RATIONAL USE OF MEDICINES

Kathleen Holloway : Department of Essential Medicines and Pharmaceutical Policies, WHO, Geneva Liset van Dijk : University of Utrecht, the Netherlands

SUMMARY


Irrational use of medicines is an extremely serious global problem that is wasteful and harmful. In developing and transitional countries, in primary care less than 40% of patients in the public sector and 30% of patients in the private sector are treated in accordance with standard treatment guidelines.
Antibiotics are misused and over-used in all regions. In Europe, some countries are using three times the amount of antibiotics per head of population compared to other countries with similar disease profiles. In developing and transitional countries, while only 70% of pneumonia cases receive an appropriate antibiotic, about half of all acute viral upper respiratory tract infection and viral diarrhoea cases receive antibiotics inappropriately. Patient adherence to treatment regimes is about 50% worldwide and lower in developing and transitional countries, where up to 50% of all dispensing events are inadequate (in terms of instructing patients and/or labelling dispensed medicines).
Harmful consequences of irrational use of medicines include unnecessary adverse medicines events, rapidly increasing antimicrobial resistance (due to over-use of antibiotics) and the spread of blood-borne infections such as HIV and hepatitis B/C (due to unsterile injections) all of which cause serious morbidity and mortality and cost billions of dollars per year.
Effective interventions to improve use of medicines are generally multi-faceted. They include provider and consumer education with supervision, group process strategies (such as peer review and self-monitoring), community case management (where community members are trained to treat childhood illness in their communities and provided with medicines and supervision to do it) and essential medicines programmes with an essential medicine supply element. Printed materials alone have little effect and for guidelines to be effective they need to be accompanied by reminders, educational outreach and feedback.
Less than half of all countries are implementing many of the basic policies needed to ensure appropriate use of medicines, such as regular monitoring of use, regular updating of clinical guidelines and having a medicine information centre for prescribers or drug (medicine) and therapeutics committees in most of their hospitals or regions.
The second International Conference on Improving Use of Medicines in 2004 and World Health Assembly Resolution WHA60.16 in 2007 recognized the difficulty of promoting rational use of medicines in fragmented health systems. They recommend a cross-cutting health system approach and the establishment of national programmes to promote rational use of medicines, which would require much more investment than governments and donors have so far been willing to give.
http://www.who.int/medicines/areas/policy/world_medicines_situation/WMS_ch14_wRational.pdf

MALARIA: RDTs, unintended consequences?

Bill Brieger : 01 Jun 2011

Results from a recently published study on “Reduction of anti-malarial consumption after rapid diagnostic tests implementation in Dar es Salaam” are being reinterpreted.
The study found that after the introduction of malaria rapid diagnostic tests in urban Tanzania the prescription of artemisinin-based combination therapy (ACT) drugs decreased and was significantly lower in intervention health facilities than the controls, which continued existing clinical diagnostic practices. Of importance, “Adherence to test result was excellent since only 7% of negative patients received an anti-malarial.”
What has given rise to concern, is that when ACT use decreased, there was an increased use of antibiotics used to treat febrile illnesses. By following up on the story, SciDev.net gathered a more detailed understanding of the implications of the finding that, “antibiotic prescription increased from 49% before to 72% after intervention.”
Valerie D’Acremont, lead author and a senior scientist at the Swiss Tropical and Public Health Institute, Switzerland, explained to SciDev.net that, “Clinicians were handing out antibiotics, instead of anti-malarial drugs, to all patients with fever who tested negative for malaria. ‘They do that to avoid putting patients at risk,’ she told SciDev.Net, ‘especially as there are no diagnostic tools for other diseases such as typhoid or pneumonia.’”

These concerns run counter to the enthusiasm with which RDTs have been greeted by researchers. For example, Uzochukwu and colleagues found that RDTs are more cost effective in terms of saving lives that clinical diagnosis. Overall costs associated with RDT use was significantly lower than both clinical diagnosis and traditional microscopy.

A study in Burkina Faso showed how real life problems can interfere with research objectives when they tried to compare treatment outcomes between RDT usa and clinical diagnosis. Compliance by prescribers after getting negative RDT results was too low (i.e. they gave malaria treatment even for negative tests) to compare. Health worker acceptance of RDTs is a problem in many countries, but obviously not in the Tanzania study.

