Development of a list with renally relevant drugs as a tool to increase medicines optimisation in patients with chronic kidney disease.

OBJECTIVES: Chronic kidney disease (CKD) is a common disorder all over the world. Therapeutic goals are early detection of declining renal function and implementation of adequate pharmacological treatments regarding underlying and secondary diseases. As therapy becomes more complex with increasing stages of CKD, a decision-making tool for healthcare professionals could help to ensure safe drug treatment in patients with CKD in the outpatient setting. Therefore, a list of renally relevant drugs as a decision-making tool was developed to improve medicines optimisation for CKD patients in the outpatient setting long term. METHODS: A renally relevant drug list (RRD-list) with renally relevant drugs, based on data from a study on medicines optimisation in patients with CKD from June 2015 to March 2018, was developed at the nephrological outpatient clinic at the Klinikum Fulda, Germany. The whole study is published elsewhere. A clinical pharmacist reviewed the patients' medications, current drug-related problems and all nephrologists' recommendations, and categorised all detected drugs into renally relevant and non-renally relevant groups. The 10 most frequently detected renally relevant drug groups were summarised in the RRD-list and extended by treatment alternatives and advice. RESULTS: The medication of 160 patients, who were receiving overall 1376 drugs, was analysed; 831 drugs were defined as renally relevant. Drug-related problems were caused by 543 renally relevant drugs. The nephrologists made 292 recommendations regarding 28 drug classes. Considering the 10 most frequent drug groups, in total 16 renally relevant drug groups with 36 drug classes were added to the RRD-list. CONCLUSIONS: The RRD-list could be an essential tool for all healthcare professionals in their daily work, such as general practitioners and community pharmacists, for the treatment of patients with renal insufficiency.

Medicines optimization for patients with chronic kidney disease in the outpatient setting: the role of the clinical pharmacist.

OBJECTIVES: Medicines optimization (MO) in patients with chronic kidney disease (CKD) is at high risk at transition points of different ambulatory care levels such as nephrologists in outpatient clinics and general practitioners (GPs). We examined if adding a clinical pharmacist to the therapeutic team promotes implementation of nephrologists' drug therapy recommendations by GPs' and reduces drug-related problems (DRPs). METHODS: A prospective, controlled intervention study was conducted in the nephrology outpatient clinic of the Klinikum Fulda, Germany. The control and intervention phases took place successively. Patients with CKD stage 3-5 and at least one concomitant disease, for example, arterial hypertension or type-2 diabetes were recruited consecutively in three subgroups (naive, 1 contact, ≥2 contacts with nephrologist) from June 2015 to May 2019. GPs' acceptance and frequency of DRPs without (control group [CG]) and with (intervention group [IG]) pharmacist's interventions were compared after 6 months. Interventions include educational training events for GPs between control- and intervention phase, medication therapy management and pharmaceutical patient counselling. KEY FINDINGS: In total, 256 patients (CG = 160, IG = 96) were recruited into the study. GPs' acceptance of nephrologists' medication recommendations increased significantly among naive patients and those with one prior contact with the nephrologist (CG/IG: naive = 72.8%/95.5%, 1 contact = 81.1%/94.4%; P < 0.001). DRPs per patient were significantly reduced in all subgroups (P < 0.001). CONCLUSIONS: Interdisciplinary collaboration between the nephrologist, GPs and clinical pharmacist resulted in better MO for patients with CKD.

[Pharmaceutical care of a patient with oral anticoagulation and renal impairment]. / Pharmazeutische Betreuung eines Patienten mit chronischer Niereninsuffizienz unter oraler Antikoagulation.

Atrial fibrillation is one of the most important indications for oral anticoagulation. Besides vitamin K antagonists, the novel oral anticoagulants dabigatran, apixaban, edoxaban and rivaroxaban are one therapy option in patients with atrial fibrillation. The following case report describes an 83-year-old female patient treated with dabigatran for secondary stroke prevention. Due to different factors, the renal function of the patient decreases significantly (acute on chronic renal failure), resulting in a re-evaluation of the current treatment. This case report is an example of decision-making 'for and against' novel oral anticoagulants versus vitamin K antagonists.

[Novel oral anticoagulants--issues in clinical practice]. / Neue orale Antikoagulanzien.

The novel oral anticoagulants (NOAC) dabigatran, apixaban, edoxaban and rivaroxaban target either thrombin or factor Xa for the prevention and treatment of thrombosis. A short introduction of the main indications for an oral anticoagulation is followed by the pharmacology of each drug, their effectiveness, selected drug-drug interactions and adverse drug events, especially bleeding. The article represents clinical aspects for the perioperative management, the possibilities for monitoring of each drug, the application in patients with renal impairment as well as different advantages and disadvantages.

Adherence to hospital discharge medication in patients with ischemic stroke: a prospective, interventional 2-phase study.

BACKGROUND AND PURPOSE: Communication between hospitals and primary care physicians is essential for the continuity of care for patients being transferred from hospital to ambulatory care. Patients are often discharged from hospital on medication regimes different from those used before hospital admission. The aim of the study was to evaluate the adherence to hospital discharge medication in patients with ischemic stroke before and after implementing a systematic approach provided by a clinical pharmacist. METHODS: Patients with transient ischemic attack/ischemic stroke taking ≥ 2 drugs during hospital stay and at discharge were prospectively recruited. In the control group, the neurologist included the medication list in the discharge letter as before. In the intervention group, the clinical pharmacist listed the medication on admission and at discharge next to each other and gave detailed information for all medication changes during hospital stay. RESULTS: Overall, 312 patients were enrolled in the study with 156 patients in each group. Significant differences between the control group and intervention group were ascertained with regard to adherence to both antithrombotic drugs (83.8% control group versus 91.9% intervention group [P=0.033]) and to statin therapy (69.8% control group versus 87.7% intervention group [P<0.001]). CONCLUSIONS: Providing detailed information on medication changes can lead to substantially improved adherence to discharge medication, probably resulting in better secondary stroke prevention.

