Sudan Journal of Rational Use of Medicine - WHOapps.who.int/medicinedocs/documents/s22198en/s22198en.pdf · Nuha Mohamed A. Agabna B. Pharm, M. Pharm , Ph.D ... Sudan Journal of Rational

Directorate General of Pharmacy

Federal Ministry of Health

Sudan Journal of Rational Use of Medicine

September 2014 - Issue No.9

S J

Patients' Adherence

•

Publication teamEditor in chief RandaAlsadigAlsaddig BSC.MSc.ClinicalPhamacyEditors Prof.AliMohamedArabi MBBS.MD ElkhatimElyasMohamed MBBS.MCOMH.DiplomaThoracicMed. HababKhalidElKheir B.Pharm.,M.Pharm.,Ph.DNuhaMohamedA.Agabna B.Pharm,M.Pharm,Ph.D DuriaHassanMerghani B.Sc.N,M.Sc.N.,Ph.D SarahA.KareemHassan B.Pharm,M.Pharm,MBA GhadaOmarShouna B.Pharm.,MScClinicalPhamacy BadreldinSaidHagnour B.Pharm,FPSM YasirMirghaniAbdalrahman B.Pharm. SawsanEltaherAhmed B.Pharm.Graphic Design MahmoudGahallaAhmedAdvisory board Prof.SamiAhmedKhalid B.Pharm.,M.Pharm.,Ph.D Prof.AbdallaO.Elkhawad B.Pharm.,M.Pharm.,Ph.D MohamedA.Zeinelabdin B.Pharm.,M.Pharm.

SudanJournalforRationalUseofMedicine(SJRUM)isaquarterlypublicationproducedbytheNationalMedicineInformationCenterandReferenceLibrary(NMICRL);DirectorateGeneral

ofPharmacy;FederalMinistryofHealth;Sudan.SJRUMisfundedbyGlobalFundandtechnicallysupportedbytheWorldHealthOrganization.ThefirstissuewaspublishedinSeptember2012.SJRUMaimstopromoteRationalUseofMedicines(RUM)throughdisseminatingprinciples,views,news,andeducatinghealthprovidersaboutrationaluseofmedicines.SJRUMtargetshealthprofessionals;prescribers,pharmacists,andnurses.Eachissueiscenteredonatheme;whichusuallyisanimportantsubjectinRUM.SJRUMhighlightsineachissuethecurrentsituationinSudanrelevanttothetheme,presentedeitherbyevidencefromlocalresearchorwithreliableanecdotalevidence.SJRUMincludesresearchstudieswhichaimtoencourageyoungresearcherstopublishtheirworkatnationalandinternationallevels.SJRUMalsoincludesasectionforeducationalmaterialsrelevanttoRUMrelyingmostlyontheWHOeducationalmaterialsandotherreliablesources.ThesectionofnewsreflectssomeimportantpublishednewsthatmayaffectRUMpractice.SJRUMincludessomeselectedcasestudies,reflectingcurrentpracticeatdifferenthealthfacilitiesinSudan,soastohighlighttheirrationalaspectsinordertoovercomethem.AspartofNMICRLactivities,medicalstudentsandthepublicareendowedwithleafletsandfliersonselectedtopicsofSJRUM.Readershavethefreedomtouseandreproduceanypartofthisjournal.Forparticipationpleasecontact:[email protected]…YoucanaccessSJRUMonlineonwww.sjrum.sd

AcknowledgementTheDirectorateGeneralofPharmacygratefullyacknowledgesthefinancialsupportoftheGlobalFundtofightagainstHIV/AIDS,TuberculosisandMalaria.ThisworkwouldnothavebeenpossiblewithouttechnicalsupportofWorldHealthOrganization.

SudanJournalofRationalUseofMedicine

Contents1

•

Contents2Editorial

3Where Are We?

4Current Topic

6

• Compliance,AdherenceandConcordance…What’sinaName?

Practice Issues • AnEpilepticChildWithPoorMedicationAdherence• WhoistoBlame?• OralAnticoagulants• AdherenceisVitalinChronicDiseases

10

12

Standard Treatment Guidelines • RedEye

Research Articles• PatientwithDiabetesType2:AssessingComplianceand

BarrierstoAdherence,NyalaCity,SouthDarfurState,Sudan

• HIV/AIDSPatientFactorsAffectingAdherencetoAntiretroviralTherapy

1617

NewsFocus • Doctors’AdvancementProgramKeepingAbreastin

MedicineandPharmacy

18

19

20

22

30

31

Useful Tips• TipsonhowtoUseAccuhaler

Questions and AnswersSuccess Stories• SouthDarfurStateMedicinesInformationCenter

Continuous Medical Education • PatientMedicationAdherence• StrategiestoImprovePatientMedicationAdherence• GuidelinestoImproveMedicationOrdersAdherence• PharmaceuticalPictogramsCanAidPatients’Adherence

Pharmacovigilance Awareness• PartnersoftheNationalPharmacovigilanceProgram

Anti-Microbial Awareness• ModeofAntibioticResistance


Dear fellows and readers

Welcometothe9thissueofSJRUM.

On behalf of the team of editors, I would like to welcome you all our distinguished readers, and present to you the ninth issue of SJRUM about patients’ adherence.

Patients adherence to treatment describes the degree to which patient follows correctly the medical advice or prescribed regimen, weather it is pharmacological, exercise, dietary or physical therapeutic regimen. It is a major public health problem that has been reported with a very high rate in the literature.

Patients' adherence to treatment is a key mediator between the medical practice and the patients' outcomes. Serious

consequences may result from lack of adherence, like therapeutic failure, reduced patient's quality of life, reduced patients' life span and higher long-term health costs. Patients’ non adherence is a multidimensional situation involving many stakeholders who should have positive roles in a concerted effort to ensure the success of adherence improving strategic programs. Healthcare providers in our beloved country Sudan are looking forward to make the paradigm shift towards the patient centered approach, so all of us need to take substantial steps to fill the gap in our practice to satisfy the allocated role, to make this inevitable shift. For example for pharmacists, the clear message is to assess each patient individually to provide the targeted intervention responsive to the patient own unique risk factors and needs.

