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Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 1
Chapter 1
Evaluation of antimalarial drugs use in
tertiary care teaching hospital
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 2
1.1 Introduction
Malaria is a tropical disease transmitted by the female Anopheles mosquito of
which Anopheles gambiae is the most efficient vector1. It is caused by infection by the
protozoan parasite of the genus plasmodium, is a disease of global importance2.
Malaria is a major cause of morbidity and mortality in the developing world3. It is a
public health problem in more than 90 countries. Each year, between 300 and 500
million new cases are reported worldwide4.
WHO now recommends that treatment policies for falciparum malaria in all
countries experiencing resistance to monotherapies such as chloroquine,
sulphadoxine-pyrimethamine and amodiaquine, should be combination therapies
preferably those containing an artemisinin derivative5.
Artemisinin also known as Qinghaosu and its derivatives are a group
of drugs that possess the most rapid action of all current drugs against Plasmodium
falciparum malaria, Treatments containing an artemisinin derivative (artemisinin-
combination therapies, ACTs) are now standard treatment worldwide for Plasmodium
falciparum malaria, artemisinin is a sesquiterpene lactone6.
India has the largest population in the world at risk of malaria, with 85%
living in malarious zones7. Around 1.5 million confirmed cases are reported annually
by the National Vector Borne Disease Control Programme (NVBDCP), of which
about 50% are due to Plasmodium falciparum8.
In recent studies, chloroquine-
resistant Plasmodium falciparum malaria has been observed with increasing
frequency across the country9. A revised National Drug Policy on Malaria has been
adopted by the Ministry of Health and Family Welfare, Govt. of India in 2010 and the
National guidelines have been prepared for healthcare personnel including clinicians
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 3
involved in the treatment of malaria10
. In 2010 artesunate plus sulphadoxine
pyrimethamine treatment became the first-line treatment throughout India7.
Malaria in pregnancy is a serious public health problem in endemic regions9.
This pathology is among the main causes of the low birth weight (LBW), resulting
from 3% to 8% neonatal and infant deaths10, 11
. This led the World Health
Organization (WHO) to recommend a package of affordable interventions including
the use of the insecticide-treated nets (ITNs), the intermittent presumptive treatment
(IPT) with sulphadoxine-pyrimethamine (SP), and the effective case management of
clinical malaria with recommended antimalarials. At least two doses of IPT-SP are
recommended during the second and third trimesters of pregnancy12
.
The occurring of clinical malaria should be treated with quinine or
artemisinin-based combinations. Quinine is considered to be a safe drug along all the
period of the pregnancy, but safety data of artemisinin derivatives during the first
trimester of pregnancy are limited, thus it should not be prescribed in this period12
.
The National Vector Borne Disease Control Program of India reported 1.6 million
cases and 1100 malaria deaths in 200914
.
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 4
Year Total cases PV cases Pf cases PF/PV ratio Population Deaths
1995 2.9 1.8 1.1 0.6 888,143 1151
1996 3.0 1.9 1.2 0.6 872,906 1010
1997 2.7 1.7 1.0 0.6 884,719 879
1998 2.2 1.2 1.0 0.9 910,884 664
1999 2.3 1.1 1.1 1.0 948,656 1048
2000 2.0 1.0 1.1 1.1 970,275 932
2001 2.1 1.1 1.0 0.9 984,579 1005
2002 1.8 0.9 0.9 1.0 1,013,942 973
2003 1.9 1.0 0.9 0.9 1,027,157 1006
2004 1.9 1.0 0.9 0.9 1,040,939 949
2005 1.8 1.0 0.8 0.8 1,082,882 963
2006 1.8 1.0 0.8 0.9 1,072,713 1707
2007 1.5 0.8 0.7 1.0 1,087,582 1311
2008 1.5 0.8 0.8 1.0 1,119,624 1055
2009 1.6 0.7 0.8 1.2 1,150,113 1144
2010 1.5 0.7 0.8 1.1 1,151,788 767
The two major human malaria species in India are Plasmodium falciparum and
Plasmodium vivex; Plasmodium malariae has been reported in the eastern India state
of Odisha, while Plasmodium ovale appears to be extremely rare if not absent.
Intriguingly, the two major infecting species vary in proportion across India. For
example, the southern state of Tamil Nadu suffers from Plasmodium vivex,
Plasmodium falciparum is the dominant parasite in Odisha, and mixed-species
infections are prevalent in the west (e.g. Gujarat state). Although Plasmodium
falciparum and Plasmodium vivax are unevenly distributed across India, this is not
due to Anopheles vector restriction (even though the vector species also differ in
geographical distribution) since both species are transmitted by the same vectors.
Historically, Plasmodium vivax has been the major infecting species; however, over
the past several years Plasmodium vivax cases have decreased: the ratio of
Plasmodium falciparum versus Plasmodium vivax malaria was 0.41 in 1985,
gradually increasing to 0.60 by 1995, and shifting to 1.01 by 2010. In states where
Plasmodium falciparum and Plasmodium vivax co-circulate, fluctuating proportions
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 5
of the two species complicate diagnosis and treatment. Treatment is based upon the
primary species identified in an infection by standard microscopy diagnosis,
subjecting all species in a single host to the same drug treatment14
.
Approximately 65% of those at risk for becoming infected with malaria in
Southeast Asia are individuals residing in India (WHO, 2007). The central and eastern
regions of India report the most malaria. Particularly the eastern states of Odisha,
West Bengal, and Jharkhand, the central states of Chhattisgarh and Madhya Pradesh,
and the western states of Gujarat, Karnataka and Rajasthan, with the largest number
of deaths reported in Odisha. Malaria cases in India are reported throughout the year,
since a perfect combination of average temperature (15–30 ℃), rainfall and
precipitation-inducing conditions persist across the different parts of the country over
all the seasons. With increasing ecological and man-made environmental change (e.g.
urbanization, construction of dams, agricultural intensification, deforestation) malaria
in India is exhibiting general trends from rural to urban malaria, from forest to plain
malaria, and from industrial to travel malaria16
. Karnataka is located in western side
of India, in the southern peninsular region. Since many years, the highest incidence in
Karnataka were recorded in regions of Bijapur, Bagalkot, Raichur, Kolar, Bellary,
Dakshina kannada and Mandya district which together accounted for more than 60%
of malaria cases.
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 6
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 7
1.2 A review of literature on evaluation of antimalarial drugs in tertiary care
teaching hospital
The brief review of literature on the earlier studies on drug use evolution of
antimalarial agent in patients were discussed as follows
Faheem et al. (2012) conducted study on drug utilization pattern of anti-
malarial drugs at a tertiary care hospital: a retrospective study. They analyzed the use
of anti-malarial agents in treatment of patients admitted to KMC Hospital, Attavar
(Mangalore) with a diagnosis of Malaria and compared it with the guidelines on
Diagnosis and Treatment of Malaria in India which were revised in 2007 by the
Ministry of Health of India. A total sample size was 478 and pattern of
Uncomplicated and complicated Malaria Parasite Infection was evaluated. In this
study it was observed that 26% of the admitted patients receive a combination of 3
anti-malarial agents, 58% received a combination of 2 antimalarial agents, while only
16% of the patients were managed with monotherapy as part of treatment.
Lumefantrine was the most commonly prescribed agent in 86.5% of the patients,
followed by Mefloquine 41.1%. Finally they concluded that there is an increased use
of Artemisinin as first line drugs in Mangalore, irrespective of the causative agent for
malaria, which is an unhealthy practice. The use of primaquine for all types of malaria
is also on the increase and this practice must be curbed too15
.
Dhara et al. (2012) evaluated drug utilization study of anti-malarial drugs in a
tertiary care hospital which was a retrospective, Single-centric study with cases of
anti-malarial drugs prescribed in duration of 1 year from Jan-2011 to Dec-2011 at
Lions General hospital, Mehsana, Gujarat, India. Data were analyzed with different
evaluations. A total of 474 cases were collected including 282 (59.49%) male and 192
(40.51%) female. Out of these 283 (59.70%) were uncomplicated, 115(24.26%) were
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 8
complicated and 76 (16.04%) were seen of non-malaria prescribed with anti-malarial
drugs. Artemisinin Combination Therapy (ACT) was prescribed in 44(7.96%)
patients. Artesunate monotherapy were prescribed in 230 (41.59%) patients.
Adherence to National Guideline in cases with Plasmodium vivax malaria is 71.53%
and for pregnant women and with mixed infection is 100%, while non adherence is
more than 80% seen in plasmodium falciparum malaria (87.39%) and clinical malaria
(84%) cases. Artesunate and Chloroquine were also prescribed in non-malarial
patients. Among all the cases IV injection of anti-malarial drugs prescribed were
48.82%. Average drug cost/prescription is INR 123.28 Rs and percentage drug cost
on injection is 87.50%. This study shows the prescribing pattern of anti-malarial drug
adherence to National Guideline therapy is low. They concluded that inappropriate
use of anti-malarial drugs among the patients is very high. So possibility of
development of resistance with anti-malarial drugs in the population will rapidly
spread and cost of the prescription will burden on the patients16
.
Dahal et al, (2012) evaluated drug use pattern in Primary Health Care (PHC)
facilities of Kaski district, Western Nepal. A total of 301 prescriptions were analyzed.
The average age of patients visiting PHC was 33.11 years (female 35.79; male 30.40).
The average number of drugs prescribed was 2.29. Percentage of encounters with at
least one antibiotic prescribed was 57% whereas encounters with at least one injection
prescribed was low 3%. The total percentage of drugs prescribed using generic names
was found to be 59.02% and percentage of drugs prescribed from EDL was 85.19%
respectively. The average consultation and dispensing time of 109 patients was 2.02
minutes and 42.52 seconds. Only 30% of patients had adequate knowledge of drug
whereas none of the drugs were adequately labeled. Percentage of drugs actually
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 9
dispensed was 89.63%. All health facilities had availability of Essential Drug List
(EDL). The total percentage of availability of key drugs in study PHCs was 89.69%17
.
Igbiks et al,(2012) evaluated the prescribing pattern of clinicians in the
general outpatient unit of the Aminu Kano Teaching Hospital, Kano (AKTH) This
was a descriptive retrospective study conducted using 500 prescriptions made at the
general outpatient unit of AKTH between April and July 2009. A total of 497
prescriptions were successfully analyzed. The average number of drugs per encounter
in the facility was 3.04. Generic prescribing was low at 42.7 % while antibiotic
prescription was high at 34.4 %. Injections were prescribed in 4 % of encounters
while 36.2, 19.1, 25.8 and 1 % of encounters had analgesics, antimalarials,
antihypertensive and anxiolytics prescribed, respectively. Vitamins were prescribed in
9.7 % of encounters18
.
Santoshkumar et al,(2010) studied prescribing pattern of anti malarial drugs
in a tertiary care hospital. It was prospective cross-sectional study was conducted for
6 months of patients visiting in Basaveshwar Teaching and General Hospital,
Gulbarga. Data were analyzed for various drug use indicators. A total of 212
prescriptions were collected, with 136 (64.15%) male and 76 (35.85%) female. There
were 128 (60.37%) Plasmodium vivax cases and 84 (39.63%) Plasmodium falciparum
cases. All Plasmodium vivax cases were treated with chloroquine alone and among
these 16 (12.5%) received radical treatment with primaquine along with chloroquine.
