What's new in critical illness and injury science? Rationale drug usage - A long way ahead!

One of the first duties of the physician is to educate the masses not to take medicines.

Irrational drug use is a global health problem, with far reaching economic consequences. Most common reasons cited are the lack of knowledge, unethical drug promotions, and irrational prescribing habits by the clinicians.[1] Studies done to document drug use patterns indicate that overprescription, multidrug prescription, misuse of unnecessary expensive drugs, and overuse of antibiotics and other medications are the major problems.[2] With up to 10%-40% of healthcare budgets spent on medicines globally, evidence suggests that more than half of all medicines in developing countries, and a substantial proportion of antibiotics in developed countries are used inappropriately, thus often wasting the scarce resources.[3]

Improving drug use would have important financial and public health benefits. Efforts to promote rational drug use started way back in the year 1977, when World Health Organization (WHO) introduced the concept of essential drugs.[3] In response to the mounting criticisms levelled against what was increasingly recognized as “the irrational use of drugs” in both the industrialized countries and the third world, the term ‘rational drug use’ was formulated at the Conference of Experts on the Rational Use of Drugs held in Nairobi in 1985: Rational drug use requires that patients receive medications appropriate to their clinical needs, in doses that meet their own requirements, for an adequate period of time, and at the lowest cost.[3]

The crisis in pharmaceuticals is an international problem which demands action at all levels-the government, the physicians, and the citizens. Globally, there is a need for drug policies which, although changing in content from one environment to another, meet the regional health needs of the world's population. At the national level, the weakness or absence of national drug policies has been found to be an important obstacle for implementing interventions to improve drug use. Measures required for the rational drug use include the development and revision of the national essential drug list, the national formulary development, amending the pharmacy act and the opening of drug information centers.[2] Although as far as policies are concerned the developed nations are far ahead, but the scenario remains bleak in the developing world, with no restriction on over the counter dispensing of antibiotics, no functioning national antibiotic policy or a national policy to contain antimicrobial resistance.[2] India, a developing economy, has taken a lead in this regard. As a commitment to combat antibiotic resistance, the landmark “Chennai Declaration” 2012 is a national initiative taken by the medical community and the Indian government.[4] Following the example, others can also take a step forward.

The present edition of the journal incudes an original article wherein the, drug utilization patterns in an Indian intensive care unit have been discussed, which opens a major debate toward the international issue of rational drug use. The article reports an overuse of drugs with average number of drugs used being more than 13, most commonly the antibiotics, inotropes/vasopressor, and H2 blockers. These figures almost match the worldwide literature, with average drugs use reported varying from 5 to 15.[15] The average number of drugs per prescription is an important index of a prescription audit. The overuse and/or misuse of drugs can lead to significant consequences, like increased costs, bacterial resistance, drug toxicities, and drug interactions.[6] Various surveillance studies report 40%-60% irrational antibiotics prescription.[6] Increasing multidrug resistance with limited availability of newer antibiotics to treat emerging multidrug-resistant clones emphasizes the urgent need for vigilant surveillance, stringent infection control practices, use of guidelines as well as antibiotic restriction policies.[6] While the critical care unit is the area of greatest antimicrobial use and the epicenter of antimicrobial resistance in most hospitals, the vulnerability of critical care patients and the complexity of their clinical management may hinder reductions in antimicrobial use.[7] In order to preserve the current antibiotic arsenal, antibiotic stewardship has been proposed to reduce overuse and the correct selection of these agents.[7] Antibiotic stewardship being a multidisciplinary endeavor, it is important to build relationships with clinicians, microbiologists and nursing staff, to have a positive impact. The Infectious Diseases Society of America recently published guidelines stating that all hospitals should develop an institutional program to enhance antimicrobial stewardship.[8]

Above all, drug utilization evaluation and internal audits at the institutional level are a must. For this pharmacovigilance, many hospitals have formalized the clinical role of the pharmacist in drug selection, use, and/or monitoring through the use of drug utilization review programs.[2] Another way forward is developing and maintaining an electronic documentation of the patients’ medical records, which may serve as a valuable tool for auditing the prescriptions frequently and for implementing the antibiotic policy.[2]

Although international agencies like WHO and International Network for Rational Use of Drugs have applied themselves to evolve standard drug use indicators from time to time, drug utilization remains a challenge for the medical fraternity, the governments and society at large. Thus, the onus to rationalize the drug usage is on all of us. So, let's the whole medical fraternity come forward, for WE only can make a difference!