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7/31/2019 JURNAL FARKIL

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INVOLVEMENT OF WARD PHARMACISTDURING THERAPUTIC PROCESS IN HOSPITALIZED GERIATRIC

PATIENTS IN DR. SARJITO HOSPITAL, YOGYAKARTA, INDONESIA

Fita Rahmawati 1,2 , Syed Azhar Syed Sulaiman 2 ,

I Dewa Putu Pramantara3

, Wasilah Rochmah3

.

1 Faculty of Pharmacy, Gadjah Mada University, Yogyakarta , Indonesia,2 School of Pharmaceutical Sciences, Universiti Sains Malaysia, Minden PulauPenang, Malaysia. 3 Department of Internal Medicine, Dr. Sardjito Hospital,

Yogyakarta , Indonesia

.

Objectives: A research carried out to know the impact of ward pharmacist s

involvement during therapeutic process to reduce drug related problems inhospitalized geriatric patients.Subjects and Methods: Research type was experimental design. Data taken byprospectively and retrospectively through medical record in 100 geriatric patientshospitalized in IRNA I interne department at Dr. Sardjito Hospital Yogyakarta.Fifty patients conducted by prospectively, ward pharmacist identified drugrelated problems and gave suggestion to the health care professional for preventand resolve drug related problems (group A). Another fifty case taken byretrospectively just for identify drug related problems without intervention (groupB). The data collected through medical record, patients medication chart,injection book; followed by interview with patients, nurse, physician and other health professional. Descriptive statistics were shown as frequencies of DrugRelated Problems (DRPs) in both goup (group A and B). Test for influence wardpharmacist in reducing drug related problems performed by Mann-Whitney test Results : Our research showed involvement of ward pharmacist in therapeuticprocess did not reduced amount of DRPS in every categories (p value > 0,05),but it might reduced the duration of DRPS. Type of suggestion which is 100 %accepted by health professionals were administration of drug to avoid drug-druginteraction, drug-nutrition interaction, and also to prevent adverse drugreactions. Other suggestion type related to complete documentation to avoidmedication errors, relieve adverse drug reaction and dosage form choice.Conclusion: Involvement of ward pharmacist during therapeutic process inhospitalized geriatric patients is important for identify, preventing and resolvedrug related problem in geriatric patients.


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INTRODUCTION

The number and proportion of elderly people in the population are

increasing as a result of improving in nutrition and public health, coupled with

advance in medicine that favor a longer life expectancy (Poi, et al., 2004). The

geriatric population in Indonesia is estimated to increase up to 414 % in 2025

compare to 1990 (Darmodjo, 2004).

Old age is associated with chronic diseases and disabilities, which in turn

require multiple medications. Nair survey was found that in a major teaching

hospital, 30% of older people were on 6-10 types of medications and 13% were

taking more than 10 types of medications each day (Nair, 1999). The high

prevalence of multiple drug use combined with age-related changes in

pharmacokinetics and pharmacodynamics makes older adults more vulnerable todrug-related problems (DRPs) (Thijs, et al., 2006)

Drug therapy problems are problems patients are undergoing that are

either caused by a drug or may be treated with a drug. The identification,

prevention, and solution of drug-related problems (DRPs), sometimes called

medicine-related problems or drug therapy problems, are the core processes of

pharmaceutical care. It is important to understand the difference between

medical problems and drug therapy problem. Any are activity to improve the use

of medicines is designed to correct or prevent actual and potential DRPs (Van

Mill, et al., 2004). These drug-related problems are summarized in Table 1

(Gharaibeh, et al., 1998).

The research about Drug Related Problems (DRPs) was done by Perst

(2003), The Minessota Pharmaceutical Care Project (1998) and Nanada, Fanale

and Cronholm (1990). Persts research was aimed to identify DRPs to geriatric

patients and obtained some forms of DRPs, such as; 25 % of ineffective drugs

included in the prescription, and secondary medicine prescript to cope with the

side effect of other medicines.