Among 84 patients with Plasmodium falciparum, 40 patients received single drug
such as quinine/ mefloquinine/artesunate/artemether. Another 44 patients received
multidrug regime like, quinine+artesunate (54.54%), quinine+mefloquine (27.27%)
and quinine+artemether (18.18%). Chloroquine was not administered to any of the
patients with Plasmodium falciparum malaria. The most common adverse effects with
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 10
chloroquine were anorexia, nausea, vomiting and tinnitus in 9.37% of the cases. With
quinine it was nausea and vomiting in 17.64%, tinnitus in 11.76% and hypoglycemia
in 2.1% of cases19
.
Anthony et al,(2013) evaluated prescription patterns and drug use among
pregnant women with febrile illnesses in Uganda. A total of 998 pregnant women
with a history of fever were interviewed and blood samples taken for diagnosis of
malaria and HIV infections. Data were captured on the drugs prescribed for the
current febrile episode and previous use of drugs especially SP, anti-retroviral drugs
(ARVs) and cotrimoxazole. Few pregnant women, 128 (12.8%) were parasitaemic for
P.falciparum; and of these, 72 (56.3%) received first-line treatment with Artemether-
lumefantrine (Coartem®) 14 (10.9%) SP and 33 (25.8%) quinine. Of the parasite
negative patients (non-malarial fevers), 186 (21.4%) received Coartem, 423 (48.6%)
SP and 19 (2.1%) cotrimoxazole. Overall, malaria was appropriately treated in 35.5%
of cases. Almost all febrile pregnant women, 91.1%, were sleeping under a mosquito
net. The majority of them, 911 (91.3%), accepted to have an HIV test done and 92
(9.2%) were HIV positive. Of the HIV positive women, 23 (25.0%) were on ARVs,
10 (10.9%) on cotrimoxazole and 30 (32.6%) on SP. A significant proportion of
women, 40 (43.5%), were on both SP and cotrimoxazole. Age and occupation were
associated with diagnosis and treatment of malaria and HIV infections20
.
Oshikoya et al,(2007) evaluated antimalarial prescriptions for children
presenting with uncomplicated Malaria to a teaching hospital in Nigeria. This was a
prospective study. A total of 3500 case files were used. In which 1855 (53.0%)
prescriptions were written for males, 1446 (41.3%) for females and 199 (5.7%)
patients with their gender not indicated. The mean age of the patients is 55.8±37.4
months. Those with ages between 12 to 72 months constituted the highest percentage
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 11
(47.6%) while those with ages 0 to 1 month constituted the lowest (1.3%). The mean
weight and the body temperature of the children were 10.3±5.5 kg and 37.2°C,
respectively. Antimalarials constituted the highest group of SP =
Sulphadoxine+pyrimethamine drugs prescribed as indicated in 2824 (80.1%) of the
case files. Antipyretic-paracetamol 2793 (79.8%) and vitamin B complex 2689
(76.8%) were the two commonly prescribed drugs with the antimalarial. While
Sulphadoxine+pyrimethamine only 564 (20.0%) was the highest antimalarial
prescribed, Artemether+lumefentine was the least 40 (1.4%). Only 23 (0.8%) of the
patients were investigated and confirmed to have malaria before prescribed
antimalarial drugs. Artemisinin-based combined drugs were the antimalarial
prescribed after the confirmation of malaria in the blood film of the investigated
patients. Artemisinin based combination drugs constitute 26.2% of all the antimalarial
prescribed, majority of which were prescribed, like other antimalarial, empirically
based on the symptoms and signs of malaria. Majority of the antimalarial drugs 2785
(98.6%) had their duration of use adequately prescribed. Of the artemisinin based
combined drugs, only Artemether+lumefentine was prescribed as a fixed combined
drug. The rest were prescribed as loose combined drugs. Sulphadoxine+
pyrimethamine and amodiaquine prescribed together were in loose forms. The
dosages of the antimalarial were adequately written for 1164 (41.2%) patients. Under
dosage and over dosage prescriptions of the antimalarial were associated with 711
(25.2%) and 302 (10.7%) patients respectively. Dosages of the antimalarial were not
stated in the case files of 647 (22.9%) patients. The dosage errors were most common
with Sulphadoxine+pyrimethamine prescriptions and least common with artemisinin,
its derivatives, combined forms and amodiaquine21
.
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 12
Martin et al,(2007) evaluated prescribing for uncomplicated malaria in
government and private health facilities in Cross River State. A665 patient records at
six private and seven government health facilities in 2003. Clinicians in the private
sector were less likely to record history or physical examination than those in public
facilities, but otherwise practice and prescribing were similar. Overall, 45% of
patients had a diagnostic blood slides; 77% were prescribed monotherapy, either
chloroquine (30.2%), sulphadoxine pyrimethamine (22.7%) or artemisinin derivatives
alone (15.8%). Some 20.8% were prescribed combination therapy; the commonest
was chloroquine with Sulphadoxine+pyrimethamine. A few patients (3.5%) were
prescribed sulphadoxine-pyrimethamine-mefloquine in the private sector, and only
3.0% patients were prescribed artemisinin combination treatments22
.
Alexander et al,(2011) evaluated pattern of the antimalarials prescription
during pregnancy in Bangui, Central African Republic. Study was conducted from
June to September 2009, A total of 565 women were enrolled for this study. Their
mean (±SD) age was 24.7 (±6.0) years (range: 15 to 45 years). A proportion of 21.8%
(n=123) has been given at least one dose of IPT-SP. Only a proportion of 8.5% of
them was given more than one dose of IPT-SP, as is recommended by the malaria
control programmed. Overall, 163 pregnant women (28.8%) were prescribed at least
once an antimalarial for a possible clinical malaria episode. The number of
antimalarials prescription ranged from 1 to 3 times per ANC cards. Eight ANC cards
contained 3 prescriptions (4.9%), and 29 ANC cards contained 2 prescriptions
(17.8%). Overall, four different groups of antimalarials were prescribed to the 163
women during the pregnancy, and the total number of those prescriptions was 208
(the mean number of antimalarials prescription per women was 1.28): quinine
(56.7%), artemisinin-based combinations (26.8%), artemisinin monotherapies
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 13
(14.4%), and other antimalarials monotherapies (chloroquine, halofantrine, and
amodiaquine). The malaria laboratory microscopy diagnosis was available in the
ANC cards for only 18.9% antimalarials prescriptions (39/208). All those results were
positive and the quinine was the only antimalarial prescribed accordingly.
Antimalarials prescription began in the second month of gestation, reaching a peak at
the sixth month of gestation. The global proportion of those prescriptions significantly
increased from the first trimester (16.8%) to the second trimester (56.3%) (value <
10−6). There were a total of 85 artemisinin components prescriptions during the
current pregnancies (30 artemisinin monotherapies and 55 artemisinin-based
combinations). Among those prescriptions, four (13.3%) prescriptions of artemisinin
monotherapies and six (10.9%) artemisinin-based combinations prescriptions
occurred in the first trimester of pregnancy. Otherwise, we recorded a total number of
118 quinine prescriptions. The number of quinine prescription in the first trimester is
24/35 (68.6%) and in the second trimester 65/117 (55.5%), while artemisinin-based
combinations Pattern of the Antimalarials Prescription during Pregnancy in Bangui,
Central African Republic are 6/35 (17.1%) for the first trimester and 40/117 for the
second, and artemisinin monotherapy is 4/35 (11.4%) for the first trimester and
22/117 (18.8%) for the second. Within each category of antimalarials, the distribution
trend increased from the first trimester to the second trimester: 24/118 (20.3%) to
65/118 (55.1%) for quinine, 6/55 (10.9%) to 30/55 (54.5%) for artemisinin-based
combinations and 4/30 (13.3%) to 22/30 (73.3%) for artemisinin monotherapies23
.
Gawde et al,(2013) evaluated drug prescription pattern in pregnant women
attending antenatal outpatient department of a tertiary care hospital. This was cross-
sectional study. Out of 760 women, one third (33.18%) women were anemic. Majority
drugs were prescribed for the treatment of upper respiratory tract infection, vaginal
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 14
discharge, and fever with chills, nausea and vomiting. The average number of drugs
per prescription was 2.27. Only 4% drugs were prescribed by their brand name and 96
% by generic name. Iron, folic acid and calcium were prescribed to all pregnant
women. Majority of the patients were prescribed Category A and B drugs. No patient
was given Category X drugs24
.
Modupe et al,(2014) evaluated prescription pattern of antimalarial drugs in a
teaching hospital in Nigeria. This was retrospective quantitative study, case record
files of 130 patients were selected, and 80.7% of the patients were prescribed
antimalarial drugs. 55.2% of patients admitted for malaria were males, 44.8% were
between 21-50 years of age. Fever (35.2%) was the most common presenting
symptom, 71.4% of the patients had diagnostic blood slides. Antimalarial drugs were
prescribed for malaria and malaria associated with other disease conditions,
artemisinin and lumefantrine was the most prescribed antimalarial agent. 44.0% of
these drugs were prescribed by trade names, 29.0% were administered orally. The
most antimalarial drug prescribed for prevention of malaria in pregnant women was
sulphadoxine-pyrimethamine, all the practitioners followed current WHO guidelines ,
half of the clinicians would prescribe parenteral antimalarial drugs for severe and
cerebral malaria, laboratory and clinical assessment were used for malaria diagnosis,
71.4% of the physicians adhered to hospital guidelines25
.
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 15
1.3 Guidelines of Diagnosis and Treatment of Malaria
The main thrust of the National Vector Borne Diseases Control Programme
(NVBDCP) is on early diagnosis and prompt, complete and effective treatment.
Malaria diagnosis is carried out by microscopic examination of blood films collected
by active and passive agencies. Health agencies and volunteers treating fever cases in
inaccessible areas are being provided with Rapid Diagnostic Test (RDT) kits (Pf
specific so far and now Bivalent RDT) for diagnosis of Malaria cases so as to provide
full radical treatment to the confirmed cases. It is stressed that all fever cases should be
suspected of malaria after ruling out other common causes and should be investigated
for confirmation of malaria by Microscopy or Rapid Diagnostic Kit (RDK) so as to
ensure treatment with full therapeutic dose with appropriate drug to all confirmed
cases. Presumptive treatment of malaria with a single dose of chloroquine has been
stopped. In all cases of suspected malaria which cannot be immediately confirmed by
tests, full treatment with chloroquine for 3 days should be given. The malaria case
management is very important for preventive serious cases and death due to malaria.
So, the private healthcare providers should also follow the common National
Guidelines for treatment of malaria as per the Drug Policy 2013. Where microscopy
result is not available within 24 hours and Bivalent RDT is used.
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 16
Note: 1) If malaria is strongly suspected, prepare & send slide for
microscopy
2) If a patient has several symptoms at any stage, then immediately refer to
nearest PHC or other healthy facility with indoor patient management or a
registered medical doctor.
3) PQ is contra-indicated in pregnancy and in children under 1 year(Infant).
Suspected malaria case
Do blood test with RDT
Positive for
P.vivex
Discard slide
Treat with:
CQ 3 days
+ PQ 14
days
Positive for
P.falciparum
Discard slide
In Northeastern
states: Age-
specific ACT-AL
for 3 days + PQ
single dose on
second day
In other states:
Treat with ACT-
SP for 3 days +
PQ Single dose on
second day
Positive for
Mixed infection
Discard slide
In Northeastern
states: Age-
specific ACT-AL
for 3 days +
Primaquine 0.25
mg per kg body
weight daily for 14
days
In other states:
SP-AST 3 days +
Primaquine 0.25
mg per kg body
weight daily for 14
days
Negative
No anti-malarial
treatment
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 17
ACT-AL:- Artemisinin-based combination therapy-Artemether-Lumefantrine
ACT-SP:- Artemisinin-based combination therapy (Artesunate+sulphadoxine-
Pyrimethamine)
CQ :- Chloroquine PQ :- Primaquine
In the view of above background the study entitled “Drug use evaluation of
anti malarial drugs in a tertiary care teaching hospital”, have undertaken by author to
study the prescribing pattern of anti-malarial drugs with following objectives
General Objective
To evaluate the use of anti-malarial drugs in the treatment of patients
diagnosed with malaria.
