Evaluation of pharmaceutical intervention in patients with hepatic insufficiency in a hospital setting

Abstract

1.1. Background: Dose adjustment in patients with hepatic insufficiency (HI) is not routinely performed in clinical practice by the difficult to quantify the liver dysfunction and the lack of dosage data for many drugs in patients with HI. There is scarce evidence on support prescription tools to identify these patients and make recommendations about their medication management. 1.2. Objective: To assess the prevalence of potentially inappropriate prescriptions susceptible to a pharmacist intervention (PI) and evaluate their satisfaction with the intervention based on the Child-Pugh (CP) and perceptions of its impact. 1.3. Setting: A Spanish large, tertiary care and academic medical hospital. 1.4. Method: This uncontrolled prospective evaluation of pharmaceutical intervention was screened patients with HI according to the calculation of the analytical blood test variables score of the Child-Pugh score (ACP)>7. The pharmacist reviewed all the order prescriptions considered potentially inappropriate to the clinical situation of liver failure. PI was classified based on five categories according to the recommendation and recorded in order to evaluate the efficiency, the acceptance rate by the clinicians and the clinical impact of negative outcomes related to medication. 1.5. Main outcome measure: Measure prevalence of potentially inappropriate prescriptions in patients with HI and categories according the PI done. 1.6. Results: A total of 8815 patients were screened over a period of 6 months, 171 of them had an ACP value >7;141 patients have exclusion criteria and our potential interventional population was 30 patients. The HI prevalence rate obtained by the CPT screening was 0.34% of the recorded hospital admissions and 318 order prescriptions, were candidates for a PI. Once clinical variables (ascites/encephalopathy) and the clinical history had been reviewed the final CP classification was: B(11 patients) and C(19 patients).Regarding the impaired liver function, 58.5% of orders were considered for potential PI, associated with a higher probability of drug related problem: dosage/frequency change:67 orders, pharmacological/analytical monitor:47, caution:43 and contraindications:29. On average we recorded a 0.97 (29/30) contraindicated order/patient. PI acceptance was 69.7%. The PI performed had a potential impact on negative outcomes related to medication; drug efficacy and safety on 12.6% and 87.4% respectively. 1.7. Conclusion: The results of our study show that about one third of the prescriptions in patients with HI are candidates for PI, mostly due to contraindications or wrong dosage. As the pharmacists’ intervention is widely accepted and appreciated by the medical community they have an important role to play by increasing the safe use of drugs.