Association between guideline recommended drugs and death in older adults with multiple chronic conditions: population based cohort study

When prescribing medications for the initiation of  a new therapy in patients with multiple chronic diseases, physicians often look to guidelines to determine their recommended treatment option.  While this is considered good practice, it is important to not look at the disease state as a singular entity when choosing a therapy for the patient to follow due to the effects that certain conditions have on one another. This study looked to analyze the association between guideline recommended drugs and death in older adults with multiple chronic disease states. To do this, 8578 adults aged 65 and older were monitored though three years of treatment. Patients involved in the study had a variety of disease states including but not limited to atrial fibrillation, chronic kidney disease, depression, diabetes,  and hyperlipidemia. Results from the study showed that over 50% of the participants received guideline recommended drugs without the consideration of other disease states. Although 15% of the patients died during the course of the study, researchers were able to determine that cardiovascular medications were associated with a decrease in mortality. Other guideline medications analyzed in the study did not show an association with reduced mortality. Overall, it was determined that choosing medication therapy for patients should only be done after fully analyzing the patients other conditions.

I believe this study is important due to the fact that guideline recommended medications are commonly dispensed in the pharmacy setting. It is thus important for us to understand how guideline drugs interact with each other to protect a patient at the point of treatment initiation. By doing this, we will be able to avoid adverse drug effects that can result due to medication interactions. I believe that this is one of the most important roles of a pharmacist because it helps promote patient well-being and increases the likelihood of medication regiment adherence. The goal of our profession is to protect patients and advise them on how to find ways to live a healthy lifestyle. The easiest way to do this is by starting at the roots of the solution.

Tinoetti M, McAvay G, Trentalange M, et al. Association between guideline recommended drugs and death in older adults with multiple chronic conditions: population based cohort study. BMJ 2015; 351: h4984

Keeping the Kidneys Safe: The Pharmacists’ Role in NSAID Avoidance

While non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen are very easy to purchase (in grocery stores and gas stations), they are one of the most common medications improperly prescribed, especially to older adults. If these are used at a high dose regularly and combined with the wrong medications, it can lead to acute kidney injury (AKI). NSAIDs inhibit the cyclooxygenase enzyme, preventing prostaglandin production. Prostaglandins help to autoregulate the dilation of arterioles in the kidney, controlling the amount of blood filtered. If AKI goes untreated long enough, self-prescribing NSAIDs can even lead to chronic kidney disease (CKD). Luckily, there are strategies that pharmacists can use to prevent patients from overusing NSAIDs at home and prevent these adverse effects.

Pharmacists can use bright stickers or post-it notes on the prescriptions of those who need medication counseling due to a high risk for AKI or CKD (patients with hypertension or diabetes). This will help the staff to remember to discuss the patient’s personal pain management system during consultations, blood pressure screenings, or when handing out the prescription. If the patient is in a rush, a handout could also be placed in with the prescription or on a pamphlet table so that the information is still available. They can also help to counsel on when to use ice or heat on a musculoskeletal issue, rather than taking an NSAID to relieve pain. This gives the patient other ways to manage their pain without taking an NSAID too frequently.

Acetaminophen could also be recommended as a pain reliever for those who are at high risk for AKI or CKD, as it is metabolized in the liver more than the kidney and is rarely seen to damage the kidney. However, this will then require that the pharmacist counsel on the maximum daily dose for acetaminophen in combination with other acetaminophen-containing medications the patient may have. This would be an optimal alternative if the patient is insistent on taking a pill for their pain, as long as the proper counseling regarding acetaminophen can be delivered.


I felt that this article had a lot of good options for educating patients with increased risk for kidney injuries against NSAID use. The repetition of seeing a helpful handout with the patient’s prescription would demonstrate the importance of the issue. The handout could serve as an additional reminder each time the patient has their prescription filled to steer clear of NSAIDs and use another pain-relieving method. This article also ties in nicely with what we are currently learning in anatomy and physiology and helped my understanding of kidney damage via non-steroidal anti-inflammatory drugs.

http://www.japha.org/article/S1544-3191(15)30021-2/fulltext

Pai, Amy B. “Keeping kidneys safe: The pharmacists’ role in NSAID avoidance in high-risk patients.” Journal of the American Pharmacists Association. 55.1 (2015) e15-e25. Web. 14 February 2016.

