Principles of Conservative Prescribing Reviewed

Laurie Barclay, MD

September 16, 2011

September 16, 2011 — Judicious prescribing is required for safe and appropriate use of medications, according to a review article published in the September 12 issue of the Archives of Internal Medicine. The review authors present a series of principles to guide more cautious and conservative prescribing, based on recent studies demonstrating problems with widely prescribed drugs.

"In striving to relieve suffering and prolong life, we often turn to medications," write Gordon D. Schiff, MD, from the Center for Patient Safety Research and Practice at Brigham and Women's Hospital, Harvard Medical School in Boston, Massachusetts, and colleagues. "This desire to help patients with the 'latest and greatest' drugs is congruent with the messages and interests of the pharmaceutical industry, but there is an alternate paradigm that represents a radical shift in prescribing attitudes and behaviors.... Although others have used labels such as healthy skepticism, more judicious, rational, careful, or cautious prescribing, we believe that the term conservative prescribing conveys an approach that goes beyond the oft-repeated physician's mantra, 'first, do no harm.'"

The principles underlying conservative prescribing include the following:

  • Consider nonpharmaceutical interventions, such as nondrug therapy, treatment or management of the underlying causes, and prevention. Various nonpharmaceutical strategies have been shown to be effective for diabetes, hypertension, insomnia, back pain, arthritis, headache, and other highly prevalent conditions. Greater focus on prevention may ultimately reduce the number of prescription drugs needed.

  • Practice more strategic prescribing, including deferring or postponing nonurgent drug treatment; avoiding drug switching unless there are clear indications; being cautious regarding unproven drug uses; and initiating therapy with only 1 new drug at a time, which facilitates identifying the drug responsible for an adverse event. For self-limiting conditions, such as rhinosinusitis, otitis media, and back pain, watchful waiting may preclude the need for drug therapy if there is spontaneous resolution.

  • Remain vigilant for adverse drug effects by having a low threshold to suspect drug reactions; being aware of drug withdrawal syndromes, particularly for drugs such as analgesics and proton pump inhibitors; and educating patients to anticipate possible adverse drug reactions.

  • Be cautious and skeptical regarding new drugs by researching unbiased information; waiting to prescribe until drugs have been on the market for a sufficient length of time; avoiding reliance on surrogate markers rather than true clinical outcomes; not stretching drug indications; not being unduly impressed by elegant molecular pharmacology; and being aware of selective drug trial reporting. Clinicians should be highly familiar with a smaller number of commonly used drugs and prescribe these rather than a larger variety of drugs about which they are less knowledgeable.

  • Collaborate with patients to implement a shared agenda by not automatically agreeing to prescribe requested drugs; considering nonadherence before prescribing additional drugs; not restarting drug treatment that was previously unsuccessful; discontinuing unnecessary medications; and respecting patients' reservations concerning drugs.

  • Consider long-term, broader effects of drugs before prescribing, while recognizing that improved systems may outweigh the marginal benefits of new drugs.

"The recent spate of revelations of undisclosed and unexpected adverse effects of drugs in multiple therapeutic categories should serve as wake-up calls for our profession to take a more sober, balanced, and cautious approach to prescribing," the study authors write. "Lest these experiences be forgotten, with the resulting failure to draw more general lessons, we urge clinicians to take a more cautious approach to prescribing and administering chemicals whose effects are imperfectly understood. While clinicians must always weigh the benefits of conservative prescribing against the risks of withholding potentially needed medications, at the very least we should seek to shift the burden of proof toward demanding a higher standard of evidence of benefit before exposing patients to the risks of drugs."

In an accompanying editor's note, Deborah Grady, MD, MPH, refers to a study suggesting that the US public erroneously believes that drugs approved by the US Food and Drug Administration (FDA) are highly effective and safe. Dr. Grady also notes that properly trained clinicians should have the responsibility of selecting the most clinically effective and safe drug.

"The recommendations by Schiff et al provide a framework for judicious prescribing that should result in significantly less use of prescription drugs (especially new drugs), fewer drug-related adverse effects, and better health outcomes," Dr. Grady writes. "Finally, my editorial on the use of opioid drugs in this issue also provides strong evidence that limiting use, limiting the dose of prescription opioids, and using other approaches for treatment of pain could provide similar pain relief but fewer adverse effects—all clear demonstrations of how prescribing less can result in better health."

This review was supported in part by the Formulary Leveraged Improved Prescribing project, funded by the Attorney General Consumer and Prescriber Education Grant Program, and a Centers for Education and Research grant from the Agency for Healthcare Research and Quality. One of the study authors (Bruce L. Lambert, PhD) has disclosed various financial or other relationships with Abbott Laboratories, Transcept Pharmaceuticals Inc, Pharm I.R. Inc, Novartis, Ortho McNeil, BLL Consulting Inc, and Med-Errs Inc.

Arch Intern Med. 2011;171:1433-1440, 1470.

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