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 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.
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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