Rationale Pharmacotherapy

Dra.Maria Caecilia N.Setiawati H., M.Sc, AptSTIFAR Yayasan Pharmasi

Semarang

Therapy approach

Nonpharmcology

Pharmcology

Pharmcotherapy

Alternative therapy

Radiotherapy

Surgery

Genetherapy

Drug therapy

Imunotherapy

• 1600 chemical agents• 40.000 formulations• 100.000 OTC

Clinical features of illness

Patient expectations

Potential consequences

Presenting symptoms

2. Understanding pathophysiology

1. Making Dx

3. Reviewing menu of Rx options

4. Selecting optimal drug/ dose for patient

5. Choosing endpoints to follow

6. Making alliance with patient, following endpoints

Clinical outcomes• efficacy• toxicity• morbidity• mortality

Patient satisfaations

Costs • direct• indirect

Functional Outcome • relief of symptoms

Patient Presentation

Process of Rational

Therapeutics

Result of Intervention

Process of rational drug therapy

Penggunaan Obat Rasional

TEPAT

Tindak lanjutDiagnosis

Indikasi

jenis obat Informasi

Dosis, cara & lama pemberian

Kondisi pasien

Prior Knowledge

HabitsScientific Information

RelationshipsWith Peers

Influenceof DrugIndustry

Workload & Staffing

Infra-structure

Authority & Supervision

Societal

InformationIntrinsic

Workplace

Workgroup

Social &CulturalFactors

Economic &Legal Factors

Faktor yang Mempengaruhi Farmakoterapi

Prescribing

Tantangan peresepan

Prescribing

Currentbest knowledge Tekanan

pasien Tekananekonomi

Waktuterbatas

IndividualpreferenceKetidak-

tahuanTekananindustri farmasi

Problems in Irrational Therapy

The pharmacotherapy process

Problems with Irrational Pharmacotherapy

Problems with Irrational Pharmacotherapy :

1. Complex diseases or health problems:Example: A patient has many symptoms, but is embarrassed to talk about the main one, so the situation does not get addressed

2. Lack of appropriate training skills by prescribers to give proper diagnosis:Example: Prescriber does not do a physical exam and prescribes drugs based solely on oral information provided by the patient

Diagnosis

3. Overworked prescribers:Example: health facility has only one prescriber, and an average of 300 patients per day to consult

4. Lack of basic diagnostic equipment and testsExample 1: No microscope or reagents to examine blood & urineExample 2: No x-ray machine to test a patient suspected of having

tuberculosis

Prescribing1. Using expensive drugs when equivalent ones are available

Example 1: The antibiotic cefalexin is more expensive than co-trimoxazole in treating simple infectionsExample 2: Ampicillin injection is prescribed when the patient could take ampicillin tablets, which are cheaper, easy to take, and involve lower risk of side effects

2. Selecting the wrong drug for the patient’s illnessExample: An antidiarrhoeal drug is prescribed when the patient is

dehydrated with simple diarrhoea and only ORS is needed

3. Prescribing several drugs when fewer drugs would provide the same effectExample: Sulfadoxine/pyrimethamine and paracetamol are prescribed when

the patient has fever, but not malaria

4. Prescribing drugs when the disease is self limiting and the patient would get better without taking any drugsExample: Ampicillin is prescribed when the patient has a simple cold, without sore throat, cough or fever

1. Wrong interpretation of the prescription:Example: Ampicillin is prescribed, but amoxicillin is dispensed.

2. Wrong quantity dispensedExample: Artemether/Lumefantrine is prescribed to be taken four

tablets two times daily for three days (should be a total of 24 tablets), but the patient only receives 16 tablets, which is sufficient for only 2 days

3. Labelling incorrect or inadequateExample: Sulphadoxine/pyrimethamine (white tablet) is dispensed, but the name of the drug is not written on the container label, meaning that the drug will be unidentifiable once the patient leaves the pharmacy

Dispensing

4. Incorrect/insufficient dispensing information:Example: paracetamol 250mg is prescribed for a

child, but only paracetamol 500mg is available in the pharmacy. The

higher dosage pill is given to the child’s mother without telling her to divide the tablet before giving it to the child

