UpToDate Lexidrug User Academy: Clinical Modules

Click on “Trissel’s IV Compatibility” to open the module.

To search on compatibility information, begin by typing the desired drug or solution name into the appropriate search box. Possible drug/solution selections will be displayed as you continue to type. Select a drug or solution by clicking the Enter key on your keyboard or by using the Add button. The selected drug(s) and solution(s) will populate the Selected Items in the left pane. To view all solution and drug compatibility results for a single drug, enter the IV Drug and Click “View Compatibility”. To view compatibility results for a list of drugs, enter multiple IV drugs and/or solutions then click “Analyze”.

The compatibility results are presented in a chart or list view, with the default chart view displaying all methods within the fields for the selected drugs and solutions. In the chart display, each compatibility pair has an indicator for the type of result found. A green “C” means the drugs are compatible. A red “I” means the drugs are incompatible, and an orange “U” symbol means there are conflicting reports. In chart view, you can filter the table to display just the Y site results. Use the reset filter button to go back to the default view.

Definitions for the following types of compatibility testing are as follows:

• Y-site Compatibility - A single drug that is administered simultaneously at a Y-site connection with another drug in a solution
• Solution Compatibility - A single drug in a solution
• Admixture Compatibility - Two drugs in a solution
• Syringe Compatibility - Two drugs in a syringe

The compatibility information presented is based on one of four (4) ratings:

C - Compatible

• No change in visible or electronically determined particulates, haziness or turbidity, frank precipitation, color, or evolution of a gas.
• All drug components in the test samples were found to be chemically stable (less than 10% loss of intact drug) for at least 24 hours under the conditions being tested.
• All drug components in the test samples were found to be chemically stable (less than 10% loss of intact drug) for the entire period of the study under the conditions being tested, even if the study period was less than 24 hours.

I - Incompatible

• A change in visible or electronically (even if not visible) particulates, haziness, or turbidity, frank precipitation, color or gas evolution occurred
• One or more drug components in the test samples exhibited a loss of intact drug greater than 10% within 24 hours under the conditions being tested.

U - Uncertain or Variable

• For research results that do not fit these conventional guidelines, the research results are designated as Uncertain or Variable. Apply judgment in using these results. Examples include:
• A transient precipitation formed upon mixing but then disappeared. The precipitate may or may not show up again later.
• Among repeat test samples, microparticulate formation was electronically determined to have formed in some samples but not others.
• The test drug in a solution was stable in one container type but not another or with some drug delivery devices but not others.
• Compatibility of a drug(s) is dependent on the manufacturer(s) of the products and/or the use of specific product formulations.
• When both compatible and incompatible study results are available for the same drug pair. Many of these may be due to differences in concentrations of either drug or in the solution diluent.
• Any other research result that does not fit the conventional guidelines of compatibility or incompatibility.

X - No data

• No data for administration methods chosen.

In the chart display, find detailed information about a specific pair of drugs and administration route by clicking on the compatibility type link within the table. The link displays the drug concentrations used in the studies, additional information on the vehicle used, and each study’s findings. Drug pairs with conflicting compatibility results may often have different concentrations used or other differences to account for the variability. Return to the chart by clicking the “X” in the top left corner of the study list.

Compatibility analyses can also be viewed in a list display, where results are shown in pairs. You can click on the compatibility icons in the list view to see the same study list and details. You can return to the Chart display by toggling back to “Chart View”.

You can also check the IV compatibility of a single drug. Enter one drug and click “View compatibility.” The default compatibility result will display the solution compatibilities for the IV Drug searched.

You can also view different drugs and solutions that are compatible by clicking the drop-down arrows. View the full Trissel’s monograph for more information on the physical and chemical characteristics of the drug.

When a drug or solution name is in the Selected Items section, a link to the Trissel’s monograph for that drug/solution will be displayed. These monographs may include formulation or reconstitution information, stability and storage information, light effects, pH, and/or other details regarding the physical/chemical properties of the drug. You can either click on the X in the top right or press the Close button to return to the previous screen.

You can use the IV Drugs/Solutions search bars on the left at any time to enter new drugs to be screened. New items will appear in the “Selected Items” field. To remove an individual drug or solution, click on the X next to the name. To clear the items from the tool, click the Clear button.

The drug identification tool, powered by Medi-Span® data, is accessed via the blue toolbar at the top of the screen. Drug I.D. is an application that allows the identification of a variety of oral, topical, and injectable dosage forms. To begin, enter known product characteristics, such as imprint, dosage form, shape, and color. You may also search using drug name, manufacturer/labeler, or identifier (NDC).

When entering an imprint code, enter each discrete marking from the tablet as a separate imprint. For example, to identify a tablet with “M” on one side and “100” on the other side, enter “M” into the “Imprint Side 1” box, then enter “100” into the “Imprint Side 2” box.

When entering the dosage form, shape, and color, select from the drop-down menu of choices in each of the respective boxes.

It is not necessary to populate all of the product characteristics into each of the boxes to be able to execute a search; however, the more information that is inputted, the fewer the search results with drugs meeting that criteria.

Note: Multiple colors can be entered by returning to the drop-down menu and selecting additional colors.

Once the search criteria have been inputted, click the Search button to execute the search. The results will be displayed according to “Exact Match Results” (if any are found), followed by “Partial Match Results."

