Drug Therapy Problems Research Articles

The missing piece: Clinical pharmacists enhancing the interprofessional nephrology clinic model

ObjectivesTo embed pharmacy residents in an interprofessional nephrology clinic to conduct medication reconciliation in targeted high-risk patients with nondialysis kidney disease. SettingThis pilot was a prospective quality improvement initiative conducted in an interprofessional outpatient nephrology clinic. Practice descriptionThe nephrology clinic team includes nephrology providers, a social worker, and a geriatrician. The team is responsible for the management of conditions such as nondialysis kidney disease, resistant hypertension, acute kidney injury, proteinuria, and nephropathy. EvaluationPrimary outcomes included the number and type of medication discrepancies and drug therapy problems identified. Secondary outcomes included the changes in care process directly resulting from the pharmacy residents’ recommendations. The perceived value of the pharmacy residents to the interprofessional team was assessed through postintervention anonymous surveys and semistructured interviews. ResultsThe pharmacy residents conducted 118 visits for 87 unique patients (mean age 73 years, 97% male) with nondialysis kidney disease (89% stages III–V), polypharmacy (87% of patients taking > 10 medications), and a heavy comorbidity burden (85% hypertension, 80% dyslipidemia, 59% diabetes mellitus type II) from January to October 2017. Pharmacists identified 344 medication discrepancies and 301 drug therapy problems, resulting in 398 changes in care process. The most frequently identified discrepancies and drug therapy problems were the omission of an active medication from the medication list (86 of 344 discrepancies, 25%) and potentially inappropriate medications (106 of 301 drug therapy problems, 35%). Pharmacists recommended 228 medication changes, provided 76 adherence devices, facilitated 24 consults or referrals, and communicated with the primary care team on 70 occasions. The interprofessional team members all strongly agreed that patients and the team benefited from the pharmacists’ involvement. ConclusionPharmacy resident–led medication reconciliation resulted in the identification and resolution of medication discrepancies and drug therapy problems, leading to changes in the care process.

Development, Testing and Results of a Patient Medication Experience Documentation Tool for Use in Comprehensive Medication Management Services.

The medication experience is an individual’s subjective experience of taking a medication in daily life and can be at the root of drug therapy problems. It is recommended that the patient-centered approach to comprehensive medication management (CMM) starts with an understanding of the patient’s medication experience. This study aims to develop a medication experience documentation tool for use in CMM services, and to understand the usefulness and challenges of using the tool in practice. The tool was developed based on previous research on patients’ medication experiences. It was tested in two rounds by ten CMM pharmacists utilizing the tool as they provided care to patients. Focus groups were conducted to revise the tool after each round and to understand pharmacists’ experiences. The tool was tested for 15 weeks in 407 patient encounters. There was at least one medication experience documented in the electronic medical record 62% of the time. Pharmacists found the tool helpful in raising awareness of the medication experience and motivational interviewing strategies, planning for follow-up visits, as a teaching tool, and making pharmacists realize the fluidity of the medication experience. The tool offered pharmacists a better way to recognize and address medication experiences affecting medication taking behaviors.

Clinical Results of Comprehensive Medication Management Services in Primary Care in Belo Horizonte.

The high prevalence of chronic diseases and use of multiple medications identified in Primary Health Care (PHC) suggest the need for the implementation of Comprehensive Medication Management (CMM) services. This study aimed to evaluate the clinical results of CMM services in a Brazilian PHC setting. A quasi-experimental study was performed with patients followed-up for two years (n = 90). Factors associated with the detection of four drug therapy problems (DTP) or more in the initial assessment were evaluated (univariate and multivariate analyses), as well as the clinical impact observed in laboratory parameters (HbA1c, Blood Pressure, LDL- and HDL-covariance analysis). A predominance of women (61.1%), a mean age of 65.5 years, and a prevalence of polypharmacy (87.8%)—use of five or more drugs—were observed. A total of 441 DTP was identified, 252 required interventions with the prescriber, 67.9% of which were accepted and 59.6% were solved. The main DTP were ‘non-adherence’ (28.1%), ‘need for additional drug therapy’ (21.8%), and ‘low dose’ (19.5%). Hypertension was positively associated with the identification of four DTP or more. A statistically significant reduction was detected in all assessed laboratory parameters (p < 0.05). CMM services contributed to the resolution of DTP and improved clinical outcomes.