Specific Objectives
• To assess rationality of anti-malarial drugs use.
• To assess potential interaction of anti-malarial drugs with other prescribed drugs.
• To evaluate cost of anti-malarial drugs prescribed.
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 18
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and public health facilities in south-east Nigeria: a descriptive study, 2007;6:55
23. Alexander Manirakiza, Pattern of the Antimalarials prescription during
pregnancy in Bangui, central African republic, 2011; 7(1):1-4.
24. Gawde SR, Bhide SS, Patel TC. Drug prescription pattern in pregnant women
attending antenatal outpatient department of a tertiary care hospital, 2013;
3(10):1-12.
25. Builders M, Degge H. Prescription pattern of Antimalarial drugs in a teaching
hospital in Nigeria, 2014; 2(1):267-276.
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 20
Chapter 2
Methodology of evaluation of antimalarial drugs use in tertiary care teaching hospital and research centre
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 21
2.1 Study Methodology
2.1.1 Study site
This study was conducted in inpatients in general medicine and Pediatrics
Departments of S.N Medical College and HSK hospital and research centre Bagalkot.
It is a 1000 bedded general hospital run by the BVV Sangh’s and it is one of the
premier institutes in Karnataka with different specialties, serving to the health care
needs of a huge population.
2.1.2. Study design
Prospective hospital based observational study.
2.1.3. Study period
The study was carried out for a period of 6 months from Nov 2013 to April
2014.
2.1.4. Study criteria
Inclusion criteria
Patients diagnosed with malaria.
Patients of all age group of either sex.
Patients receiving anti-malarial drugs.
Exclusion criteria
Patients attending outpatient department
2.1.5. Source of data
Data collected from
Case sheets of inpatients diagnosed with malaria
Treatment chart of patients, laboratory investigations of patients.
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 22
2.1.6. Data Collection
Data was collected from patient demographic details, Clinical data, Treatment
chart, Investigational reports, ADR notification form, Drug interaction and
intervention form. Data have to be collected by making personal visit to wards and all
the data are to be entered in patient data collection form.
2.1.7. Methodology
Personal visit made on daily basis to general medicine ward and pediatric
wards to identify the patients who were diagnosed with malaria. Patient demographic
details like name, age, sex, IPD No., weight was noted in specially designed patient
data collection form. Clinical history, diagnosis, laboratory investigations and
treatment regimen of the patients and discharge medications were recorded daily in
patient data collection form. Treatment chart of the patients were reviewed daily to
evaluate type of treatment regimen. Name of drug, dose, frequency, duration and cost
of treatment noted in patient data collection form. Further data were analyzed for the
anti-malarial drugs usage according to guidelines for the diagnosis and treatment of
malaria (2011). Potential drug -drug interactions in the treatment regimen have to be
assessed using Micromedex-2.0. The inpatient data collected and created separately in
computer based format, stored and retrieved when they required in MS office format.
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 23
2.2 Results
2.2.1. Demographic detail of patients characteristics
In the present prospective study the number of patient admitted in medicine
and pediatric department during study period at HSK tertiary care hospital total 98
cases, out of all cases 5 patients were of 2 years in that 2 males & 3 female patients
admitted and treated by 6(3.16%) antimalarial drugs , 3 children were of 2-6 years and
treated with 5(2.63%) antimalarial drugs. From 6-12 years age group 7 male children
were treated with 20(10.53%) antimalarial drugs and 8 patients were of 12-18 years
age group in that 4 male & 4 females, males prescribed with 6(3.16%) antimalarial
drugs females were treated 5(2.63%) antimalarial drugs. From age group 18-30 years,
22 patients were admitted out of that 12 were male prescribed with 20(10.53%)
antimalarial drugs and 10 female prescribed with 19(10.00%) antimalarial drugs. 24
patients over 30-45 age group out of that 10 were male treated with 14(7.37%)
antimalarial drugs and 14 were females treated with 27(14.21%) antimalarial drugs.
From age 45-60 years 15 patients were admitted, in that 11 were male treated with
27(14.21%) antimalarial drugs and 4 were female treated with 6(3.16%) antimalarial
drugs and in 60 years above age group 14 patients were admitted out of that 9 were
male treated with 17(8.95%) antimalarial drugs and 5 were female treated with
12(6.30%) antimalarial drugs. Results were summarized in Table no 2.2.1.
2.2.2. Cost of antimalarial drugs used in patients
During the hospital stay of the 98 cases with antimalarial drugs we find out the
cost of antimalarial drugs in each patient and results were summarized in Table 2.2.2a
to 2.2.2h.
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 24
2.2.3. Assessment of drug-drug interactions of antimalarial drug with other drugs
During the hospital stay of the 98 cases we found 36 drug-drug interactions in
prescription out of this 16(43.24%) major drug-drug interactions, 12(32.43%) moderate
drug-drug interactions, 6(18.92%) minor drug-drug interactions and 3(5.41%)
contraindicated drug-drug interactions. Results were summarized in Table 2.2.3a to
2.2.3r and figure 1.
2.2.4. Antimalarial drug prescribed for the patients
In present study the antimalarial drugs prescribed at our tertiary care hospital
was summarized in table 2.2.4a and 2.2.4b & figure 2. In briefly, 19(14.40%)
prescription of Artesunate were prescribed for patient admitted in our hospital,
Artesunate+Pyrimethamine+Sulphadoxine were prescribed in 26(19.70%)
prescription, Artemether/Lumefantrine prescribed in 23(17.42%) prescriptions,
chloroquine phosphate prescribed in 16(12.12%) prescriptions, Doxycycline
prescribed in 31(23.49%) prescriptions, Primaquine, Hydroxy chloroquine sulphate
and Quinine were prescribed in 11(8.33%), 3(2.28%) and 3(2.28%) prescriptions
respectively. Out of 98 cases artesunate were prescribed for 25(54.34%) malarial
patients from 46 malarial patients and 17(32.69%) prescriptions were of nonmalarial
patients from total 52 nonmalarial patients.
2.2.5. Pattern of malaria parasite infection in patient visiting tertiary care
hospital.
In present study 46 malarial patients were found & they were infected with
two different malarial parasites out of that Plasmodium falciparum parasite was
identified in 27(58.69%) prescriptions, Plasmodium vivax parasite was identified in
4(8.69%) prescriptions and mixed (Plasmodium falciparum + plasmodium vivex)
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 25
parasites were found in 3(6.52%) prescription, clinical malaria were identified in
3(6.52%), complicated malaria were identified in 9(19.58%). Results were
summarized in table 2.2.5.
2.2.6. Class of antimalarial drugs prescribed
During this study different class of antimalarial drugs were prescribed for
patients, in that 4-aminoquinoline were prescribed in 19(19.38%) prescriptions, 8-
aminoquinolines was prescribed in 11(11.22%) prescriptions, Cinchona Alkaloid
were prescribed in 3(3.06%) prescriptions, Sesquiterpine Lactones/sulphonamides
and sulfone/diaminopyrimidine were prescribed in 26(26.53%) prescriptions,
Sesquiterpine Lactones was prescribed in 19(19.38%) prescriptions, Sesquiterpine
Lactones/ amino alcohols were prescribed in 23(23.47%) prescriptions, Tetracycline
were prescribed in 31(31.63%) prescription. Results were summarized in table 2.2.6.
2.2.7. Pattern of drugs regimen prescribed for patients
In our study the 5 drug regimens were prescribed for patients via, 1 drug
therapy, 2 drugs therapy, 3 drugs therapy, 4 drugs therapy and 5 drugs therapy out of
this 1 drug regimen were prescribed in 34(34.69%) prescription, 2 drugs regimen
were prescribed in 24(24.48%) prescription, 30(30.61) prescription were prescribed
with 3 drugs combination, 9(9.18%) were of 4 drugs regimen & finally 1(1.02%)
prescription was found on 5 drugs regimen. Results were summarized in table 2.2.7a
to 2.2.7c.
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 26
2.2.8. Number of complicated malaria cases with treatment
In present study the antimalarial drugs prescribed for complicated malaria
cases at tertiary care hospital was summarized in table 2.2.8a and 2.2.8b. In briefly
out of 9 complicated malaria cases, Artesunate given in 2 cases one diagnosed with
ARF with complicated malaria and other Seizure disorder with malaria with LRTI
respectively, Artesunate + sulphadoxine + Pyrimethamine were given in 2 cases one
diagnosed with cirrhosis with malaria with lower limb cellulitis and other with dengue
fever with malaria, doxycycline given in 3 cases diagnosed with dengue fever with
malaria, ALD with malaria with gastritis and ALD with pancytopenia with malaria
with gastritis respectively, chloroquine given in 2 cases diagnosed with essential
hypertension with malaria, artemether & lumefantrine given in 2 cases diagnosed with
essential hypertension with malaria, primaquine given in 2 cases diagnosed with
cirrhosis with malaria with lower limb cellulitis and ARF with complicated malaria.
2.2.9. Uncomplicated malaria cases
In our present study 37 cases were uncomplicated out of that 26(70.27%)
cases were identified with Plasmodium falciparum infection, 3(8.11%) cases of
Plasmodium vivex, 1(2.70%) case of pregnant women with Plasmodium falciparum ,
4(10.81%) cases of mixed infection and 3(8.11%) cases were diagnosed with clinical
malaria. Results were summarized in table 2.2.9 and figure 3.
2.2.10. Assessment of rationality of antimalarial drugs prescription
In present prospective study, totally 46 malarial cases were prescribed with
antimalarial drugs. These patients were accesses for rationality according to
NVBDCP out of these 25 patients were rational and 21 were irrational. Here 3(12%)
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 27
were rational prescriptions and 1(4.76%) irrational prescription diagnosed with
Plasmodium vivax malaria, 13(52%) rational and 14(66.67%) irrational diagnosed
with Plasmodium falciparum malaria, 3(12%) rational and no irrational were found in
mixed malaria and 3(12%) rational and 6(28.57%) irrational were found in
complicated malaria. Finally out of 52 nonmalarial patients 9(17.3%) were prescribed
Doxycycline as prophylaxis which was rational and remaining 43(82.69%) patients
were prescribed irrationally. Result were summarized in 2.2.10, 2.2.13a to 2.2.13c and
fig.4
2.2.11. Antimalarial drugs prescribed for infectious diseases other than malaria
cases
In present study the antimalarial drugs prescribed for infectious disease other
than malaria cases at our tertiary care hospital was summarized in table 2.2.11a to
2.2.11c and figure 5. In briefly total 52 patients were found as non malarial patients,
out of this artesunate were prescribed in 13(20%) cases, artemether were prescribed in
11(19.92%) cases, hydroxychloroquine were prescribed in 3(4.62%) cases,
chloroquine were prescribed in 11(19.92%) cases, doxycycline in 19(29.23%) cases
and artesunate+sulphadoxine+pyrimithamine prescribed in 8(12.30%) cases.
2.2.12. Clinical outcome
In this study total 46 malarial patients were found out of them 22(47.83%)
patients were improved, 24(52.17%) patients were cured after treatment & finally
there are no worsened and expired cases. Results were summarized in table 2.2.12.
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 28
2.2.13. Drug use evaluation of antimalarial drugs prescribed for patients with
help of prescribing indicator.
