EVOLUTION OF CLINICAL PHARMACOLOGY: A STEP TOWARDS SAFE AND RATIONAL PRESCRIBING OF DRUGS

Abstract

Clinical Pharmacology is defined as the scientificstudy of the actions and use of drugs in humanbeings, their efficacy and safety being the centre ofinterest. Basically, it teaches us how effective andsafe a particular drug is in humans and how does thebody handle and respond to it.Clinical Pharmacology is concerned with thescientific use of drugs for rational (ethical, effective,economic and safe) treatment of patients.Purkinje1, in 1829, wrote that normally weshould simply think of making use of animals but themost reliable results may be obtained only byexperimenting on one’s own body, provided theexperimenter performs the experiment with adequatecare. Believing this concept he studied the effects ofdigitalis, camphor and belladonna on himself. Aprimitive concept of clinical pharmacology wasfounded in the minds of scientists concerned withpatient care.Sir Malcolm Lader, famous psychiatrist,stressed upon his students to always taste a drug atleast, before prescribing it, so that the prescribingdoctor may realize the experience that patient goesthrough.European regional office of World HealthOrganization ( WHO), in 1977, reported that therewas a growing concern of governments, healthauthorities and general public that, drugs were notused in medicine as efficiently and safely as theyshould be 2. This report called for an action by theEuropean community to look for the reasons of thereported concern. It was revealed that optimum use ofdrugs required the same expertise level as wasdemanded for the diagnosis of disease.The European community collectivelydecided to adopt optimum use of ethical, effective,safe and economic drugs in the treatment of patients.Soon after the implementation of this decision,benefits were experienced in the form of gradualreduction in morbidity and mortality. This approachencouraged the developed nations to work further andlook into the ultimate mechanism, which governsoptimum use of drugs in the treatment of patients.The knowledge of the scientific use of drugs inhumans, in health and disease, was r ecognized asClinical Pharmacology and application of this appliedscience as rational prescribing was therefore,established as an academic discipline in medicalschools and some universities, i.e. University ofLondon3 and was also recommended to be anessential element in the provision of health care inEurope.A sound knowledge of drugs and theiroptimum use enables a physician to give a moment’sthought to consider before prescribing, whether drugtreatment is really necessary, because, certaindiseases are self-limiting and drug intervention cansafely be avoided by careful observation of thepatient during his illness. How ever, when life of thepatient seems at risk and demands urgent drugintervention, it becomes the responsibility of theattending doctor to select safe, effective, economicand convenient drug/s .It is worth mentioning that drug treatment isnot free from complications and one should not gettrapped in the wrong belief of, “a pill for each ill”.These iatrogenic diseases are usually difficult toidentify and may go undiagnosed, with fatal out comeat times.The practice of clinical pharmacology wasmeant to improve upon prescribing habits ofclinicians in their day to day practice. Later on it tookthe shape of an academic discipline, as a full fledgedsubject to be taught in the medical institutions and insome universities in Europe. Clinical Pharmacologyand Therapeutics is not only taught but is consideredto be of sufficient importance to be classed andexamined in as a separate subject in final yearMBBS.The concept of Clinical Pharmacology, itsprospects and role in improving patient care inPakistan was first published in 1977, for creatingawareness amongst the medical professionals 4.The role of Clinical Pharmacology in undergraduate medical education was published in l980 inorder to motivate young students to take up thissubject for their profession in future 5.Nierenberg published consensus for a corecurriculum in Clinical Pharmacology for medicalstudents, in 1906 6.A workshop held in Perth, Australia, onDecember 6’ 19917, endorsed the core curriculum inClinical Pharmacology developed by Nierenberg6. Itwas recommended in the same workshop that amanual in Clinical Pharmacology should be writtenfor students to learn the subject with interest.J Ayub Me d Coll Abbottabad 2007; 19(1) 2College of Physicians & Surgeons ofPakistan approved postgraduate degree in ClinicalPharmacology in 1994.Twelve years have passed since the approvalof post-graduate qualification in ClinicalPharmacology but it seems as if no one has eitherjoined the course or has not been able to qualify. Thismay be inferred that introduction of ClinicalPharmacology and as a consequence r ational drugtherapy has been put in abeyance at the graduate andpost-graduate levels for so long.It is of concern that the concept of ClinicalPharmacology has not been taken in the correct sensein Pakistan. The general physicians seem skeptical asto what will happen to their future status afterintroduction of this specialty in the country, whereasspecialist physicians consider it an extra task oflearning about the drugs, which they claim to knowalready. On the other hand teachers of basicPharmacology stay in the basic sciences departmentsmostly. They usually refrain to conduct trials onhuman subjects for the reason, that they do not retainconfidence to handle human subjects and managedrug trials.The drugs and treatment scenario demands acollective effort as was done by the Europeancommunity. They changed their prescribing habits byscientific research to a rational approach and namedit ‘Clinical Pharmacology’. Developed nations didnot stop at improving the prescribing habits only butwent on towards post-graduate specializationsthrough continued research in the subject.A similar line of action is recommended toachieve rational therapy in Pakistan. All it needs is acollective effort and harmony of thought.A reasonable approach to introduce the sameis based on the recommended curriculum by theCollege of Physicians and Surgeons Pakistan in19948, to motivate the young under-graduate medicalstudents in their pre- clinical years to learn the basicprinciples of phenomena occurring in the living bodyas a result of administration of drugs, such asabsorption through the mucous membranes,distribution in various compartments of the body,metabolism of drugs and even various ingredients offood, etc., their utilization for different usefulpurposes, elimination of the waste products which isof no use to the body, will ultimately motivate theyoung student to find an answer to the abovementioned and learn how to make use of thesephenomena for correcting any abnormal condition inthe human body on the same lines. This Knowledgemay be provided as a pre-requisite for training inClinical Pharmacology in the form of a corecurriculum / syllabusInitially, teaching may begin with the basicknowledge of Pharmacology such as mechanisms ofactions of drugs (pharmacodynamics) andmechanisms by which the body deals with theadministered drug/s (pharmacokinetics). The studentshould start learning basic and preliminary,interesting, non-invasive, easy to perform and clearlyunder-stood practical skills in their practical classesand apply the knowledge and the skill thus gained, toclinical situations before taking up the responsibilityof patient care.All it needs, is more emphasis to attainknowledge in order to justify as to why, how andwhen a drug should be used, if at all. Once thestudent is able to justify a decision of treatment or notreatment, he is considered to have learnt ClinicalPharmacology and hence rational prescribing.In compliance with the recommendations ofPerth workshop, an attempt has been made to designa manual for under-graduate medical students , in ourinstitute.It is recommended that other institutions inthe country also adopt similar policy. It is furthersuggested that approval of teaching of ClinicalPharmacology to the under-graduate students by thePakistan Medical & Dental Council, as recommendedand approved by the College of Physicians &Surgeons Pakistan, will facilitate and givemomentum to teaching of rational therapy.