International Journal of Clinical Pharmacy

, Volume 38, Issue 5, pp 1094–1102 | Cite as

Assessing prescribing of NSAIDs, antiplatelets, and anticoagulants in Canadian family medicine using chart review

  • Kevin HamiltonEmail author
  • Christine Davis
  • Jamie Falk
  • Alex Singer
  • Shawn Bugden
Research Article


Background Drug-related problems have been identified as a major contributor to emergency room visits, hospitalizations, and death. The most commonly implicated medications are nonsteroidal anti-inflammatory drugs (NSAIDs), antiplatelets, and anticoagulants. Considering a significant proportion of these harms are preventable, indicators to identify risky prescribing before they lead to harm have been developed. Objective To examine the prevalence and patterns of potentially inappropriate prescriptions (PIPs) in a primary care population who are using high-risk medications. Setting This study was performed within two multi-disciplinary family medicine teaching clinics in Winnipeg, Canada. Method A cross-sectional electronic/paper chart audit was conducted within two multi-disciplinary family medicine teaching clinics to evaluate the prevalence of 13 evidence-based high-risk prescriptions. Patients were included if they were prescribed an oral NSAID, antiplatelet, or an anticoagulant within the 12 month period between June 2012 and June 2013. Main outcome measure The proportion of PIPs associated with an increased bleeding risk for NSAIDs, antiplatelets, and anticoagulants. Results Of the 567 patients included in the review, 198 (35 %) patients had received at least 1 PIP in the past year. The most common PIP was the use of an oral NSAID with one or more GI risk factors without adequate gastro-protection. Only 34 (6 %) of these patients received a full medication review performed by a pharmacist. Although not statistically significant, patients who received a medication review had fewer inappropriate prescriptions (27 % with review, 35 % without). Conclusion Over one-third of the patients who were using high-risk medications were using them potentially inappropriately. Although pharmacists have been shown to reduce the amount of inappropriate prescribing, very few patients using these medications were referred to the pharmacist for a full medication review. These data suggest that there is opportunity for the identification and assessment of these patients when prescribing or dispensing these high-risk medications.


Anticoagulant Antiplatelet Canada Chart review NSAID Potentially inappropriate prescriptions Primary care 



We would like to thank the Winnipeg Regional Health Authority who granted access to the required electronic medical records through Manitoba eHealth, Family Medical Centre and Kildonan Medical Centre, the University of Manitoba, College of Pharmacy for their support, and the University of Manitoba Biostatistical Consulting Unit. Finally, we would like to acknowledge Dr. Sheryl Zelenitsky for her help in the development of this manuscript.


University of Manitoba.

