hello everyone and welcome to my channel in
today's video i'm going to talk to you about a very important topic that we face on a daily basis
as clinical pharmacists it's basically how to answer a drug information question now drug
information questions are very common especially if you're on the wards on a daily basis um you get
all sorts of questions from nurses from doctors from other healthcare professionals and even
from the pharmacy team itself questions about things they don't know but you know as a clinical
pharmacist because you've been through a lot of training extra training to qualify as a clinical
pharmacist of course and one of the things we train on in a doctor of pharmacy
degree or residency program is how to answer a drug information question or a drug
information request in a professional way um now when i say in a professional way it's not like
okay um is aspiring good for this patient and then you answer yes it's good or no it's not that's
that's not what i mean there is a systematic approach that um many researchers have uh uh come
up with that we follow and uh it's a stepwise approach to answer a clinical uh question or a
drug information question and that's basically what i'm going to teach you in today's video so
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you would need to strengthen your abilities now let's get back to today's video now when i
say there is a systematic approach to answering a drug information question i'm basically
referring to the ashb systematic approach i don't know if you heard about it before to
answering drug information requests and it's like i said before it's a stepwise approach so the
first step when you get asked a drug information question is to obtain a background information so
before you can answer a drug information request it is imperative to clearly understand
the question and the circumstances surrounding the question when this is
done correctly the literature search has a direction and can be specific in terms
of which which resources to utilize complete background information enables
and an efficient and relevant answer to be provided in a timely fashion and also
complete background information ensures an appropriate and applicable uh response to
the uh requester whoever is asking the question so basically when you get asked asked a
question general questions to consider before giving an answer or something like
how how does the uh the requester want the information the person asking you do they want
the answer in person do they want it in an email do they need a something like a patient's uh
handout maybe uh some instructions uh or do they want uh something like a note in the chart of
the patient how do they want the the response um does the question pertain to a specific patient
for example that's another question you should ask yourself is there a specific case that the
requester had faced and they need answers for for certain questions on that case another question is
why is the question being asked in the first place what is the background of the situation different
backgrounds or situations can lead to different answers or different ways to answer the question
and i'm going to give you an example in a minute um other questions that should come to your mind
are how soon do they want a response do they want it right away do they want it in an hour and
two hours today tomorrow or it doesn't matter also how uh um how will uh how will the
information be used are they going to take your answer as a given and then go intervene in
a patient's therapeutic plan or maybe you should you should be more you should gather more
information and and leave some documentation so that if that's what they intend to do uh you
need to have um like some some some documentation about your recommendation um also you should know
what has been done regarding the situation to date uh maybe they had already started something
on a patient and now they want to switch to a different drug and they need your help with that
so you need to gather that information as well let me give you an example because these are a
lot of questions and of course when you are in the situation that you are being asked by a health
professional or someone um a clinical question lots and lots of questions will come to your
mind more than what i just mentioned to you but let me give you an example to uh to help you
understand how the thought process can can lead to information that hasn't been given to you so for
example you a doctor approaches you and he says um oh hey uh uh joe i have this patient who's got
uh afib um and that's atrial fibrillation and i think uh i think they might need anticoagulation
uh but i'm not sure which drug um do you have a preference um should we go with warframe
or should we go with uh one of the new doax um now that's that's the question that's all you
got imagine yourself the clinical pharmacist now you're being asked this question so a patient
who's uh 65 years old i'm sticking to 65 here because i see a lot of elderly patients
actually but i'm dropping the age of 65. 65 year old patient admitted to the hospital he
has a diagnosis of atrial fibrillation he's a male and the physician the treating physician would
like to start this patient on anticoagulation and the question is do you have a preference should we
go with warfarin or should we go with a douak let me know in the comments what do you think about
this question and how to answer it or just give me an answer is it warfarin or is it a doe act for
this patient and i will discuss this case with you in uh in future videos but uh this is an example
of a drug information question how to answer it all right not how to answer it sorry it's an
an example of a drawing information questions that you might get but how to answer it is
something that we are talking about today which is the systematic approach uh so the
first as i said uh in a minute ago the first step to answer a drug information question is to
obtain background information from the requester and when you obtain that background there are
