Selecting medicines:

The “P-medicine” concept

DR SAHIL KUMAR
DEPARTMENT OF PHARMACOLOGY
MAMC
 Outline
Rational Prescribing
Concept of p-medicines list
Selecting your set of p-medicines
P-medicine : Example
Advantages of p-medicine
Exercises
Summary
 Rational prescribing

“Rational use of medicines requires that

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 costs to the community.”
 RATIONALIZATION OF PRESCRIPTION
PRACTICES

Prescription of Rational medicines requires:

Accurate diagnosis.
Selection of best drug from the available.
Prescribing adequate drug for a sufficient length
of time.
Choosing the most suitable drug, weighing of
effectiveness, safety, and availability and cost.
 The Concept of p-medicine list

There is a need for evidence based, rational prescription.

Each GP has his/her own context with different needs and
priorities.
Scientists at the University of Groningen suggested a
method where each doctor prepares a list of essential
medicines for different conditions.
P-drug concept has been propagated by the WHO Action
Program on Essential medicines world wide.

Kawakami J, Mimura Y, Adachi I, Takeguchi N. [Application of personal drug (P-drug) seminar to clinical pharmacy
education
/ 20 in the graduate school of pharmaceutical 5sciences]. Yakugaku Zasshi. 2002 Oct;122(10):819-29
PERSONAL
PRACTICAL
PRIORITY
PREFERRED
Selecting your set of p-medicines
…
-- ah – the first one!
PROBLEM

Define the patient’s problem

DEFINE THERAPEUTIC 1. Determine the first choice

OBJECTIVE Give information/advice
CHOOSE THE TREATMENT Treat without drugs
Treat with a drug – P drug
Refer for Rx
Combinations
2. Check suitability for patient

START THE TREATMENT Write a prescription

Give info, instructions & warning
MONITOR THE TREATMENT
Monitor ( & stop ? )
treatment
 Selecting a p-treatment:
Overview
Step 1: Define the patient’s problem
Step 2: Specify the therapeutic objective
Step 3: Verify the suitability of your P-treatment
Step 4: Start the treatment
Step 5: Give information, instructions and warnings
Step 6: Monitor (and stop?) treatment
 Selecting a P-medicine: Overview

Step i : Define the diagnosis

Step ii : Specify the therapeutic objective
Step iii : Make an inventory of effective groups of
medicines
Step iv : Choose an effective group (p-group)
Step v : Choose a P-medicine
 Step iv: Choose an effective group according
to criteria

What would be your criteria to select a medicine

Efficacy
Safety
Suitability
Cost
EFFICACY:
Choose the appropriate class of drugs.
Choose the appropriate drug from the above class.

SAFETY
Lower the adverse effects, safer is the drug.
Drugs with higher Therapeutic index are easier and
safer to use.
SUITABILITY
Varies from individual to individual.
Depends on:
• Age(pediatric, geriatric)
• Sex, pregnancy
• Co-morbid conditions,hepatic and renal disorders
• Consciousness, bed ridden, vomiting,

• Drug formulation and route of drug administration

(oral drugs being better accepted than injectable)
COST COMPARISON
Per tablet , per Unit dose

Cost of one day of treatment

Cost of total cost of treatment

Cost of hospitalization, investigations, injections,

treatment of potential side effects
 Weight of criteria will differ according
to condition

Efficacy Safety Suitability Cost

% % % %

General dis. % 25 % 25 % 25 % 25 100

B. Meningitis % 80 % 20 %0 %0 100

B. Cystitis % 30 % 20 % 30 % 20 100
RIGHT THINGS TO DO:
RIGHT PATIENT
RIGHT DRUG
RIGHT DOSE
RIGHT ROUTE
RIGHT FREQUENCY
 SOURCES OF INFORMATION
PRIMARY LITERATURE
Published articles in journals
SECONDARY LITERATURE
Review articles
Newsletter
Online services eg : Cochrane collaboration
TERTIARY LITERATURE
Published books
 Example

A 52 year old Taxi driver complains of a sore throat &

cough which started 2 weeks earlier with a cold. He has
stopped sneezing but still has a cough, specially at night.
The patient is a heavy smoker who has often been advised
to stop. Further history and examination reveal nothing
special apart from a throat inflammation. The doctor
again advises the patient to stop smoking and writes a
prescription.

