06:44am Friday 15 December 2017

Less is More: Practical Principles for Prescribing Patient Medication

A new article published online June 13, 2011in the Archives of Internal Medicine series Less is More entitled “Principles of Conservative Prescribing” harvests the lessons from these experiences and outlines 24 principles for prescribers to learn and practice to avoid many of the pitfalls leading to excessive and harmful prescribing.  

The concept of “conservative prescribing,” also referred to as more judicious, rational, cautious, or skeptical prescribing, embodies lessons from recent studies demonstrating that many medications are inappropriately used and at times are associated with significant harm.  These lessons suggest the need to more thoughtfully weigh claims for drugs, especially new drugs.  The  principles also draw upon an important construct from ecological thinking—the precautionary principle—which stresses the need to anticipate potential adverse effects, even when cause-and-effect relationships are not fully established.  It urges prescribers to err on the side of precaution when uncertain about long term impacts. 

According to lead author Dr. Gordon Schiff, from the Department of General Medicine at Brigham and Women’s Hospital, Associate Professor of Medicine at Harvard Medical School, and Clinical Director of the AHRQ-funded Center for Research and Education on Therapeutics  at the University of Illinois at Chicago College of Pharmacy (CERT-UIC), physicians need to move away from a mindset that leads them to heavily prescribe the “latest and greatest” new drugs—moving from “newer and more is better” to “fewer and more time tested is best.”   He urges medical and pharmacy schools to teach not just the pharmacology of drugs, but principles that would make practitioners better and more cautious prescribers and users of drugs. 

The 24 conservative principles urge clinicians to:

  • Think beyond drugs: consider and learn how to better prescribe nondrug therapies such as diet, exercise or physical therapy; look for and treat underlying causes rather than just masking symptoms with drugs, emphasize prevention rather than just treatment. 
  • Practice more strategic prescribing: defer drug treatment if drugs can be safely started after a trial of non-drug therapy; avoid frequent and unwarranted drug switching; being circumspect about unproven drug uses; start treatment with only one new drug at a time.
  • Maintain heightened vigilance regarding adverse effects: suspect drug reactions when patients report problems while taking a medication; be aware of drug withdrawal syndromes; educate patients about side effects so they can anticipate and report reactions. 
  • Exercise caution and skepticism regarding new drugs: seek out unbiased information sources; wait until drugs have sufficient time on the market to be proven to be safe; be skeptical about surrogate markers of benefit (such as improving a lab test) rather than true clinical outcomes benefit; avoid stretching indications to include patients or diseases different than those in the clinical trials; avoid seduction by elegant molecular pharmacology without proven outcomes benefits; beware of selective drug trial reporting that highlights the positive trials and hides those that fail to show benefit.  
  • Work with patients for a shared agenda: do not automatically accede to patient requests for drugs they have heard advertised, consider non adherence before adding additional drugs; avoid restarting previously unsuccessful drug treatments; discontinue any medications that are not needed or not working; and respect patients’ own reservations about drugs.
  • Consider long-term, broader impacts: weigh not just the short term benefits but also long-term patient outcomes and ecologic impacts, recognize that improved prescribing systems and better monitoring of patients on medications may outweigh marginal benefits of new drugs.

According to Dr. Bruce Lambert, coauthor and director of the UIC CERT and pharmacy professor who specializes in communication related to medication safety,  “none of these principles are particularly novel, nor should be terribly controversial. Yet taken together they represent a radical shift in the way clinicians think about and prescribe drugs.  Ironically, this radical shift is best summed up in the term “conservative prescribing,” and would potentially save many lives and dollars should these principles be adopted by every prescriber.”


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