Pharmacotherapy assessment in chronic kidney disease: validation of the PAIR instrument for use in Brazil

Marquito, Alessandra Batista; Pinheiro, Hélady Sanders; Fernandes, Natália Maria da Silva; Paula, Rogério Baumgratz de

doi:10.1590/2175-8239-JBN-2019-0205

Alessandra Batista Marquito Correspondence to: Alessandra Batista Marquito. E-mail: alemarkito@yahoo.com.br

Universidade Federal de Juiz de Fora, Faculdade de Medicina, Programa de Pós-Graduação em Saúde, Núcleo Interdisciplinar de Estudos, Pesquisas e Tratamento em Nefrologia, Juiz de Fora, MG, Brasil.

https://orcid.org/0000-0003-0237-2521

Hélady Sanders Pinheiro

Universidade Federal de Juiz de Fora, Faculdade de Medicina, Programa de Pós-Graduação em Saúde, Núcleo Interdisciplinar de Estudos, Pesquisas e Tratamento em Nefrologia, Juiz de Fora, MG, Brasil.

Universidade Federal de Juiz de Fora, Faculdade de Medicina, Departamento de Clínica Médica, Juiz de Fora, MG, Brasil. Núcleo Interdisciplinar de Estudos, Pesquisas e Tratamento em Nefrologia, Juiz de Fora, MG, Brasil.

https://orcid.org/0000-0001-8603-1331

Natália Maria da Silva Fernandes

Universidade Federal de Juiz de Fora, Faculdade de Medicina, Programa de Pós-Graduação em Saúde, Núcleo Interdisciplinar de Estudos, Pesquisas e Tratamento em Nefrologia, Juiz de Fora, MG, Brasil.

Universidade Federal de Juiz de Fora, Faculdade de Medicina, Departamento de Clínica Médica, Juiz de Fora, MG, Brasil. Núcleo Interdisciplinar de Estudos, Pesquisas e Tratamento em Nefrologia, Juiz de Fora, MG, Brasil.

https://orcid.org/0000-0001-8728-7937

Rogério Baumgratz de Paula

Universidade Federal de Juiz de Fora, Faculdade de Medicina, Programa de Pós-Graduação em Saúde, Núcleo Interdisciplinar de Estudos, Pesquisas e Tratamento em Nefrologia, Juiz de Fora, MG, Brasil.

Universidade Federal de Juiz de Fora, Faculdade de Medicina, Departamento de Clínica Médica, Juiz de Fora, MG, Brasil. Núcleo Interdisciplinar de Estudos, Pesquisas e Tratamento em Nefrologia, Juiz de Fora, MG, Brasil.

https://orcid.org/0000-0002-7778-2907

Correspondence to: Alessandra Batista Marquito. E-mail: alemarkito@yahoo.com.br

Authors’ contributions

A. B. Marquito: literature review, data collection and analysis, writing and final approval of the paper.

H. S. Pinheiro: study design, writing, critical review and final approval of the paper.

N. M. S. Fernandes: statistical analysis of the data, critical review and final approval of the paper.

R. B. de Paula: study design, writing, critical review and final approval of the paper.

Conflict of interests

The authors declare no conflicts of personal, commercial, academic, political and financial interests in this manuscript.

