P29S01: Constipation (adverse drug effect)

Bottom line: Information on constipation (adverse drug effect) was used to justify the management of a patient (starting Buspirone while gradually stopping Lyrica). It contributed to avoid inappropriate treatment.

Level 1 outcome (situational relevance): On February 11, 2009, P29 did a search at work, by themselves, and before a phone call with a patient. The patient called the nurse who contacted P29. P29 retrieved two information hits about constipation. The reported search objective was: to address a clinical question. “He [the patient, a man in his thirties] is on Lyrica for an off-label usage for generalized anxiety disorder. […] He’s also on another drug that’s constipating, so both are constipating drugs. He’s been having significant problems with constipation since starting Lyrica in September. He was maximized on laxative therapy, and he was just unable to handle it anymore. So, we had to stop the Lyrica, but at the same time he needed to be started on another agent for anxiety […] so he could minimize the anxiety that he’d have once the Lyrica is getting out of his system. […] My question was two-fold: [first] can I stop Lyrica abruptly, and [second] can I give Lyrica and Buspirone at the same time.” According to P29, e-Therapeutics+ was more relevant than the information from another electronic resource (Up-to-Date). “[…] As a secondary question, […] I was just wondering if there was a suggested taper [in Up-to-Date]. […] I didn’t find anything there on Up-To-Date.”

Level 2 outcome (cognitive impact): Two hits were associated with a report of positive cognitive impact (see table). Regarding practice improvement and learning, P29 stated: “I’m going to have lots of patients on Lyrica and I’m sure I’m going to need [the information on the adverse events again], because it’s used for lots of things that are common, and it’s sort of the new big drug kind of thing. […] I know I’m gonna have lots of them [patients] on it, and I know I’m gonna have to take some of them off it for various reasons and so now, I know how to take them off of it. […][The drug interaction] is another piece of information that will help me take care of patients. […] I learned that Buspirone and Lyrica don’t interact.”

Retrieved information hits:

1) e-Therapeutics+ (CIRT): eCPS Tab – Keyword: Lyrica – Search for word: Taper – Adverse events following abrupt or rapid discontinuation (P29S01H01)

2) e-Therapeutics+ (CIRT): Drug interactions Tab: Keyword: Lyrica and Buspirone – Analyse – No interactions (P29S01H02)

Level 3 outcome (information use): Information on constipation as an adverse effect of a drug against anxiety, which cannot be stopped abruptly, was retrieved, and used to justify the management of a patient (information was used as presented in e-Therapeutics+). “I ran my plan by a staff, because it was a fairly big thing to do over the phone. And I just wanted to make sure they didn’t have any major problem with it, because ultimately we’re still being supervised by our staff. So I just did that, to make sure they were okay with me doing that kind of thing over the phone. If my staff had disagreed with me then I would’ve said: do you have anything else to suggest? […]I would’ve used this as an argument to fight for my point of view. […] Then I called the patient. I explained to him how we were going to taper it, what we were gonna do. I got his pharmacy number, I called the pharmacy. I gave a verbal order for the taper and to start the Buspirone, and then I made a note in the chart.”

Level 4 outcome (patient health): Regarding patient health, P29 reported that the information contributed to avoid inappropriate treatment. “My initial thought was, you can probably just stop [the Lyrica] there. So, it [the retrieved information] avoided me from doing something harmful like that. I sort of asked before I looked it, I asked the nurse, and [she said] you can probably just stop cold, you don’t need to taper it. So, in that way, […] by tapering it, he [the patient] is not gonna have the withdrawal, […] the adverse [weaning] reaction.”

Levels of outcome of information-seeking

Situational relevance	Positive cognitive impact	Information use	Patient health
Address a clinical question	Practice improved Learned something Motivated to learn Reassured	Justify choice	Avoid

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