I Can PresCribE A Drug: Mnemonic-based Teaching of Rational Prescribing

Transcription

1 236 Apil 2007 Family Medicine Fo the Office-based Teache of Family Medicine William Huang, MD Featue Edito Edito s Note: In this month s column, Kal Igla, MD; Natalie Kennie, PhamD; and Jana Bajca, MScPham, EdD, of St Michael s Hospital and the Univesity of Toonto, pesent the I Can PesCibE A Dug mnemonic, which summaizes the systematic appoach to pescibing that they teach thei esidents. Office-based teaches can similaly use this appoach to help esidents and students select the most appopate medication fo thei patients. I welcome you comments about this featue, which is also published on the STFM Web site at www. stfm.og. I also encouage all pedoctoal diectos to make copies of this featue and distibute it to thei peceptos (with the appopiate Family Medicine citation). Send you submissions to williamh@bcm. tmc.edu. William Huang, MD, Baylo College of Medicine, Depatment of Family and Community Medicine, 3701 Kiby, Suite 600, Houston, TX Fax: Submissions should be no longe than 3 4 double-spaced pages. Refeences can be used but ae not equied. Count each table o figue as one page of text. I Can PesCibE A Dug: Mnemonic-based Teaching of Rational Pescibing Kal Igla, MD; Natalie Kennie, PhamD; Jana Bajca, MScPham, EdD Rational pescibing efes to the selection of the most appopiate theapeutic egimen fo a specific patient. 1 Thee is a need to teach leanes pinciples of ational pescibing since one study found that medical students and esidents often do not pefom impotant tasks such as checking dosage calculations o seaching fo possible dug-dug inteactions pio to witing a new pesciption. 2 Futhe, pescibing o pesciption eos have been discoveed in as many as 11% of all pesciptions in pimay cae. 3 (Fam Med 2007;39(4): ) Fom the Depatment of Family and Community Medicine, St. Michael s Hospital, Toonto, and the Depatment of Family and Community Medicine (all) and the Leslie Dan Faculty of Phamacy (Ds Kennie and Bajca), Univesity of Toonto. A pevious suvey found that only 38.5% of family medicine esidency pogams offeed a fomal phamacotheapy cuiculum. 4 Moe ecently, the Society of Teaches of Family Medicine Goup on Phamacotheapy has published guidelines fo a phamacotheapy cuiculum that can be offeed duing family medicine esidency taining. 5 Pope taining in ational phamacotheapy does esult in ational pescibing habits, at least in the shot tem 6 and theefoe should be an integal pat of esidency cuicula. Seveal systematic appoaches to selection of phamacotheapy have been descibed in the liteatue. 7-9 The Wold Health Oganization has published the Guide to Good Pescibing that pomotes a global appoach to ational pescibing. 7 It includes ceating a pesonal fomulay of effective medications that ae likely to be used fequently, defining the poblem (diagnosis), specifying the theapeutic objective, ensuing that a medication fom the pesonal fomulay has poven efficacy and safety fo the patient unde consideation, infoming the patient about the teatment, and then monitoing the esults and stopping the dug when the poblem has esolved. Moe ecently, Bazaldua et al have incopoated these same pinciples including the consideation of nondug theapy into the ESSEnCE appoach to ational pescibing. 8 In his desciption of a family medicine esidency cuiculum on pescibing, Gaspa lists efficacy, convenience, safety, and cost as ational citeia in choosing pesciption dugs. 9 Not supisingly, vaious authos epot simila components that ae impotant in the ational pescibing pocess.

