Medication discrepancies in late-stage chronic kidney disease

Abstract

BackgroundLate-stage chronic kidney disease (LS-CKD) can be defined by glomerular filtration rate (GFR) 0–30 mL/min. It is a period of risk for medication discrepancies because of frequent hospitalizations, fragmented medical care, inadequate communication and polypharmacy. In this study, we sought to characterize medication discrepancies in LS-CKD.MethodsWe analyzed all patients enrolled in Northwell Health’s Healthy Transitions in LS-CKD program. All patients had estimated GFR 0–30 mL/min, not on dialysis. Medications were reviewed by a nurse at a home visit. Patients’ medication usage and practice were compared with nephrologists’ medication lists, and discrepancies were characterized. Patients were categorized as having either no discrepancies or one or more. Associations between patient characteristics and number of medication discrepancies were evaluated by chi-square or Fisher’s exact test for categorical variables, and two-sample t-test or Wilcoxon text for continuous variables.ResultsSeven hundred and thirteen patients with a median age of 70 (interquartile range 58–79) years were studied. There were 392 patients (55.0% of the study population) with at least one medication discrepancy. The therapeutic classes of medications with most frequently occurring medication discrepancies were cardiovascular, vitamins, bone and mineral disease agents, diuretics, analgesics and diabetes medications. In multivariable analysis, factors associated with higher risk of discrepancies were congestive heart failure [odds ratio (OR) 2.13; 95% confidence interval (CI) 1.44–3.16; P = 0.0002] and number of medications (OR 1.29; 95% CI 1.21–1.37; P < 0.0001).ConclusionsMedication discrepancies are common in LS-CKD, affect the majority of patients and include high-risk medication classes. Congestive heart failure and total number of medications are independently associated with greater risk for multiple drug discrepancies. The frequency of medication discrepancies indicates a need for great care in medication management of these patients.

The Relationship Between Medication Discrepancies and Hospitalization Risk Among Patients With Advanced CKD

“…Medication discrepancies are a reflection of a number of different factors that complicate medication management in chronically ill patients. In a previous study, 4 we found a diagnosis of heart failure, white race, hypertension, and the number of medications to be associated with increased number of discrepancies.…”

“…1 We have previously reported that medication discrepancies are particularly common in patients with advanced chronic kidney disease (CKD; estimated glomerular filtration rate 0 to 30 ml/min per 1.73 m 2 ) not yet on dialysis, with 55% of patients having at least 1 discrepancy. 4 It is likely that mismatches between patients' medication use and the physician's record are more of a problem in chronic diseases. These patients are often treated with a large number of drugs 5 and are cared for by multiple physicians.…”

Factors associated with the frequency of antihypertensive drug adjustments in chronic kidney disease patients: a multicentre, 2-year retrospective study

“…Frequent adjustments to medications for patients with multiple medications can lead to various problems, including poor adherence, adverse effects and concerns about the new treatment [ 10 ]. These problems might be augmented in CKD patients with increased complexity to their medication regimens requiring patients to adapt to new routines, leading to other practical difficulties associated with medication changes [ 11 ]. Furthermore, the addition of medications increases the likelihood of receiving inappropriate medication, given the higher chance of drug-drug interactions among CKD patients who have an existing complex medication profile and altered pharmacokinetic profile [ 5 , 12 ].…”

“…Furthermore, the addition of medications increases the likelihood of receiving inappropriate medication, given the higher chance of drug-drug interactions among CKD patients who have an existing complex medication profile and altered pharmacokinetic profile [ 5 , 12 ]. Frequent medication adjustments might also lead to harm if changes are not adhered to, such as unanticipated adverse events or drug interactions resulting from persistent use of medications that have been discontinued by the prescriber, or failure to achieve efficacy when the medicines were not adjusted as instructed [ 11 ].…”

Optimizing the timing of nephrology referral for patients with diabetic kidney disease

“…Interestingly, SGLT2 inhibitors may allow deprescription of drugs [ 24 ]. This is especially interesting in diabetic patients with CKD who frequently receive multiple medications, thus compromising compliance with antidiabetic drugs and increasing the risk of medication discrepancies resulting in physicians not knowing which drugs patients are actually taking [ 26 , 27 ].…”