What is your P treatment for the patient?

1. Specify the diagnosis:
Bacterial infection
Irritation of mucus membrane
Tumour in the lung
_________________________________________________

2. Specify your therapeutic objective : suppression of dry

cough
Make an inventory of possible treatments :
1. ADVICE
2. NON – MEDICINAL INTERVENTION
3. DRUG – cough suppressants (opioid, anti histaminics )
4. COMBINATIONS
5. REFERRAL
TREATMENT EFFICACY SAFETY SUITABILITY COST

Advice ++++ ++++ - -- ++++

( Unsuitable pt wont ) ( cheap )
Stop smoking

Non Medicine +/- +++ + ++++

Meditation
Medicine group
OPIOID +++ + - +
++ + -- +
ANTI HISTAMINE

Medicine
CODEINE +++ ++ + + ( 2.3 )
+++ +++ + ++ ( 1.8 )
DEXTROMETHORPHAN ++ - + +++ (0.7 )
CHLORPHENIRAMINE
 Choose a P-medicine

Efficacy Safety Suitability Cost

Medicine 1

Medicine 2

Medicine 3
Active substance , dosage form , standard dosage schedule, standard duration
TREATMENT EFFICACY SAFETY SUITABILITY COST
( 100 ) ( 60 ) ( 20 ) ( 10 ) (10 ) 100

CODEINE 55 12 5 5 77

DEXTROMETHORPHAN 55 15 5 6 81

CHLORPHENIRAMINE 50 14 5 7 75
EFFICACY , SAFETY , COST
SUITABILITY FOR THE PATIENT

Rx For A Dry & Tickling Cough After A Cold

A) AVOID SMOKING
B) PRESCRIBE : DEXTROMETHORPHAN SYRUP 5ml ,
4 Times daily for 1 week
 Advantages of p-medicine

More confidence
More convenient
Less chances of unexpected A/E & interactions
Less complications
Increase adoption of rationale drug use
Health care delivery is easy
Health care management is simple & cheaper
 P-medicine concept also helps to …

 1 )Learn how to handle pharmacological data and concepts

 2 ) New drugs
New diseases
New information
Prescribing medicines dictated to you by others

 3 ) Know alternatives when your “ p medicine” cant be used

 P – MEDICINE EXERCISE

Q1. Write a prescription for the

a) acute (mild) treatment and
b) chronic prophylaxis
of Angina Pectoris for a 62 year old man.
Acute (mild) Angina : P - Group
DRUGS Efficacy (60) Safety (20) Suitability (20) Total (100)

NITRATES ++ (55) +(12) ++(15) 82

BETA-BLOCKERS +(45) +(12) +(13) 70

CALCIUM +(35) +(12) +(13) 60

CHANNEL
BLOCKERS

POTASSIUM +(30) +(12) +(13) 55

CHANNEL
OPENERS

METABOLIC +(5) +(12) +(13) 30

MODULATORS
Acute (mild) Angina : P - Medicine
Drugs Efficacy (55) Safety (20) Suitability Cost (5) Total (100)
(20)
Glyceryl trinitrate No difference
*Sublingual tab 0.5mg 0.5-30 min (50) b/w individual (15) Rs 2.0/ tablet 85
nitrates (15) (5)

Isosorbide dinitrate
*Sublingual tab 5mg 2-30 min (45) (15) (15) Rs 2.7/ tablet 78
(3)
Isosorbide mononitrate
*Oral tab 10mg 0.5-4 hours (15) (14) Rs 2.4/tablets 73
(40) (4)
Prophylaxis of Angina : P -
Group
DRUGS Efficacy (40) Safety (30) Suitability (30) Total
(100)
NITRATES +++(38) +(25) +(15) 78

