15/10/2020

UNIVERSITAS | ycuns .
AIRLANGGA | KEDOKTERAN

Rational Drug Use

Abdul Khairul Rizki Purba, dr., M.Sc., Sp.FK., PhD
Department of Pharmacology & Therapeutics
Faculty of Medicine, University of Airlangga

khairul_purba

If...
* You are currently in the emergency department
* You are the only medical doctor
* You have a patient, 55 years old man with chest pain. H also feel cold and
sweaty. Episodes of a similar but less severe pain had occurred daily for the
previous 10 days, predominantly at rest but also when climbing the stairs
at home. The patient has multiple risk factors for coronary disease
(including type II diabetes, hypertension, and being a smoker).

* What would you do?

* How to prescribe appropriately, rationally, and quickly?
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A Personal drug (P-drug)

* A drug you are going to use regularly and with which you become
familiar
* The personal drug for a doctor and it is not for a patient!

* The concept includes:

* The name of the drug
* The dosage form For a particular disease
* The dosage schedule
* The duration of treatment

P drug selection
¢ P drug is selected for a disease and not for a particular patient
¢ The practical activity of P drug selection can reduce the chances of
irrational prescribing
* P drug can vary from doctor to doctor & country to country because
of:
* variation of cost
* availability
* national formularies
* essential drug list of the country
* personal elucidation of information
* Medical cultures and interpretation
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What about P-treatment?

* Not all cases are treated by Example constipation:

drugs * Advice: drink a lot of fluids, take
* Four possible approaches to some fruit and high fiber food
* Non-drug treatments: physical
treat:
exercise
¢ Advice, consultation, information,
* Drug treatments: if necessary >
or education
perhaps the P-drug analyses using
* Non-drug treatments laxative
¢ Drug treatments * Referral: no indication
* Referral

Rational Use of Drugs

Define the patient’s problem

Specify the therapeutic objective

Verify the suitability of your P-drug

e( Write a prescription

® Give information, instruction and warning

Monitor (and stop?) the treatment

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Step 1. Define the patient’s problem

* Disease or disorders
* Sign of underlying disease
* Psychological or social problems, anxiety
* Symptoms
* Diagnosis
¢ Patient characteristics

Step 2. Specify the therapeutic objective

° Prevention
* Prophylaxis
* Symptomatic
* Curative
* Rehabilitation
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Step 3. Verify the suitability of your P-drug

* Availability > according to clinical guidelines or evidence >

reproducible & predictable
* National drug formulary (Formularium nasional - FORNAS)
* Hospital drug formulary
* Essential medicine list (EML) — (Daftar obat esensial nasional - DOEN)
* Diagnostic and therapeutic guidelines (PDT)
* Antibiotic use guidelines (PPAB)
° Verify suitability for patient
* Contraindication
* Interactions
* Comedications

Steps of selection of P Drug

Definition of the disease: Define the problem

PwWwnNr

List the therapeutic objectives

List the drugs: Based on the classification of drugs
Choose the effective group based on the criteria’s:
Efficacy, Safety, Cost and Convenience/ suitability

5. Choose a P Drug: Choose an active substance and a dosage form,

Standard dosage schedule , duration of treatment
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Case

* Select a P drug for Urinary tract infection. Mrs. Y is a 27 year school

teacher who is suffering from uncomplicated UTI, recently it was
found that she is allergic to cotrimoxazole and her urine pregnancy
test is positive.
* Verify the suitability of the selected P drug in this case?

Components of P-drug

* Efficacy > therapeutic effects, PK/PD

* Safety > side effects, toxic effects
* Cost > medical costs (direct/indirect), pharmacoeconomics
* Convenience/Suitability > pediatrics, geriatrics, pregnancy, feeding,
renal/hepatic insufficiency, heart failure, drug interaction,
comorbidities
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P-drug

* Ascore between 0-1 is given for 4 criteria of Efficacy, Safety, Cost &
Convenience/Suitability.
* The score depends on the significance of the criteria for a disease.
* Eg. For Amoebic Dysentery- efficacy (0.4), safety (0.3), cost (0.1) and
convenience (0.2).
* This 0.4, 0.3, 0.2 and 0.1 is also called as the weight
* The total score should add up to 1 (0.4+0.3+0.1+0.2=1)

P-drug

* A group of drugs are chosen based on the classification of drugs.

