CMR training
7.4 Drug-Related Problems Reported During CMR (IV)
The community pharmacists taking accreditation training in 2006–2007 reported altogether 785 DRPs, an average of 6.5 per patient. Mean number of DRPs was higher among home-dwelling patients (7.2), than among those in the assisted-living setting (5.5) (p=0.014) but the DRPs were similar in nature. Inappropriate drug choices were the most common DRPs (n=136; 17.3% of DRPs), they most often involved hypnotics and sedatives (Table 28). Indications with no prescribed drugs were the second most common DRPs (n=125; 15.9%) and involved most often calcium supplements, lipid-lowering drugs and ACE-inhibitors.
Causes of DRPs were most often related to selection of drug or dose (n=623; 79.4% of DRPs) (Table 29). Of these, the most common was inappropriate drug selection (n=179;
22.8%). Causes related to lack of information (n=16; 2.0%) or other patient-related causes (n=21, 2.7%) were rare (Table 29).
The most common drug classes involved in DRPs were drugs affecting the nervous system (ATC class N, 28% of drugs, n=236) and cardiovascular drugs (ATC class C, 21%, n=178). The most frequently reported drug groups were antidepressants, and hypnotics and sedatives (Table 30). Three individual drugs: calcium supplement (n=39), furosemide (n=32) and paracetamol (n=27), each caused DRPs in more than 20% of the patients (Table 30), as did opioid analgesics (n=37).
Of the 785 DRPs, 83% (n=649) resulted in intervention recommendation to the physician from the pharmacist (Table 31). Physicians accepted 55% (n=360) of the recommendations as made. As a result of the case conference, interventions at the drug-level were agreed to in 51% (n=403) of DRPs (Table 31). Of these interventions, most common was to stop the drug (32% of the drug-level interventions, n=128) or to change drug dose (23%, n=93). Drug-level interventions related to analgesics were agreed to often and included e.g., discontinuation of non-steroidal anti-inflammatory drugs (NSAIDs), changing doses of paracetamol and changing opioids to other analgesics (Table 32).
117
Table 28. Most common DRPs (n=785) and the associated drug groupsin CMR patients aged 65 and older (n=121)
Drug-related problem
Home-dwelling patients (n=70)
Assisted-living patients
(n=51)
pa Three drug groups most commonly involved in the DRPs listed (n)
% n % n
P2.1. Inappropriate drug 16.2 82 19.3 54 NS Hypnotics and sedatives (16), anxiolytics (14), meprobamate (9) P2.6. No drug prescribed but clear indication 15.4 78 16.8 47 NS Calciumb (14), statins (12), ACE inhibitors (9)
P3.2. Drug dose too high or dosage regimen too frequent
11.9 60 12.5 35 NS Drugs for ulcer (16), furosemide (13), hypnotics and sedatives (10) P1.1. Side-effect suffered (non-allergic) 10.1 51 11.8 33 NS Opioid analgesics (9), ACE inhibitors (8), furosemide (7)
P3.1. Drug dose too low or dosage regimen not frequent enough
10.1 51 6.8 19 NS Paracetamol (12), calciumb (9), adrenergic inhalantsc (6) P5.1. Potential interaction 6.5 33 6.1 17 NS Antidepressants (11), warfarin (10), iron (8)
P2.5. No clear indication for drug use 5.7 29 6.4 18 NS Antidepressants (6), drugs for ulcer (3), antipsychotics (3)
Other DRPs 24.0 121 20.4 57
Total 100.0 505 100.0 280 Antidepressants (52), hypnotics and sedatives (47), calciumb (39)
a Pearson Chi-Square test
b Includes calcium supplements with vitamin D
c Includes combination products with glucocorticoids NS=not significant
118
Table 29. Causes for DRPs (n=785) in CMR patients aged 65 and older (n=121)
Cause % n
C1. Drug/Dose selection 79.4 623
C1.1. Inappropriate drug selection C1.2. Inappropriate dosage selection C1.3. More cost-effective drug available
C1.4. Pharmacokinetic problems, incl. ageing, interactions C1.5. Synergistic/preventive drug needed and not given C1.6. Deterioration/improvement of disease state C1.7. New symptom or indication revealed/presented C1.8. Manifest side effect, no other cause
C1.9.Treatment not discontinued/intervalled appropriatelya
22.8
C2.1. Inappropriate timing of administration and/or dosing intervals C2.2. Drug underused/under-administered
C2.3. Drug overused/over-administered C2.4. Therapeutic drug level not monitored C2.5. Drug abused (unregulated overuse)
C2.6. Patient unable to use drug/form as directed
4.7
C3.1. Instructions for use/taking not known
C3.2. Patient unaware of reason for drug treatment
C3.3. Patient has difficulties reading /understanding patient information form C3.4. Patient unable to understand local language
C3.5. Lack of communication between healthcare professionals
1.3
C4. Patient/Psychological 2.7 21
C4.1. Patient forgets to use/take drug C4.2. Patient has concerns with drugs C4.3. Patient suspects side-effect
C4.4. Patient unwilling to carry financial costs C4.5. Patient unwilling to bother physician C4.6. Patient unwilling to change drugs C4.7. Patient unwilling to adapt lifestyle C4.8. Burden of therapy
C4.9. Treatment not in line with health beliefs C4.10. Patient takes food that interacts with drugs C4.11. Other patient-related causea
0.4
C5.1. Prescribed drug not available (anymore)
C5.2. Prescribing error (only in case of slip of the pen) C5.3. Dispensing error (wrong drug or dose dispensed)
0
a DRP cause classes added to the PCNE Classification for DRPs version V5.01.
