Rational Drug Use
Blind faith can lead to bleeding
Patients using oral non-steroidal, anti-inflammatory drugs (NSAIDs) who suffered from acute gastrointestinal bleeding knew less about their drug's side effects or what to do if they occurred than more informed patients using the same drugs, wrote Andrew Herxheimer in the British Medical Journal. In addition to this, the study of 50 hospital patients experiencing bleeding from the gut after taking one of four common NSAIDs and 100 control patients who took the same medicines also found that those who bled followed the prescribed dosages more closely. Although Herxheimer cautioned that the results should be interpreted carefully due to the study's small size, he argues that the patients' ignorance about serious side effects made them fail to recognise warning signs of potential bleeding and led to inappropriate "so-called" compliance. When he then compared 21 patient information leaflets for this type of drug, Herxheimer found that only nine told the patient to stop taking the drug if these symptoms occurred. The others advised patients to "tell your doctor" or other similar wording. To view the full text of the article, see the BMJ website: http://www.bmj.com/archive/7130/7130e5.htm.
(British Medical Journal No.7130, Vol. 316)
Promoting rational use in Africa
Réseau Médicament et Développement ( ReMeD) is carrying out a number of actions to increase rational drug use in Africa. Earlier this year it held a teaching seminar for technical assistants sponsored by the French Ministry for Cooperation. The participants taking part in the four-day event discussed how to evaluate the provision of medicines to Africa. A roundtable discussion is now being planned in cooperation with the Ministry of Foreign Affairs for 19 October to encourage a new approach in the supply and distribution of essential, generic medicines in Africa. Delegates from the World Health Organization and the European Commission are scheduled to attend. For more information about the meetings, contact: Carinne Bruneton,ReMeD, 35 rue Daviel, 75013 Paris, France, tel: (+33-1)53 80 20 20, fax: (+33-1) 53 80 20 21 or e-mail: ReMeD75013@aol.com
Italian "miracle cure" found ineffective
A group of international cancer specialists have found that Dr. Di Bella's controversial cancer cure is ineffective and has a high incidence of side effects. Ten trials are underway to determine if the retired physiologist's special mixture of ingredients including somatostatin, bromocriptine, melatonin and vitamins actually helps treat cancer patients. The international team reported on four of the trials saying there was no sign of the tumours shrinking or responding to his treatment in any trial participants. In addition, although Di Bella had said the treatment had few side effects, the group of specialists found that about 30% of those involved in the trials experienced adverse effects including modern to severe nausea and vomiting, diarrhoea and abdominal pain.
The cancer treatment gained international attention earlier this year when media attention provoked public outcry for access to the cure. It gained prominence as an alternative to conventional chemotherapy. As a result of public clamour, Italian judges agreed that the unproven and banned cure had to be allowed and the government was forced to pay for the treatment.
(British Medical Journal)
Information is not just for grownups
The US Pharmacopeia (USP) recently drafted a position paper setting out ideas aimed at increasing children's involvement in using medicines. The guidelines were drafted after an international meeting on children and drugs was held in 1996. The principles include giving children appropriate information about drugs they use keeping in mind their age, capabilities and culture. It also advocates children's right to obtain adequate information about any clinical trial they are asked to take part in after their parents have given consent. The document's points emphasise the fact that children not only have a right to know about their medicines, but also that they want to know about them. The USP guidelines tell how this interest can be respected and encouraged.
One HAI contact has already tested the principles in practice. In Moldova, the Association DRUGS surveyed a group of 11-15 year olds in the city of Chisinau and found some interesting results. Of the 31 children surveyed, most (77%) said they use medicines when they have a cold. Only 23 % used traditional remedies. More than half the children also said their families kept a lot of drugs in the house (about 80%) and that many were bought without a prescription.
