Skip to content

fix(medications): stop loperamide resolving as an opioid for interaction alerts #2278

New issue

Have a question about this project? Sign up for a free GitHub account to open an issue and contact its maintainers and the community.

Sign up for GitHub

By clicking “Sign up for GitHub”, you agree to our terms of service and privacy statement. We’ll occasionally send you account related emails.

Already on GitHub? Sign in to your account

Merged
BigSimmo merged 11 commits into from
Aug 22, 2026
Merged

fix(medications): stop loperamide resolving as an opioid for interaction alerts #2278

Show file tree
Hide file tree
Changes from all commits
Commits
Show all changes
11 commits
Select commit Hold shift + click to select a range
77e5f73
fix(medications): stop loperamide resolving as an opioid for interact…
BigSimmo Aug 22, 2026
f32acdb
fix(medications): exclude loperamide's explanatory opioid match
BigSimmo Aug 22, 2026
0af847c
Merge branch 'main' into claude/lexicon-loperamide-overmatch
BigSimmo Aug 22, 2026
3620332
fix(medications): restore the interaction index JSON
BigSimmo Aug 22, 2026
f243609
Merge branch 'main' into claude/lexicon-loperamide-overmatch
BigSimmo Aug 22, 2026
3400b71
fix(medications): refresh lexicon review usage
BigSimmo Aug 22, 2026
f066917
test(medications): guard the two loperamide directions the existing t…
BigSimmo Aug 22, 2026
76aeebe
chore(issues): refresh the outstanding-issues snapshot for the queued…
BigSimmo Aug 22, 2026
6acab6b
Merge remote-tracking branch 'origin/main' into claude/lexicon-lopera…
BigSimmo Aug 22, 2026
c1360d3
style(medications): reformat the interaction index after the merge re…
BigSimmo Aug 22, 2026
f4263db
Merge branch 'main' into claude/lexicon-loperamide-overmatch
BigSimmo Aug 22, 2026
File filter

