Assessment and evaluation of poly pharmacy associating factors including antibiotics and nutritional supplements in hospital and community pharmacy

Assessment and evaluation of poly pharmacy associating factors including antibiotics and nutritional supplements in hospital and community pharmacy.

Abstract:This study aimed to estimate the prevalence of poly pharmacy, the use of antibiotics and nutritional supplements and to determine the factors affecting poly pharmacy in different age limits of patients. The study of pharmacoeconomics and evaluation of the safety and efficacy parameters including drug/drug interactions.A retrospective cross sectional study of prescriptions of hospitalized and community pharmacy patients were carried out in Lahore and Faisal Abad.100 prescriptions were collected (43% were female patients and 57% male patients). The prevalence of poly pharmacy (patients who take ≥5 medications) at hospitals and community pharmacy was 40%. 19% patients were calculated taking nutritional supplements. The community pharmacy prescriptions were 75% and hospitalized prescriptions were 25%. 17% drug-drug interactions were calculated. The % of drug interactions of each pharmacological class was (NSAIDs (34%), (Antihypertensive (34%), antibiotics (10%), antifungal (8%), ant diabetics (8%) and Supplements 5%).The cost of therapy per prescription per day was 174.70/PKR. About half of elderly patients are exposed to poly pharmacy. A portion of geriatrics used nutritional supplements. The factors that were associated with patient’s exposure to poly pharmacy were different diseases including diabetes, hypertension Heart Diseases, Joint pains and GIT infections.

INTRODUCTION:Polypharmacy is an untoward iatrogenic process .The use of multiple interacting medications is a costly and common problem in all age limits, mostly in elderly patients. A number drug-drug interactions and use of supplements are major problems in polypharmacy. There is a pure need of clinical interventions to reduce polypharmacy related all these issues including appropriateness of indications and drug-drug interactions (1).

The concurrent therapy of multiple medicines with nutritional supplements Indicates specific problems in all age groups, mostly in elderly patients. Elderly patients are the largest consumers of medications up to 50% suffer from chronic diseases. The increase in number of prescribed medicines and supplements may increase risk of adverse effects, drug-drug or Drug-disease interactions. Finally the pharmacoeconomic Factors should also be considered (2).

poly pharmacy concerns with safety of medications also associated with risks of adverse drug reactions, undesirable drug-drug interactions, hospitalization, medication non adherence, poorer quality of life and premature mortality.poly pharmacy may also be essential for treatment of multiple co morbid health conditions, in other cases it represent in appropriate prescribing, which represents a clinical and economic burden for both patient and society (3).

The high prevalence of co morbid conditions such as diabetes, hypertension, depression, gastrointestinal problems and joint diseases leads to prescribe a variety of medicines and experience poly pharmacy. According to recent study there is a lack of consensus on the methods used to study poly pharmacy including measurements, definitions of poly pharmacy and study samples associated with analytical methods(4).

Although there is no clear consensus on the definition of poly pharmacy, one of the most commonly used definition is the concurrent use of 5 or more drugs. This study lacks examining factors associated with poly pharmacy to understand why the prevalence of poly pharmacy differs within age limits. The factors associated with poly pharmacy may include older age, female gender, low education, poor self-reported health, high number visits to health professionals(5)

“Concurrent use of many different drugs “or “Excessive use of drugs” or“The use of an excessive number of inappropriate drugs or“The use of a number of drugs in excess of that which is clinically indicated”(6).The study shows that polypharmacy is unavoidable in elderly patients, so it is important to assess and evaluate drugs use patterns in older adults that are at high risk of potential consequences of polypharmacy. A poor response to treatment causes prompt physician to prescribe more than one medications to enhance the clinical effects. The relatively high proportion of poly pharmacy gives an advantage over monotherapy, in terms of safety and efficacy, is a matter of debate. This study has not confirmed any clinical benefits resulting from treatment with combination of more than 5 drugs. The safety of poly pharmacy may increase the risk of metabolic syndrome and other adverse and side effects. Furthermore the patients treated with poly pharmacy has higher risks of drug-drug interactions .Poly pharmacy causes a rise in cost of therapy per day (7).

