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| ORIGINAL ARTICLE |
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| Year : 2018 | Volume
: 6
| Issue : 1 | Page : 40-47 |
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The burden of polypharmacy and pattern of comorbidities among chronic kidney disease patients in clinical practice
Olumuyiwa John Fasipe1, Peter Ehizokhale Akhideno2, Oluwatosin Beatrice Ibiyemi-Fasipe1, Ayodeji Adebayo Idowu3
1 Department of Pharmacology and Therapeutics, University of Medical Sciences, Ondo City, Ondo State, Nigeria
2 Department of Internal Medicine, Irrua Specialist Teaching Hospital, Edo State, Nigeria
3 Department of General Surgery, Ekiti State University Teaching Hospital, Ado-Ekiti, Ekiti State, Nigeria
| Date of Web Publication | 11-Jun-2018 |
Correspondence Address:
Dr. Olumuyiwa John Fasipe
Medical Lecturer and Senior Physician, Department of Pharmacology and Therapeutics, Faculty of Basic Clinical Sciences, University of Medical Sciences, Ondo City, Ondo State
Nigeria
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/amhs.amhs_11_18
Introduction: The practice of polypharmacy and pattern of associated specific comorbidities/complications among chronic kidney disease (CKD) patients can predispose them to drug-related problems such as drug–drug interactions (DDIs) and adverse drug reactions (ADRs) which may be associated with increased morbidity, mortality, health-care cost, and length and frequency of hospitalization. This can also produce a negative deteriorating and counter-efficient effect on the health and treatment outcome of these patients. Materials and Methods: This was a descriptive, prospective study of 18-month duration that was carried out to review the medical case records of consented adult CKD patients attending a Nigerian tertiary kidney care hospital from January 2015 to June 2016. Results: This study involved 123 consented adult CKD patients comprising 82 (66.67%) males and 41 (33.33%) females, with a mean age of 53.81 ± 16.03 years. The most frequently prescribed medications were furosemide (88, 71.6%), enoxaparin (67, 54.47%), lisinopril (65, 52.9%), oral calcium carbonate (63, 51.2%), α-calcidol (62, 50.4%), and erythropoietin (61, 49.6%). Among these CKD patients, the prevalence of polypharmacy and renal replacement therapy was 85.37% and 56.91%, respectively. Most proportion of the respondents 45 (36.59%) had two number of comorbidities with hypertension (103, 83.70%), diabetes mellitus (39, 31.70%), obesity (24, 19.51%), heart failure (11, 8.90%), obstructive uropathy (8, 6.50%), HIV (7, 5.70%), and stroke (5, 4.10%) being the most frequent. Regarding the form of nephrological interventions being offered: Majority of the respondents, i.e., 66 (53.66%), were on maintenance dialysis, followed by 53 (43.09%) on conservative care and 4 (3.25%) on renal transplantation. Conclusion: The prevalence of polypharmacy is significantly high in these CKD patients. The practice of polypharmacy and pattern of associated specific comorbidities can indeed increase the risk of drug-related problems such as DDIs and ADRs. There is a critical need to minimize the number of prescribed medicines for these patients in order to reduce the associated morbidity, mortality, healthcare costs, and frequency and length (duration) of hospitalization.
Keywords: Chronic kidney disease, comorbidities, drug-related problems, polypharmacy, prescribed medications, prevalence
How to cite this article:
Fasipe OJ, Akhideno PE, Ibiyemi-Fasipe OB, Idowu AA. The burden of polypharmacy and pattern of comorbidities among chronic kidney disease patients in clinical practice. Arch Med Health Sci 2018;6:40-7 |
How to cite this URL:
Fasipe OJ, Akhideno PE, Ibiyemi-Fasipe OB, Idowu AA. The burden of polypharmacy and pattern of comorbidities among chronic kidney disease patients in clinical practice. Arch Med Health Sci [serial online] 2018 [cited 2023 Mar 29];6:40-7. Available from: https://www.amhsjournal.org/text.asp?2018/6/1/40/234084 |
| Introduction | |  |
Polypharmacy can be defined as the concurrent use of more than five different medications by a patient for the treatment of a particular disease or group of diseases.[1],[2],[3],[4] Chronic kidney disease (CKD) can be defined as a progressive and irreversible deterioration in the renal function of an individual over a period of at least 3 months regardless of the underlying etiology.[5] In Nigeria and worldwide, poorly controlled chronic hypertension, poorly controlled diabetes mellitus, and HIV-associated nephropathy among others are the common causes of CKD.[6],[7] CKD is associated with rising incidence and prevalence, high cost of treatment, and poor outcomes. There is evidence to suggest that early in the course of CKD, appropriate interventions may slow down its progression or completely halt the progression of the disease. Despite this, many patients with CKD present late to the nephrologists so that, at the time of initial patient assessment, all that can be offered is the preparation for renal replacement therapy. This is particularly so in resource-poor setting where among several other factors, the lack of awareness, traditional beliefs about the cause, and nature of the disease, need to pay out-of-pocket for healthcare, shortage of specialists combine to promote inappropriate healthcare-seeking behavior, and late presentation to a nephrologist.