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Points for Consideration by the Physician

• Evaluate any suspected or obvious organ dysfunction-possible relative contraindications for certain drugs. When creatinine values are available, take the time to calculate creatinine clearance. Many drugs have break points for adjustment of dosage at various levels of renal impairment. Even though an older patient's creatinine is within the "normal limits," their clearance will not be. For example, a 72-yearold, 70-kg man with a 1.4 creatinine will have a creatinine clearance of about 48.6 ml/min. This is below the level where doses or intervals of renally eliminated medicines must be adjusted. Hepatic disease will also impact doses or intervals for many drugs, particularly those which are highly protein-bound or heavily metabolized.
• Assess the patient's potential for adherence or nonadherence to the drug therapy. Remember the expense that a given prescription presents. The most brilliant prescription choice is totally ineffective if financial considerations prevent adherence to the medicine you choose. Once-a-day dosing is much easier to remember and, combined with a dosing calendar, gets excellent results. See if the patient's pharmacist offers a medication mapping service. If not, map your patient's medicines yourself.

When Selecting Drugs for Therapy

• Try to match the drug's power to the patient's problem. Avoid overprescribing-medicinal "overkill." For example: mild to moderatestress reactions (situational anxiety-tension states) respond well to antianxiety drugs; they do not require antipsychotic medication. An uncomplicated urinary tract infection with a broadly sensitive single organism does not require a broad spectrum anti-infective drug.
• Obtain a copy of the Agency for Health Care Policy and Research Clinical Practice Guidelines Number 9. The AHCPR is advocating effective and timely pain control as a basic human right. Increase your awareness of the World Health Organization Pain Ladder and the use of the agents that are primary analgesics and adjuvants. AHCPR publications are great tools to help your patients understand their medicine and their disease. Push to make pain the fifth vital sign in your hospital.
• Always check for drug-drug, drug-food, and drug-disease interactions. Remember to take a "new" drug history periodically.
• Many new oral anti-infectives are effective against pathogens which historically required intravenous therapy. Although this allows you to avoid hospitalization, it makes the patient's adherence more critical.
• Consider the desired onset of drug action (immediate versus delayed) and the consequences or benefits of that effect.
• Choose the drug with the most favorable benefit-to-risk ratio: the best clinical effects with the fewest possible adverse reactions.