Rational use of the drugs based on P-drug selection 1/17/2019 Rational use of the drugs based on P-drug selection Rovina Ruslami, dr., SpPD, PhD Dept. of Pharmacology & therapy FKUP / RSHS file name

Aim of drug management system to deliver the correct drugs to the correct patient To use the drug in accordance to principles of rational prescribing It is an essential element for effective, safe & economical use of the drugs 1/17/2019 Rational prescribing

Talk about Rational Use of the Drug (RUD) Appropriate to their clinical needs in doses Meet their own individual requirement For adequate period of time At the lowest cost to them & their community 1/17/2019 Rational prescribing

So, it has to be Correct diagnosis Appropriate indication Appropriate drug(s) Appropriate dosage, administration & duration of treatment Appropriate patient Appropriate information Appropriate evaluation & follow-up 50% 50% 1/17/2019 Rational prescribing

Appropriate indication Based on medical reasons If pharmacotherapy is the best alternative Appropriate drug(s) – P-drug concept Considering efficacy, safety, suitability and cost (ESSC) Appropriate administration If not  ineffective, harmful or uneconomical treatment 1/17/2019 Rational prescribing

Appropriate information Appropriate patient No contraindication Likelihood of AE is minimum Appropriate information As an integral part of prescribing process To ensure their correct & safe use; to ensure patient compliance Appropriate evaluation & follow up As important as other aspect, but often is neglected If not  lead to treatment failure/harmful (drug-induced problem) 1/17/2019 Rational prescribing

The drug use process 1/17/2019 Rational prescribing

Process of rational treatment 1. Define patient’s problem 2. Specify therapeutic objective: - Symptomatic - Causative 3. Verify suitability of individual patient: from available drugs (for its E, S, S, C) 4. Start the treatment 5. Give information, instruction & warning 6. Monitor (cont’ or stop) treatment 1/17/2019 Rational prescribing

Let’s imagine you’re a doctor Which is not too long from now… Rational prescribing 1/17/2019

Patient might come to you with... request complaint questions Careful observation Structured HT PE Working diagnosis Try to get their real problem, by 1/17/2019 Rational prescribing

So, in RUD… 1. Define their problem(s) And remember specific patients group Disease or disorder (Diagnosis) Sign of underlying disease Psychological or social problems Side efect of drugs Polypharmacy Non-adherence to treatment Request for preventive treatment Pregnancy Lactation Children Elderly Renal failure Hepatic failure Drug allergy 1/17/2019 Rational prescribing

Then… 2. Specify the Therapeutic Objective (TO) 3. Verify the SUITABILITY the P-drugs Active substance & dosage form Standard dosage schedule Standard duration of treatment For all above, check the Effectiveness (Indication & convenience) and Safety (CI, DDI, specific group of pts) Focus on the real problem WHAT TO BE ACHIEVED Unnecessary drug use  Irrational prophylactic prescribing  Discuss your TO with the patient 1/17/2019 Rational prescribing

When you start the treatment… Write the prescription (prescribing) Prescription is an instruction from prescribers  dispenser It has to be clear!!! Dispenser could be Pharmacist/assistant Nurse 1/17/2019 Rational prescribing

When giving prescription… It has to be clear You need to give information, instructions & warnings What is/are the drugs(s) For what (the effect) Instruction: how to take them Possible SE Warnings Next appointment EVERY THING IS CLEAR? 1/17/2019 Rational prescribing

By this step (no.5) You improve patient’s adherence (and it is very important!) R/ a well-chosen treatment Build a good doctor-patient communication (relationship) Spend time to give information, instructions & warning 1/17/2019 Rational prescribing

Last step: monitor the treatment Was it effective? Yes, disease is cured Stop the treatment Yes, but not yet complete Any SAE? Yes: reconsider dosage OR drug choice No: con’t the treatment No, disease is not cured VERIFY ALL STEPS!! 1/17/2019 Rational prescribing

Clinical setting 1. Define the problem (diagnosis) 2. Specify the TO A 45 y-o male suffered from chest pain every time he has exercise or in stressful condition and disappeared with resting. History of hypertension since 4 years ago. 1. Define the problem (diagnosis) Stable angina pectoris 2. Specify the TO To prevent the anginal symptoms (NOT CAUSATIVE) By reducing the myocardial need through: decrease preload, contractility, HR or afterload 1/17/2019 Rational prescribing

Inventory of effective groups of drug Then… 3. Choose a group according to the criteria (E, S, S, C) Inventory of effective groups of drug Nitrates B-blockers Ca-channel blockers K-channel blockers group E S C nitrates + +/- B-Blockers ++ Ca-channel blockers - K-channel blockers 1/17/2019 Rational prescribing

Last step is.. Choose a P-drug Decision made is… Note: all in tablet form Active substance: atenolol Dosage form: 50 mg tablet Dosage schedule: 50 mg, once daily Duration: accordance with monitoring interval (next visit) group E S C propranolol + +/- atenolol metoprolol bisoprolol - 1/17/2019 Rational prescribing

Patient’s personal factor The bottom line is Consider Do not forget the legal issue of prescribing Patient’s personal factor - Problem (efficacy) - Other conditions (safety) - Preference (cost) Drug’s factor - Effect - PK, AE - Dosage form, schedule (suitability) 1/17/2019 Rational prescribing

Prof. Dr. Herri SS, SpFK(K) Acknowledgement... Prof. Dr. Herri SS, SpFK(K) 1/17/2019 Rational prescribing