Formulating An Effective Response - A Structured Approach

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Drug Information: A Guide for Pharmacists, 7e
Chapter Two: Formulating an Effective Response: A Structured Approach
Amy Heck Sheehan; Joseph K. Jordan
LEARNING OBJECTIVES
Learning Objectives
After completing this chapter, the reader will be able to:
Develop strategies to overcome the impediments that prevent health care professionals from providing effective responses and
recommendations.
Outline the steps that are necessary to identify the actual drug information needs of the requestor.
List and describe the four critical factors that should be considered and systematically addressed when formulating a response.
Define analysis and synthesis, and describe their application in the process of formulating responses and recommendations.
List the elements and characteristics of effective responses to medicationrelated queries.
KEY CONCEPTS
Key Concepts
Rational pharmacotherapy can be promoted by ensuring that drug information is correctly interpreted and appropriately applied.
The absence of sufficient background information and pertinent patient data can greatly impair the process of information synthesis and
the ability to formulate effective responses.
Critical information that defines the problem and elucidates the context of the question is not readily volunteered, but must be expertly
elicited.
Providing responses and offering recommendations without knowledge of pertinent patient information, the context of the request, or
how the information will be applied can be potentially harmful.
Formulating the response requires the use of a structured, organized approach whereby critical factors are systematically considered and
thoughtfully evaluated.
Approaching a question haphazardly, or prematurely fixating on isolated details, can misdirect even the most skilled clinician.
Responses to drug information queries often must be synthesized by integrating data from diverse sources through the use of logic and
deductive reasoning.
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Health care professionals are asked to provide responses to a variety of drug information questions every day. Although the type of requestor, query,
Chapter Two: Formulating an Effective Response: A Structured Approach, Amy Heck Sheehan; Joseph K. Jordan Page 1 / 22
and setting can vary, the process of formulating responses remains consistent. This chapter introduces an organized, structured approach for
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formulating effective responses and recommendations to drug information questions.
Approaching a question haphazardly, or prematurely fixating on isolated details, can misdirect even the most skilled clinician.
Management and Science University
Responses to drug information queries often must be synthesized by integrating data from diverse sources through the use of logic and
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deductive reasoning.
Health care professionals are asked to provide responses to a variety of drug information questions every day. Although the type of requestor, query,
and setting can vary, the process of formulating responses remains consistent. This chapter introduces an organized, structured approach for
formulating effective responses and recommendations to drug information questions.
As the medical literature expands, access to drug information resources by health care professionals and the public continues to grow. Yet many
professionals and consumers lack the necessary skills to use this information effectively. Rational pharmacotherapy can be promoted by ensuring
that drug information is correctly interpreted and appropriately applied. This presents an opportunity and a challenge for pharmacists who are true
drug therapy experts and play a broader role in patient care.
Regardless of specialty or practice site, health care professionals with the responsibility for overseeing the safe and rational use of medications must
strive to develop expertise in applied pharmacotherapy. Whether working in a community setting, nursing home, outpatient clinic, hospital, or in any
other practice site, pharmacists and other health care professionals can apply their skills and knowledge for the optimal care of patients. The
pharmacist should not be relegated to the role of information dispenser or gatekeeper, but they should instead extend their knowledge of drugs and
therapeutics to the clinical management of individual patients or the care of large populations.
STEPS FOR ANSWERING A QUESTION
Accepting Responsibility and Eliminating Barriers
Health care professionals should recognize that their responsibility extends beyond simply providing an answer to a question. Rather, it is to assist in
resolving therapeutic dilemmas or managing patients’ medication regimens for their entire therapeutic outcome. Knowledge of pharmacotherapy
alone does not ensure success. Moreover, isolated information is not sufficient for formulating responses to questions or ensuring proper patient
management. In fact, it is uncommon to find comprehensive answers in the literature that completely and effectively address specific situations or
circumstances that clinicians encounter in their daily practices. Responses and recommendations must often be thoughtfully synthesized using
information and knowledge gathered from a number of diverse sources. To effectively manage the care of patients and resolve complex situations,
added skills and competence in problem solving and direct patient care are also necessary.
In order to provide meaningful responses and effective recommendations to drug information questions, real or perceived impediments must first be
overcome. One such impediment is the false perception that many drug information questions do not pertain to specific patients. Another is the
perception that the seemingly casual interactions with requestors and the lack of formal, written consultation somehow preclude the need for in
depth analysis and extensive involvement in patient management. Oversimplification of these interactions with requestors and failure to identify the
context of the question or recognize its significance can jeopardize the clinical management of patients. The absence of sufficient background
information and pertinent patient data can greatly impair the process of information synthesis and the ability to formulate effective responses.
Identifying the Genuine and Precise Need
Evolution of the Systematic Approach
Historically, the approach to answering drug information queries has centered on the use of a systematic method first described by Watanabe and
subsequently modified by others.1,2 This simple approach relied on the collection of basic information to document and categorize the request and to
subsequently develop an organized strategy for formulating cogent responses. The American Society of HealthSystem Pharmacists (ASHP) guidelines
on the pharmacist’s role in providing drug information have outlined a ninestep, systematic approach for responding to drug information requests
which includes identifying the requestor, defining the true question, obtaining background information, categorizing the question, performing a
systematic search, analyzing the information, disseminating the information, documenting the response, and performing a followup assessment.3
Although this structure remains theoretically useful from a training standpoint, if strictly applied without proper context and guidance, it has the
potential to artificially fragment the process and disrupt the natural exchange of information. Additionally, the specific approach used to respond to a
drug information request should be flexible, depending on the given practice setting and specific scenario. The full process outlined above may not be
practical in certain direct patient care settings or when an urgent response is necessary. The Pharmacists’ Patient Care Process (PPCP) has also been
used as a more general model by colleges and schools of pharmacy to provide students with a systematic, patientcentered approach to improving
medication outcomes across various practice settings.4 This approach is similar to the ASHP guidelines and Watanabe’s method. The PPCP includes
collection of all necessary information in order to understand the clinical status of the patient, followed by analysis of data, development and
implementation of an evidencebased plan, and appropriate followup. A documentation form (see Appendix 21) may be useful to guide the process
of data collection and ensure that all relevant information is considered.
Eliminating Potential Barriers
Although this structure remains theoretically useful from a training standpoint, if strictly applied without proper context and guidance, it has the
potential to artificially fragment the process and disrupt the natural exchange of information. Additionally, the specific approach used to respond to a
drug information request should be flexible, depending on the given practice setting and specific scenario. The full process outlined above may not be
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practical in certain direct patient care settings or when an urgent response is necessary. The Pharmacists’ Patient Care Process (PPCP) has also been
used as a more general model by colleges and schools of pharmacy to provide students with a systematic, patientcentered approach to improving
medication outcomes across various practice settings.4 This approach is similar to the ASHP guidelines and Watanabe’s method. The PPCP includes
collection of all necessary information in order to understand the clinical status of the patient, followed by analysis of data, development and
implementation of an evidencebased plan, and appropriate followup. A documentation form (see Appendix 21) may be useful to guide the process
of data collection and ensure that all relevant information is considered.
