Abstract
Purpose
A considerable weakness of current clinical decision support systems managing drug–drug interactions (DDI) is the high incidence of inappropriate alerts. Because DDI-induced, dose-dependent adverse events can be prevented by dosage adjustment, corresponding DDI alerts should only be issued if dosages exceed safe limits. We have designed a logical framework for a DDI alert-system that considers prescribed dosage and retrospectively evaluates the impact on the frequency of statin–drug interaction alerts.
Methods
Upper statin dose limits were extracted from the drug label (SPC) (20 statin-drug combinations) or clinical trials specifying the extent of the pharmacokinetic interaction (43 statin–drug combinations). We retrospectively assessed electronic DDI alerts and compared the number of standard alerts to alerts that took dosage into account.
Results
From among 2457 electronic prescriptions, we identified 73 high-risk statin–drug pairs. Of these, SPC dosage information classified 19 warnings as inappropriate. Data from pharmacokinetic trials took quantitative dosage information more often into consideration and classified 40 warnings as inappropriate. This is a significant reduction in the number of alerts by 55% compared to SPC-based information (26%; p < 0.001).
Conclusion
This retrospective study of pharmacokinetic statin interactions demonstrates that more than half of the DDI alerts that presented in a clinical decision support system were inappropriate if DDI-specific upper dose limits are not considered.
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References
Kuperman GJ, Bobb A, Payne T, Avery AJ, Gandhi TK, Burns G et al (2007) Medication-related clinical decision support in computerized provider order entry systems: a review. J Am Med Inform Assoc 14:29–40
van der Sijs H, Aarts J, Vulto A, Berg M (2006) Overriding of drug safety alerts in computerized physician order entry. J Am Med Inform Assoc 13:138–147
Paterno MD, Maviglia SM, Gorman PN, Seger DL, Yoshida E, Seger AC et al (2009) Tiering drug-drug interaction alerts by severity increases compliance rates. J Am Med Inform Assoc 16:40–46
Backman JT, Kivistö KT, Olkkola KT, Neuvonen PJ (1998) The area under the plasma concentration-time curve for oral midazolam is 400-fold larger during treatment with itraconazole than with rifampicin. Eur J Clin Pharmacol 54:53–58
Ucar M, Mjörndal T, Dahlqvist R (2000) HMG-CoA reductase inhibitors and myotoxicity. Drug Saf 22:441–457
Thibault A, Samid D, Tompkins AC, Figg WD, Cooper MR, Hohl RJ et al (1996) Phase 1 study of lovastatin, an inhibitor of the mevalonate pathway, in patients with cancer. Clin Cancer Res 2:483–491
Schmassmann-Suhijar D, Bullingham R, Gasser R, Schmutz J, Haefeli WE (1998) Rhabdomyolysis due to interaction of simvastatin with mibefradil. Lancet 351:1929–1930
Imamura R, Ichimaru N, Moriyama T, Shi Y, Namba Y, Nonomura N et al (2005) Long term efficacy of simvastatin in renal transplant recipients treated with cyclosporine or tacrolimus. Clin Transplant 19:616–621
Kobashigawa JA, Murphy FL, Stevenson LW, Moriguchi JD, Kawata N, Kamjoo P et al (1990) Low-dose lovastatin safely lowers cholesterol after cardiac transplantation. Circulation 82[Suppl 4]:281–283
Chen C, Mireles RJ, Campbell SD, Lin J, Mills JB, Xu JJ et al (2005) Differential interaction of 3-hydroxy-3-methylglutaryl-CoA-reductase inhibitors with ABCB1, ABCC2, and OATP1B1. Drug Metab Disp 33:537–546
Hsiang B, Zhu Y, Wang Z, Wu Y, Sasseville V, Yang WP et al (1999) A novel human hepatic organic anion transporting polypeptide (OATP2): identification of a liver-specific human organic anion transporting polypeptide and identification of rat and human hydroxymethylglutaryl-CoA reductase inhibitor transporters. J Biol Chem 274:37161–37168
