Introduction of Pharmacotherapy

8/11/2019 Introduction of Pharmacotherapy

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Pharmacotherapy I

By : Lolita


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Component of Assessment

Mid term exam : 30%

Final term exam : 30%

Task : 35% Other component / attendance : 5%


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Main Theme by System

Before mid

Rational Pharmacotherapy (1x) : Mrs. Lolita

Pain and Inflammation (4x) : Mrs. Lolita

Gastrointestinal (2x) : Mrs Woro Supadmi

After mid

Gastrointestinal (4x) : Mrs. Woro Supadmi

Infection (3x) : bacterial, viral, parasite, protozoa :

Mrs Sudewi and Lolita


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Specific Issues

Pain & Inflammation1. Nociceptic & Neuropatic pain : central,

peripheral

2. Headache disorders/cephalgia (migraine,vertigo, tension, cluster, sinus)

3. Joint pain : (osteoarthritis, rheumatoid

arthritis, gout, bursitis)4. Post-operative pain & cancer pain


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Learning Indicator

Patophysiology

Clinical Data Interpretation

Pharmacotherapy Specification of Drug


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ReferencesPrimary :

Dipiro, JT., Hamilton, CW.,Schwinghammer, TL., and Wells,BG, 2000, PharmacotherapyHandbook, McGraw Hill, NewYork.

Greene, RJ and ND Harris, 2000,Patology and Therapeutics forPharmacists : a basic for clinicalpharmacy practice

Secondary :

Lacy C. F., Armstrong L. L.,Goldman M. P., Lance L. L., 2010,Drug Information Handbook, Lexi-Comp Inc., Ohio.


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The Benefit Outcomes

Assist students in understanding the use of the

drug in specific disease

Students are able to choose the right medicine

Students are able to provide drug information (for

example about the side effects of drugs, drug

contraindications, drug interactions with other

drugs or drug interactions with food, and etc)

Students are able to interact with physicians andother medical personnel

Students help patients perform self-medication


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RationalePharmacotherapy


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Pharmacotherapy

Greek : Pharmacon & Therapeia

Pharmacotherapyis the treatment of disease through

the administration of drugs.

Choose a drug based on the types and signs of disease.

Area of pharmacy practice that is responsible for

ensuring the safe, appropriate, and economical use of

drugs in patient care.


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Therapy

Approach

Nonpharmacology

Pharmacology

Pharmacotherapy

Alternative therapy

Radiotherapy

Surgery

Genetherapy

Drug therapy

Imunotherapy

1600 chemical agents40.000 formulations100.000 OTC


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Pharmacotherapy Process

Symtoms/Signs

Diagnose

Treatment Methods

DRUG THERAPY

Drug Selection

Dosage Adjustment

Prescription

Drug Administration

Drug Utilization

Effect

Bad Response Good response


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Rational Drug Therapy

Prescribing and choosing the drug in manner

that maximizes clinical effect (maximizing

efficacy and minimazing toxicity), functional

status, overall patient satisfaction, health

quality of life at the lowest possible total cost.


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The rational use of drugs requires that patients

receive medications 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 their community. correct drug appropriate indication appropriate drug considering efficacy, safety, suitability

for the patient, and cost

appropriate dosage, administration, duration no contraindications correct dispensing, including appropriate information for

patients patient adherence to treatment

WHO conference of experts Nairobi 1985


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Clinical

featuresof illness

Patientexpectations

Potentialconsequences

Presentingsymptoms

2. Understanding

pathophysiology

1. Making Dx

3. Reviewing menuof Rx options

4. Selectingoptimal drug/dose for patient

5. Choosingendpointsto follow

6. Making alliancewith patient,followingendpoints

Clinical

outcomesefficacytoxicitymorbiditymortality

Patient

satisfaations

Costsdirectindirect

Functional Outcomerelief of symptoms

Patient Presentation Process of Rational

Therapeutics

Result of

Intervention

Process of rational drug therapy


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The Purpose of Prescribing

Maximise

effectiveness

Minimise risks

Minimise costs

Respect patients choice

The most effective

The most safest

The most affordable


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The challenge of

prescription

Prescribing

Patient Compulsion

Economic

Pressure

Limited time

Individual

preference

Unknowledge

Pharmaceutical Companies Interference


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Rational Drug Used

Right

Follow upDiagnosis

Indication

Types of drug Information

Dosage, route and frequence

Patient condition


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Why Rational Use ?

