RDT_MedEthics

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By: sweetu_luck (112 month(s) ago)

a very nice and informative presentation...sir could u pls mail it to me at: sweetu_luck@yahoo.com

By: vittal (122 month(s) ago)

Thanks. I shall mail you the power point version at the given mail ID soon. - Dr Vittal

By: Bharatvmmc (123 month(s) ago)

Hi nice presentation ! can you send me a copy at bharatvmmc@yahoo.co.in

By: vittal (126 month(s) ago)

Thank Q sir. Sorry for the delayed response. I was away. Pl. gimme your mail ID. I shall send the presentation. Regards - Dr CSN Vittal

By: bheemesh6 (126 month(s) ago)

nice presentation covering all sections.very informative . plz send me a copy. thanQ

Presentation Transcript

Rational Drug Therapy : 

Rational Drug Therapy C.S.N.Vittal Rational Drug Therapy

What Is Rationality? : 

What Is Rationality? endowed with reasoning, reason sensible sane moderate not foolish, absurd or extreme Being …

Medicine “ A Noble Profession ” : 

Medicine “ A Noble Profession ” Should we be discussing rationality?

Essential Drugs : 

Essential Drugs

Concept of Essential Drugs & Indian Scenario : 

Concept of Essential Drugs & Indian Scenario Rational Drug Therapy and Essential Drugs are two sides of a coin WHO list of ED : 312 items and 518 formulations 36 formulations with 21 FDC’s (Fixed Dose Combinations) India: The National Essential Drug List : 279 items, 489 formulations, 11 FDC’s Market : > 1 lakh formulations, 70 % FDC’s Many are non essential, useless, irrational, harmful

Slide 6: 

The Pillars of Rational Drug Therapy

The Pillars of Rational Drug Therapy : 

The Pillars of Rational Drug Therapy Genuine indication Minimum number of appropriate, familiar and inexpensive drugs of assured quality Drugs should preferably be prescribed by generic name Formulations having appropriate dosage form Oral route-optimum duration Desirably be prescribed through oral route in children Adverse Drug Reaction: anticipation, monitoring and management

What Are The Facts? : 

What Are The Facts? Irrationality has no boundaries: East-west, teaching-non teaching institutes, juniors-seniors, generalists-specialists No dearth of irrational prescriptions Market is flooded with nonessential preparations Polypharmacy is the rule

Dynamics of Irrationality : 

Dynamics of Irrationality Does any text book of medicine teach irrationality? How does it creep in? The Driving Forces: > > > > > >

Rationality as a victim of various infiltrations! : 

Rationality as a victim of various infiltrations!

1. Health care = drug therapy : 

1. Health care = drug therapy Natural inevitable consequence Automatically Habitually Compulsively

2. Incompetence : 

2. Incompetence Falling below accepted standards Ignorance Inadequate initial training Lack of CME ? ? ? ? Lack of confidence ? over use of drugs

2. Incompetence : 

2. Incompetence Falling below accepted standards ? ? ? ? Lack of confidence ? over use of drugs

2. Incompetence : 

2. Incompetence Lack of CME ? ? ? ? Lack of confidence ?overuse of drugs

2. Incompetence : 

2. Incompetence Ignorance ? ? ? ? Lack of confidence ? over use of drugs

2. Incompetence : 

2. Incompetence Inadequate initial training ? ? ? ? Lack of confidence ? over use of drugs

3.Monetary Aspects : 

3.Monetary Aspects Some grossly irrational practices : Unnecessary Injections I V fluids Admissions Surgeries Irrational prescriptions

4.Follow The Leader (Senior)! : 

4.Follow The Leader (Senior)! A trail of irrational followers Ask ‘ why' and ‘ what’ rather than ‘who’ regarding the prescription

5.Influence of Drug Industry : 

5.Influence of Drug Industry Tremendous Sole source of information on new drugs which is often biased due to commercial interest Misinformation Hiding facts

5.Influence of Drug Industry : 

5.Influence of Drug Industry Personal favors : gifts, samples, sponsored trip to conferences with family

5.Influence of Drug Industry : 

