Rational drug prescribing to essential drugs

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a beautiful ppt, illustrating the principles for prescribing, current concepts for clinical decision making, for practicing medicine and health care planning worldwide...

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  • (William Osler, founder of the Association of Physicians of Great Britain and Ireland)
    12 July 1849 – 29 December 1919
    William Osler was born in a remote part of Ontario known as Bond Head. He spent a year at Trinity College in Ontario before deciding on a career in medicine. He attended the Toronto Medical College for two years and in 1872 received his M.D. degree from McGill University in Montreal. Like many of his fellow physicians trained in Canada, Osler went abroad for postgraduate study. He studied in London, Berlin, and Vienna before returning to Canada in 1874 and joining the medical faculty at McGill. A year later he was promoted to professor. Osler was elected a fellow of the British Royal College of Physicians in 1883, one of only two Canadian fellows at that time. In 1884 he left Montreal for Philadelphia to become professor of clinical medicine at the University of Pennsylvania.
    John S. Billings recruited William Osler in 1888 to be physician-in-chief of the soon-to-open Johns Hopkins Hospital and professor of medicine at the planned school of medicine. Osler was the second appointed member of the original four medical faculty, following William H. Welch and preceding Howard A. Kelly and William S. Halsted. He revolutionized the medical curriculum of the United States and Canada, synthesizing the best of the English and German systems. Osler adapted the English system to egalitarian American principles by teaching all medical students at the bedside. He believed that students learned best by doing and clinical instruction should therefore begin with the patient and end with the patient. Books and lectures were supportive tools to this end. The same principles applied to the laboratory, and all students were expected to do some work in the bacteriology laboratory. Osler introduced the German postgraduate training system, instituting one year of general internship followed by several years of residency with increasing clinical responsibilities.
    William Osler’s book, The Principles and Practice of Medicine, first published in 1892, supported his imaginative new curriculum. It was based upon the advances in medical science of the previous fifty years and remained the standard text on clinical medicine for the next forty years.
    Osler, a superb diagnostician and clinician, was greatly esteemed by his peers in this country and abroad. In 1905 he accepted the Regius Professorship of Medicine at Oxford University, at the time the most prestigious medical appointment in the English-speaking world. He left Maryland with warm feelings for Hopkins knowing that his sixteen years spent had laid a solid foundation for the future of Hopkins medical education.
    The greater the ignorance the greater the dogmatism.
    The philosophies of one age have become the absurdities of the next, and the foolishness of yesterday has become the wisdom of tomorrow.
    The natural man has only two primal passions, to get and to beget.
    We can only instill principles, put the student in the right path, give him method, teach him how to study, and early to discern between essentials and non-essentials.
    We are here to add what we can to, not to get what we can from, Life.
    Humanity has but three great enemies: fever, famine, and war; of these by far the greatest, by far the most terrible, is fever.
    The master word [work]... is the open sesame to every portal, the great equalizer in the world, the true philosopher's stone which transmutes all the base metal of humanity into gold.
    My second fixed idea is the uselessness of men above sixty years of age, and the incalculable benefit it would be in commercial, political, and in professional life, if as a matter of course, men stopped work at this age.
    I have three personal ideals. One, to do the day's work well and not to bother about tomorrow...The second ideal has been to act the Golden Rule, as far as in me lay, toward my professional brethren and toward the patients committed to my care. And the third has been to cultivate such a measure of equanimity as would enable me to bear success with humility, the affection of my friends without pride, and to be ready when the day of sorrow and grief came to meet it with the courage befitting a man.
    Medicine is a science of uncertainty and an art of probability. Nothing in life is more wonderful than faith—the one great moving force wh
    ich we can neither weigh in the balance nor test in the crucible.
    No human being is constituted to know the truth, the whole truth, and nothing but the truth; and even the best of men must be content with fragments, with partial glimpses, never the full fruition.
    One of the first duties of the physician is to educate the masses not to take medicine.
    Soap and water and common sense are the best disinfectants.
    The best preparation for tomorrow is to do today's work superbly well.
    The desire to take medicine is perhaps the greatest feature which distinguishes man from animals.
    There are three classes of human beings: men, women and women physicians.
    There is no more difficult art to acquire than the art of observation, and for some men it is quite as difficult to record an observation in brief and plain language.
    If you listen carefully to the patient they will tell you the diagnosis.
    To have striven, to have made the effort, to have been true to certain ideals - this alone is worth the struggle.
    To study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all. (He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.)
    Variability is the law of life, and as no two faces are the same, so no two bodies are alike, and no two individuals react alike and behave alike under the abnormal conditions which we know as disease.
    The trained nurse has become one of the great blessings of humanity, taking a place beside the physician and the priest.
