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Importância de Reações Adversas a Medicamentos (RAM)

• 2 milhões de RAM anualmente nos EUA

• Cem mil mortes por ano

• Quarta causa de morte nos EUA (na frente de doenças pulmonares, diabetes, AIDS, acidentes automobilísticos

• RAM ambulatorial – incidência não estimada

• RAM em clínicas para idosos – 350 mil por ano

Custos associados a RAM

• 136 bilhões de US$ anualmente

• Maior do que custos com moléstias cardiovasculares ou tratamento de diabetes

• RAM responsável por 20% de danos ou mortes por ano em pacientes hospitalizados

• Custo hospitalar o dobro em relação a demais pacientes

Por que há tantos RAM?

• Dois terços de consultas médicas geram uma receita

• 2.8 bilhões de receitas no ano 2000 (10 por habitante dos EUA)

• RAM aumenta exponencialmente com 4 ou mais medicações

Interações Medicamentosas

• Representam 3-5% das internações de RAM que podem ser evitadas

• Importante causa no número de atendimentos ambulatórios

Por que há tantos RAM?

• Dois terços de consultas médicas geram uma receita

• 2.8 bilhões de receitas no ano 2000 (10 por habitante dos EUA)

• RAM aumenta exponencialmente com 4 ou mais medicações

Reported serious events vs outpatient prescriptions, 1998-2005.

Serious Adverse Drug Events Reported to the Food and Drug Administration, 1998-2005 - ARCH INTERN MED/VOL 167 (NO. 16), SEP 10, 2007

Estados Unidos - Idosos

Date: From: ######## ########## <############@yahoo.com.br> Subject: Parkinson - Unicamp To: [email protected]

Olá Professor, Meu nome é ########, sou alun ################ da Unicamp e fui alun do senhor.Há pouco tempo, falei com o senhor sobre minha avó de 81 anos que está usando alguns medicamentos para Parkinson entre outros.O senhor pediu para eu procurar saber a quanto tempo ela está usando tais medicamentos e dessa forma estou enviando os dados:* Mantidan (Cloridrato de amantadina): 100mg 9:00hs + 100mg 17:00hs ------4 anos de uso* Betaserc (Dicloridrato de betaistina): 16mg de manhã + 16mg no jantar -------4,5 anos de uso* Pantoprazol: 20mg de manhã -------- mais de 3 anos de uso. Começou a usar devido ao efeito colateral de um medicamento (não sei o nome) que ela tomava para osteoporose. Hoje em dia, ela usa "Evista" para osteoporose.* Evista (Cloridrato de raloxifeno): 60mg no jantar ------- 3 anos de uso* Assert (Cloridrato de sertralina): 50mg no almoço -------- 4 anos de usoDevido aos efeitos colaterais (psicoses) do Mantidan, ela passou a usar:* Haldol (haloperidol-2mg/ml): 8 gotas à noite ------- 2,5 semanas de uso* Risperidon (Risperidona): 1mg de manhã -------- 1,5 semana de uso

Creatinine clearance and drug prescriptions for the elderly. A study of 419 patients older than 70 years admitted through the emergency department

Viallon A, Guyomarch P, Marjollet O, Belin M, Robert F, Berger C, Guyomarch S, Bertrand JC.Service d'Urgence et de Reanimation, Hopital Bellevue, Saint-Etienne. [email protected]

INTRODUCTION: The incidence of drug-related adverse events increases with age. In approximately 20% of cases, these events necessitate hospitalization. By taking into account the physiological changes associated with aging when prescribing drugs, physicians can prevent some of these events. The objective of this study was to analyze the prescriptions written by general practitioners for elderly patients admitted to the emergency department in relation to the patient's creatinine clearance. PATIENTS AND METHODS: Of 968 consecutive patients older than 70 years, 419 underwent a plasma creatinine assay on admission and were included in this study. Creatinine clearance was calculated with Cockcroft's formula. The patients were classified into two groups according to creatinine clearance:<30 mL/min (group I) and >or=30 mL/min (group II). RESULTS: Creatinine clearance was<30 mL/min in 84 of the 419 patients (group I) and >or=30 mL/min in 335 (group II). Mean age was significantly higher in group I than in group II (87 +/- 6 vs 81 +/- 6 years, p<0.001), as was mean plasma creatinine concentration (113 +/- 23 vs 83 +/- 19 mmol/L, p<0.001), while mean weight was significantly lower (57 +/- 10 vs 69 +/- 13 kg, p<0.001. In group I, 82 drugs with precautions concerning renal function had been prescribed for 69 (82%) patients, and in group II, 331 such drugs for 174

