RATIONAL DRUG USE Zikria, Ph.D.

DEFINITION
The rational use of drugs requires that patients
receive medications appropriate to their clinical
needs, in doses that meet their own individual
requirements for an adequate period of time, and at
the and at the lowest cost to them and their
community.
Do The right things right (K-action)
5 `rights' of medication:
 right patient
 right drug
 right dose
 right route
 right frequency
RATIONAL DRUG USE
Logical

Sensible

Reasoned

Perceptive
DRUG USAGE
Drugs have been used in diverse societies and cultures

Drugs have been used for medical, recreational and social purposes

Pharmacists are well educated regarding conventional drug usage

Meaning by drug interactions, ADRs, ADEs

A few pharmacist know about herbal and homeopathic medications

Similarly, most of the life threatening events, such as poison control are
dealt in poison control centers or hospitals.

Nevertheless, pharmacist is the custodian of the drugs and know almost all
aspects of the drugs

Unfortunately, pharmacist – most important professional regarding drug

information, is not taking a leading role or is not being given
Most important aspect in rational drug usage is

Patient education

Which is based on learning

And learning involves three processes

Knowledge – acquire, understand, reinforce

Attitude (affective) – based on ones’s feelings, perceptions, beliefs, emotions

Behavior – knows, feels and act– in association with social and environmental
factors
Rational prescribing & dispensing demands
That patient receives;
Drugs appropriate to their needs
 Doses that meet their individual requirements

 For an adequate period of time

 At the lowest cost to them and to the community

Appropriate indication

appropriate drug

Appropriated route of administration, dosage and duration

appropriate patient

Appropriate patient information

appropriate evaluation
Rational Prescribing & dispensing Criteria:

Like any other process in healthcare, writing a

prescription should be based on a series of rational
steps.

1. Make a specific diagnosis

2. Consider the pathophysiologic implication of

diagnosis

3.Select a specific therapeutic object

4. Select a drug of choice

5.Determine the appropriate dosing regimen

6.Devise a plan for monitoring the drug’s action and

determine an end point for therapy

7. Correct dispensing – appropriate packaging and

dispensing

8.Plan a program of patient education – to ensure patient

compliance
FACTORS THAT CONTRIBUTE
TO IRRATIONAL USE OF DRUGS
 IMPACT OF INAPPROPRIATE USE OF
DRUGS
It can be seen in many ways:

Reduction in the quality of drug therapy leading to increased morbidity and mortality,

Waste of resources leading to reduced availability of other vital drugs and increased
costs

Increased risk of unwanted affects such as adverse drug reactions and the emergence of
drug resistance, e.g., malaria or multiple drug resistant tuberculosis,

Psychosocial impacts, such as when patients come to believe that there is "a pill for every
ill". This may cause an apparent increased demand for drugs.
PROBLEMS WITH RATIONAL USE OF
DRUG – PRESCRIBING & DISPENSING
CONSEQUENCES OF
IRRATIONAL DRUG USE
 Characteristics of good and bad prescribing
Good prescribing Bad prescribing

Effective Ineffective

Safe Unsafe

Patient centred and individualized Not patient centred

Acceptable to patient Not suitable for patient

Appropriate (not too little or too much) Inappropriate

Addresses expectations of patient Causes patient distress and harm

Judicious use of resources Higher cost

Well informed (evidence based) Poorly informed

Based on unbiased information Based on biased information

Low vulnerability to outside influences Vulnerable to outside influence

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No. of physicians in the U.S. = 70,000

Accidental death caused by physicians per year = 120,000

 accidental death per physicians = 0.171
(source: U.S. Dept. of Health and Human Services)

No. of gun owners in the U.S. = 80,000,000

No. of accidental gun death per year = 1500
No. of accidental gun death per gun owner = 0.0000188

Statistically doctors are approximately 9000 more dangerous than gun owners.
CASE REPORT
A female student, age 20, suffering from tonsilitis,
was seen by a doctor in a 600-bed hospital OPD. She
obtained a drug from the hospital pharmacy and took
it as instructed. She felt very weak after taking the
drug. Three days later she became severely comatose
and was admitted to the same hospital. She took
chlorpropamide 250 mg four times a day. The OPD
doctor claimed that he prescribed chloromycetine
4x250 mg daily for her tonsilitis. The patient
eventually died two weeks after hospital admission.
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WHO/INRUD
WHO/INRUD (World Health Organization/International Network of
Rational Use of Drugs) developed drug use indicators to be used as
measures of performance in three general areas related to the rational use
of drugs in primary care. They are called core drug use indicators
TYPES OF INDICATORS
Prescribing

Patient Care

Facility

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PRESCRIBING INDICATORS
The indicators of prescribing practices
 measure the performance of health care providers

 Measure several key dimensions for appropriate use of drugs.

Include practices observed in a sample of clinical encounters taking place at

outpatient health facilities for the treatment of acute or chronic illness.

These encounters can be observed

 retrospectively

 prospectively
Average number of drugs per encounter

Purpose - To measure the degree of polypharmacy.

Prerequisites - Combination drugs are counted as one.

Calculation - Average, calculated by dividing the total number of different

drug products prescribed, by the number of encounters surveyed. It is not

relevant whether the patient actually received the drugs.

Example - In health centers in Indonesia patients are prescribed an

average of 3.3 drugs per consultation.

