Learning about medicines:

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Learning about medicines

• needs a framework
• Andrew Herxheimer

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We need information to decide

• whether to use a medicine or not
• if yes, which to choose
• how to use it, for how long
• what to look out for while using it
• whether some event is connected with the medicine
• whether and how to change the dose or
• stop

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The information may not be enough to enable us
to decide because

• we dont know enough about the problem we want to
  treat
• or we cant easily apply it to our own
  circumstances
• or we lack experience confidence
• So we need to discuss it

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In deciding what to prescribe a doctor has to
consider

• the disease or problem
• the treatment
• the individual to be treated

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Half the job is having the information, the
other half, knowing what to do with it
judgments must be made. They involve facts and
values
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Weighing up benefits and harms

• can be complicated because
• the natural course of a disease varies
• an expected benefit matters more to some people
  than to others
• disadvantages of treatment, including possible
  harms, worry some more than others
• everyone has personal preferences

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Organising the information on a medicine Key
questions

• What type of medicine is it?
• Does it cure, relieve symptoms, prevent a
  problem, or help to maintain normal function?
• What are its benefits and disadvantages?
• How does it get to where it acts?
• How how fast is it eliminated?
• The bigger the dose, the bigger the effects?
• How do people differ in sensitivity to it?

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An example High blood pressure needing drug
treatment

• Ranking whats on the menu
• Effectiveness
• Safety
• Quality completeness of information
• Convenience
• Patients preference
• Cost

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Three types of drug to consider (1) a
diuretic (2) a beta-blocker (3) an ACE inhibitor

• Each helps to prevent stroke and heart attack
• Each is safe except (1) in gout,
• (2) in asthma, (3) in kidney disease
• Their side effects are mostly acceptable
• A lot is known about all three, none are new
• All are convenient to use
• (1) and (2) cost less than (3)

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Lets look at atenolol, a beta-blocker

• Benefits v. disadvantages
• atenolol reduces high BP, helps
• prevent angina, stroke, heart attack
• can worsen asthma, cause tiredness,
• cold hands feet

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Atenolol 2How does it get to where it
acts?It acts on the heart and reaches it via
the blood
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Atenolol 3How and how fast is it
eliminated?Its excreted in the urine A dose
acts for 8 to 24 hours
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Atenolol 4The bigger the dose, the bigger the
effect?Treatment can start with 25mg/day
or even less The dose can if necessary be
increased to 50 or even 100mg/dayBut higher
doses also cause side effects more often and
more intensely
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Atenolol 5Differences in individual
sensitivityMost elderly or thin people need
only small dosesWomen may need smaller doses
than menBlack people are less sensitive
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Concordance achieving shared goals in medicine
use

• To achieve shared goals,
• professionals and patients need to understand
  each other,
• and to understand how the other thinks.
• Doctors must not only inform, but listen and
  explain.
• Doctor originally meant teacher.

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But crash courses in consultations cannot do very
much

• Theres far too much else to take in
• Patients are often anxious or tense
• Time is short
• Learning/ teaching is rarely on the agenda for
  either patient or doctor

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So how should we shape the future of patient
information?

• 1. Information can only be well used by people
  with adequate information receptors. That means
  they have to understand the relevant concepts.
• 2. Ideally they should learn the rudiments of
  critical appraisal to be able to assess the
  relevance, validity reliability of information.
  
• 3. Sources of reliable health information on
  diseases, treatments, nutrition, etc must be
  identifiable as such.
• 4. Written information should be tested on
  samples of real patients, to check that most can
  use it effectively

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1. Basic concepts about medicines should be
taught in schools

• They straddle biology, domestic science and
  social science, and are easy to grasp
• They provide broader perspectives than drug
  education, which shouldnt be separate
• They are easy and interesting to illustrate from
  everyday experience and
  lend themselves to simple projects
• The students can be encouraged and helped to
  teach older family members as happens in many
  developing countries

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2. Critical appraisal workshops for patients/
consumers/ health service users can enable more
people

• to contribute their experience views to
• research agendas
• ethics committees
• health service management
• independent self-help groups
• to recognise misinformation manipulation

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3. Identifying reliable and helpful information

• Accreditation of information sources nationally
  internationally kitemarks?
• Transparent official endorsement of
  trustworthy information, eg using the DISCERN
  criteria
• Links to National electronic Library of Health
  (NeLH)
• Internet sites are a special problem

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4. Written information should be tested

• Until now most information is produced by
  professionals who decide what information
  patients/ consumers need, and not tested.
• We must involve consumers in the design of the
  information, and test leaflets, etc, on samples
  of the patients for whom they are intended, and
  improve the material until at least 80 of people
  can understand and use it effectively.
• This has been pioneered in Australia

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Pharmaceutical promotion

• The truth,
• the half-truth,
• and nothing like the truth
• Direct-to-consumer advertising of
  
• prescription medicines, as in the US,
  spreads misinformation, distorts health care,
  does not improve health, increases costs

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Last but far from least professionals must learn
from patients and carers

• Ask them what they think of the treatment
• how they use it
• Listen to their experiences eg DIPEx (Database
  of Individual Patients Experiences of illness)
• Enable patients to report adverse events directly
  to regulatory authorities companies
• Help patients to learn from the experiences of
  others

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DIPEx website

• Analysis of a broad range of peoples
  narrative descriptions of their experience
• Linked to evidence-based information about
  treatments, resources, support groups
• Overlapping information needs - presented for
  patients, family, teachers, students, health
  professionals, policy makers, researchers

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Welcome to DIPEx
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DIPEx database Narratives

• summaries of main themes from interviews
• illustrated with video, audio and written clips
  from the interviews people telling their
  stories

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DIPEx database Evidence

• descriptions of the condition, prevalence,
  prevention
• information about treatments, including evidence
  of effects
• questions and answers
• All indexed and searchable

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DIPEx studies now

• Complete on website hypertension, prostate
  cancer, breast cancer, colorectal cancer
• Current cervical screening, cervical
  cancer, testis cancer, carers of people with
  dementia
• Planned for 2002/03 epilepsy, rheumatoid
  arthritis, smoking cessation, malignant melanoma,
  lung cancer