IDENTITAS JURNAL
BAB 7. RENCANA TINDAK LANJUT DAN PROYEKSI HILIRISASI
Hasil Penelitian Hasil penelitian ini merupakan pengembangan ilmu pengetahuan di bidang Kesehatan, dimana dari hasil penelitian ini bisa bermanfaat bagi tenaga medis untuk mendeteksi terjadinya kejadian yang tidak diinginkan pada pasien lansia. Tenaga medis menjadi lebih hati-hati dalam memberikan pengobatan kepada pasien lansia, agar kejadian yang tidak diinginkan yanga berhubungan dengan pengobatan (DRP) tidak terjadi. Dengan meminimalkan kejadian DRP bisa mengurangi morbidity, mortality dan biaya yang dikeluarkan.
Rencana Tindak Lanjut
Hasil penelitian ini bisa menjadi masukan untuk membuat guideline atau panduan tersendiri untuk Indonesia yang disesuaikan dengan karakter yang ada di Indonesia terutama pola penyakit, pengobatan pasien serta system pelayanan kesehatan di Indonesia
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31 LAMPIRAN - Artikel ilmiah 1 (telah submit)
Research Article
A Comparison of Potentially Inappropriate Medications Identification Using Beers and STOPP Criteria in Hospitalized Geriatric Patients in Jakarta
Daniek Viviandhari1, Nurhasnah1, Riska Nur Sakinah1, Desi Wulandari1
1Department of Clinical and Community Pharmacy /Faculty of Pharmacy and Science/ Universitas Muhammadiyah Prof. Dr. HAMKA/Jakarta Timur/Indonesia
Correspondence:
Daniek Viviandhari
Department of Clinical and Community Pharmacy /Faculty of Pharmacy and Science/ Universitas Muhammadiyah Prof. Dr. HAMKA, Jakarta Timur,
Indonesia
[email protected], 085743129092
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A Comparison of Potentially Inappropriate Medications Identification Using Beers and STOPP Criteria in Hospitalized Geriatric Patients in Jakarta
Abstract
Potentially inappropriate medications (PIMs) associated with Adverse Drug Events (ADE) among the elderly and furtherly, causing an increase in morbidity, mortality, and also medical cost. Some of the tools frequently used to assess PIMs in geriatric patients are Beers and STOPP criteria. This study aimed to compare PIMs identification using Beers 2019 and STOPP version 2 2016 criteria in hospitalized geriatric patients at Pondok Kopi Islamic Hospital. This study used a descriptive- analytical method with a retrospective data collection method based on the analysis of medical records at Pondok Kopi Islamic Hospital period of 2018. The data population was 340 patients. The results show that of 324 patients who met the inclusion criteria with Beers 2019 criteria, PIMs were present in 136 patients (41.85%), with a total of 181 cases. Most PIMs found were on criteria 3, i.e., the use of furosemide as much as 46 cases (25.41%) and followed by spironolactone for 33 cases (18.23%). Meanwhile, out of 308 patients who met the inclusion criteria with STOPP version 2 2016 criteria, PIMs were present in 8.76% of patients (27), with a total of 34 cases. Most PIMs found was the concurrent use of aspirin and clopidogrel in 18 cases (52.94%) in patients with uncontrolled hypertension followed by NSAID use in hypertensive patients in 8 cases (23.54%). In Pondok Kopi Islamic Hospital, Beers 2019 criteria describe PIMs data better than the
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STOPP version 2 2016 criteria with consideration of data availability. Clinician and pharmacist collaboration are needed in formulating the critical supporting data.
Keywords: Beers 2019, geriatrics, PIMs, STOPP version 2 2016 criteria
Introduction
By 2050, the world's population over 60 years and older is expected to 2 billion, increase around 10% from 2015 (900 million) (1). While in Indonesia, the percentage of the elderly population has reached 7.6% of the total population (in 2010) and is projected to double to 15.77% in 2035 (2). Geriatric patients are elderly patients with multiple diseases or disorders due to a decreased organ (leads to a gradual decrease in physical and mental capacity), psychological, social, economic and environmental functions (1,3). The morbidity rate for the elderly in Indonesia was 28.62% in 2015, meaning that out of every 100 older people there were around 28 people who were ill (4). The results of Riset Kesehatan Dasar in 2018, diseases suffered by the elderly were hypertension 63.5%, dental problems 53.6%, joint disorders 18%, oral problems 17%, diabetes mellitus 5.7%, heart disease 4.5%, stroke 4.4%, kidney failure 0.8% and cancer 0.4% (2).
