• Review the patient's drug history for known drug allergies and prior drug-induced adverse reactions.
• Ask if the patient is under treatment by other healthcare providers or has ordered prescriptions from the Internet.
• Ask about all drugs used now – prescription and over-the-counter. Remember that many over-the-counter drugs were once prescription medicines.
• Include herbal remedies and nutritional supplements in your questioning. Consider a patient's history and lifestyle. Think about diseases or conditions for which the patient is at risk.
• Make certain that you're current.
• Establish the nature and severity of the disorder under consideration for drug treatment.
• Ask about significant coexisting disorders – possible absolute contraindications for certain drugs.
• Evaluate any suspected organ dysfunction – possible relative contraindications for certain drugs. When creatinine values are available, take the time to calculate creatinine clearance. Many drugs have break points for adjusting the dosage at various levels of renal impairment. Even though an older patient's creatinine is within the "normal" limits, his or her clearance won't be.
• Assess the patient's potential for compliance or noncompliance with the drug therapy. Remember the expense that a given prescription presents. Once-a-day dosing is much easier to remember and, combined with a dosing calendar, gets excellent results. See if the patient's pharmacist offers a medication mapping service. If not, map your patient's medicines yourself.
• Find out where your patients get their prescriptions filled and partner with the pharmacy to have adherence checked on EVERY refill.

When selecting drugs for therapy:

• Try to match the drug's power to the patient's problem. Avoid over-prescribing.
• Always check for drug-drug, drug-food and drug-disease interactions. Remember to take a "new" drug history periodically.
• Consider the desired onset of drug action (immediate versus delayed) and the consequences or benefits of that effect.
• Choose the drug with the most favorable benefit-to-risk ratio.
• Give due consideration to the patient's prior experience with other drugs similar to the one you're considering, and prescribe accordingly. Prescribing a second drug from the same drug class from which a patient already had an allergic or adverse drug reaction or that provided no therapeutic benefit isn't prudent.
• When you prescribe narrow-therapeutic-window drugs that require periodic blood level tests, be sure that blood sampling is done after the drug has reached its steady state.
• Set goals and time frames when you start any new medicine. Talk these over with your patient.
• Remember individual patient factors such as age, education and cultural factors.
• Think about the desired extent of effect (systemic or local).
• Select the drugs you prescribe critically, using independent, objective reviews of available information. The most-often-prescribed drug is not necessarily the best drug within its class.
• If drug treatment fails after a reasonable trial with good adherence, change to a drug of another chemical class, or consider combination therapy.
• Even "drugs of choice" in objective reviews can be poor choices when you consider the characteristics of individual patients.
• Remember the pharmacokinetic and pharmacodynamic changes that occur in those over 65 that can lead to accumulation and excessive responses to "normal" doses and dosing intervals.
• Be objective and discerning as you review the claims made for a newly released drug within a sizeable class of drugs already available. Only a small percentage of newly approved drugs each year are classified by the FDA as truly innovative or more advantageous than similar drugs in current use.

When you issue prescriptions in writing or by telephone:

• ALWAYS give both the brand and generic name.
• Consider the advantage of including both the name of the drug and the therapeutic indication on the prescription label. This will help reduce dispensing errors caused by "look-alike" and "sound-alike" drug names, prevent confusion that often occurs during concurrent use of multiple drugs (especially among the elderly), reduce mistaken identity of drug and purpose and prevent mistakenly altered dosing schedules.
• Keep dosing schedules as simple as possible. Once-a-day dosing improves compliance.
• Alert the pharmacist to "look-alike" and "sound-alike" drug names. Print the drug name and generic name on written prescriptions. Spell the drug name when prescribing by telephone.

When counseling a patient about drug therapy:

• ALWAYS stress the critical nature of adherence to health outcomes. If your patient is adherence-challenged, talk about pill boxes, bottle reminders and even pager-based systems to make sure that your patient will take the medicines.
• Briefly explain the nature of the disorder and its treatment. Use language the average person can understand.
• Provide educational material about the disorder. If the disorder is chronic (diabetes, hypertension), explain the need to continue drug therapy indefinitely, possibly for life.
• Briefly explain the name and nature of the drug(s) you're prescribing. Stress the importance of strictly following the instructions for the medicine. Tell the patient about potential adverse effects.
• Explain the need for follow-up visits to monitor the effects of drug treatment and the course of the disorder.
• Explain that drugs may not work in practice exactly as expected. Tell the patient to be alert to the possibility that a new symptom or sign may be drug-related. If one of your patients does have a novel adverse drug reaction, it is critical that you call the FDA MedWatch at 1-800-332-1088.
• Encourage the patient to call as needed about any aspect of drug treatment. Adjust drug selection and/or dosage regimens to fit individual patients.
• Give special attention to older patients on drug therapy. The elderly generally use multiple drugs concurrently and are more likely to have adverse drug effects.
• If you refer any of your patients to another physician, be certain to take a repeat medication history when they return to your care. Check for duplications in medicines by cross-referencing brand or generic names.
• Every six months, ask your patients to bring in all the prescription, nonprescription and herbal medicines that they routinely take. This kind of "brown bag" session can help you best understand the potential or actual interactions of therapies your patient is or will be taking.

Suggestions for containing the costs of drug therapy:

• When you've selected the most appropriate drug, consider its cost. If the patient requests an available generic product, direct the pharmacist to dispense one with certified bioequivalence. Because of generic product variability, caution the patient to have the prescription refilled with the identical generic product (same manufacturer) each time.
• Avoid polypharmacy whenever possible. Limit the number of drugs that the patient is taking concurrently to the fewest required.
• Carefully consider any requests from patients for a prescription drug they have learned about through direct-to-consumer advertising. Assure your patients that you will prescribe the drug that, in your judgment, is the most appropriate one for them.

More Information
The information on this page is taken from The Essential Guide to Prescription Drugs, 2005*  by James J. Rybacki, Pharm. D., who is an American Heart Association volunteer. You can select the book title above to find out more.  *This link is provided for convenience only, and is not an endorsement or assurance of the entity or any product or service.



This content is reviewed regularly. Last updated 12/12/2008.