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 < 100 F – beneficial, no discomfort – no need to suppress • Fever >100 F – beneficial but discomforting – use paracetamol (15mg/kg/dose) • Fever > 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 < 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 > 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 > 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

21. 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