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Principles Of Making Rational Drug Choices – ‘P’ Drugs

At the start of clinical training most medical students find that they don’t have a very clear idea of how to prescribe a drug for their patients or what information they need to provide. This is usually because their earlier pharmacology training has concentrated more on theory than on practice. The material was probably ‘drug-centred’, and focused on indications and side effects of different drugs. But in clinical practice the reverse approach has to be taken, from the diagnosis to the drug. Moreover, patients vary in age, gender, size and sociocultural characteristics, all of which may affect treatment choices. Patients also have their own perception of appropriate treatment, and should be fully informed partners in therapy. All this is not always taught in medical schools, and the number of hours spent on therapeutics may be low compared to traditional pharmacology teaching.

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Clinical training for undergraduate students often focuses on diagnostic rather than therapeutic skills. Sometimes students are only expected to copy the prescribing behaviour of their clinical teachers, or existing standard treatment guidelines, without explanation as to why certain treatments are chosen. Books may not be much help either. Pharmacology reference works and formularies are drug-centred, and although clinical textbooks and treatment guidelines are disease-centred and provide treatment recommendations, they rarely discuss why these therapies are chosen. Different sources may give contradictory advice.

To aid the process of unversity teaching of drug presciribing, WHO has developed an idea allowing a unified approach to solve therapeutic problems. More than 30 years ago (1994) the first edition of “Guide to good presciribing” was issued by WHO, and this guide is being republished every since.

The P-drug concept of WHO is based on the fact that in their daily practise physicians use a relatively limited number of drugs, depending on the population being served. Most general practicioners use only 40-60 drugs routinely. A primary hospital usually has about 100 drugs or so; a secondary hospital uses an arsenal of about 200 drugs. At any level of the health care system this list reflects the list of the ‘essential medicines’ – another initiative of the WHO.

Thus every young physician need to be able to make his/her own list of drugs that he/she will prescribe mostly in everyday work. This list will be his/her personal or preferred drugs – P drugs.

There are 4 criterias for selecting the P-drugs.

 

Criterias;

Efficacy – 50%

The capability of a drug to show the expected therapeutic effect.. For example, if a patient with arterial hypertension needs to be treated, efficacy will be the drug’s ability to lower blood pressure. If a drug lacks efficacy, it is useless to discuss the other criterias..

Safety – 30%

It is connected with possible adverse drug reactions.

Suitability – 10%

With every patients there are different conditions like age, pregnancy, breastfeeding, co-medication, concomitant diseases etc.

Cost – 10%

It is important for drugs to be available for most of the patients financially. Sometimes its significance might be even greater..

 

Example:

Drug group Efficacy
50%
Safety
30%
Suitability
10%
Cost
10%
Total
Beta-2 antagonist by inhalation 10
(x0.5=5.0)
9
(x0.3=2.7)
9
(x0.1=0.9)
9
(x0.1=0.9)
9.5
Antimuscarinic drugs by inhalation 8
(x0.5=4.0)
9
(x0.3=2.7)
9
(x0.1=0.9)
5
(x0.1=0.5)
8.1
Methylxantines by mouth 8
(x0.5=4.0)
5
(x0.3=1.5)
6
(x0.1=0.6)
9
(x0.1=0.9)
7.0

 

References


WHO “Guide to Good Prescribing” pdf

Clinical Pharmacology Manual For Medical Students
Stefka Valcheva-Kuzmanova, Maria Zhelyazkova-Savova

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Mohammad Saim Al Attar
Mohammad Saim Al Attar
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