Using UBC Library to Find Drug Information 2014

USING THE UBC LIBRARY TO FIND DRUG INFORMATION

Dean Giustini, UBC librarianDr. James McCormack, UBC Pharmacy

22 August 2014

A workshop for UBC PharmD students, 2014

Your thoughts…

• What do you find most challenging about finding “reliable” drug information?

• Depends on your goals

Provide Direct Patient Care as a Member of Interprofessional TeamsThe [pharmacist] shall be proficient in providing evidence-based direct patient care as a member of interprofessional teams

http://www.cshp.ca/programs/residencytraining/CHPRBinfo_e.asp


Provide Medication and Practice-Related EducationThe [pharmacist] shall respond to medication/practice-related questions &educate others.



ObjectivesBy the end of this session for PharmD students, you should be able to:

• Describe steps of a systematic approach to finding drug information and/& research

• List some useful sources of drug information• Describe search concepts ie., boolean operators, controlled

vocabulary (MeSH) & “tree structures”, explode, focus, limit(s)• Conduct efficient searches in the biomedical literature• Begin to understand potential benefits/limitations of resources

Systematic approach to drug information

1. Obtain demographics of requestor2. Obtain background information for the situation3. Determine and categorize the ultimate question4. Develop strategy, conduct search5. Critically evaluate information6. Formulate and provide response7. Follow-up, documentSee Nathan JP. Drug information--the systematic approach. J Pharm Pract. 2013; 26: 78-84. PMID 23519502

http://www.ncbi.nlm.nih.gov/pubmed/23519502



1. Obtain demographics of requestor2. Obtain background information3. Determine and categorize the ultimate question4. Develop strategy, conduct search5. Critically evaluate information6. Formulate and provide response7. Follow-up, document

Drug Information Categories• Therapeutics• Dosage/route• Adverse Drug Reaction• Pregnancy• Lactation• Identification• Availability• Compatibility• Pharmacology• Pharmacokinetics• Ingredients• Alternative/complementary therapies

Can I use diltiazem to manage focal atrial tachycardia?


Which of this patient’s medications can exacerbate

ulcerative colitis?


What are the risks to the fetus from accidental exposure to MMR vaccine in

the first trimester?


Can Arnica tablets cause bradycardia?


1. Obtain demographics of requestor2. Obtain background information3. Determine and categorize the ultimate question4. Develop strategy, conduct search5. Critically evaluate information6. Formulate and provide response7. Follow-up, document

Where do you begin?• General specific

• Background knowledge foreground knowledge

• Tertiary primary

Textbooks/e-booksPoint-of-care tools

Use secondary sources (Medline, Embase, Cochrane) to get to primary literature

General knowledge about a treatment

or disease

General knowledge about a treatment

or disease

Specific knowledge to inform clinical

decisions

Specific knowledge to inform clinical

decisions

PICOP - Patient problemI – InterventionC – Comparator or controlO - Outcome

• The PICO framework was developed for intervention/therapy questions

• Helps to define clinical question & guide searching

• A clinical question is more likely to be answered if intervention and Outcome are specified

• Not all questions fit into PICO framework… and is not necessary for “background” questions

Tertiary resources

E-Books @ UBC Library

http://hlwiki.slais.ubc.ca/index.php/File:ETherapeutics.g

Access Medicine

88 titles (e-Books)• G&G Pharmacologic Basis of Therapeutics• Katzung’s Basic & Clinical Pharmacology• Harrison’s Principles of Internal Medicine • Olson’s Poisoning & Drug Overdose• Cardiology, emergency medicine, more…

http://resources.library.ubc.ca/1258

Books@OVID

15 titles• Briggs Drugs in Pregnancy & Lactation (8th)• Wallach Interpretation of Diagnostic Tests• Oski’s Pediatrics• Marino The ICU Book


MD Consult Core Collection

40 texts, 78 journals, practice guidelines etc.•Mandell Principles & Practice of Infectious Disease•Pediatrics