Eliminating Potential Barriers
Ultimately, the success of providing an effective response will depend largely on maintaining the flow of information with minimal distractions and
unnecessary or illtimed questions. The goal should be to remove obstacles, such as those provided by lack of background or situational information,
when communicating with clinicians to determine the actual informational needs, also referred to as the ultimate question. This is particularly relevant
in clinical settings where most queries are not purely academic or general in nature. In fact, it is rational to assume that queries from health care
providers will invariably involve specific patients and unique clinical circumstances. For example, a physician who asks about the association of liver
toxicity with atorvastatin is probably not asking this question whimsically or out of curiosity. The physician most likely is caring for a patient who has
developed signs or symptoms of hepatic impairment possibly associated with the use of this medication. Although other reasonable scenarios, albeit
less likely, could have prompted this question, it would be most prudent nonetheless to consider the possibility of a patientspecific druginduced liver
injury.
Eliciting Critical Information
Even questions that are not related to patient care (refer to Case Study 21 as an example) must be viewed in their proper context. Requestors of
information are typically vague in verbalizing their needs and generally provide adequate information only when specifically asked and/or thoughtfully
prompted. Although these requestors may seem confident about their perceived needs, they may be less certain after further probing. Requestors,
regardless of background, are often uncertain about the nature and extent of information that should be disclosed in order to derive the most optimal
assistance. Critical information that defines the problem and elucidates the context of the question is not readily volunteered, but must be expertly
elicited. This can be accomplished using effective questioning strategies (asking logical questions in a logical sequence) and other means of
information gathering that are essential for formulating informed responses. Failure of the requestor to disclose critical information or clarify the
question does not obviate the need for such information or relieve the pharmacist of the duty to collect it. Although it is easy to assign blame to the
requestor for failing to disclose all the necessary information, it is ultimately the responsibility of the provider of the response to obtain this
information completely and efficiently.
Case Study 2–1
INITIAL QUESTION
What is the molecular weight of fosamprenavir calcium?
POTENTIAL RESPONSE IN THE ABSENCE OF RELEVANT BACKGROUND INFORMATION
Fosamprenavir is an oral antiretroviral agent that is indicated for the treatment of human immunodeficiency virus (HIV1) infection in combination
with other antiretroviral agents.5,6 The molecular weight of fosamprenavir is 623.7 g/mol.6
PERTINENT BACKGROUND INFORMATION
The requestor is a basic scientist who is conducting an in vitro experiment to evaluate the pharmacologic effects of fosamprenavir. She would like to
know the molecular weight of fosamprenavir so that she can perform appropriate calculations specified for this experiment.
PERTINENT PATIENT FACTORS
N/A
PERTINENT DISEASE FACTORS
N/A
Chapter Two: Formulating an Effective Response: A Structured Approach, Amy Heck Sheehan; Joseph K. Jordan
PERTINENT MEDICATION FACTORS Page 3 / 22
Fosamprenavir is a prodrug that is converted in vivo to the pharmacologically active form, amprenavir.5,6 Fosamprenavir is available for prescription
use in the United States as 700mg oral tablets and 50 mg/mL oral suspension. Amprenavir has been discontinued and is no longer commercially
information gathering that are essential for formulating informed responses. Failure of the requestor to disclose critical information or clarify the
question does not obviate the need for such information or relieve the pharmacist of the duty to collect it. Although it is easy to assign blame to the
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requestor for failing to disclose all the necessary information, it is ultimately the responsibility of the provider of the response to obtain this
information completely and efficiently.
Case Study 2–1
INITIAL QUESTION
What is the molecular weight of fosamprenavir calcium?
Fosamprenavir is an oral antiretroviral agent that is indicated for the treatment of human immunodeficiency virus (HIV1) infection in combination
with other antiretroviral agents.5,6 The molecular weight of fosamprenavir is 623.7 g/mol.6
The requestor is a basic scientist who is conducting an in vitro experiment to evaluate the pharmacologic effects of fosamprenavir. She would like to
know the molecular weight of fosamprenavir so that she can perform appropriate calculations specified for this experiment.
N/A
N/A
PERTINENT MEDICATION FACTORS
Fosamprenavir is a prodrug that is converted in vivo to the pharmacologically active form, amprenavir.5,6 Fosamprenavir is available for prescription
use in the United States as 700mg oral tablets and 50 mg/mL oral suspension. Amprenavir has been discontinued and is no longer commercially
available in the United States.
ANALYSIS AND SYNTHESIS
Considering that fosamprenavir is a prodrug that must be converted to a pharmacologically active compound in vivo, and given that this researcher
wishes to conduct an in vitro study, the researcher should use the active form of the drug in the experiment. Therefore, the true information need is
the molecular weight of amprenavir rather than fosamprenavir.
RESPONSE AND RECOMMENDATIONS
Fosamprenavir is an oral antiretroviral agent indicated for the treatment of human immunodeficiency virus (HIV1) infection in combination with
other antiretroviral agents.5,6 Because fosamprenavir is a prodrug that requires conversion to the active form, the requestor was advised to
consider using amprenavir in the experiment. The molecular weight of amprenavir is 505.6 g/mol, and is available for purchase from several
chemical vendors.7
CASE MESSAGE
This example illustrates the importance of collecting pertinent background information, even for seemingly uncomplicated questions. The question
as originally posed related simply to the physicochemical properties of the drug; after obtaining additional information, the question ultimately
pertained to both the drug’s physicochemical properties and pharmacokinetics/pharmacology.
Failure to understand exactly how the information that is provided will be used could result in an inaccurate or misleading response. In this case,
providing the molecular weight without alerting the requestor that in vitro fosamprenavir is pharmacologically inactive would have resulted in
wasted time and money, and the results of the experiment would likely have been invalid.
Good communication skills (both listening and questioning) are essential for gathering relevant information, discerning the real question, and
identifying the genuine needs of the requestor. Providing responses and offering recommendations without knowledge of pertinent patient
information, the context of the request, or how the information will be applied can be potentially harmful. For assistance in identifying some of the
questions that should be posed, please refer to Appendix 22. Even wellequipped drug information centers with trained staff are not immune to this
problem. A study of the quality of pharmacotherapy consultations provided by drug information centers in the United States found that the centers
Failure to understand exactly how the information that is provided will be used could result in an inaccurate or misleading response. In this case,
providing the molecular weight without alerting the requestor that in vitro fosamprenavir is pharmacologically inactive would have resulted in
wasted time and money, and the results of the experiment would likely have been invalid. Access Provided by:
Good communication skills (both listening and questioning) are essential for gathering relevant information, discerning the real question, and
identifying the genuine needs of the requestor. Providing responses and offering recommendations without knowledge of pertinent patient
information, the context of the request, or how the information will be applied can be potentially harmful. For assistance in identifying some of the
questions that should be posed, please refer to Appendix 22. Even wellequipped drug information centers with trained staff are not immune to this
problem. A study of the quality of pharmacotherapy consultations provided by drug information centers in the United States found that the centers
generally failed to obtain pertinent patient data, thereby risking incorrect responses and inappropriate recommendations.8
Verifying the Context of Question
Some health care professionals may be quick to attempt to answer questions without adequately understanding the context or unique circumstances
from which they evolved. They focus exclusively on the answer and ignore or fail to obtain key information needed to establish the framework of the
question. In essence, this can result in a correct response being provided to address an incorrect question. For example, in a question about the dose
of an antibiotic, an incorrect response can be formulated and inappropriate recommendations made if one fails to consider such factors as the
patient’s age, sex, condition being treated, endorgan function, weight and body composition, concomitant diseases (e.g., cystic fibrosis), possible
drug interactions, site of infection, spectrum of activity of the antimicrobial, resistance patterns, or other factors such as pregnancy or dialysis.
