Rational therapy

• 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

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

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

“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

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

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

Rational management of fever

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

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

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)

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)

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

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

Interpretation of CBC• Reliable with automated counter resultsHb 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 ALLHigh +/- ++ 0 Low Dengue

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

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

Rational management of cough

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

Recurrent Persistent Fever No fever No feverViral Bact. Atopic Non-atopic URI LRI Adenoid CF Asthma Preterm Pertusis

Sinuses CD Aspiration FB

Tonsils Immu. CHD

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

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