5.Influence of Drug Industry Sycophancy

Some myths - Perception Filters - Not Allowing Us To See Reason: : 

Some myths - Perception Filters - Not Allowing Us To See Reason: Patients in private practice are different Patients expect Injections and iv fluids as quick remedy Patient will go to other doctor New brands are appreciated Clinical freedom is our right (Circumventing the need to justify the treatment) [ We Need to Drop Them]

Ills of Irrational Therapy : 

Ills of Irrational Therapy Financial implications- more costly Adverse drug reactions False sense of security Emergence of resistant microorganisms Wastage of resources Loss of faith in medical profession Tarnished image of profession

What Can Be Done? : 

What Can Be Done? As individuals Time : Spending more time with patient explaining details of the disease and its judicious treatment would reduce need for unjustified drug usage

What Can Be Done? : 

What Can Be Done? As individuals Records – self audit Have faith in science and standard treatment protocols Follow Evidence Based Medicine Continuing Medical Education

As Group Activity : 

As Group Activity Form Action Groups: To promote Rational Therapy at various levels including community awareness

Concept of Drug Combinations -Basic Prerequisites : 

Concept of Drug Combinations -Basic Prerequisites Synergy: To achieve better therapeutic response than each alone (at least additive) One drug may reduce incidence / severity of ADR of other Convenience of administration for better compliance and reduced cost

Demerits of Combinations : 

Demerits of Combinations Dose alteration of one not possible without altering the dose of other Differing pharmacokinetics pose problems of frequency of administration Encourages polypharmacy Increased ADR and Drug interactions Increased cost Difficult to remember all the ingredients

Examples of Rational Combinations : 

Examples of Rational Combinations Antitubercular drugs-prevents development of resistance, dosage convenience Amoxycillin + Clavulinic acid ( B-Lactamase inhibitor – by irreversible binding – Suicide inhibitors) - restore activity Ampicillin + Sulbactum Imipenem + Cilastatin Pyrimethamine + Sulfadoxine Sulfamethoxazole + trimethoprim Ferrous salt + Folic acid

Examples of Irrational Combinations : 

Examples of Irrational Combinations Paracetamol + other NSAIDS Ampicillin + Cloxacillin ( Amoxy + Cloxa) Antibiotic + Antiamoebic Multivitamins So called cough and cold mixtures Antibiotics + Probiotics

Consequences of Usage of Irrational Combinations : 

Consequences of Usage of Irrational Combinations Absent or decreased efficacy Increased ADR’s Increased cost False sense of security for doctor and patient Masking / confusing / delaying - the correct diagnosis

Message for The Prescriber : 

Message for The Prescriber “Clinical freedom” at best is a cloak for ignorance & at worst is an excuse for quackery

Message for The Prescriber : 

Message for The Prescriber A doctor would do less harm by “Therapeutic Nihilism” than by optimistically overwhelming his patients with well intentioned polypharmacy

Rational use of Antipyretics : 

Rational use of Antipyretics Most often consumed drugs: prescribed or taken OTC Fever-common symptom with loads of diagnostic and therapeutic dilemmas Drug usage reflection of the dilemmas and pitfalls in management of fever

Fever - Some facts : 

Fever - Some facts Fever is a symptom and not a disease For evaluation of the disease and its response to specific therapy fever pattern can be of immense value If we ourselves are convinced about these 2 facts we can convince our patients to believe them too! Patients can be taught to record temperature.

Some Examples of Irrational Use of Antipyretics : 

Some Examples of Irrational Use of Antipyretics Giving antipyretics round the clock without even measuring temperature Giving long acting antipyretics without diagnosis of cause of fever Giving illogical combinations e.g. PCM + Nimesulide

Ill Effects of Irrational Use of Anti Pyretics : 

Ill Effects of Irrational Use of Anti Pyretics Masking of clinical picture Missed diagnosis e.g. Empyema, enteric fever, liver abscess False sense of security Increased incidence of side effects

Fever - Some Messages : 

Fever - Some Messages Temperature record is sacrosanct light house helping the clinician in making right decisions Antipyretics should be given SOS Prefer short acting drug Take patient into confidence by talking about the lurking danger in form of fever due to an undiagnosed condition

