BackgroundPrescribing cascade is the situation in which a first drug administered to a patient causes adverse reactions that are misinterpreted as a new condition, resulting in a new medication being prescribed.PurposeTo report the case of a patient who suffered serious psychiatric disorders and a cardiopulmonary arrest probably related to prescribing cascade.Material and methodsA descriptive study was made by reviewing the electronic medical record of a 55-year-old man with a history of pulmonary thromboembolism, anxiety and behaviour disorder, and chronic diarrhoea.ResultsDue to his medical history the patient was anticoagulated, and since February 2014 he was taking haloperidol 2 mg and escitalopram 15 mg daily. In September 2014, he was admitted to the Emergency Department (ED) because of acute ischaemic heart disease, with a cardiopulmonary arrest (CPA) due to a Torsades de pointes tachycardia related to a long QT secondary to haloperidol and escitalopram. Moreover, he was diagnosed with gastropathy by stress, so treatment was initiated with a proton pump inhibitor (PPI). Almost a year after the CPA, the patient was admitted to the Psychiatry Department because of the worsening of his pathology, and during the hospitalisation, low serum magnesium levels were observed (<0.20 mmol/L), which were normalised with intravenous supplements. After that, he completely recovered from his psychiatric disorders. However, 1 week later he was admitted again to the ED with similar symptoms and, again, a hypomagnesemia was shown. At this moment, the risk of gastropathy was considered lower, so pantoprazole was stopped and oral magnesium supplementation was started at discharge. This allowed the stabilisation of the patient and the withdrawal of any psychiatric drugs. Since then he is monitored quarterly.Both adverse effects mentioned were classified by Naranjo’s algorithm as ‘probable’.ConclusionPrescribing cascade is often the beginning of polypharmacy and should be taken into account by physicians. On the other hand, although in this case it was justified, we must question the need for the massive prescription of PPIs. Hypomagnesaemia is an adverse effect related to PPI, and in this case could have worsened his clinical situation, so the monitoring of magnesium levels might have an important diagnostic and therapeutic role in this patient.No conflict of interest
Background The ENEAS study points out that the 37.4% of the adverse events detected in admitted patients are directly caused by drugs. Elderly patients constitute a group susceptible to suffering adverse effects related to their medicines, due to comorbidity and polypharmacy. Purpose To analyse the ratio of patients included in a medicines reconciliation project, who were admitted with drug overdose. The type of drugs involved was also analysed. Materials and methods Retrospective observational study of patients belonging to a medicines reconciliation project admitted with drug overdose. The patients included in this project were older than 75 years, were taking at least 6 drugs a day and were living in nursing homes. The data collected from the clinical history of each patient were: age, sex, cause of admission, overdosed drug, INR and drug blood level at admission. Results 565 patients were analysed; 48 (8.5%) were admitted with pharmacological overdosing. The mean age of the overdosed patients was 85.5 years, (75% women). The most frequent drug overdosed was acenocoumarol: 40 (22.5%) out of 178 patients anti-coagulated, followed by digoxin overdose in 3 (4.41%) out of 68 patients. Another 3 patients had concomitant acenocoumarol and digoxin overdose. Finally, 1 phenytoin and 1 opiate toxicity were also observed. The mean digoxin blood level of patients with digoxin toxicity was 3.93 ng/mL. The mean International Normalised Ratio (INR) of patients with acenocoumarol toxicity was 6.51 (3.32–16.36). In these patients, acenocoumarol was suspended until a proper INR value was reached. Administration of phytomenadione was assessed depending on the INR and bleeding risk. Conclusions The proportion of elderly patients admitted with pharmacological overdosing is significant in relation to the overall patient number in this study. The drug causing the majority of toxicity cases was acenocoumarol, followed by digoxin. Both drugs could cause serious adverse effects associated with overdose. Therefore their use in elderly patients should be tightly monitored and pharmacists could play an important role in this. No conflict of interest.
BackgroundIntoxications are a cause of potentially serious hospitalisations whose treatment is commonly based on the use of specific antidotes.PurposeThe objetive of the present study was to analyse the use of specific antidotes for the treatment of rare poisonings.Material and methodsRetrospective longitudinal study. The analysed period was between June 2013 and June 2015. The variables studied were: type of antidote, number of patients, sex, age, clinical outcome indication of intoxication and time from admission to drug administration.Results33 patients (57.7% male) were analysed, 10 of whom were dismissed due to lack of data, with a mean age of 48 years. Antidotes used were: silymarin (43.48%) for the treatment of mushroom poisoning, rabies immunoglobulin (17.39%) for prophylaxis after animal bites, botulinum antitoxin (13.04%) for the treatment of botulism food, absolute alcohol (8.7%) for the treatment of methanol and ethylene glycol poisoning, methylene blue (8.7%) for methaemoglobinaemia after poisoning spinach and ifosfamide encephalopathy, dantrolene (4.35%) for the treatment of neuroleptic malignant syndrome, pralidoxime (4.35%) after organophosphate poisoning (insecticide) and digoxin antibody (4.35%) after intoxication by this drug. In 13% of cases the poisoning was intentional and 87% were casual. For 95.65% of the cases evaluated the antidote was administered within the first 24 h after admission and diagnosis. In all cases, the antidote was effective for the specific treatment for which they were meant to be used. The average length of hospital stay after the start of treatment was 5.9 days.ConclusionAdministration of antidotes is largely in line with the indications described in the bibliography. The use of these drugs at the right time is critical to reverse the effect of intoxications for which they are indicated.No conflict of interest.
Background In October 2011, selection criteria for proton pump inhibitors (PPIs) were published, recommending the use of omeprazole as a drug of choice because, at equipotent doses, it is the most cost-effective drug, compared to other PPIs. Purpose To describe the prescription profile of PPIs for different consultants and in patients who are discharged from hospital. Materials and Methods Information about the prescriptions for PPIs issued during 2011 was obtained from the pharmaceutical software. The data were analysed and classified according to therapeutic group, active principle, number of defined daily doses (DDDs), service and number of prescriptions. The percentage DDD of each active principle with respect to the PPI group as a whole was also investigated. Results During 2011, 9.654 prescriptions were written. Gastroenterology was the Medical Service with the most prescriptions, followed by Internal Medicine and Otolaryngology. The percentage DDD of each PPI prescribed in each service, related to the whole of the PPIs was: Gastroenterology: 26% omeprazole; 14% pantoprazole; 18% lansoprazole; 16% esomeprazole; 26% rabeprazole. Total, 2213 prescriptions. Otolaryngology: 55% omeprazole; 22% pantoprazole; 2% lansoprazole; 7% esomeprazole; 14% rabeprazole. Total, 1074 prescriptions. Internal Medicine: 82% omeprazole; 7% pantoprazole; 0,5% lansoprazole; 10% esomeprazole; 0,5% rabeprazole. Total, 619 prescriptions. Conclusions Omeprazole is the PPI with the highest percentage of DDD prescribed, nevertheless prescriptions for it are on the low side (less than 30% in Gastroenterology and Otolaryngology, and less than 85% in Internal Medicine); this means that there is still a lot more room for improvement. The Service which made the best selection of IPPs was Internal Medicine, followed by Otolaryngology, and finally Gastroenterology. Despite the low number of prescriptions made in hospital, compared to the ones prescribed in Primary Care, there is still a lot of work to be done to improve the selection of IPPs prescribed in hospital. No conflict of interest.
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