Book Cover for Pharmacotherapeutics for Advanced Practice Nurse
Prescribers, Sixth Edition.
Chapter 3
Rational Drug Selection
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Objectives
1. Describe the process of rational drug
prescribing
2. Discuss the drug factors influencing drug
selection
3. Identify two influences on rational
prescribing
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Overview
The process of rational drug prescribing
Drug factors influencing drug selection
Influences on rational prescribing
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The Process of Rational Drug Prescribing
Define the patient’s problem
Specify the therapeutic objective
Choose the treatment
Educate the patient
Monitor effectiveness
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Define the Patient’s Problem
Assess the patient
Develop working and differential diagnoses
Use diagnostic tests to confirm
Determine drugs effective in treating the
disorder
Develop a plan of care
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Specify the Therapeutic Objective
Clarify the goal of therapy
• Cure the disease?
• Relieve symptoms of disease?
• Replace deficiencies (e.g., insulin)?
• Long-term prevention?
• Palliative therapy?
Include the patient in shared decision
making
• Consider patient beliefs and preferences
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Choose the Treatment
Use evidence-based guidelines
Individualize for each patient (age and sex)
Consider the the pharmacokinetics and
pharmacodynamics of the drug
Determine cost-effectiveness
Novice providers use analytical, systematic
decision making
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Choose the Treatment (continued)
Experienced providers use experience and
pattern recognition
• Use more systematic approach with complex
patients
Examine the drug, dose, dosage schedule,
duration of treatment, effectiveness, and
safety
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The “I Can PresCribE A Drug” Mnemonic
Indication
Contraindications
Precautions
Cost/Compliance
Efficacy
Adverse effects
Dose/Duration/Direction
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Start Treatment
Write prescription including drug, dose, and
schedule accurately
Determine whether patient has ability to pay
for prescription
• Insurance co-pays
• Generics often less expensive
Patient usually has prescription filled at
pharmacy
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Educate the Patient
Poor adherence contributes to worsening
disease, hospital admissions, and death
Patient education should be at the 5th or 6th
grade level
Include in education:
• Purpose of medication and expected benefits
• Instructions for administration
• Potential adverse drug reactions (ADRs)
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Monitor Effectiveness
Passive monitoring: Patient is educated on
expected outcome and instructed to contact
provider
Active monitoring: Follow-up laboratory
tests or monitoring to measure therapeutic
effectiveness
• Make drug adjustments as needed
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Drug Factors Influencing Drug Selection
Pharmacokinetic factors
Pharmacodynamic factors
Therapeutic factors
Safety
Cost (to patient and to society)
Patient factors
Provider factors
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Pharmacodynamic Factors
Ease of titration influenced by the dose-
response curve of the drug
Therapeutic index
• A narrow therapeutic index is more difficult to
manage
• A wider therapeutic index is safer and requires
less monitoring
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Pharmacokinetic Factors
Absorption
Distribution
• Ability to cross blood–brain barrier
Metabolism – Cytochrome P450 (CYP450)
Excretion – evaluate renal function
Dose–response curve
Half-life will determine dosing schedule
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Therapeutic Factors
Evidence for therapeutic impact
• Randomized clinical trials (RCTs)
• Clinical practice guidelines
• Systematic reviews
Evaluate RCTs with caution
• Tend to use healthier study subjects
• Numbers needed to treat (NNT)
• Numbers needed to harm (NNH)
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Safety
Safety profile is taken into consideration
Safety profile varies by population
• Teratogens unsafe in pregnancy
• Liver or renal disease
• Contraindications or drug allergy
MedWatch report
U.S. Food and Drug Administration (FDA)
advisories or “Boxed” warnings
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Cost
Cost to patient
• High drug cost may decrease adherence
• Ask about prescription drug coverage
• Inflation Reduction Act of 2022
• Consider $4 retail pharmacy lists
Cost to society
• Thoughtful prescribing considers cost to health-
care system
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Patient Factors
Previous adverse drug reactions
Health beliefs
Current drug therapy
• Drug interactions
• Consult PharmD regarding complex drug
regimens
Patient age
Pregnancy
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Provider Factors
Ease of prescribing or monitoring
Formularies
• APRNs must be familiar with the formularies they
are allowed to prescribe
• Personal formulary: Each provider develops a
small list of drugs they are comfortable
prescribing
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Influences on Rational Prescribing
Pharmaceutical promotion
• May influence prescribing
Changes in prescribing recommendations
• When guidelines change based on new scientific
evidence, providers may need reeducating
regarding appropriate prescribing
• Clinical support intervention tools embedded
into the electronic health record may aid
education regarding current guidelines
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Summary
Review the process of rational drug
prescribing
Understand drug factors influencing drug
selection
Recognize influences on rational prescribing
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Knowledge Check
Which of the following are drug factors that
influence drug selection?
A. Patient health beliefs
B. Pharmacodynamics
C. Pharmaceutical promotion
D. Patient education
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Answer
Correct Answer: B
The pharmacodynamics (the study of the
biochemical and physiological effects of the
drug on the body) of a drug must be specific
and selective to target the tissues affected by
the disease to have the greatest therapeutic
effect with the least severe adverse effects.
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Knowledge Check (continued)
Which of the following is a step in the
systematic process of rational drug prescribing?
A. Pharmaceutical promotion
B. Pharmacokinetic factors
C. Pharmacodynamics factors
D. Specific therapeutic objective
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Answer (continued)
Correct Answer: D
The steps of the process of rational drug
prescribing includes defining the patient’s
problem, specifying the therapeutic objective,
choosing the treatment, educating the
patient, and monitoring effectiveness.
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