Adverse drug reactions as cause of admission to hospital
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《英国医生杂志》
EDITOR—The aim of our study was to elucidate the prevalence of adverse drug reactions associated with prescribed medicines. We agree with Williams and Taylor that alcohol and herbal medicines may be contributory factors but thought that our study could not accurately report on this aspect because of difficulties in verification of intake. More studies of a different design are needed in this area, and we are currently addressing the role of alcohol in warfarin related adverse drug reactions in a prospective study of 2000 patients using the AUDIT questionnaire,1 a validated instrument to assess alcohol misuse.
With regard to interactions, we accounted for all pharmaceutical preparations being taken by patients, and the example cited—for example, selective serotonin reuptake inhibitors and aspirin—would have been classified as an interaction. Saunders questions the use of over the counter non-steroidal anti-inflammatory drugs (NSAIDS), which he says are freely available. Only oral aspirin and ibuprofen are available over the counter; the other NSAIDs are prescription only medicines.
Self medication accounted for five out of the 218 aspirin related adverse reactions, while the proportion was higher for ibuprofen (nine out of 34 cases).
Laws questions our inclusion criteria, which would have included a "prescribed" overdose but excluded an intentional or accidental overdose, in accordance with a definition also put forward by the World Health Organization.2 We agree with Joseph that avoidability is an important issue, and will be covered in greater detail in a future publication. Joseph, however, misunderstands the design of our study, which looked at patients admitted to hospital with an adverse drug reaction and not high risk patients who were in hospital. We have emphasised in the paper that our study assessed harms and did not take into account the known benefits of aspirin. In relation to angiotensin converting enzyme inhibitors, these can cause renal failure in the presence and absence of prior renal impairment, but a better evidence base is needed in relation to frequency of monitoring.3
Calder and MacDonald wonder about admissions caused by epistaxis. We reported only the commonest adverse drug reactions in table 4; 31 (out of 18 820) admissions were with epistaxis, of which three were caused by warfarin.
Munir Pirmohamed, professor of clinical pharmacology
munirp@liv.ac.uk Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool L69 3GE
Sally James, research pharmacist
Wirral Hospitals NHS Trust, Wirral
Shaun Meakin, research nurse, Chris Green, senior pharmacist
Royal Liverpool University Hospital, Liverpool L7 8XP
This reply is also written by the five other authors of the paper: Andrew K Scott (consultant in care of the elderly, Wirral Hospitals NHS Trust), Thomas J Walley (professor of clinical pharmacology, Department of Pharmacology and Therapeutics, University of Liverpool), Keith Farrar (principal pharmacist, Wirral Hospitals NHS Trust), B Kevin Park (professor of pharmacology, Department of Pharmacology and Therapeutics, University of Liverpool), and Alasdair M Breckenridge (professor of clinical pharmacology, Department of Pharmacology and Therapeutics, University of Liverpool).
Competing interests: At the time of the study, AMB was chairman of the Committee on Safety of Medicines and now is chairman of the MHRA. MP is a member of the Committee on Safety of Medicines and of the subcommittee on pharmacovigilance. BKP is a member of the Committee on Safety of Medicines.
References
Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Dvelopment of Alcohol Use Disorders Identification List (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption - II. Addiction 1993;88: 791-864.
World Health Organization. International drug monitoring: the role of national centres, Technical Report Series No 498. Geneva: WHO, 1972.
Pirmohamed M, Ferner RE. Monitoring drug treatment. BMJ 2003;327: 1179-81. (3 July.)
With regard to interactions, we accounted for all pharmaceutical preparations being taken by patients, and the example cited—for example, selective serotonin reuptake inhibitors and aspirin—would have been classified as an interaction. Saunders questions the use of over the counter non-steroidal anti-inflammatory drugs (NSAIDS), which he says are freely available. Only oral aspirin and ibuprofen are available over the counter; the other NSAIDs are prescription only medicines.
Self medication accounted for five out of the 218 aspirin related adverse reactions, while the proportion was higher for ibuprofen (nine out of 34 cases).
Laws questions our inclusion criteria, which would have included a "prescribed" overdose but excluded an intentional or accidental overdose, in accordance with a definition also put forward by the World Health Organization.2 We agree with Joseph that avoidability is an important issue, and will be covered in greater detail in a future publication. Joseph, however, misunderstands the design of our study, which looked at patients admitted to hospital with an adverse drug reaction and not high risk patients who were in hospital. We have emphasised in the paper that our study assessed harms and did not take into account the known benefits of aspirin. In relation to angiotensin converting enzyme inhibitors, these can cause renal failure in the presence and absence of prior renal impairment, but a better evidence base is needed in relation to frequency of monitoring.3
Calder and MacDonald wonder about admissions caused by epistaxis. We reported only the commonest adverse drug reactions in table 4; 31 (out of 18 820) admissions were with epistaxis, of which three were caused by warfarin.
Munir Pirmohamed, professor of clinical pharmacology
munirp@liv.ac.uk Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool L69 3GE
Sally James, research pharmacist
Wirral Hospitals NHS Trust, Wirral
Shaun Meakin, research nurse, Chris Green, senior pharmacist
Royal Liverpool University Hospital, Liverpool L7 8XP
This reply is also written by the five other authors of the paper: Andrew K Scott (consultant in care of the elderly, Wirral Hospitals NHS Trust), Thomas J Walley (professor of clinical pharmacology, Department of Pharmacology and Therapeutics, University of Liverpool), Keith Farrar (principal pharmacist, Wirral Hospitals NHS Trust), B Kevin Park (professor of pharmacology, Department of Pharmacology and Therapeutics, University of Liverpool), and Alasdair M Breckenridge (professor of clinical pharmacology, Department of Pharmacology and Therapeutics, University of Liverpool).
Competing interests: At the time of the study, AMB was chairman of the Committee on Safety of Medicines and now is chairman of the MHRA. MP is a member of the Committee on Safety of Medicines and of the subcommittee on pharmacovigilance. BKP is a member of the Committee on Safety of Medicines.
References
Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Dvelopment of Alcohol Use Disorders Identification List (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption - II. Addiction 1993;88: 791-864.
World Health Organization. International drug monitoring: the role of national centres, Technical Report Series No 498. Geneva: WHO, 1972.
Pirmohamed M, Ferner RE. Monitoring drug treatment. BMJ 2003;327: 1179-81. (3 July.)