Drug Therapy Problems in NCAA Division I-A Minnesota Gopher Student-Athletes.

As with all competitive sports, in NCAA Division I-A athletics it is important to maximize controllable factors in order for each athlete to compete at his or her best. One important and controllable factor that has the potential for improvement is the athlete's medication experience. When medications are used to treat the correct condition, administered at the right time, and with the correct dose, they have the potential to improve outcomes and enhance athletic performance. As an example, it is essential that a soccer player who has asthma is using the correct inhaler, at the correct time, with proper technique, and with the correct number of puffs in order to support breathing and improve oxygen transportation during a game. Ineffective and unsafe use of medications can lead to serious diseaserelated events and also prevent an athlete from achieving their performance goals when they are not being used correctly. The goal of this project was to explore the presence and extent of drug therapy problems (DTPs) among a college athlete population. Within the 10 student-athletes who were interviewed, there were a total of 36 drug therapy problems identified, many of which were tied to a lack of understanding for their own medication regimen. This project suggests that medication-related needs may not be appropriately addressed among the college athlete population. The addition of a pharmacist on the athletic healthcare team would ensure appropriate medication use and optimization for health outcomes and overall athletic performance.

The study of adverse drug reactions of antihypertensive medicines in essential hypertension patients in Hi-Tech Medical College and Hospital, Bhubaneswar, Odisha, India

Background: Every drug has the potentiality to cause an adverse drug reaction (ADR). ADRs are a major problem in drug therapy .The aim of this study was to assess the incidence and causality of ADRs to antihypertensive agents used for the essential hypertensive patients attending at the general medicine out patients departments of Hi-Tech Medical College and Hospital, Bhubaneswar Odisha, during the time period of November 2016 to October 2018.Methods: This prospective-observational study was carried out in general medicine outpatient department of Hi-Tech Medical College and Hospital, Bhubaneswar, Odisha.Results: Out of 254 patients, 78 (30.71%) patients were developed ADRs to antihypertensive drugs. 51 (65.38%) were female and 27 (34.62%) were male. Calcium channel blockers were the commonest therapeutic class of antihypertensive drugs associated with ADRs (n = 50, 64.10%). According to WHO causality assessment scale most of the ADRs were “probable” 41 (52.56%), followed by “possible” 21 (26.92%), unclassifiable 13 (16.67%) and unlikely 3 (3.85%).Conclusions: The results of this study concluded that antihypertensive drugs able to induce the development of adverse drug reactions, which were significant cause of increase burden on health care system and decrease the quality of life, the health care professionals should take care about the rational use of antihypertensive agents. Thus, to minimize the incidence of adverse drug reaction and to increase the quality of life.

Pharmacists’ attitude, self‐reported knowledge and practice of dosage adjustment among chronic kidney disease patients in Malaysia

AbstractDrug‐related issues, such as inappropriate drug dosing, are pervasive patient issues that are particularly common among chronic kidney disease (CKD) patients. Pharmacists have the expertise to play an important role in avoiding such problems. The aim of the present study was to explore pharmacists’ self‐perceived knowledge, attitude and practice towards dosage adjustment among CKD patients. A cross‐sectional, Web‐based, self‐administered survey was conducted among 1594 registered pharmacists in Malaysia. Participants were surveyed regarding their perceived knowledge, attitude and implementation of drug dosage adjustment based on renal function among CKD patients in their practice. The study was completed by 234 pharmacists (14.7%). More than four‐fifths of respondents (n = 199) reported that they are practicing dosage adjustment. The median self‐perceived knowledge score was 27.0 (of a total of 45). Pharmacists younger than 29 years of age and those practicing in hospitals had higher knowledge of drug dosage adjustments. Female pharmacists were more likely to express interest in being involved in the identification, monitoring and resolution of drug therapy problems for CKD patients (p = 0.02). The two most common obstacles reported by pharmacists who did not practice dosage adjustment were a lack of information regarding a patient's renal function status (76%) and medical history (74%). Further training should be given to pharmacists to improve knowledge and awareness. An alert card could be implemented to record a patient's renal function to improve communication between hospitals and primary care settings.

