Rational Drug Use/Treatment

(RDU/RDT)

Nicolaski Lumbuun dr., SpFK

Clinical Pharmacologist
Faculty of Medicine - UPH
Definition :

The rational use of drugs requires that patients receive

medications appropriate to their clinical needs;
in needs, in doses that meet their own individual
requirements for an adequate period of time, and at the
and at the lowest cost to them and their community.

WHO conference of experts, Nairobi 1985

 Rational pharmacotherapy
The Concept

Rational Drug Treatment (RDU), means :

“prescribing (1)right indication right drug, in

(2)
adequate dose for the (3)sufficient duration
& (4)appropriate to the clinical needs of the
patient at (5)lowest cost
Literature’s Source :
An impression of the situation of teaching pharmacotherapy.
On the left the clinical pharmacology professor on his Clinical Pharmacology Continent
(CPC) is beavering away at his research, quite oblivious to what is happening on the
General Practice Island (GPI) where most of the drugs are prescribed.
Because of his research, the clinical pharmacology professor is also not aware of the
increasing number of students trying in vain to get his attention in order to be taught
therapeutics. The students are seen struggling across the gap towards the real world of
medical practice, ill-prepared for the task facing them, and some do not make it.
(The science education reform movement: Implications for social responsibility Ramsay, 1993)
Drugs Management Cycle
 Aspect of Irrational Drug Use

1. Diagnosis : 2. Prescribing :
 Inadequate examination  Extravagant prescribing
of patient  Over-prescribing
 Incomplete  Incorrect prescribing
communication between 
patient and doctor Under-prescribing
 Lack of documented  Multiple prescribing/ers
medical history
 Inadequate laboratory
resources
 Aspect of Irrational Drug Use

3. Dispensing : 4. Patient adherence :

 Incorrect interpretation  Inadequate verbal
of the prescription instructions
 Retrieval of wrong  Inadequate counseling
ingredients to encourage adherence
 Inaccurate counting,  Inadequate follow-up/
compounding, or support of patients
pouring  Treatments or
 Inadequate labeling instructions that do not
 Unsanitary procedures consider the patient’s
 Packaging beliefs, environment, or
culture
 Poor labeling
 Irrational Drug Use (examples)
1. Polypharmacy
– Use more medicines than are necessary. (e.g. a patient with an
upper respiratory infection receiving prescriptions for antibiotics,
cough remedies, analgesics, and multivitamins)
2. No medicine needed
3. Wrong medicines
– Use medicines that’s not base on indication nor evidence (e.g.
children with diarrhoea receiving loperamide
4. Ineffective medicines and medicines with doubtful
efficacy (uses multivitamin or tonic preparations)
5. Unsafe medicines (uses of anabolic steroids for growth or
appetite stimulation in children or athletes)
 Irrational Drug Use (examples)
6. Underuse of available effective medicines
• ORT prescribed for only a small proportion of children w/ acute diarrhea
• Many people w/ serious mental disorders were not receiving any th/
7. Incorrect use of medicines
• Patients taking antibiotics only one or two days rather than the full course
of therapy.
 Irrational Drug Use (examples)
Common Prescribing drugs that
used irrationally.
– Cyproheptadine : increase appetite in child
– INH (Isoniazid) : increase appetite in child
– Corticosteroids : weight gain in adult & child
– Rifampicin : upper respiratory tract infection
– Phenylpropanolamine / Ephedrine :
decrease appetite & body weight
– Propranolol : performance anxiety (stage
fright)
Irrational Drug Use & Health Problems

 Undertreatment / treatment inadequate

 Overtreatment / drugs overdose (toxicity)
 Drug’s abuse

Undertreatment VS Overtreatment :
In some cases the symptom make you confuse, e.g.:
– Coughing : Patient CHF who receive ACE inhibitor
– Seizure : Patient epilepsy who take anti-epileptic drugs
How you differentiate it ??
Undertreatment / treatment inadequate
 Evaluation :
– Define (specify) the therapeutic objective, determine
time & things to assess in a short time th/ to follow up

 The manual w/ a 6-step model of rational prescribing.

