Rational use of Drugs : Rational use of Drugs Prepared & Presented by Dr. Siva Reddy Challa, Professor & HOD, Dept. of Pharmacology KVSR Siddhartha College of Pharmaceutical Sciences, Siddhartha Nagar, Vijayawada-520010 Criteria for rational drug use : Criteria for rational drug use The rational use of drugs requires that patients receive medicines -------- appropriate to the their clinical needs------ ----in doses that meet their own individual requirements------- ------for an adequate period of time---------- -----at the lowest cost to them and the community- --- Important components of rationality: Important components of rationality Appropriate indication Appropriate drug Appropriate administration, dosage and duration Appropriate patient Appropriate patient information Appropriate evaluation Criteria for rational drug use : Criteria for rational drug use Correct diagnosis depending on the state of the patient Prescribing of the most efficient, safe, and economic drug treatment according to the condition of the patient Correct dispensing of the prescribed drug Appropriate packaging and labelling of the prescribed drug Patient compliance while taking the prescribed drug Factors underlying Irrational use of drugs : Factors underlying Irrational use of drugs Problems with Irrational Drug Use: Diagnosis : Problems with Irrational Drug Use: Diagnosis 1. Complex diseases or health problems: Eg: A patient has many symptoms, but is embarrassed to talk about the main one, so the situation does not get addressed 2 . Lack of appropriate training skills by prescribers to give proper diagnosis : Eg: Prescriber does not do a physical exam and prescribes drugs based solely on oral information provided by the patient Problems with Irrational Drug Use: Diagnosis : Problems with Irrational Drug Use: Diagnosis 3 . Overworked prescribers: Eg : health facility has only one prescriber, and an average of 300 patients per day to consult Lack of basic diagnostic equipment and tests Eg 1 : No microscope or reagents to examine blood and urine. Eg 2 :No x-ray machine to test a patient suspected of having tuberculosis. Problems with Irrational Drug Use: Prescribing : Problems with Irrational Drug Use: Prescribing 5 . Using expensive drugs when equivalent ones are available in the local market Eg 1: The antibiotic cephalexin health facility has only one prescriber, and an average of 300 patients per day to consult. Eg 2: Ampicillin injection is prescribed when the patient could take ampicillin tablets , which are cheaper, easy to take, and involve lower risk of side effects Problems with Irrational Drug Use: Prescribing : Problems with Irrational Drug Use: Prescribing 6. Selecting the wrong drug for the patient’s illness Eg 1: An antidiarrhoeal drug is prescribed when the patient is dehydrated with simple diarrhoea and only ORS (oral rehydration solution) is needed . Problems with Irrational Drug Use: Prescribing : Problems with Irrational Drug Use: Prescribing 7. Prescribing several drugs when fewer drugs would provide the same effect Eg 1: Sulfadoxine/pyrimethamine and paracetamol are prescribed when the patient has fever, but not malaria 8. Prescribing drugs when the disease is self limiting and the patient would get better without taking any drugs. Eg 2: Ampicillin is prescribed when the patient has a simple cold, without sore throat, cough or fever Problems with Irrational Drug Use: Dispensing : Problems with Irrational Drug Use: Dispensing 9. . Wrong interpretation of the prescription: E xample: Ampicillin is prescribed, but amoxicillin is dispensed. 10. Wrong quantity dispensed Example: Artemether/Lumefantrine is prescribed to be taken four tablets two times daily for three days (should be a total of 24 tablets), but the patient only receives 16 tablets, which is sufficient for only two days 11. Labelling incorrect or inadequate Example : sulphadoxine/pyrimethamine (white tablet) is dispensed, but the name of the drug is not written on the container label, meaning that the drug will be unidentifiable once the patient leaves the pharmacy Problems with Irrational Drug Use: Dispensing : Problems with Irrational Drug Use: Dispensing 12. Incorrect/insufficient dispensing information: Example: paracetamol 250mg is prescribed for a child, but only paracetamol 500mg is available in the pharmacy. The higher dosage pill is given to the child’s mother without telling her to divide the tablet before giving it to the child. 13. Unsanitary practices: Example: 20 tablets of paracetamol 500mg were being counted, when some tablets fell to the floor. These were picked up and dispensed to be given to the patient anyway Few examples of irrational drug use: Few examples of irrational drug use Prescribing exceedingly high doses Prescribing more toxic drugs than necessary Prescribing an unnecessary drug Prescribing a drug which leads to a drug-drug interaction Prescribing drugs with no proven benefit Prescribing expensive medicines even when cheaper and equipotent drugs are available. Few examples of irrational drug use: Few examples of irrational drug use 7. Prescribing parenteral dosage form when oral formuation prove to be beneficial. 