Before attempting to formulate responses, one must consider several important questions to ensure that they understand the context of the query and
the scope of the issue or problem (see Table 21). Without this information, there is a risk of providing general responses that do not address the
needs of the requestor. More concerning, however, is that the information provided can be misinterpreted or misapplied. This not only compromises
one’s credibility, but also can jeopardize patient care. Pharmacists must recognize the value and potential benefits of their contributions as members
of the health care team. Lack of confidence in communicating with requestors can be a limiting factor. Because a telephone call from another health
care provider or even a facetoface interaction may not be perceived as a formal request for a consult, the significance of such apparently informal
daily interactions can easily be overlooked. Interactions with physicians and other health care providers present valuable opportunities for direct
involvement in patient care. The lesson often missed is that there is a fine line between a simple, seemingly general drug information question and a
meaningful pharmacotherapy consult. Knowing the context of the question, obtaining the pertinent patient data and background information, and
understanding the true needs of the requestor often can be the difference.
Case Study 2–2
INITIAL QUESTION
Can you tell me the recommended dose of azithromycin for gastroparesis?
Azithromycin is structurally similar to erythromycin, a macrolide that has been used historically for shortterm management of gastroparesis. While
erythromycin is noted to reduce symptoms from delayed gastric emptying in either the intravenous (IV) or oral formulation, current guidelines from
the American Gastroenterology Association (AGA) do not address the role of azithromycin.9 A search of tertiary and secondary sources did note a
few reports of using IV or oral formulations of azithromycin at doses of 250–500 mg daily.10–14
The requestor is an internal medicine physician who is managing a patient with diabetic gastroparesis. A nurse recently informed the internal
medicine team of a nationwide erythromycin shortage. The physician would like to know if azithromycin is an alternative to erythromycin, and, if so,
what the appropriate dose would be for this specific patient.
CD is a 53yearold female. She is presenting today to the office with reported history of abdominal pain, persistent nausea, occasional vomiting,
decreased appetite, and flatulence for past 2 months. Currently the patient is receiving asneeded metoclopramide 10 mg by mouth (PO) 10 minutes
after meals.
Past Medical History
Type 2 diabetes mellitus × 13 years
Peripheral neuropathy × 5 years
CD is a 53yearold female. She is presenting today to the office with reported history of abdominal pain, persistent nausea, occasional vomiting,
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decreased appetite, and flatulence for past 2 months. Currently the patient is receiving asneeded metoclopramide 10 mg by mouth (PO) 10 minutes
after meals.
Type 2 diabetes mellitus × 13 years
Peripheral neuropathy × 5 years
Diabetic gastroparesis × 2 years
Hypertension × 8 years
Social History
Negative for ethanol
Negative for tobacco or illicit drugs
Current Medications and Supplements
Insulin glargine 15 units subcutaneously at bedtime
Insulin lispro 5 units subcutaneously 15 minutes before each meal
Lisinopril 10 mg PO daily
Hydrochlorothiazide 50 mg daily
Metoclopramide 10 mg PO 10 minutes after meals as needed
Atorvastatin 40 mg PO every evening
Acetaminophen 1000 mg PO every 6 hours as needed for pain
Centrum® Women daily multivitamin
Fish oil supplement
Allergies and intolerances
Morphine
Laboratory Results
Temperature 98°F, blood pressure (BP) 151/84 mmHg, heart rate (HR) 91 BPM, respiratory rate (RR) 18/min, O2 saturation 93%
Serum creatinine (SCr) 1.3 mg/dL, blood urea nitrogen (BUN) 22 mmol/dL
White blood cells (WBC) 5.4 × 109 per liter
Blood glucose (BG) 88 mg/dL, A1C 9.4% (3 months ago)
Lowdensity lipoprotein (LDL) 126 mg/dL, highdensity lipoprotein (HDL) 44 mg/dL, triglycerides (TG) 155 mg/dL
Gastroparesis is characterized by delayed gastric emptying and is most commonly associated with diabetes mellitus. The incidence increases with
the duration of diabetes and the presence of complications such as retinopathy, neuropathy, or nephropathy. Common symptoms of this condition
include nausea, vomiting, abdominal pain, and fullness. Treatment of gastroparesis generally involves modifications to diet and pharmacotherapy
with prokinetics, antiemetics, and nonopiate analgesics.9
PERTINENT MEDICATION AND SUPPLEMENT FACTORS Page 6 / 22
Erythromycin is a macrolide antibiotic with known prokinetic effects resulting from stimulation of motilin receptors in the gut. Azithromycin is also a
macrolide antibiotic but is more commonly used for infectionrelated conditions as opposed to gastrointestinal motility. As compared with
Gastroparesis is characterized by delayed gastric emptying and is most commonly associated with diabetes mellitus. The incidence increases with
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the duration of diabetes and the presence of complications such as retinopathy, neuropathy, or nephropathy. Common symptoms of this condition
include nausea, vomiting, abdominal pain, and fullness. Treatment of gastroparesis generally involves modifications to diet and pharmacotherapy
with prokinetics, antiemetics, and nonopiate analgesics.9
PERTINENT MEDICATION AND SUPPLEMENT FACTORS
Erythromycin is a macrolide antibiotic with known prokinetic effects resulting from stimulation of motilin receptors in the gut. Azithromycin is also a
macrolide antibiotic but is more commonly used for infectionrelated conditions as opposed to gastrointestinal motility. As compared with
erythromycin, azithromycin has less drug interactions and a longer halflife. While large trials comparing erythromycin and azithromycin for the
treatment of gastroparesis were not located, there are some smaller trials comparing manometry results with both agents.11–13 The administration
of IV azithromycin 250 mg infused over 30 minutes was found to have a greater effect in the postprandial period than a dose of IV erythromycin 250
mg infused over 20 minutes.11,12 Due to the long halflife of the agent, the authors argue that the product can be given once daily compared with the
four times daily regimen of erythromycin. In addition, at higher doses of 500 mg of IV azithromycin infused over 30 minutes, a greater effect on
manometry readings was noted.13 A case report describing the effectiveness of azithromycin in an elderly woman with diabetic gastroparesis notes
successful resolution of symptoms after a 3day regimen of 500 mg IV azithromycin followed by a 14day regimen of 500 mg PO azithromycin.14
As CD is already on the firstline agent for gastroparesis (i.e., metoclopramide) and is still symptomatic, erythromycin would be an option to improve
gastric emptying and symptoms from delayed gastric emptying. However, CD is not optimally taking the metoclopramide since she is taking it after
meals instead of the recommended before meals. This should be pointed out since this may be contributing to symptoms. Since erythromycin is
unavailable at the present time, azithromycin is an additional option based on similar effects seen in manometry studies.
Metoclopramide is a firstline agent for treatment of diabetic gastroparesis at a dose of 10 mg up to four times daily before meals and at bedtime.9
Taking the medication after meals, instead of the recommended 30 minutes before meals, will decrease the efficacy of the prokinetic agent. Before
making additional changes to CD’s regimen, it is worth adjusting the metoclopramide dosing.
CASE MESSAGE
This question highlights the importance of skillful problem solving. As always, collecting appropriate background information and patient data is
critical. Analyzing this information before synthesizing a logical response is paramount for effective patient management. The question as originally
presented related to medication dosing; after obtaining additional information, the question broadened to the appropriate management of the
patient’s condition, with a need to optimized use of the firstline agent. In this case, failure to recognize that the patient was inappropriately taking
metoclopramide could lead to potentially unnecessary addition of therapy for her diabetic gastroparesis.
TABLE 2–1
QUESTIONS TO CONSIDER BEFORE FORMULATING A RESPONSE
Are the requestor’s name, profession, and affiliation known?