    Live neither in the past nor in the future, but let each day's work absorb your entire energies, and satisfy your widest ambition.
  • Rational drug prescribing to essential drugs

    1. 1. thousands of miles of journey starts with a single step lao tzu
    2. 2. GIVE RELAXED ATTENTION
    3. 3. DRUG ALSO CAN DO …. ∗ HARM- From minor to serious ∗ Sometimes even FATAL…! In One survey on adverse drug events : ∗ 1% ∗ 12% ∗ 30% ∗ 57% fatal life threatening serious significant ∗ HALF of the 2,3rd events were preventable
    4. 4. RATIONAL PRESCRIBING TO ESSENTIAL DRUGS Dr. V.SATHYANARAYANAN M.B.B.S., M.D., PROFESSOR OF PHARMACOLOGY SRM MCH & RC
    5. 5. WHO STRATEGY ∗ Dr J.D. Quick, Director, Essential Drugs and Medicines Policy, ∗ Briefed on the WHO strategy for medicines, ∗ Focuses on
    6. 6. WHO STRATEGY 1. Ready access to essential medicines at affordable prices; 2. quality and safety of such medicines; 3. rational drug use; 4. effective national drug policies.
    7. 7. OUTLINE ∗ ESSENTIAL MEDICINES ∗ RATIONAL (GOOD) PRESCRIBING ∗ RATIONALIZATION OF PRESCRIPTION PRACTISES ∗ P DRUG CONCEPT ∗ PROCESS OF RATIONAL PRESCRIBING
    8. 8. ESSENTIAL MEDICINES
    9. 9. Essential medicines The concept of essential medicines A limited range of carefully selected essential medicines leads to better health care, better drug management, and lower costs Definition of essential medicines Essential medicines are those that satisfy the priority health care needs of the population (Report to WHO Executive Board, January 2002) EDC/Model List 20 Department of Essential Drugs and Medicines Policy
    10. 10. The Essential Medicines Target National list of essential medicines Registered medicines All the drugs in the world Levels of use S CHW dispensary S Health center Hospital Referral hospital Private sector EDC/Model List 21 Department of Essential Drugs and Medicines Policy Supplementary specialist medicines
    11. 11. Relation between treatment guidelines and a list of essential medicines List of common diseases and complaints Treatment choice Treatment guidelines Treatment Training Supervision EDC/Model List 22 List of essential drugs National formulary Supply of drugs Department of Essential Drugs and Medicines Policy
    12. 12. Conclusion WHO clinical guidelines are the foundation for the Model List of Essential Drugs The Model List remains a strong public health tool The WHO Essential Medicines Library is a valuable information base for all Member States, international organisations, drugs and therapeutic committees and health insurance organisations EDC/Model List 23 Department of Essential Drugs and Medicines Policy
    13. 13. RATIONAL PRESCRIBING (GOOD PRESCRIBING)
    14. 14. IMPACT OF IRRATIONAL PRESCRIBING ∗ Delay in cure ∗ More adverse effects ∗ Prolonged hospitalization ∗ Emergence of antimicrobial resistance ∗ Loss of patient’s confidence in the doctor ∗ Loss to the patient/community ∗ Lowering of health standards
    15. 15. WHAT IS GOOD PRESCRIBING ? ∗Appropriate drug ∗in the correct dose ∗of an Appropriate formulation ∗At the correct frequency of administration ∗For the correct length of time
    16. 16. GOOD PRESCRIBING INCLUDES.. ∗ not prescribing any drug at all….
    17. 17. GOOD PRESCRIBING REQUIRES: 1. DETAILED KNOWLEDGE OF THE PATHOPHYSIOLOGY OF THE DISEASE of the patient 2. CLINICAL PHARMACOLOGY OF THE DRUGS you are intended to use
    18. 18. PATHOPHYSIOLOGICAL PROCESSES IN A DISEASE
    19. 19. GOOD PRESCRIBING IS NOT SIMPLY MATCHING THE DISEASE AND THE DRUG….…!
    20. 20. INDIVIDUALISE THE THERAPY
    21. 21. TWO HELPFUL CONCEPTS FOR GOOD PRESCRIBING ∗ EVIDENCE BASED MEDICINE ∗ BENEFIT: RISK RATIO
    22. 22. EVIDENCE BASED MEDICINE
    23. 23. Clinical decisions should be based on the best scientific evidence available at the time.