[5],[6],[7],[8],[9] Usually, in CKD, there is a progressive loss of kidney function occurring over several months to years and is characterized by the gradual replacement of normal kidney architecture with fibrous tissue. The individual with the disease can no longer adequately excrete waste products, regulate acid–base balance, and maintain sodium, potassium, and water homeostasis. There are other associated complications such as anemia, hyperkalemia, metabolic acidosis, inability to maintain calcium balance, erectile dysfunction, hyperphosphatemia, and increased cardiovascular disorders such as hypertension, stroke, ischemic heart diseases, cardiac arrhythmias, and sudden cardiac arrest, which can lead to increase mortality. Patients with CKD Stages 1–3 (estimated glomerular filtration rate [eGFR] >30 mL/min/1.73 m2) are generally asymptomatic. Typically, it is not until Stages 4–5 (eGFR <30 mL/min/1.73 m2) that endocrine/metabolic derangements or disturbances in water or electrolyte balance become clinically manifest. The early stages of CKD are often completely asymptomatic despite the accumulation of numerous metabolites. Serum urea and creatinine concentrations are measured in CKD since methods for their determination are available and a rough correlation exists between serum urea and creatinine concentrations and symptoms. These substances are, however, in themselves not particularly toxic. The nature of the metabolites that are involved in the genesis of symptoms is unclear. Such metabolites must be the products of protein catabolism (since dietary protein restriction may reverse symptoms associated with CKD), and many of them must be of relatively small molecular size (since hemodialysis employing membranes which allow through only relatively small molecules improves symptoms). Little else is known with certainty. Symptoms are common when the serum urea concentration exceeds 40 mmol/L, but many patients develop uremic symptoms at lower levels of serum urea.[1],[8],[10],[11],[12] Hypertension and diabetes mellitus are the most common causes of end-stage kidney disease worldwide; therefore, control of high blood pressure (BP) and optimization of blood glucose level are essential in delaying and retarding CKD progression.[13] These necessitate the use of several medications to improve the quality of life of these patients and slow down the progression of early CKD to full-blown end-stage renal disease (ESRD). Although efficacy, compliance, and economic factors are considered in selecting drugs for treating patients with CKD, these patients are usually on polypharmacy with attendant risk for drug-related problems such as drug–drug interactions (DDIs) and adverse drug reactions (ADRs). Further, as the disease progresses, the number of prescribed medications usually increases substantially; sometimes, up to 10 or more different drugs are ingested daily by the time a patient is at CKD Stage 5 (GFR <15 ml/min/1.73 m 2).[1],[7],[8],[9],[14] The influences of the disease on drugs' pharmacokinetic and pharmacodynamic mechanism can increase the risk for drug-related problems such as DDIs and adverse drug reactions (ADRs); these further compound the problems of patients with CKD and may also increase morbidity, mortality, frequency of hospitalization, length of hospital stay, and healthcare cost, among them.[10],[11],[12],[13] CKD is a major public health problem due to its increasing incidence, prevalence, and associated high burden. The global prevalence of CKD is estimated to be 11%–13%.[14],[15],[16],[17] The prevalence of CKD in Nigeria varied between 11.4% and 18.8% from both community- and hospital-based studies.[5],[6],[7],[8],[9] Cardiovascular disease burden in CKD patients are high and are associated with increased frequency of hospitalization, morbidity, mortality, length of hospital stay, and healthcare cost.[18],[19],[20] Cardiovascular risk factors such as hypertension, diabetes mellitus, anemia, calcium phosphate abnormalities, hyperuricemia, and left ventricular hypertrophy are highly prevalent in CKD.[2],[21],[22] These are largely responsible for cardiovascular disease burden and some complications in CKD patients. Management of these cardiovascular diseases and risk factors is important in retarding progression of CKD and reducing mortality.[23],[24],[25] This involves the use of multiple-drug combination therapy in the management of CKD and its attendant complications; hence, polypharmacy is often practiced. The consequences of polypharmacy include poor patients' medication compliance due to high pill burden, increased cost of healthcare, and most importantly drug-related problems which can have deleterious effects on patients' health.[3],[26],[27] The clinical pharmacists also have a major role to play in preventing drug-related problems such as DDIs and adverse drug reactions (ADRs) associated with polypharmacy prescriptions by thoroughly and regularly evaluate the physicians' prescriptions for CKD patients before rational medication dispensing.[28],[29],[30] Therefore, integrated professional interaction should be encouraged between nephrologists/physicians and clinical pharmacists in order to optimize CKD patients' care. Vigilance by health-care workers such as nephrologists, clinical pharmacists, and nephrology nurses in detecting, diagnosing, and reporting drug-related problems, particularly in at-risk individuals such as CKD patients, is vital for continued drug safety monitoring.[4],[20],[31],[32],[33]
This study was designed to determine the prevalence of polypharmacy and pattern of associated specific comorbidities among CKD patients attending the Nephrology Clinic of a Tertiary Kidney Care Hospital, Nigeria Sub-Saharan West Africa. This will create awareness on the burden of polypharmacy and its associated specific comorbidities in renal practice and will bring to limelight the need to regularly evaluate the prescriptions of CKD patients for any medication-related problems such as DDIs and adverse drug reactions (ADRs) and in addition the need to appropriately manage any associated complication(s) and comorbid condition(s).