Drug explosion

Efforts to prevent the development of

resistance Growing awareness

Increased cost of the treatment

Consumer Protection Act. (CPA)


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% Primary Health Care patients treated

according to guidelines

0

10

20

30

40

50

60

70

1990/1 1992/3 1994/5 1996/7 1998/9 2000/1

Africa Asia

Source: WHO database on drug use 2003


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WHO, Dept. Essential Drugs and Medicines Policy

% drugs that are prescribed unnecessarilyestimated by a comparison of expected versus actual prescription

Chalker HPP 1996, Hogerzeil et al Lancet 1989, Isah et al 2000

010

20

30

40

50

60

70

80

Nepal Yemen Nigeria

% antibiotics % injections % drugs % cost


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5-55% of PHC patients receive injections -

90% may be medically unnecessary

0% 10% 20% 30% 40% 50% 60%

Eastern Caribean

Jamaica

El Salvador

Guatemala

Ecuador

L.AM ER. & CA R.

Nepal

Indonesia

Yem en

ASIA

Zimbabwe

Tanzania

Sudan

Nigeria

Cameroon

Ghana

A FR IC A

% of primary care patients receiving injections

Source: Quick et al, 1997, Managing Drug Supply

15 billion injections per year globally

half are with unsterilized needle/syringe

2.3-4.7 million infections of hepatitis B/C

and up to 160,000 infections of HIV peryear associated with injections


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30 to 60 % of PHC patients receive antibiotics -

perhaps twice what is clinically needed

0% 10% 20% 30% 40% 50% 60% 70%

Guatemala

Jamaica

El Salvador

Eastern Caribean

L.AMER. & CAR.

Bangladesh

Nepal

Indonesia

ASIA

Zimbabwe

Tanzania

Ghana

Cameroon

Swaziland

Sudan

AFRICA

% of PHC patients receiving antibiotics

Source: Quick et al, 1997, Managing Drug Supply


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Prescribing by dispensing and non-dispensing doctors in ZimbabweTrap et al 2000

2.31

28.4

58

8.65

1.67

9.5

48

13

0 10 20 30 40 50 60 70

no.drug items/Px

% Px with injections

% Px with antibiotics

consultation time (mins)

dispensing doctors non-dispensing doctors


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Problems with Irrational Pharmacotherapy :

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

2. Lack of appropriate training skills by prescribers to giveproper diagnosis:Example: Prescriber does not do a physical exam and prescribesdrugs based solely on oral information provided by the patient

Diagnosis

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 testsExample 1: No microscope or reagents to examine blood & urine

Example 2: No x-ray machine to test a patient suspected of having

tuberculosis


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Prescribing

1. Using expensive drugs when equivalent ones are availableExample 1: The antibiotic cefalexin is more expensive than co-trimoxazole in

treating simple infectionsExample 2: Ampicillin injection is prescribed when the patient could

take ampicillin tablets, which are cheaper, easy to take, andinvolve lower risk of side effects

2. Selecting the wrong drug for the patients illnessExample: 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 wouldprovide the same effect

Example: Sulfadoxine/pyrimethamine and paracetamol are prescribed whenthe patient has fever, but not malaria

4. Prescribing drugs when the disease is self limiting andthe patient would get better without taking any drugs

Example: Ampicillin is prescribed when the patient has a simple cold, withoutsore throat, cough or fever


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

2. Wrong quantity dispensedExample: 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 inadequateExample: 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 patientleaves the pharmacy

Dispensing


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4. Incorrect/insufficient dispensing information:

