8. pharmacotherapy

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  • MMS: Importance of RDU in the context of ART programs NSS: This statement was agreed by the WHO conference of experts in Nairobi in 1985 and is still the accepted definition of Rational Drug Use. It highlights the fact that rational use of medicines has many components, all of which must be in place before we can say that a drug has been rationally used. Rational use of drugs should ensure: correct drug appropriate indication appropriate drug considering efficacy, safety, suitability for the patient, and cost appropriate dosage, administration, duration no contraindications correct dispensing, including appropriate information for patients patient adherence to treatment
  • Message principal à communiquer dans cette diapositive : importance de l’u tilisation rationnelle des médicaments dans le contexte du TAR Question à discuter : quelle est l'importance d'une utilisation rationnelle des médicaments dans le contexte du TAR ? Instructions à l’attention de l’animateur : Donnez aux participants l'occasion de s'exprimer avant de montrer les réponses, mais limitez la discussion à 5 minutes maximum. L'utilisation inappropriée d’antirétroviraux (ARV) peut rapidement déclencher une certaine résistance virale et provoquer l'échec du traitement, la toxicité des médicaments et le gaspillage des ressources financières. Par conséquent, il est important de respecter des normes acceptables avant d'utiliser un traitement antirétroviral (TAR) pour que les patients puissent en retirer tous les avantages. Développement rapide de la résistance aux médicaments si l'observance thérapeutique est inférieure à 90 % Échec du traitement probable si l'observance thérapeutique est inférieure à 95 % Risque élevé de toxicité Gaspillage de ressources financières
  • Patient& Community Beliefs and (mis)information available in the Community including cultural values on therapy, patient demands& expectations, Prescriber, Dispenser Lack of drug information, limited experience and skills, fear induced prescribing (uncertain diagnosis) Incorrect generalization from experience, inability to read or interpret prescriptions, inadequately trained dispensers, poor attitude about dispensing and packaging Workplace Lack of equipment, facilities, packaging materials, lab capacity, continuing education, pressure to prescribe and dispense, insufficient staffing, inadequate supervision of practitioners. Drug Supply System: Drug Quality Problems unreliable suppliers Bad forecasting/bad quantifications Bad Inventory Management (expired drugs, Shortages, etc.) Pressure and lobbying from Industry (promotional activities and misleading claims) Drug Regulation non-essential drugs available: non-formal prescribers lack of regulation enforcement
  • MMS: familiarize participants with the components of appropriate drug use IT The purpose of this session is to familiarize participants with the components of appropriate drug use, help them identify common problems in each of these components, and enable them to come up with solutions for such problems. NSS: The drug use process can be qualified as a system that involves steps; from identifying the problem [diagnosis] through prescribing the right medicines suitable for the patient conditions, dispensing and counseling to ensure understanding of how medicines or treatment plan should be followed and adherence on the part of the patient to the treatment plan. Patients may revisit the healthcare facility for follow-up, (especially in chronic disease management, such as treatment of HIV/AIDS) and thus the cycle starts again. **Question to ask to the audience: What problems can occur in prescribing, dispensing, and packaging drugs or in patients’ use of drugs Instructions: Participants should suggest problems that could occur in each step of the process, looking first at Diagnosis – once participants have given their ideas on problems that can occur during diagnosis step then show the suggested answers on the next slide. It is not necessary to go in detail through the points listed on slides 7 – 9 – these are intended as a recap after the participants have discussed to make sure that no important areas are omitted. Once the answers shown for Diagnosis then ask for possible problems with Prescribing, before briefly showing the suggested answers. Repeat the same process for Dispensing and Adherence. Do not forget that dispensing and Adherence will be covered in separate modules so do not spend too much time on these areas, but they need to be included so that the whole drug use process is conveyed and considered. References: Managing Drug Supply: Training Series; Trainer’s Guide; M13- Appropriate Drug Use; Management Science for Health, second edition. Further reading: Guide to Good Prescribing: A practical manual; WHO Chapter 1: The process of rational treatment, page 7
  • MMS: recap the discussion on aspects of irrational drug use briefly with this slide and the following 2. NSS: Diagnosis: Inadequate examination of patient Incomplete communication between patient and doctor Lack of full medical and medication history e.g. Rifampicin in Tb treatment and Stavudine (d4t), EFV potential for teratogenicity Prescribing: Extravagant prescribing: Expensive drugs are used when less expensive equivalents are available. Over-prescribing: Prescribed drugs are not needed, or the dosage is too high. Patient has gained weight after ART and dosage is not changed. Incorrect prescribing: The wrong drugs are selected for the patient’s condition. Under-prescribing: Needed medications are not prescribed, or the dosage is inadequate. Multiple prescribing; Many drugs are used when fewer would have the same effect.
