Evidence-based prescribing

Physicians will be prompted to adhere to formulary restrictions and PBM-driven disease protocols more frequently. As a result, evidence-based prescribing may become more dependent on the use of appropriate clinical knowledge by PBMs rather than health care providers. 

Fischer MA, Avom J. Economic implications of evidence-based prescribing on hypertension Can better care cost less JAMA 2004 291 1850-1856. 

The evidence base for clinical decisions based on cost-effectiveness for the affective disorders is less clear than for schizophrenia. In bipolar disorder the primary effectiveness of the mainstay treatments, lithium and anticonvulsant pharmacotherapy, is undergoing considerable revision (Bowden et al, 2000). Until this is clarified, cost-effectiveness studies are probably premature. Nevertheless the cost burden in bipolar disorder is qualitatively similar to that in schizophrenia, with in-patient costs being the primary burden and associated social costs in treated patients. The drug costs are even less than those for schizophrenia. In Chapter 5 John Cookson suggests there is little economic evidence to drive prescribing decisions. The in-patient burden does not seem to have altered with the introduction of lithium. The only drug-related study (Keck et al, 1996) showed an obvious difference in treatment costs only when lithium was compared with sodium valproate. Since these are both cheap drugs this is unlikely to influence clinical decisions. The main question is what impact... 

An approach to selection of drugs for the treatment of patients with hypertension should be evidence-based with considerations regarding the individual s co-existing disease states, co-prescribed medications, and practical patient-specific issues including costs. 

Tannenbaum H, Bomardier C, David P, et al. An evidence-based approach to prescribing non-steroidal antiinflammatory drugs Third Canadian Consensus Conference. J Rheumatol 2006 33 140-157. 

This series of trials, and many more, has led to the dramatic change in how HRT is currently prescribed and greater understanding of the associated risks. HRT, once thought of as a cure-all for menopausal symptoms, is now a therapy that should be used only to reduce the frequency and severity of vasomotor symptoms associated with menopause in women without risk factors for CHD or breast cancer. The changes that have occurred over the years in the use of HRT further support the importance of evidence-based practice and judicious medication use. 

Training of prescribes but also all staff in the elderly care, Evidence Based Medicine, Computerised Prescriber Order Entry, Educational Outreach, inappropriate medications, documentation of clinical benefits, risk medications, drug interactions, pharmacological alterations with age. 

A large and growing number of older people across the world suffer from schizophrenia. Recommendations for their treatment are largely based on data extrapolated from studies of the use of antipsychotic medications in younger populations. In addition most manufacturers of such medications recommend prescription of reduced doses to the elderly. The evidence base for these assumptions is unclear and raises obvious questions regarding the appropriateness of such prescribing practice. 

Conscious, evidence-based and outcome oriented prescribing in concordance with the patient expectation and need to improve the patient health and quality of life... 

Addis, A., and N. Magrini. 2002. New Approaches to Analysing Prescription Data and Transfer Pharmacoepidemiological and Evidence-Based Reports to Prescribers. Pharmacoepidemiology and Drug Safety 11 721-726. 

One useful approach to tackle this problem of drug-induced illness caused by bad prescribing is known as academic detailing , in which a trained health professional meets with the physician in his or her office and functions as a source of neutral, academically oriented, evidence-based knowledge (see www.RxFacts.org). 

Evidence-based pharmacotherapy provides a succinct appreciation of the benefits of a drug, but rarely takes into account the patient s quality of life. Eor instance, intensive statin therapy is recommended because it reduces the incidence of cardiovascular death (odds ratio 0.86), myocardial infarction (odds ratio 0.84), and stroke (odds ratio 0.82) however, the increased risks for any adverse event (odds ratio 1.44), for abnormalities on liver function testing (odds ratio 4.48), for elevations in CK (odds ratio 9.97) and for adverse events requiring discontinuation of therapy (odds ratio 1.28) are less often taken into account by the prescriber. This example emphasises that individualisation is of the utmost importance to keep an acceptable benefit/risk ratio (Clin Ther 2007 29 253-60). The benefits of evidence-based pharmacotherapy may be obtained whenever concordance/compliance of the patient is adequate. However, concordance rate is slightly higher than 30% for chronic conditions, such as hypertension (Curr Hypertens Rep 2007 9 184-9), indicating that the patient has to be educated about the use of drugs, and therapy has to be individualised. 

See MeReC Briefing No. 28 (National Prescribing Centre, 2005) for further details of the evidence base relating to statins and also the Cholesterol Treatment Trialists (CTT) Collaborators (2005) meta-analysis. 

This book is about the scientific b i5is and practice of drug therapy, It is particularly intended for medical students and doctors, and indeed for anyone concerned with evidence-based drug therapy and prescribing. 

There are rare cases where established treatments are without strong evidence-based support. Two good examples exist for digoxin the treatment of mild heart failure and the treatment of cardiac asthenia, a diagnosis that is especially common in Europe, and for which relatively small doses are prescribed. When the effect of such treatments on... 

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