How can the requestor be contacted (e.g., pager, email, cellphone)?
Does the question pertain to a specific patient? If so, has pertinent patient history been obtained?
Is there a clear understanding of the question or problem?
Has the true information need (i.e., ultimate question) been determined?
Why is the question being asked? Why now?
What are the unique circumstances that generated the query?
Are the requestor’s expectations understood?
Has pertinent background information been obtained?
presented related to medication dosing; after obtaining additional information, the question broadened to the appropriate management of the
patient’s condition, with a need to optimized use of the firstline agent. In this case, failure to recognize that the patient was inappropriately taking
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metoclopramide could lead to potentially unnecessary addition of therapy for her diabetic gastroparesis.
TABLE 2–1
QUESTIONS TO CONSIDER BEFORE FORMULATING A RESPONSE
Are the requestor’s name, profession, and affiliation known?
How can the requestor be contacted (e.g., pager, email, cellphone)?
Does the question pertain to a specific patient? If so, has pertinent patient history been obtained?
Is there a clear understanding of the question or problem?
Has the true information need (i.e., ultimate question) been determined?
Why is the question being asked? Why now?
What are the unique circumstances that generated the query?
Are the requestor’s expectations understood?
Has pertinent background information been obtained?
What information is actually needed?
When is the information needed and in what format (e.g., verbal, written)?
How will the information provided be used or applied?
How has the problem or situation been managed to date?
Are there alternative explanations or management options that should be explored?
In the absence of information that provides the proper context, a question about the halflife of a medication appears rather simple. However, if the
question were posed for the purpose of assisting the requestor in determining a sufficient washout period for a crossover study, one would be remiss
if factors, other than the halflife of the parent compound, were not considered. Proper determination of a washout period also would mandate
consideration of other factors such as the activity and halflives of known metabolites; the presence of potentially interacting medications; the effects
of age, illness, or endorgan function; the persistence of pharmacodynamic effects of the medication beyond its detection in the plasma (e.g.,
omeprazole); and the effect of administration route on the apparent halflife (e.g., transdermally administered fentanyl).
The case studies in this chapter emphasize the importance of looking beyond the initial question and recognizing that the requestor’s needs often go
well beyond a superficial answer to the primary question. Pharmacists should always anticipate additional questions or concerns, including those that
are not directly asked or addressed by the requestor. These questions nonetheless must be considered if a clinical situation is to be managed
optimally. In Case Study 23, as an example, a question is posed about antibiotics as a possible cause of tooth discoloration. Although the requestor
may neglect to provide clarifying information or pose insightful questions that further inform the case, additional related issues and complementary
questions should nonetheless be considered, as these will likely be critical in determining the ultimate success of the response (see Table 22). Failure
to address such questions will undoubtedly result in either an incorrect or inadequate response.
Case Study 2–3
INITIAL QUESTION
Do any of the following antibiotics cause teeth discoloration— amoxicillin, nitrofurantoin, and sulfamethoxazoletrimethoprim?
An extensive search of tertiary and secondary literature sources noted that tooth discoloration has been seen rarely with amoxicillin.15 However,
Case Study 2–3 Access Provided by:
INITIAL QUESTION
Do any of the following antibiotics cause teeth discoloration— amoxicillin, nitrofurantoin, and sulfamethoxazoletrimethoprim?
An extensive search of tertiary and secondary literature sources noted that tooth discoloration has been seen rarely with amoxicillin.15 However,
with dental hygiene practices such as brushing or professional cleaning, this discoloration may be reversible. No documentation was found of tooth
discoloration with nitrofurantoin or sulfamethoxazoletrimethoprim.
The requestor is a urology nurse practitioner who is caring for a patient with vesicoureteral reflux (VUR). The patient had been receiving ½ teaspoon
of sulfamethoxazoletrimethoprim for about 8 months when his parent noticed darkening of his two teeth. The clinician would like to use an
antibiotic prophylaxis for VUR but wants to make sure that tooth discoloration is unlikely with choice.
AB is a 10month old male with VUR.
Febrile urinary tract infection (UTI)
Social History
N/A
Current Medications and Supplements
Trimethoprim/sulfamethoxazole (40–200 mg/5 mL) 2.5 mL daily × 8 months [stopped]
Patient is currently breastfed
Liquid multivitamin supplement (PolyViSol® with iron) 0.5 mL by mouth once daily
Allergies and Intolerances
N/A
VUR involves the retrograde passage of urine from the bladder into the upper urinary tract. Patients with VUR who develop bladder infection are at
increased risk for febrile UTIs compared with patients without VUR. The management of VUR involves preventing recurring febrile UTIs, preventing
renal injury from potential kidney infections (e.g., acute pyelonephritis), and minimizing morbidity of treatment.16–18 Antibiotic prophylaxis has
been given for several decades under the idea that sterilizing the urine will lead to less kidney infections and in turn, less kidney scarring. Children
younger than 1 year of age are recommended to receive antibiotic prophylaxis since they are more likely to suffer morbidity with acute kidney
infections than older children.18
Tooth discoloration is described as either extrinsic (i.e., outer surface) or intrinsic (i.e., within enamel). Extrinsic discoloration can be seen with tea,
coffee, tobacco, and some medications such as mouth rinses and iron salts. In contrast to intrinsic stains, extrinsic stains can usually be removed
with tooth brushing or dental scaling and polishing.15
Reports of tooth discoloration with amoxicillin, but not trimethoprimsulfamethoxazole or nitrofurantoin were found in the primary and tertiary
literature. A review of the patient’s current medication and supplements reveals an ironcontaining multivitamin. Ironcontaining products have
more reports of tooth discoloration than amoxicillin.15
Trimethoprimsulfamethoxazole and nitrofurantoin have traditionally been used for VUR prophylaxis at onehalf to onefourth of the usual Page 9 / 22
therapeutic doses for treating acute infections. Amoxicillin is not traditionally used secondary to concerns of increased likelihood of resistant
organisms.16–18
with tooth brushing or dental scaling and polishing.
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Reports of tooth discoloration with amoxicillin, but not trimethoprimsulfamethoxazole or nitrofurantoin were found in the primary and tertiary
literature. A review of the patient’s current medication and supplements reveals an ironcontaining multivitamin. Ironcontaining products have
more reports of tooth discoloration than amoxicillin.15
Trimethoprimsulfamethoxazole and nitrofurantoin have traditionally been used for VUR prophylaxis at onehalf to onefourth of the usual
therapeutic doses for treating acute infections. Amoxicillin is not traditionally used secondary to concerns of increased likelihood of resistant
organisms.16–18
As AB is less than 1 year of age and has a history of febrile UTI, it is recommended to receive antibiotic prophylaxis. Trimethoprimsulfamethoxazole
and nitrofurantoin are the most common antibiotics recommended. While AB has been on trimethoprimsulfamethoxazole for 8 months, there is no
record of having received dental cleaning during this time. Amoxicillin and nitrofurantoin are other options for VUR prophylaxis, although
amoxicillin has reports of tooth discoloration. A more likely causative factor is the liquid multivitamin containing iron. Iron supplements are usually
not needed in children who are breastfed or who get ironfortified infant formula. Since AB is still being breastfed, there is likely not a need for the
iron supplement.
