Therapeutics Process: P-Drugs & P-Treatment

THERAPEUTICS PROCESS
P-Drugs & P-Treatment
Setyawati S Karyono
Pharmacology Department
Faculty of Medicine
Brawijaya University
Example: patient 1 (G to GP)
You sit in with a general practitioner and
observe the following case :
A 52-year old becak-driver complained of a
joint pain. He also told that his stomach got
pain after drinking coffee. The patient is a
heavy smoker who has often been advised to
stop. Further history and examination reveal
nothing special.
• Choosing a treatment and writing a prescription
seems easymore difficult than it seems
• Requires a quite complex process of
professional analysis, knowledge & systematic
thinking
scientific process  clinical process
therapeutic process
The result of treatment optimal/ maximal

 no risk (slight)
Rational Treatment
The process of choosing a treatment
Scientific process
• Problem
• Therapeutic Objective
• Choose treatment
• Start treatment
• Monitor and Evaluation
In that case  first choice treatment
for joint pain
Treatment for suppressing pain

advice & drug therapy /P-drug
P-drugs base on efficacy, safety,
suitability, cost
How & not What to choose treatment

Therapeutics Process = process of
rational treatment
The process of rational treatment
Step 1. Define the patient’s problem

Step 2. Specify the therapeutic objective
What do you want to achieve with the
treatment
Step 3. Verify the suitability of your P-treatment
Check effectiveness and safety
Step 4. Start treatment
Step 5. Give information, instructions and warning
Step 6. Monitor (and stop ?) treatment
1. Define the patient’s problem.
• Disease or disorder
• Sign of underlying disease
• Psychological or social problems, anxiety
• Side effect of drugs
• Refill request (polypharmacy)
• Non-adherence to treatment
• Request for preventive treatment
• Combinations of the above
Patophysiology, manifestation of disease

Related to case?
• Joint pain
• Abdominal discomfort (after drinking
coffee and smoking)
2.Specify the therapeutic objective.
What do you want to achieve with the
treatment
• prevent a lot of unnecessary drug use

• avoid unnecessary prophylactic prescribing
• to discuss your therapeutic objective with
the patient before starting the treatment
pharmacotherapy, non pharmacotherapy,

or combination
Not drugs as a placebo
Related to case?
• Pain disappeared
• Prevent gastric irritation
3.Verify the suitability of your
P-treatment
P-Treatment & P-Drugs
Not all desease need treatment with a drug
P-treatment not always P-drug
• P-Treatmentadvice & information

non drug treatment
drug treatment
referral for treatment
combination of the above
Related to case
• Advice :
– Joint pain : ???
– Gastric irritation :???
 Non drug
 Joint pain: ???
 Gastric irritation: ???
 Drug : ????
 Referral : ???
• How do you manage to choose the
right drug for each patient in a
relatively short time?
By using P-drugs!
Personal Formulary
P-Drugs
• The drugs you have chosen to prescribe
regularly, and with which you have become
familiar. They are your priority choice for given
indications  personal , priority
• Not only the name of drug  dosage form,
dosage schedule, duration of treatment
• Formulary  essential drugs
• Enable you to avoid repeated searches for a
good drug in daily practice
• You must up date your P-drugs evidence base
How to select a P-drug:
1. Define the diagnosis

2. Specify the therapeutic objective
3. Make an inventory of effective groups
4. Choose a group according to criteria:
Efficacy, Safety, Suitability, and Cost
Conclusion: Active substance, dosage form,
Standard dosage schedule,
Standard duration
How & not What to choose treatment

An inventory of effective
groups of drugs  Joint pain
• P-Drug: related to case

Analgesic agents
efficacy safety suitability cost

1. NSAIDs
– t-NSAIDs + + + ++
– COX-2 Inhibitor + ++ + +
– Paracetamol ++ ++ ++ +++
Side effects
• Drug of choice: ????
4.Start treatment
write prescribing
Prescribing must be complete & every country

has its own regulations
Name and address of the prescriber, with
telephone number (if possible)
Name of drug, dosage form, dosage schedule
& duration of treatment
Clear hand writing  may be print out
5.Give information, instruction & warning
doctor-patient communication
Information
Instructions
} Drug & treatment
Warnings
?
• Doctor explained
about taking drugs
(why & how). The
doctor just keeps
on talking & talking
doesn’t encourage
a dialogue.
• 50% Px do not take
prescribed drugs
correctly
(irregularly or not
at all)
Patient adherance
Therapeutic success
Non adherence to treatment
• Elderly patients / too young patients
• Long time therapy
• Doesn’t understand the aim of treatment
• Dosage schedule (regiment dose) is complicated
for patients, particularly the elderly
• Side effects have occurred
• Previous bad experienced on take drugs
• Expensive drugs
• Symptoms have ceased
• etc
How to improve patient
adherence to treatment
1. Prescribe a well-chosen treatment

