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Rational Medicine Use
Medicine Selection
Rustamaji
Centre for Clinical Pharmacology and Medicine PolicyGadjah Mada University
2011
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Objective
After attending this lecture, students are expected to be
able to:
1. Explain the steps in therapeutic process
2. Explain drug selection based on safety, efficacy, suitabilityand cost
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Six steps oftherapeutic decision process
Step 1: Define the patients problem
Step 2: Specify the treatment objectiveStep 3: Select the intervention
Step 4: Start the treatment
Step 5: Give information to the patientStep 6: Monitor (or stop?) treatment
(WHO, 1994)
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Step 1:
Define the patients problem
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Define the patients problem
Patient presents with a complaint or a problem.
To treat patient, physician should make a right
diagnosis Right diagnosis based on the complaint as describe
by patient, a detailed history, physical examination,laboratory tests, X-ray and other investigation
Patient complaints are mostly linked to symptoms(is not diagnosis)
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Sore throat complaint (1)
Man, 54 years, complaint severe sore throat.No general symptoms, no fever, slightredness of throat, no their finding
Man 43 years, compliant sore throat, slight
redness on the throat, no fever, no otherfinding. Medical record mentions that hesuffers from chronic diarrhea.
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Sore throat complaint (2)
Pt 1. His complaint probably results from aminor viral infection
Pt 2. Physician should refers to medicalrecord. Pt received loperamide to treatchronic diarrhea. This drug may producereduced salivation and dry mouth as adverse
event. Pt suffer AIDS ?
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Define the patients problem
Disease or disorder (diagnosis)
Sign of underlying disease
Psychological or social problems, anxiety
Side effect of drugs Refill request (polypharmacy)
Non-adherence to treatment
Request for preventive treatment Combination
Physician formulation may different with patient perceives
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Step 2:
Specify the treatment objective
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Specify the therapeutic objective
Woman 19 years, student. Complaint of asore throat. Slight redness of the throat, noother findings. After some hesitation she tellyou that she is three month overdue. Onexamination, she is three months pregnant
Sore throat by viral infection?
Problems on pregnancy?
Patient need a drugs?
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Specify the therapeutic objective
Therapeutic objective sometimesstraightforward, sometimes less clear.
Therapeutic objective can
Make physician concentrate on the realproblem
Prevent a lot of unnecessary drug useAvoid unnecessary prophylactic drugs
Discuss your therapeutic problems with patient
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Step 3:
Select the intervention
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Select the intervention
Make the inventory of possible treatments
Information or advice
Treatment without drugs Treatment with a drug
Referral
Combination
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Selection of the medicines
Medicines should effective, safe, suitable topatient and cheaper
Effective: please check to the referencestandard to looking for the EBM
Safety : check the side effects and frequencyof side effects
Suitability : check the contraindication of thedrug
Cost: check the total cost not only the price
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Efficacy of drug
Data Pharmacodinamic
Data pharmacokinetic (ADME)
Compare the dosage and formulation onabsorption, distribution, metabolism,excretion
Efficacy should be supported by good clinicaltrial with control
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Safety
Side effects
Toxic effects (depend on dug concentration)
If possible list he incidence of side effect
Unpredictable side effect (allergic reaction)may be caused by drugs
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Suitability
Contraindication of drug related by patientcondition (renal failure, hepatic disorder,
history of allergic reaction, other disease,other drugs (possibility of interaction))
Change of patient physiology (pregnancy andlactation, extreme age)
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Suitability
Are the active substance and dosage formsuitable for this patient?
Is the standard dosage suitable for thispatient?
Is the standard duration of treatment suitablefor this patient?
Pharmacokinetic data
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Cost
Check the cheaper drug
Discuss with the patient about the drug price
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DRY COUGH
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Six steps on dry cough
Problem : Dry cough
Objective: reduce the symptoms
Intervention:
Non Drug treatment? Drugs/medicines
opioid cough suppressant
Sedative antihistamine
Start the Tx:
Information and advice: Mucous membrane will not heal due to the cough
Avoid the further irritation (smoking, traffic exhaust fume
Refer if:
Monitoring and evaluation:
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Selection of medicines
Patient suffer dry cough that can be veryinconvenient
Suppressing for a few day may have abeneficial effect
Many cough preparation available in themarket
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Select the medicines of Dry cough
Opioid cough depressant
Codein, noscapine, dextromethorfan
Morphine, methadone
Effective to suppress the cough reflex
Allows the mucous membrane to regenerate
Side effects are constipation, dizziness andsedation, depress respiratory center
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Select the medicines of Dry cough
Sedative antihistamine
diphenhydramine
The efficacy is disputed
Side effects are drowsiness
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Step 4:
Start the treatment
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Start the treatment
Write a prescription Codein 30mg 3 x daily
Prescription is an instruction from a prescriber to adispenser
Information on prescription Name and address of the prescriber with
telephone number
Date of prescription
Name and strength of the drug Dosage form and total amount
Information for the package insert
Signature or initial
Patient identity
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Step 5:
Give information to the patient
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Give informationInstruction and warning
Effect of the drugs
Why the drug is needed
Which symptoms will disappear, and which not
When the effect is expected to start
What will happened if the drug is taken
incorrectly or not at all
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Give informationInstruction and warning
Side effects
Which side effect may occur How to recognize them
How long the will continue
What action to take
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Give informationInstruction and warning
Instruction
How the drug should be taken When it should be taken
How long the treatment should continue
How the drug should be stored What to do with left-over drugs
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Give informationInstruction and warning
Warnings
When the drug should not be taken What is the maximum dose
Why the full treatment course should betaken
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Give informationInstruction and warning
Future consultation
When to come back (or not)
In what circumstances to come earlier
What information the doctor will needed at
the next appointment
f
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Give informationInstruction and warning
Everything clear ?
Ask the patient whether everythingunderstood
Ask the patient to repeated the mostimportant information
Ask whether the patient has any morequestion
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Step 6:
Monitor (or stop?) treatment
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Monitor and stop the treatment
Was the treatment effective ?
Yes and disease cured
Stop the treatment Yes but not yet completed
Any serious effect?
No : Treatment can be continued
Yes : reconsider dosage or drug choice
No : check your all steps
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Drug Selection ofangina pectoris
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Case : Angina pectoris
Problems:
Angina pectoris is a symptom
Divided to classic and variant anginapectoris; stable and unstable
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Objective of treatment
Preventive? Treatment?
Pathophysiology:Angina pectoris is caused by imbalance of
oxygen demand and oxygen supply oncardiac muscle
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Objective treatment
As soon as possible to reduce the oxygendemand by:
Decreasing prelaod Reducing he contractility
Reducing the heat rate, and
Reducing the afterload
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Medicines selection
Preload Contractility Frequency Afterload
Nitrates ++ - - ++
Beta-blocker + ++ ++ ++
Ca-channel blocker + ++ ++ ++
Site of action
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Medicines selection
Efficacy Safety Suitability Cost
Nitrates + ++ +
Beta-blocker + - -
Ca-channel blocker + - -
GNT Tab/spay + ++ +
Isosorbide dinitrate tab + ++
Isosorbide mononitrate + ++
(tab)
Conclusion : GNT, sublingual tab 1mg, 1 tab as needed, second tab if pain persists,
duration of use based on results (closed monitor).