Does anyone else find themselves relying heavily on your EMR system's medication interaction checker when prescribing medications or considering medication management? If you're like me, it’s a vital part of my workflow.
Gone are the days when health care clinicians had to have a working knowledge of hundreds of common medication interactions stored in their brains. Thank goodness! I wouldn’t have made it back then.
When it comes to psychiatric medication our patients may be on at their visit, the warnings that commonly pop up are risks of QT prolongation, changes in medication metabolism, and serotonin syndrome. The question that always lingers when these flags appear in the EMR is: Do I really have to change meds?
Making the call to change course or choosing to mentally weigh out the risk factors and side effects is our responsibility as clinicians, but it's not always straightforward. Sometimes we have to make a decision based on whether or not there is an alternative to what we want to prescribe, and if not, then deciding whether the risk of the adverse effect trumps the increased risk of not prescribing the medication at all. Being able to stratify patients by assessing their risk factors, such as if they have had recent labs (any hypokalemia?), what their vitals look like at baseline (bradycardic at baseline), or if they have recent EKGs (QT-C in the 500’s - no thank you) can help us better decide who is and isn’t high risk. These are all things to consider when that alert shows up and we contemplate clicking the “ignore” button.
Remembering those non-modifiable risk factors like whether the person has heart disease, advanced age, female sex or a history of congenital long QT syndrome can further help our decision-making. Luckily, even if we are not working at a clinic with those EMR alerts, there are free apps out there that take the guesswork out of that decision. Credible Meds and MedSafetyScan are just two of the options available. They can help delineate levels of risk and make us feel okay about prescribing that ondansetron to our vomiting patient who is on citalopram when no other alternatives are available in our clinic formulary.
Antibiotics, antifungals, opioids, muscle relaxers, and antiemetics are some of the most commonly prescribed urgent care medications that have known interactions with psychiatric medications. It's not so simple as to say that because your patient is on psychiatric medication, an entire class of medication is off the table. If this were the case, we would find ourselves unable to prescribe the bread-and-butter urgent care meds to an ever-growing percentage of our population. Instead, it brings to our attention the importance of knowing the absolute contraindications that will ensure the well-being of our patients physical and mental health.
For example, prescribing fluconazole to a patient on phenobarbital slows the metabolism of the phenobarbital and can lead to toxic serum concentrations. This combination should be avoided. Another interaction to steer clear of is prescribing NSAIDS to a patient on Lithium. Evidence shows this combination is potentially fatal as it has been shown that NSAIDS can increase serum lithium levels, alter renal clearance, and potentiate lithium toxicity.
This was a surprise to me given how cognizant I am about trying to avoid opioid pain medication prescribing in the urgent care and made me realize that even those OTC suggestions that might seem benign could wreak havoc. These are just two of many examples to avoid.
During our ever-busier, faster-paced clinic days, it is important to take the time to do our due diligence and conduct a comprehensive medication review, especially for those who work in clinics where you might not have EMR alerts. Balancing the immediate needs of our patients while recognizing the importance of potential interactions with their psych meds will prioritize the well-being of those seeking our services.
For a more in-depth look at what possible interactions eluded to, check out this month's Urgent Care RAP where Dr. Kelly Heidepriem sits down with Pharmacist Dr. Kyle Dvoracek to discuss QT prolongation and serotonin syndrome and what common urgent care medications to avoid prescribing when your patient is on psychiatric medications.