119
Table 30. Ten therapeutic drug groups most commonly involved in DRPs (n=785) in CMR patients aged 65 and older (n=121)
Drug group % n Three DRPs most frequently related to the drugs (n) Antidepressants 6.3 52 Potential interaction (11), drug dose too high (6), no
clear indication (6)
Hypnotics and sedatives 5.7 47 Inappropriate drug (16), duration of treatment too long (11), drug dose too high (10)
Calcium supplementa 4.7 39 No drug but clear indication (14), drug dose too low (9), potential interaction (4)
Antithrombotic agents 4.7 39 Potential interaction (14), inappropriate drug (4), inappropriate duplication (4), drug dose too high (4) Opioid analgesics 4.5 37 Side-effect suffered (9), inappropriate drug (8),
potential interaction (5), inappropriate drug form (5) Proton pump inhibitors 4.1 34 Drug dose too high (16), no drug but clear indication
(4), no clear indication (3) Loop diuretics
(furosemide)
3.9 32 Drug dose too high (13), side-effect suffered (7), inappropriate drug (5)
Anxiolytics 3.6 30 Inappropriate drug (14), duration of treatment too long (5), side-effect suffered (3)
Other analgesics and antipyreticsb
3.5 29 Drug dose too low (12), drug dose too high (4), patient dissatisfied with therapy (4)
Beta blocking agents 3.2 27 Side-effect suffered (5), inappropriate drug (5), no drug but clear indication (4), drug dose too low (4)
Sum 44.0 366
Others 56.0 465
Total 100 831
a Includes combination products with vitamin D
b Includes paracetamol n=27
Note that a single problem (drug-drug interaction, duplication) may involve two drugs.
120
Table 31. Interventions for DRPs (n=785) in CMR patients aged 65 and older (n=121)
Intervention % of DRPs n
I1. At prescriber level 100 785
I1.1. Prescriber informed only I1.2. Prescriber asked for information
I1.3. Intervention proposed, approved by prescriber I1.4. Intervention proposed, not approved by prescriber I1.5. Intervention proposed, outcome unknown
I1.6. Intervention proposed, carried out before case conferencea I1.7. Intervention proposed, prescriber carried out other interventiona
9.4
I2. At patient/carer level 23.2 182
I2.1. Patient (medication) counseling I2.2. Written information provided only I2.3. Patient referred to prescriber I2.4. Spoken to family member/caregiver
21.9 I3.4. Instructions for use changed I3.5. Drug stopped
I4. Other intervention or activity 9.4 74
I4.1. Other intervention (specify)b I4.2. Side effect reported to authorities
9.4 0
74 0
a Intervention classes added to the PCNE Classification for DRPs version V5.01.
b Other interventions included for example laboratory tests or dosing aids Note, that only prescriber-level interventions were available for all DRPs.
121
Table 32. Drugs most commonly involved in drug-level interventions (n=403) in CMR patients aged 65 and older (n=121)
Drug-level intervention % n Three drug groups most commonly involved in the interventions listed (n) I3.1. Drug changed 13.6 55 Opioid analgesics (6), antidepressants (5),
hypnotics and sedatives (5)
I3.2. Dosage changed 23.1 93 Paracetamol (11), drugs for peptic ulcer(11), furosemide (8)
I3.3. Formulation changed 3.2 13 Calcium supplementa (2), antidepressants (2), several single drugs (1)
I3.4. Instructions for use changed 13.2 53 Organic nitrates (7), hypnotics and sedatives (4), calciuma (4), iron (4), anxiolytics (4) I3.5. Drug stopped 31.8 128 Hypnotics and sedatives (14), NSAIDs (9),
antidepressants (8)
I3.6. New drug started 15.1 61 Calcium supplementa (9), lubricant eye drops (6), ACE inhibitors (5)
Total 100 403
NSAIDs=non-steroidal anti-inflammatory drugs
a Includes combination products with vitamin D
122
8 Discussion
8.1 Appropriateness of Pharmacotherapy Among Home-Dwelling