Kardiyorenal sendrom hastalarında kreatinin klirensine göre ilaç seçimi ve doz ayarlanmasının önemine dair farkındalığın retrospektif incelenmesi
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Tarih
2011
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Necmettin Erbakan Üniversitesi Meram Tıp Fakültesi
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info:eu-repo/semantics/openAccess
Özet
Kardiyorenal sendrom hastalarında kreatinin klirensine göre ilaç seçimi ve doz ayarlanmasının önemine dair farkındalığın retrospektif incelenmesiAmaç : Kardiyorenal sendrom hastalarında klirense göre doz ayarı gereken ilaçlarda yanlış doz verilme düzeyinin belirlenmesiGereç ve Yöntem : Çalışmamız retrospektif olarak tasarlandı. Kliniğimize kalp yetmezliği tanısı ile yatırılan , EKO ile LVEF < %40 olan hastalar belirlendi. Bu hastaların çıkış gününe ait kreatinin değeri, yaş ve cinsiyet bilgileri kullanılarak Amerikan Ulusal Böbrek Kuruluşu'nun (National Kidney Foundation) resmi sitesinde kullanıma sunulan (http://www.kidney.org/professionals/kdoqi/gfr_calculator.cfm) hesaplama aracı yardımıyla MDRD yöntemi ile hastaların tahmini kreatinin klirensleri belirlendi. Kreatinin klirensi 50 mL/dk olan toplam 388 hasta çalışmaya dahil edildi. Kardiyorenal sendromlu bu hastaların çıkış epikrizinde hastaya reçete edilen ilaçlar kaydedildi. Bu ilaçların itrah yolu ve böbrek yetmezliğinde kullanımına ve doz ayarına ait bilgiler a)Drug Prescribing in Renal Failure : Dosing Guidelines for Adults and Children 5th Edition, b)British National Formulary , c) Physicians' Desk Reference ve d) DrDrugs; Drug Guide for Physcians isimli kaynaklar taranarak kaydedildi.Bulgular : Çalışmaya 130 kadın (%33.5) , 258 erkek (%66.4) toplam 388 kardiyorenal sendrom hastası dahil edildi. Hastaların ortalama yaşı 70,25 ± 8,87 olarak hesaplandı. Erkeklerde ortalama yaş 70,44±8,89 iken kadın hastalarda ortalama yaş 69,88 ± 8,85 olduğu görüldü. Hastaların ortalama EF'si %29,52 ± 5,84 , ortalama kreatinin klirensleri ise 35,69 ± 10,89 idi. Ortalama yatış süresi ise 6,97 ± 5,57 olarak hesaplandı. Hastaların kullandığı ortalama ilaç sayısı 7,23±2,33 , bu ilaçlardan ise 3,57 ± 1,34 tanesinin renal yolla itrah edildiği ve klirense göre doz ayarı gereksinimi olduğu saptandı.ß-blokör grubu ilaç kullanımına bakıldığında tüm hasta populasyonu içinde 52 hastanın ß-blokör almadığı, geriye kalan hastalardan ise 72 hastanın renal itrahı olmayan ve bu nedenle klirense göre doz ayarlanması gerekmeyen ß-blokör kullandığı belirlendi. Renal itrahı olan ve doz ayarlanması gereken ß-blokör kullanan 254 hastanın (%75,5) doğru dozda aldığı, 10 hastanın (%2,9) ise yanlış dozda kullandığı belirlendi.ACEİ ilaçlarda 182 hastanın (%46,9) bu grup ilaç almadığı , alan 206 hastadan ise 32'sinin klirense göre doz ayarı gerekmeyen ACEİ kullandığı saptandı. Doz ayarı gereken ACEİ reçete edilen toplam 132 hastaya (%64) doğru dozda, 42'sine ise (%20,3) yanlış dozda kullandığı belirlendi. ARB ilaçlarda ise hastaların sadece 71'ine (%18.2) bu ilaçlardan reçete edildiği belirlendi. ARB kullanan 71 hastanın 69'unun klirense göre doz ayarı gerektirmeyen ARB'lerden kullandığı, sadece iki hastanın doz ayarı gerektiren ARB kullandığı ve bu iki hastanın da doğru dozda kullandığı görüldü.Spironolakton kullanımı %60,5 (235 hasta) olarak belirlenirken 10 hastaya (%4.2) yanlış dozda reçete edildiği saptandı. Digoksin kullanımı ise %36.3 (141 hasta) oranında olup 8 hastaya (%5.6) yanlış dozda verildiği görüldü.Çalışmamızda en dikkat çekici veri ise kalp yetmezliğine eşlik eden komorbiditelerin başında gelen diyabetin tedavisine yönelik yapılan yanlışlardı. Hasta populasyonumuzun %41'i (159 hasta) diyabet tanılı ve tedavi görmekte idi. Metformin kullanımı %4,3 olarak bulunurken metformin kullanan 17 hastanın 15'ine (%88,2) yanlış dozda reçete edildiği saptandı. Metformin dışı oral anti diyabetik kullanan 23 hastanın 12'sine (%52.1) yanlış dozda reçete edildiği görüldü.Sonuç : Kalp yetmezliği hastalarında renal fonksiyonlar sadece plazma kreatinin düzeyine bakılmadan, kreatinin klirensi hesaplanarak belirlenmeli ve kardiyorenal sendrom hastalarında ilaç seçimi ve doz ayarlamasında bu faktör göz önünde bulundurulmalıdır.Anahtar kelimeler : kardiyorenal sendrom, kalp yetmezliği, kreatinin klirensi
