Drug prescriptions and polypharmacy:

Overloading patients, order of the day

This article is reproduced from the Daily News of 25.7.1991 at the induction of Dr. B. D. J. de Silva as president of the College of General Practitioners, by the then immediate past president Dr. Leela Karunaratne on July 20. The following are excerpts of an illuminating and thought-provoking address by Dr. Silva to the gathering at the ceremony, whose third month death anniversary falls today.

It has been customary for past Presidents in their addresses to speak to you on various aspects of General Practice. Today I wish to address you on a topic that has interested me from the time I qualified as a doctor: 'Rational Prescribing'.

Rational prescribing has been defined by Silverman as: "Ordering the right drug for the right patient at the right time and in the right amounts with due consideration of cost".

Rational Prescribing is a subject that has been highlighted in the recent past, much has been written about it and it has been the subject of discussion at many meetings and seminars. The reason for this is the enormous increase in recent times of the availability of very potent drugs, for almost every disease.

Both the doctor and the patient have come to feel that every major or minor ailment must have a cure, or some symptomatic relief.

"A pill for every ill."

There is no doubt that pharmaceutical drugs will play a vital role in the alleviation and treatment of diseases in this country together with an effective program to improve housing, sanitation and provision of safe drinking water.

I was introduced to the subject of "Rational Prescribing," though not by this name as early as 1949, when I qualified, that is almost 41 years ago. My very first appointment was to act for Dr. D. J. T. Liyanage's House Officer who was on leave.

At the time in the General Hospital, Colombo, we had only one house officer for each consultant. Although the number of patients were the same as we see today.

I started work at 7.00 a.m., examined all the patients and met Dr. Liyanage at the entrance to the ward at about 8.00 a.m. A few of you would have known Dr. Liyanage.

He was an excellent teacher who had a classic way of teaching physical signs which we could remember to this day.

Dr. Liyanage started his ward rounds and I presented the new patients to him. First patient had fever 3 or 4 days, no physical signs. He agreed and said "give him Mist A.D.T. 1 oz T.D.S." I wrote this on the ticket and passed the ticket on to the sister. The sisters were all European nuns at that time.

The second patient had abdominal pain and vomiting with no physical signs. He agreed and said "give him Mist A.D.T. 1 oz T.D.S." and I passed the ticket over to the sister.

The third patient too, had no physical signs and was given Mist. A.D.T. 1 oz T.D.S. The ticket was handed over to the sister. The sister now whispered into my ear and asked "Doctor, what is Mist A.D.T.?" I shrugged my shoulders and went close to Dr. D. J. T. and asked him: Sir, what is Mist A.D.T.?

'Any Damn Thing'

He laughed and said, "Dr. Silva that is Any Damn Thing" and proceeded to tell me 80% or more of the diseases are S.L.D. (Self Limiting Diseases). The treatment for which is Any Damn Thing. (A.D.T.)

What Dr. D. J. T. said 40 years ago is still in my mind and that I believe is the basis of "Rational Prescribing."

I had a locum doctor in the early years of my practice. One day he asked me, "Doctor, I do locum work in about 5 dispensaries. Each doctor treats simple influenzas in a different way, but all the patients get well, how is that? I had to explain to him that influenza is a S.L.D. and treatment is A.D.T.

A doctor's role should be to watch the patient carefully and see whether the patient develops any complications which would require active treatment.

During my 40 years of practice I have always wondered why some doctors, prescribe so many drugs without knowing exactly what the patient's problems are. I am amazed at the number of potent drugs used to treat patients with undiagnosed illnesses. Voltire had this to say:

"Doctor is a man who pours drugs of which he knows little, for a sickness of which he knows less, into a body of which he knows nothing."

What he said 100 years ago seems to be applicable today. Except that present day doctors may know a little more about the body.

Most G.Ps realise that the first line of treatment is a word in the patient's ear. There is no doubt that the major part of the treatment is the communication between doctor and patient.

The sensitivity of the doctor to the individuality of the patient who feels unwell is the main part of the healing.

Medicines should be prescribed only when they are necessary and essential. The benefit of administering the medicine should be considered in relation to the risk involved. Prescribe as few drugs as possible. Whenever possible use a familiar drug, new drugs and so called magic drugs should be used with caution.

The first duty of the physician is to decide whether or not to use drugs. If drug therapy is needed the most appropriate drugs must be chosen from several alternatives that are available. He should then consider: "Is the drug safe, will it do more harm than good, is there any other way of resolving the patient's problem."

