Evaluation of Drug-Related Problems in the Chronic Kidney Disease Clinic at the University Hospital in Thailand
Main Article Content
Keywords
Abstract
Background: The chronic kidney disease (CKD) clinic plays a vital role in providing comprehensive ambulatory care for patients with CKD. Pharmacists contribute to ensuring proper drug use and identifying potential drug-related problems (DRPs). However, the evaluation of DRPs in the early phase of CKD clinic, particularly in resource-limited countries, remains limited. Objective: This study aimed to assess the prevalence of DRPs in CKD patients attending a CKD clinic, investigate the associated drug categories, and identify factors contributing to DRPs in CKD patients. Methods: A cross-sectional study was conducted from January 2020 to June 2021 among CKD patients attending a CKD clinic. Patient information records were used to collect demographic and relevant CKD data. A checklist for DRPs related to CKD progression and complications was utilized. Eight categories of unmet DRPs were examined. Multiple linear regression was used to investigate the relationship between pre-defined factors and the number of DRPs per patients. Results: The study included 80 patients with a total of 1,073 prescribed medications. The mean age was 73.1 ± 10.0 years, and the mean estimated glomerular filtration rate (eGFR) was 43.4± 12.9 mL/min/1.73 m². A total of 269 DRPs (25.1% of prescriptions) were identified, primarily involving the need for additional drug therapy (14.9%), dosage too high (6.3%), and inappropriate drug therapy (1.5%). Notably, renin-angiotensin-aldosterone system (RAAS) blockers were frequently omitted when indicated. NSAID use, non-compliance, and drug interactions were notable issues. The significant predictor of DRPs was the number of medications more than 7 items (ß = 0.258, P = 0.02). Conclusions: Implementing medication optimization in CKD care involving multidisciplinary teams and pharmacists is essential. Our study highlights the importance of ACEIs/ARBs, dosage adjustments, avoiding nephrotoxic agents, addressing non-compliance, and managing drug interactions for improved CKD care. The study identifies polypharmacy as a significant predictor of DRPs among CKD patients, facilitating targeted interventions for at-risk patients.
References
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28. Theeranut A, Methakanjanasak N, Surit P, Srina J, Sirivongs D, Adisuksodsai D. Can a multidisciplinary approach slow renal progression in CKD patients? Int J Med Sci. 2021;18(9):1975-79.
29. Jiamjariyaporn T, Ingsathit A, Tungsanga K, Banchuin C, Vipattawat K, Kanchanakorn S, et al. Effectiveness of integrated care on delaying chronic kidney disease progression in rural communities of Thailand (ESCORT study): Rationale and design of the study [NCT01978951]. BMC Nephrol. 2014;15:99. https://doi.org/10.1186/1471-2369-15-99
30. Jiamjariyapon T, Ingsathit A, Pongpirul K, Vipattawat K, Kanchanakorn S, Saetie A, et al. Effectiveness of integrated care on delaying progression of stage 3-4 chronic kidney disease in rural communities of Thailand (ESCORT study): a cluster randomized controlled trial. BMC Nephrol. 2017;18(1):83. https://doi.org/10.1186/s12882-016-0414-4
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38. Lam D, Shaikh A. Real-life prescribing of SGLT2 Inhibitors: How to handle the other medications, including glucose-lowering drugs and diuretics. Kidney360. 2021;2(4):742-46. https://doi.org/10.34067/kid.0000412021
39. Kalra S, Singh V, Nagrale D. Sodium-glucose cotransporter-2 inhibition and the glomerulus: A review. Adv Ther. 2016;33(9):1502- 18. https://doi.org/10.1007/s12325-016-0379-5
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43. Guo X, Nzerue C. How to prevent, recognize, and treat drug-induced nephrotoxicity. Cleve Clin J Med. 2002;69(4):289-90, 293- 4, 296-7 passim. https://doi.org/10.3949/ccjm.69.4.289
44. Sriperumbuduri S, Hiremath S. The case for cautious consumption: NSAIDs in chronic kidney disease. Curr Opin Nephrol Hypertens. 2019;28(2):163-70. https://doi.org/10.1097/mnh.0000000000000473
45. Rahman S, Malcoun A. Nonsteroidal antiinflammatory drugs, cyclooxygenase-2, and the kidneys. Prim Care. 2014;41(4):803- 21. https://doi.org/10.1016/j.pop.2014.09.001
46. Ho KY. Perceptions and beliefs regarding NSAIDs in the Asia-Pacific Region. J Pain Res. 2020;13:437-46. https://doi.org/10.2147/ jpr.s229387
47. Tangkiatkumjai M, Walker DM, Praditpornsilpa K, Boardman H. Association between medication adherence and clinical outcomes in patients with chronic kidney disease: A prospective cohort study. Clin Exp Nephrol. 2017;21(3):504-12. https:// doi.org/10.1007/s10157-016-1312-6
2. Li PK, Garcia-Garcia G, Lui SF, Andreoli S, Fung WW, Hradsky A, et al. Kidney health for everyone everywhere-from prevention to detection and equitable access to care. Pediatr Nephrol. 2020;35(10):1801-10. https://doi.org/10.1007/s00467-020-04604- 5.
