ESSENTIAL MEDICINE

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 INTRODUCTION
• The Alma-Ata declaration during the International Conference on Primary
Health Care in 1978 reaffirms that health is a fundamental human right
and the attainment of the highest possible level of health is a most
important worldwide social goal.

• The Alma Ata declaration has outlined the eight essential components of
primary health care and provision of essential medicines is one of them.
• Medicines are integral parts of the health care and the modern health care
is unthinkable without the availability of necessary medicines. They not
only save lives and promote health, but prevent epidemics and diseases
too.
• Accessibility to medicines is also the fundamental right of every person.
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 Concept of Essential Medicines

• Definition: Essential medicines are those that satisfy the priority health care
needs of the population.

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 Essential medicine selection cont’d
• Pattern of disease prevalence

• Benefit risk ratio: drugs which provide most favourable benefit/risk ratio is to
be selected

• Financial resources: 20% of the total expenditure on health is spent on drugs.

• Local manufacturing and storage facility

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• The WHO has developed the first essential medicines list in 1977 and since then the list
has been revised every 2 years.
• The current one is the 23rd model list released in 2023.

• The essential medicine list contains limited cost-effective and safe medicines, while the
open pharmaceutical market is flooded with large number of medicines many of which
are of doubtful value.

• The model list of WHO serves as a guide for the development of national and
institutional essential medicine list. The concept of essential medicines has been
worldwide accepted as a powerful tool to promote health equity and its impact is
remarkable as the essential medicines are proved to be one of the most cost-effective
elements in health care.

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• The implementation of the concept of essential medicines is intended to
be flexible and adaptable to many different situations; exactly which
medicines are regarded as essential remains a national responsibility.
• Experience has shown that careful selection of a limited range of
essential medicines results in a higher quality of care, better
management of medicines (including improved quality of prescribed
medicines), and a more cost‑effective use of available health resources.

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Guideline for establishing a national
program for essential medicine
• 1. Standing committee of healthcare professionals ( Competent
individuals in fields of medicine, pharmacology , peripheral health
workers
• 2. International non-proprietary (generic ) name of drugs or
pharmaceutical substances should be used whenever available
• 3. Prescribers should be provided – with cross index of non-
proprietary and proprietary names
• 4.Concise, accurate and comprehensive drug information prepared –
To serve as a pocket guide rational drug use

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Guideline for establishing a national
program for essential medicine
• 5. Quality (drug content, stability, and bioavailability)
(a) assured through testing
(b) Suppliers should provide documentation of product’s
compliance with required specification
6. Procurement policy- Based up on detailed record of turnover
7. Local level of expertise – to prescribe, administer and monitor safety
of drugs

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Guideline for establishing a national
program for essential medicine
• 8. Success of essential medicines program depends on
(a) Efficient administration of supply
(b) storage
(c) Distribution from manufacturer to end user.

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 Nigeria ESSENTIAL MEDICINE LIST
• ANAESTHETICS, PREOPERATIVE MEDICINES AND MEDICAL GASES
• GA inhalational: Halothane, lsoflurane, Nitrous oxide, Oxygen, Sevoflurane
• GA Injectables: Ketamine, Propofol
• Local anaesthetics Bupivacaine, Lidocaine, Lidocaine + Epinephrine (Adrenaline)
• Preoperative medication and anaesthetic adjuvants: Atropine, Clonidine, Diazepam
• Skeletal muscle relaxants and cholinesterase inhibitors: Atracurium, Neostigmine
• ANTIALLERGICS AND MEDICINES USED IN ANAPHYLAXIS
• Anti-histamines: Chlorpheniramine, Loratadine, Prednisolone
• Anti-anaphylactics: Dexamethasone, Epinephrine (Adrenaline) Hydrocortisone
• ANTICONVULSANTS/ANTI-EPILEPTICS: Carbamazepine, Clonazepam,
Diazepam Ethosuximide, Magnesium sulfate

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 Nigeria Essential Medicine List
ANTI-INFECTIVE MEDICINES
• Antiamoebic and antigiardiasis medicines: Metronidazole, Tinidazole

• Anthelminthics: Albendazole, Ivermectin, Mebendazole, Pyrantel pamoate

• Antibacterial medicines: Ampicillin, Amoxicillin, Amoxicillin + Clavulanic

acid, Ceftriaxone, Ciprofloxacin, cefuroxime, clarithromycin

• Antifungal medicines: Amphotericin B, Clotrimazole, Fluconazole.

• Antimalarial medicines: Artemether + Lumefantrine, ACTs

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 RATIONAL USE OF MEDICINE ….Definition

• The rational use of Medicines (RUM) is defined as “Patients receive

medications appropriate to their clinical needs, in doses that meet their own
individual requirements, for an adequate period of time, and at the lowest
cost to them and their community.”

• It is widely assumed that use of drugs by qualified doctors of modern

medicine would be rational. However, in reality, irrationality abounds in
almost every aspect of drug use. Medically inappropriate, ineffective and
economically inefficient use of drugs occurs all over the world, more so in
the developing countries.

• Rational prescribing is not just the choice of a correct drug for a disease, or
mere matching of drugs with diseases, but also the appropriateness of the
whole therapeutic set up along with follow up of the outcome. 15
 Irrationalities in prescribing
It is helpful to know the commonly encountered irrationalities in prescribing
so that a conscious effort is made to avoid them

1. Use of drug when none is needed; e.g. antibiotics for viral fevers and
nonspecific diarrhoeas.

2. Compulsive coprescription of vitamins/tonics.

3. Use of drugs not related to the diagnosis, e.g. chloroquine/ciprofloxacin for

any fever, proton pump inhibitors for any abdominal symptom.

