ARTICLE
Problems and Impact of Irrational Medicines: Use
and Tools & Interventions to Improve Medicines Use
Dr. Nirmal Gurbani*
Professor, Indian Institute of Health Management and Research (IIHMR), Jaipur and Honorary Secretary,
Rajasthan Society for Promotion of Rational Use of Drugs (RSPRUD)
Introduction
Medically inappropriate, ineffective,
and economically inefficient use of
pharmaceuticals is commonly observed
in the health care system throughout the
world especially in the developing countries.
However, various forms of inappropriate
prescribing often remain unnoticed by those
who are involved in health sector decision-
making or delivery of health services.
This problem will usually come to meet
the attention of health decision makers or
managers when there is sudden reporting
of adverse event(s) traced to particular
medicines used or an acute shortage of
pharmaceutical budget calling for cost
efficiency.
The need for promoting appropriate use
of medicines in the health care system is
not only because of the financial reasons
with which policy makers and managers
are usually most concerned. Appropriate
use of medicines is also one essential
element in achieving quality of health
and medical care for patients and the
community. Obviously, this should also
become the concern for practitioners and
pharmacists dispensing medicines. Actions
or intervention programs to promote the
appropriate use of medicines should,
therefore, be continuously implemented and
systematically incorporated as an integral
part of the health care system.
Rational Use of Medicines
The terms “appropriate” and “rational” use
of medicines can be used interchangeably.
What is rational use of medicines? What
does rational mean? People may have
different perceptions and meanings
regarding rational use of medicines, or more
specifically, regarding rational prescribing.
However, the Conference of Experts on the
Rational Use of Medicines, convened by
the World Health Organization in Nairobi in
1988 stated that:
“Rational use of medicines requires that
patients receive medications appropriate to
their clinical needs, in doses that meet their
own individual requirements for an adequate
*E-mail: nirmalgurbani@rediffmail.com
period of time, and at the lowest cost to them
and their community”
These requirements will be fulfilled if
the process of prescribing is appropriately
followed. This will include steps in defining
patient’s problems (or diagnosis); in defining
effective and safe treatments (medicines
and non-medicines); in selecting appropriate
medicines, dosage and duration; in writing a
prescription; in giving adequate information
to the patients; and in planning to evaluate
treatment responses. The definition implies
that rational use of medicines, especially
rational prescribing should meet certain
criteria as follows:
• Appropriate indication: The decision
to prescribe medicine(s) is entirely
based on medical rationale and that
medicine therapy is an effective and
safe treatment.
• Appropriate medicine: The selection of
medicines is based on efficacy, safety,
suitability and cost considerations.
• Appropriate administration, dosage and
duration.
• Appropriate patient: No contra-
indications exist and the likelihood of
adverse reactions is minimal, and the
medicine is acceptable to the patient.
• Appropriate information: Patients should
be provided with relevant, accurate,
important and clear information
regarding his or her condition and the
medication(s) that are prescribed.
• Appropriate cost: to the patient and
community.
• Appropriate monitoring: The anticipated
and unexpected effects of medications
should be appropriately monitored.
Unfortunately, in the real world, prescri-
bing patterns do not always confirm to
these criteria and can be classified as
inappropriate or irrational prescribing.
Irrational prescribing may be regarded
as “pathological” prescribing, where the
above-mentioned criteria are not fulfilled.
Common patterns of irrational prescribing,
may, therefore be manifested in the following
terms:
• The use of medicines when no medicine
therapy is indicated, e.g. antibiotics for
Pharma Times - Vol. 43 - No. 07 - July 2011
viral/upper respiratory infections and
diarrhea.
• The use of the wrong medicine for a
specific condition requiring medicine
therapy, e.g. tetracycline in childhood
diarrhoea requiring ORS.
• The use of medicines with doubtful/
unproven efficacy, e.g. the use of
antimotility agents in acute diarrhea.
• The use of medicines of uncertain
safety status, e.g. use of dipyrone,
etc.
• Failure to provide available, safe, and
effective medicines, e.g. failure to
vaccinate against measles or tetanus,
failure to prescribe ORS for acute
diarrhoea.
• The use of correct medicines with
incorrect administration, dosages, and
duration, e.g. the use of IV Metronidazole
when suppositories or oral formulations
would be appropriate.
• The use of unnecessarily expensive
medicines, e.g. the use of a third
generation, broad spectrum antimicro-
bial when a first-line, narrow spectrum,
agent is indicated.
Some examples of commonly
encountered inappropriate prescribing
practices in many health care settings
include:
• Overuse of antibiotics and antidiarrhoeals
for non-specific childhood diarrhoea.
