This document discusses rational drug use and provides strategies to promote it. It defines rational drug use according to WHO as using medicines appropriately for clinical needs in terms of drug choice, dosage, duration and cost. Common problems with irrational use include polypharmacy, overuse of antibiotics and injections. Reasons for irrational use include lack of skills/knowledge, inappropriate drug promotion, profits from drug sales, and lack of coordinated policies. Consequences are antimicrobial resistance, adverse drug reactions, and wasted resources. The document recommends educational and regulatory strategies to improve prescribing and dispensing practices and ensure appropriate drug use.

1. DOCTOR OF PHARMACY
II YEAR
Rational drug use
170101
CHAPTER-5
Introduction to Rational drug use
Dr. V. Chanukya (Pharm D)

2. Irrational drug use
• WHO estimates that more than half of all medicines are prescribed,
dispensed or sold inappropriately, and that half of all patients fail to
take them correctly.
• This incorrect use may take the form of overuse, underuse and misuse
of prescription or non-prescription medicines.
Common problems include:
• Polypharmacy (use of too many medicines);
• Overuse of antibiotics and injections;
• Failure to prescribe in accordance with clinical guidelines;
• Inappropriate self-medication.

3. Reasons for irrational use of drugs.
1. Lack of skills and knowledge
• Diagnostic uncertainty
• Lack of prescriber knowledge of optimal diagnostic
approaches
• Lack of independent information such as clinical guidelines
• Lack of opportunity for patient follow-up..

4. 2. Inappropriate unethical promotion of medicines by
pharmaceutical companies.
• Most prescribers get medicine information from pharmaceutical
companies rather than independent sources such as clinical guidelines.
• This can often lead to overuse.
• Some countries allow direct-to-consumer advertising of prescription
medicines, which may lead to patients pressuring doctors for
unnecessary medicines.

5. 3. Profits from selling medicines.
• In many countries, drug retailers prescribe and sell medicines over-
the-counter.
• The more they sell the more income they generate, leading to overuse
of medicines, particularly the more expensive medicines.
4. Unrestricted availability of medicines.
• In many countries, prescription medicines such as antibiotics, are
freely available over-the-counter.
• This leads to overuse, inappropriate self-medication and non-
adherence to dosing regimes.

6. 5. Overworked health personnel.
• Many prescribers have too little time with each patient, which can
result in poor diagnosis and treatment.
• In such circumstances prescribers rely on prescribing habit as they
do not have the time to update their knowledge of medicines.
6. Unaffordable medicines.
Where medicines are unaffordable, people may not purchase a full
course of treatment or may not purchase the medicines at all.
• Instead they may seek alternatives, such as medicines of non-assured
quality from the Internet or other sources, or medicines prescribed to
family or friends. .

7. 7. Lack of coordinated national pharmaceutical policy.
• Less than half of all countries implement the basic policies
recommended by WHO to ensure the appropriate use of medicines.
• These include appropriate measures and infrastructure for monitoring
and regulation of medicines use, and training and supervision for
prescribing health workers
Poor communication between health care professionals and
patients, demand from the patients and inferior drug products
contribute to irrational use of drugs.

8. Irrational drug use consequences
• Incorrect use of medicines occurs in all countries, causing harm to
people and wasting resources. Consequences include:
Antimicrobial resistance.
Overuse of antibiotics increases antimicrobial resistance and the number
of medicines that are no longer effective against infectious disease.
• Many surgical procedures and cancer therapies are not possible
without antibiotics to fight infection.
• Resistance prolongs illnesses and hospital stays, and can even cause
death, leading to costs of US$ 4–5 billion per year in the United States
of America and €9 billion per year in Europe.

9. Adverse drug reactions and medication errors.
• Harmful reactions to medicines caused by wrong use, or allergic
reactions to medicines can lead to increased illness, suffering and
death. Adverse drug reactions have been estimated to cost millions of
dollars each year.
Lost resources.
Between 10–40% of national health budgets are spent on medicines.
• Out-of-pocket purchases of medicines can cause severe financial
hardship to individuals and their families.
• If medicines are not prescribed and used properly, billions of dollars
of public and personal funds are wasted.

10. Eroded patient confidence.
• Exacerbated by the overuse of limited medicines, drugs may be often
out of stock or at unaffordable prices and as result erode patient
confidence.
• Poor or negative health outcomes due to inappropriate use of
medicines may also reduce confidence.
• Ineffective & unsafe treatment, exacerbation or prolongation of
illness, distress & harm to patient and increase the cost of
treatment are some of the other consequences.

