The implementation of an electronic clinical decision support (CDS) tool to inform clinicians or pharmacists of potential interactions between a patient’s myasthenia gravis (MG) and medications reduced patient exposure to potentially harmful medications, according to an article published in Muscle & Nerve.

The study found that the CDS alert system was able to reduce overall patient exposure to potentially harmful drugs by 19%. The reduction in exposure was higher for inpatient orders than outpatient orders, with 138 out of 385 instances (35.8%) being avoided for inpatients compared to 20 out of 445 instances (4.4%) for outpatients.

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“Development of an effective CDS tool for medication-disease interactions can support prescribers in selection of medications that optimally balance medication efficacy and safety for the treatment of co-morbid conditions,” the authors said.

The medication avoidance rate differed between drug classes as well, with a systemic beta-blockers avoidance rate of 18% and a 78% avoidance rate for aminoglycosides during inpatient care, as examples.

For inpatient care, the CDS tool would inform both the ordering clinician as well as the pharmacist of the potential interactions. Because of this 2-stage alert, 7.6% of medication exposures were avoided because of the pharmacist’s review after the ordering user initially overrode the warning.

Of factors that may have influenced whether an alert was overridden, the level of alert was a factor. Alerts marked as “contraindicated” were significantly less likely to be overridden than those marked as “Severe Warning” (odds ratio 0.42; 95% CI 0.32 to 0.56). Time of day also appeared to be a factor with those triggered during evening shifts being less likely to be overridden than those triggered during the day.

“Despite medication-disease interaction alerts on provider order entry and pharmacist verification, a high proportion of potentially harmful medications continued to be prescribed. Future directions include enhanced clinician education, CDS tool optimization to decrease alert fatigue, and better quantification of risk of MG exacerbation after exposure to medications that should be used with caution in this patient population,” the authors concluded.

Between November 2019 and May 2021, 2817 alerts were generated and viewed at the Massachusetts General Hospital and Brigham and Women’s Hospital. These alerts represented 830 distinct patient-medication exposures for 577 unique patients, with a third of the instances occurring in the outpatient context with the remaining third occurring during inpatient services. 


Barra ME, Webb AJ, Roberts RJ, et al. Implementation of a myasthenia gravis drug-disease interaction clinical decision support tool reduces prescribing of high-risk medications. Muscle Nerve. Published online January 23, 2023. doi:10.1002/mus.27790