Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Drug interactions and the problem with default settings

Bradley Evans, MD
Meds
February 2, 2013
Share
Tweet
Share

At some hospitals, pantoprazole is not on the formulary. So, when a patient takes clopidogrel and pantoprazole, the drugs are automatically switched to clopidogrel and omeprazole. For a proton pump inhibitor (PPI), the default is omeprazole.

The Medical Letter, the FDA and UK’s National Guidelines for Stroke recommend if patients take clopidogrel and need a PPI, avoid omeprazole and use pantoprazole instead. The concern is that omeprazole prevents activation of clopidogrel (clopidogrel is a pro-drug), and so, the drug might not work.

At some hospitals, the drug-drug interaction reporting can be adjusted by various people and committees. Reporting of the clopidogrel-omeprazole drug interaction can be disabled.

If it is true that clopidogrel in these patients is in an inactive form, then the patient should be at increased risk of having vascular events. These patients should also have more hemorrhagic complications. This might occur because the anti-platelet and anti-coagulation regimen is adjusted while the patient takes omeprazole. Later, the omeprazole might be stopped or switched to pantoprazole, and the hemorrhagic risk increases. This could all happen without the physician being particularly aware.

This is not just about clopidogrel and the PPIs, the point is that decisions have been taken out of the physician’s hands. Defaults are being set according to a general recipe, and reporting of drug interaction is altered at the whim of who knows who.

Even though hospitals talk about the importance of process and process improvement, it is hard to change process. Physicians are left having to correct errors of the process, without being exactly aware these errors even exist. It is difficult to recognize things when they are unexpected.

Decisions ought to be in the hands of the doctor (decentralized), but we all know that drug companies, hospitals, fellow doctors, insurance companies and various governmental agencies want to control our decisions. This can happen in overt or covert ways. There is even a book, Nudge, that explains how to control other people’s decisions covertly, using defaults and other behavioral tools.

This is OK provided people are nudged to make good decisions. It would be fine if it worked to make sure patients taking clopidogrel got pantoprazole and not omeprazole, but it doesn’t. These are tools and can be used by anyone, for any purpose, even for no obvious purpose at all.

One point is that it is important to recognize that defaults in the hospital system can work to make your patient sicker. This is not just clopidogrel-omeprazole, it’s patients with Parkinson’s who automatically get Phenergan and Haldol as prns, and it’s patients on topiramate admitted with kidney stones who are continued on the drug. It’s a problem with defaults.

Another point is that other people can monkey with drug-drug interactions reporting, so you need to have a simple system you control and trust.

Finally, the last point is a warning that other entities will read Nudge and thereby learn to use behavioral techniques in order to influence your decisions, probably to the detriment of your patients.

Bradley Evans is a neurologist. 

Prev

What you can learn from the flu epidemic: Get vaccinated earlier

February 2, 2013 Kevin 4
…
Next

The irony and the agony of our prescription opioid problem

February 3, 2013 Kevin 37
…

ADVERTISEMENT

Tagged as: Hospital-Based Medicine, Medications, Neurology

Post navigation

< Previous Post
What you can learn from the flu epidemic: Get vaccinated earlier
Next Post >
The irony and the agony of our prescription opioid problem

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

More by Bradley Evans, MD

  • a desk with keyboard and ipad with the kevinmd logo

    Why physicians are susceptible to hardball tactics

    Bradley Evans, MD
  • a desk with keyboard and ipad with the kevinmd logo

    Corruption of the medical literature is impossible to prevent

    Bradley Evans, MD
  • a desk with keyboard and ipad with the kevinmd logo

    3 common misconceptions about doctors

    Bradley Evans, MD

More in Meds

  • Why retail pharmacies are the future of diverse clinical trials

    Shelli Pavone
  • Why does rifaximin cost 95 percent more in the U.S. than in Asia?

    Jai Kumar, MD, Brian Nohomovich, DO, PhD and Leonid Shamban, DO
  • A world without antidepressants: What could possibly go wrong?

    Tomi Mitchell, MD
  • The truth about GLP-1 medications for weight loss: What every patient should know

    Nisha Kuruvadi, DO
  • The hidden bias in how we treat chronic pain

    Richard A. Lawhern, PhD
  • Biologics are not small molecules: the case for pre-allergy testing in an era of immune-based therapies

    Robert Trent
  • Most Popular

  • Past Week

    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
    • When did we start treating our lives like trauma?

      Maureen Gibbons, MD | Physician
    • First impressions happen online—not in your exam room

      Sara Meyer | Social media
    • How Gen Z is transforming mental health care [PODCAST]

      The Podcast by KevinMD | Podcast
    • Dedicated hypermobility clinics can transform patient care

      Katharina Schwan, MPH | Conditions
    • Why ADHD in adults is often missed—and why it matters [PODCAST]

      The Podcast by KevinMD | Podcast
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • Why recovery after illness demands dignity, not suspicion

      Trisza Leann Ray, DO | Physician
    • Why does rifaximin cost 95 percent more in the U.S. than in Asia?

      Jai Kumar, MD, Brian Nohomovich, DO, PhD and Leonid Shamban, DO | Meds
    • Why medical students are trading empathy for publications

      Vijay Rajput, MD | Education
  • Recent Posts

    • How Gen Z is transforming mental health care [PODCAST]

      The Podcast by KevinMD | Podcast
    • Nurses aren’t eating their young — we’re starving the profession

      Adam J. Wickett, BSN, RN | Conditions
    • Why wanting more from your medical career is a sign of strength

      Maureen Gibbons, MD | Physician
    • U.S. health care leadership must prepare for policy-driven change

      Lee Scheinbart, MD | Policy
    • Why the pre-med path is pushing future doctors to the brink

      Jordan Williamson, MEd | Education
    • Why the fear of being forgotten is stronger than the fear of death [PODCAST]

      The Podcast by KevinMD | Podcast

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 1 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
    • When did we start treating our lives like trauma?

      Maureen Gibbons, MD | Physician
    • First impressions happen online—not in your exam room

      Sara Meyer | Social media
    • How Gen Z is transforming mental health care [PODCAST]

      The Podcast by KevinMD | Podcast
    • Dedicated hypermobility clinics can transform patient care

      Katharina Schwan, MPH | Conditions
    • Why ADHD in adults is often missed—and why it matters [PODCAST]

      The Podcast by KevinMD | Podcast
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • Why recovery after illness demands dignity, not suspicion

      Trisza Leann Ray, DO | Physician
    • Why does rifaximin cost 95 percent more in the U.S. than in Asia?

      Jai Kumar, MD, Brian Nohomovich, DO, PhD and Leonid Shamban, DO | Meds
    • Why medical students are trading empathy for publications

      Vijay Rajput, MD | Education
  • Recent Posts

    • How Gen Z is transforming mental health care [PODCAST]

      The Podcast by KevinMD | Podcast
    • Nurses aren’t eating their young — we’re starving the profession

      Adam J. Wickett, BSN, RN | Conditions
    • Why wanting more from your medical career is a sign of strength

      Maureen Gibbons, MD | Physician
    • U.S. health care leadership must prepare for policy-driven change

      Lee Scheinbart, MD | Policy
    • Why the pre-med path is pushing future doctors to the brink

      Jordan Williamson, MEd | Education
    • Why the fear of being forgotten is stronger than the fear of death [PODCAST]

      The Podcast by KevinMD | Podcast

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Drug interactions and the problem with default settings
1 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...