Rational Drug Use A Concern for Healthcare Professionals

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Introduction:

Ineffective inappropriate and economically nonviable use of medicines is often observed in health care throughout the world. This is more often in the developing countries. The need for achieving quality use of medicines in the healthcare system is not only because of the financial reasons with which policy makers and administrators are usually most concerned. Appropriate use of drugs is also one essential element in achieving quality of health and medical care for patients and the community as a whole.

WHO defined rational use of drug as “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 the lowest cost to them and their community.”  (WHO, 1985)

The definition implies that rational use of drugs, especially rational prescribing should meet following criteria’s:

Appropriate indication: the decision to prescribe drug(s) is entirely based on medical rationale and that drug therapy is an effective and safe treatment.

Appropriate drug: the selection of drugs is based on efficacy, safety, suitability and cost considerations.

Appropriate patient: no contraindications exist and the likelihood of adverse reactions is minimal, and the drug is acceptable to the patient.

Appropriate information: Patients should be provided with relevant, accurate, important and clear information regarding his or her condition and the medications that are prescribed.

Appropriate monitoring: the anticipated and unexpected effects of medications should be appropriately monitored. 

Factors Underlying Irrational Use of Drugs

There are many different factors which affect the irrational use of drugs. In addition, different cultures view drugs in different ways, and this can affect the way drugs are used. in India this can therefore be a complex with multiple cultures , religions, dialects and castes. If one were to broadly classify the factors, they could be divided in to: those deriving from patients, chemists shop, prescribers, the workplace the supply system, industry influences, regulation, drug information and misinformation.

In each group, there can be various ways contributing to irrational use of drugs:

v Patients: drug misinformation, misleading beliefs, patient demands / expectations.

v Prescribers: lack of education and training, inappropriate role models, patient pressures, lack of objective drug information, company incentives, limited experience, misleading beliefs about drug efficacy, competition.

v Workplace: heavy patient load, pressure to prescribe, lack of adequate lab capacity, insufficient staffing.

v Drug Supply System: unreliable suppliers drug shortages, limited budgets necessitating fixed choices, expired drug supplied.

v Chemists Shops: patient pressures, profit motives, competition.

v Drug Regulation: non essential drugs available, inefficient audit system, inadequate legal implementation, and no-formal procedures.

v Industry: promotional activities, misleading claims, incentives.

Impact of Irrational drug Use

Irrational drug use can have various consequences, for the patient, the public, the health system and even the economy. A few important consequences are mentioned below:

v Reduction in the quality f drug therapy- this can lead to increased morbidity and mortality.

vWaste of resources- This can lead to reduced availability of other vital drugs and increased costs.

v Increased risk of unwanted effect- adverse drug reactions and the emergence of drug resistance.

v Psychosocial impacts-patients may believe that there is “ a pill for every ill”

A focused case of irrational drug use and its consequence- the antimicrobial misuse problem:

The problem of antimicrobial resistance was one of the important issues brought up at the world health assembly (WHA) in 2005.

The WHO says that antimicrobial resistance is one of the world’s most serious public health problems. A major reason is the irrational use of medicines According to WHO, worldwide, more than 50% of all medicines are prescribed, dispensed or sold inappropriately and 50% of patients fail to take them correctly. The consequence of this is seen directly with the misuse of antibiotics.

There is increasing antimicrobial resistance, with resistance of up to 70-90 % to original first line antibiotics for dysentery (shigella), pneumonia (Pneumococcal), gonorrhea, and hospital infections (Staph. Aureus).

A WHO policy paper on “Containing antimicrobial resistance” says that many of the microbes that cause infectious disease no longer respond to common antimicrobial drugs such as antibiotics, antiviral and antiprotozoal drugs.

The problem has reached unprecedented proportions that unless concerted action is taken worldwide; we run the risk of returning to the preantibiotic era when many more children than now died of infectious diseases and major surgery was impossible due to the risk of infection.

Fourteenth WHO model list of essential medicines (March 2005) contains only 18 approved drug combinations, whereas in India, there are innumerable examples of irrational drug combinations, which are available and can be bought without necessarily giving a prescription.

Some irrational fixed dose combinations available in the Indian Market

Sr. No.

