Appropriate Diagnosis

Prescription based merely on a desire to satisfy the patients psychological need for some time of therapy are often unsatisfactory and may result in adverse effects. To achieve exact diagnosis prescriber has to depend on clinical features and laboratory investigations.

Clinical features is most important criteria e.g. a case of pneumonia in children can easily be diagnosed by respiration rage as well as indwelling chest without the help of the laboratory investigation which are rarely available in remote/rural areas.

Secondly, 35 years old woman with symmetric joint stiffness, pain and inflammation that are worse in the morning should be considered Rheumatic arthritis.

Sometimes laboratory investigation may contribute (confuse?) in making correct diagnosis. This diagnosis and reasoning should be shared with patient. Thus if someone knows the clinical features of disease diagnosis and treats rationally, he thereby saves money, time and labor.

Pathophysiological implication of diagnosis

If the pathophysiology of disorder is well understood, the prescriber is much better condition to select safe, specific and effective therapy. For example, better knowledge of mediator of inflammation has made more effective use of NSAIDs and other agents used for Rheumatoid Arthritis. The patient should be informed about pathophysiology of disease up to a certain level.

Selection of Specific Therapeutic Objective

A therapeutic objective should be chosen for each of the pathophysiological process involved in disease. For example, reduction of inflammatory process for relieving pain in case of rheumatoid arthritis is one of the therapeutic goals. But arresting the course of the disease process in rheumatoid arthritis is a different goal that might lead to consider other drug groups.

Appropriate Indication

The prescriber should know whether drug is actually needed or not. The decision to prescribe drug is entirely based on medical rationale e.g. no drug is necessary for the treatment of viral diarrhea in children caused by rotavirus. However, if a cause of diarrhea is cholera based on epidemiological aspects, diagnosis then antibiotic should be prescribed.

Appropriate drug and Drug of choice

The selection of drug should be based on efficacy, safety, suitability, cost consideration and easy availability. Often more than one group of drugs can serve to achieve the therapeutic goal

Selection of drug of choice from among these groups should be made by considering the patient status and clinical presentation.

For certain drug characteristics, age, other disease and other therapies being taken are extremely important in finalizing the most suitable drug for the management of the present complaint e.g. penicillin sensitive individual should be given other types of antibiotics. Aspirin is contraindicated in children under 12 years of age. Flouroquinolones is contraindicated in pregnant female and children under 12 years of age. Purgative and laxatives are not given in lactating women.

Appropriate Patient

While considering the patient, the prescriber should consider his/her sensitivity to drug, i.e. whether patient is normo-sensitive to drug, Drug is contraindicated or drug may be used cautiously. For example, it is better to avoid, if possible, the use of drugs in pregnancy and lactation. However the drug may be prescribed by weighing the risk – benefit ratio of the mother and fetus. In most cases, drugs should be prescribed where no contraindication exists and possibility of adverse effects is minimum e.g. the anti-emetic should be avoided in pregnancy sickness but in case of hyperemesis gravidarum it becomes inevitable to prescribe anti-emetics.

Appropriate Dose and Dose Regimen

Right dose should be determined for the child, adult and geriatric patient. Dosing regimen is primarily determined by pharmacokinetics of the drug in the patient but history or presence of concomitant diseases such as hepatic or renal impairment must be taken into account. For example, dose of drugs should be reduced in children and elderly patients because of low drug metabolizing capacity due to less function of vital organs. Loading and maintenance doses should be written carefully and patient should be briefed about it. For Digoxin, loading dose is high for therapeutic effect and maintenance dose is low.

The dose adjustments are necessary in case of drugs which are mainly excreted through kidneys of metabolized by liver; the adjustment should be made after assessing renal or hepatic functioning and periodic monitoring of such organs be carried out throughout the chronic therapy. In case of anti-TB therapy the regular liver tests LFTs are required.

Appropriate Route of Administration

The route of administration should be selected after complete assessment of patient condition when oral route is suitable for patient. The parenteral therapy should be avoided because it will be expensive having more adverse effects and irrational**. However, when parenteral therapy is necessary, its cost and adverse effects should not deter the prescriber to recommend.

Appropriate Duration

Duration of therapy should determined by the prescriber and if possible should be mentioned on original prescfiption in case of acute problems. However, sometimes it is not possible to fix the duration of treatment in severe illness and chronic disorders. The route of administration also governs in part the duration of treatment e.g. if oral route is appropriate for a patient, IV route should not be recommendced e.g. in case of cholera, tetracycline should be used for 3 days only. If somebody uses tetracycline for 7-10 days to treat cholera that will be irrational.

Appropriate plan for monitoring drug effectrs and determine an end point for therapy

The prescriber should clearly describe to the patient the kind of anticipated and unexpected results that will be monitored and in what way, including laboratory test and signs report. For disease that need a limited course of therapy e.g. treatment of infections.

The duration of therapy should be made clear so that the patient should not stop therapy prematurely and also does not need refill of the prescription

For patient of rheumatoid arthritis, the need for prolonged, rather indefinite therapy should be explained. The prescriber should specify the changes in patient condition that would call for change in therapy e.g. a patient of rheumatoid arthritis may develop gastrointestinal bleeding and need change in therapy and prompt workup for bleeding. Major toxicities that need immediate attention should be explained to the patient in clear words.

Appropriate program for patient education

The prescriber and other members of healthcare team should be prepared to repeat, extend and reinforce the importance and necessary information transmitted to the patient as often as necessary. The more toxic the drug the greater the importance of this educational program.

Lectures By Dr. Bashir

Courtesy:

Compiled and Shared By: Habib Anwar 

habib.anwar@hotmail.com