  • MMS: recap the discussion on aspects of irrational drug use. MSS: Dispensing: Incorrect interpretation of the prescription Retrieval of wrong ingredients Inaccurate counting, compounding, or pouring: lack of Pediatric ARV formulations Inadequate labeling Unsanitary procedures Packaging: Poor-quality packaging materials Odd package size, which may require repackaging Unappealing package

Transcript

  • 1. PHARMACOTHERAPY
  • 2. PharmacotherapyPharmacotherapy Principally concerned with the safesafe and effectiveeffective management of drug administration. Implies an understanding of pharmacokinetics (PK) and pharmacodynamics (PD) so that individual dosing guidance, can be provided to optimize patient response .
  • 3. Pharmacokinetics What the body does to the drug – Absorption – Distribution – Metabolism – Elimination Pharmacodynamics What the drug does to the body – Response – Toxicity
  • 4. PharmacotherapyPharmacotherapy METABOLISM ABSORPTION ELIMINATION - Site (i.e., GIT, skin, tissue depot) - First-pass effect (oral) - Drug properties (i.e., solubility) -Pathway(s) -Sites (GIT, liver, lung) DISTRIBUTION SITE(S) FOR THERAPEUTIC EFFECT(S) SITE(S) FOR TOXIC EFFECT(S) Pharmacologic Activity Toxic Activity Free Drug in Plasma or Extracellular Fluid Distribution in Blood Cells Bound to plasma proteins - Unchanged drug - Metabolites - Sites (Tissues, fat, etc) - Binding Excretory Sites Urine, Feces, Expired AirActive/inactive metabolites
  • 5. Rational Drug Use Supported by USAID Prescribing, Dispensing, Counseling and Adherence
  • 6. Definition The 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 cost to them and their community. WHO conference of experts, Nairobi 1985
  • 7. DRUG DOSE TIME ROUTE OF ADMINISTRATION PRICE
  • 8. Importance of RDU An irrational drug use results in the following: – Treatment failure – Rapid development of drug resistance – Increase of toxicity risk – Wastage of money
  • 9. Rational Drug Use Prescriber, Dispenser & their workplaces Drug Supply System Patient & community Many Factors Influence Use of Medicines Policy, Legal and Regulatory framework
  • 10. Drug Use Process
  • 11. Diagnosis: Aspects that lead to Irrational Drug Use Inadequate examination of patient Incomplete communication between patient and doctor Lack of documented medical history Inadequate laboratory resources
  • 12. Prescription: Types of Irrational Drug Use (1) Irrational Drug Use Occurs If a Drug Is Prescribed When: Underprescribing • Needed medications are not prescribed • Dosage is inadequate • Length of treatment is too brief
  • 13. Prescription: Types of Irrational Drug Use (2) Irrational Drug Use Occurs If a Drug Is Prescribed When: Incorrect prescribing • Drug given for incorrect diagnosis • Wrong drug selected for diagnosis • Prescription prepared improperly • Adjustments not made for co-existing medical, genetic, environmental, or other factors
  • 14. Prescription: Types of Irrational Drug Use (3) Irrational Drug Use Occurs If a Drug Is Prescribed When: Extravagant prescribing • A less expensive drug provides comparable efficacy and safety • Symptomatic treatment of mild conditions diverts funds from treating serious illness • Brand-name drug used when less expensive equivalents are available
  • 15. Prescription: Types of Irrational Drug Use (4) Irrational Drug Use Occurs If a Drug Is Prescribed When: Overprescribing • Drug is not needed • Dose is too large • Treatment period is too long • Quantity dispensed is too great for current course of treatment
