Non-essential Drugs Research Articles

Drug utilization reviews to reduce inappropriate drug use and pharmaceutical costs in inpatients based on diagnosis-related group data.

Irrational pharmacotherapy and increasing pharmacy costs remain major concerns in healthcare systems. Pharmacists are expected to employ diagnosis-related group (DRG) data to analyse inpatient pharmacy utilization. This project aimed to pilot an efficient pharmacist-led programme to analyse factors related to pharmacy expenses, evaluate the rational use of drugs in batch processing, and make further interventions based on DRG data. Patients from the OB25 (caesarean section without comorbidities or complications) DRG were selected in 2018, and the most relevant factors were identified through statistical analysis. Interventions were implemented by sending monthly reports on prescribing data and drug review results for the same DRGs to the department starting in 2019. Pre-post comparisons were conducted to demonstrate changes in pharmacy costs and appropriateness at a tertiary teaching hospital with 2,300 beds in China. A total of 1,110 patients were identified from the OB25 DRG data in 2018. Multivariate linear analysis indicated that the number of items prescribed and wards substantially influenced pharmacy expenditure. Drugs labelled as vital, essential, and non-essential revealed that 46.6% of total pharmacy costs were spent on non-essential drugs, whereas 38.7% were spent on vital drugs. The use of inappropriate pharmaceuticals and drug items was substantially reduced, and the average pharmacy cost after intervention was 336.7 RMB in 2020. The benefit-cost ratio of the programme was 9.86. Interventions based on DRG data are highly efficient and feasible for reducing inpatient pharmacy costs and non-essential drug use.

Factors associated with medical consumable availability in level 1 facilities in Malawi: a secondary analysis of a facility census.

Medical consumable stock-outs negatively affect health outcomes not only by impeding or delaying the effective delivery of services but also by discouraging patients from seeking care. Consequently, supply chain strengthening is being adopted as a key component of national health strategies. However, evidence on the factors associated with increased consumable availability is limited. In this study, we used the 2018-19 Harmonised Health Facility Assessment data from Malawi to identify the factors associated with the availability of consumables in level 1 facilities, ie, rural hospitals or health centres with a small number of beds and a sparsely equipped operating room for minor procedures. We estimate a multilevel logistic regression model with a binary outcome variable representing consumable availability (of 130 consumables across 940 facilities) and explanatory variables chosen based on current evidence. Further subgroup analyses are carried out to assess the presence of effect modification by level of care, facility ownership, and a categorisation of consumables by public health or disease programme, Malawi's Essential Medicine List classification, whether the consumable is a drug or not, and level of average national availability. Our results suggest that the following characteristics had a positive association with consumable availability-level 1b facilities or community hospitals had 64% (odds ratio [OR] 1·64, 95% CI 1·37-1·97) higher odds of consumable availability than level 1a facilities or health centres, Christian Health Association of Malawi and private-for-profit ownership had 63% (1·63, 1·40-1·89) and 49% (1·49, 1·24-1·80) higher odds respectively than government-owned facilities, the availability of a computer had 46% (1·46, 1·32-1·62) higher odds than in its absence, pharmacists managing drug orders had 85% (1·85, 1·40-2·44) higher odds than a drug store clerk, proximity to the corresponding regional administrative office (facilities greater than 75 km away had 21% lower odds [0·79, 0·63-0·98] than facilities within 10 km of the district health office), and having three drug order fulfilments in the 3 months before the survey had 14% (1·14, 1·02-1·27) higher odds than one fulfilment in 3 months. Further, consumables categorised as vital in Malawi's Essential Medicine List performed considerably better with 235% (OR 3·35, 95% CI 1·60-7·05) higher odds than other essential or non-essential consumables and drugs performed worse with 79% (0·21, 0·08-0·51) lower odds than other medical consumables in terms of availability across facilities. Our results provide evidence on the areas of intervention with potential to improve consumable availability. Further exploration of the health and resource consequences of the strategies discussed will be useful in guiding investments into supply chain strengthening. UK Research and Innovation as part of the Global Challenges Research Fund (Thanzi La Onse; reference MR/P028004/1), the Wellcome Trust (Thanzi La Mawa; reference 223120/Z/21/Z), the UK Medical Research Council, the UK Department for International Development, and the EU (reference MR/R015600/1).

