On going Project Abstracts

On going Project Abstracts

1. Evaluation of potentially inappropriate medication using Beer’s criteria and guideline preparation for drug use in geriatrics

Elderly people who are at their dusk of life are prone to comorbidities, multiple prescribers and multiple medications. Hence they are always at risk of adverse drug events (ADE). Inappropriate medications for older adults are defined as medications for which the potential risk outweighs the potential benefit and for which a good alternative drug is available. The American Geriatric Society Beer’s criteria can be used as a tool to identify potentially inappropriate drugs with a high risk for adverse events. Beer’s criteria is an explicit criteria developed to identify the drugs that should be avoided in elderly. Fifty three medications encompasses the criteria, which are divided into three categories: potentially inappropriate medications(PIM) and classes to avoid in older adults, PIM to avoid in older adults with certain diseases and syndromes that the drugs listed can exacerbate and finally medications to be used with caution in older adults. The study primarily aims to evaluate the potentially inappropriate medication(PIM) use  in geriatric patients using Beer’s criteria. Evaluation of the prescription for WHO prescribing indicators, daily activity assessment of the patients with ‘The Lawton Instrumental Activities of Daily living scale’, checking for drug interactions, and monitoring of incidence of ADEs due to PIM use adds to the strength of the study. The study  began with the ethical committee approval and when 100 cases were evaluated, there were 62 presciptions with PIM. Insulin sliding scale, Prazosin, lorazepam, alprazolam, amiodarone, zolpidem, ketorolac, metoclopromide, diclofenac, indomethacin, piroxicam and trihexyphenidyl are the PIMs identified with insulin and prazosin, most frequently prescribed. Three ADEs were identified due to PIM use. It was  the General medicine department that produced more inappropriate prescriptions. The  Lawton daily assessment scores proved that patients remained less active with increase in age. When the WHO standards of prescribing indicators were compared with the study site values, there were significant difference in values so as to comply with the standard. Even though serious drug interactions were less most of the presciptions had major interactions which required close monitoring. The reason for the incidence of PIM and deviation from the WHO prescription standards can be attributed to the prevalence of multiple prescribers, influence of drug brands and finally the transition of the concept of medical service to medical industry.

2.Evaluation of the safety and efficacy of Tolvaptan in patients with Hyponatremia in tertiary care referral hospitals

Hyponatremia is the most common electrolyte disorder which increases the morbidity and mortality in hospitalized patients and its management is incompletely established in clinical practice. Tolvaptan is the first orally active, specific V2 receptor antagonist to be approved by FDA for treatment of hypervolemic and euvolemic hyponatremia under brand name Samsca. The aim of the study is to evaluate the impact of tolvaptan in hyponatremic patients regarding its efficacy and safety. Objectives include the study of changes in levels of serum sodium and serum creatinine levels, also to monitor and document adverse drug reactions. Multispecialty tertiary care referral hospitals in north Kerala are study site and the study period is 12 months. Patients of inmedicine department with a serum sodium level ˂125mEq/L and who are under tolvaptan therapy are included in the study. Study procedure involves the detection, documentation and assessment of adverse drug reaction using Naranjo causality assessment scale, modified Hart wig and Siegel scale, modified Shumock and Thornton method. Serum sodium levels were checked on the days under tolvaptan therapy and serum creatinine levels were checked at the starting and end of tolvaptan therapy. Finally the results obtained are to be analyzed to gather information regarding the safety, efficacy and renal impact of the drug. While the evaluation of 21 patients, it was observed that 90.48% belong to age group ˃60yrs. 76.19% patients were females and 23.80% patients treated with tolvaptan were under the therapy of heart failure. In 76.19% of tolvaptan treated patients, the dose used was 15mg per day. In 47.62% patients the serum sodium were normalized in ˂5 days, between 5-10 days in 38.10% and ˃10 days in 14.24%. The ADRs observed were thirst, dry mouth, polyuria, constipation and asthenia in 28.57%, 14.29%, 9.52%, 14.29% and 4.76% patients respectively. The serum creatinine levels were increased in 4.76% patients, steady in 9.52% and decreased in 4.76% patients. The data suggest that the tolvaptan is highly efficacious even in geriatric patients with a less incidence of adverse drug reactions.