For a full copy of the 10 points included in the guidelines, contact:
Patricia J. Bush, Division of Information Development (DID), United States Pharmacopeia, 12601 Twinbrook Parkway, Rockville, MD, 20852, US or at e-mail: pjb@usp.org
Generic use in Sweden
A study examining the use of generic drugs in Sweden has found that huge cost savings could be made if more generics were prescribed. In 1996, about 70% of the volume and 38% of the value of drugs sold in Sweden were generics, although they were advertised much less frequently than branded drugs. The researchers estimated that if the 50 million prescriptions filled at Swedish pharmacies in 1996 were redone using the least expensive drug possible (providing it had the same active ingredient, type of formulation and package size) the potential savings would be SEK 510 million (more than US$ 63 million) or 2.6% of the national drug bill for that year.
(Network for Pharmacoepidemiology)
Improving prescribing in Canada
One out of every two visits to a general practitioner in Canada ends with a prescription. GPs are responsible for most of the 230 million prescriptions written by Canadian doctors each year. HAI contact, Joel Lexchin, analysed the reasons behind inappropriate prescribing and found a number of factors. Lexchin found that most GPs prescribe a very limited number of drugs, usually between 121-218 of the 5,000 available on the country's market. In addition, research has shown that 50% of all GP prescriptions involve less than 30 medicines, with the drugs varying per doctor. At the same time, when questioned where they get their information about drugs, most GPs admit they rely on medical representatives in addition to peer-reviewed journals. Doctors writing the most prescriptions were found to meet with medical representatives twice as often as the average physician. As medical detailers have been shown to be drug companies' most effective form of promotion, this is a worrying fact. Lexchin also found that physicians working in government-funded community health centres prescribed more rationally than those working in private, group practices.
In the light of these facts, Lexchin endorses two strategies to improve prescribing: academic detailing and audit and feedback. Unlike one-to-one meetings with medical representatives, academic detailing is done by a trained clinical pharmacist with education as the message. Studies have shown inappropriate prescribing has been reduced by 12-49% through this method. Audit and feedback initiatives involve monitoring a doctor's prescribing pattern and then discussing it along with recommendations for better prescribing. Recognising that inappropriate prescribing is a complex problem involving a number of actors, Lexchin concludes that no single effort will always succeed. Plus, all the players, doctors, professional associations, patients and government must recognise the problem and be willing to commit time and energy to fix it. To obtain a copy of the article "Improving the Appropriateness of Physician Prescribing" contact: Joel Lexchin, 121 Walmer Rd., Toronto, Ontario, Canada M5R 2X8, tel: (+1-416) 964 7186, fax: (+1-416)923 9515 or e-mail: joel.lexchin@utoronto.ca
(International Journal of Health Services)
Psychotropics research in Europe
A group of researchers active in the EURO DURG (Drug Utilisation Research Group) has drawn up a plan for a pan-European research project on users' perspective regarding mood-modifying drugs including tranquillisers, hypnotics, antidepressants and herbal remedies. A planning meeting for the work was held in Copenhagen with the support of the WHO Pharmaceuticals Unit in March. Ten European countries are now taking part in the work including Belgium, Denmark, England, Finland, Greece, Iceland, The Netherlands, Norway, Scotland and Spain. The research will focus on:
- patients' expectations of drug treatment and reasons for using the drug;
- information about these drugs;
- the patient's relationship with the doctor and the power relationships involved;
- risk assessment and self-regulation, and;
- alternative therapies.
To take part in the project or find out more about it, contact:Anna Birna Almarsdottir, The Royal School of Pharmacy, Department of Social Pharmacy, 2 Universitetsparken, DK-2100 Copenhagen 0, Denmark; tel: (+45) 3537 0850, fax: (+45) 3537 2621 or e-mail:
Life imitates...the pharmacy?
