Transcript Document

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
1
Objectives
• Objectives:
– be able to count dimensions which are
important in drug selection
– be able to explain the method in
preparing a personal-drug (p-drug) list
– believe in the importance of rational
prescription
– be able to develop his/her own p-drug list
2
P-Drug Concept
•
P-drugs are the drugs you have chosen to
prescribe regularly, and with whom you
have become familiar.
•
They are your drugs of choice for given
indications.
•
The P-drug concept is more than just the
name of a pharmacological substance, it
also includes the dosage form, dosage
schedule and duration of treatment
3
P Drug Concept
• P-drugs enable you to avoid repeated
searches for a good drug in daily practice.
• As you use your P-drugs regularly, you will
get to know their benefits and side effects
thoroughly.
• P-drugs are your drugs of first choice for a
common condition.
4
Remember that….
A P-drug is a
drug that is
ready for action!
5
Rational prescription
“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”
6
RATIONALIZATION OF
PRESCRIPTION PRACTISES
• 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.
7
RATIONALIZATION OF
PRESCRIPTION PRACTISES
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.
8
RATIONALIZATION OF
PRESCRIPTION PRACTISES
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)
9
RATIONALIZATION OF
PRESCRIPTION PRACTISES
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.
10
Characteristics of good and bad prescribing
Good prescribing
Bad prescribing
Effective
Ineffective
Safe
Unsafe
Patient centred and individualized
Not patient centred
Acceptable to patient
Not suitable for patient
Appropriate (not too little or too much)
Inappropriate
Addresses expectations of patient
Causes patient distress and harm
Judicious use of resources
Higher cost
Well informed (evidence based)
Poorly informed
Based on unbiased information
Based on biased information
Low vulnerability to outside influences
Vulnerable to outside influence
Australian family Physician 2003
11
World Health Organisation
Guide to Good Prescribing Steps:
1. Make diagnosis
2. Set therapeutic goal for the
individual patient
3. Decide on the therapeutic approach
4. Choose a drug class
5. Choose a generic drug within
a class
6. Individualise dose, formulation,
frequency, and duration
7. Verify suitability of chosen drug
8. Write prescription
9. Inform patient
10. Monitor for effects and adverse
effects
11. Alter prescription, if necessary
12
EXAMPLE
(CASE HISTORY)
Abdullah is 62 years old and has had
three documented blood pressures
over 140/90 as well as 24 hour
ambulatory blood pressure monitoring
showing a mean daytime BP of
162/82. He is slightly overweight (BMI
28), and an ex-smoker.
He has some arthritis in his knees that
he takes Celebrex® (celecoxib) for. He
also has diet controlled diabetes, with
no evidence of diabetic complications.
13
1. Make the diagnosis
*hypertension
14
• 2. Set the therapeutic goal for the
individual patient
Therapeutic goal is the answer to the patient’s
question: ‘Why am I taking this medication’?
*prevent cardiovascular events rather than
just reducing the blood pressure per se.
15
• 3. Decide on therapeutic approach
*using pharmacological as
well as nondrug therapy
*Consideration should be given to ceasing
the Celebrex as this can aggravate hypertension.
*assessing and addressing his lipids, dietary advice,
or consideration of aspirin as primary
prevention.
16
• 4. Choose a drug class
The choice is based on their comparative
efficacy, safety, cost and suitability .
17
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
18 pharmacy
education in the graduate school of pharmaceutical sciences]. Yakugaku Zasshi. 2002 Oct;122(10):819-29
The process of rational treatment
• 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
19
http://p-drug.umin.ac.jp/34th-gakkai/slide/DrSunami/SunamiP-drug.PPT
Selecting a P-drug
• 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
20
• Efficacy
There is evidence from the HOPE study that
diabetic patients may get a mortality
benefit from angiotensin converting
enzyme (ACE) inhibitors independent of
their effect on blood pressure.
Angiotensin converting enzyme inhibitors
would also be effective in preventing diabetic
renal complications, so in terms of
efficacy, ACE inhibitors would be our
first choice, followed by thiazides.
21
• Safety
*consider the frequency as well
as the severity of adverse reactions.
*special groups
who may be particularly at risk of adverse
reactions. eg. gout with thiazides
22
• Cost
*cost to
the patient
*cost to the community
for subsided drugs.
*It also needs to
include consideration of costs associated
with monitoring, treatment failure, and
side effects.
23
• Suitability
(The convenience)
Frequency/monitoring/formulation
24
• 5. Choose a generic drug within
a class
eg. you may chose to prescribe atenolol
instead of metoprolol because it is less
lipophilic and less likely to result in
central nervous system adverse reactions,
as well as being a once daily medication.
Among the ACE inhibitors the only difference
is that captopril requires more
frequent daily dosing.
You may choose to
prescribe ramipril because it was the drug
used in the HOPE study.
25
• 6. Individualise dose, formulation,
frequency and duration
* a low dose of ACE inhibitor should be chosen
and titrated up slowly because
he is already taking celecoxib .
26
• 7. Verify the suitability of the
chosen drug.
27
• 8. Write a correct prescription
*writing the prescription is only
a small part of the whole prescribing
process.
* document the prescription
in the case notes with the date,
dose and indication to allow ease of review.
28
• 9. Provide information to the patient
discussion of the therapeutic
goal / therapeutic
approach/adverse reactions
(eg. cough with ACE
inhibitors) /rare serious reactions
(eg. angioedema with ACE inhibitors).
written information
29
• 10. Monitor for effects and adverse
Effects
In the case of Abdullah he should be brought back for monitoring of his
blood pressure, as well as renal function 1–2 weeks after
commencement of the prescribed drug.
• 11. If necessary, alter prescription
The response may be:
* alter the dose,
*cease the medication
* prescribe another agent or try alternative non-pharmacological
approaches.
30
• Using a P-drug list
*You then add the ACE inhibitor that you have chosen to
your P-drug list, and you prescribe it for
all of your diabetic hypertensives from
then on, unless there is a particular suitability
issue.
*The choice takes a bit longer the first time, but it is then
rational, appropriate and evidence based.
31
Using a P-drug list
*it also has the benefit of saving time on future consultations
because you know exactly what to prescribe.
* Also, when a new drug is being marketed for the treatment of
hypertension, in order for it to become your first line treatment on
your P-drug list, you have to see proof that it is better
than the ACE inhibitor for diabetic patients.
32
• Conclusion
• Prescribing is an important behaviour that
GPs regularly practise.
• *The WHO has developed a structured guide to
good prescribing and the steps in this
process are easy to learn and apply in day to
day practice.
33
Conclusion
Central to this process is
the development of a personal formulary
(P-drug list) where a limited number of
drugs are chosen for specific indications
with choices being made on rational and
evidence based grounds.
By prescribing according to a well founded P-drug list,
GPs can develop greater familiarity and
confidence in their prescribing with
improved outcomes for patients.
34
35