The current issue includes articles about patients non adherence; the situation in Sudan, teaching materials, relevant researches and case study reports about the topic, written by different authors and healthcare professionals, reflecting valuable experiences in their field of knowledge and expertise.

I take this opportunity as well to invite you once again to contribute your knowledge and experience to enrich our journal, as we also welcome your feedback on this issue and all other issues.

Randa AlSadig AlMahdi

Editorial2


3


Where are we from:Types of Medication Non-adherence

Factors affecting medication adherence

1. Planning and Policies Directorate, Directorate General of Pharmacy-Federal Ministry of Health

Einas S. Elwali 1

Primary

Secondary

Tertiary

Non fulfillmentPrescriptionwasneverfilledorinitiated.

Non persistentPatientstoppedtakingmedicationonhisown.Unintentional;usuallyarisefrommiscommunicationorresource/capacitylimitationormisunderstanding.

Non conformingPatientstoppedtakingmedicationonhisown.Medicationwasnottakenasprescribed.Misseddoses,incorrectdoses,dosetakenatwrongtimes.

Reference1. Jimmy, Beena, Jimmy jose. Patient medication adherence: Measures in daily practice. Oman medical journal. 2011; 155-159.2. Jing jin, Grant ES , Vernon MS Oh, Shu chuen li. Factors affecting therapeutic compliance: A review from the patient's

perspective. Ther Clin Risk Manag. 2008; 4(1): 269-286.3. Donovan JL, Blake DR. Pateint non-compliance: Deviance or reasoned decision-making. Soc Sci Med. 1992; 34(5): 507-13.

Disease factorsSocial and economic

Therapy-relatedfactors

Health care system factorsPatient - centered factors

DiseasesymptomsInabilitytogotowork

Routeofadministration

Lackofaccessibility

Demographic factors:age,ethnicity,gender,educationallevel,maritalstatus

Severityofthedisease

Costsandincome

TreatmentcomplexityLongwaitingtimePsychosocial factors:beliefs,

motivation,attitude,patient-

InformationaboutdiseaseSocialsupportDurationofthe

treatmentperiodDifficultyingettingprescriptionsfilledHealthliteracy

DiseasesymptomsVsadverseeffects

MedicationadverseeffectUnhappyclinicvisitPatientknowledge

Degreeofbehavioralchangerequired

Physicaldifficulties

Unpalatabletasteofmedication

Tobaccosmokingoralcoholintake

Asymptomaticdiseases

Specialstoragerequirementsforgetfulness


Current Topic4


Itisavery commonknowledge thatfailure to takemedicines,adverselyaffects the outcome of treatment,andplacesahugeburdenofwastedresources on the society. Threeseeminglyrelatedterms;compliance,adherence and concordance havebeen used to describemedication-

takingbehaviour inchronicillnesses.Thisevolution in the terminology isnotmerelyachangeindefinitionsbutittendstobeaconstructivedevelopmentembracestheideaofapartnershipbetween thepatientandproviderswhich isneededtoaddress thepatient’sneedsbetter.

Compliance isdefinedas“the extent to which the patient’s behaviour matches the prescriber’s recommendations” 1.However,studiesoverthepastfewdecadeshavequestioned the validity of this termbecause it refers toaprocesswhere thecliniciandecidesona suitable treatmentand the patient is expected to complywith unquestioningly, without given anyconsiderationtothepatients’perspectivesintakingtheirmedications.

Asaresult the termadherencehasbeenintroducedasareplacementforcompliancein an effort to place the clinician-patientrelationshipinitsproperperspective;henceadherencerefers to a process, in which the appropriate treatment is decided after a proper counselling with the patient. Thetermcompliancealsoimpliesthatthepatientisundernocompulsiontoacceptaparticulartreatment,andisnot tobeheldsolelyresponsiblefortheoccurrenceofnon-adherence.Accordingly,adherencehasbeen

definedas “theextent towhichaperson’sbehaviour, in takingmedication, followingadiet, and/orexecuting lifestyle changes,correspondswithagreedrecommendationsfromahealthcareprovider”2.

Lately the concept of concordance hasevolvedfromanarrowerview,emphasizingan agreement between the clinician andthepatient,which takes intoaccounteachother’s perspective onmedication taking,toabroader process consisting of open discussions with the patient regarding medication-taking, imparting information and supporting patients on long-term medication.Itisaprocess,whichentertainspatients’ views onmedication taking, andacknowledgesthatpatients’viewshavetoberespectedeveniftheymakechoices,whichappear tobe inconflictwith theclinician’sviews.

Adherence to medications causes 125,000 deaths annually and accounts for 10% to 25% of hospital and nursing home admissions 3.

Pharmacistsencountersimilarpatientsintheirdailypractice,andmanymaystruggletofindeffectivestrategiestoaddressnon-adherence.Pharmacists are in a unique position toaddressnon-adherence.Theirdrugexpertise,alongwiththeiraccessibility,makesthemidealcandidatestoaddressthissignificantproblem.Peer-reviewedshortstoriessimilartothethreecasespresentedinthisissueofSJRUMmayaddressthemisperceptionsunderlyingnon-adherence.

Although none of these terms are idealsolutiontounderstandthecomplexprocess

Compliance, Adherence and Concordance… What’s in a Name?

Sami A. Khalid1

1. Dean Faculty of Pharmacy, University of Sciences and Technology


Current Topic5

ofmedication-takingbehaviourofpatients,themovefromcompliancetoadherenceandconcordancerepresentsgenuineprogressinthisfield,whichputsthepatient’sperceptionsatthecentreofthewholeprocess.

