Drug-related pressure ulcers may be characterised by medication-related characteristics such as polypharmacy and medication changes rather than baseline immobility

1.  Approximately one in nine hospitalised patients with pressure ulcers met criteria for definite drug-related pressure ulcers (DRPU), characterised by polypharmacy and frequent medication changes rather than severe baseline immobility.

2. Antipsychotic use, medication initiation or dose adjustment, and missed anti-Parkinson’s doses were disproportionately observed in patients with definite DRPUs, highlighting medication management as a potentially modifiable contributor to pressure ulcer risk.

Evidence Rating Level: 2 (Good)

Study Rundown: This multicentre retrospective study across 20 Japanese hospitals examined medication-related characteristics in 1,113 hospitalised patients with pressure ulcers. Using predefined criteria, pharmacists classified cases as definite, probable, or no-possibility drug-related pressure ulcers (DRPUs). Definite DRPUs accounted for 11.5% of cases and were characterised by higher rates of polypharmacy, frequent medication initiation and dose changes, and greater use of antipsychotic medications. Despite developing pressure ulcers, patients in the definite DRPU group were less likely to be bedridden and demonstrated better baseline mobility, suggesting medication-related functional changes rather than immobility alone. Missed doses of anti-Parkinson’s drugs were also more frequent in this group. Ulcers in definite DRPUs were commonly moderate in depth and often occurred during hospitalisation. Although causal relationships cannot be inferred, the findings highlight distinct medication patterns associated with DRPUs and support a potential role for pharmacist-led medication review in pressure ulcer prevention. 

Click to read the study in BMJ Open

Relevant Reading: Interventions to improve the appropriate use of polypharmacy for older people.

In-Depth [retrospective observational study]: 

Pressure ulcers remain a major source of morbidity among hospitalised patients, particularly older adults, and are traditionally attributed to immobility, frailty, malnutrition, and comorbid disease. Increasing attention has been paid to medication-related contributors to reduced mobility and functional decline, such as sedation, extrapyramidal symptoms, and akinesia. Building on this concept, Mizokami et al. introduce and further characterise “drug-related pressure ulcers” (DRPUs), defined as pressure ulcers influenced by medication use, with the aim of describing associated patient and pharmacologic patterns and supporting future consensus development.

This multicentre retrospective observational study was conducted across 20 hospitals in Japan between January and December 2022. Hospital pharmacists with expertise in pressure ulcer care reviewed electronic health records of all hospitalised patients with documented pressure ulcers, regardless of whether ulcers were present on admission or developed during hospitalisation. After exclusions for missing data, 1,113 patients were included. Using predefined criteria, pharmacists classified cases into three categories: definite DRPU (clear temporal and mechanistic association between medication use and ulcer development), probable DRPU (suspected association with plausible alternative explanations), and no-possibility DRPU (no reasonable medication link).

Medication exposure was assessed in detail, including the total number of medications, polypharmacy (defined as ≥5 drugs), initiation of new medications within one month before ulcer occurrence, dose increases or decreases, and missed doses. Pressure ulcer severity and characteristics were evaluated using the DESIGN-R2020 scale by wound-care–certified professionals to ensure interfacility consistency. Statistical analyses were descriptive and comparative, with no multivariable modelling, reflecting the study’s hypothesis-generating intent.

Among the cohort, 128 patients (11.5%) were classified as having definite DRPUs, 393 as probable, and 592 as no-possibility. Demographic characteristics such as age and sex were similar across groups. Patients in the definite DRPU group had lower body mass index and body weight compared with other groups, but notably demonstrated higher functional status: they were less likely to be bedridden and more likely to maintain sitting posture or change position independently. Despite this, they developed pressure ulcers, suggesting that medication-related changes in mobility or alertness may contribute independently of baseline immobility.

Medication-related factors showed marked differences across groups. The definite DRPU group had significantly higher medication counts and a greater prevalence of polypharmacy than the no-possibility group. They also experienced substantially more frequent medication changes, including initiation of new drugs, dose escalations, dose reductions, and missed doses in the month preceding ulcer development. Psycholeptics, particularly antipsychotics, were the most commonly implicated drug class, frequently newly initiated or dose-adjusted at the time of ulcer occurrence. Missed doses of anti-Parkinson’s medications were also more common in the definite group, highlighting the potential role of fluctuating motor function.

Regarding ulcer characteristics, sacral ulcers predominated across all groups, but the definite DRPU group had a higher proportion of moderate-depth ulcers (DESIGN-R D2 and D3). Ulcers in the definite group occurred more often in hospital settings than in nursing homes, consistent with recent medication changes during acute care.

The authors emphasise that these findings are descriptive and do not establish causality. Limitations include the retrospective design, pharmacist-only data collection, lack of adjustment for key confounders, and absence of a formal inter-rater reliability assessment for DRPU classification. Nonetheless, the study provides the largest multicentre dataset to date describing DRPUs and supports the concept that medication patterns—particularly polypharmacy, frequent adjustments, and high-risk drug classes—cluster in patients with pressure ulcers not fully explained by immobility alone.

The authors conclude that pharmacist-led medication review may represent an underused strategy in pressure ulcer prevention, and that future prospective, multidisciplinary studies are needed to validate DRPUs as a clinically actionable entity.

Image: PD

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