P-Drug Concept

- Dr. Neha Agarwal

- JR 3
- Department Of Pharmacology
- AIIMS, PATNA
ALL INDIA INSTITUTE OF MEDICAL SCIENCES, PATNA 26/06/2024 1
 OVERVIEW
Introduction
Rational Prescription
Rationalization of Prescription
The concept of WHO guide to good prescribing.
Process of selection of P-drugs.
Aims and Objectives
Case Presentation
Take home message
Exercise 1
Exercise 2
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 Introduction
• P drug is also called as personal drug/ preferred drug/ priority choice of drug.

• These are the drugs that a physician is going to prescribe regularly and with which
he/she has become familiar for given indications.

• The P drug concept includes the name of a drug, dosage form, dosage schedule and
duration of treatment for a specified condition.

• P-drugs differ from country to country and between doctors.

• Each doctor prepare a list of essential drugs for different conditions.

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 Listing Of P drug varies between every individual physician due to
difference in:
1. Availability of drugs.

2. Cost of drug.

3. Different national formularies and essential drug list.

4. Medical culture.

5. Individual interpretation of drug source information.

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 Reasons why P-drug should never be the one suggested by role
model teachers/seniors guidelines/medical representatives.

The current and the most expensive drug is not necessarily the safest or most
efficacious drugs.

Development of P drugs leads to better knowledge of pharmacological

concepts and drug-related data in an effective manner.

Compiling P drugs leads to knowledge of better alternatives when the P-drug

cannot be used.

Most importantly, safety of patient lies in the hands of prescriber.

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 Rational Prescription

• Rational use of drugs 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 the lowest costs to the
community.

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 Rationalization of Prescription
 Most of the illness respond to simple, inexpensive drugs.

 There is a need for evidence based rational prescription.

 Physician should avoid:

• Use of expensive drugs.

• Use of drugs in non- specific conditions (example: Use of Vitamins).

• Use of not required forms (example: Injection in place of capsules, Syrup in place of
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tablets).
 Rational Use Of Medicine Includes Following Criteria

Appropriate indication
Appropriate medicine
Appropriate dosage
Appropriate patient
Correct dispensing
Patient adherence to treatment

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 The Concept Of WHO Guide to Good Prescribing

6 step model for rational prescribing

1. Define the patient’s problem.
2. Specify the therapeutic objective.
3a. Choose your standard treatment (P-drug).
3b. Verify the suitability of your treatment (P-drug).
4. Start treatment.
5. Give information, instructions and warnings.
6. Monitor (and stop?) treatment.
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 Process Of Selection Of P-Drug
• P- drug selection process involves 5 steps:

1. Define the diagnosis.

2. Specify the therapeutic objective.
3. Make an inventory of effective groups of drugs.
4. Choose an effective group according to criteria.
5. Choose a P-drug.

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Weight Of Criteria Will Differ According To Condition

Efficacy Safety Suitability Cost

% % % %
General 25% 25% 25% 25% 100%
disease
Bacterial 80% 20% 0% 0% 100%
Meningitis
Bladder 30% 20% 30% 20% 100%
Cystitis

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 AIM

• To prepare a list of P-drugs for a given case/condition.

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 OBJECTIVE

At the end of the session the trainees should be able:

• To count dimensions which are important in drug selection.

• To explain a method in preparing a p-drug list.

• To develop his/her own p-drug list.

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 Case Presentation

 A 60-year-old man, with no previous medical history presents to you with

complaints of chest pain. During the last month he has had several attacks
of suffocating chest pain, which began during physical labour and
disappeared quickly after he stopped. He has not smoked for 4 years. His
father and brother died of heart attack. Apart from occasionally taking
some aspirin he has not used any medication in the past year. Auscultation
reveals a murmur over the right carotid artery and the right femoral artery.
Physical examination reveals no other abnormalities. Blood pressure is
130/85, pulse 78 regular and body weight is normal.
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 Step I: Define the Diagnosis
Diagnosis-Angina Pectoris.

Types of Angina Pectoris

• Stable and unstable angina
• Classic angina pectoris and variant angina pectoris.

Both aspects have implication for treatment.

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 Step2: Specify the Therapeutic Objective

• As angina pectoris is caused by an imbalance in oxygen need and supply

in the cardiac muscle.

1. Either oxygen supply should be increased.(Stenosis cannot be dialated

with drugs in case of sclerotic obstruction).

2. Oxygen demand is to be reduced.(Decrease the preload, the contractility,

the heart rate or afterload of cardiac muscle.)

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 Step 3: Make an Inventory of Effective Groups of Drugs
• The first selection criteria for any group of drugs is efficacy.
• Weight of criteria (Efficacy, Safety, Suitability, Cost) will differ according
to condition.
• In this case, the drugs must decrease preload, contractility, heart rate,
afterload.
• There are three groups with such effect
1. Nitrates
2. Beta-blockers
3. Calcium channel blockers
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Sites of Action Of Drug Groups Used in Angina Pectoris