Anumberofstrategieshavebeensuggestedtoimproveadherenceincluding:thesimplificationofregimenbyadjustingtiming,frequencyanddosagetomatchpatients’activities;impartingknowledgebydiscussionwithphysician,nurseandpharmacistsmodifyingpatient’sbeliefs,involvingpatientsindecisionstailoringtheeducationtopatients’levelofunderstandingandevaluatingadherencebyself-reporting,billcounting4.

Perhaps,thebesttherapeuticoutcomescanberealized,atleastinpart,bytailoringthetreatmenttothepatient’slifestyle,nottheotherwayaround.

References

1. Tilson HH, Adherence or compliance? Changes in terminology. Ann Pharmacother. 2004, 38: 161-162.

2. Dunbar-Jacob J, Burke LE, Puczynski S. Clinical assessment and management of adherence to medical regimens. In: Nicassio M, Smith T, eds. Managing chronic illness: A Biological Perspectives. Washington DC: American Psychological Association, 1995, 313-341.

3. Smith DL. Compliance packaging: a patient education tool. Am Pharm. 1989, NS29 (2): 42-4, 49-53.

4. Atreja A, Bellam, Levy SR. Strategies to enhance patient adherence: making it simple

www.medscape.com/viewarticle/498339_print


An Epileptic Child With Poor Medication Adherence

Randa A. Almahdi1

Practice Issues6

Scenario

Mohammed Ali is an 11yearsoldboywholivesina small rural communitynear Khartoum.Hewasdiagnosed with toniccolonic seizures sincethe age of 8 when hisfamily took him to a

referralhospitalinKhartoum.

Since the age of 5 he started to fall downsuddenly, lose consciousness, collapse, andthenhisbodybecomesstiff.Hisfamilyandthelocal community there have amisconceptionabouthisillnessasasupernaturalphenomenonthat can be treated by going to the localtraditionalhealer(Sheikh)whothoughtitwasacurse.Thechildcontinuedexperiencingtheseepisodesandeach timehewas taken to theSheikhwhousedtogivehimsomeblessingsandherbstodrink.

MohammedAlididnotgo toschoolbecauseof his illness, when he was 8 years old, Headmittedtothehospitalandhewasdiagnosedwithepilepsyandprescribedaphenytoin300mgperdayandregularvisitsforfollowupwerescheduled.Thechildwastakinghismedicineregularly supervised by themother who hasbeen told by the doctor andpharmacist howimportant thedrug is tocontrolhiscondition.Hissymptomswerebroughtundercontrol,andhehadveryfewseizuressincethen.

As MohammedAli grew older into his earlyadolescence, he started to refuse taking hismedication, as he thought the drug causedhimsomebadeffects' like frequentpainandswellingofhisgum.Hisadherencetotreatmentwas lost gradually, he also refused to go forfollowupvisitstothehospitalandhestartedtoseizeagainfrequently.

Problems• Misconceptionandlackofcorrect

informationaboutepilepsy.

• Patientnonadherencewithprescription.

• Nomedicalfollowupforalongtime.

• Thechildwasnotinvolvedinhisowndiseaseanditstreatmenttobecomecommitted,andtheresponsibilitywasleftforthemotheralone.

• Lackofpatienteducationaboutthediseasehasdirectlyledtothenoncompliance.

Solutions • Patienteducationshouldbehighly

consideredandmonitoredtoinsurepatientcommitmenttothetreatmentplan.

• Patienteducationshouldinvolvethepatienttobecommittedtothetreatmentplan.

• Patientcounselingonmedicationandtheassociationbetweenadherencetotreatmentandcontrolofsymptoms.

.

1. Lecturer of pharmacy practice, Faculty of Pharmacy, University of Sciences and Technology


Who is to Blame?

Practice Issues7

Nuha M. Agabna1


Scenario

Farouq, isa63yearsold retiredsoldierwhosuffersfromdiabetesmellitus type II for ten years.He is covered by insuranceand receives medical servicesfrom Military health units. Hegoesmonthlyforavisit,usuallyseenbyhouseofficers,andhis

prescriptionsrefilled.Thespecialistisseenonlywhenthereisamedicalconditionthatimpliesto.

Hisdiabetesalmostnevercontrolled;hesuffershypoglycemia frequently, and his monthlycheck up shows high blood sugar. He eatswhathelikes,notcompliantwithhismedicine,and generally thinks that death comes whenit comes and taking care won’t delay it. Hebecomes confused over his medicationfrequently; he is confused with the differentpackages of medicines he gets. As resultsometimes he misses doses, or takes themmorethanoncefromadifferentpackage.Andothertimesmedicineswerenotavailableatthepharmaciesandmightstaydayswithouttakinghismedication.

Becauseofbadcareforhisfoothedevelopedgangrene/ulcers on both feet. He was givenappropriatemedicationsandadvised todressthewounddaily,alongwiththeregularmonthlyspecialist visit. Because the specializeddiabetescarecenterwastoofarhewenttoanearhealthclinicfordressing.Noimprovementwasseenovertwomonths,andonelegactuallygotworsewithspreadingwound.Hisspecialistdecidedtoadmithimforsurgeryandtoswitchtoinsulintoassisthealing.

During his hospital stay hiswife encountereda “Diabetes Patients Friends” group and oneof the members came to visit her husband.The member offered counseling and someinformation about diabetes and the currentpatient’s condition. Both husband and wife

wereastonishedbecausethisisthefirsttimetheyhearsuchatalk.Theyunderstoodalotof things and both felt that life would havebeen easier for both if they had knew thisinformationbefore.

Problems• Patient’snonadherencewith

medicationanddiet.

• Confusionovermedicationbecauseofthedifferentpackagesforthesamemedicine.

• Medicinesunavailability.

• Difficultiesaccessingspecializedhealthcare.