Percentage of drugs prescribed by generic name

Purpose - To measure the tendency to prescribe by generic name.

Prerequisites - Investigators must be aware of actual names used in the

prescription rather than only having access to the names of the products

dispensed

Calculation - Percentage

Example - In health units in Nepal an average of 44% of drugs are

prescribed by generic name.

Percentage of encounters with an antibiotic/injection prescribed

Purpose - To measure the overall level of use of two important, but commonly
overused and costly forms of drug therapy.

Prerequisites - A list must be available of all the drug products which are to be
counted as antibiotics; investigators must be instructed about which immunizations
are not to be counted as injections.

Calculation - Percentages

Example - In dispensaries in Nigeria 48% of all outpatient encounters were prescribed

one or more antibiotics, while an injection was prescribed during 37% of all
consultations.
Percentage of drugs prescribed from essential drugs list or formulary

Purpose - To measure the degree to which practices conform to a national drug

policy

Prerequisites - Copies of a published national essential drugs list or local

institutional formulary to which data on prescribed drugs can be compared

Calculation - Percentage

Example - In dispensaries in Tanzania on average 88% of drugs prescribed

appeared on the national essential drugs list.
PATIENT CARE INDICATORS

To understand way drugs are used it is important to consider what takes place at health facilities
from both the provider's and the patient's perspectives.

Patients - with a set of symptoms and complaints, and with expectations about the care they will
receive - leave with a package of drugs or with a prescription to obtain them in the private
market.

The patient care indicators - what patients experience at health facilities,

and how well they have been prepared to deal with the pharmaceuticals that have been
prescribed and dispensed.
Average consultation time

Purpose - To measure the time that medical personnel spend with

patients.

Prerequisites - accurate recording - the time between entering and leaving

the consultation room. Waiting time is not included.

Calculation - Average, calculated by dividing the total time for a series of

consultations, by the number of consultations.

Example - In Malawi patients spend an average of 2.3 minutes with health

workers in the consultation room.
Average dispensing time

Purpose - To measure the average time that personnel dispensing drugs spend with
patients.

Prerequisites - accurately recording the average time patients spent with pharmacists,
- the time between arriving at the dispensary counter and leaving. Waiting time is not
included.

Calculation - Average, calculated by dividing the total time for dispensing drugs to a
series of patients, by the number of encounters.

Example - In health centres in Tanzania patients spend an average of 78 seconds

receiving their drugs.
Percentage of drugs actually dispensed

Purpose - degree to which health facilities are able to provide the drugs

which were prescribed.

Prerequisites - Information on which drugs were prescribed, and whether

these drugs were actually dispensed at the health facility.

Calculation - Percentage,

Example - In health facilities in Nepal, 73% of prescribed drugs were

actually dispensed at the health facility.

Percentage of drugs adequately labelled

Purpose - degree to which dispensers record essential information on the

drug packages they dispense.

Prerequisites - Investigators must be able to examine the drug packages

as they are actually dispensed at the health facility.

Calculation - Percentage,

Example - In Region A only 10.2% of drugs dispensed were adequately

labelled.
Patients' knowledge of correct dosage

Purpose - effectiveness of the information given to patients on the dosage

schedule of the drugs they receive.

Prerequisites - Access to a written prescription or to a patient card against

which patients' knowledge on the dosage schedule can be checked

Calculation - Percentage,

Example - In 23 health facilities in Bangladesh 63% of patients were able

to repeat the correct dosage schedule of the drugs they had received.
HEALTH FACILITY INDICATORS

The ability to prescribe drugs rationally is influenced by many features of

the working environment.

Two particularly important components

 an adequate supply of essential drugs

 access to unbiased information about these drugs.

Availability of copy of essential drugs list or formulary

Purpose - extent to which copies of the national essential drugs list or

local formulary are available at health facilities.

Prerequisites - A national essential drugs list or a local formulary must

exist for that level of care

Calculation - Yes or no, per facility.

Example - In Country A only 28% of health facilities had a copy of the

national list of essential drugs.

 Educational, Managerial and regulatory Strategies for
intervention in Rational Drug Use
Strategies Interventions Targeted category of persons
Technical assistance
W.H.O, World Bank and Various international
International Drug Donations
organizations
Funding
-Drug registration -Ministry of Health
-Essential drug list -DRAP
Regulatory
-Laws and regulations restricting dispensing, -Ministry of Health & other relevant ministries and
prescribing & the entire pharmaceutical industry agencies.
-Establishing a priority list for drug procurement
-Establishing Drug committees -Storekeepers, Administrators, purchasers &
-Establishing price indicators Health workers
-Establishing a drug utilization information system for -All health Units
monitoring and evaluation -Accounts & Purchasers
Managerial
-establishing procedures for selection, procurement -Drug Use supervisors
and distribution -Administrators, purchaser & unit Heads
-Standard operating procedures for dispensing and -Store keepers & Dispensers
drug storage -Prescribers
-Standard diagnostic & treatment guidelines

-Formal training(curriculum review)

-Continued Medical Education -Medical &
-Increased supervision and support -In service training for all Health workers
Educational -Medical Journals, Newsletter, Treatment Guidelines -All Health workers
-Flyers, Posters, Billboards & Radio spots -Patients and community
-Community outreaches and use of Folk media -Administrators, Units Heads & Purchasers
-Drug Budgeting