Drug-Related Problems in Pulmonary Hypertension with Valvular Heart Disease

Figures & data

Figure 1 The process of drug-related problems identification.

Abbreviations: DRP, drug related problem; CICU, cardiac intensive care unit, PCNE, Pharmaceutical Care Network Europe.

Table 1 Demographic Characteristics of Study Population with Drug-Related Problems

Characteristic	Total Cohort % (n= 61)
Age, mean (SD)	47.1 (±14.2)
BMI (kg/m2 BSA)	28.9 (±6.8)
Gender, n (%)
Male	26 (43)
Female	35 (57)
Severity of pulmonary hypertension, (based on mPaP only) n (%)
Mild PH (25–40mmHg)	12 (20)
Moderate PH (41–49mmHg)	6 (10)
Severe PH (≥ 50mmHg)	43 (70)
Types of valve diseases, n (%)
Mitral valve regurgitation	38 (62)
Mitral stenosis	37 (61)
Aortic regurgitation	14 (23)
Tricuspid valve regurgitation	40 (66)
Types of procedure, n (%)
Repair	2 (3)
Replace	9 (15)
Repair and replace	50 (82)
Co-morbidities, n (%)
Atrial fibrillation	28 (46)
Hypertension	20 (33)
Gastritis	1 (2)
Hyperthyroidism	2 (3)
Asthma	9 (15)
No of cardiovascular related medications, n (%)
1 drug	1 (1.6)
2 drugs	2 (3.4)
3 drugs	11 (18)
≥4 drugs	47 (77)
Mean (SD)	4.62 (±1.16)
Number of patients with DRPs
1 DRP	24 (39.3)
2 DRPs	17 (27.9)
3 DRPs	18 (29.5)
4 DRPs	2 (3.3)
Mean (SD)	1.97 (±0.91)

Abbreviations: SD, standard deviation; BMI, body mass index; BSA, body surface area; mPaP, mean pulmonary artery pressure; PH, pulmonary hypertension; DRPs, drug-related problems.

Table 2 Types of Drug-Related Problems Identified Among Pulmonary Hypertension with Valvular Heart Disease

Primary Domain	Code	Drug-Related Problems	n	%
P1: Treatment effectiveness		All P1 problems	71	59.1
	P1.1	No effect of the drug treatment	4	3.3
	P1.2	Effect of drug treatment not optimal	61	50.8
	P1.3	Untreated symptoms or indication	6	5
P2: Treatment safety	P2.1	Adverse drug event (possibly) occurring	40	33.4
P3: Others		All P3 problems	9	7.5
	P3.2	Unnecessary drug-treatment	3	2.5
	P3.3	Unclear problem/complaint. Further clarification necessary (please use as escape only)	6	5

Table 3 Types of Causes of Drug-Related Problems in Pulmonary Hypertension with Valvular Heart Disease