| Materials and Methods | | |
This was a descriptive, prospective study carried out at the Nephrology Clinic of a Tertiary Kidney Care Hospital, Ondo City, Ondo State, Nigeria, Sub-Saharan West Africa. It receives referral from within and outside the State. One hundred and twenty-three consented adult CKD patients who were being managed at the center over an 18-month period between January 2015 and June 2016 were recruited for the study. Patients below the age of 18 years, those being managed for acute kidney injury, and adult CKD patients who did not grant their informed consent were excluded from the study. The medical case records of all the adult CKD patients were retrieved after verbal informed consent has been obtained from each of them, and the following information was extracted using a pro forma: sociodemographic data, stage of CKD, number and list of medications at the time of last clinic visit for outpatients and at the time of discharge for those that received in-patient admission care, number and list of comorbidities such as hypertension, diabetes mellitus, obesity, heart failure, HIV infection, and stroke. The serum creatinine level was used to calculate eGFR using the CKD epidemiology collaboration formula, and CKD staging was done using eGFR as follows: Stage 1 (eGFR of ≥90 ml/min with evidence of kidney damage), Stage 2 (eGFR of 60–89 ml/min with or without evidence of kidney damage), Stage 3 (eGFR of 30–59 ml/min with or without evidence of kidney damage), Stage 4 (eGFR of 15–29 ml/min with or without evidence of kidney damage), and Stage 5 (eGFR <15 ml/min with or without evidence of kidney damage).[28]
In this study, the prevalence rate for polypharmacy among these CKD patients was calculated by dividing the total number of patients taking more than five different medications concurrently by the total number of patients that participated in the study (sample size), whereas the prevalence rate for individual-specific comorbidity among these CKD patients was obtained by dividing the total number of patients having the specified comorbidity by the total number of patients that participated in the study (sample size). Data collected were encoded and analyzed using the Statistical Package for the Social Sciences (SPSS) Version 17 (released 2008; SPSS Inc., Chicago, IL, USA). Results were expressed as mean ± standard deviation or percentage values where necessary. The t-test and Chi-square test were used to compare means and proportions, respectively. The level of statistical significance was set at P < 0.05. Ethical clearance was obtained from the Health Research Ethical Committee of the Tertiary Kidney Care Hospital, Ondo, about the study. The Ethical Clearance/Protocol Research Number issued for the study was UNIMED/KCCO/NOV 2014/0007. In addition, verbal informed consent was obtained from each of the adult CKD patients whose medical case records were used, while the medical case records for those who did not grant their informed consent were excluded from the study. Consent was sought from patient's relative where the patient had impaired level of consciousness. Participants' confidentiality were respected and maintained by ensuring that no unauthorized person has access to the information on the questionnaires, that no information can be traced to the respondents (as coding system was used for the questionnaires instead of writing the patients' names on them), and that no unauthorized use of information was made.
| Results | | |
This study involved 123 consented adult CKD patients comprising 82 (66.67%) males and 41 (33.33%) females. The mean age of the study participants was 53.81 ± 16.03 years. Forty-eight (39.0%) were between 18 and 49 years, 52 (42.3%) were between 50 and 69 years, and the remaining 23 (18.7%) were 70 years and above [Table 1].
Fifty-three (43.09%) of the study participants had tertiary education, 36 (29.3%) had secondary education, 18 (14.6%) had primary education, while 16 (13.0%) had no formal education. Eighty-six (69.9%) of the study participants were in CKD Stage 5, 15 (12.2%) were in CKD Stage 4, 19 (15.5%) were in CKD Stage 3, 2 (1.6%) in CKD Stage 2, and the remaining one (0.8%) in CKD Stage 1 [Table 1].
