension, 17 (28.33%) had diabetes mellitus, and 8 (13.33%) had anaemia (Table 1). The medication prescription frequency of study population was examined. It was noted that all the patients were taking multiple medicines. A total of 636 medicines were prescribed for 60 individuals, with the average number of drugs per prescription being 10.9. According to our findings, 51% of patients took 6-10 medications (Table 2). Antibiotics were the most commonly prescribed medications (15.9%), followed by gastrointestinal drugs (11.9%), antihypertensive drugs (8.0%), and diuretic drugs (7.5%) in the study population (Table 3).

Primary Domains

The DRPs in the study population were investigated. A total of 83 DRPs were identified as primary domains, with interactions accounting for 41.3% of the total, followed by drug choice problems (16.27%), other problems (9.84%), dosing problems (8.63%), drug use problems (8.63%), and adverse reactions (1.20%) (Table 4).

The most common cause was the lack of information, followed by the drug use process 25 (30.12%), drug/ dose selection 22 (26.5%), patient/psychological 20 (24.09%), other causes 6 (7.22%), and logistics 5 (6.02%) (Table 5).

Sub Domains

As subdomains, a total of 87 DRPs were found. The most common DRPs were possible interactions 41 (47.12%), no medicine prescribed for indication 10 (11.49%), and short duration of treatment 7 (8.04%) (Table 4). Major DRP causes as subdomain included lack of communication between health care providers (29.33%), followed by incorrect scheduling of administration or dosing intervals (23.43%), and patients’ difficulties reading/understanding PILs (patient information leaflets) (19.83%) (Table 5).

Discussion

One of the global health problems that requires early diagnosis and treatment is chronic kidney disease. In India, people with CKD are 40–60% more likely to present with diabetes and hypertension. An event or situation involving medication therapy that disrupts, either explicitly or implicitly, with anticipated health results is referred to as a drug-related problem.

The present analysis revealed a 68.33% male predominance and a mean age of 46 years. Our findings were comparable to those of Subeesh VK,¹ who found that 71.25% of the participants were males and the average age was 50 years. This demonstrates that males are more likely than females to acquire CKD due to the former’s relationship with risk factors such as smoking, alcohol, hypertension (HTN), and hyperlipidaemia.

The most common comorbidities in this study were hypertension (28.33%), type 2 diabetes mellitus (13.33%), and anaemia (10%). This is in accordance with the findings of a study conducted by Subeesh VK.¹ Hypertension and diabetes are disorders that have been linked to the onset and progression of CKD, which supports the prevalence of these conditions in the study population.5 Polypharmacy in CKD is increased due to associated comorbidities and consequences. The most prevalent comorbidity among CKD patients is hypertension. Hypertension and CKD have a cyclical association. Uncontrolled hypertension, an increased risk for CKD, is associated with a quicker progression of the condition. Meanwhile, increasing renal disease may exacerbate uncontrolled hypertension due to volume expansion and increased systemic vascular resistance.⁷

In the present study, an average of 10.9 drugs were prescribed per prescription, which is a sign of polypharmacy. The simultaneous delivery of five or more drugs to a patient is referred to as polypharmacy. Because of the complexity of disease and coexisting morbidities, few researchers have proposed that the use of more than nine medicines at the same time be deemed polypharmacy.⁸ The current study findings were consistent with prior research, which revealed the mean number to be 9.16, 8.35, and 14, correspondingly.^1,9,10

DRPs were detected in 83 of 60 prescriptions in this study population. Subeesh VK¹ reported 337 DRPs, and Root et al.,⁸ identified 88 DRPs in 40 cases. The difference in the number of DRPs encountered is most likely due to the differences in research design in terms of patient criteria, hospital type, study duration, and data collection nature.

According to our findings, the number of incorrect drug interactions was highest, followed by the drug selection issue. In this study, practically all patients had polypharmacy, which could explain the occurrence of higher medication interactions.

For CKD patients who are already burdened by multimodal therapy, DRPs have consequences. DRPs are widely known to cause extended hospital stays, readmissions, higher expenses, and early demise. DRPs will be less frequent, which will improve patient outcomes and ease the cost load. Additionally, people involved may experience serious personal repercussions such as time away from job, low patient satisfaction, and a decline in confidence of public in health care.³ As a result, it is critical to put in place effective strategies to avoid and resolve DRP incidents.

Conclusion

Drug-related problems were high among CKD patients. Drug interaction was discovered to be the most prominent DRP, followed by drug choice difficulty. Identification and treatment of DRPs by a comprehensive health care team can significantly enhance the health and quality of life in these patients while also contributing to better clinical results. Pharmacists should always contact all patients to identify and resolve any drug-related problems linked to the patient’s prescriptions. Randomized controlled trials focusing on patient-oriented outcomes are required to fully comprehend the function of clinical pharmacists and the advantages of clinical pharmacy services for CKD patients.

Conflict of Interest

There is no conflict of interest, according to the authors.