The Yellow Card Scheme:
Reporting Adverse Drug
Reactions
Objectives
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What is an Adverse Drug Reaction (ADR)?
Classification of ADRs
How common are ADRs?
Identifying an ADR
How to avoid ADRs
The Yellow Card Scheme
What to report
Information to include on a Yellow Card
What is an adverse drug
reaction?
An adverse drug reaction (ADR) is an
unwanted or harmful reaction
experienced following the administration
of a drug or combination of drugs under
normal conditions of use and is suspected
to be related to the drug.
Adverse drug reaction or
adverse event
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Terms often used interchangeably not always
correct.
Adverse drug reaction is an unwanted or
harmful reaction experienced following the
administration of a drug e.g. patient
experiencing anaphylaxis shortly after taking
a drug.
Adverse event is any undesirable event
experienced by a patient while taking a drug,
regardless of whether the drug is suspected
to be related to the event e.g. patient having a
road traffic accident while on a specific
medication.
Classification of ADRs
Common ADRs
• Type A (‘Augmented’)
• Predictable, dose related
– Constipation with opioids
• Usually not severe
– Peptic ulceration following NSAID use
Classification of ADRs
Uncommon but often well recognised ADRs
• Type B (‘Bizarre’)
• Unpredictable, not dose related
• May be very severe / fatal
– Achilles tendonitis caused by quinolone
antibiotics
– Stevens-Johnson syndrome following lamotrigine
therapy
• With new drugs ADRs not well
recognised
Classification of ADRs
• Type C (`Chronic treatment effects’)
- osteoporosis with steroids
• Type D (`Delayed effects’)
- drug induced cancers
• Reports of skin cancers, lymphomas and
other cancers following topical pimecrolimus
and tacrolimus 1
• Type E (`End of treatment effects’)
– withdrawal syndromes
• Headache, anxiety, dizziness sleep
disturbances, gastro-intestinal disturbances
after stopping paroxetine.
Classification of ADRs
• Type F (`Failure of therapy’)
– unexpected failure of therapy due to drug
interaction
• St Johns Wort reducing efficacy of combined
hormonal contraceptives
• Type G (Genetic or genomic)
– Irreversible genetic damage
• Carcinogens
• Genotoxins
• Teratogens
Important factors in ADRs: DoTS
• 3 factors: Dose, Time, Susceptibility
• Dose (response) The ADR can occur
– at doses below therapeutic doses
• anaphylaxis with penicillin
– in the therapeutic dose range
• nausea with morphine
– at high doses
• liver failure with paracetamol
Important factors in ADRs
• Time (course) can be characteristic
– with the first dose
• anaphylaxis with penicillin
– early, or after a time, or with long-term treatment
• first few days: nitrate induced headache
• 10 days – 10 weeks: toxic epidermal necrolysis
• several weeks: drug-induced Cushing’s syndrome
– on stopping treatment (withdrawal)
• paroxetine withdrawal syndrome
– delayed
• clear cell cancer with stilbestrol
Important factors in ADRs
• Susceptibility of patients can be defined
Genetics – haemolysis with chloroquine in G6PD deficiency
Age – parkinsonism with prochlorperazine in the elderly
Sex – ACE-inhibitor induced cough in women
Physiological state – phenytoin in pregnancy
Exogenous drugs or foods – warfarin, cranberry juice,
and increased INR
Disease – gentamicin & deafness in renal failure
Examples of ADRs
• Common and well established ADRs
– Constipation with opioids
– Abdominal pain and diarrhoea with erythromycin therapy.
– Nausea when starting fluoxetine
– Gastrointestinal symptoms with NSAIDs
• Uncommon but well recognised ADRs
– Achilles tendonitis caused by quinolone antibiotics
– Visual field defects with vigabatrin
• Uncommon emerging ADRs
– Depression with rimonabant
– AF with bisphosphonates
– Hepatoxicity with lumiracoxib
Why are ADRs important?
• Major clinical problem – increase morbidity
and mortality.
