Teaching (clinical) pharmacology
While the focus of our curriculum is currently on the development of
novel drugs, it may be worthwhile to include more examples of drug
repurposing and the resulting research and ethical questions concerning
off-label use of old drugs in a different new settings and populations.
Thalidomide and rituximab are just some of the examples that can be used
to demonstrate the processes that lead to use in different indications
from those originally developed for a drug. (1). Students should
understand that even ”old” drugs need to go through approval if their
indications are to be expanded.
With our colleagues in medical ethics, we should make sure students
understand the proper use of off-label prescription and experimental
treatment. Just because a drug has been used for a long time does not
make it inherently safe and ”free to use”. Informed consent of the
patient is still required (2).
In the age of guidelines and EBM, we need to make sure our students and
future colleagues are prepared to deal with uncertainty when the
comforting blanket of randomised controlled studies and meta analyses is
suddenly jerked away from them. Balancing risk and benefit is one of the
most challenging parts of drug prescription, especially so at a time
like this.
Skills in critical appraisal of evidence are an essential tool of any
prescriber, even for those who are “just consumers” of science. The
recent torrent of COVID studies was a prime opportunity to practice
critical reading. When there is no time for proper peer review, each of
us must be their own reviewer. While the main burden may lie with our
colleagues teaching epidemiology and scientific methodology, we should
make sure our students leave their pharmacology course prepared to read
and appraise papers on drugs.
As is so often the case, those who are full of doubt and checking twice
were initially silent while the (over)confident were heard around the
world, with politicians gladly repeating their unsubstantiated claims
just to be seen by the public as the ones in charge, with a plan.
Preparing our students to deal with primary sources of uncertain quality
can help them make decision when guidance “from the top” disappears.
Studies of poor quality with surrogate outcomes and no control should
not be considered evidence justifying off-label use of drugs without
ethical approval and patient consent.