To improve the knowledge of medication prescribing and utilization that is clinically associated with polypharmacy in community and hospitalized patients.

Most desirable approach for measuring and monitoring drug uses to evaluate the prescribing patterns, to monitor and improve prescribing patterns in order to make medical care more rational and cost effective(8).

Furthermore knowledge of the most frequent features of patients with a high risk of exposure to poly pharmacy can help practitioners to avoid the potentially harmful effects of these prescriptions. In addition an improved understanding of medication patterns among older adults may assist health care providers in providing optimal care to patients(9).

Although polypharmacy may be unavoidable in the elderly if disease and comorbidities are to be treated appropriately, it is important to assess drug and nutritional supplement products use patterns in an older adult population at risk of the potential consequences. We carried out this study with the following objectives:

To estimate the prevalence of polypharmacy and nutritional supplement use; To identify factors associated with exposure to polypharmacy (10).

The study of prescribing patterns seeks to evaluate, monitor, and improve prescribing patterns in order to make medical care more rational and cost-effective. Furthermore, knowledge of the most frequent characteristics of patients with a high risk of exposure to poly pharmacy can help practitioners to avoid the potentially harmful effects of these prescriptions (11).

The prescribing of medicines is rapidly increasing in all aging populations where evidence based guidelines are encouraging more prescribing of preventive treatments. However with increasing co- morbidity, clinical decision making is more difficult because positions and patients both struggle to balance the benefits and risks of multiple recommended treatments. Mostly prescribers that are involved in extra care of a patient there exist greater prevalence of inappropriate prescribing. Clinical interventions to avoid poly pharmacy, such as pharmaceutical care may result in significant improvement(12).

LITERATURE REVIEW:

i) Howard M. Fillit, MD; Robert Futterman, Lawrence Sunbow, MD; Gloria P. Picariello, RN; Eileen C. Scheye, MBA; Randall K. Spoeri, PhD and John L. Roglieri, MD had examine the effects of medication reviews by primary care physicians on prescriptions written for elderly members of a Medicare managed care organizations that were at risk for polypharmacy. Study Design was Prospective study .they have screened 37,372 elderly members, 5737 (15%) were at risk for polypharmacy. Of these 2615 (46%) responded to the follow-up survey. Of the survey respondents, 1087 (42%) had gone to their primary care physician for a medication review. During the review, 96% of patients discussed their prescription medications and 72% discussed nonprescription medications they were taking. Twenty percent reported that their physician discontinued medications, 29% reported that the physician changed the dose of a medication, and 17% informed their physician about a new prescription or nonprescription medication (12). ii) Robert J. Constantine, PhD; Timothy Boaz, PhD; and Rajiv Tan don, MD had reviewedOver the past decade, antipsychotic polypharmacy has increased markedly in the United States among adult patients with schizophrenia and related disorders. Although varying definitions and methodologies make comparisons difficult, antipsychotic polypharmacy has been reported in 25% to 50% of adults with schizophrenia in inpatient settings and in 5% to 25% of patients in ambulatory settings. Increased expectations for recovery and the belief that second generation antipsychotics are better tolerated may have helped to stimulate prescribing of ≥2 concurrent antipsychotic medications. However, unclear benefits, heightened concerns about excessive dosing, an increased risk for metabolic abnormalities, and other adverse effects have necessitated a closer look at the practice (13). iii) Rhita Bennis Nechba , Moncif El M'barki Kadiri , Mounia Bennani-Ziatni, Amine Ali Zeggwagh had reported the pharmacological treatment of older adults with cognitive impairment represents a challenge for prescribing physicians, and polypharmacy is common in these complex patients. The aim of the current study is to assess prevalence and factors related to polypharmacy in a sample of nursing home (nursing home) residents with advanced cognitive impairment.Polypharmacy status was categorized into three groups: non polypharmacy (zero to four drugs), polypharmacy (five to nine drugs), and excessive polypharmacy (more than10 drugs). Polypharmacy was observed in 735 residents (50.7%) and excessive polypharmacy wasSeen in 245 (16.9% (14).

