Journal of Hospital Pharmacy and Health Services

Profile of the prescription of potentially inappropriate medications in hospitalized elderly patients

2024-11-11T09:01:35-03:00

Objective: To characterize the profile of the prescription of potentially inappropriate medications for the elderly (PIME) in hospitalized older adults, considering the aspects of necessity and safety of pharmacotherapy. Methods: A cross-sectional, retrospective, and descriptive study conducted in a high-complexity teaching hospital, assessing the profile of PIME usage in hospitalized patients aged 60 years or older, based on the 2023 Beers Criteria. Data were obtained from reports of the University Hospital Management Application (AGHUx) and compiled in a Microsoft Excel spreadsheet for interpretation and statistical analysis. To evaluate safety aspects, five classification categories contained in the Beers Criteria were used. Results: This study demonstrated that throughout the study period, 96,6% of patients used at least one PIME, and 37,3% of standardized medications appeared in at least one of the categories 2, 3, 4, or 5 of the 2023 Beers Criteria update. The most prevalent classes among the male population aged 60 to 70 years were proton pump inhibitors (PPI) (21,3%), diuretics (17,0%), and antipsychotics (8,6%), while among females aged 60 to 70 years, the use of opioids (6,3%) and benzodiazepines (6,7%) was notable. Among all prescriptions analyzed in the study, 29,8% included at least one PIME. The use of PIME is associated with the presence of polypharmacy (χ2 = 75,338; p<0,01, d= 0,52). Conclusion: This study highlighted a high prevalence of PIME in hospitalized elderly individuals at the study institution, with 96,6% of patients using at least one of these medications during hospitalization. Given the risks associated with PIME use, the need for new studies to quantify the impact of these medications on the health of hospitalized elderly people, as well as the promotion of educational actions regarding PIMs to improve monitoring the safety of therapy for elderly individuals.

Pharmacokinetics optimization of antimicrobials: a stewardship approach for pediatric patients with pneumonia and hypoalbuminemia

2025-04-30T18:38:18-03:00

Objective: To evaluate whether pharmacokinetic optimization of beta-lactam antibiotics highly bound to plasma proteins prevent escalation to broader-spectrum antibiotics in pediatric patients with complicated CAP. Methods: Retrospective cohort study in a pediatric tertiary hospital, involving patients with complicated CAP treated with optimized doses of ceftriaxone and/or oxacillin, monitored by the antimicrobial stewardship program between 2023 and 2024. Patients admitted to the wards were included, excluding those in ICUs, hemato-oncology or with treatment time less than 48 hours. Data were collected from clinical records and analyzed using SPSS v2.0, including descriptive analyses (means, standard deviation, frequencies) and inferential tests (Mann-Whitney, Student’s t-test, Chi-Square/Fisher, p<0.05). The outcomes evaluated were clinical/microbiological cure, treatment failure, and augmented renal clearance. The study followed the STROBE guidelines and was approved by the Ethics Committee (CAAE: 77560624.9.0000.0097). Results: The sample included 53 patients, of which 96.2% had complicated CAP, high prevalence of hypoalbuminemia (92.5%) and augmented renal clearance (91.3%). There was a significant reduction in escalation in 2024 (from 48.3% to 8.3%; p=0.001), decreased in the time to intervention for therapy optimization (5th vs. 3rd day, p=0.004), and reduction in total treatment duration (12.2 vs. 9.5 days, p=0.011) after protocol implementation. No adverse reactions occurred, and clinical cure without escalation was observed in 69.8% of patients. Conclusion: Pharmacokinetic optimization of beta-lactam antibiotics was effective in reducing escalation in patients with complicated CAP. The pharmacist’s role in stewardship, contributed to better clinical outcomes and safety, with positive impacts on clinical practice and adherence to the protocol.