–Harriet Lane Handbook (2014)–Nelson textbook of pediatrics

•Haddad & Winchester Clinical Management of Poisoning & Drug Overdose•The “Clinics” journals


Medicines Complete

Three excellent texts• AHFS Drug Information

– References included in electronic version– Monthly updates

• Martindale: The Complete Drug Reference– Quarterly updates

• Stockley’s Drug Interactions– Quarterly updates

http://resources.library.ubc.ca/page.php?details=medicinescomplete&id=987

Natural Standard

• Covers herbal medications• International research collaboration• Has evidence grades• Peer-reviewed• References included (hyperlinks to PubMed, etc)• Interaction checker• Updated daily

http://resources.library.ubc.ca/page.php?details=natural-standard&id=720

E-therapeutics

• Therapeutic Choices• e-CPS

– Clin Info• Clinical monitoring tools• Drug interactions with food• Drug use guides (dentistry, pregnancy, lactation)• Info on latex and nonmedicinal ingredients

• Drug Interactions (PEPID *new)

Don’t forget old fashioned resources

Limitations

• Lag time– Check frequency of editions, updates, most recent

references cited

• Incomplete information– Consider depth and scope

• Authorship• Qualifications and expertise

Clinical Practice Guidelines

• British Columbia- guidelines from MOH and BCMA– www.bcguidelines.ca– Can download all or access via computer or mobile device

(iPod/iPhone app no longer being supported)– Provides guidelines via topics as well as patient information

guides, flow sheets and summaries

– “GPAC has engaged practicing physicians in B.C. - including general practitioners and specialists - to evaluate clinical evidence, and publish clinical practice guidelines on numerous conditions, with particular focus on circumstances in British Columbia.”

http://www.bcguidelines.ca/


• CMA Infobase: Clinical Practice Guidelines– http://www.cma.ca/cpgs– Canadian Medical Association– 1200 publicly accessible evidence based CPG developed by

medical or health organizations in Canada• Developers are national or provincial agencies

– Can search by conditions, specialties

http://www.cma.ca/cpgs


• National Guidelines Clearinghouse – http://www.guideline.gov

• US based• TOPIC: disease/condition; treatment/intervention; health services

administration• Organization• May be useful when local or national guidelines are not available

• NICE Guidance (National Institute for Health and Clinical Excellence)– http://www.nice.org.uk/guidance/index.jsp?action=find– NICE Pathways (http://pathways.nice.org.uk)

• Interactive. Brings all related NICE products on a topic in a single interface

http://www.guideline.gov/

http://www.nice.org.uk/guidance/index.jsp?action=find

http://pathways.nice.org.uk/

Clinical Practice Guidelines• SIGN (Scottish Intercollegiate Guidelines Network)

– http://www.sign.ac.uk– Search by topic or assigned guideline number– Easy to see if current, out of date or withdrawn– Levels of evidence provided– Apps available for smart phones; iPad

• TRIP Database (Turning Evidence into Practice)– http://www.tripdatabase.com– Clinical search engine to find high-quality research evidence to

support practice– Meta database – combs through all guidelines– Guidelines from around the world– PICO search; Advanced search

http://www.sign.ac.uk/

http://www.tripdatabase.com/

Point of Care Tools

(subcription needed for full access)

(free but need login)

From BMJ – subscription needed

http://www.emedicine.medscape.com/



http://www.uptodate.com/index

http://dynamed.ebscohost.com/

Point of Care Tools

• From BMJ– Subscription based– App is $49.99 (Clinical Evidence Unbound)– 2000 treatments for over 200 medical conditions

“Clinical Evidence comprises an international database of high-quality, rigorously developed systematic overviews assessing the benefits and harms of treatments, and a suite of EBM resources and training materials.”

