Rational Use of Drugs and Irrational Drug Combinations

Definition
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
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.
The safe, effective, appropriate and economic use of medicines is called rational use of
drugs. The definition as such seems to be clear and straightforward. The components of this
definition can be defined as:
Safety relates to aspects like relative and absolute safety. It is well known that all
medicines have side effects, some less and some more. The safety aspects has to be
assessed from different angles. E.g. the severity of disease, the available treatment
options including medicine and non-medicine treatment, long term or short term
treatment, whether the medicine is to cure or control symptoms, any risks of overdoses
and other possible factors.
Effectiveness relates to the question of how well the medicine works in daily practice
when used by unselected populations and patient having comorbidities and other
medications. Efficacy relates to the clinical trial type of situation, where we want to know
the maximum effect of the medicine in a particular disease and when it is optimally used
in selected patients with as few confounding factors as possible, such as comorbidities
and other medicine used simultaneously.
Appropriateness refers to how a medicine is being prescribed and used in and by
patients, including aspects such as appropriate indication, with no contraindication,
appropriate dosage and administration. Duration of treatment should be optimal and the
medicine should be correctly dispensed with appropriate and sufficient information and
counselling. To achieve the intended effects, the medicine also needs to be correctly used
by the patients.
The economic aspect does not refer merely to price; rather, a cost-effectiveness approach
needs to be applied, where all factors are assessed. A somewhat more expensive medicine
is preferable to a less expensive medicine, for example because it has better treatment
outcomes or fewer side effects. We should also be aware of hidden costs, such as a need
for more extensive laboratory test, which may increase the total cost of a particular
treatment.
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. 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.
Irrational drug use:
It occurs when there is under prescribing and over prescribing, incorrect
prescribing, extravagant or multiple prescribing or poly pharmacy. In addition to these irrational
drug use also occur when inadequate instructions are given to the patients leading to low
compliance. Since the patient is unable to take drugs appropriately.
Under prescribing; when needed medication Is not prescribed or dosage prescribed is
inadequate.
Over prescribing: the prescribe drugs are not needed to the patient mean quantity of drug
dispensed is too much for current course of treatment.
Incorrect prescribing: prescribing in which wrong drug is prescribed
Incorrect dispensing: it involve wrong drug dispensing due to improper prescribing.
Extravagant prescribing: more expensive drug brand is prescribed when less expensive generic
drug is available.
Multiple prescribing: Treating the patient symptomatically instead of treating the serious
illness. Hence making the patient to use lot of his funds.
Example of irrational drug use:
1. When no therapy is indicated for example self-limiting condition such as cold and flu.
Antibiotic for viral respiratory tract infection.
2. The use of wrong drug for specific condition requiring drug therapy. E.g. antibiotic for
viral hepatitis. In Acute childhood diarrhoea use of tetracycline instead of ORS.
3. Use of drugs having uncertain safety status e.g. Dipyrone analgesic.
4. Failure to provide safe and effective drugs for example vaccination failure against
measles or tetanus.
5. Use of correct drugs with incorrect administration dosage and duration for example use
of metronidazole I.V when suppositories or oral formulation are appropriate.
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 worlds 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 dont 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 concern & the drug regulatory authorities in the interpretation of the data related
to indications & safety of drugs.
2. Faulty & inadequate training & education of medical graduates: Lack of proper clinical
training regarding writing a prescription during training period, dependency on diagnostic aid,
rather than clinical diagnosis, is increasing day by day in doctors.
3. Poor communication between health professional & patient: Medical practitioners & other
health professional giving less time to the patient & not explaining some basic information about
the use of drugs
4. Lack of diagnostic facilities/Uncertainty of diagnosis: Correct diagnosis is an important
step toward rational drug therapy. Doctors posted in remote areas have to face a lot of difficulty
in reaching to 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 & ineffective drug regulation: Absence of well-organized
drug regulatory authority & 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:
Reduction in quality of drug therapy leading to increase morbidity and mortality.
Adverse, possibly lethal effects, e.g. due to antibiotic misuse or inappropriate use of
drugs in self-medication.
Limited efficacy, e.g. in the case of under-therapeutic dosage of antibiotics, tuberculosis
or leprosy drugs.
Antibiotic resistance, due to widespread overuse of antibiotics, as well as their use in
under-therapeutic dosage.
Drug dependence, e.g. due to daily use of painkillers and tranquilizers.
Risk of infection (due to improper use of injections): injection-related disorders are
abscesses, polio, hepatitis and AIDS.
Waste of resources: Reduced availability of other vital drugs and increased cost.
Psychological impact: when patient comes to believe that there is a pill for every ill, this
may cause an apparent increase demand for drugs promoting the irrational use of drugs.