CDS DRUG EFFICACY 1

CDS Application: Efficacy of Continued Drug Therapy

Mitchell Ward

University of San Diego

December 13, 2019

CDS DRUG EFFICACY 2

Abstract

Drug efficacy is a personalized task that is difficult for providers to manage. Resistance and

tolerance can build up over time resulting in diminished effects and increased dosages. Illnesses

that call for antibiotics, chronic diseases and other conditions with continued drug use give rise

to many of the complications of drug efficacy. Implementing a clinical decision support (CDS)

rule that proposes alternative therapies to providers is a means to combat reduced drug efficacy.

Current and future complications arise from resistance and tolerance. Antibiotic resistant

germs are very hard to treat and happen often each year in the United States. Ineffective

antibiotics can lead to further problems including sepsis, surgery complications, and a weakened

immune system. Extended opioid usage brings about concerns for abuse and many significant

health problems.

This CDS rule is implemented when a provider is making the decision to fill the patient

order. Pertinent history and related drug interactions are presented along with suggested

alternative options for treatment. Alternative options are evidence-based therapies for a specific

symptom or condition. If a drug to drug interaction CDS alert is already in place, this new rule

would be an addition to make a more complete tool.

Monitoring extended drug use paired with the continued examination of efficacy can help

to further improve the drug efficacy CDS rule. Discovering more alternative options and

studying drug interaction mechanisms are both efforts to reduce resistance and tolerance while

adding more data to advance the clinical decision support. New development of drugs that are

more resistant to a reduction in efficacy compliment the benefits this CDS rule brings.
CDS DRUG EFFICACY 3

CDS Application: Efficacy of Continued Drug Therapy

Maintaining drug efficacy is a complex, individualized task for pharmacist and other

providers that requires information from multiple sources. The efficacy of a drug is its ability to

produce a desired or intended result. Resistance and tolerance are two factors that determine the

drug’s efficacy and they can vary from each individual person. Tolerance is a diminished

response, which occurs after the body adapts to the repeated use of a drug and resistance is when

microorganisms are no longer killed or inhibited by antimicrobial drugs (Lynch, 2019).

Tolerance is difficult to control, especially when there are chronic conditions being

managed by continuous medication. Prolonged use can cause an increase in liver enzyme activity

which results in a faster metabolism for the drug (Lynch, 2019). A common example is the

accelerated metabolism to opioids over time. Another possible explanation is the decrease in

number of receptors and their binding affinity to a drug over extended use (Lynch, 2019).

Microorganisms become resistant to antimicrobial drugs through a genetic change from a

mutation or gene acquisition (Lynch, 2019). Due to this modification, the resistant organisms

will eventually become predominant over the other species. Having most of the organisms

resistant to the previously functioning drug continues to reduce drug efficacy.

The addition of a clinical decision support (CDS) rule that displays information on the

previous use of drugs can assist pharmacist with solutions for decreased efficacy. Therefore, if

already in place, commonly used CDS rules for drug to drug interactions become further

enhanced.

Rationale

These combined impediments of drug efficacy, tolerance and resistance, pose a problem

for the extended and future use of many common drugs such as opioids, antibiotics and others
CDS DRUG EFFICACY 4

continually used. “Infections caused by antibiotic-resistant germs are difficult, and sometimes

impossible, to treat” (Centers for Disease Control and Prevention (CDC), 2019). The CDC

continues to state that in the U.S. there are more than 2.8 million antibiotic-resistant infections

each year. Many of these resistant germs can spread from person, animal or environment which

delivers an interconnected threat (CDC, 2019).

The clinical consequences of extended antibiotic use and resistance mirror the personal

problems that occur. Ineffective antibiotics contribute to difficulties in areas like sepsis

treatment, and surgery when infections go uncontrolled (CDC, 2019). In chronic conditions, the

CDC explains that such patients are at a higher risk for infection due to some medications ability

to weaken the immune system.