Filter by extension

Filter by extension
Conversations
Failed to load comments.
Loading
Jump to
Jump to file
Failed to load files.
Loading
Diff view
Diff view
54 changes: 2 additions & 52 deletions data/medication-interaction-index.json
View file
Open in desktop
Original file line number Diff line number Diff line change
Expand Up @@ -365,7 +365,6 @@
"codeine",
"fentanyl",
"hydromorphone-ir-iv",
"loperamide",
"methadone",
"morphine-ir-iv",
"morphine-sr-mr",
Expand Down Expand Up @@ -397,7 +396,6 @@
"fentanyl",
"gabapentin",
"hydromorphone-ir-iv",
"loperamide",
"lorazepam",
"methadone",
"midazolam",
Expand Down Expand Up @@ -492,7 +490,6 @@
"codeine",
"fentanyl",
"hydromorphone-ir-iv",
"loperamide",
"methadone",
"morphine-ir-iv",
"morphine-sr-mr",
Expand Down Expand Up @@ -719,7 +716,6 @@
"hyoscine-hydrobromide",
"imipramine",
"levomepromazine",
"loperamide",
"lorazepam",
"lurasidone",
"methadone",
Expand Down Expand Up @@ -891,7 +887,6 @@
"hyoscine-hydrobromide",
"imipramine",
"levomepromazine",
"loperamide",
"lorazepam",
"lurasidone",
"methadone",
Expand Down Expand Up @@ -943,7 +938,6 @@
"codeine",
"fentanyl",
"hydromorphone-ir-iv",
"loperamide",
"methadone",
"morphine-ir-iv",
"morphine-sr-mr",
Expand Down Expand Up @@ -1130,7 +1124,6 @@
"fentanyl",
"gabapentin",
"hydromorphone-ir-iv",
"loperamide",
"lorazepam",
"methadone",
"midazolam",
Expand Down Expand Up @@ -1293,7 +1286,6 @@
"fentanyl",
"fluoxetine",
"hydromorphone-ir-iv",
"loperamide",
"methadone",
"morphine-ir-iv",
"morphine-sr-mr",
Expand Down Expand Up @@ -3729,7 +3721,6 @@
"hyoscine-hydrobromide",
"imipramine",
"levomepromazine",
"loperamide",
"lorazepam",
"lurasidone",
"methadone",
Expand Down Expand Up @@ -3836,7 +3827,6 @@
"hyoscine-butylbromide",
"imipramine",
"levomepromazine",
"loperamide",
"lorazepam",
"lurasidone",
"methadone",
Expand Down Expand Up @@ -3995,7 +3985,6 @@
"diazepam",
"fentanyl",
"hydromorphone-ir-iv",
"loperamide",
"lorazepam",
"methadone",
"midazolam",
Expand Down Expand Up @@ -4081,23 +4070,8 @@
"rowKey": "Pharmacokinetic",
"rowIndex": 0,
"severity": "moderate",
"counterparties": [
"buprenorphine-naloxone",
"buprenorphine-patch",
"buprenorphine-sl-depot",
"codeine",
"fentanyl",
"hydromorphone-ir-iv",
"methadone",
"morphine-ir-iv",
"morphine-sr-mr",
"oxycodone-ir",
"oxycodone-sr-mr",
"tapentadol-sr",
"tramadol-ir",
"verapamil"
],
"termIds": ["azole-antifungals", "opioids", "pgp"],
"counterparties": ["verapamil"],
"termIds": ["azole-antifungals", "pgp"],
"resolved": false,
"note": "MODERATE — P-gp inhibitors (e.g., Verapamil, Ketoconazole) can theoretically push loperamide across the blood-brain barrier, causing opioid sedation, but rare at normal doses."
}
Expand Down Expand Up @@ -5932,7 +5906,6 @@
"diazepam",
"fentanyl",
"hydromorphone-ir-iv",
"loperamide",
"lorazepam",
"methadone",
"midazolam",
Expand Down Expand Up @@ -6152,7 +6125,6 @@
"diazepam",
"fentanyl",
"hydromorphone-ir-iv",
"loperamide",
"lorazepam",
"methadone",
"midazolam",
Expand Down Expand Up @@ -6407,7 +6379,6 @@
"codeine",
"fentanyl",
"hydromorphone-ir-iv",
"loperamide",
"methadone",
"morphine-ir-iv",
"morphine-sr-mr",
Expand Down Expand Up @@ -6550,7 +6521,6 @@
"diazepam",
"fentanyl",
"hydromorphone-ir-iv",
"loperamide",
"lorazepam",
"methadone",
"midazolam",
Expand Down Expand Up @@ -6658,7 +6628,6 @@
"codeine",
"fentanyl",
"hydromorphone-ir-iv",
"loperamide",
"methadone",
"morphine-ir-iv",
"morphine-sr-mr",
Expand Down Expand Up @@ -6696,7 +6665,6 @@
"codeine",
"fentanyl",
"hydromorphone-ir-iv",
"loperamide",
"methadone",
"morphine-ir-iv",
"morphine-sr-mr",
Expand Down Expand Up @@ -6734,7 +6702,6 @@
"codeine",
"fentanyl",
"hydromorphone-ir-iv",
"loperamide",
"methadone",
"morphine-ir-iv",
"morphine-sr-mr",
Expand Down Expand Up @@ -6772,7 +6739,6 @@
"codeine",
"fentanyl",
"hydromorphone-ir-iv",
"loperamide",
"methadone",
"morphine-ir-iv",
