domingo, 20 de diciembre de 2009

Contraindicated Medication Use in Dialysis Patients Undergoing Percutaneous Coronary Intervention - AHRQ Patient Safety Network

Contraindicated medication use in dialysis patients undergoing percutaneous coronary intervention.
Tsai TT, Maddox TM, Roe MT, et al; for the National Cardiovascular Data Registry. JAMA. 2009;302:2458-2464.

Patients hospitalized for cardiac problems are vulnerable to experiencing medication errors, as they are commonly prescribed high-risk medications such as anticoagulants and antiplatelet agents. This analysis of more than 22,000 hemodialysis patients undergoing percutaneous coronary interventions (PCI) (for example, angioplasty) found that 22.3% were administered either enoxaparin or eptifibatide, medications that are contraindicated in dialysis patients due to excessive bleeding risk. This risk was borne out in the study, as patients who received the contraindicated medications did in fact have more major bleeding episodes. The high prevalence of serious medication errors in this study argues for education and use of forcing functions to prevent misuse of these medications.

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Contraindicated Medication Use in Dialysis Patients Undergoing Percutaneous Coronary Intervention
Thomas T. Tsai, MD, MSc; Thomas M. Maddox, MD, MSc; Matthew T. Roe, MD, MHS; David Dai, PhD; Karen P. Alexander, MD; P. Michael Ho, MD, PhD; John C. Messenger, MD; Brahmajee K. Nallamothu, MD, MPH; Eric D. Peterson, MD, MPH; John S. Rumsfeld, MD, PhD; for the National Cardiovascular Data Registry
JAMA. 2009;302(22):2458-2464.

Context The US Food and Drug Administration guides clinicians through drug labeling of medications that are contraindicated or not recommended for use in specific patient groups. Little is known about the use of such medications and their effects on outcomes in clinical practice.

Objective To investigate the use of the contraindicated/not-recommended agents enoxaparin and eptifibatide among dialysis patients undergoing percutaneous coronary intervention (PCI) and their association with outcomes.

Design, Setting, and Participants Data from 829 US hospitals on 22 778 dialysis patients who underwent PCI between January 1, 2004, and August 31, 2008.

Main Outcome Measures In-hospital bleeding and death.

Results Five thousand eighty-four patients (22.3%) received a contraindicated antithrombotic; of these patients, 2375 (46.7%) received enoxaparin, 3261 (64.1%) received eptifibatide, and 552 (10.9%) received both. Compared with patients who did not receive a contraindicated antithrombotic, patients who did had higher rates of in-hospital bleeding (5.6% vs 2.9%; odds ratio [OR], 1.93; 95% confidence interval [CI],1.66-2.23) and death (6.5% vs 3.9%; OR, 1.68; 95% CI, 1.46-1.95). After multivariable adjustment, patients receiving contraindicated antithrombotics had significantly higher risks of in-hospital bleeding (OR, 1.66; 95% CI, 1.43-1.92) and death (OR, 1.24; 95% CI, 1.04-1.48). In 10 158 patients matched by propensity scores, receipt of contraindicated antithrombotics remained significantly associated with in-hospital bleeding (OR, 1.63; 95% CI, 1.35-1.98) but not in-hospital death (OR, 1.15; 95% CI, 0.97-1.36).

Conclusions In a sample of dialysis patients undergoing PCI, 22.3% received a contraindicated antithrombotic medication. In propensity-matched analysis, receipt of these medications was significantly associated with an increased risk of in-hospital major bleeding.

Author Affiliations: Denver VA Medical Center, Denver, Colorado (Drs Tsai, Maddox, Ho, and Rumsfeld); University of Colorado Denver (Drs Tsai, Maddox, Ho, Messenger, and Rumsfeld); Colorado Cardiovascular Outcomes Research Group, Denver (Drs Tsai, Maddox, Ho, and Rumsfeld); Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina (Drs Roe, Dai, Alexander, and Peterson); and Ann Arbor VA Medical Center, University of Michigan Hospital, Ann Arbor (Dr Nallamothu).

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