Asberg A (2003) Interactions between cyclosporin and lipid-lowering drugs. Implications for organ transplant recipients. Drugs 63:367–378
Omar MA, Wilson JP (2002) FDA adverse event reports on statin-associated rhabdomyolysis. Ann Pharmacother 36:288–295
Baxter K (ed) (2007) Stockley’s drug interactions, 8th edn. Pharmaceutical Press, Chicago London
Lendac Data Systems: DRUGDEX® System (database on CD-ROM). Thomson Healthcare, Greenwood Village
Tobert JA (1988) Efficacy and long-term adverse effect pattern of lovastatin. Am J Cardiol 62:28J–34J
Holdaas H, Felström B, Jardine AG, Holme I, Nyberg G, Fauchald P et al, on behalf of the assessment of LEscol in renal transplantation (ALERT) study investigators (2003) Effect of fluvastatin on cardiac outcomes in renal transplant recipients: a multicentre, randomised, placebo-controlled trial. Lancet 361:2024–2031
Launay-Vachar V, Izzedine H, Deray G (2005) Statins’ dosage in patients with renal failure and cyclosporine drug-drug interaction in transplant patients. Int J Clin Cardiol 101:9–17
Kirchheiner J, Kudlicz D, Meisel C, Bauer S, Meineke I, Roots I et al (2003) Influence of CYP2C9 polymorphisms on the pharmacokinetics and cholesterol-lowering activity of (-)-3S, 5R-fluvastatin and (+)-3R, 5S-fluvastatin in healthy volunteers. Clin Pharmacol Ther 74:186–194
Höppener RJ, Kuyer A, Meijer JW, Hulsman J (1980) Correlation between daily fluctuations of carbamazepine serum levels and intermittent side effects. Epilepsia 21:341–350
Haefeli WE (2007) Drug-drug interactions with levodopa modulating treatment responses in Parkinson’s disease. J Neurol 254[Suppl 4]:IV/29–IV/36
Asberg A, Hartmann A, Fjeldså E, Bergan S, Holdaas H (2001) Bilateral pharmacokinetic interaction between cyclosporine A and atorvastatin in renal transplant recipients. Am J Transplant 1:382–386
Hermann M, Asberg A, Christensen H, Holdaas H, Hartmann A, Reubsaet JL (2004) Substantially elevated levels of atorvastatin and metabolites in cyclosporine-treated renal transplant recipients. Clin Pharmacol Ther 75:101–109
Lemahieu WP, Hermann M, Asberg A, Verbeke K, Holdaas H, Vanrenterghem Y et al (2005) Combined therapy with atorvastatin and calcineurin inhibitors: no interactions with tacrolimus. Am J Transplant 5:2236–2243
Amsden GW, Kuye O, Wei GC (2002) A study of the interaction potential of azithromycin and clarithromycin with atorvastatin in healthy volunteers. J Clin Pharmacol 42:444–449
Jacobson TA (2004) Comparative pharmacokinetic interaction profiles of pravastatin, simvastatin, and atorvastatin when coadministered with cytochrome P450 inhibitors. Am J Cardiol 94:1140–1146
Gerber JG, Rosenkranz SL, Fichtenbaum CJ, Vega JM, Yang A, Alston BL, AIDS Clinical Trials Group A5108 Team et al (2005) Effect of Efavirenz on the Pharmacokinetics of Simvastatin, Atorvastatin, and Pravastatin. Results of AIDS Clinical Trials Group 5108 Study. J Acquir Immune Defic Syndr 39:307–312
Siedlik PH, Olson SC, Yang BB, Stern RH (1999) Erythromycin coadministration increases plasma atorvastatin concentrations. J Clin Pharmacol 39:501–504
Backman JT, Luurila H, Neuvonen M, Neuvonen PJ (2005) Rifampin markedly decreases and gemfibrozil increases the plasma concentrations of atorvastatin and its metabolites. Clin Pharmacol Ther 78:154–167
Kantola T, Kivistö KT, Neuvonen PJ (1998) Effect of itraconazole on the pharmacokinetics of atorvastatin. Clin Pharmacol Ther 64:58–65
Mazzu AL, Lasseter KC, Shamblen EC, Agarwal V, Lettieri J, Sundaresen P (2000) Itraconazole alters the pharmacokinetics of atorvastatin to a greater extent than either cerivastatin or pravastatin. Clin Pharmacol Ther 68:391–400
Hsyu PH, Schultz-Smith MD, Lillibridge JH, Lewis RH, Kerr BM (2001) Pharmacokinetic interactions between nelfinavir and 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors atorvastatin and simvastatin. Antimicrob Agents Chemother 45:3445–3450