Research shows that polypharmacy is common in older adults (5).
Polypharmacy can be described as the use of multiple medications, usually referred to as five or more prescribed drugs per day. Polypharmacy can also be explained as the administration of more medications than are clinically indicated, and this means patients receive unnecessary drug use (6). There is a strong relationship between
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polypharmacy and negative clinical consequences (5). When the number of drugs taken increases, the risk of ADR (Adverse Drug Reaction) increases exponentially.
Polypharmacy may also lead to medication incompliance, low quality of life, and unnecessary drug expenses (6).
Reducing medication errors in geriatric patients involves the use of a standard list of drugs classified according to the risks and benefits generated, aimed at guiding doctors when choosing treatment for patients, including the Beers and STOPP criteria methods. Beers criteria is one of the most commonly used explicit criteria because its application is the easiest to follow, the data obtained are reproducible, have strong evidence, are inexpensive, and can identify potential inaccuracies in drug use (7). The STOPP criteria comprise potentially unsuitable drugs as Potentially Inappropriate Medication (PIMs) (8,9).
A study in Cyprus using Beers 2015 criteria stated that there were 16.9%
PIMs during hospitalization at University Hospital (10). Another similar study conducted at a tertiary hospital in Saudi Arabia found that the prevalence of PIMs to be avoided among older adults was 57.6% (11).
A study conducted in Turkey found 14.8% of inappropriate drug use according to STOPP criteria (12). Another study in Malaysia stated PIM prevalence was 34.9%. The occurrence of PIM increases by 20% as the number of medications prescribed increased (13). Research conducted in Indonesia showed 17% of patients with chronic kidney disease obtained an average of one PIMs, while 38.9% of patients with osteoarthritis obtained an average of one PIMs (14,15).
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The results of PIMs with the Beers and STOPP screening tool have not been well documented in Indonesia, especially in hospitals in Jakarta. The researcher found the necessity to assess PIMs based on Beers and STOPP criteria to reduce the incidence of Adverse Drug Events (ADE). This research also compares the result of PIMs from Beers and STOPP criteria. This evaluation is expected to be a standard or guideline for hospitals in the treatment of geriatric patients by sorting out what laboratory data or physical examination is essential to check so that PIM can be appropriately assessed, either with Beers 2019 criteria or STOPP version 2 2016 criteria.
The objective of this research is to obtain information about the patient characteristics, find out and identify PIMs in geriatric patients according to Beers and STOPP criteria, and to compare PIMs using Beers and STOPP criteria at Pondok Kopi Islamic Hospital. The differences between this research and other similar researches that had been conducted in Jakarta were the comparison of PIMs using Beers and STOPP, also the higher number of samples.
Methods
This retrospective study was descriptive using Beers 2019 criteria and STOPP toolkit supporting medication review version 2 2016. The population of this study is all geriatric inpatients at Pondok Kopi Islamic Hospital 2018 period. The sampling method used was purposive sampling, i.e., respondents who met the inclusion criteria. The samples of this study were all geriatric inpatient at Pondok
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Kopi Islamic Hospital 2018 period that met the following inclusion criteria and exclusion criteria.
Inclusion criteria: patients aged ≥ 60 years, patients had complete medical record data, including age, sex, diagnosis, drug use, and laboratory data. Exclusion criteria: geriatric hospitalized patients at Pondok Kopi Islamic Hospital 2018 period which had no adequate laboratory data.
The research permit was obtained before the data were taken. The research proposal was submitted to the Ethics Committee of Faculty of Pharmacy and Science, Universitas Muhammadiyah Prof. Dr. HAMKA. This study had received the Ethical Approval test and with the protocol number 03/19.09/0178 and was declared to pass the study ethics. The data obtained (from medical records) was then recapitulated for data analysis to get a frequency distribution, and the proportion of the variable (patient characteristic) of the study. Data were then assessed for PIMs. The proportion of the samples identified to have PIMs and what drugs have the most PIMs will be determined from Beers and STOPP criteria. Then, the PIMs using Beers and STOPP criteria were compared.
