TABLE 1.
DDI Alert Refinements by the AAG During February 2015–February 2017
| Category | Frequency, % | Override Rate, % | Refinement Date | Alert Refinement Strategy | AAG Clinical Rationale for Alert Refinement |
|---|---|---|---|---|---|
| Potassium and potassium-sparing diuretics | 9.2 | 95.9 | December 14, 2015 | Alert only when previous potassium level was >4.8 mEq/L or when no potassium level has been obtained in 7 d. | Serum potassium monitored routinely. Risk of unnoticed hyperkalemia present when patient is not monitored or has high serum potassium at initiation. |
| Potassium ACEI and/or ARB | 6.7 | 95.8 | December 14, 2015 | Alert only when previous potassium level was >4.8 mEq/L or when no potassium level has been obtained in 7 d. | Serum potassium monitored routinely. Risk of unnoticed hyperkalemia present when patient is not monitored or has high serum potassium at initiation. |
| Posaconazole and H2 receptor blocker or PPI | 4.1 | 95.0 | December 14, 2015 | Alert only fires when posaconazole solution is ordered. | Absorption affected by gastric pH only for oral solution dosage form of posaconazole. |
| Potassium and anticholinergics | 2.2 | 94.4 | December 14, 2015 | Alert only fires when anticholinergic is ordered with extended-release potassium. | Risk of gastric damage due to delayed gastric emptying of anticholinergics only for extended-release dosage forms of potassium. |
| Fluoroquinolones and steroids | 1.2 | 95.9 | December 14, 2015 | Suppress | This extended a previous suppression of an individual DDI alert before the AAG formation to the class-class level. |
| Iohexol (intrathecal only) and lidocaine | 1.1 | 90.8 | December 14, 2015 | Suppress (suppression of all Iohexol intrathecal DDI alert interactions that occurred in July 2016) | Iohexol is not administered via the intrathecal route in our patient population. |
| Methotrexate and P-glycoprotein inhibitors | 0.7 | 98.3 | December 14, 2015 | Suppress | Methotrexate doses are monitored and adjusted via pharmacokinetic monitoring. |
| Diuretics and aminoglycosides | 0.7 | 92.9 | December 14, 2015 | Suppress | Benefits of both medications outweigh risk of ototoxicity and nephrotoxicity. Patients are evaluated for both toxicity risks during evaluation before ordering. |
| NSAID and NSAID | 3.4 | 90.1 | March 9, 2016 | Alert only fires for 2 inpatient NSAID orders. | Alert fired inappropriately for outpatient NSAID orders with inpatient ones. Alert only relevant when 2 active inpatient NSAID orders are present. |
| CNS depressant and CNS depressant | 0.5 | 89.0 | March 9, 2016 | Suppress | Potential increased risk of CNS depression monitored closely in our patient population. |
| Methotrexate and PPI | 3.6 | 90.3 | August 26, 2016 | Alert only fires with high-dose methotrexate (doses >300 mg/m2). | Elimination of methotrexate at high doses is impaired by PPIs. |
| 5HT3 antagonist and serotonin modulator | 6.3 | 95.3 | September 12, 2016 | Suppress | Majority of patient population receives serotonin antagonist. Low risk of serotonin syndrome that will be detected from inpatient and frequent outpatient clinic monitoring. |
| Midazolam and CYP3A4 inhibitor | 1.6 | 94.4 | September 12, 2016 | Suppress on the basis of analysis of all CYP3A4 substrates and inhibitor interactions. | CYP3A4 inhibition clinically insignificant for this medication for our patient population. |
| Fentanyl and CYP3A4 inhibitor | 0.4 | 97.8 | September 12, 2016 | Suppress on the basis of analysis of all CYP3A4 substrates and inhibitor interactions. | CYP3A4 inhibition clinically insignificant for this medication for our patient population. |
| Methadone and CYP3A4 inhibitor | 0.3 | 94.3 | September 12, 2016 | Suppress on the basis of analysis of all CYP3A4 substrates and inhibitor interactions. | CYP3A4 inhibition clinically insignificant for this medication for our patient population. |
| Oxycodone and CYP3A4 inhibitor | 0.3 | 92.5 | September 12, 2016 | Suppress on the basis of analysis of all CYP3A4 substrates and inhibitor interactions. | CYP3A4 inhibition clinically insignificant for this medication for our patient population. |
| Citalopram and CYP3A4 inhibitor | 0.1 | 98.6 | September 12, 2016 | Suppress on the basis of analysis of all CYP3A4 substrates and inhibitor interactions. | CYP3A4 inhibition clinically insignificant for this medication for our patient population. |
| Salmeterol and CYP3A4 inhibitor | 0.1 | 97.3 | September 12, 2016 | Suppress on the basis of analysis of all CYP3A4 substrates and inhibitor interactions. | CYP3A4 inhibition clinically insignificant for this medication for our patient population. |
| Escitalopram and CYP3A4 inhibitor | 0.1 | 95.4 | September 12, 2016 | Suppress on the basis of analysis of all CYP3A4 substrates and inhibitor interactions. | CYP3A4 inhibition clinically insignificant for this medication for our patient population. |
| Itraconazole and CYP3A4 inhibitor | 0.1 | 95.9 | September 12, 2016 | Suppress on the basis of analysis of all CYP3A4 substrates and inhibitor interactions. | CYP3A4 inhibition clinically insignificant for this medication for our patient population. |
| Oxycodone and CYP3A4 inhibitor | 0.1 | 91.4 | September 12, 2016 | Suppress on the basis of analysis of all CYP3A4 substrates and inhibitor interactions. | CYP3A4 inhibition clinically insignificant for this medication for our patient population. |
| Fluticasone and CYP3A4 inhibitor | 0.1 | 94.8 | September 12, 2016 | Suppress on the basis of analysis of all CYP3A4 substrates and inhibitor interactions. | CYP3A4 inhibition clinically insignificant for this medication for our patient population. |
| Olanzapine and benzodiazepines | 1.5 | 96 | November 21, 2016 | Suppress | DDI occurs only with intramuscular formulations of both drugs. Olanzapine is not orderable via intramuscular route at our institution. |
| Deferasirox and NSAIDs | 1.3 | 97 | November 21, 2016 | Suppress for all NSAIDs (previously on suppressed for ibuprofen). | This extended a previous suppression of an individual DDI alert before the AAG formation to the class-class level. |
| Tacrolimus and spironolactone | 1 | 97 | November 21, 2016 | Alert only when previous potassium level was >4.8 mEq/L or when no potassium level has been obtained in 7 d. | Serum potassium monitored routinely. Risk of unnoticed hyperkalemia present when patient is not monitored or has high serum potassium at initiation. |
None of the refinements above were detailed as DDIs that should always be active in pediatric EHRs.20 ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin II receptor blocker; CNS, central nervous system; CYP3A4, cytochrome P450 3A4; PPI, proton pump inhibitor.