Rational use of medicines: What does the word ‘rational’ mean?

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As doctors taking care of patients, our guiding principles remain ‘beneficence (act in the best interest of the patient)’ and ‘non maleficence (do no harm)’. Medicines cure, control and prevent disease. Hence, rational use of medicines is a very important aspect of patient care as it impacts patient outcomes.

What does the word ‘rational’ mean? The dictionary meaning of the word ‘rational’ as defined in the Oxford English Dictionary is that which is “based on reasoning or reason” or that which is “sensible, sane and moderate”.

In 1985, the World Health Organization (WHO) convened a Conference of Experts on the Rational Use of Drugs in Nairobi in 1985, which defined the rational use of medicines as “The rational use of drugs requires that patients receive medicines 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 the community”.

The ‘Five Rights’ of safe medication administration by the Institute of Healthcare Improvement also advocate the same: Right patient, Right drug, Right time, Right dose and Right route. Four more ‘Rights’ have been added to this: Right documentation, Right action (reason for prescribing the medication), Right form and the Right response.

So, why is rational use of drug important? Globally, medicines are being overused, underused or misused. Common types of irrational medicine use include:

• Polypharmacy i.e. use of too many medicines in a patient
• Use of antimicrobials, often in inadequate dosage, for non-bacterial infections
• Over-use of injections when oral formulations would be more appropriate
• Not prescribing drugs as per clinical guidelines
• Inappropriate self-medication, often of prescription-only medicines

Irrational use of drugs may cause adverse drug reactions, wastes precious resources and results in health hazards, most notable being antimicrobial resistance, which has now become a major public health problem, one which will leave us practically with no options to treat infections, if not checked in time.

Lack of knowledge or being unaware about drugs and their adverse effects has often been cited as a prime reason for irrational use of medicines, which also has legal implications.

Ignorance therefore is not a defense. Doctors should be aware of the drugs used in the National List of Essential Medicines (NLEM). They should appreciate that drugs included in the NLEM are comparable to non-NLEM drugs; they are also significantly chea

Doctors should also know about the concept of ‘Price to Retailer’ i.e. the price of a drug at which it is sold to a retailer which includes duties and does not include local taxes. This ‘Price to Retailer’ is fixed by the government.

My definition of rational use of medicine is “Optimal drug, optimal duration, minimum time, earliest IV to oral switch and affordable”.

Indian Medical Association (IMA) has launched a series of initiatives in this regard. “Jaroorat Bhi Hai Kya” is one such campaign to promote rational use of drugs and/or rational ordering of investigations and hospitalizations. Off-label use of drugs and/or procedures should be used very carefully and not without the approval of the Ethics Committee. We have planned similar campaigns “Use Wisely not Wildly”, “Will it benefit” and “Think Before you Ink”.

Forget me Not: IMA Campaign for the Elderly

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The global demography is changing with a considerable increase in the older population in almost all countries. A greater understanding of etiopathogenesis of many diseases leading to newer and more effective treatment options has improved life expectancy. Not just medical advances, economic growth and social development too have contributed to the rising aging population.

“According to Population Census 2011 there are nearly 104 million elderly persons (aged 60 years or above) in India” (Elderly in India 2016 Report). “The global share of older people aged 60 years or over is expected to increase from 11.7% in 2013 to 21.1% by 2050. Presently, about two thirds of the world’s older persons live in developing countries. By 2050, nearly 8 in 10 of the world’s older population will live in the less developed regions. An Indian born in 1950 could expect to live for 37 years, whereas today India’s life expectancy at birth nearly doubled to 68 years, by 2050, it is projected to increase to 76 years. As a result, India’s population will rise from 1.3 billion today to an estimated 1.7 billion by 2050, with a much larger elderly share of around 340 million” (Press Information Bureau, March 22, 2016).

