Prescribing QT-prolonging medications with known torsades de pointes (TdP) risk to older dialysis-dependent patients is a common practice among non-nephrologists, as highlighted in a recent cross-sectional study. The study revealed that a significant percentage of Medicare patients with kidney failure receiving in-center hemodialysis were prescribed medications with known TdP risk, raising concerns about patient safety and potential adverse outcomes.
According to the study by Jennifer Flythe, MD, MPH, and colleagues, 52.9% of patients filled an outpatient prescription for one of the seven most frequently filled QT-prolonging medications with known TdP risk. Alarmingly, the majority of these prescriptions occurred outside of an acute care event, with less than 25% being prescribed within 1 week of such an event. Furthermore, a significant portion of these prescriptions (80.2%) originated from non-nephrologists, indicating a lack of awareness or understanding of the risks associated with these medications.
Patients receiving hemodialysis are already at a higher risk for drug-related harms due to altered drug metabolism and the presence of multiple comorbid conditions. The study highlighted that these patients were often managed by multiple clinicians and were prescribed numerous medications, increasing the likelihood of potential drug interactions and adverse effects. QT-prolonging medications with known TdP risk have been linked to a higher risk of sudden cardiac death, a leading cause of mortality in hemodialysis patients.
Recommendations for Clinicians
To address the issue of inappropriate prescribing practices, clinicians are urged to perform regular medication reconciliation checks and to closely monitor for potentially interacting medications. Virginia Wang, PhD, of Duke University School of Medicine, emphasized the importance of clinician education on high-risk medications, dedicated resources for medication reconciliation, and improving medication monitoring systems at dispensing pharmacies and prescription drug plans. Better coordination of care and prevention of risky medication prescriptions are critical to improving patient safety in this vulnerable population.
The researchers suggested that the findings of the study are likely a “microcosm of a larger issue” of risky prescription practices among individuals receiving maintenance hemodialysis. Future studies should investigate prescribing patterns of other potentially harmful medications, such as opioids, benzodiazepines, sedative hypnotics, and muscle relaxants. It is essential to gain a better understanding of the factors contributing to these prescription practices and to develop targeted interventions to ensure the safe and appropriate use of medications in hemodialysis patients.
The prescribing of QT-prolonging medications with known TdP risk to hemodialysis patients by non-nephrologists in nonacute settings poses a significant threat to patient safety. Clinicians must prioritize medication safety, conduct regular medication reconciliation checks, and enhance communication and collaboration among healthcare providers to prevent adverse drug events and improve patient outcomes in this vulnerable population.
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