"morphine-sr-mr",
Expand Down Expand Up @@ -6824,7 +6790,6 @@
"codeine",
"fentanyl",
"hydromorphone-ir-iv",
"loperamide",
"methadone",
"morphine-ir-iv",
"morphine-sr-mr",
Expand Down Expand Up @@ -6862,7 +6827,6 @@
"codeine",
"fentanyl",
"hydromorphone-ir-iv",
"loperamide",
"methadone",
"morphine-ir-iv",
"morphine-sr-mr",
Expand Down Expand Up @@ -6900,7 +6864,6 @@
"codeine",
"fentanyl",
"hydromorphone-ir-iv",
"loperamide",
"methadone",
"morphine-ir-iv",
"morphine-sr-mr",
Expand Down Expand Up @@ -7132,7 +7095,6 @@
"diazepam",
"fentanyl",
"hydromorphone-ir-iv",
"loperamide",
"lorazepam",
"methadone",
"midazolam",
Expand Down Expand Up @@ -7251,7 +7213,6 @@
"diazepam",
"fentanyl",
"hydromorphone-ir-iv",
"loperamide",
"lorazepam",
"methadone",
"midazolam",
Expand Down Expand Up @@ -7352,7 +7313,6 @@
"codeine",
"fentanyl",
"hydromorphone-ir-iv",
"loperamide",
"methadone",
"morphine-ir-iv",
"morphine-sr-mr",
Expand Down Expand Up @@ -7400,7 +7360,6 @@
"diazepam",
"fentanyl",
"hydromorphone-ir-iv",
"loperamide",
"lorazepam",
"methadone",
"midazolam",
Expand Down Expand Up @@ -7437,7 +7396,6 @@
"diazepam",
"fentanyl",
"hydromorphone-ir-iv",
"loperamide",
"lorazepam",
"methadone",
"midazolam",
Expand Down Expand Up @@ -7474,7 +7432,6 @@
"diazepam",
"fentanyl",
"hydromorphone-ir-iv",
"loperamide",
"lorazepam",
"methadone",
"midazolam",
Expand Down Expand Up @@ -7755,7 +7712,6 @@
"diazepam",
"fentanyl",
"hydromorphone-ir-iv",
"loperamide",
"lorazepam",
"methadone",
"midazolam",
Expand Down Expand Up @@ -7946,7 +7902,6 @@
"diazepam",
"fentanyl",
"hydromorphone-ir-iv",
"loperamide",
"lorazepam",
"methadone",
"midazolam",
Expand Down Expand Up @@ -8303,7 +8258,6 @@
"diazepam",
"fentanyl",
"hydromorphone-ir-iv",
"loperamide",
"lorazepam",
"methadone",
"midazolam",
Expand Down Expand Up @@ -8500,7 +8454,6 @@
"diazepam",
"fentanyl",
"hydromorphone-ir-iv",
"loperamide",
"lorazepam",
"methadone",
"midazolam",
Expand Down Expand Up @@ -8624,7 +8577,6 @@
"diazepam",
"fentanyl",
"hydromorphone-ir-iv",
"loperamide",
"lorazepam",
"methadone",
"midazolam",
Expand Down Expand Up @@ -8847,7 +8799,6 @@
"diazepam",
"fentanyl",
"hydromorphone-ir-iv",
"loperamide",
"lorazepam",
"methadone",
"midazolam",
Expand Down Expand Up @@ -8946,7 +8897,6 @@
"hydromorphone-ir-iv",
"indapamide",
"labetalol",
"loperamide",
"lorazepam",
"methadone",
"metoprolol",
Expand Down
8 changes: 7 additions & 1 deletion data/outstanding-issues-snapshot.json
View file
Open in desktop
Original file line number Diff line number Diff line change
Expand Up @@ -10,7 +10,7 @@
"p2": 43,
"p3": 33,
"queued": 11,
"pending": 31,
"pending": 32,
"resolved": 359
},
"queue": [
Expand Down Expand Up @@ -871,6 +871,12 @@
"summary": "#HDYCQP: Resolved 2026-08-21: mergeability classifies merged/closed PRs as successful skips before unknown-state retry; both workflow call sites pass state and merged, with offline self-test coverage.",
"created_at": "2026-08-21"
},
{
"request_id": "296db779-44cb-4817-9592-3ebf22aca38b",
"action": "update",
"summary": "#1YPV51: detail → PARTIAL PROGRESS 2026-08-22, NOT a clinical sign-off. The sign-off block in docs/medication-interaction-lexicon-review.md is deliberately still empty and the document still reads Status: UNREVIEWED, because a Clinical Lead read of the 37-term sheet has still not happened. What DID happen: the owner reviewed seven specific questions raised from the report and one real defect was found and fixed. FIXED: loperamide was resolving as a member of the opioids term because the selector matches the substring Opioid and the catalogue classifies it Peripheral Opioid Agonist. It is P-gp-restricted at therapeutic doses and does not contribute to the sedation and respiratory-depression rows that term drives (35 of 36 rows CRITICAL or HIGH). It is now deny-listed alongside naltrexone and naloxone, which were already