LECTURE OBJECTIVES

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LECTURE OBJECTIVES

• At the conclusion of the lecture, the student
  will be able to
• Identify the need for a system to answer drug
  information questions
• Respond to a drug information question using the
  steps in the systematic process
• Distinguish literature by its type
• Diagram a database search using Boolean logic and
  field names

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SYSTEMATIC SEARCHING

• WHY?

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SYSTEMATIC SEARCHING--WHY?

• RECEIVED 1101AM September 11, 2001
• Hello from New York City,
• I realize this may be a little late, however we
  are currently being put on alert for
  bioterrorism. Do any of you have or do you know
  of a source that identifies a protocol for
  bioterrorism? I am looking for a chart or table
  where all the medications are outlined for each
  disease state (e.g., anthrax, tularaemia) and the
  doses for children and adults, prophylaxis and
  treatment.
• Any help would be appreciated......
• Many thanks!
• Clinical Coordinator of Drug Information
  Services, Brookdale University Hospital and
  Medical Center Brooklyn, NY 11212

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INFORMATION EXPLOSION

• Need to be able to get to that knowledge that is
  needed while swimming in information
• Do that with a systematic approach

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GOOD DECISIONS

• Any process for decision-making involves 4 steps
• Frame the dilemma (question in this case)
• Launch a strategic investigation
• Weigh the information (pros and cons)
• Take stock (reassess the answer)

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ANSWERING QUESTIONS

• Most medication information is answering
  questions
• Actual
• Perceived (counseling)
• This systematic process will allow provision of
  drug information
• Which includes medication information

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SYSTEMATIC SEARCHING

• SAVES TIME
• Most likely place first
• Toxicity, pharmacokinetics, drug interactions,
  adverse reactions
• once reported, usually will not be published
  again unless major development occurs

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RESPONSIBILITY OF PHARMACISTS

• Extends beyond SIMPLY answering medication- or
  drug-related questions
• Manage patient medication regimens
• Assist in resolving therapeutic dilemmas

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ROLE OF PHARMACISTS

• Clinical pharmacotherapy management of
• Individuals
• Populations
• Ensure that drug information is
• Appropriately interpreted
• Correctly applied

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COLLECTING DATA

• Fine line between a general answer and a
  pharmacotherapy consult
• Need the basic information on the factors
• Patient
• Disease
• Medication
• Special Factors

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SYSTEMATIC SEARCHING

• I. DEMOGRAPHICS
• Information to get about the person asking the
  question

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SYSTEMATIC SEARCHING

• II. BACKGROUND
• QUESTIONS TO ASK ABOUT THE PATIENT

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SYSTEMATIC SEARCHING

• III. DETERMINE THE ULTIMATE QUESTION

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CLARIFICATION

• KEY WORDS
• GENERIC NAME
• DISEASE STATE
• ACRONYMS

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COMPLEXITY

• Multiple Names for Same Drug
• Different generics in different countries
• Code names and Brand names
• Chemical names and formulas
• CAS number
• Chemical Abstract Service
• Only unique identifier
• NDC number
• National Drug Code

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PROPRANOLOL

• Inderal
• 1-(1-methylethyl)amino-3-(1-naphthalenyloxy)-2-p
  ropanol
• C16H21NO2
• AY-64043
• ICI-45520
• CAS 318-98-9
• NDC Inderal 60mg 100 package 00046-0426-81
• ?-Adrenergic blocking agent
• Antianginal
• Antihypertensive
• Migraine prophylaxis

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SYSTEMATIC SEARCHING

• IV. CLASSIFY THE QUESTION
• Develops a strategy

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WHERE CAN INFORMATION BE FOUND?

• Where can you find the tax tables and schedules
  you need to determine your federal income tax for
  2005?
• A. The 2004 federal tax booklet
• B. The 2005 federal tax booklet
• C. The 2005 state tax booklet

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CLASSIFICATION

• DRUG UTILIZATION 17.1
• ADVERSE EFFECTS 10.6
• LAW/ECONOMICS- 10.5
• DRUG REVIEW- 10.4
• IDENTIFICATION 9.6
• AVAILABILITY-8.0
• THERAPEUTIC USE 7.2
• TOXICITY 6.6
• DOSAGE 6.3
• THERAPEUTIC COMPATIBILITY- 6.0

• DRUG LITERATURE EVALUATION 5.2
• LABORATORY VALUES- 3.1
• BIOPHARMACEUTICS-2.7
• THERAPEUTIC ACTION 2.3
• PHARMACEUTICAL COMPATIBILITY 2.2
• CONTRAINDICATIONS-1.6
• PATIENT INSTRUCTIONS 0.1
• WY DIC FY2004

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COLLECTING THE DATA

• A FLOW-CHART MAY BE USED

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CLARIFY, REFINE, CLASSIFY
QUESTION RECEIVED
Incorrect
SPECIFIC TEXTS
STANDARD TEXTS
No Information
Incomplete answer
INDEXES
CHECK CLARIFYING STEP
PERIODICALS Reviews Primary
Correct
Complete answer
Incomplete answer
COMMUNICATE ANSWER
OTHER ELECTRONIC SOURCES Including the internet
Incomplete answer
CONSULTANTS AND COMPANIES
DOCUMENT
Incomplete answer
OTHER DRUG INFORMATION CENTERS
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LITERATURE HIERARCHY
1 PRIMARY LITERATURE
2 SECONDARY LITERATURE
3 GENERAL REFERENCE WORKS TERTIARY
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TERTIARY LITERATURE

