Table 3

Actual messages in e-prescribing software—pain medications

Trigger drug	Short warning	Text displayed if prescriber presses the more button	Alternative medications shown
Indomethacin	Warning—high risk of CNS ADRs in the elderly …more	‘Indomethacin produces the most CNS adverse effects such as headache, vertigo, and dizziness of all NSAIDs when used chronically. Although all NSAIDs may increase the risk of serious GI complications such as perforation, obstruction and haemorrhage (especially in elderly patients), potent agents such as indomethacin also have an increased risk over other NSAID and COX-2 inhibitors. Acute renal failure, hypertension, and worsening heart failure also occur in elderly patients.’	Acetaminophen (±codeine) Lidocaine patch Celecoxib: osteoarthritis 200 mg QD or in divided doses; rheumatoid arthritis 100-200 mg BID Ibuprofen: 2400 mg/24 h (every 8–12 h) or naproxen for short-term use Tramadol Opiate such as morphine Choline magnesium trisalicylate: 5500 mg/24 h (every 8–12 h)
Ketoralac	Warning—high risk of GI bleed, renal failure, elevated BP and CHF in the elderly …more	‘Ketoralac has significant adverse effects including serious GI complications such as perforation, obstruction and haemorrhage especially in elderly patients. Ketoralac is not appropropriate for chronic use. Acute renal failure, hypertension, and worsening heart failure also occur in elderly patients.’	Acetaminophen (±codeine) Lidocaine patch Celecoxib: osteoarthritis 200 mg every day or in divided doses; rheumatoid arthritis 100–200 mg twice daily Ibuprofen: 2400 mg/24 h (every 8–12 h) or naproxen for short-term use Tramadol Opiate such as morphine Choline magnesium trisalicylate: 5500 mg/24 h (every 8–12 h)
Piroxicam	Warning—high risk of GI bleed, renal failure, elevated BP and CHF in the elderly … more	‘Piroxicam has significant adverse effects including serious GI complications such as perforation, obstruction and haemorrhage especially in elderly patients. Acute renal failure, hypertension, and worsening heart failure also occur in elderly patients.’	Acetaminophen (±codeine) Lidocaine patch Celecoxib: osteoarthritis 200 mg every day or in divided doses; rheumatoid arthritis 100-200 mg twice daily Ibuprofen: 2400 mg/24 h (every 8–12 h) or naproxen for short-term use Tramadol Opiate such as morphine Choline magnesium trisalicylate: 5500 mg/24 h (every 8–12 h)
Propoxyphene	Warning—lack of efficacy in the elderly with increased risk of ADRs … more	‘Propoxyphene is an opioid analgesic that has been available for many years, despite limited efficacy even when compared with acetaminophen or aspirin. Propoxyphene may cause constipation and cognitive impairment, as well as other CNS effects. Several epidemiological studies have identified an association between cognitive impairment with propoxyphene and an increased risk of falls and fractures in elderly adults. In addition, many propoxyphene products also contain acetaminophen which may result in unintentional overdoses and hepatotoxicity if the elderly individual is taking other RX or OTC products containing acetaminophen.’	Acetaminophen ±codeine Celecoxib Ibuprofen Naproxen short term only Opiates such as morphine

ADR, adverse drug reaction; BP, blood pressure; CHF, chronic heart failure; COX-2, cyclo-oxygenase-2; CNS, central nervous system; GI, gastrointestinal; NSAID, non-steroidal anti-inflammatory drug; OTC, over the counter; RX, prescription; TCA, tricyclic antidepressant.