Pharmaceutical Promotions and Compliance with Community-Acquired Pneumonia Prescribing Guidelines by General Practitioners in Mbarara

Background: Generic prescribing effectively reduces dispensing errors and promotes the availability, access and quality of pharmaceutical products in health facilities or pharmacies. However, in Uganda, non-compliance with treatment guidelines is prevalent, with evidence of some General Practitioners (GPs) prescribing non-essential and obsolete drugs. This study examines the role of pharmaceutical promotions in creating awareness of new medicines among GPs and the potential influence of these promotions on prescribing practices.
 Methods: The study used a qualitative phenomenological research design. Key informant interviews were conducted with 33 experienced GPs from nine hospitals in Mbarara City, Uganda. The transcribed interviews were analysed using content analysis.
 Results: Most GPs were male (78.79%), aged between 41-50 years (30.30%), with a work experience of 6-10 years (39.39%). All GPs had at least been exposed to pharmaceutical promotions such as free samples, visits from medical representatives, and Continuing Medical Education sessions. Most GPs had a positive outlook on these promotions, which they believed were informative, educational, and beneficial. However, the more GPs depend on pharmaceutical promotions, the less likely they are to follow the national or international guidelines for generic prescribing.
 Conclusion: The study highlights the importance of ethical pharmaceutical promotion and the need for strict regulation by the National Drug Authority (NDA) to ensure that promotional activities do not compromise patient care and public health outcomes. The study recommends that GPs be more critical of the information and incentives provided during such promotions and should be trained in rational prescribing and evidence-based medicine.

Analysis of drug list used in E Hospital in 2021

Objective: General analysis and analysis according to ABC/VEN of drugs list (DL) used at Hospital E (HE) from January 1, 2021 to December 31, 2021 by retrospective analysis. Research subjects and methods: Descriptive and retrospective study of all DL used at Hospital E from January 1 to December 31, 2021, drug use report of Hospital E in 2021 and related documents regarding DL of Hospital E from January 1 to December 31, 2021. Exploiting data at the Faculty of Pharmacy Hospital E, combined with exploiting the DL management software of the Faculty of Pharmacy, Hospital E in 2021. Results: The structure of DL HE in 2021 includes 566 drugs divided into 28 groups of pharmacological effects (PE), foreign drugs dominate over domestic drugs, single-component drugs account for a larger proportion, parenteral drugs, infusion predominates. According to ABC analysis: Group A accounted for 77.38% of value with 112 drugs divided into 19 groups of physical exercise. Group B accounted for 15.03% of value with 113 drugs divided into 22 groups PE. Group C accounted for 7.59% of value. According to VEN analysis: the vital drugs (V) have 105/566 drugs, accounting for 18.55% of the items. Essential drugs (E) have 401/566 drugs, accounting for 70.85% of items. Non-essential drugs (N) have 60/566 drugs, accounting for 10.60% of the items. According to the ABC/VEN matrix: The most important group (I): including AV, AE, AN, BV, CV: 35.87% items, 80.55% value. The important group (II): including BE, BN, CE: 58.65% items, 18.55% value. The less important group (III): CN: 5.48% items and 0.90% value. Key words: Drugs List (DL); Hospital E (HE); ABC/VEN matrix; Original brand name medicine (OBNM).