Drug Group Preload Contractility Heart Afterload

Rate/Frequency

Nitrates ++ - - ++

Beta- blockers + ++ ++ ++

Calcium channel + ++ ++ ++
blockers

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 Step 4: Choose an effective group according to the criteria
• The pharmacological action of these three groups needs further comparison.
• Evaluate efficacy, safety, suitability and cost of treatment.
• Efficacy-All groups (Nitrates, Beta blockers, Calcium channel blockers) contain
drugs or dosage forms with a rapid effect.
• Safety- All drug groups have side effects.
• Suitability- Dosage form should be one that can be handled by the patient and
should gurantee a rapid effect. (All-injectibles so disadvantage, Nitrates-
sublingual so an advantage)
• Cost- Prices differ between brands and are more linked to individual drug
products than to drug groups.(Glyceryl trinitrate SL-Rs 3, Isosorbide dinitrate SL-
Rs 1, Isosorbite mononitrate-Rs 6.
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Comparison between three drug groups used in Angina Pectoris
Drug Group Efficacy (PD) Safety (Side Effects) Suitability (C/I, Cost
dosage)
Nitrates PD-Peripheral vasodialation, Flushing, headache, Cardiac GTN- Rs 3
tolerance. temporary tachycardia. failure,hypotension,rais Isosorbide dinitrate- Rs
PK-High first pass Nitrate poisoning due ed intracranial 2
metabolism. to longlasting oral pressure. Isosorbide
dosage. Anaemia. mononitrate-Rs 6

Beta blockers PD-Reduce heart rate and Hypotension, Hypotension, Metoprolol- Rs 3.4
contractility. Congestive sinus Congestive heart Propanolol- Rs 1.3
PK-Lipophilicity increases bradycardia, AV block. failure, Bradycardia,
passage through BBB. Provocation of AV block, Sick sinus
asthma,Cold hands and syndrome.
feet, Hypoglycemia, Asthma,Raynaud’s
Impotence. disease, Diabetes,
Drowsiness, decreased Liver dysfunction.
reactions.

Calcium channel PD- Coronary and peripheral Tachycardia, dizziness, Hypotension, Amlodipine- Rs 0.4
blockers vasodialation,Reduced heart flushing, hypotension, Congestive heart Diltiazem- Rs 0.9
rate and contractility
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Congestive heart failure, AV block, sick Verapamil-
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Rs 0.46
PK-Half life is 5 hours. failure, sinus sinus syndrome
bradycardia,AV block
Choose an effective group according to criteria ( Give scores from 1-4 and multiply by criteria
coefficient).

Efficacy Safety Suitability Cost Total

40% 30% 20% 10% 100%

Nitrates 4 (1.6) 3 (0.9) 3 (0.6) 4 (0.4) 3.5

Beta blockers 4 (1.6) 3 (0.9) 2 (0.4) 3 (0.3) 3.2

Calcium 4 (1.6) 3 (0.9) 2 (0.4) 3 (0.3) 3.2

channel
blockers

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 Step 5: Choose a P-drug
Efficacy Safety Suitability Cost Total
40% 30% 20% 10% 100%

Isosorbide 4 (1.6) 3 (0.9) 3 (0.6) 4 (0.4) 3.5

dinitrate

Glyceril 4 (1.6) 3 (0.9) 4 (0.8) 2 (0.2) 3.5

trinitrate

Isosorbide 3 (1.2) 3 (0.9) 3 (0.6) 1 (0.1) 2.8

mononitrate

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 P drug form for this Exercise
Comparing above parameters
• Nitrates can be chosen as p-drug for Angina.
• Indication- Stable Angina Pectoris
P drug 1 (1st choice)
• Name- Isosorbide dinitrate
• Dose available- 5mg, 50 tablets package
• Use- One tablet sublingually when pain arises.
• Duration- Until next visit.
P drug 2 (2nd choice)
• Name- Glyceryl trinitrate
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Choose a standard dosage schedule
• As the drug is to be taken during an acute attack, there is no strict dosage
schedule.
• The drug should be removed from the mouth as soon as the pain is gone.
• If the pain persists, a second tablet can be taken after 5-10 minutes.
• If it persist after a second tablet, the patient should be told to contact a doctor
immediately.
Choose a standard duration of the treatment
• Duration of the treatment should be determined by the need for follow- up.
• In general only a small supply of glyceryl trinitrate tablets should be prescribed as
the active substance is volatile.
• The tabet may become ineffective after some time.
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 Take Home Message

 P drug is not always drug of choice.

 We have to develop own P-drug and personal formulary.

 By this process, we will be able to achieve one of the goal of WHO- Rational use
of drugs.
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 EXERCISE 1
Q1. Select p-drug for the given case/disease condition.
Anil Verma, a 42 years old male, presents to you and you found him to be diabetic during
routine medical check-up. He does not experience any symptoms related to increased blood
glucose (postprandial blood sugar 160 mg/dl). Physical examination reveals his BP 160/130
mm Hg, weight 76 kg, height 5 feet 10 inches. No other abnormality is found. Comment on
selection of your p-drug for treatment of hypertension in your patient.
a. What is the patient’s problem?
b. What is the goal of treatment in this patient?
c. Prepare a list of effective group/groups of your choice for the given condition giving
justification.
d. Choose the most appropriate drug/drugs from your chosen group of drugs based on
efficacy, safety, suitability, cost, for this patient.
e. Write the prescription with suitable instruction and follow-up for this patient.
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 Exercise 2
Q2. A 28 years old pregnant lady (gestational age of 8 weeks) is found to be diabetic
during routine medical check-up. She does not experience any symptoms related to
increased blood glucose (postprandial blood sugar 160 mg/dl). Physical examination
reveals his BP 160/130 mm Hg, weight 62 kg, height 5 feet 1 inches. No other
abnormality is found. Comment on selection of your p-drug for management of
increased blood pressure of your patient.
a. What is the patient’s problem?
b. What is the goal of treatment in this patient?
c. Prepare a list of effective group/groups of your choice for the given condition
giving justification.
d. Choose the most appropriate drug/drugs from your chosen group of drugs based
on efficacy, safety, suitability, cost, for this patient.
e. Write the prescription with suitable instruction and follow-up for this patient .
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