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Rational  use  of  the  drug  (RUD)  

Rovina  Ruslami,  dr.,  SpPD,  PhD  
Dept.  of  Pharmacology  &  Therapy,  Faculty  of  Medicine,  UNPAD  
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Aim  of  patient’s  management  (treatment)  

q  To  get  rid  of  their  problems(s)  
q  Complains  (symptoms)  
q  Disorder/disease  

 
Management    

Pathogenesis     Pathophysiology    

causal   symptoms   signs  

Antibiotics   Analgesics   Diuretics  

Surgery     Antihistamine        
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Causal  or  symptomatic  

Non  
Pharmacology    
pharmacology  

Life-­‐style  
The  drugs  
changes  

Surgery  

physiotherapy  

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In  using  drugs  (medications)  

You  have  to  know  the  drugs  you’ll  give  (prescribe)    

to  your  patient  

otherwise  

Create  other  
No  use  
problems  

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otherwise  

Create  other  
No  use  
problems  

Not  solve  the  problem   Antibiotics  

•  Drug  resistance  
Problem  is  still  there  
Adverse  event  
Worsen   •  Toxicity  

Cost  é  
Die    

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Some  examples…  

Incorrect  drug  of  choice  

Incorrect  dose  
•  Too  low  
•  Too  high  

Incorrect  administration  
•  i.v  vs.  i.m;  p.o  vs.  s.l  

Incorrect  information  à  affect  PK/PD  à  inefficiency  

•  Drug  dosing  
•  Drug-­‐drug  interaction  
•  Drug-­‐food  interaction  

Ignoring  (forget)  contra-­‐indication  

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Is  using  the  drug    that  complicated???  

No  

•   Be  rational  
• Use  the  drug  appropriately  
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Talk  about  Rational  Use  of  the  Drug  

(RUD)  

Appropriate  to  their  clinical  needs  in  doses  

Meet  their  own  individual  requirement  

For  adequate  period  of  time  

At  the  lowest  cost  to  them  &  their  community  

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So,  it  has  to  be  

Correct  diagnosis   50%

Appropriate  indication  

Appropriate  drug(s)  
Appropriate  dosage,  admnistration&  duration  of  
treatment  
50%
Appropriate  patient  

Appropriate  information  

Appropriate  evaluation  &  follow-­‐up  

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Appropriate  indica-on  
•  Based  on  medical  reasons  
•  If  pharmacotherapy  is  the  best  alterna-ve    

Appropriate  drug(s)  –  P-­‐drug  concept  

•  Considering  efficacy,  safety,  suitability  and  cost  (ESSC)  

Appropriate  administra-on  
•  If  not  à  ineffec-ve,  harmful  or  uneconomical  treatment  

Rational  prescribing   1/2/13  

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Appropriate  pa-ent  
•  No  contraindica-on  
•  Likelihood  of  AE  is  minimum  

Appropriate  informa-on  
•  As  an  integral  part  of  prescribing  process  
•  To  ensure  their  correct  &  safe  use;  to  ensure  pa-ent  compliance  

Appropriate  evalua-on  &  follow  up  

•  As  important  as  other  aspect,  but  oKen  is  neglected  
•  If  not  à  lead  to  treatment  failure/harmful  (drug-­‐induced  problem)  
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The  drug  use  process  

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Process  of  rational  use  of  the  drug  

(treatment)  

Monitor  (contInue  or  stop)  

Define  patient’s  problem  
treatment  

Specify  therapeutic  objective:  

Give  information,  
-­‐  Symptomatic  
instruction  &  warning  
-­‐  Causative    

Verify  suitability  of  individual  

patient:  from  available  drugs                 Start  the  treatment  
(for  its  E,  S,  S,  C)  

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So,  in  RUD…  

And  remember  specific  

1.  Define  their  problem(s)  
patients  group  

Disease  or  disorder  (Diagnosis)   Pregnancy  

Sign  of  underlying  disease   Lacta-on  

Psychological  or  social  problems   Children  

Side  efect  of  drugs   Elderly  

Polypharmacy   Renal  failure  

Non-­‐adherence  to  treatment   Hepa-c  failure  

Request  for  preven.ve  treatment   Drug  allergy  

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Then…  

2.  Specify  the  Therapeutic   3.  Verify  the  SUITABILITY  the  

Objective  (TO)   P-­‐drugs  

Focus  on  the  real  problem   Ac-ve  substance  &  dosage  form  

WHAT  TO  BE  ACHIEVED  

Standard  dosage  schedule  

Unnecessary  drug  use  L    

Standard  dura-on  of  
Irra-onal  prophylac-c   treatment  
prescribing  L  
For  all  above,  check  the  Effec.veness  
(Indica-on  &  convenience)  and  Safety  (CI,  
Discuss  your  TO  with  the  pa-ent   DDI,  specific  group  of  pts)  

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Process  of  rational  use  of  the  drug  

(treatment)  

Monitor  (cont’  or  stop)  

Define  patient’s  problem  
treatment  

Specify  therapeutic  objective:  

