Research on medication use in the neonatal intensive care unit

Introduction: Research on medication use aims at assessing how much of current pharmacotherapy is rational. In neonates, this is hampered by extensive off-label drug use and limited knowledge.

Areas covered: We report on medication use research and have conducted a systematic review of observational studies on medication use to provide an updated overview on characteristics, objectives, methods, and patterns in hospitalized neonates. Moreover, a review on aspects of medication use for opioids, anti-epileptics, gastric acid-related disorders and respiratory stimulants with emphasis on trends and impact of interventions is presented, illustrating how research on medication use can contribute to improved neonatal pharmacotherapy and more focused research. Medication use reports describe patterns and provide signals on irrational use, benchmarking, or can guide research priorities. Moreover, this may generate information on how neonatal health topics and their pharmacotherapy are handled over time or across regions.

Expert opinion: Research on medicine utilization is relevant, since it will inform us on aspects like trends, variability, or about the impact and pattern of implementation of guidelines in neonates. Further progress necessitates to merge datasets on medication use with clinical characteristics, and perinatal drug use remains an area in need of additional research.     

Improving medication safety in a neonatal intensive care unit.

PURPOSE: A revision of the medication-use process intended to reduce errors on a neonatal intensive care unit (NICU) is described. SUMMARY: A multidisciplinary team conducted a systematic review and implemented multifaceted changes to improve the NICU's medication-use process. These changes were made to improve safety and consistency and make the system more user-friendly. A distinct, unit-specific formulary was created for the drug products used on the NICU. Rules were built into the order-entry computer system for these NICU formulary items to identify doses outside the documented range on the basis of body weight. A unit-specific reference was developed detailing all formulary mnemonics, oral drug compounding and i.v. admixture procedures, and guidelines for appropriate product selection. Emergency medication sheets listing the calculated doses by weight for critical or urgent medications were developed; these sheets are provided for every new admission and are updated weekly. End-product-testing procedures for i.v. admixtures and a medication-checking process for the unit's automated dispensing machine were implemented. CONCLUSION: Systematic changes in the medication-use process designed to reduce the opportunity for errors were implemented on an NICU.     

Respiratory therapy unit dose medication distribution.

A unit dose system for distribution of respiratory therapy medication is described. One unit dose cart, containing respiratory therapy medication for each patient and equipment for administration of the medication, is used for each floor. Syringes are prefilled by the pharmacy for unit dose use. Storage and stability data are given for normal saline, isoproterenol, acetylcysteine, and combinations of these drugs. Cost factors of this respiratory therapy medication distribution system are discussed.     

Prescribing patterns and the use of therapeutic drug monitoring of psychotropic medication in a psychiatric high-security unit

The aim of this study was to investigate the use of psychotropic medication and therapeutic drug monitoring in a high-security psychiatric unit and to compare the doses and serum concentrations both with the recommended intervals and with the doses and serum concentrations in a control group. One hundred thirty-two patients were admitted in the period from January 2000 to December 2005. All available samples were used when comparing serum concentrations and doses with the recommended ranges. For the comparison of doses and serum concentration-to-dose (C:D) ratios with the control group only 1 sample from each patient was used. A total of 459 analyses of 27 different drugs in samples from 8 women and 73 men were included. The median number of therapeutic drug monitoring analyses per patient was 4 (range 1-29). Thirty-seven of the 81 patients (46%) used 2 or more antipsychotics at the same time. Clozapine, lamotrigine, olanzapine, quetiapine, ziprasidone, and zuclopenthixol were often given in doses above the recommended. The serum levels were frequently above those recommended for clozapine, olanzapine, quetiapine, risperidone, ziprasidone, and zuclopenthixol. The serum levels were significantly higher in the study group than in the control group for clozapine, lamotrigine, quetiapine, and zuclopenthixol. The given dose was significantly higher in the study group than in the control group for clozapine, lamotrigine and zuclopenthixol. The C:D ratio was significantly lower in the study group than in the control group for olanzapine but higher for quetiapine. The non-evidence based practice of high-dose polypharmacy with several antipsychotics is widely used in this unit. The use of higher doses in the study group than in the control group was not due to differences in metabolism or adherence to treatment between the 2 groups. The frequent use of therapeutic drug monitoring did not seem to have a great impact on the prescribed doses.     

