Guide to Good Prescribing - A Practical Manual
(1994; 115 pages) [French] [Spanish] View the PDF document
Table of Contents
View the documentAcknowledgments
View the documentWhy you need this book
Open this folder and view contentsPart 1: Overview
Close this folderPart 2: Selecting your P(ersonal) drugs
View the documentChapter 2. Introduction to P-drugs
View the documentChapter 3. Example of selecting a P-drug: angina pectoris
Open this folder and view contentsChapter 4. Guidelines for selecting P-drugs
View the documentChapter 5. P-drug and P-treatment
Open this folder and view contentsPart 3: Treating your patients
Open this folder and view contentsPart 4: Keeping up-to-date
Open this folder and view contentsAnnexes
View the documentBack Cover
 

Chapter 5. P-drug and P-treatment

Not all health problems need treatment with drugs. As explained in Chapter l, the treatment can consist of advice and information, non-drug therapy, drug treatments, referral for treatment, or combinations of these. Making an inventory of effective treatment alternatives is especially important in order not to forget that non-drug treatment is often possible and desirable. Never jump to the conclusion that your P-drug should be prescribed! As with selecting your P-drugs, the criteria of efficacy, safety, suitability and cost should be used when comparing treatment alternatives. The examples illustrate how this works in practice.

Exercise

Make a list of possible effective and safe treatments for the following common patient problems: constipation, acute diarrhoea with mild dehydration in a child, and a superficial open wound. Then choose your P-treatment for each. The answers are discussed below.

Constipation

Constipation is usually defined as a failure to pass stools for at least a week. The list of possible effective treatments is as follows.

Advice and information:

Drink a lot of fluids, eat fruit and high fibre food. Only go to the toilet when the need is felt. Do not try to pass stools by force. Reassure patient that nothing points to serious disease.

Non-drug treatment:

Physical exercise.

Drug treatment:

Laxative (your P-drug).

Referral for treatment:

Not indicated.

In many cases advice and non-drug treatment will solve the problem. Because of tolerance, laxatives are only effective for a short period and may then lead to abuse and eventually even to electrolyte disturbances. The first treatment plan, your P-treatment, should therefore be advice; not drugs! If the constipation is severe (and temporary) your P-drug could be prescribed, e.g. senna tablets for a few days. If it persists, further examination is needed to exclude other diseases, e.g. a colon carcinoma.

Acute watery diarrhoea with mild dehydration in a child

In acute diarrhoea with mild dehydration in a child, the main objective of the treatment is to prevent further dehydration and to rehydrate; the goal is not to cure the infection! The inventory of possible effective treatments is therefore:

Advice and information:

Continue breast feeding and other regular feeding; careful observation.

Non-drug treatment:

Additional fluids (rice water, fruit juice, homemade sugar/salt solution).

Drug treatment:

Oral rehydration solution (ORS), oral or by nasogastric tube.

Referral for treatment:

Not necessary.

Your advice will prevent further dehydration, but will not cure it, and extra fluids and ORS will be needed to correct the loss of water and electrolytes. Metronidazole and antibiotics, such as cotrimoxazole or ampicillin, are not listed in the inventory because these are not effective in treating watery diarrhoea. Antibiotics are only indicated for persistent bloody and/or slimy diarrhoea, which is much less common than watery diarrhoea; metronidazole is mainly used for proven amoebiasis. Antidiarrhoeal drugs, such as loperamide and diphenoxylate, are not indicated, especially for children, as they mask the continuing loss of body fluids into the intestines and may give the false impression that ‘something is being done’.

Your P-treatment is therefore: advice to continue feeding and to give extra fluids (including home made solutions or ORS, depending on the national treatment guidelines), and to observe the child carefully.

Superficial open wound

The therapeutic objective in the treatment of an open wound is to promote healing and to prevent infection. The inventory of possible treatments is:

Advice and information:

Regularly inspect the wound; return in case of wound infection or fever.

Non-drug treatment:

Clean and dress the wound.

Drug treatment:

Antitetanus prophylaxis.


Antibiotics (local, systemic).

Referral for treatment:

Not necessary.

The wound should be cleaned and dressed, and tetanus prophylaxis should probably be given. All patients with an open wound should be warned about possible signs of infection, and to return immediately if these occur. Local antibiotics are never indicated in wound infections because of their low penetration and the risk of sensibilization. Systemic antibiotics are rarely indicated for prophylactic purposes, except in some defined cases such as intestinal surgery. They will not prevent infection, as permeability into the wound tissue is low, but they can have serious side effects (allergy, diarrhoea) and may cause resistance.

Your P-treatment for a superficial open wound is therefore to clean and dress the wound, give antitetanus prophylaxis, and advice on regular wound inspection. No drugs!

Conclusion

These three examples show that for common complaints the treatment of first choice often does not include any drugs. Advice and information are often sufficient, as in the case of constipation. Advice, fluids and rehydration are essential in the treatment of acute watery diarrhoea, rather than antidiarrhoeals or antibiotics. Dressing and advice are essential in the case of open wounds, not antibiotics.

In more serious cases, e.g. persistent constipation, serious dehydration in a small child or a deep open wound, referral may be the treatment of choice, and not ‘stronger’ drugs. Referral can therefore also be your P-treatment, e.g. when no facilities exist for further examination or treatment.

 

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