Table 3 Examples of clinical pharmacist recommendations*
Recommendation category | Sample pharmacist recommendation |
|---|---|
DRP causes | |
C1.2 Inappropriate drug (within guidelines but otherwise contra-indicated) | |
Use of metoclopramide in patients over 65 years of age | Medication change was recommended |
C1.4 Inappropriate combination of drugs or drugs and herbal medication | |
Meropenem- Valproic acid | It was recommended to stop the use of meropenem |
Ciprofloxacin-Enteral nutrition | It was recommended to take a 1-h break from feeding before and after ciprofloxacin administration |
Phenytoin-Enteral nutrition | It was recommended to take a 1-h break from feeding before and after phenytoin administration |
Clarithromycin-Midazolam | A reduction in midazolam dose was recommended |
C1.5 Inappropriate duplication of therapeutic group or active ingredient | |
Tiotropium bromid- ipratropium bromide | It was recommended to stop ipratropium bromide |
C3.1 Drug dose too low | |
Use of meropenem IV 0.5 g twice a day in a patient receiving CRRT | It was recommended to increase the dose of meropenem to 1 g twice a day |
Use of Ampicillin sulbactam IV 2 g twice a day | It was recommended to increase the dose to 3 g 3 times a day |
C3.2 Drug dose too high | |
Use of Colistin IV 150 mg twice a day | It was recommended to reduce the dose to 110 mg twice a day in the patient with a CrCl of 50 |
Use of Fluconazole IV 400 mg | It was recommended to reduce the dose to 200 mg in patients with a CrCl below 50 |
C3.3 Dosage regimen not frequent enough | |
Use of Teicoplanin every 72 h | It was recommended to be every 48 h in patients receiving CRRT |
C3.4 Dosage regimen too frequent | |
Teicoplanin every 48 h | It was recommended to be every 72 h in patients receiving hemodialysis |
Ranitidine IV 50 mg 3 times per day | It was recommended to reduce the dose to 50 mg once a day in patients with a CrCl below 50 |
C3.5 Dose timing instructions wrong, unclear or missing | |
Not taking additional doses after dialysis in the treatment of colistin | An additional 50 mg dose was recommended after hemodialysis |
No or missing colistin loading dose | 300 mg colistin loading dose was recommended |
C6.1 Inappropriate timing of administration and/or dosing intervals | |
Clarithromycin IV 500 mg 2 times a day | In patients receiving hemodialysis or with a CrCl less than 10, 500 mg once daily was recommended |
Use of teicoplanin in patients receiving plasmapheresis | Since teicoplanin is a highly protein-bound drug, it was recommended to be given at least 4 h after plasmapheresis |