RATIONAL USE OF MEDICINES: CAN WE PROMOTE

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About Authors:
Languluri Reddenna
Department of Pharmacy Practice,
Rajiv Gandhi Institute of Medical Sciences,
Kadapa, Andhra Pradesh, India-516003
reddennapharmd@gmail.com

Abstract
Rational use of drugs can be defined as prescribing the right drug, in sufficient dose for the adequate duration and suitable to the clinical requirements of the patients at least cost. Causes of irrational use comprise not have of knowledge, skills or self-determining information, unhampered accessibility of medicines, overburden of health personnel, unsuitable promotion of medicines and earnings motives from selling medicines. In appropriate drug usecan have dire consequences; it has been associated with hospitalization and evencaused deaths of inpatients in health carefacilities. A variety of situations and circumstancespromote irrational use of medicines. Rational use of medication saves lives, confines undesired toxicity, adverse events and maximize on the benefits that can be imitative from best use of medications. According to surveys conducted in 2004 by HAI Africa and WHO in 11 Sub-Saharan Africa countries in 2004, the average accessibility of the essential medicines in public health facilities was below 70%. Communication between professionals and consumers is essential to the enhancement of rational use of medicines. It is essential to recommence collaboration of physicians and pharmacists concerning accurate and competent drugs prescribing. Governments, private health care institutions, entity health care providers and patients all have an accountability to endorse rational use of medicines. Professionals should provide information to the customers about the name of the medicine, the intention for which the medicine is being taken, dose, frequency of use, and duration of use.

REFERENCE ID: PHARMATUTOR-ART-2140

Introduction
Rational use of drugs can be defined as prescribing the right drug, in sufficient dose for the adequate duration and suitable to the clinical requirements of the patients at least cost.^[1] The thought of rational drug use throughout the earlier period was the premise of diverse national & international gatherings. A variety of studies conducted in urbanized as well as in budding countries during precedent years concerning the safe & effective use of drugs demonstrate that irrational drug use is a comprehensive occurrence & simply fewprescriptions pretext rational use of drugs.^[2] Management with medicines is the majority cost-effective therapeutic interventions recognized and the fraction of nation wide health budget sex hausted on medicines ranges amid 10% and 20% in urbanizedcountries and amid20% and 40% inbudding countries. Over 50% of the entire medicines universal are prescribed, dispensed or sold improperly and 50% of patients not make the grade to take them accurately. Rational drug use attained further consequence currently in terms of therapeutic, socio economical and lawful characteristic. As a result, it is awfully stern with the aim of a lot of medicine is used in animproper and unreason able approach.^[3]

Reasons for irrational use of drugs
1. Be short of information
2. Defective, insufficient training and education of HCPs
3. underprivileged communication between HCPs and patient
4. Not have diagnostic services
5. Insist from the patient
6. Substandard drug supply system and hopeless drug regulation
7. Promotional performance of pharmaceutical industries^[4]

Types of irrational use of medicines
· Polypharmacy
· Inappropriate use of antibiotics
· Excess use of injections
· Not accordance with clinical guidelines
· Self- medication^[5]

People frequently have awfully rational reasonsfor using medicines irrationally. Causes ofirrational use comprise not have of knowledge, skills or self-determining information, unhampered accessibility of medicines, over burden of health personnel, unsuitable promotion of medicines and earnings motives from selling medicines. In the last 20 years progress has been made to promote rational use of medicine. The primary action to correcting irrational use of medicines is to quantify it. On the other hand, rational use of medicines forall medical circumstances is elemental to the prerequisite of wide spread access to satisfactory health care, fulfilment of health-related individual human rights. It is consequently essential that methods taken to progress the rational use of medicines. Since the effort of the precedent 20 years and the confirmation accessible at two international conferences on recuperating the use of medicines (ICIUM 1997 and 2004), greatly is notorious about promotion of rationaluse of medicines. ^[6]

Mainstay interventions to promote rational use of medicines
· A mandated multi-disciplinary nationalized body to organize medicineuse policies
· Clinical guidelines
· Essential medicines lists based on treatments of choice
· Drugs and therapeutics committees in districts and hospitals
· Problem-based pharmacotherapy training in undergraduate programme
· Progressing in-service medical education as a licensure prerequisite
· Control, audit and comment
· Sovereign information on medicines
· Public education about medicines
· Averting of perverse financial incentives
· Suitable and obligatory regulation^[7]

Strategies to promote rational use of medicines

Governments
· Doing a situational investigation
· Assess the impact of programmes in terms ofmedicine use, quality of service and costs
· Means of access with doctors and MPs
· Engage customers and the media
· World Health Organization (WHO) make recommendations to Ministry of Health (MOH)to establish units, with adequate possessions, dedicated promoting rational use of medicines

NGOs
· Campaigner for the benefits of rational use of medicinesfrom public health and financial perspectives
· Comprise a rational use of medicines indicator ineachscheme
· MOH/WHO to organize NGOs in associationwith public, regarding actionspertaining to rational use of medicines

WHO
· Assign personnel in every region with a detailedcommandto work in teamwork with MOHs to endorserational use of medicines
· Maintain countries to launch a division on rational useof medicines within the MOH
· Enterprise advocacy
· Financial statement for actions on rational use of medicines^[8]

1. Measuring the impact/obtaining the evidence: Conducting cost benefit analysis; given thatcost implication of irrational drug use; quantifyingthe drug maltreatment; documenting the expenditure in requisites of encumber ofailment, mortality and morbidity due to irrational use.

