REVIEW ARTICLE

RATIONAL PRESCRIBING & PRESCRIPTION WRITING: ROLE OF CLINICAL

PHARMACOLOGIST TO IMPROVE THE PATIENT QUALITY OF CARE
Anil Kumar P.1,*, Padma L.2, Veena D.R.3, Bhaskar R.4
1,4PG Student, 2HOD & Professor, 3Associate Professor, Dept. of Pharmacology,
Dr B.R. Ambedkar Medical College & Hospital, Bangalore.

*Corresponding Author:
E-mail: [email protected]

INTRODUCTION inflammation that are worse in the morning. There is

Once a patient with a clinical problem has no history of joint injury or infection. She has
been evaluated and a diagnosis has been reached, the attempted to self-medicate with aspirin and
practitioner can often select from a variety of acetaminophen but is not satisfied with the results.
therapeutic approaches. Medication, surgery, Should you write a prescription for her? If so, what
psychiatric treatment, radiation, physical therapy, steps should you take? These questions are answered
health education, counseling, further consultation, in the discussion that follows.
and no therapy are some of the options available. Of
these options, drug therapy is by far the one most Rational Prescribing
frequently chosen. In most cases, this requires the Like any other process in health care, writing a
writing of a prescription. A written prescription is the prescription should be based on a series of rational
prescriber's order to prepare or dispense a specific steps.
treatment—usually medication—for a specific 1. Make a specific diagnosis: Prescriptions based
patient. When a patient comes for an office visit, the merely on a desire to satisfy the patient's
physician or other authorized health professional psychological need for some type of therapy are
prescribes medications 67% of the time and an often unsatisfactory and may result in adverse
average of one prescription per office visit are written effects. A specific diagnosis, even if it is
because more than one prescription may be written at tentative, is required to move to the next step.
a single visit. The treatment of diseases by the use of For example, in the patient described in the case
essential drugs, prescribed by their generic names, study, a diagnosis of rheumatoid arthritis would
has been emphasized by the WHO and the National be considered. This diagnosis and the reasoning
Health Policy of India. We conclude that the underlying it should be shared with the patient.
prescription monitoring studies provide a bridge 2. Consider the pathophysiologic implications of
between areas like rational use of drugs, the diagnosis: If the disorder is well understood,
pharmacovigilance and evidence based medicine, the prescriber is in a much better position to offer
pharmacoeconomics, pharmacogenetics and eco effective therapy. For example, increasing
pharmacovigilance. In India, this is the need of the knowledge about the mediators of inflammation
hour to utilize the data generated by so many makes possible more effective use of non
prescription pattern monitoring studies done in every steroidal anti-inflammatory drugs (NSAIDs) and
state and on every drug, so that the main aim of other agents used in rheumatoid arthritis. The
promoting rational use of drugs is fulfilled.1 patient should be provided with the appropriate
By estimating the concentration, time level and amount of information about the
curves, and plasma concentration Vs effect curves we pathophysiology. Many pharmacies and disease-
can interpret the drug response/drug effect, so that we oriented public and private agencies (e.g.,
can adjust the dose/change the drug in order to American Heart Association, American Cancer
improve the patient quality of care and also to Society and Arthritis Foundation) provide
prevent antimicrobial resistance/AMS-antimicrobial information sheets suitable for patients.
stewardship. The physical form of the prescription, 3. Select a specific therapeutic objective (as a
common prescribing errors, and legal requirements part of evidence based medicine): A
that govern various features of the prescribing therapeutic objective should be chosen for each
process are reviewed. Finally, some of the social and of the pathophysiologic processes defined in the
economic factors involved in prescribing and drug preceding step. In a patient with rheumatoid
use are explained. arthritis, relief of pain by reduction of the
inflammatory process is one of the major
CASE STUDY therapeutic goals that identify the drug groups
A 35-year-old woman presents with that will be considered. Arresting the course of
complaints of symmetric joint stiffness, pain, and the disease process in rheumatoid arthritis is a
Indian Journal of Pharmacy and Pharmacology, April-June 2015;2(2);134-138 134
P. Kumar A. et al. Rational Prescribing & Prescription Writing: Role of Clinical Pharmacologist to Improve the….

