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Table 2 Clinically relevant DRPs identified by clinical pharmacists and discussed with the health care team

From: Drug-related problems and medication reviews among old people with dementia

Type of DRPs Identified problem/potential problem Identified no. of DRPs (no. acted upon) Drugs involved (frequency)
Suspected adverse drug reaction (n = 41) Acute renal failure 1 (1) Irbesartan
Anemia 1 (0) Acetylsalicylic acid
Confusion 3 (3) Metoprolol, morphine, solifenacin
Fall 7 (5) Alfuzosin, candesartan, citalopram, mirtazapine, oxazepam, zopiclone (2)
Fatigue 5 (4) Mianserin, morphine (2), olanzapine, propiomazine
Hallucinations 1 (1) Citalopram
Hypercalcemia 1 (1) Bendroflumethiazide
Hyperkalemia 1 (1) Spironolactone
Hypochloremia, high CO2 1 (1) Furosemide
Hypokalemia 1 (1) Furosemide
Hyponatremia 2 (1) Buspirone, losartan
Hypotension 2 (2) Alfuzosin (2)
Increased INR 1 (0) Avlosulfon
Liver disorder 2 (2) Simvastatin (2)
Nausea 4 (3) Codeine/acetaminophen, galantamine, levetiracetam, metformin
Edema 1 (1) Amlodipine
Orthostatic hypotension 2 (1) Bendroflumethiazide, isosorbide mononitrate
Seizure 1 (0) Donepezil
Sleeping problems 1 (1) Bisoprolol
Thrombocytopenia 1 (1) Valproic acid
Urinary retention 2 (2) Amitriptyline, citalopram
Dosage too high (44) Dosage too high according to indication/guidelines 18 (15) Acetylsalicylic acid (5), allopurinol, citalopram (2), folic acid (4), metoclopramide, omeprazole, risperidone, trihexyphenidyla (2), zuclopenthixol
Dosage too high according to patient response 10 (8) Bisoprolol, clomethiazole, furosemide (2), isosorbide mononitrate, levothyroxine (2), mirtazapine, potassium, spironolactone
Dosage too high according to liver function 1 (1) Acetaminophen
Dosage too high according to renal function 12 (12) Allopurinol, digoxin (3), enalapril, fondaparinux, glipizide, memantine (3), metformin, sucralfate
Dosage too high according to maximum dose per day 2 (2) Acetaminophen (2)
Lack of gradual dose increase 1 (1) Rivastigmine
Dosage too low (14) Dosage too low according to indication/guidelines 14 (14) Acetylsalicylic acidb, amoxicillin (2), calcium (2), dalteparin, ferrous succinate, flucloxacillin, ipratropium, losartan, omeprazole (2), pivecillinam, sodium picosulfatec
Ineffective/Inappropriate drug (54) Inappropriate drug according to cost 4 (4) Escitalopram, oxycodone (2), pregabalin
Inappropriate drug according to renal function 12 (12) Glibenclamide (2), hydrochlorothiazide, ibumetin, ketoprofen, metformin (2), morphine (2), nitrofurantoin, tramadol (2)
Inappropriate drug according to liver function 1 (1) Clomethiazole
Inappropriate drug according to guidelines 4 (3) Acetylsalicylic acid/dipyramidole, lactitol, methenamine hippurate, oxycodone + buprenorphine
Drugs that should be avoided in the elderly 17 (10) Amitriptyline, diazepam, fesoterodine, flunitrazepam, haloperidol, hydroxyzine, propiomazine (3), solifenacin, tolterodine (2), tramadol, triazolam, zolpidem (3)
Heart failure 6 (6) Acetaminophen soluble tablet qd, acetylcysteine soluble tablet qd, diclofenac, ibuprofen, naproxen, potassiumd
Atrial fibrillation 1 (0) Propranolol
Hyperkalemia 2 (2) Potassium IV (2)
Hypertension 4 (3) Acetaminophen soluble tablet qd (2), atenolol, pindolol
Myocardial infarction, past 1 (1) Medroxyprogesterone acetate
Palpitations 1 (1) Metoprolol sustained-release tablet
Risk in this specific patient group 1 (0) Codeine/acetaminophen + acetaminophen PRN
Interaction (23) Interactions 23 (16) Alendronat + calcium
   Calcium + ciprofloxacin
   Carbamazepine + citalopram
   Carbamazepine + doxycycline
   cholestyramine (PRN) + Warfarin + levothyroxine + furosemide
   Doxycycline + calcium
   Ferrous glycine sulfate + levothyroxine
   Ferrous glycine sulfate + levodopa/benserazide
   Ferrous succinate + calcium + levothyroxine
   Ferrous succinate + calcium (4)
   Ferrous succinate + ciprofloxacin
   Ferrous succinate + levothyroxine (2)
   Levothyroxine + magnesium hydroxide
   Levothyroxine + magnesiumhydroxide + calcium
