Drug & Disease Updates
Alert Fatigue
Clinical Question of the Month

Picture Quiz: Eye Findings & Heart Disease

FDA MedWatch Alerts
Flu FAQ: CDC 2011-12 Influenza Immunization Recommendations
Epocrates EssentialPoints Activities Now Available for Android Users
Epocrates Now Supports BlackBerry OS 7
DocAlert: Editor's Pick
Epocrates Introduces iPhone Mobile App for EHR
App Overload!
What's This Disease?

A mentor wiser than me once said, "unless your work is about technology, the technology should be invisible", snapping into perspective the idea that digital means are used to enhance and facilitate natural human behavior. In wake of a rampantly digitizing culture where we are richly assaulted with information, how do we gain our bearings?

This issue brings you the release of the iPhone mobile app for Epocrates EHR, designed for seamless integration into your daily workflow in solo and small practices. Read on to learn about delayed-release vs. extended-release products, Dr. Anne Meneghetti’s first clinical alert received from a dot matrix printer, how "eye findings" relate to heart disease, and more.

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Clinical Editorial

Alert Fatigue
Anne Meneghetti, MD
Director, Clinical Communications, Epocrates

After a grueling night on call as a resident, shortly after the sun rose I trudged like a zombie into the hospital staff lounge. Inside my mail slot was a single letter. The enclosed page had obviously rolled off a dot-matrix printer. "Dear Dr. Meneghetti," it began. The anonymous writer went on to inform me that I had prescribed the drug furosemide for "Mr. Smith", a near-octogenarian recently hospitalized for florid CHF. "Furosemide is a diuretic. Mr. Smith has a diagnosis of dehydration. Diuretics are contraindicated in patients with dehydration, Dr. Meneghetti." The letter urged me to promptly address this potentially dangerous situation. In the cartoon version of this scene, steam would be coming out of my ears, and the following thought bubble would appear above my head:
How dare they insinuate that I would diurese a volume-depleted patient? How dare they dredge up some ancient transient diagnosis and use it in a current drug-condition alert? How dare they use the postal service to deliver what they believed to be an urgent medical communication?

I had just received my first clinical alert.

If I had had more molecules of ATP circulating in my body at the time, I might have had the energy to track down the source of this alert and express my dismay; however, my desire for sleep won out. I wadded the letter into tiny ball and tossed it into the nearest receptacle.

There are many well-meaning individuals in the world who want to improve patient care by alerting us. The advent of EHRs has created new opportunities for preventing medical errors through drug-drug, drug-allergy, and drug-condition checking. I wholeheartedly welcome these advancements. However, when alerts are inaccurate, out of context, or irrelevant, they unnecessarily gum-up the flow of clinical practice. Worse still, there is some evidence that intrusive hard-stop alerts may unintentionally lead to delays in therapy.1

Most alerts are overridden. A study2 done some years ago reported that physicians override 49% to 96% of drug safety alerts. Clinicians may become so accustomed to dismissing irrelevant alerts, that they might not pay adequate attention to the rare life-saving ones. Much like a game of Whac-a-Mole®, repeatedly dismissing irrelevant alerts might improve my hand-eye coordination, but it does little to improve patient care. To avoid alert fatigue, find yourself an EHR that prioritizes alerts, allows you to decide which alerts can actually stop you in your tracks, and remembers your previous choices for a given patient. Look for systems that direct different types of alerts to the appropriate members of your team. A good EHR should know the difference between drug reactions like "erythromycin -> slight nausea" and "penicillin -> anaphylactic shock". Clinicians are human, and technology can offer valuable decision support. I believe that intelligently designed EHR alert systems with a high signal-to-noise ratio can help make patient care safer.

We welcome your insights on the value of clinical alerts; email us with your perspective.

1 Unintended effects of a computerized physician order entry nearly hard-stop alert to prevent a drug interaction. Arch Intern Med. 2010 Sep 27;170(17):1578-83.

2 Overriding of Drug Safety Alerts in Computerized Physician Order Entry. Am Med Inform Assoc. 2006 Mar-Apr; 13(2): 138–147.