2 Fo the Office-based Teache of Family Medicine Vol. 39, No Afte focus goups of esidents and faculty identified a need to develop a systematic appoach to dug pescibing, the Family Medicine Residency Pogam of St. Michael s Hospital, a fully-affiliated teaching institution within the Univesity of Toonto, developed and adopted a fomal cuiculum in 2001 focusing on elevant phamacotheapeutics knowledge and medication pescibing skills. Since then, though the theapeutics cuiculum, esidents have leaned a systematic appoach to pescibing, easily emembeed by the mnemonic, I Can PesCibE A Dug, that isolates specific steps that lead to an individualized selection of a medication fo a specific patient. This pape descibes this appoach and the elated medication knowledge that the leane will need to conside at each step, which will ideally lead to the best medication being pescibed to a specific patient. This tool can be used by family medicine esidents duing thei esidency taining as well as by medical students doing thei clinical otations. I Can PesCibE A Dug Mnemonic The mnemonic, compised of seven components elated to ational pescibing, stats with the leane ceating a list of all potential phamacotheapeutic and nondug altenatives. This is followed by a sequence of steps that systematically eliminate o etain cetain altenatives fom the initial list. The end esult is a selection of the best medication fo a patient at a given time. Table 1 shows how this mnemonic can be applied to a specific patient situation and potential dug infomation esouces that can be used o accessed by the leane to acquie the phamacotheapeutic content fo each step. 1. Indication The fist step is to identify the diagnosis fo the patient and decide if theapy is indicated. The leane must conside the geneal goals of theapy as well as the needs and expectations of the patient. The leane may access theapeutic infomation fom clinical pactice guidelines as well as othe available evidence fom clinical tials o systematic eviews. Fom this evidence, the leane identifies all potentially effective altenatives fo theapy, both dug and nondug, and leans if medication is indicated. 2. Containdications The second step is to detemine if any medications ae absolutely containdicated and thus need to be eliminated fom the list of potential altenatives. This pompts the leane to conside dug allegies, Table 1 Use of the I Can PesCibE A Dug Mnemonic Case Scenaio: Ms DM, a 67-yea-old woman (weight 70 kg, ideal body weight 65 kg), pesents with pooly contolled diabetes mellitus (A1c 8.4%). She is cuently teated with glybuide 10 mg by mouth twice pe day. He past medical histoy is significant fo myocadial infaction complicated by congestive heat failue 1 yea ago (symptoms now stable). He medications include: glybuide 10 mg twice pe day, gemfibozil 600 mg twice pe day, amipil 10 mg once pe day, aspiin 81 mg once pe day, Fuosemide 40 mg once pe day. Mnemonic Components Case Example Desciption Potential Resouce Type Indication I Teatment is indicated to achieve optimal contol of glycemia of an A1c < 7%. In this case, the patient is cuently taking glybuide at a maximum dose, and combination theapy is ecommended fom clinical pactice guidelines, along with lifestyle changes. (Infomation such as this can be found in ecent evidence-based clinical pactice guidelines on diabetes mellitus ) Evidence fom clinical tials Evidence-based clinical pactice guidelines Evidence fom systematic eviews (including Cochane eviews 14 o Clinical Evidence eviews 15 ) Potential theapeutic available altenatives to choose fom include: biguanides (eg, metfomin) glitazones (eg, pioglitazone, osiglitazone) α-glucosidase inhibitos (eg, acabose) insulin secetagogues (eg, nateglinide, epeglinide) insulin Due to this patient s histoy of congestive heat failue, one can eliminate glitazones as a potential choice. 12,16,17 C a n Containdications Dug poduct monogaphs, including those fom: Published dug infomation efeences Electonic dug infomation databases such as Epocates, 18 Lexi-comp, 19 and Micomedex Healthcae Seies 20 (continued on next page)

3 238 Apil 2007 Family Medicine Table 1 (continued) Mnemonic Components Case Example Desciption Potential Resouce Type Pecautions Pegnancy and lactation as a pecaution is not applicable in this case. P e s C i b E Cost/ Compliance Laboatoy indices that should be pefomed pio to dug theapy include a seum ceatinine and live enzymes. Potential dug-dug inteactions should be consideed. In this case, one can eliminate epaglinide (a shot-acting secetagogue) as a potential choice, since when used in combination with gemfibozil, it may cause sevee and polonged hypoglycemia. 