Medication discrepancies, such as taking different doses of a drug than prescribed, occur in most patients with stage 4 to 5 chronic kidney disease (CKD) not on dialysis, and some of these discrepancies might pose serious risks, according to researchers.

During late-stage CKD (LS-CKD), patients experience frequent hospitalizations, fragmented medical care, inadequate communication, and polypharmacy, Steven Fishbane, MD, and his colleagues at Hofstra Northwell School of Medicine in Great Neck, New York, explained in an online report in Clinical Kidney Journal. Of 713 patients aged 58 to 79 years from Northwell Health’s Healthy Transitions in LS-CKD program, 55% had at least 1 medication discrepancy. Nearly 12% of patients had 2 discrepancies, and more than 12% had 5 or more. Discrepancies were between nephrologists’ medication lists and drugs reported to a visiting nurse by patients and their caregivers (including a review of pill bottles).

The top missteps were patients taking a medication not on a nephrologists’ list, not taking a specified medication, taking different doses, or following a different frequency. By therapeutic class, medication mishaps were more common with cardiovascular drugs (15.5%, involving mostly renin angiotensin aldosterone system inhibitors and beta blockers), vitamins (11%), bone and mineral disease drugs (8.9%), diuretics (7%), analgesics (6.7%), and diabetes medications (5%).

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Having congestive heart failure more than doubled the likelilhood of medication discrepancies, based on multivariate analysis. Taking a greater number of medications likewise increased risk by 29%.

“It is likely that concordant cardiac disease creates important vulnerabilities in medication management in LS-CKD,” Dr Fishbane and his colleagues stated. “The diseases complicate and confound treatment of each other. Medications such as renin angiotensin aldosterone system inhibitors and diuretics are adjusted frequently in response to cardiac, renal or electrolyte disturbances.”

The team emphasized that nephrologists play a key role in medication safety. “Ongoing medication review and reconciliation by the provider is essential for longitudinal maintenance of medication safety. When discrepancies develop between the medications that the provider intends for the patient to be taking and those actually being used, there is increased risk for loss of efficacy or adverse events.”

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Ibrahim J, Hazzan AD, Mathew AT, Sakhiya V, Zhang M, Halinski C, and Fishbane S. Medication discrepancies in late-stage chronic kidney disease. Clin Kid J, 2017, 1–6. doi: 10.1093/ckj/sfx135