• Indiscriminate use of injections, e.g. in
malaria treatment
• Multiple medicine prescriptions
• Excessive use of antibiotics for treating
minor ARI
• Minerals and tonics for malnutrition
• Abbreviations like PCM (paracetamol),
THP (trihexyphenidyl), TFP
(trifluoperazine), TCA (to come after)
Factors Underlying Irrational Use of
Medicines
There are many different factors, which
affect the irrational use of medicines. In
addition, different cultures view medicines
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in different ways, and this can affect the
way medicines are used. The major forces
can be categorized as those deriving from
patients, prescribers, the workplace, the
supply system including industry influences,
regulation, medicine information and
misinformation, and combinations of these
factors.
• Patients - Medicine misinformation
- Misleading beliefs
- Patient demands/
expectations
• Prescribers - Lack of education and
training
- Inappropriate role models
- Lack of objective
medicine information
- Generalization of limited
experience
- Misleading beliefs about
medicines efficacy
• Workplace - Heavy patient load
- Pressure to prescribe
- Lack of adequate lab
capacity
- Insufficient staffing
• Medicine Supply System -
Unreliable suppliers
- Medicines shortages
- Expired medicines
supplied
• Medicine Regulation
- Non-essential medicines
available
- Non-formal prescribers
- Lack of regulation
enforcement
• Industry - Promotional activities
- Misleading claims
All of these factors are affected by
changes in national and global practices.
For example, the frequent use of injections
is declining in many African countries
because of the fear of AIDS. In some
countries, however, the use of injections
remains high due to false assumption of
prescribers that injections will improve
patient satisfaction.
Consumers may have a very different
perspective as what is rational.
The medicine use system is complex and
varies from country to country. Medicines
may be imported or manufactured locally.
The medicines may be used in hospitals
or health centers, by private practitioners
and often in a pharmacy or medicine shop
where OTC preparations are sold. In some
countries, practically all medicines are
available over the counter! Finally, public
includes a very wide range of people with
differing knowledge, beliefs and attitudes
about medicines.
Pharma Times - Vol. 43 - No. 07 - July 2011
Impact of Inappropriate Use of
Medicines
The impact of this irrational use of
medicines can be seen in many ways:
• Reduction in the quality of medicines
therapy leading to increased morbidity
and mortality.
• Waste of resources leading to reduced
availability of other vital medicines and
increased costs.
• Increased risk of unwanted effects such
as adverse medicine reactions and the
emergence of medicine resistance,
e.g., malaria or multiple medicine
resistant tuberculosis.
• Psychosocial impacts, such as when pa-
tients come to believe that there is “a pill
for every ill”. This may cause an apparent
increased demand for medicines.
Strategies to Improve Use
of Medicines
There are four major strategies to
improve use of medicines, namely;
• Educational: to inform or persuade
health providers and consumers
through training programmes, seminars,
circulation of literature, print and
electronic media, etc.
• Managerial: to guide clinical practice
as per evidence based Standard
Treatment Guidelines (STGs) while
ensuring adequate laboratory capacity,
availability of medicines and information
system tuned to medicines under
STGs.
• Regulatory: to restrict choices pertaining
to practice/prescribing, market control
with enforcement.
• Economic: to offer incentives to
Institutions, providers and patients
adhering to rational use of medicines
policies.
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Tools and Interventions to
Improve Use of Medicines
Methods, tools and intervention do exist
to improve the use of medicines. The WHO
supports following measures to promote
rational use of medicines:
• A national / state level body to coordinate
medicine use policies
• Clinical guidelines / protocol/STGs
• Essential Medicines List (EML)
• Drugs & Therapeutic Committees
(DTCs) in hospitals
• Problem-based pharmacotherapy
training to undergraduates
• Continuing in-service medical and
pharmaceutical education as a licensure
requirement
• Supervision, prescription audit and
feedback
• Independent information on medicines
• Public education about medicines
• Avoidance of perverse financial
incentives at all levels
• Appropriate and enforced regulations
• Sufficient funds to ensure availability of
medicines
Conclusions
Health is considered a basic human
right under UN perspective and Millennium
Development Goals (MDGs). In spite of all
the advances in the field of health care,
medicines have remained core and will
continue to remain as core in the healthcare.
Usually, use of medicines is the end of any
therapeutic consultation. Medicines are
different from other consumer products;
therefore, they should be used carefully
& rationally. Health professionals have a
responsibility to ensure that the right drug is
prescribed, dispensed and taken. Therapies
need to be tailored to suit local experience,
practices and requirements. Improving
drug use improves the quality of care and
frequently lowers cost. Methods exist to
measure drug use and to change practices.