In our study average number of drugs prescribed for patients were 1.42 and for
these patients 44.897% I.V injection were prescribed. Results were summarized in
table 2.2.14.
2.2.14. Cost benefit analysis of antimalarial drug prescribed.
In our present study average drug cost prescribed for patients were found 1085.22
rupees and percentage drug cost on injection were found 86.51% which was a core
region for increased cost on patient the data were summarized in table 2.2.15.
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 29
Table 2.2.1.Demographic detail of patients characteristics
Age Gender
Number of
cases
Number of antimalarial
drug prescribed
Antimalarial drug prescribed
(%)
0 - 02 years M 02 06 03.16%
F 03 06 03.16%
02 -06 years M 03 05 02.63%
F 00 00 00.00%
06 - 12 years M 07 20 10.53%
F 00 00 00.00%
12 - 18 years M 04 06 03.16%
F 04 05 02.63%
18 - 30 years M 12 20 10.53%
F 10 19 10.00%
30 - 45 years M 10 14 07.37%
F 14 27 14.21%
45 -60 years M 11 27 14.21%
F 04 06 03.16%
60 ≥ above M 09 17 08.95%
F 05 12 06.30%
Total M 58 115 60.52%
F 40 75 39.48%
(F=Female and M=Male)
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 30
Table 2.2.2a. Cost of antimalarial drugs used in patients.
I.P No. Gender Name of antimalarial drugs Cost of therapy
(Rs)
32597 F Tab Lariago (chloroquine) 8.40
5468 F Inj Larinate (Artesunate pyrimethamine
sulphadoxine)120 mg
1272.00
14-5694 F Inj Falcigo (Artesunate) 120 mg 2544.00
3261 F Tab lumerex 80 mg (Artesunate/artemethar) &
Tab Lariago (chloroquine)
126.80
2498 F Inj Falcigo (Artesunate) 120 mg
Tab Malirid DS (Primaquine)
Tab lumerex 80 mg (Artesunate/artemethar)
1011.94
9538 F Inj Falcigo (Artesunate) 120 mg 2975.00
3242 F Inj Falcigo (Artesunate)120 mg 5950.00
14-5810 F Cap Doxy (Doxycycline) 100 mg 6.35
6083 F Inj Larinate (Artesunate pyrimethamine sulphadoxine)
60 mg
1392.00
6088 F Inj Larinate (Artesunate pyrimethamine
sulphadoxine)60 mg
2320.00
10470 M Tab Doxy (Doxycycline) 100 mg 5092.00
5139 M Tab hydroxyl chloroquine sulfate 200 mg 212.40
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 31
Table 2.2.2b. Cost of antimalarial drugs used in patients.
I.P No. Gender Name of antimalarial drugs Cost of therapy
(Rs)
13-30635 M Inj Larinate (Artesunate pyrimethamine
sulphadoxine)60 mg
1856.00
13-30478 M Inj Larinate (Artesunate pyrimethamine
sulphadoxine)60 mg
Tab Doxy (Doxycycline) 100 mg
3256.88
14-5664 M Tab Doxy (Doxycycline) 100 mg 9.42
28160 M Tab Doxy (Doxycycline) 100 mg 17.76
10218 M Tab Doxy (Doxycycline) 100 mg 17.76
28167 M Tab Doxy (Doxycycline) 100 mg 11.84
9536 M Inj Falcigo (Artesunate) 120 mg 2550.00
29529 M Inj Larinate (Artesunate pyrimethamine
sulphadoxine)120 mg
Tab Larinate (Artesunate pyrimethamine sulphadoxine)
200 mg
1069.32
11718 M Tab Doxy (Doxycycline) 100 mg 14.80
3240 M Inj Falcigo (Artesunate) 120 mg 5100.00
12315 M Tab Doxy (Doxycycline) 100 mg 20.72
2812 M Inj Larinate (Artesunate pyrimethamine
sulphadoxine)120 mg
Tab Lariago (chloroquine)500 mg
1706.48
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 32
Table 2.2.2c. Cost of antimalarial drugs used in patients.
I.P No. Gender Name of antimalarial drugs Cost of therapy
(Rs)
14-4113 M Tab Lariago (chloroquine) 11.20
31305 M Tab Malirid DS (Primaquine) 15 mg
Inj Larinate (Artesunate pyrimethamine
sulphadoxine)120 mg
3395.88
27408 M Tab Doxy (Doxycycline) 100 mg
Inj Falcigo (Artesunate) 120 mg
5111.68
32609 M Tab Doxy (Doxycycline) 100 mg
Inj Falcigo (Artesunate) 120 mg
Tab lumerex (Artesunate/artemethar) 80 mg
1731.00
2533 M Tab Malirid DS (Primaquine) 15 mg
Inj Larinate (Artesunate pyrimethamine sulphadoxine)
120 mg
1885.16
29908 M Inj Larinate (Artesunate pyrimethamine sulphadoxine)
60 mg
1856.00
5689 M T.Lariago (chloroquine)
16.80
5259 M T. Larinate (Artesunate pyrimethamine sulphadoxine)
kit
1272.00
3268 F T.lumerax (artemether/lumefantrine)80mg 242.40
29238 M I. Larinate (Artesunate pyrimethamine sulphadoxine)
60mg
I. Quinine
3327.60
576 M I.falcigo (Artesunate) 120mg
T.doxy 100mg
1710.80
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 33
Table 2.2.2d. Cost of antimalarial drugs used in patients.
I.P No. Gender Name of antimalarial drugs Cost of therapy
(Rs)
2372/14 M T.lumerax (artemether/lumefantrine) 80mg 170.48
T.doxy (doxycycline)100mg
28670 F T.lumerax (artemether/lumefantrine) 80mg 176.40
T.doxy (doxycycline) 100mg
13-32510 M T.Lariago (chloroquine) 13.76
29700 F I.falcigo(Artesunate)120mg 1696.00
29321 M I.falcigo (Artesunate) 120mg 1705.72
T.malirid (Primaquine) 15mg
598 M I.falcigo (Artesunate) 120mg 3469.76
T.malirid (Primaquine) 15mg
3261 F T.lumerax (artemether/lumefantrine) 80mg 571.20
T.Lariago (chloroquine)
3132 M T.falcigo (Artesunate) 50mg 194.84
T.doxy (doxycycline) 100mg
329 M T.lumerax (artemether/lumefantrine) 80mg 202.00
31470 F T.lumerax (artemether/lumefantrine) 80mg 121.20
740 M I.rezQ (quinine sulfate) 400mg 159.20
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 34
Table 2.2.2e. Cost of antimalarial drugs used in patients.
I.P No. Gender Name of antimalarial drugs Cost of therapy
(Rs)
5156 F T.zyQ (hydroxychloroquine sulphate) 200mg 138.55
9386 M T.lumerax (artemether/lumefantrine) 80mg 121.20
10557 M T.lumerax (artemether/lumefantrine) 80mg 80.80
9536/14 M I.falcigo (Artesunate) 120mg 4240.00
9121 M T.doxy (doxycycline) 100mg 23.68
8486 F T.lumerax (artemether/lumefantrine) 80mg 121.20
8856 F I.falcigo (Artesunate) 120mg 4240.00
9031 M T.doxy (doxycycline) 100mg 14.80
14/9643 F I.falcigo (Artesunate) 120mg 4240.00
20658 M T.lumerax (artemether/lumefantrine) 80mg 121.20
10554 M T.lumerax (artemether/lumefantrine) 80mg 161.60
4144 M T.zyQ (hydroxychloroquine sulphate) 200mg 73.35
8727 F Inj.larinate (Artesunate pyrimethamine sulphadoxine)
120mg
1856.00
29905 F Inj.Larinate (Artesunate pyrimethamine sulphadoxine)
15mg
Tab primaquine 2.5mg
581.00
31087 M Inj larinate (Artesunate pyrimethamine sulphadoxine)
20mg
232.00
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 35
Table 2.2.2f. Cost of antimalarial drugs used in patients.
I.P No. Gender Name of antimalarial drugs Cost of therapy
(Rs)
594 F Syp lumerax (artemether/lumefantrine) 74.52
2905 M Inj.Larinate (Artesunate pyrimethamine sulphadoxine)
30mg
348.00
9410 M Inj.Larinate (Artesunate pyrimethamine sulphadoxine)
40mg
77.00
30478 M Inj.Larinate (Artesunate pyrimethamine sulphadoxine)
40mg
T.doxy (doxycycline) 100mg
1087.45
30635 M Inj Larinate (Artesunate pyrimethamine sulphadoxine)
55mg
Tab Larinate kit (Artesunate pyrimethamine
sulphadoxine)
444.00
8428 F I.falcigo (Artesunate) 120mg
T lumerax (artemether/lumefantrine) 80mg
1056.00
31470 F T lumerax (artemether/lumefantrine) 80mg 226.00
11355 M T lumerax (artemether/lumefantrine) 40mg
T Lariago (chloroquine)
152.20
4859 M T.doxy (doxycycline) 100 mg 6.30
3973 M T.lumerax (artemether/lumefantrine) 80mg
T.malirid DS (Primaquine)
171.45
11032 F Inj.Larinate (Artesunate pyrimethamine sulphadoxine)
120mg
2320.00
5542 M Tab.lariago DS (chloroquine) 4.20
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 36
Table 2.2.2g. Cost of antimalarial drugs used in patients.
I.P No. Gender Name of antimalarial drugs Cost of therapy
(Rs)
29067 F T.malarid DS (Primaquine)
T.doxy (doxycycline) 100mg
Tab.rez Q (quinine) 300mg
1561.50
9170 F T.falcigo (Artesunate) 120mg
T.doxy (doxycycline) 100mg
1830.00
10317 F Tab.Larinate kit(Artesunate pyrimethamine
sulphadoxine)
212.00
4880 M T.falcigo (Artesunate) 120mg
T.lumerax (artemether/lumefantrine) 80mg
2412.00
4709 F Inj.larinate (Artesunate pyrimethamine sulphadoxine)
120mg
T.Lariago (chloroquine) 600mg
854.26
11681 F T.doxy (doxycycline) 100mg 6.30
2788 M T.lumerax (artemether/lumefantrine) 80mg
T.doxy (doxycycline) 100mg
186.00
4113 M T.Lariago (chloroquine) 3.40
10774 F T.lumerax (artemether/lumefantrine) 80mg 120.00
29760 F T.lumerax (artemether/lumefantrine) 80mg
T.doxy (doxycycline) 100mg
T.malarid DS (Primaquine) 15mg
232.00
7018 F T.Lariago DS (chloroquine) 500mg 7.00
11499 M T.Lariago (chloroquine) 250mg 7.00
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 37
Table 2.2.2h. Cost of antimalarial drugs used in patients.
I.P No. Gender Name of antimalarial drugs Cost of therapy
(Rs)
6527 F Inj.larinate (Artesunate pyrimethamine sulphadoxine)
120mg
1856.00
10967 F Inj.larinate (Artesunate pyrimethamine sulphadoxine)
120mg
1160.00
8974 F T.doxy (doxycycline) 100mg
T.Lariago DS (chloroquine)
30.00
7170 F I.falcigo (Artesunate) 120mg
T.doxy (doxycycline) 100mg
3593.40
31751 M Inj.larinate (Artesunate pyrimethamine sulphadoxine)
120mg
1856.00
6247 F T.doxy (doxycycline) 100mg
T.Lariago DS (chloroquine)
31.00
10743 F T.doxy (doxycycline) 100mg 22.00
5691 M T.doxy (doxycycline) 100mg
T.Lariago DS (chloroquine)
31.00
32606 M Inj.falcigo (Artesunate) 120mg
Tab.malarid DS (primaquine) 15mg
4989.00
5143 M Inj.larinate (Artesunate pyrimethamine sulphadoxine)
80mg
Tab.malarid DS (primaquine)
323.00
11280 F T.doxy (doxycycline) 100mg 15.75
3152 F T.lumerax (artemether/lumefantrine) 80mg
Tab.malarid DS (primaquine)
288.00
11390 M T.doxy 100mg (doxycycline) 15.75
( F=Female and M=Male)
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 38
Table 2.2.3a. Patient demographic details with drug interaction and its details.
