MO378: The Importance of Community Pharmacy in Chronic Kidney Disease Patient Management. Drug Dosage Adjustment and Nephrotoxicity Detection
Authors: Cámara Ramos Iker , Escribá Martí Gema , Escudero Quesada Veronica , Salar Ibáñez Luis , Climent Maite 
Published: May 2022

Abstract

BACKGROUND AND AIMS
Chronic kidney disease (CKD) is a common problem in patients over 60 years of age. It´s necessary to control the administration of nephrotoxic drugs and to adjust the dosage of drugs eliminated by kidneys. Community pharmacists can improve risk stratification and management of stage 3A chronic kidney disease [1]. Using a point-of-care technology [2] screening to identify CKD in a community pharmacy is feasible. Then, a drug dosing adjustment service for elderly patients with renal impairment can increase the proportion of adequate drug dosing and improve the drug-related problems of the patient [3]. This study was designed and executed together between pharmacists, primary care physicians and nephrologists, as they all contribute to complete and efficient patient management.
The purpose of this study is to prove the community pharmacy's capabilities in the detection of nephrotoxic drugs and dose adjustment in CKD patients together with the prescriber for better patient management.

METHOD
Before we've started the study, we've run a precision and method comparison testing to internally validate the StatSensor Express POC meter used in this study. Briefly, it has been done by measuring 35 blood samples against a reference method in a hospital central laboratory. The data were analyzed using statistical methods, as recently published. [4].
The inclusion criteria for this study were defined as follows. Patients over 60 years old that have been prescribed with at least one nephrotoxic drug or drugs that may need dose adjustment. The identified patients were invited for capillary blood creatinine test (StatSensor Express, Nova Biomedical). Glomerular filtration rate (eGFR) is calculated using CKD-EPI. If eGFR &lt;60 mL/minute the medication is analyzed. Depending on the results, the patients are referred to the Primary Care physicians with the proposed treatment changes. The decisions are recorded and analysed to complete the study, as shown in the result section.

RESULTS
552 patients in 15 pharmacies were included. 179 (32.4%) eGFR &lt;60 had prescribed a total of 1552 drugs of which 32 (2.1%) are nephrotoxic and their withdrawal is proposed. 110 (7.1%) are used at doses higher than those recommended and their adjustment is requested. They correspond to 23 (12.8%) and 64 (35.8%) patients respectively, and 17 of them (9.5%) to both. Total of 70 (39.1%) patients.
The physicians accept the withdrawal of 9 (28.1%) nephrotoxic drugs and the adjustment/withdrawal of the dose of 30 (27.3%) corresponding to 8 and 23 patients respectively, and 6 of them to both. Total of 25 (35.7%) patients.
It equals to a change proposal in 142 (9.1%) of the analysed drugs that use 70 (12.7%) of the 552 patients included. About 39 (2.5%) were modified in 25 (4.5%) patients.

CONCLUSION
Chronic kidney disease (CKD) is a major health problem with an increasing incidence and prevalence worldwide, particularly in elderly patients. Elderly patients often require multiple and complex treatments involving many different drug types, among them drugs that are known to be nephrotoxic. In individuals with underlying but undiagnosed kidney impairment, they can have both acute and chronic effects on kidney function.
Our results show that almost 10% of total patients included in this study would benefit from a proposed change in treatment if an objective determination of their kidney function was made available.
In the pharmacy setting, where these patients are frequently presented with their prescriptions, this information should and can be provided. Our study suggests a potential interest for generalized POC eGFR determination in pharmacies in order to allow more accurate and efficient patient management in an appropriately targeted population. Specific attention must be given to cost-effectiveness, taking into account both the higher price of POC testing and the burden of kidney injury attributable to nephrotoxic drugs.
We conclude that the community pharmacy can be a valuable partner for Primary Care physicians in CKD patient management.