11. Rational Drug Use

12. Introduction
• The concept of rational drug use is age old, as evident by the
statement made by the Alexandrian physician Herophilus 300 B.C
that is “Medicines are nothing in themselves but are the very hands
of god if employed with reason & prudence.”
• The concept of rational drug use during the past few years has been
the theme of various national & international gatherings.
• Various studies conducted in developed as well as in developing
countries during past few years regarding the safe & effective use of
drugs show that irrational drug use is a global phenomenon & only
few prescriptions justify rational use of drugs.

13. Definition
Rational Use of Drugs :
• The World Health Organization has defined Rational Use of Drugs as
follows:
• “The rational use of drugs requires that patients receive medicines
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 the community.”
• In simplest words rational use means “prescribing right drug, in
adequate dose for the sufficient duration & appropriate to the clinical
needs of the patient at lowest cost.

14. • The above definition places emphasis on the following:
– Dispensing of the correct drug;
– Appropriate indication - that is, the reason to prescribed is based on
sound medical considerations;
– Appropriate medicine, considering efficacy, safety, suitability for the
patient and cost.
– Appropriate dosage and quality of medicines. Quantity sufficient to last
for duration of the treatment.
– Correct dispensing including appropriate information to patients about
the prescribed medicines;
– Patient adherence to treatment.

15. Factors led to RDU
• Rational drug use attained more significance nowadays in terms of
medical, socio economical and legal aspect.
Factors that have led sudden realization for rational drug use are.
1. Drug explosion:- Increase in the number of drugs available has
incredibly complicated the choice of appropriate drug for particular
indication.
2. Efforts to prevent the development of resistance :– Irrational use
of drugs may lead to the premature demise of highly efficacious &
life saving new antimicrobial drug due to development of resistance.

16. 3. Growing awareness:- Today, the information about drug
development, it’s uses & adverse effects travel from one end of the
planet to the other end with amazing speed through various media.
4. Increased cost of the treatment:- Increase in cost of the drug
increases economic burden on the public as well as on the
government. This can be reduced by rational drug use.
5. Consumer protection Act. (CPA):- Extension of CPA in medical
profession may restrict the irrational use of drugs.
Factors led to RDU

17. What can be done to improve rational use of
medicines?
• WHO advises countries to implement national programmes to
promote rational use of medicines through policies, structures,
information and education. These include:
1. A national body to coordinate policies on medicine use and
monitor their impact;
2. Evidence-based clinical guidelines for training, supervision and
supporting decision-making about medicines;
3. Lists of essential medicines used for medicine procurement and
insurance reimbursement;

18. 4. Drug and therapeutics committees in districts and hospitals to
monitor and implement interventions to improve the use of
medicines;
5. Problem-based training in pharmacotherapy and prescribing in
undergraduate curricula;
6. Continuing medical education as a requirement of licensure;
7. Publicly available independent and unbiased information about
medicines for health personnel and consumers;
8. Public education about medicines;

19. 9. Elimination of financial incentives that lead to improper prescribing,
such as prescribers selling medicines for profit to supplement their
income;
10. Regulations to ensure that promotional activities meet ethical criteria
11. Adequate funding to ensure availability of medicines and health
personnel.
• The most effective approach to improving medicines use in primary
care in developing countries is a combination of education and
supervision of health personnel, consumer education, and ensuring an
adequate supply of appropriate medicines.

20. Requirement for rational drug use
1. Adequate diagnosis
For a correct diagnosis to be made, the prescriber must have adequate knowledge
and motivation, private examination facilities, and sufficient time to take a history,
perform an examination, and explain to the patient the diagnosis and treatment.
2. Correct prescribing
To prescribe correctly, the prescriber must know which drug to prescribe for which
diagnosis or complaint and when treatment without drugs is appropriate.
3. Appropriate dispensing
For correct dispensing to occur, the dispenser must be trained, have adequate time,
have the necessary materials (containers, labels), and have a dispensary where it is
possible to communicate with patients.

