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Alarm Fatigue

I missed a drug interaction warning the other day when I prescribed a sulfa antibiotic to Barton, a COPD patient who is also taking dofetilide, an uncommon antiarrhythmic.

The pharmacy called me to question the prescription, and I quickly changed it to a cephalosporin.

The big red warning had popped up on my computer screen, but I x-ed it away with my right thumb on the trackball without reading the warning. Quite honestly, I am so used to getting irrelevant warnings that it has become a reflex to bring the cursor to the spot where I can make the warning go away after a quick glance at it. Even though I have chosen the setting “Pop up drug interaction window only when the interaction is severe”, I get the pop up with almost every prescription.

Today I went back to Barton’s chart and looked at his interaction screen.

With the Bactrim DS no longer there, the first of the red boxes was a major interaction between his 81 mg aspirin and his Pradaxa (dabigatran) – two blood thinners are more likely to make you bleed than one. That is basic knowledge, even common sense.

The next red box was a moderate interaction between his baby aspirin and his lisinopril. Theoretically, higher doses of NSAIDs can interfere with the blood pressure lowering properties of ACE inhibitors. That is very basic knowledge, too.

The third red box, another moderate interaction, was between the aspirin and his steroid-bronchodilator inhaler. Theoretically, steroids and aspirin can increase the risk for stomach irritation and supposedly, the pharmacologic effect of aspirin may be decreased by the inhaler.

After these came several warnings labeled “extreme caution” and some that were “not recommended”. The scrolling seemed endless, so I printed out the warnings instead. They filled eight pages. I counted 61 “extreme caution” warnings, from metoprolol and diabetes to the poor man’s steroid-antifungal cream and his diabetes. Beta blockers can, at least theoretically, decrease the tremors and other warning symptoms of low blood sugar, and oral steroids can raise blood sugars, but a mild steroid cream doesn’t do that.

There were 32 “use cautiously”, many of them quite tangential, like the blessed fungus cream and Barton’s history of hepatitis C.

On the last two pages were the dietary warnings, including not to swallow your atorvastatin with grapefruit juice, or to mix your pain pills with alcohol.

I hate to sound uppity, but no amount of pop-up interaction alerts or other forms of “decision support” can replace basic medical education. In Barton’s case, the only warning I needed was the one about his dofetilide, which he gets from his cardiologist, and the antibiotic I wanted to prescribe. The aspirin-Pradaxa interaction is common sense, and the baby aspirin-Symbicort interaction is nonsense. And if I were to even read through the eight pages worth of precautions and “use with caution”, I would have doubled the 15 minutes it took to assess and document his infection in the first place. Or I could have listened to a tutorial about evaluating lung sounds – how much coaching do the EMR designers think we need?

So, here is my suggestion: Make these warnings behave like some computerized card games – let users decide based on their skill level whether to get all the warnings or only the critical ones that are not generic class effects we all learned in pharmacology class. Because when everything is a red alert, alarm fatigue sets in and all the warnings are wasted.

It reminds me of the story about the boy who cried wolf…

Three Challenges in the Art of Prescribing Warfarin

The blood thinner we have used for so many years is gradually being replaced by the novel anticoagulants, which don’t require laboratory monitoring and have fewer interactions. But for some indications, warfarin is still preferred and for many patients, it is still by far the more affordable anticoagulant.

Dosing warfarin has always been an art and it seems to be less often mastered than it used to be. The three challenges are drug interactions, food interactions and dosing schedules.

DRUG INTERACTIONS

Just the other day, I was covering for a colleague and got an urgent message that her patient had a supratherapeutic INR – too much thinning of his blood. I asked the medical assistant to find out if the patient was taking any new medications, like ciprofloxacin, that might interact with the warfarin. I just threw that drug name out because it is such a common and overlooked interaction. Sure enough, somebody else had prescribed ciprofloxacin two days earlier for a urinary infection.

I played detective and tracked down the urine culture, which showed the coli bacteria were resistant to ciprofloxacin, but sensitive to nitrofurantoin (safe) and Bactrim (unsafe). I messaged the prescribing provider, who changed the patient’s antibiotic to nitrofurantoin, so I just ordered the warfarin held for two days.

Many providers seem to be unaware or less paranoid than I am about drugs that interact with warfarin. I once had a patient end up in the intensive care unit with critical internal bleeding because I prescribed levofloxacin with plans to check her INR every couple of days during her antibiotic course. That was clearly not cautious enough in her case.

I have seen great variability in how much other drugs affect the effect of warfarin, especially azithromycin, amoxicillin-clavulanate and also acetaminophen and prednisone, both of which in most people doesn’t seem to cause much trouble. But I worry about all of them, plus sulfamethoxazole, metronidazole, fluconazole, NSAIDs (obviously) and new starts of amiodarone, sertraline, carbamazepine and many others. Over the counter agents to worry about include fish oil, ginkgo biloba and St Johns Wort.

This is not a complete listing, and since most of us have EMRs that warn us of interactions you would think close calls like this would never happen. The problem here is the multitude of basic warnings providers know in their sleep, so that the less famous issues drown among the unnecessary alerts (see my posts about Alarm Fatigue).

I end up using epocrates’ interaction checker on my iPhone to double check sometimes, but, as I said, I’ve been burned so I know this stuff know.

FOOD INTERACTIONS

Warfarin interferes with the role of vitamin K in the coagulation process. Therefore, if you flood your system with foods rich in vitamin K, which is the pharmacological antidote to warfarin, you decrease the effectiveness of warfarin. A week before my ciprofloxacin case, one of my own patients suddenly had a low INR. “Ask him if he’s been eating fiddleheads”, I told Autumn. Sure enough, this Maine spring delicacy was the culprit. The season is short and he wasn’t going to have more, he said, so I didn’t change his dose schedule.

A lot of people are under the impression they cannot eat green vegetables while on warfarin. I tell them that’s like saying you can’t open your windows in the winter if you heat with wood. Imagine you know how many logs to put in the wood stove at certain outdoor temperatures. Then imagine you decide to open a window now and then. You would then have to adjust your fire whenever you opened the window, compensating for the heat loss. If you instead decided to leave a crack open all the time, you would quickly figure out your new firewood budget.

So I simply tell my patients, “eat all the greens you want, but be sure to keep the amount the same every day”.

DOSING WARFARIN: DON’T DRIVE LIKE YOU’RE MR. MAGOO AND PLEASE LEARN FROM YOUR MISTAKES

Mr. Magoo is like me without my glasses. If I were to drive in a snowstorm without my glasses, I would only see a couple of feet in front of me and I would be turning my steering wheel a lot more than necessary. I wouldn’t be able to tell if I was entering a small or a big curve, for instance. If I could see further ahead, I would make smaller corrections. Many providers will look at the current INR value and the previous one, and the current warfarin dose. Then they change the dose. Unless you have a flowsheet that tells you that the last time you made that change, bad things happened, you will make the same poor choice again. On paper, such flowsheets are easy to maintain, but – believe it or not – in many EMRs it is just too darn cumbersome to do.

I have a three ring binder with all my warfarin patients’ flowsheets. It helps me avoid Mr. Magoo type errors and it also serves as a low tech way of making sure no warfarin patients fall off my radar screen. Autumn or I sometimes just flip through the binder to make sure our flock doesn’t wander off, so to speak.

An old fashioned method of managing an old fashioned medication…

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

BOOKS BY HANS DUVEFELT, MD

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