• Clinical reference database with more than 3100 evidence based clinical summaries, updated daily

• App for smart phones, tablets

http://dynamed.ebscohost.com/

• AKA Medscape• http://emedicine.medscape.com• Free but need to register

• “Medscape from WebMD offers specialists, primary care physicians, and other health professionals the Web's most robust and integrated medical information and educational tools. After a simple, 1-time, free registration, Medscape from WebMD automatically delivers to you a personalized specialty site that best fits your registration profile.”

http://emedicine.medscape.com/

http://www.emedicine.medscape.com/

• Access via UBC Library• “Evidence is summarized where possible from systematic reviews

of primary research. The main source of evidence has been from the Cochrane Collaboration, which provides highly structured systematic reviews, with evidence included or excluded based on explicit quality-related criteria, and often using meta-analyses to increase the power of the findings of numerous studies.”

• “In the absence of such aggregated trial data, where appropriate, there may be inclusion of individual research papers retrieved from Medline and Embase in order to identify the highest quality evidence for specific medical therapies in situations where it might be relevant to point-of-care decisions.”


• www.uptodate.com• Subscription required• Free area (but need to register: www.freeuptodate.com)

• “The knowledge contained in UpToDate is evidence-based and continuously updated, but it is not merely an aggregation and report of the latest research; UpToDate presents a comprehensive synthesis of the evidence, followed by recommendations that can be acted on at the point of care.”

http://www.uptodate.com/

http://www.freeuptodate.com/

http://www.uptodate.com/index

Point of Care ToolsKetchum AM, et al. Type of evidence behind point-of-care clinical information products: a bibliometric analysis. J Med Internet Res. 2011; 13(1):e21.




BMJ Clin Evidence DynaMed

FirstConsult UpToDate


“… summary products, such as POC products, vary in content as determined by differences in literature cited for the same topics in different products, quality regarding types of evidence cited, and currency. There are no standards for guidance on developing content for these products. Users should be aware of this and judiciously appraise POC product information content when using resources to obtain information for applying evidence-based practice principles.”

International Pharmaceutical Abstracts (IPA)

• Who: Thomson Scientific and American Society of Health-System Pharmacists

• What: 300,000+ records from around the world incl. all 50 State pharmacy journals

• Why: Pharmacy practice and admin, compounding and stability, herbal and alternative therapy; conference coverage

• Where: OvidSP• How: keyword searching

Web of Science (WoS)

• Who: Thomson Reuters• What: articles from 7,500 scholarly and technical

journals from more than 3,300 publishers in over 80 countries; conference proceedings (abstracts)

• Why: Another large biomedical database – good for conference abstracts, and for citation tracking*

• Where: Web of Science (indexes and databases)• How: keyword searching (dropdown menu)

More advanced stuff…

Grey literature

• Adverse drug reactions/pharmacovigilance– National pharmacovigilance programs– Reactions Weekly (Springer Link)

• Health Technology Assessments– CADTH, FDA, EMA, UK, Spain

• Systematic reviews, scientific discussion papers – insider look at unpublished data made available to regulators

Clinical trial registries

Why?• Need to consider all the available evidence in decision

making• Publication bias and selective reporting are barriers• Avoid unnecessary duplication of studies and identify

gaps in research• Increase awareness of ongoing research

–Facilitate recruitment and collaboration• Data checking as part of the registration process may

improve qualityWHO International Clinical Trials Registry Platform (ICTRP)http://www.who.int/ictrp/trial_reg/en/index.html

Clinical trials registries

Primary registries

Meta registries

*

http://www.who.int/ictrp/en/

http://clinicaltrials.gov/

http://www.controlled-trials.com/

http://clinicaltrials.ifpma.org/clinicaltrials/no_cache/en/myportal/index.htm

Clinical trials registries• 1. Primary Register and Trial ID # • 2. Date of Registration in Primary

Register• 3. Secondary ID#s • 4. Source(s) of Monetary or Material• Support• 5. Primary Sponsor • 6. Secondary Sponsor(s) • 7. Contact for Public Queries • 8. Contact for Scientific Queries • 9. Public Title • 10. Scientific Title

• 11. Countries of Recruitment• 12. Health Condition(s) or Problem(s)

