Rational therapy

1

• Rational therapy

2

• Rationality endowed by reasoning
• Should be integral part of noble profession
• Present scenario irrationality at all levels /
  plenty of irrational formulations to choose from
  / polypharmacy a rule
• Essential drugs and rational therapy are two
  sides of the coin

3
Pillars of rational drug therapy

• Genuine indication
• Minimum number of drugs
• Inexpensive and appropriate formulation
• Preferably oral route avoid injections
• Monitor adverse drug reaction
• Patient education related to drugs and disease

4
Dynamics of irrationality

• Health care drug therapy
  Drug prescription natural inevitable
  consequence
• Lack of confidence leads to drug overuse
• Dearth of senior leaders as Role models
• Influence of drug industry only source of
  knowledge to many / biased information /
  incentives for prescriptions

5
Justification of irrational drug prescriptions

• Patients in private practice are different
• One cannot take a chance
• Patients expect quick relief
• Otherwise they may change the doctor
• Polytherapy obviates need for proper diagnosis
• Error of commission is acceptable but not error
  of omission

6
Effects of irrational therapy

• False sense of security
• Masking / confusing / delaying correct diagnosis
• Emergence of drug resistant organisms
• Increased cost higher drug reactions
• Wastage of resources
• Loss of faith in medical profession

7
Solutions

• Adequate time for detailed communication
• Be transparent and confident
• Documentation of explained statements
• Follow science and standard protocols
• Continued medical education
• Record keeping and self audit

8

• Rational management
• of fever

9
Facts about fever

• Fever results from Pyrogenic cytokines that are
  meant to enhance immunity
• Cytokine induced immunity best at 103 F
• Fever is protective it inhibits pathogens
• Fever pattern a clue to diagnosis may be
  blunted by use of potent antipyretics
• Avoid hyperpyrexia, simple febrile seizure and
  discomfort / ensure hydration

10
Should fever be suppressed?

• Fever lt 100 F beneficial, no discomfort no
  need to suppress
• Fever gt100 F beneficial but discomforting use
  paracetamol (15mg/kg/dose)
• Fever gt 104 F beneficial but may harm use
  paracetamol and tepid water sponge
• Paracetamol an ideal antipyretic Ibuprofen an
  alternative Nimesulide not safe

11
Rational action - first 3-4 days, judge probable
cause

• Acute onset of fever acute infection
• Rule out potentially serious age lt 3 mths /
  drowsy, irritable, confused / tachypnea, chest
  retractions / disproportionate HR-RR / oliguria
  
• Pattern of fever irregular (malaria) / rhythmic
  temporary response after paracetamol (viral, bact)

12
Rational action - first 3-4 days, judge probable
cause

• Onset and progression high at onset, better by
  D4 (viral), Peaking by D4 (bacterial)
• Behavior during inter-febrile period normal
  (viral, malaria), sick (bacterial)

13
Drug treatment first 3-4 days

• Clinical evidence of acute bacterial infection
  tonsilopharyngitis, otitis, bacillary dysentery,
  lymphadenitis choose appropriate first
  generation oral antibiotic
• No clue paracetamol and observe closely

14
Drug treatment first 3-4 days

• Fever continues gt 4 days, investigate -
  CBC, urinalysis, chest x-ray
  (CSF in infants, blood culture in older
  children)
• Consider empirical antibiotic based on
  epidemiology

15
Interpretation of CBC

• Reliable with automated counter results
• Hb TC P L E Pl
  Disease
• N 0 N
  Ac.bact.inf.
• N Low 0 Low
  Typhoid
• N 0 N
  Ac.viral inf.
• Low /- Low
  Malaria
• N N
  TB/chr.inf.
• N High
  Sys.Inf.
• Low Low
  ALL
• High /- 0 Low
  Dengue

16
Persistent fever gt 7-8 days

• If empirical antibiotic fails and no clue on
  investigations, review diagnosis (inf.other than
  routine / TB / non-infective conditions)
• No empirical antibiotic unless reasoned
  (macrolide for amoxy failed pneumonia)
• If two antibiotics fail, change diagnosis

17
Summary

• Fever is rarely an emergency but rule out
  potentially serious condition
• Once ruled out, use paracetamol SOS and cautious
  periodic follow-up
• Prescribe antibiotic only if diagnosis is certain
  or order relevant tests prior to it
• Proper documentation a must

18

• Rational management
• of cough

19
Core knowledge

• Significant cough a major symptom airway
  disease - severe cough larger airways, mild
  cough smaller airways / mild cough secondary
  symptom pleuroparenchymal disease
• Airway disease bronchitis (allergic - afebrile,
  viral - with fever), inhaled FB, pressure of
  mediastinal mass, rarely acute bacterial
  infection (mycoplasma) or chronic bacterial (TB)
• Antibiotic rarely required for severe cough

20

• Recurrent
  Persistent
• Fever No fever
  No fever
• Viral Bact. Atopic Non-atopic
• URI LRI
• Adenoid CF Asthma Preterm
  Pertusis
• Sinuses CD Aspiration
  FB
• Tonsils Immu.
  CHD

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Treatment

• Specific therapy
  Antibiotic for bacterial infection
• Symptomatic therapy
  Scientifically, cough syrup no remedy
  Practically, need for relief of discomfort
  Antihistamine / cough suppressant on SOS basis
  Bronchodilator in HRaD / no mucolytics
  
• Prophylactic therapy for persistent asthma
  No prophylactic antibiotic

22
Summary

• Severe the cough, less is the chance of
  pleuroparenchymal disease, rare is the need for
  chest x-ray and / or antibiotic
• Scientifically no treatment for cough but relief
  of discomfort is necessary
• Use cough sedative (dextromethorphan or
  pholcodeine) and / or antihistamines
• Bronchodilator for spasmodic cough