Drug Information Drug Information ResourcesResources

Learning GoalsLearning Goals

To understand the magnitude of health information To understand the magnitude of health information available todayavailable today

To be able to classify questions as background or To be able to classify questions as background or foregroundforeground

To understand the differences between primary, To understand the differences between primary, secondary, and tertiary resourcessecondary, and tertiary resources

To be able to develop a Systematic Approach for To be able to develop a Systematic Approach for Answering a Drug Information RequestAnswering a Drug Information Request

The Growth of Medical InformationThe Growth of Medical InformationIndexed Citations Added to MEDLINE (i.e. PubMed) by Fiscal Year

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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

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

For a drug information question, which would you consult?For a drug information question, which would you consult?

Journal Textbook

Background v. Foreground QuestionsBackground v. Foreground Questions

Background QuestionsBackground Questions

Question is broad in scopeQuestion is broad in scope

Answer is general knowledge in fieldAnswer is general knowledge in field

Can best be addressed with tertiary resourcesCan best be addressed with tertiary resources

E.g. Is a drug available in the Saudi Arabia?E.g. Is a drug available in the Saudi Arabia?

What is a drugWhat is a drug’’s mechanism of s mechanism of action?action?

When is a drug contraindicated?When is a drug contraindicated?

Foreground QuestionsForeground Questions

Question is narrow in scopeQuestion is narrow in scope

Answer may require examining new or conflicting evidenceAnswer may require examining new or conflicting evidence

Can best be addressed with secondary and primary resourcesCan best be addressed with secondary and primary resources

E.g. How effective is a new drug when compared to E.g. How effective is a new drug when compared to

drugs that are already on the market?drugs that are already on the market?

Are there clinical trials supporting an off-label Are there clinical trials supporting an off-label use of a use of a

drug in a specific population?drug in a specific population?

Resource Types:Resource Types:

Primary Primary

SecondarySecondary

TertiaryTertiary

Primary ResourcesPrimary Resources

Scientific journalsScientific journals

Provide original studies or reportsProvide original studies or reports

E.g. Clinical trial, case series, case reportE.g. Clinical trial, case series, case report

Good for foreground questionsGood for foreground questions

Scope is narrowScope is narrow

Good when topic is new or new data has Good when topic is new or new data has been publishedbeen published

Primary ResourcesPrimary ResourcesAdv:Adv:

Most current evidenceMost current evidence

Provide data on new drugsProvide data on new drugs

Can personally assess validity of studiesCan personally assess validity of studies

Disadv:Disadv:May not lead one to best decision because of limited scopeMay not lead one to best decision because of limited scope

Data can be poor or controversialData can be poor or controversial

Every study has limitationsEvery study has limitations

Too complex for patientsToo complex for patients

Secondary ResourcesSecondary Resources

Bibliographic databases that provide abstracts or Bibliographic databases that provide abstracts or full-text of studies full-text of studies

Good for foreground questionsGood for foreground questions

Secondary ResourcesSecondary Resources

Adv:Adv:Can construct searches to find specific information Can construct searches to find specific information

at high granularityat high granularity

Disadv:Disadv:Often require more expertise to use than primary or Often require more expertise to use than primary or

tertiary tertiary resourcesresources

Retrieved references must be filtered for qualityRetrieved references must be filtered for quality

Must track down resources before looking for answersMust track down resources before looking for answers

Too complex for patientsToo complex for patients

Tertiary ResourcesTertiary Resources

Compilations of knowledge in the fieldCompilations of knowledge in the field

E.g. Textbooks, handbooks, online drug compendiaE.g. Textbooks, handbooks, online drug compendia

Good for background questionsGood for background questions

Scope is broadScope is broad

Tertiary ResourcesTertiary ResourcesAdv:Adv:

Provide comprehensive information Provide comprehensive information

Information reflects views of multiple experts in fieldInformation reflects views of multiple experts in field

Fast, easy to use, and may be good for patientsFast, easy to use, and may be good for patients

Disadv:Disadv:Usually at least 2 years out of date by publicationUsually at least 2 years out of date by publication

High dependency on interpretation of authors**High dependency on interpretation of authors**

**Pharmacists can address this by consulting at least **Pharmacists can address this by consulting at least 2 tertiary resources to find corroborating information2 tertiary resources to find corroborating information

