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8/18/2019 1204 Pujiarto A
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COMPOUNDING
POLYPHARMACYPRESCRIPTION IN
INDONESIA
Purnamawati Pudjiarto;Arifianto, Arifianto;
Farian Sakinah;
Yulianto Kurniawan
Concern & Caring ParentsFoundation
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ABSTRACTCompounding Polypharmacy Prescription In Indonesia
Pudjiarto, Purnamawati Sujud; Arifianto, Arifianto; Sakinah, Farian; Kurniawan, Yulianto
Problems: The WHO-EML stated that “The custom in some places is to treat sick childrenwith a mixture of several medicines ("puyer"), not necessarily all appropriate to their
needs. Adult solid dosages forms are mixed together, ground to a powder, and the
powder divided into assumed pediatric doses then dispensed for administration to the
child. The Committee recommended that this irrational practice should not be used.”
However, resistance to change is very strong.
Objective: To study the “puyer” prescribing for children diagnosed with 4 viral infections (do
not need antibiotic) URI, fever, acute cough (without fever and signs of URI), acute GE;
and to see the change of “puyer” and types of medicine consumed after beingeducated.
Method: Intervention (done by doctors-trainers): written materials, FGD (6 months,3 weekly
meeting), “boosters” through the mailing list. Pre intervention, participants submit
prescriptions, data of illness-consumption of puyer, questioner.
Setting: Jakarta, 2004-2006.
Study Population: members of our mailing list from Indonesia.
Results: 160 eligible e-mails. Pre-post intervention, puyer prescribed 67.4%-24.7% andconsumed 65.4%vs4%, respectively. The most prescribed were antibiotic, steroid,
antipyretic, antihistamines; which changed significantly post intervention.
URI: median of medicines was 5, maximum 8, puyer 77.4%.
Fever: Median 4, maximum 8 medicines, puyer 72.6%.
Diarrhea: median 3, maximum 7 medicines, puyer 55.4%.
Cough: median 4, maximum 11 medicines, puyer 87.0%. Generic for URI, Fever,
acute GE and acute cough 16.9, 9.7, 3.6, and 18.4% respectively.Pre-post intervention, types of medicine: (1) antibiotic for URI 64.6%vs3.8%; GE
40.9%vs1.7%; fever 87.3%vs6.4%; coughs 46.3% vs 5.2%; (2) ORS for GE 4.6%vs68.7%.
(3) antitussive-mucolytic 86.9%vs21.2%. Knowledge 7.4vs96.2%. Seeking information
23.2%vs96.4%.
Conclusion: Puyer opens a window toward irrational polypharmacy that are potentially
harmful and costly. Consumer education is important to reduce irrational polypharmacy
puyer and to improve patient safety.
Funding sources: Concern & Caring Parent Foundation
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INTRODUCTION
• Irrational use of medicine problems :
– In Indonesia, a survey in Denpasar, Bali, showedthat 84,4% of pediatric prescriptions contain
more than 4 active ingredients. In West
Sumatera, the average medicines perscribed for
children with URI is 3.69 medicines. A study
under the MOH, Indonesia found that theaverage number of medications for each patient
is 3,49.
– In some areas of West Sumatera, Indonesia, the
rate of antibiotic use is more than 90%.
– Data from our mailing list
([email protected]) showed that 73%
reported of having been given antibiotics.
– The highest expenditure is for antibiotics (63% of
expenditure in URI), followed by cough-cold
remedies, analgesics.
– The cost of medications for diarrhea and URI is
68% of the total cost of health care for the
under-fives and 38% for above 5 years and 36%
of total health expenditure for drugs.
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OBJECTIVES
To understand the prescribing pattern in pediatrics
• Specific objectives
– Data on polypharmacy for children with URI, fever,
coughs, acute gastroenteritis.
– Data on the prescribed medications and number
of medications for those four ailments.
– Data on the rate of antibiotic use for those 4
health conditions.
– Data on generic use in those 4 conditions.
– Data on compliance to the standard treatment
guideline.
Fig 1. Processing compounding medicines or
PUYER (clockwise)
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METHOD
• Sample Population
– Members of [email protected] mailing list
• Data collection (2004-2006) – Emailed prescriptions or prescription’s
copy for children with URI, fever, coughs
acute GE; sent by parents before and afterintervention
• Inclusion criteria:
– Emails should contain chronologicalproblems (symptoms and signs),
– Emails should mention the age and weightof the child
– Emails should report the prescriptions,the name of all the medications, clearlyand or prescriptions are sent asattachments.
