RATIONAL USE OF DRUGS

07/29/24
Outline
 Rational use of medicines
 Reasons of irrational use of drugs
 Examples
 Rational Prescribing, Strategies and drug use indicators
 Conclusion

Rational Use of Drugs 07/29/24

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 lowest cost to them and their community”
(WHO, 1985)
‘Criteria’ for Using Medicines

RUD fulfils following criteria;

•Appropriate indication
•Appropriate drug
•Affordable
•Correctly dispensed
•Appropriate administration, dosage and duration
•Appropriate patient
•Appropriate patient information
Rational Use of Drugs 07/29/24
Adherence
 Adherence has been defined as the extent to which a
patient's behaviour matches the agreed recommendation
from the prescriber.
 When a patient is non-adherent this can be classified as
intentional or unintentional non-adherence.
 Unintentional non-adherence occurs when the patient
wishes to follow the treatment plan agreed with the
prescriber, but is unable to do so because of circumstances
beyond their control. Examples of this include forgetting to
take the medicine at the defined time or an inability to use
the device prescribed.

Ethical Practice and Rational Use of Medicines 07/29/24

Cont…
 Strategies to overcome such obstacles include medication
reminder charts, use of multi-compartment medication dose
systems, large print for those with poor eyesight etc.
 Intentional non-adherence occurs when the patient
decides he/she does not wish to follow the agreed treatment
plan. This may occur because of the patient's beliefs,
his/her perceptions or motivation. Therefore, it is important
that all of these aspects are included in the discussion
between the patient and prescriber when the treatment plan
is developed.
Studies have demonstrated that between 35% and
50% of medicines prescribed for chronic conditions
arePractice
Ethical not taken asUse
and Rational recommended
of Medicines 07/29/24
Pharmaceutical Care
Clinical Pharmacy ----- a set of functions that promote
the safe, effective and economic use of medicines for
individual patients.

Pharmaceutical Care: The responsible provision of

drug therapy for the purpose of achieving definite
outcomes that improve a patient’s quality of life.
“ The need to focus on outcomes of medicines use” .

- A landmark in Pharmacy Practice.

Ethical Practice and Rational Use of Medicines 07/29/24

Medicine related problems (MRPs)
Untreated indication
Treatment without indication
Improper drug selection
Too little drug
Too much drug
Non-compliance
Adverse drug reaction
Drug interaction

Ethical Practice and Rational Use of Medicines 07/29/24

Benefits of Pharmaceutical Care
An example:
In US, Pharmacists participation in physician ward rounds
has been shown to reduce adverse drug events 78% and 66%
in general medical and intensive care settings respectively.
A study covering 1029 US hospitals that both centrally based
and patient specific clinical pharmacy services are associated
with reduced mortality rates.
These services involved were: medicine information, clinical
research performed by pharmacists, active pharmacist
participation in meetings and pharmacists undertaking
admission medication histories.


Ethical Practice and Rational Use of Medicines 07/29/24

 Reasons for Irrational use of
Drugs
1. Lack of information
2. Role models – Practitioners (Physicians,
Pharmacists, Nurses) – Academicians (Teachers &
researchers)
3. Lack of diagnostic facilities/Uncertainty of
diagnosis – medicine for all possible causes
4. Demand from the patient
5. Patient load in hospitals and clinics
6. Promotional activities of pharmaceutical
industries
7. Defective drug supply system & ineffective drug
regulation
Rational Use of drugs 07/29/24
Examples of Irrational Use of Medicine
 Poly Pharmacy
Average no. of medicines per prescription
 Unnecessary medication/ no medicine needed
Antibiotics misuse (RTIs)
 Wrong Medicine
Less than 40% patients are treated with appropriate
medicine
 Ineffective Medicine/ Medicine with doubtful efficacy
Multivitamins, Tonics
 Unsafe Medicines
Anabolic steroids for athletes and as appetizers for children
Underuse of available effective medicine
No therapy for mental disorders
Oral rehydration therapy for diarrhoea
Incorrect use of medication
Incomplete antibiotic therapy

o Unnecessary use of expensive medicines

o Incorrect dosing – under or overdose
Vicious Circle Leading to Irrational Drug
Use
Hazards of Irrational Use
1. Ineffective & unsafe treatment
 over-treatment of mild illness
 inadequate treatment of serious illness
2. prolongation of illness
3. Distress & harm to patient
4. Increase the cost of treatment
5. Increased drug resistance - misuse of anti-
infective drugs
6. Increased Adverse Drug Events
7. Increased morbidity and mortality

Rational Use of Drugs 07/29/24

 Rational Prescribing (Guidelines)

Define patient problem and establish therapeutic goal.