excluded for the same class of reason. Proven, not asserted: regenerating the index with and without the change alters 35 medications, removes loperamide as a counterparty from every one of them, adds nothing anywhere, and leaves resolvedRows/unresolvedRows/rowsWithCatalogueTarget unchanged at 392/133/440. FOUR OTHER CHANGES WERE PROPOSED AND WITHDRAWN after reading the implementation: adding moclobemide to maois, removing atomoxetine from snris, folding the Z-drugs into benzodiazepines, and splitting antihistamines by sedation. All four would have overridden deliberate catalogue classifications (moclobemide is subclass RIMA not MAOI; atomoxetine is subclass SNRI (Non-stimulant); zolpidem and zopiclone are class Sedative subclass Z-Drug) or broken a term's meaning. The sedation concern they were aimed at is carried by the cns-depressants term, which is kind: mechanism and deliberately unenumerable, so it warns on no specific drug by design. TWO QUESTIONS REMAIN FOR THE OWNER, both catalogue-level rather than lexicon-level: (1) should moclobemide's RIMA classification make it fire serotonergic interaction warnings alongside the irreversible MAOIs; (2) is atomoxetine correctly classed SNRI for interaction purposes. STILL OPEN: the full clinical read. Do not close this row without explicit owner confirmation that the review was actually carried out.",
"created_at": "2026-08-22"
},
{
"request_id": "2b98cd3b-a7be-454b-a819-9d6a42d52423",
"action": "done",
Expand Down
3 changes: 2 additions & 1 deletion docs/medication-interaction-lexicon-review.md
View file
Open in desktop
Original file line number Diff line number Diff line change
Expand Up @@ -27,7 +27,7 @@ CRITICAL or HIGH. Start at the top — the table is sorted by severe usage.
| Term | Matches these phrases | Rows | Severe | Resolves to |
| -------------------------- | -------------------------------------------------------------------------------------------------------- | ---- | ------ | ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- |
| `nsaids` | nsaids, nsaid | 40 | 39 | **8** — Aspirin, Celecoxib, Diclofenac, Ibuprofen, Ketorolac, Meloxicam, Naproxen, Parecoxib |
| `opioids` | opioids, opioid, opioid analgesia, opiates, full agonists | 36 | 35 | **14** — Buprenorphine (SL/depot), Buprenorphine + naloxone, Buprenorphine patch, Codeine, Fentanyl, Hydromorphone (IR/IV), Loperamide, Methadone, Morphine (IR/IV), Morphine SR / MR, Oxycodone IR, Oxycodone SR / MR, Tapentadol SR, Tramadol IR |
| `opioids` | opioids, opioid, opioid analgesia, opiates, full agonists | 35 | 35 | **13** — Buprenorphine (SL/depot), Buprenorphine + naloxone, Buprenorphine patch, Codeine, Fentanyl, Hydromorphone (IR/IV), Methadone, Morphine (IR/IV), Morphine SR / MR, Oxycodone IR, Oxycodone SR / MR, Tapentadol SR, Tramadol IR |
| `benzodiazepines` | benzodiazepines, benzodiazepine, benzos, benzo | 32 | 32 | **8** — Alprazolam, Clonazepam, Diazepam, Lorazepam, Midazolam, Nitrazepam, Oxazepam, Temazepam |
| `beta-blockers` | beta-blockers, beta blockers, beta-blocker, beta blocker, non-selective beta-blockers | 23 | 22 | **7** — Atenolol, Bisoprolol, Carvedilol, Labetalol, Metoprolol, Propranolol, Sotalol |
| `ssris` | ssris, ssri | 22 | 20 | **6** — Citalopram, Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline |
Expand Down Expand Up @@ -74,6 +74,7 @@ Drugs a selector would otherwise have swept in. Each is a clinical claim worth c
| `benzodiazepines` | Olanzapine (wafer/ODT) | class `Antipsychotic`, subclass `SGA / Thienobenzodiazepine` |
| `opioids` | Naltrexone | class `Addiction`, subclass `Opioid Antagonist` |
| `opioids` | Naloxone | class `Antidote`, subclass `Opioid Antagonist` |
| `opioids` | Loperamide | class `Antidiarrhoeal`, subclass `Peripheral Opioid Agonist` |
| `anticoagulants` | Aspirin | class `Anticoagulant`, subclass `Antiplatelet / NSAID` |