• Exclusion criteria:
– Do not provide clear or complete reportsmentioned above and or
– Did not write clearly/correctly the nameof all the drugs or only mentioned someof the drugs being given for their children
– Drop out
mailto:[email protected]:[email protected]:[email protected]:[email protected]
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RESULTSTable 1. Overall picture of the prescribing pattern
URI
(55)
Fever
(43)
Diarrhea
(27)
Coughs
(41) Total medicines 260 186 83 186
Median 5 4 3 4
Max 8 9 7 11
% Puyer 77.4 72.6 55.4 87
% Antibiotics(% generics) 54.5 7 86.4 0 74.1 5 46.3 10.5
% Generics 16.9 9.7 3.6 19.4
% medicines
-Steroid
-Anti Histamine
-Anti Convulsion
-Anti Pyretics
-Supplement
61.8
50.9
16.4 36.4
21.8
41.9
53.5
55.8 79.1
34.9
44.4
18.5
11.1 29.6
51.9
60.9
36.6
14.6 17.1
2.4
Figure 2. Examples
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Table 2. Miscellaneous “medications” for URI,
fever, coughs, diarrhea
URI FEVER COUGHS DIARRHEA
Isoprinosine Isoprinosine Vit B6 Anti fever
Nonflamin
Vit B complex Ketotifen Anti
histamine
Vit B
complex
Mycostatine Isoniazide Vit V complex
Vit B6 Cobazim Cimetidine Colostrum
Nicotinamide Imboost
Colostrum
bovine
Digestive
enzyme
Becombion Cariamyl Cariamyl
Low lactose
milk
Cobazim Toplexil syr
Stimuno Polysylane
Lactobacillus Echinaceae
Transpulmin
balsam
ImboostKetotifen
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PRESCRIBING PATTERN
010
2030405060708090
100
P e r c e n t ( % )
Medicines for Fever
Generic
Branded
Medicines for URI
0
10
20
3040
50
60
70
M u c o l y
t i c s
C o r t i c o s t e
r o i d s
A n t i b i o t i c s
D e c o n g e s t a n t s
A n t i h i s t a m
i n e s
B r o n c h o d i l a t o r s
A n t i p y r e t i c s
O t h e r
A n t i c o n
v u l s a
n t s
A n t i t u s s i v
e s
A n t i e m e t i c s
P e r c e n t
( % )
Generic
Branded
Medicines for Diarrhea
01020304050607080
O R S
A n t i b i o t i c s
P r o b i o t i c s
A n t i e
m e t i c s O
t h e r
A n t i h i s t a m i n e
A n t i c
o n v u
l s a n t s
A d s o r b e n t s
A n t i m
o t i l i t y
A n t i p y r e t i c s
E n z y m e
S u p p l e m e n t
P e r c e n t ( % )
Generic
Branded
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PRESCRIBING PATTERN (2)Medicines for Cough
0102030405060708090
100
B r o n c h o
d i l a t o r s
M u c o l y t i c
s
C o r t i c o s t e
r o i d s
A n t i b i o t i c
s
A n t i h i s
t a m i n e
s
D e c o n g e s t a n t s O t h e
r
A
n t i p y
r e t i c
s
A n t i c o n v u l s a
n t s
A n t i t u
s s i v e
s
A n t i e m
e t i c s
P e r c e n t ( % )
Generic
Branded
0
10
2030
40
50
P e r c e n t ( % )
Bronchodilators for Cough
Generic
Branded
Steroids for Cough
0
10
20
30
40
50
60
B e t a
m e t h a
s o n e
D e x a
m e t h a
s o n e
M e t h y
l p r e d n i s o
l o n e
P r e d
n i s o n e
T r i a
m c i n
o l o n
P e r c e n t ( % )
Generic
Branded
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ANTIBIOTIC PRESCRIBING PATTERN
Antibiotics for Fever
0
5
10
15
20
25
A m o x i c i l l i
n e
A z i t h
r o m y c i n
C e p h a
d r o x y l
C e p h r
a d i n e
C e p h y
x i m
C h l
o r a m
p h e n i c
o l
C l a
r i t h r
o m y c i n
C o t r i m
o x a z
o l e
E r y t h r
o m y c i n
S p i r a
m y c i n
P e r c e n t ( % )
Generic
Branded
Antibiotics for Diarrhea
05
101520253035
C e p h a d
r o x y l
C h l o
r a m p h e
n i c o l
C e p h r a
d i n e
C o t r i
m o x a z o l e
M e t r o n i d a
z o l e
P o l y m
y x y n
C l o x a c i l l i n
N i f u
r o x a z i d
e
M y c o s
t a t i n
P e r c e n t ( % )
Generic
Branded
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ANTIBIOTIC PRESCRIBING PATTERN (2)
Antibiotics for Cough
0
5
10
15
20
25
A m o x i c i l l i n
e
A z i t h
r o m y c i n
C e p h
a d r o x y l
C e p h
r a d i n e
C e p h
y x i m
C e p h
a c l o
r
C l a r i t h
r o m y c i n
C o t r i
m o x
a z o l e
E r y t h r
o m y c i n
S p i r a
m y c i n
P e r c e n t ( % )
Generic
Branded
Antibiotics is the third most frequent
drug for URI (54.54%) such as:
Amoxycillin :(27,27%; mostly non
generic), followed by
cefadroxil, cefradine, spyramicine (all
together are 15,15%).
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PRESCRIBING PATTERN
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
URI GE Fever Coughs
Antibiotic Use
Pre
Post
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
ORS Antitussive
Changes of drug use
Pre
Post
Puyer consumed
65.40%
4%
Pre
Post
Puyer prescription
67.40%
24.70%P re
Post
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CONCLUSIONS
Overprescribing of symptomatic medicines
(antitussive, antiemetic, adsorbents, antipyretic) Overprescribing of antibiotics;
Overprescribing (abusive use) of steroids;
Overprescribing of none guideline related
medicines e.g antihistamines, bronchodilators,
anticonvulsants;
Overprescribing of unnecessary medicines e.g
mucolytic, decongestants (never proven to be
effective yet already banned for under 6 years)
Overprescribing of multivitamin, supplements
(e.g. immunomodulators, “appetite stimulants”)
The above-mentioned data showed that
(1) Doctors often prescribe medicines that have not
yet been proven to be effective for those 4
conditions;(2)Doctors often prescribe “strong” medicines which
harm outweigh the benefit;
(3)Doctors often prescribe supplements and
products that are not needed by these children
(4)Further study need to be conducted to convince
related parties the importance of improving
prescribing practice particularly for children