Analysis of pharmaceutical supply of breast cancer patients

The aim: to conduct a clinical and economic analysis of the state of pharmaceutical support for patients with breast cancer in women. Materials and methods. During the research, data from the National List of Essential Medicines, the 14th State Formulary of Medicines, the Ukrainian clinical protocol, the clinical protocols of Great Britain and the United States of America for the treatment of breast cancer, and a depersonalized database of drug prescriptions were used. The research used such methods as clinical-economic, organizational-economic, mathematical-statistical, graphic, grouping and generalization. Research results. It was established that 46 schemes of schemes for the treatment of breast cancer are presented in Ukrainian and international clinical protocols (Great Britain, USA). In all three protocols, there were 5 regimens for the treatment of breast cancer, such as CMF (Cyclophosphamide, Methotrexat, Fluorouracil), AC (Doxorubicin, Cyclophosphamide), DC (Docetaxel, Cyclophosphamide), TC (Trastuzumab, Capecitabin), EC (Epirubicin, Cyclophosphamide). Analysis of the pharmaceutical component in the protocols for individual drugs showed that they included 23 drugs according to the INN, which belong to the group of antineoplastic drugs. The Ukrainian clinical protocol includes 17 drugs, the British protocol – 14 drugs, and the American one – 15 drugs. The frequency analysis of antineoplastic drugs included in the Ukrainian clinical protocol revealed the TOP-3 in terms of drug prescription frequency: L01A A01 Cyclophosphamide (Ki=0.037), L01C D02 Docetaxel (Ki=0.029), L01D B01 Doxorubicin (Ki=0.026). The largest number of prescribed drugs are vital drugs – 61.96 %, the smallest share – essential drugs – 2.17 %, and the share of non-essential drugs is 35.87 %. The ABC analysis made it possible to determine the group of the most expensive drugs in the treatment of breast cancer - these are antineoplastic and immunomodulating agents. The total expenses for this group amounted to UAH 772,459.96, which according to the US dollar exchange rate of the National Bank of Ukraine at the end of August 2022 was USD 21,122.77. According to the analysis of the matrix of the integrated ABC-VEN-frequency analysis, it was established that the largest number of prescriptions belonged to the group of less expensive and vital drugs (B/V) – 7 drugs (48.73 % of the total amount. At the same time, the largest amount of expenses is observed in for the A/V group – UAH 772,459.96 (52.83 % of all costs directed to the pharmaceutical support of patients). The results of the structural analysis of the group of the most expensive drugs showed that the highest costs were characteristic of L01CD02 Docetaxel (UAH 1166,531.31; 39.81 % of the total cost in the group), and the lowest – for L01DB01 Doxorubicin – UAH 63,694.14 (5.46 %, respectively). Conclusions. According to the results of the conducted research, it was established that the largest costs fall on the group of essential drugs (1047735.07 UAH, 71.65 % of all costs). This determines the need for further pharmacoeconomic calculations of breast cancer treatment to optimize the costs of antineoplastic drugs

Pharmacotherapy of Mental Illness in the Mental Health Centers in Kosovo During 2021

Background- Treatment of mental illness with pharmacotherapy is strictly monitored in clinical centers dedicated to this purpose. While in most of developed countries this practice is well established, in Kosovo, in absence of such system, there is the need for further and continues investigation in this context with the aim to better monitor the therapy. 
 Aim of the study - This work aims to analyze and investigate the treatment of the patients with mental illness in the Mental Health Centers in Kosovo.
 Methods - The methodology of this research work is based on the specific guidelines published by the WHO. Handbook of the World Health Organization (WHO). All patients’ data were obtained from protocol books of the treated patients. For each city, 30 patients which were selected according to the theory of probability, were analyzed. A total of 209 patients were enrolled in the study. Regarding the pharmacotherapeutic characteristics we have analyzed the way of treatment of mental illnesses according to the groups of drugs and centers. The diseases were categorized according to the International Classification of Diseases - Revision 10. 
 Results - Drugs were mainly administered through mouth, per os (PO) (82.4%). According to the clinics there was no significant change as per administration route of the drugs (ChiTest = 28, p > 0.11) (Tab.3). Almost, 2/3 of the prescribed drugs were non-essential (66.1%). Considering the class of the therapeutic drugs, over half of them were antipsychotic (53.2%), whereas in a percentage of 17.2% and 13.8% were anticholinergic and anxiolytic/hypnotic drugs, accordingly. These classes of drugs were 84.2% of the overall used drugs. Taken together, In the Mental Health Centers in Kosovo, drugs are mainly administered orally, with only 17.6% of the cases treated parenterally. The majority of the drugs used are the non-essential drugs, with antipsychotics being the most prescribed ones.
 Conclusions - Furthermore, the study highlights the use of the third-line therapy as a first choice, and the use of effective drugs with low safety profile such as: Clozapine 84.62% (from SDA group). Moreover, ineffective drugs are used in 1.92% of patients and non-compliance of treatment with drug indications was found in 5.77% of cases.

