Good prescribing

(Who)

Definisi
A prescription is an instruction from a

don't try to
imitate such
behaviour at this
point in your
training!
prescriber to a dispenser

outlined
Part 1: The process of rational treatment

Kasus : (anda sedang menemai dokter umum

praktik)
Seorang Bapak 52-tahun, sopir taxi, mengeluh

tenggorokan sakit dan batuk-batuk sejak 2 minggu

lalu bersamaan dengan flu.
Bersin-bersin telah berhenti tapi tidak dengan
batuknya, terutama malam hari
Bapak ini perokok berat walaupun sudah sering
diingatkan untuk berhenti
Dalam pemeriksaan fisik lanjutan, tidak ditemukan
hal-hal mencurigakan kecuali inflamasi tenggorokan
Dokter menyarankan untuk menghentikan rokok dan
mulai menulis resep
codeine tablets 15 mg, 1 tablet 3 kali sehari selama 3
hari

Part 1
The process of rational treatment
Step 1:

Part 2: Selecting your P-drugs

i

Criteria for the selection of essential drugs

(WHO)
Priority should be given to drugs of proven efficacy and

safety, in order to meet the needs of the majority of the

people.
Unnecessary duplication of drugs and dosage forms should
be avoided.
Only those drugs for which adequate scientific data are
available from controlled clinical trials and/or
epidemiological studies and for which evidence of
performance in general use in a variety of settings has been
obtained, should be selected.
Newly released products should only be included if they
have distinct advantages over products currently in use.
Each drug must meet adequate standards of quality,
including when necessary bioavailability, and stability under
the anticipated conditions of storage and use.
The international nonproprietary name (INN, generic name)

Criteria for the selection of essential drugs (WHO)

The cost of treatment, and especially the cost/benefit

ratio of a drug or a dosage form, is a major selection

criterion.
Where two or more drugs appear to be similar, preference

should be given to :
(1) drugs which have been most thoroughly investigated;
(2) drugs with the most favourable pharmacokinetic properties;

an
(3) drugs for which reliable local manufacturing facilities exist.
Most essential drugs should be formulated as single

compounds. Fixed-ratio combination products are only

acceptable when the dosage of each ingredient meets the
requirements of a defined population group and when the
combination has a proven advantage over single compounds
administered separately in therapeutic effect, safety,
compliance or cost.

Efficacy, safety and cost

Efficacy: Most prescribers choose drugs on the

grounds of efficacy, while side effects are only

taken into consideration after they have been
encountered.
This means that too many patients are treated
with a drug that is stronger or more
sophisticated than necessary (e.g. the use of
wide spectrum antibiotics for simple infections).
Another problem is that your P-drug may score
favourably on an aspect that is of little clinical
relevance.

Efficacy, safety and cost

Safety: Each drug has side effects, even

your P-drugs.
It is estimated that up to 10% of hospital
admissions are due to adverse drug
reactions. Not all drug induced injury can
be prevented, but much of it is caused by
inappropriate selection or dosage of drugs,
and you can prevent that.
For many side effects, high risk groups can
be distinguished.

Efficacy, safety and cost

Cost: Your ideal choice in terms of efficacy and safety may also be the

most expensive drug, and in case of limited resources this may not be
possible. Sometimes you will have to choose between treating a small
number of patients with a very expensive drug, and treating a
much larger number of patients with a drug which is less ideal
but still acceptable.
The conditions of health insurance and reimbursement schemes may also
have to be considered. The best drug in terms of efficacy and safety may
not (or only partially) be reimbursed; patients may request you to
prescribe the reimbursed drug, rather than the best one. Where free
distribution or reimbursement schemes do not exist, the patient will have
to purchase the drug in a private pharmacy.
When too many drugs are prescribed the patient may only buy some of
them, or insufficient quantities. In these circumstances you should make
sure that you only prescribe drugs that are really necessary, available
and affordable.
You, the prescriber, should decide which drugs are the most
important, not the patient or the pharmacist.

General characteristics of dosage

forms
Systemic dosage forms
oral (mixture, syrup, tablet (coated, slow-release), powder,

capsule)
sublingual (tablet, aerosol)
rectal (suppository, rectiol)
inhalation (gasses, vapour)
injections (subcutaneous, intramuscular, intravenous, infusion)
Local dosage forms
skin (ointment, cream, lotion, paste)
sense organ (eye drops/ointment, ear drops, nose drops)
oral/local (tablets, mixture)
rectal/local (suppository, enema)
vaginal (tablet, ovule, cream)
inhalation/local (aerosol, powder)

General characteristics of dosage

forms
Oral forms
efficacy: (-) uncertain absorption and first-pass metabolism, (+)

gradual effect
safety: (-) low peak values, uncertain absorption, gastric irritation
convenience: (-)? handling (children, elderly)
Sublingual tablets and aerosols
efficacy: (+) act rapidly, no first-pass metabolism
Safety: (-) easy overdose
convenience: (-) aerosol difficult to handle, (+) tablets easy to use

Rectal preparations
efficacy: (-) uncertain absorption, (+) no first-pass metabolism,

rectiol fast effect

safety: (-) local irritation
convenience: (+) in case of nausea, vomiting and problems with
swallowing

General characteristics of dosage

forms
Inhalation gasses and vapours
efficacy: (+) fast effect
safety: (-) local irritation
convenience: (-) need handling by trained staff

Injections
efficacy: (+) fast effect, no first-pass metabolism, accurate

dosage possible
safety: (-) overdose possible, sterility often a problem
convenience: (-) painful, need trained staff, more costly than
oral forms
Topical preparations
efficacy: (+) high concentrations possible, limited systemic

penetration
safety: (-) sensitization in case of antibiotics, (+) few side effects
convenience: (-) some vaginal forms difficult to handle

Part 3: Treating your patients

STEP 1

High risk factors/groups

Pregnancy
Lactation
Children
Elderly
Renal failure
Hepatic failure
History of drug
allergy
Other diseases
Other medication

Relation between ADME

factors and plasma concentration
Plasma concentration curve will drop if:
Absorption is low
Distribution is high
Metabolism is high
Excretion is high

Plasma concentration curve will rise if:

Absorption is high
Distribution is low
Metabolism is low
Excretion is low

MENULIS RESEP
Legal obligation to write clearly

Doctors are legally obliged to write clearly,

as emphasized in the UK Court of Appeal
ruling in the following case. A doctor had
written a prescription for Amoxil tablets
(amoxicillin). The pharmacist misread this
and dispensed Daonil (glibenclamide)
instead. The patient was not a diabetic and
suffered permanent brain damage as a
result of taking the drug.

RESEP MELIPUTI