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Drug and Disease
Viral gastroenteritis in adults
Seborrheic dermatitis
Evaluation of peripheral edema
Vitamin B3 deficiency
Essential tremor
Evaluation of dyspepsia
Evaluation of anemia
drug updates
Cheratussin AC
(first-time generic for Cosmegen)
estrogens, esterified/ methyltestosterone
(generic for Estratest)
(chlorhexidine/isopropyl alcohol topical)
Iophen C-NR
Lupron Depot-Ped 3 Month
(sodium nitrite/sodium thiosulfate)
Nucynta ER
(butalbital/acetaminophen/ caffeine)
Robitussin Night Time Cough, Cold & Flu (New Formulation)
(acetaminophen/ diphenhydramine/ phenylephrine)
Robitussin Peak Cold Nasal Relief
Robitussin Peak Cold Nighttime Multi-Symptom Cold
(acetaminophen/ diphenhydramine/ phenylephrine)
Robitussin Peak Cold Nighttime Nasal Relief
(acetaminophen/ chlorpheniramine/ phenylephrine)
Sucrets Sore Throat Original Formula
(hexylresorcinol oropharyngeal)
(acetaminophen/caffeine/ dihydrocodeine)
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Joshua L. Conrad, Pharm.D.
Managing Editor, Medical Information, Epocrates

Q: I have started seeing the abbreviation "DR" in the drug monographs.  What does that stand for?

A: Recently, Epocrates' medical editors completed a project to identify delayed-release products, which we have designated as "DR", in our drug database. Delayed-release (also commonly called "enteric-coated") products release their active ingredients at a time other than promptly after administration, typically after the tablet or capsule has passed beyond the stomach and into the duodenum. Epocrates also identifies extended-release (also commonly called "sustained-release" or "controlled-release") products with the abbreviation "ER".

Delayed-release (DR) products differ from extended-release (ER) products in that DR products are designed to release their active ingredients relatively quickly after a specific period of time or above a set pH, while ER products are designed to release a steady amount of their active ingredients over a longer period of time. The DR mechanism is most commonly used either to protect the gastric mucosa from a product's ingredients (e.g., as with "enteric-coated" aspirin) or to protect the product's ingredients from the gastric pH (e.g., as with pancrelipase products). In contrast, the ER mechanism is most commonly employed to provide a more sustained, steady, and predictable drug action and to prolong the required dosing interval (e.g., as with ER opioid products).

For more information on other Epocrates abbreviations, access the Help feature on your version of Epocrates for mobile devices or online.

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Picture Quiz: Eye Findings & Heart Disease
Anne Meneghetti, MD

Which of these eye findings is associated with cardiovascular disease?

Read the DocAlert Editor’s Pick for the answer.

Image Credits: Epocrates Disease Reference

FDA Medwatch Safety Alerts

Prescription drugs:  Drospirenone: FDA has not yet reached a conclusion, but remains concerned about potential increased risk of blood clots with the use of drospirenone-containing birth control pills. Celexa (citalopram hydrobromide): The antidepressant Celexa should no longer be used at doses >40 mg/day, because it can cause abnormalities in cardiac electrical activity; those with hypokalemia or hypomagnesemia are at particular risk. Saphris (asenapine maleate): Serious allergic reactions include anaphylaxis, angioedema, hypotension, and other features. Zofran (ondansetron): The drug may increase the risk of developing prolongation of the QT interval, leading to potentially fatal heart rhythms. Reclast (zoledronic acid): Reclast is contraindicated in patients with creatinine clearance <35 mL/min or in patients with evidence of acute renal impairment; screen patients prior to administering the drug. Tumor Necrosis Factor-alpha (TNFα) Blockers: Legionella and Listeria infection risks were added to the warnings for this drug class, including Remicade (infliximab), Enbrel (etanercept), Humira (adalimumab), Cimzia (certolizumab pegol), and Simponi (golimumab). Qualitest Pharmaceuticals Oral Contraceptives: A packaging error may result in an incorrect daily regimen.