He should then decide on the dose, inter dose interval, route of administration and duration of treatment.

He should take special precautions when prescribing drugs during pregnancy and lactation. Orgonogenesis occurs up to the 50th day of conception. It is therefore prudent to avoid all drugs during this period.

Careful attention must be paid when prescribing for patients with liver and kidney diseases, the elderly and those operating machines or driving vehicles.

Efficacy

Incorrect use of drugs cause a lot of morbidity and mortality. An estimated 3.5% of all hospital admissions in the UK are wholly or largely a result of adverse drug reactions. In some African countries hospital admissions for adverse effect of drugs is as high as 10%.

The aim of rational use of drugs is to promote better and more effective use through consideration for efficacy, safety and cost.

The quality of prescribing is definitely dependent on the physicians knowledge about drugs. It is important for the physician to acquire a good and thorough knowledge of a limited number of well established drugs of proven efficacy. A physician should not use a new drug just because it is novel and extensively promoted.

To promote rational drug use, serious attention must be paid to the regular provision of unbiased authoritative up-to-date and independent information on the efficacy and safety of drugs.

The provision of drug information is a national responsibility. There is a massive increase in recent times in the number of new drugs available. It is thus too much to expect of a busy physician to make a critical judgement on the efficacy and safety of every new drug.

Unfortunately in the absence of a suitable initiative from the government and the medical profession, the pharmaceutical industry has assumed the responsibility of providing the physician with drug information free of cost.

The information so supplied is unsatisfactory as it is product based. The utility of such information is limited because the information is biased in favour of the drug being promoted.

In 1977 the late Prof. Bibile recommended to the Formulary Committee the Amalgamation of the "Sri Lanka Practitioner" journal of the IMPA with the official publication of the National Formulary Committee "The Prescriber."

He suggested that the joint publication be issued free to all doctors. Today we have neither. The state is responsible for ensuring that drugs are available at a reasonable price to the patient. Since public money is involved the state could be accused of failing to carry out its duties if drug costs are ignored.

It is therefore, mandatory that the state regulates drug prices and doctors keep their prescription costs within reasonable limits. The government must be commended for introducing a gazette giving the maximum prices of drugs through the fair trading commission.

This information by itself is inadequate to make doctors prescribe rationally. Measures should be adopted to persuade doctors to prescribe standard preparations and generic preparations and refrain from prescribing preparations of doubtful and unethical character.

Doctors should be given more detailed information about the therapeutic value of new drugs. With this in view the state should provide the doctors with a national formulary.

This should give the doctors the names of standard drugs, therapeutic value, side effects, contraindications, precautions, drugs interactions and dosage.

It is important that regular publications be sent to doctors, containing information mainly during epidemics, giving their prevalence mode of spread and proper management and choice of correct antibiotics.

Moral duty

The prescribing physician is the major contributor to the increasing cost of drug treatment. Many of the drugs prescribed are irrational, unnecessary and even wasteful. Irrational prescribing costs the country millions of rupees.

It is therefore the moral duty of every physician to ensure that the patients under his care are not made to pay for drugs that are too expensive and are not indicated. Due restraint is needed to avoid unnecessary and wasteful prescription of drugs.

In studies conducted in UK it has been found that doctors from India, Pakistan and Sri Lanka are high cost prescribers suggesting that the undergraduate should have a better training in Rational Prescribing.

A visiting G.P. from the Royal College of G.P. observed our G.P.'s working and commented thus:

"Every consultation is accompanied by a prescription for several items. Antibiotics are prescribed so frequently even when not strictly indicated".

For the physician it is important to acquire a good knowledge of a limited number of well established drugs of proven efficacy and safety and use them at the right time for the right patient.

From the 4th-30th November 1990, I saw a total of 3426 patients, only 55 patients needed antibiotics other than Sulphas, Tetracycline and Oral Penicillin which was available at my dispensary. The other antibiotics used were Amphicillin for 35 patients, Cloxacillin for 8, Erythromycin for 7 and Amoxycillin for 5.

Polypharmacy or prescribing multiplicity of drugs for one ailment seems to be a common practice today.

In a study of Sri Lankan mothers who obtained drugs for their children's illnesses more than half of them received four or more kinds of drugs.

Polypharmacy is irrational and should be avoided. It is unlikely that a patient could take more than three drugs without supervision.

Polypharmacy encourages poor diagnosis. It also demonstrates that the physician is not sure of his diagnosis. Polypharmacy will certainly do more harm than good to the patient, now, as well as in the future!