5. Unsanitary practices:Example: 20 tablets of paracetamol 500mg were

being counted, when some tablets fell to the floor. These were picked up and dispensed to be given to the patient anyway

Packaging

1. Poor quality of packaging materialExample: packaging material must protect the drug against the sun and humidity in order to ensure the integrity and quality of the dosage form required by the patient

2. Inadequate container size when repackaging the productExample: the size of the packaging material must conform to the quantity of medication dispensed. In the case of oral drugs, too large a container could cause break-up of the items packed within

3. Inadequate labelling and identification of the drug After the patient leaves the health centre and arrives home, it is very

easy to forget instructions given by the prescriber and dispenser.

At the very minimum, the following information must be written on the container label:

• Name of patient• Date drug was dispensed• Name of the drug• Strength of the drug• Quantity dispensed• Instructions on how to take the drug during the day (example: 1

tablet 4 times daily)• Instructions on how long to take the drug • Comments, instructions or warnings specific to the drug

(example, take with milk, may cause drowsiness)

Poor Compliance

Compliance is the degree to which the patient carries out the physician’s instructions on how to take the prescribed drug and treatment. Many studies about outpatient compliance carried out in developing countries indicate that only about 50% of patients follow the instructions given by the physician

Poor Compliance

Causes of poor compliance include:1. Improper labelling

Neither the name of the patient, nor the name of the drug is on the container labels when dispensed. If two or more drugs are dispensed together, the patent does not know which drug he/she is taking

2. Inadequate instructions:The instructions on dosage frequency must be written on the drug label, or the patient could forget how to take it when he/she arrives home and becomes involved in other activities

3. Treatment /instructions that do not consider the socio-economic and cultural aspects of the patient

Example: In cases where the patient does not know how to read, proper instructions would include graphic symbols of how to take the drug.

For a treatment of three days, for example, you could number the days 1 to 3, and then below each day, make a mark for each time the drug must be taken that day

Explanations Poor Compliance :

Lack of knowledge Influenced by others Negative attitudes Own experience Own perceptions Difficult/complicated regimen Extremes of age and need for assistance

Improve Rational Therapy

1. Educational

Intervention Type

2. Managerial

3. Financial

4. Regulatory

Prescribers

Consumers

Promotion of Rational Drug Use 1. Improve the Consultation Process

• Take a complete history of patient’s illness. Verify the main reason the patient came to the clinic, all accompanying symptoms, and the way the problem developed over time

• Perform a physical examination relevant to the patient's symptoms and medical history

• Prescribe drugs and treatment according to Standard treatment guidelines

• Do laboratory exams relevant to complaints. When no laboratory is available, the prescriber could visually examine the body fluids for evidence of disease

2. Improve Prescribing Habits

• When many drugs are prescribed for a patient, verify that they are absolutely necessary for treating the diagnosed condition

• Use standard treatment schemes for common illnesses

• Verify a second time that the drug is appropriate before dispensing it to the patient

3. Improve Dispensing Practices:

• Recruit and train competent personnel

• Organize the dispensing area so it allows for efficient work flow, can be easily cleaned, and is secure against theft

• Verify the quantity of the drug that is being dispensed to patient

• Give correct and adequate instructions to the patient

• Provide appropriate dispensing tools

4. Improve Compliance:

• Label the prescription container adequately (written or in symbols) before dispensing to the patient

• After giving instructions to the patient about how to take the drug, ask for feedback to verify the patient’s understanding of drug dosage

• Consider local beliefs and customs that influence drug use when prescribing and dispensing

• Drug therapy involves a great deal more than matching the name of the drug to the name of disease;

• It requires knowledge, judgment, skill and wisdom, but above all a sense of responsibility;

• A book can provide knowledge and can contribute to the formation of judgment, but it can do little to impart skill and wisdom, which are the products of experience and innate and acquired capacities.

Summary

• Pengetahuan yang luas (learned) • Kecerdikan (smartness)• Akal sehat (common sense)• Wawasan (insight)• Sikap hati-hati (prudent)• Pemahaman terhadap norma kebenaran • Kemampuan mencerna (ability to digest)• Penalaran (reasoning)

Kearifan (Wisdom)