Regarding the form of nephrological interventions being offered: Majority of the respondents – 66 (53.66%) were on maintenance dialysis, followed by 53 (43.09%) on conservative care and 4 (3.25%) on renal transplantation [Table 1].
In this study, the range for number of associated comorbidities was 0–6 diseases, with a mean of 2.33 ± 1.09 diseases per patient. Most proportion of the respondents 45 (36.59%) had two comorbidities, followed by 36 (29.27%) with three comorbidities, 23 (18.70%) with only one comorbidity, and 11 (8.94%) with four comorbidities [Table 1]. The most common specific comorbidities were hypertension in 103 (83.70%), diabetes mellitus in 39 (31.70%), obesity in 24 (19.51%), heart failure in 11 (8.9%), obstructive uropathy in 8 (6.5%), HIV in 7 (5.7%), and stroke in 5 (4.1%) [Table 1].
Their mean body mass index (BMI) was 25.71 ± 5.09 kg/m 2; 55 (44.72%) had normal BMI (18.50–24.99 kg/m 2), followed by 39 (31.71%) with overweight BMI (25.00–29.99 kg/m 2), 18 (14.63%) with mild/Grade-1 obesity (30.00–34.99 kg/m 2), 5 (4.07%) each with moderate/Grade-2 obesity (35.00–39.99 kg/m 2) and underweight (≤18.49 kg/m 2), respectively, and only one (0.81%) with morbid/Grade-3 obesity (≥40.00 kg/m 2) [Table 1].
A total number of 1237 medications were prescribed for the study participants, and the mean number of prescribed medications per patient was 10.06 ± 3.97. Eighteen CKD patients (14.6%) were on ≤5 medications, 43 (35.0%) were on 6–10 medications, 51 (41.5%) were on 11–15 medications, and 11 (8.9%) were on ≥16 medications [Table 1].
In this study, polypharmacy (the concurrent use of more than five different medications by a patient) was observed among 105 CKD patients (85.37%). The most frequently prescribed medications were furosemide (88, 71.6%), enoxaparin (67, 54.47%), lisinopril (65, 52.9%), oral calcium carbonate (63, 51.22%), α-calcidol (62, 50.4%), erythropoietin (61, 49.6%), intravenous iron sucrose (60, 48.8%), amlodipine (56, 45.5%), hydrochlorthiazide (53, 43.1%), folic acid (53, 43.1%), and oral ferrous sulfate (50, 40.7%) [Table 2]. Prophylactic low-molecular-weight heparin (clexane/enoxaparin) was prescribed for these CKD patients with symptomatic ESRDs that are undergoing maintenance hemodialysis (MHD) sections so as to prevent hemocoagulopathy disorder in them. In addition, these CKD patients with diabetic ketoacidosis/hyperosmolar hyperglycemic state (DKA/HHS), ischemic stroke, varicose veins, valvular heart diseases, ischemic heart disease, atrial fibrillation or/and prolonged immobility may also be prescribed prophylactic clexane/enoxaparin to prevent the occurrence of deep vein thrombosis or cardiogenic thrombosis and subsequent thromboembolism phenomenon in them. The route of administration is subcutaneous (SC) usually at a dose of 40 mg (4000 IU) once daily before the commencement of hemodialysis section. Duration and frequency of administration among CKD patients are determined by the clotting profile (international normalized ratio [INR] value between the range of 0.8–1.3 is usually the desirable target) and also at the discretion of the nephrologist physician depending on the primary indication/purpose for usage such as for MHD sections in symptomatic ESRD patients or for ESRD/pre-ESRD CKD patients with DKA/HHS, ischemic stroke, varicose veins, valvular heart diseases, ischemic heart disease, atrial fibrillation, or/and prolonged immobility.