IV) John D. Gilbert a, Ian F. Musgrave b, Claire Hoban b, Roger W. Bard had studied short treatment for irritable bowel with the following herbs: Astragals propinquus, Codonopsis pilosula, Peoria sp., Atractylodes microcephaly, Pueraria sp., Poria cocoa, Dioscorea opposita, Patronize, Psoralea corylifolia, Alpine katsumadai, Glycyrrhizin uralensis and Dolomite solei sp. a 43-year- old woman developed acute severe liver failure requiring liver transplantation. Histo pathological examination of the liver showed massive hepatic necrosis in keeping with drug/chemical toxicity. While numerous studies have evaluated the effect of polypharmacy. As this case demonstrates that fulminant hepatic failure and death may be caused by the concomitant use of a number of herbal products, the possibility of untoward effects from herbal polypharmacy must be increasingly considered in the evaluation of medico legal cases(15).

v) S.H. Zyoud ,A.B. Abd-Alhafez, A.O. Hussein , I.S. Abu-Shehab, S.W. Al-Jabi andW.M. Sweileh. They have aimed to estimate the prevalence of polypharmacy, polyherbacy and nutritional supplement use and to determine the factors affecting polypharmacy in geriatric patients. A prospective cross-sectional study of a group of hospitalized patients was carried out at Al- Wattani governmental hospital, Nablus, Palestine. Participant demographics and information about the current use of prescribed medications, herbal products and nutritional supplements were collected. The prevalence of polypharmacy (patients who take >5 medications) at hospital discharge was 51%. Eighty participants (26.7%) reported taking two or more herbal products (polyherbacy). Thirty-six participants (12.1%) reported taking two or more vitamins/mineral supplements. About half of elderly patients are exposed to polypharmacy at Al-Watani hospital. Also, a portion of geriatrics used herbal product and nutritional supplements. The factors that were associated with patient’s exposure to polypharmacy were: living with family, diabetes mellitus, heart failure, general weakness, and joint pain. Interventions to reduce the high-level polypharmacy in the elderly during their stay in a government hospital in Palestine should focus more on patients with diabetes mellitus, heart failure, and joint pain (2). vi) Syed Imran Haider, ZahidAnsari, Loretta Vaughan, Helen Matters and Eric EmersonThis study fills a void in research in polypharmacy and associated factors, and provides a high quality and reliable data for planning service delivery in both the health and disability services; has direct application to evidence-based policy development and strategic planning across the government departments, disability service providers, health service providers and the wider community; and informs policy development and medication safety and quality activities. Some population groups with ID may be exposed to higher levels of adverse effects of medicines, while at the same time having impaired capacity to protect themselves from the harmful effects of these medicines (16).vii) Jan Jaracz, Edyta Tetera-Rudnick, Dominika Kujath, Agnieszka Raczyn´ ska, Sebastian Stoszek Wojciech Czernas, Piotr Wierzbinski f, Adam Moniakowski g, Krystyna Jaracz and Janusz Rybakowski have studied the concurrent use of two or more antipsychotic drugs in schizophrenia. The aim of this study was to investigate the range of APP in schizophrenic patients discharged from psychiatric units in Poland, and to determine its demographical and clinical correlates. Data on the pharmacological treatment of 207 patients with a diagnosis of schizophrenia, discharged from six psychiatric hospitals from September–December 2011 were recorded by experienced psychiatrists. Clinical and demographical information was obtained on each patient. The severity of symptoms at admission, and their improvement during hospitalization were assessed using the Clinical Global Impression Scale. Results: At discharge, 52.7% of the patients were prescribed one, 42.5% two and 4.8% three antipsychotic drugs (AP). When two AP were applied, it was usually a combination of two second generation antipsychotics (SGA) (46%), or of both first generation antipsychotics (FGA) and SGA (48%). The SGA’s olanzapine and risperidone were those most commonly prescribed. Patients treated with two or more AP had a higher number of previous hospitalizations than patients receiving antipsychotic monotherapy. Mood stabilizers were prescribed for nearly one third of the patients, while antidepressants and benzodiazepines were prescribed for fewer than 10%. Conclusions: The prevalence of polypharmacy in Poland is similar to that reported in other countries (17).