Retrospective evaluation of awareness regarding drug choice and dose adjustment with respect to creatinin clearance in patients with cardiorenal syndromeObjective : To determine the overdose rate of drugs that require renal dose adjustment in patients with cardiorenal syndromeMaterial and Method : Heart failure paitents were retrospectively searched in hospital database. Echocardiography report program was used and patients with an EF ?40% were excluded. Plasma creatinine values of heart failure patients with EF < 40%, on the day of discharge, were noted. Estimated creatinine clearance was calculated using MDRD creatinine clearance calculator found at National Kidney Foundation?s offical website (http://www.kidney.org/professionals/kdoqi/gfr_calculator.cfm ). Patients with eGFR of > 50mL/min were excluded. A total of 388 patients with LVEF < 40% and eGFR ? 50mL/min were enrolled in the study. Drugs prescribed on the day of discharge, for these patients were recorded. Information regarding pharmacokinetics and renal dose adjustments about the drugs were recorded from these sources; a)Drug Prescribing in Renal Failure : Dosing Guidelines for Adults and Children 5th Edition, b)British National Formulary, c) Physicians? Desk Reference and d) DrDrugs; Drug Guide for Physcians.Results : A total of 388 patients with cardiorenal syndrome, 130 women (33,5%) and 258 men (66.4) were enrolled in the study. Mean age was 70,25±8,87 for the total patient population , 70,44±8.89 for men and 69,88±8,85 for women. Mean EF was 29,52±5,84 and mean eGFR was 35,69±10,89 . Hospitalization duration was 6,97 ± 5,57 days. Mean number of drugs prescribed for each patient was 7,23±2,33 and 3,57 ± 1,34 of these were found to be renally excreted and required renal dose adjustment.ß-blockers were prescribed for 336 patients, 72 patients had ß-blockers that did not need dose adjustment. There were 264 patients who used renally excreted ß-blockers, 254 of them (75,5%) got right dose and 10 patients (2,9%) were prescribed excessive dosages.ACEI group of drugs were prescribed for only 182 of the total patient population (46,9%). Thirty two patients were prescribed ACEI that did not require renal dose adjustment. Of 202 patients who recieved ACEI that required renal dose adjustment, 132 had right dose (64%) and 42 had excessive doses (20,3%). ARB group of drugs were prescribed to only 71 patients, 69 of whom had ARBs that does not need dose adjustment. Only two patients were prescribed renally excreted ARBs and both of them got the right doses.Spironolactone use was 60,5% (235 patients) among study population. 10 patients (4,2%) had excessive dosages. Digoxin use was 36,3% (141 patients) and 8 patients (5,6%) were prescribed excessive dosages.The most striking findings in our study was misuses about oral antidiabetics used to treat diabetes, which is one of the most frequent comorbidities accompanying heart failure. 159 patients (41%) were diagnosed with diabetes and treated either with oral antidiabetics, insulin or both. Metformin use was 4,3% and 15 out of 17 patients were prescribed excessive doses (88,2%) . Oral antidiabetics other than metformin were prescribed to 23 patients and 12 of them recieved excessive doses (52,1%).Conclusion : Renal functions in patients with heart failure should be carefully evaluated, not only with plasma creatinine levels, but also with eGFR estimation using one of the approved methods and drug choice and dose adjustment should be based on patients? level of renal impairment.Keywords: cardiorenal syndrome, heart failure, creatinine clearance