• Lackofcounselingandpatienteducation.

Solutions• Patienteducationandcounseling

isanimportantpartofsuccessfuldiseasemanagement.Theprocesshastoberepeatedmanytimestoensurefullunderstandingandhencecompliance.Writteninformationcouldbeuseful;theywouldbeavailableforthepatientaspeoplegenerallydon’tgetallwhatissaid.

• Whenswitchingbrandpharmaceuticals;thepharmacistmustexplaintothepatient/co-patientandensureunderstanding.

1. Lecturer of pharmacology, Faculty of Dentistry, University of Khartoum

8


Oral Anticoagulants

SenarioNissreen E. Mohamed 1

Practice Issues

1. Clinical pharmacist, Ahmed Gasim Cardiac Surgery and Renal Transplantation Center (AGCSRTC)

MohamedAhmedis43yearsoldbusdriverdiagnosedwithdeepveinthrombosisontheleftlegonemonthagosooralanticoagulant;warfarinwasprescribedfor six months. Lastweekhewasadmittedto

hospitalwithischemicstorkmostprobablybecauseofanembolusfromhisthrombosedleg.Propermanagementwasprovidedforhimandstrokesignswereimproved.TheappropriatedoseofwarfarinwasgivenaccordingtohisinternationalNormalized

Ratio(INR)andaspirin.DuringcounselingsessiontheclinicalpharmacistknewthatMohamedwastoldbyhispreviousphysicianthatwarfarinmaycausesome(troubles),andthatwasthereasonhewasnotadheredtohismedication.Hecompletelystoppedwarfarinwhenhisgummildlybled.Theclinicalpharmacistexplainedtohimthatstoppingthemedicationwasthecauseofthestroke.Theproperinformationtousewarfarin;adherencewiththetreatment,drug–druganddrug–foodinteractionsandpropermonitoringofINR,weregiventoMohamedAhmed.

Problems• Misleadinginformationwasgiventothe

patientinsteadofpropercounselingatfirsttime.

• Thepatientdiscontinuedhistreatmentbyhimself.

• Failureoftreatmentduetonon-adherencetomedication.

• Informationgiventopatientsabouttheirmedicationsshouldbebalancedtoinvolvetheimportanceandbenefitsfromusingmedicinesaswellasserioussideeffectslikebleeding.

Solution• Patientcounselingshouldbean

essentialpartoftherapeuticplanbecauseimpropercounselingcanleadtofailureoftherapyespeciallyformedicationsuchaswarfarinwhichrequiresclosemonitoring.

• Medicalstaffshouldbetrainedtodeliverpropercounselingregardingimportantmedicineslikeoralanticoagulants,usingverbalandwrittenmaterials.

• Patienteducationisanimportantelementthatleadstosuccessoftherapeuticplan.

• Deficiencyofclinicalpharmacyservicesmightleadtoserioushealthproblem.

Adherence is Vital in Chronic Diseases

A37years old pregnantlady, of 167 cmheightand96kgbodyweight,arrived to her regularantenatal care clinic.Upon measuring herb l o od p r e s su r e , i twas 150/100 mm Hg,

whichwasconsideredanelevatedsystolicanddiastolic bloodpressure, accordingly,diagnosisof hypertensionwasmade.Thepatienthadnormalhepaticandrenalfunctions.Shestatedthatshehasnohistoryofelevatedbloodpressure,deniedanyhistoryofchronicmedicationuseexceptparacetamolperneed.Thepatienthasreportedaremarkablerecentweightgainoverthepasttwoyears,attributingthistohersedentarylifestyleandstressfulworkloadbecauseofhernewjob.

The treating physician prescribed to her oralmethyl dopa tablets 250mg twice daily andadvised her to reduce her weight and to dosomeexercise.Onemonthlater,shecametothedoctorforascheduledfollow-upvisit,shehadnochange inherbodyweight,whileherbloodpressurereadinghasshownareductionin systolic blood pressure and elevation inherdiastolicbloodpressure, thereadingwas140/110 mmHg. The patient also admittedthatshedidnotdoanyexercise,butshewastaking her prescribed medication exactly aswasprescribed.Thedoctorthencontactedthepharmacy to cross check that the pharmacydispensedthisprescriptiononthesamedate,which was true, so he asked the patient tobring her medication bottle in her next visitto the clinic, fixed in two weeks time.Whenthepatientbroughthermedicationbottle, thedoctor found some remaining tablets in the

9


bottle, whichmust have been empty by thistime, if the patient was compliant with herprescribedregimen.Moreover,thepatienttoldthedoctorthattherearesometabletskeptinatissuepaperinhercabinetaswell.Thedoctorrealizedthathispatientwasnotadherentwithhermedicationorder.

Problems • Thepatientwasnotadherentwithher

prescribeddrugregimen,orwiththeexerciseandweightreductionaswasadvisedbyhertreatingdoctor.

• Thepatienthaskeptsomeofhertabletsoutsidetheiroriginalcontainer,withthepotentialofconfusingthemwithothermedications,ifavailable.

• Itwasobviousthatthispatienthasnotbeencounseledabouthermedicationandhowimportanttoadherewiththedoctor'sadvises.

Solutions• Thediagnosisofhypertensionshould

bemadeafterthreeconsistentlyhighmeasurementsofbloodpressure.

• Doctorsandpharmacistsarerequiredtodoanefforttomakesurethatpatientswilladheretotheirprescribedmedicationregimensasprescribed.

• Interventionsthatcontributetoimproveadherencelikepatienteducationandpatientcounselingareveryimportantwithspecialconsiderationtochronicdiseasesfornewlydiagnosedpatients.

Sawsan E. Ahmed1

Practice Issues

1. Medicines’ Information Center pharmacist, Omdurman Maternity Hospital

Senario

Non adherence with the prescribedtreatment regimen is a real problemthat results in treatment failure andconsequently,increasedmorbidityandmortality.