Fichtenbaum CJ, Gerber JG, Rosenkranz SL, Segal Y, Aberg JA, Blaschke T et al, NIAID AIDS Clinical Trials Group (2002) Pharmacokinetic interactions between protease inhibitors and statins in HIV seronegative volunteers: ACTG Study A5047. AIDS 16:569–577
Park JW, Siekmeier R, Lattke P, Merz M, Mix C, Schüler S et al (2001) Pharmacokinetics and pharmacodynamics of fluvastatin in heart transplant recipients taking cyclosporine A. J Cardiovasc Pharmacol Ther 6:351–361
Goldberg R, Roth D (1996) Evaluation of fluvastatin in the treatment of hypercholesterolemia in renal transplant recipients taking cyclosporine. Transplantation 62:1559–1564
Kantola T, Backman JT, Niemi M, Kivistö KT, Neuvonen PJ (2000) Effect of fluconazole on plasma fluvastatin and pravastatin concentrations. Eur J Clin Pharmacol 56:225–229
Kivistö KT, Kantola T, Neuvonen PJ (1998) Different effects of itraconazole on the pharmacokinetics of fluvastatin and lovastatin. Br J Clin Pharmacol 46:49–53
Gullestad L, Nordal KP, Berg KJ, Cheng H, Schwartz MS, Simonsen S (1999) Interaction between lovastatin and cyclosporine A after heart and kidney transplantation. Transplant Proc 31:2163–2165
Olbricht C, Wanner C, Eisenhauer T, Kliem V, Doll R, Boddaert M et al (1997) Accumulation of lovastatin, but not pravastatin, in the blood of cyclosporine-treated kidney graft patients after multiple doses. Clin Pharmacol Ther 62:311–321
Bramer SL, Brisson J, Corey AE, Mallikaarjun S (1999) Effect of multiple cilostazol doses on single dose lovastatin pharmacokinetics in healthy volunteers. Clin Pharmacokinet 37[Suppl 2]:69–77
Azie NE, Brater DC, Becker PA, Jones DR, Hall SD (1998) The interaction of diltiazem with lovastatin and pravastatin. Clin Pharmacol Ther 64:369–377
Kyrklund C, Backman JT, Kivistö KT, Neuvonen M, Laitila J, Neuvonen PJ (2001) Plasma concentrations of active lovastatin acid are markedly increased by gemfibrozil but not by bezafibrate. Clin Pharmacol Ther 69:340–345
Neuvonen PJ, Jalava KM (1996) Itraconazole drastically increases plasma concentrations of lovastatin and lovastatin acid. Clin Pharmacol Ther 60:54–61
Ring BJ, Patterson BE, Mitchell MI, Vandenbranden M, Gillespie J, Bedding AW et al (2005) Effect of tadalafil on cytochrome P450 3A4-mediated clearance: studies in vitro and in vivo. Clin Pharmacol Ther 77:63–75
Becquemont L, Neuvonen M, Verstuyft C, Jaillon P, Letierce A, Neuvonen PJ, Funck-Brentano C (2007) Amiodarone interacts with simvastatin but not with pravastatin disposition kinetics. Clin Pharmacol Ther 81:679–684
Park JW, Siekmeier R, Merz M, Krell B, Harder S, März W et al (2002) Pharmacokinetics of pravastatin in heart-transplant patients taking cyclosporin A. Int J Clin Pharmacol Ther 40:439–450
Regazzi MB, Iacona I, Campana C, Raddato V, Lesi C, Perani G et al (1993) Altered disposition of pravastatin following concomitant drug therapy with cyclosporin A in transplant recipients. Transplant Proc 25:2732–2734
Kyrklund C, Backman JT, Neuvonen M, Neuvonen PJ (2003) Gemfibrozil increases plasma pravastatin concentrations and reduces pravastatin renal clearance. Clin Pharmacol Ther 73:538–544
Neuvonen PJ, Kantola T, Kivistö KT (1998) Simvastatin but not pravastatin is very susceptible to interaction with the CYP3A4 inhibitor itraconazole. Clin Pharmacol Ther 63:332–341
Aberg JA, Rosenkranz SL, Fichtenbaum CJ, Alston BL, Brobst SW, Segal Y, ACTG A5108 team et al (2006) Pharmacokinetic interaction between nelfinavir and pravastatin in HIV-seronegative volunteers: ACTG Study A5108. AIDS 20:725–729
Kyrklund C, Backman JT, Neuvonen M, Neuvonen PJ (2003) Effect of rifampicin on pravastatin pharmacokinetics in healthy subjects. Br J Clin Pharmacol 57:181–187
