Table 2.
Drug-related problems identified by clinical pharmacists
| Type of DRP | Identified problem | No. of DRPs (no. acted upon) | Drugs involved (frequency) |
|---|---|---|---|
| Adverse drug reaction (n = 11) | Anaemia, thrombocytopenia | 1 (1) | [Leflunomide, methotrexate] |
| Blurred vision | 1 (1) | [Paracetamol + codeine] | |
| Oedema | 1 (1) | Felodipine | |
| Heart failure | 1 (1) | Celecoxib | |
| Hypokalaemia | 1 (1) | [Candesartan + hydrochlorthiazide] | |
| Hyponatremia | 1 (1) | Enalapril | |
| Nausea and fatigue | 2 (2) | Digoxin (2) | |
| Reduced renal function | 1 (1) | Mesalazine | |
| Repeated urinary tract infections | 1 (1) | Saxagliptin | |
| Tremors | 1 (1) | [Formoterol, tiotropium bromide] | |
| Dosage too high (n = 12) | Dosage too high according to indication or guidelines | 12 (11) | Candesartan, cefotaxime, ciprofloxacin, digoxin, esomeprazole, folic acid (2), gabapentin, hydroxyzine, ipratropium, metformin, rivaroxaban |
| Dosage too low (n = 3) | Dosage too low according to indication or guidelines | 3 (3) | Budesonide inhaler, cefotaxime, pregabalin |
| Inappropriate drug (n = 39) | Allergy | 1 (1) | Flucloxacillin |
| Diagnoses | |||
| Asthma | 1 (0) | Metoprolol | |
| Arrhythmia | 4 (2) | [Bromhexine + ephedrine], SSRI, indacaterol, salmeterol | |
| Heart failure | 2 (2) | [Diclofenac + misoprostol], NSAID | |
| Drugs that should be avoided in the elderly | 14 (12) | Diazepam (2), flunitrazepam, flupentixol, hydroxyzine (2), propiomazine (3), [propiomazine, zolpidem], tramadol, zolpidem (2) | |
| Inappropriate analgesic drug | 1 (1) | Oxycodone (short acting) | |
| Inappropriate drug according to guidelines | 2 (1) | Dihydroergotamine, quinine | |
| Inappropriate drug according to renal function | 9 (8) | Acetylcysteine (effervescent tablets), atenolol, glibenclamide, glucose-Na–K, morphine, NSAID (4) | |
| Inappropriate drug according to treatment time | 1 (1) | Metoclopramide | |
| Inappropriate drug when opioid treated | 1 (1) | Sterculia | |
| Inappropriate formulation | 1 (1) | Paracetamol | |
| Several prescriptions of the same drug | 1 (1) | Carvedilol | |
| Wrong diagnosis | 1 (1) | B vitamins | |
| Ineffective drug (n = 1) | Low GFR | 1 (1) | Thiazide |
| Interaction (n = 21) | C interactions | 12 (11) | Esomeprazole-doxycycline |
| Levothyroxine-calcium + vitamin D (2) | |||
| Magnesium-iron | |||
| Methotrexate-phenoxymethylpencillin | |||
| NSAID-rivaroxaban | |||
| NSAID-ticagrelor (2) | |||
| SSRI-ASA | |||
| Ticagrelor-simvastatin | |||
| Warfarin-erythromycin | |||
| Warfarin-omega 3 | |||
| D interactions | 4 (3) | Ciprofloxacin-calcium + vitamin D | |
| Hydroxyzine-flecainide | |||
| SSRI-ciprofloxacin | |||
| Warfarin-ASA | |||
| C and D interaction | 1 (1) | Hydroxyzine-SSRI-omeprazole | |
| Unspecified | 4 (4) | Dabrafenib-fentanyl | |
| Dabrafenib-omeprazole | |||
| Warfarin-herbal remedy (2) | |||
| Monitoring needed (n = 4) | Laboratory value | ||
| CO2tot | 1 (1) | Acetazolamide | |
| General blood sample | 1 (1) | Several drugs | |
| HbA1c | 1 (1) | Repaglinide | |
| Thyroid status | 1 (1) | Levothyroxine | |
| Need additional drug therapy (n = 12) | Heart failure | 1 (0) | Spironolactone |
| Homocysteine elevated | 1 (1) | Folic acid | |
| Increased risk of obstipation | 4 (4) | Laxative, morphine without laxatives (3) | |
| Increased risk of ulcus | 3 (2) | [Bortezomib, clopidogrel and deltisone without PPI], [dalteparin and prednisolone without PPI], [prednisolone and warfarin without PPI] | |
| Myocardial infarction | 1 (1) | Enalapril | |
| PTH elevated | 1 (0) | Alfacalcidol | |
| S-ferritin low | 1 (1) | Iron | |
| Non-compliance (n = 10) | Handling problems—inhalation technique | 2 (1) | [Budesonide + formoterol, terbutaline], [fluticasone + salmeterol, tiotropium bromide] |
| Medication is not taken according to the medication list | 1 (1) | Several drugs | |
| Overuse compared to the prescription | 1 (1) | Formoterol | |
| The medicine is taken according to an old prescription | 1 (1) | Methotrexate | |
| Underuse compared with the prescription | 5 (5) | [Budesonide + formoterol, tiotropium bromide], [eplerenone, furosemide, lerkanidipine], [ipratropium, simvastatin], iron, ticagrelor | |
| Transition error (n = 4) | Wrong dose or time of dose in medical records | 3 (2) | Isorbide mononitrate, levothyroxine, methotrexate |
| Wrong information about the drug in medical records | 1 (1) | Ezetimibe | |
| Unnecessary drug therapy (n = 6) | No indication | 6 (5) | Calcium + vitamin D, omeprazole, potassium, prednisolone, simvastatin, [vitamin B12, folic acid, pyridoxine] |
| Other (n = 10) | 10 (10) | Abnormal laboratory value detected (high MCV, low Hb) (2), [ACE inhibitor, ARB], amlodipine, calcium, calcium + vitamin D, metformin, metoprolol, spironolactone, sterculia | |
Drugs in square brackets were counted as one DRP in the medication reviews. Plus symbols were used to indicate combination medications. Interactions were divided according to Janusmed interactions classification system [19]. C interactions were considered clinically significant but manageable, and D interactions were considered clinically significant and should be avoided [19]. The category ‘other’ included DRPs concerning wrong formulation and patient’s request about treatment choice, for example
ACE angiotensin-converting enzyme, ARB angiotensin receptor blocker, ASA acetylsalicylic acid, DRP drug-related problem, GFR glomerular filtration rate, Hb haemoglobin, MCV mean corpuscular volume, NSAIDs non-steroidal anti-inflammatory drugs, PPI proton pump inhibitor, PTH parathyroid hormone, SSRI selective serotonin reuptake inhibitor