Volume , Issue

The first installment of the BaseCamp Rx column, The Right Stuff, asked readers to “Know Your Drugs: Make sure you are fully informed about the drugs you are carrying and administering (if allowed).” It reviewed the Rights of Medication Administration—the tenets that should be followed not only in a professional setting, but I will add, for personal use as well. If you’ve been trained in medicine, nursing, pharmacy, EMS, etc., then you have taken pharmacology courses and have formally learned the proper uses of medication administration. But if you aren’t formally trained, do you know enough about the medications that you are putting into your own body?

The following Rights are applicable whether you are a practitioner recommending or providing a medication for a patient, or it’s for you:

  • Right Patient: The medication belongs to the correct person
  • Right Time: The medication is dosed correctly according to the appropriate schedule
  • Right Medication: The medication is for the correct person and correct for the condition
  • Right Dosage: The medication is the correct dosage for the person and for the condition
  • Right Route: The medication is being administered via the correct route: oral, sublingual, topical, parenteral, etc.
  • Right Expiration Date: This appears on the original manufacturer's package or the pharmacy bottle label (as discussed in the May 2021 and November 2015 installments of this column)
  • Right Response: Make sure the drug you gave resulted in the desired pharmacologic effect, especially if given for an acute situation

Drug Information Sources

In addition to textbooks and professional online resources, there is an overwhelming tsunami of print magazines, websites, apps, social media sites (think movie stars), etc. providing information about health, herbs, supplements, magic potions, illicit and licit drugs. But like a tsunami, some of this information rushes onto the scene, then recedes just as quickly. Healthcare professionals are trained on those drug information resources that are the best for their particular field of practice, which can be very expensive and/or accessible only through a university/college or practice setting. For those that don’t have access to costly subscriptions or don’t want to pay for them, there are some terrific free websites and apps that provide accurate and useful drug information.

I will be the first to admit, although I haven’t practiced in a pharmacy for quite some time, that these days, many prescribing healthcare practitioners (physicians, PAs, NPs) and even pharmacists may not take enough time counseling their patients on prescription drugs, nor inquiring about whether they are taking any over-the-counter medications, herbs, supplements, and recreational drugs, including alcohol (and think THC with more and more states legalizing it.) So, if you are a wilderness medicine practitioner prescribing or administering a medication or you’re packing a personal medical kit for a wilderness trip, you need to be familiar with not only the drugs being administered for an allergic reaction or traveler’s diarrhea, for example, but you should also consider other substances being taken and what they are being taken for.

Prescribing Information

Nothing replaces the drug prescribing information or package insert (PI), available for both prescription and many OTC drugs, for the most complete information on indications (disease/condition being treated), dosage and administration, adverse reactions, contraindications/warnings/precautions, drug interactions, dosage forms and strengths, storage and handling, and use in special populations like the elderly, pediatrics, and pregnancy/breast feeding. But no one really wants to plow through the entire PI, not even physicians—the FDA adopted the Physician Labeling Rule in 2001 to make the prescribing information more readable and well, understandable for busy practitioners. And sometimes a full PI is not available for products that have been generic for years, or the PI is outdated.

Remember that the information about a drug in the prescribing information is considered on- label, but drugs can be used off-label as well, that is, for an indication, dose, or population that is not in the PI. Generally, this is done under the direction of a prescriber.

The Physician’s Desk Reference (PDR) is sort of the bible of PIs, as it used to be a hardcopy compilation of PIs and pharmaceutical manufacturer contact information. The burly tome, weighing almost 5 pounds, was finally discontinued in 2017 after a 74 year run, but is now renamed the Prescribers’ Digital Reference and is available online (pdr.net), and as the app mobilePDR®. The site also contains information about nonprescription drugs, but not herbs or supplements; the latter used to be available in previous hardcopy versions. In the “Using Drug Information Resources to Search” below, you’ll see that pdr.net may contain off-label information as well.

Another extremely comprehensive source for product labels is [email protected], but for the average user, there is much more wheat than chaff here. For those that want whole grain, though, this site from the FDA seems to have it all. Although not nearly as comprehensive, DailyMed, from the National Library of Medicine (NLM), is much more user-friendly, and includes photos as well.

Pill Identification

Calling a poison center or drug information center (in a hospital, for example) that used Identidex®, or buying a PDR and plowing through all of the photos in the front of the book used to be the only way to identify that pill that rolled under the bed or what that blue one is in the bottle of pills you threw together the last time you traveled. Like identifying potential edible mushrooms or plants, it’s a good idea to use more than one pill identifier, unless with the first identification, it jars your memory.

Believe it or not (of course you can believe it), you can type in the color, shape, imprint – or any combination of these – into google.com and it will quickly come up with sites that have pill identifiers.

Drug Interaction (DI) Checker

It’s important to ascertain whether clinically relevant drug interactions are going to occur with currently taken medications, including OTC drugs, as well as herbs, supplements, alcohol, and recreational drugs, although there usually is not information regarding the latter. So something that was once relegated to a prescriber or pharmacy is now in the hands of anyone with a smartphone or computer. If an important drug interaction has been identified, it would be prudent to discuss this with the prescribing physician or pharmacist.

