Rational Prescribing

Question 1

Parish PA states that prescribing should follow what criteria?

Answer 1

• Necessary.
• Effective.
• Safe.
• Appropriate.
• Economic – a more expensive drug may save money in the long run by preventing hospital admissions.

Question 2

Expand on the concept of necessary prescribing.

Answer 2

Certain conditions are self-limiting and therefore may not need drug treatment to resolve the patient’s condition; treatment may only need to be by lifestyle changes. However, some doctors feel pressure to prescribe medication to end a consultation and get a patient to leave. Diseases themselves may be drug induced.

Question 3

Expand on the concept of effective prescribing.

Answer 3

We should aim to provide evidence-based treatments, basing prescription guidelines off of proper drug trials. The national standard for guidelines is NICE, which is based on proper evidence; there are also local guidelines.

Question 4

Define evidence-based practice.

Answer 4

“the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic
research.”

Question 5

Define number needed to treat (NNT).

Answer 5

NNT expresses the number of people who would need to receive an intervention to prevent one event of interest.

Question 6

Define number needed to harm (NNH).

Answer 6

NNH expresses the number of people who would need to receive an intervention for one person to suffer a harmful event of interest.

Question 7

Give some reliable sources of evidence for rational prescribing.

Answer 7

• NICE (and Technology Appraisals).
• NSF (National Service Framework).
• SIGN (Scottish Intercollegiate Guidelines Network).
• National Specialist Interest groups.
- E.g. Joint Cardiac Societies, British Thoracic Society, National Osteoporosis Society.
• Royal Colleges, e.g. Royal College of Practitioners.

Question 8

Expand on the concept of safe prescribing.

Answer 8

One should assess the side effect profile and other possible implications of using the medicine with that specific patient (see appropriate). CHMP warnings and black triangle status should also be taken into account.

Question 9

Expand on the concept of appropriate prescribing.

Answer 9

The patients intentional and non-intentional compliance issues must be taken into account (ability to take/use, regimen, etc.). One should also consider co-morbidities, hepatic/renal function, and drug interactions.

Question 10

Expand on the concept of economic prescribing.

Answer 10

This is the last, not the first, thing to consider. Rather than cost minimisation, one should look for cost effectiveness; wider than drugs themselves. Careful consideration should be given to premium-price preparations (e.g. MR, isomers, posh delivery modes).

Question 11

What are the advantages of generic prescribing?

Answer 11

• Saves money.
• One name reduces the potential for confusion.
• Guide to the drug’s pharmacology.
• Improves stock control.

Question 12

What are the disadvantages of generic prescribing?

Answer 12

• Patient confidence and confusion because of differing:
o Sizes.
o Shapes.
o Colours.
o Packaging.
• Different excipients can cause ADRs.
• Problems recalling faulty medicines if using subcontractors to manufacture.

Question 13

What drugs should be prescribed by brand?

Answer 13

• Certain drugs with a narrow therapeutic index.
o e.g. lithium, ciclosporin; phenytoin and carbamazepine, theophylline (also MR).
• Certain modified or controlled release drugs.
o e.g. MR diltiazem, nifedipine and mesalazine, transdermal strong opioids.
• Certain administration devices.
o e.g. CFC-free beclomethasone.
• Multiple ingredient products
o e.g. oral contraceptives, emollient creams.
• ‘Biosimilar’ medicines
o e.g. epoetin alfa, epoetin zeta.