Combinations

Irrationality

1

Norfloxacin+ Metronidazole; Norfloxacin+Tindazole; Norfloxacin+tindazole+Loperamide; Norfloxacin+Tinidazole+Dicycloamine; Norfloxacin+Ornidazole; Ciprofloxacin+Tinidazole; ofloxacin+Tinidazole; Ofloxacin+Metronidazole; Ofloxacin+Ornidazole; Gatifolxacin+Ornidazole.

Though claimed to be broad spectrum, combining (antiameobic) with fluroquinolone (antibacterial) is irrational because patient suffers only from one type of diarrhea. Using this combination adds to cost, adverse effects ad may encourage resistance.

2

Nimesulide+Diclofenac; Nimesulide+Dicycloamine+Simethicone; Nimesulide + Paracetamol; Nimesulide+ Cetrizine + Pseudophedrine; Nimesulide + Paracetamol+ Tizanidine.

Nimesulide is a controversial drug, has been banned in many countries. It is a sorry state of affairs that its combinations are readily available over the counter. Combining two NSAIDs may increase the side effects of both the NSAIDs. There is little documentary, evidence that a preparation containing more than one analgesic is more effective than a single ingredient preparation.

3

Amoxycillin+ Cloxacillin.

Amoxycillin is inactive against staphylococcus as most strains produce β lactamase and cloxacillin is not so active against streptococci. For any given, infection, one of the components is useless but adds to cost and adverse effect. Since amount of each drug is halved, efficacy is reduced and chances of selecting strains are increased.

 

4

Domperidine+ Rabeprazole; Domperidone + Esomeprazole.

Increased incidence of rhabdomyolysis

5

Simvastatin + Nicotinic acid; Atrovastatin + Nicotinic acid

Probability of myopathy is increased

6

Enalpril+ Losartan.

Combining two drugs affecting the same pathway is irrational ; it doesn’t add to efficacy

7

Diazepam+Dried aluminum hydroxide gel +aluminum glycinate + oxyphenonium; Diazepam+ Magaldrate + Oxyphenonium; Diazepam+ Dried alumininum hydroxide gel + magnesium trisilicate+ Dimethylpolysiloxane. 

Antacids raise the gastric pH and reduce the absorption of benzodiazepines

8

Cetrizine + Phenylpropanolamine + Dextromethorpan; Cetrizine + Phenylpropanolamine +Paracetamol; Levocetrizine+ Paracetamol+ Phenylpropanolamine.

Phenylpropanolamine is banned drug; yet it’s a part of many cold remedies. Besides its potential to cause stroke (more so in hypertensive) , it can aggravate diabetes , glaucoma and prostate enlargement .

9

Cisapride+ Omeprazole; Mosapride+ Pantoprazole

In patients with gastro esophageal reflux disease, the use of this combination has shown no benefit due to addition of prokinetic agents.

What needs to be done

Today, rational use of drug/ pharmaceutical is an issue of the at most importance. The growing concern is not only for promotion of appropriate use of pharmaceuticals in the health care delivery and its economic considerations but also to provide health related quality of life (HRQL) for a community.

v The hit and trial method of combining drugs should be replaced by a rational and logical basis for bringing out a fixed dose drug formulation. Operational, statistical and mathematical models constitute a highly versatile framework for mechanism based modeling (pharmacokinetic/ pharmacodynamic) by taking signal transduction properties of the drug combination into account. Sound scientific research should underline the development and production of drug combinations.

v There is a need to carefully monitor and censor misleading claims by the pharmaceutical industry. Some degree of irresponsibility on the part of the pharmaceutical industry and lack of vigilance of government agencies underlies the increased popularity of irrational drug combinations. Most advertisements in many of the medical journals published from India fail to mention important details pertaining to correct usage of drug combinations. Clinical pharmacist can play an important role in guiding and imparting knowledge to the public.

v There is a need to strengthen the mechanism for continuing professional development of practitioners to ensure that they have the necessary knowledge and skills to prescribe rationally. Perhaps the insistence that prescribers especially those in private practice should undergo a continuing medical education (CME) course once in year on newer combinations, new drug molecules introduced in to market and adverse drug reaction will go to a long way in curbing irrational prescribing.

v Adverse drug reactions (ADR) reporting should be made mandatory as they are in developed countries. Pharmacovigilance should be more effective.

v Hospitals should constitute drugs and therapeutics review committee to rationalize prescribing.

v Finally, medical schools and postgraduate colleges must take the responsibility of training students and young doctors how to assess new drug combinations more logically. Unless we encourage our students to think rationally and independently this menace will continue to grow.