Factors that interfere with the quality of warfarin treatment in patients with atrial fibrillation in the real-world context

2025-05-04T09:33:29-03:00

Objective: To characterize patients with atrial fibrillation (AF) treated at an anticoagulation clinic in Brazil who use warfarin and to identify factors associated with the quality of oral anticoagulation, measured by the Time in Therapeutic Range (TTR). Methods: Crosssectional study conducted between April and July 2019, involving patients with AF using warfarin under outpatient follow-up. The Mini-Mental State Examination (MMSE), the Short Assessment of Health Literacy for Portuguese-speaking Adults (SAHLPA-18), and the Oral Anticoagulation Knowledge (OAK) Test were applied. TTR was calculated based on the International Normalized Ratio (INR) and was considered adequate when ≥60%. Pharmacotherapy complexity was assessed using the Medication Regimen Complexity Index (MRCI). Data were analyzed using Student’s t-test, Chi-square or Fisher’s exact test, and logistic regression to calculate the odds ratio (OR). Results: The mean age of the 82 patients was 66.77 ± 9.54 years, with a predominance of males (52.44%). Most patients had low health literacy (75.58%) and 37.21% were using highly complex pharmacotherapies. Female sex and pharmacotherapy complexity were significantly associated with TTR < 60% (p < 0.05). Conclusion: The control of oral anticoagulation with warfarin may be influenced by factors such as sex and therapeutic complexity. Targeted interventions, including intensive pharmaceutical follow-up and educational strategies, may enhance therapeutic effectiveness in patients with AF.

Rational use of acute gastric mucosal injury prophylaxis in intensive care unit without compromising patient safety: a cohort study

2025-04-23T10:05:19-03:00

Background Acute gastric mucosal injury poses a significant risk of gastrointestinal bleeding in intensive care unit patients. Prophylaxis is frequently applied but its indiscriminate use may cause adverse effects. Objective: To evaluate the effectiveness and safety of a rational prophylaxis protocol for acute gastric mucosal lesions in critically ill patients based on clinical risk criteria. Methods: Retrospective observational study with a comparative analysis between two periods: cohort 1 (January to December 2021), before the protocol implementation, and cohort 2 (January to December 2022), after adopting the protocol based on the criteria proposed by Ye et al. (2020). The outcomes analyzed were the use of proton pump inhibitors (PPIs), upper gastrointestinal bleeding (UGIB), ventilator-associated pneumonia (VAP), and Clostridioides difficile infection. Results: A total of 1,614 patients were included, 641 in the pre-exposure group and 973 in the post-exposure group. There was no difference in age, sex, disease severity, previous comorbidities, or use of intensive therapies between groups. The results indicated a significant reduction in proton pump inhibitors use, from 51% in the pre-exposure group to 40% in the post-exposure group (P < 0.001). Furthermore, no significant differences were observed between groups for diagnostic outcomes of gastrointestinal bleeding, respiratory complications, healthcare-associated infections, duration of mechanical ventilation, length of hospital stay, or mortality. Conclusion: The protocol for the rational use of proton pump inhibitors was effective in reducing the use of these drugs without compromising the safety and clinical outcomes of intensive care unit patients. These results must be confirmed by randomized control trials.

Evaluation of Pharmaceutical Interventions for Dose Adjustment in Critically Ill Patients with Renal Dysfunction

2025-04-30T10:08:59-03:00

Objective: To evaluate pharmaceutical interventions for dose adjustments in renal failure patients in intensive care units (ICUs), considering acceptance by prescribers and the distribution of medications by therapeutic class. Methods: This prospective crosssectional study was conducted from November 1, 2024, to January 31, 2025, involving critically ill patients with acute or chronic renal insufficiency. Prescriptions from patients in the hospital’s four ICUs (Adult General ICU, Neonatal ICU, Pediatric ICU, and Cardiac ICU) requiring dose adjustments based on renal function (GFR < 60 mL/min/1.73 m² or on dialysis) were included. Prescriptions of patients with normal renal function (GFR > 60 mL/min/1.73 m²) or those with correct dose adjustments by the prescriber were excluded. Interventions were recorded in the Soul MV system, based on UpToDate, Micromedex, and Sanford Guide, and were performed through rounds, direct, or telephone contact. Medications were classified using the Anatomical Therapeutic Chemical Classification System (ATC). Results: A total of 2,616 prescriptions were analyzed, of which 96.9% did not require dose adjustment. In 80 prescriptions (3.1%), the adjustment was needed but not performed. Clinical pharmacists made 109 interventions in 41 patients with renal injury. Most interventions (71.6%) were based on GFR, and 28.4% were based on dialysis modality. The acceptance rate of interventions was 68.8%. The adjusted medications were primarily anti-infectives (78%), followed by hematological agents (14%), cardiovascular (4%), nervous system (3%), and gastrointestinal (1%). Conclusion: The study highlights the importance of clinical pharmacists in dose adjustment management for critically ill patients with renal dysfunction, emphasizing their role in improving treatment safety and efficacy.