Drug-related problems in patients with ischemic stroke in hospital.

BACKGROUND: Drug therapy is getting more complex, thus making it more challenging to prescribe appropriate drug therapy. Accordingly, in clinical practice, a wide range of drug-related problems (DRP) may arise; they are relatively common in hospitalised patients and can result in patient morbidity and mortality, and increased costs. OBJECTIVE: The objective was to investigate the nature and frequency of DRPs along with pharmaceutical interventions to address them in patients with ischemic stroke from hospital admission to discharge. METHOD: From January to June 2011 patients with ischemic stroke, who were taking >2 drugs during hospital stay and at discharge, were recruited. A clinical pharmacist performed medication reconciliation on admission, and checked the medication records during the hospital stay regularly. DRPs were categorized by APS-Doc. Results In total, DRPs occurred in 105/155 (67.7 %) patients: Overall 271 DRPs were documented, with a mean of 1.8 ± 2.0 DRPs per patient. The DRPs occurred mainly in the categories "drug", "indication", and "dosage". CONCLUSION: In conclusion, DRPs are relatively common in hospitalised patients and may occur at any part of the prescribing process. The clinical pharmacist can provide a valuable contribution in the multidisciplinary team to an optimized pharmacotherapy in patients with ischemic stroke.

Health-related quality of life after ischemic stroke: the impact of pharmaceutical interventions on drug therapy (pharmaceutical care concept).

BACKGROUND: Health-related quality of life (HRQoL) after stroke is an important healthcare measure. Pharmaceutical Care (PC) is an evolving concept to optimize drug-therapy, minimize drug-related problems, and improve HRQoL of patients. The purpose of this study was to evaluate the impact of PC on HRQoL, as determined by Short Form 36 (SF-36) among patients after TIA or ischemic stroke one-year following their initial entry in hospital. METHODS: Patients were assigned to either an intervention (IG) or a control group (CG). The individual assignment of the patient to IG or CG depended on the community pharmacy to which the patients were assigned for care. Community pharmacies either delivered standard care (CG) or provided intensified PC (IG). Pharmacists who are members of the "Quality Assurance Working Group" (QAWG) provided PC for patients in IG. RESULTS: 255 patients were recruited (IG: n = 90; CG: n = 165) between 06/2004 to 01/2007. During the study, the HRQoL of the patients in IG did not change significantly. In the CG, a significant decrease in the HRQoL was observed in 7/8 subscales and in both summary measures of SF-36. CONCLUSIONS: This is the first follow-up study in Germany involving a major community hospital, rehabilitation hospitals, community pharmacies and general practitioners investigating the impact of PC on HRQoL of patients after ischemic stroke. Our findings indicate that an intensified education and care of patients after ischemic stroke by dedicated pharmacists based on a concept of PC may maintain the HRQoL of IG patients.

Pharmaceutical care for patients with ischemic stroke: improving the patients quality of life.

OBJECTIVES: To improve patients health-related quality of life (HQL) after transient ischemic attack (TIA) or ischemic stroke; to guarantee an effective secondary prevention; to increase the patient's satisfaction with recommendations regarding their medication by pharmacists. SETTING: Stroke Unit, neurological ward at the Klinikum Fulda, rehabilitation hospitals and community-based pharmacies in the region of Fulda, Germany. METHOD: Patients with TIA or ischemic stroke were included. The patients were assigned to an intervention group (IG) or a control group (CG). The individual assignment of patients to IG or CG was based on the type of the local pharmacy to which patients belong. Community-based pharmacies either delivered standard care (CG) or provided additional intensified pharmaceutical care (PC; IG). Pharmacies delivering PC belong to a pre-existing "Quality Assurance Working Group" (QAWG). To evaluate the patient's HQL, the Short Form-36 (SF-36) was used at study entry in hospital and at 12 months. The secondary prevention was documented at study entry in hospital and at 12 months. The patients' satisfaction was measured by a questionnaire at the end of the study. MAIN OUTCOME MEASURES: Patients' HQL; secondary prevention; patients' satisfaction with recommendations of the pharmacists with regards to their medication. RESULTS: Out of 1316 patients screened for participation in this study, 255 were recruited with 90/255 patients assigned to the IG and 165/255 patients assigned to the CG. During the study, the HQL of the patients in the IG did not change significantly. A significant decrease in the HQL was observed for the CG in 7/8 subscales and in both summary measures of the SF-36. After 12 months, 85.3% of the patients in the IG and 86.3% of the patients in the CG were treated with antiplatelet drugs or oral anticoagulants in accordance to treatment guidelines. Patients in the IG were significantly more satisfied with the individualized recommendations of the pharmacists than patients in the CG. CONCLUSION: Our findings indicate that an intensified PC of patients after ischemic stroke by dedicated pharmacists may have a positive impact on HQL and patients' satisfaction. PC in this study had no impact on adherence to secondary prevention medication.

[Pharmaceutical care for a patient with ischemic stroke]. / Pharmazeutische Betreuung eines Patienten mit zerebraler Ischämie im stationären Bereich.

A 61-year-old patient with a sudden numbness of the right arm and hand and signs of amnestic aphasia is admitted to the stroke unit with the diagnosis of an acute ischemic stroke for systemic thrombolysis. Based on a case-report, drug-related problems are discussed according to the SOAP scheme. Aspects of pharmaceutical care such as counselling by a pharmacist about secondary prevention, discharge information and a pharmaceutical care plan in the community pharmacy are described.