DRPs is common during the treatment of CKD patients due to multi-morbidity associated polypharmacy and pharmacokinetic change. By far, this is the first study to observe the incidence and symptoms of DRPs in inpatients with renal disease in a Chinese large-scale hospital.
The frequency of DRPs (45.95%)in 914 nephropathic patients with an average of 0.51 DRP per patient, within the scope reviewed by the interval documented (12–87%). A total of 463 DRPs were detected. These data suggest that similar to the other countries, the DRPs is also familiar in patients with kidney disease in China.
The major reasons of DRPs were drug/dose selection (89.85%) using PCNE v9.00, a general DRP analysis method . In terms of drug selection, the irrational use of antibiotics (32.84%) and cardiovascular agents (28.66%) were the main reason, which is similar to other studies [14–16]. We found that the most common comorbidities of CKD patients were hypertension (74.84%) and diabetes mellitus (34.79%), that might explain why the abuse of cardiovascular agents were universal. The DRPs related cardiovascular agents were largely due to the unreasonable drug combination and inappropriate drug selection in this study. For instance, it has been observed that losartan potassium hydrochlorothiazide tablet combined with irbesartan tablet. This is a typical irrational drug combination on account of the both drugs containing the same mechanism composition (losartan, irbesartan). Long-term use of Clonidine was inappropriate for CKD patients because of central nervous system suppression function. Whereas, the wrong dosage and treatment course contributed the majority of DRPs involved anti-microbials. Most antibacterial drugs, including levofloxacin, vancomycin and part of β-lactams, need dose adjustment accompanied by deterioration of renal function. However, we found that the dosage of the antibacterial in the prescription of CKD patients were usually higher than that allowed by instructions. In addition, some antibacterial agents, such as metronidazole, needed no dosage adjustment in CKD patients. Hence, incorrect antibacterial drug dosage was a common problem, which could lead to poor anti-infective treatment effect or aggravate kidney dysfunction.
The valuable contribution of pharmacists to drug therapy in CKD patients, including drug dosage adjustment, adverse reaction detection, blood concentration monitoring and medical education, has been documented in 2 systematic reviews [17, 18]. 85.53% of pharmacist’s suggestions on medicines were accepted by clinician, and 84.23% of DRPs were solved. The advice on medicine dosage adjustment was easy to accept. By contrast, pharmacist would face more difficulties when recommending doctors to replace the drug regimen in our observation. Compared to perindopril, fosinophil is more difficult to remove by dialysis due to the high plasma protein binding rate. In a hemodialysis patient with hypertension, clinical pharmacist’s suggestion concerning replacing perindopril with fosinophil was not adopted in this study. Some suggestions were rejected by patients for cost. Blood concentration monitoring of immunosuppressant, such as cyclosporin A and tacrolimus, was often remarkably difficult to implement by reason of the high price and long waiting time. Physician and patients, in general, accepted the vast majority of recommendations of pharmacist.
Comorbidity and polypharmacy are the factors in the occurrence of DRPs, which had been proved in several studies [4, 16, 19]. Length of hospitalization longer than 5 days would increase the possibility of DRPs in 2 research results [19, 20]. We got the similar conclusions in this study, comorbid diseases, polypharmacy and hospitalization days were predictors of DRPs whether in univariable or multivariate logistics regression model.
Some studies results support that stage of CKD was the independent risk factors for DRPs [4, 19–21]. We found that only renal insufficiency on stage 4 was remarkably correlated with DRPs via multivariate logistic regression analysis. The possible reasons are as follows: patients with the final stage of the renal insufficiency (CKD5) were receiving regular dialysis usually, who will easily get more attention from clinician. Besides, the nephrologists clearly know whether the medicine is appropriate and how to adjust the dose in dialysis patients. We observed that tailored approach for CKD patients at stage 4 might be more complicated and difficult for doctors. Dapagliflozin, for instance, is forbidden in dialysis patients; whereas, many clinicians ignore that it is also contraindicated when eGFR is under 30 ml/min/1.73m2. These data might remind us the sever renal insufficiency patients with or without undergoing dialysis, long for more care from both clinicians and pharmacists.