A review of AB’s current medications reveals one agent, a liquid multivitamin containing iron, which has been reported to cause extrinsic tooth
discoloration. This discoloration is usually reversible with tooth brushing and polishing.15 Trimethoprimsulfamethoxazole has not previously been
reported to cause tooth discoloration but it cannot be ruled out as a possible cause. The practitioner was advised to consult a dentist for cleaning of
the extrinsic discoloration and to discuss discontinuing the ironcontaining multivitamin supplement with the parents. If the staining returns after
discontinuation of the iron supplement, then transition to nitrofurantoin could be considered.
CASE MESSAGE
This question highlights the importance of skillful problem solving. As always, collecting appropriate background information and patient data is
critical. Analyzing this information before synthesizing a logical response is paramount for effective patient management. While the classification of
the original drug information request (adverse effect) did not change in the process of addressing the question, obtaining an accurate medication
list broadened the list of potential list of medications that could be associated with the adverse effect in this particular patient. In this case, failure to
recognize that the patient was receiving a liquid multivitamin with iron could have led to possible suboptimal antibiotic prophylactic therapy for
VUR.
TABLE 2–2
IMPORTANT QUESTIONS NOT POSED BY THE REQUESTOR
Initial query posed by requestor: Do any of the following antibiotics cause tooth discoloration—amoxicillin, nitrofurantoin, and sulfamethoxazole
trimethoprim?
What is the incidence of antibioticinduced tooth discoloration?
Are specific antibiotic agents (i.e., amoxicillin, nitrofurantoin, or sulfamethoxazoletrimethoprim) more likely to cause tooth discoloration than others?
Are there any known predisposing factors?
Is the pathogenesis of this adverse effect understood?
How does the tooth discoloration typically present?
Are there any characteristic subjective or objective findings?
Does tooth discoloration caused by antibiotics differ from that caused by other medications, or other etiologies?
Is the tooth discoloration dose related?
Page 10 / 22
How severe can it become?
list broadened the list of potential list of medications that could be associated with the adverse effect in this particular patient. In this case, failure to
recognize that the patient was receiving a liquid multivitamin with iron could have led to possible suboptimal antibiotic prophylactic therapy for
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VUR.
TABLE 2–2
IMPORTANT QUESTIONS NOT POSED BY THE REQUESTOR
Initial query posed by requestor: Do any of the following antibiotics cause tooth discoloration—amoxicillin, nitrofurantoin, and sulfamethoxazole
trimethoprim?
What is the incidence of antibioticinduced tooth discoloration?
Are specific antibiotic agents (i.e., amoxicillin, nitrofurantoin, or sulfamethoxazoletrimethoprim) more likely to cause tooth discoloration than others?
Are there any known predisposing factors?
Is the pathogenesis of this adverse effect understood?
How does the tooth discoloration typically present?
Are there any characteristic subjective or objective findings?
Does tooth discoloration caused by antibiotics differ from that caused by other medications, or other etiologies?
Is the tooth discoloration dose related?
How severe can it become?
Is antibiotic tooth discoloration reversible?
How is antibioticinduced tooth discoloration usually managed?
Are there other antibiotics available that can be used in place of the patient’s current agents?
Are there alternative explanations for the tooth discoloration in this patient (including other medications, medication combinations, or underlying medical
conditions)?
What complications, if any, can be expected?
To expertly address requests for drug information, clinicians also must depend on their patient care skills, problemsolving skills, insight, and
professional judgment. Computer databases and other specialized information sources can assist in identifying critical data, but overreliance on such
resources without careful attention to pertinent background information and patient data can mislead even the most experienced clinician.
FORMULATING THE RESPONSE
Building a Database and Assessing Critical Factors
Formulating a response comprises a series of steps that must be performed completely, objectively, and in a logical sequence. The steps in the process
include obtaining pertinent background information, identifying other relevant factors and unique or special circumstances, assembling and
organizing a database of the patient information, gathering information about relevant disease states, and collecting medication information.
Formulating the response requires the use of a structured, organized approach whereby critical factors are systematically considered and thoughtfully
evaluated. Table 23 outlines in detail the specific types of information that may need to be considered for each of the four critical factors depending
on the nature of the query. A more thorough list of possible background questions is found in Appendix 22. It should be noted that only some of this
information may be pertinent for a given query or case scenario.
TABLE 2–3
FACTORS TO BE CONSIDERED WHEN FORMULATING A RESPONSE
include obtaining pertinent background information, identifying other relevant factors and unique or special circumstances, assembling and
organizing a database of the patient information, gathering information about relevant disease states, and collecting medication information.
Formulating the response requires the use of a structured, organized approach whereby critical factors are systematically considered and thoughtfully
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evaluated. Table 23 outlines in detail the specific types of information that may need to be considered for each of the four critical factors depending
on the nature of the query. A more thorough list of possible background questions is found in Appendix 22. It should be noted that only some of this
information may be pertinent for a given query or case scenario.
TABLE 2–3
FACTORS TO BE CONSIDERED WHEN FORMULATING A RESPONSE
Pertinent Background Information, Special Circumstances, and Other Factors
Setting
Context
Sequence and time frame of events
Rationale for the question
Event(s) prompting the question
Unusual or special circumstances (including medical errors)
Acuity and time constraints
Scope of question
Desired detail or depth of response
Limitations of available information or resources
Completeness, sufficiency, and quality of the information
Applicability and generalizability of the information available to address the question
Patient Factors
Demographics (e.g., name, age, height, weight, gender, race/ethnic group, and setting)
Primary diagnosis and medical problem list
Allergies/intolerances
Endorgan function, immune function, nutritional status
Chief complaint
History of present illness
Past medical history (including surgeries, radiation exposure, immunizations, psychiatric illnesses, and so forth)
Family history and genetic makeup
Social history (e.g., alcohol intake, smoking, substance abuse, exposure to environmental or occupational toxins, employment, income, education, religion,
travel, diet, physical activity, stress, risky behavior, and compliance with treatment regimen)
Review of body systems
Medications (prescribed, nonprescription, and complementary/alternative)
Physical examination
Family history and genetic makeup
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Social history (e.g., alcohol intake, smoking, substance abuse, exposure to environmental or occupational toxins, employment, income, education, religion,
travel, diet, physical activity, stress, risky behavior, and compliance with treatment regimen)
Review of body systems
Medications (prescribed, nonprescription, and complementary/alternative)
Physical examination
Laboratory tests
Diagnostic studies or procedures
Disease Factors
Definition
Epidemiology (including incidence and prevalence)
Etiology
Pathophysiology (for infectious diseases consider site of infection, organism susceptibility, resistance patterns, and so forth)
Clinical findings (signs and symptoms, laboratory tests, diagnostic studies)a
Diagnosis
Treatment (medical, surgical, radiation, biologic and gene therapies, other)
Prevention and control
Risk factors
Complications
Prognosis
Medication Factors
Name of medication or substance (proprietary, nonproprietary, other)
Status and availability (investigational, nonprescription, prescription, orphan, foreign, complementary/alternative)
Physicochemical properties
Pharmacology and pharmacodynamics
Pharmacokinetics (liberation, absorption, distribution, metabolism, and elimination)
Pharmacogenomics
Indications (Food and Drug Administration [FDA] approved and unlabeled)
Uses (diagnosis, prevention, replacement, or treatment)
Adverse effects
Allergy
Page 13 / 22
Crossallergenicity or crossreactivity
Indications (Food and Drug Administration [FDA] approved and unlabeled)
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Uses (diagnosis, prevention, replacement, or treatment)
Adverse effects
Allergy
Crossallergenicity or crossreactivity
Contraindications and precautions
Effects of age, organ system function, disease, pregnancy, extracorporeal circulation, or other conditions or environments
Mutagenicity and carcinogenicity
Effect on fertility, pregnancy, and lactation
Acute or chronic toxicity
Drug interactions (drug–disease, drug–drug, or drug–food)
Laboratory test interference (analytical or physiologic effects)
Administration (routes, methods)
Dosage and schedule
Dosage forms, formulations, preservatives, excipients, product appearance, delivery systems
Monitoring parameters (therapeutic or toxic)
Product preparation (procedures, methods)
Compatibility and stability
aFactors such as disease or symptom onset, duration, frequency, and severity must always be carefully assessed.