    24. 24. SOURCES FOR EVIDENCES This can be obtained from: ∗Standard text books ( NEWEST EDITION ) ∗Review articles from leading journals ∗Other doctors (lectures, CME etc.) ∗Systematic review of clinical trials (published and unpublished) ∗Websites and Database
    25. 25. EVIDENCE-BASED MEDICINE Therapeutic decisions should be rationally guided by,
    26. 26. Rigorous analysis of the best available evidence
    27. 27. Unbiased analysis
    28. 28. BENEFIT:RISK RATIO IN PRESCRIBING
    29. 29. THE BENEFIT:RISK RATIO IN PRESCRIBING ∗ Benefits to the patient is accompanied by the risk of Adverse effects ∗ Always try to assess the likely Benefit : risk ratio before instituting therapy.
    30. 30. EXAMPLE ∗ Choice of an antibiotic in UTI in a 2 month pregnant woman.
    31. 31. HOW TO CHOOSE A DRUG ?
    32. 32. HOW TO CHOOSE A DRUG ? ∗Ask the following sequence of questions before writing the prescription ∗Is the drug therapy Indicated ?!! ∗Which drug? ∗Which class---which group----which particular drug ∗Which route? ∗Which formulation? ∗What dosage regimen?
    33. 33. WHICH ROUTE OF ADMINISTRATION?
    34. 34. WHAT DOSE ?
    35. 35. WHICH FORMULATION ?
    36. 36. HOW FREQUENTLY?
    37. 37. FOR HOW LONG ?
    38. 38. With experience, the process becomes automatic..
    39. 39. GOOD PRESCRIBING IS TO GIVE: ∗ RIGHT DRUG IN THE RIGHT DOSE ∗ IN THE RIGHT FORMULATION ∗ AT THE RIGHT FREQUENCY ∗ FOR THE RIGHT DURATION
    40. 40. P-DRUG CONCEPT
    41. 41. P-Drug Concept ∗ P-drugs are the drugs you have chosen to prescribe regularly, ∗ with whom you have become familiar. ∗ They are your drugs of choice for given indications ∗ choosing and using only 50-60 drugs only among 1000s 92
    42. 42. 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 93
    43. 43. ADVANTAGES OF USING P DRUGS ∗ more convenient ∗ more confidence ∗ can be able to master easily ∗ drug effects predictable ∗ less chances of unexpected Adverse effects and drug interactions ∗ Less complications / 20 94
    44. 44. ADVANTAGES OF USING P DRUGS / 20 ∗ Possibility of adopting to rational drug use ∗ Less burden on the physicians ∗ Health care delivery is easy ∗ Health care management is simple ∗ Less health care costs 95
    45. 45. P- DRUG Remember that…. A P-drug is a drug that is ready for action! 96
    46. 46. WHO model (Guide to Good Prescribing) Process of Rational Prescribing Define the patient’s problem Specify the Therapeutic objective Verify whether your P-Treatment is suitable for this patient Start the Treatment Give information, instructions and warnings Monitor and stop treatment 14 Feb. 2002 JSPS visit Showa University ARN
    47. 47. WHO model (Guide to Good Prescribing) Process of Rational Prescribing –Rahman’s modification Define the patient’s problem (after careful evaluation) Specify the Therapeutic objective Management Plan (Pharmacological and Non-pharmacological) Choose and verify P-Drug Write Prescription Give information, instructions and warnings Execute Treatment Cont./stop treatment 14 Feb. 2002 Monitor and stop treatment JSPS visit Showa University Review treatment ARN
    48. 48.  Do The right things right (K-action) 5 `rights' of medication:  right patient  right drug  right dose  right route  right frequency 14 Feb. 2002 JSPS visit Showa University ARN
    49. 49. RATIONALIZATION OF PRESCRIPTION PRACTISES
    50. 50. RATIONALIZATION OF PRESCRIPTION PRACTISES / 20 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) 103
    51. 51. 1. 2. 3. 4. 5. 6. 7. 8. PROCESS OF RATIONAL PRESCRIBING Establish a diagnosis Define therapeutic problem and goal Select the right drug by good prescribing Provide proper information Monitor compliance Monitor goal Modify if needed Monitor ADR if occur & modify
    52. 52. INSTRUCTIONS TO THE PATIENT ∗ Effects of the drug ∗ Side effects ∗ Why, How and when instructions ∗ Precautions/ warnings
    53. 53. SUMMARY ∗ Drugs need to be used rationally ∗ Irrational use of drugs may be devastating ∗ There are many challenges in tackling irrational use of drugs ∗ Focus of activities should be at international, national, prescribers and consumers level ∗ P drug concept can be applied widely ∗ Doctors must maintain the noble status of their profession
    54. 54. CONCLUSION It is our duty to provide health care for mankind through rational approach and providing rational management as part of overall rational patient care…...
    55. 55. The good physician treats the disease; The great physician treats the patient who has the disease !
    56. 56. / 20 116
    57. 57. 117 / 20
    58. 58. THANK YOU..
    59. 59. TIMING

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