Prof. Carlo Fonseka Time to revisit rational drug prescribing



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The late Prof. Carlo Fonseka was one of the leading rationalists we ever had, and I feel that someone should write about a topic which was perhaps very close to his heart: that is rational prescribing of drugs.


Being a simple noncontroversial person and a physiologist he probably didn’t want to talk about a discipline which he did not belong to. But his association with the Father of Rational prescribing, the late Prof. Senaka Bibile, may have contributed to his thoughts on this topic, which he commented on privately. They had lots of things in common other than rationality. They were both ardent socialists with their hearts going out to the less privileged and the down trodden. Even though I was not fortunate enough to be taught by this master teacher, we at Peradeniya Medical Faculty have heard a lot about him and listened to him on a few occasions.


What is rational prescribing? This is the process of delivery of drugs to patients that are the most effective, with the least side effects, easily available, without interaction with other drugs, and cheap. As a former student of late Prof. Bibile we were taught about this topic and what was learnt was adopted during our clinical practice. He was also fair by some consultants who have great faith in drugs produced by a known company allowing the use of trade name, as well as the patient by including the generic name also in the prescription, since the latter is usually cheaper. Generic name is the scientific name of the drug and different companies would produce their own brands of the generic drug. He used to instruct us to write the brand name and the generic within parenthesis so that if the branded drug is not available the generic could be dispensed, provided the patient agrees.


Unfortunately, some medical officers do not stick to these side guidelines resulting in innumerable difficulties to the patients. Some of these problems include prescribing of very expensive drugs (some with dubious effectiveness), unavailability in pharmacies close by, drugs with lots of side effects and also expensive. But the most unscientific and sometimes even dangerous practice is the use of several drugs to treat a single disease. This is called ‘polypharmacy’ and could be called the bane of modern medicine. This practice transcends both Consultants (some of them at least) and some junior doctors making the patient to pay dearly. When they do not have sufficient funds they purchase only a few days’ supply leading to other complications, including half treated illnesses. Some junior doctors too adopt this practice both in the hospitals and in their private dispensaries. Prescribing such a lot of unwanted drugs could be a factor contributing to the shortage of drugs in government hospitals.


Another factor the doctors should consider when prescribing a large number of drugs is the effect on the patient’s quality of life. It is pointless prescribing highly potent drugs for a patient who is in his eighties, when he becomes intolerant to these drugs and develop other side effects such as gastritis and even kidney failure.


Misuse of antibiotics could lead to ‘antibiotic resistance’ where the germ develops insensitivity when the drug becomes ineffective when used again. This is a huge problem all over the world, mostly in the third world countries where even quacks prescribe antibiotics.


A close relative of polypharmacy is ‘polytesting’, where certain doctors order unnecessary and unwanted laboratory tests causing a huge financial loss to the patient. Most capable clinicians use least amount of investigations and depend entirely on their clinical judgment to treat the patient.


DR. UPALI ILLANAGSEKERA


Retired Professor of Medicine,


Kandy


 
 
 
 
 
 
 
 
 
 
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