Medical professionals need to "take a more sober, balanced, and cautious approach to prescribing," according to a panel of a physicians, pharmacists, and educators who devised a list of 24 recommendations aimed at helping providers – especially young providers – achieve that goal.
Plenty of evidence suggests that "medications are commonly used inappropriately, overused, and associated with significant harm," the panelists wrote in a review article published online June 13 in the Archives of Internal Medicine.
"We urge clinicians to take a more cautious approach to prescribing and administering chemicals whose effects are imperfectly understood," said Dr. Gordon D. Schiff of the Center for Patient Safety Research and Practice, Boston, and his associates.
The six authors of the paper based their recommendations on evidence and "lessons from recent studies demonstrating problems with widely prescribed medications."
The principles are aimed at younger physicians and trainees "who lack historical knowledge of past drug harms and withdrawals from the market," and they are intended to counterbalance messages from pharmaceutical companies and pressure from patients.
Their recommendations include the following:
• Seek nondrug alternatives before prescribing. "Clinicians should broaden their repertoire to become more skilled and effective at counseling and prescribing exercise, physical therapy, diet changes, smoking cessation, orthotics, or surgery when appropriate.
"Substantial literature supports initiating nonpharmacologic measures as initial or preferred therapy for a range of conditions commonly treated with drugs, such as hypertension, diabetes, insomnia, back pain, arthritis, and headache," Dr. Schiff and his colleagues wrote (Arch. Intern. Med. 2011 June 13 [doi:10.1001/archinternmed.2011.256]).
• Consider potentially treatable, underlying causes of a medical problem rather than just treating the symptoms with a drug. For example, before prescribing a drug for erectile dysfunction, consider whether impotence might be a sign of marital discord, a pituitary problem, a sign of diabetes, or a drug-induced condition.
• Emphasize prevention. For example, "smoking cessation efforts save many more lives than [do] costly chemotherapies for smoking-related cancers."
• Use the "test of time" whenever possible. "Especially when dealing with undiagnosed symptoms or potentially self-limiting conditions, use restraint rather than reflex prescribing to avoid giving drugs that can confuse the clinical picture and compound uncertainties. Reassurance and close follow-up can often be as effective and acceptable to the patient as writing a prescription," they noted.
• Use only a few drugs, and learn to use them well. "By learning in depth how to use a more limited subset of medications and mastering dosing, adverse effects, interactions, and even what the tablets look like, clinicians will be in a better position to prevent errors and anticipate problems."
• Avoid frequent switching to new drugs without clear, compelling, evidence-based reasons. "Examples of irrational and often counterproductive medication changes include switching inpatient antibiotics frequently, switching new patients to a physician’s favorite medications even though the patient is stable [on other medications], or changing a regimen that has not had sufficient time to work."
• Start treatment with one drug at a time. "Temper the urge to start treatment with medications for a new patient’s hypertension, urinary tract infection, dyspepsia, headaches, and toenail infection – all on the first visit. When she develops a rash, or even reports dramatic improvement, you will not know which drug was responsible."
• Keep a high index of suspicion for adverse drug effects. "No matter how unusual or unlikely a symptom a patient reports, for any problem that develops while a patient is taking a medication, always consider that it might be drug related."
• Educate patients about possible adverse effects to ensure that they are recognized as early as possible.
• Learn about new drugs and new indications from trustworthy, unbiased sources. "Avoid education from pharmaceutical representatives or ‘experts’ with conflicts of interest; instead turn to independent drug bulletins," such as the Medical Letter, Prescrire, or Worst Pills, Best Pills, they noted.
• Do not rush to use newly marketed drugs. Long-term and rarer adverse effects cannot have been identified because too few patients have been exposed and not enough time has elapsed. Moreover, real-world patients are much more complex than are subjects in clinical trials, so the effect of new drugs on their preexisting conditions and complicated drug regimens is not yet known.
• Be certain that the drug improves actual patient-centered clinical outcomes rather than just treating or masking a surrogate marker. "There is a growing body of literature demonstrating situations where surrogate improvements do not translate into clinical benefits," such as longer survival or improved quality of life.
• Do not hastily or uncritically succumb to patient requests for drugs, especially drugs that they have heard advertised.