(52%) patients. Of the 82 drugs prescribed in group I that required precaution, 47 (57%) were contraindicated or prescribed at an inappropriate dose in view of the creatinine clearance. Irrespective of pharmacokinetic parameters, the mean number of drugs taken per patient was 5 +/- 2 in group I and 6 +/-2 in group II. CONCLUSION: In prescribing drugs for elderly patients, especially those whose weight is low, careful attention should be paid to renal function.

Antiretroviral Drug Dosing Errors in HIV-InfectedPatients Undergoing Hemodialysis

Jérôme Tourret, Isabelle Tostivint,1 Sophie Tézenas Du Montcel,2 Svetlana Karie,1 Vincent Launay-Vacher,1 Cécile Vigneau,3 Christel Bessette,1 Gilbert Deray,1 and Corinne Isnard Bagnis1 Nephrology and 2Biostatistics Departments, Groupe Hospitalier Pitié-Salpêtrière, and 3Nephrology Department, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, and 4INSERM U722, Université Paris 7 Denis Diderot, Site Xavier Bichat, Paris, France

Clinical Infectious Diseases 2007; 45:779–84


• Background. Several studies have revealed the frequency of antiretroviral (ARV) drug prescription errors. We nalyzed highly active antiretroviral therapy (HAART) prescribing practices for human immunodeficiency virus (HIV)–infected patients undergoing hemodialysis in France.


• Methods. Prescribed ARV drug doses in our cohort (consisting of all HIV-infected patients who underwent hemodialysis from 1 January 2002 and were prospectively followed up until 1 January 2004) were compared with the recommended doses for patients undergoing hemodialysis. The log-rank test was used to compare the outcomes among different groups of treated patients.


• Results. One hundred seven of the 129 patients in our cohort received a total of 317 ARV drugs, 59% of which were improperly prescribed.


• The dosing was too low for 18% of the patients and too high for 39% of the patients. Twenty-eight patients (26%) did not receive any of their ARV drugs at the recommended dose.


• Among the patients who received HAART, those who were prescribed an insufficient dose of a PI were not statistically distinguishable from the others in terms of age, sex, ethnicity, diabetic comorbidity, HIVassociated nephropathy diagnosis, hepatitis B virus and/or hepatitis C virus coinfections, duration of dialysis, and duration of HIV infection.


1.00

0.75

0.50

0.25

0.000 6 12 18 24

Time, months

Pro

port

ion

of p

atie

nts

w

ho

surv

ived Underprescribed PI

No underprescribed PI

No. Of patients at riskUnderprescribed PI 30 28 24 23 23No underprescribed PI 66 66 63 62 60

Antiretroviral Drug Dosing Errors in HIV-Infected Patients Undergoing Hemodialysis - HIV/AIDS • CID 2007:45 (15 September)


• For dialyzable ARV drugs, the delay between ARV drug receipt by the patients and dialysis sessions was not respected in 9% of cases, and in 73% of cases, it was not known whether the patients took the ARV drugs before or after dialysis sessions.

Inappropriate prescribing in an older ED population

• Fredric M. Hustey MD*, Nicole Wallis MD, Jonathan Miller MD

Department of Emergency Medicine, Cleveland Clinic, Cleveland, OH 44195, USA

Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH 44195, USA

Department of Emergency Medicine, MetroHealth Medica

• American Journal of Emergency Medicine (2007) 25, 804–807


• The objective of this study was to determine the prevalence of potentially inappropriate medication (PIMs) use in older emergency department (ED) patients based on the updated 2002 Beers criteria. This was a retrospective analysis of 352 consecutive ED visits by patients aged 65 years and older. The mean number of medications taken was 8.4 per patient. In the study population, 111 (32%; 95% confidence interval [CI], 27-36) of 352 patients were taking at least 1 PIM at ED presentation.


