Appling Drug Information Skills on

Adverse Drug Reaction

Evaluation

Edwina Yi-Chun Chiang, R.Ph., M.S.

Taipei Medical University-Wan Fang Hospital

Outline

Evaluation of Adverse Drug Reaction (ADR)
 Causality
 Severity
 Preventability

Data collection points

Drug Information Resources of ADR

Example
 Phenytoin induced Steven-Johnson Syndromes

Exercise
 Amiodarone induced pulmonary fibrosis

Edwina Y. Chiang 2
Objectives

After the current lecture you should be able to
 Speak out all of the three aspects of ADR evaluation
 Write down four important drug information resources
of ADR (must include three textbooks)
 Speak out at least five items to collect from ADR
literature

Edwina Y. Chiang 3
Taiwan ADR Reporting System

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Adverse Drug Reaction
Evaluation
Severity of ADR
Level Description
Minor No antidote, therapy or prolongation of
hospitalization is required
Moderate Requires a change in drug therapy, specific
treatment, or an increase in hospitalization
Severe Potentially life-threatening causes
permanent damage or requires intensive
medical care
Fatal Directly or indirectly contributes to the death
of the patient
Edwina Y. Chiang 6
 Naranjo Causality Scale
Item Y N U
1. Are there previous conclusive reports of this reaction? +1 0 0
2. Did the adverse reaction event appear after the suspected drug was administered? +2 -1 0
3. Did the adverse reaction improve when the drug was discontinued or a specific
antagonist was administered? +1 0 0
4. Did the adverse reaction reappear when the drug was readministered? +2 -1 0
5. Are there alternative causes (other than the drug) that could on their own have caused
the reaction? -1 +2 0
6. Did the reaction reappear when a placebo was given? -1 +1 0
7. Was the drug detected in the blood (or other fluids) in concentrations known to be toxic? +1 0 0
8. Was the reaction more severe when the dose was increased or less severe when the
dose was decreased? +1 0 0
9. Did the patient have a similar reaction to the same or similar drugs at any previous
exposure? +1 0 0
10. Was the adverse event confirmed by any objective evidence? +1 0 0
Total Score
Definite ADR ≧ 9 Probable ADR 5-8 Possible ADR 1-4 Doubtful ≦ 0
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 Category of DILI

Liver injuries are classified in three categories and defined
Category of DILI Defined

Hepatocellular Liver injuries ALT > 2 N or R ≥ 5

Cholestatic liver injuries ALP > 2 N or R ≤ 2

ALT > 2 N and

Mixed liver injuries
An increase in ALP and 2 < R <5

1.DILI: drug induced liver injury 2.N: normal range

3.R: ratio serum activity ALT/ALP 4.Data measured together at time of recognition.