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Table I. Types and description of drug related problems

Problem Description

Untreated indication

Improper drug selection

Sub therapeutic dosage

Failure to receive drugs

Over dose

Adverse drug reaction

Drug interaction

Drug use without indication

The patient has a medical problem that requiresdrug therapy but is not receiving a drug for thatindication

The patient has a drug indication but taking thewrong drug

The patient has a medical problem that is beingtreated with too little of the correct drug.

The patient has a medical problem that is the resultof not receiving a drug (e.g. for pharmaceutical,psychological, sociological or economic reasons)

The patient has a medical problem that is beingtreated with too much of correct drug (ie, toxicity)

The patient has a medical problem that is the resultof an adverse drug reaction

The patient has a medical problem that is the resultof a drug-drug, drug-food, or drug-laboratoryinteraction

The patient is taking a drug for no medically validindication

The Minnesota pharmaceutical Care Project has identified the existence

of 5533 DRPs to 9399 patients (not only to the geriatric). The result of the

research showed that more than 1400 patient were suffering more than one DRP

category during the medication. The kind of DRPs found for example 15 % of

DRPs is identified to the patients accepted inaccurate drugs, 8 % of patients

accept therapy without clear indication, 6 % are over dosage, 16 % accept subtherapy dosage, 21 % are suffering ADR (Adverse Drug Reaction), and 11 % of

patients fail in accepting the drugs (Cipolle,et al., 1998). The research of Nanada,

Fanale, and Cronholm shows that the percentage of geriatric patients being


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hospitalized at hospital due to DRPs is approximately 17 %, 6 times bigger than

the patients in general.

Some studies showed that involvement of pharmacist during therapeutic

process could reduce incident of drug related problems. Mangasuli and Rao

studies (2004) showed that clinical pharmacist interventions can have a positive

impact on reducing drug-related errors in overall patient care. During the study

pharmacist gave 178 interventions, and the interventions by pharmacists were

accepted and the prescriptions altered accordingly in 139 cases (78.1%).

Drug-related problems (DRPs) are prevalent in hospitalized patients

especially in elderly, but study about drug related problems and impact of ward

pharmacist along therapeutic process in Indonesian elderly still limited.

OBJECTIVE

A research carried out to know the impact of ward pharmacists

involvement during therapeutic process to reduce drug related problems in

hospitalized geriatric patients.

METHOD

Research type was experimental design. Data taken by prospectively and

retrospectively through medical record in 100 geriatric patients hospitalized in

IRNA I interne department at Dr. Sardjito Hospital Yogyakarta. The geriatric

patient was patient with 65 years and above acording to WHO definision. .

Fifty patients conducted by prospectively, ward pharmacist identified drug

related problems and gave suggestion to the health care professional for prevent

and resolve drug related problems (group A). Another fifty case taken by

retrospectively just for identify drug related problems without intervention (group

B). Drug Related Problems was judged by pharmacist-physician discussion.

Drug related problems were divided into eight categories as follows:

1. Unnecessary drug therapy

2. Untreated indication

3. Wrong drug


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4. Dosage too low

5. Dosage too high

6. Adverse Drug Reaction (ADR)

7. Drug interaction (Clinically significant )

8. Failure to receive the drug

The data collected through medical record, patients medication chart,

injection book; followed by interview with patients, nurse, physician and other

health professional.

Descriptive statistics were shown as frequencies of Drug Related

Problems (DRPs) in both goup (group A and B). Test for influence ward

pharmacist in reducing drug related problems performed by Mann-Whitney test

RESULT AND DISCUSSION

Of the 100 cases of hospitalized geriatric patients 74.6.3% were women.

Their ages range from 66 to 90 years, with the average age was 72,03 6,57 (

SD). Majority of patients ages were between 65-79 years old. Yogyakarta

province has the highest proportion of older population (13.72%) in Indonesia.