Kajian Drug Related Problems (DRPs) Terhadap Pengobatan Pasien Stroke Iskemik di Rumah Sakit Pusat Otak Nasional Jakarta Periode Januari – Desember 2015 S

This study aims to determine the percentage of DRPs of ptients with ischemic stroke at Brain Center National Hospital Jakarta. Based on data from the WHO 2006, each year there are approximately 13 million new stroke patients of which approximatelly 4,4 million of them die within 12 months.When patients undergo a treatment, most patients achieve optimal results that heal diseases suffered by patients but not least the failure in therapy. Therefore, the contribution required to identify, resolve and prevent problems in drug therapy known as Drug Related Problems (DRPs). The method used in this study is cross sectional. Total sample data obtained as many as 360 samples. The results showed indications without drugs of 55.62%, drugs without indication of 15.17%, drug interactions of 10.11%, patients fail to receive the drug of 7.86%, side effects of 6.18% and less drug selection right of 5.06%. Data show that the highest percentage of DRPs are indications without drugs.

Legal and Medical Aspects of Off-Label Medication Use. Point of View

The current state of the Russian and foreign regulatory framework for off-label prescription of medicines is presented in the article. The existing problems of this specific drug therapy and possible solutions are described. Unfortunately, there are some gaps in the Russian legislation regarding the off-label medication use. Based on the clinical reality, in some cases, the “off-label” drugs prescription can be justified by the clinical condition of the patient, the lack of alternative approved drugs, and the availability of published scientific data that create the prerequisites for the effectiveness of this approach. When off-label drug prescribing as a forced measure, the doctor must provide a rationale for this prescription in the medical documentation, the conclusion of the consultation (with the participation of relevant specialists and the clinical pharmacologist) or the medical commission (with the participation of the administration representative), and the written informed consent of the patient or his legal representative. This information should be actively communicated to doctors in order to increase their legal literacy and prevent possible negative and legal consequences.

Evaluation of Pharmacist Involvement in Medicare Wellness Visits

Purpose: To evaluate the difference in the number of drug therapy interventions between patients seen by pharmacists and patients seen by nonpharmacist providers during Medicare Annual Wellness Visits (AWVs). Methods: Pharmacists completed the medication history portion of AWVs at a primary care, interdisciplinary clinic in Central Texas. Drug therapy problems were collected and compared to those identified by physicians conducting AWVs. Drug therapy problems were grouped into 4 categories: indication, effectiveness, safety, and adherence. Each category was divided into subcategories to further specify the problem. Results: Fifty patients received an AWV in each group. Pharmacists identified more drug therapy problems in all 4 categories as compared to physicians (100 vs 20 interventions, respectively) and significant differences were detected in most subcategories: indication without medication (P = .005), suboptimal regimen (P = .0034), drug–drug interaction (P = .0267), warning/precaution requiring additional monitoring (P = .0267), nonadherence (P = .0058), and patient lack of understanding medication therapy (P = .005). Conclusion: Pharmacist involvement in AWVs helped identify drug therapy problems.

Non-dispensing pharmacists' actions and solutions of drug therapy problems among elderly polypharmacy patients in primary care.