Assessment of role of clinical pharmacist in the evaluation of prescriptions in a tertiary care teaching hospital: a prospective observational study

Background: Prescribing of medicines is an integral part of the provision of health care. For effective and safe treatment, it is essential that prescribing and administration of drug should be evaluated from time to time. Prescription errors account for 70% medication errors that could potentially results in adverse drug reactions.
 Aim and objectives: The purpose of the study to identify errors, major factors which are responsible for the occurrence of medication errors, and to analyse the role of clinical pharmacist in medication errors and to observe the adverse drug reactions.
 Methodology: A Prospective observational study was conducted in MNR medical College and Hospital, Sangareddy district. The data was collected from the inpatients of General Medicine department by using standard case report form through direct patient interview and collected data was analysed to identify medication errors and adverse drug reactions.
 Results: 500 prescriptions were analysed, in that 300 prescriptions presented with different types of medication errors. For medication errors the prevalence of females is more than males. Age group between 31-50 showing medication errors. 141 were found to be prescribing errors, 62 administration errors, 69 dispensing errors and 28 monitoring errors. Incidence of dose and strength errors (50.35%), wrong time administration errors (51.61%), wrong drug administration errors (21.73%), monitoring not requested (50%). Prescribing errors were more common in general medicine department. Essential and non-essential drugs, level of severity, were found to be statistically significant (P value <0.05).
 Conclusion: Clinical pharmacist should act as an effective medical staff by conducting awareness and education programs for nursing staff and other health care professionals regarding detection, reporting and occurrence of medication errors.

Antiviral and anti-inflammatory drugs to combat COVID-19: Effects on cardiac ion channels and risk of ventricular arrhythmias.

Introduction: Drugs with no indication for the treatment of cardiovascular diseases (e.g., drugs employed to treat COVID-19) can increase the risk of arrhythmias. Of interest, a six-fold increase in the number of arrhythmic events was reported in patients with severe COVID-19. In this study, we reviewed (i) the pro-arrhythmic action of drugs given to patients with COVID-19 infection, and (ii) the effects of inflammatory cytokines on cardiac ion channels and possible generation of arrhythmias. Methods: We conducted a literature search on the drugs with purported or demonstrated efficacy against COVID-19 disease, emphasizing the mechanisms by which anti-COVID-19 drugs and inflammatory cytokines interfere with cardiac ion channels. Results: Antibiotics (azithromycin), antimalarials (hydroxychloroquine, chloroquine), antivirals (ritonavir/lopinavir, atazanavir), and some of the tyrosine kinase inhibitors (vandetanib) could induce long QT and increase risk for ventricular arrhythmias. The pro-arrhythmic action results from drug-induced inhibition of Kv11.1 (hERG) channels interfering with the repolarizing potassium IKr currents, leading to long QT and increased risk of triggered arrhythmias. At higher concentrations, these drugs may interfere with IKs, IK1, and/or Ito potassium currents, and even inhibit sodium (INa) and calcium (ICa) currents, inducing additional cardiac toxicity. Ibrutinib, an inhibitor of Bruton’s TK, increased the incidence of atrial fibrillation and ventricular tachycardia associated with a short QT interval. Inflammatory cytokines IL-6 and TNF-α inhibit IKr and Ito repolarizing potassium currents. High levels of inflammatory cytokines could contribute to the arrhythmic events. For remdesivir, favipiravir, dexamethasone, tocilizumab, anakinra, baricitinib, and monoclonal antibodies (bamlanivimab, etesevimab, and casirivimab), no evidence supports significant effects on cardiac ion channels, changes in the QT interval, and increased risk for ventricular arrhythmias. Conclusion: This study supports the concept of hERG channel promiscuity. Different drug classes given to COVID-19 patients might delay repolarization, and increase the risk of ventricular arrhythmias. The presence of comorbid pro-arrhythmic disease states, and elevated levels of pro-arrhythmic cytokines, could increase the risk of ventricular arrhythmias. Discontinuation of nonessential drugs and correction of electrolyte abnormalities could prevent severe ventricular arrhythmias. Altogether, the most effective therapies against COVID-19 (remdesivir, dexamethasone, monoclonal antibodies) lack pro-arrhythmic activity.