The statistical data related with life expectancy for elderly in Yogyakarta, were 72

years old for women and 69 years old for men (BPS, 1998). The characteristics

of geriatric patients hospitalized are shown in Table 1.

Table 1: Characteristics of hospitalized geriatric patients

Variables Percentage of case of casesGender

Female 74.6 Age group (years)

65-6970-7980 and over

43.346.310.4

The result of the study showed that drug related problems occurred in

79.1 % patients who had at least one or more DRPs (maximize 5 DRPs in one

patient). We identified the existence of 121 events DRPs. The most commonly


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presented problems were drug use without indication/ unnecessary drug therapy

and wrong drug (Table II).

Table II. Percentage of patient with drug-related problems

Types of drug related problems Percentage

IndicationNeeds therapyUnnecessary drug therapy

EfficacyWrong drugDosage too Low

Safety ADRDosage too high

Compliance

6.655.4

14.07.4

5.89.11.7

The causes of unnecessary drug therapy were no medical indication and

non drug therapy more appropriate. The agent mostly common associated with

no medical indication were ranitidine and antibiotics. In some cases, ranitidine

was prescribed to prevent side effect/prophylactic therapy in low dose aspirin in

patient without peptic ulcer history. This problem classified into prescribing

cascade. The "prescribing cascade" begins whe n an adverse drug reaction ismisinterpreted as a new medical condition. Another drug is then prescribed, and

the patient is placed at risk of developing additional adverse effects relating to

this potentially unnecessary treatment. To prevent the prescribing cascade,

doctors should always consider any new signs and symptoms as a possible

consequence of current drug treatment. Before any new drug treatment is

started, the need for the drug should be re-evaluated and a non-drug treatment

should be considered. If drug treatment is necessary, the lowest feasible dose of

the drug should be used and alternative drugs with fewer adverse effects

considered (Rochon and Gurwitz, 1997 ).

Unnecessary drug therapy also was caused by no medical indication for

antibiotic prescribing (patient with normal white blood count (WBC), afebrile,

normal urinalysis, normal Thorax X-ray). Patients who are exposed to


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unnecessary drug therapies can only realize the toxic potential of that drug and

have little or no chance of realizing any positive outcome associated with such

unnecessary treatment. The cost of unnecessary drug therapy should also be

considered, because the patients must pay the direct expenses associated with

the consumption of unnecessary drug therapies (Cipolle, et al., 1998).

Some causes of wrong drug were more effective drug available,

potentially inappropriate for elderly patients and contraindication in geriatric

patient. Some agents most commonly associated with potentially inappropriate

for elderly patient were diazepam, parafin liq (laxative), and uneffective

antibiotic due to resistension prblem. Long acting benzodiazepines (diazepam)

have a long half-life in elderly patients (often several days), producing prolonged

sedation and increasing the risk of falls and fractures. Diazepam is potentiallyinappropriate for elderly. Short and intermediate-acting benzodiazepines are

preferred if a benzodiazepine is required (Fick, et al., 2003)

Inappropriate dose of some drugs (dosage too high) were largely caused

by non-adjusted dosage for patients with renal disorder. While our study showed

that number of adverse drug reactions was 5,8 %. The World Health

Organization (WHO) describes ADRs as the noxious and unintended drug affect,

which occurs at doses employed in man for prophylaxis, diagnosis or therapy

(Gharaibeh, 1998). Research into the incidence of adverse drug reactions

(ADRs) among elderly people has yielded greatly varying results with estimates

of incidence in hospitalized patients ranging from 1.5% to 35%. Several studies

have assessed the association between age and ADRs. The results have been

variable, but a trend for a relationship between age and increased incidence of

ADRs has been established (Walker and Wynne, 1994).