To evaluate the process of clinical medication review for elderly patients with polypharmacy performed by non-dispensing pharmacists embedded in general practice. The aim was to identify the number and type of drug therapy problems and to assess how and to what extent drug therapy problems were actually solved. An observational cross-sectional study, conducted in nine general practices in the Netherlands between June 2014 and June 2015. On three pre-set dates, the non-dispensing pharmacists completed an online data form about the last 10 patients who completed all stages of clinical medication review. Outcomes were the type and number of drug therapy problems, the extent to which recommendations were implemented and the percentage of drug therapy problems that were eventually solved. Interventions were divided as either preventive (aimed at following prophylactic guidelines) or corrective (aimed at active patient problems). In total, 1292 drug therapy problems were identified among 270 patients, with a median of 5 (interquartile range 3) drug therapy problems per patient, mainly related to overtreatment (24%) and undertreatment (21%). The non-dispensing pharmacists most frequently recommended to stop medication (32%). Overall, 83% of the proposed recommendations were implemented; 57% were preventive, and 35% were corrective interventions (8% could not be assessed). Almost two-third (64%) of the corrective interventions actually solved the drug therapy problem. Non-dispensing pharmacists integrated in general practice identified a large number of drug therapy problems and successfully implemented a proportionally high number of recommendations that solved the majority of drug therapy problems.

Implementing a pharmacist-led in-home medication coaching service via community-based partnerships

ObjectivesTo describe one independent pharmacy group’s experience delivering and being reimbursed for in-home medication coaching, or home visits, to high-risk and high-complexity community-dwelling patients. SettingA nondispensing clinical division of an independent community pharmacy in Seattle, Washington. Practice innovationA community pharmacist–led in-home medication coaching program delivered through partnerships with 3 community-based organizations for referrals and payment over a 4.5-year period. Community-based partners included a state comprehensive care management program, a local health system’s cardiology clinic, and the local Area Agency on Aging. EvaluationA retrospective analysis of patient demographics, drug therapy problems, interventions, and pharmacy and technician time was conducted with the use of the pharmacy’s internal patient care documentation and billing systems from January 1, 2012, to June 31, 2016. ResultsA total of 462 home visits (142 initial, 320 follow-up) were conducted with 142 patients. Patients averaged 13 disease states (range 3–31) and 16 medications (range 1–44) at their initial visit. Pharmacists identified an average of 11 drug therapy problems per patient (range 1–36) and performed an average of 13 interventions per patient (range 1–48). The most common drug therapy problem identified was nonadherence, and the most common intervention performed was education. The median pharmacist time in the home was 1.5 hours (range 0.67–2.75) for an initial visit and 1 hour (range 0.08–2.25) for a follow-up visit. ConclusionHome visits can be successfully implemented by community pharmacists to provide care to high-risk and high-complexity community-dwelling patients. Our experience may inform other community pharmacy organizations looking to develop similar home visit services.

Evaluation of Collaborative Medication Reviews for High-Risk Older Adults

Despite the widespread use of medication reviews, many older adults are still exposed to the risks of polypharmacy. To quantify and describe the drug therapy problems identified and interventions undertaken by pharmacists before and after implementation (on July 1, 2015) of collaborative medication review for high-risk older adult patients (> 80 years of age). A retrospective single-centre pre-post cohort study was conducted between July 1, 2014, and July 31, 2016, to characterize the impact of collaborative medication reviews-consisting of a thorough medication review by a pharmacist and care conferences with the hospitalist and family physician-on prescribing patterns in an Acute Care for Elders unit. A standardized template was used to conduct medication reviews for the post-implementation group, whereas a chart review was conducted for the pre-implementation group. The primary outcomes were the number of drug therapy problems identified by the clinical pharmacists and the associated interventions by the pharmacists, which were categorized as clinical or compliance interventions. Secondary outcomes included the number of medications at discharge, the rate of hospital readmission within 30 days, and the length of hospital stay. A total of 137 patients were identified for inclusion in either the pre-implementation group (n = 70) or the post-implementation group (n = 67). After implementation of collaborative medication reviews, there were statistically significant increases in the mean number of drug therapy problems identified (p < 0.001), the mean number of interventions undertaken (p = 0.004), and the median length of hospital stay (p < 0.001). There was no difference between the 2 groups in the number of medications at discharge, the proportion of patients taking more than 5 medications at discharge, or readmission within 30 days. At the study institution, implementation of a quality improvement program that included pharmacist-led medication reviews and collaborative care conferences involving community and hospital care providers helped to improve documentation by clinical pharmacists of potential medication-related problems and led to more interventions to optimize patients' medication regimens.