Impact of hospitalisation in an acute medical geriatric unit on potentially inappropriate medication use

BACKGROUND AND OBJECTIVE: Potentially inappropriate medication use is a major safety issue in the elderly and may cause a substantial proportion of drug-related hospital admissions. Hospitalisation could result in a change in the quantity and type of drugs, but its effect on potentially inappropriate drug use is still unknown. The aim of this study was to estimate the potentially inappropriate medication prevalence in patients > or =70 years of age at admission to and at discharge from an acute medical geriatric unit, and to identify the factors associated with no longer being a potentially inappropriate drug user at hospital discharge. METHODS: A prospective drug surveillance study was undertaken in 2018 elderly patients (> or =70 years of age) admitted to an acute medical geriatric unit in Limoges University Hospital, France. Prescribing patterns were established at admission and at discharge. Potentially inappropriate medication use was evaluated according to a list derived from the Beers criteria and adapted to French practice. "To be no longer a potentially inappropriate drug user at discharge" was defined as using at least one potentially inappropriate medication at admission and not using it at discharge. RESULTS: The numbers of drugs used at admission/discharge were 6.2 +/- 3.1/5.4 +/- 2.5. The prevalence of potentially inappropriate medication use decreased from 66% (95% CI 63.8, 68.0) at admission to 43.6% (95% CI 41.3, 45.9) at discharge. At discharge, 535 subjects were no longer potentially inappropriate medication users. Multivariate analysis showed that no longer being a potentially inappropriate medication user was associated with the number of drugs used (4-6 drugs vs < or =3 odds ratio [OR] 1.20; 95% CI 0.86, 1.68; 7-9 drugs vs < or =3 OR 1.37; 95% CI 0.97, 1.93; > or =10 drugs vs < or =3 OR 1.64; 95% CI 1.10, 2.44), age (80-89 years vs 70-79 years OR 1.38; 95% CI 1.03, 1.85; > or =90 years vs 70-79 years OR 1.69; 95% CI 1.22, 2.83), cerebral vasodilator use (OR 2.87; 95% CI 2.31, 3.57), analgesic use (OR 1.54; 95% CI 1.06, 2.25) and concomitant use of psychotropic drugs of the same therapeutic class (OR 1.94; 95% CI 1.29, 2.92). CONCLUSION: Hospitalisation in geriatric services results in a reduction in potentially inappropriate medication use. Improved pharmacological education of practitioners, especially with regard to drug adverse effects, is desirable to improve management of geriatric patients.     

Analysis of missing medication episodes in a unit dose system

The unit dose drug distribution system at The Buffalo General Hospital in Buffalo, New York, was evaluated by an analysis of cases in which doses of medication were missing from the unit dose administration cart. When a dose was missing, the medication administration nurse reported the occurrence to the pharmacy. When time permitted, the cause of the missing dose was determined and recorded. Thirty causes for missing doses are cited. The causes were found to arise from misuse of the unit dose system by nurses, misunderstandings between the Nursery and Pharmacy Departments, or from oversights on the part of nurses or pharmacy personnel. Missing doses can be prevented in the future by instructing nurses in the use of the system, improving communication between the Departments of Pharmacy and Nursing concerning the needs of the patients, and being aware of mistakes that can occur so care can be taken to prevent them in both departments.     

Safety in medication use

International Journal of Clinical Pharmacy -     

Patterns of antihypertensive medication use in hemodialysis patients.

PURPOSE: Patterns of antihypertensive drug use in patients undergoing long-term hemodialysis therapy were studied. METHODS: Patients attending seven outpatient hemodialysis units in Ohio were eligible for the study if they had been receiving the treatment for at least three months. Demographic and clinical data were obtained from patient interviews and computerized databases, and blood pressure (BP) measurements were obtained before dialysis. Labeled names and dosages of antihypertensive drugs were recorded from containers the patients brought with them. Patients were asked to describe their adherence to the medications, their ability to afford the drugs, and their knowledge and beliefs about hypertension. Physical impairments in taking medication were also evaluated. RESULTS: The frequency of hypertension was 89% in the 270 participants. Antihypertensive drugs were prescribed for 76% of the patients; 25% required three or more drugs. Hypertensive patients who were not receiving antihypertensive drugs (14%) had significantly higher BP than patients who were. Calcium-channel blockers were prescribed for 60% of patients, angiotensin-converting-enzyme inhibitors for 33%, and beta-blockers for 34%. Eighty-three percent said the cost of drugs was never a problem, and 23% said they sometimes forgot to take their medication. Almost all patients said they would not stop taking antihypertensive drugs if they were feeling better and agreed that monitoring BP was important. Twenty-two percent could not read the warning on a standard tablet container, and 12% could not remove one tablet from the container. CONCLUSION: Multidrug antihypertensive therapy was common among hemodialysis patients and was associated with significantly lower BP; calcium-channel blockers were the most frequently prescribed agents. Most patients said they could afford drugs and reported good adherence to antihypertensive drug therapy.     