3.Prevalence, risk factors and antimicrobial susceptibility pattern of extended spectrum beta lactamase producing micro organisms in a tertiary care hospital

                    Antimicrobial agents are one of the most commonly prescribed groups of drugs for treating various infectious diseases. Bacterial resistance to antimicrobial treatment is emerging as one of the global public health treats at the beginning of the 21^st century. The wide spread use and in sometimes the misuse of antibiotics in all healthcare facilities over the past several decades has been regarded as the contributing factor in the development of resistance. Extended Spectrum Beta Lactamase (ESBLs) are enzymes produced by certain bacteria that can make them resistant to certain antibiotics. The main mechanism of bacterial resistance to Beta lactam class of antibiotics is the production of Beta lactamase, which can hydrolyze these antibiotics before they reach the penicillin binding protein located at the cytoplasmic membrane. These enzymes produce resistance to a variety of β-lactam antibiotics including extended spectrum penicillins, 3^rd generation cephalosporins and monobactams. They are often shows cross resistance to many other classes of antibiotics such as fluoroquinolones and aminoglycosides by additional mechanisms, thus further limiting treatment options. At present, ESBLs has been increasing as a serious nosocomial and community pathogen having the property multidrug resistance. Resistance pattern vary internationally, and even locally, from one institution to the other. It is important to know the national and also the local institutional prevalence in order to adjust antimicrobial therapies and try to avoid a further increase in rate. The development and spread of ESBL is most likely caused by over use of expanded spectrum cephalosporins in hospital setting. With this in mind, the early detection of ESBL strains and judicious use of antibiotics and proper implementation of infection control strategies are essential to prevent the spread of this thread in the community. The study began with ethical committee approval and out of 50 cases evaluated 58% cases where urinary tract infections, 16% were surgical site infections, 14% were respiratory tract infections and 12% were blood stream infections. In this study most prevalent organism that causes ESBL infections were Escherichia coli (62%). Most prevalent risk factors include increased age, length of hospital stay and previous co morbidities such as the diabetes, renal failure etc.

4.Prevalence of risk factors, drug related problems and treatment pattern of acute coronary syndrome in a tertiary care hospital

                   ACS is one of the leading cause of morbidity and mortality in the world. ACS is a term that includes all clinical syndromes compatible with acute myocardial ischemia resulting from an imbalance between myocardial oxygen demand and supply. This is related to the high prevalence of cardiovascular risk factors. The purpose of the study is to estimate the prevalence of cardiovascular risk factors and to document the number and types of drug related problems that have been identified. The most important findings of this study is that out of 50 patients diagnosed with ACS, major cardiovascular risk factor are highly prevalent in men. Most risk factors generally become more prevalent as one gets older, increasing the risk for ACS with advancing age. Smoking among males was consistently high, being highest among those 30-59 years old. Prevalence of hypertension and diabetes were equally higher in both men and women with increasing age. The study has delineated several unique characteristics that influence the cardiovascular health of the people, including a low degree of control of high blood pressure, a high rate of incidence of diabetes, a fairly high rate dyslipidemia and an extremely high percentage who smoke and consume alcohol. Other less common risk factors that made contribution to the progression of the disease were family history of coronary artery disease, depression, stress, saturated fat intake, COPD. The study also aimed to estimate drug related problems (DRPs) associated with pharmacotherapy. DRP is defined as “an event or circumstance involving drug therapy that actually or potentially interferes with desired health outcomes”. Out of 61 DRPs identified, 52.5% drug interactions and 16.3% ADRs were present. In clinical practice, several drugs can be used together, yet close monitoring is fundamental. Around 6.5% of the patients did not adhere to diet control, physical activity, and medications. This problem will lead to the worsening of the disease. The treatment pattern followed for most of the patients adhere to the recommendations of the current practice guidelines. By providing patient education and reducing DRPs the quality of life can be improved and thereby preventing the ACS morbidity and mortality.