DUR lecture

Question 1

Authorized, structured, ongoing review of physician prescribing,pharmacist dispensing, and patient use of medication

Comprehensive quality improvement measure
Ensures prescribed drugs are appropriate, medically necessary,and not likely to result in medication-related problems

Reviewed against predetermined criteria

May result in therapy modification

Answer 1

DUR (Drug Utilization Review)

Question 2

DUR is the same as:
▪ DUE: Drug Utilization Evaluation
▪ MUE: Medication Utilization Evaluation

Question 3

Prospective DURs:
Drug-disease contraindications

Drug-drug interactions

Drug-patient precautions

Drug dosage modification

Inappropriate duration

Clinical abuse/misuse

Question 4

______________ involve evaluating a patient’s plan drug therapy before medication is dispensed we are doing it before the patient gets anything so this process allows us as pharmacists to identify and resolve issues before the patient actually receives the medication. We can catch things before they even reach our patients…looking at med dosage, drug drug interactions, duplicate therapy. These occur when a new drug is going to be brought on board, look at pt’s disease states, chronic disease before new drug comes about, any drug that pt is already on before the new drug comes about what patient factors might be specific and important for our patient that’s getting a new drug…does their age come into play, does their gender come into play, did they have allergies that would make it so that this new drug therapy would be inappropriate for them, are they pregnant, are they lactating all of this would fall under drug patient precautions

Look at past medical history in regards to how they have using certain medications (are they following an adherent schedule to their chronic disease state medications, are they being described a controlled medication and they are consistently early filling it every single month, these are all things we can look at ahead of time and pick things up and twick things ahead of time before the patient receives the medication

Answer 4

Prospective DURs

Question 5

_______________performed during the course of treatment, it involves ongoing monitoring of drug therapy, seen in the institutional setting where we as a pharmacist are able to alert prescribers to potential problems and intervene in drug drug interactions and duplicate therapies, over or under utilization, excessive or insufficient dosing, all occurring while patient is taking a medication

In institutional settings patients receive multiple medications and this periodic review of their records can detect actual or potential issues.

Patient in an institutional setting are getting regular labs done as well, so perhaps antibiotics that are based on lab values will be changed,stopped, or started based on laboratory findings

Answer 5

Concurrent DURs

Question 6

_____________occurs after patient has received the medication, (simplest DUR to perform since therapy has already been given); these are used a lot of times to detect patterns in past prescribing,dispensing, or administering drugs and use to prevent recurrence of inappropriate use,abuse, etc; can serve as a means for developing prospective standards and target interventions

Answer 6

Retrospective DURs

Question 7

Concurrent DURs
▪ Drug-drug interactions
▪ Drug-dosage modifications
▪ Drug-disease interactions
▪ Over and underutilization
▪ Drug-patient precautions
▪ Therapeutic interchange

Question 8

Retrospective DURs
▪ Therapeutic appropriateness and/or duplication
▪ Over and underutilization
▪ Appropriate generic use
▪ Clinical abuse/misuse
▪ Drug-disease contraindications
▪ Drug-drug interactions
▪ Incorrect drug dosage
▪ Inappropriate duration of treatment
▪ Use of formulary medications whenever appropriate

Question 9

Everything we do in DUR is based on predetermined criteria

2023 Update to the American Geriatrics Society (AGS) Beers® Criteria:Potentially Inappropriate Medication Use in Older Adults

Briggs Drugs in Pregnancy and Lactation

Drug databases:Micromedex,Lexidrug,UpToDate

Question 10

Drug Interactions

______________
Absorption
Distribution
Metabolism
Excretion

Answer 10

Pharmacokinetic

Question 11

________________
Additive effect

Antagonistic effect

Answer 11

Pharmacodynamic

Question 12

Severity Scale

Minor (Level 3) – _____________
Major (Level 2) – CONSIDER INTERVENTION
Severe (Level 1) – ________________

Document - if you don’t document, it did not happen!

Answer 12

be aware

requires intervention

Question 13

__________________: Constantly bombarded with popups you become to a point where your blind to them your not even noticing them anymore…taking a break…do a reset by walking away as well

Answer 13

Alert Fatigue

Question 14

You can directly improve the quality of care for patients by
striving to prevent the use of unnecessary or inappropriate drug
therapy, prevent adverse drug reactions, and improve overall
drug effectiveness.

