Principles of Monitoring Drug Therapy

This lecture by Dr. Bruce Clayton occurred on Thursday, August 26th

Study Materials
Required reading: Principles of Monitoring Drug Therapy Handout
 * Link to handout
 * link to flowchart
 * Link to Panopto

Describe the principles of rational therapeutics.

 * Rational therapeutics means "prescribing drugs to maximize the chances of efficacy and to minimize drug-induced illness". Rational therapeutics strives to individualize the therapeutic plan to match the needs of a particular patient by following the scientific principles of medicine and pharmacology
 * Set the legitimately expected results of therapy (as to efficacy and lower limits of toxicity) before beginning. Use those objectives to monitor drug effects and to signal the need for qualitative or quantitative changes in therapy.
 * A logical approach to therapy results in rational prescribing of even the most common medications. Requirements for rational therapy include:
 * 1. Reasonable certainty of the diagnosis


 * 2. Understanding the pathophysiology of the disease


 * 3. Understanding the pharmacology of the drug that could be used


 * 4. Choosing the drug and dose that are likely to be optimal for the specific patient


 * 5. Picking end points of efficacy and toxicity, and vigorously monitoring the patient to check for those end point


 * 6. Developing a contract or alliance with the patient and keeping it; being willing to alter the therapeutic regimen if objective evidence of drug efficacy is not seen or if unacceptable toxicity is encountered.


 * Every qualitative (choosing a drug) and quantitative (doses; how often and how much) therapeutic decision should be individualized and optimized.
 * More than knowledge about probable drug interactions is needed to prevent them. An attitude that encourages anticipation of the possible effects of any change in a patient's drug regimen should be developed.
 * The physician (pharmacist) must put the patient's welfare first and practice rational therapeutics. The physician (pharmacist) cannot do either when (he/she) consciously or unconsciously has a material interest in which drug is prescribed. Such real and potential conflicts of interest not only can undermine the practitioner-patient relationship, but also can undermine public confidence in the profession
 * Choosing appropriate end points of efficacy may not be straight-forward. Targets and goals may change as understanding of the disease or the drugs changes.
 * Only when the physician (Pharmacist) approaches each prescription as the beginning of a therapeutic experiment (an experiment with an N = 1) of uncertain outcome, and not as a concluding act to an office visit, will the chances that the experiment will be as safe, effective and fruitful as possible be optimized.

Appropriate therapeutic choices are not simple, but they can appear to be. Guidelines are available to treat almost everything; the resilience of human physiology frequently makes up for pharmacologic overkill, and when it doesn't, drug-induced complications can mimic and therefore be attributed to disease-induced problems. When therapy fails, we frequently can attribute the failure to the disease and escape blame. Probably nowhere else in professional life are mistakes so easily hidden, even from ourselves. But there is another side to the story. The rewards for appropriate therapeutic decisions, no matter how time-consuming and how expendable others will tell you such tinkering is, can be the biggest ones in health care. Consider preventing a stroke, relieving pain, curing pneumonia, compensating for threatening imbalances in electrolytes, managing a seizure, relieving depression, curing leukemia, or preventing blindness. These therapeutic acts require unusual skill and time, but they are the essence of why many have entered the practice of healthcare. These accomplishments do not come from simply following guidelines. They come from individualization of a therapeutic plan that is based on the physician's (pharmacist’s, physician assistant’s, nurse practitioner’s) mastery of the core facts, skills, and attitudes of the discipline of clinical pharmacology.