Drugs - Paracetamol : 

Drugs - Paracetamol Oldest, time tested Indisputably the safest Shortest acting Perceived problems: Ineffective, common Fact: It is effective, if given in right dose Dose: 15-20 mg/kg/dose x 4-6 hr Max 90mg/kg/day

Drugs - Paracetamol : 

Worst Enemies of Medical Profession > > > Drugs - Paracetamol Professional Colleagues

Drugs - : 

Drugs - Ibuprofen : Dose: 8-10 mg/kg can be given 6-8 hrly Safe when used for short durations Anti inflammatory Nimesulide : Long acting Dose: 1.5 mg/kg/dose 8-12 hrly Potential liver and renal toxicity Aspirin : Not to be used in children : - epidemiological association between salicylate usage and Reye’s syndrome

Rational Use of Antibiotics : 

Rational Use of Antibiotics Antibiotics need not be prescribed in all cases of fever Fever of viral etiology does not require antibiotics Antibiotics are not antipyretics!

Infections : 

Infections Large Bulk Of Pediatric Practice Antimicrobials Also Form Large Chunk Of Our Prescription Problem Of Plenty -You Have Many Choices But At Whose Cost?

The Three Way Test For Antibiotics : 

The Three Way Test For Antibiotics Is It Bacterial Infection? Can I Know or At Least Make A Wise Guess As To The Identity Of Culprit Bug? Which Is The Most Appropriate Antibiotic? * Safety * Efficacy * Cost

URTI - Is It Bacterial? : 

URTI - Is It Bacterial? Intensity of Fever Localization of Symptoms Exudates over Tonsils Lymphadenopathy CBC

URTI - Contd.. Which Organism? : 

URTI - Contd.. Which Organism? Commonest: Streptococcus ( GABHS ) Most Are Still Sensitive To Penicillin Amoxycillin : Drug Of Choice Dose 50 mg/Kg x 10 days Others: Cephelexin, Macrolides, Cotrimoxazole

Diarrheal Diseases Acute Gastroenteritis : 

Diarrheal Diseases Acute Gastroenteritis Large Chunk : Viral – Rotavirus Even if Bacterial – Self Limiting IAP Task Force Recommendation Blood In Stool : Cotrimoxazole, Nalidixic Acid, Norfloxacin, 3rd Generation Oral Cephalosporin x 5 days Stool Routine Ex - Not Indicated Stool Culture - Useless

Diarrheal Diseases - Contd.. : 

Diarrheal Diseases - Contd.. Amoebic Dysentery : Very Uncommon Diagnosis : Trophozoites In Stool Combination Of A/B + AA : Height Of Irrationality ! Mainstay of Therapy in diarrheal disease is The Discovery Of The 20th Century ORS

Medical Ethics : 

Medical Ethics

Medical ethics : 

Medical ethics Medical ethics is grounded in philosophical ethics, it concerns itself with the ethical questions and dilemmas in medicine. Medical ethics is not any special ethics but an ethics which deals with special cases from medical practice.

Doctor-patient relationship : 

Doctor-patient relationship Medical ethics has three centres: doctor, patient and society. Its centre is the doctor-patient relationship.

The moral duties of the doctor : 

The moral duties of the doctor The duty to help, cure The duty to promote and protect the patient’s health The duty to inform The duty to confidentiality The duty to protect the patient’s life The duty to respect the patient’s autonomy The duty to protect privacy The duty to respect the patient’s dignity

The moral rights of the patient : 

The moral rights of the patient The right to high quality medical service The right to autonomous choice The right to decide The right to be informed The right to privacy The right to health education The right to dignity

Principles of biomedical ethics : 

Principles of biomedical ethics Nonmaleficence Beneficence Respect for autonomy Justice

Hippocratic oath5-4 centuries B.C. : 

Hippocratic oath5-4 centuries B.C. An obligation of nonmaleficence and an obligation of beneficence are both expressed in the Hippocratic oath: “I will use treatment to help the sick according to my ability and judgement, but I will never use it to injure or wrong them.”

Slide 67: 

Thank you - Vittal

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