Domperidone Prescribing Practices Questionnaire

Dear Colleagues,

You have been invited to participate in this study to help us better understand current prescribing practices of Domperidone.

Domperidone (Motilium) is a unique dopamine receptor antagonist with both pro-kinetic and anti-emetic properties. It is widely used as a principle therapy in the management of gastrointestinal motility disorders. We are currently involved in a quality assurance project investigating the Domperidone prescribing practices amongst physicians. Ultimately, the goal for this project is the identification of areas for improvement with respect to current Domperidone prescribing practices, and the safety of its use based on clinical indications. This is an investigator initiated project and is not funded by a pharmaceutical industry. The project has been approved by the Research Ethical Board of our hospital.

Below you will find a very brief questionnaire consisting of only 11 questions relating to your current prescribing practices with respect to Domperidone.

We truly hope that you will find it possible to support us in this project.

Question Title

* 1. Were you aware of the advisory issued by Health Canada in March of 2012 regarding domperidone use?

Yes

Question Title

* 2. What general area of medicine do you practice within?

Primary Care

General Internal Medicine

Gastroenterology

Intensive Care

General Surgery

Other Internal or Surgical subspecialty

Question Title

* 3. What condition or clinical indication do you most often prescribe Domperidone for?

Diabetic gastroparesis

Gastroesophageal reflux disease (GERD)

Chronic/subacute gastritis

Anti-emetic

Parkinson’s disease with anti-parkinsonian agents

Do not prescribe Domperidone

Other Medical Conditions

Question Title

* 4. In what clinical environment do you most often prescribe Domperidone?

Primary Care clinic

Urgent Care clinic

Emergency Department

In-Hospital ward

Intensive Care Unit

Do not prescribe Domperidone

Other:

Question Title

* 5. Is Domperidone usually prescribed as part of an automatic order set in your practice?

Yes

Question Title

* 6. Do you usually request a screening ECG/reference a recent ECG prior to prescribing Domperidone?

Yes

Question Title

* 7. Do you reference/document a prolonged QT interval on the screening/reference ECG?

Yes

Question Title

* 8. Do you usually request screening electrolytes/reference recent electrolytes (including potassium, calcium and magnesium) prior to prescribing domperidone?

Yes

Do not prescribe Domperidone

Question Title

* 9. Do you usually exercise greater caution in prescribing Domperidone to patients with a history of arrhythmia or with advanced heart disease (cardiomyopathy with grade 3 or 4 LV dysfunction)?

Yes

Do not prescribe Domperidone

Question Title

* 10. Do you usually exercise greater caution in prescribing Domperidone to patients using other medications that are known to prolong the QT interval (such as tricyclic antidepressants, antipsychotic, macrolide and fluoroquinalone antibiotics)?

Yes

Do not prescribe Domperidone