Schiff, 2011 Principles of Conservative Prescribing

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Can medicine reclaim its soul from the pharmaceutical industry? New attention is given to what used to be a guiding principle in clinical practice.

Principles of Conservative Prescribing

Gordon D. Schiff, MD; William L. Galanter, MD, PhD; Jay Duhig, MA; Amy E. Lodolce, PharmD, BCPS; Michael J. Koronkowski, PharmD; Bruce L. Lambert, PhD

Arch Intern Med. Published online June 13, 2011. Abstract at http://archinte.ama-assn.org/cgi/content/short/archinternmed.2011.256 (See 2009 Promoting More Conservative Prescribing. Schiff, et al at http://www.mediafire.com/?bf6gl0d0qpcdeal)

Judicious prescribing is a prerequisite for safe and appropriate medication use. Based on evidence and lessons from recent studies demonstrating problems with widely prescribed medications, we offer a series of principles as a prescription for more cautious and conservative prescribing. These principles urge clinicians to
(1) think beyond drugs (consider nondrug therapy, treatable underlying causes, and prevention);
(2) practice more strategic prescribing (defer nonurgent drug treatment; avoid unwarranted drug switching; be circumspect about unproven drug uses; and start treatment with only 1 new drug at a time);

(3) maintain heightened vigilance regarding adverse effects (suspect drug reactions; be aware of withdrawal syndromes; and educate patients to anticipate reactions);
(4) exercise caution and skepticism regarding new drugs (seek out unbiased information; wait until drugs have sufficient time on the market; be skeptical about surrogate rather than true clinical outcomes; avoid stretching indications; avoid seduction by elegant molecular pharmacology; beware of selective drug trial reporting);
(5) work with patients for a shared agenda (do not automatically accede to drug requests; consider nonadherence before adding drugs to regimen; avoid restarting previously unsuccessful drug treatment; discontinue treatment with unneeded medications; and respect patients' reservations about drugs); and
(6) consider long-term, broader impacts (weigh long-term outcomes, and recognize that improved systems may outweigh marginal benefits of new drugs).