Busti AJ, Bain AM, Hall RG 2nd, Bedimo RG, Leff RD, Meek C et al (2008) Effects of atazanavir/ritonavir or fosamprenovir/ritonavir on the pharmacokinetics of rosuvastatin. J Cardiovasc Pharmacol 51:605–610
Simonson SG, Raza A, Martin PD, Mitchell PD, Jarcho JA, Brown CD et al (2004) Rosuvastatin pharmacokinetics in heart transplant recipients administered an antirejection regimen including cyclosporine. Clin Pharmacol Ther 76:176–177
Cooper KJ, Mertin PD, Dane AL, Warwick MJ, Raza A, Schneck DW (2003) The effect of erythromycin on the pharmacokinetics of rosuvastatin. Eur J Clin Pharmacol 59:51–56
Schneck DW, Birmingham BK, Zalikowski JA, Mitchell PD, Wang Y, Martin PD et al (2004) The effect of gemfibrozil on the pharmacokinetics of rosuvastatin. Clin Pharmacol Ther 75:455–463
Cooper KJ, Martin PD, Dane AL, Warwick MJ, Schneck DW, Cantarini MV (2003) Effect of itraconazole on the pharmacokinetics of rosuvastatin. Clin Pharmacol Ther 73:322–329
Kiser JJ, Gerber JG, Predhomme JA, Wolfe P, Flynn DM, Hoody DW (2008) Drug/drug interaction between lopinavir/ritonavir and rosuvastatin in healthy volunteers. J Acquir Immune Defic Syndr 47:570–578
Nishio S, Watanabe H, Kosuge K, Uchida S, Hayashi H, Ohashi K (2005) Interaction between amlodipine and simvastatin in patients with hypercholesterolemia and hypertension. Hypertens Res 28:223–237
Dingemanse J, Schaarschmidt D, van Giersbergen PLM (2003) Investigation of the mutual pharmacokinetic interactions between bosentan, a dual endothelin receptor antagonist, and simvastatin. Clin Pharmacokinet 42:293–301
Ichimaru N, Takahara S, Kokado Y, Wang JD, Hatori M, Kameoka H et al (2001) Changes in lipid metabolism and effect of simvastatin in renal transplant recipients induced by cyclosporine or tacrolimus. Atherosclerosis 158:417–423
Arnadottir M, Eriksson LO, Thysell H, Karkas JD (1993) Plasma concentration profiles of simvastatin 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitory activity in kidney transplant recipients with and without ciclosporin. Nephron 65:410–413
Watanabe H, Kosuge K, Nishio S, Yamada H, Uchida S, Satoh H et al (2004) Pharmacokinetic and pharmacodynamic interactions between simvastatin and diltiazem in patients with hypercholesterolemia and hypertension. Life Sci 76:281–292
Mousa O, Brater DC, Sunblad KJ, Hall SD (2000) The interaction of diltiazem with simvastatin. Clin Pharmacol Ther 67:267–274
Kantola T, Kivistö KT, Neuvonen PJ (1998) Erythromycin and verapamil considerably increase serum simvastatin and simvastatin acid concentrations. Clin Pharmacol Ther 64:177–182
Backman JT, Kyrklund C, Kivistö KT, Wang JS, Neuvonen PJ (2000) Plasma concentrations of active simvastatin acid are increased by gemfibrozil. Clin Pharmacol Ther 68:122–129
O’Brien SG, Meinhardt P, Bond E, Beck J, Peng B, Dutreix C et al (2003) Effects of imatinib mesylate (STI571, Glivec) on the pharmacokinetics of simvastatin, a cytochrome p450 3A4 substrate, in patients with chronic myeloid leukaemia. Br J Cancer 89:1855–1859
Kyrklund C, Backman JT, Kivistö KT, Neuvonen M, Laitila J, Neuvonen PJ (2000) Rifampin greatly reduces plasma simvastatin and simvastatin acid concentrations. Clin Pharmacol Ther 68:592–597
Acknowledgments
The work was supported in part by the chamber of pharmacists, Baden-Wuerttemberg, Germany.
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Hanna Marita Seidling and Caroline Henrike Storch contributed equally to the work
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Seidling, H.M., Storch, C.H., Bertsche, T. et al. Successful strategy to improve the specificity of electronic statin–drug interaction alerts. Eur J Clin Pharmacol 65, 1149–1157 (2009). https://doi.org/10.1007/s00228-009-0704-x
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DOI: https://doi.org/10.1007/s00228-009-0704-x