Question

Q1. Explain briefly The challenges and dilemmas related to prescribing?

Q2. What are the general principles apply in relation to prescribing?

Answer 1

Challenges and Dilemmas related to prescribing :

Education

The provision of teaching in clinical pharmacology and therapeutics is an important part of encouraging balanced prescribing. This applies not only to medical students and doctors, but also to other prescribers, who nowadays, at least in the UK, include pharmacists and nurses. Since an understanding of the pathophysiology of disease and diagnostic methods is important, these matters should form a part of the education of those groups. Prescribers who are not clinically qualified should be encouraged to liaise with clinicians whenever necessary. This is part of the principle , that one should not prescribe outside the limitations of one's knowledge, skills, and experience. Teaching should include instruction on how to read primary literature and guidelines critically.

Several studies have shown that newly qualified doctors in the UK are poorly prepared to be prescribers . In the hope of repairing this deficiency, the Deans of UK Medical Schools have agreed that prescribing abilities should be assessed in the final year of undergraduate training . In conjunction with this, an e-learning program has been developed by the British Pharmacological Society and is to be made available free to all medical students in the UK .

Revalidation of qualified prescribers should include assessment of their prescribing abilities and a set of safety indicators to facilitate this in general practice has been developed .

Information

Clear unambiguous information is an important prerequisite to support balanced prescribing. In the UK this is provided by publications such the BNF and the BNF for Children, which are produced with the UK primarily in mind, but also with an eye to international use .

Guidelines produced by learned societies and national bodies can be useful in directing clinical practice in individual cases. However, there are times when guidelines do not apply and prescribers need to be alert to the needs of the individual patient. For their part, those who produce guidelines need to be aware of this and to tailor their guidelines to allow flexibility. Local medicines and therapeutics committees should have the power to dictate local policy in the light of national guidelines .

Monitoring

Unless drug therapy is carefully monitored during long term treatment, appropriate changes to dosage regimens may not be made and adverse reactions or reduced efficacy can result. However, there is a dearth of satisfactory information on how the long-term effects, beneficial and harmful, of most medications should be monitored and what actions should be taken as a result .

Medication errors

Medication errors are a continuing source of adverse drug reactions and are difficult to eradicate. For example, in one UK study of 124 260 prescriptions in 19 hospitals over 7 days, 11 077 (8.9%) contained errors . The error rates were 8.4% for first year doctors, 10.3% for second year doctors (when they become independent prescribers), 8.3% for those in fixed-term specialty training posts, and 5.9% for consultants. Experience helps, but education is still necessary. Indeed, of the five recommendations that the authors of that report made, four dealt with education. The fifth was that prescribing systems should be improved, such as by the introduction of a uniform prescription chart in all UK hospitals, as has already been done throughout Wales. This has not yet happened, although it has been the subject of a report . A major challenge lies in persuading hospital prescribers that such a chart will be beneficial, of which there is already evidence from studies in Australia , and persuading them that a chart that they themselves have not been involved in designing should be introduced. If electronic prescribing is introduced nationally, a uniform chart will certainly be needed, and the sooner a national printed chart is introduced the better.

General principles apply in relation to prescribing :

1.Be clear about the reasons for prescribing

• Establish an accurate diagnosis whenever possible (although this may often be difficult)
• Be clear in what way the patient is likely to gain from the prescribed medicines (benefits) and what harms may occur from treating or not treating

2. Take into account the patient’s medication history before prescribing

• Obtain an accurate list of current and recent medications (including over-the-counter and alternative medicines) and undertake medication reconciliation
• Obtain a history of prior adverse drug reactions, interactions, and drug allergies and avoid drugs that may cause a recurrence
• This information may come from patients, carers, or other healthcare practitioners
• You can’t know about all interactions, so look them up, for example in the British National Formulary (BNF), which can be downloaded to your phone free if you work for the UK NHS

3. Take into account other factors that might alter the benefits and harms of treatment

• Consider other individual factors that might influence the prescription (e.g. genetic factors, physiological changes with age and pregnancy, or impaired kidney, liver, or heart function)

4. Take into account the patient’s ideas, concerns, and expectations

• Seek to form a partnership with the patient when selecting treatments, making sure that they understand and agree with the reasons for taking the medicine

5. Select effective, safe, and cost-effective medicines individualized for the patient

• Be clear in what way the patient is likely to gain from the prescribed medicines (benefits)
• Be clear about the dual risks of the harms of treatment and the harms from not treating
• These two principles together form the benefit-harm balance (do the likely benefits outweigh the likely harms) and the risk-risk balance (do the likely harms of treating outweigh the likely harms of not treating)
• Whenever possible these judgments should be based on published evidence
• Prescribe licensed medicines for licensed indications
• Do not prescribe medicines “off-label” or outside standard practice unless satisfied that an alternative medicine would not meet the patient’s needs (this decision will be based on evidence and/or experience of the likely benefit-harm balance)
• Do not prescribe unlicensed medicines, except in unusual circumstances
• See Box 3 below for the differences between licensed medicines, unlicensed medicines, and off-label prescribing.
• Choose the best formulation, dose, frequency, route of administration, and duration of treatment
• In most cases, start with a low dose and increase gradually, monitoring the patient’s response
• Occasionally (e.g. glucocorticosteroids, warfarin, amiodarone) a loading dose may be needed

6. Adhere to national guidelines and local formularies where appropriate

• Be aware of guidance produced by respected bodies (increasingly available via decision support systems), but always consider the individual needs of the patient
• Select medicines with regard to costs and needs of other patients (healthcare resources are finite)
• Be able to identify, access, and use reliable and validated sources of information (e.g. the British National Formularies), and evaluate potentially less reliable information critically

7. Write unambiguous legal prescriptions using the correct documentation

• Be aware of common factors that cause medication errors and know how to avoid them

8. Monitor the outcomes of treatment, both beneficial and adverse

• Identify how the beneficial and adverse effects of treatment can be assessed
• Understand how to alter the prescription as a result of this information
• Know how to report suspected adverse drug reactions (in the UK via the Yellow Card scheme)

9. Communicate and document prescribing decisions and the reasons for them

• Communicate clearly with patients, their carers, and colleagues; this will encourage adherence to therapy
• Give patients important information about how to take the medicine, what benefits might arise, adverse reactions (especially those that will require urgent review), and any monitoring that is required
• Warn them about possible adverse drug interactions (e.g. statins with grapefruit juice)
• Use the health record and other means to document prescribing decisions accurately

10. Prescribe within the limitations of your knowledge, skills, and experience

• Always seek to keep the knowledge and skills that are relevant to your practice up to date
• Be prepared to seek the advice and support of suitably qualified professional colleagues
• Make sure that, where appropriate, prescriptions are checked (e.g. calculations of intravenous doses)