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

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, trihexyphenidyl^a (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 acid^b, amoxicillin (2), calcium (2), dalteparin, ferrous succinate, flucloxacillin, ipratropium, losartan, omeprazole (2), pivecillinam, sodium picosulfate^c

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, potassium^d

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 tests^e

1 (1)

Acetaminophen

Lack of serum digoxin test

1 (1)

Digoxin

Lack of serum hemoglobin A_1c 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 tests^f

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)

Gabapentin^g

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, omeprazole^h

Handling problems – inhalation technique

2 (2)

Budesonide, terbutaline^h

Budesonide, indacaterol, terbutaline, tiotropium^h

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 acid^j

warfarin + clopidogrel^k