Rational use of drugs:

an overview
The rational use of drugs requires that patients receive medications
appropriate to their clinical needs, in doses that meet their own
individual requirements for an adequate period of time, and at the
lowest cost to them and their community.
WHO conference of experts Nairobi 1985

• correct drug
• appropriate indication
• appropriate drug considering efficacy, safety, suitability for the patient, and cost
• appropriate dosage, administration, duration
• no contraindications
• correct dispensing, including appropriate information for patients
• patient adherence to treatment
 Many Factors Influence Use of Medicines
Intrinsic
Prior Knowledge
Scientific
Habits
Information Information

Influence Social &

of Drug Cultural
Industry Factors
Treatment Societal
Workload &
Choices Economic &
Staffing Legal Factors

Workplace Infra- Authority &

structure Relationships Supervision
With Peers
Workgroup
Adverse drug events
Source: Review by White et al,
Pharmacoeconomics, 1999, 15(5):445-458

• 4-6th leading cause of death in the USA

• estimated costs from drug-related morbidity & mortality 30
million-130 billion US$ in the USA
• 4-6% of hospitalisations in the USA & Australia
• commonest, costliest events include bleeding, cardiac
arrhythmia, confusion, diarrhoea, fever, hypotension, itching,
vomiting, rash, renal failure
 5-55% of PHC patients receive injections
- 90% may be medically unnecessary
Source: Quick et al, 1997, Managing Drug Supply
A F R IC A

G ha na

C a m e ro o n

N ige ria

S uda n

T a nza nia

Z im ba bwe

A S IA

Yemen

Indo ne s ia

N e pa l
 15 billion injections per year globally
L.A M E R . & C A R .

E c ua do r  half are with unsterilized needle/syringe

G ua t e m a la

E l S a lv a do r
 2.3-4.7 million infections of hepatitis B/C and
J a m a ic a up to 160,000 infections of HIV per year
E a s t e rn C a ribe a n
associated with injections

0% 10% 20% 30% 40% 50% 60%

% of primary care patients receiving injections
Overuse and misuse of antimicrobials contributes
to antimicrobial resistance
Source: WHO country data 2000-3
• Malaria
• choroquine resistance in 81/92 countries
• Tuberculosis
• 0-17 % primary multi-drug resistance
• HIV/AIDS
• 0-25 % primary resistance to at least one anti-retroviral
• Gonorrhoea
• 5-98 % penicillin resistance in N. gonorrhoeae
• Pneumonia and bacterial meningitis
• 0-70 % penicillin resistance in S. pneumoniae
• Diarrhoea: shigellosis
• 10-90% ampicillin resistance, 5-95% cotrimoxazole resistance
• Hospital infections
• 0-70% S. Aureus resistance to all penicillins & cephalosporins
Strategies to Improve Use of Drugs
Educational: Managerial:
 Inform or persuade  Guide clinical practice
– Health providers – Information systems/STGs
– Consumers – Drug supply / lab capacity

Use of Medicines

Economic: Regulatory:
 Offer incentives  Restrict choices
– Institutions – Market or practice controls
– Providers and patients – Enforcement
 Educational Strategies
Goal: to inform or persuade
• Training for Providers
• Undergraduate education
• Continuing in-service medical education (seminars, workshops)
• Face-to-face persuasive outreach e.g. academic detailing
• Clinical supervision or consultation
• Printed Materials
• Clinical literature and newsletters
• Formularies or therapeutics manuals
• Persuasive print materials
• Media-Based Approaches
• Posters
• Audio tapes, plays
• Radio, television
 Treatment of ARI by prescriber type

80
70
% ARI cases treated

60
50
40
30
20
10
0
Cough syrup use Approp.ABs in Inapprop.ABs in STG compliance
pneumonia viral URTI

Doctor (n=20,18,40,12) Paramedic/nurse (n=13,94,69,61)

THANKS