2. Create a good doctor-patient
relationship
3. Take the time to give information,
instructions and warnings
How to improve patient adherence
to treatment (con’t)
A well chosen drug treatment consists of

• Considered P-drug
• Few drugs as possible (preferably only
one), with rapid action, with as few side
effects as possible
• Appropriate dosage form, with a simple
dosage schedule (one or two times daily),
and for the shortest possible duration
How to improve patient adherence to
treatment (con’t)
A good doctor-patient relationship
• Respect for the patient's feelings and viewpoint
• Try understanding and willingness to the patient
• In a dialogue, empowers the patient as a partner
in therapy.
Patients need
“information”, “instructions”, “warnings”
to provide them with the knowledge to accept
and follow the treatment and to acquire the
necessary skills to take the drugs appropriately
Information
• In some studies less than 60% of patients had
understood how to take the drugs they had received.
• Information should be given in clear, common language
• Ask patients to repeat in their own words some of the
core information, to be sure that it has been
understood.
• Information A functional name, such as a ‘heart pill’ is
often easier to remember and clearer in terms of
indication.
• Make a simple aids (leaflet, figure etc)
• Information to family/ other person  for baby/elderly
patients, invalid patients or non cooperative  should
be assistance to take drugs
The minimum information that should
be given to the patient
1. Effects of the drug 
• Why the drug is needed
• Which symptoms will disappear, and which will not
• When the effect is expected to start
• What will happen if the drug is taken incorrectly
or not at all
2. Side effects
• Which side effects may occur
• How to recognize them
• How long they will continue
• How serious they are
• What action to take
3. Instructions
• How the drug should be taken
• When it should be taken
• How long the treatment should continue
• How the drug should be stored
• What to do with left-over drugs
4. Warnings
• When the drug should not be taken
• What is the maximum dose
• Why the full treatment course should be taken
5. Future consultations
• When to come back (or not)
• In what circumstances to come earlier
• What information the doctor will need at the next
appointment
6. Everything clear?
• Ask the patient whether everything is understood
• Ask the patient to repeat the most important
information
• Ask whether the patient has any more questions
Not Enough Time For Communication ?
No, if doctor makes
personal formulary
- P-drug & P-treatment

- information that need for P-drug
6. Monitor (and stop ?) the treatment.
Was the treatment effective ?
A. Yes, and disease cured  Stop the treatment

B. Yes, but not yet completed  Any serious side
effects ?
No : treatment can
continue
Yes: reconsider
dosage or drug choice
C. No, disease not cured  Verify all steps
Exercisedoctor-patient communication
1. Woman, 28 years. Vaginal trichomonas
infection. R/metronidazole 500 mg, 1
vaginal tablet daily for 10 days.
2. Man, 45 years. Newly diagnosed

essential hypertension. R/atenolol 50
mg, 1 tablet daily.
Patient vaginal trichomonas
• As in any infection the patient should be told why the
course has to be finished completely, even when the
symptoms disappear after two days. The patient should
also be informed that treatment is useless if the
partner is not treated as well. Careful and clear
instructions are needed for vaginal tablets. If possible,
pictures or leaflets should be used to show the
procedure. Side effects of metronidazole are a metal
taste, diarrhoea or vomiting, especially with alcohol, and
dark urine. Give a clear warning against the use of
alcohol.
Patient essential hypertension
• The problem with the treatment of hypertension is
that patients rarely experience any positive effect of
the drugs, yet they have to take them for a long time.
Adherence to treatment may be very poor if they are
not told why they should take the drug, and if
treatment is not monitored regularly. The patient
should be told that the drug prevents complications
of high blood pressure (angina, heart attack, cerebral
problems). You can also say that you will try to
decrease the dosage after three months, or even stop
the drug entirely. Remember to check whether the
patient has a history of asthma.

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THERAPEUTICS PROCESS

P-Drugs & P-Treatment

The result of treatment optimal/ maximal

The process of choosing a treatment

Treatment for suppressing pain

How & not What to choose treatment

Step 1. Define the patient’s problem

Patophysiology, manifestation of disease

• prevent a lot of unnecessary drug use

pharmacotherapy, non pharmacotherapy,

• P-Treatmentadvice & information

1. Define the diagnosis

How & not What to choose treatment

• P-Drug: related to case

efficacy safety suitability cost

Prescribing must be complete & every country

1. Prescribe a well-chosen treatment

A well chosen drug treatment consists of

- P-drug & P-treatment

A. Yes, and disease cured  Stop the treatment

2. Man, 45 years. Newly diagnosed

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