Safety profile of Trastuzumab deruxtecan in patients with advanced HER2+ breast cancer: an active pharmacovigilance study

2025-02-24T09:17:48-03:00

Objective: To analyze the safety profile of the drug Trastuzumab deruxtecan and describe the clinical and epidemiological characteristics of patients diagnosed with advanced breast cancer as HER2 positive. Methods: This is a retrospective observational study, approved by the Research Ethics Committee, in which patients with HER2 positive breast cancer undergoing chemotherapy based on Trastuzumab deruxtecan were evaluated through the hospital management system, from March/2022 to March/2024, finding the adverse events presented, clinical and epidemiological data, as well as information regarding the treatment. The events presented in previous treatments were considered in order to avoid brightness bias. Causality was assessed by the Naranjo Algorithm and severity by the Common Terminology Criteria for Adverse Events methodology. Results: 45 patients were selected, 3 of which were excluded due to loss of follow-up. Of the group of patients analyzed, 33% did not report any complications or complaints arising from Trastuzumab deruxtecan and previous protocols. Some patients presented more than one adverse event, all of which were considered. Among the observations, the following stand out: nausea and vomiting (78.6%), followed by asthenia (46.4%), alopecia (32.1%), constipation (21.4%), mucositis (14.3%) and loss of appetite (10.7%). Regarding the causality profile, it was found that 31.5% were defined as definite and 68.5% as probable, with the majority defined as grade 1 (67.1%). Conclusion: The results reflect agreement with the literature regarding the profile, severity and causality of the events. It is suggested that real-life studies be conducted with a larger population and for a longer period to evaluate the long-term safety profile.

Study on patient safety and rational use of medicines: Assessment of potential drug interactions in prescriptions for elderly patients

2025-01-23T21:54:59-03:00

Drug therapy is the most widely used alternative and represents a major advance in the treatment of diseases. However, inappropriate use of medications can aggravate comorbidities and compromise patient safety, becoming a public health problem. Polypharmacy is especially common in the elderly, increasing the risk of drug interactions. Objectives: this study aimed to analyze potential drug interactions in elderly patients admitted to the cardiology ward of a university hospital. Methods: the drug prescriptions prescribed at admission and discharge of hospitalized elderly patients were evaluated, and drug interactions were checked using two software: Medscape and Drugs. com. Results: the most frequent drug interactions, according to the mechanism classification, were pharmacodynamic, both in Drugs. com (89%) and in Medscape (69%). In terms of severity, the most frequent were moderate, both at admission (776) and at discharge (929) in Drugs.com, and in Medscape also 760 (admission) and 904 (discharge). The most prevalent associated drugs were clopidogrel and acetylsalicylic acid (141). Most patients included in the study had more than five prescribed medications (89.14% at admission and 92.12% at discharge), which may be related to the increase in the number of potential drug interactions. Conclusions: the present study contributes to the reflection on therapeutic alternatives, dose adjustment and adequacy of drug posology.