so many things that you should ask or try to gather information about such as demographics
disease factors medication factors like past medication history past medical history and any
other factors pertaining to the case of course the next step which is step number two
in the systematic approach after you've gathered demographic information and you've
gathered background information about the patient or the case or the question step number two is to
categorize the request so you have a question now and we have so many categories in in
pharmacy that you need to categorize this question uh based on so examples
of categories are adverse drug reactions is this a question about an adverse drug
reaction for example do you think that i i have a patient with who has a history
of penicillin allergy do you think if i use meropenem uh the patient would react so this is
a question about adverse drug reactions of drugs or also a patient who uh um suddenly developed uh
um something like uh uh hallucinations for example and they don't have any history of hallucinations
before and when you look at their medications they just started a prednisone 50 milligrams
daily for their copd exacerbation for example do you think the question is do you think that
prednisone could have caused the hallucinations in this patient that's a question that should
be categorized as an adverse drug reaction question and then it will help you in
your search later on in in the next steps other categories that we have are availability
is it a question about a drug whether or not it's available in the united states or in canada
or available in whatever country you uh practice in also there is a category about dosage and
administration which is basically how much should i give this patient should give them 10 milligrams
or 15 milligrams or 5 ml or 10 ml administration do you prefer is it available as oral sorry can
i give it orally or injectable or suppositories stuff like that other categories could be
drug interactions and drug interactions there are many of them it could be a drug drug
interaction question or a drug food interaction or a drug disease interaction so there are so
many uh different drug interactions it could be a question about pregnancy and lactation is this
drug safe in pregnancy and lactation or not or it could be a general information question like uh
what's the mechanism of action of this drug just a general pharmacology question it could also be
an identification question which we get sometimes in the emergency department when when a patient
overdoses on something and they only have some pills in their hands or in their pocket and we
want to identify the drug that they overdosed on the patient is completely not responsive and we
need some identification to know to understand what the medication is so that we can give an
anti-toxic um sometimes we also get questions from a category such as uh pharmaceutics like is this
something that we can maybe uh prepare in a liquid form like questions about extreme perennial
formulations all the time it could be a formal economics question as well to do some cost
comparisons and stuff like that uh it could be a pharmacokinetics question like we get that a lot
as clinical pharmacists like what the half-life of this drug um what is the half-life of this drug or
how long do you think it will stay in the body or is this drug highly bioavailable can i
switch from iv to oral at the same dose range stuff like that we also get questions about
categories such as physical stability how long is this drug going to be stable for whether it's
intravenous or or liquid or cream or something like that uh other categories uh could be
uh something like therapeutic use what is for example what is the drug of choice in
this indication or in this case um is this indication an approved uh uh labeled indication
by fda to treat with this drug drug finally um a very common category that we
get questions about is toxicology what is the antidote for this drug or what do
you recommend to do with this case of uh overdose of a certain drug such as maybe digoxin so this
is basically the step number two just categorize the request now moving on to step number three
which is searching the literature now this is a very important step because right now you're going
to have to search literature different types of literature to find out the answer the best answer
to that question in order to maximize your search efficiency and accuracy it is actually
necessary to develop a search strategy and before developing a search strategy
it's necessary that we have the same understandings of different terms
what do i mean by that search terms you should always search under the generic drug
name let's say the doctor asked you about a brand name of a drug like say he told you i want to
know if xerel2 is good for this patient you should never go search about xarelto you should go search
about the generic drug name which is rivaroxaban and the reason for that i'm going to
tell you in a minute the reason for that i mean i took zarel to as an example but
i should have chosen a different example the reason is trade names could be different in
in different countries so um for example a trade a drug that has a trade name in north america
or let's say let's stick to xarelto if xarelto is a north american trade name it might be named
something else in the middle east for example so let's say that the doctor is practicing in india
but he's from the states and he said zarelto there might not be any relative in india
so that might confuse the pharmacist so the first thing is convert that name into
a generic name see what's the generic is and then do your search on or in the literature
um now the medical literature search you have three different types of literature and uh i i
talked about that in a different video too if you don't know how to do literature research or
what are the different types of literature there are primary secondary and tertiary literatures um
i'm not gonna go in detail about the differences you can do that um you can just check out the
