ubc pharmacy residents 2013

Using the UBC Library & finding drug information

Dean Giustini, UBC LibraryKathy McInnes, DPICJuly 2013

Systematic approach to drug information

1. Obtain demographics of requestor2. Obtain background information for the situation3. Determine and categorize the ultimate question4. Develop strategy, conduct search5. Critically evaluate information6. Formulate and provide response7. Follow-up, document

http://hlwiki.slais.ubc.ca/index.php/UBC_Pharmacy_Handout_2013

Systematic approach to drug information1. Obtain demographics of requestor2. Obtain background information3. Determine and categorize the ultimate question4. Develop strategy, conduct search5. Critically evaluate information6. Formulate and provide response7. Follow-up, document

Drug Information Categories• Therapeutics• Dosage/route• Adverse Drug Reaction• Pregnancy• Lactation• Identification• Availability• Compatability• Pharmacology• Pharmacokinetics• Ingredients• Alternative/complementary therapies

Can I use diltiazem to manage focal atrial

tachycardia?

Drug Information Categories• Therapeutics• Dosage/route• Adverse Drug Reaction• Pregnancy• Lactation• Identification• Availability• Compatibility• Pharmacology• Pharmacokinetics• Ingredients• Alternative/complementary therapies

Which of this patient’s medications can exacerbate

ulcerative colitis?

Drug Information Categories• Therapeutics• Dosage/route• Adverse Drug Reaction• Pregnancy• Lactation• Identification• Availability• Compatibility• Pharmacology• Pharmacokinetics• Ingredients• Alternative/complementary therapies

What are the risks to the fetus from accidental exposure to MMR vaccine

in the first trimester?

Drug Information Categories• Therapeutics• Dosage/route• Adverse Drug Reaction• Pregnancy• Lactation• Identification• Availability• Compatibility• Pharmacology• Pharmacokinetics• Ingredients• Alternative/complementary therapies

Can Arnica tablets cause bradycardia?

Systematic approach to drug information

1. Obtain demographics of requestor2. Obtain background information3. Determine and categorize the ultimate question4. Develop strategy, conduct search5. Critically evaluate information6. Formulate and provide response7. Follow-up, document

PICOP - Patient problemI – InterventionC – Comparator or controlO - Outcome

• The PICO framework was developed for intervention/therapy questions.

• Helps clearly define the clinical question and guides selecting terms for searching.

• A clinical question is more likely to be answered if at least the Intervention and the Outcome are specified.

• Not all questions fit neatly into the PICO framework… not necessary for “background” questions.

Where do you begin?• General specific

• Background knowledge foreground knowledge

• Tertiary primary

Textbooks/e-books

Point-of-care tools

Consult secondary sources (Medline,

Embase, Cochrane) to get to primary

literature

General knowledge

about illness or disease

General knowledge

about illness or disease

Specific knowledge to inform clinical

decisions

Specific knowledge to inform clinical

decisions

E-Books @ UBC Library

Access Medicine40 titles (e-Books)• G&G Pharmacologic Basis of Therapeutics• Katzung Basic & Clinical Pharmacology• Olson’s Poisoning & Drug Overdose• Harrison’s Principles of Internal Medicine

Books@OVID15 titles• Briggs Drugs in Pregnancy & Lactation (8th)• Wallach Interpretation of Diagnostic Tests• Oski’s Pediatrics• Marino The ICU Book

MD Consult Core Collection40 texts, 78 journals, practice guidelines etc.• Haddad & Winchester Clinical Management of Poisoning & Drug Overdose• Palliative Medicine• Mandell Principles & Practice of Infectious Disease• Pediatrics – Harriet Lane Handbook; Nelson textbook of pediatrics

Medicines CompleteThree excellent texts• AHFS Drug Information

• References included in electronic version• Monthly updates

• Martindale: The Complete Drug Reference• Quarterly updates

• Stockley’s Drug Interactions• Quarterly updates

Sorted by class

Sorted by therapeutic use or

alphabetically

Sorted by class or alphabetically

Other ebooks• STAT!Ref platform has changed (May 2013)• ACP Medicine (American College of Physicians)

• Various medical topics• Red Book: Report of Committee on Infectious

Diseases (Pediatric Resource)• Vaccine information; care of children in special

circumstances• Summary of Infectious Diseases

Natural Standard• Covers herbal medications• International research collaboration• Has evidence grades• Peer-reviewed• References included• Updated daily

E-therapeutics• Therapeutic Choices• e-CPS

• Clin Info• Clinical monitoring tools• Drug interactions with food• Drug use guides (dentistry, pregnancy, lactation)• Info on latex and nonmedicinal ingredients

• Drug Interactions (Lexi-Interact)

Don’t forget print!

Mobile apps• Available for smart phones and tablets• Micromedex (PHSA has this)

• Differs from online 2.0 version. DI is free.• Dosing, MOA, available strengths, kinetics, IV compatibility, toxicology

• Lexicomp (LMPS – not sure about others)• Same info as online product. Not free.• Drugs, infectious diseases, patient education information• Interactions, iv compatibility, toxicology

• Medscape • Same as online version. Both are free.• Drug monographs (not detailed), drug interaction checker, medical conditions,

procedures• News – can subscribe to daily news

Limitations• Lag time

• Check frequency of editions, updates, most recent references cited

• Incomplete information• Consider depth and scope

• Authorship• Qualifications and expertise

Clinical Practice Guidelines• British Columbia- guidelines from MOH and BCMA

• www.bcguidelines.ca• Can download all or access via computer or mobile device

(iPod/iPhone app no longer being supported)• Provides guidelines via topics as well as patient information

guides, flow sheets and summaries

• “GPAC has engaged practicing physicians in B.C. - including general practitioners and specialists - to evaluate clinical evidence, and publish clinical practice guidelines on numerous conditions, with particular focus on circumstances in British Columbia.”