When trying to answer a clinical question, the best strategy is often to When trying to answer a clinical question, the best strategy is often to consult resources in the following order:consult resources in the following order:

Tertiary, Secondary, PrimaryTertiary, Secondary, Primary

Tertiary resources are good when:Tertiary resources are good when:

The answer to a question is basic factual knowledge in the fieldThe answer to a question is basic factual knowledge in the field

The question was studied extensively and a conclusion was madeThe question was studied extensively and a conclusion was made

Many experts have addressed the question and agree on answerMany experts have addressed the question and agree on answer

Secondary and primary resources are good when:Secondary and primary resources are good when:

A question is new and has never been studiedA question is new and has never been studied

There is no consensus among experts; various opinions aboundThere is no consensus among experts; various opinions abound

There is conflicting evidence and the question needs further studyThere is conflicting evidence and the question needs further study

Resource TableResource Table

Primary

Resources

JAPhA JAMA Pharmacotherapy

New England Journal of Medicine

Annals of Internal Medicine AJHP

Secondary

Resources

PubMed/Ovid MEDLINE

Cochrane Database of Systematic Reviews

DARE TRIP

National Guideline Clearinghouse

Tertiary

Resources

Access Pharmacy UpToDate

Drug Facts and Comparisons

Epocrates Lexi-Comp Micromedex

Clinical Pharmacology

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.

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.

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.

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.

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.

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.

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.

STAYING UP TO DATEWith 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 PublicationsThere 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.

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.

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.

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

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

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

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)

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

Step 5: Perform Evaluation, Analysis, and Synthesis

•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

Step 6: Formulate and Provide Response

•Methods of documentation (examples) Paper form, Logbook, Computer database

•Reasons for documentations (examples)1. Justification of pharmacist's professional value to the institution2. Future reference for repetitive drug information requests3. Protective measure against legal liability

•Methods of follow-up Mail survey, Phone call, Written communication

•Reasons for follow-up1. Provide the requestor with additional information that supports or changes a prior recommendation2. Obtain feedback concerning the quality of the service

Step 7: Conduct Follow-Up and Documentation

Determining the Ultimate QuestionDetermining the Ultimate Question

44 y.o. male44 y.o. male

High blood pressureHigh blood pressure

Rx ACE inhibitorRx ACE inhibitor

Develops dry coughDevelops dry cough

Ultimate Question:

Question Type:

Resource Type:

Major Concepts (i.e. search terms):

Is cough a side effect of ACE inhibitors?

Background

Tertiary

ACE inhibitors, side effects, cough

Categorizing the Ultimate QuestionCategorizing the Ultimate Question

Adverse effectsAdverse effects

AvailabilityAvailability

Compatibility/stabilityCompatibility/stability

CompoundingCompounding

Dosing/administrationDosing/administration

Drug interactionDrug interaction

HerbalHerbal

IdentificationIdentification

PharmacokineticsPharmacokinetics

PharmacologyPharmacology

Poisoning/toxicologyPoisoning/toxicology

Pregnancy/lactationPregnancy/lactation

Therapeutic useTherapeutic use

The Big PictureThe Big Picture

1.1. Secure Demographics of RequestorSecure Demographics of Requestor

2.2. Obtain background info/understand contextObtain background info/understand context

3.3. Determine ultimate questionDetermine ultimate question

4.4. Select and search appropriate resourcesSelect and search appropriate resources

5.5. Evaluate and analyze information foundEvaluate and analyze information found

6.6. Draw conclusion and formulate responseDraw conclusion and formulate response

7.7. Follow-Up and DocumentationFollow-Up and Documentation

Addressing a Drug Info NeedAddressing a Drug Info Need

Medication Therapy Review AssignmentMedication Therapy Review Assignment

References used to support recommendation:References used to support recommendation:

Student 1 GoogleStudent 1 Google

WikipediaWikipedia

Student 2 Drug Facts and ComparisonsStudent 2 Drug Facts and Comparisons

Lexi-CompLexi-Comp

WRONG

RIGHT

assignmentassignment

What is the strongest type of evidence-What is the strongest type of evidence-based clinical studies?based clinical studies?

Short answer!!!Short answer!!!No wikipedia!!No wikipedia!!