Extracting and Structuring Drug Information to Improve e-Prescription and Streamline Medical Treatment

Currently, physicians are using the patient electronic health record (EHR) to support their practice. The Romanian healthcare system switched to the electronic prescription starting with 2012. Physicians use the electronic medical record and health card to access patient data whenever available. To improve the medical act, we propose a tool supporting the prescription process, structuring and extracting important information from drug characteristics leaflets (prospectus). The application processes data extracted from around 3.000 medical prospectuses using several Romanian language Web sources. The drug leaflet data is structured on sections: therapeutic action, contraindications, mode of administration, adverse reactions, etc. A stemming algorithm has been applied to each section, extracting the root of the word for an easy search. The result is a text in an *.xml file. After structuring step, the application searches in the structured file the necessary information to prescribe the patient’s medication as closely as possible related to patient state. The application suggests all the drugs matching the patient's disease and are not contraindicated, or enter in conflict with other diseases, treatments or allergies of the patient, and the physician may select the best solution for the given situation

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Prevalence of potentially harmful multidrug interactions on medication lists of elderly ambulatory patients

Background: It has been hypothesized that polypharmacy may increase the frequency of multidrug interactions (MDIs) where one drug interacts with two or more other drugs, amplifying the risk of associated adverse drug events (ADEs). The main objective of this study was to determine the prevalence of MDIs in medication lists of elderly ambulatory patients and to identify the medications most commonly involved in MDIs that amplify the risk of ADEs. Methods: Medication lists stored in the electronic health record (EHR) of 6,545 outpatients ≥60 years old were extracted from the enterprise data warehouse. Network analysis identified patients with three or more interacting medications from their medication lists. Potentially harmful interactions were identified from the enterprise drug-drug interaction alerting system. MDIs were considered to amplify the risk if interactions could increase the probability of ADEs. Results: MDIs were identified in 1.3 % of the medication lists, the majority of which involved three interacting drugs (75.6 %) while the remainder involved four (15.6 %) or five or more (8.9 %) interacting drugs. The average number of medications on the lists was 3.1 ± 2.3 in patients with no drug interactions and 8.6 ± 3.4 in patients with MDIs. The prevalence of MDIs on medication lists was greater than 10 % in patients prescribed bupropion, tramadol, trazodone, cyclobenzaprine, fluoxetine, ondansetron, or quetiapine and greater than 20 % in patients prescribed amiodarone or methotrexate. All MDIs were potentially risk-amplifying due to pharmacodynamic interactions, where three or more medications were associated with the same ADE, or pharmacokinetic, where two or more drugs reduced the metabolism of a third drug. The most common drugs involved in MDIs were psychotropic, comprising 35.1 % of all drugs involved. The most common serious potential ADEs associated with the interactions were serotonin syndrome, seizures, prolonged QT interval and bleeding. Conclusions: An identifiable number of medications, the majority of which are psychotropic, may be involved in MDIs in elderly ambulatory patients which may amplify the risk of serious ADEs. To mitigate the risk, providers will need to pay special attention to the overlapping drug-drug interactions which result in MDIs

The effect of ICU-tailored drug-drug interaction alerts on medication prescribing and monitoring: Protocol for a cluster randomized stepped-wedge trial

Background: Drug-drug interactions (DDIs) can cause patient harm. Between 46 and 90% of patients admitted to the Intensive Care Unit (ICU) are exposed to potential DDIs (pDDIs). This rate is twice as high as patients on general wards. Clinical decision support systems (CDSSs) have shown their potential to prevent pDDIs. However, the literature shows that there is considerable room for improvement of CDSSs, in particular by increasing the clinical relevance of the pDDI alerts they generate and thereby reducing alert fatigue. However, consensus on which pDDIs are clinically relevant in the ICU setting is lacking. The primary aim of this study is to evaluate the effect of alerts based on only clinically relevant interactions for the ICU setting on the prevention of pDDIs among Dutch ICUs. Methods: To define the clinically relevant pDDIs, we will follow a rigorous two-step Delphi procedure in which a national expert panel will assess which pDDIs are perceived clinically relevant for the Dutch ICU setting. The intervention is the CDSS that generates alerts based on the clinically relevant pDDIs. The intervention will be evaluated in a stepped-wedge trial. A total of 12 Dutch adult ICUs using the same patient data management system, in which the CDSS will operate, were invited to participate in the trial. Of the 12 ICUs, 9 agreed to participate and will be enrolled in the trial. Our primary outcome measure is the incidence of clinically relevant pDDIs per 1000 medication administrations. Discussion: This study will identify pDDIs relevant for the ICU setting. It will also enhance our understanding of the effectiveness of alerts confined to clinically relevant pDDIs. Both of these contributions can facilitate the successful implementation of CDSSs in the ICU and in other domains as well. Trial registration: Nederlands Trial register Identifier: NL6762. Registered November 26, 2018

