1. Clinical Pharmacist Intervention in Cardiac Patients With Renal Impairment Elham Al-Shammari, B.Sc. Pharm. Hisham Abou-Auda, Ph. D. Meshal Al-Mutairi, Pharm. D. Supervised by

3. Having clinical pharmacist during physician rounds will decrease preventable adverse drug events especially in intensive care unit. Adverse drug events were the sixth leading cause of death in USA in 1994 with 10.9% of all hospital patients. Introduction

4. Pharmacists working beside the dispensing windows miss the opportunity to assist physicians in rational prescribing. Addressing medical errors is one strategy to improve safety of medication For every $1 invested in clinical pharmacy services, $4 in benefit is expected Introduction

5. $45.6 billion in direct health care costs would be avoided even when this kind of service led to 4-fold increase in fee association. A review of the economic benefit of clinical pharmacy services through 59 articles published between 1996 to 2000 performed by Center for Pharmacoeconomics Research and Department of Pharmacy Practice, University of Illinois at Chicago, USA Introduction

7. Evaluate the role of clinical pharmacist in dosage adjustment in patients with renal impairment Objectives Through clinical observation, patients with cardiac problems were in high risk to develop renal impairment. Therefore, this study was conducted to: Assess the cost impact of clinical pharmacist’s intervention.

9. Prince Sultan Cardiac Center in Riyadh. 160 full-capacity beds 5,304 admissions / year. Patients with cardiac problems. Scheduled procedures and also serves outpatient and emergency clinics. Prince Sultan Cardiac Center in Riyadh. 160 full-capacity beds 5,304 admissions / year. Patients with cardiac problems. Scheduled procedures and also serves outpatient and emergency clinics. Study Setting Methodology

10. Study Design Prospective, observational and interventional study. Five days a week for four weeks during July 2004. Approved by the P&T Committee to be provided by PSCC Pharmacy Department. Prospective, observational and interventional study. Five days a week for four weeks during July 2004. Approved by the P&T Committee to be provided by PSCC Pharmacy Department. Methodology

11. Institutional Board Review was obtained. The study was also approved by the Ethical Committee in PSCC. The study was conducted according to Helsinki Declaration and the safety of all patients was insured.

12. Ceftazidime, Cefuroxime, Ciprofloxacin, Digoxin, Piperacillin/tazobactam (tazosin), Ranitidine. (extensive use & high acquisition cost). Ceftazidime, Cefuroxime, Ciprofloxacin, Digoxin, Piperacillin/tazobactam (tazosin), Ranitidine. (extensive use & high acquisition cost). Methodology Drugs to be Monitored :

13. Identify patients receiving these drugs on daily basis, Review their demographic data and assess laboratory findings. Recommended appropriate dosing adjustment according to renal function. Identify patients receiving these drugs on daily basis, Review their demographic data and assess laboratory findings. Recommended appropriate dosing adjustment according to renal function. Intervention Protocol: Methodology

14. Inclusion and Exclusion Criteria All hospitalized cardiac patients 18 years of age or older. Receiving one or more of the study medications. All hospitalized cardiac patients 18 years of age or older. Receiving one or more of the study medications. Methodology

15. Outcome Measures Methodology Ethical considerations. Clinical outcome. Cost avoidance will be determined by calculating the difference between the costs of the original and adjusted regimens. Ethical considerations. Clinical outcome. Cost avoidance will be determined by calculating the difference between the costs of the original and adjusted regimens.

16. Data Collection Demographic data. Lab findings: S cr, drug levels, BUN, etc. Diagnosis and underlying disease (e.g. CHF). Demographic data. Lab findings: S cr, drug levels, BUN, etc. Diagnosis and underlying disease (e.g. CHF). Methodology

17. Cockcroft and Gault equation Data Collection, cont’ Methodology Female; 85% [ 140 – age] W 72 S cr CL cr ( Males) =

18. Data Collection, cont’ Methodology Jellife method CL cr = 98 – 0.8 (age – 20) S cr Female; 90%

19. Appropriate dose adjustment when needed. Calculation of cost avoidance and extrapolation of the results to one year. Appropriate dose adjustment when needed. Calculation of cost avoidance and extrapolation of the results to one year. Methodology Data Collection, cont’

20. Statistical Analysis Methodology SPSS version 13.0 Frequencies Condescriptives Parametric or Nonparametric tests.

22. Male Female Age W W IBW Ht 52.9 ± 15 (N = 45) 52.9 ± 15 (N = 45) 52 ± 15 (N = 42) 52 ± 15 (N = 42) p (sig.) 0.773 (NS) 44 ± 17 (N = 44) 44 ± 17 (N = 44) 63.2 ± 12.6 (N = 42) 63.2 ± 12.6 (N = 42) 0.001 (S) 0.001 (S) 63.5 ± 5.6 (N = 42) 63.5 ± 5.6 (N = 42) 64.3 ± 98.3 (N = 39) 64.3 ± 98.3 (N = 39) 0.959 (NS) 0.959 (NS) 77.5 ± 35 (N = 43) 77.5 ± 35 (N = 43) 79.5 ± 38.5 (N = 38) 79.5 ± 38.5 (N = 38) 0.839 (NS) 0.839 (NS)

23. CHF ICU 27.6 % 72.4 % 42.5 % 57.5 %

24. CL Cr (ml/min) 0 20 40 60 80 100 120 0 20 40 608010305070 Ejection fraction (%) r = 0.374, p = 0.002

25. CL Cr =35.23 + 0.605 (Ejection Fraction)

26. p<0.0001 0 0 20 40 60 80 100 120 140 160 100200 300 400 CRCL (ml/min) SCR (umol/L)

27. p < 0.0001 0 10 20 30 40 50 60 70 80 9020406080 100 120 140 160 CRCL (ml/min) AGE

28. Renal Impairment Categories

30. Dose Adjustment 13.8 %

31. Drugs Involved

32. 287,609 384,358 Min. saving Max. saving 869.59 650.66 During study Annual saving

33. Digoxin CL = CL cr + 20 Without CHF Digoxin CL = CL cr + 40 With CHF

34. 20 0 100 200 300 120 406080 CRCL (ml/min) Digoxin CL (observed) p = 0.878

35. p = 0.256 Digoxin CL (observed) Digoxin CL (predicted) 406080 100 120140160 0 200 300

37. Equations for predicting Digoxin CL cannot be applied to our population ? Future investigation ? Saving lives, reducing adverse events Pharmacist intervention can save between SR 287,609 and SR 384,358 Equations for predicting Digoxin CL cannot be applied to our population ? Future investigation ? Saving lives, reducing adverse events Pharmacist intervention can save between SR 287,609 and SR 384,358 Discussion & conclusion

38. Role of pharmacist: prescription monitoring, reduction in length of hospital stays, incidence of adverse drug reactions total cost. Discussion & conclusion