Rationale Pharmacotherapy

Dra.Maria Caecilia N.Setiawati H., M.Sc, Apt

STIFAR Yayasan Pharmasi
Semarang

Radiotherapy

Nonpharmcology

Surgery
Alternative therapy

Therapy
approach
Pharmcology

1600 chemical agents

40.000 formulations
100.000 OTC

Drug therapy
Pharmcotherapy

Imunotherapy
Genetherapy

Process of rational drug therapy

Patient Presentation

Presenting
symptoms
Clinical
features
of illness

Process of Rational
Therapeutics

2. Understanding
pathophysiology

1. Making Dx
Patient
expectations

Potential
consequences

3. Reviewing menu
of Rx options
4. Selecting
optimal drug/
dose for patient

6. Making alliance
with patient,
following
endpoints

5. Choosing
endpoints
to follow

Result of
Intervention

Functional Outcome
relief of symptoms
Clinical outcomes
efficacy
toxicity
morbidity
mortality

Patient
satisfaations
Costs
direct
indirect

Penggunaan Obat
Rasional
Tindak lanjut

Diagnosis

Indikasi

jenis obat

TEPAT

Kondisi pasien

Informasi

Dosis, cara & lama pemberian

Faktor yang Mempengaruhi

Farmakoterapi
Information
Scientific
Information

Prior
Knowledge

Intrinsic
Habits

Influence
of Drug
Industry

Social &
Cultural
Factors

Societal
Workload &
Staffing

Workplace

Economic &
Legal Factors

Prescribing
Infrastructure

Relationships
With Peers

Authority &
Supervision

Workgroup

Tantangan
peresepan
Current
best knowledge Tekanan
pasien

Prescribing

Tekanan
industri farmasi

Tekanan
ekonomi
Waktu
terbatas

Individual
Ketidak- preference
tahuan

Problems in Irrational Therapy

Problems with Irrational Pharmacotherapy

The pharmacotherapy process

Problems with Irrational Pharmacotherapy :

Diagnosis
1. Complex diseases or health problems:
Example: A patient has many symptoms, but is embarrassed to
talk about the main one, so the situation does not get addressed

2. Lack of appropriate training skills by prescribers to give

proper diagnosis:
Example: Prescriber does not do a physical exam and prescribes
drugs based solely on oral information provided by the patient

3. Overworked prescribers:
Example: health facility has only one prescriber, and an average
of 300 patients per day to consult

4. Lack of basic diagnostic equipment and tests

Example 1: No microscope or reagents to examine blood & urine
Example 2: No x-ray machine to test a patient suspected of having
tuberculosis

Prescribing
1. Using expensive drugs when equivalent ones are available
Example 1: The antibiotic cefalexin is more expensive than co-trimoxazole in
treating simple infections
Example 2: Ampicillin injection is prescribed when the patient could
take ampicillin tablets, which are cheaper, easy to take, and
involve lower risk of side effects

2. Selecting the wrong drug for the patients illness

Example:
An antidiarrhoeal drug is prescribed when the patient is
dehydrated with simple diarrhoea and only ORS is needed

3. Prescribing several drugs when fewer drugs would

provide the same effect
Example: Sulfadoxine/pyrimethamine and paracetamol are prescribed when
the patient has fever, but not malaria

4. Prescribing drugs when the disease is self limiting and

the patient would get better without taking any drugs
Example: Ampicillin is prescribed when the patient has a simple cold, without
sore throat, cough or fever

Dispensing
1. Wrong interpretation of the prescription:
Example: Ampicillin is prescribed, but amoxicillin is dispensed.

2. Wrong quantity dispensed

Example: Artemether/Lumefantrine is prescribed to be taken four
tablets two times daily for three days (should be a total of 24 tablets),
but the patient only receives 16 tablets, which is sufficient for only 2
days

3. Labelling incorrect or inadequate

Example: Sulphadoxine/pyrimethamine (white tablet) is dispensed, but
the name of the drug is not written on the container label,
meaning that the drug will be unidentifiable once the patient
leaves the pharmacy

4. Incorrect/insufficient dispensing information:

Example: paracetamol 250mg is prescribed for a
child, but
only paracetamol 500mg is
available in the pharmacy. The
higher
dosage pill is given to the childs mother
without
telling her to divide the tablet before giving it to the child

