Joyce A. Generali

Evaluation and implications of natural product use in preoperative patients: a retrospective review

BackgroundMedication Reconciliation and Medication Safety are two themes emphasized in a variety of healthcare organizations. As a result, health care facilities have established methods for obtaining a patients medication history. However, these methods may vary among institutions or even among the health care professionals in a single institution, and studies have shown that patients are reluctant to disclose their complementary and alternative medicine use to any health care professional. This lack of disclosure is important in surgical patients because of potential herbal interactions with medications and drugs used during the surgical procedure; and the potential for adverse reactions including effects on coagulation, blood pressure, sedation, electrolytes or diuresis. Therefore, the objectives of this study are to identify patterns of natural product use, to identify potential complications among patients scheduled for surgery, to improve existing medication reconciliation efforts, and to develop discontinuation guidelines for the use of these products prior to surgery.MethodsA retrospective review of surgery patients presenting to the Anesthesia Preoperative Evaluation Clinic (APEC) at the University of Kansas Hospital was conducted to identify the prevalence of natural product use. The following data was collected: patient age; gender; allergy information; date of medication history; number of days prior to surgery; source of medication history; credentials of person obtaining the history; number and name of prescription medications, over-the-counter medications and natural products; and natural product dosage. Following the collection of data and analysis of the most common natural products used, possible complications and interactions were identified, and a protocol regarding the pre-operative use of natural products was developed and implemented.ResultsApproximately one-fourth of patients seen in the APEC indicated the use of natural products. Patients taking natural products were significantly older, were more likely to undergo cardiac or chest surgery, and were more likely to be taking more prescription and non-prescription medications (all p < 0.001).ConclusionBased on the results of this study, it is concluded that there is a need for established guidelines regarding discontinuation of selected natural products prior to surgery and further education is needed concerning the perioperative implications of natural products.

A comparison of pharmaceutical manufacturers as a source of drug information to a telephone inquiry: generic vs brand.

A telephone survey was conducted to evaluate and compare drug information received from the pharmaceutical manufacturer in response to a drug interaction question concerning concurrent administration of tetracycline and cimetidine. This study assumes that the pharmaceutical company may often be consulted by the hospital pharmacist seeking information about a particular medication. Forty-five pharmaceutical companies, all marketing tetracycline products, were selected for the study. A conversation protocol was utilized. It was designed to assure consistency and evaluate information received for accuracy, response time, clinical judgement offered, and referrals. Forty pharmaceutical manufacturers responded: 18 brand manufacturers and 22 generic companies. Eleven companies provided information on the interaction identified. Five manufacturers stated that there were no contraindications to concurrent administration of the drugs, one company identified a similar interaction, and five manufacturers successfully provided information identifying the interaction with supportive documentation. Two of the five companies offered clinical judgement as to the clinical significance of the interaction. Both reached different conclusions. The mean time of all phone calls was 4.29 minutes (range 0.39 to 15.41 minutes). The investigator was referred to outside sources by twelve companies. In this study, brand manufacturers performed better than generic companies. Results indicate that few manufacturers are organized to answer drug information requests involving current information sources in a response to a telephone request.

Hypertensive Crisis Resulting from Avocados and a MAO Inhibitor

A hypertensive episode precipitated by avocados in a patient on tranylcypromine is described. The patient complained of severe throbbing headache, chest pain, and diaphoresis upon visiting the emergency room. Intravenous phentolamine was administered repeatedly to treat elevated blood pressure. Approximately 4 1/2 hours later, the patients blood pressure stabilized, and he was released after a short period of observation. This is the first documented case of avocado-induced hypertensive crisis.

Lidocaine : Cough (fentanyl induced)

This Hospital Pharmacy feature is extracted from Off-Label Drug Facts, a publication available from Wolters Kluwer Health. Off-Label Drug Facts is a practitioner-oriented resource for information about specific drug uses that are unapproved by the US Food and Drug Administration. This new guide to the literature enables the health care professional or clinician to quickly identify published studies on off-label uses and determine if a specific use is rational in a patient care scenario. References direct the reader to the full literature for more comprehensive information before patient care decisions are made. Direct questions or comments regarding Off-Label Drug Uses to jgeneral@ku.edu.