IP.NO &
DOD
AGE
&
SEX
DIAGNOSIS ANTIMALARIAL
DRUG
CLASS OF
ANTIMALARIAL
THERAPY DRUG
INTERACTION
DRUG INTERACTION
DETAIL
2812
3/2/14
37
Y/M
Fever /
meningitis
Artesunate and
chloroquine phosphate
Sesquiterpine lactones
&
4-aminoquinolines
2 drugs
therapy
Chloroquine
phosphate
with
Ondansetron
Concurrent use of
chloroquine and
Ondansetron may result in
an increased risk of QT
interval
prolongation
2498
31/1/14
40
Y/F
Complicated
malaria
Artesunate and
Artemethar/lumefantrine
& primaquine
Sesquiterpine lactones
& 8-aminoquinolines &
4 drugs
therapy
Artemethar/
lumefantrine
with
Ondansetron
Concurrent use of
artemether/lumefantrine
and Ondansetron may
result in an increased risk
of QT
Interval prolongation.
27408
14/11/13
55
Y/M
Meningo
encephalitis
Doxycycline and
Artesunate
Tetracycline &
Sesquiterpine lactones
2 drugs
therapy
1)Midazolam
HCl-
Thiophylline
Concurrent use of both
may result in decrease the
benzodiazepine
effectiveness
2)amikacine
sulphate-
pipracillin
sodium
Concurrent use of both
may result in amino
glycoside efficacy
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 39
Table 2.2.3b. Patient demographic details with drug interaction and its details.
IP.NO &
DOD
AGE
&
SEX
DIAGNOSIS ANTIMALARIAL
DRUG
CLASS OF
ANTIMALARIAL
THERAPY DRUG
INTERACTION
DRUG INTERACTION
DETAIL
5664
3/3/14
12
Y/M
Fever /
Hodgkin’s
lymphoma
Doxycycline Tetracycline 1 drug
therapy
Doxycycline-
rifampin
Concurrent use of both
may result in an reduced
doxycycline serum
concentration and potential
loss of doxycycline
efficacy
3261
7/2/14
38
Y/F
Essential HTN
with malaria
Artemethar/lumefantrine
and chloroquine
phosphate
Sesquiterpine lactones
&
4-aminoquinolines
3 drugs
therapy
−
30635
12/12/13
9 Y/M Malaria /
dengue fever
Artesunate
Pyrimithamine
sulphadoxine
Sesquiterpine lactones 3 drugs
therapy
_
30478
12/12/13
8 Y/M Malaria /
dengue fever
Artesunate and
Doxycycline
Sesquiterpine lactones
& tetracycline
2 drugs
therapy
_
32597
4/1/13
25
Y/F
UTI chloroquine phosphate 4-aminoquinolines 1 drug
therapy
_
4113
19/2/14
32
Y/M
Cervical
lymphatic
disorder
chloroquine phosphate 4-aminoquinolines 1 drug
therapy
_
32609
4/1/14
50
Y/M
Malaria chloroquine phosphate
and Doxycycline and
Artemethar/lumefantrine
4-aminoquinolines &
tetracycline&
Sesquiterpine lactones
4 drugs
therapy
_
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 40
Table 2.2.3c. Patient demographic details with drug interaction and its details.
IP.NO &
DOD
AGE
&
SEX
DIAGNOSIS ANTIMALARIAL
DRUG
CLASS OF
ANTIMALARIAL
THERAPY DRUG
INTERACTION
DRUG INTERACTION
DETAIL
5810
4/3/14
70
Y/F
Fever ↓
evaluation /
LRTI
Doxycycline Tetracycline 1 drug
therapy
_
31305
31/12/13
46
Y/M
Complicated
malaria
Artesunate
Pyrimithamine
sulphadoxine and
primaquine
Sesquiterpine lactones
&
8-aminoquinolines
4 drugs
therapy
_
2533
31/1/14
60
Y/M
Complicated
malaria
Artesunate
Pyrimithamine
sulphadoxine and
primaquine
Sesquiterpine lactones
&
8-aminoquinolines
4 drugs
therapy
_
5468
27/2/14
40
Y/F
Pyogenic
meningitis
Artesunate Sesquiterpine lactones 1 drug
therapy
_
29908
1/1/14
62
Y/M
Malaria Artesunate
Pyrimithamine
sulphadoxine
Sesquiterpine lactones 3 drugs
therapy
_
5694
3/2/14
32
Y/F
Anemia with
liver disease
Chloroquine 4-aminoquinolines 1 drug
therapy
_
29529
30/11/13
21
Y/M
Malaria Artesunate
Pyrimithamine
sulphadoxine
Sesquiterpine lactones 3 drugs
therapy
_
10470
17/4/14
2 Y/M Ricketsial
fever
Doxycycline Tetracycline 1 drug
therapy
_
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 41
Table 2.2.3d. Patient demographic details with drug interaction and its details.
IP.NO &
DOD
AGE
&
SEX
DIAGNOSIS ANTIMALARIAL
DRUG
CLASS OF
ANTIMALARIAL
THERAPY DRUG
INTERACTION
DRUG INTERACTION
DETAIL
5139
10/3/14
6 Y/M SLE
& gangrenous
4th
toe
Hydroxyl chloroquine
sulphate
Aminoquinoline 1 drug
therapy
_
28160
17/12/13
28
Y/M
ALD with
malaria with
gastritis
Doxycycline Tetracycline 1 drug
therapy
Ciprofloxacin&
ondensetron
Concurrent use of
ciprofloxacin and
Ondansetron may result in
an increased risk of QT
interval
Prolongation.
Aluminium
hydroxide/magn
esium hydroxide
& ciprofloxacin
Concurrent use of
ciprofloxacin and antacids
may result in decreased
ciprofloxacin
effectiveness.
Aluminium
hydroxide/magn
esium hydroxide
& doxycycline
concurrent use of
aluminum, calcium or
magnesium containing
products and tetracycline
May result in decreased
effectiveness of
tetracycline.
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 42
Table 2.2.3e. Patient demographic details with drug interaction and its details.
IP.NO &
DOD
AGE
&
SEX
DIAGNOSIS ANTIMALARIAL
DRUG
CLASS OF
ANTIMALARIAL
THERAPY DRUG
INTERACTION
DRUG INTERACTION
DETAIL
10218
17/4/14
29
Y/M
Malaria Doxycycline Tetracycline 1 drug
therapy
_
28617
16/11/13
24
Y/M
ALD with
pancytopenia
with gastritis
Doxycycline Tetracycline 1 drug
therapy
_
9536
10/4/14
30
Y/M
Viral fever Artesunate Sesquiterpine lactones 1 drug
therapy
_
11718
30/4/14
45
Y/M
Retroviral
disease with
AGE
Doxycycline Tetracycline 1 drug
therapy
_
3240
11/3/14
35
Y/M
Malaria Artesunate Sesquiterpine lactones 1 drug
therapy
_
12315
27/3/14
35
Y/M
Malaria Doxycycline Tetracycline 1 drugs
therapy
_
6083
3/3/14
70
Y/F
Clinical
malaria
Artesunate
Pyrimithamine
sulphadoxine
Sesquiterpine lactones 3 drugs
therapy
_
9538
7/4/14
32
Y/F
Malaria Artesunate Sesquiterpine lactones 1 drugs
therapy
_
3242
11/2/14
35
Y/F
Malaria Artesunate Sesquiterpine lactones 1 drug
therapy
_
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 43
Table 2.2.3f. Patient demographic details with drug interaction and its details.
IP.NO &
DOD
AGE &
SEX
DIAGNOSIS ANTIMALARIAL
DRUG
CLASS OF
ANTIMALARIAL
THERAPY DRUG
INTERACTION
DRUG INTERACTION
DETAIL
6088
5/2/14
68 Y/F Clinical
malaria
Artesunate
Pyrimithamine
sulphadoxine
Sesquiterpine lactones 1 drugs
therapy
_
2788
5/2/14
28 Y/M Viral fever Lumefantrine
Artemether
Doxycycline
Amino alcohols
Sesquiterpine lactones
tetracycline’s
3 drugs
therapy
Artemether
+azithromycin
Concurrent use of both
may result in increase the
risk of QT interval
prolongatation
32606
8/1/13
56 Y/M ARF with
complicated
malaria
Artesunate
Primaquine
Sesquiterpine lactones
8-aminoquinolines
2 drugs
therapy
_ _
3152
7/2/14
70 Y/F Malaria with
bronchitis
Primaquine
Lumefantrine
Artemether
8-aminoquinolines
Amino alcohols
Sesquiterpine lactones
3 drugs
therapy
_
_
29067
25/11/13
19 Y/F Malaria Doxycycline
Quinine
Primaquine
Tetracycline
Cinchona alkaloids
8-aminoquinolines
3 drugs
therapy
_
_
5542
26/2/14
19 Y/M Viral fever Chloroquine 4-aminoquinolines
1 drug
therapy
_ _
3972
12/2/14
18 Y/M Uncomplicat
ed malaria
Lumefantrine
Artemether
Primaquine
Amino alcohols
Sesquiterpine lactones
8-aminoquinolines
3 drugs
therapy
_
_
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 44
Table 2.2.3g. Patient demographic details with drug interaction and its details.
IP.NO &
DOD
AGE &
SEX
DIAGNOSIS ANTIMALARIAL
DRUG
CLASS OF
ANTIMALARIAL
THERAPY DRUG
INTERACTION
DRUG INTERACTION
DETAIL
30478
17/12/13
8 Y/M Dengue fever Doxycycline
Artesunate
Sulphadoxine
pyrimethamine
Tetracycline
Sesquiterpine lactones
4 drugs
therapy
Ceftriaxone+
lactated ringer
solution
Ofloxacin+zinc
gluconate
Chloramphenicol
+ acetaminophen
Concurrent use of both
may result in formation
of Ceftriaxone calcium
precipitate
Concurrent use of both
may result in decrease in
efficacy of ofloxacine
Concurrent use of both
may result in
chloramphenicol toxicity
29905
19/12/13
8M/F Malaria Artesunate
Sulphadoxine
pyrimethamine
Primaquine
Sesquiterpine lactones
8-aminoquinolines
4 drugs
therapy
Ceftriaxone+
lactated ringer
solution/
Concurrent use of both
may result in formation
of Ceftriaxone calcium
precipitate
31470
22/12/13
15Y/F Severe
anemia
Lumefantrine
Artemether
Amino alcohols
Sesquiterpine lactones
2 drugs
therapy
_
_
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 45
Table 2.2.3h. Patient demographic details with drug interaction and its details.