viii) Alessandra Iurlo, Anna Ubertis, Silvia Artuso, Cristina Bucelli, Tommaso Radice, Manuela Zappa, Daniele Cattaneo, Daniela Mari and Agostino Cortelezzi have studied that Older patients’ comorbidity and polypharmacy can significantly influence the success of the treatment, as well as the cognitive and psycho-social aspects. A significant proportion of chronic myeloid leukemia (CML) patients are “elderly”: in the past the aim of therapy in this subset of patients was only to contain the leukemic mass, but nowadays, with the advent of the protein-tyrosine kinase inhibitors, also elderly patients can access these treatments. We want to assess if even old CML patients, with a correct geriatric evaluation, can be successfully treated with protein-tyrosine kinase inhibitors(18). ix) Davide L. Vetranoa, Matteo Tosatoa, Giuseppe Colloca, Eva Topinkova,Daniela Fialova,Jacob Gindin, Henri€ette G. van der Roest, Francesco Landia, Rosa LiperotiRoberto Bernabei andGraziano Onder Conducted a cross-sectional analysis of 1449 nursing home residents with advancedCognitive impairment participating to the Services and Health for Elderly in Long Term Care(SHELTER) project, a study collecting information on residents admitted to 57 nursing home in eight countries. Polypharmacy status was categorized into three groups: non polypharmacy(Zero to four drugs), polypharmacy (five to nine drugs), and excessive polypharmacy was observed in 735 residents (50.7%) and excessive polypharmacy was seen in 245 (16.9%). Compared with non polypharmacy, excessive polypharmacy was associated directly with ischemic heart disease. Polypharmacy and excessive polypharmacy are common among nursing home residents with advanced cognitive impairment. Determinants of polypharmacy status include not only comorbidities, but also specific symptoms, age, and functional status (19).x) Howard M. Fillit, MD; Robert Futterman, PhD; Burton I. Orland, RPh; Terrence Chim, RPh; Lawrence Susnow, MD; Gloria P. Picariello, RN; Eileen C. Scheye, MBA; Randall K. Spoeri, PhD; John L. Roglieri, MD; and Samuel W. Warburton, MD. We conducted a study to demonstrate the prevalence of polypharmacy (defined as receiving 5 or more prescription medications during the 3-month study period) among Elderly members of our managed care organization. Two years later, elderly members identified as being at risk for polypharmacy were sent a letter encouraging them to schedule a medication review with their primary care physician. Each primary care physician was provided with clinical practice guidelines on polypharmacy and patient-specific medication management reports. Patients and physicians were subsequently mailed a survey to assess the impact of the medication review program on prescribing practices. During the review, 96% of patients discussed their prescription medications and 72% discussed nonprescription medications they were taking. Twenty percent reported that their physician discontinued medications, 29% reported that the physician changed the dose of a medication, and 17% informed their physician about a new prescription or nonprescription medication they were taking (20).

Study design:

This was the retrospective and cross sectional study involved 100 prescriptions that were collected from hospitalized and community patients of Lahore and Faisalabad regions.

Sample size:

The assuming average number of prescriptions that were collected from community and hospitalized patients of Lahore and Faisalabad regions is 100 prescriptions. This number was used as a guide to calculate sample size needed for this study. A convenience sample of 100 prescriptions’ was collected between September and October 2014.

Sample technique:

First of all, a sampling frame was prepared and then with simple random technique sample of 100 prescriptions was selected including both community and hospitalized patients.

Inclusion and exclusion criteria:

The inclusion criteria for patients were:

Hospitalized and community patients aged 30 to 70 years old, willing to participate in the study.

Patients who were (>30 or <70) years old excluded from the study.