Example: paracetamol 250mg is prescribed for a

child, but only paracetamol 500mg isavailable in the pharmacy. The higherdosage pill is given to the childs motherwithout telling her to divide the tabletbefore giving it to the child

5. Unsanitary practices:

Example: 20 tablets of paracetamol 500mg werebeing counted, when some tablets fell to the floor.These were picked up and dispensed to be given to the

patient anyway


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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 ofthe items packed within


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Poor Compliance

Compliance is the degree to which the patientcarries out the physicians instructions onhow to take the prescribed drug and

treatment.Many studies about outpatient compliance carriedout in developing countries indicate that only about50% of patients follow the instructions given by the

physician


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Poor Compliance

Causes of poor compliance include:

1. Improper labelling

Neither the name of the patient, nor the name of thedrug is on the container labels when dispensed. If

two or more drugs are dispensed together, thepatent 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 couldforget how to take it when he/she arrives home andbecomes involved in other activities


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3. Treatment /instructions that do not consider the

socio-economic and cultural aspects of thepatient

Example: In cases where the patient does not know how

to read, proper instructions would includegraphic 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 eachtime the drug must be taken that day


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Explanations Poor Compliance :

Lack of knowledge

Influenced by others

Negative attitudes

Own experience

Own perceptions

Difficult/complicated regimenExtremes of age and need for assistance


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Consequences in Irrational Therapy


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Public Health and Economic Consequences

Adverse possibil i ty lethal effects, e.g. due to antibiotic

misuse or inappropriate use of drugs in selfmedications

L imited eff icacy, e.g. in the case of under-therapeutic

dosage of antibiotic, tuberculosis or leprosy drugs

Antibiotic resistance, due to widespread overuse of

antibiotics as well as their use in under-therapeutic

dosage

Drug dependence, e.g. due to daily use of pain killersand of tranquilizers

Risk of infection due to improper use of injections:

abscesses, polio, hepatitis and HIV/AIDS


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Adverse drug eventsReview by White et al, Pharmacoeconomics, 1999, 15(5):445-458

4-6th leading cause of death in the USA

Estimated costs from drug-related morbidity &

mortality 30 million-130 billion US$ in the USA

4-6% of hospitalisations in the USA & Australia

commonest, costliest events include bleeding,

cardiac arrhythmia, confusion, diarrhoea, fever,

hypotension, itching, vomiting, rash, renal failure


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Overuse and misuse of antimicrobials contributes

to antimicrobial resistance

Malaria

choroquine resistance in 81/92 countries

Tuberculosis

2 - 40 % primary multi-drug resistance

Gonorrhoea 5 - 98 % penicillin resistance in N. gonorrhoeae

Pneumonia and bacterial meningitis

12 - 55 % penicillin resistance in S. pneumoniae

Diarrhoea: shigellosis

10-90+ % amp, 5-95% TMP/SMZ resistance

Source: DAP, EMC, GTB, CHD (1997)


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Ecomomic consequences

Inappropriate drug use or irrational therapyhave also a impact on household and nationalhealth budgets,

Example :- the use of expensive brand-name product

while cheaper generic drug are available,

- combinations preparation,- multi-drug prescribing


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Improve Rational Therapy


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Educational

InterventionType

Managerial

Financial

Regulatory

Prescribers

Consumers


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3. Managerial Strategies Essential drug list

Kit system distribution

Pre-printed order form

Stock control

Course-of-therapy packaging

Effective package labelling

4. Financial interventions Drugs are sold at a slightly higher price to create a fund for

improving PHC services

Making people pay for drugs could reduce overconsumption

Improve drug supply and cost-sharing

5. Regulatory strategies Banning unsafe drugs

Limiting the import of drugs on the market

I i d / i


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Interventions targeted at consumers/patients

1. Educational materials

Patient education Public education

2. Managerial stategies

Course of therapy packagingBlister packs facilitated patient adherence to

leprosy treatment

The use of antimalarial drug packaging resulted

in a significant improvement in patientcompliance


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3. Financial interventions

Community revolving drug funds

4. Regulatory strategies Regulatory strategies are not targeted at

consumers


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Six Key Steps When Practising

