E-drug: WHA 2001-Essential Drugs List
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With respect to the suggestions of Medecins Sans Frontieres about the
WHO Model List of Essential Drugs, I have some comments:
The essential drugs concept was developed many years ago to
articulate the principle that everyone in a population should have
access to those drugs that treat most of the illnesses of the
population before resources were used for other drugs. A list of
drugs that would illustrate this concept was developed and named a
Model List. Over the past 23 years, the essential drugs concept has
become generally accepted and the list developed as a model for how
to implement the concept has evolved into many things in addition to
being an example of how to implement the essential drugs concept.
I think the principle issue with respect to the WHO Essential Drugs
Model List is that there are now so many different purposes for the
List that one single Model List of Essential Drugs can no longer fill
the needs for this form of guidance in therapeutics. Thus, different
purposes require different lists. In fact, a small meeting held in
1995 with the report published in 1996 (Clinical Pharmacology and
Therapeutics 59: 251-7) was not able to define a single primary
purpose for the Model List. Thus, I support the idea proposed of
having more than one list with a clear principle purpose articulated
for each list. I question if only two lists, one of cheap drugs and
one of expensive drugs, is the best way to give guidance for
therapeutics or even for the implementation of the essential drugs
concept.
For example: There is a big difference in what is needed for safe and
effective use of expensive drugs that are easy to use with little
laboratory support such as the statins for cholesterol lowering and
drugs that are both expensive, difficult to use safely and
effectively, and require much laboratory support such as the protease
inhibitors with reverse transcriptase inhibitors in highly active
antiretroviral therapy (HAART). In my opinion, useful guidance by WHO
should differentiate between these two types of expensive drugs.
Further consideration may indicate additional categories of useful
drugs that require their own lists. For example, the drugs to treat
tuberculosis are not very difficult to use. But a proper program to
make essential anti-tuberculosis drugs, especially the second line
drugs, available should include making available methods for ensuring
adherence to the treatment regimen also available. Non-adherence to
therapeutic regimens facilitates the selection and spread of
resistant strains of bacilli . Here there is much more involved in
the guidance for setting up a tuberculosis control program than just
making expensive drugs
for tuberculosis available if the harm to the people in the country over
time is not to exceed the benefit since spreading resistant organisms
through an inadequate program will limit the value of implementing a
comprehensive adequate program in the future.
The essential drugs concept is key to rational therapeutics
everywhere and is used under various names in addition to "essential
drugs". Anything the World Health Assembly can do to strengthen the
overall WHO Essential Drugs program is valuable. And making
important drugs available to poor people at costs they can afford is
a necessary and essential goal. But careful thought must be given to
each specific recommendation so that unintended adverse consequences,
either for the individual patient or for the population at risk, will
not exceed the benefits actually produced by real world
implementation of the recommendation.
Marcus Reidenberg
Marcus M. Reidenberg, MD
Professor of Pharmacology and Medicine
Head, Division of Clinical Pharmacology
Weill Medical College of Cornell University
Editor, Clinical Pharmacology and Therapeutics
1300 York Ave., Box 70
New York, NY 10021
e-mail mmreid@med.cornell.edu
phone (212) 746-6227
fax (212) 746-8835
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