16,17 In consulting dug benefit fomulaies, one may eliminate some altenatives due to thei excessive cost. Fo example, acabose and insulin secetagogues may have limited coveage based on specific citeia. One may ule out the use of insulin at this stage since the need fo subcutaneous administation is inconvenient fo the patient and has the potential to lead to noncompliance. Resouces on medications duing pegnancy and lactation (eg, Biggs et al. Dugs in Pegnancy and Lactation 21 ) Dug poduct monogaphs fom o electonic dug infomation databases Dug inteaction efeences including: Published efeences 22,23 Electonic dug infomation databases Dug benefit o managed cae fomulaies Dug poduct monogaphs fom o electonic dug infomation databases Efficacy One can ule out acabose at this stage as it usually poduces only a mean decease in A1c of 0.5% to 0.8%, which is inadequate fo this case scenaio. 12,13 Othe oal hypoglycemic altenatives such as insulin secetagogues and metfomin ae likely to poduce an aveage A1c loweing of 1.0% to 1.5%. 12 Use of dug classes with simila mechanisms of action (eg, sulfonylueas and insulin secetagogues) is less effective than combination theapy with agents that have diffeent mechanisms of action. 13 Fo this eason, use of insulin secetagogues such as nateglinide can be uled out at this stage. Evidence fom clinical tials Evidence-based clinical pactice guidelines Evidence fom systematic eviews (including Cochane eviews 14 o Clinical Evidence eviews 15 ) Metfomin, when used in obese patients, may impove cadiovascula outcomes, which would be of futhe benefit fo this patient. 24 At this stage, one ealizes that metfomin is a good option. Fasting blood glucose and A1c will need to be monitoed to detemine the effectiveness of dug theapy. A Advese effects Potential common and seious side effects fo potential teatment altenatives ae consideed, discussed with the patient, and monitoed. Fo example, with metfomin, a common side effect is gastointestinal intoleance, while moe-seious but ae side effects include hypoglycemia and lactic acidosis. 16,17 Dug poduct monogaphs fom o electonic dug infomation databases Advese dug eaction epots (such as US Food and Dug Administation Safety Alets 25 ) Consideing the step-wise pocess above, metfomin is detemined as the most appopiate altenative fo this case, as othe theapeutic altenatives have been uled out. D u g Dose/Duation/ Diection An appopiate stating dose fo this patient would be metfomin 500 1,000 mg oally each day and titate by 500 mg incements evey 7 days if home blood suga eadings emain high, to a maximal dose of 2,500 mg/day based on efficacy and toleability. 16,17 Dug poduct monogaphs fom published dug infomation efeences o electonic dug infomation databases

4 Fo the Office-based Teache of Family Medicine Vol. 39, No majo ogan disease (eg, enal o hepatic, etc) o othe concomitant disease in a given patient that would containdicate the use of each theapeutic option. Dug poduct monogaphs that can be found in witten efeences o electonic database poducts can be useful esouces fo this type of infomation. 3. Pecautions The evaluation of pecautions has thee distinct steps that may lead to futhe educing the list of potential altenatives. Fist, the leane consides if the patient is pegnant o lactating. Second, the leane is asked to detemine if thee ae any laboatoy indices that need to be assessed pio to stating theapy to ensue that all potential pecautions have been consideed. Thid, the leane consides the patient s medical histoy and othe dug theapy the patient may be taking to ascetain if thee ae any significant dug-disease o dugdug inteactions with the theapeutic option in question. Dug poduct monogaphs can be useful fo this step as well as specialized esouces on dug-dug inteactions and the use of medications in pegnancy and lactation. 4. Cost/Compliance This step pompts the leane to inquie about dug coveage the patient possesses and whethe the theapeutic option is coveed. The leane should also detemine the cost of the medications being consideed and conside which dug fomulation allows fo bette compliance o easie administation, such as those that minimize the fequency of dosing. 5. Efficacy The leane now must conside the efficacy of teatment and compae the elative efficacy of the altenatives that emain as potential choices. In this step, the leane consides whethe thee ae any patient-elated factos elating to efficacy that could influence the decision and what paametes will indicate that the theapy being consideed is effective. On many occasions, the leane may also consult applicable evidence fom clinical tials, systematic eviews, o clinical pactice guidelines to ensue the most efficacious medication is chosen. 6. Advese Dug Effects The leane then consides not only the common advese dug eactions a patient may encounte as a esult of the theapy but also the potentially seious side effects that could futhe influence the choice of dug theapy. Dug poduct monogaphs fom witten efeences o electonic databases ae useful esouces fo this step. At this point in the stepwise pocess, the leane has naowed down the choice to the best possible phamacotheapeutic altenative and is eady to poceed with step Dosage/Duation/Diection The leane must detemine the appopiate dosage, duation of theapy, and any additional diections fo the specific patient scenaio. Dug poduct monogaphs fom witten efeences o electonic databases ae potential esouces fo this step. Once the appopiate theapy is selected, the mnemonic can seve as a communication famewok when discussing the ationale fo theapy with a patient. Failue to conside o infom patients of impotant aspects of new medications, such as the name, pupose, advese effects, and duation of theapy, may lead to nonadheence by the patient. 