Concurrent Drug Utilization Review for Patient Safety

What Is Drug Utilization Review?

Drug utilization review (DUR) is a systematic process of evaluating prescription drug use to ensure medications are used appropriately, safely, and effectively. DUR programs are mandated by federal law for Medicaid programs and are widely implemented by insurance plans, PBMs, and pharmacy systems. Pharmacy technicians encounter DUR alerts daily and must understand their purpose, types, and appropriate responses.

The Omnibus Budget Reconciliation Act of 1990 (OBRA-90) established the federal requirement for DUR programs in Medicaid. Since then, DUR has become a standard component of pharmacy practice across all practice settings and insurance programs.

Types of Drug Utilization Review

Prospective DUR

Prospective DUR occurs before the medication is dispensed and is the most common type encountered in daily pharmacy practice. When a prescription claim is submitted electronically, the PBM or pharmacy system automatically screens for potential problems. This real-time screening allows issues to be identified and resolved before the patient receives the medication.

Concurrent DUR

Concurrent DUR occurs during the course of therapy and monitors ongoing medication use patterns. It may involve reviewing therapy duration, monitoring for dosage adjustments based on lab values, and ensuring patients are receiving recommended monitoring. Concurrent DUR is particularly important for chronic medications that require ongoing evaluation.

Retrospective DUR

Retrospective DUR analyzes prescribing and dispensing patterns after medications have been dispensed. This population-based approach identifies trends, outliers, and opportunities for improvement. Results may be used to develop educational interventions for prescribers, update formulary policies, or identify patients who may benefit from medication therapy management.

Common DUR Alert Categories

Drug-Drug Interactions (DDIs)

Drug-drug interaction alerts are among the most frequent DUR alerts. Pharmacy systems classify interactions by severity:

Severe/Contraindicated: Combinations that should never be used together due to potentially life-threatening consequences. Examples include linezolid with serotonergic drugs (serotonin syndrome risk) or methotrexate with trimethoprim (bone marrow suppression).
Major: Combinations that may require dose adjustments, enhanced monitoring, or alternative therapy. Examples include warfarin with NSAIDs (increased bleeding risk) or ACE inhibitors with potassium supplements (hyperkalemia risk).
Moderate: Combinations that may have clinical significance but are often manageable with monitoring. These generate the most alerts and require pharmacist judgment about clinical relevance.

Therapeutic Duplication

Therapeutic duplication alerts fire when two medications from the same drug class are prescribed simultaneously. While sometimes intentional (such as two antihypertensives for blood pressure control), duplication may indicate prescribing errors or lack of coordination between multiple prescribers. Common examples include two NSAIDs, two benzodiazepines, or two proton pump inhibitors.

Drug-Disease Contraindications

These alerts identify medications that are contraindicated or require caution in patients with specific medical conditions documented in their profile. Examples include NSAIDs in patients with renal disease, metformin in patients with severe kidney impairment, or beta-blockers in patients with severe asthma.

Age-Related Warnings

Certain medications carry increased risks in elderly or pediatric populations. The Beers Criteria (published by the American Geriatrics Society) identifies potentially inappropriate medications for older adults, including long-acting benzodiazepines, anticholinergic medications, and certain muscle relaxants. DUR systems flag prescriptions for these medications in patients over 65.

Dose Range Checks

DUR systems compare prescribed doses against established maximum and minimum dose ranges. Alerts fire when doses exceed recommended maximums or fall below typical therapeutic minimums. These checks are particularly important for medications with narrow therapeutic indexes and for pediatric weight-based dosing.

Early Refill Alerts

Early refill alerts identify prescriptions being filled before the expected completion date of the previous fill. While sometimes legitimate (vacation supply, dose change, lost medication), early refills may indicate potential misuse or diversion, particularly for controlled substances.

Pharmacy Technician Responsibilities

Pharmacy technicians encounter DUR alerts throughout the prescription processing workflow:

Alert identification: Recognizing when the pharmacy system generates a DUR alert during claim processing
Documentation: Recording alert details accurately for pharmacist review
Pharmacist notification: Ensuring all clinically significant alerts are brought to the pharmacist's attention promptly
Alert resolution: After the pharmacist reviews and makes a clinical decision, processing the appropriate override code or contacting the prescriber as directed
Patient profile maintenance: Keeping patient allergy information, condition codes, and medication histories current to support accurate DUR screening

Alert Fatigue

One of the biggest challenges in DUR is alert fatigue, which occurs when clinicians receive so many alerts that they begin to routinely override them without careful evaluation. Studies show that up to 90% of DUR alerts are overridden by pharmacists. While many overrides are clinically appropriate, alert fatigue can lead to important warnings being missed. Efforts to improve DUR systems focus on reducing low-value alerts and ensuring high-severity alerts receive proper attention.

PTCB Exam Tips

DUR is a key patient safety topic on the PTCB exam. Focus on understanding the three types of DUR, common alert categories, and the pharmacy technician's role in the DUR process. Use our practice questions and flashcards to reinforce your knowledge of drug interactions and safety screening concepts.