Medical devices: Medtronic SynchroMed II Implantable Infusion Pump: Potential for reduced battery performance; ShoulderFlex Massager, King International: Risk of strangulation; H & P Industries Povidone Iodine Swabsticks, Prep Solutions, Scrub Solutions, Prep Gel: Inadequate microbial testing; H & P Industries Povidone Iodine Prep Pads: Potential microbial contamination


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Flu FAQ: CDC 2011-12 Influenza Immunization Recommendations

Q: If the virus strains in the vaccine are the same as last season, why vaccinatepatients this year too?
A:  Protection wanes over time. Vaccinate everyone ≥6 months old each year.

Q: Do children 6 mo - 8 yo still need 2 doses?
A:  If they received 1 or more doses of 2010-11 vaccine, then only 1 dose is needed this season; otherwise they need 2 doses of 2011-12 vaccine.

Q: When should I start and stop vaccinating?
A:  Begin vaccinating as soon as vaccine is available and continue vaccinating through the remainder of the flu season (which can last as late as May).

Q: Are newer types of flu vaccines preferred?
A:  CDC and ACIP do not have a preferential recommendation for any particular flu vaccine. Consult the ACIP influenza vaccine statement and its updates for details on specific vaccines.

Q: Is egg allergy a contraindication for influenza vaccination?
A:  If egg allergy is limited to hives, patients should receive TIV (not FluMist) from clinicians familiar with allergy reaction management, if patients can be observed for 30 min after each dose.

Source:  CDC.gov/flu

Influenza vaccines in Epocrates Rx

Afluria, Agriflu, Fluarix, FluLaval, FluMist, Fluvirin, Fluzone, Fluzone High-Dose, Fluzone Intradermal

Epocrates EssentialPoints Activities Now Available for Android Users

Clinical Product Details, Made More Convenient.
EssentialPoints Mobile Detail Programs provide timely, self-guided clinical learning opportunities for busy healthcare professionals. Many offer complimentary access to the Epocrates Essentials clinical reference suite for completion. View a complete list of activities by tapping on "EssentialPoints" in the "Tools" section of the application. Go to the Android Marketplace and update the Epocrates application to see the EssentialPoints activities.

Epocrates Now Supports BlackBerry OS 7
A new version of Epocrates for BlackBerry, which includes bug fixes to calculators and log in functionality, is now available for download. For update instructions, view our FAQ article or visit get.epocrates.com

DocAlert: Editor's Pick
Monique Yohanan, MD, MPH
Physician Editor, Epocrates

BMJ 2011; 343:d5497 doi: 10.1136/bmj.d5497

Xanthelasmata, arcus corneae, and ischaemic vascular disease and death in general population: prospective cohort study

Christoffersen M, et al.

Link to free full-text PDF

Design Prospective population based cohort study.

Participants 12,745 people aged 20-93 years free of ischaemic vascular disease at baseline and followed from 1976-8 until May 2009 with 100% complete follow-up.

Conclusion Xanthelasmata predict risk of myocardial infarction, ischaemic heart disease, severe atherosclerosis, and death in the general population, independently of well known cardiovascular risk factors, including plasma cholesterol and triglyceride concentrations. In contrast, arcus corneae is not an important independent predictor of risk.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

© 2011 BMJ Publishing Group Ltd.


Epocrates Introduces iPhone Mobile App for EHR

Our new Epocrates EHR iPhone mobile app quickly and easily integrates into the daily workflow of the prescribing Epocrates EHR user. At any time, from anywhere, it provides the ability to access and view a patient’s chart, view appointments, write prescriptions, and more.

Visit our Website to learn about the many ways Epocrates EHR can put the power in your hands.


What's New with Epocrates

App Overload!

With thousands of professional medical apps, it can be tough to find the ones you want in an app store. 45% of U.S. healthcare professionals with smartphones have downloaded 50 or more apps!

Relief from App Overload is coming soon by way of a smart new design for Epocrates on iOS, featuring an App Directory. Learn more



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