The elderly people are using more medication than younger people. The

shadow side of multiple drug use however, is the frequent occurrence of drug

related problems such as drug-drug interactions. A drug-drug interaction is said

to occur when the effects of one drug are changed by the presence of another

drug. The outcome can be harmful if the interaction causes an increase in the

toxicity of the drug. A reduction in efficacy due to an interaction can sometimes


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be just as harmful as an increase. Puckett and Visconti study (1971) revealed

that 113 (4.7%) were taking combinations of drugs that could interact, but

evidence of interactions was observed in only seven patients, representing only

0.3%. During our study, we found that almost all cases have drug-drug

interaction but none of them have clinical significance.

. All the interventions (fifty patients), over a period of 2 month between

July and August 2008, were evaluated for their appropriateness. First, ward

pharmacist identified drug related problems then they gave the suggestion to

the health care professional for prevent and resolve drug related problems. A

number of 30 suggestion have been given to physician, nurse and pharmacist (at

dispensing unit). The suggestion given by ward pharmacist during ward round

together with physician, nurse and pharmacist. Most of the suggestion bypharmacists were accepted (86.7 %). Type of intervention given by pharmacist

related with the problem as follows:

1. Improper drug administration to avoid drug-drug and drug food , and to reduce

ADR

2. Improper dosage related with patients renal status

3. Improper selection of drug.

4. Unnecesary drug therapy

5. Other matters that could influence outcame therapy such as medication errors

Type and number of intervention given by ward pharmacist seen in Table III.

Table III Type and number of intervention given by ward pharmacist

No Type of intervention Type of interventionagreed by physician

Type of interventionrefused by physician

1 Improper drug administration- drug-food interaction- drug-drug interaction- to reduce ADR

7 0

2 Medication errors 2 03 Unnecesary drug therapy 6 14 Resolved of ADRs 3 05 Improper dosage related with

patients renal status 5 1

6 Improper selection of drug. . 2 27 Improper dosage form 1 0Jumlah 26 4


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Type of suggestion which is 100 % accepted by health professionals were

related with drug administration in case of occured of drug-drug interaction, drug-

nutrition interaction, and also to prevent adverse drug reactions. Other

suggestion type related to complete documentation to avoid medication errors,

resolved adverse drug reaction and dosage form choice accepted by physician

as well.

Our research showed involvement of ward pharmacist in therapeutic

process did not reduced amount of DRPS in every categories (p value > 0,05)

(Table IV and V).

Table IV Compare mean of drug related problem between two groupType of DRP Group A Group B

Min Max Mean Min Max Mean

DRP1 Indication needstherapy ,00 1,00 ,0800 ,00 1,00 ,2353

DRP2 Indication unnecessarydrug therapy ,00 4,00 1,0000 ,00 4,00 1,0000

DRP3 Efficacy wrong drug ,00 2,00 ,2200 ,00 2,00 ,3529DRP4 Efficacy dosage too low ,00 1,00 ,1000 ,00 1,00 ,2353DRP5 Safety ADRs ,00 1,00 ,0600 ,00 2,00 ,2353

DRP6 Safety dosage too high ,00 2,00 ,1600 ,00 2,00 ,1765Note: Group A : Group without pharmacist interventionGroup B : Group with pharmacist intervention

Table V Mann Whitney Test between two group

DRP1 DRP2 DRP3 DRP4 DRP5 DRP6Mann-Whitney U 359,000 394,500 377,000 367,500 374,000 425,000Wilcoxon W 1634,000 547,500 1652,000 1642,500 1649,000 578,000Z -1,693 -,466 -,978 -1,403 -1,485 ,000

Asymp. Sig. (2-tailed) ,090 ,641 ,328 ,161 ,138 1,000

Note : DRP1 = Indication needs therapyDRP2 = Indication unnecessary drug therapyDRP3 = Efficacy wrong drugDRP4 = Efficacy dosage too lowDRP5 = Safety ADRDRP6 = Safety dosage too high


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The most reason of non significance between groups is that in our research most

of the suggestion given by pharmacist after pharmacist found DRPs already

exist. However, it might reduced the duration of DRPs through the pharmacist

intervention and resolved DRPs as well.

