INVOLVEMENT OF WARD PHARMACIST DURING THERAPUTIC PROCESS IN HOSPITALIZED GERIATRIC PATIENTS IN DR.SARJITO HOSPITAL, YOGYAKARTA, INDONESIA Fita Rahmawati 1,2 , Syed Azhar Syed Sulaiman 2 , I Dewa Putu Pramantara 3, Wasilah Rochmah 3. 1 2 Faculty of Pharmacy, Gadjah Mada University, Yogyakarta , Indonesia, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Minden Pulau Penang, 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 in hospitalized geriatric patients. Subjects and Methods: 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. 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). The data collected through medical record, patient‟s 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 Results : Our research showed involvement of ward pharmacist in therapeutic process 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-drug interaction, drug-nutrition interaction, and also to prevent adverse drug reactions. Other suggestion type related to complete documentation to avoid medication errors, relieve adverse drug reaction and dosage form choice. 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. 1 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 to drug-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). Perst‟s 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. 2 Table I. Types and description of drug related problems Problem Untreated indication Description The patient has a medical problem that requires drug therapy but is not receiving a drug for that indication The patient has a drug indication but taking the wrong drug The patient has a medical problem that is being treated with too little of the correct drug. The patient has a medical problem that is the result of not receiving a drug (e.g. for pharmaceutical, psychological, sociological or economic reasons) The patient has a medical problem that is being treated with too much of correct drug (ie, toxicity) The patient has a medical problem that is the result of an adverse drug reaction The patient has a medical problem that is the result of a drug-drug, drug-food, or drug-laboratory interaction The patient is taking a drug for no medically valid indication Improper drug selection Sub therapeutic dosage Failure to receive drugs Over dose Adverse drug reaction Drug interaction Drug use without indication 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 sub therapy 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 3 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 pharmacist‟s 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 4 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, patient‟s medication chart, injection book; followed by interview with patients, nurse, physician and other health professional. Descriptive statistics were shown as frequencies Problems (DRPs) in both goup (group A and B). of Drug Related 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 Gender Female Age group (years) 65-69 70-79 80 and over Percentage of case of cases 74.6 43.3 46.3 10.4 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 5 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 Indication Needs therapy Unnecessary drug therapy Efficacy Wrong drug Dosage too Low Safety ADR Dosage too high Compliance Percentage 6.6 55.4 14.0 7.4 5.8 9.1 1.7 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 when an adverse drug reaction is misinterpreted 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 6 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 diazepam, parafin liq (laxative), and uneffective for elderly patient were 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 potentially inappropriate 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 7 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 by pharmacists 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 patient‟s 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 intervention agreed by physician Type of intervention refused by physician 0 1 Improper drug administration 7 - drug-food interaction - drug-drug interaction - to reduce ADR 2 Medication errors 2 3 Unnecesary drug therapy 6 4 Resolved of ADRs 3 5 Improper dosage related with 5 patient‟s renal status 6 Improper selection of drug. . 2 7 Improper dosage form 1 Jumlah 26 0 1 0 1 2 0 4 8 Type of suggestion which is 100 % accepted by health professionals were related with drug administration in case of occured of drug-drug interaction, drugnutrition 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 group Type of DRP Min DRP1 Indication needs therapy DRP2 Indication unnecessary drug therapy DRP3 Efficacy wrong drug DRP4 Efficacy dosage too low DRP5 Safety ADRs DRP6 Safety dosage too high ,00 ,00 ,00 ,00 ,00 ,00 Group A Max 1,00 4,00 2,00 1,00 1,00 2,00 Mean ,0800 1,0000 ,2200 ,1000 ,0600 ,1600 Min ,00 ,00 ,00 ,00 ,00 ,00 Group B Max 1,00 4,00 2,00 1,00 2,00 2,00 Mean ,2353 1,0000 ,3529 ,2353 ,2353 ,1765 Note: Group A : Group without pharmacist intervention Group B : Group with pharmacist intervention Table V Mann Whitney Test between two group DRP1 DRP2 359,000 394,500 1634,000 547,500 -1,693 -,466 DRP3 377,000 1652,000 -,978 DRP4 367,500 1642,500 -1,403 ,161 DRP5 374,000 1649,000 -1,485 ,138 DRP6 425,000 578,000 ,000 1,000 Mann-Whitney U Wilcoxon W Z Asymp. Sig. (2,090 ,641 ,328 tailed) Note : DRP1 = Indication needs therapy DRP2 = Indication unnecessary drug therapy DRP3 = Efficacy wrong drug DRP4 = Efficacy dosage too low DRP5 = Safety ADR DRP6 = Safety dosage too high 9 The most reason of non significance between groups is that in our research most of the suggestion given by pharmacist after pharmacist found DRP‟s 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. 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