|
Cost
Cost includes consideration of the cost to the
patient as well as to the community for subsidised drugs. It also needs
to include consideration of costs associated with monitoring, treatment
failure, and side effects.
Suitability
The convenience of a drug is a broad issue based on the drug’s
formulation, frequency of dosing, monitoring requirements, etc. An easy
to swallow once daily tablet is available for most antihypertensives,
but convenience would also be based on the choice of agents that do not
require regular blood tests or other forms of additional monitoring, as
well as the simplicity of dosing, e.g. one dose fits all versus careful
titration to effect. So considering all of these issues we would choose
an ACE inhibitor for Lionel.
5.
Choose a generic drug within a class
Similar considerations of comparative efficacy, safety, cost and
suitability apply, e.g. you may chose to prescribe atenolol instead of
metoprolol because it is less lipophilic and less likely to result in
central nervous system adverse reactions, as well as being a once daily
medication. Among the ACE inhibitors the only difference is that
captopril requires more frequent daily dosing. You may choose to
prescribe ramipril because it was the drug used in the HOPE study.
6.
Individualise dose, formulation, frequency and duration
The only individualisation that would need to be done for Lionel is the
starting dose: a low dose of ACE inhibitor should be chosen and titrated
up slowly because he is already taking celecoxib and the combination can
result in acute renal failure in susceptible patients.11
This would be another good reason to cease the celecoxib.
7.
Verify the suitability of the chosen drug
Most suitability issues are related to safety and common examples are
contraindications, drug allergies, or previous adverse drug reactions.
For ACE inhibitors these are usually rare, e.g. angioedema, bilateral
renal artery stenosis, unilateral renal artery stenosis to single
functional kidney. Other suitability issues include the cost, method of
drug administration, or in the case of children’s antibiotics, the
taste.
BACK
NEXT
|
|
8.
Write a correct prescription
This is the part they tried to teach you in that one hour lecture in
medical school! As you can see, writing the prescription is only a small
part of the whole prescribing process. It is useful to document the
prescription in the case notes with the date, dose and indication to
allow ease of review.
9.
Provide information to the patient
This should include a discussion of the therapeutic goal as well as the
therapeutic approach. Likely adverse reactions should be explained (e.g.
cough with ACE inhibitors) as well as rare but serious reactions (e.g.
angioedema with ACE inhibitors). Unfortunately, there never seems to be
enough time to go over these issues adequately. It is helpful to give
the patient some written information such as the consumers medicines
information or other resource, ask them to read it and write down any
questions for the next review.
10.
Monitor for effects and adverse effects
This aspect of prescribing is often the worst carried out. Every
prescription is really a therapeutic trial, as each patient may or may
not have either efficacy or toxicity with a particular dose. So, if you
don’t monitor the patient, how will you know? Poor prescribing often
results when patients continue to take ineffective costly medication
that may be associated with adverse reactions, or result in a
significant drug-drug or drug-disease interaction without any monitoring
or follow up. No wonder so many patients are noncompliant! You should
also not feel guilty about the need for review. Many cases of
noncompliance and wasted prescriptions are due to patient adverse
reactions or lack of efficacy, and if you can pick these up with
relevant monitoring, both the patient and the health system will thank
you.
In
the case of Lionel he should be brought back for monitoring of his blood
pressure, as well as renal function 1–2 weeks after commencement
of the prescribed drug.
(Continued) ....
|