Conflicts of interest



  1. 1.
    Hepler CD, Strand L. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm. 1990;47:533–43.PubMedGoogle Scholar
  2. 2.
    Gurwitz J, Field TS, Avorn J, McCormick D, Jain S, Eckler M, et al. Incidence and preventability of adverse drug events in nursing homes. Am J Med. 2000;109:87–94.CrossRefPubMedGoogle Scholar
  3. 3.
    Winterstein AG, Sauer BC, Hepler CD, Poole C. Preventable drug-related hospital admissions. Ann Pharmacother. 2002;36:1238–48.CrossRefPubMedGoogle Scholar
  4. 4.
    Samoy LJ, Zed PJ, Wilbur K, Balen RM, Abu-Laban RB, Roberts M. Drug-related hospitalizations in a tertiary care internal medicine service of a Canadian hospital: a prospective study. Pharmacotherapy. 2006;26:1578–86.CrossRefPubMedGoogle Scholar
  5. 5.
    Spinewine A, Schmader KE, Barber N, Hughes C, Lapane KL, Swine C, et al. Appropriate prescribing in elderly people 1: how well can it be measured and optimised? Lancet. 2007;370:173–84.CrossRefPubMedGoogle Scholar
  6. 6.
    Ernst FR, Grizzle AJ. Drug-related morbidity and mortality: updating the cost-of-illness model. J Am Pharm Assoc. 2001;41:192–9.CrossRefGoogle Scholar
  7. 7.
    Lanza FL, Chan FKL, Quigley EMM. Guidelines for prevention of NSAID-related ulcer complications. Am J Gastroenterol. 2009;104:728–38.CrossRefPubMedGoogle Scholar
  8. 8.
    Vandvik PO, Lincoff AM, Gore JM, Gutterman DD, Sonnenberg FA, Alonso-Coello P, et al. Primary and secondary prevention of cardiovascular disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141:e637S–68S.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, et al. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141:e419S–94S.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Avery AJ, Rodgers S, Cantrill JA, Armstrong S, Cresswell K, Eden M, et al. A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis. Lancet. 2012;6736:1–10.Google Scholar
  11. 11.
    Gallagher P, Ryan C, Byrne S, Kennedy J, Mahony DO. STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther. 2008;46:72–83.CrossRefPubMedGoogle Scholar
  12. 12.
    Fick D, Semla T, Beizer J, Brandt N, Dombrowski R, DuBeau C, et al. American Geriatrics Society Updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60:616–31.CrossRefGoogle Scholar
  13. 13.
    Howard RL, Avery AJ, Slavenburg S, Royal S, Pipe G, Lucassen P, et al. Which drugs cause preventable admissions to hospital? A systematic review. Br J Clin Pharmacol. 2007;63:136–47.CrossRefPubMedGoogle Scholar
  14. 14.
    Wester K, Jönsson AK, Spigset O, Druid H, Hägg S. Incidence of fatal adverse drug reactions: a population based study. Br J Clin Pharmacol. 2008;65:573–9.CrossRefPubMedGoogle Scholar
  15. 15.
    Bayoumi I, Dolovich L, Hutchison B, Holbrook A. Medication-related emergency department visits and hospitalizations among older adults. Can Fam Physician. 2014;60:e217–22.PubMedPubMedCentralGoogle Scholar
  16. 16.
    Warlé-Van Herwaarden M, Kramers C, Sturkenboom M, van den Bemt P, De Smet P. Targeting outpatient drug safety: recommendations of the dutch HARM-Wrestling task force. Drug Saf. 2012;35:245–59.CrossRefPubMedGoogle Scholar
  17. 17.
    Budnitz DS, Pollock DA, Weidenbach KN, Mendelsohn AB, Schroeder TJ, Annest JL. National surveillance of emergency department visits for outpatient adverse drug events. J Am Med Assoc. 2006;296:1858–66.CrossRefGoogle Scholar
  18. 18.
    Patterson SM, Hughes C, Kerse N, Cardwell CR, Bradley MC. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev. 2012;5:CD008165. doi: 10.1002/14651858.CD008165.pub2.
  19. 19.
    Nkansah N, Mostovetsky O, Yu C, Chheng T, Beney J, Bond CM, et al. Effect of outpatient pharmacists’ non-dispensing roles on patient outcomes and prescribing patterns. Cochrane Database Syst Rev. 2010;7:CD000336. doi: 10.1002/14651858.CD000336.pub2.
  20. 20.
    Cipolle R, Strand L, Morley P. Pharmaceutical care practice: the clinician’s guide. 2nd ed. New York: McGraw-Hill; 2004.Google Scholar
  21. 21.
    WHO Collaborating Centre for Drug Statistics Methodology, Guidelines for ATC classification and DDD assignment 2013. Oslo; 2012.Google Scholar
  22. 22.
    Robertson HA, MacKinnon NJ. Development of a list of consensus-approved clinical indicators of preventable drug-related morbidity in older adults. Clin Ther. 2002;24:1595–613.CrossRefPubMedGoogle Scholar
  23. 23.
    Rius C, Pérez G, Martínez JM, Bares M, Schiaffino A, Gispert R, et al. An adaptation of Charlson comorbidity index predicted subsequent mortality in a health survey. J Clin Epidemiol. 2004;57:403–8.CrossRefPubMedGoogle Scholar
  24. 24.
    Morris CJ, Rodgers S, Hammersley VS, Avery AJ, Cantrill JA. Indicators for preventable drug related morbidity: application in primary care. Qual Saf Heal Care. 2004;13:181–5.CrossRefGoogle Scholar
  25. 25.
    Thomsen LA, Winterstein AG, Søndergaard B, Haugbølle LS, Melander A. Systematic review of the incidence and characteristics of preventable adverse drug events in ambulatory care. Ann Pharmacother. 2007;41:1411–26.CrossRefPubMedGoogle Scholar
  26. 26.
    Warlé-van Herwaarden MF, Koffeman AR, Valkhoff VE, 't Jong GW, Kramers C, Sturkenboom MC, et al. Time-trends in the prescribing of gastroprotective agents to primary care patients initiating low-dose aspirin or non-steroidal anti-inflammatory drugs: a population-based cohort study. Br J Clin Pharmacol. 2015;80:589–98. doi: 10.1111/bcp.12626.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Uchino K, Hernandez AV. Dabigatran association with higher risk of acute coronary events: meta-analysis of noninferiority randomized controlled trials. Arch Intern Med. 2012;172:397–402.CrossRefPubMedGoogle Scholar
  28. 28.
    Yilmaz S, Bayan K, Dursun M, Canoruç F, Kilinç N, Tüzün Y, et al. Does adding misoprostol to standard intravenous proton pump inhibitor protocol improve the outcome of Aspirin/NSAID-induced upper gastrointestinal bleeding? Dig Dis Sci. 2007;52:110–8.CrossRefPubMedGoogle Scholar
  29. 29.
    Silverstein FE, Graham DY, Senior JR, Davies HW, Struthers BJ, Bittman RM, et al. Misoprostol reduces serious gastrointestinal complications in patients with rheumatoid arthritis receiving nonsteroidal anti-inflammatory drugs. A randomized, double-blind, placebo-controlled trial. Ann Intern Med. 1995;123:241–9.CrossRefPubMedGoogle Scholar
  30. 30.
    Rostom A, Dube C, Wells G, Tugwell P, Welch V, Jolicoeur E, et al. Prevention of NSAID-induced gastroduodenal ulcers. Cochrane Database Syst Rev. 2002;4:CD002296.Google Scholar

Copyright information

© Springer International Publishing 2016

Authors and Affiliations

  • Kevin Hamilton
    • 1
    Email author
  • Christine Davis
    • 1
  • Jamie Falk
    • 1
  • Alex Singer
    • 2
  • Shawn Bugden
    • 1
  1. 1.College of Pharmacy, Faculty of Health SciencesUniversity of ManitobaWinnipegCanada
  2. 2.College of Medicine, Faculty of Health SciencesUniversity of ManitobaWinnipegCanada

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