SIX STEPS

Rustamaji
Faculty of Medicine
Universitas Gadjah Mada
2011

Objective
After attending this lecture, students are expected to be
able to:
1.
2.

Explain the steps in therapeutic process

Explain drug selection based on safety, efficacy,
suitability and cost

Six steps of

therapeutic decision
process
Step
Step
Step
Step
Step
Step

1:
2:
3:
4:
5:
6:

Define the patients problem

Specify the treatment objective
Select the intervention
Start the treatment
Give information to the patient
Monitor (or stop?) treatment

(WHO,
1994)

Step 1:
Define the patients problem

Define the patients

problem
Patient presents with a complaint or a problem.
To treat patient, physician should make a right
diagnosis
Right diagnosis based on the complaint as
describe by patient, a detailed history, physical
examination, laboratory tests, X-ray and other
investigation
Patient complaints are mostly linked to symptoms
(is not diagnosis)

Define the patients

problem

Disease or disorder (diagnosis)

Sign of underlying disease
Psychological or social problems, anxiety
Side effect of drugs
Refill request (polypharmacy)
Non-adherence to treatment
Request for preventive treatment
Combination
Physician formulation may different with patient perceives

Step 2:
Specify the treatment
objective

Specify the therapeutic

objective
Therapeutic objective sometimes
straightforward, sometimes less clear.
Therapeutic objective can
Make physician concentrate on the
real problem
Prevent a lot of unnecessary drug use
Avoid unnecessary prophylactic drugs
Discuss your therapeutic problems with patient

Step 3:
Select the intervention

Select the intervention

Make the inventory of possible
treatments

Information or advice
Treatment without drugs
Treatment with a drug
Referral
Combination

Selection of the medicines

Medicines should effective, safe,
suitable to patient and cheaper
Effective: please check to the reference
standard to looking for the EBM
Safety : check the side effects and
frequency of side effects
Suitability : check the contraindication
of the drug
Cost: check the total cost not only the
price

Efficacy of drug
Data Pharmacodinamic
Data pharmacokinetic (ADME)
Compare the dosage and formulation
on absorption, distribution,
metabolism, excretion
Efficacy should be supported by good
clinical trial with control

Safety
Side effects
Toxic effects (depend on dug
concentration)
If possible list he incidence of side effect
Unpredictable side effect (allergic
reaction) may be caused by drugs

Suitability
Contraindication of drug related by
patient condition (renal failure, hepatic
disorder, history of allergic reaction,
other disease, other drugs (possibility of
interaction))
Change of patient physiology
(pregnancy and lactation, extreme age)

Suitability
Are the active substance and dosage
form suitable for this patient?
Is the standard dosage suitable for this
patient?
Is the standard duration of treatment
suitable for this patient?
Pharmacokinetic data

Cost
Check the cheaper drug

Discuss with the patient about the drug

price

Selection of medicines
Patient suffer dry cough that can be
very inconvenient
Suppressing for a few day may have a
beneficial effect
Many cough preparation available in the
market

Step 4:
Start the treatment

Start the treatment

Write a prescription
Codein 30mg 3 x daily
Prescription is an instruction from a prescriber to a
dispenser
Information on prescription
Name and address of the prescriber with
telephone number
Date of prescription
Name and strength of the drug
Dosage form and total amount
Information for the package insert
Signature or initial
Patient identity

Step 5:
Give information to the patient

Give information
Instruction and warning
Effect of the drugs
Why the drug is needed
Which symptoms will disappear, and
which not
When the effect is expected to start
What will happened if the drug is taken
incorrectly or not at all

Give information
Instruction and warning
Side effects

Which side effect may occur

How to recognize them
How long the will continue
What action to take

Give information
Instruction and warning
Instruction
How the drug should be taken
When it should be taken
How long the treatment should
continue
How the drug should be stored
What to do with left-over drugs

Give information
Instruction and warning
Warnings
When the drug should not be taken
What is the maximum dose
Why the full treatment course should
be taken

Give information
Instruction and warning
Future consultation
When to come back (or not)
In what circumstances to come earlier
What information the doctor will
needed at the next appointment

Give information
Instruction and warning
Everything clear ?
Ask the patient whether everything
understood
Ask the patient to repeated the most
important information
Ask whether the patient has any more
question

Step 6:
Monitor (or stop?) treatment

Monitor and stop the

treatment
Was the treatment effective ?
Yes and disease cured
Stop the treatment
Yes but not yet completed
Any serious effect?
No : Treatment can be continued
Yes : reconsider dosage or drug choice

No : check your all steps