DRUG INFORMATION QUESTIONS
Robert D. Beckett, PharmD, BCPS
CASE
E.B. is a pharmacy student on the first week of her internal medicine APPE rotation. She has been working hard to keep up to date with her patients every morning before rounds and has been pretty successful integrating with the medical team. So far, her role has mostly been performing medication reconciliation and counseling prior to discharge following a hospital protocol. As she electronically documents a warfarin education session performed with her preceptor, she encounters the intern on her medical team who looks very flustered. He sees her, rushes over, and says, “Oh good, a pharmacist. Can amoxicillin cause muscle pain?” E.B. checks her drug information software on her smartphone and quickly responds that it does not and recommends starting acetaminophen 500 mg every 4 to 6 hours as needed for muscle pain.
WHY IT’S ESSENTIAL
Healthcare professionals and patients look to pharmacists to provide accurate, clear, concise, evidence-based drug information. Pharmacy students on IPPE and APPE rotations will frequently receive requests for drug information. While specialty drug information rotations are often available, skills in drug information are vital to success in all rotations across all practice settings. Developing a comprehensive, systematic approach to answering drug information questions is crucial for success in experiential education, and a strong foundation in drug information can greatly enhance your practice as a licensed professional.
THE SEVEN STEP MODIFIED SYSTEMATIC APPROACH
Developing a comprehensive, systematic approach to answering drug information questions is the best way to ensure that high-quality, evidence-based information is provided to a patient, healthcare professional, or preceptor. It is paramount that only accurate information is provided, especially when that information will be used to make patient care decisions. Although there are other published systematic approaches to providing drug information, the Seven Step Modified Systematic Approach is a well-recognized, frequently used strategy.1-4 Although the components of each step are essential to providing high-quality drug information, efforts should be made to achieve a natural flow of professional communication with the requestor and avoid fragmentation of this process, especially as you obtain greater experience.1
“Developing my own systematic way to answer drug information questions that come up on rounds has made the process much easier. I used to dread receiving drug information questions until I took the time to think critically about how I was answering them.”—Student
Step 1: Identify Demographics
Understanding who will be using the information provided is vital to preparing a meaningful drug information response.1-4 Although it is often easy to identify the demographics of the requestor if he or she is a preceptor or member of the medical team, you may also receive drug information requests remotely via e-mail or telephone. When receiving a drug information request from an unknown individual, greet that person politely and clarify your role as a pharmacy student. Even though identifying the demographics is listed as the first step in the Modified Approach, it is also appropriate to integrate identification of the demographics throughout the encounter (i.e., Steps 1 through 3). Key information to obtain includes requestor name, education level, affiliation, and role in the context of the question (e.g., patient, caretaker, healthcare provider).
Step 2: Determine Background Information
Once it is clear to whom you are speaking, it is vital to obtain sufficient background information to answer the question.1-4 This is often a challenging step, as you must identify the most relevant information when very little is given voluntarily. Additionally, the requestor may not understand why specific background information is needed and may pressure you to rush through this process. A good way to approach this challenge is to first ask the requestor whether his or her question pertains to a specific patient. This question enables the requestor to provide an introduction to the situation and allows you to identify relevant background questions based on the type of question being asked. This step is frequently omitted by students and professionals. Clarifying the appropriate background information is essential in determining the true information needed and responding appropriately.5 Suggested relevant background questions for patient-specific inquiries, based on question type, are provided in Table 5-1.1-4 During this step, it is also important to identify which resources have already been consulted to help clarify the context of the question and possibly prevent duplication of efforts.
“An effective drug information response is completely dependent on gathering appropriate background information from the requestor.”—Preceptor
QUICK TIP
For questions received via e-mail, it is often helpful to do a brief literature search before obtaining background information, giving you more context and confidence when discussing the question with the requestor.
One subset of drug information questions that may require a different approach to determining the background information is assignment-type questions—in-depth drug information questions assigned as long-term projects to complete throughout the rotation—that are commonly assigned by preceptors of clinical and drug information APPE rotations. These questions are less likely to be based on a specific patient, and the background information obtained should reflect that.