The mean systolic BP of the respondents was 164.19 ± 35.12 mmHg while their mean diastolic BP was 95.73 ± 19.08 mmHg. According to the British Hypertensive Society/World Health Organization classification of BP, most proportions of the respondents 47 (38.21%) had severe (Grade-3) hypertension, followed by 30 (24.39%) with moderate (Grade-2) hypertension, 26 (21.14%) with mild (Grade-1) hypertension, 8 (6.50%) with normal BP, and 6 (4.88%) each with optimal BP and high normal BP, respectively [Table 3]. Furthermore, 83 (67.48%) had combined systolic-diastolic hypertension, followed by 18 (14.63%) with isolated systolic hypertension and 2 (1.63%) with isolated diastolic hypertension [Table 3]. | Table 3: Blood pressure severity category and blood pressure grading for the respondents
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Amongst these CKD patients, the prevalence of polypharmacy and renal replacement therapy was 85.37% and 56.91%, respectively, while the prevalence for the most common specific comorbidities such as hypertension, diabetes mellitus, obesity, heart failure, obstructive uropathy, HIV, and stroke was 83.70%, 31.70%, 19.51%, 8.90%, 6.50%, 5.70%, and 4.10%, respectively [Table 4]. | Table 4: Prevalence of polypharmacy, renal replacement therapy, and specific comorbidities among the chronic kidney disease population
Click here to view |
In this study, there was a statistically significant association between the number of prescribed medications and the eGFR (pre-ESRD and ESRD) for the respondents with P < 0.0001. This implies that the number of prescribed medications increases as the eGFR declines in advance CKD stage patients [Table 5]. | Table 5: Test for associations between parameters for the study population
Click here to view |
In addition, among these CKD patients recruited for this study, there was also a statistically significant association between those with diabetes mellitus and obesity with P < 0·0001. This implies that those patients with obesity are highly predisposed and at risk of developing diabetes mellitus [Table 5].
| Discussion | | |
Regarding sex distribution, our study was similar to the study conducted by Marquito et al., 2014[22] on CKD patients at the NIEPEN Federal University of Juiz de Fora, Brazil, where majority of the respondents, 305 (54.7%), were males. This showed that CKD was more predominant among males which can be attributed to their rugged lifestyles such as indulgence in chronic smoking, chronic alcohol consumption, poor nutritional feeding habit, inadequate exercise, multiple sexual partners, and poor healthcare-seeking behavior. On the other hand, our study disagreed with the one conducted by Sgnaolin et al., 2014[19] in a hospital hemodialysis unit in Brazil where 65 patients were included in the study with a mean age of 59.1 ± 14.7 years and 33 (50.8%) being women.
Concerning BMI status, the study conducted by Marquito et al.[22] in which majority of the respondents 372 (66.7%) were either overweight or obese also agreed with our study in which 63 (51.22%) were either overweight or obese. This increased BMI (overweight or obesity) had a positive correlation with the increasing prevalence of acquired CKD in this study as a risk factor.
Regarding the CKD staging and eGFR, this study where majority of the respondents – 86 (69.92%) – belonged to CKD Stage 5 agreed with the study by Rama et al., 2012[20] where 113 (68.48%) belonged to CKD Stage 5 but disagreed with the study by Marquito et al.[22] in which most respondents – 265 (47.5%) – belonged to CKD Stage 3. This disparity can be attributed to the different variations in the serum creatinine levels of the respondents which were used to calculate their eGFRs.
Furthermore, regarding nephrological interventions being offered in this study, majority of the respondents were on maintenance dialysis 66 (53.66%) in contrast to the study by Marquito et al.[22] where most of the respondents – 521 (93.37%) – were on conservative care. This disparity was attributed to the fact that most respondents in this study were ESRD/CKD Stage 5 as opposed to pre-ESRD CKD Stages 1-4 in the study by Marquito et al.[22]
In this study, the mean prescribed medications per patient was 10.06 ± 3.97. This is slightly higher than 7.87 ± 2.44 reported by Al-Ramahi et al.[21] However, Rama et al.[20] reported higher mean prescribed drugs per patient of 12.08 ± 6.30 as compared to the finding in this present study. Our study population involved both nondialyzed and dialyzed patients unlike the study by Al-Ramahi et al.[21] that involved only CKD patients on MHD. Patients who are on regular MHD may require less numbers of drugs for BP control; hence, this may possibly explain the lower mean number of prescribed medications. The practice of polypharmacy in the management of CKD is, however, not surprising because they have high number of cardiovascular risk factors, comorbidities, and complications, such as hypertension, diabetes mellitus, heart failure, arrhythmias, anemia, hyperuricemia, and calcium-phosphate abnormalities which are managed by a combination of drugs.
This study shows that 105 (85.37%) patients were on polypharmacy (i.e., the concurrent use of more than five different medications by a patient) which was similar to the study conducted by Sgnaolin et al.[19] where 57 (87.7%) patients were also on polypharmacy.
The most common comorbidities in this study were hypertension and diabetes which agreed with the previous studies conducted by Sgnaolin et al.[19] and Marquito et al.[22] This can be attributed to the fact that both conditions are the leading etiologies of acquired CKD in Nigeria, Sub-Saharan West Africa region, and worldwide.
