C H A P T E R 1

Introduction
Gregory J. Hughes, PharmD, BCPS, BCGP

In the internal medicine setting, managing the large assortment of tests, procedures, and medi-
cations encountered on a daily basis can be a daunting task. For students and early trainees, the
challenges can seem insurmountable. Tests, procedures, and medications are nearly ubiquitous
parts of patients’ histories and are heavily relied upon in modern medicine. These three types of
interventions have roles in the diagnostic process and therapeutic management of patients. Each
test, procedure, and medication carries with it a rich history, including indications for use as well
as potential effectiveness, complications, and toxicities. As the field learns more about each, data
accumulates and best practices evolve.
Effectively using tests, procedures, and medications is contingent upon understanding the
nuances of each intervention. While some have clinical applications supported by robust evi-
dence-based research, other applications are eminence-based or rely on inferred assumptions.
Appreciating this distinction is an essential and challenging aspect of making patient-specific
decisions. For ease of reading, throughout the remainder of this chapter, the term “procedure”
will include both what are typically thought of as “tests” and things typically called “procedures.”
The difficulty in making complex clinical decisions is inevitably compounded by interference,
or the potential for interference, between procedures and medications. Some medications can
be beneficial in the diagnostic and therapeutic process by increasing the yield of a procedure
or reducing certain risks. Other combinations of medications and procedures can be harmful
by causing complications, decreasing accuracy, or even requiring a procedure to be rescheduled.
Awareness of these interactions has practical impacts on logistics, safety, and patient education. A
key challenge for healthcare professionals is managing the multitude of scenarios that arise in a
resourceful and timely manner.
Answers to clinical questions about the interactions between procedures and medications
can be difficult to find. They vary in quality of evidence from randomized controlled trials to
expert opinion. Prior to the publication of this text, healthcare professionals were left to their
own research skills to scour a gamut of references, including primary literature, tertiary databases,
professional guidelines, and generic internet queries. This text streamlines the process by helping
healthcare professionals navigate the vast amount of information available.
The following chapters present healthcare professionals with an understanding of how proce-
dures and medications interact with one another in a single compendium. While providing many
details, the text should not be mistaken for a comprehensive instruction manual for performing
procedures or the last and final word on a complex clinical question.
This book is organized in the following manner. Chapters 2 through 6 discuss and provide guid-
ance on topics that are widely relevant to the diagnostic and therapeutic process and are therefore
applicable to the remainder of the book. These include chapters on the diagnostic process itself
(Chapters 2 and 3), chapters on anticoagulation and glycemic management in the periprocedural
period (Chapters 4 and 5), and an introductory to anesthesia (Chapter 6). Chapters 7 through 60
each detail a procedure or group of procedures and are arranged alphabetically by procedure name.
Each procedure-based chapter follows the same organized, logical, and easy-to-follow format.
Each chapter begins with a “Background” section, which provides a brief description of the proce-
dure. Often, the etymology of the procedure is included, as it may help early trainees understand

1
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2 A MEDICATION GUIDE TO INTERNAL MEDICINE TESTS AND PROCEDURES

medical terminology and appreciate the importance of nomenclature. Then, the role of the pro-
cedure is described in the “How To Use It” section. This section details the circumstances in
which the procedure is typically performed or its indications in addition to the type of infor-
mation the procedure may garner. Next, in the “How It Is Done” section, the physical logistics
of the procedure are described. While not intended to be a full instruction manual, this section
includes enough information for a clinician to properly describe the procedure to a new practi-
tioner, trainee, or patient (who may be nervous about undergoing a procedure for the first time).
It also includes standard information such as the setting in which the procedure takes place (e.g.,
outpatient, at the bedside, in a radiology suite), whether the patient will be awake for the proce-
dure, an approximation of the procedure duration, and how a “normal” result might be described.
The focus of each chapter lies in the “Medication Implications” section. This section describes,
as appropriate, which medications should be given or held before, during, or following the pro-
cedure. For example, certain procedures intrinsically involve a medication (e.g., dexamethasone
in a dexamethasone suppression test). Some medications improve the yield of a procedure (e.g.,
iodinated contrast media in computed tomography). Others must be discontinued to avoid harm
or invalidation of the results (e.g., caffeine before a stress test, opioids before a gastric emptying
study). Some chapters, where appropriate, discuss pharmacotherapy for the most common diag-
noses (e.g., antibiotics for pneumonia). The “Medication Implications” section includes rationales
and specific logistics for timing and dosing, when reasonable, as well as discusses if the procedure
can identify adverse medication effects. References are included throughout all chapters for read-
ers seeking additional information or details.

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