What are the basic medicines that should be stocked in a general medicine clinic?

Essential Medications for a General Medicine Clinic

A general medicine clinic should stock medications across multiple therapeutic categories to manage common acute and chronic conditions, with particular emphasis on antihypertensives, diabetes medications, analgesics, and emergency antidotes based on the clinic's specific patient population and hazard vulnerability assessment.

Core Medication Categories

Cardiovascular Medications

Antihypertensive agents are fundamental, as multiple-drug therapy is typically required to achieve blood pressure targets in most patients 1. Your formulary should include:

• ACE inhibitors or ARBs as first-line agents for hypertension, particularly in patients with diabetes, albuminuria, or established coronary artery disease 1
• Thiazide-like diuretics for blood pressure reduction and as combination therapy 1
• Dihydropyridine calcium channel blockers (such as long-acting nifedipine) for additional blood pressure control 1
• Beta blockers remain important for patients with coronary artery disease and as first-line therapy in certain populations 1

The evidence strongly supports having multiple classes available because achieving blood pressure control below 140/90 mmHg requires two or more agents from different pharmacologic classes in approximately 50% of patients 2. For patients with blood pressure ≥160/100 mmHg, prompt initiation of two drugs or a single-pill combination is recommended 1.

Diabetes Management Medications

Formularies must provide access to short-, medium-, and long-acting insulins plus multiple classes of oral medications 1. Essential categories include:

• Rapid-acting insulin analogs for mealtime coverage and flexibility with meal timing 1
• Long-acting basal insulins for background glucose control 1
• Metformin (biguanides) as first-line oral therapy 1
• Insulin secretagogues (sulfonylureas) for additional glucose lowering 1
• Alpha-glucosidase inhibitors and thiazolidinediones to complete the therapeutic options 1

Glucagon must be immediately available for emergency treatment of severe hypoglycemia, particularly in patients on insulin or sulfonylureas 1.

Analgesics and Anti-inflammatory Medications

Ibuprofen should be stocked as it has a long history of safe and effective use as an OTC analgesic/antipyretic 3, 4. Available strengths include 400 mg, 600 mg, and 800 mg tablets 3.

Critical caveat: Ibuprofen can interfere with antihypertensive drug efficacy, causing mean increases in blood pressure of 6-7 mmHg in patients on multiple antihypertensive medications 5. When prescribing NSAIDs to hypertensive patients, monitor blood pressure closely and consider acetaminophen as an alternative 5, 4.

Emergency Antidotes

Every clinic providing emergency care must perform a hazard vulnerability assessment to determine specific antidote needs 1. The assessment should consider:

• Pharmaceutical products widely available in the community (acetaminophen, opioids, benzodiazepines, anticholinergics) 1
• Local industries and practices (agricultural chemicals, transportation routes) 1
• Referral patterns from surrounding areas 1

At minimum, stock these immediately-available antidotes 1:

• Naloxone (20-40 mg minimum stock) for opioid overdose 1
• Flumazenil (6-12 mg) for benzodiazepine reversal, though use cautiously in mixed overdoses 1
• Glucagon (90-250 mg) for severe hypoglycemia and beta-blocker overdose 1
• Activated charcoal for reducing drug absorption (though not technically an antidote) 1

Within 1-hour availability 1:

• Fomepizole (preferred over ethanol) for toxic alcohol ingestion due to simplicity of use and reduced medication errors 1
• Hydroxocobalamin (preferred over sodium nitrite/thiosulfate) for cyanide toxicity due to wider indications and ease of use 1
• Physostigmine for anticholinergic toxicity 1

Medication Selection Strategy

Create a personal formulary by selecting one or two drugs from each class for conditions you commonly treat 6. Base selections on:

1. Efficacy from large, methodologically sound clinical trials evaluating meaningful clinical outcomes 6
2. Safety profile including adverse effects, drug interactions, and extent of clinical experience 6
3. Patient acceptability considering dosing frequency and tolerability 6
4. Cost considerations without compromising quality 6

Critical Drug Interactions to Monitor

NSAIDs interact with multiple medication classes 4:

• Aspirin (reduced antiplatelet effect)
• Antihypertensives (reduced efficacy) 5, 4
• Antidepressants (increased bleeding risk)
• Alcohol (gastrointestinal toxicity) 4

ACE inhibitors and ARBs should never be combined, nor should either be combined with direct renin inhibitors, due to increased risk of hyperkalemia, syncope, and acute kidney injury without added cardiovascular benefit 1.

Practical Implementation

Stock medications at dosing frequencies consistent with treatment plans 1. For insulin-dependent patients, ensure rapid-acting analogs can be administered immediately before meals to accommodate schedule disruptions 1.

Monitor serum creatinine, estimated glomerular filtration rate, and potassium levels at least annually in patients on ACE inhibitors, ARBs, or diuretics 1.

Establish systems to identify patients at high risk for medication-related emergencies, particularly those on insulin, sulfonylureas, or multiple antihypertensives 1.