other video that i have about literature research but to give you a brief idea about it a
primary literature is basically original articles uh published in journals so that's the
primary literature that's the actual research uh secondary literatures um they're
something like uh they're basically uh bibliographical indexing systems such as pubmed
uh uh medline and bays these uh platforms these are considered as secondary literatures
so you might not find the information say in a tertiary literature so you move to secondary
literature couldn't find the information moved to a primary literature and so on a territory
literature is basically your textbooks reference textbooks or even computerized
systems that are similar to textbooks but they they usually get updated every two or
three years they're not very up to date so usually we start our search with a tertiary
literature because it's the easiest to access and then if you don't find the answer
you move to a secondary literature and then if you don't find the answer you
move through the primary literature so this is just a rule of thumb okay if
you need more information about tertiary scenario and primary literatures check out
my other video about literature evaluation now let's say you found the
answer in one of those literatures the first thing you have to do is
to review the general references and uh then you should um consult or check in and more than one reference to see if
the answer is actually uh accurate and up-to-date and uh is the same actually in different
references so let's say we found two or three tertiary references and all of them say or give
you the same answer to that question then it's pretty obvious that this is the answer this is
actually the correct answer for that question but let's say you found you didn't find any answers on
in a tertiary in a book so you move to secondary literature you found something close to the
answer like it's not a very strong answer but you found something some information and then
you moved to um you looked in other secondary references you couldn't find anything so you moved
to a primary literature and you found extensive answers over there and if they are similar
to the answers you found in your secondary literature then you can make an informed decision
that this is pretty much the answer that we need and then you move to the next
step which is step number four step number four in this systematic approach is
actually to evaluate the literature that you just got the answer from so say
i found my answers in a book um whatever book it is and or let's say i i
searched on lexicomp and i found all my answers over there now i have to evaluate the literature
you need to look at the references you need to see how strong the references are
where did the answer come from do some basic evaluation and again if you don't
know how to evaluate the literature check out my other video about literature evaluation
and it will be very helpful to you because as a clinical pharmacist this is one thing the
one of the things that we do that nobody else does physicians don't do it nurses don't do it they
learn about it but they don't do it and uh pretty much no other healthcare professional does
literature evaluation so you should be the master in literature evaluation that will make
you really really different from others and would would you would really master um these
literature uh analysis uh uh uh thing that we do and or we should do on a daily basis actually
whenever even before we make recommendations we don't analyze or evaluate guidelines because
guidelines are have already been evaluated by so many people internationally or nationally
but we should evaluate the literature before we uh use any of them as a reference and that
would be your step four evaluate the literature and let's say you did that and it's a pretty
robust literature that you found the answer in then you move on to step number five which is
formulate a response you need to formulate a response for tenant to the request that the
requester gave you and to formulate a response you could write it down in the chart you could
form the doctor or the nurse or whoever asked you the question and give them the answer or you can
just go and meet with that person if they want an in-person answer or you can email them or fax them
whatever works for the requester just formulate your response and give it to them in the way they
like the last step in this process and i know it feels too long but if you do it on a daily basis
this process doesn't take uh an hour of your day the last step step number six i'm sorry step
number six is follow up with a requester um actually i lied there should be another step
so step number six should be um document your response you need to document you need some
sort of documentation for liability and also for future references you need to document
your uh response and then step number seven would be to follow up with the requester if
uh if the treatment plan worked or the answer that you gave them helped at all always always
always do follow-ups with requesters with patience with anyone you need to follow up because this is
important to know if your plan is working or if the patient needs help or if
the requester needs more help so that would be your step number
seven so it's actually seven steps um on how to professionally answer a drug information
question now let's give you an example here to see if you're going to answer uh using
this approach or using a different approach let's say a nurse approached you and she asked if
uh if she could like she has a patient on laculus uh 30 mils orally every four hours
um on a scheduled uh uh times and she's asking if she can give the same
dose uh rectally so this is a question that she needs an answer right away because the
patient is unable to take anything orally suddenly the patient became irresponsive and they
need to they need to give the patient uh molecules because apparently for at this dose it's not
for constipation anymore it's for something else maybe hepatic encephalopathy so yeah it