Reliable and Free Drug Information Websites and Apps

As noted above, there is A LOT of drug information out there available to graze on. But what is safe to consume? Be very wary of personal testimonials—an N of 1 or even 5 doesn’t mean that peculiar adverse reaction will happen if you or your mother take the same drug. Use reliable and trusted sources of information.

Below are listed what I think are websites and apps that provide reliable and free sources of drug (and disease) information. There are many sites and apps that provide drug pricing information; a good example is GoodRx.

Name  Type  Drug info search  Pill ID Interaction checker
 Comments
 Drugs.com  app, web  x  x  x  Need to create free account
 Epocrates  app  x  x  x  Free account; upgrade to “Plus” for more content
 Medline Plus  web  x      From NLM; includes herbs and supplements too
 Medscape  app, web  x  x  x  Create a free account
 Rxlist.com  web  x      Create a free account
 WebMD  app, web  x  x  x  Consumer-oriented

Using Drug Information Resources to Search

As an example, let’s use a drug and indication that is near and dear to wilderness medicine, acetazolamide (tablets) prescribed for acute mountain sickness prophylaxis. Here’s what you will find if you search on this drug using the various resources.

Prescribing Information

From the prescribing information accessed from DailyMed:

Acute Mountain Sickness

Dosage is 500 mg to 1,000 mg daily, in divided doses. In circumstances of rapid ascent, such as in rescue or military operations, the higher dose level of 1,000 mg is recommended.  It is preferable to initiate dosing 24 hours to 48 hours before ascent and to continue for 48 hours while at high altitude, or longer as necessary to control symptoms.

However, as noted above, pdr.net. can contain off-label information (see the WMS clinical practice guidelines on altitude illness, the clinical practice guidelines mentioned below):

For altitude sickness prophylaxis, including prevention of high altitude cerebral edema. Oral dosage (regular-release tablets)

Adults
125 mg PO twice daily is recommended by clinical practice guidelines.  Prophylactic medications should be considered in addition to slow ascent for moderate- to high-risk situations. Start prophylaxis with acetazolamide the day prior to ascent if possible; however, beneficial effects are still seen if started the day of ascent.  Continue prophylaxis for 2 to 3 days after reaching the target altitude or until descent is initiated.  The FDA-approved dosage is 500 to 1,000 mg PO daily, in divided doses, beginning 24 to 48 hours before ascent and continuing for 48 hours while at high altitude.  In circumstances of rapid ascent, such as rescue or military operations, 1,000 mg PO daily, in divided doses, is recommended.  Although effective, higher prophylactic doses (i.e., 500 to 1,000 mg daily) may be associated with increased side effects such as paresthesias, urinary frequency, and dysgeusia.

Infants†, Children†, and Adolescents† 2.5 mg/kg/dose PO every 12 hours (maximum: 125 mg/dose) is recommended by clinical practice guidelines.  Prophylactic medications are not routinely recommended for pediatric patients; slow ascent is preferred.  If a rapid ascent is unavoidable or the patient is at high risk of developing altitude sickness, start prophylaxis with acetazolamide the day prior to ascent if possible; however, beneficial effects are still seen if started the day of ascent.  Continue prophylaxis for 2 to 3 days after reaching the target altitude or until descent is initiated.

Drug Interactions

 Using WebMD’s drug interaction checker, a significant DI was found between acetazolamide and aspirin, which may be an OTC drug being taken for various reasons.  Note:  Add the drugs separately before searching and read the Disclaimer.

Pill Identification

This one is always the most fun. Using Medscape’s app (iOS) or website (medscape.com, under Drugs & Diseases), entering “S 572” into the Pill Identifier yielded this:

But a simple search on google yielded the same thing, displaying the results from several sites that contain pill ID tools

Price

In GoodRx, type in your zip code and it displays local pharmacies. The site also contains a photo of one manufacturer’s tablet (since acetazolamide is generic, there may be a number of companies that sell it).

Free EMS/Wilderness Medicine Drug Information Apps/Websites

There are a number of well-respected wilderness medicine textbooks, but they aren’t really practical for the field unless you’re training for a backpacking trip ( Auerbach’s 2-volume set is 13 pounds!). Field guides are more portable (Forgey’s is 1 pound). Purchased textbooks can be accessed online with programs like inkling.com, but this would require a reliable internet connection. And these texts aren’t free, of course.

Epocrates was the only website and app that I could find that provided some free wilderness medicine content under their Drugs - Emergency section, Anaphylaxis and Toxicity: Envenomations, and Immunizations, Routine Adult Vaccines, Routine Pediatric Vaccines, and Travel Vaccines.  

From: Epocrates app (iOS)

From: Epocrates app (iOS)

From: Epocrates app (iOS)

And speaking of vaccines, the best source of free information is always the CDC website and various apps they offer.

Did I Leave Anything Out?

Are there any free drug information resources (especially for wilderness medicine) that you use that I missed? Please let me know! Shoot an email to [email protected].

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