THE ROLE OF THE CLINICAL PHARMACOLOGIST During the last two decades the number of drugs has increased enormously and so has our understanding of the complexity of their action and potential for adverse effects. In contrast undergraduate training and teaching in clinical pharmacology has not necessarily shown a parallel improvement, thus the importance of the clinical pharmacologist is becoming ever greater. Relationships between the pharmacologist, the GP and the hospital doctor How much do doctors in general practice need to know about such things as drug action, kinetics, concentrations in body fluids, etc? Probably all they need to know is something about first order and zero order reactions, half-life, distribution, body 'compartments' and clearance rates and to understand about multiple dosing. Drug monitoring and individual titration of doses according to plasma levels are now being advocated for such drugs as

antibiotics, cardiac drugs, salicylates, tranquillisers and antidepressants, but such procedures may require instrumentation and manpower which are beyond the hospital's ability to supply. The relationship between kinetics and therapeutics is a complex one, and doctors often fmd it difficult to keep abreast of pharmacological literature, preferring to rely on the clinical pharmacologist who may also be called upon to advise on 'bioequivalence' between brand name drugs. Professional freedom to prescribe can lead to costly overprescribing and this may be due to the doctor's lack of training or experience. Most doctors would probably welcome guidance on the best drugs for a given clinical condition. To this end, hospital drug committees provide drug formularies and drug information literature. The local coordinator is the pharmacologist, and the success of such a scheme depends upon the recommendations being adhered to. In Britain, in drug information booklets circulated within certain health districts, first choice and alternative choice drugs are named under the appropriate drug class, and guidance is given concerning indications and precautions, followed by a discussion of the clinical pharmacology, and drug costs. Most doctors adhere to the recommendations, with any variation depending upon trial use and local discussion. Clinical pharmacologists and the government The most pressing need at present is for productive discussion between pharmacologist and government on rationalising the anomalies of Britain's funding for prescribing. Too many doctors obtain their drug information solely from MIMS, while the new British National Formulary undoubtedly offers more needed information. It is to be hoped that future editions may contain even more in the way of recommendations. Another useful reference, despite some criticism levelled at it, is the Drugs and Therapeutics Bulletin. Clinical pharmacologists have often been able to influence government decisions for the better: for example the long standing rigorous requirements for preclinical drug testing have often meant in the past that drug companies have moved their research to foreign countries, thereby depriving local expertise of funds. Clinical pharmacologists contributed to the recent legislative changes, which have much improved this situation. The clinical pharmacologist and the public Probably the greatest challenge to the pharmacologist at the moment is the communication of knowledge to the public about the relative safety of drugs: the expectations of benefits obtainable from medicines and the concept of risk of adverse reactions. The public can no longer demand or expect absolute efficacy with absolute safety. These communications must be endorsed by doctors in all aspects of the media. Future research is being directed more and more towards preventative medicine, and the public will expect preventative drugs to have a very high safety factor when used long term. This of course is going to be difficult to achieve, indeed there have already been instances whereby intervention has tended to produce more morbidity and mortality than might be anticipated from the original disorder. It is vital that the pharmacologist educate the public into realistic expectations. 'In the past the doctor has enjoyed his taciturn reputation, the silent repository of clinical knowledge. It cannot be so now. Ignorance is no longer bliss, even if it was so in the past, and the public at large, and our patients in particular, want us to talk to them.' Turner, P: Journal of the Royal Society of Medicine 75: 77 (Feb 1982)

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lNPHARMA 3 Mar 1982

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