J Hepatol 1990;11:272-6
J Clin Epidemiol 1993;46:1323-30
Edwina Y. Chiang 8
 Causality Assessment of Drug-induced Liver Disease
Hepatocellular Type Injury (RUCAM)-1
Item Description Score
1. Time to onset
Incompatible Before starting the drug or more than 15 days after stopping Unrelated
the drug (except for slowly metabolized drugs)
Unknown When information is not available to calculate ID
*From the beginning of the drug Initial Treatment Subsequent Treatment
Suggestive 5~90 days 1~15 days +2
Compatible <5 or >90 days > 15 days +1
*From cessation of drug
Compatible ≤ 15 days ≤ 15 days +1
2. Course Difference between the peak of ALT and ULN
After cessation of the drug
Highly suggestive Decrease ≥50% within 8 days +3
Suggestive Decrease ≥50% within 30 days +2
Compatible Not applicable +1
Inconclusive No information or Decrease ≥50% after the 30th days 0
Against the role of the drug Decrease <50% after the 30th days or recurrent increase -2
If the drug is continued or inconclusive All situations 0
3. Risk factors
Ethanol Presence +1
Absence 0
Age ≥55 years +1
Age <55 years 0
ID = Insufficient documentation; ULN = Upper limit of normal
 Causality Assessment of Drug-induced Liver Disease
Hepatocellular Type Injury (RUCAM)-2
Item Description Score
4.Concomitant drug(s)
None or no information or concomitant drug with incompatible time to onset 0
Concomitant drug with compatible or suggestive time to onset -1
Concomitant drug known as hepatotoxin and with compatible or suggestive time to onset -2
Concomitant drug with evidence for its role in this case -3
5.Search for non drug causes
*Gr I(6 causes): HAV, HBV, HCV, biliary obstruction, alcoholism, Rule out Gr I&II +2
acute hypotension Rule out 6 of Gr I +1
*Gr II: CMV, EBV, Herpes virus infection, other underlying disease Rule out 5 or 4 of Gr I 0
Rule out <4 of Gr I -2
Non drug cause highly Probable -3
6. Previous information of hepatotoxicity of the drug
Reaction labeled in the product characteristics +2
Reaction published but unlabelled +1
Reaction unknown 0
7. Rechallenge
Positive Doubling of ALT with the drug alone +3
Compatible Doubling of ALT with the drugs given at the time of the 1st reaction +1
Negative Increase of ALT but <ULN in the same condition as for the 1st reaction -2
Not done or not interpretable Other situations 0
8. Plasma concentration as toxic +3
9. Validated lab. Test Positive +3
Negative -3
Not interpretable or not available 0
*≤0: excluded * 1~2: unlikely * 3~5: possible * 6~8: probable *>8: highly probable Total:
 Causality Assessment of Drug-induced Liver Disease
Cholestatic or Mixed Injury (RUCAM)-1
Item Description Score
1. Time to onset
Incompatible Before starting the drug or more than 30 days after stopping the Unrelated
drug (except for slowly metabolized drugs)
Unknown When information is not available to calculate ID
*From the beginning of the drug Initial Treatment Subsequent Treatment
Suggestive 5~90 days 1~90 days +2
Compatible <5 or >90 days > 90days +1
*From cessation of drug
Compatible ≤ 30 days ≤ 30 days +1
2. Course Difference between the peak of ALP (or T.Bil) and ULN
After cessation of the drug
Highly suggestive Not applicable +3
Suggestive Decrease ≥50% within 180 days +2
Compatible Decrease <50% within 180 days +1
Inconclusive Persistence or increase or no information 0
Against the role of the drug Not applicable -2
If the drug is continued inconclusive All situations 0
3. Risk factors
Ethanol or Pregnancy Presence +1
Absence 0
Age ≥55 years +1
Age <55 years 0
ID = Insufficient documentation; ULN = Upper limit of normal
 Causality Assessment of Drug-induced Liver Disease
Cholestatic or Mixed Injury (RUCAM)-2
Item Description Score
4.Concomitant drug(s)
None or no information or concomitant drug with incompatible time to onset 0
Concomitant drug with compatible or suggestive time to onset -1
Concomitant drug known as hepatotoxin and with compatible or suggestive time to onset -2
Concomitant drug with evidence for its role in this case -3
5.Search for non drug causes
*Gr I(6 causes): HAV, HBV, HCV, biliary obstruction, alcoholism, Rule out Gr I&II +2
acute hypotension Rule out 6 of Gr I +1
*Gr II: CMV, EBV, Herpes virus infection, other underlying disease Rule out 5 or 4 of Gr I 0
Rule out <4 of Gr I -2
Non drug cause highly probable -3
6. Previous information of hepatotoxicity of the drug
Reaction labeled in the product characteristics +2
Reaction published but unlabelled +1
Reaction unknown 0
7. Rechallenge
Positive Doubling of ALP (or T. Bil) with the drug alone +3
Compatible Doubling of ALP (or T. Bil) with drugs given at the time of the 1st reaction +1
Negative Increase of ALP (or T. Bil) but <N in the same condition as the 1st reaction -2
Not done or not interpretable Other situations 0
8. Plasma concentration as toxic +3
9. Validated lab. Test Positive +3
Negative -3
Not interpretable or not available 0
*≤0: excluded * 1~2: unlikely * 3~5: possible * 6~8: probable *>8: highly probable Total:
A Causal Relation between
the Drug and Thrombocytopenia
Description Criterion
(1) Therapy with the candidate drug preceded thrombocytopenia and
(2) recovery from thrombocytopenia was complete and sustained 1
after therapy with the drug discontinued
(1) The candidate drug was the only drug used before the onset of
thrombocytopenia or
(2) other drugs were continued or reintroduced after discontinuation 2
of therapy with the candidate drug with a sustained normal platelet
count
Other causes for thrombocytopenia were excluded 3
Re-exposure to the candidate drug resulted in recurrent
4
thrombocytopenia
Definition Level of evidence
Definite: criteria 1, 2, 3, and 4 met I
Probable: criteria 1, 2, and 3 met II
Possible: criteria 1 met III
Unlikely: criteria 1 not met IV
Definite DIT Probable DIT Possible DIT Unlikely DIT Level:
DIT: Drug induced thrombocytopenia Ann Intern Med 1998; 29(11): 886-90.
 Preventability of ADR
Item Y N
1 Was the drug involved in the ADR considered not considered appropriate
Y N
for the patient’s clinical condition?
2 Was the dose, route, and frequency of administration not appropriate for
Y N
the patient’s age, weight and/or disease state?
3 Were required therapeutic drug monitoring or other necessary laboratory
Y N
tests not performed?
4 Was there a history of allergy or previous reactions to the drug? Y N
5 Was a drug interaction involved in the reaction? Y N
6 Was a toxic serum level documented? Y N
7 Was poor compliance involved in the reaction? Y N
Result: Preventable
Unpreventable
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Classification of Adverse Drug Reactions

