The Rational

use of drugs
R. Anita Indriyanti
Department of Pharmacology
Bandung Islamic University
 Introduction

 The aim of any drugs management

system :
• to deliver the correct drugs to the patient who needs
that medicine

 In order to achieve this goal :

• Drug therapy should be undertaken in accordance with
principles of rational prescribing

 The principles of rational prescribing :

• Essential element for effective, safe and economical use
of medicines
Rational Use of Drugs (RUD)
(WHO, 1985)

 When patients receive medication :

 Rational Use of Drug
• Appropriate to their clinical needs in
doses that meet their own individual
requirements
• For an adequate period of time
• At the lowest cost to them & their
community

– (conference of experts on RUD)

 Criteria of RUD (WHO, 1987)

 Correct diagnosis
 Appropriate indication
 Appropriate drug (s)
 Appropriate dosage, administration & duration of treatment
 Appropriate patient
 Appropriate information
 Appropriate evaluation & follow-up
(Managing Drug Supply, 1997)
 Appropriate indication
• The reason to prescribe is based on medical reasons
• Pharmacotherapy is proven to be the best alternative
for treatment
 Appropriate drug (s)
• Considering efficacy, safety, suitability for patient, and
cost
 Appropriate administration
Failure to take these considerations into account may result in ineffective,
harmful and/or uneconomical treatment
 Appropriate patient
• No contraindications exist
• The likelihood of adverse reactions is minimal
 Appropriate information
• Proper information to the patient is an integral part of
the prescribing process
• Needed to ensure their correct & safe use and to
improve patient compliance
 Appropriate evaluation & follow-up
• The importance & the need for careful monitoring is
often neglected
• Eventually lead to therapeutic failure or occurrences
of drug-induced problems
 The process of rational treatment
(who, 1994)

• Step 1 : define the patient problem

• Step 2 : specify the therapeutic objective
• Step 3 :verify the suitability of P-treatment
(Personal-treatment)
• Step 4 : start the treatment
• Step 5 : give information, instruction & warnings
• Step 6 : monitor (and/or stop?) treatment
# Define the Diagnosis
Example : Stable angina pectoris
# Specify Therapeutic Aim
• Prevention of anginal symptoms
• Reduce myocardial oxygen need by
decreasing preload, contractility, heart rate
or afterload (Remember Physiology of CVS)
# Make Inventory of Effective groups
• Nitrates
• -blockers
• Calcium channel blockers
• Potassium channel openers
 Choose a Group According to Criteria
Efficacy Safety Suitability Cost
• Nitrates (tablet) + +/- +/- +/-
• -blockers + +/- ++ +
(tablet)
• Calcium channel + +/- + -
blockers (tablet)
• Potassium + +/- +/- -
channel
openers (tablet)
  Choose a P-drug (from Beta blockers)
Efficacy Safety Suitability Cost

• Propanolol + +/- +/- +

(tablet)
• Atenolol (tablet) + +/- + +

• Metoprolol (tablet) + +/- +/- +

• Bisoprolol (tablet) + +/- + -

 Conclusion

• P-drug is……………………
• Active substance, Atenolol, 50 mg
tablet
• Dosage form
• Dosage schedule 50 mg once daily
• Duration
• Length of moniitoring
• Interval
 Irrational use of drugs (=IRUD)

 Occurs in all countries

 Examples of IRUD :

• No drug needed
• Wrong drugs
• Ineffective drugs & drugs with doubtful efficacy
• Unsafe drugs
• Underuse of available effective drugs
• Incorrect use of drugs
 Criteria of IRUD

 Medically inappropriate
• Inappropriate indications
• Inappropriate dosage, administration and duration of
treatment
• Inappropriate information

 Risk-benefit ratio > 1

 Classification of IRUD
(Quick, 1988)

 Extravagant prescribing
 Over prescribing
 Incorrect prescribing
 Multiple prescribing
 Under prescribing
 Extravagant Prescribing
The use of an expensive, usually newer, drug when a less
expensive older drug would provide the same effectiveness
and safety (examples ?)

 Over prescribing
 The use of drugs for conditions for which they are
ineffective (examples ?)
 Dose too large & too long (examples?)
Incorrect Prescribing
 The use of the wrong drug for a condition
 The used of drug for incorrect diagnosis
 Multiple Prescribing
The unnecessary use of more than one drug for the
same condition
 Under Prescribing
The use of drug at sub-therapeutic dosages for a
condition
 Adverse impact of IRUD

 Impact on quality of drug therapy

and medical care
 Impact on adverse drug reactions
(ADR) & bacterial resistance
 Impact on cost
 Psychosocial impact
 Impact on quality of drug therapy & medical care :
• Reduce the quality of patient care & outcome of treatment
• Underuse of ORS (oral rehydration solution) for acute diarrhea
can hinder the goal of treatment

 Impact on ADR & bacterial resistancy

• ADR increases when drugs are prescribed unnecessary
• Over/under dosage of antimicrobial agents lead to rapid
emergence of microbial resistance
Impact on cost
• Overuses of drugs causes excessive spending on
pharmaceutical of financial resources
• Inappropriate underuse of drugs at early stage of
disease, may also produce excess cost by increasing
the probability of prolonged disease & hospitalization
• Psychosocial impact
• Patients inappropriate reliance on drugs
 Factors underlying IRUD

 Health system

 Prescription writer

 Dispenser

 Patient & community

 Strategy to improve drugs
use
 Educational approach
 Managerial approach
 Regulation approach
 Drug information
• Bulletin
• Drug Information System
 Educational strategies
 Training prescription writer
 Formal & continuing education
 Supervisory visit
 Group lecturers/seminar/workshops

 Printed materials
 Clinical literatures & newsletters
 Treatment guidelines/drug formularies

 Approaches based on face-to-face contact

 Educational outreach
 Patient education
 Influencing opinion leaders
 Managerial strategies
 Approach to selection, procurement & distribution
 Limited procurement lists
 DUR & feedback; Cost information
 Hospital & regional drug committees

 Prescribing & dispensing approaches

 Structured drug order forms
 Standard diagnostic & treatment guidelines
 Course-of-therapy packaging

 Financing (price setting, capitation-based budgeting)

REGULATION STRATEGIES

 Drug registration

 Limited drug lists

 Prescribing restrictions

 Dispensing restrictions
 THANK YOU
Be positive, Think positive,
Act positive