High-alert drugs are drugs that bear a heightened risk of causing significant patient harm when they are used in error.
High-alert drugs carry a significant risk of causing serious injury or death to patients when they are used in error. Although mistakes may or may not be more common with these drugs, the consequences of an error are clearly more devastating to patients.
For years, the Institute for Safe Medication Practices (ISMP) has published a list of high-alert medications for acute care settings. ISMP gives the following strategies to reduce the risk of errors and minimize harm.
- Standardizing the ordering, storage, preparation, and administration of these medications
- Improving access to information about these drugs
- Limiting access to high-alert medications
- Using auxiliary labels and automated alerts
- Employing redundancies
High Alert Drugs
The following medicines should ‘ring alarm bells’ as having important interactions:
- Warfarin
- Statins
- Macrolide Antibiotics
- Calcium Channel Blockers
- Azole antifungals
- SSRIs – fluoxetine
- Amiodarone
- Digoxin
- Rifampicin, Isoniazid
- Antiepileptic medicines – particularly carbamazepine, phenytoin; less so valproate
Important Drug Interactions of High Alert Drugs
Warfarin
Monitor INR and patient closely when adding metronidazole, ciprofloxacin, cotrimoxazole, clarithromycin, doxycycline, fluconazole, azathioprine, rifampicin, isoniazid, carbamazepine, phenytoin, sulfasalazine, amiodarone Adjust dose of warfarin, at the outset, when adding these drugs Switch to LMWH or UFH
Atorvastatin
Do not use with verapamil, clarithromycin, itraconazole, fluconazole, ciclosporine Monitor CPK levels Switch to rosuvastatin (with warfarin, atorvastatin may be better) when adding any of these drugs
Clarithromycin
Do not use with atorvastatin, digoxin, warfarin, dabigatran, rivaroxaban, apixaban, colchicine, phenytoin, carbamazepine and drugs that prolong QT interval May use azithromycin or another antibiotic in patients taking any of these drugs
Itraconazole, Fluconazole
Do not use with atorvastatin, dabigatran, rivaroxaban, apixaban, digoxin
Use carefully with warfarin, carbamazepine, phenytoin, rifampicin
Digoxin
Do not use with clarithromycin, itraconazole, ciclosporine, verapamil, diltiazem Use carefully with diuretics, amiodarone, rifampicin, phenytoin, carbamazepine
Rifampicin, Isoniazid
Use carefully with hepatotoxic drugs Use carefully with phenytoin, carbamazepine, warfarin, digoxin, calcium channel blockers, oral contraceptives, corticosteroids, sulfonylureas, macrolide antibiotics, azole antifungals
Carbamazepine, Phenytoin
Do not use with clarithromycin, oral contraceptive pills Use carefully with warfarin, itraconazole, isoniazid, rifampicin
Amiodarone
Use carefully with digoxin, warfarin, carbamazepine, phenytoin, and drugs that prolong QT interval
Sildenafil
Do not use with nitrates
Allopurinol
Do not use with azathioprine
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