Sensitization to

Rational Use

of Medicine

2nd Professional is “Transition Professional”

Welcome to the “Pragmatic world of

Doctors”

Process of Drug Use

Diagnosis Prescribing

DispensingAdherence

Follow-up

Drug • It is a single active constituent of medicament

that is used or intended to be used to modify or explore physiological systems or pathological states for the benefit of the recipient

Medicine• Contains both drug and excepients, binders,

stabilizers etc. A medicine may contain more than one drug

• A layman associate drug more commonly to substances of abuse, so terminology changed from RDU to RUM

Introduction• Drug therapy does not simply mean

matching the name of the drug to the name of the disease.• It requires knowledge, judgment,

skill, wisdom and above all the sense of responsibility.

• The rational use of drugs requires that patients receive medicines 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 the community

World Health Organization

• Rule of Right• Right drug• Right patient• Right dosage• Right cost

• SANE criteria• Safety• Affordability• Need• Efficacy

Steps of RUM

Defining patient’s problem• First and most essential step– Complaint of the patient– Detailed history – Physical examination– Laboratory investigations

• Always keep your eyes, ears and nose open• Make diagnosis integrating all findings

Specify the therapeutic objective• Before starting treatment be clear what you

want to achieve with the treatment– Cure– Control– Prophylaxis

• Establishing therapeutic objective before-hand will prevent lot of unnecessary drug use

Choose right treatment• Advice and information - Life style modification• Non-drug treatment

• “Pill for every ill” ו “Patients have craving for medicines” ×

• Role of placebo

• Drug treatment– “No cook-book recipe approach”– Individualized treatment• Choose a group• Choose drug among that group

• Referral

Information to Patient• A well informed patient is most likely to stick

to the treatment• Discuss the treatment with your patient• Always answer their queries• Try to clear their disbeliefs, misconceptions– Makes patient an informed partner in the therapy– Improves patient’s compliance

An example• Patient’s problem

• Watery diarrhea with mild dehydration in a child

• Therapeutic objective• Prevention of further dehydration

• Choose treatment• Advice & information

– Continue breast feeding, other regular feeding– Careful observation

• Non-drug treatment– Additional fluids, rice water, curd, fruit juice

• Drug treatment– Oral rehydration solution

• Referral– Not required in this case

Factors promoting irrational use of medicine

• Prevailing misconceptions about use of drug• General practitioners• Patients• Factors indirectly related to drugs• Market driven forces• Lack of reliable and independent source of

drug information• Overworked doctors

Prevailing misconceptions• “The trade name (expensive) brands

of a drug are definitely more effective than the generic (cheaper) brands of the same drug”

• Many studies have proved that this is wrong• In more than 90% cases there is no difference

in efficacy between generic and trade brands

• Always prescribe by generic name

• “A newly introduced drug is always better and safer than the existing drugs of the same group available in the market and it is especially so if the new drug happens to be an imported one”

• On the contrary new drug is definitely more expensive and its true safety can be established only after several years of use

• Try to use time tested drugs. Avoid using “me too drugs”

• “Covering a patient under broad therapeutic umbrella (empirical polypharmacy or drug cocktail) is adequate/indicated in all complex clinical conditions”

• This is true only in life-threatening situations for a period of 2-3 days until a specific diagnosis is possible

• Always make correct diagnosis. Avoid polypharmacy unless warranted

• “Fixed drug combinations are designed on sound therapeutic basis to make drug therapy simpler”

• With few exceptions (cotrimoxazole, OCPs), It is not so. A number of these FDCs are not based on rational considerations.

• Every ingredient of the combination may not be indicated for each and every patient.

• Avoid using irrational combinations

Indirectly related to drugs• Lack of independent and reliable

drug information– Dependency on MRs• “Drug promotion” vs “Drug information”• Brand oriented advertisement – Therapeutic jungle• Negative results concealed

• Overworked physicians• Lack of CMEs• Availability of OTC drugs

Consequences• Burden on resources - Wastage• Development of ADRs• Drug resistance – NDM-1

Some common examples• Common cold – Use of antibiotics• Watery diarrhea in a child – antibiotics• Uterine contraction in early pregnancy – Use of

progesterone• FDCs – Ampi + Clox, Panto + Dome• Prescription of allopathic drugs by graduates in

other system of medicine• Corticosteroids, antibiotics, multivitamins and

tonics are by far the most common drugs used irrationally

How to promote RUMAt individual level

• Acquire adequate knowledge of a limited number of well established drugs of proven efficacy and well documented side-effects (P-drugs)

• Do not change among equivalent drugs on whim/fancy/material consideration

• Do not use new drug just because it is novel or is being promoted extensively

• For >90% drugs, generics are as good and much cheaper than the branded formulations

continued……….• Use treatment regimens that are simple to

follow and are cheaper• Avoid polypharmacy, as it encourages sloppy

diagnosis• Check dose and inter-dose interval regularly• Avoid repeat prescriptions as a routine• Review regularly• Inform your patients, ensure their participation

At hospital level• Hospital drug formulary• Hospital antibiotic/infection committee• Drug information centre (DIC)• Adverse drug reaction (ADR) monitoring

At National level• Independent drug information• National drug formulary• Brochures for patients

A word for the wise

“Practicing what we teach remains a big

challenge”The essence of EBM. BMJ 2004;329:991-2

Thank you