10 Discussion Ou I Can PesCibE A Dug appoach is complementay to othe appoaches epoted peviously and povides an additional famewok that leanes can use to lean how to choose medications fo individual patients. In addition to the key factos in medication selection epoted by othes, 7-9 ou appoach emphasizes that leanes conside all possible effective phamacotheapeutic altenatives and also explicitly eminds them to addess issues such as containdications and pecautions. By going though each step of this appoach and including o excluding medications based on individual patient factos, the leane will aive at the most suitable medication fo the patient and also be able to explain to the patient why that medication was selected. The I Can PesCibE A Dug mnemonic has seved as a useful famewok fo deliveing a phamacotheapeutics cuiculum to family medicine esidents at St. Michael s Hospital, Toonto. When discussing specific patients and thei need fo dug theapy, office-based teaches of family medicine can use this appoach to help students o esidents lean how to select the most appopiate medication fo the patient. Coesponding Autho: Adess coespondence to D Igla, 30 Bond Steet, Toonto, Ontaio M5B 1W8, Canada , ext Fax: iglak@smh.toonto.on.ca. REFERENCES 1. Knollmann BC, Smyth BJ, Ganett CE, et al. Pesonal digital assistant-based dug efeence softwae as tools to impove ational pescibing: benchmak citeia and pefomance. Clin Phamacol The 2005; 78(1): Gabutt JM, Highstein G, Jeffe DB, Dunagan WC, Fase VJ. Safe medication pescibing: taining and expeience of medical students and housestaff at a lage teaching hospital. Acad Med 2005;80(6): Sandas J, Esmail A. The fequency and natue of medical eo in pimay cae: undestanding the divesity acoss studies. Fam Pact 2003;20(3): Dickeson LM, Denham AM, Lynch T. The state of clinical phamacy pactice in family pactice esidency pogams. Fam Med 2002;34(9): Bazaldua O, Ables AZ, Dickeson LM, et al. Suggested guidelines fo phamacotheapy cuicula in family medicine esidency taining: ecommendations fom the Society of Teaches of Family Medicine Goup on Phamacotheapy. Fam Med 2005;37(2):

5 240 Apil 2007 Family Medicine 6. Kaaalp A, Akici A, Kocabasoglu YE, Oktay S. What do gaduates think about a 2-week ational phamacotheapy couse in the fifth yea of medical education? Med Teach 2003; 25(5): de Vies TPGM, Henning RH, Hogezeil HV, Fesle DA. Guide to good pescibing: a pactical manual. Geneva, Switzeland: Wold Health Oganization, Action Pogamme on Essential Dugs, Bazaldua O, Pollock M, Roaten S, Dobbie A. Teaching the ESSEnCE of office-based pescibing. Fam Med 2006;38(5): Gaspa DL. Choosing pesciption dugs ationally: a cuiculum fo a family pactice esidency pogam. Acad Med 1995;70(5): Tan DM, Heitage J, Pateniti DA, Hays RD, Kavitz RL, Wenge NS. Physician communication when pescibing new medications. Ach Inten Med 2006;166: Ameican Diabetes Association. Standads of medical cae in diabetes Diabetes Cae 2006;29(suppl 1):S4-S Canadian Diabetes Association Clinical Pactice Guidelines Expet Committee. Canadian Diabetes Association 2003 Clinical Pactice Guidelines fo the Pevention and Management of Diabetes in Canada. Can J Diabetes 2003;27(suppl 2):S1-S Nathan DM, Buse JB, Davidson MB, Heine RJ, Holman RR, Zinman SB. Management of hypeglycemia in type 2 diabetes. A consensus algoithm fo the initiation and adjustment of theapy; a consensus statement fom the Ameican Diabetes Association and the Euopean Association fo the Study of Diabetes. Diabetologia 2006;49: The Cochane Collaboation. Available at Accessed Novembe 16, BMJ clinical evidence. Available at www. clinicalevidence.com. Accessed Novembe 16, Repchinsky C, ed. Compendium of phamaceuticals and specialties. Ottawa, Ontaio: Canadian Phamacists Association, Dug facts and compaison 2006, 60th edition. St Louis: Woltes Kluwe Health, Inc, Epocates. Available at com. Accessed Novembe 16, Lexi-Comp. Available at Accessed Novembe 16, Micomedex Healthcae Seies. Available at Accessed Novembe 16, Biggs GG, Feeman RK, Yaffe SJ. Dugs in pegnancy and lactation, seventh edition. Philadelphia: Lippincott Williams and Wilkins, Hansten PD, Hon JR. Hansten and Hon s dug inteactions, analysis, and management (updated quately). St. Louis: Woltes Kluwe Health, Inc, Tato DS, ed. Dug inteaction facts (updated quately). St. Louis: Woltes Kluwe Health, Inc, UK Pospective Diabetes Study Goup. Effect of intensive blood-glucose contol with metfomin on complications in oveweight patients with type 2 diabetes (UKPDS 34). Lancet 1998;352: US Food and Dug Administation. Medical poduct safety infomation. Available at Accessed Novembe 16, 2006.