By Definition rational use of drug (RUD)mean use of the right drug for the right period for actual cause of illness. To select the right drug the diagnosis needs to be correct. Many diseases can be diagnosed from their symptoms and signs.Who has time to take proper history when 100’s of patients are seen daily ? Even Aneamia ,Pulse , chest sound are not recorded. A large number of cases which require.-
Investigations -often minimum but at times elaborate clinicopathological biochemical , Radiological including imaging procedures operative interventions like laparoscopic visualisation. etc. In a country like India where an overwhelming majority of the population have to pay from their pockets for these investigation how can a practitioner prescribe rationally when the patient cannot afford the necessary investigation to make a correct diagnosis possible, but its possible if proper time is spent for history and clinical signs in 80 to 90% of cases diagnosis can be correct ? Perhaps no where is it more evident than in the therapy of long continued fever, cough, weight loss, lethargy, anaemia etc. what does a practitioner do in such a situation ? He /She takes recourse to either astrotherapy or polytherapy, astrotheraphy may be defined as the practice of astrology in therapeutic practice and poly therapy refers to prescribing for a wide range of infections, respiratory tract infection urinary tract infection enteric fever malaria together
Selection of the right drug required not only correct diagnosis but also the correct choice of the remedy where indicated to make a correct choice of drug (s) one should have correct ( i.e. Complete unbiased and objective ) information about the drugs they prescribe for this In the first place the prescriber should feel the urge to gather information beyond what is supplied by there manufacturers by medical representatives.One should attend CME symposia, conference , seminar , reading of periodicals , searching through internet.Unfortunately all these elements are absent in our country or of substandard quality or influenced by drug manufacturing companies by way of sponsorship, Then quite naturally a question may arise who is supposed to provide the information ?.However it is known the world over that the information when provided by the drug manufacturers contain biased half thryths and often blatant lies. In Many economically advanced countries, the governments bear the responsibility of providing up to date and objective information about drugs licensed by them to all registered medical practitioners of the country concerned. Many non government bodies (e.g prescrire group in France ) also provide quality information to subscribers thousands of practitioners pay for such information Governments of underdeveloped countries like India do not by and large consider it their responsibility to act as watch dogs not the drug markets Nor do they encourage private initiatives like BODHI. Obviously enterprises like BODHI have very few care takers for such reasons mentioned above.
Next comes the question of drugs rational use demands the availability of rational drug and absence of irrational fixed dose combination drug and drugs of questionable effectiveness. Rational drugs may be used irrationally ? Moreover if irrational drugs are allowed to be markerted in the country then by sheer rules of the markets they will be prescribed and administered (consumed ) An example of two will help to illustrate the point. Text books of medicine and pharmacology unequivocally mention that dried ferrous sulphate or ferrous fumarate in the tablet form is the drug of choice for the therapy of iron deficiency aneamia our survey showed that there is few formulation of either of the drugs available in the markets. Almost all heamatinic formulations available in the country either contain iron salts or complexes of inferior quality of a hodge podge of iron salts vitamins laxatives animal liver etc. ( notwithstanding the possibility of transmission of the so called mad cow disease ) And what not Then there are combinations of antibiotics like ampicillin and cloxacillin ( more than a Hundred brand names) combination of antibiotics with antiprotozoals (again hundreds of brand names) when no text books worth the name ever advocate the combinations.
Therefore, the success or failure of the campaign on RUD or relative RUD to make it sound less ambitious in any country is a question of availability or/ nonavailability of irrational drugs.
Well the government is indifferent to say the least. The drug manufacturers are by and large unscrupulous. The patients are unaware and therefore unconcerned But what are international bodies which are crying themselves hoarse about essential drugs and all that doing? Has anyone heard a word from them about irrational drug that have practically elbowed rational drugs out of the shlves in drug outlets ? A teasing question but who is there to listen ?
It is obvious that it is very difficult for practitioners to stick to RUD i.e to put into practice what they were taught as students of medical science indeed with the mighty drug companies corrupt bureaucrats and doctors with weak morals arrayed against him the practitioner often finds himself too feeble to rise to the challenge.
What is the way out then ? It is no use aiming to high one has to be realistic. There are practitioners who refuse to compromise their values and their number is by no means small but they do not have a common forum which can effectively fight against such formidable odds.So as things stand a conscientious practitioner has to fight the battle by himself if he staunchly keeps to RUD ignoring the practice of his unscrupulous colleagues and the patients demands his practice will be imperilled in no times some allowance has to be made and there fore we have to go for relative RUD .
The practitioner can follow say, three principles to start with one He may prescribe an irrational drug because the patient is insistent but he may at the same time tell the patient : Well , I write a cough syrup because you demand it but as far as my knowledge goes, it does you a lot of harm and practically not good at all: or if you think you are better off with this tonic I’ll prescribe it for you , but believe me there is no scientific reason in its favour and so on. If such a rational message comes every time an irrational prescription made under duress, a time may come hopefully when irrational patients, at least a significant section of them, will see reason and change their drug culture attitute.
What we are suggesting in to many words is a kind of education for patients. AND it has to be education worth its name. The practitioner may have to explain things in a non technical manners, but a doctor who places ethics and dignity above money will have to pay the price. The price is not too high considering the potential benefits to community and satisfection for himself of noble practice.
Lastly, the practitioner may say :’ there are many brands of the same drug marketed by different companies. I suggest the one that costs least, for I have no information that the low cost is at the cost of quality. Very often the high price of a particular brand may have nothing to do with the intrinsic quality of the drug; it may be due only to other reasons such as advertisements, high salaries and perks of the employees and executives in particular free sample ,Gift, Commission to doctors We suggest each conscientious practitioner to stick to his gun in the battle for RUD. And these are examples of the ways he can fight and at the same time defend for himself. The lonely RUD practitioner has to carve out his own path. For those who are at a loss these suggestions may not be altogether irrelevant or impracticable.
DR. C. K. PATEL M.S.,D.G.O.F.I.C.S
DR.RAJENDRA KOTHARI M.S.,E.N.T.
Dr Bharat Makwana M.D.