Rational Use of Drug
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Introduction
The aim of any drug management system is to delver the correct
drug to the patient who needs that medicine. The steps of selection,
procurement, and distribution are necessary precursors to the
rational use of drug.
The conference of Experts on the Rational Use of Drugs, convened
by the World Health Organization (WHO) in Nairobi in 1985, defined
rational use of drug as follows:
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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.
Depending on the context, however, many factors
influence what is considered rational.
It may be rational, for example, for a drug seller
to sell antibiotics without a prescription to earn
enough income to survive.
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Criteria
But the term rational use of drug in biomedical context includes
the following criteria:
1. Correct drug
2. Appropriate indication – that is, the reason to prescribe is based
on sound medical considerations
3. Appropriate drug, considering efficacy, safety, suitability for the
patient, and cost
4. Appropriate dosage, administration and duration of treatment
5. Appropriate patient – that is, no contraindication exist, and the
likelihood of adverse reaction is minimal
6. Correct dispensing, including appropriate information for patient
about the prescribed medicines
7. Patient adherence to treatment
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Steps for following Criteria's:
To confirm with these criteria, prescribers should follow a standard
process of prescribing, which starts with a diagnosis to define the
problems that requires intervention. Next, the therapeutic goal
should be defined.
The prescriber must have to decide which treatment is required,
based on up-to-date drug and therapeutic information, to achieve
the desired goal for individual patient.
When the decision of treatment with drugs to the patient is made,
the best drug for the patient is selected based on efficacy, safety,
suitability, and cost.
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Then dose, route of administration, and duration of treatment are
determined, taking into account the condition of the patient
When prescribing a drug, the prescriber should provide proper
information to the patient about the drug and the patient’s
condition.
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The drug should then be dispensed to the patient in a safe and
hygienic manner, making sure that the patient understands the
dosage and course of therapy; then patients takes the drug.
Adherence occurs if the patient
(and the community)
understands and appreciates
the value of taking specific
drugs for the specific
indications.
Drug Use Process
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Examples of Irrational drug Use
Irrational drug use occurs in all countries. These include cases in which
• no drug needed;
• the wrong drugs;
• the ineffective drugs and drugs with doubtful efficacy,
• prescribing of unsafe drug;
• Under-use of available effective drugs and
• incorrect use of drugs.
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No Drug Needed-
Use of drugs when none is needed includes many non-therapeutic
uses of pharmaceuticals. For example, in many countries, the
majority of children suffering from minor upper respiratory tract
infections are treated with antibiotics.
Similarly, unnecessary and ineffective antimicrobial or antidiarrheals,
instead of oral rehydration salt (ORS), are indiscriminately prescribed
for many children with acute diarrhea.
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Wrong Drugs-
In some countries, for example, many children with streptococcal
pharyngitis are not properly treated with narrow-spectrum
penicillin. Instead, tetracycline, a drug that is not recommended
for the prophylaxis of rheumatic fever following streptococcal
pharyngitis and that has serious side effects for children, is usually
prescribed
Ineffective Drugs and Drugs with Doubtful Efficacy-
Excessive and unnecessary use of multivitamin preparation or
tonics is an example of this prescribing pattern
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Unsafe Drugs-
The likelihood of adverse reactions outweighs the therapeutic
effects when unsafe drugs are prescribed. Common examples
include the use of anabolic steroids for growth and appetite
stimulation in children or athletes. In many countries, dipyrone
(metamizole), a drug banned in most developed countries, is used
indiscriminately in both health facilities and the community for a
large variety of minor aliments.
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Under-use of Available Effective Drugs-
In West Java, Indonesia, a study showed a few years ago that ORS
was prescribed for only a small portion of children with acute
diarrhea. Regrettably, the underuse of effective oral rehydration
therapy for acute diarrhea in children still occurs in many countries
Incorrect Use of Drugs-
Injectable preparations are commonly overused. Another frequent
incorrect use of drugs is giving a patient only one- or two-days
supply of antibiotics rather than the full course of therapy
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Impact on Quality of Drug Therapy and Medical Care
Inappropriate prescribing practice can, directly or indirectly,
jeopardize the quality of patient care and negatively influence the
outcome of treatment. The underuse of ORS for acute diarrhea, for
instance, can hinder the goal of treatment; namely, to prevent or
treat dehydration and thus to prevent death in diarrhea.