Red Eye10Standards Treatment Guidelines

Introduction Commoncausesofredeyeinclude:• Conjunctivitis(viral,bacterial,allergicor

chemical).• Foreignbody,conjunctival,cornealor

subtarsal(undertheuppereyelid).• Cornealulceration.• Burns(acid,alkaliorthermal).• Bluntinjury;byabluntobjectmaycause

hyphema(bloodintheanteriorchamber).• Penetratinginjury(typicallybyasharp

objecte.g.astickcausecornealorscleralpenetration).

• Lidlaceration(inlidorcanaliculus).• Subconjunctivalhemorrhage.

Otheruncommoncausesincludeiritis,scleritis,episcleritisandacutecongestiveglaucoma,whichrequirereferral.

Signs, Symptoms and History Obtainathroughhistorytoidentifyifthereisapossibilityofoculartrauma,contactlenswear,thetimeandcourseoftherednessandthepresenceofeyepain,itchanddischarge.Diagnostic signs:Patientsmaypresentwithanarrayofsymptomsdependingontheetiologyoftheredeye.Patientswhopresentwithpain,photophobiaandwaterydischargemayhaveaforeignbody,atraumaticcornealulcer,herpeticulceroracuteglaucoma.Dull,achingeyepainisthemainpresentationwithiritis,scleritisandepiscleritis.Subconjunctivalhemorrhagemaybecausedbytraumaoritcouldalsobecausedbyvigorouscoughingorvomiting.Traumatotheeyecanpresentwithfocalconjunctivalinjectionoririsinjury.1. Conjunctivitis: 1.1. Infective conjunctivitis:Causedbybacteriaandresultsinastickydischargeinbotheyeswithclearcornea,normalpupilandnormalvisionandredeyes.Infectiveconjunctivitisintheneonateusuallyoccursintheseconddayofbirthduetoeyeexposuretobacteriaduringbirth.Itisabacterialswellingoftheeyeandcanleadtopurulentdischargeandeyelidswelling.(Chlamydiaandgonorrhoeainfectionsrequireurgentreferral).• Viralconjunctivitis:waterydischarge,

redeyesanditch.• Allergicconjunctivitis:redeyes,

excessivelacrimationanditch.1.2. Corneal ulcer:whitespotormarkonthecorneawhichstainswithfluroscein.Therednessismostmarkedaroundthecornea,excessivewaterydischarge(lacrimation)+significantphotophobia.Thereareseveralcausesforcornealulcersmostimportantly vitaminA deficiency,malnutrition,longstandingconjunctivitisandherpessimplexandherpeszosteropthalmicus.2.Iritis:Thepupilissmallandbecomesirregularasitdilates.Therednessismostmarkedaroundthecornea,waterydischarge(lacrimation)+significantphoto phobia. Patients should be referred tosecondarycare.3.Acute glaucoma:rednessisgeneralizedandtheeyeisverypainfulwithpoorvision,dilatedpupil,raisedintraocularpressureandshallowanteriorchamber.Thecorneaishazyduetofluids.Patientsshouldbereferredtosecondarycare.

Investigations Theeyeshouldbeexaminedcarefullybyinspectingtheeyelidsandtheirundersurface.Aslitlampshouldbeusedtoexaminetheconjunctiva,pupil,irisandcornea.Ifsuspectingacornealabrasionorulcer,staintheeyeusingflurosceinbeforetheexamination.Ifsuspectingtrauma,examineforenophthalmos,diplopia,subconjunctivalhemorrhage,hyphemaandretinaldetachment.Visualacuityshouldalwaysbemeasuredinpatientspresentingwitheyecomplaintsusingageappropriate-visualacuitychart.

Criteria for same day referral:1. Moderatetosevereeyepainorphotophobia2. Markedrednessoftheeye3. Reducevisualacuity4. Suspectedpenetratingeyeinjury5. Irritantconjunctivitis6. Neonatalconjunctivitis7. Scleritis

(Patientswithsuspectedraisedintraocularpressureshouldbegivenintravenousacetazolamideandpilocarpineeyedropsbeforeurgent referral tosecondarycare)

SudanJournalofRationalUseofMedicineSudanJournalofRationalUseofMedicine

11Standards Treatment Guidelines

Non Pharmacological Management(Seeunderseparateconditionsbelow)PharmacologicalManagement(Seeunderseparateconditionsbelow)1. Eye Tear• Donotplaceanythingontheeyeincluding

eyeointmentoreyedrops.• Placeasteriledressingtocovertheeye.• Givesystemicantibiotics.• Referthepatienttotheophthalmologistfor

samedayassessment.2. Allergic Conjunctivitis• Maybeseasonalandoccurswithother

symptomssuchasrhinorrheaandsneezing.

• Administerantihistamineeyedrops– ketotifenorsodiumcromoglycate

• Advisepatienttoavoidsuspectedallergens.

• Inseveresymptoms,givesteroideyedropsinadditiontoamildsteroide.g.fluorometholone.Ifnoimprovementthengivesdexamethasoneeyedropswithsubsequenttaperinginadditiontoamastcellsstabilizere.g.sodiumcromoglycateeyedrops(2%forchildrenand4%foradults)

3. Infective Conjunctivitis (Adult)• Infectiveconjunctivitiscausedby

bacteria.• Washtheeyesdailywithcleanwater.• Administertetracyclineeyeointmentevery

8hoursfor7days,orchloramphenicol.• Referthepatienttothespecialistifno

improvementinthreedays.

4. Infective conjunctivitis (Neonate)• Removepusfromtheeyeusingsterile

gauzeeveryhour.• Administertetracyclineointmentthree

timesdaily.• Refertheinfanttothehospital.

5. Corneal Ulcer• Administertetracyclineointmenttotheeye

everyhour.• Administersystemicantibiotice.g.

