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Table 3 Description of drug therapy problems

From: Preventing hospital admissions by reviewing medication (PHARM) in primary care: design of the cluster randomised, controlled, multi-centre PHARM-study

Drug therapy problem Common causes of drug therapy problem Examples
Additional drug therapy required • A medical condition requires the initiation of drug therapy.
• Preventive drug therapy is required to reduce the risk of developing a new condition (according to the national guidelines).
• A medical condition requires additional pharmacotherapy to produce an additive of synergistic effect.
• The patient is suffering from pain with no analgesic therapy.
• A patient with chronic heart failure due to left ventricular systolic dysfunction, without an ACE-inhibitor or an angiotensin receptor blocker.
• A patient with atrial fibrillation without antithrombotic therapy.
• Calcium and vitamin D supplements for a patient with osteoporosis who is already taking a bisphosphonate.
Unnecessary drug therapy • There is no current valid medical indication for the drug therapy for the individual patient.
• Multiple drug products are being used for a medical condition that requires single drug therapy.
• The medical condition is more appropriately treated with non-drug therapy or lifestyle changes.
• Drug therapy is being taken to treat an avoidable adverse event associated with another medication.
• Lifestile ( e.g. drug abuse, alcohol use, diet, smoking) is causing the problem.
• A patient is using a low dose of aspirin without a high risk of cardiovascular disease or any signs of a cardiovascular disease.
• A patient is using three different laxative products in an attempt to treat his constipation.
• A patient is using a benzodiazepine every night as a hypnotic drug for three years while it is better to recommend alternative sleeping patterns, sleep hygiene and exercise.
• A patient is using furosemide to prevent swollen ankles.
• A patient is using paracetamol combined with codeine (500/10) and is suffering from constipation which is treated with lactulose and bisacodyl occasionally.
• A patient uses a protonpump inhibitor to treat dyspepsia associated with alcohol abuse.
Ineffective drug therapy • The drug is not effective for the medical problem.
• The drug product is not the most effective for the indication being treated.
• The formulation of the drug products is inappropriate.
• The drug is not effective because of the characteristics of the patient. (e.g. renal impairment, hepatic function)
• A patient is using an antibiotic for a common cold (viral infection).
• A patient with benign prostatic hyperplasia uses doxasozine for more than four years.
• • A patient with severe COPD uses salbutamol in a turbuhaler.
• A patient with renal impairment uses a thiazide to lower the blood pressure.
Dosage too low • The dose is too low to produce the desired outcome.
• The dosage interval is too long to produce the desired outcome.
• A drug-drug interaction reduces the amount of active drug available and the dose is not adjusted too produce the desired outcome.
• The duration of the drug therapy is too short to produce the desired outcome.
• A patient is prescribed simvastatine 10 mg every other day after a myocardial infarction.
• A patient uses 500 mg paracetamol, only twice a day, to control chronic pain in osteoarthritis.
• A patient uses 375 mg amoxicilline, only once a day, to treat an airway infection.
• A patient uses acenocoumarole and vitamin K.
• A patient uses paroxetine for 4 days to treat anxiety.
Adverse drug event • The drug causes an undesirable reaction that is not dose-related.
• A safer product is required due to risk factors.
• A drug interaction, with another drug or food, causes an undesirable reaction that is not dose-related.
• The drug is contraindicated due to risk factors or other diseases.
• The drug causes an allergic reaction.
• A drug dosage was increased or decreased too fast.
• A drug alters the patient's laboratory test results due to interference from a drug he/she uses.
• A patient on a low dose of aspirin is experiencing bruises.
• An elderly patient uses flurazepam to sleep and is experiencing drowsiness at day time.
• A patient who uses methotrexate gets prescribed co-trimoxazole for an infection (increase of anti-folate effect which can result in haematopoietic suppression).
• A patient gets prescribed indometacin to control chronic pain, which is contraindicated because of his/her history with a peptic ulcer.
• A patient is prescribed flucloxacillin for a dermal infection and develops a rash after the second dose.
• A patient who uses prednisolone 20 mg every day for the last 6 months for arthritis symptoms iss instructed to take 10 mg for 2 more days and then discontinues the medication.
• A patient had high blood glucose levels, due to the start of prednisolone therapy.
• Positive ketone test in urine due to captopril use.
Dosage too high • The drug causes an undesirable reaction due to too high dose.
• The dosing frequency of the drug is too short.
• The duration of drug therapy is too long.
• The drug dose is too high in the patient because of its characteristics (excretion).
• A drug-drug interaction occurs resulting in a toxic reaction to the drug.
• The dose of the drug was administered too rapidly.
• A patient develops bradycardia resulting from a high (0.5 mg) daily dose of digoxine.
• Hyperkaleamia after a dose of amiloride 10 mg three times a day.
• A patient who experienes nasal congestion uses a nasal spray with xylometazoline for four weeks.
• A patient with impaired renal function (CrCl: 20 ml/min) is prescribed a normal dose of 300 mg allopurinole a day, which causes nausea.
• A patient has an increased INR after given metronidazole while also using acenocoumarole.
• Cardiac arrest after infusion of a bolus of potassium phosphate (5 ml intravenously) instead of slow infusion.
Drug use problem • • The patient does not understand the instructions.
• The patient prefers not to take the medication.
• • The patient forgets to take the medication.
• • The patient cannot administer the drug appropriately him/herself.
• • The drug therapy does not comply with the lifestyle of the patient.
• • The patient has no access to the medication.
• The patient uses naproxen only when pain is unbearable while it is prescribed three times a day.
• The patient is afraid of taking fluvoxamine because of possible side-effects.
• The patient forgets to take his antihypertensive medication.
• The patient is unable to administer the timolol eyedrops for her glaucoma.
• A patient does not take furosemide because of attending activities at home.
• A patient is not able to fetch the medication at the pharmacy.