Feature: Improper meds given to 20% of dialysis patients undergoing PCI

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Two blood-thinning drugs, enoxaparin and eptifibatide, commonly administered to dialysis patients undergoing PCI, have been found to increase patients' risk of in-hospital bleeding, a study published Dec. 9 in the Journal of the American Medical Association ( JAMA) found. Lead author Thomas T. Tsai, MD, told Cardiovascular Business News that the study reflects a larger problem of medical administration errors in the U.S., and called for better IT tools to warn physicians about contraindicated medications.

Tsai, director of interventional cardiology at the Denver VA Medical Center, and colleagues analyzed 22,778 dialysis patients who underwent PCI between January 2004 and August 2008. They found that 20 percent of them were prescribed anti-thrombotic medication—enoxaparin (Lovenox; Sanofi-Aventis) or eptifibatide (Integrilin; Millennium Pharmaceuticals)—which researchers said they should not have received.

Of those 20 percent, 47 percent received enoxaparin, 64 percent received eptifibatide and 11 percent received both. Researchers found that rates of in-hospital bleeding in patients administered the contraindicated anti-thrombotic medications increased by 5.6 percent.

According to the study, 100,000 deaths annually are linked to medication errors from adverse drug reactions or wrongly administered drugs.

“I think there is a broader message here: the results of this study illustrate the continued problem of medication errors in the U.S.,” said Tsai. Although this study specifically refers to dialysis patients, other studies have shown a connection to other errors of administered medication in other sectors of the population.

He explained that health IT tools need to do a better job of alerting physicians when they have improperly ordered medication with such systems as a computerized provider order entry (CPOE).

Various patient populations such as the elderly or, in this case, dialysis patients metabolize medications differently. Physicians need help from health IT tools. Such IT systems can ask physicians questions about the patient. "Is this patient on dialysis or does the patient have impaired renal function? With our answers, the system then tells us whether or not we can or can’t prescribe certain medications,” Tsai said.

He explained that in the cath lab, 60 combinations of medications and more than 1,000 different permutations can be configured for each patient.

In this regard, Tsai said that health IT tools such as clinical path order sets in the CPOE that are geared toward cardiac patients can actually be harmful to some patients with other maladies.

Tsai offered that “amending those types of tool kits to take into consideration these less commonly encountered patients would be huge.” He urged that these clinical path order sets be amended to incorporate reflection of renal function.

Enoxaparin and eptifibatide are “very frequently” administered to the general population. Tsai said that IT tool kits could be the culprit why these two drugs are overused, especially when they are contraindicated and not recommended for specific patients groups, like dialysis patients.

These anti-thrombotic medications have been linked to an increased risk of bleeding in dialysis patients because these patients do not have proper function of the kidney to flush the medications out of the blood stream. Because these are blood thinners, Tsai said the dosage accumulates in the blood increasing the risk of bleeding.

Patients with impaired renal function were given inappropriate doses of these two medications as if they had a normal functioning kidney, which led to the increased bleeding, according to Tsai.

He also noted that there are alternative medications such as unfractionated heparin, which can be administered to dialysis patients: “It’s not as if we are pressured to use these two medications because there’s no other alternative," he said.

“When you have two pieces of the puzzle -- contraindicated medications associated with increased bleeding -- it should be enough evidence to alert the community that these medications should not be used, and if you’re using them, you should stop,” said Tsai.

Amending clinical path order sets would allow clinicians to improve this problem, he concluded.