Studied• 13. Intervention(s) • 14. Key Inclusion and Exclusion• Criteria• 15. Study Type• 16. Date of First Enrollment• 17. Target Sample Size• 18. Recruitment Status• 19. Primary Outcome(s)• 20. Key Secondary Outcomes

WHO 20-item minimum data set

Some registries offer more information and bonus features, e.g. links to publications, added annotations; pediatric, geographical and active/complete/resulted filters; international language searching

Clinical trials registries

Limitations• Less than ½ of trials registered at ClinicalTrials.gov are published in peer-reviewed journals within 30 months of completion. Median time to publication for those trials that were published: 23 months. ~1/3 of registered trials remain unpublished after median of 51 months after completion.

• Despite guidelines, details on therapy and info on outcomes sometimes or often missing.

•Other examples…Viability of some registries… e.g. Current Controlled Trials

Ross JS et al. BMJ. 2012; 344:d7292. Viergever & Ghersi. PLoS ONE. 2011; 6(2): e14701. doi:10.1371/journal.pone.0014701

Mobile apps• Available for smart phones and tablets• Micromedex (PHSA has this)

– Differs from online 2.0 version. DI is free.– Dosing, MOA, available strengths, kinetics, IV

compatibility, toxicology• Lexicomp (LMPS – not sure about others)

– Same info as online product. Not free.– Drugs, infectious diseases, patient education

information– Interactions, iv compatibility, toxicology

• Medscape – Same as online version. Both are free.– Drug monographs (not detailed), drug interaction

checker, medical conditions, procedures– News – can subscribe to daily news

Communicating

1. Obtain demographics of requestor2. Obtain background information for the situation3. Determine and categorize the ultimate question4. Develop strategy, conduct search5. Critically evaluate information6. Formulate and provide response7. Follow-up, documentSee Nathan JP. Drug information--the systematic approach. J Pharm Pract. 2013; 26: 78-84. PMID 23519502



Communicating

What are the desired characteristics of a drug information response?

• timely• current• accurate• complete• concise• well referenced• clear and logical• objective and balanced• free of bias or flaws• applicable and appropriate for

specific circumstances

• answers important related questions

• addresses specific management of patients or situation

Communicating

What should a response contain?•Not every response will require all of these components, but in general…

• Basic structure: introduction, body and conclusion

• A restatement or summary of the question• A statement of any pertinent assumptions made (e.g. age or weight, renal

function in the absence of lab data)• A brief summary statement of the response• Discussion - more details supporting your response, including background

information, review of evidence (including flaws, biases), other factors considered

• Conclusions and recommendations based on, and consistent with, evidence presented

• References

Communicating

Tips for writing:

• Keep it simple• Break complicated discussions into sections and use headings• Some ways to organize and present evidence:

– Chronological (e.g. case reports, evolving evidence)– Strength of evidence (increasing, or decreasing)– Compare/contrast (pros/cons – for controversial or equivocal findings)

• Use tables to succinctly present data• Do not feel you need to include everything you found, e.g. exclude weaker

evidence if stronger evidence exists

Communicating

Tips for verbal communication:

• If the response is complicated, ask if the requestor has time to discuss it• Should be a dialogue with the requestor (e.g. get feedback – is the information

clear and understood? Was the question answered satisfactorily? Is further follow up required?)

• Tailor the level of information and terminology to the requestor – be prepared to clarify if necessary

• Can follow up with supplementary material

Communicating

Tips for verbal communication:

• “...good verbal communication skills, from confident delivery to correct pronunciation of all terms, is imperative…”

• “Often the delivery of a complete response is analogous to the delivery of a presentation or lecture – one must be prepared for additional questions and, therefore, the information presented is only part of the responder’s total knowledge and preparation on the subject.” (Malone 2006)

Malone PM, Kier KL, Stanovich JE (eds.). Drug information. A guide for pharmacists. 3rd ed. New York: McGraw-Hill; 2006.

See also: Nathan JP. Drug information--the systematic approach. J Pharm Pract. 2013; 26: 78-84.