21. 4. Patient adherence to treatment (compliance)
Patient adherence to treatment is dependent on understanding and acceptance of the
treatment; this results from effective communication between prescriber, dispenser
and patient.
5. Measuring drug use
In any situation, measurement of present practices, followed by investigation of the
underlying reasons for practices that represent problems, should precede the
development of interventions.
• Once the priority problem has been identified, further investigations
utilizing qualitative techniques such as observation, focus group
discussions, in-depth interviews, questionnaires and simulated patients
are required

22. WHO advocates 12 key interventions to promote
more rational use:
1. Establishment of a multidisciplinary national body to coordinate
policies on medicine use
2. Use of clinical guidelines
3. Development and use of national essential medicines list
4. Establishment of drug and therapeutics committees in districts and
hospitals
5. Inclusion of problem-based pharmacotherapy training in
undergraduate curriculam

23. WHO advocates 12 key interventions to promote
more rational use:
6. Continuing in-service medical education as a licensure requirement
7. Supervision, audit and feedback
8. Use of independent information on medicines
9. Public education about medicines
10. Avoidance of perverse financial incentives
11. Use of appropriate and enforced regulation
12. Sufficient government expenditure to ensure availability of
medicines and staff.

24. Steps to promote rational drug use:
• Educational and training strategies
– Training prescribers
• By providing more knowledge in subjects like basic
pharmacology, clinical pharmacology and therapeutics
– Existing prescribers
• By providing continuing education and training programs in the for, of
seminars, work shops, group discussions, online classes etc
– Educational outreaches
– Providing drug use education for patients and public

25. Regulatory measures
• Drug registration
• Evaluation of drugs and product information
• Scheduling of drugs for its different level of use
• Controlling of dispensing
• Control over health care professions
• Control over manufacturing and sales of drugs
• Control over promotions of pharmaceuticals

26. Management strategies
• Selection, preparation of budget, procurement and distribution
of drugs
• Limitation on drugs procurement list
• Drug utilization review and feed back from patients for
effectiveness of drugs

27. Steps to improve rational drug prescribing
Step:- I
Identify the patient’s problem based on symptoms & recognize
the need for action.
Step:-II
Diagnosis of the disease.
Identify underlying cause & motivating factors.
This may be specific as in infectious disease or non specific.
Step:-III
List possible intervention or treatment.
This may be non drug treatment or drug treatment.

28. Step:- IV
Start the treatment by writing an accurate & complete
prescription e.g. name of drugs with dosage forms, dosage
schedule & total duration of the treatment.
Step:-V
Given proper information instruction & warning regarding the
treatment given e.g. side effects(ADR), dosage schedule &
dangers/risk of stopping the therapy suddenly.
Step:-VI
Monitor the treatment to check, if the particular treatment has
solved the patient’s problem done either by passive monitoring by
patient itself or active monitoring by physician.

29. WHO –core drug use indicators for RDU
• The drug use indicators would be measured within a defined
geographic or administrative area, either to describe drug use at a
given point in time or to monitor changes over time.
• All of the data needed to measure the core indicators are collected
from medical records or direct observations at individual health
facilities.
• The following are the core drug use indicators which are considered
as the minimum set of measures to be calculated during a single
drug use indicators survey.

30. MARCH -2019 170101 /Chapter-3 /S30
EDUCATION FOR PEACE & PROGRESS
COPY RIGHTS RESERVED
Santhiram College of Pharmacy, Nandyal
WHO -Core drug use indicators
Prescribing indicators
• Average number of drugs per
encounter
• Percentage of drugs prescribed by
generic name
• Percentage of encounters with an
antibiotic prescribed
• Percentage of encounters with an
injection prescribed
• Percentage of drugs prescribed
from essential drugs list or
formulary
Patient care indicators
• Average consultation time
• Average dispensing time
• Percentage of drugs actually
dispensed
• Percentage of drugs adequately
labelled
• Patients know ledge of correct
dosage

31. Facility indicators
Availability of copy of essential drugs list or formulary
Availability of key drugs
Prescribing indicators
Indicator Purpose
Average number of drugs per encounter To measure the degree of poly pharmacy
Percentage of drugs prescribed by generic
name
To measure tendency to prescribe in
generics
Percentage of encounters with an antibiotic
prescribed
To measure the number of antibiotics
prescribed
Percentage of encounters with an injection
prescribed
To measure the number of injections
prescribed
Percentage of drugs prescribed from
essential drugs list or formulary
To measure the tendency to prescribe
drugs as per NEML or NEDL

32. Role of pharmacists in promoting rational use
of medicines
• Pharmacist is a crucial link between patient and other healthcare
professionals.
• The outreach of pharmacist is tremendous, both in hospital
pharmacies as well as in community pharmacies.
• Pharmacists are the first contact with the community for any illness.
• Above all the community by has tremendous faith in pharmacists and
find them easily accessible.