Evaluation of Omeprazole prescription for stress ulcer prophylaxis in a public trauma referral hospital: monocentric cross-sectional study

2025-02-13T17:43:11-03:00

Objective: To evaluate the compliance to indication and prescription of Omeprazole, for stress ulcer prophylaxis in intensive care units and and hospital wards, in a public emergency and urgency hospital that is a referral in trauma, according to scientific evidence and criteria used in the present study. Method: This is a retrospective cross-sectional study. The research was carried out over a period of one day, on March 15,2023. Clinical data, previous medical history, health conditions, and eletronic prescriptions were analysed. Data were collected from all hospitalized patients aged 18 years or older. Patients without a Hospital Admission Authorization and those using omeprazole for other treatment purposes were excluded. To assess the indication for prophylaxis, the recommendations from the UpToDate database were used, on the risk factors for stress ulcers, in this database, were also listed in the guideline of the Portuguese Society of Intensive Care or in the BMJ-Best Practice, according to the practice guideline “Gastrointestinal bleeding prophylaxis for critically ill patients: a clinical practice guideline”. The data were analysed in the R software, version 4.1.1, and the results were presented in tables. Results: A total of 307 patients were screened, of whom 254 were considered eligible for evaluation of prophylaxis indication. Overall, 61.4%of patients showed adequate use. However, for 72.8% of patients prescribed omeprazole, there was no indication for its use, and among patients with an indication, prophylaxis was omitted for 17.1%. The non-critical patients’ wards had a percentage of 88.9% of patients prescribed prophylaxis, but without indication, while intensive care units had 31.4%. Conclusion: The study showed a considerable inadequacy in the use of stress ulcer prophylaxis in non-critical wards and, although smaller, a relevant inadequacy in intensive care units. Therefore, stands out the importance of establishing institutional interventions, such as a clinical protocol, to guide prescription practice.

Judicial demands and drug supply profile by the Ministry of Health in a public university hospital

2025-05-02T22:04:52-03:00

Objective: To characterize the judicial demands and drug supply profile by the Ministry of Health in an intravenous admixture center (CMIV) of a public university hospital. Methods: This was a cross-sectional, descriptive, and retrospective study conducted through the analysis of the CMIV database of the public university hospital from 2012 to 2024 for the legal claims profile and from 2015 to 2024 for the medication supply profile by the MS. Results: Over a 13-year period, 860 patients involved in legal claims were treated by the CMIV, ranging from 6 to 286 patients per year. A total of 16,520 doses were prepared, with an average of 1,271 preparations per year. The number of distinct medications involved in legal claims was 58. The most legally demanded medications were Bortezomib, Rituximab, and Cetuximab. Regarding the supply of medications by the MS, over the 10 years analyzed, a total of 824 patients were treated, ranging from 96 to 208 patients per year. A total of 11,600 doses were prepared, with an average of 1,160 preparations per year. These data correspond to the use of only five medications supplied by the MS during the study period: trastuzumab, rituximab, asparaginase, pertuzumab, and dactinomycin. Conclusion: The study highlighted the strategic role of CMIV in the provision of judicialized drugs, especially in onco-hematological treatments. It revealed shortcomings in the incorporation of new technologies by the Brazilian Unified Health System (SUS) and the resulting strain on hospital infrastructure. The findings underscore the need for adequate structural resources, trained personnel, and an accessible, integrated database to support more efficient and sustainable public health policies, aimed at reducing judicialization and promoting equitable access to healthcare.

Polypharmacy in Patients with Neurological Injuries in a Public Hospital Rehabilitation Unit in the Federal District: a cross-sectional study

2025-04-30T17:46:41-03:00

Purpose: To estimate the prevalence of polypharmacy in patients admitted to a rehabilitation unit in Brazil and investigate associations with sociodemographic and clinical characteristics. Methods: A descriptive and analytical cross-sectional study with retrospective data collection from 99 patients admitted to the rehabilitation unit in the Federal District, Brazil, between January and December 2022. Patients aged ≥18 years with neurological injuries who were discharged from the hospital were included, excluding those with incomplete data or communication difficulties. Variables such as age, sex, race/color, nutritional status, level of functional dependence, and the presence of hypertension, diabetes and dyslipidemia were analyzed. The number of medications was categorized as less than 5, 5 to 9, and 10 or more, and associations were assessed using Fisher’s exact test (p<0.05). Results: Among the evaluated patients (n = 99), polypharmacy was identified in 90.9% of cases, with a mean of 8.59 ± 3.06 medications per patient. Regarding the sociodemographic profile, 71.7% were male and the mean age was 46.1 ± 15.4 years. The most common injuries were traumatic spinal cord injuries (40.4%) and non-traumatic brain injuries (21.3%). A significant association was found between polypharmacy and sex, nutritional status, and diabetes. Conclusion: The high prevalence of polypharmacy in rehabilitation patients highlights the complexity of their clinical management and underscores the need for pharmaceutical care in this population.