Impact of pharmaceutical price controls on the cost of cardiovascular drugs: does essentiality matter?

ABSTRACT Background With the goal of improving the affordability of medicines, governments across the globe have instituted various forms of price controls. Since 2013, India has been regulating the prices of drugs included in its national list of essential medicines (NLEM). Here we evaluate the cost variations among available cardiovascular drugs and perform cost-analysis comparing essential and non-essential drugs. Methods Data on listed prices of selected cardiovascular drugs – essential (NLEM) and non-essential (NNLEM) – were sourced from multiple drug information compendia. Price of medications was calculated in cost-per-defined-daily-dose (DDD)-units and NLEM vs. NNLEM drugs were compared. Regression analysis was used to explore the determinants of percentage cost variation (PCV) of drugs. Results The median-cost/DDD of essential medicines was lower as compared to non-essential ones for all therapeutic drug classes, with greatest difference observed for antianginals and least for heart failure medicines. There were substantial cost variations with values in excess of 1000% for six medicines, all being essential. The regression analysis failed to demonstrate a significant effect of essentiality on PCV (β = 0.19, P = 0.314). Conclusions Our analyses demonstrate considerable cost variations for some essential cardiovascular medicines. Given the need for prolonged and often, lifelong-treatment, there is significant potential for cost savings based on chosen brand, highlighting the need for patient as well as prescriber education.

Effects of restrictive reimbursement on the prescribing and expenditures on non-essential lipid-lowering drugs.

The rapid cost escalation of the government employee scheme in Thailand was driven by the overprescription of non-essential drugs (NEDs), which were not listed in the National Lists of Essential Medicines. A restrictive reimbursement policy implemented in October 2012 required prescribers to base the prescription of NEDs on six criteria, including A and B for safety, C for effectiveness, D for availability, and E and F for costs, hence known as the A-F policy. The A-F policy was examined in terms of its outcomes regarding the prescription volume and reimbursement expenditure for lipid-lowering drugs (LLDs). Data on LLD prescription in 2012-2015 from outpatient settings in 29 public hospitals were standardized using quantities based on the World Health Organization's Anatomical, Therapeutic and Chemical (ATC) classification and the defined daily dose (DDD) system. The policy effects were estimated using an interrupted time-series analysis. The restrictive reimbursement policy decreased both the prescription volume and the reimbursement value of non-essential LLDs. Within the first month of policy implementation, the percentage of NEDs, as defined by DDDs and reimbursement expenditure, immediately decreased by 15.1 and 15.2% points in provincial hospitals and by 8.3 and 4.4% points in military hospitals, respectively. The prescription of NEDs continued to decrease thereafter, despite there being no statistically significant changes in the trend of decreased prescribing compared with the prepolicy period. The decrease in the prescription of NEDs resulted in the declining reimbursed amount per day and stable expenditure of LLDs as a whole. The effectiveness on the A-F restrictive reimbursement on NED prescribing helped stabilize the expenditure on LLDs.

Deprescribing in end-of-life care

The aim of deprescribing in end-of-life care is to improve the patient's quality of life by reducing their drug burden. It is essential to engage the patients and enable them to make choices about medications by discussing their preferences and implement a pharmacy management plan. Withdrawing medications during the end stages of life is extremely complex because the period of care varies substantially. The aim of this article is to address polypharmacy within end-of-life care. It will review which medications should be stopped by examining the non-essential and essential drugs. The intention is to encourage an approach to care which provides an equal balance between treatment and patient expectation.

Deprescribing in end-of-life care.