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 DoTS Classification of ADR

Relation to dose

Time course

Susceptibility factors

Br Med J 2003;327:1222-5

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 (1) Relation to Dose
Items Reactive dose

Toxic reactions Supra-therapeutic doses

Collateral reactions Standard therapeutic doses

Sub-therapeutic dose
Hyper-susceptibility reaction
in susceptable individuals

Edwina Y. Chiang 17
 (2) Time Course
Items Reactive timing
Time independent Any time during the course
Time dependent
Immediate or rapid reactions Occur when drug administered too rapidly
First-dose reactions Occur after 1st dose
Early reactions Occur early after therapy begin
Intermediate reactions Occur after a period of time, then less risk
during long-term therapy
Late reactions Occur with continued or repeated exposure
Withdrawal reactions Occur when, after a long-term treatment, a
drug is withdrawn or the dose is reduced
Delayed reactions Occur some time after exposure or even if the
drug is stopped

Edwina Y. Chiang 18
 (3) Susceptibility Factors
Items Reactive factors
Gender
Age Age related enzyme activity loss
Genetic Inheritable enzyme deficiency
Physiological variation

Drug-drug interactions, Drug-food

Exogenous factors
interactions, smoking

Disease Comorbidity

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What data should we collect from
adverse drug reaction literature?
Data to Collect

Incidence, risk factors

Clinical manifestation
 Outcome, symptoms
 Time course: onset / duration
 Dose relation

Mechanism

Management
 Treatment, monitoring parameter

Strength of evidence

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Adverse Drug Reaction
Literature Resources
Drug Information Resources

Textbook
 Drug Information Resources
Davies’s Textbook of
Adverse Drug Reactions

Most current edition

 Publisher

Chapman and Hall Medical
 5th Edition, 1998
 ISBN: 0412824809
 Contents by “affected organ”

Edwina Y. Chiang 24
 Drug Information Resources
Drug-Induced Diseases:
Prevention, Detection, and Management

Most current edition

 Publisher: American Society of
Health-System Pharmacists
(ASHP)
 1st edition, 2005
 ISBN: 1585280860
 Contents by “affected organ”

Edwina Y. Chiang 25
 Drug Information Resources
Meyler’s Side Effects of Drugs
International Encyclopedia of Adverse Drug Reactions
and Interactions

Most current edition

 Publisher: Elsevier Science
 15th Edition, 2006
 ISBN: 0444509984

Example edition
 14th
Edition, 2000
 ISBN: 0444500936
 Contents by “drug class”

Edwina Y. Chiang 26
 Drug Information Resources
Side Effects of Drugs, Annual 30

Abbreviation: SEDA-30

Most current edition
 Publisher: Elsevier
 30st edition, 2008 (annually)
 ISBN: 978 0 444 52767 7
 Contents by “drug class”

 Reviewing publications of 2005

Edwina Y. Chiang 27
Drug Information Resources

Database
 Drug Information Resources
Micromedex—Health Care Series

Keyword:
Drug name

DRUGDEX® Evaluation
 Cautions

Adverse reactions

Edwina Y. Chiang 29
Drug Information Resources

Review Articles
 Drug Information Resources
Review Articles

Journals with good review articles on adverse
drug reactions
 New England Journal of Medicine
 Drug Safety

Edwina Y. Chiang 31
 Drug Information Resources
New England Journal of Medicine

Official journal of Massachusetts Medical Society

 Impact factor: 50.017 (JCR 2008)
 Top 1% in “Medicine, general & internal”