TABLE 5-1. SUGGESTED BACKGROUND QUESTIONS BASED ON QUESTION TYPE
| QUESTION TYPE | SUGGESTED BACKGROUND QUESTIONS |
| Dosing/Pharmacotherapy | What is the patient’s age? Sex? Weight? Height? What is the indication for the medication? What is the patient’s renal function? Hepatic function? Is the patient suspected of having an adverse reaction? Is the patient well nourished? Taking medications by mouth? What other medications is the patient taking? Recently taken? Is the patient taking any nonprescription medications? Dietary supplements? Does the patient have any chronic disease states? Allergies? If female of child-bearing age, is the patient pregnant? |
| Interactions | Is an interaction already suspected of occurring? Is there a suspected adverse event? What other medications is the patient taking? Doses? Is the patient taking any nonprescription medications? Dietary supplements? When is the patient taking the medication(s)? How long has the patient been taking the medication(s)? Is intravenous compatibility a concern? What is the patient’s current medical status? What steps have been taken in the management of the patient? If female of child-bearing age, is the patient pregnant? |
| Adverse Reactions | Has a reaction already been experienced? How severe? Has it resolved? What were the signs and symptoms of the reaction? What other medications is the patient taking? Recently taken? Is the patient taking any nonprescription medications? Dietary supplements? How long has the patient been taking the medication in question? What other medications is the patient taking? What doses? Does the patient have any chronic disease states? What steps have been taken in the management of the patient? Does the patient have any known allergies or intolerances? If female of child-bearing age, is the patient pregnant? |
| Pregnancy/Lactation | How many weeks pregnant is the patient? How old is the breast-fed infant? What is the indication for the medication in question? What is the patient’s age? Sex (if infant)? Weight? Height? What is the patient’s renal function? Hepatic function? What other medications is the patient taking? Doses? Is the patient taking any nonprescription medications? Dietary supplements? What chronic disease states does the patient have? |
CASE QUESTION
E.B. reconsidered her response to the intern’s question and determined that the question was being asked about L.R., a patient E.B. has not been following. E.B. identified L.R. as a 57-year-old woman who was started on amoxicillin 3 days ago for a urinary tract infection and has since experienced dull, achy muscle pain. What additional questions should E.B. ask of the intern?
Step 3: Determine the True Question
It has been estimated that up to 85% of questions received at some drug information centers differ in a significant way from the actually researched inquiry and the information ultimately provided to the patient.6 Frequently, requestors will ask the question in a way that is biased based on individual experience.1-4,6 For example, if a patient is experiencing an adverse effect, the healthcare provider may associate the adverse effect with the medication started most recently and phrase the question in a restrictive way (e.g., “Can amoxicillin cause muscle pain?”). This association could distract you from considering other medications that may cause an adverse effect several weeks or even years after initiating treatment. It is your responsibility to determine the true question being asked by carefully gathering background information. In the example cited above, the true question might be, “Could any of the patient’s medications be contributing to dull, achy muscle pain experienced for the past 3 days?”
QUICK TIP
It may take a couple tries to determine the true question—do not get discouraged, even if you realize that you may be researching the wrong question after several hours of work. It sometimes happens!
Once the true question has been determined, it is important to clarify expectations for a response with the requestor.1-4 Pharmacotherapy questions requiring in-depth research may take several days to complete, as opposed to adverse effect or dosing questions that could be rapidly addressed using tertiary references. You should determine when a response is needed, considering the context of the situation and input from the requestor. For example, if a question pertains to a patient due to be discharged later in the day, your time frame should consider this information. The requestor’s preferred mode of response (e.g., e-mail, telephone) should also be determined.
Step 4: Develop a Search Strategy
Once the requestor’s demographics are secured, sufficient background information has been obtained, and the true information needed has been determined, it is helpful to prospectively develop a plan for obtaining the drug information necessary to answer the question.1-4 In general, a search strategy should flow from tertiary to secondary to, finally, primary information. As alluded to above, many questions can be answered using tertiary references, whereas others will require detailed assessment of the primary literature (see the Resources section below for a complete description of tertiary, secondary, and primary literature). A good search strategy, incorporating the resources described, is vital to providing evidence-based drug information.
Depth of review should depend on the audience, question type, type of information requested, and time frame.1-4 Additionally, you should consider what resources have already been consulted by the requestor. For example, if tertiary resources have been exhausted, a search of the primary literature may be necessary. Determining whether a question requires review of primary literature is an acquired skill that takes time to develop. Search strategies should consider the resources available from the college/school of pharmacy and from the practice site.4 Early in your clinical rotation, it is a good idea to inquire about the availability of electronic and print resources and how to access them.