different therapeutic goal, which might lead to effects that will be monitored and in what way,
consideration of other drug groups and including laboratory tests (LFT- for Mtx) and
prescriptions. signs and symptoms that the patient should
4. Select a drug of choice/p-drug concept report. For conditions that call for a limited
(preferred drug or physician’s choice): One or course of therapy (e.g., most infections), the
more drug groups will be suggested by each of duration of therapy should be made clear so that
the therapeutic goals specified in the preceding the patient does not stop taking the drug
step. Selection of a drug of choice from among prematurely and understands why the
these groups follows from a consideration of the prescription probably need not be renewed. For
specific characteristics of the patient and the the patient with rheumatoid arthritis, the need for
clinical presentation. For certain drugs, prolonged—perhaps indefinite—therapy should
characteristics such as age, other diseases, and be explained. The prescriber should also specify
other drugs being taken are extremely important any changes in the patient's condition that would
in determining the most suitable drug for call for changes in therapy. In patients with
management of the present complaint. In the rheumatoid arthritis, development of
example of the patient with probable rheumatoid gastrointestinal bleeding would require an
arthritis, it would be important to know whether immediate change in drug therapy and a prompt
the patient has a history of aspirin intolerance or workup of the bleeding. Major toxicities that
ulcer disease, whether the cost of medication is require immediate attention should be explained
an especially important factor and the nature of clearly to the patient
the patient's insurance coverage, and whether 7. Plan a program of patient education: The
there is a need for once-daily dosing. Based on prescriber and other members of the health team
this information, a drug would probably be should be prepared to repeat, extend, and
selected from the NSAID group. If the patient is reinforce the information transmitted to the
intolerant of aspirin and does not have ulcer patient as often as necessary. The more toxic the
disease but does have a need for low-cost drug prescribed, the greater the importance of
treatment, ibuprofen or naproxen would be a this educational program. The importance of
rational choice. Physician should prefer for the informing and involving the patient in each of
prescription of generic drugs which are cost the above steps must be recognized.
effective (pharmacoeconomics). Poly pharmacy 8. Improving the patient compliance/adherence
in which the number of drugs/encounter was < to the treatment: Provide and encourage use of
2.5 was minimal, but that a large proportion of medication counseling, use mechanical
the prescriptions contained two or more drugs compliance aids as needed (compliance
could result in adverse drug-drug interactions. packaging, colour coding, use appropriate dosage
The most frequently prescribed drugs were anti- forms and schedules for each individual patient.
infectives and analgesics accounting for over
76% in HCs and 82% in HSs and in most cases THE PRESCRIPTION
they are probably prescribed with little Although a prescription can be written on
justification.2 any piece of paper (as long as all of the legal
5. Determine the appropriate dosing regimen elements are present), it usually takes a specific form.
depending up on patient condition: The dosing All prescriptions must include the following
regimen is determined primarily by the information:
pharmacokinetics of the drug in that patient. If Prescriber Name, with contact details
the patient is known to have disease of the (perhaps incorporated as header/footer of
organs required for elimination of the drug prescription); Date of prescription; Patient Name
selected, adjustment of the average regimen is and/or registration number (R/N), Date of Birth
needed. For a drug such as ibuprofen, which is and/or Age. Approved medicine name (avoid
eliminated mainly by the kidneys, renal function abbreviations, prefer generic name) Dosage strength
should be assessed. If renal function is normal, (with appropriate units); Route of administration or
the half-life of ibuprofen (about 2 hours) requires dosage form e.g. tablet; Frequency of administration
administration three or four times daily. The or dosing interval e.g. three times a day or every 6
dose suggested in drug handbooks, and the hours; Duration of therapy or duration of supply;
manufacturer's literature is 400–800 mg four Signature and initials of prescriber.
times daily. For practical purposes, the following
6. Devise a plan for monitoring the drug's action approximate conversions are useful:
(drug safety surveillance) and determine an
end point for therapy: The prescriber should be
able to describe to the patient the kinds of drug
Indian Journal of Pharmacy and Pharmacology, April-June 2015;2(2);134-138 135
P. Kumar A. et al. Rational Prescribing & Prescription Writing: Role of Clinical Pharmacologist to Improve the….