Doxycycline100mgcapsulesevery12hours.• AdministervitaminA100,000I.U.for

children• Referthepatienttoophthalmologisturgently.• EyeLesions

6. Foreign Body• Carefullyremovetheforeignbodywitha

cottonswabifitislyingsuperficiallyintheeye.Iftheobjectisembedded,referthepatientforremoval.

• Administertetracyclineointmentoncea night.

• Referthepatientifnoimprovementoccursafter24hours.

7. Corneal scratch• Administertetracyclineointmentonceat

night.• Closetheeyewithsteriledressing.• Referthepatienttothespecialistifno

improvementoccursafter3days.8. Subconjunctival Hemorrhage• Bedrestfor5days• Referifnoimprovementoccursafter3days.

9. Eyelid tears• Checktheeyecarefullyforothernon-

immediatelyapparenteyelidtears.• Closetheeyewithsteriledressing.• Administersystemicantibioticse.g.

Doxycycline100mgcapsulesevery 12hours.

• Refertothespecialist.

10. Chemical and heat burns• Washtheeyewithcopiousamountsof

sterilewater.• Administertetracyclineointment.• Referurgentlytothespecialist.

Follow-upPatientsshouldbeseenevery24hoursandreferredifworseningofthesymptomsoccurs.Prevention Patientsshouldbeadvisedtokeepforeignobjectsandchemicalsawayfromtheeye.Ininstanceswhereaneyebandageshasbeenplace,nottoremoveitwithoutthedoctor’sadvice.

Reference Sudan National Standard Treatment Guidelines, Directorate General of Pharmacy, Federal Ministry of Health, Sudan, 2014


IntroductionInSudan,therearefewarticlespublishedaboutadherencetomedications.Thecurrentneedforassessingmedicationsadherenceprovidegoodopportunitytoimplementinterventionaladherencerelatedstudies. Inacross-sectionalstudyofpatientswithhypertension,factorsassociatedwithadherence,statusofbloodpressure(BP)controlandoccurrenceofcomplicationswereassessed.Despitethattheadherenceratewasreasonable,36.8%ofpatientswerenon-compliantbecausetheycouldnotafford tobuyantihypertensivedrugs.Thesepatientsexperienceduncontrolledbloodpressure(BP)andothercomplications1.

Theaimofthisstudywastoinvestigatethelevelofcomplianceand theassociationsbetweeneducationlevel,occupation,incomeandageusingtheBriefMedicationQuestionnaire(BMQ)2.

MethodsThiswasapartofamulti-centerdescriptivestudy,including10publichealthclinicsinNyalaSouthDarfur.Thestudyemployed300patientswithtypetwodiabetes,aged18-79yearsonoralhypoglycaemicdrugstakingfourormoreothermedicines(whethercardiovasculardrugsornot).Demographics,medicalinformationandlaboratory resultswerecollectedbeside theBMQwhichassessesfourbarrierstoadherence;namelyregiment,beliefs,recallandaccesstomedication.Datawasanalyzedstatisticallytodeterminesignificance.

Results and DiscussionRegardingregimenthescreeningindicatedanon-adherencewithcurrentdrugregimen,whereatotalscoreoffivewasobtainedoutoffive.

Patient with Diabetes Type 2: Assessing Compliance and Barriers to Adherence, Nyala City, South Darfur State, SudanAhmedD.Ahmed1,AsimA.Elnour2,MirghaniA.Yousif3

Thescreenwaspositivedenotingnon-adherencewithdiabetesandcardiovascularmedicationsasindicatedbythehighscore.

Screeningforbeliefbarrierindicatednegativebeliefsormotivationalbarriersregardingefficacy,adversesideeffectsandotherconcernsregardingagivendruganditseffects,wherethetotalscoreobtainedwastwo.

The twoquestions:whetherpatient’s receiveamultipledoseregimen(2ormoretimes/day)and/orreportanydifficultyrememberinghis/hermedications,wereusedtodetectrecallbarrier(totalscores=2.0).Thepopulationscoredtwoconfirmedthepresenceofrecallbarriers.

Resultsdisplayeddifficultypayingformedicationanddifficultygettingrefillsintimeindicatingaccessbarrierstocompliance(totalscores=2.0)Theresultsshowedthataccessrepresentedcertaindegreeofhindrancetomedicationadherence.

Todeterminecorrelationbetweenscreenanddemographic parameters, person correlationcoefficientwasusedat final followsup.ThefindingsrevealedthateducationhadasignificantnegativecorrelationwithRegimen,Belief,Recallandaccessscreenswhichwere(-0.54,-0.11,-0.16and-0.4)respectively.Thisindicatedthatpatientswithhigheducationlevelhadlowscreenscores, which entails that patient’s level ofmedicationadherencewasimproved.

TherewassignificantpositivecorrelationbetweentheoccupationandRegimen,Belief,Recall,andAccessscreenswithcorrelationcoefficients(0.38,0.16,0.008and0.14);respectively.However;theassociationwasnotsignificantinRecallscreen(P=0.154).Thishasalsoindicatedthatpatient

12Research Articles

1. Department of Pharmaceutics, Faculty of Pharmacy, Gezira University, Sudan, [email protected]. Consultant Clinical Pharmacist, Al Ain Hospital, United Arab Emirates 3. College of Pharmacy, Clinical Pharmacy, Taif University, Saudia Arabia

13


References:1. Elzubier A G, Husain AA, Suleiman IA, Hamid ZA. Drug Compliance among Hypertensive Patients in Kassala, Eastern

Sudan. Eastern Mediterranean Health Journal, Vol. 6, 2000, pp. 100-105. 2. SvarstadBL, Chewning BA, SleathBL, Claesson C. The Brief Medication Questionnaire: A Tool for Screening Patient

Adherence and Barriers to Adherence. Patient Education and Counseling, Vol. 37, No. 2, 1999, pp. 113-124. 3. Adepu R and ARri SSM. Influence of Structured Patient Education on Therapeutic Outcomes in Diabetes and Hypertensive

Patients. Asian Journal of Pharmaceutical and Clinical Research, Vol. 3, No. 3, 2010.

with occupation had low screen scores,whichentailsthatpatient’slevelofmedicationadherencewasimproved.