   Warfarin + diclofenac (2)
   Warfarin + ginkgo biloba
   Warfarin + prednisolone
   Warfarin + citalopram
Monitoring need (13) Lack of liver function testse 1 (1) Acetaminophen
Lack of serum digoxin test 1 (1) Digoxin
Lack of serum hemoglobin A1c test 1 (1)  
Lack of serum homocysteine test 1 (1) Vitamin B combination
Lack of serum potassium test 2 (2) Spironolactone (2)
Lack of serum potassium and serum creatinine tests 1 (1) Enalapril and spironolactone
Lack of serum uric acid test 1 (1) Diazoxide
Lack of thyroid function tests 4 (4) Levothyroxine (4)
Lack of thyroid function testsf 1 (1)  
Needs additional drug therapy/untreated/undertreated indication (37) Asthma 1 (1) Short-acting inhaled beta-2-agonist
Heart failure 8 (6) ACE-inhibitor (4), beta-blocker (2), spironolactone (2)
Hypertension 1 (1) ACE-inhibitor
Hypokalemia 1 (1) Potassium
Increased risk of obstipation 7 (5) Opioids without laxantia (7)
Increased risk of ulcus 5 (4) Clopidogrel, acetylsalicylic acid + galantamine without PPI
   Prednisolone + acetylsalicylic acid + donepezil without PPI
   Prednisolone + acetylsalicylic acid without PPI
   Warfarin + prednisolone without PPI
   Previous ulcus, PPI discontinued by mistake
Myocardial infarction, past 2 (0) Beta-blocker, acetylsalicylic acid
Osteoporosis/vertebral compression fracture 3 (2) 1 (1) Calcium/vitamin D3 (3)
Bisphosphonate
Pain 1 (1) Acetaminophen
Seizure 1 (1) Gabapenting
Stroke, past 3 (2) Anticoagulant (3)
Stroke, past 1 (0) Statin
TIA, past 1 (1) Anticoagulant
Wernicke-Korsakoff syndrome 1 (1) Vitamin B combination
Noncompliance (4) Handling problems – crushing 1 (0) Doxazosin sustained-release tablet, hydroxycarbamide, metoprolol sustained-release tablet, morphine sustained-release tablet, omeprazoleh
Handling problems – inhalation technique 2 (2) Budesonide, terbutalineh
Budesonide, indacaterol, terbutaline, tiotropiumh
Overuse 1 (0) Hydroxyzine
Transition error (26) Wrong dose or time of dose in the medical record 11 (9) Citalopram, digoxin, hydralazine, mianserin(2), mirtazapine, pramipexole, risperidone, vitamin B, zolpidem, zopiclone
Drug incorrectly registered in the medical record 6 (6) Ciprofloxacin, fluconazoli, metformin, metoprolol, mianserin, simvastatin
Drug is missing in the medical record 8 (7) Acetaminophen (2), acetylsalicylic acid, bimatoprost/timolol, citalopram, ibuprofen, levothyroxine, memantine,
Wrong information about the drug in the medical record 1 (0) Ketobemidone
Unnecessary drug therapy (54) No indication for drug use 48 (41) Alendronat, allopurinol, amlodipine (2), bendroflumethiazide, carbamazepine, citalopram, clemastine, codeine/acetaminophen, cyanocobalamin/folic acid/pyridoxine hydrochloride, enalapril, ferrous succinate (2), folic acid, folic acid/cyanocobalamin (2), furosemide (5), gabapentin, haloperidol (2), ibumetin, loperamide, losartan, magnesium hydroxide (3), metformin (4), metoprolol, acetaminophen, potassium(4),
prednisolone, probenecide, ranitidine, simvastatin, sodium hydrogen carbonate (2), zopiclone (2)
Inappropriate duplication 6 (6) Estradiol vaginal ring + estradiol vaginal tablet
lactulose + macrogol/electrolytes (3)
warfarin + acetylsalicylic acidj
warfarin + clopidogrelk
  1. Abbreviations: DRP drug-related problem, LMWH low molecular weight heparin, PPI proton pump inhibitors, PRN Pro Re Nata, TIA transient ischemic attack
  2. aDose of antipsychotic lowered, but not trihexyphenidyl (Table 3)
  3. bThe patient had atrial fibrillation
  4. cPrescribed PRN
  5. dSpironolactone suggested
  6. eThe patient was overusing acetaminophen
  7. fThe patient had atrial fibrillation
  8. gGabapentine discontinued as doctors thought the indication was pain; really, it was epilepsy
  9. hClassified as one DRP
  10. iFluconazol in the category interaction (with citalopram) in Table 3
  11. jWarfarin prescribed instead of acetylsalicylic acid, both treatments continued by mistake
  12. kWarfarin prescribed instead of clopidogrel, both treatments continued by mistake
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