Assessment and evaluation of poly pharmacy associating factors including antibiotics and nutritional supplements in hospital and community pharmacy.

Abstract:This study aimed to estimate the prevalence of poly pharmacy, the use of antibiotics and nutritional supplements and to determine the factors affecting poly pharmacy in different age limits of patients. The study of pharmacoeconomics and evaluation of the safety and efficacy parameters including drug/drug interactions.

A retrospective cross sectional study of prescriptions of hospitalized and community pharmacy patients were carried out in Lahore and Faisal Abad.

100 prescriptions were collected (43% were female patients and 57% male patients). The prevalence of poly pharmacy (patients who take ≥5 medications) at hospitals and community pharmacy was 40%.

19% patients were reported taking nutritional supplements. The % of the community pharmacy prescriptions was 75% and hospital admitted prescriptions were 25%.

17% drug-drug interactions were reported. The% of drug interactions of each pharmacological classes were (NSAIDs (34%),

(Antihypertensive (34%), antibiotics (10%), antifungal (8%), ant diabetics (8%) Supplements 5%).The cost of therapy per prescription/day was 174.70/PKR.

About half of elderly patients are exposed to poly pharmacy. A portion of geriatrics used nutritional supplements. The factors that were associated with patients exposure to poly pharmacy were different diseases including diabetes, hypertensionHeart Diseases, Joint pains and GIT infections. Pharmacoeconomic analysis shows that in 60% patients medications were according to international standard while in 40% patients were irrational.

1) NO: OF MALE AND FEMALE PATIENTS IN DIFFERENT AGE GROUPS:

Age limits No: of patients No:of female patients No: of male patients30-34 9 4 535-38 16 8 839-42 12 5 743-46 18 8 1047-50 20 9 11 51-54 6 2 455-58 4 1 3

59-62 5 2 3

63-66 2 1 1

67-70 8 3 5

TOTAL 100 43 57

% OF MALE PATIENTS

57%

% OF FEMALE PATIENTS

43%

% OF MALE AND FEMALE PATIENTS

2) AVERAGE NO: OF DRUGS PRESCRIBED= 420/100 = 4.20

3) % of the antibiotic classes used in all age limits:

AGE LIMITS NAME OF ANTIBIOTICS

ANTIBIOTIC CLASS

30-34 VIBRAMYCIN TetracyclineCEFIXIME 3rd generation cephalosporinLEVOFLOXCACINE 2nd generation

flouroquinoloneCLINDAMYCINE Lincomycin classSULFAMETHOXAZOL Protein synthesis inhibitorTRIMETHOPRIM Protein synthesis inhibitorAZITHROMYCINE MacrolideFLAGYL Metronidazole

35-38 CEFUROXIME 2nd generation cephalosporinFLAGYL MetronidazoleCIPROFLOXACINE 2nd generation

flouroquinoloneLEVOFLOXACINE 3rd generation

flouroquinoloneTOBRAMYCIN penicillin antibioticMOXIFLOXACINE 4th generation cephalosporinCEFTRIAXONE 3rd generation cephalosporinAMOXICILLINE penicillin antibioticCEFIXIME 3rd generation cephalosporinFLAGYL METRONIDAZOL

39-42 CEFTRIAXONE 3rd generation cephalosporinAMOXICILLINE penicillin antibioticFLAGYL METRONIDAZOL

43-46 AMOXICILLINE penicillin antibioticOFLOXACINE 2nd generation

flouroquinoloneCIPROFLOXACINE 2nd generation

flouroquinoloneFLAGYL METRONIDAZOLCLARITHROMYCINE MacrolideCEFACLOR 2nd generation cephalosporin

47-50 CEFTRIAXONE 3rd generation cephalosporinFLAGYL METRONIDAZOLCEFUROXIME 2nd generation cephalosporinFLAGYL METRONIDAZOL

51-54 CIPROFLOXACINE 2nd generation flouroquinolone

FLAGYL METRONIDAZOLAMOXICILLINE penicillin antibioticCEFTRIAXONE 3rd generation cephalosporin

55-58 GENTAMYCIN nitro imidazole antibioticCLARITHROMYCINFLAGYL METRONIDAZOL

59-62 CIPROFLOXACIN 3rd generation cephalosporin

METRONIDAZOL nitro imidazole antibiotic63-66 AMOXICILLINE penicillin antibiotic

CIPROFLOXACINE Flouroquinolones67-70 LEVOFLOXACINE Flouroquinolones

AMOXICILLINE penicillin antibioticMOXIFLOCACINE 4th generation cephalosporinCEFTRIAXONE 3rd generation cephalosporinFLAGYL METRONIDAZOL

% of the antibiotic classes used in all age limits:

ANTIBIOTICCLASSES

CEPHALOSPORINS FLUROQUINOLONES MACROLIDES PENICILLINS TETRACYCLINE FOLICACID SYNTHESIS INHIBITOR

METRONIDAZOL

% USED 32 18 5 15 2 5 23

% OF ANTIBIOTICS USED IN AGE LIMITS

CEPHALOSPORINS (32%)

METRONIDAZOL (23%)

FLOUROQUINOLONES (18%)

PENICILLINS (15%)

FOLIC ACID SYNTHESIS INHIBITOR (5%)

TETRACYCLINES (2%)

4)Names of the supplements used in patients:

Sr no: Name of supplement

Active ingredients

1 VITAMIN K1 phytonadione

2 FEFOL FOLIC ACID+CALCIUM

3 alpha keto acid Histidine, L-Tyrosine, L-lysine, nitrogen & calcium.