Keeping kidneys safe: The pharmacist’s role in NSAID avoidance in high-risk patients

The use of NSAIDs, both prescription and OTC, continues to grow each year. Furthermore, NSAIDs are one of the most common drug classes inappropriately prescribed to older patient populations. This is an alarming issues as NSAIDs can lead to long-term complications putting at-risk patients at a higher chance of developing an acute kidney injury (AKI), which can lead to the development or progression of chronic kidney disease (CKD). It was found that 5% of patients with documented kidney disease use OTC NSAIDs on a regularly basis with 66.1% of those patients using NSAIDS for over a year.

Over 70 million prescriptions are filled each year for NSAIDs, while an additional 30 billion are purchased over the counter. NSAIDs put patients at risk for an acute kidney injury because they can lead to a disruption of blood flow to the kidneys. Reduced blood flow and kidney function results in symptoms that can be recognized as elevated blood urea nitrogen and serum creatinine levels, decreased urine output, and weight gain. Additionally, NSAIDs inhibit prostaglandin-mediated renin release, which can lead to hyperkalemia as the kidney’s ability to excrete potassium is reduced.

Chronic kidney disease is a public health epidemic, with 26 million Americans living with CKD and another 20 million at risk for developing it.  The major causes of CKD are diabetes and hypertension, making it a highly preventable disease if high-risk patients are recognized and their drug therapies optimized. Therefore, the majority of NSAID-induced AKI leading to CKD can be avoided.

Community pharmacy NSAID-counseling at the time of dispensing or purchase of OTCs allows for frequent patient interaction and continuous education. Similar targeted counseling in community pharmacies has proven to be effecting, providing hope that pharmacists can successfully educate patients on the risks of NSAIDs and development of kidney complications. Even without significant lab data, pharmacists can review patient medication profiles and screen for certain risk factors that may predispose a patient to developing an AKI. Risk factors include antihypertensive medications, especially ACEs, ARBs, and diuretics, anti-diabetics, digoxin, or any other medications used to treat chronic liver disease. After high-risk patients have been identified, pharmacists can initiate counseling on the dangers of using NSAIDs by marking their prescriptions with brightly colored stickers or tags as a reminder. In a busy pharmacy with limited time, patients can be provided with brochures and handouts out on the safe use of NSAIDS. If patients are resistant to stopping the use of NSAIDs, pharmacists can counsel them on the taking the lowest possible dose for no more than 10 days.

I found this article to be very interesting and also extremely relevant to what we are currently leaning in anatomy about kidney function. Furthermore, this article explores another way in which pharmacists can provide care and improve the health of our patients. Even as student pharmacists, we can be aware of the prominent use of NSAIDs and must recognize when they can be detrimental to a patient’s well-being. By being informed that older population and those with diabetes or hypertension are at a greater risk for developing an acute kidney injury when using an NSAID, we can better recognize high-risk patients and possibly prevent complications from occurring. This may be especially relevant as we begin going to our Silver Scripts sites and caring for older adults who especially susceptive to CKD. We must remember to ask about over-the-counter medications that our patient may be taking, including NSAIDs, and be prepared to counsel them on dangers and safe use to prevent injury or costly hospitalization.

 

Reference:

J Am Pharm Assoc. 2015;55:15-25.

http://www.japha.org/article/S1544-3191(15)30021-2/pdf

Proton Pump Inhibitor Use and the Risk of Chronic Kidney Disease

This study looks at the effects of proton pump inhibitors (PPIs) on disease states, as it is one of the most commonly prescribed drug classes. Furthermore, only 25-70% of PPIs have an appropriate indication. Thus, these therapies may be overused. This study focuses on the relationship between PPI use and the development of chronic kidney disease (CKD). Of the risk factors currently known, the prevalence of the disease cannot be fully explained. Thus, iatrogenic risk factors must be observed to help explain the rates of both CKD and acute kidney injury.

In this study, Lazarus and colleagues looked at 10,482 participants of the Atherosclerosis Risk in Communities study. Results were replicated in a study of the Geisinger Health System consisting of 248,751 patients. In the population of participants from the ARIC study, it was found after adjusting for other factors that participants using PPIs had 1.45 times the risk for incident chronic kidney disease. Participants using PPIs were 1.72 times more likely than nonusers to develop an acute kidney injury. The results of the Geisinger Health System analysis confirmed the results and supported the findings through use of direct laboratory measurements. Overall, PPI use was found to be an independent risk factor for both acute kidney injury and chronic kidney disease. The association of PPI use and kidney disease does not necessarily indicate that PPIs directly cause kidney damage. Further investigation into this is needed.