In this study, the prevalence rate of polypharmacy among those CKD patients was 85.37% which was similar to the prevalence reported by Sgnaolin et al. (87.7%). This revealed that about 85 patients out of every 100 diagnosed CKD patients recruited for this study were being prescribed more than five different medications for every clinic visit for outpatient care or during hospital discharge for inpatient admissions. This, therefore, emphasized on the need for physicians and clinical pharmacists to regularly evaluate prescriptions of CKD patients for possible medication-related problems. Differences in methodology, average number of medications per prescription, average number of associated specific comorbidities/complications per patient, and CKD stage of the studied population could account for the slight variations in the prevalence rates of polypharmacy in these different studies.[2],[18],[19],[20],[21],[22] In this study, the number of medications per prescription and the number of associated specific comorbidities/complications per patient were found to be the major determinants of prevalence rate for polypharmacy among these CKD patients.
The prevalence of renal replacement therapy in this study was 56.91% which was higher than the report by Marquito et al.[22] (6.63%) but lower than the prevalence value reported by Rama et al.[20] (68.48%). This showed that about 57 patients out of every 100 diagnosed CKD patients recruited for this study were on renal replacement therapy. Once again, this disparity was attributed to the fact that most respondents in this study were ESRD/CKD Stage 5 as opposed to pre-ESRD CKD Stages 1-4 in the study by Marquito et al.[22]
The most frequently prescribed medications in this study were furosemide, enoxaparin, lisinopril, and oral calcium carbonate. This agreed with the previous studies done by Chinwendu et al.,[33] Al-Ramahi et al.,[21] Marquito et al.[22] and Sgnaolin et al.[19] where furosemide, lisinopril and oral calcium carbonate were reported as amongst the most frequently prescribed medications for CKD patients in clinical practice. Prophylactic low-molecular-weight heparin (clexane/enoxaparin) was prescribed for these CKD patients with symptomatic ESRD that are undergoing MHD sections so as to prevent hemocoagulopathy disorder in them. In addition, these CKD patients with DKA/HHS, ischemic stroke, varicose veins, valvular heart diseases, ischemic heart disease, atrial fibrillation, or/and prolonged immobility may also be prescribed prophylactic clexane/enoxaparin to prevent the occurrence of deep vein thrombosis or cardiogenic thrombosis and subsequent thromboembolism phenomenon in them. The route of administration is SC usually at a dose of 40 mg (4000 IU) once daily before the commencement of hemodialysis section. Duration and frequency of administration among CKD patients are determined by the clotting profile (INR value between the range of 0.8–1.3 is usually the desirable target) and also at the discretion of the Nephrologist physician depending on the primary indication/purpose for usage such as for MHD sections in symptomatic ESRD patients or for ESRD/pre-ESRD CKD patients with DKA/HHS, ischemic stroke, varicose veins, valvular heart diseases, ischemic heart disease, atrial fibrillation, or/and prolonged immobility.
In addition, there was a statistically significant association between the number of prescribed medications and the eGFR (pre-ESRD and ESRD staging) for the respondents in this study with P < 0·0001. This implies that the number of prescribed medications increases as the eGFR declines in advance CKD stage patients. This finding also agreed with the previous studies done by Sgnaolin et al.,[19] Rama et al.,[20] and Marquito et al.[22] Furthermore, among these CKD patients recruited for this study, there was also a statistically significant association between those with diabetes mellitus and obesity with P < 0·0001. This implies that those patients with obesity are highly predisposed and at risk of developing diabetes mellitus.
Regarding risk factors that affect the prevalence of polypharmacy in this study, we found out that the number of medications per prescription, number of associated specific comorbidities/complications per patient, increasing age, low eGFR, obesity/overweight, form of nephrological intervention offered, hypertension, and diabetes mellitus (P< 0.05 for all) were the risk factors associated with and predisposed CKD patients to polypharmacy.
This study has brought to limelight the magnitude and burden of polypharmacy with associated specific comorbidities/complications among CKD patients and the need to take proactive steps to prevent the occurrence of drug-related problems such as drug-drug interactions (DDIs) and adverse drug reactions (ADRs) in these patients.
| Conclusions | | |
The prevalence of polypharmacy is significantly high among those CKD patients. The practice of polypharmacy and pattern of associated specific comorbidities/complications can increase the risk of drug-related problems such as DDIs and adverse drug reactions (ADRs), hence the need to minimize the number of prescribed medications for these patients in order to reduce associated morbidity, mortality, healthcare costs, and frequency and length (duration) of hospitalization. In this study, the number of medications per prescription and number of associated specific comorbidities/complications per patient were found to be the major determinants of prevalence rate for polypharmacy among these CKD patients. The number of prescribed medications increases as the eGFR declines in advance CKD stage patients; nephrologists/physicians and clinical pharmacists should regularly review the prescriptions of CKD patients to avoid and prevent drug-related problems such as DDIs and adverse drug reactions (ADRs) in them.