* Each group a score between 1-10 is given on all the 4 criteria after
comparing with all the groups of drugs (higher score indicates a
better value)
* The value is then multiplied by the weight in all the categories
* Then the values are added together and the group which is having the
highest score is the selected group
* The same method is followed in selection of sub group and the
particular drug from the selected group of drugs.
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EEE CC
50% 20% 20% 10%
Cotrimoxazole 8(4) 7(1.4) 8(1.6) 3(0.8) 7.8
Penicillin 8(4) 9(1.8) 8(1.6) 7(0.7) 8.1
Fluoroquinolones _8(4) 6(1.2) 7(1.4) 6(0.6) 72)
Aminoglycosides 9(4.5) 6(1.2) 7(1.4) 7(0.7) 7.8
Urinary antiseptics 7(3.5) (1.6) 8(1.6) 3(0.8) ED)

[EEC 50% 20% 20% 10%

Cotrimoxazole 8(4) 7(1.4) 8(1.6) 3(0.8) 7.8
Ampi-sulbactam 8(4) 9(1.8) 8(1.6) 7(0.7) 8.1
Ciprofloxacin 8(4) 6(1.2) 7(1.2) 6(0.6) V2
Gentamycin 9(4.5) 6(1.2) 7(1.2) 7(0.7) 7.8
Urinary antiseptics 7(3.5) (1.6) 8(1.6) 3(0.8) ED)

Step 4. Write a prescription

* Name, address, telephone of the
prescriber
* date
* generic/brand name of the drug,
strength
=—=

* dosage form, total amount

¢ label: instructions, warnings
* Name, address, age of the patient
* signature or initials of the
prescriber
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Rational drug use

* Appropriate indication
* Appropriate drug
* Appropriate patient
¢ Appropriate dosage
* Side effect precaution

Appropriate indication

* The decision to prescribe drug(s) Not appropriate:

is entirely based on medical
rationale and the drug therapy is
an effective and safe treatment
* Common cold > amoxicillin
* Loss appetite in children >
ciproheptadin
* Myalgia > cobalamin injection
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Appropriate drug

* The selection of drugs is based Not appropriate:

on efficacy, safety, suitability, * Unfordable > branded name
and cost considerations. . .
* GO > tetracycline (not effective)

Appropriate dosage
* Appropriate dose regiment Not appropriate:
* Appropriate route * Simvastatin > morning
administrations * Ketoconazole > ac
* Appropriate the timing of * Captopril > pc
administrations
* Captopril > 1x/d
* Appropriate dose intervals
* Dexamethasone > 1x a.n.
* Appropriate the duration in drug
administration
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Appropriate patient

* No contraindications exist Not appropriate:

* the likelihood of adverse * 3 years old > ciprofloxacin,
reactions is minimal tetracycline
* the drug is acceptable to the * Pregnant women > tetracycline,
patient NSAIDs
* pediatrics, geriatrics, pregnancy, «BPH > buscopan
feeding, renal/hepatic .
insufficiency, heart failure, drug HT + DM ~ propranolol
interaction, comorbidities * HT + asthma > propranolol
* Hepatitis + fever > acetaminophen

Side effect precaution

* SE related to DDIs Not appropriate:

* Life threatening side effects * Prolong use of dexamethasone
* Moderate-severe side effects * CTM > driver
* Undesired effects * Ciprofloxacin > tendineae
fracture
* Propranolol for DM
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Step 5: Give information, instructions and

warnings
* Effects of the drug
* Side-effects
* Instructions
° Warnings
* Future consultation
* Everything clear?

Step 6: Monitor (and stop?) the treatment

Was the treatmant effective?

a.Yes,and disease cured;-stop the treatment
b.Yes,but not yet completed;
* any serious sideeffect?
* no--- treatment continue
* yes--- reconsider dosage or drug choice
c.No, disease not cured;
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