Question | Answer |
The Process of Rational Drug Prescribing | Define the patient’s problem/Specify the therapeutic objective/Collaborate with the patient/Choose the treatment/Educate the pt/Monitor effectiveness. |
Define the Patient’s Problem | Assess patient.
Develop working and differential diagnosis.
Use diagnostic tests to confirm. |
Specify the Therapeutic Objective | Goal of treatment: Cure the disease?
Relieve symptoms of disease?
Replacing deficiencies (e.g., insulin)?
Long-term prevention? |
Collaborate With the Patient | The World Health Organization recommends including patient in developing therapeutic objective of drug therapy. |
Choose the Treatment | Use evidence-based guidelines/Individualize for each patient/Novice providers use analytic, step-by-step decision making/Experienced providers use exp & pattern recognition/Use more systematic approach with complex patients. |
The I Can PresCribE A Drug Mnemonic | Indication - Contraindications - Precautions -
Cost/Compliance - Efficacy - Adverse effects -
Dose/Duration/Direction |
Start Treatment | Patient usually fills prescription at pharmacy.
When writing prescription, discuss whether pt has ability to pay for prescrip
Insurance copays/Generics often less expensive
$4 retail lists |
Educate the Patient | Poor adherence contributes to worsening disease, hospital admissions, and death.
Pt ed at the 5th or 6th gr level/Include in ed purpose of medication/Instructions for administration
Adverse drug reactions (ADRs) |
Monitor Effectiveness | Passive monitoring: Pt is ed on expected outcome and instructed to contact provider.
Active monitoring: f/u lab tests or monitoring to measure therapeutic effectiveness |
Drug Factors Influencing Drug Selection | Pharmacokinetic factors/Pharmacodynamic factors
Therapeutic factors/Safety /Cost (to patient and to society)/Patient factors/Provider factors |
Pharmacokinetic Factors | Bioavailability /CYP 450 metabolism/Renal /elimination/Dose-concentration curve /Half-life |
Therapeutic Factors | Evidence for therapeutic impact: Clinical trials/Clinical practice guidelines/Systematic reviews
Randomized controlled trials: Extrapolate with caution |
Safety | Safety profile is taken into consideration/ varies by population: Teratogens/Liver or renal disease/Drug allergy
MedWatch report
U.S. Food and Drug Administration advisories |
Cost | Cost to patient: High drug cost outlay by patient may decrease adherence/Ask about prescription drug coverage/Consider $4 retail pharmacy lists.
Cost to society: Thoughtful prescribing considers cost to health system. |
Patient Factors | Previous ADRs/Health beliefs
Current drug therapy: Drug interactions/Consult PharmD regarding complex drug regimens.
Patient age/Pregnancy |
Provider Factors | Ease of prescribing or monitoring
Formularies: Nurse practitioners need to be familiar with the formulary they are allowed to prescribe.
Personal formulary: Each provider develops a small list of drugs they are comfortable prescribing. |
Influences on Rational Prescribing | Pharmaceutical promotion: May influence prescribing
When prescribing recom change: When guidelines change, providers may need to be coached or reeducated regarding appropriate prescribing. |