The Tanzania experience led SciDev.net to interview Action on Antibiotic Resistance (ReAct) that pointed out the lack of easy to use tests for other febrile conditions (pneumonia, typhoid, viral fevers) in primary care settings as a problem. Part of the problem is lack of rigorous adherence to clinical algorithms and guidance, and possibly a desire to give anything just to make the patient happy.

Again, the lead author of the Tanzania study was quoted by SciDev.net as saying that, “Ideally, with training and the implementation of clinical guidelines, it’s possible to reduce antibiotic use from 80 per cent to 25 per cent of patients.” Simply put, health care providers can change their behavior. This need for training and supervision increases as we expand treatment for febrile and other illnesses into the community. According to MCHIP (USAID) …
Experts agree that 60% of the 9.7 million children who die annually could be spared if we just delivered the life-saving interventions that we already have to families that need them most. These interventions include: antibiotics for pneumonia, dysentery and newborn sepsis; antimalarials; and oral rehydration packets and zinc supplements for diarrhea. Unfortunately the use of these interventions is low in most developing countries because services that deliver them are not accessible, not available, not of good quality, and/or not demanded.
The call therefore is for integrated case management at all level using all the tools currently available. We certainly do not want children to survive because of better malaria case management, while at the same time spurring antibiotic resistance that will threaten those same lives.

——–
One final note - the Tanzania study was based in an urban setting. Urban areas are generally less hospitable to malaria-carrying anopheles mosquitoes. One therefore wonders if the apparent large increase in antibiotic use was a result of fewer expected actual malaria cases in a city? Do we need different guidelines and training to orient health workers to the different ecological settings where malaria is endemic?
http://www.malariafreefuture.org/blog/?p=1217

MALARIA: Malaria test success drives up antibiotic misuse

Barbara Axt : 20 May 2011

 Flickr/MikeBlyth: In many clinics there are no tools for diagnosing non-malarial fevers

Antibiotic misuse has soared in an African capital as an unforeseen consequence of improving the diagnosis of malaria, according to a study.
A team testing the roll-out of fast, accurate tests for malaria in Dar es Salaam, Tanzania, found that antibiotic prescriptions for fever rose by nearly a quarter, from 49 to 72 per cent, raising fears that the behaviour will contribute to growing antibiotic resistance.
The team was assessing the impact of rapid diagnostic tests for malaria, which replaced the less precise microscope diagnosis in three hospitals and three health facilities in the capital. Eighteen months after the tests were rolled out, prescriptions of antimalarial drugs dropped from being given to three quarters of patients to just a fifth.
The results reflect a success for the tests in reducing the inappropriate prescribing of anti-malarial drugs, a major contributor to the growth in resistance to drugs such as artemisinin, a problem about which there is grave international concern.
But, as a consequence, said Valerie D'Acremont, lead author and a senior scientist at the Swiss Tropical and Public Health Institute, Switzerland, clinicians were handing out antibiotics, instead of anti-malarial drugs, to all patients with fever who tested negative for malaria.
"They do that to avoid putting patients at risk," she told SciDev.Net, "especially as there are no diagnostic tools for other diseases such as typhoid or pneumonia. The increase in absolute use of antibiotics is a mathematical consequence of knowing that fewer patients have malaria."
D'Acremont said that there is a serious risk that the introduction of the malaria tests will lead to a widespread increase in the use of antibiotics across the continent.
"Ideally, with training and the implementation of clinical guidelines, it's possible to reduce antibiotic use from 80 per cent to 25 per cent of patients," she said, citing an earlier study the team conducted, also in Tanzania.
Andreas Heddini, director of Action on Antibiotic Resistance (ReAct), said: "Ideally there would be tests for malaria and for bacterial infections, but these are unlikely to become available for the next years. In the meantime, much can be achieved with training.
"The big challenge is that in countries with weak health systems it is difficult to have a cautious approach to infections. You can't ask someone to come back in a few days if the symptoms get worse."
The team, which included scientists from Tanzania's City Medical Office of Health, the Ministry of Health and Social Welfare, and Ifakara Health Institute, published its results in Malaria Journal last month (29 April).
http://www.scidev.net/en/news/malaria-test-success-drives-up-antibiotic-use.html