The aim of deprescribing in end-of-life care is to improve the patient's quality of life by reducing their drug burden. It is essential to engage the patients and enable them to make choices about medications by discussing their preferences and implement a pharmacy management plan. Withdrawing medications during the end stages of life is extremely complex because the period of care varies substantially. The aim of this article is to address polypharmacy within end-of-life care. It will review which medications should be stopped by examining the non-essential and essential drugs. The intention is to encourage an approach to care which provides an equal balance between treatment and patient expectation.

Clinical and economic analysis of medicinal prescriptions for children and adolescents with Helicobacter pylori-associated gastroduodenal pathology

The significant prevalence of chronic gastritis and/or duodenitis among children and adolescents, the ability of H. pylori to induce serious complications lead to the importance of effective anti-helicobacter therapy.
 The aim of the work was to determine the rationality of prescribed drugs and the expediency of financial expenses for pharmacotherapy of chronic gastritis and/or duodenitis associated with H. pylori and gastro-esophageal reflux disease based on the results of a retrospective clinical and economic analysis of medical prescriptions in Dnipro.
 The material for the study were the 92 prescription sheets (form No. 003-4/y) of stationary patients aged 5–17 years with a diagnosis of chronic gastritis and/or duodenitis associated with H. pylori and gastro-esophageal reflux disease undergoing treatment at the Dnipropetrovsk Children's City Clinical Hospital № 6 for the period 2012–2017.
 Analysis of the prescriptions frequency, their ranking for cost and importance for the treatment were carried out using pharmacoeconomic methods: ABC-, VEN-, frequency analysis and integrated frequency/ABC/VEN analysis.
 Frequency analysis of treatment regimens showed that only 47.8% of patients were prescribed a «gold standard» of treatment, while 52.2% of patients had medical prescriptions that did not comply with the national treatment protocols adopted by the Ministry of Health of Ukraine. It was found that in the structure of medical prescriptions for the treatment of chronic gastritis and/or duodenitis associated with H. pylori and GERD, there was excessive use of non-essential drugs «N» (43.9%), which were prescribed almost in the same volume as vital drugs «V» (56.1%).
 According to the ABC-analysis, it was established, that the main financial resources were spent on the medicines of six groups: dietary supplements for normalization and maintenance of normal intestinal microflora, omeprazole, mozapride, clarithromycin, domperidone and amoxicillin. It was found, that on average one patient was prescribed 6.6 preparations worth 722.42 UAH.
 It can be concluded that the main funds was not spent on the necessary and important medicines for the treatment of the studied nosologies.

Clinical and economic analysis of pharmacotherapy of children with acute nasopharyngitis

The analysis of 47 medical records of children with the diagnosis of acute nasopharyngitis, who received treatment of common forms of acute respiratory viral infections – acute nasopharyngitis (ANP) during August 2015 – January 2016 has been conducted. For the treatment of children 75 drugs from 39 INN belonging to 15 pharmacotherapeutic groups were prescribed. According to the integrated ABC /VEN / frequency analysis it has been determined how irrational prescriptions affected the amount of the money spent on inappropriate ANP pharmacotherapy in children. According to the results of formal VEN-analysis conducted by the National Drug Formulary of Ukraine (NDFU)/unified clinical protocols of the primary care (UCPPC) of adults and children with acute respiratory infections it has been found that the group of non-essential drugs contained 9/26 INN drugs with “N” index, they were prescribed 82/145 times (35.04/64.01% of the total prescriptions – 234), respectively, and their costs were 38.64 and 63.91% of the total cost of pharmacotherapy per 47 patients – 16,365.08 UAH. Both medical regulatory documents did not contain 4 INN drugs that were prescribed 11 times (4.70%), and costs for them were 3.67% of the total cost for the pharmacotherapy. Therefore, in this medical preventive institution the optimization of costs for ANP pharmacotherapy is necessary by reducing prescriptions of non-essential drugs according to medical regulatory requirements: NDFU (the 7-th edition, 2015) and UCPPC of adults and children with acute respiratory infection (2014).

