Rational Drug Selection

Question 1

The Process of Rational Drug Prescribing

Answer 1

Define the patient's problem
Specify the therapeutic objective
Collaborate with the patient
Choose the treatment
Educate the patient
Monitor effectiveness

Question 2

Define the Patients Problem

Answer 2

Assess the patient
Develop working and differential diagnosis
Use diagnostic tests to confirm

Question 3

Specify the Therapeutic Objective

Answer 3

Goal of treatment
Cure the disease
Relieve symptoms of the disease
Replace deficiencies 
Long-term prevention

Question 4

Collaborate with the patient

Answer 4

The World Health Organization recommends including the patient in developing the therapeutic objectives of drug therapy

Question 5

Choose the Treatment

Answer 5

Use evidence-based guidelines
Individualize for each patient
Consider the pharmacokinetics and pharmacodynamics of the drug
Determine cost-effectiveness
Novice providers use analytical, step-by-step decision making

Question 6

The “I Can Prescribe a Drug” Mnemonic

Answer 6

Indication
Contraindications
Precautions
Cost/Compliance
Efficacy
Adverse effects
Dose/Duration/Direction

Question 7

Start Treatment

Answer 7

Patient usually has prescription filled at pharmacy
When writing a prescription, discuss whether patient has ability to pay for prescription
-Insurance copays
-Generics often less expensive
-$4 retail lists

Question 8

Educate Patient

Answer 8

Poor adherence contributes to worsening disease, hospital admissions, and death
Patient education should be at the 5th or 6th grade level
Include in education:
-Purpose of medication
-Instructions for administration
-Adverse drug reactions

Question 9

Monitor Effectiveness

Answer 9

Passive monitoring: Patient is educated on expected outcome and instructed to contact provider
Active monitoring: Follow-up laboratory tests or monitoring to measure therapeutic effectiveness

Question 10

Drug Factors Influencing Drug Selection

Answer 10

Pharmacokinetic factors
Pharmacodynamic factors
Therapeutic factors
Safety
Cost (to patient and society)
Patient factors
Provider factors

Question 11

Pharmacodynamic Factors

Answer 11

Ease of titration
Therapeutic index
-A narrow therapeutic index is more difficult to manage
-A wide therapeutic index is safer and requires less monitoring

Question 12

Pharmacokinetic Factors

Answer 12

Distribution 
-Ability to cross blood brain barrier
Cytochrome P450 (CYP450) metabolism
Renal elimination
Dose-concentration curve
Half-life

Question 13

Therapeutic Factors

Answer 13

Evidence for therapeutic impact
-Clinical trials
-Clinical practice guidelines
-Systematic reviews
Randomized controlled trials
-Extrapolate with caution
Numbers needed to treat (NNT)
Numbers needed to harm (NNH)

Question 14

Safety

Answer 14

Safety profile is taken into consideration
Safety profile varies by population
-Teratogens
-Liver or renal disease
-Drug allergy
MedWatch Report
U.S. Food and Drug Administration advisories

Question 15

Cost

Answer 15

Cost to patient
-High drug cost outlay by patient may decrease adherence
-Ask about prescription drug coverage
-Consider $4 retail pharmacy list
Cost to society
0Thoughful prescribing considers cost to healthcare system

Question 16

Patient Factors

Answer 16

Previous ADRs
Health beliefs
Current drug therapy
-Drug interactions
-Consult PharmD regarding complex drug regimens
Patient age
Pregnancy

Question 17

Provider Factor

Answer 17

Ease of prescribing or monitoring
Formularies
-NP needs to be familiar with the formularies they are allowed to prescribe
-Personal formulary: Each provider develops a small list of drugs they are comfortable prescribing

Question 18

Influences on Rational Prescribing

Answer 18

Pharmaceutical promotion
-May influence prescribing
Changes in prescribing recommendations
-When guidelines change, providers may need to be coached or reeducated regarding appropriate prescribing