SIX STEPS Rustamaji Faculty of Medicine Universitas Gadjah Mada 2011
SIX STEPS RustamajiFaculty of MedicineUniversitas Gadjah Mada2011
ObjectiveAfter attending this lecture, students are expected to be able to:
Explain the steps in therapeutic process Explain drug selection based on safety, efficacy, suitability and cost
Six steps of therapeutic decision processStep 1: Define the patients problemStep 2: Specify the treatment objectiveStep 3: Select the interventionStep 4: Start the treatmentStep 5: Give information to the patientStep 6: Monitor (or stop?) treatment(WHO, 1994)
Step 1:
Define the patients problem
Define the patients problemPatient presents with a complaint or a problem.To treat patient, physician should make a right diagnosisRight diagnosis based on the complaint as describe by patient, a detailed history, physical examination, laboratory tests, X-ray and other investigationPatient complaints are mostly linked to symptoms (is not diagnosis)
Define the patients problemDisease or disorder (diagnosis)Sign of underlying diseasePsychological or social problems, anxietySide effect of drugsRefill request (polypharmacy)Non-adherence to treatmentRequest for preventive treatmentCombination
Physician formulation may different with patient perceives
Step 2:
Specify the treatment objective
Specify the therapeutic objectiveTherapeutic objective sometimes straightforward, sometimes less clear.
Therapeutic objective canMake physician concentrate on the real problemPrevent a lot of unnecessary drug useAvoid unnecessary prophylactic drugs
Discuss your therapeutic problems with patient
Step 3:
Select the intervention
Select the interventionMake the inventory of possible treatments
Information or adviceTreatment without drugsTreatment with a drugReferralCombination
Selection of the medicinesMedicines should effective, safe, suitable to patient and cheaperEffective: please check to the reference standard to looking for the EBMSafety : check the side effects and frequency of side effectsSuitability : check the contraindication of the drug Cost: check the total cost not only the price
Efficacy of drugData Pharmacodinamic
Data pharmacokinetic (ADME)Compare the dosage and formulation on absorption, distribution, metabolism, excretion
Efficacy should be supported by good clinical trial with control
SafetySide effects
Toxic effects (depend on dug concentration)
If possible list he incidence of side effect
Unpredictable side effect (allergic reaction) may be caused by drugs
SuitabilityContraindication of drug related by patient condition (renal failure, hepatic disorder, history of allergic reaction, other disease, other drugs (possibility of interaction))
Change of patient physiology (pregnancy and lactation, extreme age)
SuitabilityAre the active substance and dosage form suitable for this patient?
Is the standard dosage suitable for this patient?
Is the standard duration of treatment suitable for this patient?Pharmacokinetic data
CostCheck the cheaper drug
Discuss with the patient about the drug price
Selection of medicines
Patient suffer dry cough that can be very inconvenient
Suppressing for a few day may have a beneficial effect
Many cough preparation available in the market
Step 4:
Start the treatment
Start the treatment Write a prescriptionCodein 30mg 3 x dailyPrescription is an instruction from a prescriber to a dispenserInformation on prescriptionName and address of the prescriber with telephone numberDate of prescription Name and strength of the drugDosage form and total amountInformation for the package insertSignature or initialPatient identity
Step 5:
Give information to the patient
Give information Instruction and warningEffect of the drugs
Why the drug is neededWhich symptoms will disappear, and which notWhen the effect is expected to startWhat will happened if the drug is taken incorrectly or not at all
Give information Instruction and warningSide effects
Which side effect may occurHow to recognize themHow long the will continueWhat action to take
Give information Instruction and warningInstruction
How the drug should be takenWhen it should be takenHow long the treatment should continueHow the drug should be storedWhat to do with left-over drugs
Give information Instruction and warningWarnings
When the drug should not be takenWhat is the maximum doseWhy the full treatment course should be taken
Give information Instruction and warningFuture consultation
When to come back (or not)In what circumstances to come earlierWhat information the doctor will needed at the next appointment
Give information Instruction and warningEverything clear ?
Ask the patient whether everything understoodAsk the patient to repeated the most important informationAsk whether the patient has any more question
Step 6:
Monitor (or stop?) treatment
Monitor and stop the treatmentWas the treatment effective ?Yes and disease cured Stop the treatmentYes but not yet completedAny serious effect?No : Treatment can be continuedYes : reconsider dosage or drug choice No : check your all steps