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Allergy & Intolerance Drug Sub-project questions

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Open Questions

Scope & Governance

  1. How do we present guidance?
    1. False categories (seafood) - may provide frequency but omit value from heuristic list.
    2. Mislabeled categories (iodine contrast vs. high osmolality contrast) - can't distinguish with the data we have
    3. Distinguishing allergies from side effects (e.g., denying azithromycin due to erythromycin sensitivity better managed by contraindications) - can't distinguish with the data we have
    4. Criticality - to what extent can we prioritize substances based on likelihood that sensitivity may be critical? - can't distinguish with the data we have; see what USP comes up with

Domains

  1. How do we vaccines
    1. Many vaccines below threshold.
    2. TNF below threshold, and it's a toxin anyway
    3. Vaccines above threshold have more specific RxNorm values
      1. influenza virus vaccine, inactivated; Influenza Virus Vaccine, flu vaccines, INFLUENZA VACCINE TR-S 11 (PF): RxNorm values are specific to a, b, c
      2. pertussis vaccines: Pertussis Vaccine [RxCUI = 8080] - seems distinct from acellular variants
      3. Pneumococcal vaccine: 23 types, ditto.
      4. DTP Vaccine: no generic concept, ditto.
      5. VARICELLA VIRUS VACCINE LIVE, ditto
    4. Should we then use SCT for vaccines for now? E.g.,SCT 396433007 |Pertussis vaccine (substance)|?
    5. Other biologics below threshold

Specific Questions

  1. Need to specify route for certain substances?
    1. See sheet of iodine & media terms here
    2. Iodine: is povidone always topical? (Can be ophthalmic, but below threshold) Is it ever systemic?
    3. aloe vera topical - always?
  1. ASPIRIN BUFFERED. Aspirin? Or ASA + Al(OH)3 + CaCO3 + Mg(OH)2?
  2. iodinated glycerol: this substance, or is this about iodine?
  3. Tegaderm. Propose: hydrocolloid (substance)
  4. Simvastatin, atorvastatin, pravastatin, rosuvastatin: distinct, or cross-reactive "statin"?
  5. Tape: How many kinds of tape do we need - plastic, paper, surgical, adhesive, medical, cordran, silk, steristrip, opsite, transparent? Or is this really about adhesive?
    1. Is adhesive one substance or do brands differ?
  6. Metal, nickel, trace metals? Top 500 has only nickel sulfate.
  7. Do we need acetaminophen, aspirin, naproxen or does NSAIDs do the job?
  8. Beta Lactamase Inhibitors: no class in SCT

Closed Questions

Scope

  1. How do we confirm quality?
    1. Process
      1. Acquire maps.
      2. If count(maps) > 1 and they agree, status is ok.
      3. If count(maps) < 2, acquire more maps.
      4. If count(maps) > 1 and they disagree, review.
  2. Encode and then combine, or combine and then encode?
    1. Encoding is required to combine
  3. How do we weight lists?
    1. Use filtered rankings to assess divergence, but no weighting in frequency list.
  4. Rank all substances from contributed lists, or only those to a chosen level (97%, 99%, etc.)?
    1. Identified substances with counts > 500 (individually ~0.0017%; aggregate 0.71%)
    2. Actually, 1000. 4/19/17.
    3. Include frequency ratios in resulting list; users may choose their own thresholds.
  5. How do we harmonize frequency thresholds for drugs (1000) & food (lower)?
    1. Separate lists.
  6. Should we provide a single mapping per code or a multiple mapping table?
    1. Tentatively, one. More later if requested.
  7. Should we provide a single value set for substances or multiple sets for drugs, food, other?
    1. In VSAC, the sets have values from a single system, so we are looking at several value sets, possibly with a "grouping" value set to tie them together.
  8. Stewardship: who owns and maintains the list? Patient Care? Vocabulary? Someone else?
    1. For now, Patient Care

Domains

  1. Include substances only, or also null and negative values?
    1. Use is the criterion: include what is used. Agreed 10/19
    2. Specific negatives are rare; we anticipate two (nka & nkda).
  2. Negatives: we have NKA, NKDA, NKFA. Do we need NKEA, NKFDA?
    1. Frequency is the criterion.
  3. How do we identify herbals, supplements
    1. As other medications, if in RxNorm
  4. How do we identify environmentals
    1. SNOMED CT, which supports classification (e.g., 'wasp venom' vs many species-specific terms in UNII).

System Choice

  1. What system(s) should be used for encoding?
    1. Assumption: do we need to choose, or can we provide a list of substances with all pertinent code assignments?
    2. Criteria
      1. Maximal coverage of identified requirements
      2. Ability to add missing items
      3. Freely available
      4. International
    3. Candidates
      1. SNOMED CT: substances, classes; mixtures only as products. Licensing issue.
      2. RxNorm: substances & mixtures. No license issue, but US realm.
      3. NDF-RT: classes only. Class definitions problematic.
      4. UNII: substances only. US realm. no relationships (e.g., of salts)
      5. ATC: classes only. Class definitions problematic.
      6. INN: no access to list; tbd
      7. Proposal to use whatever G-SRS chooses to use. Will evaluate when available.
    4. Answer: for now, RxNorm (substances - IN & mixtures - MIN) and SNOMED CT (classes) meet our needs. When G-SRS can provide data for comparison and testing, we can confirm whether it also meets our needs and decide whether to map or replace the US realm list.

Details

  1. Salt forms of medications are not relevant to the purpose of this list. Incidences recorded as salt forms should be summed to the incidence of the general form (e.g., codeine sulfate as codeine).
    1. Salts in solution have limited effect on the active moiety. This does not mean that an intolerance reaction dependent on a salt is not possible; only that it is not common enough to merit inclusion in this list.
  2. Route can be significant.
    1. Enterally administered aspirin does not cross-react with topical salycilates. Topical salycilates should be specified as topical. Similarly, sensitivity to topical iodine preparations is not cross-reactive with intravenously administered iodine.
      1. confirm cross-reactivity. whether iodine can be the problem is a different question.
  3. How do we identify supply items (latex, adhesive)
    1. Latex: RxNorm
    2. Adhesive: SCT classifier 418920007 |Adhesive agent (substance)|
  4. Food/Drug items: record as both or as one?
    1. Eggs, lactose, fish oil, caffeine, alcohol
    2. Multiple lists. Include question in ballot (RxNorm drug caffeine + SCT food caffeine)
    3. Are Sulfites & Nitrites are food
  5. Penicillins
    1. There may be truly cross-reactive subgroups but we don't have the data to identify them.
  6. Opioids: synonymous with "narcotic analgesics", "Morphine derivatives"
  7. Salicylates: We have Aspirin and Salicylates. "Topical" values below threshold.
  8. Estrogens. Class.
  9. Iodinated contrast media
    1. Keep 'iodinated contrast media'
    2. Consider describing "high osmolality contrast media" in guidance; no actual instances for list.
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