Chapter 2 – Rational drug selection and prescription writing
Responsibility of prescribing
Do not prescribe without a documented provider-patient relationship
Do not prescribe for self, family or friends
Document an H&P, including discussions regarding risk factors, side effects, or
therapy options
Document a plan for drug monitoring or titration (if applicable)
Document consults with other providers
Drug selection
Cost
Cost is one of the main reasons patients do not adhere to medications, making
patient financial status an important piece of information
Providers should ask patients if costs prohibit them from obtaining their medications
Costs of drugs can vary per pharmacy, i.e. $4 generic list, Walmart pricing, etc.
All health plans through the ACA are required to include prescription drug coverage
Guidelines
Follow current guidelines (AHA, ACC, Infectious Disease Society of America, ADA, etc)
Provide individualized care and document when deviating from the standard of care
Availability
Every facility and pharmacy provides drugs according to a formulary
A formulary is selected by a panel of pharmacists and providers and subject to
regulatory guidelines such as CMS, and depends on drug supplies, drug costs,
rebates, and generics
Substitute with drugs according the formulary
Interactions
Polypharmacy increases the risk of interactions
Assess for all OTC, herbals, alternative medicine, and prescriptions
For any low-risk interactions, discuss with patient, document, then prescribe
Side effects
All meds have side effects, some adverse, some beneficial
Assess for side effects upon initiating, stopping or changing a medication
When assessing risk-to-benefit ratio, consider the severity of side effects
Allergies
Critical to determine severity of allergic reactions
Hepatic and renal function
Many drugs are metabolized and eliminated by the liver and kidneys
Impairment can lead to increased adverse effects or overdose
Implement hepatic and renal dosing if unable to choose an alternate medication
Avoid drugs that are contraindicated in renal or hepatic dysfunction at all costs
Need for monitoring
Common meds requiring monitoring: warfarin, lithium, opioids, and
immunosuppressive therapies
Best to avoid these meds if the patient can not attend frequent lab appts, take meds
reliably, or be easily contacted.
Special populations
Responsibility of prescribing
Do not prescribe without a documented provider-patient relationship
Do not prescribe for self, family or friends
Document an H&P, including discussions regarding risk factors, side effects, or
therapy options
Document a plan for drug monitoring or titration (if applicable)
Document consults with other providers
Drug selection
Cost
Cost is one of the main reasons patients do not adhere to medications, making
patient financial status an important piece of information
Providers should ask patients if costs prohibit them from obtaining their medications
Costs of drugs can vary per pharmacy, i.e. $4 generic list, Walmart pricing, etc.
All health plans through the ACA are required to include prescription drug coverage
Guidelines
Follow current guidelines (AHA, ACC, Infectious Disease Society of America, ADA, etc)
Provide individualized care and document when deviating from the standard of care
Availability
Every facility and pharmacy provides drugs according to a formulary
A formulary is selected by a panel of pharmacists and providers and subject to
regulatory guidelines such as CMS, and depends on drug supplies, drug costs,
rebates, and generics
Substitute with drugs according the formulary
Interactions
Polypharmacy increases the risk of interactions
Assess for all OTC, herbals, alternative medicine, and prescriptions
For any low-risk interactions, discuss with patient, document, then prescribe
Side effects
All meds have side effects, some adverse, some beneficial
Assess for side effects upon initiating, stopping or changing a medication
When assessing risk-to-benefit ratio, consider the severity of side effects
Allergies
Critical to determine severity of allergic reactions
Hepatic and renal function
Many drugs are metabolized and eliminated by the liver and kidneys
Impairment can lead to increased adverse effects or overdose
Implement hepatic and renal dosing if unable to choose an alternate medication
Avoid drugs that are contraindicated in renal or hepatic dysfunction at all costs
Need for monitoring
Common meds requiring monitoring: warfarin, lithium, opioids, and
immunosuppressive therapies
Best to avoid these meds if the patient can not attend frequent lab appts, take meds
reliably, or be easily contacted.
Special populations