BETA-BLOCKERS ++(35) ++(28) ++(25) 83

CALCIUM ++(30) +(25) +(20) 75

CHANNEL
BLOCKERS
POTASSIUM +(20) +(25) +(15) 60
CHANNEL
OPENERS
METABOLIC +(20) +(25) +(15) 60
MODULATORS
 Prophylaxis of Angina : P -
Medicine
Drugs Efficacy (30) Safety (25) Suitability (25) Cost (20) Total
(100)
Atenolol (20) (20) (5) 70
All equally effective
(25)

Metoprolol (20) (20) (3) 68

(25)

Propranolol Contraindicated (20) 59

(25) in variant (4)
angina (10)
 Dr. Shashank Pandey
(MBBS, MD Medicine)
Regn. No. DMC/R/2204
Medicine O.P.D. No. 12,
Vardhaman Hospital, Delhi – 92
Phone : 011-22775035, Email : Shashank.p@gmail.com
Date: 20/02/2018
Name of the patient Satya Sharma
Address 17-D, Pocket – C, Mayur Vihar Phase – 2, Delhi – 110091
Age and Sex 62 years/ Male
Rx
• Tab. GLYCERYL TRINITRATE 5mg SUBLINGUAL STAT
One tablet should be taken.
If symptoms do not resolve, may be repeated at 5 minute intervals for 3 doses.
• Tab. ATENOLOL 25 mg OD
• Follow up in 2 weeks

Signature
(Dr. Shashank Pandey)
Stamp
DISPENSED
Date : 23/03/2016 Pharmacist : Mr. Rajesh
Name of the Pharmacy City : Delhi
 P – MEDICINE EXERCISE

2. Write a prescription for chronic prophylaxis

of Angina Pectoris for an asthmatic 62 year old
man.
Asthmatic with Chronic Angina
: P - Group
DRUGS Efficacy (40) Safety (30) Suitability (30) Total
(100)
NITRATES +++(38) +(25) +(15) 78

BETA-BLOCKERS ++(35) +(25) (0) 60

CALCIUM ++(33) +(25) +(22) 80

CHANNEL
BLOCKERS
POTASSIUM +(20) +(25) +(15) 60
CHANNEL
OPENERS
METABOLIC +(20) +(25) +(15) 60
MODULATORS
 Asthmatic with Chronic Angina
: P - Medicine
Drugs Efficacy (30) Safety (25) Suitability (25) Cost (20) Total
(100)

Amlodipine (25) (23) (20) (10) 78

Nifedipine (25) (20) (15) (10) 70

Diltiazem (15) (15) (15) (15) 60

Verapamil (20) (10) (15) (15) 60

 Dr. Shashank Pandey
(MBBS, MD Medicine)
Regn. No. DMC/R/2204
Medicine O.P.D. No. 12,
Vardhaman Hospital, Delhi – 92
Phone : 011-22775035, Email : Shashank.p@gmail.com
Date: 20/02/2018
Name of the patient Satya Sharma
Address 17-D, Pocket – C, Mayur Vihar Phase – 2, Delhi – 110091
Age and Sex 62 years/ Male
Rx
• Tab AMLODIPINE 2.5 mg OD
• Follow up in 2 weeks

Signature
(Dr. Shashank Pandey)
Stamp
DISPENSED
Date : 23/03/2016 Pharmacist : Mr. Rajesh
Name of the Pharmacy City : Delhi
 SUMMARY

I. Rational II. Selecting your III. Treating your

therapeutics set of ‘P’ medicine patients
 SUMMARY
How to select a P- medicine ?
Define the diagnosis
Specify the therapeutic objective
Make an inventory of effective groups
Choose a group according to criteria
Choose a medicine from the chosen groups according to
criteria
“There are no prescriptions for life.”
― Marty Rubin