P18S08: Antidepressants interactions and
cross tapering
Bottom line: Information on antidepressants interactions and cross
tapering was used to maintain the management plan for a patient (discontinue
one medication and change the dosage of another), and to persuade a colleague to make this change. There
were no information-related patient health outcomes.
Level 1 outcome (situational relevance): On December 2, 2008, P18 did a search at work, by themselves, and
after an encounter with a patient. They retrieved two information hits about
antidepressants interactions and cross tapering. The reported search objectives were: to address a
clinical question, to exchange information with other health professionals, and
to plan, manage or coordinate tasks with other health professionals. “[The patient] was a man, […] more than
sixty-five. […] He was admitted for depression and he was being worked up to go
for ECT (electroconvulsive
therapy). […] But the next day, the nurses came by
and asked me if I could clarify with the doctor in influencing dosing because
he [the patient] hadn’t been eating, and he was not doing well. He had declined
overnight. So I went back to check the chart to see what happened to cause the
decline overnight. […] The patient had been on moclobemide [monoamine oxydase
inhibitor]. So he [the doctor] discontinued that when he [the patient] came
into the hospital. And the patient had […] also been on Remeron 7.5
[tetracyclic]. So he tolerated that, but then after the discontinuation of the
moclobemide, the doctor increased his Remeron to 15 and then 30, and then also
added venlafaxine at 37.5 [serotonin-norepinephrine reuptake inhibitor]. But
all of this happened within about 3 days. And he [the doctor] didn’t give the
appropriate wash-out. I was concerned that if the patient wasn’t doing well and
then if we continued to give insulin and if there was a potential for a
serotonin syndrome. […] I wanted to find out which medication interacts with
moclobemide […] and how to deal with it. […] I wanted a solution to help him
[the doctor] plan how he was going to treat this patient.”According to P18, the information from e-Therapeutics+ was in agreement
and equally relevant as the information from another electronic resource (Up-to-Date).
Level 2 outcome (cognitive impact): The two hits were associated with a report of
positive cognitive impact (see table). Regarding learning, P18 stated: “Some of these drugs
are things that stand out anyways, as they commonly interact, but… [I] probably
didn’t realize […] [some interactions] right away. [...] I
needed to double check. [...]It confirmed what I knew [about the
2-week [wash out period].-”
Retrieved
information hits:
1) e-Therapeutics+ (CIRT): Drug Interactions Tab – Moclobemide +
Remeron + Venlafaxine – interactions and wash-out periods – (P18S08H01)
2) e-Therapeutics+ (CIRT): e-CPS
Tab – Moclobemide – CPhA monograph - Table 2 on drug interactions (P18S08H02)
Level 3 outcome
(information use): Information on antidepressants interactions and cross
tapering was retrieved, and used to better understand a specific issue with
respect to the management of the patient, to maintain (be more certain about) the
management plan for a patient (discontinue one medication and change the dosage
of another), and to persuade a colleague to make this change (information used as presented in eT+). “I was gonna change [patient] medication [before the search]. I couldn’t find the staff doctor so I asked
another staff and she was fine [with my plan]. We held insulin and discontinued
the venlafaxine and decreased the dose of Remeron. […] She [the doctor] was ok
with me making the change because I gave her the history of the patient and
rationalized why I needed to do it. […] She understood where it [the
information] was coming from and agreed with me. […] The next morning I also
reviewed the case with him [the treating doctor] just to explain why I made the
changes that I did. He agreed and he was glad that I had done it. […] He agreed
with the same rationale that I had that the patient
would be treated with ECT so we didn’t need to use drugs right away.”
Level 4 outcome (patient health): Without these
information hits, P18’s management of the patient would have been the same. There
was no clear relationship between the information use and patient health
outcomes.
Levels of outcome of information-seeking
|
Situational relevance |
Positive cognitive
impact |
Information use |
Patient health |
|
Address a clinical question Exchange information Manage patient care |
Learned something Reminded something Confirmed Reassured |
Persuade Be more certain Understand issue |
No outcome |