1. / 201 The Personal Drug List Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax: 4970847

2. / 202 Aim: At the end of this presentation, the participants will know how to develop their own p-drug lists. Objectives: At the end of this session, the trainees should; –be able to count dimensions which are important in drug selection –be able to explain the method in preparing a p-drug list –believe in the importance of rational prescription –be able to develop his/her own p-drug list Aim-Objectives

3. / 203 “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 costs to the community” Rational prescription

4. / 204 Introduction of Essential drug list limits the use of non-essential drugs. Provided details of pharmacokinetics help the physician in selecting right kind of drug and dosage form. RATIONALIZATION OF PRESCRIPTION PRACTISES

5. / 205 Prescription of Rational drugs requires: Accurate diagnosis. Selection of best drug from the available. Prescribing adequate drug for a sufficient length of time. Choosing the most suitable drug, weighing of effectiveness, safety, and availability and cost. RATIONALIZATION OF PRESCRIPTION PRACTISES

6. / 206 Most of the illness respond to simple, inexpensive drugs, Physician should avoid : Use of expensive drugs. Use of drugs in nonspecific conditions (e.g., use of vitamins). Use of not required forms (e.g. injection in place of capsules, syrup in place of tablets) RATIONALIZATION OF PRESCRIPTION PRACTISES

7. / 207 Most of the illness respond to simple, inexpensive drugs, even of improve with no therapy at all. Physician should avoid : Multiple drug prescription (bullet treatment) even if it is considered in the best of the patient in a given situation. RATIONALIZATION OF PRESCRIPTION PRACTISES

8. / 208 The Concept of p-drug list There is a need for evidence based, rational prescription Each GP has his/her own context with different needs and priorities Scientists at the University of Groningen suggested a method where each doctor prepares a list of essential drugs for different conditions P-drug concept has been propagated by the WHO Action Program on Essential Drugs world wide Kawakami J, Mimura Y, Adachi I, Takeguchi N. [Application of personal drug (P-drug) seminar to clinical pharmacy education in the graduate school of pharmaceutical sciences]. Yakugaku Zasshi. 2002 Oct;122(10):819-29

9. / 209 Step 1: Define the patient ’ s problem Step 2: Specify the therapeutic objective Step 3: Verify the suitability of your P-treatment Step 4: Start the treatment Step 5: Give information, instructions and warnings Step 6: Monitor (and stop?) treatment http://p-drug.umin.ac.jp/34th-gakkai/slide/DrSunami/SunamiP-drug.PPT The process of rational treatment

10. / 2010 Step i : Define the diagnosis Step ii : Specify the therapeutic objective Step iii : Make an inventory of effective groups of drugs Step iv : Choose an effective group according to criteria Step v : Choose a P-drug Selecting a P-drug

11. / 2011 Imagine you go shopping for a shirt. What would be your criteria to select a product? –Efficacy –Safety –Suitability –Cost Step iv: Choose an effective group according to criteria

12. / 2012 Weight of criteria will differ according to condition Efficacy Safety SuitabilityCost B. Meningitis B. Cystitis % % % % 25 General dis. % 80% 0 % 20 % 30 % 20% 30% 20 100

13. / 2013 P-drug example: angina pectoris Step i : Define the diagnosis –60 y male. Since one month repeated attacks of constricting chest pain starting with exercise and relieving with rest –Diagnosis: stable angina pectoris due to partial coronary occlusion and myocardial ischemia.

14. / 2014 P-drug example: angina pectoris Step ii : Specify the therapeutic objective –To prevent pain coming with effort –To decrease the oxygen need of myocardium –To increase the perfusion of myocardium

15. / 2015 P-drug example: angina pectoris Step iii : Make an inventory of effective groups of drugs (look for the evidence) PreloadContractilityRateAfterload Nitrates + + - - Beta- blockers + ++ Ca channel blockers + ++

16. / 2016 P-drug example: angina pectoris Step iii : Make an inventory of effective groups of drugs (look for the evidence) Efficacy (pharmacodynamics)Safety (Side effects)Suitability (Contraind.) Nitrates Peripheral vasodilatationHeadache, nitrate intoxication Hypotension, SIIP, anemia, Sildenafil (Viagra) usage Beta-blockers Decrease in heart contractility and rate Hypotension, bradiarrythmia, impotence Asthma, raynould, decompansated heart failure, DM, severe bradicardia Calcium channel blockers Coronary and peripheral vasodilatation, decrease in heart rate and contractility Hypotension, dizziness, bradicardia, Heart f. Hypotension, congestive heart failure, AV block

17. / 2017 P-drug example: angina pectoris Step iv : Choose a group according to criteria (give scores from 1-4. multiply by the criteria coefficient) Efficacy (40 %) Safety (30 %) Suitability (20 %) Cost (10 %) Total (100 %) Nitrates4 (1.6)3 (0.9)3 (0.6)4 (0.4) 3.5 Beta-blockers 4 (1.6)3 (0.9)2 (0.4)3 (0.3)3.2 Ca channel blockers 4 (1.6)3 (0.9)2 (0.4)3 (0.3)3.2

18. / 2018 P-drug example: angina pectoris Step v : Choose a P-drug (choose your brand name from the medicine available in the market) Efficacy (40 %) Safety (30 %) Suitability (20 %) Cost (10 %) Total (100 %) Isosorbid dinitrate tablets sublingual 5 mg 4 (1.6)3 (0.9)3 (0.6)4 (0.4) 3.5 Glyceril trinitrate spray4 (1.6) 3 (0.9)4 (0.8)2 (0.2) 3.5 Isosorbid dinitrate tablets 10 mg 3 (1.2)3 (0.9)3 (0.6)3 (0.3) 3.0 Isosorbid mononitrate tablets 3(1.2)3 (0.9)3 (0.6)3 (0.3) 3.0

19. / 2019 P-drug form for this exercise Indication: stable angina pectoris P-drug 1 (first choice) Name:Isosorbid dinitrate Dose available: 5mg, 50 tablets package Use: One tablet sublingually when pain arises Duration: Until next control visit P-drug 2 (second choice) Name:Glyceril trinitrate Dose available: … Use: … Duration: …

20. / 2020