On the Search Results screen, additional information can be viewed for each of the products displayed by clicking anywhere on that product’s description. The additional information retrieved includes a larger image (when available), NDC, manufacturer, a written description of the imprint code, Rx/OTC classification, and a bioequivalency rating. Click “Search UpToDate Lexidrug” to perform a search on the generic drug name across Lexidrug. To return to the Search Results screen, click the “Search Results” tab.

The Interactions tool is accessed via the blue tool bar at the top of the screen. This drug and herbal interaction analysis tool is designed to identify potential drug-drug interactions, drug-allergy interactions, and duplicate therapy interactions. Begin by entering the list of medications and known drug allergies to be analyzed. The interactions tool allows users to enter medications (both prescription and over-the-counter), natural products, foods and/or alcohol.

Allergies may be entered by medication name (e.g., aspirin) or by the pharmacologic class (e.g., salicylates).

To enter an item, begin typing a keyword into the “Drugs” and/or “Allergies” box in the left pane. After you enter at least two (2) characters, suggested terms will populate, and you can select the desired term from the list. Continue this process until all items are added. To remove an item from the list, uncheck the selected box next to the product you wish to remove. Once the list is complete, click the Analyze button to perform an analysis. If you are looking to see all interactions for a single drug, click on Single Drug Analysis next to the name of any drug that has been added to the drug list. If only a single drug is entered, click View Interactions to see the list of all interactions for the single drug.

The Duplicate Drug Therapy feature is automatically checked to provide information about selected medications that are considered duplicate therapies because they belong to the same pharmacologic class. If you do not want the duplicate therapy screening to be performed, the box can be unchecked prior to selecting the Analyze button.

The Interaction Analysis screen provides a summary of interactions organized by drug-drug, drug-allergy, and duplicate therapy sections. The summary statements include the search terms used, along with the corresponding generic name(s), if applicable. An assigned risk rating (A, B, C, D or X) appears next to each drug-drug and drug-allergy interaction. Each letter represents a different level of urgency in responding to the identified interactions.

You can jump to a particular screening category or filter the interactions that are displayed on the Interaction Analysis screen by using the available drop- down menus. You may filter by drugs or allergies entered and/or by various risk ratings. To remove the filters selected, simply click the Reset Filters button to return to the full, unfiltered interaction analysis results. In addition to the risk rating scale, dependencies associated with a particular drug interaction will also be listed. The risk ratings and dependencies are defined in more detail below.

Dependencies and risk rating scale

Dependencies (if applicable): Identifies various factors that may influence the occurrence or severity of the interaction. The factors may involve patient-specific variables, such as organ dysfunction (e.g., renal/hepatic), smoking status, genotype (e.g., VKORC1 haplotype), or phenotype (e.g., CYP2D6 poor metabolizer). Additional factors may relate to specific pharmaceutical dosage forms, routes of administration and/or specific dosing regimens. The presence of one or more factors may result in an increased risk and/or severity of interaction, or conversely, disqualify an interaction. Highlighting this information at the top of the monograph helps the clinician evaluate the interaction relevance for a specific patient.

Risk Rating: Provides an indicator to help a clinician quickly decide how to respond to the interaction data. Each drug-drug interaction is assigned a risk rating of A, B, C, D, or X. The progression from A to X shows, as a general matter, an increasing urgency associated with the data. In general, A and B monographs are of more academic than clinical concern. Monographs rated C, D, or X indicate situations that will likely demand a clinician’s attention. The text of the “Patient Management” section of the monographs will provide assistance regarding responses that may be generally useful for many patients. Each drug-allergy interaction is assigned a risk rating of X. The definition of each risk rating is as follows:

Click on the interaction link to review the Interaction Monograph. This monograph will provide detailed information, including:

• Interacting members, class exceptions
• Patient management
• Fully referenced discussion of the available literature
• References (including PubMed links when appropriate)

Click on the hyperlinked allergy link to review the allergy monograph. This monograph will provide detailed information, including:

• Reactions reported as well as other relevant information for the clinician
• Fully referenced discussion of the available literature
• References (including PubMed links when appropriate)

To return to the Interaction Analysis summary page, click on the “Interaction Analysis” tab at the top of the content panel. To return to the initial search screen to enter an additional item, click on the “Drugs” tab at the top of the content panel.

The Clear button will clear all items from the list and allow the user to start a new regimen.

The Calculators tool is accessed via the blue tool bar at the top of the screen.

Upon opening the tool, you are presented with an alphabetical list of the available calculators in the left panel. Select the desired calculation by searching for keywords in the "Calculator Lookup" box or by scrolling through the list of calculators displayed. The "Browse Category" drop-down menu can be used to browse a specific subset of calculators. The available categories include Adult, Conversions, Dental, Emergency Drugs, General, Infusions, International (SI Units), Pediatric, Pharmacokinetics, Renal Function Estimation, and Toxicology. Click on the desired calculator, and it will appear in the right content panel.

To perform a calculation, enter in the required variables. You can enter the value and then change the units, if necessary. Once all the inputs are entered, click the Calculate button to perform the calculation.

To help ensure patient safety, input data is checked against accepted values/ranges throughout the calculation process. When an input is restricted, click on the Input button to display the accepted range. If a value is entered that falls outside of the accepted range, a warning will be displayed after the Calculate button is clicked. This warning will instruct the user to correct the value that is out of range before the calculation can be performed.

To start over, click the Reset button to clear all values and begin the calculation again.

To print a calculation, click the Print button in the upper right corner of the content panel and the printer options will be displayed.

To return to the main Lexidrug application, click on the Home button in the top left of the page.