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Rational prescription. C H Chen Nov., 2001. Mr. Wong, 65 years old, attended for follow up . Ex-smoker, non drinker Come for medications 2-monthly as usual Good tolerance to med. Apart from on and off dizziness, but no history of syncope Problem lists : HT, IHD, AF, Dizziness.

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Rational prescription l.jpg

Rational prescription

C H Chen

Nov., 2001

Mr wong 65 years old attended for follow up l.jpg
Mr. Wong, 65 years old, attended for follow up

Ex-smoker, non drinker

Come for medications 2-monthly as usual

Good tolerance to med. Apart from on and off dizziness, but no history of syncope

Problem lists : HT, IHD, AF, Dizziness

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Con’t ( case 1 )

  • Drug lists ( total 8 weeks of med.)

  • isordil 10mg tds po

  • Digoxin 0.25mg qd po

  • Adalat retard 40mg bd po

  • Natrilix 2.5mg om po

  • Stemetil 1 tab tds po prn

  • Panadol 500mg qid po prn

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What will you do ? (case 1 )

  • Continue current regime for 8 weeks more ?

  • Any things do you want to know ?

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Case 1

  • BP this time > 102/78

  • Pulse 68 regular

  • Physical exam revealed no sign of acute heart failure, but mild pitting ankle edema only

  • No evidence of GIB, no pallor

  • HS dual , no definite murmur heard

  • Clinically not in distress

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Case 1

  • Previous BP : range from 98 to 180 systolic and 60 to 100 diastolic

  • No ECG available in the old files

  • Digoxin and isordil was prescribed by one of his private physician previously as he was told that he got IHD and arrthymia.

  • Latest elecrolyte in Sept., 1999 > K 3.3 with normal creatinine, corresponding notes reviewed encourage fruit intake.

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Discussion (Case 1 )

  • Blood pressure control

  • Diagnosis of AF and IHD

  • Dizziness

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Good prescribing

  • What do patients want and need?

    • Advice

    • Cure: symptom relief

    • Prognosis

    • Certificates

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4 aims to achieve for prescribers

  • Maximize effectiveness

  • Minimize risks

  • Minimize costs

  • Respect the patient’s choice

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Maximize effectiveness

  • Pharmacological manipulation of the body to improve or remove a condition

  • Use some objective, numerical measurement to assess effect ( eg., BP measurement for BP control )

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Minimize risks

  • Reduce probability of an untoward happening resulting from drug treatment

  • Include transient, minor side effect and adverse drug reaction

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Respect the patient’s choice

  • Ethical/practical choice behind patient

  • Informed choice

  • Ironically, complying with patient’s choice of treatment means poor prescriber

  • Patients are more satisfied if doctors listen to their views, negotiating the details of drug treatment may improves compliance

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  • Effectiveness and risks

  • Cost effectiveness and patient’s choice

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Rational prescribing

  • Correct diagnosis

  • Appropriate drug, dose, route and duration

  • Simple regimen

  • Avoid drugs if therapeutic advantage not supported by independent evidence

  • Avoid drugs with poor risk/benefit ratios

  • Review regularly and terminate if no longer needed

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The most powerful drug: doctor

  • Understanding

  • Explanation

  • Reassurance and prognosis

  • Placebo effect

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Adverse drug reaction (ADR)

  • Generally under-reported

  • A threat to patient’s health and quality of care

  • Generates significant expenses

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  • Unwanted or unintended effects of a medicine which occur during its proper use

  • Extrinsic and intrinsic factors

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  • Extrinsic

  • > Errors in manufacturing, supplying, prescribling, giving or taking medicine

  • Intrinsic

  • > inherent properties of the medicine itself may cause unwanted effects

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Medication related problems

  • Prescription cascade

    • Misinterpretation of an adverse drug event as another medical condition

      Prescription of additional medications

  • Non-adherence

    • poor therapeutic outcomes

      higher dosages or more potent therapies

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  • Survey done at one of the university hospital in Switzerland

  • 6 months of surveying to all primary admissions to medical emergency department