Question 15

Drug-disease
Metformin/ESRD
Pseudoephedrine/Severe HTN
Non-selective beta-blocker/Asthma

Question 16

Drug-drug
Statins and Azole Antifungals

Drug-patient
Aricept® 40 mg for 38-year-old male
Ativan® 1 mg for 78-year-old female
Amoxicillin 500 mg in patient with allergy to penicillin

Drug-dosage
Nitrofurantoin (Macrobid/Macrodantin)
Weight-Based Dosing (ABW/IBW/Adjusted IBW)

Question 17

Examples
Inappropriate duration
Standard antibiotic therapy
Chronic medication therapy

Clinical abuse/misuse
Early fills
Adherence

Drug-food/alcohol/tobacco/herb
Statins and grapefruit juice

Question 18

As a pharmacist we never guess, it says Zithromax and the directions are take 2 tablets twice a day and then 1 tablet daily for the next 4 days could mean….but as a pharmacist its not our job to guess…we as pharmacists have to ask
Keep patient safe is important

Question 19

In a retrospective DUR, a pt’s medical chart or computerized records maybe screened to determine whether the drug therapy might have approved criteria, and it can aid providers in providing care for their patients so for an example say an analysis was done of member prescription utilization in order to identify a group of patients whose therapy didn’t meet approved guidelines so you could use a retrospective review of a group of patients with asthma according to their medical and pharmacy history should be using orally inhaled steroids but according to the information we have they weren’t getting that…they weren’t getting therapy according to guidelines…we can help and make change

Question 20

There is very similar points here we can still do drug drug interactions, we can do incorrect drug dosage but again its all after the patient has received the medication

Question 21

Everything we do in DUR is based on predetermined criteria

Question 22

Resources used are called for BEERs criteria:Medication classes that are recommended to be avoided in our older adult population and there are also medication classes that should be used with caution or avoided in certain pts with certain diseases or conditions…its important that we look at our older individuals because they are most vulnerable population in that they process drugs differently than others in different age categories

Question 23

A drug might end up on the Beers criteria if they increase the risk of negative side effects, more harmful in older pts because they are processing medications differently

Briggs Drugs in Pregnancy and Lactation-when pt is pregnant or lactating..could be more of a risk to unborn child or newborn infant

Question 24

With the ____________ interaction one drug effects the others ADME

Answer 24

pharmacokinetic

Question 25

________________two drugs have a additive effect or antagonist effect.

Answer 25

Pharmacodynamic

Question 26

With the ___________ interaction one drug effects the others ADME

Answer 26

pharmacokinetic

Question 27

___________interaction is a pt is taking ciprofloxacin for an acute infection and they are on olanzapine for chronic treatment of their schizophrenia. Two drugs together causes a ____________interaction in that the ciprofloxacin blocks the enzyme that breaks down olanzapine because that enzyme is blocked that means that there are high blood levels of olanzapine that occur when in turn may cause muscle spasm and predispose the patient to falls that would be especially concerning in an individual that is of an older age and are already at a risk for falls

Answer 27

pharmacokinetic

pharmacokinetic

Question 28

A __________________ interaction is if a patient is taking aspirin for instance which is a salicylate and are using it for cardio protection on a regular basis and say they add ibuprofen which is a NSAID used for pain on top of that. The NSAID may enhance the adverse effect of the salicylate meaning they both have that risk of bleeding and now that risk has been increased by taking the two together so an additive effect

Answer 28

pharmacodynamic

Question 29

Minor-ex:patient is on digoxin and now they are getting a prescription for Lasix…many pts with heart failure would be on digoxin and Lasix and in resources it will just say to monitor therapy

Question 30

Severe–>pt drinking alcohol while pt is on metronidazole and if they do that then there is what is called a disulfiram reaction that would occur from doing both and you could get flushing,headache.vomiting, sweating, tachycardia and feel absolutely beyond miserable….pharmacist has to make sure pt is not taking alcohol or alcohol in over the counter cough medicine

Question 31

Certain medications are weight based

There are certain medications based on certain weights

Statins with grapefruit juice…how much grapefruit juice for there to be an interaction and what would be the result…metronizadole and alcohol what does that look like…how many days before therapy and how many days after therapy cannot take alcohol
St john’s wort…fexofenadine, Allegra
Medications for schizophrenia and smoking tobacco so the specific would be the tobacco and medications for schizophrenia…what medications do they take for schizophrenia might have a potential interaction with tobacco

Question 32

Statins with grapefruit juice…how much grapefruit juice for there to be an interaction and what would be the result

Question 33

metronizadole and alcohol what does that look like…how many days before therapy and how many days after therapy cannot take alcohol

Question 34

St john’s wort…fexofenadine, Allegra