4 Surbex-z Nicotinamide:100mg, Riboflavin (Vitamin B2):15mg, Thiamine HCl (Vitamin B1):15mg, Tocopherol (Vitamin E):30IU, Zinc Oxide:22.5mg, Ascorbic Acid:500mg,Cyanocobalamin:12mcg, Folic Acid:150mcg, Pyridoxine:20mg]

5 Polybion-z Nicotinamide:50mg, Riboflavin (Vitamin B2):15mg, Thiamine HCl (Vitamin B1):15mg, Ascorbic Acid:300mg,Cyanocobalamin:10mcg,Pyridoxine:10mg

6 INDROP-D VITAMIN D

7 Iberet folic Ferrous Sulphate:525mg,Nicotinamide:30mg, Riboflavin (Vitamin B2):6mg, Thiamine HCl (Vitamin B1):6mg, Ascorbic Acid:500mg, Calcium Pantothenate:10mg,Cyanocobalamin:25mcg, Folic Acid:0.8mg, Pyridoxine:5mg

8 Maltofer syrup Iron Hydroxide Poly Maltose Complex:50mg/5ml

9 Osteo d Alfacalcidol 0.5mg10 Avemar Silicon dioxide, maltodextrin,fructose,sodium chloride

11 Myfol Folic acid12 Ferfix- Folic Acid:0.35mg, Iron Hydroxide Poly Maltose Complex:100mg

13 Divasas Nicotinic Acid:20mg, Retinol (Vitamin A):5000IU, Riboflavin (Vitamin B2):1.7mg, Thiamine HCl (Vitamin B1):1.5mg, Tocopherol (Vitamin E):30mg, Ascorbic Acid:60mg, Calciferol:400IU,Cyanocobalamin:6mcg, Iron Salts:18mg, Iodine:150mcg,Magnesium Oxides and Hydroxides:100mg,Pyridoxine:2mg,

14 QALSAN -D Calcium Carbonate:1250mg, Cholecalciferol:125IU

15 Bevidox Thiamine HCl (Vitamin B1):100mg/3ml,Cyanocobalamin:1000mcg/3ml,Pyridoxine:100mg/3ml]

16 cremafinn Paraffin:1.25ml/5ml, Magnesium Oxides and Hydroxides:3.5ml/5m

17 Sangbion Manganese:0.2mg,Cyanocobalamin:7.5mcg, Folic Acid:1mg, Copper:0.2mg

18 CAL-C Calcium Lactate, Ascorbic Acid:, Calcium Carbonate:

19 Trihemic Tocopherol (Vitamin E):30IU,Ascorbic Acid:600mg,Cyanocobalamin:25mcg, Folic Acid:1mg, Ferrous Fumarate:350mg

% of prescriptions with and without supplements:

% OF PRESCRIPTIONS WITH AND WITHOUT SUPPLEMENTS

PRESCRIPTIONS WITHOUT SUPPLEMENTS(81%)

PRESCRIPTIONS WITH SUPPLEMENTS(19%)

5) % of drug-drug interactions in prescriptions:

17%

83%

% OF DRUG-DRUG INTERACTIONS IN PRESCRIPTIONS

PRESCRIPTIONS WITH D-D INTERACTIONS(17%)

PRESCRIPTIONS WITHOUT D-D INTERACTIONS(83%)

6) % OF INTERACTIONS OF DIFFERENT PHARMACOLOGICAL CLASSES:

% OF INTERACTIONS OF DIFFERENT PHARMACOLOGICAL CLASSES

NSAIDs(34%)

ANTIHYPERTENSIVE(34%)

ANTIBIOTICS(10)

ANTIFUNGALS(8%)

ANTIDIABETICS(8%)

SUPPLEMENTS(5%)

OTHERS(1%)

TABLE OF D-D INTERACTIONS:

Sr Drug+drug interaction mechanism Significance Out put Management

no: level1 Ciprofloxacin+calcium

supplementsGI absorption of QUINOLONES may be decreased.

2 Decreased pharmacologic effects of QUINOLONES

Concurrent use cannot be avoided.

2 aspirin+glimepiridine Aspirin reduces basal glucose levels and (↑es ) insulin secretion also inhibition of prostaglandin synthesis may inhibit insulin responses to glucose.

