Rational use of Medicine: Irrational use of medicines is a major problem worldwide. 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. The overuse, underuse or misuse of medicines results in wastage of scarce resources and widespread health hazards. Examples of irrational use of medicines include: use of too many medicines per patient ("poly-pharmacy"); inappropriate use of antimicrobials, often in inadequate dosage, for non-bacterial infections; over-use of injections when oral formulations would be more appropriate; failure to prescribe in accordance with clinical guidelines; inappropriate self-medication, often of prescription-only medicines; non-adherence to dosing regimes. Evidence based medicine: Evidence-based medicine (EBM) is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients."The aim of EBM is to integrate the experience of the clinician, the values of the patient, and the best available scientific information to guide decision-making about clinical management. The term was originally used to describe an approach to teaching the practice of medicine and improving decisions by individual physicians about individual patients. Therapeutic drug monitoring: Therapeutic drug monitoring (TDM) is a branch of clinical chemistry and clinical pharmacology that specializes in the measurement of medication levels in blood. Its main focus is on drugs with a narrow therapeutic range, i.e. drugs that can easily be under- or overdosed.

1. Rational Use of Medicine,
Evidence Based Medicine,
TDM
Dr. Jeenal Mistry
Senior resident,
Dept. of Pharmacology,
GMERS Medical College, Navsari.
Date: 16th January 2024

2. OUTLINES
02 03
04
01
Rational Use
of Medicine
Evidence Based
Medicine
Therapeutic
Drug Monitoring
2

3. What is Rational
Use of Medicine?
Key principles Why is it important?
The appropriate use of medicines to optimize patient outcomes
Evidence-based decision
making, patient-centered
approach, and continuous
monitoring
To ensure safe, effective, and cost-efficient healthcare
Rational Use of Medicine

4. RATIONAL USE OF MEDICINE
As per the WHO — ‘rational use of medicines requires that the patients receive
medication 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 to their community’.

5. RATIONAL PRESCRIBING
Appropriate
indication
Appropriate drug
Appropriate
dose, route and
duration
Appropriate
patient
Correct
dispensing
Adequate
monitoring
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6. FACTORS INFLUENCING PRESCRIBING
01
Knowledge
02
Role models
03
Patient load
04
Attitude
05
Imprecise
diagnosis
06
Drug promotion
and unrealistic
claims
07
Unethical
inducements
08
Patient’s
demands

7. IRRATIONALITIES IN PRESCRIBING
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 Use of drug when none is needed; e.g.antibiotics for viral fevers and nonspecific
diarrhoeas.
 Compulsive coprescription of vitamins/tonics.
 Prescribing ineffective/doubtful efficacy drugs, e.g. antioxidants, cough mixtures,
memory enhancers, oral serratiopeptidase for injuries/swellings, etc.
 Unnecessary use of drug combinations, e.g. ciprofloxacin + tinidazole for any case of
diarrhoea, ampicillin + cloxacillin for staphylococcal infection, routine use of ibuprofen +
paracetamol as analgesic.
 Polypharmacy without regard to drug interactions: each prescription on an average has
3–4 drugs, some may have as many as 10–12 drugs, of which many are combinations.

8. IMPACT OF IRRATIONAL PRESCRIBING
8
 Delay/inability in affording relief/cure of disease.
 More adverse drug effects.
 Prolongation of hospitalization; loss of many days.
 Increased morbidity and mortality.
 Emergence of microbial resistance.
 Financial loss to the patient/community.
 Loss of patient’s confidence in the doctor.
 Lowering of health standards of patients/community.
 Perpetuation of public health problem.

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PROCESS OF RATIONAL PRESCRIBING
Establish a diagnosis (at least provisional). Provide proper information and instructions
about the medication.
Define therapeutic problem(s), e.g. pain,
infection, etc.
Monitor adherence to the medication
(compliance).
Define therapeutic goals to be achieved, e.g.
symptom relief, cure, prevention of
complications, etc.
Monitor the extent to which therapeutic goal is
achieved, e.g. BP lowering, peptic ulcer healing,
etc.
Select the class of drug capable of achieving
each goal.
Modify therapy if needed.
Identify the drug (from the class selected) based
on: Efficacy, Safety, Suitability, Cost
Monitor any adverse drug events that occur, and
modify therapy if needed.
Decide the route, dose, duration of treatment,
considering patient’s condition.

10. INFORMATION/INSTRUCTIONS TO THE PATIENT
EFFECTS OF THE
DRUG
SIDE EFFECTS
INSTRUCTIONS
PRECAUTION/
WARNING
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15. EVIDENCE-BASED MEDICINE
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17. Why EBM is important?
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Information overload and time constraints
Need high quality, filtered information to make informed decisions
Value of scientific knowledge for decision making
Decisions should not be based only on intuition, opinion or unreliable
information

18. THERAPEUTIC
DRUG
MONITORING
18
It Is the use of drug concentration measurements in body fluids as an aid to the
management of drug therapy for the cure, alleviation or prevention of disease.

19. WHY IS IT NECESSARY ?
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 There are a number of drugs for which desired (or toxic) effects cannot readily
be assessed clinically, but are related to the amount of drug in the body.
 Also for some drugs the desired effect (and various unwanted effects) may be
very sensitive to the drug concentration at a given time.
 Logical approach to control the effect of the drug is to limit the amount that is
given to the patient.
Hallworth M, Watson I. Therapeutic Drug Monitoring clinical guide. 4th ed. Illinois: Abbott diagnostics; 2017.

20. DRUGS SUITABLE FOR MONITORING
Narrow
therapeutic
range
Therapeutic
effect can not
be readily
assessed by
clinical
observation
Reasonable relationship between
the drug levels in plasma & the
pharmacological or toxic effects
Large individual
variability in steady
state plasma
concentration exist
at any given dose
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21. When TDM is unnecessary
Wide therapeutic
range
The pharmacological effects
can be clinically quantified
Dosage need not
be individualized
Clinical outcome is
unrelated/ unestablished
to plasma concentration.
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22. CLINICAL SIGNIFICANCE OF TDM
1
2
3
4
5
6
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Maximizes
efficacy
Avoids toxicity
Identifies
therapeutic failure
(Non compliance)
Facilitates
adjustment of
dosage
Facilitates the
therapeutic effect of drug
by achieving target drug
concentration
Identify poisoning,
drug toxicity and drug
abuse

23. EXAMPLES OF DRUGS REQUIRING TDM
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 A- Aminoglycosides (E.g. Gentamicin)
 Drug-Digitalis
 Possessing- Phenytoin (Anti-epileptics)
 Low-Lithium
 Therapeutic-Tricyclic antidepressants
 Index- Immunomodulators (e.g. Cyclosporine)

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