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| + | #REDIRECT [[CDS]] |
| − | <table style="background-color: FFFFFF;" border="12">
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| − | From: Rochon PA, Field TS, Bates DW, Lee M, Gavendo L, Erramuspe-Mainard J, Judge J, Gurwitz JH. [http://www.ncbi.nlm.nih.gov/pubmed/16181180?ordinalpos=10&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum Computerized physician order entry with clinical decision support in the long-term care setting: insights from the Baycrest Centre for Geriatric Care]. J Am Geriatr Soc. 2005 Oct;53(10):1780-9. Accessed 2-10-2009
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| − | <th>Warning Messages Targeting Prescribing Decisions Designed to Prevent Adverse Drug Events in Long-Term Care</th> <tr>
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| − | <table style="background-color: FFFFFF;" border="4">
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| − | <th align=left>Scenario Description</th><th align=left>Warning/Message</th>
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| − | <tr><td align=left>Warfarin order in setting of most-recent INR of >3</td>
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| − | <td> WARNING—BLEEDING RISK --
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| − | INR is ——. Current INR is high. Reduce WARFARIN dose and/or monitor closely.<tr>
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| − | <td align=left>Warfarin interaction with trimethoprim/sulfamethoxazole, amoxicillin/clavulanate</td>
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| − | <td> WARNING—BLEEDING RISK -- This drug can interact profoundly with WARFARIN. Consider an alternative antibiotic or monitor very closely. Repeat the INR in 3 days and consider reducing warfarin dose.<tr>
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| − | <td align=left>Warfarin-antibiotic interaction</td>
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| − | <td> WARNING—BLEEDING RISK -- This drug interacts with WARFARIN. Repeat the INR in 3 days. Consider reducing warfarin dose.<tr>
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| − | <td align=left>Warfarin-nonantibiotic interaction (e.g., amiodarone)</td>
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| − | <td> WARNING—BLEEDING RISK -- This drug interacts with WARFARIN. Monitor very closely. Repeat the INR in 3 days.<tr>
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| − | <td align=left>Warfarin-antiplatelet drug or NSAID interaction</td>
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| − | <td> WARNING—BLEEDING RISK -- The use of WARFARIN with NSAIDs and/or ANTIPLATELET AGENTS increases bleeding risk. Reevaluate need for concomitant therapy.<tr>
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| − | <td align=left>Warfarin-nonantibiotic interaction (e.g., amiodarone)</td>
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| − | <td> WARNING—BLEEDING RISK -- This drug interacts with WARFARIN. Monitor very closely. Repeat the INR in 3 days.<tr>
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| − | <td align=left>Antiplatelet drug—NSAID interaction</td>
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| − | <td> WARNING—BLEEDING RISK -- The use of ANTIPLATELET AGENTS with NSAIDs increases bleeding risk. Evaluate need for concomitant therapy.<tr>
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| − | <td align=left>Any use of NSAIDs, ACE inhibitors, diuretics in resident with BUN and/or creatinine above certain threshold level</td>
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| − | <td> WARNING—RENAL INSUFFICIENCY RISK -- Current BUN=——, Creatinine=——. Worsening renal insufficiency can result from ACE inhibitors, angiotensin receptor blockers (e.g., losartan), diuretics, and NSAIDs. Evaluate medication regimen and monitor BUN and CREATININE closely. <tr>
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| − | <td align=left>Any drug therapy that can increase potassium level (ACE inhibitors, potassium-sparing diuretics, potassium supplements, NSAIDs)</td>
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| − | <td> WARNING—HYPERKALEMIA RISK -- Most recent POTASSIUM is —. HYPERKALEMIA can result from therapy with any of the following: ACE inhibitors, angiotensin receptor blockers (e.g., losartan), potassium-sparing diuretics, NSAIDs, and mineralocorticoids. Reevaluate medication regimen and monitor POTASSIUM level closely.<tr>
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| − | <td align=left>Any new prescription for thiazide or loop diuretic therapy</td>
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| − | <td> WARNING—HYPOKALEMIA RISK -- Hypokalemia can result from use of thiazide and loop diuretics. Check POTASSIUM level in 7–10 days and continue monitoring. <tr>
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| − | <td align=left>Anticholinergic medications (e.g., nortriptyline)</td>
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| − | <td>WARNING—RISK OF ANTICHOLINERGIC EFFECTS -- This drug poses a high risk of dry mouth, constipation, urinary retention, and delirium. Use the lowest feasible dose. Monitor closely for these effects. <tr>
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| − | <td align=left>Oxybutynin and tolterodine</td>
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| − | <td>WARNING—RISK OF URINARY RETENTION -- Order a bladder scan 7 days after initiation of therapy or any change in dose and monitor. <tr>
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| − | <td align=left>Opioid therapy</td>
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| − | <td>WARNING—CONSTIPATION RISK -- Opiates can cause constipation. Monitor closely and prevent constipation. Choose a laxative other than docusate sodium. Order a scheduled dose.