IP.NO &
DOD
AGE &
SEX
DIAGNOSIS ANTIMALARIAL
DRUG
CLASS OF
ANTIMALARIAL
THERAPY DRUG
INTERACTION
DRUG INTERACTION
DETAIL
2905
6/2/14
5Y/M Iron def.
nutritional
anemia
Artesunate
Sulphadoxine
pyrimethamine
Sesquiterpine lactones
3 drugs
therapy
_
_
30635
13/12/13
9Y/M Dengue fever Artesunate
Sulphadoxine
pyrimethamine
Sesquiterpine lactones
3 drugs
therapy
_
_
4709
21/2/14
27Y/F Malaria Artesunate
Sulphadoxine
pyrimethamine
Chloroquine
Sesquiterpine lactones
4-aminoquinolines
4 drugs
therapy
Ceftriaxone+
lactated ringer
solution
Chloroquine
+Ondansetron
Concurrent use of both
may result in formation of
ceftriaxone calcium
precipitate
Concurrent use of
CHLOROQUINE and
ONDANSETRON may
result in an increased risk
of QT interval
prolongation
31087
20/12/13
10M/M Seizure with
LRTI
Artesunate
Sulphadoxine
pyrimethamine
Sesquiterpine lactones
3 drugs
therapy
Lorazepam+
phenobarbiton
Concurrent use of both
may result in additive
respiratory depression
594
9/1/14
2Y/F Malaria Lumefantrine
Artemether
Amino alcohols
Sesquiterpine lactones
2 drugs
therapy
_ _
29760
3/12/13
35Y/F Malaria Lumefantrine
Artemether
Primaquine
Doxycycline
Amino alcohols
Sesquiterpine lactones
8-aminoquinolines
Tetracycline
4 drugs
therapy
Doxycycline+
iron
Concurrent use of both
may result in decrease
tetracycline and iron
effectiveness
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 46
Table 2.2.3i. Patient demographic details with drug interaction and its details.
IP.NO &
DOD
AGE &
SEX
DIAGNOSIS ANTIMALARIAL
DRUG
CLASS OF
ANTIMALARIAL
THERAPY DRUG
INTERACTION
DRUG INTERACTION
DETAIL
31751
31/12/13
55Y/M Tuberculosis Artesunate
Sulphadoxine
pyrimethamine
Sesquiterpine lactones
3 drugs
therapy
Levofloxacin+
Moxifloxacin
Moxifloxacin+
Rifampin
Amino
glycosides+
Penicillin
Concurrent use of both
may result in increase the
risk of QT interval
Prolongation
Concurrent use of both
may result in decrease
moxifloxacin exposure and
plasma concentration
Concurrent use of both
may result in loss of amino
glycoside efficacy
8974
7/3/14
45 Y/f malaria Chloroquine
doxycycline
4-aminoquinolines
tetracycline’s
2 drugs
therapy
Budesonide+
dihydroergotami
ne
budesonide will decrease
the level or effect of
dihydroergotamine by
affecting hepatic/intestinal
enzyme CYP3A4
metabolism. Monitor
closely.
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 47
Table 2.2.3j. Patient demographic details with drug interaction and its details.
IP.NO
& DOD
AGE &
SEX
DIAGNOSIS ANTIMALARIAL
DRUG
CLASS OF
ANTIMALARIAL
THERAPY DRUG
INTERACTION
DRUG INTERACTION
DETAIL
8727
7/4/14
6 M/F malaria Artesunate
Sulphadoxine
pyrimethamine
Sesquiterpine lactones
3 drugs
therapy
Mefenamic acid
+furosemide
Mefenamic acid increases
and furosemide decreases
serum potassium. Effect of
interaction is not clear,
use caution. Potential for
interaction, monitor.
7170
29/3/14
50 Y/F Acute GE Artesunate
Doxycycline
Sesquiterpine lactones
Tetracycline
2 drugs
therapy
Artemether+
Ondansetron
Artemether/lumefantrine
and Ondansetron both
increase QTc interval.
6247
10/3/14
55 Y/F Dengue fever Chloroquine
doxycycline
4-aminoquinolines
tetracycline
2 drugs
therapy
Doxycycline+
Ceftriaxone
Doxycycline decreases
effects of Ceftriaxone by
pharmacodynamic
antagonism. Significant
interaction
Possible, monitor closely.
bacteriostatic agents may
inhibit the effects of
bactericidal agents
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 48
Table 2.2.3k. Patient demographic details with drug interaction and its details.
IP.NO
& DOD
AGE &
SEX
DIAGNOSIS ANTIMALARIAL
DRUG
CLASS OF
ANTIMALARIAL
THERAPY DRUG
INTERACTION
DRUG INTERACTION
DETAIL
7018
14/3/14
36 Y/F Viral fever Chloroquine 4-aminoquinolines
1 drug
therapy
Chloroquine
+tramadol
Chloroquine will increase
the level or effect of
tramadol by affecting
hepatic enzyme CYP2D6
metabolism.
Minor or non-significant
interaction.
10743
22/4/14
55 Y/F Brucellosis Doxycycline Tetracycline 1 drug
therapy
Doxycycline
+Ceftriaxone
Doxycycline decreases
effects of Ceftriaxone by
pharmacodynamic
antagonism. Significant
interaction
Possible, monitor closely.
Bacteriostatic agents may
inhibit the effects of
bactericidal agents.
10774
24/4/14
35 Y/F Viral fever Artesunate
Sesquiterpine lactones
1 drug
therapy
Azithromycin+
Lumefantrine
Artemether
Azithromycin and
Artemether/lumefantrine
both increase QT interval.
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 49
Table 2.2.3l. Patient demographic details with drug interaction and its details.
IP.NO
& DOD
AGE &
SEX
DIAGNOSIS ANTIMALARIAL
DRUG
CLASS OF
ANTIMALARIAL
THERAPY DRUG
INTERACTION
DRUG INTERACTION
DETAIL
4880
29/4/14
22 Y/M Pancytopenia Artesunate
Artemether
lumefantrine
Sesquiterpine lactones
Amino alcohols
2 drugs
therapy
Levofloxacin
+Lumefantrine
Artemether
Levofloxacin and
artemether/lumefantrine
both increase QT interval
4113
32 Y/M Cervical
lymph nodes
Chloroquine 4-aminoquinoline 1 drug
therapy
Furosemide
+Torsemide
Furosemide and
Torsemide both decrease
serum potassium.
8428
8/4/14
15 Y/F Massive
Splenomegaly
with
thalasemia
Artesunate
Artemether
lumefantrine
Sesquiterpine lactones
Amino alcohols
3 drugs
therapy
Artemether
+Ondansetron
Artemether/lumefantrine
and Ondansetron both
increase QT interval.
5143
3/3/14
65 Y/M Cirrhosis of
liver+malaria+
cellulitis
Artesunate
Sulphadoxine
pyrimethamine
Primaquine
Sesquiterpine lactones
8-aminoquinolines
4 drugs
therapy
Metronidazole+
artemether
Artemether/lumefantrine
and Ondansetron both
increase QT interval.
6527
10/3/14
38 Y/F Enteric fever Artesunate
Sulphadoxine
pyrimethamine
Sesquiterpine lactones
3 drugs
therapy
10317
15/4/14
20 Y/F Viral fever Artesunate
Sulphadoxine
pyrimethamine
Sesquiterpine lactones
3 drugs
therapy
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 50
Table 2.2.3m. Patient demographic details with drug interaction and its details.
IP.NO
& DOD
AGE &
SEX
DIAGNOSIS ANTIMALARIAL
DRUG
CLASS OF
ANTIMALARIAL
THERAPY DRUG
INTERACTION
DRUG INTERACTION
DETAIL
9410
10/4/14
6 Y/F Viral
hemorrhagic
fever
Artesunate
Sulphadoxine
pyrimethamine
Sesquiterpine lactones
3 drugs
therapy
11390
8/4/14
52 Y/M Viral fever Doxycycline Tetracycline 1 drug
therapy
576
11/1/14
50 Y/M Acute febrile
Illness &
viral fever
Artesunate &
doxycycline
Sesquiterpine lactones &
tetracycline
2 drugs
therapy
Aluminium
hydroxide &
Doxycycline
Concurrent use of
Aluminum, Calcium or
Magnesium containing
products and Tetracycline
may result in decreased
effectiveness of
Tetracycline
2372
31/1/14
20 Y/M Fever of
unknown
origin &dog
bite
Artemether/
Lumefantrine &
doxycycline
Sesquiterpine lactones &
Tetracycline
3 drugs
therapy
Artemether/
Lumefantrine &
Azithromycin
Concurrent use of
Artemether/ lumefantrine
and Azithromycin may
result in an increased risk
of QT interval
prolongation.
3268
20/2/14
70 Y/F Malaria Artemether/
Lumefantrine
Sesquiterpine lactones 2 drugs
therapy
Iron &
pantoprazole
Concurrent use of Iron and
Pantoprazole may result in
reduced iron
bioavailability.
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 51
Table 2.2.3n. Patient demographic details with drug interaction and its details.
IP.NO
& DOD
AGE &
SEX
DIAGNOSIS ANTIMALARIAL
DRUG
CLASS OF
ANTIMALARIAL
THERAPY DRUG
INTERACTION
DRUG INTERACTION
DETAIL
11032
23/4/14
17 Y/M Viral fever Artesunate
Sulphadoxine
Pyrimethamine
Sesquiterpine lactones
3 drugs
therapy
10967
24/4/14
40 Y/F Splenomegaly Artesunate
Sulphadoxine
Pyrimethamine
Sesquiterpine lactones
3 drugs
therapy
11355
26/4/14
17 Y/M Malaria Chloroquine
Artemether
lumefantrine
4 Aminoquinoline
Sesquiterpine lactones
Amino alcohols
3 drugs
therapy
5691
30/2/14
55 Y/F Viral fever Chloroquine
Doxycycline
4-aminoquinolines
Tetracycline
2 drugs
therapy
11681
28/4/14
28 Y/F Appendicitis Doxycycline Tetracycline 1 drug
therapy
11280
22/4/14
70 Y/F Viral fever Doxycycline Tetracycline 1 drug
therapy
11032
23/4/14
17 Y/M Viral fever Artesunate Sesquiterpine lactones
1 drug
therapy
9170
28/4/14
20 Y/F Septicemia Artesunate
Doxycycline
Sesquiterpine lactones
Tetracycline
2 drugs
therapy
11499
28/4/14
23 Y/M Amoebic liver
abscess
Artesunate
Sesquiterpine lactones
1 drug
therapy
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 52
Table 2.2.3o. Patient demographic details with drug interaction and its details.
IP.NO &
DOD
AGE &
SEX
DIAGNOSIS ANTIMALARIAL
DRUG
CLASS OF
ANTIMALARIAL
THERAPY DRUG
INTERACTION
DRUG INTERACTION
DETAIL
28670
23/11/13
20 Y/F Dengue fever Artemether/
Lumefantrine &
Doxycycline
Sesquiterpine lactones &
Tetracycline
3 drugs
therapy
Artemether/
Lumefantrine &
Levofloxacin
Concurrent use of
Artemether/ Lumefantrine
and Levofloxacin may
result in an increased risk
of QT interval
prolongation.
29238
30/11/13
11 Y/M PF malaria Quinine &
Primaquine
Artesunate
Sulphadoxine
pyrimethamine
Sesquiterpine lactones &
cinchona
Alkaloid & 8-
aminoquinoline
5 drugs
therapy
Quinine &
Ondansetron
Concurrent use of
Ondansetron and Quinine
may result in an increased
risk of QT interval
prolongation.
29700
1/12/13
24 Y/F PF malaria &
Enteric fever
Artesunate Sesquiterpine lactones 1 drug
therapy
_ _
740
22/1/14
7 Y/F Malaria fever Quinine sulfate Cinchona alkaloid 1 drug
therapy
_ _
329
13/1/14
32 Y/M Malaria Artemether/
Lumefantrine
Sesquiterpine lactones 2 drugs
therapy
_ _
598
14/1/14
40 Y/M PF malaria Artesunate &
Primaquine
Sesquiterpine lactones &
8-aminoglycoside
2 drugs
therapy
_
_
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 53
Table 2.2.3p. Patient demographic details with drug interaction and its details.