VEN and frequency analysis of the quality of pharmacotherapy of patients with chronic hepatitis

VEN and frequency analysis were used to analyze the quality of pharmacotherapy of 79 patients with chronic hepatitis (CH) who were treated in a healthcare institution (HCI) in the city of Dnipropetrovskin 2015. It has been found that pharmacotherapy at the HCI corresponded to main areas of the treatment specified in the clinical protocol of medical care (CPMC) to patients with CH.It has confirmed the rationality of drug prescriptions. However, a significant number of prescriptions per a patient (on average 8.9 drugs) indicates the polypharmacy in this department of the HCI. Moreover, according to the results of the formal VEN analysis a significant number of drugs with the index N (non-essential drugs) has been determined; it indicates the need for correction of drug prescription by doctors at this HCI in accordance with the current science-based medical regulations – the National Drug Formulary of Ukraine (the 7th edition) and the CPMC to patients with CH – by reducing prescriptions of non-essential drugs that are not included in these regulations. Today, being developed 11 years ago, the CPMC to patients with CH needs to be updated since it does not meet modern requirements to the current science-based medical practice guidelines that allow making the best clinical decisions in favour of the patient in accordance with the requirements of evidence-based medicine.

Coverage Decisions and the Court: A Public Health Perspective on Glucosamine Reimbursement in Thailand

—Thailand achieves universal health coverage through the introduction of three benefit schemes: the Civil Servant Medical Benefit Scheme (CSMBS), Social Security Scheme, and Universal Coverage Scheme. The primary benefit package of these schemes includes all medicines referenced in the National List of Essential Medicines. However, the CSMBS pays for nonessential drugs (NEDs) for particular conditions. The CSMBS's cost escalation prompted the Ministry of Finance to tightly control drug expenditure. In 2010, glucosamine—an NED—was prohibited from CSMBS reimbursement. Subsequently, a dispute was lodged at the Administrative Court by two CSMBS beneficiaries. The court ruled that glucosamine reimbursement should be reinstated in the CSMBS scheme based on two grounds: the Royal College of Orthopedic Surgeons of Thailand's clinical practice guidelines and an argument with reference to Article 78(8) of the 2007 Constitution mandating the state to provide appropriate benefits to government and state officials. Our comments are based on two factors: (1) the integrity of evidence that the Court applied and (2) the ruling with reference to Constitution Article 78(8) as it conflicts with Article 51, which aims to ensure equal rights to health services by all citizens. Because court cases concerning health care coverage in Thailand may expand in the future, we call upon the public to discuss the following issue: whether the court should rule on the inclusion of particular interventions or whether it should focus on the integrity of the coverage decision-making process. Similar lessons can be drawn from the experiences of countries in Latin America and Europe. In any case, all concerned parties including the court should be equipped with a good understanding of the complexity of the country's health systems in either option.

STOPP Criteriaを用いた高齢者のポリファーマシーに対する薬剤師による介入

Polypharmacy, the co-prescribing of nonessential drugs and inappropriate prescriptions, is a worldwide issue and is a factor affecting the increase in adverse drug reactions, drug-drug and drug-disease state interactions, and the growth in medical spending. In this study, we evaluated the current status of polypharmacy in elderly patients at Kobe University Hospital and the efficacy for screening and intervention against potentially inappropriate medications (PIMs) with the screening tool of older persons' potentially inappropriate prescriptions (STOPP) criteria formulated by a pharmacist. Of 301 study patients, 81 (26.9%) patients with PIMs were identified using the STOPP criteria, and these patients had a significantly higher number of prescribed drugs than other patients. Moreover, there was a correlation between the number of prescribed drugs and the percentage of patients identified using the STOPP criteria. The STOPP criteria identified 125 cases to be PIMs, and the prescriptions were changed for 35 (28%) of them. In 125 cases of PIMs, 61 cases had been strongly recommended prescription changes by pharmacists, of which 32 cases (52.5%) had been changed. Several prescription changes were often associated with the administration of nonsteroidal anti-inflammatory drugs. Based on our findings, we suggest that the STOPP criteria are useful for screening PIMs in Japanese patients and are a helpful tool for managing polypharmacy. The benefits of this approach for pharmacists should be multilaterally evaluated by the assessment of patients and medical economic outcomes in the future.