Drug therapy assessment in chronic kidney disease
Inadequate use (inadequate dose or contraindicated medication)
1. The patient is receiving a contraindicated medication, a non-steroidal anti-inflammatory agent.
2. The patient is receiving a very high dose of gabapentin:
GFR 30-59 mL/min: maximum dose of 1,400 mg/day, oral;
GFR 15-29 mL/min: maximum dose of 700 mg/day, oral;
GFR 10-14 mL/min: maximum dose of 300 mg/day, oral;
GFR < 10 mL/min: maximum dose of 150 mg/day, oral.
3. The patient is receiving a contraindicated drug, meperidine.
4. The patient is receiving a very high dose of pregabalin.
GFR 30-59 mL/min: maximum dose of 300 mg/day, oral;
GFR 15-29 mL/min: maximum dose of 150 mg/day, oral;
GFR < 15 mL/min: maximum dose of 75 mg/day, oral.
5. The patient is receiving a very high dose of an antiviral agent (acyclovir, valacyclovir, fancyclovir), according to the dose-adjustments tables for kidney disease.
6. The patient is receiving a very high dose of cephalosporin, according to the dose-adjustment tables for kidney disease.
7. The patient is receiving a very high dose of a neuraminidase inhibitor (oseltamivir, for instance), according to the dose-adjustment tables for kidney disease.
8. The patient is receiving nitrofurantoin, which is contraindicated in kidney disease (GFR < 60 mL/min).
9. The patient is receiving a very high dose of penicillin, according to the dose-adjustment tables for kidney disease.
10. The patient is receiving a very high dose of quinolone, according to the dose-adjustment tables for kidney disease.
11. The patient is receiving a very high dose of sulfonamide, according to the dose-adjustment tables for kidney disease.
12. The patient is receiving a very high dose of tetracycline, according to the dose-adjustment tables for kidney disease.
13. The patient is receiving a very high dose of a triazol (fluconazole, for instance), according to the dose-adjustment tables for kidney disease.
14. The patient is receiving a very high dose of a beta blocker, according to the dose-adjustment tables for kidney disease.
15. The patient is receiving a very high dose of fenofibrate nanocrystals.
GFR 20-50 mL/min: maximum dose of 48 mg/day, oral.
16. The patient has a GFR < 25 mL/min and is receiving a contraindicated medication, acarbose.
17. The patient has a GFR < 30 mL/min and is receiving a contraindicated medication, metformine.
18. The patient is receiving a very high dose of ranitidine.
GFR < 50 mL/min: maximum dose of 150 mg/day, oral.
If needed, it can be increased to 150 mg/day, twice a day, if the GFR is between 30 and 50 mL/min.
19. The patient is receiving a very high dose of allopurinol.
GFR 41-60 mL/min: Maximum dose of 150 mg/day, oral, once a day;
GFR 21-40 mL/min: Maximum dose of 100 mg/day, oral, on alternate days;
GFR 10-20 mL/min: Maximum dose of 100 mg/day, oral, on alternate days;
GFR < 10 mL/min: Maximum dose of 100 mg/day, oral, every three days.
20. The patient is receiving a very high dose of colchicine, as prophylaxis for gout:
GFR < 50 mL/min: chronic treatment not recommended.
The patient is receiving a very high dose of colchicine for an acute treatment:
GFR 35-50 mL/min: maximum dose of 0.6 mg/day;
GFR < 35 mL/min: maximum dose of 0.3 mg, oral, once a day, or 0.6 mg, oral, on alternate days.
21. The patient with a GFR < 30 mL/min is taking a contraindicated medication, a bisphosphonate (alendronate, etidronate, risedronate).
22. The patient is receiving a very high dose of varenicline.
Inadequate blood pressure
GFR 10-30 mL/min: maximum dose of 0.5 mg, oral, twice a day;
GFR < 10 mL/min: maximum dose of 0.5 mg, oral, once a day.
Inadequate blood pressure
23. The patient requires medication treatment, because his blood pressure is > 130/80 mmHg, but he is not receiving it.
24. The patient is receiving a very low dose of his anti-hypertensive drug and, consequently, his blood pressure is > 130/80 mmHg.
Hypoglycemia secondary to sulfonylurea
25. The patient is developing an adverse reaction (hypoglycemia) after taking his oral hypoglycemia medication (a second-generation sulfonylurea: glibenclamide).
Interaction and drug taken inadequately
26. The patient is developing a drug interaction between calcium carbonate and an antibiotic (tetracycline or fluoroquinolone, except moxifloxacin).
27. The patient is developing a drug interaction between calcium and iron taken concomitantly, per os.
28. The patient is not taking his phosphorus scavenger (calcium carbonate, calcium acetate, sevelamer or lanthanum) adequately.
29. The patient is developing a drug interaction between his phosphorus scavenger (calcium carbonate, calcium acetate, sevelamer or lanthanum and levothyroxine).
30. The patient is developing a drug interaction between sevelamer or lanthanum, and ciprofloxacin.
31. The patient is not taking his vitamin D (calcitriol or alfacalcidol) adequately.
32. The patient is not taking his calcium polystyrene sulphonate adequately.
33. The patient needs to the referred to treatment or follow-up on smoke cessation, but has not received it.
Problems associated with medication not requiring medical prescription or natural health product
34. The patient is taking medication contraindicated for kidney disease, one antacid with calcium, magnesium, aluminum and/or sodium.
35. The patient is developing an adverse reaction (hypertension) to pseudoephedrine or phenylephrine.
36. The patient is taking a laxative, which is contraindicated for the kidney.
37. The patient is receiving a medication contraindicated for the patient with kidney disease, a polyvitamin enriched with vitamin A.
38. The patient with chronic kidney disease is receiving a very high dose of an ascorbic acid supplement (vitamin C) > 250 mg/day.
39. The patient is receiving a natural product, which is contraindicated in kidney disease, a garlic supplement.
40. The patient is receiving a natural product, contraindicated for transplanted patients with kidney disease, echinacea.
41. The patient is receiving a natural product contraindicated in kidney disease, ginkgo biloba.
42. The patient is receiving a natural product that is contraindicated for transplanted patients, climbing fig (Ficus pumila).
43. The patient is receiving a natural product that is contraindicated in kidney disease, klammath weed (Hypericum perforatum).
44. The patient is receiving a natural product that is contraindicated in kidney disease, liquorice root (Glycyrrhiza glabra).

