Drug Information Resources

1. Drug Information Resources

2. Learning Goals To understand the magnitude of health information available today To be able to classify questions as background or foreground To understand the differences between primary, secondary, and tertiary resources To be able to develop a Systematic Approach for Answering a Drug Information Request

3. The Growth of Medical Information ?? Indexed Citations Added to MEDLINE (i.e. PubMed) by Fiscal Year U.S. National Library of Medicine. National Institutes of Health. Reviewed 25 March 2009.http://www.nlm.nih.gov/bsd/stats/cit_added.html#1

4. How does one navigate the information overload without getting overwhelmed and confused?

5. For a drug information question, which would you consult? Journal Textbook

6. Background v. Foreground Questions

7. Background Questions Question is broad in scope Answer is general knowledge in field Can best be addressed with tertiary resources E.g. Is a drug available in the Saudi Arabia? What is a drug’s mechanism of action? When is a drug contraindicated?

8. Foreground Questions Question is narrow in scope Answer may require examining new or conflicting evidence Can best be addressed with secondary and primary resources E.g. How effective is a new drug when compared to drugs that are already on the market? Are there clinical trials supporting an off-label use of a drug in a specific population?

9. Resource Types: Primary Secondary Tertiary

10. Primary Resources Scientific journals Provide original studies or reports E.g. Clinical trial, case series, case report Good for foreground questions Scope is narrow Good when topic is new or new data has been published

11. Primary Resources Adv: Most current evidence Provide data on new drugs Can personally assess validity of studies Disadv: May not lead one to best decision because of limited scope Data can be poor or controversial Every study has limitations Too complex for patients

13. Secondary Resources Bibliographic databases that provide abstracts or full-text of studies Good for foreground questions

15. Secondary Resources Adv: Can construct searches to find specific information at high granularity Disadv: Often require more expertise to use than primary or tertiary resources Retrieved references must be filtered for quality Must track down resources before looking for answers Too complex for patients

16. Tertiary Resources Compilations of knowledge in the field E.g. Textbooks, handbooks, online drug compendia Good for background questions Scope is broad

17. Tertiary Resources Adv: Provide comprehensive information Information reflects views of multiple experts in field Fast, easy to use, and may be good for patients Disadv: Usually at least 2 years out of date by publication High dependency on interpretation of authors** **Pharmacists can address this by consulting at least 2 tertiary resources to find corroborating information

18. When trying to answer a clinical question, the best strategy is often to consult resources in the following order: Tertiary, Secondary, Primary Tertiary resources are good when: The answer to a question is basic factual knowledge in the field The question was studied extensively and a conclusion was made Many experts have addressed the question and agree on answer Secondary and primary resources are good when: A question is new and has never been studied There is no consensus among experts; various opinions abound There is conflicting evidence and the question needs further study

21. Resource Table

23. Drug Facts and Comparisons (F&C) This is one of the drug information resources best known by pharmacists.Although it is available in many different formats (i.e., bound books, CD-ROM, Web access), the most common source utilized is the loose-leaf binder that offers monthly updates to provide the most recent FDA-approved and off-label information regarding prescription and OTC medications. Information in F&C is organized by therapeutic topic, and use of the index is necessary in order to function within this reference. F&C utilizes helpful summary and comparison tables in order to facilitate easy comparison of products within the same class. For example, this reference would be useful when comparing oral contraceptives and their active ingredients.

24. Physicians’ Desk Reference (PDR) The PDR is a compilation of drug package inserts. It does not include all prescription medications because of space limitations. A new PDR is published every year; however, it is important to note that the information may not be updated with each annual publication. It is also important to note that only FDA-approved indications and dosages can be found within the PDR.

25. American Hospital Formulary Service (AHFS) Drug Information: This resource is published by the American Society of Health-System Pharmacists, and it provides data on FDA-approved and off-label uses of prescription medications, similarly to F&C. The difference between the two references is that AHFS Drug Information provides more detailed information with evidence-based support, especially for a drug’s off-label use. This is one of AHFS’s biggest advantages over other tertiary references. AHFS is published annually, but it is also available as a Web-based reference and for personal digital assistants (PDAs). The text is organized by pharmacologic classes, requiring an index to search information efficiently.

26. Drug Information Handbook Lexi-Comp’s Drug Information Handbook is one of the most compact text references available for pharmacists. This resource contains abbreviated monographs on prescription medications and is well known for its useful charts and comparison tables. It is easy to use and is organized in alphabetical order according to a drug’s generic name. The handbook provides useful information when perform potential drug-supplement interaction reviews. The online version is especially useful because it is frequently updated, while the print version is published once annually.

27. Micromedex Micromedex is a popular Web-based resource. Using one search box, a clinician is able to search many different databases that include detailed and summarized drug information, toxicology, alternative medicine, and reproductive risk evaluation. Micromedex’s detailed information highlights Drugdex, PDR, and Martindale’s (for use in searching foreign medications). The toxicology information that is included with these resources is trademarked as Poisindex and Identidex. Poisindex identifies ingredients for commercial, biological, and pharmaceutical products and delivers summarized toxicology data.

28. Food and Drug Administration: The FDA’s Web site is an important source of information regarding the most recent drug-related news, including drug approvals, recalls, and safety warnings. It is the home of MedWatch, the national adverse event reporting system (AERS). Users will also find the Orange Book with therapeutic equivalency codes at this site. Centers for Disease Control and Prevention (CDC): The CDC Web site is an essential resource when looking for information regarding prevention and treatment of infectious diseases. There is an abundance of information to be found on topics regarding infectious disease, including annually updated immunization recommendations and scheduling, travelers’ health, and treatment guidelines for infectious diseases.

