Background Concomitant treatment with renin-angiotensin system inhibitors (ACEI/ARB), diuretics and non-steroidal anti-inflammatory drugs (NSAID) has been named as triple whammy (TW). This interaction can produce acute kidney injury (AKI).
Purpose To implement a strategy in order to avoid the development of AKI due to TW interaction.
Material and methods A so-called ‘Avoiding TW strategy’ was implemented including the following activities: a multidisciplinary group (nephrologists, general practitioners (GP) and clinical pharmacists (CP)) was established to design the strategy; evidence on TW interaction and AKI was assessed; criteria for selection of candidates for intervention was agreed (concomitant use of ACEI/ARB, diuretics and NSAID); CP presented the programme to GPs; patients who were candidates for intervention were retrieved through an in-house developed software (OBSERVA) integrated in electronic clinical records in our region; a deprescription proposal was included in all retrieved clinical records with information about the risk of developing AKI due to the combination, suggesting the doctor to withdraw the NSAID and, if this was not possible, monitoring renal function and serum potassium levels was recommended; and valuation of NSAID withdrawal was planned.
Results The TW optimisation strategy was created and 1699 proposals were sent in August 2018. NSAID deprescription proposals were distributed among the different groups: M01AE (propionic acid derivatives): 54.3%; M01AH (coxibs): 27.8%; M01AB (acetic acid derivatives): 15.0%; M01AC (oxicams): 2.7%; M01AG (fenamates): 0.1%; and M01AX (other NSAID): 0.1%.
Preliminary results, 2 months after the implementation, showed that 15% of proposals were evaluated by GPs, with an acceptance rate of 82%.
Conclusion Pharmacological interactions must be considered even more when they cause important morbidity such as AKI.
CP intervention through electronic clinical records optimises pharmacotherapy and may reduce adverse events and improve patients’ safety.
References and/or acknowledgements 1. García MDP, Sánchez JG, Laso E, et al. Analysis of a design to detect triple whammy in patients with digoxin therapy. https://ejhp.bmj.com/content/23/Suppl_1/A193.1
No conflict of interest.