CHARACTERISTICS	Patientes n = 100 (n/%)
CHARACTERISTICS	N	%
Gender
Female	55	55
Male	45	45
Age (yrs)
≤ 19	0	0
20 - 29	1	1
30 - 39	2	2
40 - 49	6	6
50 - 59	20	20
≥ 60	71	71
Race
White	52	52
Black	23	23
Brown	25	25
Level of education
Can't read/write	10	10
Literate	4	4
Incomplete Elementary school	59	59
Complete Elementary school	13	13
Incomplete High school	3	3
Complete High school	7	7
Incomplete Higher education	1	1
Complete Higher education	3	3
Smoking	10	10
Alcohol abuse	9	9
Number of medications
2 to 4	22	22
5 to 10	67	67
More than 11	11	11
CKD stage
1	1	1
2	6	6
3a	17	17
3b	38	38
4	32	32
5	6	6
Body Mass Index (BMI)
Underweight	0	0
Healthy weight	21	21
Overweight	29	29
Obesity	48	48
No data	2	2
Baseline disease
Hypertensive nephropathy	23	23
Diabetic nephropathy	23	23
Non-Steroidal anti-Inflammatory Nephropathy	2	2
Undetermined	55	55
Comorbidities
Diabetes	59	59
Hypertension	96	96
Acute Myocardial Infarction	9	9
Cerebrovascular Accident	8	8
Comorbidities/patient
1	22	22
2	40	40
3	28	28
4 or more	10	10

Drug Related Problem	Frequency N (%)
Inadequate use (inappropriate dosage or contra-indicated agent)	42 (33.3)
Non-steroidal anti-inflammatory (DRP 1)	16
Nitrofurantoin (DRP 8)	2
Beta blocker (DRP 14)	2
Fenofibrato. (DRP 15)	3
Metformin (DRP 17)	7
Ranitidine (DRP 18)	4
Allopurinol (DRP 19)	6
Bisphosphonate - alendronate, etidronate, risedronate (DRP 21)	2
Non-optimal blood pressure	38 (30.2)
Low dose of the antihypertensive agent (DRP 24)	38
Hypoglycaemia secondary to sulfonylurea	1 (0.8)
Hypoglycaemia after taking glyburide (DRP 25)	1
Interaction and drug taken inadequately	43 (34.1)
Vitamin D (calcitriol ou alfacalcidol) (DRP 31)	33
No treatment or follow-up on smoking cessation (DRP 33)	10
Problems related to an over-the-counter medication or a natural health product	2 (1.6)
Purgative not indicated (DRP 36)	2

Drug Related Problem	Inter-rater Reliability (n=100) κ^* * Cohen's kappa coefficient.	Test-Retest Reliability (n = 30) κ^* * Cohen's kappa coefficient.
Inadequate use (inappropriate dosage or contra-indicated agent)
Nitrofurantoin (DRP 8)	0.662	1.000
Metformin (DRP 17)	0.646	1.000
Allopurinol (DRP 19)	0.790	1.000
Non-optimal blood pressure
Low dose of the antihypertensive agent (DRP 24)	0.723	0.856
Interaction and drug taken inadequately
Vitamin D (calcitriol ou alfacalcidol) (DRP 31)	0.580	0.791
No treatment or follow-up on smoking cessation (DRP 33)	0.942	1.000

[1] Correspondence to: Alessandra Batista Marquito. E-mail: alemarkito@yahoo.com.br

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Pharmacotherapy assessment in chronic kidney disease: validation of the PAIR instrument for use in Brazil

Abstract