How to improve drug dosing for patients with renal impairment in primary care - a cluster-randomized controlled trial

Antje Erler,Ferdinand M Gerlach,Justine Rochon,Martin Beyer,Thomas Rath,Kristina Saal,Walter E Haefeli,Juliana J Petersen

doi:10.1186/1471-2296-13-91

Abstract

BackgroundPatients with chronic kidney disease (CKD) are at increased risk for inappropriate or potentially harmful prescribing. The aim of this study was to examine whether a multifaceted intervention including the use of a software programme for the estimation of creatinine clearance and recommendation of individual dosage requirements may improve correct dosage adjustment of relevant medications for patients with CKD in primary care.MethodsA cluster-randomized controlled trial was conducted between January and December 2007 in small primary care practices in Germany. Practices were randomly allocated to intervention or control groups. In each practice, we included patients with known CKD and elderly patients (≥70 years) suffering from hypertension. The practices in the intervention group received interactive training and were provided a software programme to assist with individual dose adjustment. The control group performed usual care. Data were collected at baseline and at 6 months. The outcome measures, analyzed across individual patients, included prescriptions exceeding recommended maximum daily doses, with the primary outcome being prescriptions exceeding recommended standard daily doses by more than 30%.ResultsData from 44 general practitioners and 404 patients are included. The intervention was effective in reducing prescriptions exceeding the maximum daily dose per patients, with a trend in reducing prescriptions exceeding the standard daily dose by more than 30%.ConclusionsA multifaceted intervention including the use of a software program effectively reduced inappropriately high doses of renally excreted medications in patients with CKD in the setting of small primary care practices.Trial registrationCurrent Controlled Trials ISRCTN02900734

Highlights

Patients with chronic kidney disease (CKD) are at increased risk for inappropriate or potentially harmful prescribing
Our intervention reduced the proportion of patients with prescriptions exceeding the recommended maximum daily dose, with a trend in reducing the proportion of patients with at least one prescription exceeding the recommended standard daily dose by more than 30%
Studies show that treatment with ACEI and angiotensinreceptor blockers (ARB) reduces the progression of CKD [9], e.g. Benazepril was associated with a 52% reduction in the level of proteinuria and a 23% reduction in the rate of decline in renal function [31]

Summary

Introduction

Patients with chronic kidney disease (CKD) are at increased risk for inappropriate or potentially harmful prescribing. The care family physicians provide to populations at risk puts them in a position to help detect CKD early and prevent progression [12]. Detection of CKD requires estimation of creatinine clearance, because the measurement of serum creatinine alone can be misleading, especially in elderly populations [13,14]. Recommendations on dosage adjustment are missing in up to 70% of the summaries of product characteristics provided by the pharmaceutical industry, and in other information sources available to family physicians [18], leading to the prescription of inappropriately high medication dosages in primary care [19]

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