– Step 1: Define/identify the patient’s problem  making D/ and DD/
– Step 2: Specify the therapeutic objective
– Step 3: Choose your standard treatment and verify its suitability
– Step 4: Start treatment
– Step 5: Give information, instructions, and warnings
– Step 6: Monitor (and stop?) treatment
 Nierenberg DW, Melmon KL. Introduction to Clinical Pharmacology and Rational Therapeutics
In: Carruthers SG, Hoffman BB, Melmon KL, Nierenberg DW, eds.
Clinical Pharmacology: Basic Principles in Therapeutic. 4th ed. New york: Mc Graw-Hill 2000:3-62.
 Drug’s Overdose
Type of Drug overdose (inc. adverse drug reaction) :
•Due to medication, e.g. sensitivity to certain drug,
drug’s property, drugs interaction
•Drugs abuse, illicit drugs that used to get high, may
be taken became overdose
•Exposure to chemicals, plants, and other toxic
substances, e.g. OP, CO poisoning & mushroom
poisoning
Early Detection & Identification
 The History taking of consume or intake any substance/s
 The SYMPTOMS of overdose can be fatal wo/ intervention
 The RESPONSE to an Over Dose patient is critical
 Overdose death CAN BE PREVENTED

Who’s At Risk?
 Everyone who uses drugs
 Any period of abstinence (withdrawal)
 Release from prison or jail
 Any major life transition/major disappointment
 Family conflict
 General Symptoms
• can vary, depending on the type of drug (properties, mechanism of action)
• single or combined with another substance

 Awake, but unable to  Throwing-up

talk  Passing out
 Body is very limp  Choking sounds, or a
 Face is very pale gurgling noise
 Pulse is slow, erratic or  Breathing is very slow and
absence shallow, erratic or has
stopped
 Specific Symptom of alcohol over dose
• Determine of Blood Alcohol Concentration/Level (BAC/BAL)
– BAC 0.02-0.03 (=20-30mg/dL)slight euphoria, loss of shyness
– BAC 0.04-0.06  Feeling high (epuhoria) with relaxation, a sensation of
warmth, lowered caution, minor impairment of reasoning and memory
– BAC 0.07-0.09  slight impairment of balance, speech, vision, and
hearing. Reduced judgment and self-control.
– BAC 0.08  being legally intoxicated (binge drinking)
– BAC 0.1-0.125  significant impairment of motor coordination and loss
of judgment, slurred speech, impaired balance, vision
– BAC 0.13-0.15  gross motor impaired, lack of physical control
– BAC 0.25  need assisstence in walking, total mental confusion,
dysphoria, nausea-vomiting.
– BAC 0.3  loss of conciousness followed by coma, >0,4 death due to
respiratory arrest
 Alcohol (ethanol) abuse
• Acute  high amount of ethanol concentration
• Chronic  small to medium amount ingested routinely
Ethanol metabolism Where alcohol metabolism
take place
 Alcohol-Drugs Interactions
• Fact & reality around alcohol
– Some medications—including painkillers and cough, cold, and allergy
remedies—contain ≥1 ingredient that can react with alcohol.
– Certain medicines contain up to 10% alcohol. Cough syrup and
laxatives* may have some of the highest alcohol concentrations.
– Alcohol affects women differently#  higher alcohol blood level
– Older people facing greater risk  slower rate of alcohol metabolism
– Timing is important Alcohol and medicines can interact harmfully
even if they are not taken at the same time.
• https://www.soberlink.com/products-containing-alcohol/
• # https://pubs.niaaa.nih.gov/publications/aa46.htm

Alcohol – Drugs Interactions…… How are the

mechanism?
 Management of Drugs Overdose
 Immediate measures of patient status for in every
case of intoxication regardless of cause, with :
1. Support Vital Functions
2. Identify drug poisoning
3. Reduce the amount of drug in the body
 Principle of the Treatment :
Treat the patient, not the poison", promptly
Supportive therapy essential
Maintain respiration and circulation – primary
Judge progress of intoxication by: Measuring and charting
vital signs and reflexes
 Handling of Toxicant
• 1st Goal - keep concentration of poison as
low as possible by preventing absorption and
increasing elimination

