It's another hectic day in the office. You are evaluating a complicated new patient, who presents with multiple medical and psychiatric problems. Over the next 50 minutes, you're going to have to make a number of medication decisions, and you don't have the time to dig around in your bookcase, nor have you spent enough time in the gym to be able to heave around your PDR. You need all the relevant information in one spot, and you'd prefer to access it while you are sitting and talking to your patient.
These are precisely the sorts of situations that handheld databases are made for. But which one should you use?
I have been testing three of the most popular databases on my PalmOne Tungsten E2: Epocrates (www.epocrates.com), iFacts (www.skyscape.com), and Lexi-comp (www.lexi.com). Why did I choose these particular programs to test? Two of them (iFacts and Lexi-comp) were recently given top reviews in an article on drug-interaction software (Am J Health-Syst Pharm 2004;61(4):380-385). Epocrates fared poorly in that article, but it is one of the few free options available, and deserves a test drive on that basis alone.
I tested each program with two tasks:
1) Looking up drug information on Daytrana (methylphenidate transdermal system), and
2) Looking up drug interaction information for combining sumitriptan and fluoxetine.
Epocrates Vitals: Downloaded from www.epocrates.com. Free version includes drug database and drug interactions software. Paid versions range from $60 to $150 per year and include databases on alternative medications, symptoms and diseases, and lab interpretation.
I found Epocrates to be the least painful of all the programs to download and to sync into my Palm. While easy on the wallet, this comes at the price of a commercial presence. When I first opened the program after installing it, for example, I was presented with four "doc alert" messages, two of which were essentially ads for drug companies. For example, one "alert" reported, "If you have concerns about prescribing sedative-hypnotics for older adults…." Tapping "Continue" brought me to an ad for Takeda's Rozerem.
To be fair, you can easily skip over ads by tapping your home icon and then restarting the program. An ePocrates spokesperson said that the company limits sponsored doc alerts to one out of five, and that the sponsoring company is always disclosed. I suppose this is a reasonable price to pay for free software….
Tapping "Daytrana" brought me directly to a well-organized screen listing everything I would want to know quickly in order to prescribe it, including the indication, doses available, and concise instructions on of how to dose and titrate it. In order to find more information, I tapped on a drop-down menu for a list of categories. Tapping "adverse reactions" brought me to a list of 15 "serious reactions" (10 of which were labeled "rare”) and 21 "common" side effects. This was a fairly unhelpful laundry list of symptoms; there was no indication of how common symptoms were or whether their prevalence was greater than placebo.
The drug interactions program on Epocrates is called "multicheck" and is easy and intuitive to use, but the information provided was sparse. When I entered "Prozac" and "Imitrex," I was told to "Avoid/Use alternatives." Tapping further [?on what], I got "weigh risk/benefit: combo may incr. risk of serotonin syndrome (additive effects)." There was no more specific information available.
iFacts Vitals: Sold by Skyscape (www.skyscape.com), a company that sells many classic textbooks to be used on handheld devices. I tested the iFacts Drug Interactions Facts ($69.95) and A to Z Drug Facts ($49.95).
Tapping Daytrana brought me to a generic page on methylphenidate, with no information specific to Daytrana. On the right side of the screen was a confusing stack of boxes with tappable abbreviations linking to other categories. I assume these are readily memorized if you stick with the program but they look like digital hieroglyphics at first glance. There is also a drop-down menu with 15 categories, and I had to scroll quite a ways down to locate "dosing." Tapping this heading brought me to Daytrana dosing instructions, but annoyingly, in order to find the available patch sizes, I had to scroll through a description of Concerta. Tapping "adverse reactions" was a pleasant A to Z surprise, since this was a concise list of adverse events by organ system, and included prevalence, percentages, a major advantage over Epocrates.
While I was unimpressed with A to Z, the iFacts Drug Interactions program was a winner, particularly when compared with Epocrates. After entering Prozac and Imitrex, I was initially brought to a quick facts screen with a big numeral "2." iFacts summarizes clinical significance with a scale from 1 (highly significant) to 5 (only theoretically significant). Under the 2, I read: "Onset: Rapid; Severity: Moderate deterioration of patient's mental status; Documentation: Suspected." Tapping "details" delivered a wealth of information about this. Of particular interest was the "Discussion" section, which was a concise literature review on this interaction, including references.
Lexicomp As was the case with iFacts Drugs A to Z, tapping Daytrana on Lexicomp brought me to a generic methylphenidate page. Lexicomp features any black box warnings on the very first page you open, so my first impression of Daytrana was that "Misuse of Amphetamines May Cause Sudden Death...." Fair enough.
In order to find more information, though, I had to face a pull-down menu with no fewer than 44 items, an exhausting list that tempted me to close the program in favor of bench-pressing the PDR. Persevering, your intrepid reporter scrolled through the entire list to locate dosing information on the patch, which was hidden between paragraphs describing all the other methylphenidate products. The adverse reactions section was similar to iFacts in that it included clinically useful prevalence percentages.
Lexicomp's drug interaction program is called Lexi-interact, and I found it more useful than Epocrates but less useful than iFacts. Figuring out how to get the results of interactions took me a while, because when you tap the "analyze" button, you simply get a list of the medications you requested, sans analysis. After spending a few minutes in screen-tapping purgatory, I figured out where to tap and got information at a similar level of descriptive detail as in iFacts, but slightly vaguer and oriented more toward categories of drugs rather than the specific drugs of interest.
Bottom-line recommendations For very quick and telegraphic drug facts, I recommend springing 0 dollars and 0 cents for the Epocrates basic edition. The premium edition provides information on alternative treatments, not worth the price in my own fairly conventional practice but helpful if you have many patients who ask your opinion of the "dietary supplements" that many of them are surely taking. For drug interactions, I highly recommend making the $70 investment in iFacts Drug Interactions, which was more user-friendly than Lexi-interact.
By the way, I also perused several of the handheld textbooks that are available through various sources, such as APA's Psychiatry-online and iFacts. Suffice it to say that offering textbooks on a 2-inch wide screen is not one of modern technology's crowning achievements. Instead, I'd recommend shelling out about $300 for Sony's newest Portable Reader, which has a 6-inch diagonal screen and new "E-ink" technology that makes the display a pleasure to read. So many toys, so little time!
TCPR Verdict: Epocrates for speed, iFacts for interactions