8. Usage of certain drugs by the patients for minor ailments without consulting the physician 9. Usage of potent drugs in high doses to obtain quick relief from the sufferings 10. The patients usually do not complete the prescribed regimen and cease the administration half way through the course, when the symptoms begin to subside. Reasons for irrational use of drugs: Reasons for irrational use of drugs In India, Lack of sources to provide unbiased information regarding the currently used drugs . Prescribers rely more upon the medical representatives. This results in biased drug information leading to irrational drug use. In India, Lack of proper training for the medical students and physicians in writing appropriate and ideal prescription patterns Lack of diagnostic facilities in rural areas causes difficulties to the prescribers to reach a conclusion. This also results in polypharmacy. In India, patients want quick relief from the ailments. There is a pressure on physicians to prescribe the drugs for self limiting symptoms Reasons for irrational use of drugs: Reasons for irrational use of drugs 5. Due to ineffective control of drug regulatory authorities, due to availability of even “schedule H” drugs over the counter, there has been a rampant rise in irrational use of drugs 6. The prescribers are also influenced towards prescribing the drugs whose manufacturers offer many incentives 7. In India, the patient has more liberty to decide by themselves whether to purchase all the drugs prescribed or only some of them 8. Both prescribed and OTC drugs are easily available which results in self medication Consequences of irrational use of drugs: Consequences of irrational use of drugs Irrational use of novel anti-microbial agents have led to the development of resistance Irrational drug use does not produce the desired therapeutic outcomes. This results in additional pain and discomfort to the patient The patient or government has to bear the increased cost of the treatment Avoidable mistakes to avoid irrational drug use: Avoidable mistakes to avoid irrational drug use Prescribing multiple drugs Prescribing to keep up with latest fad Prescribing an older drug out of habit Prescribing in order to satisfy the expectations of the patient Prescribing out of pressure from drug companies other prescribers or media Guidelines for rational prescribing: Guidelines for rational prescribing Define the patient problem and then specify the therapeutic objective for this problem in this particular patient Decide whether drug is needed to achieve your therapeutic objective. Use drugs only when indicated and when the potential benefits outweighs the potential risks If the drug therapy is indicated, consider the various treatment alternatives. Choose a drug of proven efficacy and safety. The drug must also be suitable for the individual patient and be affordable. Choose a dose which is suitable for the individual patient. Careful dose adjustments is required for the children, elderly, patients with renal and hepatic impairment Guidelines for rational prescribing: Guidelines for rational prescribing Avoid using more than one drug of the same chemical class at the same time Inform the patient how to take medication, how long it will take to work, how long to continue with the treatment and possible side effects and what to do if they occur Monitor the effects of treatment If treatment has not been effective, try and identify and why. ---you should reconsider the diagnosis ---reconsider the therapeutic objective ---reconsider the treatment which was chosen ---whether the dose was too low ---whether the patient actually used the drug in the way which was intended -----whether monitoring is correct Decide whether the drug should be continued at the present dose, at a different dose or stopped. Continue treatment only if the original therapeutic objective is still relevant Promotion of rational drug use: Promotion of rational drug use Improve the Consultation Process Take a complete history of patient’s illness. Verify the main reason the patient came to the clinic, all accompanying symptoms, and the way the problem developed over time Perform a physical examination relevant to the patient's symptoms and medical history Prescribe drugs and treatment according to Standard treatment guidelines Do laboratory exams relevant to complaints. When no laboratory is available, the prescriber could visually examine the body fluids for evidence of disease Promotion of rational drug use: Promotion of rational drug use Improve Prescribing Habits When many drugs are prescribed for a patient, verify that they are absolutely necessary for treating the diagnosed condition Use standard treatment schemes for common illnesses Verify a second time that the drug is appropriate before dispensing it to the patient Promotion of rational drug use: Promotion of rational drug use Improve Dispensing Practices: Recruit and train competent personnel Organize the dispensing area so it allows for efficient work flow, can be easily cleaned, and is secure against theft Verify the quantity of the drug that is being dispensed to patient Give correct and adequate instructions to the patient Provide appropriate dispensing tools Promotion of rational drug use: Promotion of rational drug use Improve Compliance: Label the prescription container adequately (written or in symbols) before dispensing to the