Operational definitions:

For the purpose of the study, certain operational terms were defined poly pharmacy was defined as the use of multiple medications by a patient, generally older adults (those aged over 65 years).More specifically, it is often defined as the use of five or more regular medications. Medication was defined as any substance used for treatment or prevention of disease.

Methodology:

The retrospective cross sectional study was conducted among the community and hospitalized patients. For this purpose 100 prescriptions were collected including both community and hospitalized patients. Data was collected through quantitative and statistical analysis.

Then calculate the percentage prevalence of polypharmacy, percentage usage of antibiotics, percentage prevalence of nutritional supplements, and percentage of drug-drug interactions in all prescriptions.

Separately calculate the percentage of prescriptions of male and female patients and calculate

The average cost of prescription per day among the community and hospitalized patients to evaluate the pharmacoeconomics.

RESULTS:

TOTAL NO: OF PRESCRIPTIONS TAKEN IN STUDY WERE 100.

1) NO: OF MALE AND FEMALE PATIENTS IN DIFFERENT AGE GROUPS: (TABLE:1)

Age limits No: of patients No: of female patients No: of male patients30-34 9 4 535-38 16 8 839-42 12 5 743-46 18 8 1047-50 20 9 11 51-54 6 2 455-58 4 1 359-62 5 2 3

63-66 2 1 1

67-70 8 3 5

TOTAL 100 43 57

% OF MALE PATIENTS

57%

% OF FEMALE PATIENTS

43%

% OF MALE AND FEMALE PATIENTS

2) % of the antibiotic classes used in all age limits :

(TABLE: 2)

AGE LIMITS NAME OF ANTIBIOTICS ANTIBIOTIC CLASS30-34 VIBRAMYCIN Tetracycline

CEFIXIME 3rd generation cephalosporin

LEVOFLOXCACINE 2nd generation flouroquinolone

CLINDAMYCINE Lincomycin classSULFAMETHOXAZOL Protein synthesis

inhibitorTRIMETHOPRIM Protein synthesis

inhibitorAZITHROMYCINE Macrolide METRONIDAZOL ANTIPROTOZOAL

35-38 CEFUROXIME 2nd generation cephalosporin

METRONIDAZOL ANTIPROTOZOALCIPROFLOXACINE 2nd generation

flouroquinolone

LEVOFLOXACINE 3rd generation flouroquinolone

TOBRAMYCIN penicillin antibioticMOXIFLOXACINE 4th generation

cephalosporinCEFTRIAXONE 3rd generation

cephalosporinAMOXICILLINE penicillin antibioticCEFIXIME 3rd generation

cephalosporinMETRONIDAZOL antiprotozoal

39-42 CEFTRIAXONE 3rd generation cephalosporin

AMOXICILLINE penicillin antibioticMETRONIDAZOL ANTIPROTOZOAL

43-46 AMOXICILLINE penicillin antibioticOFLOXACINE 2nd generation

flouroquinoloneCIPROFLOXACINE 2nd generation

flouroquinoloneMETRONIDAZOL antiprotozoalCLARITHROMYCINE MacrolideCEFACLOR 2nd generation

cephalosporin47-50 CEFTRIAXONE 3rd generation

cephalosporinFLAGYL METRONIDAZOLCEFUROXIME 2nd generation

cephalosporinMETRONIDAZOL antiprotozoal

51-54 CIPROFLOXACINE 2nd generation flouroquinolone

METRONIDAZOL ANTIPROTOZOALAMOXICILLINE penicillin antibioticCEFTRIAXONE 3rd generation

cephalosporin

3) % of the antibiotic classes used in all age limits:

% OF ANTIBIOTICS USED IN AGE LIMITS

CEPHALOSPORINS (32%)

METRONIDAZOL (23%)

FLOUROQUINOLONES (18%)

PENICILLINS (15%)

FOLIC ACID SYNTHESIS INHIBITOR (5%)

TETRACYCLINES (2%)

4)Names of the supplements used in patients:

(TABLE: 3)

Sr no:

Name of supplement Active ingredients1 VITAMIN K1 Phytonadione2 FEFOL FOLIC ACID+CALCIUM3 alpha keto acid Histidine, L-Tyrosine, L-lysine, nitrogen & calcium.

