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Adverse drug reactions - Management
Additional information

  • Assess the nature and severity of the reaction:
    • This will determine whether urgent action is required or whether the individual can be managed in primary care. See Managing a suspected reaction for further information:
      • For example, a cough due to an angiotensin-converting enzyme inhibitor can be troublesome but not life threatening, but an anaphylactic reaction is a medical emergency.
    • The nature of the presenting condition may strongly suggest that it is an adverse drug reaction (ADR). For example, the following conditions are often ADRs:
      • Acute dystonias
      • Blood dyscrasias
      • Skin reactions, such as Stevens–Johnson syndrome and toxic epidermal necrolysis
      • Neuroleptic malignant syndrome
  • Take a history of the presenting symptoms:
    • Timing:
      • The time from when use of the medicine was started to when the reaction develops may be characteristic of the reaction (e.g. anaphylaxis usually develops within a few minutes of parenteral drug administration).
      • If the drug was stopped, the time it took for the reaction to abate will often be related to the known duration of action of the drug.
    • Relationship to dose:
      • Adverse drug reactions are often dose related and may be minimized by reducing the dose.
      • If the symptoms resolve when the medicine is withdrawn, the symptoms may have been associated with the medicine although it could still have been coincidental.
      • If a medicine is reintroduced and symptoms recur, the medicine is most probably responsible. However, deliberate re-challenge is only very rarely justified (clinically and ethically) after serious adverse reactions because of the risks involved.
    • Other possible causes:
      • The symptoms may be a manifestation of the person's underlying illness or another disease.
      • Other medications (including self-medication and herbal remedies) could be responsible.
      • Consider the possibility of drug interactions (including with food and drinks).
  • Consider the drug history and review any history of allergy or previous adverse drug reactions:
    • Take a complete drug history including when the drug was started, what dose is being taken, what other drugs are being taken and whether the patient is also on over-the-counter or herbal medicines.
    • Check whether the person ever had similar symptoms or presentation in the past when taking other drugs (from the same or a different drug class) or has a history of atopy or of adverse drug reactions with different presentation(s).
    • Even if a drug has been withdrawn some time before, it may have been responsible for the adverse effect if it has a very long duration of action (e.g. amiodarone).
  • Review the adverse effect profile of the drug:
    • Are the signs and symptoms in keeping with the documented adverse effect profile of the drug?
    • Has the ADR been reported before?
      • This can be checked with the readily available sources of information listed below.
    • How common is the suspected adverse reaction?
    • Readily available sources of information regarding the ADR profile of individual drugs include:
      • The British National Formulary (BNF), available online.
      • The electronic Medicines Compendium (www.medicines.org.uk). A complete listing of suspected ADRs reported to this agency through the Yellow Card scheme by health care professionals and patients is available for individual drugs. These reports (termed Drug Analysis Prints) can be accessed online.
      • Regional and district medicine information services. Details of regional centres and other useful contacts can be found in the front of the BNF and BNFC (or online). Local services can found by contacting the medicines information department or the hospital pharmacy in major hospitals.
  • Consider further examinations and investigations:
    • Are specific investigations and laboratory tests required (e.g. liver or renal function tests)?
    • Will the adverse drug reaction lead to further complications (e.g. gastrointestinal bleeding)?
    • Is drug monitoring necessary (e.g. checking the serum digoxin concentration in a person with suspected toxicity)?

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