Prevalence of the use of medications requiring renal adjustment in critical care units of a public hospital
DOI:
https://doi.org/10.30968/rbfhss.2024.154.1205Abstract
Objective: To evaluate, among the most prescribed medications in the Intensive Care Units (ICU) of a public teaching hospital, those that require dose adjustment according to renal function, and to present the role of the pharmacist in this care setting. Methods: A cross-sectional observational study was conducted, with data collected from medication prescriptions through reports generated by the institution’s Hospital Information System from 2015 to 2019. Step 1: Based on the list of all medications prescribed during this period in two ICUs of the institution, the prevalence of prescription was calculated. For the 100 most used medications, a search was conducted on the Uptodate platform regarding the need for dose adjustment based on renal function. The data were compiled into a Microsoft Excel spreadsheet. Step 2: The compiled data were presented to five clinical pharmacists from the institution, who assessed the severity and likelihood of occurrence of potential nonadjustment of doses for the 10 most prevalent medications that require it, using the Hazard Score Matrix. Results: Of the 100 most prevalent, a total of 34 medications were identified that require dose adjustment, with the most predominant classes being antimicrobials (41.2%), followed by those related to the cardiovascular system (20.6%) and the central nervous system (17.6%). The medications that scored highest when evaluated by the Hazard Score Matrix were morphine and regular insulin, followed by enoxaparin and potassium chloride. It was noted that dose adjustment is necessary not only to reduce adverse reactions or nephrotoxicity but also to ensure therapeutic effectiveness. Conclusion: This study emphasized the importance of adjusting medication doses in critically ill patients with renal dysfunction. Many frequently prescribed medications require dose modifications to ensure safety and effectiveness, particularly those classified as ‘high-alert’ due to their narrow therapeutic range. Collaboration between physicians and pharmacists is essential for minimizing risks in this context. Additionally, the use of risk analysis tools, such as HFMEA, facilitates the implementation of preventive interventions and dose adjustment protocols.
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Hoste EA, Bagshaw SM, Bellomo R, et al. Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study. Intensive Care Med. 2015 Aug;41(8):1411-23. doi: 10.1007/s00134-015-3934-7.
Preslaski CR, Lat I, MacLaren R, Poston J. Pharmacist contributions as members of the multidisciplinary ICU team. Chest. 2013 Nov;144(5):1687-1695. doi: 10.1378/chest.12-1615.
Pilau R, Hegele V, Heineck I. Atuação do farmacêutico clínico em unidade de terapia intensiva adulto: uma revisão da literatura. Rev Bras Farm Hosp Serv Saude. 2014;5(1):19-24.
Rahn B, Zonzini FH, Mendes AM. Hospital Medication Review: risk and network analysis. Rev Bras Farm Hosp Serv Saude. 2023;14(4):0995. DOI: 10.30968/rbfhss.2023.144.0995.
Braga TB, Pfaffenbach G, Weiss DP, et al. Point prevalence of drug prescriptions for elderly and non-elderly inpatients in a teaching hospital. Sao Paulo Med J. 2004 Mar 4;122(2):48-52. doi: 10.1590/s1516-31802004000200003.
Rasmussen L, Pratt N, Hansen MR, et al. Using the “proportion of patients covered” and the Kaplan-Meier survival analysis to describe treatment persistence. Pharmacoepidemiol Drug Saf. 2018 Aug;27(8):867-871. doi: 10.1002/pds.4582.
Mantel-Teeuwisse AK, Klungel OH, Verschuren WM, et al. Comparison of different methods to estimate prevalence of drug use by using pharmacy records. J Clin Epidemiol. 2001 Nov;54(11):1181-6. doi: 10.1016/s0895-4356(01)00396-1.
DeRosier J, Stalhandske E, Bagian JP, et al. Using Health Care Failure Mode and Effect Analysis: The VA National Center for Patient Safety’s Prospective Risk Analysis System. Jt Comm J Qual Improv. 2002;28(5):248-267. DOI:10.1016/s1070-3241(02)28025-6.
Costa R, Ferreira I, Pedroso A, et al. A Reflection on the Use of Enoxaparin Based on Three Case Reports. Eur J Case Rep Intern Med. 2018;5(12):001000. DOI: 10.12890/2018_001000.
Kim GH, Han JS. Therapeutic Approach to Hypokalemia. Nephron. 2002;92(1):28-32. DOI: 10.1159/000065374.
Kraft MD, Btaiche IF, Sacks GS, Kudsk KA. Treatment of electrolyte disorders in adult patients in the intensive care unit. Am J Health Syst Pharm. 2005;62(16):1663-1682.
