Hospital Pharmacy - February 2018 - 42

Hospital Pharmacy 53(1)

Table 1. Demographic Variables.
Demographic
Male gender, no. (%)
Age, years, mean ± SD
Actual body weight, kg, mean ± SD
Platelet count, × 103/µL, mean ± SD
Serum creatinine, mg/dL, mean ± SD

Value
19 (76)
48.5 ± 10.1
86.8 ± 17.7
117.0 ± 30.4
0.80 ± 0.19

An estimated 1.1% of the United States population has an
alcohol use disorder with a co-occurring drug use disorder.7
Pharmacological management of withdrawal from alcohol
and opioids involves treatment symptoms of withdrawal,
where withdrawal symptoms can be quantified to allow
symptom-triggered therapy.8 Medications used to treat alcohol withdrawal symptoms include benzodiazepines, anticonvulsants, β-blockers, and α2-adrenergic agonists.8 Medications
used in the management of opioid withdrawal symptoms
include α2-adrenergic agonists, benzodiazepines, NSAIDs,
and antiemetics.9

Problem
At our institution, patients with thrombocytopenia (platelet
count <150 000/µL) related to alcoholism undergoing both alcohol and opioid detoxification are likely to be inadvertently
ordered ibuprofen, as it is an automatic/preselected standard
order within the opioid withdrawal protocol order set, where it
is included to treat bone, muscle, joint, or other pain.8
Furthermore, these patients may be routinely receiving benzodiazepines and α2-adrenergic agonists to manage other alcohol
and opioid withdrawal symptoms, such as anxiety and insomnia.8,9 Administration of these medications can cause hypotension, sedation, and depression of central nervous system, which
can heighten the risk of falls.10 The unintentional combination
of ibuprofen and thrombocytopenia, coupled with an increased
risk of falls, can compound the risk for bleeding in these patients.

Rationale for the Study
Based on several case reports within our institution, we
believe that patients who are undergoing alcohol and opioid
detoxification and have concomitant alcohol-related thrombocytopenia may routinely be prescribed and administered
ibuprofen. To date, there have been no studies published that
evaluate the incidence of ibuprofen administration in this
patient population within a health-systems setting. The purpose of this study is to evaluate the incidence of ibuprofen
administration in this patient population.

Methods
This study was a single-center, cross-sectional, prospective,
observational study, conducted from November 1, 2016, to

March 31, 2017. Approval was granted by the Quality
Improvement Review Committee of the institution prior to
the start of data collection. During the study period, a daily
manual review of electronic health records was conducted
for patients admitted to the detoxification unit of the hospital. Patients who (1) were of age 18 years or more, (2) were
ordered both alcohol and opioid detoxification protocols, and
(3) had a platelet count of less than 150 000/µL were included
in the study. For each patient meeting the inclusion criteria,
the following data were collected: age, gender, actual body
weight, platelet count, serum creatinine, administration of
any anticoagulant and/or antiplatelet medications, presence
of an active order for ibuprofen, dosage strength, and the
number of ibuprofen doses administered, if any. Descriptive
statistics were used to express the data as frequency, percentage, and mean with standard deviation (SD).

Results
Five hundred twenty-six patients' electronic health records
were reviewed within the study period. A total of 25 patients
met the inclusion criteria. The demographic characteristics
of patients included in the analysis are shown in Table 1.
Eighteen (72%) patients had an active order for ibuprofen as
a preselected order within the opioid withdrawal protocol
order set. Ibuprofen order was discontinued by a physician in
7 (28%) patients. Of the 18 patients with an active ibuprofen
order, 9 (50%) patients received ibuprofen. The mean ± SD
ibuprofen dose received within was 481.8 mg ± 159.3 mg.
All patients who received ibuprofen received only 1 dose.
None of the patients who met the inclusion criteria received
any other NSAID besides ibuprofen. Furthermore, none of
the patients received any anticoagulant or antiplatelet
medication.
Because the bleeding risk may be higher when the platelet count is <100 000/µL, which could be further compounded by concomitant ibuprofen administration, the
patients were divided into 2 groups based on the platelet
count-one with a platelet count of <100 000/µL and the
other with a platelet count of ≥100 000/µL. Of the 18 patients
with an active ibuprofen order, 3 (16.7%) had a platelet
count of <100 000/µL and 15 (83.3%) had a platelet count of
≥100 000/µL. Within the group with a <100 000/µL platelet
count, all 3 (100%) patients received ibuprofen, whereas
only 10 (66.7%) patients received ibuprofen order within
the ≥100 000/µL platelet count group, as illustrated in Table
2. Hence, the likelihood of receiving ibuprofen in presence
of an active ibuprofen order was higher in <100 000/µL
platelet count group as compared with the ≥100 000/µL
platelet count group, 100% and 66.7%, respectively.
Furthermore, patients within the <100 000/µL platelet count
group received a higher mean ± SD ibuprofen dose when
compared with patients within the ≥100 000/µL platelet
count group, 666.7 mg ± 188.6 mg and 452.6 mg ± 130.7
mg, respectively.

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