IP.NO &
DOD
AGE &
SEX
DIAGNOSIS ANTIMALARIAL
DRUG
CLASS OF
ANTIMALARIAL
THERAPY DRUG
INTERACTION
DRUG INTERACTION
DETAIL
13-
32510
2/12/14
16 Y/M Acute febrile
illness with
LRTI
Chloroquine 4-aminoglycosides 1 drug
therapy
_ _
29321
29/11/13
25 Y/M Jaundice↓
evaluation
with
malaria
Doxycycline &
Artesunate &
Primaquine
Sesquiterpine lactones &
Tetracycline &8-
aminoglycosides
3 drugs
therapy
_ _
3132
6/2/14
50 Y/M Malaria Doxycycline &
Artesunate
Sesquiterpine lactones &
Tetracycline
2 drugs
therapy
_ _
5259
3/3/14
55 Y/M Anemia with
Thrombocyto
penia
Artesunate
Sulphadoxine
pyrimethamine
Sesquiterpine lactones 3 drugs
therapy
_ _
31470
20/12/13
15 Y/F Severe
anemia
Artemether/
Lumefantrine
Sesquiterpine lactones 2 drugs
therapy
_ _
3261
10/2/14
38 Y/F HTN &
malaria
Artemether/
Lumefantrine &
Chloroquine
Sesquiterpine lactones &
4-aminoquinolones
3 drugs
therapy
_ _
5689
3/3/14
35 Y/M Pain abd.↓
Evaluation
Artesunate Sesquiterpine lactones 1 drug
therapy
_ _
5156
7/3/14
20 Y/F Rheumatoid
arthritis
Hydroxychloroquine
sulphate
1 drug
therapy
Methotrexate-
Rabeprazole
Concurrent use of
Methotrexate and
Rabeprazole may result in
increased risk of
Methotrexate toxicity.
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 54
Table 2.2.3q. Patient demographic details with drug interaction and its details.
IP.NO &
DOD
AGE &
SEX
DIAGNOSIS ANTIMALARIAL
DRUG
CLASS OF
ANTIMALARIAL
THERAPY DRUG
INTERACTION
DRUG INTERACTION
DETAIL
10557
17/4/14
70 Y/M ARF with
LRTI
Artemether/
Lumefantrine
Sesquiterpine lactones 1 drug
therapy
_ _
9121
8/4/14
68 Y/M AGE with
dehydration
Doxycycline Tetracycline 1 drug
therapy
_ _
20658
22/4/14
66 Y/M LRTI Artemether/
Lumefantrine
Sesquiterpine lactones 1 drug
therapy
_ _
9386
7/4/14
60 Y/M Viral fever Artemether/
Lumefantrine
Sesquiterpine lactones 1 drug
therapy
_ _
9031
11/3/14
60 Y/M AGE Doxycycline Tetracycline 1 drug
therapy
_ _
10554
12/4/14
64 Y/M Malaria fever Artemether/
Lumefantrine
Sesquiterpine lactones 1 drug
therapy
_ _
8856
14/3/14
32 Y/F Malaria Artesunate Sesquiterpine lactones 1 drug
therapy
_ _
8486
8/4/14
43 Y/F Malaria Artemether/
Lumefantrine
Sesquiterpine lactones 1 drug
therapy
_ _
9536/14
9/4/14
30 Y/M Malaria Artesunate Sesquiterpine lactones 1 drug
therapy
_ _
14/9643
28/3/14
15 Y/F Viral fever Artesunate Sesquiterpine lactones 1 drug
therapy
_ _
4144
27/2/14
22 Y/M Arthritis Hydroxychloroquine
sulphate
1 drug
therapy
_ _
(M=male , F=female , Y=years)
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 55
Table 2.2.3r. Patient demographic details with drug interaction and its details.
Drug interaction Number of drug interaction Percentage
Major 16 43.24%
Moderate 12 32.43%
Minor 6 18.92%
Contraindication 3 05.41%
Total 37 100%
Major: - The interaction may be life threatening and/or require medical intervention to minimize or prevent sever adverse effect
Moderate: - The interaction may result in exacerbation of the patient condition and/or require an alteration in therapy
Minor: - The interaction would have limited clinical event. Manifestation may include an increase in the frequency or severity of
the side effect but generally would not require a major alteration in therapy
Contraindicated: - The drugs are contraindicated for concurrent use
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 56
Table 2.2.3s. Drug-drug interaction of artemisinin derivatives with other drugs in malaria and nonmalarial cases.
Infection Drug-drug interactions Percentage
Malarial cases(n=46) 1 2.17%
Nonmalarial cases(n=52) 7 13.46%
Figure 1. Table of drug interactions
43%
33%
19%
5%
Percantage
Major
Moderate
Minor
Contraindicated
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 57
Table 2.2.4a. Antimalarial drugs prescribed for patient visiting tertiary care hospital
Name of drugs
Numbers of prescription
percentage of prescription
Artesunate
19
14.40%
Aretsunate+Pyrimethamine+Sulphadoxine
26
19.70%
Artemether/Lumefantrine
23
17.42%
Chloroquine phosphate
16
12.12%
Doxycycline
31
23.49%
Primaquine
11
8.33%
Hydroxy chloroquine sulphate
03
2.28%
Quinine
03
2.28%
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 58
Figure 2. Percentage of prescription of antimalarial drugs
14%
20%
18% 12%
24%
8% 2% 2%
Percentage of prescription of antimalarial drugs
Artesunate
Aretsunate+Pyrimethamine+Sulphadoxine
Artemether/Lumefantrine
Chloroquine phosphate
Doxycycline
Primaquine
Hydroxy chloroquine sulfate
Quinine
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 59
Table 2.2.4b. Artesunate prescribed for patient visiting tertiary care hospital
Antimalarial
drug
Malaria cases(n=46) Non malarial cases(n=52)
Number of
prescription
Percentage
(%)
Number of
prescription
Percentage
(%)
Artesunate 25 54.34 17 32.69
Table 2.2.5. Pattern of malaria parasite infection in patient visiting tertiary care hospital.
Malaria parasite Number of prescription Percentage of prescription
Plasmodium falciparum 27 58.69%
Plasmodium vivax 4 08.69%
Mixed 3 6.52%
Clinical malaria 3 6.52%
Complicated malaria 9 19.5%
Total(n) 46 100%
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 60
Table 2.2.6. Class of antimalarial drugs used in treatment of patients.
Serial
number
Class Total no of prescriptions
(n= 132)
Percentage
1 4 Aminoquinoline 19 19.38%
2 8 Aminoquinoline 11 11.22%
3 Cinchona alkaloid 03 03.06%
5 Sesquiterpine lactones 19 19.38%
6 Sesquiterpine lactones/sulphonamides and
sulfone/diaminopyrimidine
26 26.53%
7 Sesquiterpine lactones/amino alcohols 23 23.47%
8 Tetracycline 31 31.63%
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 61
Table 2.2.7a. Pattern of drugs regimen prescribed for patients.
Drug regimen Name of drugs Number of prescriptions Percentage
1 drug therapy Artesunate 08 8.17%
Chloroquine 08 8.17%
Doxycycline 14 14.29%
Hydroxychloroquine sulphate 03 3.06%
Quinine sulfate 01 1.02%
Total 34 34.69%
2 drugs therapy Artesunate+doxycycline 06 6.12%
Artesunate+primaquine 03 3.06%
Artemether+lumefentine 11 11.22%
Artesunate+quinine 01 1.02%
Doxycycline+chloroquine 03 3.06%
Total 24 24.48%
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 62
Table 2.2.7b. Pattern of drugs regimen prescribed for patients.
Drug regimen Name of drugs Number of prescriptions Percentage
3 drugs therapy Artesunate + Artemether + Chloroquine 01 1.02%
Artesunate + Pyrimethamine + Sulphadoxine 17 17.35%
Artesunate + Artemether + primaquine 01 1.02%
Artesunate + Artemether + doxycycline 01 1.02%
Artemether + lumefantrine + Chloroquine 02 2.04%
Artesunate + Artemether + lumefantrine 02 2.04%
Primaquine + Doxycycline + quinine 01 1.02%
Artemether + lumefantrine + Doxycycline 03 3.06%
Artemether + lumefantrine + primaquine 02 2.04%
Total 30 30.61%
4 drugs therapy Artemether + lumefantrine + Doxycycline + primaquine 01 1.02%
Artesunate + pyrimithamine + sulphadoxine + Chloroquine 02 2.04%
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 63
Table 2.2.7c. Pattern of drugs prescribed for malaria in combination
Drug regimen Name of drugs Number of prescriptions Percentage
4 drugs therapy Artesunate + pyrimithamine + sulphadoxine + Doxycycline 02 2.04%
Artesunate + pyrimithamine + sulphadoxine + Primaquine 04 4.08%
Total 09 9.18%
5 drugs therapy Artesunate + Pyrimethamine + Sulphadoxine + Primaquine +
quinine
01 1.02%
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 64
Table 2.2.8a. Number of complicated malaria cases with treatment
Clinical
features
No.
of
cases
Antimalarial treatment
Artesunate Artesunate+sulphadoxine+
Pyrimithamine
Doxycycline Chloroquine Artemether & lumefantrine Primaquine
Essential
hypertension
with malaria
2 2 2
dengue fever
with malaria
1 1 1
ALD with
malaria with
gastritis
1 1
ALD with
pancytopenia
with malaria
with gastritis
1 1
ARF with
complicated
malaria
1 1 1
Acute
bronchitis
with malaria
1 1
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 65
Table 2.2.8b. Number of complicated malaria cases with treatment
Clinical
features
No.
of
cases
Antimalarial treatment
Artesunate Artesunate+sulphadoxine+
Pyrimithamine
Doxycycline Chloroquine Artemether & lumefantrine Primaquine
Cirrhosis
with malaria
with lower
limb
cellulitis
1 1 1
Seizure
disorder with
malaria with
LRTI
1 1
Total 9 2 2 3 2 3 2
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 66
Table 2.2.9. Number of uncomplicated malaria cases
Condition Numbers of cases Percentage
Plasmodium vivax 3 8.11 %
Plasmodium falciparum 26 70.27%
Pregnant women with plasmodium
falciparum
1 2.70%
Mixed 4 10.81%
Clinical malaria 3 8.11%
Total 37 100%
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 67
Figure 3. Number of uncomplicated malaria cases
8%
70%
3%
11%
8%
Plasmodium vivax
Plasmodium falciperum
Pregnant women withplasmodium falciperum
Mixed
clinical malaria
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 68
Table 2.2.10. Assessment of rationality of antimalarial drugs prescribed for patient according to guidelines.
Condition Treatment
Rational Irrational
Total Percentage Total Percentage
Plasmodium vivax 03 12% 01 04.76%
Plasmodium falciparum 13 52% 14 66.67%
Mixed 03 12% 00 00.00%
Clinical malaria 03 12% 00 00.00%
Complicated malaria 03 12% 06 28.57%
Total 25 100% 21 100%
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 69
Figure 4. Assessment of rationality of antimalarial drugs prescribed for patient according to guidelines.
0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00%
plasmodium vivax
plasmodium falciperum
mixed
clinical malaria
complicated malaria
Percentage
Con
dit
ion
of
dis
ease
irrational
rational
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 70
Table 2.2.11a. Antimalarial drugs prescribed for infectious diseases other than malaria cases.