Golan DE. Princípios de Farmacologia - A Base Fisiopatológica da Farmacologia. 3ed. Rio de Janeiro: Guanabara Koogan, 2014. E-book. Disponível em: https://integrada.minhabiblioteca.com.br/reader/books/978-85-277-2600-9/epubcfi/6/2%5B%3Bvnd.vst.idref%3Dcover%5D!/4/2/2%4051:88.
Neves MDF, Sá JR, Morais LA, et al. Tratamento da Hiperglicemia no Paciente com Diabete Melito e Doença Renal Crônica. J Bras Nefrol. 2009;31(1):21-27.
Dilken O, Ince C, Kapucu A, et al. Furosemide exacerbated the impairment of renal function, oxygenation and medullary damage in a rat model of renal ischemia/reperfusion induced AKI. Intensive Care Med Exp. 2023;11(1):25. DOI:10.1186/s40635-023-00509-3.
King S, Forbes K, Hanks GW, et al. A systematic review of the use of opioid medication for those with moderate to severe cancer pain and renal impairment: a European Palliative Care Research Collaborative opioid guidelines project. Palliat Med. 2011;25(5):525-552. DOI: 10.1177/0269216311406313.
Dean M. Opioids in renal failure and dialysis patients. J Pain Symptom Manage. 2004;28(5):497-504. doi:10.1016/j.jpainsymman.2004.02.021.
Caraceni A, Hanks G, Kaasa S, et al; European Palliative Care Research Collaborative (EPCRC); European Association for Palliative Care (EAPC). Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. Lancet Oncol. 2012;13(2):e58-e68. doi:10.1016/S1470-2045(12)70040-2.
Nemecek BD, Hammond DA. Demystifying drug dosing in renal dysfunction. American Society of Health-System Pharmacists; 2019.
Jacobi J, Fraser GL, Coursin DB, et al; Task Force of the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM), American Society of Health-System Pharmacists (ASHP), American College of Chest Physicians. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med. 2002;30(1):119-141. doi:10.1097/00003246-200201000-00020.
Niscola P, Scaramucci L, Vischini G, et al. The use of major analgesics in patients with renal dysfunction. Curr Drug Targets. 2010;11(6):752-758. doi:10.2174/138945010791170879.
Marques FE, de Souza ORP, Bezerra JL, et al. Uso de antibióticos na insuficiência renal: necessidade de ajustes posológicos e doses individualizadas. Res Soc Dev. 2020;9(11):e94791110567. DOI:10.33448/rsd-v9i11.10567.
Gan Y, Meng X, Lei N, et al. Meropenem Pharmacokinetics and Target Attainment in Critically Ill Patients. Infect Drug Resist. 2023;16(1):3989-3997. DOI: 10.2147/IDR.S408572.
Burger R, Guidi M, Calpini V, et al. Effect of renal clearance and continuous renal replacement therapy on appropriateness of recommended meropenem dosing regimens in critically ill patients with susceptible life threatening infections. J Antimicrob Chemother. 2018;73(12):3413-3422. DOI:10.1093/jac/dky370.
Katzung BG, Vanderah TW. Farmacologia básica e clínica. 15 ed. Porto Alegre: AMGH, 2023. E-book. Disponível em: https://integrada.minhabiblioteca.com.br/#/books/9786558040194/.
Clonidine: Drug Information - Plataforma UptoDate. 26. Lehmann CR, Heironimus JD, Collins CB, et al. Metoclopramide kinetics in patients with impaired renal function and clearance by hemodialysis. Clin Pharmacol Ther. 1985;37(3):284-289. DOI: 10.1038/clpt.1985.41.
Sirota RA, Kimmel PL, Trichtinger MD, et al. Metoclopramide- induced parkinsonism in hemodialysis patients: report of two cases. Arch Intern Med. 1986;146(10):2070-2071. DOI:10.1001/archinte.1986.00360220252041.
Sukkha S, Rattanavipanon W, Chamroenwit B, et al. Quality assessment and cost saving of renal dosing recommendation by clinical pharmacists at medical wards in Thailand. International Journal of Clinical Pharmacy, v. 42, n. 2, p. 610–616. https://doi.org/10.1007/s11096-020-01016-1.
Zafar R, Rehman IU, Shah Y, et al. Knowledge, attitude and perceptions of pharmacists regarding renal dose adjustment among chronic kidney disease patients in Pakistan. J Pharm Policy Pract. 2023 Sep 19;16(1):102. doi: 10.1186/s40545-023-00606-4.
Alikhani R, Pai MP. Reconsideration of the current models of estimated kidney function-based drug dose adjustment in older adults: The role of biological age. Clin Transl Sci. 2023;16(11):2095-2105. doi: 10.1111/cts.13643.
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