Retrospective evaluation of awareness regarding drug choice and dose adjustment with respect to creatinin clearance in patients with cardiorenal syndromeObjective : To determine the overdose rate of drugs that require renal dose adjustment in patients with cardiorenal syndromeMaterial and Method : Heart failure paitents were retrospectively searched in hospital database. Echocardiography report program was used and patients with an EF ?40% were excluded. Plasma creatinine values of heart failure patients with EF < 40%, on the day of discharge, were noted. Estimated creatinine clearance was calculated using MDRD creatinine clearance calculator found at National Kidney Foundation?s offical website (http://www.kidney.org/professionals/kdoqi/gfr_calculator.cfm ). Patients with eGFR of > 50mL/min were excluded. A total of 388 patients with LVEF < 40% and eGFR ? 50mL/min were enrolled in the study. Drugs prescribed on the day of discharge, for these patients were recorded. Information regarding pharmacokinetics and renal dose adjustments about the drugs were recorded from these sources; a)Drug Prescribing in Renal Failure : Dosing Guidelines for Adults and Children 5th Edition, b)British National Formulary, c) Physicians? Desk Reference and d) DrDrugs; Drug Guide for Physcians.Results : A total of 388 patients with cardiorenal syndrome, 130 women (33,5%) and 258 men (66.4) were enrolled in the study. Mean age was 70,25±8,87 for the total patient population , 70,44±8.89 for men and 69,88±8,85 for women. Mean EF was 29,52±5,84 and mean eGFR was 35,69±10,89 . Hospitalization duration was 6,97 ± 5,57 days. Mean number of drugs prescribed for each patient was 7,23±2,33 and 3,57 ± 1,34 of these were found to be renally excreted and required renal dose adjustment.ß-blockers were prescribed for 336 patients, 72 patients had ß-blockers that did not need dose adjustment. There were 264 patients who used renally excreted ß-blockers, 254 of them (75,5%) got right dose and 10 patients (2,9%) were prescribed excessive dosages.ACEI group of drugs were prescribed for only 182 of the total patient population (46,9%). Thirty two patients were prescribed ACEI that did not require renal dose adjustment. Of 202 patients who recieved ACEI that required renal dose adjustment, 132 had right dose (64%) and 42 had excessive doses (20,3%). ARB group of drugs were prescribed to only 71 patients, 69 of whom had ARBs that does not need dose adjustment. Only two patients were prescribed renally excreted ARBs and both of them got the right doses.Spironolactone use was 60,5% (235 patients) among study population. 10 patients (4,2%) had excessive dosages. Digoxin use was 36,3% (141 patients) and 8 patients (5,6%) were prescribed excessive dosages.The most striking findings in our study was misuses about oral antidiabetics used to treat diabetes, which is one of the most frequent comorbidities accompanying heart failure. 159 patients (41%) were diagnosed with diabetes and treated either with oral antidiabetics, insulin or both. Metformin use was 4,3% and 15 out of 17 patients were prescribed excessive doses (88,2%) . Oral antidiabetics other than metformin were prescribed to 23 patients and 12 of them recieved excessive doses (52,1%).Conclusion : Renal functions in patients with heart failure should be carefully evaluated, not only with plasma creatinine levels, but also with eGFR estimation using one of the approved methods and drug choice and dose adjustment should be based on patients? level of renal impairment.Keywords: cardiorenal syndrome, heart failure, creatinine clearance
Açıklama
Anahtar Kelimeler
Böbrek yetmezliği, Kidney failure, Böbrek yetmezliği-kronik, Kidney failure-chronic, Doz-cevap ilişkisi-ilaç, Dose-response relationship-drug
Kaynak
WoS Q Değeri
Scopus Q Değeri
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Künye
Altunbaş, G. (2011). Kardiyorenal sendrom hastalarında kreatinin klirensine göre ilaç seçimi ve doz ayarlanmasının önemine dair farkındalığın retrospektif incelenmesi. (Yayınlanmamış tıpta uzmanlık tezi) Necmettin Erbakan Üniversitesi, Meram Tıp Fakültesi Dahili Tıp Bilimleri Bölümü Kardiyoloji Anabilim Dalı, Konya.