Prevalence of drug-drug interactions and clinical relevance for treatment with oral anticoagulants

The aim of this thesis was to describe prevalences and frequencies of potential DDIs in the Swedish outpatient population, and the clinical effects in treatment with oral anticoagulants. Two cross-sectional studies were conducted to establish the prevalence and frequency of potential DDIs among Swedish outpatients. Study I included the whole outpatient population in Sweden, and study II the pediatric outpatient population. The prevalence of clinically relevant potential DDIs among patients with at least two drugs was 19 % and 1.4 % respectively. The proportions of clinically relevant DDIs that potentially lead to reduced treatment effect were 49 % of class D interactions (recommendation to avoid) and 54 % of class C interactions (may require e.g. dose adjustment) in the whole population. The corresponding proportions were and 48 % and 32 % in the pediatric population. A limited number of drugs were involved in a large proportion of potential DDIs. Furthermore, many of the clinically relevant DDIs may lead to reduced treatment effect, an aspect of interactions that may be underestimated in clinical practice. In study III, a cohort of warfarin patients was studied to analyze the longitudinal effects of initiation of amiodarone therapy on warfarin dose and INR. The mean weekly warfarin dose was 24.6 % lower after initiation of amiodarone (95 % CI, 23.5–25.6 %; P < 0.001). Mean weekly INR peaked the third week of concomitant treatment. The fraction of patients with an INR over 3 was 37.1 % at that point, compared to 11.7 % at baseline. The increased risk of bleeding or thromboembolism, potentially associated with DDIs among patients treated with non-vitamin K antagonist oral anticoagulants (NOACs), was investigated with survival analyses in study IV. Atrial fibrillation outpatients were included in the cohort. Compared to patients not exposed to the interacting group of drugs, exposure to potential pharmacodynamic DDIs were associated with an increased risk of any severe bleed, for patients with apixaban HR (95 % CI) 1.47 (1.33-1.63), rivaroxaban 1.7 (1.49-1.92), and dabigatran 1.26 (1.05-1.52). In addition, exposure to CYP3A4 and/or P-gp inhibitors was associated with an increased risk of any severe bleed for patients treated with apixaban 1.23 (1.01-1.5). No significant effects could be established for patients exposed to inducers of CYP3A4 and/or P-gp. In conclusion, one fifth of patients with at least two drugs in the whole Swedish outpatient population was exposed to potential DDIs. The identified drugs and potential clinical consequences need to be considered in clinical practice to avoid adverse events. Patients initiated on amiodarone during warfarin treatment had a mean dose reduction of 25 % and close monitoring during the first weeks is important to avoid supratherapeutic anticoagulant effect. Pharmacodynamic and pharmacokinetic DDIs with NOACs expose atrial fibrillation patients to increased risk of bleeding. These DDIs are important to consider from a risk benefit assessment perspective in patients treated with NOACs

Atheoretical Versus Theory-Based Approaches in Promoting Safer ADHD-Medication Prescribing for Adults

Gaps between treatment guidelines and medical decisions persist despite interventions with physicians, which are mostly atheoretical. The purpose of this retrospective cross-sectional study was to compare atheoretical and theory-based logistic regression models of a binary outcome: potentially unsafe prescribing of attention-deficit hyperactivity disorder (ADHD) medications to adults. Social cognitive theory and self-determination theory provided the framework for the study. Predictors were framed as social cognitive theoretical constructs: knowledge (e.g., physician specialty) and environmental influence (e.g., interventions). Atheoretical hypotheses were based on legislation mandating meaningful use of electronic health records and computerized decision support (CDS). Theory-based hypotheses were derived from literature on cognition in medicine and on the controlled motivation construct in self-determination theory. Research questions addressed associations of CDS and meaningful use with the outcome and fit of competing models. The sample included office-based physician visits made by patients aged \u3e 17 years with ADHD (n = 810) or potentially unsafe medical conditions (n = 9,101), recorded in a U.S. database in 2014–2016. Findings for the atheoretical model were reduced odds of the outcome with CDS, and nonsignificant improvement in model fit using theory. Supporting the self-determination theory-based hypothesis, odds were increased with meaningful use. This study adds to research suggesting autonomy as a core issue in medicine. Positive social change may result from psychology-based strategies to empower physicians through participation in developing clinically relevant information systems