29. American Society of Health-System Pharmacists: One of the most useful aspects of this Web site is that it provides information about drug shortages, including recommendations for alternative treatments. Medscape: Medscape is a free Internet resource that provides health care professional–specific information. It is organized into sections by medical specialty, including one for pharmacists. The Web site provides numerous items of evidence-based information, including free access to some journals and many useful review articles.

30. STAYING UP TO DATE With the ever-changing field of medicine, pharmacists are faced with new information on a daily basis. To provide optimum patient care, pharmacists must stay abreast of current events in health care, updated clinical guidelines, and new drugs and indications. There are many options to help individual pharmacists stay current, including participating in professional organizations and publications. Many of the resources discussed above may also serve as a way for pharmacists to stay current. Pharmacy Publications There are many pharmacy magazines, such as U.S. Pharmacist, Pharmacy Times, and Drug Topics, that offer information on a variety of topics, including clinical reviews, pharmacy law, patient education, nonprescription products, and product news, as well as continuing education (CE) courses.

31. Pharmacist’s Letter (PL) PL is a Web-based service offered to pharmacists through a yearly subscription. PL’s services include brief, well-summarized discussions of topics currently in health care news. Useful comparison charts with links to their detailed documents are available. Detailed documents that accompany most of the PL’s summaries direct the clinician to primary resources for further information. Pharmacists may also obtain CE credits through programs offered through PL’s services. American Pharmacists Association The Web site www.pharmacist.com provides updates in drug news in a concise, easy-to-read format. It provides information from the FDA Web site as well as updates in clinical pharmacy practice and new drug products.

32. Systematic Approach for Answering a Drug Information Request: The Seven Steps Step 1: Secure Demographics of Requestor The requestor's "profession" (e.g., physician, pharmacist, nurse, lay person) should indicate educational experience and knowledge base; therefore, the individual receiving the query can use this information to determine the appropriate mannerism (in terms of educational level) to formulate and deliver the response.

33. Step 2: Obtain Background Information Background information aids in clarifying the question and is a critical step in the process The question may not be stated concisely or the requestor may not know how to ask the question To formulate an acceptable response, both the caller and researcher must have a clear understanding of the ultimate question

34. Step 3: Determine and Categorize the Ultimate Question • A vital step in the systematic approach • Allows for efficient use of the resources by providing the foundation of a logical progression process. An all-inclusive resource with data to answer every drug information question does not exist. References contain specific types of information. Numerous topic specific resources are available (e.g, drug interactions, infectious disease, internal medicine) • Classification of a request aids in developing a more effective search strategy. Selecting the resource with the highest probability of containing the desired information can decrease the time requirement and increase the accuracy of the response. Otherwise, unnecessary time and energy may be expended on searching references unable to produce the needed facts

35. Examples of question classifications • Adverse Drug Reaction/Contraindication • Availability • Dose • Drug compatibility/stability

36. Step 4: Develop Strategy and Conduct Search • Be familiar with the three types of information sources in the literature hierarchy • Begin with the established knowledge located within the tertiary literature (e.g.,textbooks) due to the condensed, easy-to-use format of the information presented • Progress through the secondary literature (e.g., MEDLINE, International Pharmaceutical Abstracts [IPA]) to the primary literature (e.g., controlled clinical trails)

37. Step 5: Perform Evaluation, Analysis, and Synthesis Confirm information with other references to assure consistency between various resources. While authors, editors, and publishers attempt to assure the reliability of the information published, most resources include a disclaimer statement since errors do occur occasionally

38. Step 6: Formulate and Provide Response • Restate the question and any pertinent background information. This allows the requestor to be informed of the question and focused on the impending response • Provide the information and recommendation (if applicable) • In addition, a brief review of the search strategy and references reviewed may be included in the response as a confirmation to the comprehensive search conducted • Compose the response at the requestor's comprehension level

39. Step 7: Conduct Follow-Up and Documentation • Methods of documentation (examples) • Paper form, Logbook, Computer database • Reasons for documentations (examples) • Justification of pharmacist's professional value to the institution • Future reference for repetitive drug information requests • Protective measure against legal liability • Methods of follow-up • Mail survey, Phone call, Written communication • Reasons for follow-up • Provide the requestor with additional information that supports or changes a prior recommendation • Obtain feedback concerning the quality of the service

40. Determining the Ultimate Question 44 y.o. male High blood pressure Rx ACE inhibitor Develops dry cough Ultimate Question: Is cough a side effect of ACE inhibitors? Question Type: Background Resource Type: Tertiary Major Concepts (i.e. search terms): ACE inhibitors, side effects, cough

41. Categorizing the Ultimate Question Adverse effects Availability Compatibility/stability Compounding Dosing/administration Drug interaction Herbal Identification Pharmacokinetics Pharmacology Poisoning/toxicology Pregnancy/lactation Therapeutic use

42. The Big Picture Secure Demographics of Requestor Obtain background info/understand context Determine ultimate question Select and search appropriate resources Evaluate and analyze information found Draw conclusion and formulate response Follow-Up and Documentation Addressing a Drug Info Need

43. Medication Therapy Review Assignment References used to support recommendation: WRONG Student 1 Google Wikipedia RIGHT Student 2 Drug Facts and Comparisons Lexi-Comp