Usage Guidelines
This book is an attempt to give guidelines for treatment of common diseases, keeping in mind the rational use of drugs for each clinical condition. It is assumed that patient has been fully evaluated and all co-morbidities identified. Treatment of patient would involve a holistic approach and would require the expertise of the treating physician in formulating a treatment plan.
We describe groups of patients and make suggestions intended to apply to average patient in each group. However, patients will differ greatly in their presentation, treatment preference and capacities, in their history of response to previous treatments, their family history of response to treatment, and their tolerance for different side effects, therefore, the experts first line recommendations may not be appropriate in all circumstance.
It begins at the point when the doctor has already diagnosed a patient as suffering from that particular disease and has evaluated the patient to ascertain the presence of other concomitant disorders and other medical factors that may affect the diagnosis of treatment of patient. We assume clinicians using these guidelines are familiar with assessment and diagnostic issues. This book deals with only treatment of individual diseases.
It is divided into twenty chapters. First two chapters deal with general diseases and emergencies which may be common to all specialties. The aim is to provide complete management of commonly encountered diseases and emergency cases with clear instructions for referral (when, where and how) to a higher center with facilities for appropriate management. Rest of the chapters deal with common diseases in each specialty namely medicine, ENT, eye, skin, gynaecology and obstetrics, psychiatry, orthopaedic, surgery and paediatrics. The paediatric section provides treatment of diseases specifically encountered in paediatric age group. Other diseases, which are commonly encountered in adults as well, are discussed in the respective sections with doses in children.
Treatment up to tertiary care has been given as the group felt that one publication for all levels can serve as complete reference for most priority diseases since it would allow practitioners at lower level to read treatment at higher levels which may be an advantage in emergency cases and is at the least educational.
The format of guidelines is such that is gives only a few salient features of the disease and some important diagnostic tests followed by nonpharmacological and pharmacological treatment. Nonpharmacological treatment being an important aspect has been described very clearly. Pharmacological treatment deals with drug therapy.
Drugs are selected on the basis of balanced criteria of efficacy, safety, suitability and cost. Drugs are mentioned generic names only. Combination drugs are not included in the treatment except for some topical preparation e.g., in eye, ENT and skin preparations. These combinations were selected on the basis of appropriate ingredients and availability in the market.
Whenever drug choices are given for the treatment of a disease, they are listed in order of their preference. Wherever there are many equi-efficacious alternatives available only 2-3 preferable choices are mentioned to enable flexibility in the treatment. Drug choices are demarcated by ‘Or’. If several drugs are required concomitantly for treatment they are mentioned as 1,2,3 and so on. Drugs that lack evidence of efficacy and safety but are being used in practice, have not been mentioned in the treatment guidelines for obvious reasons. Drug dose is given as range wherever required in per kilogram dose with maximum tolerated dose. The frequency, route and special precautions are mentioned very clearly. Modification of treatment after monitoring the response in the next important step described in the pharmacotherapy. Generally the text is given in telegraphic language and rationale for a particular choice of drug or modality of treatment is not mentioned.
If a particular treatment needed mention at several places viz fever, shock, pain relief, in that case details are given in one section with a ‘note for details see relevant section’.
No treatment is complete without a good communication with the patient about prognosis, natural course of the disease, precautions and important side effects of drugs. There is a section on patient education at the end of each treatment guideline.
We have relied on expert opinion precisely because we are asking crucial questions that are not well answered by the literature. One thing that the history of medicine teaches us is that expert opinion at any given time can be very wrong. Accumulating research will ultimately reveal better and clearer answers. Clinicians should therefore stay abreast of the literature for developments. We will continue to revise the guidelines periodically based on new research information and on reassessment of expert opinion to keep them up-to-dat.
No set of guidelines cn ever improve practice if read just once. These guidelines are meant to be used in an ongoing way, since each patient’s status and phase of illness will require different interventions at different times. We believe the guideline recommendations will reinforce your best judgement when you are in familiar territory and help you with new suggestions when you are in a quandary.