Recommendations
- Whenever the clinical pharmacist(s) that are involved in the rational dispensing of CKD patients' medications detect the presence of any drug combinations that can lead to drug-related problems such as DDIs and adverse drug reactions (ADRs) in their prescriptions, he/she should alert the doctor(s) involved and inform them of the impending problem so that feasible alternative prescriptions can be made and the error corrected as this will involve more cost in pharmacist and doctor's time, but the hospital should make this mandatory. This approach will save lives and reduce morbidity, mortality, frequency of hospitalization, length of hospital stay, and healthcare costs
- A cordial integrated relationship between healthcare professionals –(nephrologists/physicians, nephrology nurses, and clinical pharmacists) should be encouraged in order to optimize CKD patients' care and to reduce the occurrence of drug-related problems such as DDIs and adverse drug reactions (ADRs) associated with polypharmacy prescriptions among them
- Regular organization of health education awareness program on the prevention of CKD and its associated complications among the general public should be done by healthcare professionals coupled with adequate support from the government.
What is known about this topic?
- The management of CKD with its associated comorbidities/complications often requires the use of polypharmacy.
What this study adds to the body of knowledge?
- To the best of our knowledge, no significant study has been conducted on the prevalence of polypharmacy and its determinant factors among CKD patients in Nigeria
- This study revealed the prevalence rate of polypharmacy and pattern of associated specific comorbidities among CKD patients in Nigeria and Africa
- This study revealed that the number of medications per prescription and the number of associated specific comorbidities/complications per patient are the major determinants of prevalence rate for polypharmacy among CKD patients
- This use of polypharmacy practice for medication prescription among CKD patients can predispose them to drug-related problems such as such as DDIs and adverse drug reactions (ADRs), hence the need to minimize the number of prescribed medications.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Victoria M, Matteo C, Marco T, Erica G, Roberta C, Speranza R. Polypharmacy in kidney disease patients. Curr Kidney Dis 2014;11:212-9.  |
| 2. | Flesch MI, Erdmann E. The problem of polypharmacy in chronic kidney disease. Curr Cardiol Rep 2006;8:217-25. |
| 3. | Mason NA, Bakus JL. Strategies for reducing polypharmacy and other medication-related problems in chronic kidney disease. Semin Dial 2010;23:55-61. [ PUBMED] |
| 4. | Mason NA. Polypharmacy and medication-related complications in the chronic kidney disease patient. Curr Opin Nephrol Hypertens 2011;20:492-7. [ PUBMED] |
| 5. | Hill NR, Fatoba ST, Oke JL, Hirst JA, O'Callaghan CA, Lasserson DS, et al. Global prevalence of chronic kidney disease – A systematic review and meta-analysis. PLoS One 2016;11:e0158765. |
| 6. | Odubanjo MO, Oluwasola AO, Kadiri S. The epidemiology of end-stage renal disease in Nigeria: The way forward. Int Urol Nephrol 2011;43:785-92. [ PUBMED] |
| 7. | Akinsola W, Odesanmi WO, Ogunniyi JO, Ladipo GO. Diseases causing chronic renal failure in Nigerians – A prospective study of 100 cases. Afr J Med Med Sci 1989;18:131-7. [ PUBMED] |
| 8. | Ulasi II, Ijoma CK, Onodugo OD, Arodiwe EB, Ifebunandu NA, Okoye JU. Towards prevention of chronic kidney disease in Nigeria: A community-based study in Southeast Nigeria. Kidney Int Suppl 2013;3:195-201. |
| 9. | Oluyombo R, Ayodele OE, Akinwusi PO, Okunola OO, Akinsola A, Arogundade FA, et al. Acommunity study of the prevalence, risk factors and pattern of chronic kidney disease in Osun state, South West Nigeria. West Afr J Med 2013;32:85-92. [ PUBMED] |
| 10. | Liu M, Li XC, Lu L, Cao Y, Sun RR, Chen S, et al. Cardiovascular disease and its relationship with chronic kidney disease. Eur Rev Med Pharmacol Sci 2014;18:2918-26. [ PUBMED] |
| 11. | Levin A, Hemmelgarn B, Culleton B, Tobe S, McFarlane P, Ruzicka M, et al. Guidelines for the management of chronic kidney disease. CMAJ 2008;179:1154-62. [ PUBMED] |