• Among 101 of 193 patients discharged home from the ED with a new prescription, 13 (13%; 95% CI, 6-19) were also given PIMs.

Inappropriate prescribing in the elderly

• Journal of Clinical Pharmacy and Therapeutics (2007) 32, 113–121

Inappropriate prescribing in the elderly

• Prescription of potentially inappropriate medications to older people is highly prevalent in the United States and Europe, ranging from 12% in community-dwelling elderly to 40% in nursing home residents.

Incorrect use of orlistat and sibutramine in clinical practice

• To investigate how the antiobesity drugs orlistat and sibutramin are prescribed in relation to the approved indications and the Swedish subsidiary rules.

Eur J Clin Pharmacol (2007) 63:205–209


• Methods - Anonymous survey to prescribers of a random sample of 2000 out of 20,000 prescription of orlistat and sibutramin.


• Results - The response rate was around 65%. About half of the patients were not treated in accordance with the approved indications and a fourth of the patients prescribed sibutramin had one or several contraindications to the drug. The subsidiary rules were not followed in the majority of cases.


• Conclusion - Deviation from the approved indications and subsidiary criteria of orlistat and

sibutramin is a question of waste of medical and economic resources. Prescribing of sibutramin to patients with contraindications is a serious health hazard.

At 04:59 PM 1/1/2008, you wrote: Minha avó tem 72 anos, tem diabetes mellitus tipo 2 há aproximadamente quatro anos.Atualmente, tal doença está controlada, sendo os níveis glicêmicos da minha avó normais (ela submete-se a controle periódico mensal). Não apresenta distúrbios hepáticos ou renais. Ela tem um histórico de depressão e, há alguns anos, teve um episódio de “relatar” certas histórias que, com o tempo, mostraram-se inverídicas. Nesta época, ela fazia um tratamento para emagrecer, e tomava fórmulas manipuladas pelo seu médico. Após certa resistência, ela concordou em ir a um psiquiatra, que lhe comunicou serem tais fórmulas as causadoras de sua “confusão” mental. Descontinuou o seu uso, administrando drogas desintoxicantes. Após esse tratamento com o psiquiatra, não houve mais problemas.

Os medicamentos que ela toma: * Xenical (Orlistat) comprimido com 120 mg. Toma antes das refeições. Inibidor da lípase intestinal. * Fluoxetina (manipulada) - cápsula de 30 mg. Toma uma vez ao dia. * Vazy (cloridrato de sibutramina) comprimidos de 15 mg. Toma uma cápsula ao dia. * Oroxadin comprimidos de 100 mg. Toma um comprimido ao dia. * Caldê para osteoporose. * Cloridrato de metformina comrpimidos de 500 mg. Toma antes das refeições. * Miosan (cloridrato de ciclobenzaprina) comprimidos de 5 mg, uma vez ao dia. Tomou faz pouco tempo, porque apresentou dor nas costas. * norfloxacino 400mg. Tomou faz pouco tempo, pois apresentou cistite

Medication dosing errors in hospitalized patients with renal impairment: a study in Palestine

• Background and Aim Reduced renal function requires dose adjustment for certain drugs to avoid toxicity. The aim of this study was to determine whether appropriate dosage adjustments were made for drugs that are nephrotoxic, excreted, or metabolized (TEM medications) by the kidney in patients with renal impairment. Results A total of 78 patients had calculated creatinine clearance 59 ml/min. Those patients were prescribed a total of 1001 lines of prescription medication. Dosage adjustment was necessary for 193 TEM medications. Analysis of TEM medications with guidelines for adjustment indicated that 73.58% (142) were found to be inappropriate and 26.42% (51) were found to be appropriate.

• Pharmacoepidemiology and drug safety 2007; 16: 908–912

Medication dosing errors in hospitalized patients with renal impairment: a study in Palestine

• Conclusion In our study, a wide range of dosing errors was common among patients with renal impairment that was common during hospitalization. Continued medical education in the field of clinical pharmacokinetics is important for physicians.

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