Withrespecttoincome,significantnegativecorrelationswasobservedwithRegimenandBeliefscreens,(-0.32and-0.14);respectively.However;theassociationwasnotsignificantwiththerecallandaccessscreens(P=0.961;0.64)respectively.

When income increased the regimen and belief would have decreased, which means improvement of adherence.

Regardingpatients’agetherewassignificantcorrelationonlywith regimenscreen,withacorrelationcoefficientsof0.13(P=0.029).Thismeansthatolderparticipantshadlowadherence.

The impactofpooradherencegrowsas theburden of chronic diseases grows too. Theconsequencesofpooradherencetolong-termtherapiesarepoorhealthoutcomesandincreasedhealthcarecosts,henceimprovingadherenceenhancespatients’safety3.Acorrelationbetweenthe screen and demographic parameters isdisplayedintable1.

Table 1 Correlation between the screen and demographic parameters at final stage (N= 300)

Patient socio-demographic parameter(Final assessment, stage 3) Regimen Belief Recall Access Total

EducationPearsonCorrelation -0.54 -0.11 -0.06 -0.16 -0.4

Pvalue 0.001* 0.049* 0.329 0.004* 0.001*

OccupationPearsonCorrelation 0.38 0.16 0.08 0.14 0.32

Pvalue 0.001* 0.007* 0.154 0.017* 0.001*

IncomePearsonCorrelation -0.32 -0.14 0.00 -0.03 -0.2

Pvalue 0.001* 0.014* 0.961 0.64 0.001*

AgePearsonCorrelation 0.13 0.04 0.05 0.06 0.12

Pvalue 0.029* 0.521 0.391 0.267 0.036

Total number (at each sub row) 300 300 300 300 300

Key: *P<0.05.

Conclusion and RecommendationsAnegativeassociationwasobservedbetweeneducationallevel,incomeandoccupation;whilepositiveassociationwasobservedforageonvariousBMQscreenscores.

Thisfindingdictatestheimportanceofeducatingandtrainingthepatientstoremovebarrierstomedicationsadherence.

Research Articles

14


Research Articles

Introduction

Humanimmunodeficiencyv i r u s / A c q u i r e di m m u n o d e f i c i e n c ysyndrome (HIV/AIDS)i s t he f ou r t h mos tcommoncauseofdeathin theworld1.Globally,3 4 m i l l i o n p e o p l e

were livingwithHIVat theendof 2011 1.

HighlyActiveAntiretroviralTreatment(HAART)has dramatically reduced mortality andmorbidityduetoHIVinfection1,2.

Introduction of antiretroviral therapyhavetransferredthediseasecoursefromafatalincurableintoachronicmanageableinfection.However,incompleteadherencetomedicationis themostcontributingfactor in treatmentfailureandthedevelopmentofresistance.

Adherence to antiretroviral therapy wasdefined as to take 95%of the prescribedAnti-retroviral(ARV)drugscorrectly intherightdose,frequencyandtime.Eventhough,anadherencelevelof70-90%toARTdrugsis found to be acceptable and effective.Factorsthatleadtonon-adherencefellintothreecategories; those related topatients(e.g. educational level and psychologicalstatus) , relatedto thepatient’s interactionwithhealthcareproviderandothersrelatedto clinical factors (e.g. pill's burden, dosefrequencyoftheprescribedregimenandthedrugsadversereactions).

Theobjectivesofthisstudyweretoexamine

the level of adherenceof patients to theirtherapyandtoexplorefactorsassociatedwithpatients'non-adherenceamongHIV/AIDSpatientsreceivingARTdrugs.

MethodsThisisacrosssectionalclinicalcenterbasedsurvey done on 310 adults HIV positivepatientsinagesofmorethan16yearsoldwhoaretakingHAARTdrugsforatleast6monthspriortothesurvey,whoareregisteredinOmdurmanteachinghospitalSudanNationalAIDSProgram (SNAP) center.Omdurmancenter is the largestonereceivingpatientsresidingbothinsideandoutsideKhartoumcity.

Thedatawerecollectedusinginterviewsandquestionnaireforms,fromtwosources;keyinformants (were the healthcareworkers)and patients' medical records to fill thepredeterminedstudyvariables.

The study variables were grouped intodemographics,sociocultural,socioeconomicalvariables,and treatment relatedvariables.Other factors such as; quality of care,confidentiality of information, educationalservicesandcounselingonusingdrugswerealsotakenintoconsideration3.

Results and DiscussionThe respondents were 191 males and119 females.Among the total number ofthe respondents (70%) have startedARTtreatmentregimensatstage3ofdisease,withtimeelapsedsincediagnosis ranged from6months to twoyears. Subjectsadherent

HIV/AIDS Patient Factors Affecting Adherence to Antiretroviral Therapy

In Omdurman Teaching Hospital 2012

EslamAbdelhameed1,MustfaKhidir2

1. Pharmacy Specialization Board, [email protected]. Faculty of medicine and health sciences, Elneelain University

Research Articles


15to treatmentwere66.1%,while33.9%werenot.Amongmalestheadherentswere71.7%comparedto57.1%amongfemales(p=0.008).Otherfactorsfoundtoinfluenceadherencelevelbesidegender,weremaritalstatus;marriedwere 70.7%, divorcedwere 53.8%, singleswere67.3%adherentand50%widowed(p=0.051).ResearchfindingshaveemphasizedtheimportanceofsocialsupportinthetreatmentofHIVpatients,family,communitymembersandpeersinimprovingARTadherence4.