I found the information presented in this study to be very interesting considering that PPIs are so commonly prescribed. I know personally at the pharmacy I work at that multiple omeprazole prescriptions are counted on a daily basis. As future pharmacists, maybe we should consider showing caution to extensive PPI use. In our role, we could counsel patients on the risk factors presented here along with recommending PPIs over the counter less frequently for patients who may be at risk. As stated above, 25-70% of PPIs are not even appropriately indicated in the patients who are using them. A question for my colleagues: do you think a direct cause and effect relationship should be established before limiting PPI use? Or, rather, do you find the information presented here to be significant for limiting the prevalence of PPI use?

Citation:

Lazarus B, Chen Y, Wilson F, et al. Proton pump inhibitor use and the risk of chronic kidney disease. JAMA Intern Med. 2016; 176(2): 238-246.

http://archinte.jamanetwork.com/article.aspx?articleid=2481157

Community pharmacist screening for chronic kidney disease

The authors conducted this study as a part of the RxEACH study, which assesses reduction of cardiovascular risk intervention versus usual care as led by pharmacists. This part of the study analyzed pharmacists’ application of the CKD Clinical Pathway criteria (which is an online tool to aid practitioners in diagnosis and management of those with CKD) to screen their patients who are at risk for chronic kidney disease. CKD is defined as a reduction in kidney function with a GFR less than 60 mL/min/1.73m^2 or markers of kidney damage for more than 3 months. Markers of kidney damage includes albuminaria greater than 3 mg/mmol or any abnormalities in urine sediment or renal imaging. The pharmacists systematically identified patient based on their prescriptions (looking for oral hypoglycemic, antihypertensives, lipid-lowering, antiplatelet, and anticoagulants). They also checked the patient’s lab values. Once a patient iss eligible, the patient was screened based on serum creatinine, GFR, and urine albumin-to-creatinine for 12 months. Patients were categorized into the following: no CKD, known CKD, and unrecognized CKD. Of the 720 patients, 60% had known CKD. Forty percent of those with CKD had unrecognized CKD. Overall, the study identified a high number of unrecognized CKD patients, emphasizing the importance of expanding the pharmacist’s role to include laboratory testing and adjusting medication regimens according to those results. Because the study was conducted on patients with a high risk for cardiovascular disease, the results may be higher than in an otherwise healthy population.

Can Pharm J. 2016;149(1):13-17.
I think this study really shows the healthcare world just how important the role of the pharmacist is. We are more than just dispensers. We can optimize a patient’s medication regimen based on the health of their kidneys. Additionally, we can identify patients at risk for chronic kidney disease that a physician may otherwise not have diagnosed. In addition to screening patients for CKD, what other disease may a pharmacist be able to screen for? How can we as student pharmacists advocate for the expansion of the role of the pharmacist to include these screenings at all pharmacy locations?

Correlation between Proton Pump Inhibitor Use and the Development of Chronic Kidney Disease

Proton pump inhibitors, or PPIs, are a class of drugs commonly prescribed to treat GERD and that had over 15 million users in America in 2013.  These drugs have been known to cause adverse side effects, including acute kidney injury. Based on this potential for kidney damage, a group of researchers developed a study to test their hypothesis that the use of PPIs was correlated to an increase in kidney ailments, particularly chronic kidney disease, or CKD. The study compared 10,482 patients who received either PPI therapy, H2 Receptor Antagonist Therapy, or no therapy. These patients were selected from communities in four different states, and the trials were carried out by six different universities located in these communities who studied patients over a median of 13.9 years per patient. Patient medication use was determined primarily by an annual over the phone follow ups, with patients also being asked to visit researchers a total of five times with at least three years between each visit, starting in 1987 and ending in 2013.

This study determined that patients using PPIs were 1.45 times as likely to develop CKD as a patient who was taking H2 Receptor Antagonist therapy or no therapy. A second study was conducted by the Geisinger Health System, which examined 248,751 patients for a mean of about six years per patient. This study also determined that PPI use increased the likelihood of developing CKD, while neither study suggested that H2 Receptor Antagonist use was associated with an increased risk of CKD. These studies demonstrated a correlation between PPI use and CKD development, but further studies would be needed to determine if the cause of kidney damage is actually the PPI. However, these studies suggest caution may be appropriate when recommending PPI therapy, and may also necessitate further study and research into whether over the counter PPIs need additional regulation in order to cut down on the prevalence of CKD.

 

Lazarus B, Chen Y, et al. Proton pump inhibitor use and the risk of chronic kidney disease. JAMA Intern Med. doi:10.1001/jamainternmed.2015.7193 (Published 11 January 2016).