|
11.
If necessary, alter prescription
The response may be to alter the dose, cease the medication, prescribe
another agent or try alternative non-pharmacological approaches. If
Lionel’s blood pressure does not meet targets, then the dose should be
increased, and eventually a low dose thiazide should be added in.
Using
a P-drug list
Now you may look at this and think it is far too much work for a 10
minute consultation! The important issue is that you only have to go
through the process of choosing the correct drug for diabetic
hypertensives once. You then add the ACE inhibitor that you have chosen
to your P-drug list, and you prescribe it for all of your diabetic
hypertensives from then on, unless there is a particular suitability
issue. The choice takes a bit longer the first time, but it is then
rational, appropriate and evidence based. It also has the benefit of
saving time on future consultations because you know exactly what to
prescribe. Also, when a new drug is being marketed for the treatment of
hypertension, in order for it to become your first line treatment on
your P-drug list, you have to see proof that it is better than the ACE
inhibitor for diabetic patients. The angiotensin receptor antagonists
have been shown recently to improve renal complications in diabetic
patients with underlying nephropathy. However, these studies did not
show a mortality benefit. Hence, you may wish to put an angiotensin
receptor antagonist on your P-drug list for diabetic hypertensive
patients with nephropathy.
BACK
NEXT |
|
Table
1. Characteristics of good and bad prescribing (modified from 4)
|
Good prescribing |
Bad prescribing |
| Effective |
Ineffective |
| Safe |
Unsafe |
| Patient
centered and individualized |
Not
patient centered |
| Acceptable
to patient |
Not
suitable for patient |
| Appropriate
(not too little or too much) |
Inappropriate |
| Addresses
expectations of patient |
Causes
patient distress & harm |
| Judicious
use of resources |
Higher
cost |
| Well
informed (evidence based) |
Poorly
informed |
| Based
on unbiased information |
Based
on biased information |
| Low
vulnerability to outside influences |
Vulnerable to outside influence |
Conclusion
Prescribing is an important behaviour that GPs regularly practice, but
it has previously been poorly taught in medical schools. The WHO has
developed a structured guide to good prescribing and the steps in this
process are easy to learn and apply in day-to-day practice. Central to
this process is the development of a personal formulary (P-drug list)
where a limited number of drugs
are chosen for specific indications
|