3. Hudson JQ. Chronic kidney disease: management of secondary complications. In: DiPiro JT, Yee GC, Haines ST, Nolin TD, Ellingrod VL, Posey L. editor. DiPiro’s Pharmacotherapy: A pathophysiologic approach [Internet]. 12th ed. McGraw Hill; 2023. [cited 2023 June 16]. Available from: https://accesspharmacy.mhmedical.com/content.aspx?bookid=3097§ionid=269070177
4. Holm H, Bjerke K, Holst L, Mathiesen L. Use of renal risk drugs in patients with renal impairment. Int J Clin Pharm. 2015;37(6):1136-42. https://doi.org/10.1007/s11096-015-0175-3
5. Njeri LW, Ogallo WO, Nyamu DG, Opanga SA, Birichi AR. Medication-related problems among adult chronic kidney disease patients in a sub-Saharan tertiary hospital. Int J Clin Pharm. 2018;40(5):1217-24. https://doi.org/10.1007/s11096-018-0651-7
6. AbuRuz SM, Alrashdan Y, Jarab A, Jaber D, Alawwa IA. Evaluation of the impact of pharmaceutical care service on hospitalized patients with chronic kidney disease in Jordan. Int J Clin Pharm. 2013;35(5):780-9. https://doi.org/10.1007/s11096-013-9806- 8
7. Gheewala PA, Peterson GM, Curtain CM, Nishtala PS, Hannan PJ, Castelino RL. Impact of the pharmacist medication review services on drug-related problems and potentially inappropriate prescribing of renally cleared medications in residents of aged care facilities. Drugs Aging. 2014;31(11):825-35. https://doi.org/10.1007/s40266-014-0208-y
8. Cerfon MA, Vernaudon J, Gervais F, Morelon E, Coste MH, Krolak-Salmon P, et al. Drug-related problems in older patients with advanced chronic kidney disease identified during pretransplant comprehensive geriatric assessment. Nephrol Ther. 2022;18(1):45-51. https://doi.org/10.1016/j.nephro.2021.08.006
9. Imamura Y, Takahashi Y, Hayashi T, Iwamoto M, Nakamura R, Goto M, et al. Usefulness of multidisciplinary care to prevent worsening renal function in chronic kidney disease. Clin Exp Nephrol. 2019;23(4):484-92. https://doi.org/10.1007/s10157- 018-1658-z
10. Schütze A, Hohmann C, Haubitz M, Radziwill R, Benöhr P. Medicines optimization for patients with chronic kidney disease in the outpatient setting: The role of the clinical pharmacist. Int J Pharm Pract. 2021;29(6):587-97. https://doi.org/10.1093/ijpp/ riab033
11. Al Raiisi F, Stewart D, Fernandez-Llimos F, Salgado TM, Mohamed MF, Cunningham S. Clinical pharmacy practice in the care of chronic kidney disease patients: A systematic review. Int J Clin Pharm. 2019;41(3):630-66. https://doi.org/10.1007/s11096- 019-00816-4
12. Jones SA, Bhandari S. The prevalence of potentially inappropriate medication prescribing in elderly patients with chronic kidney disease. Postgrad Med J. 2013;89(1051):247-50. https://doi.org/10.1136/postgradmedj-2012-130889
13. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm. 1990;47(3):533-43.
14. Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work Group. KDIGO 2020 clinical practice guideline for diabetes management in chronic kidney disease. Kidney Int. 2020;98(4S):S1-S115. https://doi.org/10.1016/j.kint.2020.06.019
15. Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group. KDIGO 2021 clinical practice guideline for the management of blood pressure in chronic kidney disease. Kidney Int. 2021;99(3S):S1-S87. https://doi.org/10.1016/j. kint.2020.11.003
16. Kidney Disease: Improving Global Outcomes (KDIGO) Lipid Work Group. KDIGO 2013 clinical practice guideline for lipid management in chronic kidney disease. Kidney Int. Suppl. 2013;3:259-305. https://doi.org/10.1053/j.ajkd.2014.10.005
17. Kidney Disease: Improving Global Outcomes (KDIGO) Anemia Work Group. KDIGO 2012 clinical practice guideline for anemia in chronic kidney disease. Kidney Int. Suppl. 2012;2:279-335.
18. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int. Suppl. 2013;3:1-150. https://doi.org/10.1038/ki.2013.243
19. Kidney Disease: Improving Global Outcomes (KDIGO) Glomerular Diseases Work Group. KDIGO 2021 clinical practice guideline for the management of glomerular diseases. Kidney Int. 2021;100(4S):S1-S276. https://doi.org/10.1016/j.kint.2021.05.021
20. MerativeTM Micromedex® [Internet]. DRUGDEX® (electronic version). Merative, Ann Arbor, Michigan, USA. [cited 2023 June 16]. Available from: https://www.micromedexsolutions.com/
21. MerativeTM Micromedex® [Internet]. Drug Interaction Checking (electronic version). Merative, Ann Arbor, Michigan, USA. [cited 2023 June 16]. Available from: https://www.micromedexsolutions.com/
22. Raphael KL. Metabolic acidosis in CKD: Core Curriculum 2019. Am J Kidney Dis. 2019;74(2):263-75.
23. UMHS Chronic kidney disease guideline: Quality department guidelines for clinical care ambulatory [Internet]. 2019 [cited 2023 June 25]. Available from: https://www.med.umich.edu/1info/FHP/practiceguides/kidney/CKD.pdf
24. Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: A report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. Circulation. 2019;139(25):e1082-e1143. https://doi.org/10.1161/cir.0000000000000625
25. Renal Association Clinical Practice Guidelines. Treatment of acute hyperkalaemia in adults [Internet]. 2020 [cited 2023 June 25]. Available from: https://ukkidney.org/sites/renal.org/files/RENAL%20ASSOCIATION%20HYPERKALAEMIA%20GUIDELINE%20 -%20JULY%202022%20V2_0.pdf
26. The Nephrology Society of Thailand. Clinical practice recommendations for evaluation and management of chronic kidney disease in adults 2022 (revised edition) [Internet]. 2022 [cited 2023 June 16]. Available from: https://www.nephrothai.org
27. Wilson Vanvoorhis CR, Morgan BL. Understanding power and rules of thumb for determining sample sizes. Tutor Quant Methods Psychol. 2007;3:43‐50.
28. Theeranut A, Methakanjanasak N, Surit P, Srina J, Sirivongs D, Adisuksodsai D. Can a multidisciplinary approach slow renal progression in CKD patients? Int J Med Sci. 2021;18(9):1975-79.
29. Jiamjariyaporn T, Ingsathit A, Tungsanga K, Banchuin C, Vipattawat K, Kanchanakorn S, et al. Effectiveness of integrated care on delaying chronic kidney disease progression in rural communities of Thailand (ESCORT study): Rationale and design of the study [NCT01978951]. BMC Nephrol. 2014;15:99. https://doi.org/10.1186/1471-2369-15-99
30. Jiamjariyapon T, Ingsathit A, Pongpirul K, Vipattawat K, Kanchanakorn S, Saetie A, et al. Effectiveness of integrated care on delaying progression of stage 3-4 chronic kidney disease in rural communities of Thailand (ESCORT study): a cluster randomized controlled trial. BMC Nephrol. 2017;18(1):83. https://doi.org/10.1186/s12882-016-0414-4
31. Mongaret C, Aubert L, Lestrille A, Albaut V, Kreit P, Herlem E, et al. The role of community pharmacists in the detection of clinically relevant drug-related problems in chronic kidney disease patients. Pharmacy (Basel). 2020;8(2):89. https://doi. org/10.3390/pharmacy8020089
32. Barnes KD, Tayal NH, Lehman AM, Beatty SJ. Pharmacist-driven renal medication dosing intervention in a primary care patientcentered medical home. Pharmacotherapy. 2014;34(12):1330-5. https://doi.org/10.1002/phar.1508
33. Pourrat X, Sipert AS, Gatault P, Sautenet B, Hay N, Guinard F, et al. Community pharmacist intervention in patients with renal impairment. Int J Clin Pharm. 2015;37(6):1172-9. https://doi.org/10.1007/s11096-015-0182-4
34. de Boer IH, Khunti K, Sadusky T, Tuttle KR, Neumiller JJ, Rhee CM, et al. Diabetes management in chronic kidney disease: a consensus report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO). Diabetes Care. 2022;45(12):3075-90. https://doi.org/10.2337/dci22-0027
35. Ikizler TA, Burrowes JD, Byham-Gray LD, Campbell KL, Carrero JJ, Chan W, et al. KDOQI Clinical practice guideline for nutrition in CKD: 2020 update. Am J Kidney Dis. 2020;76(3 Suppl 1):S1-S107. https://doi.org/10.1053/j.ajkd.2020.05.006