Approach Pharmacotherapeutics

1. Making an accurate diagnosis

2. Understanding the pathophysiology of disease

3. Reviewing the menu of pharmacotherapeutic options

4. Selecting patient-spesific drug and dose

5. Selection end point to follow

6. Maintaining a therapeutic alliance with the patient


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Approach to rational therapeutics

1. Knowing the diagnosis with reasonable certainly

i. Problem that lead to empiric therapy

Febrile leukemic patient, now neutropenic

with chemotherapy, who is approptriately

started on broad-spectrum antibiotics.

ii. Inappropriate acceptance of empiric treatment

The rule for treatment of febrile

immunosuppressed patient often are

generalized and applied to other populationof patient who donot cancer, have not

recieved chemotherapy, are not

immunosuppressed and are not neutropenic.


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2. Understanding the pathophysiology of the patients

disease

i. Confusion between syndrome and disease

Hyponatremia (psychogenic polydepsia,

bronchogenic carcinoma, servere lossed of

salt and water, adrenal insufficiency)

ii. Being misled by a name Lupus erythematosus and lupus

anticoagulant

iii. Further advantages of understanding the disease

Proper understanding of disease not onlyleads to appropriate therapeutic plan but also

appropriate preventive measures as well


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3. Understanding the pharmacology of useful

drugsi. Drugs that have no evidence of efficacy

ii. Prescribing drugs because it makes

sense

iii. Factors that perpetuate incorrect

information about drugs

4 O ti i i l ti f d d d


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4. Optimizing selection of drug and dose

The option of not using a drug.

New drug information not provided by the

manufacture Increasing knowledge of drugsadverse effects

Impact of drug costs

Irrational beliefs

Detailing and counterdetailing

Conflicts of interest.5. Selection of appropriate therapeutic end point

Appropriate end points of efficacy

End point reflecting toxicity

The prescription as an experiment

6. The physician-patient relationship

Patient-physician communication can affect the

choice of therapy and its outcome

Attention to rational therapeutics

Guiding Principles of Pharmacotherapy


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Guiding Principles of Pharmacotherapy

1. There should be justified and documented indication for everymedication that is used

2. A medication should be used at the lowest dosage and for the

shorten duration that is likely to achieve the desired outcome.3. When patient is adequated treated with a single dose,

monotherapy is preferred4. Newly approach medication should be used only if there are clear

advantages over older medication.5. Whenever possible, the selection of a medication regimen should

be based upon evidence obtained from controlled clinical trial.6. The timing of drug administration should be considered as a

possible influence on drug efficacy, adverse effects, andinteractions with other drugs and food.

7. A medication regimen should be simplified as much as possible to

enhance patient adherence.8. A patients prescription of illness or the risks and benefits oftherapy may affect adherence and treatment outcome.

9. Careful observation of a patients response to treatment isnecessary to confirm efficacy, prevent, detect, or manage adverseeffect, assess compliance, and determine the need for dosage

adjustment or discontinuation of drug therapy.

Guiding Principles of Pharmacotherapy (cont )


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10. A medication should not be given by injection when givingby mouth would be just as effective and safe.

11. Before medications are used, lifestyle modification shouldbe made, when indicated, to obviate the need for drugtherapy or to enhance pharmacotherapy outcome.

12. Initiation of drug regimen should be done with fullrecognition that a medication may cause a disease, sign,

symptom, syndrome or abnormal laboratory test.13. When a variety of drugs are equally efficacious and equallysafe, the drug that result in the lowest health care cost or ismost convenient for the patient should be chosen.

14. When making a decision about drug therapy for individualpatients, societal effects should be considered.

15. The possible reasons for failure of medication regimeninclude inappropriate drug selection, poor adherence,improper drug dose or interval, misdiagnosis, concurrentillness, interaction with foods or drugs, environmentalfactors, or genetic factors.

Guiding Principles of Pharmacotherapy (cont. .)

Documents

Introduction of Pharmacotherapy