1 grain (gr) = 0.065 grams (g), often rounded to 60 authorize "as needed" (prn) use that fails to state what
milligrams (mg) conditions will justify the need.
15 gr = 1 g
1 ounce (oz) by volume = 30 milliliters (mL) Poor Prescription Writing: Poor prescription
1 teaspoonful (tsp) = 5 mL writing is traditionally exemplified by illegible
1 tablespoonful (tbsp) = 15 mL handwriting. However, other types of poor writing
1 quart (qt) = 1000 mL are common and often more dangerous. One of the
1 minim = 1 drop (gtt) most important is the misplaced or ambiguous
20 drops = 1 mL decimal point. Thus ".1" is easily misread as "1," a
2.2 pounds (lb) = 1 kilogram (kg). tenfold overdose, if the decimal point is not
unmistakably clear. This danger is easily avoided by
Indicators of prescribing quality (WHO CORE always preceding the decimal point with a zero. On
INDICATORS) the other hand, appending an unnecessary zero after a
Average no. of medicines per encounter, decimal point increases the risk of a tenfold overdose,
percentage of medications prescribed by generic because "1.0 mg" is easily misread as "10 mg,"
name, percentage of encounters in which whereas "1 mg" is not. The slash or virgule ("/") was
antibiotics/injection is prescribed, percentage of traditionally used as a substitute for a decimal point.
medicines prescribed from EML (essential medicines This should be abandoned because it is too easily
list in formulary), average consultation time, misread as the numeral "1." Similarly, the
prescription in accordance with STGs (standard abbreviation "U" for units should never be used
treatment guidelines), percentage of patients treated because "10U" is easily misread as "100"; the word
without medication, percentage of the patients "units" should always be written out. Doses in
satisfied with the care that they received. micrograms should always have this unit written out
because the abbreviated form ("g") is very easily
Prescribing Errors: Frequent use of antibiotics, misread as "mg," a 1000-fold overdose! Orders for
irrational fixed dose combinations and preparations drugs specifying only the number of dosage units and
of uncertain efficacy, inadequate labeling of not the total dose required should not be filled if
dispensed drugs and lack of access to standard tools more than one size dosage unit exists for that drug.
for rational drug use such as locally adapted essential For example, ordering "one ampule of furosemide" is
drugs list, formularies and standard treatment unacceptable because furosemide is available in
guidelines were some of the ampules that contain 20, 40, or 100 mg of the drug.
problematic prescribing and dispensing trends3. All The abbreviation "OD" should be used (if at all) only
prescription orders should be legible, unambiguous, to mean "the right eye"; it has been used for "every
dated (and timed in the case of a chart order), and day" and has caused inappropriate administration of
signed clearly for optimal communication between drugs into the eye. Similarly, "Q.D." or "QD" should
prescriber, pharmacist, and nurse. Furthermore, a not be used because it is often read as "QID,"
good prescription or chart order should contain resulting in four daily doses instead of one.
sufficient information to permit the pharmacist or Acronyms and abbreviations such as "ASA"
nurse to discover possible errors before the drug is (aspirin), "5-ASA" (5-aminosalicylic acid), "6MP"
dispensed or administered. (6-mercaptopurine), etc, should not be used; drug
Several types of prescribing errors are names should be written out. Unclear handwriting
particularly common. These include: can be lethal when drugs with similar names but very
different effects are available, e.g., acetazolamide and
Omission of Information: Errors of omission are acetohexamide, methotrexate and metolazone. In this
common in hospital orders and may include situation, errors are best avoided by noting the
instructions to "resume pre-op meds," which assumes indication for the drug in the body of the prescription,
that a full and accurate record of the "pre-op meds" is e.g., "acetazolamide, for glaucoma."
available; "continue present IV fluids," which fails to
state exactly what fluids are to be given, in what Inappropriate Drug Prescriptions: Prescribing an
volume, and over what time period; or "continue eye inappropriate drug for a particular patient results
drops," which omits mention of which eye is to be from failure to recognize contraindications imposed
treated as well as the drug, concentration, and by other diseases the patient may have, failure to
frequency of administration. Chart orders may also obtain information about other drugs the patient is
fail to discontinue a prior medication when a new one taking (including over-the-counter drugs), or failure
is begun; may fail to state whether a regular or long- to recognize possible physicochemical
acting form is to be used; may fail to specify a incompatibilities between drugs that may react with
strength or notation for long-acting forms; or may each other. The manufacturer's package insert usually
contains similar information. Physicians should
Indian Journal of Pharmacy and Pharmacology, April-June 2015;2(2);134-138 136
P. Kumar A. et al. Rational Prescribing & Prescription Writing: Role of Clinical Pharmacologist to Improve the….