• 2nd Goal - counteract toxicological effects at

effector site, if possible

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Checklist of emergency evaluation and treatment procedures
General Treatment of a Comatose Patient
o There are several general antidotes that are used in the
treatment of comatose patients upon presentation at the
hospital.
o Consider to treat all patients who come into the hospital in
a coma with glucose, insulin and naloxone.
o Use drugs to treat emergent conditions, ie:
 Seizures – anticonvulsants (benzodiazepine; lorazepam, diazepam)
 Cardiac Dysrhythmias – anti-arrhythmias (amiodarone, lidocaine)
 Severe Agitation – anxiolytics (short acting benzodiazepine)

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 Removal of the Drug (Emesis)
• Utilize syrup of Ipecac to Induce
emesis to remove unabsorbed drug.
• Emesis inducers
– Mechanical by stroking posterior
pharynx
– Apomorphine parenteral
– Syrup of ipecac 30 ml (1 oz) followed by
one glass of water (150-200 ml)
– Contraindications?

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 Contraindications of Emesis

• Emesis is contraindicated in cases of:

• Petroleum hydrocarbon solvent – chemical pneumonitis
• Caustic acid or alkali agent (rupture)
• Seizing Patient
• Comatose Patient

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 Removal of the Drug
(Gastric Lavage)
• Gastric Lavage – washing of the
stomach. (early tx.)

• A tube is inserted through the

nose or mouth, down the
esophagus, and into the stomach.
Sometimes a topical anesthetic
may be applied to minimize
irritation and gagging as the tube
is being placed.

• Stomach contents can be removed

using suction immediately or after
irrigating w/ fluids through the
tube.

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 Activated Charcoal/Cathartics
• Activated Charcoal (AC)
• Used to bind compounds and to prevent absorption in the GI
tracts. (many drugs)
• Contraindicated with caustic agents and petroleum distillates
due to the lack of adsorption of these agents by the charcoal
and risk of vomiting associated with the charcoal
• use of charcoal & ipecac concurrently not recommended

• Cathartics
• Promotes rapid passage of poison through the GI tract
• Counteracts the constipative effects of AC
• I.E. sorbitol, Mg Citrate, Mg Sulfate

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 Removal of the Drug (Other)
• Alteration of pH of urine – to enhance excretion of the drug, useful for
salicylates, chlorpropamide, etc
• Diuresis – often used in conjunction with urine pH alteration
• Dilution with water – useful in the treatment of skin or eye exposure to
harmful agents. ( no neutralizers)
• Demulcents – soothes mucous membranes and coats the stomach, i.e.
milk of magnesia
• Purgation
• Used for ingestion of enteric coated tablets when time after ingestion is
longer than one hour
• Use saline cathartics such as sodium or magnesium sulfate
• Hemodialysis – blood transverses a semipermeable membrane that is
bathed in dialysis solution or dialysate. Drugs or toxins diffuse across
this membrane. (high protein binding drugs)

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 B. Antidotal Treatments
A. Heavy Metals
Chelators (BAL, EDTA) complexes with the metals
making them inert
B. Heparin
Protamine (base) binds to acidic heparin to terminate
its action and is excreted by glomerular filtration.
C. Toxins-
Botulinum Toxin
Most potent poison known, rapidly absorbed and
prevents ACH release from nerve terminals
Tx: ABCs, lavage, emesis, charcoal, Trivalent anti-toxin
Mortality of 70% to 10% with treatment

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• D. Organophosphates
• Pralidoxime is a nucleophillic reagent that ties up the
organophosphates and permits its excretion.

• E. Cyanide
• Binds to cytochrome oxidase, LD50= 2mg/kg
• Causes death in 1 to 15 minutes at high doses.
• Chelator is made in the body, methemoglobin
• Give Amyl Nitrites, Na Nitrite & Na Thiosulphate;
Hydroxocobalamin with O2 and whole blood .

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 DISPOSITION OF THE PATIENT
• All patients w/ potentially serious overdose, observed at least 6-8h
• Signs-symptoms of intoxication can develop during this time (due to
delayed or redistribution of the toxic agent)
• If specific drug levels are determined, obtain repeated serum levels
to be certain (should be decreasing as expected)
• Most patients will need observation ICU, depends on the potential
for serious cardiorespiratory complications.
• Patient w/ suicidal intent must be kept under close observation.
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