Polypharmacy and Medication-Related Problems in Hemodialysis Patients: A Call for Deprescribing

Abstract

Polypharmacy is a common problem among hemodialysis patients. It is associated with increased hospital admissions, morbidity, mortality, Medication-Related Problems (MRPs), and expenditures. There is a paucity of data on the prevalence of polypharmacy in our setting. This study aims to determine the prevalence of polypharmacy and MRPs and to assess its predictors. We conducted a cross-sectional study in the outpatient hemodialysis unit. A pharmacy resident assessed electronic prescribing records to identify MRPs and discussed therapeutic interventions to enhance effective therapeutic regimens over a three months period. Eighty-three patients were included. The median age was 63 (Interquartile range; IQR = 22), 50% were males, and the mean number of co-morbidities was 3.14 ± 1.64. The prevalence of polypharmacy was 97.6% with a 95% CI (91.6%–99.7%). Medication use without indication, was the highest identified MRPs at 36% (102/280), followed by subtherapeutic dosing at 23% (65/280), and overdosing at 15% (41/280). The number of comorbidities, the presence of ischemic heart disease, and respiratory diseases were the main predictors of the increased number of medications. Polypharmacy is highly prevalent among the Saudi hemodialysis population. A review of the medications prescribed by the pharmacist facilitated the identification of MRPs and provided opportunities for deprescribing to optimize medication use and to reduce polypharmacy in hemodialysis patients.

Clinical pharmacy practice in the care of Chronic Kidney Disease patients: a systematic review

“…The majority of processes (often labelled as interventions) included medication chart review to identify any drug-related problems (DRPs) [ 15 – 31 ]. Many studies reported pharmacists’ interventions in: modifying drug doses and recommending new pharmacotherapy; [ 16 , 19 , 21 – 23 , 25 – 27 , 29 , 30 , 32 – 40 , 52 , 59 ]; interacting with a member of the multidisciplinary team; [ 15 – 17 , 19 – 21 , 23 – 25 , 27 , 31 , 32 , 34 – 38 , 40 – 43 ] requesting and monitoring laboratory parameters; [ 15 , 23 , 25 , 27 , 33 , 34 , 36 , 37 , 43 ] assessing appropriateness of medications prescribed for hospitalised patients at each point of care; [ 17 , 22 , 29 , 30 , 35 – 38 , 40 , 57 ]. Fewer studies described pharmacist processes at out-patient, pharmacist-led clinics relating to the management of specific CKD complications, such as anaemia; [ 34 , 39 , 44 ] hypertension and diabetes; [ 54 ] managing hypertension through telemedicine; [ 41 ] optimising dyslipidaemia management; [ 37 , 45 ] improving haemoglobin A1c levels (HbA1c); [ 43 ] and emphasising smoking cessation.…”

“…A number of studies reported pharmacists’ participation in ward rounds [ 17 , 22 , 35 , 37 , 38 , 40 ], providing educational sessions to healthcare professionals [ 22 , 34 ] and performing activities such as medication use evaluations [ 34 ]. There were no reports of pharmacist prescribing activities; one study described the process of deprescribing to optimise medication use [ 59 ].…”

“…Across all studies, the pharmacists identified 5302 drug-related problems in 2933 patients. Pharmacists made 3160 recommendations to healthcare professionals with an acceptance rate varying from 33.3% in a community setting; [ 16 ] 46.43% in a dialysis unit; [ 59 ] to around 95% in hospital settings [ 17 , 24 , 42 , 51 , 52 , 57 ]. Only three studies reported the clinical significance of recommendations.…”

Warfarin in nonvalvular atrial fibrillation—Time for a change?

“…24,28,29 Why is anticoagulation quality in HD patients with warfarin worse than that seen in patients with normal kidney function? Some of this could be explained by an increase in the number of comorbid illnesses, increased antibiotic exposure, 30 changes in intestinal flora, reduced vitamin K intake and vitamin K deficiency, 31 polypharmacy with variable adherence 32 and warfarin discontinuation or reversal for procedures.…”

Issues with deprescribing in haemodialysis: a qualitative study of patient and provider experiences

“…Patients undergoing haemodialysis receive on average 10–17 regular medications, which increase the risk of inappropriate medication use, [ 1–4 ] and medication‐related problems such as improper drug selection, and absence, of indication, or adverse drug reactions. [ 5 ] Pill burden is also independently associated with a decreased health‐related quality of life.…”