realize that the pregnancy categories by themselves example, the measured volume of "teaspoons" ranges
provide little guidance for the physician treating from 2.5 to 7.8 ml. The parents should obtain a
pregnant women. For example, angiotensin- calibrated medicine spoon or syringe from the
converting enzyme (ACE) inhibitors such as pharmacy. These devices improve the accuracy of
captopril cause developmental toxicity (Category X) dose measurements and simplify administration of
only after the first trimester. Physicians' primary drugs to children.
responsibility remains treating the pregnant patient. When evaluating compliance, it is often
However, the risks of withholding treatment to the helpful to ask if an attempt has been made to give a
mother because of possible risks to the fetus have to further dose after the child has spilled half of what
be considered as well. Physicochemical was offered. The parents may not always be able to
incompatibilities are of particular concern when say with confidence how much of a dose the child
parenteral administration is planned. For example, actually received. The parents must be told whether
certain insulin preparations should not be mixed. or not to wake the infant for its every-6-hour dose
Similarly, the simultaneous administration of day or night. These matters should be discussed and
antacids or products high in metal content may made clear, and no assumptions should be made
compromise the absorption of many drugs in the about what the parents may or may not do.
intestine, e.g., tetracyclines. Noncompliance frequently occurs when antibiotics
By doing prescription audits (both are prescribed to treat otitis media or urinary tract
outpatient, inpatient and in ICU) regularly in the infections and the child feels well after 4 or 5 days of
primary, secondary and tertiary health care facilities therapy. The parents may not feel there is any reason
and in govt. medical colleges and hospitals by to continue giving the medicine even though it was
clinical pharmacologist can give some inputs to the prescribed for 10 or 14 days. This common situation
prescribing doctors/physicians so that together by should be anticipated so the parents can be told why
team work we can improve the patient quality of life it is important to continue giving the medicine for the
and also the quality of care. TDM (therapeutic drug prescribed period even if the child seems to be
monitoring) if the patient is not responding to the "cured."
appropriate dose of antimicrobial agents or anti- Pediatric Drug Dosage: Because of differences in
convulsants. By doing TDM we can check the serum pharmacokinetics in infants and children, simple
plasma concentration levels so that we can adjust the proportionate reduction in the adult dose may not be
dose. In some of the individuals we can see the adequate to determine a safe and effective pediatric
genetic polymorphism (altered response to the dose. The most reliable pediatric dose information is
particular group of drug-can be due to genetic usually that provided by the manufacturer in the
mutations in the specific enzyme.eg. NAT (N- acetyl package insert. However, such information is not
transfers enzyme for metabolizing INH) can be seen. available for the majority of products, even when
This can be seen with antipsychotics or studies have been published in the medical literature,
antidepressants and also with warfarin. reflecting the reluctance of manufacturers to label
their products for children. Recently, the FDA has
Pediatric Dosage Forms & Compliance: moved toward more explicit expectations that
Suspensions contain undissolved particles of drug manufacturers test their new products in infants and
that must be distributed throughout the vehicle by children. Still, most drugs in the common
shaking. If shaking is not thorough each time a dose formularies, e.g., Physicians' Desk Reference, are not
is given, the first doses from the bottle may contain specifically approved for children, in part because
less drug than the last doses, with the result that less manufacturers often lack the economic incentive to
than the expected plasma concentration or effect of evaluate drugs for use in the pediatric market. Most
the drug may be achieved early in the course of drugs approved for use in children have
therapy. Conversely, toxicity may occur late in the recommended pediatric doses, generally stated as
course of therapy, when it is not expected. This milligrams per kilogram or per pound. In the absence
uneven distribution is a potential cause of inefficacy of explicit pediatric dose recommendations, an
or toxicity in children taking phenytoin suspensions. approximation can be made by any of several
It is thus essential that the prescriber know the form methods based on age, weight, or surface area. These
in which the drug will be dispensed and provide rules are not precise and should not be used if the
proper instructions to the pharmacist and patient or manufacturer provides a pediatric dose. When
parent. pediatric doses are calculated (either from one of the
Compliance may be more difficult to methods set forth below or from a manufacturer's
achieve in pediatric practice than otherwise, since it dose), the pediatric dose should never exceed the
involves not only the parent's conscientious effort to adult dose. Interventions to rectify over prescription
follow directions but also such practical matters as of antibiotics and syrup formulations, inadequate
measuring errors, spilling, and spitting out. For labeling of drugs and lack of access to an essential
Indian Journal of Pharmacy and Pharmacology, April-June 2015;2(2);134-138 137
P. Kumar A. et al. Rational Prescribing & Prescription Writing: Role of Clinical Pharmacologist to Improve the….