4 Surbex-z Nicotinamide:100mg, Riboflavin (Vitamin B2):15mg, Thiamine HCl (Vitamin B1):15mg, Tocopherol (Vitamin E):30IU, Zinc Oxide:22.5mg, Ascorbic Acid:500mg,Cyanocobalamin:12mcg, Folic Acid:150mcg, Pyridoxine:20mg]

5 Polybion-z Nicotinamide:50mg, Riboflavin (Vitamin B2):15mg, Thiamine HCl (Vitamin B1):15mg, Ascorbic Acid:300mg,Cyanocobalamin:10mcg,Pyridoxine:10mg

6 INDROP-D VITAMIN D

7 Iberet folic Ferrous Sulphate:525mg,Nicotinamide:30mg, Riboflavin (Vitamin B2):6mg, Thiamine HCl (Vitamin B1):6mg, Ascorbic Acid:500mg, Calcium Pantothenate:10mg,Cyanocobalamin:25mcg, Folic Acid:0.8mg, Pyridoxine:5mg

8 Maltofer syrup Iron Hydroxide Poly Maltose Complex:50mg/5ml9 Osteo d Alfacalcidol 0.5mg10 Avemar Silicon dioxide, maltodextrin,fructose,sodium chloride11 Myfol Folic acid12 Ferfix-F Folic Acid:0.35mg, Iron Hydroxide Poly Maltose

Complex:100mg13 Divasas Nicotinic Acid:20mg, Retinol (Vitamin A):5000IU, Riboflavin

(Vitamin B2):1.7mg, Thiamine HCl (VitaminB1):1.5mg, Tocopherol (Vitamin E):30mg, Ascorbic Acid:60mg, Calciferol:400IU,Cyanocobalamin:6mcg, Iron Salts:18mg, Iodine:150mcg,Magnesium Oxides and Hydroxides:100mg,Pyridoxine:2mg,

14 QALSAN -D Calcium Carbonate:1250mg, Cholecalciferol:125IU15 Bevidox Thiamine HCl (Vitamin

B1):100mg/3ml,Cyanocobalamin:1000mcg/3ml,Pyridoxine:100mg/3ml]

16 cremafinn Paraffin:1.25ml/5ml, Magnesium Oxides and Hydroxides:3.5ml/5m

17 Sangbion Manganese:0.2mg,Cyanocobalamin:7.5mcg, Folic Acid:1mg, Copper:0.2mg

18 CAL-C Calcium Lactate, Ascorbic Acid:, Calcium Carbonate:19 Trihemic Tocopherol (Vitamin E):30IU,Ascorbic

Acid:600mg,Cyanocobalamin:25mcg, Folic Acid:1mg, Ferrous Fumarate:350mg

5) % prevalence of nutritional supplements:

% prevalence of nutritional supplements

% of patients using supplements

% of patients not using supplements

7)% of prescriptions with and without supplements:

% OF PRESCRIPTIONS WITH AND WITHOUT SUPPLEMENTS

PRESCRIPTIONS WITHOUT SUPPLEMENTS(81%)

PRESCRIPTIONS WITH SUPPLEMENTS(19%)

8) % of drug-drug interactions in prescriptions:

17%

83%

% OF DRUG-DRUG INTERACTIONS IN PRESCRIPTIONS

PRESCRIPTIONS WITH D-D INTERACTIONS(17%)

PRESCRIPTIONS WITHOUT D-D INTERACTIONS(83%)

9) % OF INTERACTIONS OF DIFFERENT PHARMACOLOGICAL CLASSES:

% OF INTERACTIONS OF DIFFERENT PHARMACOLOGICAL CLASSES

NSAIDs(34%)

ANTIHYPERTENSIVE(34%)

ANTIBIOTICS(10)

ANTIFUNGALS(8%)

ANTIDIABETICS(8%)

SUPPLEMENTS(5%)

OTHERS(1%)

Drug-Drug INTERACTIONS: (TABLE: 4)

ALL OF THE DRUG-DRUG INTERACTIONS ARE ASSESSED FROM TEXTBOOK

DRUG INTERACTION FACTS 2009: THE AUTHORITY ON DRUG INTERACTIONS BY DAVID S. TATRO , PUBLISHED JULY 1ST 2008 BY LIPPINCOTT WILLIAMS & WILKINS.

