Best prescribing principles for special groups

Medical prescription is a legal written order from a qualified prescriber to a qualified dispenser which contains instructions to dispense or compound and administer specified medicines to a clearly mentioned patient. Prescriber, means any medical practitioner who is licensed or authorized to write prescription.
Prescriber, means any medical practitioner who is licensed or authorized to write prescription.

Medicines should be prescribed only when they are necessary, and in all cases the benefit of administering the medicine should be considered in relation to the risk involved. This is particularly important during pregnancy, when the risk to both mother and fetus must be considered

It is important to discuss treatment options carefully with the patient to ensure that the patient is content to take the medicine as prescribed. In particular, the patient should be helped to distinguish the adverse effects of prescribed drugs from the effects of the medical disorder. When the beneficial effects of the medicine are likely to be delayed, the patient should be advised of this.

Prescription writing

Prescriptions should be written legibly in ink or otherwise so as to be indelible, should be dated, should state the name and address of the patient, the address of the prescriber, an indication of the type of prescriber, and should be signed in ink by the prescriber. The age and the date of birth of the patient should preferably be stated, and it is a legal requirement in the case of prescription-only medicines to state the age for children under 12 years.

Prescribing for children

Children, and particularly neonates, differ from adults in their response to drugs. Special care is needed in the neonatal period (first 28 days of life) and doses should always be calculated with care. At this age, the risk of toxicity is increased by reduced drug clearance and differing target organ sensitivity.

Whenever possible, intramuscular injections should be avoided in children because they are painful. Where possible, medicines for children should be prescribed within the terms of the marketing authorization (product licence). However, many children may require medicines not specifically licensed for paediatric use.

Prescribing in hepatic impairment

Liver disease may alter the response to drugs in several ways as indicated below, and drug prescribing should be kept to a minimum in all patients with severe liver disease. The main problems occur in patients with jaundice, ascites, or evidence of encephalopathy.

Impaired drug metabolism:  Metabolism by the liver is the main route of elimination for many drugs, but hepatic reserve is large and liver disease has to be severe before important changes in drug metabolism occur. Routine liver-function tests are a poor guide to the capacity of the liver to metabolise drugs, and in the individual patient it is not possible to predict the extent to which the metabolism of a particular drug may be impaired.

Hypoproteinaemia: The hypoalbuminaemia in severe liver disease is associated with reduced protein binding and increased toxicity of some highly proteinbound drugs such as phenytoin and prednisolone.

Fluid overload: Oedema and ascites in chronic liver disease can be exacerbated by drugs that give rise to fluid retention, e.g. NSAIDs and corticosteroids.

Hepatotoxic drugs:  Hepatotoxicity is either doserelated or unpredictable (idiosyncratic). Drugs that cause dose-related toxicity may do so at lower doses in the presence of hepatic impairment than in individuals with normal liver function, and some drugs that produce reactions of the idiosyncratic kind do so more frequently in patients with liver disease. These drugs should be avoided or used very carefully in patients with liver disease.

Prescribing in pregnancy

Drugs should be prescribed in pregnancy only if the expected benefit to the mother is thought to be greater than the risk to the fetus, and all drugs should be avoided if possible during the first trimester. Drugs which have been extensively used in pregnancy and appear to be usually safe should be prescribed in preference to new or untried drugs; and the smallest effective dose should be used.

Few drugs have been shown conclusively to be teratogenic in humans, but no drug is safe beyond all doubt in early pregnancy. Screening procedures are available when there is a known risk of certain defects.

Prescribing in breast-feeding

The amount of drug transferred in breast milk is rarely sufficient to produce a discernible effect on the infant. This applies particularly to drugs that are poorly absorbed and need to be given parenterally. However, there is a theoretical possibility that a small amount of drug present in breast milk can induce a hypersensitivity reaction.

A clinical effect can occur in the infant if a pharmacologically significant quantity of the drug is present in milk. For some drugs (e.g. fluvastatin), the ratio between the concentration in milk and that in maternal plasma may be high enough to expose the infant to adverse effects. Some infants, such as those born prematurely or who have jaundice, are at a slightly higher risk of toxicity. Some drugs inhibit the infant’s sucking reflex (e.g. phenobarbital) while others can affect lactation (e.g. bromocriptine).

Prescribing for the elderly

Elderly patients often receive multiple drugs for their multiple diseases. This greatly increases the risk of drug interactions as well as adverse reactions, and may affect compliance. The balance of benefit and harm of some medicines may be altered in the elderly. Therefore, elderly patients’ medicines should be reviewed regularly and medicines which are not of benefit should be stopped.

Frail elderly patients may have difficulty swallowing tablets; if left in the mouth, ulceration may develop. They should always be encouraged to take their tablets or capsules with enough fluid, and whilst in an upright position to avoid the possibility of oesophageal ulceration.

Prescribing in palliative care

The number of drugs should be as few as possible, for even the taking of medicine may be an effort. Oral medication is usually satisfactory unless there is severe nausea and vomiting, dysphagia, weakness, or coma, when parenteral medication may be necessary.

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