Prescribing

Introduction To prescribe means: - to authorize by means of a written prescription the supply of medicine. Occasionally, It involves - advising patients on suitable care or medication that can be bought without prescription. - the act of writing a prescription after all process decisions have been taken.

Introduction Factors that motivate an appropriately qualified individual to prescribe are Rational approach - Use evidence - has outcome goals. - evaluate alternative medications. - match the best available medication.

Introduction Factors that motivate an appropriately qualified individual to prescribe are Emotional element - prescriber to smaller or greater extent are responsive to appeal from - patient -pharmaceutical industry - professional colleagues - their own instincts.

Rational and effective prescribing Rational and effective use of medications save lives and improves the quality of life for many patients. It require the patient to receive medication - appropriate to their clinical needs - in doses that meet their individual requirements - for an adequate period of time - at lowest cost to patient and community. 5-rights: “The right drug, in the right place, at the right time, at the right dose for the right duration”.

Rational and effective prescribing Good prescribing has four components. - Maximize effectiveness. - Minimize risk. - Minimize cost. - Respect patient choices.

Rational and effective prescribing Good prescribing has four components. - Maximize effectiveness. - Minimize risk. - Minimize cost. - Respect patient choices.

Rational and effective prescribing Inappropriate prescribing Characterized by: - prescribing medicines for self limiting diseases. - prescribing medicines of limited clinical value. - prescribing too low dose of a medicine. - continuing to prescribe a medicine for too long period. - not prescribing a medicine for an appropriate duration. - prescribing a medicine that is inappropriate for the disorder to be treated.

Rational and effective prescribing Inappropriate prescribing Lead to - Distress. - Ill health. - Hospitalization. -Death. ( Higher morbidity and mortality)

A systematic approach to prescribing Consultation skills and Competencies The consultation is a fundamental part of the prescribing process and the prescriber must understand and utilize this to help them practice effectively.

A systematic approach to prescribing Consultation skills and Competencies The skills that are needed to be utilized in the consultation. Interpersonal skills: the ability to communicate and make relationships with patients. Reasoning skills: the ability to gather appropriate information, interpret the information and then apply it both in diagnosis and management. Practical skills: the ability to perform physical examinations and use clinical instruments.

A systematic approach to prescribing Consultation skills and Competencies Consultation styles 1) Task Oriented Consultation Task 1: identification and management of presenting problems. Task 2: Management of continuing problems. (the consultation is an opportunity to ensure previous medical issues are resolving).

A systematic approach to prescribing Consultation skills and Competencies Consultation styles 1) Task Oriented Consultation Task 3: Opportunistic anticipatory care (the consultation provides opportunities for education on healthy lifestyles ,,,) Task 4: Modification of the patient’s help seeking behavior. (prescribers need to ensure patients know when it is advantageous to seek their help).

A systematic approach to prescribing Consultation skills and Competencies Consultation styles 2) Patient-centered consultation Consultation should be an active dialogue that involve the patient. Prescribers must encourage the patient to discuss not only their presenting symptoms but also their feelings and thoughts about the condition and its treatment.

3) Evidence-based consultation A systematic approach to prescribing Consultation skills and Competencies Consultation styles 3) Evidence-based consultation - systematically developed consultation to assist practitioner and patient decisions about health care for specific circumstances.

A systematic approach to prescribing Consultation skills and Competencies Consultation styles 4) Open consultation The prescriber is aware of and seeks to understand and respect patient beliefs and expectations along with the cultural, language and religious implications that may impact upon an individual’s ability or willingness to offer certain information or undertake recommended interventions or treatment.

A systematic approach to prescribing Consultation skills and Competencies Typical stages of Consultation Patient Attend prescriber’s clinic Offer symptoms. Listen and communicate with the prescriber (discuss his co-morbidities, medication history, … ) Influence agenda of consultation.

A systematic approach to prescribing Consultation skills and Competencies Typical stages of Consultation Prescriber Assess attending patient's symptoms, medical and medication history. Listen and communicate with the patient. Focus on a working diagnosis. Consider the differential diagnosis. Identify and undertake investigations required to aid diagnosis. Make diagnosis. Prescribe medication or non-pharmacological intervention. Arrange follow-up

A systematic approach to prescribing Consultation skills and Competencies Typical stages of Consultation Prescriber "The good physician treats the disease, the great physician treats the patient." William Osler, 1849-1919

A systematic approach to prescribing Gathering relevant information Medication history Prescribed medicines - Name, strength, dose, frequency. - Duration of treatment. - Medication knowledge. - Adherence - Adverse effect. For relevant medications during the past 6 months

A systematic approach to prescribing Gathering relevant information Medical history OLDCARTS Onset: when did it start? (acute vs gradual) Location: where is it/ what part of the body does it affect? Duration: how long did it last? How often does it occur? Characteristics: what it is like? How bad is it? Associated signs and symptoms: Does anything else accompany the problem? (severity) Relieving or aggravating factors: Does anything make it better or worse? Treatment: what treatment have been tried already? Summarize: repeat your understanding of all the situations to ensure all necessary facts are obtained.

A systematic approach to prescribing Gathering relevant information Medical history OLDCARTS Onset: when did it start? (acute vs gradual) Location: where is it/ what part of the body does it affect? Duration: how long did it last? How often does it occur? Characteristics: what it is like? How bad is it? Aggravating factors: Does anything make it worse? Relieving factors: Does anything make it better? Treatment: what treatment have been tried already? Severity: How the symptoms are severe?

A systematic approach to prescribing Prescribing Main aims of prescribing Cure the symptoms. Cure the conditions. Aid the diagnosis.

A systematic approach to prescribing Prescribing Medication selection What is the drug? (optimum dose, duration) What is the drug used for? How effective is the drug? (Evidence-based) How safe is the drug? (ADR, D-D, monitoring) Who should not receive the drug? Does the drug provide value for money?

A systematic approach to prescribing Prescribing Medication review Undertaking a medication review before prescribing medicines for long term treatment. NO TEARS

A systematic approach to prescribing Prescribing NO TEARS N: Need and indication If the treatment is still indicated. Whether the diagnosis is confirmed. Is the medication is inappropriately continued. Is there is a need to change the dose

A systematic approach to prescribing Prescribing NO TEARS O: Open question Identify what the patient understands about his medications. Which medicine he is taking appropriately. Ask by indirect questions!

A systematic approach to prescribing Prescribing NO TEARS T: Test and monitoring The prescriber should explore whether the disease is under control and symptoms are relieved adequately. Tests that may be required to assess disease control.

A systematic approach to prescribing Prescribing NO TEARS E: evidence and guidelines New guidelines and new evidence based practice.

A systematic approach to prescribing Prescribing NO TEARS A: adverse effects Avoid prescribing cascade: Don’t treat an avoidable ADR.

A systematic approach to prescribing Prescribing NO TEARS R: risk reduction and prevention. This is an opportunistic session for screening for alcohol, smoking, obesity, family history. Identify patients at risk to develop ADR.

A systematic approach to prescribing Prescribing NO TEARS S: simplification and switching Switch to more simple regimen (sustained release).