Sr no

Drug - Drug interaction mechanism Significance level

Out put Management

1 Ciprofloxacin +calcium supplements

GI absorption of QUINOLONES may be decreased.

2 Decreased pharmacologic effects of QUINOLONES

Concurrent use cannot be avoided.

2 aspirin+ glimepiridine Aspirin reduces basal glucose levels and (↑es) insulin secretion also inhibition of prostaglandin synthesis may inhibit insulin responses to glucose.

2 ↑es hypoglycemic effect

Monitor the patient's blood glucose. If hypoglycemia develops, consider decreasing the SULFONYLUREA dose

3 ASPIRIN+DICLOFENAC SODIUM

Competitive inhibition of the acetylation site of cyclooxygenase in the platelet.

1 ↓es cadioprotectivity and ↑es gastric irritation via aspirin

SELECT analgesics that do not interfere with antiplatelet effect (eg, acetaminophen).

4 NORTRIPTYLINE+LEVOFLOXACIN

MECHANISM IS UNKNOWN

1 may (↑es) torsades de pointes

Other quinolone antibiotics that do not prolong the QTc interval (USED)

5 ASPIRIN+PROPRANOLOL SALICYLATES may inhibit biosynthesis of prostaglandins involved in the antihypertensive activity

2may (↓es) activity of propranolol

Monitor BP. If an interaction is suspected, consider lowering the dose of the SALICYLATE

6 FLUCONAZOL+STEROIDS Inhibition of CORTICOSTEROID metabolism (CYP3A4) and decrease in elimination.

2 may ↑es toxicity of steroids

Closely monitor patients for CORTICOSTEROID adverse effects. Adjust dose as needed

7 LOSARTAN+FLUCONAZOL

inhibition of metabolism (CYP2C9) of LOSARTAN by FLUCONAZOLE

3 may ↑es antihypertensive effects

Closely monitor blood pressure response to LOSARTAN when FLUCONAZOLE is started, stopped, or changed in dosage

8 METHOTREXATE+MEFENAMIC ACID

Reduced renal clearance is suspected.

1 may ↑es MTX toxicity

Monitor for renal impairment that could predispose to MTX toxicity

9 ASPIRIN+PROPRANOLOL SALICYLATES may inhibit biosynthesis of prostaglandins involved in the antihypertensive activity

2 may (↓es) activity of propranolol

Monitor BP. If an interaction is suspected, consider lowering the dose of the SALICYLATE

10 piroxicam and NSAIDs and 3 ↑es risk of gastric Use caution when co-

acetaminophen with (ALENDRONATE)

BISPHOSPHONATES may be synergistic with respect to causing gastric ulcers.

ulceration administering these agents

11 OMEPRAZOL+CYANOCOBALMIN

OMEPRAZOLE-induced hypo hydria or achlorhydria may decrease the absorption of vitamin B12.

5 MAY (↓es)therapeutic action of VITAMIN B12

If both drugs are to be given chronically, consider administering VITAMIN B12 parenteraly.

12 ASPIRIN+OMEPRAZOL (PPI) may increase in gastric pH results in a more rapid dissolution and release of SALICYLATE.

3 may (↑es)gastric side effects

Patients at risk of serious gastric disorders due to the release of SALICYLATES in the stomach should avoid concurrent use of these agents.

13Aspirin+captopril

DUE TO Inhibition of prostaglandin synthesis

MAY (↓es)hypotensive and vasodilator effects of the ACE INHIBITOR

Adjust ASPIRIN dosage to less than 100 mg/day; convert to non-aspirin antiplatelet agent; or continue ASPIRIN and convert patient from ACE INHIBITOR to angiotensin-receptor blocker.