Edwina Y. Chiang 32
 Drug Information Resources
Drug Safety

Official journal of International

Society of Pharmacovigilance
(ISoP)

Impact factor: 3.537 (JCR 2008)
 Top 10.9% in “Toxicology”
 Top22.4% in “Pharmacology &
pharmacy”

Edwina Y. Chiang 33
Drug Information Resources

Original Articles
 Drug Information Resources
Original Articles

Search for relevant articles
 Ovid Medline or PubMed

Retrieve target articles
 Randomized control trials?
 Cohort studies? Or Case-Control studies?
 Case series or case report

Literature evaluation
 Quality
 Applicability

Edwina Y. Chiang 35
PRACTICE
Data to Collect

Incidence, risk factors

Clinical manifestation
 Symptoms, outcome
 Time course: onset / duration
 Dose relation

Mechanism

Management
 Treatment, monitoring parameter

Strength of evidence

Edwina Y. Chiang 37
 ADR Literature Review
Phenytoin induced
Stevens-Johnson Syndrome

醫師打電話來說有一位44歲男性病人發生皮膚問題，
他懷疑是Phenytoin induced Stevens-Johnson
Syndrome (SJS)。
 據描述，病人使用Phenytoin後40天發生皮膚疹
(長的很像
標靶)，第45天發現嘴巴黏膜有潰爛，，eosinophil升高，
皮膚科醫師會診過，診斷為SJS, 已經做了支持療法
 因為時間點，不知是否該停用Phenytoin，詢問您的意見

 請問，此不良反應可能與Phenytoin有關嗎？根據相關文
獻，您認為醫師該不該停用Phenytoin?

Edwina Y. Chiang 38
 ADR Literature Review
General Drug Safety of Etanercept

你在輪值藥物資訊櫃檯時，病人拿了一樣針劑過來
問你，它是不是有什麼副作用。
 你看了藥名是Etanercept

 病人說他是因為類風濕性關節炎，醫師新開了這個藥品，
但是他之前都是吃口服的藥品，第一次要打針，他很擔心
副作用，想知道用這個藥有沒有什麼需要注意的地方

Edwina Y. Chiang 39
 ADR Literature Review
Amiodarone Induced Pulmonary Fibrosis

你在進行藥事照顧的時候發現一個病人肺功能在近
三個月間持續下降
 痰液一直無法培養出任何相關病原，白血球計數也很正常，
病人沒有發燒的症狀，胸腔X光檢查發現肺浸潤與纖維化，
醫師也無法確定到底病人為何展現肺炎樣的表現。
 病人過去沒有下呼吸道感染的病史，只有四個月前，病人
因為心室心律不整嚴重，藥物從原本的Beta-blocker加上
Amiodarone.
 Amiodarone可能與病人的反應有關嗎？

 該如何處理這個反應？
Edwina Y. Chiang 40
 References

Aronson JK and Ferner RE. Joining the DoTS: new
approach to classifying adverse drug reactions. BMJ
2003;327:1222-1225.

Dans AL, Dans LF, Guyatt GH, et al. Users’ guides to the
medical literature: XIV. How to decide on the applicability of
clinical trial results to your patient. JAMA 1998;279(7)545-9.

Edwards IR and Aronson JK. Adverse drug reactions:
definitions, diagnosis, and management. Lancet 2000; 356:
1255–59

Etminan M, Samii A. Pharmacoepidemiology I: a review of
pharmacoepidemiologic study designs. Pharmacotherapy
2004;24(8):964-9.
Edwina Y. Chiang 41
 References

Guyatt GH, Sackett DL, Cook DJ. User's Guides to the
medical literature: II. How to use an article about therapy or
prevention. A. Are the results of the study valid? JAMA
1993;270(21):2598-601.

Guyatt GH, Sackett DL, Cook DJ. User's Guides to the
medical literature: II. How to use an article about therapy or
prevention. B. What were the results and will they help me
in caring for my patients? JAMA 1994;271(1):59-63.

Mosdell KW. Literature evaluation I: controlled clinical trials.
In: Malone PM, Mosdell KW, Kier KL, Stanovich JE, eds.
Drug Information: A Guide for Pharmacists. 2nd ed. New
York, NY: McGraw-Hill; 2001:133-172.

Edwina Y. Chiang 42
Thank You!