Use drug only when indicated and when potential benefits outweigh
the risk.
Choose a drug of proven efficacy and safety and must be suitable
for individual patient.
Avoid using more than one drug of the same chemical class at the
same time.
Inform the patient.
Monitor the effects of treatment.
Decide whether the drug should be continued at the present dose or
stopped.
If treatment has not been effective, identify the reason.
Rational Prescribing Decisions
There is no universally agreed definition of good
prescribing.
The prescriber should have the following four aims:
• Maximise effectiveness
• Minimise risks
• Minimise costs
• Respect the patient's choices.
---Can be applied:
-individual patient
-Wider population (Drug and Therapeutic committee)
Ethical Practice and Rational Use of Medicines 07/29/24
Rational Prescribing Decisions
A popular framework : STEPS
STEPS model includes five criteria for deciding the
choice of treatment
Safety
Tolerability
Effectiveness
Price
Simplicity
(Ref: Roger Walker)

Ethical Practice and Rational Use of Medicines 07/29/24

Strategies to improve Rational Drug Use…

(Reference: Roger Walker 5th ed.)

Ethical Practice and Rational Use of Medicines 07/29/24

Educational Strategies
Training for prescribers
The Guide to Good Prescribing

• WHO has produced a Guide for Good Prescribing - a

problem-based method
• Developed by Groningen University in collaboration
with 15 WHO offices and professionals from 30
countries
• Field tested in 7 sites
• Suitable for medical students, post grads, and nurses
• widely translated and available on the WHO
medicines website
 Managerial Strategies
Changes in selection, procurement, distribution to
ensure availability of essential drugs
• Essential Drug Lists, morbidity-based
quantification
Strategies aimed at prescribers
• targeted face-to-face supervision with audit, peer
group monitoring, structured order forms,
evidence-based standard treatment guidelines
Dispensing strategies
• course of treatment, packaging, labelling, generic
substitution
• Formularies
• Guidelines
• Examples of accredited guidelines are those produced by NICE
(National Institute for Health and Clinical Excellence,
www.nice.org.uk)
• and SIGN (Scottish Intercollegiate Guideline Network, www.sign.ac.uk
).
• Clinical Knowledge support systems
• Clinical knowledge summaries (www.cks.nhs.uk) is a decision
support system developed for use in primary care; helps with
differential diagnosis, suggests investigations and referral criteria, and
gives screens that can be shared between the patient and the
prescriber in the surgery.
Economic Strategies
Avoid perverse financial incentives
• prescribers’ salaries from drug sales
• insurance policies that reimburse non-essential
drugs or incorrect doses
• flat prescription fees that encourage
polypharmacy by charging the same amount
irrespective of number of drug items or quantity
of each item
 Regulatory Strategies
Drug registration
Banning unsafe drugs - but beware unexpected results
• Substitution of a second inappropriate drug after
banning a first inappropriate or unsafe drug
Regulating the use of different drugs to different levels
of the health sector e.g.
• Licensing prescribers and drug outlets
• Scheduling drugs into prescription-only & over-the-
counter
Regulating pharmaceutical promotional activities
Core Policies to Promote RUM

1) A mandated multi-disciplinary national body to

coordinate medicine use policies
2) Clinical guidelines
3) Essential medicines list based on treatments of choice
4) Drugs and therapeutics committees in districts and
hospitals
5) Problem-based pharmacotherapy training in
undergraduate curricula
6) Continuing in-service medical education as a
requirement for granting license to carry out a trade or
profession.
7) Supervision, audit and feedback
8) Independent information on medicines
9) Public education about medicines
10) Avoidance of perverse financial incentives
11) Appropriate and enforced regulation
12) Sufficient government expenditure to ensure availability
of medicines and staff
 SOME BROAD CATEGORIES OF DRUGS
WHICH ARE MISUSED OR IRRATIONALLY
USED

ANTIBIOTICS
• Penicillins
• Ampicillin
• Amoxicillin
• Tetracyclins
MUSCULO-SKELETAL DRUGS
• Dextropropoxyphene
• Aspirin
• Ibuprofen

29
CENTRAL NERVOUS SYSTEM DRUGS
• Diazepam
• Lorazepam
• Imipramine,Nortriptalline and Amitriptalline
ALIMENTARY SYSTEM DRUGS
• Antacids
• Laxatives,Purgatives and Lubricants
• Antidiarrhoeals
RESPIRATORY SYSTEM DRUGS
• Bromhexine
• Salbutamol

30
HORMONES
• Estrogen-Progestin combination in high doses(EF forte) used to cause
abortion
• Anabolic steroids like androlone,stanozolol
VITAMINS
OTHER MISCELLANEOUS DRUGS
• Naphazoline and Xylometazoline
• Oral Antidiabetic drugs:Glibenclamide,Gliclazide,metformin

