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Table 3 Description of drug therapy problems

From: Preventing hospital admissions by reviewing medication (PHARM) in primary care: design of the cluster randomised, controlled, multi-centre PHARM-study

Drug therapy problem Common causes of drug therapy problem Examples
Additional drug therapy required • A medical condition requires the initiation of drug therapy. • Preventive drug therapy is required to reduce the risk of developing a new condition (according to the national guidelines). • A medical condition requires additional pharmacotherapy to produce an additive of synergistic effect. • The patient is suffering from pain with no analgesic therapy. • A patient with chronic heart failure due to left ventricular systolic dysfunction, without an ACE-inhibitor or an angiotensin receptor blocker. • A patient with atrial fibrillation without antithrombotic therapy. • Calcium and vitamin D supplements for a patient with osteoporosis who is already taking a bisphosphonate.
Unnecessary drug therapy • There is no current valid medical indication for the drug therapy for the individual patient. • Multiple drug products are being used for a medical condition that requires single drug therapy. • The medical condition is more appropriately treated with non-drug therapy or lifestyle changes. • Drug therapy is being taken to treat an avoidable adverse event associated with another medication. • Lifestile ( e.g. drug abuse, alcohol use, diet, smoking) is causing the problem. • A patient is using a low dose of aspirin without a high risk of cardiovascular disease or any signs of a cardiovascular disease. • A patient is using three different laxative products in an attempt to treat his constipation. • A patient is using a benzodiazepine every night as a hypnotic drug for three years while it is better to recommend alternative sleeping patterns, sleep hygiene and exercise. • A patient is using furosemide to prevent swollen ankles. • A patient is using paracetamol combined with codeine (500/10) and is suffering from constipation which is treated with lactulose and bisacodyl occasionally. • A patient uses a protonpump inhibitor to treat dyspepsia associated with alcohol abuse.
Ineffective drug therapy • The drug is not effective for the medical problem. • The drug product is not the most effective for the indication being treated. • The formulation of the drug products is inappropriate. • The drug is not effective because of the characteristics of the patient. (e.g. renal impairment, hepatic function) • A patient is using an antibiotic for a common cold (viral infection). • A patient with benign prostatic hyperplasia uses doxasozine for more than four years. • • A patient with severe COPD uses salbutamol in a turbuhaler. • A patient with renal impairment uses a thiazide to lower the blood pressure.
Dosage too low • The dose is too low to produce the desired outcome. • The dosage interval is too long to produce the desired outcome. • A drug-drug interaction reduces the amount of active drug available and the dose is not adjusted too produce the desired outcome. • The duration of the drug therapy is too short to produce the desired outcome. • A patient is prescribed simvastatine 10 mg every other day after a myocardial infarction. • A patient uses 500 mg paracetamol, only twice a day, to control chronic pain in osteoarthritis. • A patient uses 375 mg amoxicilline, only once a day, to treat an airway infection. • A patient uses acenocoumarole and vitamin K. • A patient uses paroxetine for 4 days to treat anxiety.
Adverse drug event • The drug causes an undesirable reaction that is not dose-related. • A safer product is required due to risk factors. • A drug interaction, with another drug or food, causes an undesirable reaction that is not dose-related. • The drug is contraindicated due to risk factors or other diseases. • The drug causes an allergic reaction. • A drug dosage was increased or decreased too fast. • A drug alters the patient's laboratory test results due to interference from a drug he/she uses. • A patient on a low dose of aspirin is experiencing bruises. • An elderly patient uses flurazepam to sleep and is experiencing drowsiness at day time. • A patient who uses methotrexate gets prescribed co-trimoxazole for an infection (increase of anti-folate effect which can result in haematopoietic suppression). • A patient gets prescribed indometacin to control chronic pain, which is contraindicated because of his/her history with a peptic ulcer. • A patient is prescribed flucloxacillin for a dermal infection and develops a rash after the second dose. • A patient who uses prednisolone 20 mg every day for the last 6 months for arthritis symptoms iss instructed to take 10 mg for 2 more days and then discontinues the medication. • A patient had high blood glucose levels, due to the start of prednisolone therapy. • Positive ketone test in urine due to captopril use.
Dosage too high • The drug causes an undesirable reaction due to too high dose. • The dosing frequency of the drug is too short. • The duration of drug therapy is too long. • The drug dose is too high in the patient because of its characteristics (excretion). • A drug-drug interaction occurs resulting in a toxic reaction to the drug. • The dose of the drug was administered too rapidly. • A patient develops bradycardia resulting from a high (0.5 mg) daily dose of digoxine. • Hyperkaleamia after a dose of amiloride 10 mg three times a day. • A patient who experienes nasal congestion uses a nasal spray with xylometazoline for four weeks. • A patient with impaired renal function (CrCl: 20 ml/min) is prescribed a normal dose of 300 mg allopurinole a day, which causes nausea. • A patient has an increased INR after given metronidazole while also using acenocoumarole. • Cardiac arrest after infusion of a bolus of potassium phosphate (5 ml intravenously) instead of slow infusion.
Drug use problem • • The patient does not understand the instructions. • The patient prefers not to take the medication. • • The patient forgets to take the medication. • • The patient cannot administer the drug appropriately him/herself. • • The drug therapy does not comply with the lifestyle of the patient. • • The patient has no access to the medication. • The patient uses naproxen only when pain is unbearable while it is prescribed three times a day. • The patient is afraid of taking fluvoxamine because of possible side-effects. • The patient forgets to take his antihypertensive medication. • The patient is unable to administer the timolol eyedrops for her glaucoma. • A patient does not take furosemide because of attending activities at home. • A patient is not able to fetch the medication at the pharmacy.