Drug-Related Problems in Hospitalised Patients with Chronic Kidney Disease

Abstract

Chronic Kidney Disease (CKD) is one of the leading causes of mortality globally. Multiple comorbidities and altered pharmacokinetics are common in patients with CKD, which can have long-lasting consequences on quality of life and make CKD patients vulnerable to drug-related problems (DRPs). Most of the drug-related problems (DRPs) are preventable upon identifying the origin and causes of the problem. A DRP is defined as "an event or circumstance involving drug therapy that actually or potentially interferes with desired health outcomes". This thesis aimed to investigate the types, characteristics, severity, causes, most commonly involved drug classes and risk factors of DRPs in hospitalised patients with CKD and explore healthcare professionals’ perspectives in relation to DRP causes, challenges, and preventive strategies in hospitalised CKD patients. The body of work presented in this thesis was conducted in four stages to achieve the study aims. First of all, a systematic review was conducted to investigate the prevalence and nature of DRPs among hospital in-patients with CKD. A total of 20 studies were included in the review. DRPs prevalence in CKD was reported between 12% and 87%. The most common DRPs included ineffective treatment, inappropriate drug choice, and dosing problems. Antibiotics, H2-antihistamine and oral antidiabetics (metformin) were common drug classes involved in DRPs. Factors associated with DRPs included severity of CKD, the number of medications taken, age, length of hospital stay, and gender. However, there was no well-designed prevalence studies of DRPs in hospitalised CKD patients (stage 1-4) that also capture the related risk factors to allow prevention, monitoring and early intervention. Second study involved a prospective evaluation to investigate the types, characteristics, severity, causes, most common involved drug classes, and risk factors for DRPs in hospitalised patients with CKD. Patients admitted to hospital were included and followed up until discharge. A total of 375 DRPs were identified in 240 patients (64%) with an average prevalence of 0.96 (±0.9) per patient. Majority of DRPs 55% were in stage-3 CKD. Treatment effectiveness was the most frequent DRP type (57.3%). The majority of DRPs were moderate in severity 84% and preventable 91.5%. The most common drugs group involved were blood and blood forming organs (19.8%). Hospital stays over 5 days and using ≥ 6 drugs were independent factors for DRPs in CKD hospitalised patients with (OR 6.5, 95% CI 3.2 – 13.2; P= <0.001) and (OR 6.3, 95% CI 2.9 – 13.5; P= <0.001), respectively. The third study involved evaluation of prescribing pattern in hospitalised CKD patients with reference to WHO prescribing indicators. The average number of drugs per patient was 11 (±4.9), the percentage of patients requiring a prescription of an antibiotic was 61.8%, the percentage of patients requiring a prescription of injection was 93.5%, the percentage of drugs prescribed by generic name was 90.2%, and the percentage of drugs prescribed from essential drugs list or formulary was 88.9%. The most frequent drug group prescribed were alimentary tract and metabolism (22%). A qualitative study was then undertaken to explore the causes, challenges, and preventative strategies of DRPs in hospitalised CKD patients. A total of 20 HCPs were recruited from UHB trust. This study showed that DRPs in hospitalised CKD were often encountered in practice. Several challenges which centred around HCPs, the healthcare system and management, patient, and drug and disease were amongst commonly reported barriers. Overall, this thesis provided up to date data to demonstrate high prevalence of DRPs in CKD patients and the nature of DRPs in CKD patients. Further research on the applicability and efficacy of the presented preventative strategies to overcome contributory factors and barriers faced by healthcare professionals and patients is required. Further research is also required to explore patient experiences of DRPs and their perspectives on prevention strategies.