Our research found that involved of ward pharmacist during therapeutic

process for geriatric hospitalized patient is very important especially as drug

informant. The most of question came from physician related with drug of choice,

pharmacokinetics of the drug, drug interaction, the drug price, and drug

adjustment in renal disease.

Therefore, the whole health care system such as patients, community,

nurses, general practitioners, hospital staff and pharmacists should work together

for older people. Communication between all these professionals is vital toimprove appropriate prescriptions and thereby patient outcomes (Nair, 1999).

CONCLUSION

Involvement of ward pharmacist during therapeutic process in hospitalized

geriatric patients is important for identify, preventing and resolve drug related

problem in geriatric patients.

REFERENCE

Cipole, R.J., Strand, L.M., Morley, P.C., 1998, Pharmaceutical Care practice ,McGraw-Hill, New York, p. 73 95, 115 119.

Central Statistics Bureau (1998) Projection of Indone sian Population in everyprovince year 1995 to 2005. BPS (Jakarta); 1998.

Darmodjo, R.B., 2004, Trough Healthy and Active Ageing to Successful Ageing,Naskah Lengkap Konggres Nasional III dan Temu Ilmiah Nasional II

Perhimpunan Gerontologi Medik Indonesia, Yogyakarta, p. 2-10.

Fick, D.M., Cooper, J.W., Wade, W.E., Waller, J.L., Maclean, R., Beers, M. H.,2003, Updating the Beers Criteria for Potentially Inappropriate MedicationUse in Older Adults, Arch intern Med, Vol.163, p. 2716-2724.

Gharaibeh, M.N., Greenberg, H.E., Waldan, S.A., 1998, Adverse Drug reaction : A review, Drug Information Journal , Vol. 33, p. 323-338.


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Nair, B., 1999, Older people and medications: what is the right prescription ? ,Aust Prescr, Vol. 22 , p. 130-1

Puckett, W.H., Visconti, J.A., 1971, An epidemiological study of the clinical

significance of drug-drug interaction in a private community hospital. Am J Hosp Pharm, Vol. 28, p. 247.

Prest, M., 2003, Penggunaan Obat Pada Lanjut Usia dalam : Farmasi Klinis(Clinical Pharmacy) Menuju Pengobatan Rasional dan PenghargaanPilihan Pasien, PT Elex Media Komputindo, Jakarta, hal. 203-208

Poi, P.J.H., Forsyth, D.R., Chan, D.K.Y., 2004, Services for older people inMalaysia: issues and challenges, Age and Ageing , Vol. 33 No 5. p. 444-446

Rochon, P.A., Gurwitz, J.H., 1997, Education and debate: Optimizing drugtreatment for elderly people: the prescribing cascade, BMJ , Vol.315,p.1096-1099

Semla, T.P., Beizer, J.L., Higbee, M.D., 2004, Geriatric dosage handbook , 9 thed, Lexi-Comp Inc, USA

Thijs, H.A.M.V., Fred, H.P.D., Ton, M.D, Toine, C.G.E., 2006, Identification of potential drug-related problems in the elderly: the role of the communitypharmacist, Pharm World Sci , Vol. 28, p. 33 - 38

Van Mill JWF, Westerlund LOT, Schaefer MA, 2004, Drug-Related ProblemClassification System, Ann Pharmacother , Vol. 38, p. 857-67

Walker, J., Wynne, H., 1994, Review: the frequency and severity of adverse drugreactions in elderly people, Age and Ageing , Vol.23, No. 3, p.255-259http://findarticles.com/p/articles/mi_m2459/is_n3_v23/ai_15465854

Mangasuli, S., & Rao Padma, G.M., 2006, Clinical interventions: A preliminarysurvey in South Indian teaching hospital, Indian J Pharmacol ; 38:361-362

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