CASE QUESTION
Through her collection of background information, E.B. determined that L.R. has been taking simvastatin 80 mg by mouth daily and lisinopril 10 mg by mouth daily for about 2 years, in addition to her recent prescription for amoxicillin 500 mg by mouth three times daily. Should E.B. consult primary literature, tertiary literature, or both to answer her original question?
Step 5: Evaluate, Analyze, Synthesize
This step describes appropriate action that should be taken once the necessary drug information references have been identified.1-4
Evaluate: Every source of information should be assessed prior to use. As a pharmacy student with many responsibilities, it can be tempting to use information from the first source identified; however, careful evaluation will often reveal that a source may not be the most appropriate to use. Every reference should be evaluated for applicability to the question, completeness, and quality of information (see the Resources section for tips on evaluating tertiary resources and Chapter 4 for a detailed discussion of primary literature evaluation).
Analyze: Once a resource has been determined to be useful and appropriate for answering a drug information question, detailed extraction and analysis of the material is essential for compiling accurate information in preparation for a response. It may be helpful to create a chart or table detailing research findings obtained from different references.
Synthesize: Synthesis is the process of reviewing all of the information obtained from various sources and integrating those results in a cohesive way. When compiling information from multiple sources, it can be tempting to list findings in a stepwise format; however, when providing drug information, it is vital to integrate all information obtained into an overarching body of evidence that answers the true question being asked.
QUICK TIP
Consider entering all information from primary literature into a table to allow for rapid evaluation, analysis, and synthesis, particularly if many studies are needed to answer the question.
Step 6: Formulate Response
Various formats for provision of drug information responses are described in the Responses section below. These formats may include memoranda, e-mail, structured discussion, charts and tables, monographs, class reviews, and written papers.1-4 The format ultimately used for a drug information response will differ greatly depending on the audience, time frame, type of question, and type of information requested; however, there are common qualities (easily remembered with six Cs) that every response should achieve:
Correct: The information provided, most importantly, should accurately reflect the best evidence available. Accuracy of the response will ultimately depend on careful evaluation and analysis of all relevant references obtained. If the accuracy of any information is in question, a good rule is to not dispense that information. Another rule of thumb is to verify drug information with a preceptor prior to distribution.
Conscientious: All relevant evidence obtained during the literature search should be discussed in the response. This is especially important when conflicting results are identified. For example, when researching whether continuous infusion or intermittent bolus is the preferred strategy for delivering pain control to patients receiving palliative care, divergent recommendations can be found. It is your responsibility to provide both sides of the argument and to build a final recommendation based on both sets of information.
Complete: The response should address every facet of the question. If the question was regarding a specific patient, it is the responsibility of the pharmacy professional to identify and suggest resolution for all drug-related problems identified. For example, if the original question concerned a potential drug–drug interaction and an unrelated dosing error was identified, that information should be addressed in the response. Additionally, if a problem was identified with a particular therapy, dose, etc., you should suggest a solution.
Concise: In the effort to provide complete information, pharmacy students often produce drug information responses that become excessively wordy. It is important to use a scientific writing style that provides information as succinctly as possible. Bear in mind that most healthcare professionals are extremely busy, and if the drug information response appears excessively long, they may ignore the recommendations altogether.
Critical: As the information from various resources is discussed, it is appropriate to direct the reader’s attention toward major limitations of those resources that were identified during Step 5. For example, if a complicated therapeutic issue has been addressed only via observational studies, it is a significant limitation that will be important for the audience to know. For patient-specific questions, it is critical to compare and contrast the patient with the Food and Drug Administration (FDA)-approved population for a medication or the patient population included in a clinical trial.
Clear: The drug information response should be presented in an understandable way that provides the audience with an unambiguous summary of the research findings and a definitive recommendation for proceeding. Even if there is no obvious single recommendation or if the research findings are conflicting, that information should be stated.
Step 7: Follow-Up
Once the response has been formulated and delivered to the audience, your job is still not done! Facilitating appropriate follow-up is, unfortunately, an area of weakness for many pharmacy students and seasoned professionals. Follow-up should first consist of appropriate documentation, which is vital for reducing liability, assessing the quality of service provided, and facilitating rapid responses to commonly asked questions.1-4
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