Organization and functioning of an adverse drug reaction clinic

An investigation into adverse drug reaction monitoring by United Kingdom hospital pharmacy departments

Prior to the nationwide introduction of the Committee on Safety of Medicines “yellow card” adverse drug reaction reporting for hospital pharmacists, a study was carried out to investigate the activities undertaken by hospital pharmacists in adverse drug reaction (ADR) reporting. A survey of 200 United Kingdom hospitals was conducted and 172 (86 per cent) questionnaires were returned. Local ADR reporting schemes were in operation in 26 (15.1 per cent) surveyed hospitals. The majority used locally designed cards to report ADRs. The most common reasons for the lack of a local ADR scheme (n=141) were staffing, the fact that a scheme had never been considered, time factors and the lack of perceived need to operate a scheme. Of these 141 departments, 80.1 per cent said they would consider implementing schemes in their hospital. With the inclusion of pharmacists in the CSM “yellow card” scheme, there is an incentive for them to become officially and further involved in the management and reporting of ADRs. Local ADR reporting schemes encourage pharmacovigilance and could allow pharmacists to take a leading role in this area of clinical practice.

Adverse drug reaction monitoring by United Kingdom hospital pharmacy departments: impact of the introduction of “yellow card” reporting for pharmacists

Objective

To assess the impact of the introduction of hospital pharmacist “yellow card” adverse drug reaction (ADR) reporting on the operation of local schemes.

Method

Prepiloted postal questionnaire sent to hospitals in 1998 following up a previous survey two years earlier.

Setting

Clinical services managers for 200 hospital pharmacies that had been randomly selected for the previous survey.

Key findings

One hundred and fifty usable questionnaires (75 per cent) were returned. Twenty-eight departments (18.9 per cent), compared with 26 departments (15.1 per cent) in 1996, operated ADR reporting schemes. Of a total of 440 local ADR reports made to participating departments, 70.0 per cent (312) were forwarded to the Committee on Safety of Medicines, a significantly higher percentage than the 14.9 per cent in the previous study (P=0.001). Only eight hospitals (5.4 per cent) had schemes for monitoring newly marketed or “black triangle” drugs. Ninety-four departments (62.3 per cent) had supported education and training activities. Of the hospitals without a scheme, 15 (12.5 per cent) said they had definite plans to introduce one in their hospital, 40 (33.3 per cent) had probable plans to introduce one and 65 (54.2 per cent) had no such plans.

Conclusion

Pharmacists' involvement in the CSM yellow card scheme appears to have had little impact on local initiatives. In areas where these local schemes have been implemented and educational activities provided, drug information pharmacists appear to have a significant role. From the results of this study, even in hospitals with local or in-house schemes, gross under-reporting of ADRs remains a major problem.

Communication regarding adverse drug reactions between secondary and primary care: a postal questionnaire survey of general practitioners

GPs are not always informed that their patient suffered an adverse drug reaction (ADR) while in hospital. We have conducted a postal questionnaire survey of 270 GPs in order to elicit their views regarding provision of information from secondary care regarding ADRs. Of the 141 (52.2%) GPs that replied, 127 (90.1%) saw patients that had experienced an ADR in hospital. Of these GPs, 113 (89%) stated that they encountered instances where no record of the ADR existed in patients' discharge documentation. Where written information was absent, GPs are reliant on information given to them by patients. Of those responding, none were 'very confident' of this information, while 92 (78.6%) were 'uncertain' or 'very uncertain' of this information. A sample notification form was developed. GPs were generally satisfied with its content and 110 (82.7%) thought that patients should receive a copy. Almost all GPs (135 (97.8%)) felt that it would be appropriate to provide patients with ADR warning cards. Ensuring that patients and their carers are aware of drugs to which they may be allergic or intolerant through verbal and written methods should minimize the unnecessary risks of inadvertent re-exposure.

The spectrum of cutaneous reactions associated with diltiazem: three cases and a review of the literature

BACKGROUND

Cutaneous reactions ranging from exanthems to severe adverse events have been reported in association with calcium channel blockers.

OBJECTIVE

Our purpose was to document cutaneous eruptions resulting from use of diltiazem.

METHODS

We describe three patients who experienced a cutaneous reaction (i.e., hypersensitivity syndrome reaction, pruritic exanthematous eruption, and acute generalized exanthematous pustulosis) possibly induced by diltiazem, summarize adverse reaction reports obtained from the Health Protection Branch, and review the literature on calcium channel blockers inducing cutaneous reactions.

RESULTS

Of the 315 cases of possible diltiazem-induced adverse reactions that were reported to the Health Protection Branch, 151 (48%) were cutaneous. The number of diltiazem-induced cutaneous events was significantly greater than those induced by either nifedipine or verapamil. However, no difference was found in the proportion of serious cutaneous adverse events to either of the three drugs.

CONCLUSION

Diltiazem has been associated with a variety of cutaneous reactions that appear to occur more frequently than with other calcium channel blockers.

Knowledge of and attitudes about adverse drug reaction reporting among Rhode Island pharmacists

OBJECTIVE

To survey pharmacists' knowledge of the adverse drug reaction (ADR) reporting process, as well as the nature and seriousness of ADRs observed by pharmacists, and to determine how pharmacists perceive their role in monitoring and reporting suspected reactions.

DESIGN

A survey was mailed to 793 Rhode Island pharmacists with a 40% (318) response rate.

RESULTS

Two hundred and thirty-five surveys were reviewed for final analysis. Pharmacists in retail settings were more likely than hospital pharmacists to be aware of ADRs relating to therapeutic inequivalence and over-the-counter products, and more likely to ask the patient about ADRs (40% vs 16%). Hospital pharmacists were more likely to receive ADR information from physicians (40% vs 15%). Almost all pharmacists (97%) believed that action should be taken when a serious ADR is suspected. Younger pharmacists (< 45 y) were more willing to contact the physician and refer the patient to medical attention.

CONCLUSIONS

Our results show that fewer than half of the respondents (41%) claimed to have observed a serious ADR (potentially life-threatening or requiring hospitalization), although almost all (97%) believed that pharmacists should take some action when a serious ADR is suspected. The influence of the practice setting, the number of years in practice, and the number of hours worked per week influenced the reporting practices and attitudes.

Mechanisms of unpredictable adverse drug reactions

Adverse drug reactions are common problems associated with therapy, and are major sources of morbidity and mortality. There are numerous types of drug reactions, including predictable drug reactions such as side effects, toxicity, drug interactions and secondary effects that can be anticipated when planning therapy. There are also a number of unpredicted adverse effects, which are unexpected consequences of therapy. The least severe unpredicted adverse drug reaction is intolerance, which appears to be an exaggeration of pharmacological or toxic effects of the drug among vulnerable subsets of patients. Some of the most severe and life-threatening adverse drug reactions are allergic. These adverse effects can be mediated by a number of mechanisms, including the development of drug-specific IgE, serum-sickness-like reactions in response to drug-antibody complexes, direct release of inflammatory mediators, or involvement of the immune system by mechanisms that are poorly understood. Idiosyncratic adverse drug reactions are a heterogeneous group of adverse effects that are not predictable from the pharmacological actions of the drug. Many of these reactions occur as a consequence of pharmacogenetic variations in drug bioactivation and drug or metabolite detoxification or clearance. The physician must be vigilant for the possibility of unpredictable adverse drug reactions during or after therapy. Research currently underway may afford the opportunity to predict, and hopefully prevent, some of these adverse reactions in the future.