– ADRs are related to 6.5% hospital admissions in
adults, and 2.1% in children 2
– 6.7% hospitalised patients suffer`serious’ ADRs 1
– 0.15% of hospital patients suffer fatal ADRs (= 5700
deaths per year) 1,2
– ADRS are 4th leading cause of death in the USA 1
– Increase hospital stay. ADRs result in the use of
seven 800 bed UK hospitals per year.2
– Financial burden on NHS £466m 2
– Up to 40% patients in the community experience
ADRs 3
1 Lazarou J, Pomeranz BH, Corey PN. Incidence of ADRs in hospitalised patients. JAMA .1998; 279: 1200-1205.
2 Pirmohamed M, James S, Meakin S et al. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18
820 patients. BMJ. 2004; 329(7456):15-9.
3 Martyrs C. Adverse reactions to drugs in general practice. BMJ 1979; 2: 1194-1197
ADRs can also…
• Adversely affect patient compliance
• Reduce available choice of drug
treatment
• Reduce potential efficacy of drug
treatment
• Reduce quality of life
• Cause diagnostic confusion
• Reduce a patient’s confidence in their
healthcare professional(s)
Who might get an ADR?
Anyone who takes a medicine!
Differential diagnosis should include the
possibility of an ADR if the patient is taking any
form of medication
Who is most at risk from ADRs?
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The elderly
Children
Co-existing diseases
Females
Atopic individuals
Polypharmacy
– 50% of patients on 5
drugs or more
ADRs are an increasing public
health problem
• Factors:
– Increase in elderly population (4 x as likely to
have ADR)1
– Increase in polypharmacy
– Increase in availability of OTC medicines
– Increase in use of herbal/traditional medicines
– Increase in medicines available via the internet
1 Pharm
World & Science 2002;24(2):46-54)
Are ADRs avoidable?
• 70% ADRs are potentially avoidable 1
• More rational Prescribing
– Avoid unnecessary drug use
– Dose optimisation – identify drugs known to produce dose-related
side effects
– Avoid / reduce drug interactions
– Consider prophylactic therapy where appropriate
– Avoid new / black triangle drugs
– Avoid prescribing contra-indicated drugs
– Drug use in an inappropriate clinical indication
– Check drug history before prescribing
• Consider risk factors for ADRs
– Polypharmacy
– Age extremes
– Reduced hepatic and renal function
• Patient counselling re ADR’s 2
• Better monitoring of treatment 3
• Better communication 4
1 Howard et al BJCP 2007 Feb;63(2):136-47
2 BMJ 2006;333:522
3 BMJ 2003;327;1179-1181
4 Archives of Internal medicine 2006;145(4):284-293
What should raise
your suspicion?
•Timing with drug treatment.
•Abnormal clinical measurements while on drug
therapy e.g. B.P, temp, pulse, blood glucose and
weight
•Abnormal laboratory results while on drug
therapy. Could be biochemical or haematological
•New therapy started which could be used to treat
ADR
•Patient risk factors
•Listen to patients own concerns
Assessing causality
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Nature of the reaction
Timing
Relationship to dose
Other possible causes for the symptoms
Improvement when drug(s) stopped
Has reaction been reported before
Dechallenge/Rechallenge
How common are ADRs?
• Drugs most commonly implicated include NSAID,
aspirin, diuretics and warfarin1
• Aspirin was most frequent cause for admission 2
– 18% ADR related admissions
– 162 (74%) patients on aspirin 75mg OD
– 157 (72%) gastro-intestinal bleeding
• In the UK Non Steroidal Anti-Inflammatory Drug
(NSAID) use alone accounts for3
– 65,000 emergency admissions/year
– 12,000 ulcer bleeding episodes/year
– 2,000 deaths/year
1 Howard RL et al. Which drugs cause preventable admissions to hospital? A systematic review. Br J Clin Pharmacol 2007; 63:(2)136-147
2 Pirmohamed M et al. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18 820 patients. BMJ. 2004; 329(7456):15-9.
3. Blower et al. Emergency admissions for upper gastrointestinal disease and their relation to NSAID use. Aliment Pharmacol Ther 1997; 11: 283-291
The Yellow Card Scheme
• Introduced in 1964 after thalidomide tragedy
• Spontaneous reports of suspected adverse drug
reactions.
