Medication burden and inappropriate prescription risk among elderly with advanced chronic kidney disease

Abstract

Background: Elderly patients with chronic kidney disease (CKD) frequently present comorbidities that put them at risk of polypharmacy and medication-related problems. This study aims to describe the overall medication profile of patients aged ≥75 years with advanced CKD from a multicenter French study and specifically the renally (RIMs) and potentially inappropriate-for-the-elderly medications (PIMs) that they take.Methods: This is a cross-sectional analysis of medication profiles of individuals aged ≥75 years with eGFR < 20 ml/min/1.73 m2 followed by a nephrologist, who collected their active prescriptions at the study inclusion visit. Medication profiles were first analyzed according to route of administration, therapeutic classification. Second, patients were classified according to their risk of potential medication-related problems, based on whether the prescription was a RIM or a PIM. RIMs and PIMs have been defined according to renal appropriateness guidelines and to Beer's criteria in the elderly. RIMs were subclassified by 4 types of category: (a) contraindication; (b) dose modification is recommended based on creatinine clearance (CrCl); (c) dose modification based on CrCl is not recommended but a maximum daily dose is mentioned, (d) no specific recommendations based on CrCl: "use with caution", "avoid in severe impairment", "careful monitoring of dose is required" "reduce the dose". Results:We collected 5196 individual medication prescriptions for 556 patients, for a median of 9 daily medications [7][8][9][10][11]. Antihypertensive agents, antithrombotics, and antianemics were the classes most frequently prescribed. Moreover, 77.0% of patients had at least 1 medication classified as a RIM. They accounted 31.3% of the drugs prescribed and 9.25% was contraindicated drugs. At least 1 PIM was taken by 57.6 and 45.5% of patients had at least one medication classified as RIM and PIM. The prescriptions most frequently requiring reassessment due to potential adverse effects were for proton pump inhibitors and allopurinol. The PIMs for which deprescription is especially important in this population are rilmenidine, long-term benzodiazepines, and anticholinergic drugs such as hydroxyzine.(Continued on next page) Conclusion: We showed potential drug-related problems in elderly patients with advanced CKD. Healthcare providers must reassess each medication prescribed for this population, particularly the specific medications identified here.Trial registration: NCT02910908.

Chronic Kidney Disease Management in General Practice: A Focus on Inappropriate Drugs Prescriptions

“…The elderly have a higher prevalence of risk factors related to the onset and the progression of CKD [31]. Furthermore, older people daily take a broad number of drugs, thus increasing the probability of inappropriate prescriptions [32,33]. Multimorbidity was very common in patients with CKD and the number of comorbidities was linked with a faster decline of the renal function [34].…”

“…An increased number of prescriptions was found with an increased stage of CKD (G3a-G5): G3a: 113 (60-187); G3b: 152 (91-229); G4/G5: 196 (117-65), as well as the number of different active substances prescribed: G3a: 18 (12-25); G3b: 22 (15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29); G4/G5: 25 (20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33). The frequency of comorbidities stratified by the severity of CKD are shown in Supplementary Table S2.…”

Kidney Disease in Diabetic Patients: From Pathophysiology to Pharmacological Aspects with a Focus on Therapeutic Inertia

“…Specifically, nonsteroidal anti-inflammatory drugs were the most prescribed nephrotoxic drugs to CKD patients, with nimesulide and diclofenac being most frequently used [113]. A recent cross-sectional analysis of the medication profiles of 556 patients diagnosed with CKD documented that 77% of them had at least one drug classified as renally-inappropriate, accounting for 31.3% of the drugs prescribed, and 9.25% were contraindicated drugs [114].…”

Kidney Disease Management in the Hospital Setting: A Focus on Inappropriate Drug Prescriptions in Older Patients

“…Older adults with GFR <60 ml/min/1.73 m 2 may have altered renal excreted drug pharmacokinetics and an increased risk of drug interactions which usually leads to an adjustment of their dosages to avoid toxicity (KDIGO, 2013). Older people take a broad number of medications daily, thus increasing the probability of inappropriate prescriptions (Formica et al, 2018;Roux-Marson et al, 2020). Moreover, the use of inappropriate drug prescriptions could lead to a possible worsening and progression of CKD (Schmidt et al, 2019).…”

“…A recent Italian retrospective population-based study in a general practice setting showed that 56.8% of CKD affected patients received inappropriate prescriptions with a significantly greater probability when treated with more drugs, with more comorbidities and during the end stages of CKD (Barbieri et al, 2020). Nevertheless, the management of older patients with GFR <60 ml/min/1.73 m 2 in the hospital setting is a little-discussed issue in recent literature (Tesfaye et al, 2019;Roux-Marson et al, 2020;Troncoso-Mariño et al, 2021). Hospital admissions provide an opportunity to re-evaluate treatment regimens in patients with GFR <60 ml/ min/1.73 m 2 and, better familiarity with nephrotoxic drugs by a physician in collaboration with a pharmacologist, could help identify appropriate preventive strategies for the management of these patients at discharge.…”