For patientrelated questions, development of a patientspecific database is one of the first steps in preparing a response. This requires the collection
of pertinent information from the patient, caregivers, health care providers, medical chart, and other patient records. A comprehensive medication
history also is essential. This database would invariably include information that overlaps with the medical and nursing databases.
Case Study 2–4
INITIAL QUESTION
What is the maximum dose of rizatriptan?
Rizatriptan is an oral selective serotonin 5HT1B/1D receptor agonist indicated for the acute treatment of migraine headache.19 The recommended
dose for acute migraine is 5–10 mg. If the migraine resumes or symptoms have not subsided within 2 hours, a second dose may be administered.
The maximum daily dose is 30 mg in a 24hour time period.19
The requestor is a medical resident who is caring for a patient with migraine headaches. The patient has experienced an increased intensity and
frequency of migraines over the past several months. She reports that she has experienced two to three migraines per week over the past month.
The patient uses 5 mg of rizatriptan for treatment of acute migraine attacks. This has worked in the past. However, recently she has required a
second dose for complete resolution of symptoms. The medical resident would like to know if higher doses of rizatriptan have been studied. He is
1B/1D
dose for acute migraine is 5–10 mg. If the migraine resumes or symptoms have not subsided within 2 hours, a second dose may be administered.
The maximum daily dose is 30 mg in a 24hour time period.19 Access Provided by:
The requestor is a medical resident who is caring for a patient with migraine headaches. The patient has experienced an increased intensity and
frequency of migraines over the past several months. She reports that she has experienced two to three migraines per week over the past month.
The patient uses 5 mg of rizatriptan for treatment of acute migraine attacks. This has worked in the past. However, recently she has required a
second dose for complete resolution of symptoms. The medical resident would like to know if higher doses of rizatriptan have been studied. He is
planning to increase the patient’s dose of rizatriptan to provide more rapid relief to the patient.
EF is a 27yearold woman who has suffered from migraine headaches for the last 7 years. She presents today complaining of increased frequency
and intensity of migraine headaches over the past month. The migraines are now affecting her job performance as a teacher, and she has recently
missed several days of work.
Recurrent migraine headaches
Depression
Social History
EF is a kindergarten teacher and lives with her husband
EF denies alcohol and tobacco use
Current Medications
Rizatriptan 5 mg orally for acute migraine
Bupropion 150 mg twice daily
Loratadine 10 mg daily
Allergies/Intolerances
Nonsteroidal antiinflammatory drugs (NSAIDs) (anaphylaxis)
Migraine is characterized by episodic attacks of severe headaches that are associated with throbbing pain, nausea, vomiting, and photophobia, with
or without aura.20 If not treated, the duration of a migraine headache can range from 4 hours to several days. Recommended treatments for the
management of acute migraine include acetaminophen, NSAIDs, selective serotonin 5HT1B/1D receptor agonists, antiemetics, and
dihydroergotamine.21 For patients who experience greater than six migraines per month or have very severe symptoms that are not relieved by
acute treatment, use of preventive treatments are recommended.22 Firstline preventive treatments with established efficacy include antiepileptic
drugs (e.g., valproate, topiramate) and betaadrenergic blocking agents (e.g., metoprolol, propranolol).23
PERTINENT MEDICATION FACTORS
The recommended dose of rizatriptan for treatment of migraine in adults is 5–10 mg. If the migraine resumes or symptoms have subsided with 2
hours, a second dose may be administered. The maximum daily dose is 30 mg in a 24hour time period.19 A dose of 10 mg may provide greater
efficacy over a dose of 5 mg. However, adverse events of selective serotonin 5HT1B/1D receptor agonists have been shown to be doserelated. In
clinical trials, patients who received 40 mg of rizatriptan reported dizziness and somnolence.19
Although increasing EF’s dose of rizatriptan to 10 mg may provide greater efficacy for acute migraine relief, doses above this level are associated
with a higher incidence of adverse effects. Review of EF’s migraine history reveals that she is a candidate for preventive treatment. Addition of a
preventive treatment will likely have a greater clinical impact than increasing the rizatriptan dose by reducing the frequency of migraine headaches
that she has been experiencing.
efficacy over a dose of 5 mg. However, adverse events of selective serotonin 5HT1B/1D receptor agonists have been shown to be doserelated. In
clinical trials, patients who received 40 mg of rizatriptan reported dizziness and somnolence.19 Access Provided by:
Although increasing EF’s dose of rizatriptan to 10 mg may provide greater efficacy for acute migraine relief, doses above this level are associated
with a higher incidence of adverse effects. Review of EF’s migraine history reveals that she is a candidate for preventive treatment. Addition of a
preventive treatment will likely have a greater clinical impact than increasing the rizatriptan dose by reducing the frequency of migraine headaches
that she has been experiencing.
The practitioner was advised that the maximum dose of rizatriptan during a 24hour period is 30 mg. Although it may be reasonable to increase EF’s
dose for acute migraine relief to 10 mg, EF should also be started on a preventive treatment, such as valproate, to minimize the frequency of
migraine headaches that she has been experiencing. Because the patient is of childbearing potential, the specific choice of a preventive treatment
should be discussed with the patient with consideration of any plans to become pregnant.
CASE MESSAGE
This example demonstrates the importance of understanding proper context of the query. In this case, the pharmacist must collect critical
background information to determine the actual drug information needed. The question originally appeared to be related directly to drug dosing.
However, once information related to the critical factors was gathered, the true information need became clear: how to optimally manage the
patient’s disease state. Had the pharmacist failed to collect pertinent patient information, the physician may have increased the dose of rizatriptan
after being told that the maximum dose is 30 mg in a 24hour time period. Given this patient’s migraine history, it would be more important to offer a
clinical recommendation: also consider the addition of a preventive treatment in order to minimize the total number of migraine attacks. Moreover,
larger doses of this medication are associated with a higher incidence of adverse effects.
Once these data are collected and carefully assembled, they must be critically analyzed and evaluated in the proper context before final responses and
recommendations are synthesized. Background reading on topics related to the query (e.g., diseases, medications, and laboratory tests) is often
essential. This process also often involves careful evaluation of the literature (see Chapters 4 and 5). To effectively perform the steps outlined
previously, one must begin with a broad perspective (i.e., observing the big picture) to avoid losing sight of important information. Approaching a
question haphazardly, or prematurely fixating on isolated details, can misdirect even the most skilled clinician.
Analysis and Synthesis
Analysis and synthesis of information are among the most critical steps in formulating responses and recommendations. Together, they assist in
forming opinions, arriving at judgments, and ultimately drawing conclusions. Analysis is the critical assessment of the nature, merit, and significance
of individual elements, ideas, or factors. Functionally, it involves separating the information into its isolated parts so that each can be critically
assessed. Analysis requires thoughtful review and evaluation of the quality and overall weight of available evidence. Although this process requires
consideration of all relevant positive findings, pertinent negative findings should not be overlooked.