Opioid usage is often prescribed for pain therapy which brings up safety and efficacy

concerns as well. More people died from drug overdoses in 2014 than any year prior and about

eighty percent of new heroin users are previous opioid abusers (Just Think Twice, n.d.). The

longer patients are prescribed opioids, the higher the risk for overdose and other significant

problems including gastrointestinal, respiratory, musculoskeletal, cardiac, immune, central

nervous system, and endocrine (Baldini, Von Korff & Lin, 2012).

Utilization

The CDS rule works to display the drug being prescribed and how long it has been

prescribed for along with similar or related medications. The rule is only activated once a set

amount or time has passed while using a drug. Supplemental information would be provided to

suggest either alternate therapy or considerations to end or reduce the prescription. For example,

if an antibiotic has been continuously used to fight bacteria and is not reaching the intended

result, a suggestion for the use of bacteriophage therapy in place of the antibiotic would appear
CDS DRUG EFFICACY 5

(Allen, 2017). A few proposals for opioid alternatives would include considerations for physical

therapy, surgery, acupuncture, nerve blocks, and potentially stem cell therapy (American Society

of Anaesthesiologists, n.d.). The provider will then have the options to view and select other

therapies, continue with medication, or an option to select that the patient refused alternate

options. The alternative suggestion provided will reflect evidence-based research treatment

options for the specific condition once the criteria threshold, amount or time, is met.

Timing for the CDS rule would appear when the provider is determining whether to fill

the prescription. This rule would be in sync with a drug to drug interaction CDS if it is already in

place. Incorporating the two clinical decision support rules into one, more complete assistive tool

can further the knowledge and care of the provider. The CDS rule provides more options for care

to accommodate for patient specific needs with the objective to increase patient satisfaction and

catalyze improved treatment.

Summary

Emphasis should be on monitoring extended drug usage more closely. The continued

examination of drug efficacy can help to point out mechanisms to produce drugs that avoid

resistance better and have longer therapeutic responses (Université de Montréal, 2012). Focusing

on specific processes like receptor recycling and other receptor to drug interactions over the

course of continuous medication can improve the CDS rule further. Discovering more

information on certain mechanisms or drugs could provide more suggestions to pharmacist for

alternative options. Employing alternative therapies can reduce the total amount of a medication

used in treatment. The amount that a drug is used is a major component of tolerance therefore

reducing the amount can delay or halt an increase in tolerance (Lynch, 2019). Studying

interaction mechanisms and drug usage over time adds more data for the CDS rule which can in
CDS DRUG EFFICACY 6

turn provide additional treatment options and medications that are more resilient to a loss

efficacy.
CDS DRUG EFFICACY 7

References

Allen, H. K. (2017). Alternatives to Antibiotics: Why and How. NAM Perspectives. doi:
10.31478/201707g
American Society of Anaesthesiologists. (n.d.). Pain Management - Non-Opioid Treatment for
Chronic Pain. Retrieved from https://www.asahq.org/whensecondscount/pain-
management/non-opioid-treatment/#:~:targetText=What%20are%20some
%20alternatives%20to%20opioids%3F,these%20are%20all%20they%20need
Baldini, A., Von Korff, M., & Lin, E. H. (2012). A Review of Potential Adverse Effects of
Long-Term Opioid Therapy: A Practitioner's Guide. The primary care companion for
CNS disorders, 14(3). doi:10.4088/PCC.11m01326
Centers for Disease Control and Prevention (CDC). (2019, November). About Antimicrobial
Resistance. Retrieved from
https://www.cdc.gov/drugresistance/about.html#:~:targetText=Antibiotic%20resistance
%20happens%20when%20germs,and%20sometimes%20impossible%2C%20to%20treat.
Just Think Twice. (n.d.). Facts About Opioids and Heroin. Retrieved from
https://www.justthinktwice.gov/facts-about-opioids-and-heroin
Lynch, S. (2019, July). Tolerance and Resistance. Retrieved from
https://www.merckmanuals.com/professional/clinical-pharmacology/factors-affecting-
response-to-drugs/tolerance-and-resistance.
Université de Montréal. (2012, April 3). Why some pain drugs become less effective over time.
ScienceDaily. Retrieved from
www.sciencedaily.com/releases/2012/04/120403171925.htm