Renal Drug Dosage Adjustment According to Estimated Creatinine Clearance in Hospitalized Patients With Heart Failure

Abstract

It is of clinical importance to determine creatinine clearance and adjust doses of prescribed drugs accordingly in patients with heart failure to prevent untoward effects. There is a scarcity of studies in the literature investigating this issue particularly in patients with heart failure, in whom many have impaired kidney function. The purpose of this study was to determine the degree of awareness of medication prescription as to creatinine clearance in patients hospitalized with heart failure. Patients hospitalized with a diagnosis of heart failure were retrospectively evaluated. Among screened charts, patients with left ventricular ejection fraction <40% and an estimated glomerular filtration rate (eGFR) of ≤50 mL/min were included in the analysis. The medications and respective doses prescribed at discharge were recorded. Medications requiring renal dose adjustment were determined and evaluated for appropriate dosing according to eGFR. A total of 388 patients with concomitant heart failure and renal dysfunction were included in the study. The total number of prescribed medications was 2808 and 48.3% (1357 medications) required renal dose adjustment. Of the 1357 medications, 12.6% (171 medications) were found to be inappropriately prescribed according to eGFR. The most common inappropriately prescribed medications were famotidine, metformin, perindopril, and ramipril. A significant portion of medications used in heart failure requires dose adjustment. Our results showed that in a typical cohort of patients with heart failure, many drugs are prescribed at inappropriately high doses according to creatinine clearance. Awareness should be increased among physicians caring for patients with heart failure to prevent adverse events related to medications.

Evaluation of renal drug dosing adjustment in chronic kidney disease patients at two university hospitals in Lebanon

“…The latter finding can be explained by the fact that beta-blockers were among the most commonly prescribed class of medication requiring adjustment similar to the results obtained by Bailie et al 23. Furthermore, the inadequate adjustment rate of beta-blockers in the present study was 83.6% far more than the 3.78% attained with Altunbas et al 19…”

“…Altunbas et al . reported significantly lower rates of 12.6%, but the rate was explained by authors by the fact that the study patients had higher degrees of renal dysfunction, compared to other studies, and thus required nephrology consultation and more careful drug prescription 19. Another similar study was carried out at a governmental hospital in Palestine, indicated that only 26.42% of medications were found to be appropriately adjusted, compared to 73.58% inappropriately adjusted medication orders 20…”

“…The rate of inappropriate prescriptions obtained in our study is considered to be high. Several reasons may contribute to inappropriate drug dosing in renal failure 16,19,21. These include not reviewing renal function tests before prescribing, which was reflected by the high number of exclusions due to missing serum creatinine level in our patients’ charts.…”

“…Furthermore, computerized systems are becoming significantly helpful in this area. It has been shown that using computerized physician order entry and clinical decision support system was able to decrease rates of medication dosing errors 19…”

Assessment of medication Dosage Adjustment in Hospitalized Patients with Chronic Kidney Disease

“…Whereas, Altunbas et al reported considerably lower prevalence of medication dosing errors (12.6%), however the authors explained that majority of the study participants had renal impairment thereby necessitating nephrology consultation and optimized drug regimen, which could limit the generalizability of study findings. 36 In developed nations, the active involvements of clinical pharmacists coupled with computerized dosage optimization systems are primarily responsible for the appropriate medication therapy. Most automated dosage adjustment systems automatically alert the healthcare professionals including physicians and clinical pharmacist regarding renal function status and the need for dose optimization.…”