Primary Domain	Code	Drug-Related Problems	n	%
C1: Drug selection		All C1 causes	96	19
	C1.1	Inappropriate drug according to guidelines/formulary	16	3.1
	C1.2	Inappropriate drug (within guidelines but otherwise contra-indicated)	6	1.2
	C1.3	No indication for drug	10	2
	C1.4	Inappropriate combination of drugs, or drugs and herbal medications, or drugs and dietary supplements	52	10.3
	C1.6	No or incomplete drug treatment in spite of existing indication	8	1.6
	C1.7	Too many drugs prescribed for indication	4	0.8
C2: Drug form	C2.1	Inappropriate drug form (for this patient)	4	0.8
C3: Dose selection		All C3 causes	90	17.9
	C3.1	Drug dose too low	41	8.2
	C3.2	Drug dose too high	45	8.9
	C3.5	Dose timing instructions wrong, unclear or missing	4	0.8
C4: Treatment duration		All C4 causes	31	6.2
	C4.1	Duration of treatment too short	10	2
	C4.2	Duration of treatment too long	21	4.2
C5: Dispensing		All C5 causes	31	6.1
	C5.3	Wrong drug, strength or dosage advised (OTC)	15	3
	C5.4	Wrong drug or strength dispense	16	3.1
C6: Drug use process		All C6 causes	66	12.7
	C6.1	Inappropriate timing of administration or dosing intervals	39	7.7
	C6.2	Drug under-administered	5	0.9
	C6.3	Drug over-administered	17	3.4
	C6.4	Drug not administered at all	1	0.2
	C6.5	Wrong drug administered	1	0.2
	C6.6	Drug administered via wrong route	3	0.6
C7: Patient related		All C7 causes	74	14.1
	C7.1	Patient uses/takes less drug than prescribed or does not take the drug at all	25	5
	C7.2	Patient uses/takes more drug than prescribed	14	2.8
	C7.5	Patient takes food that interacts	31	6.2
	C7.6	Patient stores drug inappropriately	2	0.4
	C7.9	Patient unable to use drug/form as directed	1	0.2
	C7.10	Patient unable to understand instructions properly	1	0.2
C9: Other		All C9 causes	111	21.7
	C9.1	No or inappropriate outcome monitoring (incl. TDM.)	93	18.6
	C9.2	Other cause; specify	17	3.4
	C9.3	No obvious cause	1	0.2

Abbreviations: OTC, over the counter; incl, including; TDM, therapeutic drug monitoring.

Table 4 The Incidence of Drug-Related Problems in Pulmonary Hypertension with Valvular Heart Disease

Name of Drug Involved (According to Pharmacology Group)	No of Patients Received the Drug (n)	No of Patient with Manifested DRPs (n)	Incidence of DRPs Per Type of Drug (%)	Total No. of DRPs (n)	Incidence of DRPs Per Overall (%)
Antiarrhythmic, class III	10	8	80	10	8.3
Antibiotics	28	8	28.6	34	28.4
Antiepileptics	4	0	0	4	3.3
Antithrombotic agents	25	9	36	32	26.7
Analgesics and antipyretics	1	0	0	1	0.8
Adrenergic, inhalants	1	0	0	1	0.8
Iron preparations	6	1	16.7	6	5
Antihypertensive	3	2	66.7	3	2.5
Cardiac glycosides	8	0	0	9	7.5
Catecholamine	1	1	100	1	0.8
Diuretics	4	1	25	4	3.3
Electrolyte’s solutions	5	2	40	6	5
Proton pump inhibitors	2	0	0	2	1.7
PDE-5 Inhibitors	3	2	66.7	3	2.5
HMG CoA reductase inhibitors	2	0	0	2	1.7
Others	2	0	0	2	1.7

Abbreviations: DRPs, drug related problems; PDE-5 inhibitors, phosphodiesterase-5 inhibitors; HMG-CoA, 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitors.

Table 5 The Incidence of Adverse Drug Reactions in Pulmonary Hypertension with Valvular Heart Disease

Name of Drug Involved (According to Pharmacology Group)	No of Patients Received the Drug (n)	No of Patients Manifested ADRs (n)	Incidence of ADRs Per Type of Drug (%)
Antiarrhythmic, class III	10	7	70
Antibiotics	28	3	11
Antiepileptics	4	0	0
Antithrombotic agents	25	8	32
Analgesics and antipyretics	1	0	0
Adrenergic, inhalants	1	0	0
Iron preparations	6	0	0
Antihypertensive	3	1	33
Cardiac glycosides	8	0	0
Catecholamine	1	1	100
Diuretics	4	0	0
Electrolyte’s solutions	5	0	0
Proton pump inhibitors	2	0	0
PDE-5 Inhibitors	3	1	33
HMG CoA reductase inhibitors	2	0	0
Others	2	0	0

Abbreviations: ADRs, adverse drug reactions; PDE-5 inhibitors, phosphodiesterase-5 inhibitors; HMG-CoA, 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitors.

Figure 2 Simplified network diagram between the types and causes of drug related problems (DRPs).