title: Identifying high risk medications causing potential drug-drug interactions in outpatients: A prescription database study based on an online surveillance system.
abstract: Drug-drug interactions (DDIs) are a significant cause for adverse drug events (ADEs). DDIs are often predictable and preventable, but their prevention and management require systematic service development. Most DDI studies focus on interaction rates in hospitalized patients. Less is known of DDIs in outpatients, particularly how community pharmacists could contribute to DDI management by applying their surveillance systems for identifying high-risk medications.
  
  
  
  The study was related to the implementation of the first online DDI surveillance system in Finnish community pharmacies. The goal was to demonstrate how community pharmacies can utilize their prospective surveillance system 1) for identifying high risk medications causing potential DDIs in outpatients, 2) for collaborative service development with local physicians, and 3) for academic risk management research purposes.
  
  
  
  All DDI alerts given by the online surveillance system were collected during a one-month period in 16 out of 17 University Pharmacy outlets in Finland, covering approximately 10% of the national outpatient prescription volume. The surveillance system was based on the FASS database, which categorizes DDIs into four classes (A-D) according to their clinical significance.
  
  
  
  Potential drug-drug DDIs were analyzed for 276,891 dispensed community pharmacy prescriptions. Potential DDIs were associated with 10.8%, or 31,110 of these prescriptions. Clinically significant interaction alerts categorized as FASS classes D (most severe, should be avoided) and C (clinically significant but controllable) were associated with 0.5% and 7.0% of the prescriptions, respectively. Methotrexate and warfarin had the highest risk of causing potentially serious (class D) interactions. These interaction alerts were most frequently between methotrexate and NSAIDs and warfarin and NSAIDs. In general, NSAIDs were the most commonly interacting drugs in this study.
  
  
  
  This study demonstrates that community pharmacies can actively contribute to DDI risk management and systematically use their surveillance systems for identifying patients having clinically significant DDIs. The findings also indicate that the majority of potentially serious interactions in outpatients involve a limited number of drugs, particularly NSAIDs, warfarin and methotrexate. Further research should focus on community pharmacists' involvement in DDI risk management in collaboration with local health care providers.
authors.affiliation: Clinical Pharmacy Group, University of Helsinki, Finland. Electronic address: terhi.toivo@helsinki.fi.
authors.forename: T M
authors.initials: TM
authors.lastname: Toivo
authors.affiliation: University Pharmacy, Helsinki, Finland.
authors.forename: J A V
authors.initials: JA
authors.lastname: Mikkola
authors.affiliation: Department of Pharmacology, Drug Development and Therapeutics, University of Turku, Turku, Finland; Medbase Ltd, Turku, Finland.
authors.forename: K
authors.initials: K
authors.lastname: Laine
authors.affiliation: Clinical Pharmacy Group, University of Helsinki, Finland.
authors.forename: M
authors.initials: M
authors.lastname: Airaksinen
mesh_terms: D016907:Adverse Drug Reaction Reporting Systems / Q000706:statistics & numerical data*; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000008:administration & dosage / Q000009:adverse effects; D003157:Community Pharmacy Services / Q000706:statistics & numerical data*; D003299:Cooperative Behavior; D016208:Databases, Factual; D004347:Drug Interactions; D064420:Drug-Related Side Effects and Adverse Reactions / Q000453:epidemiology*; D005387:Finland; D006801:Humans; D008727:Methotrexate / Q000008:administration & dosage / Q000009:adverse effects; D010045:Outpatients; D010595:Pharmacists / Q000458:organization & administration; D055553:Prescription Drugs / Q000008:administration & dosage / Q000009:adverse effects*; D024382:Professional Role; D012189:Retrospective Studies; D014859:Warfarin / Q000008:administration & dosage / Q000009:adverse effects
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal; D055553:Prescription Drugs; D014859:Warfarin; D008727:Methotrexate
keywords: Community pharmacy; Drug–drug interaction; Outpatient; Prescription; Risk management; Service development