  • Total about 7% of admissions related to ADR

  • Most common being of GIB, follow by febrile neutropenia

  • Anti-cancer drugs in 22.7% of cases

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Anticoagulants, analgesic and non-steroidal anti-inflammatory drugs in 8 % of cases each

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Case 2

  • Mr. Chan, 60 years old, attended for follow up as usual

  • Chronic smoker, social drinker

  • Presented with exertional dysneoa and wheezing

  • Associated with chronic dry cough

  • No recent hospitalization

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Case 2

  • Claimed good drug compliance with regular usage of puffer

  • ET > level ground only

  • Problem list : COAD, HT

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Drugs list

  • Ventolin puff 2 puffs qid prn

  • Atrovent puff 2 puffs qid prn

  • Theodur 100mg tds po

  • Bricanyl durule 7.5mg bd po

  • Ventolin 4mg tds po

  • Inderal 40mg tds po

  • Betaloc 50mg bd po

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Case 2

  • Clinically not in distress with occ. Coughing only

  • Chest occ. Rhonchi with poor expansion of lung and hence poor air entry

  • BP 155/90, P 66 with occ. Ectopic heart beat

  • PFR 130/150

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Discussion (case 2 )

  • Coad control

  • BP control

  • Side effect profiles

  • Alternative choice of agents

  • Treatment other than drugs

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Are Hong Kong doctors over-prescribing?

  • Expenditure on drugs per capita in HK 2-3X that of UK

  • Items prescribed:

    • HK Government OPD:just under 3

    • UK:just over 1

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A pill for every ill??

Random sample of 1068 HK Chinese interviewed by telephone done in 1995

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  • 40% thought illnesses always needed drug treatment

  • 76% expected prescription

  • Almost 100% got prescription in their last consultation

  • 85% prescription > 3 or more drugs

  • < 50% finished all the medication

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  • Younger age and higher education associated with less likelihood of expecting prescription

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  • Chinese do not expect a pill for every ill but doctors prescribe in nearly 100% of consultations

  • Doctors created high expectation for a prescription in every consultation through their own prescribing habit

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The influence of patients’ hopes of receiving a prescription on doctors’ perceptions and the decision to prescribe: a questionnaire survey

BMJ Vol 315 6 Dec 97

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  • Questionnaires to patients waiting to see GP and to doctors immediately after their consultations

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  • 544 unselected patients consulting 15 GP

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  • 67% patient hope for prescription

  • Doctors perceived 56% patients wanted prescriptions

  • 59% doctors prescribed

  • 25% of patients hoped for a prescription did not receive one

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  • Decision to prescribe was closely related to actual and perceived expectations, the latter being more significant

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Over-prescription of antibiotics in primary care

  • 20-50% believed to be unnecessary

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Factors responsible for inappropriate antibiotic use

  • Patient factors

    • Misconception about what antibiotics do

    • Misconception about healing power of antibiotics

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Factors responsible for inappropriate antibiotic use

  • Physician factors

    • Real or perceived patient pressure

    • Economic concern for self e.g. loss of clients

    • Physician fallibility:inadequate knowledge

    • Uncertainty of the diagnosis

    • Easing himself ( something done )

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Factors responsible for inappropriate antibiotic use

  • Other factors

    • Cost saving pressures to substitute therapy for diagnostic test

    • Reduce appointment time per patient

    • Misleading advertisement

    • Cultural factor

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Final comments

  • Do he needs prescriptions

  • Is it indicated

  • Adverse drug reactions

  • Risk and benefits ratio

  • Polypharmacy

  • Always review drug lists

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Review drug regimen

  • All new medication should started as a trial

  • Substitute instead of adding on new medications

  • Look for signs of adverse reactions and drug induced problems

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Improving rational prescription

  • Physician training

    >more training to communicate with patients about risk and benefit

    >training in decision analysis

    >undergraduate/continuing education in therapeutics

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Improving rational prescription

  • Patient education

  • Public need to be educated about the risks and benefits of medical interventions