• Acts as an early warning system to identify
ADRs and risk factors
• Over 600,000 confidential reports have been
received in UK
• Doctors, dentists, pharmacists, coroners,
nurses, midwifes, health visitors
• Non-medical prescribers
• and now patients
• MHRA can detect duplicate reports
Patients can report
suspected side effects:
• online at
www.yellowcard.gov.uk
• using the form inside this
leaflet found in pharmacies
• by calling the Yellow Card
hotline on 0808 100 3352
Why report ADRs?
• Important role in patient safety
• Allows continual safety monitoring of drugs
– old & new
• New drugs - lack of experience on adverse effects
– Exposure in about 1500 people only
– Short duration
– Unlikely to detect ADRs
• Less frequent than 1/1500
• With long latency
– Lack of experience in special patient groups
• Elderly, children, pregnancy, multiple disease,
polypharmacy
• To detect rare adverse effects
Strengths of Yellow Card
Scheme
• Acts as ‘early warning system’ for identification
of previously unrecognised reactions
• Provides information about factors which
predispose patients to ADRs
• Allows comparisons of ADR ‘profiles’ between
products within same therapeutic class
• Continual safety monitoring of a product
throughout its life span as a therapeutic agent
Weaknesses of Yellow Card
Scheme
• Cannot provide estimates of risk as
– true number of cases is underestimated
– total number of patients exposed is unknown
• Relies on ADR being recognised
• Not all ADRs are reported
– Only 10% serious reactions reported
• May be stimulated by promotion and publicity
• Reporting high for newly marketed drugs and
falls off over time
• Reports do not imply causality
Why are reporting rates low?
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Too busy
Not sure what to report
Uncertain of the threshold for a serious reaction
Not easy to find a Yellow Card
Not my responsibility
It takes too long to complete a card
Reporting generates too much extra work
Duplication
Belief that serious ADRs will be identified in clinical
trials
• Confidentiality
Completing a Yellow Card
On-line
•Simple
•Fast
•Drop-down menus
•Allows reporter to
register on the site
•The Yellow Card
can be saved at
any time
www.yellowcard.gov.uk
Who can report?
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Doctors, dentists, coroners
Hospital pharmacists - 1997
Community pharmacists - 1999
Nurses, midwives and health visitors - 2002
Patients – 2008 (pilot scheme from October 2005)
Pharmaceutical companies have a legal obligation to
report
• Over 600,000 reports received to date on voluntary
basis
• MHRA can detect duplicate reports
What to report
• Report all suspected adverse drug reactions for
– new drugs (marked ▼) - even if mild
– established drugs that are serious - even if well
recognised
Serious reactions include those which are fatal, lifethreatening, disabling or incapacitating, result in or
prolong hospitalisation, congenital abnormalities or
medically significant
• Reactions in children
• Drug interactions
• Herbal medicines
Causality does not need to be established
Black triangle drugs▼
• ▼indicates that the CHM/MHRA are intensively
monitoring that product
• ▼will be assigned to a product because:• the drug is new to the UK market
• the drug is being administered to the patient either by a
new route of administration or a new formulation which
is considered may have an impact on the already
established risk/benefit profile of that drug
• The drug is being administered for a new indication
Areas of special interest
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Children
Elderly
Delayed drug effects (e.g. cancers)
Congenital anomalies
Herbal remedies
OTC medicines
HIV medicines
If you suspect an ADR…
Do not assume someone else will report it
• Only 2-4% of all ADRs are reported
• Only 10% of serious suspected ADRs are
reported
Do you have to be completely certain that
what you have seen is an ADR?
