PHARMACEUTICAL CARE ISSUES (PCIs) IN ADULT END-STAGE RENAL DISEASE (ESRD) PATIENTS ON DIALYSIS

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• PHARMACEUTICAL CARE ISSUES (PCIs) IN ADULT
  END-STAGE RENAL DISEASE (ESRD) PATIENTS ON
  DIALYSIS
• MANJULAA DEVI SUBRAMANIAM
• M.Pharm, B.Pharm, R Ph., MMPS
• Pharmacy Department
• Hospital Kuala Lumpur
• Assoc Prof Dr. Rosnani Hashim (UKM)
• Pharm Adyani Mohd Redzuan (UKM)
• Pharm Datin Fadillah Othman (Hospital Selayang)

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OUTLINE

• Study background / Introduction
• Objectives
• Study design Methodology
• Results Discussion
• Limitations
• Conclusion

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INTRODUCTION

• Pharmaceutical care the responsible provision
  of drug therapy for the purpose of achieving
  definite outcomes that improve a patients
  quality of life (Hepler Strand 1990)
• Each hemodialysis patient take 10-12
  medications/day with 20-30 doses/day (Grabe et
  al. 1997).
• High risk for drug-related problems (DRPs) that
  lead to increased morbidity and mortality
  (Possidente et al. 1999) core pharmaceutical
  care issues that warrant attention by pharmacists
  

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Studies showing pharmacist intervention improves
ESRD patient care

• Hudson et al. 2002
• Manley et al. 2000
• Possidente et al. 1999
• Grabe et al. 1997
• Kaplan et al. 1994
• Tang et al. 1993
• Stoutakis et al. 1978

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OBJECTIVES

• To identify and describe pharmaceutical care
  issues in managing adult ESRD patients on
  dialysis in a local government-affiliated
  hospital setting.
• To compare pharmaceutical care issues between
  patients on hemodialysis and continuous
  ambulatory peritoneal dialysis.
• To identify presence of co-morbidities and
  disease-related problems in ESRD patients and
  study its effect on pharmaceutical care issues.

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METHODOLOGY
HD group (N43)

• DATA COLLECTION
• - Patient demographics
• Medication prescribed
• Lab results
• Progress notes

Identification of Pharmaceutical Care Issues I
EVALUATION ANALYSIS
CAPD group (N32)
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• Categories of identified PCIs are
• - therapeutic choices / prescribing error
• - adverse drug reaction / interaction
• - drug administration
• - predisposing factors
• - special pharmaceutical services

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RESULTS DISCUSSION
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Cumulative Pharmaceutical Care Issues (PCIs)
A total of 914 care issues were idenfified
(n75). Mean 12.19 ? 3.61
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Pharmaceutical Care Issues (PCIs) by dialysis type

• Difference of PCIs between dialysis groups not
  significant with p 0.138 (pgt0.05).

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Categories of Pharmaceutical Care Issues (PCIs)
by Dialysis Type Therapeutic Choices
Hemodialysis
CAPD

• Inapp dosing phosphate binder, vit D analogues,
  IV iron EPO dose ? or ? without regards to lab
  values e.g., overdose of CaCO3 ? risk of
  vascular calcification calciphylaxis (Elder
  2004).
• Add drug not presc no Rx for antiplatelets,
  antidiabetic agents or ACEI.
• USRDS 1998 40 of HD pts with DM not Rx with
  antidiabetic agents.

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Categories of Pharmaceutical Care Issues (PCIs)
by Dialysis Type Adverse reaction / Monitoring
CAPD
Hemodialysis

• DI- CaCO3- PO iron Calcium ? iron absorption
  by 30-40 despite severity of interaction
  classified as minor (ONeil-Cutting Crosby
  1986).
• USRDS 2004 Only 25 of ESRD pts with DM receive
  recomm HbA1c few receive lipid panels.

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Categories of Pharmaceutical Care Issues (PCIs)
by Dialysis Type Drug Administration

• Precaution/complex administration involves EPO,
  insulin, IV iron, unconventional dosing of
  antihypertensives.
• Requires special instructions on administration,
  storage and monitoring.
• Prescription of T.Prazosin 10mg tds on non-dial
  days and 5 mg tds on dialy days to prevent
  intradialytic hypotension involves complex adm.

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Categories of Pharmaceutical Care Issues (PCIs)
by Dialysis Type Predisposing factors
Hemodialysis
CAPD

• Fluid/diet restriction to achieve target dry
  weight and BP PO4 restr in diet.
• ? PO4 level linked to burden of coronary artery
  calcification in dialysis pt (Goodman 2000).

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Categories of Pharmaceutical Care Issues (PCIs)
by Dialysis Type Special Requirements
Hemodialysis
CAPD

• Special mon CS, T, FBC, ABGs, Ca/PO4/iPTH,
  Ca-PO4 product, iron indices, coagulations, BP
  glycemic indices.
• Staff education Pt on drugs requiring TDM
  (sampling time), complex adm (monitoring of
  hypersensitive reactions), IVdrugs (requiring
  dilution).

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• Total 176 Mean 2.35 ? 1.12
• Correlation Co-morbidities PCIs (r0.411
  p0.0001).
• More co-morbid cond, more PCIs will be
  encountered (Joyce et al. 2005)
• ESRD pt have average 5 co-morbidities with CHF,
  DM,CHD, vascular disease and MI as the most
  common ones (USRDS 1999)

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• Total 268 Mean 3.57 ? 1.19
• Correlation number of disease-related problems
  number of PCIs (r0.365, p0.001).
• Management of co-morbid conditions preventive
  care e.g., immunizations for hepatitis likely to
  improve outcomes (Nissenson 2004).

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Number of medications prescribed

• Total number of medications prescribed in the
  study period 1096

Mean Mode Median Minimum Maximum
14.61 ? 4.93 10 and 14 14.0 7 26

• USRDS 1998 median of 8 prescribed meds and as
  many as 15 or 20 meds.
• no. of meds pose for more PCIs and ?drug-related
  morbidity
• (Manley et al. 2000).

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Types of medication class involvement in the DRPs

• R. osteodystrophy inappropriate dose and
  indication without Rx.
• Anemia inadequate monitoring of iron indices
  and inappropriate dose.
• Cardiac inappropriate dosing of
  antihypertensives not treated to target BP
  lack of Rx for ACEI

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LIMITATIONS

• Study was conducted in a short period of 12
  months.
• No compilation on patients actual compliance.
  Compliance data was from patients progress
  notes.
• Other aspects of PCIs eg., illegal charting,
  dispensing errors, administration errors were not
  investigated.
• Quality of life of patients were not studied.
  This was due to the retrospective design of the
  study.

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CONCLUSION

• PCIs were present at a high rate in our local
  dialysis setting and did not significantly differ
  between both dialysis groups.
• The most commonly observed / on-need PCIs were
  affected kinetics, special monitoring,
  inappropriate dose, patient counseling and
  precaution/complex administration.
• The most common co-morbidity was hypertension and
  disease-related problem was hyperparathyroidism
  and the number of these problems were positively
  correlated with number of PCIs.
• Provision of Pharmaceutical Care can improve
  patients outcomes.

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THANK YOU
ACKNOWLEDGEMENT Assoc Prof Dr. Rosnani Hashim
(UKM) Adyani Mohd Redzuan (UKM) Datin Fadillah
Othman (Hospital Selayang) Dr. Ghazali Ahmad
Kutty (Hospital Kuala Lumpur) Dr. Bee Boon Cheak
(Hospital Selayang)