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Drug Related Problems

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Drug related problem Drug related problems (DRPs) are prevalent and causing considerable patient morbidity and mortality. Many of these DRPs are preventable through following the guidelines and rational drug used. There are many factors controlling the DRP occurrence such as patient age, disease status, drug characteristics, etc.

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High risk factors 1. Elderly (> 65 years); due to age related changes in pharmacodynamic and pharmacokinetics 2. Acute diseases such as acute renal failure, sepsis, etc… 3.

Patients with many chronic diseases; diabetes, hypertension, heart disease, liver problem, AIDS, etc… 4. Patients with renal impairment or haemodialysis 5. Patients in special situations; pregnancy, lactation, 6. Certain diseases and their medications: cancer, diabetes, heart failure. 7. Polypharmacy (taken many drugs > 5 drugs) 8. Drug; certain drug classes are commonly involved e. g. Warfarin, insulin, digoxin, TCAs, etc… Classification of drug-related problems 1. Inappropriate drug choice: Unjustified deviation from management guidelines consensus therapeutic can worsen the condition.

Deviations that are based on the patient’s individual treatment goal and risk factors are not considered to be DRPs (e. g. Antibiotic used for viral infection. Furosemide prescribed for patient with hypokalemia). 2. Lack of necessary drug: Either one or more drugs are missing according to established guidelines or a medical problem is being treated with too little of the appropriate drug (under-prescribed) or appropriate drugs may be not used for maximum effectiveness. Moreover, duration of treatment may be too short which can lead to incomplete treatment.

Deviations from guidelines that are based on the patient’s individual treatment goals and risk factors are not considered to be DRPs (e. g. B-blockers in heart failure or post-MI, stop diuretic before edema treated or loop diuretic used only for resistant edema). 3. Unnecessary drug and Duplication: A drug is unnecessary if the indication is no longer present, with continuation/prolonged use or double prescription of two or more drugs from the same therapeutic group or gives the same result. This intensifies their therapeutic effect and side effects.

Duplication also can occur when more than one physician prescribes medications to a single patient or when a patient takes over-the-counter drugs with the same active ingredient (e. g. Long-term antibiotic prescribed for simple infection. Used of Ibuprofen and diclofenac concomitantly. 4. Incomplete medication history taking: Inappropriate integration of patient’s medical history can lead to many interactions due to lack of patient’s information such as hypersensitivity “medication allergy”, other diseases, OTC or herbal and medication used (e. g.

Patient has allergy to penicillin). 5. Inappropriate dose or regimen: Dosing too high (overdose) or too low dose. Suboptimal dosing (including dosing time and formulation) according to established national/international guidelines, including frequency of dosing or duration of therapy. Deviations that are based on the patient’s individual treatment goal and risk factors are not considered to be DRPs (e. g. too high ACE inhibitor dose prescribed in relation to kidney function. Too low paracetamol dose use in relation to symptom-giving arthritis). . Adverse drug reaction (ADR): Any noxious, unintended, and undesired effect of a drug, which occurs at doses in humans for prophylaxis, diagnosis, or therapy (e. g. orthostatic hypotension happens with blood pressure lowering drug or intolerance dry cough due to ACE inhibitor). 7. Interaction: Drug–drug interaction, drug-food interaction, drug-disease interaction, drug-herbal, etc… An interaction is occurring when the effect of a drug is changed by the presence of another drug, food, drink, herbal or some environmental chemical agent.

Drug combinations with intended overall effect are not considered to be DRP (e. g. Drug–drug interaction; Furosemide and digitalis (increased effect/toxicity of digitalis with hypokalemia). Drug-food interaction; Amiodarone and Grapefruit, Grapefruit and Simvastatin (increase drug serum concentrations), or Tetracycline and calcium. Drug-disease interaction; used NSAIDs in chronic renal impairment). 8. Discontinuation of needed medication: Some times discontinuation of medication without reasonable medical indication can lead to therapeutic failure or a problem in treatment plan.

In addition, stop some medications before controlling the disease or have good monitoring method can lead to failure in treatment plan (e. g. discontinue antibiotic before finishing its therapeutic course or stop Heparin injection before or just on start of Warfarin). 9. Contraindication: the used of some drugs are prohibited for some patients because to harmful risks of using these drugs are exceeding the benefits of their effect (e. g. ACE inhibitor uses in treating high blood pressure in a pregnant lady or using sulfa-drug in G6PD deficiency patients). 10.

Abrupt stoppage medication: for certain medications, abrupt stopping can exacerbate the problem or lead to complications related to drug. The stopping process should be gradually (e. g. abruptly stopping B-blocker in MI patients or stopping Corticosteroid suddenly). 11. Untreated medical conditions: can lead to worsening of the disease or may lead to more serious problems (e. g. untreated dyslipidemia in patients with other risk factors). 12. Lack of necessary monitoring: Monitoring with respect to effects and toxicity of drugs is not done or does not adhere to guidelines (e. . INR for Warfarin. Thyroid function tests in patients taking levothyroxine 13. Others: In general, DRPs that do not belong to aforementioned categories. References 1. Bemt P and Egberts A (2007) Drug-related problems: definitions and classification. Journal of European Association of hospital Pharmacists (EAHP), 13, pp 62-64. 1. Lee S, Schwemm A, Reist J, Cantrell M, Andreski M, Doucette W, Chrischilles E and Farris K (2009) Pharmacists’ and pharmacy students’ ability to identify drug-related problems using TIMER (tool to improve medications in the elderly via review).

American Journal of Pharmaceutical Education, 73, 3, pp 52-62 2. PCNE Classification for drug related problems (2006) Pharmaceutical Care Network Europe Foundation. Available from World Wide Web: http://www. pcne. org/dokumenter/DRP/PCNE %20classification%20V5. 01. pdf 2. Ruscin M (2009) Drug-Related Problems in the Elderly. Merck, Available from World Wide Web: http://www. merck. com/mmpe/sec23/ch341/ch341e. html 3. Ruths S, Viktil KK, Blix HS. Classification of drug-related problems. Tidsskr Nor Leageforen 2007; 127: 3073–6 Prescription Auditing Sheet

Patients Name Age: years Drug related problem: |Inappropriate drug choice |Lack of necessary drug | |Unnecessary drug and Duplication |Incomplete medication history taking | |5. Inappropriate dose or regimen |6. Adverse drug reaction | |7. Interaction |8.

Discontinuation of needed medication | |9. Contraindication |10. Abrupt stoppage medication | |11. Untreated medical condition |12. Lack of necessary monitoring | |13. Others | | Specification of the problem (and intervention if any): )……………………………………………………………………………………… ………………………………………………………………………………………….. ( )……………………………………………………………………………………… ………………………………………………………………………………………….. ( )……………………………………………………………………………………… ………………………………………………………………………………………….. ( )………………………………………………………………………………………… ………………………………………………………………………………………….. ( )……………………………………………………………………………………… ………………………………………………………………………………………….. Patient Resume Age: Sex: Drug Allergies: Medical History – – – – – – – Medication History – – – – – Laboratory Data base

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