Rational Drug Treatment2011

Rational Drug TreatmentNicolaski Lumbuun dr., SpFKClinical PharmacologistFaculty of Medicine - UPH

Rational pharmacotherapyRational or based on reason would mean science or evidence based

Rational pharmacotherapy DEFINITION

In simplest words, means :

prescribing right drug, in adequate dose for the sufficient duration & appropriate to the clinical needs of the patient at lowest cost

Factors that led realization for rational drug use Drug explosion:Increase in the number of drugs available has incredibly complicated the choice of appropriate drug for particular indication.Efforts to prevent the development of resistance:Irrational use of drugs may lead to the premature demise of highly efficacious & life saving new antimicrobial drug due to development of resistance.Growing awareness:Today, the information about drug development, its uses & adverse effects travel from one end of the planet to the other end with amazing speed through various media.4. Increased cost of the treatment:Increase in cost of the drug increases economic burden on the public as well as on the government. This can be reduced by rational drug use.5. Consumer protection Act. (YLKI=lembaga perlindungan konsumen):Extension of CPA in medical profession may restrict the irrational use of drugs.

REASONS FOR IRRATIONAL USE OF DRUGSLack of informationFaulty & inadequate training & education of medical graduates : Lack of proper clinical training regarding writing a prescription during training period, dependency on diagnostic aid, rather then clinical diagnosis, is increasing day by day in doctorsPoor communication between health professional & patientLack of diagnostic facilities/Uncertainty of diagnosisDemand from the patient Defective drug supply system & ineffective drug regulationPromotional activities of pharmaceutical industries

HAZARDS OF IRRATIONAL USE OF DRUGSIrrational use of drugs may lead to:1. Ineffective & unsafe treatment2. Exacerbation or prolongation of illness3. Distress & harm to patient4. Increase the cost of treatment

Medication-Related ProblemIn US, estimates of as many as high as 200,000 people may die of medication-related problems or adverse drug reactions (ADR) / year. Simonson et al. Medication Related Problems in the elderly, Drugs & Aging, 2005Risk of clinically serious ADR is 4 / 100 prescriptions, 1in 1000 will die.Prescription drugs 80% of ADR, OTC 20% of ADREstimates of 5-17% of hospital admissions are related to ADRIf adverse drug effects were classified as a distinct disease, it would rank as the fifth leading cause of death in the US. Lasorou et al. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA, 1998.Medication-related problems/ADRs are estimated to cost the US $200 billion annually. Cameron. Preventing medication-related problems among older Americans. Manag Care Interface, 1998.

MEASURES TO PROMOTE RATIONAL DRUG USEDrugs cannot be used rationally, unless every one involved in the pharmaceutical supply chain has access to objective information about the drug they buy and use. Knowledge & ideas about drugs are constantly changing & a clinician is expected to know about the new development in drug therapy.

The pre-requisities of rational drug useCritical assessment & evaluation of benefits & risk of drug used.

Compare the advantages, disadvantages, safety & cost of the drug with existing drug for some indication.

OBSTACLES EXIST IN RATIONAL DRUG USEVarious obstacles in rational drug use are:1. Lack of objective information & of continuing education & training in pharmacology.2. Lack of well organized drug regulatory authority & supply of drugs.3. Presence of large number of drugs in the market & the lucrative methods of promotion of drugs employed by pharmaceutical industries.4. The prevalent belief that every ill has a pill.

STEPS TO IMPROVE RATIONAL DRUGPRESCRIBING

Step:- I (Patient Presentation)

Identify the patients problem based symptoms & recognize the need for action.Attention & think carefully for presenting symptom & clinical feature of patient illness. (listening/patient)Try to find & tell the patient about the potential consequences of their problems.(communication)Ask or try to know what is the patient expectations of his problems and the medications (Empathy)

Step:-II (Proccess of Rational Therapeutics)Making diagnosis of the disease. Identify underlying cause & motivating factors. Understanding patophysiology of the underlying cause.Review the treatment options.Selecting the optimal treatments.Choosing end points to follow.Maintaining alliance with the patient to reach the end points.

Selecting the optimal treatmentsList possible intervention or treatment. This maybe non drug treatment or drug treatment. Drug must be chosen from different alternatives based on efficacy, convenience & safety of drugs including, drug inter-actions & high risk group of patients.Start the treatment by writing an accurate & complete prescription e.g. name of drugs with dosage forms, dosage schedule & total duration of the treatment.Given proper information instruction & warning regarding the treatment given e.g. side effects(ADR), dosage schedule & dangers/risk of stopping the therapy suddenly

Maintaining alliance with the patientMonitor the treatment to check, if the particular treatment has solved the patients problem. It may be:Passive monitoring done by the patient himself. Explain him what to do if the treatment is not effective or if too many side effect occursActive monitoring done by physician and he make an appointment to check the response of the treatment.If the particular treatment has not solved the patients problem back to step II

Step:-III (Result of Intervention)Assess the result/outcome of treatment.Functional outcomes relief of the symptomClinically outcomes : Efficacy ToxicityAllergyMorbidityMortalityPatient satisfactionsCost

Nierenberg DW, Melmon KL. Introduction to Clinical Pharmacology and Rational TherapeuticsIn: Carruthers SG, Hoffman BB, Melmon KL, Nierenberg DW, eds. Clinical Pharmacology: Basic Principles in Therapeutic. 4th ed. New york: Mc Graw-Hill 2000: 713-36.

What do you need to know about your treatment?If you are going to be using a drug you need to know a number of things about it:

An ideal situationIndication for drug therapy in relation to all prevailing circumstances: age, disease, pregnancy, sex, nutrition, concomitant drug use or other strategy.

Choice of drug according to factual criteria: pathophysiology, mechanism of action, the above conditions, characteristics of drug product.

Drug treatment should be carried out according to knowledge based principles: choice of dose, evaluation of effect, dose adjustment, therapy and adverse effect monitoring.

Therapy should be withdrawn when a defined and preset endpoint has been reached.

An ideal situation

New drugs New knowledge about old drugsHow to use the drug-treatment guidelinesContinuous drug communication is the basis for rational drug use !!!!

Drug committees and Public drug information centres (komite bidang kajian obat dan pelayanan kefarmasian, PB-IDI)Drug regulatory agencies (Badan POM)Clinical Pharmacologist or PharmaciesIndependant drug bulletins i.e. Drugs, The International PrescriberMedical technology assessment and research organisationsNon commercial drug information

From darkness into lightDrug monographs :Presentation of all, including unpublished, clinical trialsSafety assessmentComments on the value of the drug

ConclusionIndiscriminate use of drugs not only waste scarce resources that could otherwise be spent on other essential services, but also leads to drug induced disease. The drug control authority, the teaching institutes, drug industries, YLKI & the patient himself may be helpful for rational drug use.Drug authority must circulate the list of essential drugs which could be updated from time to time. It must monitor the safe & proper use of these drugs & enforce a uniform regulation for promotional literature.

Teaching institute must conduct regular research work & proper training of undergraduates & post graduates. Motivation of BPOM to organize various programmes for public awareness.The patient himself should observe strict compliance to the physician prescription & never indulge in self medication.Conclusion

To conclude, the demands of rational drug use :Availability of essential & life saving drugs Unbiased drug information with generic name.Adequate quality control & drug control.Withdrawal of hazardous & irrational drugs.Drug legislation reform.Conclusion

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