4. Selection of wrong drug, e.g. tetracycline/ ciprofloxacin for pharyngitis, β blocker

as antihypertensive for asthmatic patient.
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 Irrationalities in prescribing

5. Prescribing ineffective/doubtful efficacy drugs, e.g. serratiopeptidase for

injuries/ swellings, antioxidants, cough mixtures, memory enhancers,
etc
6. Incorrect route of administration: injection when the drug can be given
orally.
7. Incorrect dose: either underdosing or overdosing; especially occurs in
children.
8. Incorrect duration of treatment, e.g. prolonged postsurgical use of
antibiotics or stoppage of antibiotics as soon as relief is obtained, such as
in tuberculosis.

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 Irrationalities in prescribing
9. Unnecessary use of drug combinations, e.g. Ibuprofen and diclofenac for
pains
10. Unnecessary use of expensive medicines when cheaper drugs are equally
effective; craze for latest drugs, e.g. routine use of newer antibiotics
11. Unsafe use of drugs, e.g. corticosteroids for fever, anabolic steroids in
children, use of single antitubercular drug.
11. Polypharmacy without regard to drug interactions: each prescription on an
average has 3–4 drugs, some may have as many as 10–12 drugs, of
which many are combinations.

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 Consequences of irrational prescribing

Irrational prescribing has a number of adverse consequences for the patient

as well as the community. The important ones are:
1. Delay/inability in affording relief/cure of disease.
2. More adverse drug effects.
3. Prolongation of hospitalization; loss of man days.
4. Increased morbidity and mortality.
5. Emergence of microbial resistance.

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Consequences of irrational
prescribing
6. Financial loss to the patient/community.
7. Loss of patient’s confidence in the doctor.
8. Lowering of health standards of patients/community.
9. Perpetuation of public health problem.

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 Factors influencing prescribing
1. Knowledge of the prescriber.
2. Role models: one tends to follow prescribing practices of one’s teachers or
senior/popular physicians.
3. Patient load: heavy load tends to foster routinized symptom based
prescribing.
4. Attitude to afford prompt symptomatic relief at all cost.
5. Imprecise diagnosis: medication is given to cover all possible causes of the
illness.
6. Drug promotion and unrealistic claims by manufacturers.
7. Unethical inducements (gifts, dinner parties, conference delegation, etc.).
8. Patient’s demands: many patients are not satisfied unless medication is
prescribed; misconceptions, unrealistic expectations, ‘pill for every ill’ belief.
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 Process of rational prescribing

Rational prescribing is a stepwise process of scientifically analyzing the

therapeutic set up based on relevant inputs about the patient as well as the
drug, and then taking appropriate decisions.

It does not end with handing over the prescription to the patient, but extends
to subsequent monitoring, periodic evaluations and modifications as at when
needed, till the therapeutic goals are achieved.

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 Process of rational prescribing
1. Establish a diagnosis (at least provisional).

2. Define therapeutic problem(s), e.g. pain, infection, etc.

3. Define therapeutic goals to be achieved, e.g. symptom relief, cure,

prevention of complications, etc.

4. Select the class of drug capable of achieving each goal.

5. Identify the drug (from the class selected) based on: Efficacy Safety For the
particular patient Suitability Cost
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 Process of rational prescribing
6. Decide the route, dose, duration of treatment, considering patient’s
condition.

7. Provide proper information and instructions about the medication.

8. Monitor adherence to the medication (compliance).

9. Monitor the extent to which therapeutic goal is achieved, e.g. BP lowering,

peptic ulcer healing, etc.

10. Modify therapy if needed.

11. Monitor any adverse drug events that occur, and modify therapy if needed.
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 Information/instructions to the patient
• Rational prescribing also includes giving relevant and adequate information to the
patient about the drug(s) and disease, as well as necessary instructions to be followed.

• Effects of the drug e.g Antidepressant will take weeks to act. Diabetes, Parkinsonism
can only be ameliorated, but not cured. Tuberculosis will worsen and may prove fatal if
the drug is not taken as advised.

• Side effects: Communicating the common side effects without discouraging the patient
is a skill to be developed.

• Instructions: How and when to take the drug ( inhalers, transdermal patches) how long
to take the drug; when to come back to the doctor; diet and exercise if needed.
• Precautions/warnings: Driving (with conventional antihistaminics) or drinking (with
metronidazole), risk of allergy or any serious reaction, etc.
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 EXPIRY DATE OF PHARMACEUTICALS

• The expiry date does not mean that the medicine has actually been found
to lose potency or become toxic after it, but simply that quality of the
medicine is not assured beyond the expiry date, and the manufacturer is
not liable if any harm arises from the use of the product.
• Infact, studies have shown that majority of solid oral dosage forms
(tablets/capsules, etc.) stored under ordinary conditions in unopened
containers remained stable for 1–5 years (some even up to 25 years) after
the expiry date.
• Liquid formulations (oral and parenteral) are less stable. Suspensions clump
by freezing. Injectable solutions may develop precipitates, become cloudy
or discoloured by prolonged storage. Adrenaline injection (in ampoules) has
been found to lose potency few months after the expiry date of 1 year (it
gets oxidized).
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