Drug use in a trauma intensive-care unit

Medication prescribing patterns and costs of specific drug therapies in a trauma intensive-care unit (TICU) were studied. Demographic data and total drug use (scheduled, p.r.n., and single-dose medications) were recorded for all patients admitted to a TICU whose length of stay exceeded 24 hours. Scheduled and p.r.n. medications were categorized into major drug classes for purposes of analysis. Cost estimates were calculated for all scheduled medications. Correlations were made between demographic variables, injury severity indices, drug use, and length of stay by using simple linear regression. A one-way ANOVA was used to compare drug use between the trauma types. For the 278 patients who met the inclusion criteria, the mean +/- S.D. number of drugs prescribed was 9.1 +/- 6.5. Scheduled medications accounted for 58% of total drug use. Mean +/- S.D. duration of scheduled drug therapy was 5.0 +/- 4.8 days. Age (by decade), injury severity score, trauma score, and length of stay correlated with total and scheduled drug use per patient. Drug use (total, scheduled, and p.r.n.) did not differ significantly by trauma type. Antimicrobial therapy, stress ulcer prophylaxis, and bronchodilator therapy accounted for more than 66% of all scheduled drugs used; total cost estimates for these three drug categories exceeded $47,000 over the six-month study period. Analgesics, antipyretics, sedatives, and muscle relaxants constituted nearly 75% of all p.r.n. drug orders. Drug use in the TICU was extensive. The drug categories identified in this study may be useful in future cost containment efforts and initiation of drug use evaluations.     

Night medication in rheumatoid arthritis. III. the use of sulindac.

A double-blind controlled trial was carried out in 18 in-patients with classical or definite rheumatoid arthritis to assess the effectiveness of night-time medication with 100 mg indomethacin plus 10 mg diazepam, 200 mg sulindac, and 200 mg sulindac plus 10 mg diazepam in improving sleep and reducing night pain and the duration of morning stiffness. Patients received each treatment regimen for 1 night. The results from the 17 patients completing the full trial protocol indicated that indomethacin plus diazepam was the most effective of the three regimens, although the differences did not reach conventional statistical significance. It is suggested that in further such studies with sulindac a larger dose and a longer duration of treatment should be used.     

Impact of clozapine on medication use in a state hospital

Medical records of 90 consecutive patients who started clozapine were reviewed to see how this drug is being used with other psychotropic medications and to evaluate what impact it has had on the drug regimens of these patients. Data from up to 6 months before to 12 months after clozapine's initiation was included. The percent of patients receiving medications for antipsychotic side effects decreased from 86% 6 months prior to clozapine to 13% 12 months after. The use of benzodiazepines decreased from 43% to 23% during this time period as did lithium use from 57% to 17%. While 28% of the patients were receiving carbamazepine prior to starting clozapine, no patients remained on this drug concurrently with clozapine. The average number of psychiatric medications per patient decreased from 3.39 +/- 1.37 6 months prior to clozapine to 1.61 +/- .83 at month 12. Concern for drug interactions along with clozapine's reduced incidence of extrapyramidal side effects and increased efficacy contributed to the reduction in medication use observed.     

Night medication in rheumatoid arthritis. III. The use of sulindac

Summary

A double-blind controlled trial was carried out in 18 in-patients with classical or definite rheumatoid arthritis to assess the effectiveness of night-time medication with 100?mg indomethacin plus 10?mg diazepam, 200?mg sulindac, and 200?mg sulindac plus 10?mg diazepam in improving sleep and reducing night pain and the duration of morning stiffness. Patients received each treatment regimen for 1 night. The results from the 17 patients completing the full trial protocol indicated that indomethacin plus diazepam was the most effective of the three regimens, although the differences did not reach conventional statistical significance. It is suggested that in further such studies with sulindac a larger dose and a longer duration of treatment should be used.     

Drug use in a surgical intensive care unit

A retrospective review of drug usage in 180 patients admitted to a surgical intensive care unit was conducted. The average stay was three days and the total and daily number of drugs averaged 7.6 and 5.6, respectively. The most common drug class used was antibiotics, with cefazolin being the most commonly used antibiotic. Other commonly used drugs include analgesics, diuretics, H2-antagonists, vasoactive drugs and inotropes, antacids, and antiarrhythmics. This study indicates that patients admitted to a surgical intensive care unit are exposed to a variety of potent drugs, often given in combination over a short time period. Although further studies are needed to delineate specific aspects of drug use and patient characteristics, this study suggests that there is a need for close monitoring of drug therapy in these patients with special attention to reduction of drug costs.