Condition number
of
patient
Antimalarial drug prescribed (n=65)
Artesunate Artesunate+sulphadoxine+
pyrimithamine
Doxycycline Chloroquine Hydroxy
chloroquine
Artemether
lumefantrine
Acute gastroenteritis with
Retroviral disease
1 1
Acute gastroenteritis with
dehydration
2 1 2
Acute gastroenteritis 1 1
Alcoholic liver disease 1 1
Anemia with liver disease 1 1
Acute renal failure with
LRTI
1 1
Amoebic liver abscess 1 1
Appendicitis 1 1
Anemia 2 2 1
Brucellocesis 1 1
Cervical lymphatic disease 2 2
Dengue fever 1 1 1
Enteric fever 1 1
Fever with chills 2 2
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 71
Table 2.2.11b. Antimalarial drugs prescribed for infectious diseases other than malaria cases.
Condition Number
of
patient
Antimalarial drug prescribed (n=65)
Artesunate Artesunate+sulphadoxine+
pyrimithamine
Doxycycline Chloroquine Hydroxy
chloroquine
Artemether
lumefantrine
Fever ↓ evaluation 3 2 1 1
GERD 1 1
Hodgkin’s lymphoma 1 1
LRTI 4 2 1 1
Meningo encephalitis 1 1 1
Pyogenic meningitis 1 1
Pain abdomen ↓evaluation 1 1
Pancytopenia 1 1 1
PTB 1 1
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 72
Table 2.2.11c. Antimalarial drugs prescribed for infectious diseases other than malaria cases.
Condition Number
of
patient
Antimalarial drug prescribed (n=65)
Artesunate Artesunate+sulphadoxine+
pyrimithamine
Doxycycline Chloroquine Hydroxy
chloroquine
Artemether
lumefantrine
Rheumatoid arthritis 2 2
Ricketsial fever 1 1
SLE 1 1
Splenomegaly with
thalasemia
1 1 1
Splenomegaly 1 1
Septicemia 1 1 1
Severe anemia 1 1 1
Viral fever 12 5 3 3 3 1
UTI 1 1
Total 52 13(20%) 8(12.30%) 19(29.23%) 11(19.92%) 3(4.62%) 11(19.92%)
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 73
Figure 5. Antimalarial drugs prescribed in infectious diseases other than malaria cases
13
8
19
11
3
11
0 2 4 6 8 10 12 14 16 18 20
Artesunate
Artesunate+Sulphadoxine+Pyrimithamine
Doxycycline
Chloroquine
Hydroxy chloroquine
Artemether/lumefentrine
Number of patients
An
tim
ala
rial
dru
gs
Numbers of patients
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 74
Table 2.2.12. Clinical outcome
Outcome Number of patients Percentage
Improved 22 47.83%
Cured 24 52.17%
Worsened 00 00.00%
Expired 00 00.00%
Total 46 100%
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 75
Table 2.2.13a. Assessment of rationality of antimalarial drugs for uncomplicated malaria as per national vector borne disease control
programme.
I.p. no. Disease Treatment given Comments
11355 Malaria(PF) Chloroquine
artemether/lumefantrine
According to guidelines primaquine is recommended on day 2.
594 Malaria(PF) artemether/lumefantrine According to guidelines primaquine is recommended on day 2.
8727 Malaria(PF) Artesunate
Pyrimethamine
Sulphadoxine
According to guidelines primaquine is recommended on day 2.
30635 Malaria(PF) Artesunate
Pyrimethamine
Sulphadoxine
According to guidelines primaquine is recommended on day 2.
329 Malaria(PF) Artemether/lumefantrine According to guidelines primaquine is recommended on day 2.
9643 Malaria(PF) Artesunate
According to guidelines ACT-AL or ACT-SP is recommended and primaquine is recommended on
day 2.
8856 Malaria(PF) Artesunate
According to guidelines ACT-AL or ACT-SP is recommended and primaquine is recommended on
day 2.
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 76
Table 2.2.13b. Assessment of rationality of antimalarial drugs for uncomplicated malaria as per national vector borne disease control
programme.
I.p. no. Disease Treatment given Comments
29905 Malaria(PF) Artesunate
Pyrimethamine
Sulphadoxine
According to guidelines primaquine is recommended on day 2.
3242 Malaria(PF) Artesunate
According to guidelines ACT-AL or ACT-SP is recommended and primaquine is recommended on
day 2.
30635 Malaria(PF) Artesunate
Pyrimethamine
Sulphadoxine
According to guidelines primaquine is recommended on day 2.
10554 Malaria(PF) Artemether/lumefantrine According to guidelines primaquine is recommended on day 2.
95361 Malaria(PF) Artesunate
According to guidelines ACT-AL or ACT-SP is recommended and primaquine is recommended on
day 2.
8486 Malaria(PF) Artemether/lumefantrine According to guidelines primaquine is recommended on day 2.
9538 Malaria(PF) Artesunate
According to guidelines ACT-AL or ACT-SP is recommended and primaquine is recommended on
day 2.
3240 Malaria(PF) Artesunate
According to guidelines ACT-AL or ACT-SP is recommended and primaquine is recommended on
day 2.
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 77
Table 2.2.13c. Assessment of rationality of antimalarial drugs for complicated malaria as per national vector borne disease control programme.
I.p. no. Disease Treatment given Comments
5259 Anemia with
thrombocytopenia
with malaria(PV)
Artesunate
Pyrimethamine
Sulphadoxine
According to guidelines primaquine is given for 14 days.
29700 Malaria(PF) with
enteric fever
Artesunate
According to guidelines ACT-AL or ACT-SP is recommended and primaquine is recommended on
day 2.
30478 Dengue with
malaria
Artesunate
Pyrimethamine
Sulphadoxine
Doxycycline
According to guidelines primaquine is recommended on 2nd day.
28160 ALD with malaria
with gastritis
Doxycycline According to guideline quinine is recommended for 3 days.
28617 ALD with
pancytopenia
with malaria with
gastritis
Artesunate
According to guidelines ACT-AL or ACT-SP is recommended and primaquine is recommended on
day 2.
32606 ARF with malaria Artesunate
According to guidelines ACT-AL or ACT-SP is recommended and primaquine is recommended on
day 2.
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 78
Table 2.2.14. Drug use evaluation of antimalarial drugs prescribed for patients
with help of prescribing indicator.
Indicator Data
Average no of drug 1.42
I.V. injection(percentage) 44.897%
Formula 1 (n=98)
Average number of drugs =
=
= 1.42
Formula 2 (n=43)
I.V. injection (percentage) =
=
= 44.897 %
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 79
Table 2.2.15. Cost of antimalarial drug prescribed for patient visiting tertiary
care hospital.
Indicator Data
Average drug cost 1085.22 Rs
Percentage drug cost on injection 86.51 %
Formula 3 (n=98)
Average drug cost/ prescription =
=
= 1085.22 Rs.
Formula 4
Percentage of drug cost spent on injection =
=
= 86.51 %
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 80
2.3 Discussion and conclusion
Drug use indicator as defined by WHO has provided easy & convenient
measures to assess optimal drug used in health facilities. Malaria is one of the major
public health problems of the country. Prompt & effective treatment is important for
preventing the transmission of malaria. In view of this we studied drug use of
antimalarial in malaria patients.
In present study, during 6 months 98 patients were admitted in hospital. The
demographic details of patients admitting in hospital shows male patients were more
number (60.52%) & female were less (39.48%) which was also seen in previous
studies conducted in various areas1,2
and this reflecting that the prevalence of the
disease was higher among adult patients in this region during the study.
During six months of study, out of 98 patients prescribed with antimalarial
drugs, only 46 patients showed malarial infection and 52 patients diagnosed with
nonmalarial infection. Out of 46 malarial cases 78.78% of patients were serum
positive for Plasmodium falciparum and 21.22% were with Plasmodium vivax and
mixed type of infection. This indicates Plasmodium falciparum is more common in
this area of Karnataka for malarial infection. This report was similar to the previous
study3.
During the study period, major prescription of antimalarial agents were
Artesunate (14.4%), Artesunate Sulfadoxine and Pyrimethamine (19.70%),
Artemether/Lumefantrine (17.42%), Chloroquine (12.12%) and others 2 to 8% were
observed. The Artesunate were prescribed alone, which leads to development of
resistance according to national vector borne disease control programme (NVBDCP).
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 81
NVBDCP recommended Artesunate should be given in combination with
Sulfadoxine/Pyrimethamine or lumefantrine.
In our study 3 drug combination therapy prescribed more (30.61%) for
inpatients of our hospital followed by two drugs combinations. In this combination
therapy almost all combination contain artemisinin derivatives which was in accord
with guidelines for diagnosis and treatment of malaria and similar study were done
previously4.
Rationality of antimalarial drug prescription was accessed by NVBDCP.
During the study we observed antimalarial drug given for 46 malarial infection
patients in these 45.65% irrational prescriptions found and out of 52 nonmalarial
patients 82.69% irrational prescriptions were found. This indicates antimalarials
prescribed irrationally more especially in nonmalarial patients. Thus, there is a need to
educate health care workers. 2.17 % of prescriptions were showed potential drug-
drug interaction of artemisinin derivatives in malarial patients but in non-malarial
patients 13.46% of potential drug-drug interactions were found which indicate DDIs
were more in nonmalarial cases.
After evaluation of this study by prescribing indicators it shows 44.879 % of
I.V. injections were prescribed, this will increase cost of the prescriptions as injections
are costlier then oral therapy. Not only quality but also cost of the antimalarial drugs
was important component of drug utilization study. As in our study drug cost on
injection is 86.51% out of total cost which indicated artemisinin derivatives were used
more because these are available as I.V preparations only and are much more
expensive than conventional antimalarial drugs this result were comparable with study
done in Gujarat3.
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 82
In conclusion this study shows that inappropriate use of antimalarial drugs was
high among patient with plasmodium falciparum and nonmalarial patients. Irrational
prescriptions are high which indicate non adherence to guidelines. Cost of therapy is
very high thus it contribute economic burden on patients. Bagalkot is endemic for
plasmodium falciparum & plasmodium vivax malaria and there is requirement of
rational prescriptions for betterment of therapy for malaria. This result should inform
education of health professional and rational drug use policy and to reduce the cost of
prescription.
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 83
Reference
1. Costa AD, Bhartiya S, Eltayb A, Nandeswar S and Diwan VK. Patterns of
Drug Use in the Public Sector Primary Health Centers of Bhopal District.
Pharm World Sci 2008; 30: 584-9.
2. Lamichhane D, Giri BR, Pathak OK, Panta OB and Sankar PR. Morbidity
Profile and Prescribing Patterns among Outpatients in a Teaching Hospital in
Western Nepal. McGill J Med. 2006; 9(2): 126-33.
3. Dhara L, Rina D and C.N.Patel, Drug utilization study of antimalarial drugs in
a tertiary care hospital, 2012;2(4):761-77
4. Alexander ND, Carole.F, Alex. A. Pattern of drug utilization for treatment of
uncomplicated malaria in urban. Ghana following national treatment policy
change to artemisinin combinational therapy malaria journal 2009; 8(2):1-8.
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 84
Annexure
Department of Clinical Pharmacy, H.S.K. COP, Bagalkot Page 85
Annexure 1
[Antimalarial drug cost documentation from]
Name of the Staff Incharge :
Signature of staff Incharge :
Remarks of the staff Incharge :
Name of
drug
Cost of
drug
1 2 3 4 5 6 7 8 9 10 Cost per
day
Total
[Total Day × cost per day]
Total
Recommended