| 12. | Alebiosu CO, Ayodele OE. The global burden of chronic kidney disease and the way forward. Ethn Dis 2005;15:418-23. [ PUBMED] |
| 13. | Riemer E, Werling E, Kribs M, Hamman De Compte A, Dimitrov Y. Medical prescriptions in haemodialysis patients: Critical analysis. Nephrol Ther 2005;1:234-40. [ PUBMED] |
| 14. | Babua C, Kalyesubula R, Okello E, Kakande B, Sebatta E, Mungoma M, et al. Cardiovascular risk factors among patients with chronic kidney disease attending a tertiary hospital in Uganda. Cardiovasc J Afr 2015;26:177-80. [ PUBMED] |
| 15. | Edwards IR, Aronson JK. Adverse drug reactions: Definitions, diagnosis, and management. Lancet 2000;356:1255-9. [ PUBMED] |
| 16. | Pirmohamed M, James S, Meakin S, Green C, Scott AK, Walley TJ, et al. Adverse drug reactions as cause of admission to hospital: Prospective analysis of 18 820 patients. BMJ 2004;329:15-9. [ PUBMED] |
| 17. | Manley HJ, Cannella CA, Bailie GR, St. Peter WL. Medication-related problems in ambulatory hemodialysis patients: A pooled analysis. Am J Kidney Dis 2005;46:669-80. |
| 18. | Al-Hajje AH, Atoui F, Awada S, Rachidi S, Zein S, Salameh P, et al. Drug-related problems identified by clinical pharmacist's students and pharmacist's interventions. Ann Pharm Fr 2012;70:169-76. |
| 19. | Sgnaolin V, Sgnaolin V, Engroff P, De Carli A, Figueiredo AE. Assessment of used medications and drug-drug interactions among chronic renal failure patients. Sci Med 2014;24:329-35. |
| 20. | Rama M, Viswanathan G, Acharya LD, Attur RP, Reddy PN, Raghavan SV, et al. Assessment of drug-drug interactions among renal failure patients of nephrology ward in a South Indian tertiary care hospital. Indian J Pharm Sci 2012;74:63-8. [ PUBMED] [Full text] |
| 21. | Al-Ramahi R, Raddad AR, Rashed AO, Bsharat A, Abu-Ghazaleh D, Yasin E, et al. Evaluation of potential drug- drug interactions among Palestinian hemodialysis patients. BMC Nephrol 2016;17:96. [ PUBMED] |
| 22. | Marquito AB, Fernandes NM, Colugnati FA, de Paula RB. Identifying potential drug interactions in chronic kidney disease patients. J Bras Nefrol 2014;36:26-34. [ PUBMED] |
| 23. | Hedge S, Udaykumar P, Manjuprasad MS. Potential drug interactions in chronic kidney disease patients. A cross-sectional study. Int J Recent Trends Sci Technol 2015;16:56-60. |
| 24. | Shad MU, Marsh C, Preskorn SH. The economic consequences of a drug-drug interaction. J Clin Psychopharmacol 2001;21:119-20. [ PUBMED] |
| 25. | Fernández-Llimós F, Tuneu L, Baena MI, Garcia-Delgado A, Faus MJ. Morbidity and mortality associated with pharmacotherapy. Evolution and current concept of drug-related problems. Curr Pharm Des 2004;10:3947-67. |
| 26. | Cardone KE, Bacchus S, Assimon MM, Pai AB, Manley HJ. Medication-related problems in CKD. Adv Chronic Kidney Dis 2010;17:404-12. [ PUBMED] |
| 27. | Manley HJ, Drayer DK, Muther RS. Medication-related problem type and appearance rate in ambulatory hemodialysis patients. BMC Nephrol 2003;4:10. [ PUBMED] |
| 28. | International Society of Nephrology. Kidney Disease Improving Global Outcome (KDIGO) 2012 clinical practice guideline for evaluation and management of CKD. Kidney Int Suppl 2013;3:1-150. |
| 29. | Manley HJ, McClaran ML, Overbay DK, Wright MA, Reid GM, Bender WL, et al. Factors associated with medication-related problems in ambulatory hemodialysis patients. Am J Kidney Dis 2003;41:386-93. [ PUBMED] |
| 30. | Eiam-Ong S, Sitprija V. Comorbidities in patients with end-stage renal disease in developing countries. Artif Organs 2002;26:753-6. [ PUBMED] |
| 31. | Kadiri S, Arije A. Temporal variations and meteorological factors in hospital admissions of chronic renal failure in South West Nigeria. West Afr J Med 1999;18:49-51. [ PUBMED] |
| 32. | Grabe DW, Low CL, Bailie GR, Eisele G. Evaluation of drug-related problems in an outpatient hemodialysis unit and the impact of a clinical pharmacist. Clin Nephrol 1997;47:117-21. [ PUBMED] |
| 33. | Chinwendu AK, Joda AE, Oyetunde OO, Udezi WA. Evaluation of drug-drug interactions among chronic kidney disease patients of nephrology unit in the university of Nigeria teaching hospital, Ituku-Ozalla, Enugu State. J Basic Clin Pharma 2017;8:S049-53. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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