Rational Use of Drugs and Irrational Drug Combinations

Irrational use of medicines is a global phenomenon. Rational use of drugs may be defined as: Patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and the lowest cost to them and their community. Overuse, polypharmacy and incorrect use of drugs are the most common problems of drug use today. Irrational use of drugs may result due to various reasons at various levels including the prescribing errors and over the counter drugs. Irrational use of medicines may lead to serious negative health and economic consequences. Many irrational drug combinations are available in the Indian market. Proper implementation of rational use of drugs will improve the quality of life and result in better community healthcare.

The Alma-Ata declaration, during the International Conference on Primary Health Care in 1978, reaffirms that health is a fundamental human right and the attainment of the highest possible level of health is a most important worldwide social goal.1 Medicines are an integral part of the health care system and modern health care is unthinkable without the availability of necessary medicines. They not only save lives and promote health, but prevent epidemics and diseases too. Medications are undoubtedly one of the weapons of mankind to fight disease and illness. Accessibility to medication is a fundamental right of every person.2

Ever since the accessibility of modern medicine increased all over the world , increasing incidents of its misuse in the form of overprescribing, multi -drug prescribing, use of unnecessary expensive drugs, selfmedication and overuse of antibiotics and injections have started. Thus, medications are starting to be misused.

Irrational drug use is a global phenomenon now. Medically inappropriate, ineffective and economically inefficient use of drugs occur all over the world. The scenario in developing countries is the worst. According to the reports of NRHM India, irrational drug use is a widely pervasive, irrational practice of medicine and is a matter of serious concern, especially for a developing country like India. 3, 4

The concept of rational drug use is age old, as evident by the statement made by the Alexandrian physician, Herophilus, in 300 B.C that “Medicines are nothing in themselves, but are the very hands of god if employed with reason & prudence" 5 In simplest words rational use means "patient receiving appropriate drug to clinical needs, in adequate dose for the sufficient duration and at the lowest cost possible." As per the WHO (1985), the definition of rational use of medicines - "Patients receive medications 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 their community." 6,7

In addition to above definition, which is from the angle of medical therapeutic view, rational use of drugs can also be viewed from the consumers perspectives. What is rational in a medical sense may not be rational for the consumer and vice versa. For the consumer, the rationality of using a drug is based on the (re) interpretation of its value for daily life, influenced by cultural perceptions and economic conditions.8 In India, therefore it can be a complex one with multiple cultures, religions, dialects and castes. For example, in North-east India, as Malaria is endemic in nature, people may buy and keep a few antimalarial tablets to be consumed whenever bouts of malarial attack comes, never bothering to complete the whole course of the medicine. Or, as most part of north eastern India is tough hilly terrain, people may prefer to spend money on analgesic tablets, and particularly injections to relieve their misery and to be able to carry on their normal works of earning livelihood, while good food and rest would have been better for their health.

Therefore, in understanding the actual meaning of rational use of drugs, both perspectives may need to be considered. However, the present overview on rational use of drugs shall be restricted to the medical perspective only.

The problem of irrational use
As per WHO, irrational or non-rational use is the use of medicines in a way that is not compliant with rational use as defined above. It was reported that worldwide, more than 50% of all medicines are prescribed, dispensed, or sold inappropriately, while 50% of patients fail to take them correctly. Moreover, about one-third of the world’s population lacks access to essential medicines. Common examples of irrational medicine use are:

Overuse of drugs and injections: occurs as a consequence of overprescribing as well as overconsumption. It concerns particularly the use and prescription of antibiotics, antidiarrhoeals, painkillers, injections and cough and cold preparations. Injections have long had a special connotation as particularly powerful and fast acting medicines.

Multi-drug use or polypharmacy: The number of drugs per prescription is often more than needed, with an average of 2.4 up to ten drugs, while generally one or two drugs would have sufficed. Multi-drug use is also common among consumers who purchase their drugs (over the counter drugs).