Once the information has been carefully analyzed, synthesis can begin. Synthesis is the careful, systematic, and orderly process of combining or
blending varied and diverse elements, ideas, or factors into a coherent response. Responses to drug information queries often must be
synthesized by integrating data from diverse sources through the use of logic and deductive reasoning. This process relies not only on the type and
quality of the data gathered, but also on how the data are organized, viewed, and evaluated. Synthesis, as it relates to pharmacotherapy, involves the
careful integration of critical information about the patient, disease, and medication along with pertinent background information to arrive at a
judgment or conclusion. Synthesis can give existing information new meaning and, in effect, create new knowledge. The use of analysis and synthesis
to formulate a response is similar to assembling a jigsaw puzzle. If the pieces are identified and then grouped, organized, and assembled correctly, the
image will be comprehensible. However, if too many of the pieces are missing—as may be the case if patient information or if supporting evidence is
incomplete or absent—or are not arranged logically (e.g., when information is not evaluated, interpreted, or applied correctly), formulating a cogent
response may prove difficult or altogether impossible.
Responses and Recommendations
An effective response obviously must adequately address and answer the question. It should also be tailored to the specific requestor. For example, a
nurse with a straightforward question may need a very different type of response compared to a prescriber with a more complicated question. Other
characteristics of effective responses and recommendations are outlined in Table 24. The response to a question must include a restatement of the
request and clear identification of the problems, issues, and circumstances. The response should begin with an introduction to the topic and
systematically present the specific findings. Pertinent background information and patient data should be succinctly addressed. Conclusions and
recommendations are also included in the response along with pertinent reference citations from the literature. In formulating responses, one should
response may prove difficult or altogether impossible.
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Responses and Recommendations
An effective response obviously must adequately address and answer the question. It should also be tailored to the specific requestor. For example, a
nurse with a straightforward question may need a very different type of response compared to a prescriber with a more complicated question. Other
characteristics of effective responses and recommendations are outlined in Table 24. The response to a question must include a restatement of the
request and clear identification of the problems, issues, and circumstances. The response should begin with an introduction to the topic and
systematically present the specific findings. Pertinent background information and patient data should be succinctly addressed. Conclusions and
recommendations are also included in the response along with pertinent reference citations from the literature. In formulating responses, one should
disclose the available information that is most relevant to the question and present all reasonable options and alternatives along with an explanation
and evaluation of each. Specific recommendations must be scientifically sound, evidencebased, clearly justified, and well documented. A carefully
written record of the response must be maintained for followup and legal reasons. The records may be confidentially maintained in a patient’s
medical record or in the provider’s secure electronic database.
TABLE 2–4
DESIRED CHARACTERISTICS OF A RESPONSE
Timely
Current
Accurate
Complete
Concise
Supported by the best available evidence
Wellreferenced
Clear and logical
Objective and balanced
Free of bias or flaws
Applicable and appropriate for specific circumstances
Answers important related questions
Addresses specific management of patients or situations
Considers local regulations, policies, and formulary (if applicable)
Followup
When recommendations are made, followup always should be provided in a timely manner. Followup is required for assessment of outcomes and,
when necessary, to reevaluate the recommendations and make appropriate modifications; it is also a hallmark of a true professional and
demonstrates a commitment to patient care. Furthermore, followup allows the provider of the information to know if their recommendations were
accepted and implemented. Finally, followup also allows the provider to receive valuable feedback from other clinicians and to learn from the overall
experience.
CONCLUSION
Formulating effective responses and recommendations requires the use of a structured, organized approach whereby critical factors are
systematically considered and thoughtfully evaluated. The steps in this process include organizing relevant patient information, gathering information
about the disease states and affected body systems, collecting medication information, obtaining pertinent background information, and identifying
when necessary, to reevaluate the recommendations and make appropriate modifications; it is also a hallmark of a true professional and
demonstrates a commitment to patient care. Furthermore, followup allows the provider of the information to know if their recommendations were
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accepted and implemented. Finally, followup also allows the provider to receive valuable feedback from other clinicians and to learn from the overall
experience.
CONCLUSION
Formulating effective responses and recommendations requires the use of a structured, organized approach whereby critical factors are
systematically considered and thoughtfully evaluated. The steps in this process include organizing relevant patient information, gathering information
about the disease states and affected body systems, collecting medication information, obtaining pertinent background information, and identifying
other relevant factors that can potentially influence outcomes. Once these data are collected and carefully assembled, they must be critically analyzed
and evaluated in the proper context. Responses and recommendations are synthesized by integrating information from diverse sources through the
use of logic and deductive reasoning.
SELFASSESSMENT QUESTIONS
1. Which of the following best describes the pharmacist’s responsibility during the process of responding to drug information questions?
a. Coordinating purchase of appropriate drug information resources
b. Educating clinicians about appropriate drug information resources
c. Ensuring that drug information is correctly interpreted and applied
d. Providing clinicians with ready access to electronic resources
2. Which of the following steps of the systematic approach is conducted after providing a response to a drug information request?
a. Categorizing the question
b. Identifying the requestor
c. Followup on patient outcomes
d. Analyzing the information
3. Which of the following strategies can help clinicians overcome barriers when collecting pertinent patient information for responses to drug
information responses?
a. Advanced training in literature searching
b. Accepting responsibility for patient outcomes
c. Acknowledging most requests are not patient specific
d. All the above
4. Which of the following factors can greatly impair a clinicians’ ability to formulate an effective response for a drug information request?
a. Absence of sufficient background information
b. Lack of specialty training in drug information
c. Absence of specialty board certification
d. Lack of dedication to patient care
5. Which of the following statements are correct regarding the steps of the systematic approach for responding to drug information requests?
a. The full approach may not be practical for certain practice settings.
b. The steps must always be completed in a specific order.
c. It is acceptable to skip collecting pertinent background information. Page 18 / 22
d. All the above.
d. Lack of dedication to patient care
5. Which of the following statements are correct regarding the steps of the systematic approach for responding to drug information requests?
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a. The full approach may not be practical for certain practice settings.
b. The steps must always be completed in a specific order.
c. It is acceptable to skip collecting pertinent background information.
d. All the above.
6. Which of the following can improve the process of data collection when a clinician is receiving a drug information request?
a. Minimizing distractions to information flow
b. Using a standard data collection form for all requests
c. Using effective questioning strategies
d. All the above
7. Which of the following factors are important to consider when responding to a question regarding an adverse drug event?
a. Incidence of adverse drug event
b. Sequence and time frame of events
c. Predisposing factors for adverse event
d. All the above
8. Which of the following is the first step in preparing an effective response to a patientspecific drug information request?
a. Development of a patientspecific database
b. Critical analysis of relevant literature
c. Synthesis of information from diverse resources
d. Use of deductive reasoning and logic
9. Which of the following steps of the systematic approach to responding to drug information requests involves careful evaluation and interpretation
of available information?
a. Evaluate
b. Categorize
c. Analyze
d. Disseminate
10. Which of the following are the four critical factors to be considered when formulating a response to a drug information request?
a. Disease incidence, severity, duration, and prognosis
b. Primary, secondary, and tertiary literature resources
c. Patient, disease, medication, and pertinent background
d. Identity, question category, documentation, and followup
11. Which of the following statements is true regarding the process of eliciting critical background information from a requestor?
a. The requestor should be blamed for failure to disclose critical information.
b. Communication skills are essential for gathering relevant information.
c. It is the requestor’s responsibility to provide relevant background information.
c. Patient, disease, medication, and pertinent background
d. Identity, question category, documentation, and followup Access Provided by:
11. Which of the following statements is true regarding the process of eliciting critical background information from a requestor?
a. The requestor should be blamed for failure to disclose critical information.
b. Communication skills are essential for gathering relevant information.
c. It is the requestor’s responsibility to provide relevant background information.
d. Gathering background information is not essential to formulation of a response.