Drug therapy problems among patients with cardiovascular disease admitted to the medical ward and had a follow-up at the ambulatory clinic of Hiwot Fana Specialized University Hospital: The case of a tertiary hospital in eastern Ethiopia.

Background:Pharmacotherapy is important in reducing morbidity and mortality related to cardiovascular diseases. However, these advantages are limited by drug therapy problems that can impact on a patient’s quality of life, prolong hospital stays, and increase the overall burden of healthcare expenditures. Therefore, this study was aimed to assess drug therapy problems among patients with cardiovascular diseases who were hospitalized and received follow-up at the ambulatory clinic of Hiwot Fana Specialized University Hospital.Methods:An institution-based cross-sectional study design was used to collect data from patients with cardiovascular diseases who were admitted to the medical ward and those who had received follow-up at the ambulatory clinic of Hiwot Fana Specialized University Hospital. The collected data were coded, entered, and analyzed using SPSS version 16. The associations of selected categorical variables were done using binary logistic and multivariate logistic regression analyses.Results:Out of 216 study participants, females accounted for 123 (57%), whereas 93 (43%) of them were males. Among cardiovascular diseases identified in the medical ward and ambulatory clinics of Hiwot Fana Specialized University Hospital, congestive heart failure 96 (44.4%) and hypertension 93 (43.1%) were the two most commonly diagnosed disorders. Of the total participants involved in the study, 131 (60.65%) had drug therapy problems. Among the seven classes of drug therapy problems assessed, the most commonly observed was the need for additional drug therapy 76 (58%); followed by cases related to unnecessary drug therapy and noncompliance both of which were estimated to be 16 (12.2%). In addition, of independent variables, only the use of more than three drugs was significantly associated in both binary logistic (crude odds ratio = 0.41, 95% confidence interval = 0.234–0.719, p = 0.002) and multivariate logistic regressions (adjusted odds ratio = 4.86, 95% confidence interval = 1.625–14.536, p = 0.005) as compared with those patients who were using less than three drugs.Conclusion:The findings of the study indicated that more than half of the study participants experienced drug therapy problems, for which 58% required additional drug therapy. The risk of drug therapy problem is found to increase with the use of more than three drugs. Since these problems are adversely affecting the treatment outcome of patients, this is an area which requires special attention and the cooperation of healthcare professionals to tackle it.

A Review on Drug Therapy Problems

Drug therapy problems are the clinical territory of the pharmaceutical care practitioner and the resolution of identifying drug therapy problem help patients to achieve their goals of therapy and understand the best possible outcome from drug therapy. Drug therapy problem represent the foremost responsibility of pharmaceutical care practitioner. Medication Therapy Management is medical care provided by the pharmacists whose aim is to optimize drug therapy and improve therapeutic outcomes for patients. It is medical care provided by the pharmacists whose aim is to optimize drug therapy and improve therapeutic outcomes for patients. Medication Therapy Management includes five core components: A medication therapy review [MTR], Personal medication record [PMR], Medication rela Documentation Ted action plan [MAP] Intervention and or referral, and Documentation and follow up. These proposed methods were successfully applied for simultaneous maintenance of the patient pharmacist relationship[1]

Drug Therapy Problems and Determinants among Ambulatory Type 2 Diabetes Mellitus Patients: Pharmacists’ Intervention in South-East Ethiopia