## Terms that resolve to no catalogue drug
Expand Down
11 changes: 11 additions & 0 deletions docs/outstanding-issues-inbox/296db779-44cb-4817-9592-3ebf22aca38b.json
View file
Open in desktop
Original file line number Diff line number Diff line change
@@ -0,0 +1,11 @@
{
"version": 2,
"id": "296db779-44cb-4817-9592-3ebf22aca38b",
"createdOn": "2026-08-22",
"action": "update",
"payload": {
"id": "#1YPV51",
"detail": "PARTIAL PROGRESS 2026-08-22, NOT a clinical sign-off. The sign-off block in docs/medication-interaction-lexicon-review.md is deliberately still empty and the document still reads Status: UNREVIEWED, because a Clinical Lead read of the 37-term sheet has still not happened. What DID happen: the owner reviewed seven specific questions raised from the report and one real defect was found and fixed. FIXED: loperamide was resolving as a member of the opioids term because the selector matches the substring Opioid and the catalogue classifies it Peripheral Opioid Agonist. It is P-gp-restricted at therapeutic doses and does not contribute to the sedation and respiratory-depression rows that term drives (35 of 36 rows CRITICAL or HIGH). It is now deny-listed alongside naltrexone and naloxone, which were already excluded for the same class of reason. Proven, not asserted: regenerating the index with and without the change alters 35 medications, removes loperamide as a counterparty from every one of them, adds nothing anywhere, and leaves resolvedRows/unresolvedRows/rowsWithCatalogueTarget unchanged at 392/133/440. FOUR OTHER CHANGES WERE PROPOSED AND WITHDRAWN after reading the implementation: adding moclobemide to maois, removing atomoxetine from snris, folding the Z-drugs into benzodiazepines, and splitting antihistamines by sedation. All four would have overridden deliberate catalogue classifications (moclobemide is subclass RIMA not MAOI; atomoxetine is subclass SNRI (Non-stimulant); zolpidem and zopiclone are class Sedative subclass Z-Drug) or broken a term's meaning. The sedation concern they were aimed at is carried by the cns-depressants term, which is kind: mechanism and deliberately unenumerable, so it warns on no specific drug by design. TWO QUESTIONS REMAIN FOR THE OWNER, both catalogue-level rather than lexicon-level: (1) should moclobemide's RIMA classification make it fire serotonergic interaction warnings alongside the irreversible MAOIs; (2) is atomoxetine correctly classed SNRI for interaction purposes. STILL OPEN: the full clinical read. Do not close this row without explicit owner confirmation that the review was actually carried out.",
"baseRowFingerprint": "474e5feba5b3f5d8fc1cd5230994a22d6d9c642c22498922e2b286f6b43b75b4"
}
}
Loading
Loading