patient. After giving instructions to the patient about how to take the drug, ask for feedback to verify the patient’s understanding of drug dosage. Consider local beliefs and customs that influence drug use when prescribing and dispensing WHO definition of “Rational Use of Drugs”: WHO definition of “Rational Use of Drugs” WHO drug use indicators: 1.Prescribing indicators : WHO drug use indicators: 1.Prescribing indicators Average no. of drugs per prescription Percentage of drugs prescribed by generic name. Percentage of encounters with an antibiotic prescribed. Percentage of encounters with an injection prescribed. Percentage of drugs prescribed from an essential drug list or formulary. WHO drug use indicators: 2.Patient care indicators : WHO drug use indicators: 2.Patient care indicators Average consultation time. Average dispensing time. Percentage of drugs actually dispensed. Percentage of drugs adequately labeled. Patient knowledge of correct dosage. WHO drug use indicators: 3.Facility indicators : WHO drug use indicators: 3.Facility indicators Availability of copy of essential drugs list or formulary. Availability of key drugs WHO drug use indicators: 4.Prescribing indicators : WHO drug use indicators: 4.Prescribing indicators Percentage of patients treated without drugs. Average drug cost per encounter. Percentage of drug cost on antibiotics. Percentage of drug costs spent on injections. Prescription in accordance with treatment guidelines. Percentage of patients satisfied with the care they received. Percentage of health facilities with access to impartial information. Rational use of Antibiotics : Rational use of Antibiotics Use antibiotics only when indicated . Viral and self limiting bacterial disease does not benefit from the use of antibiotics. Where appropriate, specimens for Gram stain, culture and sensitivity testing should be obtained before commencing antibiotic therapy. Rational use of Antibiotics : Rational use of Antibiotics When antibiotic is indicated, the choice of agent should be based on factors such as ----spectrum of activity in relation to the known or suspected organism, -----Safety -----Clinical response -----Cost -----ease of use -----ability to kill resistant organisms -----Severity of the illness -----whether prophylactic or empirical therapy ------Identification of one or more pathogens Rational use of Antibiotics : Rational use of Antibiotics Where appropriate, specimens for Gram stain, culture and sensitivity testing should be obtained before commencing antibiotic therapy. An adequate dose and duration of treatment is essential for all antibiotic therapy indicated. Viral and self limiting bacterial disease does not benefit from the use of antibiotics. Rational use of Antibiotics : Rational use of Antibiotics A history of allergy or other adverse effect to the drug under consideration should always be sought . Prophylactic use of antibiotics should be restricted. Empirical antibiotic therapy should be based on local epidemiological data on potential pathogens and their patterns of sensitivity. Rational use of Antibiotics : Rational use of Antibiotics Antibiotic therapy directed at specific organisms should include --------- the most effective ----------least toxic ----------narrowest spectrum agent Oral therapy should be used in preference to parenteral therapy. -----Parenteral therapy is associated with ------Greater risk of serious adverse effects, ------much higher drug cost, ------additional cost of syringes, needles, ------risk of infection Rational use of Antibiotics : Rational use of Antibiotics Antibiotic combinations should only be used where indicated --------- to extend the spectrum of cover in mixed injections ----------to achieve a synergistic bactericidal effect ----------to prevent the emergence of resistant organisms eg ; in the therapy of TB Topical antibiotics should be restricted to a proven indications like eye infections. Reserve new antibiotics for situations where serious infections are not responding to conventional antibiotics. Rational use of Injections : Unnecessary use of injections are associated with : Rational use of Injections : Unnecessary use of injections are associated with Unnecessary use of injections are associated with -- higher costs --increased need for trained staff. --increased time to administer the drug. --possible transmission of serious pathogens like HIV --increased risk of adverse drug reactions --risk of abscess formation if injections are unhygenically administered Rational use of Injections : Rational use of Injections General use of injections are restricted to the following situations. Oral administration is not tolerated or is not possible. Eg: swallowing problem or unconsciousness. If there is a clear absorption problem. Eg: vomiting, severe diarrhoea. The drug of choice is only formulated as a parenteral product. Eg: insulin, gentamicin Rational use of Injections : Rational use of Injections General use of injections are restricted to the following situations. High tissue concentrations are needed and are not achieved by oral administration. Eg: Treatment of meningitis, osteomyelitis. Urgent treatment is required due to severe and rapidly progressing illness. Eg: Septicemia The patient is unlikely to comply with oral treatment.