Give  information,  
-­‐  Symptomatic  
instruction  &  warning  
-­‐  Causative    

Verify  suitability  of  individual  

patient:  from  available  drugs                 Start  the  treatment  
(for  its  E,  S,  S,  C)  

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When  you  start  the  treatment…    

q  Write  the  prescription  (prescribing)  

q  Prescription  is  an  instruction  from  prescribers  à  
dispenser  
q  It  has  to  be  clear!!!  
q  Dispenser  could  be    

q  Pharmacist/assistant  
q  Nurse    

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When  giving  prescription…  

q  It  has  to  be  clear  

q  You  need  to  give  information,  instructions  &  warnings  
What  is/are  the  drugs(s)  
For  what  (the  effect)  
Instruc-on:  how  to  take  them  
Possible  SE  
Warnings  
Next  appointment  
EVERY  THING  IS  CLEAR?  
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By  this  step  (no.5)  

q  You  improve  patient’s  adherence  (and  it  is  very  

important!)  

q  R/  a  well-­‐chosen  treatment  

q  Build  a  good  doctor-­‐patient  communication  
(relationship)  
q  Spend  time  to  give  information,  instructions  &  
warning  
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Last  step:  monitor  the  treatment  

Yes,  disease  is   Stop  the  

cured   treatment  

Yes:  reconsider  
Was  it   dosage  OR  drug  
Yes,  but  not   choice  
effec-ve?   Any  SAE?  
yet  complete  
No:  con’t  the  
treatment  
No,  disease  is   VERIFY  ALL  
not  cured   STEPS!!  

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So…  

NOT  ENOUGH  
Understanding  pathogenesis  &  pathophysiology  
Of  the  disease  is  very  fundamental  
Understanding  the  properties  of  the  drugs  will  be  given  
is  also  very  important  
Otherwise  
Irrational  use  of  the  drugs  
(IrUD)  
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IrUD  

Occurs  in  all  

countries,  every   When  we  say  it  IRUD?  
where  

Examples:  
-­‐  No  drug  needed   Why  it’s  happened?  
-­‐  Wrong  drug,  etc  

What  are  the  bad  

impact  of  IRUD?  

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IrUD:  why  it’s  happened?  

Community  
Health  
Patient    
system  

Prescription  
writer   IrUD   Dispenser    

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IrUD:  types  
EXTRAVAGANT  PRESCRIBING  
•  Expensive  &  newer  drugs  instead  of  
•  Less  expensive  &  older  drug  WITH  SAME  EFFICACY  &  SAFETY  

OVER  PRESCRIBING  
•  AB  for  common  cold  
•  Too  long  or  too    large  dose  

INCORRECT  PRESCRIBING  (wrong  drug  /  wrong  D/)  

•  Headache  à  anti  hypertensive  agent  
•  Myalgia  à  steroid  OR  alopurinol  

MULTIPLE  PRESCRIBING  
•  Use  >  1  drugs  for  1  condition/symptom  

UNDER  PRESCRIBING  
•  Insufficient  dosage  

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Bad  impact  of  IrUD  

Efficacy  L  à  treatment  outcome  

Adverse  events  

Bacterial  resistance  

Costly  

Psychosocial  impact  -­‐  traumatize  

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how  to  improve  the  drug  use  then?  

Strategy…  

Educational   n  Patient/community/doctor/drug  dispenser  

 
Managerial     n  Hospital  &  community  à  stewardship  
 
 
Regulation   n  Restrictions    
 
Drug   n  Bulletin,  Drug  Information  System  
information  

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Educational  strategies:  evidence-­‐based  

practice  

Training   •  Formal  /  continuing  education  

•  Supervisory  visit  
prescribers   •  Group  lecturers/seminar/workshop/etc  

Printed   •  Newsletter,  literatures,  journals  

materials   •  Treatment  guidelines,  drug  formularies  

Face-­‐to-­‐face   •  Educational  outreach  

•  Patient  education  
approach   •  Influencing  opinion  leaders  

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Managerial  strategies  

Approach  to  selection,   •  Limited  procurement  list  

procurement  &  
•  RUD  &  feedback,  cost  information  
distribution  

•  Structured  drug  order  forms  

Prescribing  &   •  Standard  diagnostic  &  treatment  guidelines  
dispensing  approach  
•  Course-­‐of-­‐therapy  packaging  

•  price  setting  
Financing   •  capitation-­‐based  budgeting  
•  Universal  coverage  (by  2014)  

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Regulation  strategies  

Drug  registration  

Limited  drug  lists  

Prescribing  restriction  
•  Antibiotic  stewardship  program  

Dispensing  restriction  

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Take  home  message  

q  Understanding  the  nature  of  the  disease  

q  Pathogenesis  
q  Pathophysiology  

q  Understanding  the  profile  of  the  drugs  will  be  used  
q  Prescribing  is  one  of  the  fundamental  element  in  RUD  
q  Use  your  brain  –  knowledge  
 your  heart  –  wisdom  
 all  information  available  –  the  latest  evidence  
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acknowledgement  

q  Prof.  Dr.  Herri  S.  Sastramihardja,  dr.,  SpFK(K)  

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