12. Which of the following are potential consequences of providing responses and offering recommendations without knowledge of pertinent patient
information?
a. General response that does not meet the needs of the requestor
b. Damage to the clinician’s reputation
c. Patient harm or death
d. All the above
13. Which of the following involves integration of information about the patient, disease, and medication to arrive at a judgment or conclusion?
a. Synthesis
b. Analysis
c. Research
d. Integration
14. Which of the following are desired characteristics of a wellformulated drug information response?
a. Timely, accurate, and complete
b. Applicable and appropriate for specific circumstance
c. Supported by best available evidence
d. All the above
15. Which of the following assumptions is appropriate when receiving a drug information question from health care professional?
a. Question is usually academic or general in nature.
b. Commonly prompted by drug company representatives.
c. Likely involves specific patients and unique clinical circumstances.
d. All the above.
REFERENCES
1. Watanabe AS, Conner CS. Principles of drug information services. Hamilton (IL): Drug Intelligence Publications Inc.; 1978.
2. Galt KA, Calis KA, Turcasso NM. Clinical skills program: module 3 drug information. Bethesda (MD): American Society of HealthSystem Pharmacists
Inc.; 1995.
3. Ghaibi S, Ipema H, Gabay M, American Society of HealthSystem Pharmacists. ASHP guidelines on the pharmacist’s role in providing drug
information. Am J HealthSyst Pharm. 2015;72(7):573–7. [PubMed: 25788512]
4. The Joint Commission of Pharmacy Practitioners. The pharmacists’ patient care process [Internet]. c2014 [cited 2019 Aug 27]. Available from:
https://jcpp.net/patientcareprocess/.
2. Galt KA, Calis KA, Turcasso NM. Clinical skills program: module 3 drug information. Bethesda (MD): American Society of HealthSystem Pharmacists
Access Provided by:
Inc.; 1995.
3. Ghaibi S, Ipema H, Gabay M, American Society of HealthSystem Pharmacists. ASHP guidelines on the pharmacist’s role in providing drug
information. Am J HealthSyst Pharm. 2015;72(7):573–7. [PubMed: 25788512]
4. The Joint Commission of Pharmacy Practitioners. The pharmacists’ patient care process [Internet]. c2014 [cited 2019 Aug 27]. Available from:
https://jcpp.net/patientcareprocess/.
5. McEvoy GK AHFS drug information 2019. Bethesda (MD): American Society of HealthSystem Pharmacists; 2019.
6. Lexiva [package insert]. Cambridge (MA): Vertex Pharmaceuticals Inc.; 2019.
7. National Center for Biotechnology Information. PubChem Open Chemistry Database CID=65016 [Internet]. Bethesda (MD): U.S. National Library of
Medicine; c2005–2017 [cited 2019 Aug 27]. Available from: https://pubchem.ncbi.nlm.nih.gov/compound/65016.
8. Calis KA, Anderson DW, Auth DA, Mays DA, Turcasso NM, Meyer CC, Young LR Quality of pharmacotherapy consultations provided by drug
information centers in the United States. Pharmacotherapy. 2000;20(7):830–6. [PubMed: 10907973]
9. Camilleri M, Parkman HP, Shafi MA, Abell TL, Gerson L. Clinical guideline: management of gastroparesis. Am J Gastroenterol. 2013;108:18–37.
[PubMed: 23147521]
10. Potter TG, Snider KR. Azithromycin for the treatment of gastroparesis. Ann Pharmacother. 2013;47:411–5. [PubMed: 23447477]
11. Larson JM, Tavakkoli A, Drane WE, Toskes PP, Moshiree B. Advantages of azithromycin over erythromycin in improving the gastric emptying half
time in adult patients with gastroparesis. J Neurogastroenterol Motil. 2010;16:407–13. [PubMed: 21103422]
12. Chini P, Toskes PP, Waseem S, Hou W, McDonald R, Moshiree B. Effect of azithromycin on small bowel motility in patients with gastrointestinal
dysmotility. Scand J Gastroenterol. 2012;47:422–7. [PubMed: 22364597]
13. Moshiree B, McDonald R, Hou W, Toskes PP. Comparison of the effect of azithromycin versus erythromycin on antroduodenal pressure profiles of
patients with chronic functional gastrointestinal pain and gastroparesis. Dig Dis Sci. 2010;55:675–83. [PubMed: 19924535]
14. Sutera L, Domingues LJ, Belvedere M, Putignano E, Vernuccio L, Ferlisi A, Fazio G, Costanza G, Barbagallo M. Azithromycin in an older woman
with diabetic gastroparesis. Am J Ther. 2008;15:85–8. [PubMed: 18223358]
15. Kumar A, Kumar V, Singh J, Hooda A, Dutta S. Druginduced discoloration of teeth: an updated review. Clin Pediatr. 2012;51:181–5.
16. Roberts KB, for the Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management. Urinary tract
infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics.
2011;128:595–610. [PubMed: 21873693]
17. Peters CA, Skoog SJ, Arant BS, Copp HL, Elder JS, Hudson RG, Khoury AE, Lorenzo AJ, Pohl HG, Shapiro E, Snodgrass WT, Diaz M. Summary of
the AUA guideline on management of primary vesicoureteral reflux in children. J Urol. 2010;184:1134–44. [PubMed: 20650499]
18. Tullwus K. Vesicoureteral reflux in children. Lancet. 2015;385:371–9. [PubMed: 25164069]
19. Maxalt [package insert]. Whitehouse Station (NJ): Merck & Co Inc.; 2019.
20. Charles A. The evolution of a migraine attack: a review of recent evidence. Headache. 2013;53(2):413. [PubMed: 23278169]
21. Marmura MJ, Silberstein SD, Schwedt TJ. The acute treatment of migraine in adults: the American Headache Society Evidence Assessment of
Migraine Pharmacotherapies. Headache. 2015;55(1):3–20. [PubMed: 25600718]
22. Lipton RB, Bigal ME, Diamond M, Freitag F, Reed ML, Steward WF, The American Migraine Prevalence and Prevention Advisory Group. Migraine
prevalence, disease burden, and the need for preventive therapy. Neurology. 2007;68:343–9. [PubMed: 17261680]
23. Silberstein SD, Holland S, Freitag F, Dodick DW, Argoff C, Ashman E. Evidencebased guideline update: pharmacologic treatment for episodic
migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache
Society. Neurology. 2012;78(17):1337–45. [PubMed: 22529202]
21. Marmura MJ, Silberstein SD, Schwedt TJ. The acute treatment of migraine in adults: the American Headache Society Evidence Assessment of
Access Provided by:
Migraine Pharmacotherapies. Headache. 2015;55(1):3–20. [PubMed: 25600718]
22. Lipton RB, Bigal ME, Diamond M, Freitag F, Reed ML, Steward WF, The American Migraine Prevalence and Prevention Advisory Group. Migraine
prevalence, disease burden, and the need for preventive therapy. Neurology. 2007;68:343–9. [PubMed: 17261680]
23. Silberstein SD, Holland S, Freitag F, Dodick DW, Argoff C, Ashman E. Evidencebased guideline update: pharmacologic treatment for episodic
migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache
Society. Neurology. 2012;78(17):1337–45. [PubMed: 22529202]

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