Medicines form a major component of the cost of modern medical care. Concern has been raised the world over about the increasing cost of modern drug treatment. In this article we look at a major initiative that has been shown to lead to more rational use of medicines, decrease the cost of treatment and improve drug use.
Drug and Therapeutics Committee
Studies have shown that per capita wastage of resources from inefficient and irrational use of medicines is greatest in hospitals. The Drug and Therapeutics Committee (DTC; also called Medicine and Therapeutics Committee or MTC, or Pharmacy and Therapeutics Committee) is a forum to bring together various individuals involved in use of medicines. The committee usually involves a surgeon, an internal medicine specialist, a gynecologist, a pediatrician, an infectious disease specialist, and a representative from general practice. It also includes a clinical pharmacologist, a nurse, a pharmacist, a clinical microbiologist and an administration representative. DTC/MTC is common in developed nations, but in Nepal only few hospitals have a DTC/MTC. These include TU Teaching Hospital, Patan Hospital, KIST Medical College Hospital and Manipal Teaching Hospital. DTCs play an important role in ensuring ‘proper’ use of medicines.
Standards of prescribing
DTC plays an important role in ensuring standards of medicine prescribing. In many countries, standard treatment guidelines (STGs) have been developed for common diseases. STG describes the diagnosis (signs and symptoms, examination and investigations) and management of the disease. These guidelines are produced by a group of experts after extensive discussion and consultation with other stakeholders and have been shown worldwide to improve quality of care. In Nepal, STGs have been produced for primary health care. At higher levels of care, STGs have not been universally accepted. DTC can check whether prescribing is according to STGs.
There are a set of indicators called ‘drug use indicators’ that give an idea about prescribing in a particular hospital. The parameters looked into are average number of drugs per prescription, prescribing by generic name (the non commercial name of a drug, for example Amoxicillin), prescribing from the national essential drug list and use of antibiotics and injections. Cost of drugs per prescription can also be noted. Regular monitoring, feedback and intervention will ensure better quality prescribing.
Regulating promotion and pharmacovigilance
Aggressive pharmaceutical promotion has been shown to lead to irrational use of medicines. More expensive medicines and newer medicines are strongly promoted. DTC can regulate promotion. Unless there are other compelling reasons it is always better to use an ‘older’ drug that has been in the market for a longer time and whose side effects, precautions and contraindications are better known. Drugs are first tested on animals and later undergo testing in humans (called ‘clinical trials’). These trials are conducted only in a limited number of people, and women and children are often excluded. Thus, by the time a drug reaches the market its adverse effects in certain sections of the population, like pregnant and lactating women and children, and uncommon adverse effects in normal populations, may not be known. Even after a drug is marketed it continues to be monitored for adverse drug reactions (ADRs) for a number of years. This gives information on its use in normal populations under a wide range of conditions.
Monitoring ADRs is called ‘Pharmacovigilance’. Every country should have its own pharmacovigilance program as the genetic make up, diet, use of other medicines and many other factors are different. Nepal is a member of the international ADR monitoring program. In Nepal only few hospitals report ADRs to the national center. A strong pharmacovigilance program is important to ensure ADRs are detected early, unsafe drugs are withdrawn from the market and the use of medicines is made safer.
Currently, ADRs are reported by regional centers using an online program called Vigiflow to the Department of Drug Administration at Bijuli Bazaar, Kathmandu (the national center). From there reports are transmitted to the international center in Uppsala, Sweden. ADRs are stored, studied and analyzed using an international database.
Drug information services
Another area where DTC can improve medicine use in a hospital is supporting provision of impartial, objective information about medicines to doctors and other prescribers. A major and easily accessible source of information is that provided by drug companies. Drug information centers (DICs) are common, especially in teaching hospitals in developed nations. In Nepal, DICs are functioning at TU Teaching Hospital in Kathmandu and Manipal Teaching Hospital in Pokhara, among others. A National Poison Information Center functions in Kathmandu and KIST Medical College provides drug information services as a pilot project.
District level DTCs
For smaller health centers and private clinics it is recommended to have DTC at a district level. This already exists in many developed nations. These district level DTCs will support and promote a more rational use of medicines. In Nepal, many workshops to promote DTCs have been conducted and the concept is spreading in both teaching and government hospitals.
What DTC means to you as a consumer
As a consumer, DTC ensures you a better quality of medicine use in the hospital or health facility, lower cost, and better treatment outcomes. So information about the presence of a DTC, whether DTC regulates the functioning of the hospital pharmacy, regularity of meetings of DTC and initiatives like drug information services and pharmacovigilance are important to you as a healthcare consumer.