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| − | <tr>
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| − | <td align=left>Concomitant use of prednisone or thiazide diuretic and hypoglycemic agent</td>
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| − | <td>WARNING—RISK OF HYPERGLYCEMIA -- Oral corticosteroids and hydrochlorothiazide can worsen glucose control. Monitor finger sticks carefully. <tr>
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| − | <td align=left>Digoxin therapy</td>
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| − | <td>WARNING—RISK OF DRUG TOXICITY -- Digoxin doses should rarely exceed 0.125 mg per day because of reduced renal clearance in elderly. Recheck digoxin level with any change in dose.
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| − | <tr>
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| − | <td align=left>Dose suggestions for benzodiazepines, NSAIDs, and antipsychotics</td>
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| − | <td>WARNING—DOSE RECOMMENDATION -- The recommended initial dose of this drug is — mg. High doses increase risk of side effects.
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| − | <tr>
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| − | <td align=left>Long-acting benzodiazepines</td>
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| − | <td>WARNING—RISK OF SEDATING EFFECTS -- Diazepam, clonazepam, chlordiazepoxide, nitrazepam, and bromazepam have a very long half-life, increasing risk for CNS side effects. Consider substituting a short-acting benzodiazepine such as oxazepam if appropriate. <tr>
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| − | <td align=left>Muscle relaxants and antispasmodic drugs</td>
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| − | <td>WARNING—RISK OF SEDATING EFFECTS -- Most muscle relaxants and antispasmodics are poorly tolerated, leading to anticholinergic effects and sedation. Try to avoid their use.
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| − | <tr>
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| − | <td align=left>Low TSH in setting of thyroid replacement therapy</td>
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| − | <td>WARNING—OVERTREATMENT -- Current TSH: ——. A low TSH level in the setting of thyroid replacement therapy may reflect toxicity (even when other thyroid function tests are normal). Reduce dose of thyroid replacement therapy. Recheck TSH in 6 weeks. <tr>
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| − | <td align=left>Phenytoin initiation</td>
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| − | <td>WARNING—MONITOR DRUG LEVEL -- Most recent phenytoin level: ———. Order phenytoin level 5–7 days after initiation of therapy or any change in dose. <tr>
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| − | <td align=left>Serious drug-drug interaction with amiodarone (e.g., interaction with quinidine)</td>
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| − | <td>SERIOUS DRUG-DRUG INTERACTION -- Amiodarone can increase the levels of many drugs. Check for interactions. Monitor closely. <tr>
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| − | <td align=left>Serious drug-drug interaction with phenytoin (e.g., interaction with trimethoprim/sulfamethoxazole)</td>
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| − | <td>SERIOUS DRUG-DRUG INTERACTION -- This combination can affect phenytoin levels. Monitor closely. <tr>
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| − | <td align=left>Serious drug-drug interaction with lithium</td>
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| − | <td>SERIOUS DRUG-DRUG INTERACTION -- In general, the concomitant use of NSAIDs, diuretics, or ACE inhibitors with lithium should be avoided because of toxicity risk. <tr>
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| − | <td align=left>Serious drug-drug interaction with selegiline (e.g., interaction with SSRIs)</td>
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| − | <td>SERIOUS DRUG-DRUG INTERACTION -- This combination can lead to a serotonin-like syndrome, a potentially life-threatening event. <tr>
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| − | <td align=left>Serious drug-drug interaction with digoxin (e.g., interaction with verapamil)</td>
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| − | <td>SERIOUS DRUG-DRUG INTERACTION -- This combination can lead to digoxin toxicity. Monitor digoxin level closely. <tr>
