1. PHARMACEUTICAL CARE ISSUES (PCIs) IN ADULT END-STAGE RENAL DISEASE (ESRD) PATIENTS ON DIALYSIS MANJULAA DEVI SUBRAMANIAM M.Pharm, B.Pharm, R Ph., MMPS Pharmacy Department Hospital Kuala Lumpur Assoc Prof Dr. Rosnani Hashim (UKM) Pharm Adyani Mohd Redzuan (UKM) Pharm Datin Fadillah Othman (Hospital Selayang)

2. OUTLINE Study background / Introduction Objectives Study design & Methodology Results & Discussion LimitationsConclusion

3. INTRODUCTION Pharmaceutical care : the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life (Hepler & Strand 1990) Each hemodialysis patient take 10-12 medications/day with 20-30 doses/day (Grabe et al. 1997). High risk for drug-related problems (DRPs) that lead to increased morbidity and mortality (Possidente et al. 1999) – core pharmaceutical care issues that warrant attention by pharmacists

4. Studies showing pharmacist intervention improves ESRD patient care: Hudson et al. 2002 Manley et al. 2000 Possidente et al. 1999 Grabe et al. 1997 Kaplan et al. 1994 Tang et al. 1993 Stoutakis et al. 1978

5. OBJECTIVES 1. To identify and describe pharmaceutical care issues in managing adult ESRD patients on dialysis in a local government-affiliated hospital setting. 2. To compare pharmaceutical care issues between patients on hemodialysis and continuous ambulatory peritoneal dialysis. 3. To identify presence of co-morbidities and disease-related problems in ESRD patients and study its effect on pharmaceutical care issues.

6. METHODOLOGY CAPD group (N=32) HD group (N=43) DATA COLLECTION - Patient demographics -Medication prescribed -Lab results -Progress notes Identification of Pharmaceutical Care Issues I EVALUATION & ANALYSIS

7. Categories of identified PCIs are: - therapeutic choices / prescribing error - adverse drug reaction / interaction - drug administration - predisposing factors - special pharmaceutical services

8. RESULTS & DISCUSSION

9. Cumulative Pharmaceutical Care Issues (PCIs) A total of 914 care issues were idenfified (n=75). Mean = 12.19  3.61

10. Pharmaceutical Care Issues (PCIs) by dialysis type Difference of PCIs between dialysis groups not significant with p = 0.138 (p>0.05).

11. Categories of Pharmaceutical Care Issues (PCIs) by Dialysis Type : Therapeutic Choices HemodialysisCAPD Inapp dosing – phosphate binder, vit D analogues, IV iron & EPO dose  or  without regards to lab values e.g., overdose of CaCO3  risk of vascular calcification & calciphylaxis (Elder 2004). Add drug not presc – no Rx for antiplatelets, antidiabetic agents or ACEI. USRDS 1998: 40% of HD pts with DM not Rx with antidiabetic agents.

12. Categories of Pharmaceutical Care Issues (PCIs) by Dialysis Type : Adverse reaction / Monitoring Hemodialysis CAPD DI:- CaCO3- PO iron; Calcium  iron absorption by 30-40% despite severity of interaction classified as minor (O’Neil-Cutting & Crosby 1986). USRDS 2004: Only 25% of ESRD pts with DM receive recomm HbA1c & few receive lipid panels.

13. Categories of Pharmaceutical Care Issues (PCIs) by Dialysis Type : Drug Administration Precaution/complex administration: involves EPO, insulin, IV iron, & unconventional dosing of antihypertensives. Requires special instructions on administration, storage and monitoring. Prescription of T.Prazosin 10mg tds on non-dial days and 5 mg tds on dialy days to prevent intradialytic hypotension involves complex adm.

14. Categories of Pharmaceutical Care Issues (PCIs) by Dialysis Type : Predisposing factors Hemodialysis CAPD Fluid/diet restriction : to achieve target dry weight and BP & PO4 restr in diet.  PO4 level linked to burden of coronary artery calcification in dialysis pt (Goodman 2000).

15. Categories of Pharmaceutical Care Issues (PCIs) by Dialysis Type : Special Requirements Hemodialysis CAPD Special mon: C&S, T°, FBC, ABGs, Ca/PO4/iPTH, Ca-PO4 product, iron indices, coagulations, BP & glycemic indices. Staff education: Pt on drugs requiring TDM (sampling time), complex adm (monitoring of hypersensitive reactions), IVdrugs (requiring dilution).

16. Total = 176; Mean = 2.35  1.12 Correlation : Co-morbidities & PCIs (r=0.411 ; p=0.0001). More co-morbid cond, more PCIs will be encountered (Joyce et al. 2005) ESRD pt have average 5 co-morbidities with CHF, DM,CHD, vascular disease and MI as the most common ones (USRDS 1999)

17. Total = 268; Mean =3.57  1.19 Correlation : number of disease-related problems & number of PCIs (r=0.365, p=0.001). Management of co-morbid conditions & preventive care e.g., immunizations for hepatitis likely to improve outcomes (Nissenson 2004).

18. Number of medications prescribed Total number of medications prescribed in the study period = 1096 MeanModeMedianMinimumMaximum 14.61  4.93 10 and 1414.0726 USRDS 1998: median of 8 prescribed meds and as many as 15 or 20 meds.  no. of meds pose for more PCIs and  drug-related morbidity (Manley et al. 2000).

19. Types of medication class involvement in the DRPs R. osteodystrophy: inappropriate dose and indication without Rx. Anemia: inadequate monitoring of iron indices and inappropriate dose. Cardiac: inappropriate dosing of antihypertensives & not treated to target BP; lack of Rx for ACEI

20. LIMITATIONS Study was conducted in a short period of 12 months. No compilation on patient’s actual compliance. Compliance data was from patient’s progress notes. Other aspects of PCIs eg., illegal charting, dispensing errors, administration errors were not investigated. Quality of life of patients were not studied. This was due to the retrospective design of the study.

21. CONCLUSION PCIs were present at a high rate in our local dialysis setting and did not significantly differ between both dialysis groups. The most commonly observed / on-need PCIs were affected kinetics, special monitoring, inappropriate dose, patient counseling and precaution/complex administration. The most common co-morbidity was hypertension and disease-related problem was hyperparathyroidism and the number of these problems were positively correlated with number of PCIs. Provision of Pharmaceutical Care can improve patient’s outcomes.

22. THANK YOU ACKNOWLEDGEMENT Assoc Prof Dr. Rosnani Hashim (UKM) Adyani Mohd Redzuan (UKM) Datin Fadillah Othman (Hospital Selayang) Dr. Ghazali Ahmad Kutty (Hospital Kuala Lumpur) Dr. Bee Boon Cheak (Hospital Selayang)