Conclusion

The effective interventions for improving rational use of drugs can be expected from all the members of the health care delivery team. There also needs a political will from decision makers so that these interventions are likely to be implemented on a countrywide basis so as to uplift the medical and all allied paramedical professions. The steps taken in this direction will be helpful to reduce morbidity and mortality rate associated with the drug use. It also will improve the allocation of the resources leading for better availability of necessary drugs with proper costs. At the receiving drug end, patients will be benefited with decreased risk of unwanted affects such as adverse drug reactions and the mergence of drug resistance. Promoting the rational use of drugs will finally results in improved quality, increased accessibility and better quality of life for the community. 

“Health professional actively participate and involve in promoting rational drug use to achieve health related quality of life.”

About Author:

Atul M. Kadam

Atul M. Kadam
Lecturer , College of Pharmacy, Peth-Vadgaon, Kolhapur.

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Comments

Amol Malpani's picture

Dear Atul,
Nice choice of topic and you compile it well. But it will be better (I feel) if you put light on some points like chronotherapeutical drug delivery and homeopathy system of medicine which are mainly based upon rational drug design. But still all and all nice one.
Keep it up, best wishes for future.

Regards,
Amol.

Atul Kadam's picture

Thanks lot , Yah Surely in my next article i will try to cover up points siggestsed by you
Regards
Atul

Pharmacistk's picture

Great Article !!! Keep coming with such Articles !!!!

Anis's picture

Hi Atul
It is really a nice topic covering practically all sections by which drugs are irrationaly used but I belive that self awareness is the most vital thing that can prevent one from adverse effects.
Best Regards,
Anisur

Atul Kadam's picture

Dear Anisur ,
Thanks lot

NITIRAJ's picture

Great done

nitiraj
NITIRAJ's picture

GREAT INFORMATIVE TO STUDENTS POINT OF VIEW

nitiraj
Santosh kumar. JH's picture

Now a days most of the doctors are very commerical following the practice of polypharmacy, prescribing more than a required drug i.e unnecessary prescribing antibiotics, painkillers etc.., This blog may change their mind set towards the safety of pateint.

Deepa Chauhan's picture

Good and Valuable article

Tapanshah's picture

I think Pharmacists should come together and come up with the cases of irrational prescriptions and medication errors. There are multiple benefits of doing this:
- With sufficient evidence, the irrational prescriptions which are written due to lack of information can be stopped by the prescribers.
- The ones who write irrational prescriptions in spite of being aware of the same for commercial interest can be brought to the notice of public and government.
- Role of a Clinical Pharmacist in the pharmaceutical care can be more convincingly debated.
- We can same our families and friends from the ire of irrational use of drugs and medication errors by virtue of our knowledge.

Lets put up every single case of irrational prescription and medication error that we come across on this forum and discuss the same. We can all give inputs. Obviously we would hide the prescribers and the patients by discuss this objectively.

Atul Kadam's picture

Dear Sir
Thanks for your comment yah it’s true. Actually it’s a big issue concerning from all point of views as when I was working as a clinical pharmacist in one of hospital I have came across so many such cases . The first thing that should do is change our educational policies till we are in ER 1991 now its 2011is coming. Bcoz I think our syllabi is manly industry oriented there is little stress on subjects like pharmacothrapeutics or clinical pharmacology. First of all; all over India there should be uniform syllabus of all pharmacy courses D.Pharm, B.Pharm & M.Pharm and in that they should include subjects like clinical pharmacy, pharmacotherpaeutics which shall cover all aspects RDU, ADR, ME ADE patient counseling, Medication therapy review etc. So that Pharmacist should be recognized as a integral part of healthcare system.
Here I will quote some there examples normally the In patients in hospital unnecessary prescribed with multivitamins and ranitidine , along with this irrational prescribing medication error is another big issue that we should address ..
I think your idea is really good one and for same through pharmainfo we should start a one discussion group on yahoo mail or here and every time we put some topic and carryout healthy discussion on same . Here I would like to quote save life recruit more pharmacist safe rations save life, pharmacist for safe staffing. We miss more by not seeing but by not looking

Dr.S.Gunasakaran's picture

Dear Atul,

Nice article. Nowadays, the development of antimicrobial resitance also seems to be major concern due to the irrational use of antimicrobials among patients.

Dr.S.Gunasakaran,MBBS,MD. Head - Clinical Research & Medical Affairs www.clinicalresearchsociety.org/forum