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| − | <td align=left>Serious drug-drug interaction with monoamine oxidase inhibitors (e.g., interaction with SSRIs)</td>
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| − | <td>SERIOUS DRUG-DRUG INTERACTION -- This combination can lead to serotonin syndrome, a potentially life-threatening event. <tr>
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| − | <td align=left>Serious drug-drug interaction with theophylline (e.g., interaction with quinolones)</td>
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| − | <td>SERIOUS DRUG-DRUG INTERACTION -- This combination can lead to theophylline toxicity. Monitor theophylline level closely. <tr>
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| − | <td align=left>Serious drug interaction between phenobarbital and warfarin</td>
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| − | <td>SERIOUS DRUG-DRUG INTERACTION -- Phenobarbital can reduce the effect of warfarin. Monitor INR closely. <tr>
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| − | <td align=left>Serious drug-drug interaction with bromocriptine (e.g., interaction with pseudoephedrine)</td>
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| − | <td>SERIOUS DRUG-DRUG INTERACTION -- This combination can lead to severe hypertension and seizures. <tr>
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| − | <td align=left>Serious drug interaction between allopurinol and thiazide diuretics</td>
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| − | <td>SERIOUS DRUG-DRUG INTERACTION -- This combination can lead to an increased risk of hypersensitivity reactions to allopurinol. <tr>
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| − | <td align=left>Serious drug interaction between clozapine and risperidone</td>
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| − | <td>SERIOUS DRUG-DRUG INTERACTION -- This combination may increase the risk of toxicity from risperidone. Monitor closely. <tr>
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| − | <td align=left>Serious drug-drug interaction with clozapine (e.g., interaction with citalopram)</td>
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| − | <td>SERIOUS DRUG-DRUG INTERACTION -- This combination may increase the risk of toxicity from clozapine. Monitor closely. <tr>
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| − | <td align=left>Serious drug-drug interaction with tramadol (e.g., interaction with paroxetine)</td>
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| − | <td>SERIOUS DRUG-DRUG INTERACTION -- Avoid this combination; may increase the risk of seizures.
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| − | <tr>
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| − | <td align=left>Serious drug interaction between SSRIs and tricyclic antidepressants</td>
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| − | <td>SERIOUS DRUG-DRUG INTERACTION -- Use this combination with extreme caution. This may cause toxic tricyclic levels. <tr>
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| − | <td align=left>Serious drug-drug interaction with methotrexate (e.g., interaction with phenytoin)</td>
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| − | <td>SERIOUS DRUG-DRUG INTERACTION -- This combination can increase the risk of methotrexate toxicity. <tr>
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| − | <td align=left>Serious drug interaction between quinidine and itraconazole</td>
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| − | <td>SERIOUS DRUG-DRUG INTERACTION -- This combination can increase the risk of quinidine toxicity and should be avoided. <tr>
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| − | <td align=left>Serious drug-drug interaction which which QT interval prolongation risk (e.g., macrolides and phenothiazines)</td>
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| − | <td>SERIOUS DRUG-DRUG INTERACTION: QT prolongation risk. These agents may produce QT interval prolongation and should not be used together.
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| − | <tr>
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| − | INR=international normalized ratio; NSAIDs=nonsteroidal antiinflammatory drugs; ACE inhibitors=angiotensin-converting enzyme inhibitors; BUN=blood urea nitrogen; SSRIs=selective serotonin reuptake inhibitors; CNS=central nervous system; TSH=thyroid-stimulating hormone.
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