Pharmacist-led antiretroviral stewardship helps eliminate medication errors

An antiretroviral stewardship programme led by an HIV-specialized pharmacist can improve the safety of people living with HIV (PLHIV) by reducing medication errors, as shown in a Singapore study presented at ECCMID 2023.

In a 6-month pilot stewardship programme implemented in Singapore General Hospital, the HIV pharmacist identified 55 drug-related problems, of which 23 (42 percent) were missed by the general pharmacists. The most common problems were inappropriate dosing regimens (n=14, 25 percent), drug-drug interactions with antiretroviral therapies (ARTs; n=14, 24 percent), and complex medication regimens (n=10, 18 percent). [ECCMID 2023, abstract P2320]

Cases of inappropriate dosing regimens involved lack of renal dose adjustments for nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs), inappropriate doses for opportunistic infection treatment or prophylaxis, and inappropriate doses for drugs not related to HIV, reported lead study researcher Dr Ng Chua of Singapore General Hospital.

Meanwhile, drug-drug interaction cases included rilpivirine with gastric acid suppressants, dolutegravir (DTG) with polyvalent cations, protease inhibitors (PIs) with statins, PIs with direct-acting oral anticoagulants, DTG with metformin, and DTG with rifampicin, Chua said.

Finally, complex medication regimens involved the use of older generation ART with frequent daily doses, polypharmacy, inconvenient regimen such as unnecessary halving of lamivudine tablets, and failure to switch to a cost-effective, single-pill regimen for DTG/abacavir/lamivudine combination. Other cases of drug problems were concerned with adverse drug events, crushing of ARTs, missed vaccination, and problems from medications not related to HIV.

The findings suggest that an “antiretroviral stewardship programme that involves pharmacists with in-depth knowledge of ART pharmacology is essential in reducing drug-related problems and improving the overall management of people living with HIV,” Chua said.

For the pilot antiretroviral stewardship programme assessed in the current study, an HIV-specialized pharmacist dedicated 6–8 hours a week in reviewing the medications received by hospitalized patients with HIV. This pharmacist also conducted twice-weekly ward rounds with the infectious diseases inpatient service, medication counselling of all newly diagnosed individuals in both inpatient and outpatient settings, and reinforced adherence counselling for PLHIV who are not compliant with their ART prescriptions.

Over a period of 6 months, the pharmacist reviewed medication lists from a total of 133 hospital admissions from 105 PLHIV, which translated to an average caseload of seven patients a day. A total of 20 patients received counselling from the pharmacist, among whom 11 (55 percent) were newly diagnosed with HIV.

The pharmacist also intervened in the 55 drug-related problems identified, and all but one intervention was accepted by the physicians. Problems such as drug-drug interactions (n=10, 43 percent) and complex medication regimens (n=5, 22 percent) were often missed by the general pharmacists.

“This is probably due to the general pharmacists’ lack of familiarity with the availability of single-tablet ART regimens and common drug-drug interactions involving ART,” Chua pointed out.

“PLHIV are at risk of medication errors related to ART and concomitant medications prescribed for the treatment of acute and chronic comorbidities. There has been a greater call to action to implement antiretroviral stewardship programmes in recent years to reduce the occurrence and duration of medication errors to enhance patient safety,” the researcher added.

Chua added that the pilot programme helped to identify knowledge gaps among general pharmacists and align educational initiatives accordingly.