• 3º
• GENERAL REFERENCE WORKS
• TEXTBOOKS
• REVIEW ARTICLES
• MONOGRAPHS
• MASS MEDIA REPORTS/NEWS
• INFORMATION NOT REPORTED BY THE ORIGINAL
  RESEARCHERS
• DATABASES SUCH AS MicroMedex

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PRIMARY LITERATURE

• 1º
• ORIGINAL RESEARCH
• USUALLY ARTICLES
• MAY BE LETTERS, CASES, OR OTHER FORMS
• ARTICLES MAY BE IDENTIFIED BY METHODS AND RESULTS
  SECTIONS

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PERIODICALS

• CAN BE PRIMARY OR TERTIARY
• NAMES CAN CHANGE
• EACH PERIODICAL HAS AN OFFICIAL ABBREVIATION
• LIST OF SERIALS INDEXED FOR ONLINE USERS
• http//www.ncbi.nlm.nih.gov/entrez/

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SECONDARY LITERATURE

• 2º
• INDEXING AND ABSTRACTING SERVICES
• GATEWAY TO PRIMARY LITERATURE

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SECONDARY LITERATURE

• MEDLINE
• EMBASE
• INTERNATIONAL PHARMACEUTICAL ABSTRACTS
• SPECIALTY
• INPHARMA and REACTIONS
• DIALOG, DATASTAR/KNIGHT-RIDER, OVID,
  SILVERPLATTER
• COLLECTIONS OF OTHER DATABASES
• BIBLIOGRAPHIES REFERENCES

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OTHER RESOURCES

• INTERNET
• LISTSERV
• Experts
• PROFESSIONAL ORGANIZATIONS
• PHARMACEUTICAL MANUFACTURERS
• DRUG INFORMATION CENTERS POISON CENTERS, HOT
  LINES

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DATABASE SEARCHING

• DATA
• DATABASE
• Fields
• Key words

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MEDLINE CITATION
RECORD NO. 99153380 AUTHOR Cannas F
Tanasijevic MJ Ma'luf N Bates DW ADDRESS
Harvard Medical School, Boston, Mass, USA. TITLE
Evaluating the appropriateness of digoxin level
monitoring. SOURCE Arch Intern Med (7FS), 1999
Feb 22 159 (4) 363-8 LANGUAGE English COUNTRY
PUB. UNITED STATES ANNOUNCEMENT 9905 PUB.
TYPE JOURNAL ARTICLE WWW.NLM.NIH.GOV
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MEDLINE ABSTRACT
ABSTRACT BACKGROUND Digoxin level
determinations can be useful misused. METHODS
Explicit appropriateness criteria were adapted
from published criteria. The main outcome measure
was the proportion of digoxin levels with an
appropriate indication. RESULTS Among inpatient
levels, only 16 were appropriate. Of the 189
digoxin levels considered inappropriate, only 26
(14) had a result of 2.3 nmol/L or more. One
result led to a change in therapy, but none of
the patients were believed to experience a toxic
reaction. Among the inappropriate levels, 87 of
patients underwent early routine monitoring
before a steady state was achieved. CONCLUSIONS
A high proportion of digoxin levels were
inappropriate, particularly among inpatients. In
both groups, the primary reason tests were judged
inappropriate was early routine monitoring. Few
inappropriate tests resulted in important data.
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MESH HEADINGS
MESH HEADINGS Cardiotonic Agents--blood (BL)
Digoxin--blood (BL) Monitoring,
Physiologic--standards (ST) Patient Selection
Unnecessary Procedures Aged Female Human
Male Support, U.S. Gov't, P.H.S. CHEMICAL SUBS
0 (Cardiotonic Agents) 20830-75-5
(Digoxin) GRANT NO. R01 HS08927 HS
AHCPR STANDARD NO. 0003-9926 DATES Entered
990304
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What I like about this information age is that
people dont have to know anything!!!
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BOOLEAN LOGIC
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BOOLEAN LOGIC
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BOOLEAN LOGIC
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SYSTEMATIC SEARCHING

• V. DATA
• What do you do with it after you find it?
• EVALUATION
• ANALYSIS
• SYNTHESIS

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LAG TIME

• Propose study and get it funded
• Conduct study and analyze study
• Write and submit for publication
• Peer review (refereed)
• Make recommended changes
• Scheduled for publication
• Indexing by the indexing system
• Use of information in review articles or
  textbooks

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EVALUATION OF LITERATURE

• Do the authors have expertise
• Some may use their expertise to promote
  information not supported by evidence
• Is this the most recent edition
• May need older editions for some information
• Are statements of fact supported by citations
• Compendia such as USP DI, Facts, AHFS DI
• Is the reference likely to contain the
  information
• Based on the classification of the reference
• Is the reference clear, concise, and easy-to-use
• Headings, charts
• Other aspects for primary literature later in
  course

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LOGICAL ARGUMENT

• Present all viewpoints
• State the assessment of the literature
• what is the superior viewpoint
• Present the reasons the other viewpoints are weak
• Present the reasons for the superior viewpoint
• Restate the concluding statement to support the
  superior viewpoint

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SYSTEMATIC SEARCHING

• VI. RESPONSE
• FORMULATION AND PROVISION
• Make sure that you understood the requestors
  needs ULTIMATE QUESTION
• Restate it
• Make sure that you relayed the information in an
  understandable manner if verbal, have them
  restate the answer
• Make sure that you satisfied the needs
• Requestors sometimes have additional questions

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CHARACTERISTICS OF RESPONSE

• Timely
• Current
• Accurate
• Complete
• Concise
• Well Referenced
• Clear and logical
• Objective and balanced

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SYSTEMATIC SEARCHING

• FOLLOW-UP
• F0LLOW THROUGH
• DOCUMENTATION