Background: Type 2 diabetes mellitus is a major public health problem which affects the large number of people worldwide. Diabetes mellitus patients are at high risk of experiencing drug therapy problems due to different factors. Involvement of pharmacists in the management of diabetes mellitus has been shown to reduce the incidence of drug therapy problems. Objectives: To assess the prevalence of drug therapy problems, pharmacists’ intervention and determinants of drug therapy problems in the management of type 2 diabetes mellitus patients. Methods: Facility based prospective cross sectional study was conducted among ambulatory type 2 diabetes mellitus patients at Madda Walabu University Goba Referral Hospital from April 1, 2017 to June 30, 2017. Data was analyzed using SPSS version 22. Descriptive statistics was performed to determine the proportion of drug therapy problems and pharmacist acceptance rate. Logistic regressions analysis was performed to identify determinants of drug therapy problems. A p-value of less than 0.05 was considered as statistically significant. Result: A total of 216 type 2 diabetes mellitus participants were included, of these 52.8% were males. The mean age of study participants was 57.07 ± 13.126 years. Among the study participants, 88% have at least one drug therapy problems. Needs additional drug therapy was the most frequent (50.2%) followed by non-compliance (21.7%). Metformin with glibenclimide and insulin were the most frequently prescribed anti diabetic drugs accounts for 40.3% and 27.8%, respectively. The recommendation done by pharmacists were 94%, the most common intervention done was to add new drug (50.2%). The acceptance rate for the interventions done was 72.6%. Conclusion: The prevalence of drug therapy problems among type 2 diabetes patients was high. Statin and metformin use not optimized. The involvement of clinical pharmacists in problems intervention should be promoted to decrease drug related risk and increase medication adherence of the diabetic patients.

Study on colorectal cancer using air-liquid interface organoid culture method

Colorectal cancer is a disease with high unmet medical needs. An increase in the number of cancer patients who are resistant to anti-cancer drugs is one of factors that increase the number of fatalities. Since there was no suitable experimental model to recapitulate the tumor environment in which various cells in the tissues exist, it was extremely difficult to develop a medicine that overcomes the anti-cancer drug resistance in each colorectal cancer patient. In this review, we describe the current status and problems of drug therapy for colorectal cancer patients, and introduce our study to develop the new targeting drugs using human colon tissue-derived air liquid interface organoid culture method.

The Excellence of Pharmacy Service: Past, Present and Future

Pharmacy education continues to evolve to better prepare pharmacists for their roles and responsibilities in an increasingly complex health care environment with advanced patient health needs. Another important factor is the pharmacists themselves. Over the past 50 years, the role of pharmacists has evolved along with the health care needs of our population. In addition to dispensing medications and ensuring patient safety, today’s pharmacists are taking a larger role as medical counselors, educators and advocates. They are integral part of the health care team, and are among the most trusted and accessible health care professionals. This accessibility allows them to perform more patient care activities, including counseling, medication management, and preventive care screenings. Beyond the care provided to individual patients, pharmacists have expanded their reach to influence the public health of communities. A pharmacist is uniquely positioned to provide disease state management through appropriate medication therapy management that has been demonstrated to improve patient outcomes and decrease overall health care costs. This role is more important than ever as the environment is demanding new practice and payment models that are required to further optimize care and outcomes while addressing the unsustainable increases in health care costs. All people who take medications are at risk of actual or potential drug therapy problems. These problems are a significant source of morbidity and mortality when left undetected and unresolved and drive huge costs across the health system. As drug therapy experts, pharmacists provide drug therapy management services built around a partnership between the pharmacist, the patient (or his or her caregiver), physicians and other members of a patient’s health care team.

A CASE REPORT ON DIGOXIN INTOXICATION IN A CLINICAL PHARMACIST’S PERSPECTIVE

Context: Digoxin is a commonly used inotropic drug that has a narrow therapeutic range and is monitored poorly for its plasma concentration. It is commonly used in the management of cardiovascular disorders for its inotropic effects. Increased risk of chronic digoxin toxicity among the patients receiving digoxin pharmacotherapy is related to its narrow therapeutic range. Apart from its inotropic properties, it can also produce chronotropic and dromotropic effect. Its serum levels vary due to changes in body weight, age, renal function, hepatic impairment, and concomitant drug administrations. Patients receiving digoxin should be monitored periodically for potential drug interactions, adverse effects, toxicity, and other drug-related problems. Symptoms of digoxin-induced cardiotoxicity are difficult to be identified and may become fatal too. Therapeutic drug monitoring will play a significant role in reducing such drug therapy problems and will ensure safety and efficacy of the given drug. Case Report: We report a case of chronic digoxin toxicity in a 22-year-old male with congestive cardiac failure - Class IV and atrial fibrillation with ventricular bigeminy. Results: Patient’s renal parameters were elevated and among electrolytes, sodium level was decreased and potassium level was increased. A reduction in the volume of the distribution of digoxin, due to impairment of renal function or congestive cardiac failure, might be one of the reasons for digoxin toxicity. Drug therapy problems (DTPs) such as untreated indication, inappropriate drug therapy, potential major drug-drug interactions, and drugs prescribed when contraindicated were observed. Conclusion: Monitoring digoxin drug therapy can bring down the risk of digoxin intoxication.