No
Information to include on a
Yellow Card
4 critical pieces of information that
must be included on the report : Suspected drug(s)
 Suspect reaction(s)
 Patient details
 Reporter details
Suspected Drug(s)
• Name of medicine
– including brand and batch number if known
• Route of administration
• Daily dose
• Date medicine started
– and stopped if applicable
• Reason why the medication was given
• Multiple drugs can be listed if more than one
drug is suspected of causing the reaction
Suspect reaction(s)
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Describe the reaction
Include a diagnosis if relevant
Include when the reaction occurred
whether the reaction was considered to
be serious and complete tick box for
reasons why
• Document if any treatment was given for
the reaction
• Eventual outcome tick relevant box
Patient Details
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Sex of the patient
Age at time of reaction
Weight if known
Do not need to know name or DOB as this
could identify patient and break patient
confidentiality
• Patients initials and local identification
number (hospital or practice number)
which will identify patient to you in the event
of future correspondence
Reporter details
• Must be completed in all cases
• Name and full address
– Need to acknowledge receipt of report
and follow up further information if
necessary.
• Profession
Additional useful information
• Other medication in the last three months
including herbal and over the counter meds.
• Use additional sheets if necessary.
• If no other meds are being taken or if no more
information is available say so
• Include details of any:
– rechallenges
– relevant medical history
– test results
– known allergies
– suspected drug interactions
What happens to a Yellow card
once received?
Yellow Cards Adverse Drug
Reaction
reports
Acknowledgmen
t and/or followup for more info
Provision of
information
Report details
entered to
Sentinel
database
Commit to
database
Assessment
Signal
detection
Impact
Analysis
Signal
Evaluation and
Prioritisation
Risk-benefit
evaluation and
advice from
CHM
Regulatory
action and
communication
How is the Yellow Card data used
to improve patient safety?
1. Changes to SPC e.g. restriction in use,
special warnings and precautions
2. Publication of
3. Issue of ‘Dear Healthcare professional’
letters
4. Drug Analysis Prints (DAPs)
5. Withdrawal of a medicines if patient safety is
threatened
Drug Safety Update
•Published monthly
•Register for alerts
http://www.mhra.gov.uk/
Publications/Safetyguid
ance/DrugSafetyUpdate/
index.htm
Drug Analysis Prints (DAPs)
• Complete list of all suspected ADRs reported via
yellow card scheme for named suspect drug
• Inclusion of a particular reaction does not
necessarily mean it has been caused by the drug
• Certain reported reactions are conditions which
occur spontaneously
• Should not be used for determining incidence
• Reporting rates are influenced by seriousness of
ADR, ease of recognition, extent of use
www.mhra.gov.uk/daps
System
Organ
Class
Totals
Reactions
under
High Level
Term (HLT)
Reaction
Preferred
Term (PT)
Examples of ADRs identified
by Yellow Card Scheme
• Vigabatrin and visual field defects
– 3 reports severe persistent visual field constriction
– detected 2-3 years after starting therapy
– resulted in a change of recommended dosage, range of
indications and addition of warnings
• Cyproterone acetate and hepatotoxicity
– dose related
– restricted indications
– requirement for hepatic function monitoring
• Alendronate and severe oesophageal reactions
– warnings and revised dosing instructions
• Varenicline and depression and suicidal ideation
– reports received in the 1st 12 months after launch
– addition of warnings and monitoring in patients with
history of psychiatric illness
Where to find ADR information
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Reference texts
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British National Formulary (BNF)
Summary of Product Characteristics (SPC)
Martindale
AHFS Drug information
Meyler’s 'The Side effects of drugs
Davies’ textbook Adverse Drug Reactions
Lee’s textbook Adverse Drug Reactions
Journals
– Adverse Drug Reaction Bulletin
– Drug Safety Update
– Medline/Embase/Pharmline search
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Electronic sources
– Micromedex
– www.mhra.gov.uk
“All health-care professionals
have a responsibility to inform
colleagues about clinically
important adverse drug
reactions that they detect, even
if a well-recognised or causal
link is uncertain.”
Edwards IR and Aronson JK. Adverse drug reactions: definitions, diagnosis, and
management. Lancet 2000; 356: 1255-59
If you suspect an ADR….
do not assume someone else
will report it!
www.mhra.gov.uk/yellowcard