Intermittent versus continuous infusion of vancomycin in pediatrics: which is the most effective and safest option?

2025-05-06T17:45:33-03:00

Objectives: To describe and analyze vancomycin serum levels achieved by intermittent and continuous infusion, as well as Clinical and microbiological outcomes and the occurrence of adverse events in pediatric patients with probable or confirmed infections by penicillin‑resistant Gram‑positive bacteria. Methods: Quantitative, observational study with retrospective and prospective data collection conducted from August 2021 to August 2024 in a pediatric hospital. Analyzed parameters included serum levels obtained after transitioning from intermittent to continuous infusion; treatment‑related nephrotoxicity; clinical and microbiological outcomes; and adverse events. Results: Seventy‑one patients were included; most were infants (63.4%), male (61.9%), and had a neurological comorbidity (49.3%), with initiation of continuous infusion in an intensive care unit (57.7%). Most infections involved the central nervous system, and the most frequently isolated bacteria were coagulase‑negative Staphylococcus. Median serum level during intermittent infusion was 9.4 mg/L and during continuous infusion was 17.7 mg/L (reference range: 8–25 mg/L). Vancomycin level monitoring was performed 2.6 times less often during continuous infusion. Microbiological and clinical cure was observed in 76.3% of antibiogram‑guided treatments, and clinical cure in 62.2% of empirical treatments. There were no deaths or initiation of renal replacement therapy within 30 days after antibiotic completion. Nephrotoxicity was less frequent with continuous than intermitente infusion (56.3% vs. 64.8%), with a 4.86‑fold higher risk of acute kidney injury during intermittent infusion, and a 1% increase in the risk of nephrotoxicity for each unit decrease in creatinine clearance. More adverse events occurred with continuous than intermittent infusion, primarily process errors. In most patients, infusion was administered via a venous access dedicated exclusively to vancomycin, and no infusion reactions were observed. Conclusion: The analysis indicated that continuous vancomycin infusion was an effective alternative with manageable adverse events in the study population and demonstrated a more favorable renal safety profile. However, implementation of continuous infusion requires strict adherence to institutional protocols, ongoing staff training, and process monitoring by the clinical pharmacy to minimize operational errors and ensure patient safety.

Adjustment of drug dosage according to glomerular filtration rate in elderly people admitted to intensive care units

2025-03-17T18:18:10-03:00

Objective: This study aimed to evaluate dose adjustment based on glomerular filtration rate in elderly patients admitted to Intensive Care Units. Methods: This is a retrospective cross-sectional study conducted with patients aged ≥ 60 years admitted to Intensive Care Units of a public hospital. To evaluate medications requiring dose adjustment according to glomerular filtration rate (GFR), the first prescription after 48 hours of ICU admission was considered. All medications requiring dose adjustment based on GFR were evaluated throughout the patient’s hospitalization period in the ICU, as well as creatinine tests for calculating GFR on the day of medication use, to assess the need for dose adjustment individually for each medication. Results: Among the 189 patients analyzed, 757 medications requiring dose adjustment based on GFR were identified, distributed among 38 different drugs. Of these, 55.4% actually required adjustment during hospitalization, but only 16.7% received dose adjustment. Of the prescribed medications that require dose adjustment based on glomerular filtration rate and did not receive this adjustment: 68.9% were for patients with nephropathy, 84.4% for patients with altered creatinine who died, 73.3% for patients who underwent hemodialysis, 86.8% for patients who were evaluated by a pharmacist, and 74.7% for patients who were evaluated by a nephrologist. Conclusion: This study identified that dose adjustment based on glomerular filtration rate in elderly patients admitted to the ICU was mostly performed for antibiotics, leaving other medications that act on the cardiovascular, digestive, and metabolic systems without dose adjustment.