Bridging the Gap for Patient Safety: Medication Reconciliation

Communicating information about medication changes at the interfaces of patient care — also known as “medication reconciliation” — is an important practical tool for guiding a patient safely through a complicated health care system. Promoting and ensuring medication safety across the health care system remains a primary concern for health professionals, particularly pharmacists. Although much information about actual and potential errors in the medication process in institutional settings has been published, there is less information about such errors in the ambulatory sector. Because most US health care systems are not integrated, a patient’s journey from the community setting to a hospital and back is fraught with transition points and these frequently include changes in medications. It has been suggested that almost half of medication errors occur at important transition points in care — primarily during hospital admission or discharge — when medication orders are frequently rewritten. A recent study examining the medication reconciliation process upon admission to and discharge from an adult surgical intensive care unit (ICU) revealed that 94% of the patients had orders changed after an ICU stay. By reviewing and verifying all medications and allergies within 24 hours after admission, and comparing those to orders written at discharge, nearly all medication errors in discharge prescribing were avoided by the end of the study. Implementing this survey into the current system was a successful collaborative effort between nursing, pharmacy, and medicine. Admission survey tools should not be limited to gathering information only about medications. A recent publication, ISMP’s Medication Safety Assessment Tool for Hospitals recommends that “a complete drug history, including prescription and over the counter medications, vitamins, herbal products, and illicit drugs” be obtained from every inpatient and outpatient during hospital admission or initial encounter (including the preadmission process). Hospital Pharmacy is deeply interested in helping pharmacists bridge the information gap between ambulatory and institutional care, and encourages pharmacists to share their experiences in successful medication reconciliation programs.

Analgesics, Anticonvulsants, and Anti-infectives

“Black-box” warnings report valuable postmarketing safety data about prescription drugs, keeping practitioners informed about potential adverse events, drug interactions, key dosing information, monitoring and administration requirements, and at-risk patient populations. They are especially crucial for newly approved agents. A list of agents with black-box warnings does not currently exist; however Hospital Pharmacy will be publishing comprehensive lists by drug category in this column until November 2002. At that time, a complete list in wall chart form will be released. Hospital Pharmacy will update the data as salient information becomes available.

Antineoplastics, Vitamins, and Miscellaneous Agents

“Black box” warnings report valuable postmarketing safety data about prescription drugs – keeping practitioners informed about potential adverse events, drug interactions, key dosing recommendations, monitoring and administration requirements, and at-risk patient populations. Beginning in August 2002 and ending with this issue, Hospital Pharmacy has published comprehensive lists of black box data by drug category. To purchase a complete list in wall chart form, contact Facts and Comparisons at 800-223-0554 or visit the journal Web site at www.hospitalpharmacyjournal.com. Hospital Pharmacy will update these lists as salient data become available.

Amantadine: Multiple Sclerosis–Related Fatigue

This Hospital Pharmacy feature is extracted from Off-Label Drug Facts, a publication available from Wolters Kluwer Health. Off-Label Drug Facts is a practitioner-oriented resource for information about specific drug uses that are unapproved by the US Food and Drug Administration. This new guide to the literature enables the health care professional or clinician to quickly identify published studies on off-label uses and determine if a specific use is rational in a patient care scenario. References direct the reader to the full literature for more comprehensive information before patient care decisions are made. Direct questions or comments regarding Off-Label Drug Uses to jgeneral@ku.edu.

Inpatient Prescribing and Monitoring of Fentanyl Transdermal Systems: Adherence to Safety Regulations

Background National safety guidelines were developed to minimize the occurrence of serious adverse drug events (ADEs) associated with the use of the fentanyl transdermal system (FTS), however, reports of use in opioid-naïve patients for treatment of acute pain and associated ADEs continue to occur. Objective To evaluate the prescribing patterns of the FTS for adherence to recent US regulatory recommendations and identify the impact of health information technology (HIT) on adherence rates. Methods A retrospective pre- and postintervention analysis was performed in hospitalized adult patients receiving FTS. Electronic medication order instructions and text questions were incorporated into FTS electronic medication orders. The primary outcome measure was adherence of FTS medication orders to regulatory guidelines defined as (a) a new order in an opioid-tolerant patient for use in moderate to severe chronic pain or (b) continuation of the documented home dose in use for at least 7 days. Safety measures included respiratory rate and documented ADEs. Results Adherence rates were significantly increased in the postintervention cohort as compared to the preintervention cohort (48.7% vs 85.0%; P < .0001). Incidence of ADEs was significantly lower post intervention (34.7% vs 23.3%; P = .043), including a lower incidence of respiratory depression (16.7% vs 8.3%; P = .043). Documentation was increased in the postintervention cohort (76% vs 100%). However, supporting documentation confirmed responses in only 59.2% of records reviewed. Conclusions Incorporation of HIT via electronic order text questions increased overall adherence rates to regulatory recommendations, increased documentation, and decreased the rate of associated ADEs.

Oxymetazoline (Topical): Rosacea

This Hospital Pharmacy feature is extracted from Off-Label Drug Facts, a publication available from Wolters Kluwer Health. Off-Label Drug Facts is a practitioner-oriented resource for information about specific drug uses that are unapproved by the US Food and Drug Administration. This new guide to the literature enables the health care professional or clinician to quickly identify published studies on off-label uses and determine if a specific use is rational in a patient care scenario. References direct the reader to the full literature for more comprehensive information before patient care decisions are made. Direct questions or comments regarding Off-Label Drug Uses to jgeneral@kumc.edu.