Trendy types in London looking for the latest hot spot, can join the league of pop stars, artists, models and fashion icons hanging out at the new restaurant "Pharmacy". Diners find themselves surrounded by cabinets filled with bottles and boxes and face wallpaper depicting drawings of well known and imaginary drugs. A neon sign over the downstairs bar offers "prescriptions" and brave drinkers can order a Prozac Fizz (champagne cocktail) or a Medical Solution (made from vodka).
(De Telegraaf)
Pharmacy Guide Gains Readership
Two years ago, Georgina Stock launched the first issue of the newsletter Practical Pharmacy with the intent of filling the gap in training materials and information on managing drug supply in developing country situations. Since then, the newsletter has gained a great deal of attention from health workers in sub-Saharan Africa and Asia, the Middle East, Latin America, Europe, the US and Australia and its circulation has grown from 250 to 2,500.
Most of the newsletter's readers are nurses, pharmacists, pharmacy assistants and doctors who work at district or health-centre level, although Practical Pharmacy is also sent to universities and a variety of NGOs including women's groups and health information libraries. The project is supported by the UK Department for International Development and ECHO International Health Services.
Stock believes the newsletter has become so successful because it uses a simple, easy-to-read format and focuses on practical ideas that people can use in their daily work. Each issue highlights the principles behind good working practices rather than focusing on specific drugs. This makes the information appropriate for a wide range of health workers in many different countries. Stock now plans to broaden its readership by producing Practical Pharmacy in French and Spanish as well as English.
Copies of the newsletter can be obtained free-of-charge and bulk mailings are available for those unable to make copies but able to distribute the newsletter to other health workers.
To subscribe to the newsletter, contact: Georgina Stock, 66 Chiltern Road, Baldock, Herts, SG7 6LS, United Kingdom, e-mail: GSTOCK1@compuserve.com
Tamoxifen trials
When investigators halted a trial on tamoxifen 14 months early on what they called "ethical grounds" the news was met with mixed reactions. DES Action Canada published a letter emphasising that "the trial had not shown...that tamoxifen can prevent breast cancer. The drug may merely have delayed onset of the disease in some participants." The fact also remains that in the name of prevention a toxic drug was given to healthy women. While the study's authors concluded that the drug greatly reduced the incidence of cancer so sharply that they felt withholding the drug from the control group would be unethical, not all of the findings were reassuring for women. The study also found that those taking tamoxifen had 135% more cases of endometrial cancer than those taking the placebo. They also experienced more blood clots (47 cases versus 25). Importantly, the number of serious related health problems occurring in the study's group of women older than 50 (60% of the study's participants) was greater than the reduction of expected breast cancers. DES Canada reports that when the trial started, a US-based women's health group labelled this medicalisation of healthy women a case of "'disease substitution' not disease prevention."
(DES Action Canada Newsletter, issue 54, spring 1998)
Moldovan pharmacists learn about rational drug use
In Moldova today, most drugs can be purchased without a prescription. Many pharmacists see the profit to be made from selling medicines and as a result, consumers can receive unsafe or ineffective medicines-at a high price. The Association DRUGS organised a training programme for 36 post-graduate pharmacy students and faculty members at the State Medical University of Moldova to inform them about rational drug use topics. During the five-day meeting, the participants admitted that there is pressure on pharmacists not to look up drug information in the presence of a patient. There is also a lack of reference material available in the local language, forcing most pharmacists to wrestle with English-language texts. In addition, a survey done by the Association found that only 7% of the pharmacists polled knew who to tell about adverse drug reactions. At the same time, 76% expressed interest in learning more about side effects and ways to collect and analyse such information. The Association believes that the participants' high level of interest may mean that pharmacists could provide a crucial link in collecting information about side effects.
A follow-up discussion held in July focused on adverse drug reactions and brought together state agencies, academicians, health care professionals and pharmacists. The group developed a set of recommendations aimed at creating an information and education programme on drug side effects. Association DRUGS is now carrying out a pilot project with volunteers to collect information about side effects and develop a standard adverse effect notification form.
(Association DRUGS correspondence)
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