Adverse Event Reporting for Medications and Vaccines Before and During the COVID-19 Pandemic: An Observational and Retrospective Study

2025-02-17T17:14:03-03:00

Objective: Compare the profile of suspected adverse events (AE) reports associated with medicines and vaccines before and during the COVID-19 pandemic. Method: An observational, retrospective study was conducted using data extracted from the VigiMed database. Spreadsheets were reviewed and processed, starting with the exclusion of the lines that had incomplete and uninterpretable data on the following variations related to the patient, related to the AE, related to the medication/vaccine and related to the notifier. Following database extract, reports were categorized into two groups: Group 1 (G1), before the pandemic; and Group 2 (G2), during the pandemic. Categorical variables were compared using absolute and relative frequency. Results: There was no difference between the notification profiles in the two groups about the sex and age of the individuals affected by AE related to medicines and vaccines. The notifiers in G1 were predominantly pharmacists (77.5%) while in G2, it was the consumers (55.9%). With respect to the products that were the target of the notifications, in G1 the most prevalent classes were analgesics, antibiotics and antineoplastics. In G2, there were vaccines against COVID-19 and immunosuppressants. About reports of suspected fatal AE related to medicines and vaccines, the most prevalent products in G1 were antimicrobials and antiepileptics, while G2 included antineoplastics, COVID-19 vaccines and immunosuppressants. Conclusion: The comparative of AE to drugs and vaccines notifications revealed that the COVID-19 pandemic contributed to a change in the profile of the notifiers, as well as in the type of product targeted by the notifications most frequently reported. These findings highlight the landscape of pharmacovigilance during public health emergencies.

Availability of antimicrobials in a university hospital complex in southeastern Brazil

2025-03-26T11:37:19-03:00

Objective: This study aimed to determine the profile of antimicrobials available in a university hospital complex in southeastern Brazil . Methods: Drug utilization study. Antimicrobials available in clinical practice were identified by researching the Anatomical Therapeutic Chemical (ATC) classification system, The new antimicrobials were identified through research Food and Drug Administration, the European Medicines Agency and the Brazilian National Health Surveillance Agency (ANVISA). The antimicrobials available at the university hospital complex were identified by consulting the hospital drug formulary. Antibacterials were classified according to the WHO AWaRE system. Forgotten antibiotics, defined as old antibiotics, often without patent, used in specific indications that provide treatment for infections of multi-resistant bacteria were identified. Results: A total of 301 antimicrobials for systemic use were identified, 20 antifungals, 43 antivirals and 238 antibacterials, 46.2% registered in Brazil and 19.6% available at the university hospital complex. Among antibacterials, 37 were classified as forgotten antibiotics and 21 as new antibacterials. Regarding the ATC classification the available medications were from the following groups: Antibacterials for systemic use (76.3%), followed by antifungals for systemic use (18.6%) and Antivirals for systemic use (5.1%). According to the WHO AWaRE, 21 of the 45 antibacterials available were in the Access group (46.7%), 17 (37.8%) in the Watch group, and 7 (15.5%) in the Reserve group. Concerning the 21 new antimicrobials agents, seven are registered in Brazil and belongs to the Reserve group of AWaRE classification. Conclusion: The antimicrobials available at the university hospital complex are predominantly antibacterials belonging to the Access group of the AWaRE classification, as well as several forgotten antibiotics. Antibacterials needed to treat infections caused by multidrug-resistant bacteria are also available. antifungals from different therapeutic classes are also available, but the number of antivirals is low. The incorporation of new antimicrobials into the drug formulary of the university hospital complex was reduced.

Pharmacotherapeutic Follow-up Using Telepharmacy: Experience in Argentina

2025-06-04T15:06:52-03:00