Rational Use of Medicines

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Chapter: Essential pharmacology : Aspects Of Pharmacotherapy; Clinical Pharmacology And Drug Development

It is widely assumed that use of drugs by qualified doctors of modern medicine would be rational. However, in reality, irrationality abounds in almost every aspect of drug use. Medically inappropriate, ineffective and economically inefficient use of drugs occurs all over the world, more so in the developing countries.


RATIONAL USE OF MEDICINES

 

It is widely assumed that use of drugs by qualified doctors of modern medicine would be rational. However, in reality, irrationality abounds in almost every aspect of drug use. Medically inappropriate, ineffective and economically inefficient use of drugs occurs all over the world, more so in the developing countries. As per the WHO — ‘rational use of medicines requires that the patients receive medication appropriate to their clinical needs in doses that meet their own individual requirements for an adequate period of time, and at the lowest cost to them and to their community’.

 

Rational use of medicines addresses every step in the supply use chain of drugs, i.e. selection, procurement, storage, prescribing, dispensing, monitoring and feedback. However, only rational prescribing and related aspects are dealt here.

 

Rational Prescribing

 

Rational prescribing is not just the choice of a correct drug for a disease, or mere matching of drugs with diseases, but also the appropriateness of the whole therapeutic set up along with follow up of the outcome. The criteria to evaluate rational prescribing are:

  

§  Appropriate indication: the reason to prescribe the medicine is based on sound medical considerations.

§  Appropriate drug in efficacy, tolerability, safety, and suitability for the patient.

§  Appropriate dose, route and duration according to specific features of the patient.

§  Appropriate patient: no contraindications exist; drug acceptable to the patient; likelihood of adverse effect is minimal and less than the expected benefit.

§  Correct dispensing with appropriate information/instruction to the patient.

§  Adequate monitoring of patient’s adherence to medication, as well as of anticipated beneficial and untoward effects of the medication.

 

There is no doubt that knowledge of the prescriber about drugs and disease is the most important determinant of his/her prescribing pattern, but it has been demonstrated time and again that simply improving knowledge has failed to promote rational drug use. A variety of other factors influence prescribing as summarized below.

 

Knowledge of the prescriber.

§  Role models: one tends to follow prescribing practices of one’s teachers or senior/popular physicians.

§  Patient load: heavy load tends to promote rutinized symptom based prescribing.

§  Attetude to afford prompt symptomatic relief at all cost.

§  Imprecise diagnosis: medication is given to cover all possible causes of the illness.

§  Drug promotion and exaggerated claims by manufacturers.

§  Unethical inducements (gifts, dinner parties, conference delegation, etc.).

§  Patient’s demands: many are not satisfied unless medication is prescribed; misconceptions, unrealistic expectations, ‘pill for every ill’ belief.

 

 

Irrationalities In Prescribing

 

It is helpful to know the commonly encountered irrationalities in prescribing so that a conscious effort is made to avoid them.

 

§  Use of drug when none is needed; e.g. antibiotics for viral fevers and nonspecific diarrhoeas.

 

§  Compulsive coprescription of vitamins/tonics.

 

§  Use of drugs not related to the diagnosis, e.g. chloroquine/ciprofloxacin for any fever, proton pump inhibitors for any abdominal symptom.

 

§  Selection of wrong drug, e.g. tetracycline/ ciprofloxacin for pharyngitis, β blocker as antihypertensive for asthmatic patient.

§  Prescribing ineffective/doubtful efficacy drugs, e.g. serratiopeptidase for injuries/ swellings, antioxidants, cough mixtures, memory enhancers, etc.

 

§  Incorrect route of administration: injection when the drug can be given orally.

 

§  Incorrect dose: either underdosing or overdosing; especially occurs in children.

 

§  Incorrect duration of treatment, e.g. prolonged postsurgical use of antibiotics, stoppage of antibiotics as soon as relief is obtained, such as in tuberculosis.

 

§  Unnecessary use of drug combinations, e.g. ciprofloxacin + tinidazole for diarrhoea, ampicillin + cloxacillin for staphylococcal infection, ibuprofen + paracetamol as analgesic.

 

§  Unnecessary use of expensive medicines when cheaper drugs are equally effective; craze for latest drugs, e.g. routine use of newer antibiotics.

 

§  Unsafe use of drugs, e.g. corticosteroids for fever, anabolic steroids in children, use of single antitubercular drug.

 

§  Polypharmacy without regard to drug interactions: each prescription on an average has 3–4 drugs, some may have as many as 10–12 drugs, of which many are combinations.

 

Irrational prescribing has a number of adverse consequences for the patient as well as the community. The important ones are:

Impact of irrational prescribing

§  Delay/inability in affording relief/cure of disease.

§  More adverse drug effects.

§  Prolongation of hospitalization; loss of man days.

§  Increased morbidity and mortality.

§  Emergence of microbial resistance.

§  Financial loss to the patient/community.

§  Loss of patient’s confidence in the doctor.

§  Lowering of health standards of patients/ community.

§  Perpetuation of public health problem.

 

Process of Rational Prescribing

Process of rational prescribi

• Establish a diagnosis (at least provisional).

•  Define therapeutic problem(s), e.g. pain, infection, etc.

•  Define therapeutic goals to be achieved, e.g. symptom relief, cure, prevention of complications, etc.

•  Select the class of drug capable of achieving each goal.

 

§  Decide the route, dose, duration of treatment, considering patient’s condition.

§  Provide proper information and instructions about the medication.

§  Monitor adherence to the medication (compliance).

§  Monitor the extent to which therapeutic goal is achieved, e.g. BP lowering, peptic ulcer healing, etc.

§  Modify therapy if needed.

§  Monitor any adverse drug events that occur, and modify therapy if needed.

 

 

Rational prescribing is a stepwise process of scientifically analyzing the therapeutic set upbased on relevant inputs about the patient as well as the drug, and then taking appropriate decisions. It does not end with handing over the prescription to the patient, but extends to subsequent monitoring, periodic evaluations and modifications as and when needed, till the therapeutic goals are achieved. The important steps are summarized in the box.

 

Information/Instructions To The Patient

 

Rational prescribing also includes giving relevant and adequate information to the patient about the drug(s) and disease, as well as necessary instructions to be followed.

 

Effects Of The Drug

 

Which symptoms will disappear and when (e.g. antidepressant will take weeks to act); whether disease will be cured or not (e.g. diabetes, parkinsonism can only be ameliorated, but not cured), what happens if the drug is not taken as advised (e.g. tuberculosis will worsen and may prove fatal).

 

Side Effects

 

There is considerable debate as to how much the patient should be told about the side effects. Detailed descriptions may have a suggestive effect or may scare the patient and dissuade him from taking the drug, while not informing tantamounts to negligence and may upset the unaware patient. Communicating the common side effects without discouraging the patient is a skill to be developed.

 

Instructions

 

How and when to take the drug (special dosage forms like inhalers, transdermal patches, etc. may need demonstration); how long to take the drug; when to come back to the doctor; instructions about diet and exercise if needed; what laboratory tests are needed, e.g. prothrombin time with oral anticoagulants, leucocyte count with anticancer drugs.

 

Precautions/Warnings

 

What precautions to take; what not to do, e.g. driving (with conventional antihistaminics) or drinking (with metronidazole), or standing still (after sublingual glyceryl trinitrate); risk of allergy or any serious reaction, etc.

 

In the end it should be ensured that the instructions have been properly understood by the patient. Rational prescribing, thus, is a comprehensive process.

 

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