14 Aspirin+insulin The serum glucose-lowering action of INSULIN may be potentiated.

2 acute INSULIN response to a glucose load is enhanced

Monitor blood glucose concentrations and tailor the INSULIN regimen as needed.

15 ASPIRIN+RINGER LACTATE

Urine alkalization leads to increased renal clearance and reduced serum levels of SALICYLATES

3 Renal clearance of SALICYLATES increases dramatically above urine pH 7.

The patient receiving concurrent URINARY ALKALINIZER and anti-inflammatory SALICYLATE therapy may require higher than expected SALICYLATE doses

16 CLARITHROMYCIN+OMEPRAZOL

CLARITHROMYCIN may inhibit the metabolism (cytochrome P450 3A4 and 2C19) of OMEPRAZOLE,

3 MAY(↑es) concentrations of CLARITHROMYCIN and OMEPRAZOLE

no special action is needed. Co -administration of these agents may be beneficial in the treatment of Helicobacter pylori

17 ATENOLOL+AMINOPHYLINE

Pharmacologic antagonism. BETA-BLOCKERS may reduce demethylation of THEOPHYLLINE.

2 MAY (↓es) elimination of THEOPHYLLINE

Monitor plasma THEOPHYLLINE levels when a BETA-BLOCKER is added or deleted from a regimen

10) Average Cost of 100 prescriptions = 17468/100 = 174.70

AVERAGE COST/PRESCRIPTION/DAY = 174.70

11) AVERAGE NO: OF DRUGS PRESCRIBED= 420/100 = 4.20

12) % OF PRESCRIPTIONS:

% OF TYPES OF PRESCRIPTIONS:

COMMUNITY PHARMACY PRESCRIPTIONS(75%)

HOSPITAL ADMITTED PRESCRIPTIONS(25%)

13) Prevalence of polypharmacy:

% prevalence of polypharmacy

(patients who take ≥5 medications) 40%

(patients who take <5 medications): 60%

Discussion:THE estimates of the prevalence of polypharmacy vary, often because of the differences in definitions of the number of medications that must be taken to constitute poly pharmacy. This study estimates the prevalence of poly pharmacy, drug-drug interactions and nutritional supplements. The current study showed that the percentage of patients who were taking five or more than five medications was 40 percent, the risk of inappropriate use of antibiotics, supplements and other medicines in community living and hospitalized patients has been described and analyzed in drug-drug interactions.

All of our study findings indicate that hospitalization did not lead to a reduction in the number of drugs taken .In contrast; it led to an increase in the prevalence of poly pharmacy. This suggests that most disorders effecting elderly people are a chronic and need sable therapy. In addition, hospitalization leads to new diseases diagnosis that requires further drugs or more new and complex therapy.

According to our results NSAIDs and antihypertensive were the most commonly used medications. In this study, the factors that were significantly associated with patient’s exposure to poly pharmacy were diabetes mellitus, hypertension, general weakness and joint pains. There are many clinical factors associated with polypharmacy in the elderly, some diseases such as hypertension, diabetes mellitus and diseases associated with pain were significantly co related with poly pharmacy.

One of the purposes of the current study was to analyze the prevalence of nutritional supplements use in all age limits. The major strength of the study is that it is the first one in Lahore that presents data on the prevalence of poly pharmacy and nutritional supplements used among hospitalized and community elderly patients. Therefore the results of this study will be important in the optimization of health care practices.

Over all, this study was subject to a few limitations. Firstly, our results may not be generalized to the entire population of Lahore. Additionally, it was difficult to track certain relationships with poly pharmacy. For example adverse drug reactions and non-adherence.

Furthermore the study was not designed to evaluate the appropriateness of the drug therapy or any adverse clinical outcomes resulting from polypharmcay.

Conclusions and recommendations:

About 40% patients were exposed to polypharmacy in community and hospitalized patients.

The calculated percentage of drug-drug interaction is 17%.

The percentage prevalence of nutritional supplements is 19%.

REFERENCES:

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