2 ↑es hypoglycemic effect

Monitor the patient's blood glucose. If hypoglycemia develops, consider decreasing the SULFONYLUREA dose

3 ASPIRIN+DICLOFENAC SODIUM Competitive inhibition of the acetylation site of cyclooxygenase in the platelet.

1 ↓es cadioprotectivity and ↑es gastric irritation via aspirin

SELECT analgesics that do not interfere with antiplatelet effect (eg, acetaminophen).

4 NORTRIPTYLINE+LEVOFLOXACIN

MECHANISM IS UNKNOWN

1 may (↑es) torsades de pointes

Other quinolone antibiotics that do not prolong the QTc interval (USED)

5 ASPIRIN+PROPRANOLOL SALICYLATES may inhibit biosynthesis of prostaglandins involved in the antihypertensive activity

2may (↓es) activity of propranolol

Monitor BP. If an interaction is suspected, consider lowering the dose of the SALICYLATE

6 FLUCONAZOL+STEROIDS Inhibition of CORTICOSTEROID metabolism (CYP3A4) and decrease in elimination.

2 may ↑es toxicity of steroids

Closely monitor patients for CORTICOSTEROID adverse effects. Adjust dose as needed

7 LOSARTAN+FLUCONAZOL inhibition of metabolism (CYP2C9) of LOSARTAN by FLUCONAZOLE

3 may ↑es antihypertensive effects

Closely monitor blood pressure response to LOSARTAN when FLUCONAZOLE is started, stopped, or changed in dosage

8 METHOTREXATE+MEFENAMIC ACID

Reduced renal clearance is suspected.

1 may ↑es MTX toxicity

Monitor for renal impairment that could predispose to MTX toxicity

9 ASPIRIN+PROPRANOLOL SALICYLATES may inhibit biosynthesis of prostaglandins involved in the antihypertensive activity

2 may (↓es) activity of propranolol

Monitor BP. If an interaction is suspected, consider lowering the dose of the SALICYLATE

10 piroxicam and acetaminophen with (ALENDRONATE)

NSAIDs and BISPHOSPHONATES may be synergistic with respect to causing gastric ulcers.

3 ↑es risk of gastric ulceration

Use caution when co- administering these agents

11 OMEPRAZOL+CYANOCOBALMIN

OMEPRAZOLE-induced hypo hydria or achlorhydria may decrease the absorption of vitamin B12.

5 MAY (↓es)therapeutic action of VITAMIN B12

If both drugs are to be given chronically, consider administering VITAMIN B12 parenterally.

12 ASPIRIN+OMEPRAZOL (PPI) may increase in gastric pH results in a more rapid dissolution and release of SALICYLATE.

3 may (↑es)gastric side effects

Patients at risk of serious gastric disorders due to the release of SALICYLATES in the stomach should avoid concurrent use of these agents.

13Aspirin+captopril

DUE TO Inhibition of prostaglandin synthesis

MAY (↓es)hypotensive and vasodilator effects of the ACE INHIBITOR

Adjust ASPIRIN dosage to less than 100 mg/day; convert to non-aspirin antiplatelet agent; or continue ASPIRIN and convert patient from ACE INHIBITOR to angiotensin-receptor blocker.

14 Aspirin+insulin The serum glucose-lowering action of INSULIN may be potentiated.

2 acute INSULIN response to a glucose load is enhanced

Monitor blood glucose concentrations and tailor the INSULIN regimen as needed.

15 ASPIRIN+RINGER LACTATE Urine alkalinization leads to increased renal clearance and reduced serum levels of SALICYLATES

3 Renal clearance of SALICYLATES increases dramatically above urine pH 7.

The patient receiving concurrent URINARY ALKALINIZER and anti-inflammatory SALICYLATE therapy may require higher than expected SALICYLATE doses

16 CLARITHROMYCIN+OMEPRAZOL CLARITHROMYCIN may inhibit the metabolism (cytochrome P450 3A4 and 2C19) of OMEPRAZOLE,

3 MAY(↑es) concentrations of CLARITHROMYCIN and OMEPRAZOLE

no special action is needed. Co -administration of these agents may be beneficial in the treatment of Helicobacter pylori

17 ATENOLOL+AMINOPHYLINE Pharmacologic antagonism. BETA-BLOCKERS may reduce demethylation of THEOPHYLLINE.

2 MAY (↓es) elimination of THEOPHYLLINE

Monitor plasma THEOPHYLLINE levels when a BETA-BLOCKER is added or deleted from a regimen

Reference: DRUG INTERACTION FACTS 2009: THE AUTHORITY ON DRUG INTERACTIONS BY DAVID S. TATRO , PUBLISHED JULY 1ST 2008 BY LIPPINCOTT WILLIAMS & WILKINS.

(7) COST /PRESCRIPTION/DAY:

Average Cost of 100 prescriptions = 17468/100 = 174.70

COST/PRESCRIPTION/day = 174.70

8) % OF PRESCRIPTIONS:

% OF TYPES OF PRESCRIPTIONS:

COMMUNITY PHARMACY PRESCRIPTIONS(75%)

HOSPITAL ADMITTED PRESCRIPTIONS(25%)

% of community pharmacy prescription % of hospital admitted prescriptions75 25