Dъvidas

1

• Dúvidas
• denucci_at_dglnet.com
• Arquivo
• Administração de drogas por via endovenosa -
  bôlus
• Solicitar aulas para
• guilherme_at_lexxa.com.br

2
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

3
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

4
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

5
Interações Medicamentosas

• Representam 3-5 das internações de RAM que podem
  ser evitadas
• Importante causa no número de atendimentos
  ambulatórios

6
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

7
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
8
Estados Unidos - Idosos

• 12 da população
• 31 das prescrições
• 18 consomem pelo menos uma medicação considerada
  não apropriada para a idade

9
Date From
lt_at_yahoo.com.brgt Subject Parkinson -
Unicamp To denucci_at_gdenucci.com 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 900hs 100mg
1700hs  ------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 uso Devido 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
10
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.
alain.viallon_at_univ-st-etienne.fr 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 clearancelt30
mL/min (group I) and gtor30 mL/min (group II).
RESULTS Creatinine clearance waslt30 mL/min in 84
of the 419 patients (group I) and gtor30 mL/min
in 335 (group II). Mean age was significantly
higher in group I than in group II (87 /- 6 vs
81 /- 6 years, plt0.001), as was mean plasma
creatinine concentration (113 /- 23 vs 83 /- 19
mmol/L, plt0.001), while mean weight was
significantly lower (57 /- 10 vs 69 /- 13 kg,
plt0.001. 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.
11
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 4577984

12
Antiretroviral Drug Dosing Errors in
HIV-InfectedPatients Undergoing Hemodialysis

• 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.

13
Antiretroviral Drug Dosing Errors in
HIV-InfectedPatients Undergoing Hemodialysis

• 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.

14
Antiretroviral Drug Dosing Errors in
HIV-InfectedPatients Undergoing Hemodialysis

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

15
Antiretroviral Drug Dosing Errors in
HIV-InfectedPatients Undergoing Hemodialysis

• 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.

16
Antiretroviral Drug Dosing Errors in
HIV-InfectedPatients Undergoing Hemodialysis

• 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.

17
Antiretroviral Drug Dosing Errors in
HIV-InfectedPatients Undergoing Hemodialysis
No underprescribed PI
1.00 0.75 0.50 0.25 0.00
Underprescribed PI
Proportion of patients who survived
0 6 12
18 24
Time, months
No. Of patients at risk Underprescribed PI
30 28 24
23 23 No underprescribed PI 66
66 63 62
60
Antiretroviral Drug Dosing Errors in HIV-Infected
Patients Undergoing Hemodialysis - HIV/AIDS CID
200745 (15 September)
18
Antiretroviral Drug Dosing Errors in
HIV-InfectedPatients Undergoing Hemodialysis

• 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.

19
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,
  804807

20
Inappropriate prescribing in an older ED
population

• 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.

21
Inappropriate prescribing in an older ED
population

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

22
Inappropriate prescribing in the elderly

• Journal of Clinical Pharmacy and Therapeutics
  (2007) 32, 113121

23
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.

24
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) 63205209

25
Incorrect use of orlistat and sibutramine in
clinical practice

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

26
Incorrect use of orlistat and sibutramine in
clinical practice

• 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.

27
Incorrect use of orlistat and sibutramine in
clinical practice

• 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.

28
At 0459 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
29
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
  908912

30
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.