Prescription, cost, compliance


SOME SUGGESTIONS FOR

Reducing risks - Reducing costs - Facilitating compliance



It is possible to promote a more rational use of medicines, as much for safety as for cost, by a judicious choice of therapeutic regimens and the resulting lists of medicines.

Limiting the use of injectable drugs

Numerous patients demand treatment with injectable drugs, which they imagine to be more effective. Certain prescribers also believe that injections and infusions are more technical acts and thus increase their credibility.

Parenteral treatment is always more costly than oral treatment. The price of the drug itself is higher for an equal dose of active ingredient. It requires costly disposable material. It exposes patients to complications due to poorly tolerated products (abscesses, necrosis due to IM quinine injections or antibacterials, etc.) or badly performed injection techniques (symptoms of overdose after a IV injection given too rapidly, sciatic nerve damage, etc.). If disposable injection supplies are re-used, there is a risk of bacterial or viral contamination (tetanus, hepatitis, HIV, etc.).

When both oral and injectable drugs are equally effective, parenteral administration is only justified in case of emergency, digestive intolerance or when a patient is unable to take oral medication. Oral drugs should replace injectable drugs as soon as possible during the course of treatment.

Limiting the use of syrups and oral suspensions

Taking liquid drugs is often easier, especially for young children and more so if they are sweetened or flavoured. It is, however, recommended to limit their use for numerous reasons:

 Risk of incorrect usage
Outside of hospitals, determining the correct dosage is hazardous: spoons never contain standard volumes (soup spoons, dessert spoons, tea spoons). Oral suspensions should be prepared with a specified amount of clean water, and well shaken prior to administration. There is therefore a risk of overdose or giving an insufficient dosage.
Some oral suspensions must be kept refrigerated; their storage at room temperature is limited to a few days, and with syrups there is a risk of fermentation.
In numerous countries syrups are thought of as "cough medicine". Confusion between cough mixtures and antibacterial suspensions or syrups is common.

– Economic considerations
Compared to the price of tablets or capsules, the price of syrups and oral suspensions is considerably higher. Even using a powder for subsequent reconstitution, the costs may be 2 to 7 times higher than an equivalent dose due to the cost of the bottle itself and higher transportation costs due to weight and volume.

Studying the choice of treatment regimens

The choice of a treatment regimen often influences compliance and cost. The shortest and least divided (1 to 2 doses per day) treatments are most often recommended. Single dose treatments are ideal, when indicated.

For the treatment of malaria, tuberculosis and HIV infection, fixed-dose combinations (coformulated tablets) should preferably be used in order to improve compliance.

Considering non-essential medicines and placebos

In developing countries as in industrialised countries, patients with psychosomatic complaints are numerous. The problems that motivate their consultations may not necessarily be remedied with a drug prescription. Is it always possible or desirable to send these patients home without a prescription for a symptomatic drugs or placebo? If so, what placebo should be prescribed?

When national drug policy is strict and allows neither the use of placebos nor non-essential symptomatic drugs, other products are often used in an abusive manner, such as chloroquine, aspirin, and even antibacterials.

Conversely, a placebo may take the place of an effective and needed drug. This risk is real, but seems less frequent, which makes the introduction of placebos on a list of essential drugs relevant. Multivitamins may present a type of harmless and inexpensive placebo. Their composition generally corresponds to preventive treatment of vitamin deficiency and they have no contra–indications.

Numerous non-prescription drug products (tonics, oral liver treatments presented in ampoules) have no therapeutic value and, due to their price, cannot be used as placebos.