2. Formation of alliances: Providefacts to communities on the acquaintances between irrationaldrug use and their lack of access to valuable and safe drugs;incorporate RUM needs in development programmes.

3. CommunicationStrategies: Providing regular updates to the mediaon positive messages for RUM; highlighting consequences ofirrational drug use such as deaths from resistant organisms;naming and shaming activities promoting irrational drug use.

4. Empowerment of consumers: Carrying out simple rational drug useactivities within the communities to ensure step by step learningof RUM; providing communities with information to enablethem and grassroots groups to demand appropriate use of theirmedicines.

5. Providing practical messages: Marketing widely the Swedish model onantibiotic use; replicating and publicising the positive ICIUMoutcomes more widely, sharing successful local experienceswithin the country through support of local WHO offices and/orMinistries of Health.

6. Advocacy and lobbying: Making RUM part of training curriculum;making presentation on RUM at all possible venues; providingpoliticians with data for their deliberations in parliament; providingfactual sheets on RUM to lobbyists.

7. Address at global level: Passing of a strong resolution on RUMat the World Health Assembly, allocating of funds for promotingRUM in the budgets, including RUM as a requirement inagreements, addressing RUM as part of strengthening healthsystems.

8. Address industry power: Providing leadership in addressing excessesof the pharmaceutical industry that lead to irrational drug use;holding industry accountable to their social responsibilities.^[9]

In appropriate use of medicines is aserious concern, especially when it affects the more vulnerable people and occurs for extended durations. In appropriate drug usecan have dire consequences; it has been associated with hospitalization and evencaused deaths of inpatients in health carefacilities. A variety of situations and circumstances promote irrational use of medicines.^[10]

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Self-medication
Self medication may also be facilitated bycertain situations including:
· Poor access to desirable health carebecause of high costs, long distance anddiscriminatory policies;

· Poor regulation and/or implementation of regulations on prescription drugs andpharmacy practices (with profit motives overriding the professional requirements);

· Overzealous advertisements of medications, that make claims of efficacy and scope of use but conceal adverse effects;

· Poorly informed public on matters ofhealth and self-care;

· High burden of diseases, many of themwith overlapping symptoms, e.g. pain, fever, insomnia and depression arecommon symptoms for different conditionswhich require different medication but the correct medicine can only bedetermined by consultating a medicalpractitioner for diagnosis;

· Poverty which puts consultations out ofreach for people who cannot afford to payfor professional health care services.

From a psychological viewpoint, the most general cause of self medication arises from complaints of insomnia or lack of sleep at night. Temporary insomnia which lasts for only a short time may be treated for extended periods of time devoid ofdirection by practisedpersons and this leads to dependence to otherwise superior medicines and gives a ghastly name, not only to the medicines but also to the doctors who advise them. ^[11]

Commonly misused medicines
The most usually used medicationsworld over are analgesics and antibiotics. These medicines are frequentlyused incorrectly because they takenfor the wrong reasons (wrongdrug used to treat exacting symptoms) and used wrongly (taken for inaccurate periodsor in wrong amounts). This mistreatment has unwanted outcomes. The wide spread mistreatment is non-adherence and a lot of patients not succeed to acquirethe full course prescribed. A fewer familiar but escalating dilemma of irrational use of medicines is the use wrongly of cough mixtures containing codeine. It is obvious from the preceding that rational use of medicines is a significant existing concern that has a lot ofchief psychological aspects, distressing professional and lay persons and demands accomplishment by all.^[12]

Rational use of medication saves lives, confines undesired toxicity, adverse events and maximize on the benefits that can be imitative from best use of medications. Patients are optimistic to forever acquire suggestion from a healthcare provider to construe symptoms of an illness and the suitable remedy. Patients must knowledge able about rational drug use through the mass media or through private consultation for maximum gains to bederived from the medications availableto them. Between 25 to 30% of patients who attend primary health care facilitiesdo so because of minor, but common psychiatric disorders. ^[13]

