Original Study
Potentially Inappropriate Prescribing of Primarily Renally Cleared Medications for Older Veterans Affairs Nursing Home Patients

Accepted for presentation at the American Geriatrics Society Annual Meeting, Orlando, FL, May 15, 2010.
https://doi.org/10.1016/j.jamda.2010.04.008Get rights and content

Background

Inappropriate prescribing of primarily renally cleared medications in older patients with kidney disease can lead to adverse outcomes.

Objectives

To estimate the prevalence of potentially inappropriate prescribing of 21 primarily renally cleared medications based on 2 separate estimates of renal function and to identify factors associated with this form of suboptimal prescribing in older VA nursing home (NH) patients.

Design

Longitudinal study

Participants

Participants were 1304 patients, aged 65 years or older, admitted between January 1, 2004, and June 30, 2005, for 90 days or more to 1 of 133 VA NHs.

Main Measures

Potentially inappropriate prescribing of primarily renally cleared medications determined by estimating creatinine clearance using the Cockcroft Gault (CG) and Modification of Diet in Renal Disease (MDRD) equations and applying explicit guidelines for contraindicated medications and dosing.

Key Results

The median estimated creatinine clearance via CG was 67 mL/min, whereas it was 80 mL/min/1.73m2 with the MDRD. Overall, 11.89% patients via CG and only 5.98% via MDRD had evidence of potentially inappropriate prescribing of at least 1 renally cleared medication. The most commonly involved medications were ranitidine, glyburide, gabapentin, and nitrofurantoin. Factors associated with potentially inappropriate prescribing as per the CG were age older than 85 (adjusted odds ratio [AOR] 4.24, 95% confidence interval [CI] 2.42–7.43), obesity (AOR 0.26, 95% CI 0.14–0.50) and having multiple comorbidities (AOR 1.09 for each unit increase in the Charlson comorbidity index, 95% CI 1.01–1.19).

Conclusions

Potentially inappropriate prescribing of renally cleared medications is common in older VA NH patients. Intervention studies to improve the prescribing of primarily renally cleared medications in nursing homes are needed.

Section snippets

Study Design, Setting, and Sample

This was a longitudinal study of 3480 patients admitted to any one of the 133 VA NHs (now called Community Living Centers) located in the United States between January 1, 2004, and June 30, 2005. A total of 1531 patients were included because they were 65 years of age or older at the time of admission, were long-stay patients (resided for ≥90 days), had at least 2 serum creatinine measurements within the previous 180 days, and received 1 of 21 primarily renally cleared medications (Appendix 1).

Results

Table 1 shows the characteristics of patients receiving one or more primarily renally cleared medications. Most patients were male and had multiple comorbidities. One in 5 patients were obese (BMI >30). Of these latter, only 22 of 271 had a BMI greater than 40. CKD was present in 26.22% of patients. The median estimated renal function using the Cockcroft-Gault and MDRD equations were 67 mL/min and 80 mL/min/1.73m2, respectively. When compared with the Cockcroft-Gault equation, the mean

Discussion

This study showed that more than 1 in 10 older long-stay patients in VA nursing homes had potentially inappropriate prescribing of primarily renally cleared medications when evidence-based, consensus-derived criteria were used. This is considerably less than the 42% rate of prescribing problems found in 456 patients prescribed 1 of 20 primarily renally cleared drugs reported in the study by Papaioannou et al9 in 4 long-term care facilities in 3 Canadian cities. It is also less than the 46% of

Acknowledgments

We acknowledge the support and access to MDS data provided by Christa M. Hojlo, PhD, RN, NHA, Director VA Nursing Home Care, VA Central Office, and Nick Castle, PhD, from the Graduate School of Public Health, University of Pittsburgh, for his earlier help with MDS data.

References (40)

  • M. Schetz et al.

    Drug-induced acute kidney disease

    Cur Opin Crit Care

    (2005)
  • K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification

    Am J Kidney Dis

    (2002)
  • A.S. Go et al.

    Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization

    N Engl J Med

    (2004)
  • A.S. Levey et al.

    National Kidney Foundation Practice Guidelines for Chronic Kidney Disease: evaluation, classification and stratification

    Ann Intern Med

    (2003)
  • A. Papaioannou et al.

    Assessment of adherence to renal dosing guidelines in long-term care facilities

    J Am Geriatr Soc

    (2000)
  • A.R. Rahimi et al.

    Improper renal dosing in long-term care facilities

    South Med J

    (2008)
  • L. Vidal et al.

    Systematic comparison of drug information regarding adjustment of dose for renal function

    BMJ

    (2005)
  • W.J. Spruill et al.

    Continuing the use of the Cockcroft–Gault equation for drug dosing in patients with impaired renal function

    Clin Pharmacol Ther

    (2009)
  • J.T. Hanlon et al.

    Racial differences in medication use among older long stay veteran nursing home care unit patients

    Consult Pharm

    (2009)
  • V. Mor

    A comprehensive clinical assessment tool to inform policy and practice: applications of the Minimum Data Set

    Med Care

    (2004)
  • Cited by (49)

    • Impact of a Clinical Decision Support System on Inappropriate Prescription of Glucose-lowering Agents for Patients With Renal Insufficiency in an Ambulatory Care Setting

      2022, Clinical Therapeutics
      Citation Excerpt :

      In clinical practice, many drugs, including glucose-lowering drugs, need dose adjustment according to the patient's renal function. Previous studies indicated that inappropriate dosing is common among patients with renal insufficiency,3–7 causing patient harm.8–10 Clinical decision support systems (CDSS) for drug dosing in patients with renal insufficiency have been integrated with computerized physician order entry (CPOE) systems to reduce prescribing errors and improve the overall quality of medicine usage.11–16

    • Management of Renal Disorders and the Pharmacist's Role: Chronic Kidney Disease

      2019, Encyclopedia of Pharmacy Practice and Clinical Pharmacy: Volumes 1-3
    • Special Issues in Therapeutic Drug Monitoring in Patients With Uremia, Liver Disease, and in Critically Ill Patients

      2016, Clinical Challenges in Therapeutic Drug Monitoring: Special Populations, Physiological Conditions, and Pharmacogenomics
    View all citing articles on Scopus

    There was no funding for the current study. S.M.H. was supported by a National Institutes of Health Roadmap Multidisciplinary Clinical Research Career Development Award grant (K12 RR023267). J.T.H. was supported by the following: National Institute of Aging grants (R01AG027017, P30AG024827, T32 AG021885, K07AG033174, R01AG034056), a National Institute of Mental Health grant (R34 MH082682), a National Institute of Nursing Research grant (R01 NR010135), an Agency for Healthcare Research and Quality grant (R01 HS017695), and a VA Health Services Research grant (IIR-06–062).

    View full text