Rational Prescribing and Deprescribing

Rational Prescribing - Smart Pill Choices

• Rational Use of Drugs (RUD) (WHO): Patients receive medications appropriate to their clinical needs, in doses meeting individual requirements, for an adequate period, at the lowest cost.
• Core principles: Appropriate indication, drug (📌 ESSC: Efficacy, Safety, Suitability, Cost), dosage, duration, patient; cost-effectiveness.
• P-drugs (Personal drugs): First-choice drugs for common conditions, selected via ESSC criteria.
• Benefits: ↑ Quality of care, ↓ costs, ↓ Adverse Drug Reactions (ADRs).

⭐ Key objective of Essential Medicines List (EML): Ensure availability of safe, effective, affordable medicines for priority conditions, promoting rational use.

Prescribing Process - Rx Right Steps

• Ideal Prescription Components:

  • Prescriber & patient details, date
  • Superscription (Rx symbol)
  • Inscription (Drug name, strength, dosage form, quantity)
  • Subscription (Pharmacist instructions)
  • Signatura (Patient instructions)
  • Prescriber signature & registration no.

• Common Prescribing Errors:

  • Incorrect drug, dose, route, frequency, duration.
  • Illegible handwriting, ambiguous abbreviations.
  • Failure to check allergies/interactions.

⭐ Indian Legal Aspects (Scheduled Drugs):

• Schedule H: Prescription only.
• Schedule H1: Stricter; maintain register, specific labeling (e.g., "dangerous to take without medical advice").
• Schedule X: Narcotic/Psychotropic; special license, triplicate Rx, detailed records.

Polypharmacy & Deprescribing - Pill Purge Power

• Polypharmacy: Concurrent use of ≥5 drugs, common in elderly.

  • Prescribing cascade: Adverse Drug Reaction (ADR) misinterpreted as new condition, leading to new drug prescription.
  • Risks: ↑ADRs, drug-drug interactions, non-adherence, ↑healthcare costs, functional decline, cognitive impairment.

• Deprescribing: Systematic process of identifying & discontinuing drugs when harms outweigh benefits.

  • Goals: ↓Pill burden, ↓ADRs, improve Quality of Life (QoL), ↓costs.

• Deprescribing Process:

• Tools for PIMs: Beers Criteria (elderly), STOPP/START criteria, MedStopper.

⭐ High-risk (Beers): Benzodiazepines in elderly → ↑risk of falls, cognitive impairment, dependence.

Special Considerations - Tailored Therapy Tactics

• Elderly: ↓Renal/hepatic function, altered drug sensitivity. ↑ADRs. Use Beers criteria, STOPP/START tools.
• Pregnancy: Assess risk-benefit. Use safest drug, lowest effective dose, shortest duration. Note FDA categories (A,B,C,D,X) & PLLR.

  ⭐ Valproate: High teratogenic risk (e.g., neural tube defects).

• Lactation: Check drug passage into milk (e.g., LactMed). Consider dose, timing, infant age.
• Pediatrics: Dose by mg/kg or Body Surface Area ($BSA$). Different ADME profile; risk of off-label use.
• Renal/Hepatic Impairment: Dose adjustment often needed (e.g., CrCl for renal: $CrCl = \frac{(140-age) \times weight (kg)}{72 \times Serum Creatinine (mg/dL)} (\times 0.85 \text{ if female})$). Avoid specific drugs.

Medication Safety - Error-Proof Elixirs

• ME: Preventable medication error. ADE: Harm from drug (ME or ADR).
• ME Types: Prescribing, dispensing, LASA. Prevent: 📌 5 Rights (P,D,D,R,T), CPOE, Tall Man.
• ADRs: Noxious, unintended.
  • Type A: Dose-dependent, predictable.
  • Type B: Non-dose-dependent, unpredictable.

⭐ Type A: pharmacological, common (insulin hypoglycemia). Type B: immune, rare (penicillin anaphylaxis).

• Pharmacovigilance: Detect, assess, prevent & report ADRs (PvPI).

High‑Yield Points - ⚡ Biggest Takeaways

• Rational prescribing involves the WHO six-step process and the P-drug concept.
• Polypharmacy (≥5 drugs) is a significant risk, particularly in elderly patients.
• Deprescribing reduces medication burden using tools like Beers criteria or STOPP/START.
• Prioritize identifying and managing Adverse Drug Reactions (ADRs); report via pharmacovigilance.
• Medication reconciliation is key at all care transitions to prevent errors.
• Antibiotic stewardship is crucial to combat growing antimicrobial resistance.