Incorrect drug use: involves the wrong drug for a specific condition(e.g. antibiotics or antidiarrhoeals for childhood diarrhoea), drugs of doubtful efficacy (e.g. antimotility agents for diarrhoea), or use of drugs in the wrong dosage (which is often the case with antibiotics, ORS and antimalarials). Incorrect drug use occurs in the sense of incorrect prescribing as well as inappropriate use by consumer.

Reason for irrational use of drugs
There are several reasons which may contribute to irrational use of drugs in our country:

1. Lack of information: Unlike many developed countries we don't have regular facilities, which provide us with up to date, unbiased information on the currently used drugs. The majority of our practitioners rely on medical representatives. There are differences between pharmaceutical companies and the drug regulatory authorities in the interpretation of the data related to indications and safety of drugs.

2. Faulty and inadequate training and education of medical graduates: Lack of proper clinical training regarding writing a prescription during training period, dependency on diagnostic aids, rather than clinical diagnosis, is increasing day by day in doctors.

3. Poor communication between health professional and patient: Medical practitioners and other health professional giving less time to the patient and not explaining some basic information about the use of drugs

4. Lack of diagnostic facilities/Uncertainty of diagnosis: Correct diagnosis is an important step towards rational drug therapy. Doctors posted in remote areas have to face a lot of difficulty in arriving at a precise diagnosis due to non-availability of diagnostic facilities. This promotes poly -pharmacy.

5. Demand from the patient: To satisfy the patient expectations and demand of quick relief, clinicians prescribe drugs for every single complaint. Also , there is a belief that 'every ill has a pill'. All these increase the tendency of polypharmacy.

6. Defective drug supply system and ineffective drug regulation: Absence of well-organized drug regulatory authority and presence of large numbers of drugs in the market leads to irrational use of drugs.

7. Promotional activities of pharmaceutical industries: The lucrative promotional programmes of the various pharmaceutical industries influence the drug prescribing

Impact of irrational use of drugs
Some of the public health and economic consequences of irrational use of drugs are:

Adverse, possibly lethal effects; due to misuse or inappropriate use of drugs in self-medication. 10

Limited efficacy; in the case of undertherapeutic dosage of antibiotics, tuberculosis or leprosy drugs.

Antibiotic resistance; due to widespread overuse of antibiotics, as well as their use in under-therapeutic dosage.11,12

Drug dependence; due to daily use of painkillers and tranquilizers. 13

Risk of infection; due to improper use of injections. Injection-related disorders are abscesses, polio, hepatitis and AIDS.14

Waste of resources; reduced availability of other vital drugs and increased cost.

The WHO says that antimicrobial resistance is one of the world's most serious public health problems worldwide. According to WHO, a major reason for the irrational use of medicines is due to the fact that more than 50% of all medicines are prescribed, dispensed or sold inappropriately and 50% of patients fail to take them correctly. The consequence of this is seen directly with the misuse of antibiotics.

The WHO model list of essential medicines contains only about two dozen approved drug combinations, whereas in India, there are innumerable examples of irrational drug combinations, which are available and can be bought without necessarily giving a prescription.

The issue of rational use of medicines has been debated since decades along with the essential medicine (EM) concept. Most of the economically developed and some developing countries have a medicine policy and their essential medicine list is regularly updated.15 Publication of EM list by Govt. of India in 2003 was a major step towards implementation of rational use of medicines. As of now, India has started to adopt policies of generic use, teaching and training the EM concept at the undergraduate level, pharmacovigilance programs and prescription audits, all contributing to the greater goal of rational use of medicines. On its proper implementation, it would be very helpful to reduce morbidity and mortality rates associated with drug use. It also will improve the allocation of resources leading to better availability of necessary drugs with proper costing. Overall, patients will benefit via decreased risk of unwanted effects such as adverse drug reactions and drug resistance. Promoting the rational use of medicines would definitely help mankind to fight diseases and illnesses for a better tomorrow.