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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