so this evaluation was an extensive in
look into the literature regarding any sort
of pharmacokinetic pharmacokinetic data that we could
find looking at select drug interactions with
the newer and i quietly glance and
really what we wanted to do was
raise awareness of the significance of the
interactions based on what data that we
could come up with although the data
are limited and then subsequently make recommendations
so number one was really to sort
of highlight the importance of drug interactions
and they do exist with the new
iran's i quite the alliance the more
importantly to also died clinicians on how
to best manage them and order to
minimize patient rest because the biggest risk
that we impose with these drug interactions
is potentially bleeding however there are other
identified drug interactions that can
and ultimately do the opposite which is
results and sub therapeutic levels of anti
quite relation putting patients at harm for
thrombolysis ballot events as well
so as a result of publishing this
particular the article we have tried to
develop and i'll work with our computer
system are yeah march to develop drug
interaction alerts that more appropriately quantify the
level of interaction as opposed to
i'm just saying a potential exists for
example amie around and a doe act
saying that there's a potential increased risk
of bleeding with a combination does not
necessarily help a clinician make a well
informed decision and so what we've tried
to do
oh and many the questions that i
get asked our how do i interpret
this information and apply it to my
patient so with the research and the
literature review that we did we were
able to more appropriately quantify again with
what information we could find available
and give a swiss more specific direction
so for example if to medications interact
that results in a two or three
fold increase in serum concentrations of an
anti quite violent then there would be
likely enhance concern for bleeding converse to
that if you're levels dropped or a
be concerned
for thrum when bala aggress so it
really is a function of the questions
that i receive as whether or not
there's a significant drug interaction between certain
agents and day and i quite lance
and if so what is my best
approach for management how do i deal
with it based on what information i
have available
and it comes out burger commonly because
obviously in the cardiovascular arena and i
cry guns were used all the time
so it's a very common question to
come up and core and very commonly
for drug interactions to fire if you
have your alert system set up in
your ear mmr and then subsequently trying
to figure out how to
manage them as probably the biggest challenge
so again that the information that we
have is really to raise awareness and
it really sort of helps clinicians have
a little bit more information at their
disposal to assist with making decisions so
for example if you find that you
have a drug that interacts with an
anti quite like that
imposes and enhanced bleeding rest then the
question the first question then becomes is
whether or not the anti wigan can
be changed and i can keep the
the agent i want to use or
can i adjusted dose of an f
one or both of these agents in
order to keep the drugs on board
or should i play
lately avoid it and so the severity
and the degree of interaction and having
that information available really helps to highlight
sort of what i should do
if the combination can't be avoided and
you need to make an adjustment then
the next thing that has to be
i'm
i guess more so thought out is
how frequently do i need to monitor
this patient what other parameters well fact
the potential drug drug interactions or may
get worse such as someone who as
renal impairments or another medication that also
interact so you have a poly pharmacy
that comes into play so
much of this is still very very
relevant and as we get more clinical
practice information more studies are done more
pharmacokinetic studies are published in case reports
we can continue to compile all that
information and keep clinicians and form and
how to best manage these parts
killer issues and clinical practice
so what in the process of doing
right now that this was a joint
effort from another myself and other colleagues
that are not to sell at my
institution but how i've tried to implement
it here is working with our i
t department
who helps develop our alert systems within
our jamar and what we have attempted
to do is identify those key drug
interactions and place in to the alert
see exactly what the pharmacokinetic data shows
so rather than saying this
combination may result in increased risk of
bleeding if we have information available what
we're instituting into that is to say
that this combination has been shown to
increase the level of the anti coagulant
by x amount so that clinicians have
an idea of how much that occurs
now it's awesome
important to keep in mind that many
if are all of the pharmacokinetic studies
that are done are often done in
healthy volunteers younger patients that don't have
a lot of or abilities so that
information that we have has to be
taken within the context of how those
pharmacokinetic studies were conducted and what pay
patients they were conducted in realizing that
in a more sicker patient with more
calmer abilities the risk is likely going
to be greater so again you have
to sort of take everything into contact
with what you're actually evaluating
why think what's important is to reach
out and to utilize your resources for
getting information that you need to make
a well informed decision we need more
studies we need more specific drug interaction
data that we arm you know we
just don't have the studies that we
do have a very very small
very difficult to extrapolate and so for
clinicians it becomes a a point where
it becomes a point of frustration because
you get the alerts you don't know
how to interpret them who why reach
out to and that's where i think
your pharmacists on your team can really
be a truly value carotene men
nber because they can help decipher through
a lot of that information or at
least help put you in the right
direction or work jointly on trying to
sort it out when it's a very
complex situation and that's where that team
based approach the patient care really does
have a lot of value and it
really helps overall to be able to
manage these patients appropriately
they just because there's so much information
to digest for every single patient that
has many many calm abilities many many
medications and that the combinations of some
of these just don't play well with
one another