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.