Heart disease, dementia, diabetes, arthritis, cataract, sleep problems, depression, anxiety are some of the common health conditions prevalent in the elderly. And, most of these conditions co-exist, giving rise to polypharmacy, which has its own associated set of problems. In addition to these are the issues of disability, financial insecurity, isolation, loneliness, neglect. Left alone at home, they are also exposed to crime. From being usefully occupied for most part of their lives, they find themselves with plenty of time on their hands post-retirement.

Hence, the challenges are not just health related but also economic and social.

The elderly are a vulnerable group and need to be looked after. They can still contribute to the society. By neglecting them, we are losing out on their skill and years of experience.

Efforts need to be made to improve quality of their lives and integrate them in the society. Health care for this population group in particular should be accessible and affordable; they need to be protected from ill-treatment and neglect. Those who wish to be productively engaged should be encouraged to do so.

“Article 41, a Directive Principle of State Policy, provides that the State shall, within the limits of its economic capacity and development, make effective provision for securing the right of public assistance in cases of old age. The Maintenance and Welfare of Parents and senior Citizen Act, 2007, also known as “Senior Citizens Act” explicitly states that it should be the duty of the children to maintain their parents.” (Press Information Bureau, October 1, 2015).

“The National Policy on Older Persons (NPOP) announced in 1999 envisages State support for the elderly to ensure financial and food security, health care, shelter, protection against abuse and exploitation, and training of human resources for their care and support etc. The policy also covers issues like social security, intergenerational bonding, family as the primary caretaker, role of Non-Governmental Organizations, training of manpower, research and training.” (Press Information Bureau, August 5, 2014)

The “National Programme for the Health Care of Elderly” (NPHCE) was launched in the year 2010 to address health related problems of elderly people. Last year, the Ministry of Health & Family Welfare launched the Longitudinal Ageing Study in India (LASI) to generate data on various issues of the elderly. It will survey more than 60,000 elderly over 25 years plan.

October 1 has been designated as the International Day of Older Persons by the United Nations to raise awareness about issues affecting the elderly.

“Forget me Not” is a campaign proposed by the Indian Medical Association (IMA) for the elderly population enabling them to lead a healthy and productive life with dignity. Doctors need to be trained to take care of the special needs of the older people. As doctors, we should not only provide them medical care, but also be a support to them.

Dr KK Aggarwal
National President IMA and HCFI

Today is Doctors’ Day

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Doctors’ Day is celebrated in India on 1st July every year to mark the Birth & Death anniversary of Bharat Ratna Awardee, Dr Bidhan Chandra Roy (Dr BC Roy).

Dr BC Roy was born in 1882 in Patna, Bihar and after doing his medical graduation in Kolkata and MRCP and FRCS at London, he started his career as a physician in Patna in 1911. He taught in Patna Medical College and in Carmichael Medical College.

He was a true freedom fighter and joined Mahatma Gandhi in Civil Disobedience Movement. In the field of politics, he became a leader of the Indian National Congress and later Chief Minister of West Bengal. In 1976, he was conferred Bharat Ratna and Dr B C Roy National award were constituted in his name the same year.

He left us on 1st July, 1962 but his soul is still remains in the collective consciousness of the medical profession of our country.

The demand for a Doctors’ Day originated in Kolkata by Kidderpore Branch in 1989 under the Presidentship of Dr Santanu Banerjee and Dr Pradip Kumar Chatterjee as the Secretary.

Later, the state working committees of IMA Bengal and the IMA Bengal State Council in 1989 resolved to declare 1st July as Doctors’ day under the Presidentship of Dr Ashok Chaudhuri.

The forwarded resolution was considered by IMA Central Working Committee held on 24th & 25th April, 1991 under the then National President, Dr Ram Janma Singh and IMA declared 1st July as Doctors’ Day starting from 1st July 1991.

IMA persuaded the Government of India to accept it as National Doctors’ day and 1st July 1992 became the historical Doctors’ day when it was accepted and recognized by the Govt. of India. (With inputs from IMA Bengal, Dr Sanjoy Banerjee)

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