  • 16. Prescription: Types of Irrational Drug Use (5) Irrational Drug Use Occurs If a Drug Is Prescribed When: Multiple prescribing  Two or more medications are used when fewer would achieve same effect  Several related conditions are treated when treatment of primary condition would improve or cure the other conditions
  • 17. Dispensing: Types of Irrational Drug Use Incorrect interpretation of the prescription Retrieval of wrong ingredients Inaccurate counting, compounding, or pouring Inadequate labeling Unsanitary procedures Packaging: – Poor-quality packaging materials – Odd package size, which may require repackaging – Unappealing package
  • 18. Adherence vs Compliance Adherence: The act or quality of sticking to something; steady devotion; the act of adhering The acceptance of an active role in ones health care Compliance: the act of yielding, conforming,
  • 19. Consequences of Poor Adherence For the individual: – Treatment failure: incomplete viral suppression, continued destruction of the immune system, disease progression – Drug resistance: emergency of resistant viral strains – Limited future treatment options: more complex treatment, more toxicity, uncertain prognosis
  • 20. SLEPT IN AWAY FROM HOME RAN OUT OF PILLS FELT ILL FELT BETTERPILLS DO NOT HELP FEAR SIDE EFFECTS DID NOT WANT OTHERS TO SEE FAMILY SAID NO TO MEDICATION FORGOT / BUSY DID NOT UNDERSTAND INSTRUCTION S MISSED DOSES TAKING PILL HOLIDAYS UNABLE to CARE FOR SELF Adherence: Why do Patients Miss Doses? (Barriers to adherence) Let’s find together a solution for your problem •I am listening •You can trust me •I understand •I suggest… •What do you think? •I’ll explain to you how to take these medicines
  • 21. Other Barriers to adherence Communication difficulties Literacy levels Inadequate knowledge of disease Inadequate understanding of effectiveness of medications Lack of social support Discomfort with disclosure status Difficult life conditions Alcohol and drug use Depression and other psychiatric problems
  • 22. Adherence Multi-disciplinary Roles Same message from all! Adherence Message for the patient Doctors Adherence Nurse Pharmacist Family/ Friends Counselor Social Worker
  • 23. Methods and Challenges of Measuring Adherence Self reports Pill counts Pharmacy records Provider estimate Pill identification test Biological markers Electronic devices Measuring drug levels
  • 24. A multi-disciplinary team work is required to achieve Rational Drug Use !!! Doctor Pharmacist Counselor / Treatment supporter Nurse Community
  • 25. CLASSES of DRUGS Drugs affecting the Autonomic Nervous System Drugs affecting the CNS – Antiparkinson drug – Anti-anxiety – Hypnotic drugs – CNS Stimulants – Anesthetics – Antidepressant drugs – Anti-epilepsy
  • 26. Drugs affecting Cardiovascular system – Drugs for congestive heart failure – Anti-arrythmic drugs – Antianginal drugs – Antihypertensive drugs – Drugs affecting blood – Antihyperlipidemic drugs
  • 27. Drugs affecting respiratory system Diuretic drugs Gastro-intestinal drugs Antiemetics Oral Hypoglycemic drugs and Insulin Hormones of the Pituitary and thyroid Steroid hormones Anti-inflammatory drugs
  • 28. Chemotherapeutic drugs – Antibacterial – Antifungal – Antiprotozoal – Anthelmintic – Antiviral – Anticancer