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curriculum.[2] Rai has recommended the inclusion of the ‘P-drug’ Choose an appropriate drug and mention its dosage schedule
concept in the UGPP curriculum.[3]
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and duration of treatment.
The conference of experts on the rational use of drugs,
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convened by the World Health Organization in Nairobi in 1985, Answer
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stated that: “Rational use of drugs requires that patients receive The process of choosing a P-drug can be divided into five
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medications appropriate to their clinical needs, in doses that steps:[4]
meet their own individual requirements for an adequate period 1. Define the diagnosis
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of time, at the lowest cost to them and their community.” This 2. Specify the therapeutic objective
goal can be achieved by acquiring knowledge of the principles 3. Make an inventory of effective groups of drugs
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of rational drug usage during undergraduate training. This 4. Choose an effective group according to criteria
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correspondence emphasizes the importance of this concept. 5. Choose a P-drug
What is a P-drug?[4] Step 1: Define the diagnosis
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latest and the most expensive drug is not necessarily the best,
they produce amoebic abscess and systemic disease. Some
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he / she cannot pass on to others. While physicians can and poor hygienie plays a major role in the spread of the disease;
should draw on expert opinion and consensus guidelines, they avoidance of contaminated food and water as well as proper
should always think for themselves. sanitation can help in prevention of transmission of the disease.
But in this example, we will discuss drug treatment only. Here,
Example for selecting a P-drug for acute amoebic the specific therapeutic objectives would be to treat the signs
dysentery and symptoms, eradicate the disease and prevent transmission
Amoebiasis is one of the common infections encountered of the disease and further complications.
in clinical practice and it is relatively easy to understand the Step 3: Make an inventory of effective groups of drugs
pathophysiology as well as the treatment of amoebiasis. Efficacy is the first criterion for any group of drugs.[4] In this
Therefore, we have selected the example of acute amoebic case, the drugs must have antiamoebic activity. There are five
dysentery and analyzed it in consultation with standard groups with such an effect:
textbooks of pharmacology.[5-8] 1. Nitroimidazoles [e.g, metronidazole, tinidazole,
Nitroimidazoles
! Pharmacodynamics ! Side effects ! Contraindications
Amoebicidal action Relatively frequent, but non-serious in nature Neurological disorders, blood
! Pharmacokinetics Nausea, anorexia, metallic taste, abdominal dyscrasias, 1st trimester of pregnancy,
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Complete absorption from small intestine pain (most common) chronic alcoholism
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Wide distribution Headache, glossitis, dryness of mouth, ! Drug interactions
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Metabolism in the liver transient neutropenia (less frequent) With alcohol, warfarin, lithium,
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Urinary excretion Neurotoxic effects like vertigo, dizziness, phenobarbitone, rifampicin
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Plasma half life (8-29 hours) numbness of extremities (on prolonged use)
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Alkaloids
! Pharmacodynamics ! Side effects ! Contraindications
! Pharmacokinetics
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Potent and directly acting amoebicides Highly toxic
Frequent nausea, vomiting
Presence of cardiac/renal disease,
Pregnancy
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Administration by S.C./I.M. injections, Abdominal cramps, diarrhoea,
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Amide
! Pharmacodynamics ! Side effects
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it is preferably a luminal amoebicide and less Occasional nausea, itching and rarely urticaria
effective in invasive amoebic dysentery
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8-Hydroxyquinolines
! Pharmacodynamics ! Side effects ! Not recommended during pregnancy
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Kill the cysts forming trophozoites in Well tolerable and for children
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Do not have tissue amoebicidal action, not very pruritus Iodism (due to chronic iodine
effective in acute amoebic dysentery overload) Neuropathic syndrome: subacute
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Antibiotics
! Pharmacodynamics ! Side effects ! Should not be used during pregnancy,
1. Tetracyclines: Epigastric pain, nausea, vomiting, diarrhoea lactation and in children
Direct inhibition of amoebae (irritant effets)
only at high concentration Dose related toxicity: Liver and kidney damage,
phototoxicity, adverse effects on teeth
and bones, antianabolic,
Hypersensitivity, Superinfections
2. Paromomycin: ! Side effects
Antiamoebic action Rare with oral doses but include abdominal
pain and cramping, epigastric pain, nausea,
vomiting, steatorrhoea, diarrhoea, rash,
headache
Same risks of nephrotoxicity and ototoxicity
seen with other aminoglycosides
(parenteral route)
S.C.-subcutaneous, I.M.-intramuscular
Table 2
Comparison between drugs within the group of nitroimidazoloes
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selection for a specific condition.[4] Among the five groups, Duration of treatment for acute intestinal amoebiasis is
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nitroimidazoles and alkaloids are very efficacious for acute usually 5-7 days with 400 mg metronidazole.
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amoebic dysentery while the remaining groups are less For this case, metronidazole (oral route) would be the P-drug
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efficacious. The mean effective concentration for most listed in one’s personal formulary, i.e, Tablet metronidazole 400
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susceptible protozoa (≤ 8 µg/ml) is achieved within 0.25-4 mg three times a day for five days followed by Tablet Diloxanide
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hours with a single dose of metronidazole 500 mg. furoate 500 mg three times a day for 10 days.
Safety To conclude, awareness among undergraduates about the
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All drug groups have side effects; alkaloids are highly toxic drugs rational use of drugs can be increased by inclusion of similar
while there is a greater chance of side effects with the antibiotic
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group as compared to the nitroimidazole group. hypertension, acute bronchial asthma, peptic ulcer etc.) in the
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Suitability UGPP curriculum.
This is usually linked to an individual and hence, is not
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considered during compilation of a list of P-drugs.[4] In this D.M. Parmar, S.P. Jadav
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Step 5: Choose a P-drug 2. Bhavsar VH. Experiences regarding modiÞcations of the teaching and evaluation
Choose an active substance and a dosage form pattern in practical pharmacology. Indian J Pharmacol 2004;36:385-6.
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five drugs hardly differ in contraindications and possible drug prescribing: A practical manual. World Health Organization: Geneva; 1994
interactions. However, better tolerability (no nausea, vomiting (WHO/DAP/94.11).
5. Phillips MA, Stanley SL Jr. Chemotherapy of protozoal infections: Amoebiasis,
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6. Tripathi KD. Essentials of medical pharmacology. 5th ed. Jaypee Brothers Medical
active agent. This should be followed by a luminal amoebicide Publishers (P) Ltd: New Delhi, India; 2003.
to prevent carrier state (diloxanide furoate is the rational 7. Rang HP, Dale MM, Ritter JM, Moore PK. Pharmacology. 5th ed. Churchill Liv-
ingstone: Edinburgh; 2003.
choice for this).
8. Sharma HL, Sharma KK. Principles of pharmacology. 1st ed. Paras Medical
Choose a standard dosage schedule Publisher: Hyderabad, India; 2007.
For acute intestinal amoebiasis, metronidazole 400 9. Malik S, editor. Indian drug review. Mediworld Publications Pvt. Ltd: Gurgaon,
mg three times a day is sufficient (plasma half-life of India; 2006.