Rational User of Drugs The Hospital pharmacy series got diverted into various other issues as they were also very much pertinent to understand the concept and functioning of Hospital pharmacy. This happened due to some good interactions from students and teachers. Here I am reviving the series with the 'RATIONAL USE OF DRUGS'. R U D concept is essential and perhaps imminent when we are managing the hospital with public funds or when we dealing with the people with less income. Rational Use of Drugs Irrational medication - a major challenge The issue has gained a very great importance as the irrational medication is happening due to; i. Irrational formulations in the market, ii. Irrational prescriptions, iii. Patients adding their own OTC choices iv. Patients discontinuing the treatment in the midway v. Patients shifting to new clinic / doctor mid way during the treatment etc. The irrational formulations with various drug molecules and multi-drug formulations have been flooding the market with exclusive commercial interest with bizarre claims. Most of the time, such claims are either trivial or non-verifiable. They have also reduced the therapeutics to an oversimplified quack-friendly equation like 'Symptoms to Drugs' leading to self-medication. Manufacturers and sale promoters are professionals. Manufacturers compete in the market by blowing up and glorifying trivial / gimmick changes in the formula / label / packing / an additional ingredient. Their job is to keep on feeling the pulse of the clinicians and the people to understand not only the demand but also their mindset. They play with the product to make it look more and more appealing and acceptable and also strategically exploit the mindset and the demand in one stroke. Other factors 1. Over-prescribing, 2. Under-dosage, 3. Over-dosage, 4. Prescribing to oblige the market force, 5. Prescribing under Patient's pressure to get instant relief, 6. Lack of medication counseling facility, 7. Pharmacist's absence or silence - are the other factors that have added and compounded the issue resulting in intentional or unintentional irrational medication Thus, the irrational medication has become a major challenge to the therapeutics. The 'Rational' therapy means the therapy that uses the well established time tested easily available drug molecules preferably single drug formulation that is least expensive among the available alternates. It is like; 'AVOIDING HIGH END WEAPONS FOR LOW END JOB' Why the emphasis on Rational Use of Drugs? The emphasis on Rational Use of Drugs is to ensure that; 1. Only time tested and well established medicines are used at least in the institutions that are maintained by public funds. 2. The money of the patient or of the institution-maintained by public fund is not unnecessarily spent for irrational drugs in the name of therapy. 3. The patient or the institution is not used for experimenting some new drug molecules or formulations promoted by pharma companies. 4. The money of the patient or of the institution is not spent unnecessarily on certain expensively designed or packed formulation or on a 'Brand' when the same molecule in simpler and inexpensive design or packing is available at a very affordable price. 5. The patients are not driven from clinic-to-clinic in search of affordable treatment. Now the immediate issue that bounces on our face is the 'Quality' Is it wrong to go in for the best quality? No, it is not wrong but good to go in for the best quality. But, what is needed is what is this 'BEST' and which is the 'BEST'?. When it comes to drug standard, there is nothing like good, better best. With the enforcement of the revised Schedule 'M' in the Drugs & Cosmetics Rules under the Drugs & Cosmetics Act 1940, the manufacturing and quality check standards have been well upgraded to the WHO approved international standards that ensures production and marketing of drugs of 'Assured Quality'. However, just as anywhere else, prevalence of certain black-sheeps in the pharma market pushing poor quality brands and generics cannot be ruled out. This issue has been well addressed and taken care by the law to safeguard the people and as such cannot be considered as a major deterrent to adopt 'Rational Use of Drugs policy'. 'Irrational' is a relative term The term 'Irrational' is a comparative term. A drug molecule or a formulation can be called 'Irrational' only when an identical 'rational' unit is available. The 'rational' or irrational' status of a drug is a personal issue subjective to the Clinician, patient and Institution. Law and the Ethics; It is very interesting to understand that 'Irrational formulation / prescription' though is 'unethical' is not illegal. The law always looks into the minimum needs to approve a drug or its formulation/s. The minimum needs are; 1. Safety, 2. Indication 3. Stability, 4. Standard 5. Price - only in certain category -of the drug formulation. The law has no scope to view a product as 'Rational' / 'Irrational'. Therefore the 'Irrational' feel is a relative term perceived by an individual. Therefore, 'Rational / Irrational' is only a ethical concept. Irrational prescription Unfortunately; 1. 'A pill for every ill' appears to be the order of the day. 2. People responsible for manufacturing, marketing on the one side and the some of the clinicians listing the drugs to match every complaint and observations in the prescription on the other side is leading literally to an irrational 'Poly-pharmacy'. 3. Irrational advice also happens when the diagnosis is unclear and cloudy. Multiple drugs and formulations (Shot-gun prescription) comes in as a handy tool to prescribe with an intention of hitting the target at least by one! An 'Irrational' prescription; A prescription can be considered as 'Irrational'; 1. If the advice is without proper diagnosis 2. If the advice is for 'Over-dose' or for an 'Under-dose' medication 3. If prescription is unnecessarily loaded with drugs 4. If prescription is for abnormally long / short period. 