5. Unsanitary practices:
Example: 20 tablets of paracetamol 500mg were
being
counted, when some tablets fell to the floor.
These were picked
up and dispensed to be given to the
patient anyway

Packaging
1. Poor quality of packaging material
Example:

packaging material must protect the drug against the

sun and humidity in order to ensure the integrity and
quality of the dosage form required by the patient

2. Inadequate container size when repackaging the

product
Example:

the size of the packaging material must conform to the

quantity of medication dispensed. In the case of oral
drugs, too large a container could cause break-up of
the items packed within

3. Inadequate labelling and identification of the drug

After the patient leaves the health centre and arrives home, it is very easy
to forget instructions given by the prescriber and dispenser.
At the very minimum, the following information must be written on the
container label:
Name of patient
Date drug was dispensed
Name of the drug
Strength of the drug
Quantity dispensed
Instructions on how to take the drug during the day (example: 1
tablet 4 times daily)
Instructions on how long to take the drug
Comments, instructions or warnings specific to the drug (example,
take with milk, may cause drowsiness)

Poor Compliance
Compliance is the degree to which the patient
carries out the physicians instructions on
how to take the prescribed drug and
treatment.
Many studies about outpatient compliance carried
out in developing countries indicate that only about
50% of patients follow the instructions given by the
physician

Poor Compliance
Causes of poor compliance include:
1. Improper labelling
Neither the name of the patient, nor the name of the
drug is on the container labels when dispensed. If
two or more drugs are dispensed together, the
patent does not know which drug he/she is taking
2. Inadequate instructions:
The instructions on dosage frequency must be
written on the drug label, or the patient could
forget how to take it when he/she arrives home and
becomes involved in other activities

3. Treatment /instructions that do not consider

the socio-economic and cultural aspects of the
patient
Example: In cases where the patient does not know how
to read, proper instructions would include
graphic
symbols of how to take the drug.
For a treatment of three days, for example, you could number the
days 1 to 3, and then below each day, make a mark for each time
the drug must be taken that day

Explanations Poor Compliance :

Lack of knowledge
Influenced by others
Negative attitudes
Own experience
Own perceptions
Difficult/complicated regimen
Extremes of age and need for assistance

Improve Rational Therapy

1. Educational

2. Managerial

Prescribers

Intervention
Type
3. Financial

4. Regulatory

Consumers

Promotion of Rational Drug Use

1. Improve the Consultation Process
Take a complete history of patients illness. Verify the
main reason the patient came to the clinic, all
accompanying symptoms, and the way the problem
developed over time
Perform a physical examination relevant to the
patient's symptoms and medical history
Prescribe drugs and treatment according to Standard
treatment guidelines
Do laboratory exams relevant to complaints. When no
laboratory is available, the prescriber could visually
examine the body fluids for evidence of disease

2. Improve Prescribing Habits

When many drugs are prescribed for a patient, verify that

they are absolutely necessary for treating the diagnosed
condition
Use standard treatment schemes for common illnesses
Verify a second time that the drug is appropriate before
dispensing it to the patient

3. Improve Dispensing Practices:

Recruit and train competent personnel

Organize the dispensing area so it allows for
efficient work flow, can be easily cleaned, and is
secure against theft
Verify the quantity of the drug that is being
dispensed to patient
Give correct and adequate instructions to the
patient
Provide appropriate dispensing tools

4. Improve Compliance:
Label the prescription container adequately
(written or in symbols) before dispensing to
the patient
After giving instructions to the patient about
how to take the drug, ask for feedback to verify
the patients understanding of drug dosage
Consider local beliefs and customs that
influence drug use when prescribing and
dispensing

Summary
Drug therapy involves a great deal more
than matching the name of the drug to the
name of disease;
It requires knowledge, judgment, skill and
wisdom, but above all a sense of
responsibility;
A book can provide knowledge and can
contribute to the formation of judgment,
but it can do little to impart skill and
wisdom, which are the products of
experience and innate and acquired
capacities.

Kearifan (Wisdom)

Pengetahuan yang luas (learned)

Kecerdikan (smartness)
Akal sehat (common sense)
Wawasan (insight)
Sikap hati-hati (prudent)
Pemahaman terhadap norma kebenaran
Kemampuan mencerna (ability to digest)
Penalaran (reasoning)