31
RATIONAL DRUG USE CAN BE MONITORED BY

• Aggregate medicine consumption data:

• WHO drug use indicators
• The Anatomical Therapeutic Chemical (ATC) classification and
defined daily dose (DDD) methodology
• Drug Utilisation review(DUR) or focused drug use evaluation
• Qualitative methods

32
 Selected WHO drug use indicators
 Prescribing indicators:
 Average number of medicines prescribed per patient encounter
 % of medicines prescribed by generic name
 % of encounters with an antibiotic prescribed
 % of encounters with an injection prescribed
 % of medicines prescribed from essential medicines list or
formulary
 Patient care indicators
 Average consultation time:
 Average dispensing time
 % of medicine actually dispensed
 % of medicines adequately labelled
 % of patients with knowledge of correct doses.
Facility indicators
Availability of essential medicines list or formulary to practitioners
Availability of clinical guidelines
% of key medicines available
Complementary drug use indicators:
 Percentage of patients treated without drugs.
 Average drug cost per encounter.
 Percentage of drug costs spent an Antibiotics.
 Percentage of drug costs spent an Injections.
 Prescriptions in accordance with treatment guidelines.
 Percentage of patients satisfied with the care they received.
2nd International Conference for Improving Use of
Medicines, Chiang Mai, Thailand, 2004
472 participants from 70 countries

http://www.icium.org

Recommendations for countries to:

 Implement national medicines programmes to improve
medicines use
 Scale up successful interventions
 Implement interventions to address community medicines
use
 Health systems with no national
programs:
•No coordinated action
•No monitoring of use of medicines
Situational analysis

WHO facilitating
multi-stakeholder Develop
Modify
action in countries national plans
action plans
of action

Implement & evaluate

national action plans using
govt & local donor funds

Health systems with national programs:

•Coordinated action
•Regular monitoring of use of medicine

Department of Essential Medicines and Pharmaceutical Policy

TBS 2009
 Creating the WHO Essential Drugs Library
to facilitate the work of national committees

Evidence- Summary of clinical

based clinical guideline
guideline
WHO Model
Formulary
Reasons for inclusion WHO
Systematic reviews Model List
Key references

Cost: Quality information:

- per unit
- per treatment - Basic quality tests
- per month - Internat. Pharmacopoea
- per case prevented - Reference standards

Department of Essential Medicines and Pharmaceutical Policy

TBS 2009
 WHO-sponsored training programmes

• INRUD/MSH/WHO: Promoting the rational use of drugs

• MSH/WHO: Drug and therapeutic committees
• Groningen University, The Netherlands / WHO:
Problem-based pharmacotherapy
• Amsterdam University, The Netherlands / WHO:
Promoting rational use of drugs in the community
• Newcastle, Australia / WHO: Pharmaco-economics
• Boston University, USA / WHO: Drug Policy Issues

Department of Essential Medicines and Pharmaceutical Policy

TBS 2009
 Global monitoring and identifying effective
strategies to promote rational use of medicines

• WHO/EMP databases on drug use and policy

– quantitative data on medicines use and interventions to
improve medicines use from 1990 to present day
– data from MOHs on pharmaceutical policies every 4 years –
1999, 2003, 2007
• ICIUM3 in 2011
– 3rd international conference on improving the use of
medicines (ICIUM3)
• Surveillance of antimicrobial use & resistance
– method for community-based surveillance in poor settings
– interventional approach for improving use in private sector

Department of Essential Medicines and Pharmaceutical Policy

TBS 2009
 Conclusions

• Irrational use of medicines is a very serious global

public health problem.

• Much is known about how to improve rational use of

medicines but much more needs to be done
– policy implementation at the national level
– implementation and evaluation of more interventions,
particularly managerial, economic and regulatory interventions

• Rational use of medicines could be greatly improved if

a fraction of the resources spent on medicines were
spent on improving use.

Department of Essential Medicines and Pharmaceutical Policy

TBS 2009
References..
1) Irrational drug combinations; Need to sensitize
undergraduates. Gautam, C.S. Aditya S. Ind.J. Pharmacol;
Vol. 38, 3, June 06, 169-170.
2) Essential drugs and Rational Therapeutics Text book of
Pharmacology S.D. Seth 1st Ed.1997, 783-791.
3) Essential drugs and Rational Therapeutics Text book of
Pharmacology S.D. Seth 2nd Ed.2004, 907-916
4) Organization behaviour and community health
promoting rational drug use among health professionals
Uma Tekur and Isha Gupta Publication from state institute
of health and family welfare; Rajasthan 2nd ed. 1998, 273-
276
Rational use of Drugs 07/29/24