drugs list are necessary to further CONCLUSION

improve rational drug use.4 The ultimate goals of studying and
intervening in medicines use practice include:
Special Pharmacodynamic Features in the Improving the quality of healthcare through
Neonate: The appropriate use of drugs has made effective and safe use of pharmaceuticals and
possible the survival of neonates with severe improving cost effectiveness of health care through
abnormalities who would otherwise die within days economic and efficient use of pharmaceuticals.
or weeks after birth. For example, administration of Strategies to improve rational prescribing can be
indomethacin causes the rapid closure of a patent characterized as targeted or system oriented
ductus arteriosus, which would otherwise require approaches. Programs to ensure rational use of
surgical closure in an infant with a normal heart. medicines should be an integral part of health and
Infusion of prostaglandin E1 analogues (alprostadil), medical care services. The responsibility for
on the other hand, causes the ductus to remain open, promoting rational use of medicines belongs to
which can be lifesaving in an infant with decision maker, administrators and clinicians as well
transposition of the great vessels or tetralogy of as health care professionals, consumers, educators
Fallot. An unexpected effect of such infusion has and pharmaceutical companies.
been described. The drug caused antral hyperplasia
with gastric outlet obstruction as a clinical REFERENCES
manifestation in 6 of 74 infants who received it. This 1. Jaine S, Upadhyaya.P, Goyal.J, kumar.A. a systematic
phenomenon appears to be dose-dependent. Neonates review of prescription pattern monitoring studies and
their effectiveness in promoting rational use of medicines,
are also more sensitive to the central depressant persp.cilini.research 2015:2.
effects of opioids than are older children and adults, 2. Deta.Z, Abula.T, Beyene.L. Assessement of rational drug
necessitating extra caution when they are exposed to use and prescribing in primary health care facilities in
some narcotics (e.g., codeine) through breast milk. North West Ethiopia. East Africa med .j,1997,12:758-63.
Physiologic processes that influence pharmacokinetic 3. Hazra.A, Tripathi.SK, Alam.MS. Prescribing and
variables in the infant change significantly in the first dispensing activities at the health facilities of a non-
governmental organization.Natl.Med.J.india,2000,4:177-
year of life, particularly during the first few months. 82.
Therefore, special attention must be paid to 4. Karande.S, Sankhe.P, Kulkarni.M Patterns of prescription
pharmacokinetics in this age group. and drug dispensing. Indian. j.of paed.2005,2:117-21.

Electronic Prescribing: The era of e-prescribing has

begun. Its implementation is still expensive, but the
subsequent benefits to patients and savings in
personnel costs, along with its integration with
electronic medical records, drug inventory control,
and billing, point to the wide use of e-prescribing in
the future. Computerized prescription ordering
eliminates some of the subjective features of
prescribing. Thus, if the proper information is entered
correctly in the electronic system, medication errors
due to illegible handwriting, incorrect dose, incorrect
medication for medical condition, and drug
interactions can be reduced, because each
prescription can be linked to high-quality drug
databases that check that the information on the
prescription is appropriate for the patient (e.g., age,
weight, gender, condition, lab values, disease being
treated, concurrent medications) and that known
warnings and potential problems are brought to the
attention of the physician, pharmacist, and patient.
Such systems must not be used as a substitute for
personal attention to the individual patient by
healthcare workers but, rather, as an adjunct measure
that ensures safe, high-quality, efficient care.

Indian Journal of Pharmacy and Pharmacology, April-June 2015;2(2);134-138 138