looks like your ammonia the patient's ammonia is really high and um the patient needs the
lactoballos but we can't give it by mouth the patient is not responding and they don't
have a tube or something to give the medication so what do you do should we give it directly at
the same nose or not now again let's do let's go over the steps that we just mentioned number
one is gather more information background information so ask the nurse or probably the
nurse told you this is for a patient ask the nurse which patient it is and then the nurse
would tell you okay it's uh room 52 for example so you look at room i tell her okay give me a
minute look up the patient to see what are we treating the do the patient actually need the
lactulose or not so you'll pull up a room 52's profile on the computer or in the chart
and look at the patient demographics okay she's a female she's 35 years old she has a
diagnosis of cirrhosis and hepatic encephalopathy she's got no allergies to drugs um the chief
complaint is that she she was admitted due to a reduction in her level of consciousness and
she's a female she she's overweight uh patient past medical history she drinks a lot uh
family history they drink a lot as well um father died of uh of hepatic uh cirrhosis uh
social history she drinks a lot she smokes a lot and when you look at her medications
she's not on any medications at home you look at her laboratory results the
first thing you look at the abnormal results you see ammonia ammonia levels up in the 90s or
hundreds um you look at at the the the previous uh consultation notes from the doctor and you see
that everything confirms hepatic encephalopathy and even her presentation and the current uh um
way she she's presenting uh so you you kind of have an idea now that she uh that patient actually
needs the uh lactulose and maybe because she hasn't been responding very well since admission
they haven't been able to give her the lactulose and and that caused the ammonia to accumulate more
and more and now she's completely irresponsible um you look up the lactulose now and uh to see if
if the dose prescribed is actually correct so now we need to move to step number two to categorize
the request so this is basically um a slash administration a kind of a request they want to
know if their route of administration is okay at the same dose uh so here you go we categorized the
question right away that was easy moving to step number three search the literature and i am going
to pull up uh lexicomp now and look at lactulose to see if the dose is proper and if if we can
actually switch to an uh um a rectal dose that is similar to the overall dose and by the way i
mentioned lexicon because we use lexicomp a lot as pharmacists but you can use any tertiary
literature you want or you have in hand some people like to use up to date database which is
pretty similar to lexicomp actually i think they have lexicomp integrated in it and some people use
other uh literature any anything you have in hand that should be fine um so i'm gonna look
up lactobac here and see uh what the dose is for hepatic encephalopathy which
would be different from the constipation treatment dose and it it tells me okay for hepatic
enzypothy treatment there's a treatment dose and there is a prevention dose we don't want a
prevention because this patient already has hepatic encephalopathy so when you look under
treatment doors you'll find two different dosing uh methods one is oral and the other one is rectal
and says alternative route oral route it says 30 to 45 mils every one or two hours to induce two
soft stools per day and then reduce the dose and then when you look under a rectal you'll see
that it says it's a retention enema and you have to give 200 grams or 300 ml of lactulose dissolved
in 700 mils of normal saline or water retain them for 30 to 60 minutes rectally and then you can
repeat that every four to eight hours based on responsiveness to therapy so that those as you
can see is completely different from the oral dose so that helps you formulate an answer now i
mean you could do literature evaluation first and look at literatures but this is a very acute
case right now so there's no time to do some more literature evaluation especially that it says
manufacturers labeling under the doors so this is actually what the manufacturer recommends so
there's no need to do any further research maybe there's a a different way to do the enema this
is actually what the manufacturer recommends and now you can formulate your answer
you can look back to the nurse though hey i found out the answer you should do it this way
not that way and this is exactly how you should do it and give her the instructions and you can
show her what you found or you can write it down for her remember we have to document our answers
so basically you can go to the chart or whatever system you have and write down that we are
switching from the oral to the rectal form or formulation of the drug because the patient
is not responding and unable to take anything orally and make sure to document how the dose
should be given 200 grams and or 300 mils of laculos and 700 ml of water or normal saline
and that's a retention anima how often should be repeated and when should it be reassessed
uh and also uh yeah then now your job is done you answered the question and
then you should follow up with that nurse or whoever nurse is taking care of the
patient the next day and also follow up with the patient to see if the patient is responding
now is uh are they responding to therapy or not and uh yeah and then you're done that's
how we answer the question based on that uh systematic approach that i just talked about
let me know what you think in the comments and if you've tried that in your practice is it working
is it not working what challenges you face and remember we had a case uh earlier in this video
uh which anti-coagulation to choose and i'm i'm expecting answers from you guys and i'm gonna tell
you the right answer in the comments but i want you to uh brainstorm it and let me know what you
think thanks for watching today's video and stay tuned thank you