Many of theseconditions are presented to the medical providers as complaints of headache, backache, abdominal and other bodypains. The overwhelmed, overworked and undertrained primaryhealth care provider who does nothave time to delve into the underlyingcause of the symptoms simply takesthe shortcut of the irrational drug useto quickly attend to the high number of patients. Health is an individual accountability. Intriguing care of one’s body andhealth and the health of one’s family should the main concern of every human being. The accountability of personal health has handed over to the healthcare system and the faith is thatdoctors, pharmacists and other healthcare professionals are accountable forhealth. This results in enslavementon health professionals andneglects one’s personal liability ofhealth. One alarming statistic shows that, 300,000 patients arehospitalized yearly inGermany because of illnesses caused by using up of medications. An approximate one third of the world’s population is deficient in regular access to essential medicines with this numeral increasing to over 50% of the population in the poorest parts of Africa and Asia.^[14] The mannercustomers used medicinesis predisposed by a extensive assortment of factorsinclude: knowledge about use, thecost of medicines, regulatory systems, civilizing factors, neighbourhood beliefs, communication between themand prescribers to certifyaccurate useof the drugs, outpatient support, way into intention information on medicines and mercantile endorsement. According to surveys conducted in 2004by HAI Africa and WHO in 11 Sub-SaharanAfrica countries in 2004, the average accessibility of the essential medicines inpublic health facilities was below 70%.This way that many patients who go topublic health facilities for treatment frequentlygo reverse home without attainment the medicinesthey need. Some of these patients have to way out to buying the essential medication from the private segment wherethey are more costly. The troubleis that essential medicines are not reasonableto widely hold of the population.Some segments of the inhabitants have developed a misconception that the expensive medicines aremore effective than the cheaper generic versions. In most developing countries, national drug regulatory agencies do not have enoughqualified personnel, financial resources and equipment. As a result the function of regulating the importation, distribution, promotion, and sale of medicines is not adequate. This has resulted in medicines being dispensed by unqualified personnelin facilities that are not licensed to providethese services. To exacerbate the situation, qualified health professionals are often concentrated in the urban areas. ^[15]

Communication between professionals and consumers is essential to the enhancement of rational use ofmedicines. Professionals should afford the following information to the consumers: the name ofthe medicine, the purpose for whichthe medicine is being taken, dose, frequency of use, and duration of use. The prescribed and dispensed medicines should also be accurately labelled demonstrating the above information. The dearth of qualified health personnelin public health facilities has resultedin insufficient labelling of medications by prescribers and dispensers, and in not enough time spent by them to notify the consumers on how to takethe medicine because the most imperative sources of information for customers about medicines are doctors, followed by the pharmacists, then nurses and other healthcare personnel. Customers particularly in the developing countries are not often consultedon the treatment judgment. With miniatureor no monitoring of drug prescribing, these might have severe implications for suitable drug use and patient care. Besides, the current circumstances shows that self-regulation by the medical profession has disastrous. In the majority of errors deduced professional guidance to pharmacists would help to avoid them. Day to-day tests and normal revision of prescriptions would change the treatment and reduce the risk of adverse reactions which emergeas a result of maltreatment of the preparations. It is essential to recommence collaboration of physicians and pharmacists concerning accurate and competent drugs prescribing. ^[16]

Indicators of rational use of drugs
The mainstay indicators to assess drug usage are,

Prescribing indicators:

1.    Average number of drugs per prescription

2.    Percentage of generic drugs prescribed

3.    Percentage of antibiotics prescribed per prescription

4.    Percentage of injectables prescribed per prescription

5.    Percentage of drugs prescribed from essential medicines list of the hospital/institution.

Patient care indicators:

1.    Average consultation of time

2.    Average dispensing time

3.    Percentage of drugs actually dispensed

4.    Percentage of drugs adequately labelled

5.    Patient’s knowledge of correct dosage

Health facility indicators:

1.    Availability of essential medicines list or formulary

2.    Availability of key drugs for some general health problems.

Steps to advance rational drug prescribing

Step: I
Recognize the patient’s crisis based on symptoms & distinguish the need for action.

Step:-II
Diagnosis of the disease
· Recognize primary cause&fascinating factors.

Step:-III
List out possible intervention or treatment
This includes non pharmacological treatment or drug treatment. Drugmust elected from diverse alternatives basedon efficacy, convenience & safety of drugsincluding, drug inter-actions & high risk group ofpatients.

Step:-IV
Commence the treatment by writing aprecise&comprehensive prescription e.g. name of drugs withdosage forms, dosage schedule & total durationof the treatment.

Step:-V
Specified proper information
· Instruction & caution concerning the treatment given e.g. sideeffects(ADR), dosage schedule & dangers/risk ofstopping the therapy abruptly.

Step:-VI
Supervise the treatment to check, if the exacting treatment has solved the patient’s problem. It maybe:
(a) Passive monitoring – done by the patienthimself. Explain the patient what to do if the treatmentis not efficient or if too many side effect occurs
(b) Active monitoring done by physician and he make an appointment to check the responseof the treatment.^[17-21]

Conclusion
Irrational use of medicines continues to be a severe and extensive community health problem. Governments, private health care institutions, entity health care providersand patients all have an accountability to endorse rational use of medicines. Patients must be well-informed about rational drug use in the course ofthe mass media or through private consultation for greatest gains to beimitative from the medications accessibleto them. Professionals should provide information to the customers about the name of theme dicine, the intention for which the medicine is being taken,dose, frequency of use and duration of use.

References
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