326 DRESS syndrome should be included in the differential diagnosis of life-threatening systemic symptoms in patients with cystic fibrosis

A stable 20-year-old patient with CF (M, F508del/F508del, last FEV1: 92% pr) was admitted for sudden onset of high-grade fever, FEV1 drop (72% pr) without increased cough, diffuse pain and generalized lymphadenopathies. Initial check-up revealed the presence of prominent and very recent bilateral hilar lymphadenopathies along with a marked inflammatory syndrome. In 4 weeks, IgG level has risen from 15.7 to 30.4 g/L. Within 24 hours, the patient developed a generalized non-pruritic purpuric rash. Despite broad-spectrum IV AB (tobramycin and ceftazidime), daily fever persisted (up to 40°C). On the 6th day, the clinical picture worsened and became life-threatening with impaired renal function, multiple serositis, need for supplemental oxygen, hepatic cytolysis and coagulation abnormalities, major hypergammaglobulinemia (43.9 g/L) and marked hypereosinophilia (4.870/µL). At this point, all non-essential drugs were interrupted with the exception of ceftazidime. Within 7 days, clinical, biological and radiological features all improved. The patient was released under his previous outpatient treatment and without precise diagnosis as all hematologic, autoimmune and viral detection tests were negative. He came back 2 days later due to the recurrence of malaise, fever, rash and biological abnormalities. Rifampicin and moxifloxacin were immediately interrupted and the picture resolved quickly. The patient then disclosed that he kept taking these drugs (no more prescribed) till day 6 of the hospitalization. We concluded that our patient suffered from a drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome, rifampicin being the most likely causal agent.

Psychosis in Parkinson's disease: identification, prevention and treatment.

Psychosis in Parkinson's disease (PD) is a frequent condition affecting >20 % of all PD patients. It is characterized by vivid dreams, nightmares, illusions, delusions and mostly visual hallucinations. Typically psychosis occurs in the late stage of PD, affecting up to 70 % of the patients following a disease duration of 20 years or more, and can severely interfere with the care of the patients, especially if the patients develop delusions. Psychosis is the principal cause of admission to a nursing home for PD patients. Hence, preemptive identification of risk factors, and avoidance and elimination of triggers are most important measures against psychosis in PD patients. Secondarily, pharmaceutical measures are being undertaken successively, including simplification of medication regimes, discontinuation of non-essential CNS-active drugs, ordered reduction of antiparkinsonian drugs, addition of cholesterinase inhibitors in cognitively impaired patients, and finally addition of antipsychotic medication with limited parkinsonian side effects. As psychosis in PD is a frequent and important problem, we set out to write a state-of-the-art guideline for its identification and treatment.

Impact of Drug Policy on Improving Access to Medicines In Delhi.

To assess the impact of drug policy on improving access to essential medicines in Delhi The quantity of drugs procured from the Essential Drugs List (EDL) and outside the EDL; money spent on these; changes in stock out days for the key drugs. The implementation strategy includes elements of drug policy like use of EDL & STG, improved procurement system, training on drugs management & rational use of drugs. Retrospective data collected from stock registers. The data for two years before (1993-1994,1994-1995) and two years after (2000-2001,2001-2002) the drug policy was assessed. Data collected from two large public sector hospitals in Delhi that serve a large section of the population through convenient purposive sampling method. After the implementation of the drug policy, the availability of drugs increased by 25% in the large and 98% in the medium hospital. The drugs procured from the EDL increased from 62% to 78% in the large and 74% to 87% in the medium hospital. Of the total expenditure, the money spent on essential drugs increased from 73% to 85% in the large and 87% to 93% in the medium hospital, whereas money spent on nonessential drugs decreased from 27% to 15% in the large and 13% to 7% in the medium hospital. The average number of stock out days for key dugs decreased from 33 to 16 days in the large and from 143 days to 33 days in the medium hospital. The utilization pattern of health services by patients increased by 8% in the large and by 35% in the medium hospital. The implementation of the drug policy in the state of Delhi increased availability of essential drugs. This kind of intervention can serve as a model for improving access to medicines by implementing an effective drug.