Inflammatory bowel diseases: course peculiarities and drug therapy in pregnant women. Lactation. Personal matters (by the materials of the second european consensus on reproduction and pregnancy in patients with inflammatory bowel diseases, 2015)

The paper presents a continuation of discussion regarding personal matters on the course of inflammatory bowel diseases (IBD) such as ulcerative colitis (UC) and Crohn’s disease (KD) in pregnant women, including the problems of basic drug therapy of the main disease both during pregnancy and lactation period. Separately, there are data on safety of conducted therapy, indications for surgical treatment and use of biological genetically engeneered drugs. The paper is based on the materials of “The Second European Consensus on Reproduction and Pregnancy in Patients with Inflammatory Bowel Diseases, 2015”. The main positions are presented according to the criteria of evidence-based medicine.

Clinical Utility of Pharmacogenetic Testing and a Clinical Decision Support Tool to Enhance the Identification of Drug Therapy Problems Through Medication Therapy Management in Polypharmacy Patients.

In polypharmacy patients, medication therapy management (MTM) services provide a comprehensive review of current medications and future treatment goals. Pharmacogenetics (PGx) may further optimize the identification of potential drug therapy problems (DTPs); however, the clinical utility of PGx information with a clinical decision support tool (CDST) in an MTM setting in identifying DTPs has not been systematically assessed. To assess the clinical utility of an MTM service enhanced by pharmacogenetic test results and a clinical decision support tool. This study was a post hoc analysis of the data obtained from an open-label, randomized, observational trial. Polypharmacy patients eligible for MTM service were randomly assigned to 3 intervention arms: standard MTM (SMTM), MTM incorporating CDST (CMTM), and CMTM further enhanced by PGx test results of CYP450 and VKORC1 enzymes (PGxMTM). Allocation for this post hoc analysis was based on patient adherence to the research protocol and completion of a PGx test. The number of DTPs per patient was compared across the 3 arms using analysis of variance. In addition, the frequency of serious DTPs as a categorical variable (grade 3 or above vs. lower grade) was compared across the 3 arms between PGx driven and non-PGx driven DTP recommendations. Statistical significance was tested using the chi-square test. The level of agreement between the DTP seriousness and the acceptance made by prescribers was presented as Cohen's kappa coefficient. Numbers of patients after cohort reallocation based on completion of PGx testing were 104, 180, and 58 for the SMTM, CMTM, and PGxMTM arms, respectively. On average, 3.08 DTPs were identified for each patient, which was nearly identical across all 3 arms. Blinded clinical pharmacists considered seriousness (grade 3 or 4) in 31% of the PGx-related DTPs in comparison with 4.9% of the non-PGx DTPs (P < 0.001). The more serious (i.e., grade 3 or above) DTP recommendations were more likely to be accepted by prescribers with the odds ratios of 1.95 (P = 0.05) and 2.39 (P = 0.15), when the analysis was performed for all DTPs and DTPs from the PGxMTM arm only, respectively. MTM enhanced by PGx testing and the clinical decision support tool did not increase the number of DTPs identified. However, PGx testing and the decision support software helps pharmacists determine more serious DTPs, and resulting subsequent recommendations were more readily accepted by a prescriber. Future study of the patient safety outcomes and overall health care costs associated with the utility of the decision support is warranted. No funding was received for conducting the post hoc analysis presented in this study. Magness is employed by Magellan Health, which received funding from Genelex for costs to administrate the medication management program. The open-label randomized trial was sponsored by Genelex (Clinicaltrials.gov ID number NCT02428660). PGx tests were provided and laboratory analysis was performed by Genelex. Valerie Baron is an employee of YouScript, which created the clinical decision support tool used in this study and formerly was part of Genelex. The other authors have nothing to disclose.