Drug Monitoring

For this to work, there are a number of important elements (While some of this is stating the obvious, it helps me to stay focused)

1. I need to get the right information

• Accurate, valid  and reliable-at the end of it all, people need to be confident in the information and find it easy to check things out further if they wish
• The information needs to be well researched, identified regarding source (i.e. references for those who want it)- perhaps this is a place where academic cooperation between pharmacists and docs could move things forward
• There needs to be a mechanism for updating or maintaining the information, ensuring it is the most current available information-this is also a place for academic cooperation as above; maybe a subcommittee of keeners could advance a project such as this and the “author” in my drug ref could be “TDM subcommittee” whom everyone could choose to trust to minimize the number of posts they needed to look at or turn on (or off).

1. Information needs to be presented "at the point of care"; there are at least 3 separate times

• When contemplating prescribing a medication
• When actually prescribing or renewing the medication
• When adding another drug that impacts on the first drug (this is much more ambitious)

2. The information needs to be presented at various levels of complexity with some user control i.e. via drop-down boxes; the opportunity to customize the amount of information will improve user acceptance: this is perhaps the hardest bit to get right, but format will be critical.

3. The user needs to be able to customize the way in which the information is reviewed or presented to them. Customizing the information’s format will enhance its usefulness and user acceptance.

4. Further levels of complexity can be added by individual users (Martin’s quote: I guess at some stage it would be lovely if the machine would remind us that the patient was on lithium but these items were still outstanding - this I would recommend as a pull clinical decision support system (CDSS) that was a report one could generate monthly on all you patients taking lithium and then could choose to place ticklers into the chart, or other alternatives.....such as sending appointments or asking the nurse to call etc)

Your examples David re lithium (see working document) were helpful but led to some questions:

1. When done as a “bulletin” does it automatically show up when prescribed.  Is this the best way to get it to show up when prescribed or is it better in some other “home”;  this looks like a good place to put the “bare bones” info which would show up when prescribing or renewing and would allow one to “copy/paste” the info into reminders if wished or directly onto a lab req.  The layout   looks good; the drug name who has posted it, what is the news source, etc; I’m wondering how much one could customize the types of  info in the bulletin.  Do you need to have a drug ATC code in here, etc. 
2. For the “guideline”, there are lots of good sections or headings such as level of evidence, consequence, etc and while these don’t directly relate to what we are trying to do, they can be made to work as per David’s example.  It looks like the format in the XML body is impt to make it work as a layout, but how particular does this have to be; I’m wondering re the level of “programming” which seems basic but...; this might be the best place to put a more robust form of the TDM recommendations, ie the basic details and the tables, references as well as any comments re levels of evidence, something about how the evidence was obtained and when last updated, other details when needed. This seems better than a link to a PDF file.  Once again do we need things like the drug ATC code in here?  This could be the place where people would go when they wanted to dig deeper.

Overall our group has a good start on the evidence review and I would like to get at least 4 o r 5  drugs ready to go for the April 19-20 meetings, but would appreciate some input. 

A FEW OTHER QUESTIONS AND CONSIDERATIONS:

·         What if any are the implications (including medico legal) of putting this kind of info in my drug ref?

·         Are there concerns re imbedding citations in my drug ref?

·         The color of the warning seems to vary-thoughts?

·         Is the interactions section of my drug ref the best place to put these, or should they also/instead be put in the guidelines document?

·         Currently the warning comes up if the drug is prescribed de novo from the data base, but not from favourites-will this change?

·         If The patient is on the drug already and another drug as prescribed, the warning for the first drug comes up. For example, for a patient who is on Plavix and Zoloft, when the Zoloft is represcribed, the Plavix warning comes up. This is irrespective of the nature of the warning and whether or not one is represcribed in the Plavix at that time.  Inherently this means that warnings are coming up which can and should be ignored for that encounter

·         How limited is the space for a “bulletin” and is this different from a warning?

·         The “hide” button does not seem to be working; how will this work in the future?

·         Can more than one hyperlink be added to a bulletin or guideline and show up in the encounter field when prescribing?

Thanks for your input all.  I would be happy to start putting details into MYDRUGREF once I have a sense how best to proceed for some alpha/beta testing before April 19.

Regards, Cam

This is An example of the research to date: more to follow.

Amiodarone Monitoring (see working document):

Baseline: ECG, CXR, PFT’s, LFT’s, TSH/T4, and eye exam if baseline visual impairment

Follow-up:

            Q6mo: AST, ALT, TSH, T4

            Yearly; ECG, CKR

            PRN for symptoms: PFT’s, ophthalmology exam

Important interactions:

Antiobiotics (macrolides and quinolones can prolong QT)

Digoxin (increases digoxin concentrations – reduce dose by 50% and monitor levels)

B-blockers (may act synergistically w/ amiodarone to cause symptomatic bradyarrhythmia)

CCB (may act synergistically w/ amiodarone to cause symptomatic bradyarrhythmia)

Warfarin (amiodarone potentiates effect of warfarin – decrease dose by 25% and follow INR)