Rational Drug Use

1. Use of medicine when no drug therapy is needed (antibiotics in viral upper respiratory tract infections)
2. Use of wrong medication for conditions requiring specific drug therapy (Fixed drug combination of Norfloxacin and Metronidazole in diarrhea)
3. Use of medicine of doubtful or unproven efficacy (Vitamins in the absence of deficiency)
4. Use of medicine of uncertain safety (ayurvedic bhasmas)
5. Failure to prescribe available, safe and effective agents (Under use of antidepressants or antihypertensives)
6. Incorrect administration, dosages or duration.
7. Use of too many drugs per patient (Polypharmacy)
8. Use of injections when oral formulations available
9. Inappropriate self-medication, often of prescription only medicine
10. Incorrect treatment of disorders
11. Poor compliance

1. Misinformation, misleading beliefs or inability to communicate symptoms correctly on part of the patient.
• Wants quick response - believes injections work faster
• Unhappy if no medicine prescribed
• compliance is big problem - once symptoms subside, stops treatment
• Adherence of patients to a treatment program is necessary for the success of the program. Non-adherence or non compliance results from factors related to the drug, the patient, the prescriber and the environment.
  
• Almost all drugs available OTC
  
2. Lack of accurate and correct information of newer agents, workload and pressure to prescribe on part of the prescribers
• Poor diagnostic support - empirical treatment
  
• No evidence based guidelines readily available
• Continuing education programmes
  
3. Poor medical facilities and supply of drugs
• Vaccines and many other drugs not stored at required temparature
• Over 80,000 formulations in the country, many doubtful value
  
4. Inadequate drug regulation -
• Process for marketing approval of new drugs
• Controls on OTC drugs
• More effective definition of prescriber
• Quality assurance of products
• good drug distribution systems
• availability and price control of essential drugs
• Unbiased drug information
• Unethical promotion of drugs
  

• Poor quality of health care delivery - Increased morbidity and mortality
• Waste of scant resources on using wrong medicine
• Irrational drug use leads to ineffective and unsafe treatment, worsening or prolonging of illness and adverse drug reactions.
  
• It also unnecessarily adds to the economic burden of the patients, the government or the insurance system.
  
• The widespread antibiotic resistance is also partly a result of irrational use of antibiotics.
  

1. Define the patient's problem - define the therapeutic objective

2. Use drug only when indicated and when potential benefits outweigh any risks

1. seriousness of the problem to be treated
   
2. efficacy of the drug to be used
   
3. severity and incidence of possible ADRs
   
4. safety and efficacy of alternative drugs if any
   
• e.g., phenylbutazone, commonly used in the treatment of osteoarthritis in the past, because of its high benefit-to-risk ratio, is currently replaced with safer drugs.
5. Assessment of benefit-to-risk ratio may not always be easy. The following examples show this problem:
• The benefit of adding digoxin to a diuretic and vasodilator vis- à-vis the risk of its toxicity in the treatment of congestive cardiac failure. This might depend on the cause of the heart failure, patient compliance, renal function and ease of monitoring of plasma digoxin concentration
  
• The benefit from a course of antibiotic in treating urinary tract infection in two months pregnant as compared to the risk of treatment to the fetus. Here the risk of teratogenesis needs to be compared to the risk of renal damage to the mother as a result of untreated infection
  

3. Choose a drug of proven efficacy and safety, which is suitable and affordable for the patient

• The use of International Non Proprietary Names (INN) or generic names of drugs in prescribing is an essential component of good prescribing practice. This is because generic drugs are less costly, an important factor in our country, and for a generic prescription any suitable product can be dispensed hence avoiding delay while looking for a specific brand.
  
• Avoid same class drug

4. Choose suitable dose

1. Route of administration: e.g.,
   
• Crystalline penicillin is given by intravenous route for severe infections; Intramuscular benzathine penicillin monthly or oral penicillin daily can be given for rheumatic fever prophylaxis.
  
• Beta agonists like salbutamol are given through nebulizers or inhalers in acute asthmatic attack for fast action.
2. Formulations : e.g.,
   

• Timing of drug administration: The following are examples where timing is very important
  
• To minimize ADR: tricyclic antidepressants to avoid dry mouth and drowsiness better to take it at bed time; potent diuretics better be given in the morning to avoid disturbance during the night
  
• Timing of symptoms: e.g., anginal attack, use of antacids
  
• Timing in relation to meals: penicillin to be administered before meal; aspirin to be administered with meal
• Inform the patient - dose, duration, adverse effects if any
• Monitor treatment
• If drug ineffective find reason, any changes needed or monitoring required
• Whether to continue drug or stop

• Depends on the nature of the disease or symptom: e.g., A single dose of aspirin for headache;Insulin for chronic therapy; treatment with H₂ blockers require six weeks as healing occurs with in this period, but longer periods of nightly administration may be required to prevent recurrence.
• Duration of treatment of infection depends on: The infecting organisms , Site of infection, Response to treatment, Dosage of antibiotics

• Informing and persuading prescriber - from students to practicing clinicians and community (teaching, seminars, face to face talks, distribution of printed matter, television etc)

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