5. If prescription contains antibiotics as a preventive measure for purposes other than surgery 6. If prescription contains new drugs without considering the effectiveness of available time tested ones. 7. If prescription is loaded with Cortisones to gain popularity 8. If prescription is for an unwarranted hormones 9. If prescription is based on promotional gimmick - But none of these issues can be proved nor can be questioned in the routine course. - Hence the issue is left to the ethical consciousness of the clinician and that of the pharmacist. But the pharmacist is warned not counter the prescription on this score, but to tactfully bring it to the notice of the clinicians impersonally. Patient's pressure; Irrational medication also happens sometimes unintentionally when; 1. Patients / their attendants' exaccerate the problem that makes even a simple self limiting health problem look something quite serious. 2. Patients complain to the doctor too frequently expecting better and better medication. 3. The patients are not properly counseled on the treatment course. Example; a. Patient on antibiotic should be informed that he cannot expect relief unless he completes 48 hour of medication. b. Patient on analgesic / antipyretic should be informed that it takes sometimes two doses to get the desired relief and also that he cannot expect absolute pain-free condition till the wound heals - Otherwise the patient may repeat the dose too frequently or move on to another clinician resulting in unintentional irrational therapy. 'Expensive is more effective' This is a false belief among the patients - a weakness successfully being exploited. - 'Patients pleading with the doctor not to mind the cost of treatment', like a filmy dialogue, is a common sight in any clinic. The intention is that wouldn't mind to go any length to save their kin. - This weakness is being fully exploited by the pharma companies with high priced gimmick formulations, packing, presentation and strategic promotion - Clinician on his part again uses such opportunity to oblige the market force. Patient centered issue This is a patient centered issue. The issue should be considered keeping the patient in close focus and what ever advice is given by a Clinical expert / pharmacist should be in the best interest of the patient only. The patient submits for the treatment out of trust and he cannot be faulted for irrational medication. The choice of drug selection lies on the clinician and some times on the pharmacist also. Such being the case, both the clinician and the pharmacist have ethical obligation not to exploit the trust reposed by the patient with 'Irrational advice', for whatever reason. Disadvantages of irrational Use of Drugs i. Expensive formulations simply drain the patient's money with no extra advantage. The patient wouldn't buy the full course / quantity prescribed, if the cost is prohibitive. ii. The innocent patient may buy only the least inexpensive drug item in the prescription defeating the very purpose of consultation, and package therapy. iii. Many a time prolonged illness or secondary drug induced illness due to irrational medication may cripple his economy leaving a choice for his family to chose between food and medicine or sometimes some one's education iv. Being unable to comply with the advice, the patient may turn to self-medication or to quacks. v. Prescription particularly with irrational Antibiotics, Cortisone, hormone, Analgesics, sedatives etc do more harm than good in the long run. How the pharmacist can help in promoting RUD Well, in India majority of the pharmacists are undergraduates. One needs much more depth of knowledge and capability to understand the formulation / prescription comprehensively. Hence most of the formulations and prescriptions are getting dispensed without any professional check / audit. Nevertheless, the pharmacist should update his knowledge, capability and learn the skill to promote Rational Use of Drugs: 1. The pharmacist should study the formulation / combination fully in the light of the claims of the manufacturer. 2. The pharmacist should keep track of the quantity procured by the patient and watch out for the patient's tendency to buy irrational quantity disproportionate to the prescription. 3. The pharmacist should keep a silent watch on patient to know whether he / she is changing over to another clinician being unable to buy the drugs / being not satisfied with the relief. 4. The pharmacist should discuss academically the observed facts with colleagues and academicians to understand their views and experience, but never reveal the name of the patient or the doctor 5. Pharmacists should attend conferences / seminars and workshops on Rational Use of Drugs organized by professional organizations. 6. The pharmacist perhaps is the best-suited person to educate and help the patients in situations like; i. Irrational self medication ii. Sharing the drugs of others in the family iii. Using the left over drugs iv. Consuming certain non-prescription drugs along with the prescribed drugs. 7. Pharmacist should not hesitate to discuss the issue with the clinicians, the information of the following type (with out disclosing the identity of the patient) i. Patients not buying full course of medication due to high cost, ii. Patient not buying / consuming all the medicine as prescribed due to more number of drugs being prescribed. iii. Patient changing over to self medication or changing over to quacks - This would definitely help the clinicians to be more rationale in prescribing. >>