Clinical Practice Guidelines• CMA Infobase: Clinical Practice Guidelines

• http://www.cma.ca/cpgs• Canadian Medical Association• 1200 publicly accessible evidence based CPG developed by

medical or health organizations in Canada• Developers are national or provincial agencies

• Can search by conditions, specialties

Clinical Practice Guidelines• National Guidelines Clearinghouse

• http://www.guideline.gov• US based• TOPIC: disease/condition; treatment/intervention; health services

administration• Organization• May be useful when local or national guidelines are not available

• NICE Guidance (National Institute for Health and Clinical Excellence)• http://www.nice.org.uk/guidance/index.jsp?action=find• NICE Pathways (http://pathways.nice.org.uk)

• Interactive. Brings all related NICE products on a topic in a single interface

Clinical Practice Guidelines• SIGN (Scottish Intercollegiate Guidelines Network)

• http://www.sign.ac.uk• Search by topic or assigned guideline number• Easy to see if current, out of date or withdrawn• Levels of evidence provided• Apps available for smart phones; iPad

• TRIP Database (Turning Evidence into Practice)• http://www.tripdatabase.com• Clinical search engine to find high-quality research evidence to

support practice• Meta database – combs through all guidelines• Guidelines from around the world• PICO search; Advanced search

Point of Care Tools

Point of Care Tools

(Subcription needed for full access)

(free but need login)

In UBC Library

In UBC Library

In UBC Library

• From BMJ• Subscription based• App is $49.99 (Clinical Evidence Unbound)• 2000 treatments for over 200 medical conditions

“Clinical Evidence comprises an international database of high-quality, rigorously developed systematic overviews assessing the benefits and harms of treatments, and a suite of EBM resources and training materials.”

• Clinical reference database with more than 3100 evidence based clinical summaries update daily

• App for smart phones, tablets

• AKA Medscape• http://emedicine.medscape.com• Free but need to register

• “Medscape from WebMD offers specialists, primary care physicians, and other health professionals the Web's most robust and integrated medical information and educational tools. After a simple, 1-time, free registration, Medscape from WebMD automatically delivers to you a personalized specialty site that best fits your registration profile.”

• Access via UBC Library• “Evidence is summarized where possible from systematic reviews

of primary research. The main source of evidence has been from the Cochrane Collaboration, which provides highly structured systematic reviews, with evidence included or excluded based on explicit quality-related criteria, and often using meta-analyses to increase the power of the findings of numerous studies.”

• “In the absence of such aggregated trial data, where appropriate, there may be inclusion of individual research papers retrieved from Medline and Embase in order to identify the highest quality evidence for specific medical therapies in situations where it might be relevant to point-of-care decisions.”

• www.uptodate.com• Subscription required• Free area (but need to register: www.freeuptodate.com)

• “The knowledge contained in UpToDate is evidence-based and continuously updated, but it is not merely an aggregation and report of the latest research; UpToDate presents a comprehensive synthesis of the evidence, followed by recommendations that can be acted on at the point of care.”

Point-of-Care toolsKetchum AM, et al. Type of evidence behind point-of-care clinical information products: a bibliometric analysis. J Med Internet Res. 2011; 13(1):e21.

“… summary products, such as POC products, vary in content as determined by differences in literature cited for the same topics in different products, quality regarding types of evidence cited, and currency. There are no standards for guidance on developing content for these products. Users should be aware of this and judiciously appraise POC product information content when using resources to obtain information for applying evidence-based practice principles.”

Clinical trial registriesWhy?•Need to consider all the available evidence in decision making•Publication bias and selective reporting are barriers•Avoid unnecessary duplication of studies and identify gaps in research•Increase awareness of ongoing research

– Facilitate recruitment and collaboration

•Data checking as part of the registration process may improve quality

WHO International Clinical Trials Registry Platform (ICTRP)http://www.who.int/ictrp/trial_reg/en/index.html

Clinical trials registriesPrimary registries

Meta registries

*

Clinical trials registriesWHO 20-item minimum data set

Some registries offer more information and bonus features, e.g. links to publications, added annotations; pediatric, geographical and active/complete/resulted filters; international language searching

Clinical trials registriesLimitations• Less than ½ of trials registered at ClinicalTrials.gov are published in peer-reviewed journals within 30 months of completion. Median time to publication for those trials that were published: 23 months. ~1/3 of registered trials remain unpublished after median of 51 months after completion.

• Despite guidelines, details on therapy and info on outcomes sometimes or often missing.

•Other examples…Viability of some registries… e.g. Current Controlled Trials

Ross JS et al. BMJ. 2012; 344:d7292. Viergever & Ghersi. PLoS ONE. 2011; 6(2): e14701. doi:10.1371/journal.pone.0014701

International Pharmaceutical Abstracts (IPA)

• Who: Thomson Scientific and American Society of Health-System Pharmacists

• What: 300,000+ records from around the world incl. all 50 State pharmacy journals

• Why: Pharmacy practice and admin, compounding and stability, herbal and alternative therapy; conference coverage

• Where: OvidSP• How: keyword searching

Grey literature• Adverse drug reactions/pharmacovigilance

• National pharmacovigilance programs• search Reactions Weekly (via IngentaConnect)

• Health Technology Assessments• CADTH, FDA, EMA, UK

• Scientific discussion papers – insider look at unpublished data made available to regulators

For more information: http://hlwiki.slais.ubc.ca/index.php/Grey_literature