33. • Pharmacists have been recognized as having key role to
play in –
A. Strengthening effective drug management.
B. Overcoming chronic shortages of essential medicines.
C. Combating problems with fake and inferior quality medicines
D. Increasing efforts to educate public to promote compliance with
drug therapy.

34. Roles of pharmacists at different stages of
medication use as below
Prescribing Stage
1. Clarify and verify prescription if not sure or not clear
2. Establish protocols and order sets for special prescriptions
3. Monitor all medication profiles
4. Maintain open communication channels with physicians
5. Educate physicians about dangerous abbreviations

35. 6. Provide input in patients medication regimens
7. Encourage physicians to use protocols and preprinted order forms
8. Support and facilitate implementation of computerized physician
order entry systems
9. Provide disease information by counselling
10. Check the prescription for drug interactions, medication errors
11. Conduct patient interviews and extract valuable information
regarding drug history, drug abuse and drug allergy

36. Dispensing Stage
Before dispensing
• Provide valuable inputs as a Member of Drugs and therapeutic
committee in selecting and preparing EML.
• Help in selection of essential drugs, procurement, maintaining the
inventory control
• Involve in drug proper storage of drugs and removing expired and
deteriorated drugs
• Redesign workflow to achieve efficiency and to facilitate safety
checking

37. During dispensing
• Monitoring the automation dispensing
• Reorganize drug storage and shelving to separate drugs with
similar names
• Make use of computerized clinical information
• Be more vigilant with high-risk medications and high-risk
patients, e.g., establish a system of double-checks
• Communicate clearly with nurses and patients
• Provide proper patient education regarding usage of drugs

38. Transcribing and Administering Stages
• Check whether transcribing is done correctly with out errors
• Ensure that nurses and patients are administering drugs in a proper
way
• Help in calculation of doses for special population
• Support and facilitate use of electronic medication administration
records (MARs)
• Check and compare each patient’s MAR at least daily to ensure that
orders are interpreted correctly and carried out
• Support the use of point-of-care dispensing cabinets.

39. Monitoring Stage
• Follow up laboratory results and/or blood level monitoring
• Screen automatic stop orders for drugs that require reactivation
• Perform daily review of drug profiles to spot potential problems like
adverse reactions and side effects
• Report the adverse effects to pharmacovigilance officials
• Establish rapport and effective communication with nurses

40. Rational Use of Antibiotics
• Antibiotics are the most important weapons in our hands.
• Each one of them have been invented after spending considerable
amount of time, energy and money.
• Therefore, we cannot afford to lose them.
• We must exercise considerable restraint in prescribing antibacterials
and restrict the use of antibacterials to only certain definite
indications.

41. • Indications for antibacterial therapy
1. Definitive therapy: This is for proven bacterial infections.
Antibiotics (read antibacterials) are drugs to tackle bacteria and
hence should be restricted for the treatment of bacterial infections
only.
2. Empirical therapy: Empirical antibacterial therapy should be
restricted to critical cases, when time is inadequate for identification
and isolation of the bacteria and reasonably strong doubt of bacterial
infection exists. In such situations, drugs that cover the most
probable infective agent/s should be used.

42. Prophylactic therapy: Antimicrobial prophylaxis is administered to
susceptible patients to prevent specific infections that can cause definite
detrimental effect.
• These include antitubercular prophylaxis, anti rheumatic prophylaxis,
anti endocarditis prophylaxis and prophylactic use of antimicrobials in
invasive medical procedures etc.
• In all these situations, only narrow spectrum and specific drugs are
used.
• It should be remembered that there is no single prophylaxis to 'prevent
all' possible bacterial infections

43. Rational Use of Injections
• Safe and appropriate use of injections can be achieved by adopting a
three part strategy:
Changing behaviour of health care workers and patients
• Twenty years into the HIV pandemic, knowledge of HIV among
patients and health care workers in some countries has driven
consumer demand for safe injection equipment and irreversibly
improved injection practices.
• With growing knowledge of HCV and HBV, similar patterns of
consumer demand for safe injections should emerge.
• HIV prevention programmes can be expanded to include injection
safety components. .

44. Ensuring availability of equipment and supplies
• Simply increasing the availability of safe injection equipment can
stimulate demand and improve practices.
Managing waste safely and appropriately
• As waste disposal is frequently not an integral part of health planning,
unsafe waste management is common However, when it is
appropriately planned, significant results ensue.
• National health care waste management strategies require a national
policy to manage health care waste, a comprehensive system for
implementation, improved awareness and training of health workers at
all levels, as well as the selection of appropriate options for the local
solutions