A DI Rotation: Drug interactions? No, Drug Information!

Posted by H. Tran at Tuesday, July 21, 2015

We are in our last week of our second rotation. I’m currently on my Drug Information rotation in Ann Arbor and it’s been a great experience. My daily tasks have revolved around sharing phone duties with another P4 student, which entails answering drug information questions that come in. These questions could come from anyone -- nurses, physicians, pharmacists, psychiatrists, etc., and could be about anything.  Some of the more interesting ones I’ve received were questions regarding appropriateness of using medications off-label (not FDA-indicated). For starters, a psychiatrist inquired about using N-acetylcysteine (NAC) for an autistic patient’s aggressive behavior who had experienced tardive dyskinesia (adverse effect) from their risperidone.  Specifically, they were asking if NAC would cause problems for this patient.  Another interesting request I had was to find a recipe to compound a topical cream of paromomycin for cutaneous leishmaniasis.  You are probably thinking, “Paramo—leishmani—what?!” That was exactly my reaction.

To address these questions, the first thing I did was review the patient’s charts to assess appropriateness of the requested therapy given the patient’s medication list and medical diagnoses. The review includes side effects, kidney/liver function, drug interactions, and any other precautionary measures that would ensure safe and efficacious use of the therapy. I then referred to the literature to support any responses I would provide the requester. Because these therapies were off-label uses, the literature would be the most appropriate resource to support my response. NAC is FDA-indicated and routinely used in case of acetaminophen overdoses, but luckily, NAC has been recently studied for neurologic disorders. I pulled the evidence from the literature and provided the articles to the requester for him to make his own clinical decision based off the outcomes from these studies. From a pharmacy standpoint, I acknowledge whether or not a therapy is appropriate given a medication and problem list. Once I’m ready to make my response/recommendation, I bring it to my preceptor to sign off on, and away it goes!

The request for a recipe was a little more difficult.  Paromomycin is an antibiotic that isn’t on formulary where the requester is situated.  It comes only as a capsule formulation, so finding a recipe was a challenge. Through a literature search, I found a military-based recipe that I provided the requester.  Topical paromomycin is so uncommonly used that it came down to utilizing a recipe that one doctor created for military use. Some of the other drug information questions I received were related to drug stability, drug interactions, if a drug would be safe for a given patient, and alternative therapy options.

When I’m not on phone duty, I work on various projects.  My main project is to create monographs of new drugs that are/may be considered for formulary. I give a rundown of the drug (general description, indication, mechanism of action, side effects, costs, clinical studies, etc.) and compile it all into a monograph.  The drugs I’m working on are ivabradine and combination product sacubitril/valsartan, which are new heart failure medications. The ivabradine monograph will be presented at the Pharmacy and Therapeutics Committee meeting for review of approval and addition to formulary, while sacubitril/valsartan has a novel mechanism of action that will likely be considered for addition to formulary as well. Separately, I also looked into revising guidelines on ketamine use in the emergency department. I surveyed policies and guidelines from various institutions across the nation and compiled the data for the pain management committee to review.

All in all, I never thought drug information was like this. It’s something new every day with different questions for you to problem-solve through. Whether or not you’re interested in drug information, the skills you develop in efficient navigation of references (and knowing what references to use!) would help pharmacists in any setting. I’m glad I had this as my second rotation as it has already made feel more comfortable and efficient in searching through references and studies for answers during my future rotations.