Results
Data from 340 patients were obtained, but only 324 patients met the inclusion criteria as respondents for Beers 2019 criteria, and only 308 patients met the inclusion criteria as respondents for the STOPP version 2 2016 criteria.
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Excluded samples were patients with no laboratory data needed for PIMs identification.
Patient characteristic
Table 1 showed the distribution of patients based on patient characteristics.
The major respondents were female (54.12%). This result is in line with the data in 2017 of the elderly population in Indonesia, which states that the number of older women is higher at 9.53% compared to older men at 8.54% (4). Most respondents aged 60-74 years (81.17%). Based on data of the population pyramid in Indonesia, from 1971 until 2035, the population aged 60-64 is higher than other elderly groups, the population aged > 75 years has the smallest proportion but predicted to increase 2-fold from 2020 to 2035 (16).
Most respondents were hospitalized for 2-5 days (78.24%), with the most common diagnoses was gastrointestinal disorder (28.23%), and most respondents have one disease (57.94%). The majority of respondents used 6-10 medicines (60.60%). Polypharmacy is a strong risk factor for ADR. The elderly are more prone to ADR due to comorbidity, polypharmacy, and drug sensitivity (17).
There are other risk factors associated with polypharmacy, such as unwanted side effects (ADEs), low compliance with drug use, and high risk of geriatric syndrome (18). Prior studies proved that the probability of ADR among geriatric patients is 6% approximately when two drugs are taken, then increases to 50% when five drugs are taken, and becomes 100% when eight or more drugs are taken concomitantly. A study from Malaysia found the incidence of polypharmacy among geriatric inpatients was 62.8% and was associated with the high prevalence
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of cardiovascular diseases and diabetes mellitus (17). From those previous researches, it can be stated that there is a relationship between the increasing number of drugs used with PIMs, and as seen on table 1, cardiovascular and endocrine disorders rank second and third on samples, and this can be seen as a factor that leads to polypharmacy on this research.
Potentially Inappropriate Medication (PIMs) based on Beers 2019 Criteria and STOPP version 2 2016 criteria
Based on table 2, PIMs are more commonly found using Beers criteria due to the availability of supporting data, i.e., laboratory data.
Potentially Inappropriate Medication (PIMs) Based on Beers 2019 Criteria According to Beers 2019 criteria, in category 1 (potentially inappropriate drugs for older people), the most used were benzodiazepines (alprazolam) with a percentage of 13.26%, as seen on table 3. These results are in line with the previous study, which stated that most drugs included in PIM category 1 are benzodiazepines (19). Category 2 (potentially inappropriate drugs because of drug-diseases interactions that can worsen the disease) is the PIMs event with the smallest prevalence. Category 3 (drugs which used with particular concern) have the highest number of PIMs events (moderate quality of evidence and strong recommendation).
In category 5 (drugs should be avoided or reduced in dosage by assessing the level of kidney function in the elderly), most PIMs were the use of ranitidine (16.02%).
Potentially Inappropriate Medication (PIMs) Based on STOPP version 2 2016 Criteria
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According to the STOPP version 2 2016 criteria, the most common PIMs were the use of aspirin or clopidogrel in a patient with uncontrolled hypertension (52.94%). Other common PIMs were the use of NSAIDs in a patient with uncontrolled hypertension (23.54%).
Discussion
Beers criteria provide a higher chance for patients to be evaluated compared to STOPP criteria. The STOPP criteria require more specific supporting data to assess PIMs in geriatric patients. In this study, 32 data with STOPP criteria could not be evaluated because they did not have PO2, PCO2, and potassium serum data.
In Beers criteria, only 16 data were found incomplete (creatinine serum) to be evaluated. Similar research also found out that PIMs are found more by the Beers criteria compared to STOPP criteria, with the prevalence of PIMs was 26.31%, 51.8%, 58.1%, 71.9% with Beers, compared to STOPP with the prevalence of PIMs was 14.03%, 33.8%, 44.0%, 67.3% (20–23).
In category 1, the use of benzodiazepine drugs in the elderly should be avoided because older people have increased sensitivity to benzodiazepines and decreased long-term metabolism of drugs. All benzodiazepines increase the risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents in the elderly (24).
In category 2, NSAIDs use in elderly patients who have chronic kidney disease with creatinine clearance levels <30 mL/min should be avoided because it can increase the risk of acute kidney injury and decrease kidney function. NSAID