The dog's blog no. 17 Top tips for good prescribing

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This blog is named after Moscow, Veterinary Prescriber's rescue hound.

It's that time of year when new vets are starting in practice. Among the many new responsibilities will be prescribing medicines. But prescribing is not easy. It involves many factors: making an accurate diagnosis; picking the right drug from a range of alternatives; choosing the appropriate dose and duration of treatment; considering the characteristics of the patient that might affect susceptibility to adverse reactions; thinking about interactions; and what's more, taking into consideration client characteristics (e.g. preferences, budget) and other practicalities (e.g. palatability, whether a licensed medicine exists). Here are some tips for good prescribing:

1. Be clear about the reasons for prescribing.

  • Establish an accurate diagnosis wherever possible.

  • Be clear in what way the patient is likely to gain from prescribing the medicine (benefits) and what harms may occur from treating, or not treating. These two principles form the benefit-harm balance. Do the likely harms of treatment outweigh the likely harms of no treatment?

2. Take into account the patient’s medication history before prescribing.

  • Their current and recent medications, and also any non-prescription and herbal medicines or supplements.

  • Get a history of previous adverse reactions, interactions and allergies.

3. Take into account other factors that might alter the benefits and harms of the treatment.

  • For example breed, age, pregnancy, impaired kidney or liver function.

4. Consider the client’s ideas, concerns and expectations.

  • Seek to form a partnership with the client when selecting treatments, making sure they understand and agree the reasons for treatment.

5. Select safe and effective medicines.

  • Wherever possible base your assessment of benefit-harm on published evidence.

  • Choose the best formulation, route of administration, and duration of treatment.

  • Where possible use a licensed medicine. Only prescribe medicines that are unlicensed, ‘off label’, or outside standard practice if you're satisfied that there is no licensed alternative to meet the patient's needs, and prescribe in line with the 'cascade'.

  • Use reliable, validated sources of information.

6. Monitor the outcomes of treatment – the benefits and the harms.

  • Identify how the benefits and harms of the treatment can be assessed.

  • Understand how to alter the prescription based on the results of monitoring (including stopping the treatment).

  • Know how to report adverse effects.

7. Communicate and document prescribing decisions and the reasons for them

  • Communicate clearly with the client and with colleagues.

  • Give clients important information about how to use the medicines, what benefits to expect, what adverse effects to look out for (especially those that need urgent action) and any monitoring that is needed.

8. Prescribe within the limits of your knowledge, skills and experience.

  • Keep knowledge and skills relevant to practice up-to-date.

  • Be prepared to seek the advice and support of suitably qualified colleagues.

  • Make sure that (where appropriate) prescriptions are checked (e.g. calculations of intravenous doses).

Credit: adapted from the British Pharmacological Society's Ten Principles of Good Prescribing.

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