Rational pharmacotherapy

rational pharmacotherapy

1. Rational pharmacotherapy Dr. Renu Yadav Resident Pharmacology “Medicine is an art whose magic and creative ability have long been recognized as residing in the interpersonal aspects of patient–physician relationship”

2. scheme History Rational pharmacotherapy Irrational pharmacotherapy Process of rational prescribing Conclusion

3. history The concept of the rational use of medicines is an old one (300 B.C), when the Greek physician Herophilus said that “medicines are nothing in themselves, but are the very hands of god if employed with reason and prudence” (prudence = cautiousness)

4. In 1985, WHO definition “Patients receive medications 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 their community”

5. Rational pharmacotherapy Rational – A decision/act based on clear thought and reason Latin word – “ rationalis ”- reasonable/ logical

6. These four stages are Diagnosis. Prescribing. Dispensing. Patient adherence. From a medical perspective, the inappropriate use of medicines can begin at any of the four mainstages of the medicines use cycle.

7. Good prescribing aims Good prescribing is one that achieves the four aims, namely: (1) To maximize effectiveness; (2) Minimize risks; (3) Minimize costs; and (4) Respect the patient’s choices.

8. Irrational prescribing This may manifest in five different ways, namely: under-prescribing. over-prescribing. incorrect prescribing. extravagant prescribing. multiple prescribing.

9. Under prescribing A 5 year old boy (weight -15kg) diagnosed with otitis media is prescribed Syp . Amoxycillin (200mg/5ml) 2.5ml three times a day for 5 days.

10. Over-prescribing A 20 year old male suffering from follicutis of mild grade since 2 days, was prescribed IV ceftriaxone 2g bd for 7 days.

11. Wrong prescription A 55 years old known asthmatic presents to casualty with BP 180/100 mm Hg, ECG shows no significant abnormality. He was prescribed propranolol 40mg OD for control of hypertension.

12. Multiple prescribing A 14 years old female is suffering from acne vulgaris (grade 2) is prescribed Tab doxy 100mg BD, Tab isotretinoin 20mg once a day, Clindamycin gel, Tretinoin cream, Adapalene gel, Benzoyl peroxide cream,

13. The process of rational prescribing Case : A 52-year old taxi-driver complains of a sore throat and cough which started two weeks earlier with a cold. He has stopped sneezing but still has a cough, especially at night. The patient is a heavy smoker. Further history and examination reveal nothing special, apart from a throat inflammation. The doctor advises him to stop smoking, and writes a prescription for Codeine tablets 15 mg, 1 tablet 3 times daily for 3 days.

14. p-drug P-drugs are the drugs you have chosen to prescribe regularly, and with which you have become familiar. They are your priority choice for given indications.

15. P- drug & p-treatment The key point is that not all diseases need to be treated with a drug. Not every P-treatment includes a P-drug!

16. Constipation List of possible effective treatments is as follows. Advice and information : - Drink a lot of fluids, eat fruit and high fibre diet - Do not try to pass stools by force. - Reassure patient Non-drug treatment : Physical exercise. Drug treatment : Laxative (your P-drug). Referral for treatment : Not indicated.

17. Steps in choosing a p-drug Define the diagnosis Specify the therapeutic objective Make an inventory of effective groups of drugs Choose an effective group according to criteria Choose a P-drug

18. Example of selecting p-drug ANGINA PECTORIS: A 60-year old man, with no previous medical history. During the last month he has had several attacks of suffocating chest pain, which began during physical labour and disappeared quickly after he stopped. He has not smoked for four years. His father and brother died of a heart attack. Apart from occasionally taking some aspirin he has not used any medication in the past year.

19. What is your p- drug? Woman, 22 years, 2 months pregnant. Large abscess on her right forearm. You conclude that she will need surgery fast, but in the meantime you want to relieve the pain. She visited a physician who prescribed acetylsalicylic acid (aspirin) tablets. What is your P-drug?

20. good prescription aims Example A doctor had written a prescription for Amoxil tablets (amoxicillin). The pharmacist misread this and dispensed Daonil (glibenclamide) instead. The patient was not a diabetic and suffered permanent brain damage as a result of taking the drug

21. Principles of good Prescribing Source : Goodman and Gilman’s pharmacological basis of therapeutics

22. Provide the patient’s diagnosis on the prescription order Write clearly. Poor handwriting is a well-known and preventable cause of dispensing errors In emergency situations : Immediate administration is necessary No appropriate alternative treatment is available It is not reasonably possible for the physician to provide a written prescription prior to the dispensing

23. Write all using metric measurements of weight and volume Use Arabic (decimal) numerals rather than Roman numerals (e.g., does “IL-II” mean “IL-11” or “IL-2”?) Use leading zeros (0.125 milligrams, not .125 milligrams);never trailing zeros (5 milligrams, not 5.0 milligrams). Avoid abbreviating drug names and directions

24. Instructions to the patient 1.Effects of the drug 2. Side effects 3. Instructions 4. Warnings 5 . F uture consultations 6. Ask if Everything clear?

25. What advise will you give? Boy, 5 years. Diagnosed with Pneumonia. R/amoxicillin syrup, 5 ml (= 250 mg) three times daily.

26. monitor

27. Can the treatment be stopped? Man, 40 years. Review visit after pneumonia, treated with oral ampicillin (2 grams daily) for one week. No symptoms remain, only slight unproductive cough. Examination normal

28. WHO advocates 12 key interventions to promote more rational use: Establishment of a multidisciplinary national body to coordinate policies on medicine use Use of clinical guidelines Development and use of national essential medicines list Establishment of drug and therapeutics committees in districts and hospitals Inclusion of problem-based pharmacotherapy training in undergraduate curricula Continuing in-service medical education as a licensure requirement

29. 7. Supervision, audit and feedback 8. Use of independent information on medicines 9. Public education about medicines 10. Avoidance of perverse financial incentives 11. Use of appropriate and enforced regulation 12. Sufficient government expenditure to ensure availability of medicines and staff. …… contd

30. rational drug use prevents….. Ineffective treatment Increased financial burden Wastage of resourses Antibiotic resistance