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CDP 09-388 – HSR&D Study

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CDP 09-388
Preventing Long-term Adverse Drug Reactions: Glucocorticoids as a Model (CDA 07-221)
Liron Caplan MD PhD
Rocky Mountain Regional VA Medical Center, Aurora, CO
Aurora, CO
Funding Period: September 2009 - September 2012

BACKGROUND/RATIONALE:
Adverse Drug Reactions (ADRs) represent a high-risk and high-volume problem. Understanding and improving preventive measures for drugs with cumulative toxicities would provide a model for avoiding numerous adverse drug reactions of long latency (ADRLL). Glucocorticoids are a classic example of medications that exhibit ADRLLs, insofar as prolonged exposure can result in glucocorticoid-induced osteoporosis (GIO) and glucocorticoid-induced diabetes (GID).

OBJECTIVE(S):
The objectives of this study were to examine the current processes providers, pharmacists, and nurses use to avoid ADRLLs, and to explore barriers/facilitators to ADRLLs avoidance, in order to develop an intervention to prevent ADRLLs.

METHODS:
This qualitative study utilized open-ended, in-depth interviews with 14 medical care providers, pharmacists, and nurses who treat patients susceptible to ADRLLs. Participants were recruited via an e-mail announcement to the Denver VAMC staff and word of mouth. Using glucocorticoid-induced osteoporosis as an example ADRLL, the interviews were recorded and transcribed. Data were analyzed utilizing a team-based, constant comparative method of inductive analysis with Atlas.ti software.

FINDINGS/RESULTS:
Study participants verified there was no standard existing method to track ADRLLs systematically. They identified several barriers and some facilitators to tracking potential ADRLLs. 1) Staff equivocate regarding computer reminders/prompts; they appreciate the goal, but express concern that prompts are over-used and often ignored. 2) Staff remain extremely busy, seeing numerous patients with multiple comorbidities in a limited time. In this setting, tracking ADRLLs becomes secondary to treating veterans' primary health issues. 3) Patients often fail to appear for appointments and receive concurrent care at outside facilities, complicating care coordination. 4) Risk of ADRLLs is in tension with, and potentially subservient to, the immediate benefit of the prescribed medications (e.g. short-term pain relief). 5) Communication among VA providers, pharmacists, and nurses was generally characterized as strong.

IMPACT:
Posited interventions to reduce the risk of ADRLLs must be responsive to the VA culture and incorporate characteristics of unique ADRLLs. Because of computerized reminder fatigue, severe ADRLLs may require direct intervention by live personnel (e.g., a pharmacist). For uncertain ADRLLs and those with lower risk, interviewees advocated for simple, accurate, and useful reminders, which may incorporate the duration of medication exposures and automatic calculation of cumulative dosage. Strong channels of communication among multi-disciplinary providers might be leveraged to better track and prevent ADRLLs.

PUBLICATIONS:

Journal Articles

  1. Song M, Hu Q, Wang Y, Liu L, Zhao J, Wang Q, Caplan LR. Susceptibility Vessel Sign in Isolated Brainstem Infarction with Large Artery Occlusion. European neurology. 2016 May 13; 75(5-6):251-256.
  2. Amarenco P, Lavallée PC, Labreuche J, Albers GW, Bornstein NM, Canhão P, Caplan LR, Donnan GA, Ferro JM, Hennerici MG, Molina C, Rothwell PM, Sissani L, Školoudík D, Steg PG, Touboul PJ, Uchiyama S, Vicaut É, Wong LK, TIAregistry.org Investigators. One-Year Risk of Stroke after Transient Ischemic Attack or Minor Stroke. The New England journal of medicine. 2016 Apr 21; 374(16):1533-42.
  3. Davis LA, Polk B, Mann A, Wolff RK, Kerr GS, Reimold AM, Cannon GW, Mikuls TR, Caplan L. Folic acid pathway single nucleotide polymorphisms associated with methotrexate significant adverse events in United States veterans with rheumatoid arthritis. Clinical and Experimental Rheumatology. 2014 May 1; 32(3):324-32.
  4. Hirsh JM, Davis LA, Quinzanos I, Keniston A, Caplan L. Health literacy predicts discrepancies between traditional written patient assessments and verbally administered assessments in rheumatoid arthritis. The Journal of rheumatology. 2014 Feb 1; 41(2):256-64.
  5. Caplan L, Hines AE, Williams E, Prochazka AV, Saag KG, Cunningham F, Hutt E. An observational study of glucocorticoid-induced osteoporosis prophylaxis in a national cohort of male veterans with rheumatoid arthritis. Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 2011 Jan 1; 22(1):305-15.
Conference Presentations

  1. Caplan L, Hutt EA, Hines A, Prochazka AV, Haverhals LM, Williams ET. An observational study of glucocorticoid induced osteoporosis prophylaxis in a national cohort of male Veterans with rheumatoid arthritis. Poster session presented at: VA HSR&D Career Development Annual Meeting; 2010 Feb 25; San Francisco, CA.


DRA: Health Systems, Diabetes and Related Disorders, Musculoskeletal Disorders
DRE: Prevention, Treatment - Efficacy/Effectiveness Clinical Trial
Keywords: Career Development
MeSH Terms: none

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