36. National Kidney Foundation. K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis. 2003;42(4 Suppl 3):S1-201.
37. Evans M, Morgan AR, Whyte MB, Hanif W, Bain SC, Kalra PA et al. New therapeutic horizons in chronic kidney disease: The role of SGLT2 inhibitors in clinical practice. Drugs. 2022;82(2):97-108. https://doi.org/10.1007/s40265-021-01655-2
38. Lam D, Shaikh A. Real-life prescribing of SGLT2 Inhibitors: How to handle the other medications, including glucose-lowering drugs and diuretics. Kidney360. 2021;2(4):742-46. https://doi.org/10.34067/kid.0000412021
39. Kalra S, Singh V, Nagrale D. Sodium-glucose cotransporter-2 inhibition and the glomerulus: A review. Adv Ther. 2016;33(9):1502- 18. https://doi.org/10.1007/s12325-016-0379-5
40. Jardiance [package insert]. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals, Inc. 2023.
41. Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work Group. KDIGO 2022 clinical practice guideline for diabetes management in chronic kidney disease. Kidney Int. 2022;102(5S):S1-S127. https://doi.org/10.1016/j.kint.2022.06.008
42. The EMPA-KIDNEY Collaborative Group; Herrington WG, Staplin N, Wanner C, Green JB, Hauske SJ, et al. Empagliflozin in patients with chronic kidney disease. N Engl J Med. 2023;388(2):117-27. https://doi.org/10.1056/nejmoa2204233
43. Guo X, Nzerue C. How to prevent, recognize, and treat drug-induced nephrotoxicity. Cleve Clin J Med. 2002;69(4):289-90, 293- 4, 296-7 passim. https://doi.org/10.3949/ccjm.69.4.289
44. Sriperumbuduri S, Hiremath S. The case for cautious consumption: NSAIDs in chronic kidney disease. Curr Opin Nephrol Hypertens. 2019;28(2):163-70. https://doi.org/10.1097/mnh.0000000000000473
45. Rahman S, Malcoun A. Nonsteroidal antiinflammatory drugs, cyclooxygenase-2, and the kidneys. Prim Care. 2014;41(4):803- 21. https://doi.org/10.1016/j.pop.2014.09.001
46. Ho KY. Perceptions and beliefs regarding NSAIDs in the Asia-Pacific Region. J Pain Res. 2020;13:437-46. https://doi.org/10.2147/ jpr.s229387
47. Tangkiatkumjai M, Walker DM, Praditpornsilpa K, Boardman H. Association between medication adherence and clinical outcomes in patients with chronic kidney disease: A prospective cohort study. Clin Exp Nephrol. 2017;21(3):504-12. https:// doi.org/10.1007/s10157-016-1312-6
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Evaluation of Drug-Related Problems in the Chronic Kidney Disease Clinic at the University Hospital in Thailand. Pharm Pract (Granada) [Internet]. 2024 May 31 [cited 2025 Apr. 25];22(2):1-11. Available from: https://pharmacypractice.org/index.php/pp/article/view/2949
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Evaluation of Drug-Related Problems in the Chronic Kidney Disease Clinic at the University Hospital in Thailand. Pharm Pract (Granada) [Internet]. 2024 May 31 [cited 2025 Apr. 25];22(2):1-11. Available from: https://pharmacypractice.org/index.php/pp/article/view/2949