The likelihood of adverse drug reactions increases when drugs are
prescribed unnecessarily. Misuse of injectable products in Indonesia,
for example, has been implicated in a high incidence of anaphylactic
shock. Over-dosage or under-dosage of antibiotics or
chemotherapeutic agents also leads to the rapid emergence of
resistant of bacteria or the malaria parasite.
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Impact on Cost-
Overuse of drugs, even essential ones, causes excessive spending
on pharmaceuticals and waste of financial resources, by both
patients and the health care system. In many countries,
expenditures on nonessential pharmaceuticals products such as
multivitamins or cough mixtures drain limited financial resources that
could be allocated for more essential and vital products, such as
vaccines or antibiotics. Inappropriate undersue of drugs at an early
stage of a disease may also produce excess costs by increasing the
probability of prolonged disease and eventual hospitalization.
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• Psychological Impact-
• Over-prescribing communicates to patients that they need
medications for any and all conditions, even trivial ones. The
concept is that there is a pill for every ill is harmful Patients come to
rely on drugs, and this reliance increases the demand for them.
Patients may demand unnecessary injections because during their
years of exposure to modern health service they have come
accustomed to having practioners administer injections.
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Factors Underlying Irrational Use of Drugs
Many interrelated factors influence drug use. The health supply
system, prescriber, dispenser, patient and Community are all
involved in the therapeutic process and all can contribute to
irrational use of drug in a variety of ways.
Factors Influencing Prescribing-
A. Health supply system
Inefficiencies in the system
Unreliable supply lead to a lack of confidence in
Drug shortage the system by the prescriber
Expired drugs and patient. The patient
Wrong drugs demands treatment, and the
prescriber feels obliged to give
what is available.
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B. Prescriber
Lack of training may have received
inadequate training, or
Poor role models prescribing practices may
Inadequate information have become outdated due to
a lack of continuing education
Financial interest
C. Dispenser
Patient load The quality of dispensing
Shortage of materials may be affected by the
training and supervising the
No supervision dispenser has received and
Poor training the drug information
available to the dispenser
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d. Patient and Community
Cultural beliefs
Short consulting time
Prescriber’s attitudes and communication skill
Lack of printed information
Community beliefs about the efficacy of the certain
drugs or route of administration
there may a belief that injection is more powerful that capsules, or
capsules are more effective than tablets
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Strategies to Improve Drug Use
Before attempting to change drug use, the scale of the problem
should assess and quantified. The underlying reasons for the
problem behavior then need to be investigated. Quantitative and
qualitative methods are used for assessing drug use. It is a mistake
to intervene before understanding the reason for a problem
behavior.
Whatever problem is being addressed, impartial drug and
therapeutic information is needed. Such information can serve as
the basis for standard treatment guidelines or therapeutic standards.
Information can be made available actively through drug bulletins or
in a largely passive manner through drug information centers.
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Several strategies exist for an intervention to change prescribing
practices. These approaches can be characterized as educational,
managerial, or regulatory. Whichever approaches is used; the
intervention should focus on specific problem behaviors and should
target prescribers or facilities with a high incidence of the problem
being addressed.
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WHO Drug Use Indicators (Out patient facilities)
A. Core Drug Use Indicators
Prescribing Indicators-
a) Average number of drugs per encounter
b) Percentage of drugs prescribed by generic name
c) Percentage of encounters with an antibiotic prescribed
d) Percentage of encounters with an injection prescribed
e) Percentage of drugs prescribed from essential drugs list or
formulary
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Patient Care Indicators-
a) Average Consultation time
b) Average dispensing time
c) Percentage of drugs actually dispensed
d) Percentage of drugs adequately labeled.
e) Patients' knowledge of correct dosage
Health Facility Indicators-
a) Availability of a copy of essential drugs list or formulary
b) Available of key drugs
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B. Complementary Drug Use Indicators
a) Percentage of patient treated without drugs
b) Average drug cost per encounter
c) Percentage of drug costs spent on antibiotics
d) Percentage of drug costs spent on injections
e) Prescription in accordance with treatment guidelines
f) Percentage of patients satisfied with the care they received
g) Percentage of health facilities with access to impartial drug
information
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