Theeducational levelwas found to slightlyaffectadherence,thosewhowereatprimaryeducationwere55.7%,77.4%atsecondaryschoollevel,80.5%wereuniversitygraduates(p=0.001).Employmentwasanotherfactorthatinfluenceadherence,70.6%of theoccupiedwereadherentversus29.4%non-adherent.Amongthosewhowereunemployed;48.1%wereadherent,while51.9%werenonadherent(p=0.002).

Asignificantnegativeassociationaswellexistedbetween travelling time to the center andincreasedcostsoftreatmentwithadherence,(p=0.005).

In-spiteofthenegativeassociation,patientsstillprefertoreceivetheirhealthcareservicesfromSNAPcenters thatare far located from theirresidencesbecauseofthestigmaandsocialfears.

References1. Marcellin F, Boyer S, Protopopescu C, Dia A, Ongolo-Zogo P, Koulla-Shiro S, Abega SC, Abe C, Moatti JP, Spire B, Carrieri

MP: Determinants of unplanned antiretroviral treatment interruptions among people living international Health 2008, 13(12):1470-8.

2. Byakika-Tusiime J, Oyugi JH, Tumwikirize WA, Katabira ET, Mugyenyi PN, Bangsberg DR: Adherence to HIV antiretroviral therapy in HIV+ Ugandan patients purchasing therapy. International Journal of STD AIDS 2005, 16:38-41.

3. Mills et al.,2006 Mills, EJ, Nachega, JB, Buchan, I, Orbinski, J, Attaran, A, Singh, S, Rachlis, B, Wu, P, Cooper, C, Thabane, L, Wilson, K, Guyatt, GH & Bangsberg, DR. 2006. Adherence to antiretroviral therapy in Sub-Saharan Africa and North America. A Meta-analysis. Journal of American Medical Association 296(6):679-690.).available at www.jama.ama-assn.org

4. Nakiyemba A., Aurugai D A, Kwasa R and Oyobba T (2005). Factors that facilitate or constrain adherence to ART among adults in Uganda: A pre- interventional study.

Other factors that havepositivelyaffectedpatients’ adherence to treatment were;knowledge about ART and counseling(p=0.002).Furtherquestioningpatientsaboutreasonsfornon-adherencehasshownthat:forgetfulness(48%),drugsoutofstock(32%),appearanceoftroublesomesideeffects(7.6%),andtoomanypills(3.4%).

Bycheckingpatients'medicalrecords,reportshaveshownthat53%didn’tmissanydose,18%missedonedose, 14.8%missed twodoses,and10.6%missedthreedoseswhilejust3.2%have.However,thesereportswerein contradictionwith the direct responsesfrompatientswhichhaverevealedpatients'adherencelevel lowerthanthatreported intheirmedicalrecords.

ConclusionThissurveyhaspointedclearlyanumberoffactorsthathaveinfluencedthelevelofpatients'adherenceto treatment;amongwhichage,gender,andlevelofeducation,travelingtime,travellingcost,maritalstatus,employment,stigmaandgoodcounselingaboutdrugs.ThestudyhasfinallyrecommendednewerpoliciestobeintroducedintheoverallcareplanforbestmanagementofHIV/AIDSpatients.


16News

WHO says it is ethical to use experimental drug ZMapp in management of EBOLA

WHO, August 2014

TheWHOhasrecentlyissuedastatementtoallowtheuseoftheexperimentaldrugZMappinthemanagementofEbolainfection.TherecentoutbreakofEbola infectionisthelargesttodateandhasclaimedthelivesofmorethan1000patientssinceitbeganintheWestAfricancountry;GuineainMarch2014.It is highly contagious and spread withinhumansthroughcontactwithbodilyexcretionsfrominfectedindividualswhoshowsymptoms.Thediseasestartswithnon-specificsymptomssuchasfever,myalgiaandasorethroatbutprogresses rapidly tocauseahaemorrhagicfeverwithafatalityrateof90%.

ThereiscurrentlynoknowncureorvaccineforEbolabutanexperimentaldrugthatconsistsofacocktailofantibodieshasbeenrecentlyusedtosuccessfullytreattwoAmericanaidworkerswhowereevacuated to theUSAafterbeinginfectedwiththeviruswhiletreatingpatientsinWestAfrica.

Thedrughasbeenusedsofarinmonkeyswithgoodresultsbuttherearenostudiesinhumansintermsofefficacyandsafety.Inviewoftherecentoutbreak,theWHOconvenedapanelofMedicalethiciststodiscussthepossibilityofusinganexperimentaldrugknownasZMappforthetreatmentofEbolapatients.Theexpertsissuedastatementstatingthatunderthecurrentcircumstances,itmaybeconsideredethicaltousethisdruginEbolainfectedpatientandurgedhealthcareworkersusing thedrug to reportpatientoutcomesinordertosharetheresultswithinthemedicalcommunity.

News Clarithromycin associated with increased risk of cardiac events.Schembri et al, BMJ, 2014A study conducted in Scotland has shownan increased association between the useof clarithromycin and cardiac events. Theresearchers compared the outcomes of twogroupsof patients admittedwith communityacquiredpneumoniaandchronicobstructivepulmonary disease into NHS hospitals inScotland.Cardiovasculareventsweredefinedas hospital admissionswith acute coronarysyndrome, decompensated cardiac failure,seriousarrhythmia,orsuddencardiacdeathwithinoneyearofdischargefromhospital.

Asignificantassociationwas foundbetweenclarithromycinuseandcardiovasculareventsandmortality.Longerdurationsofclarithromycinusewereassociatedwithmorecardiovascularevents.Whiletheuseofβlactamantibioticsordoxycyclinewasnotassociatedwithincreasedcardiovascular events inpatientswithacuteexacerbationsofchronicobstructivepulmonarydisease,suggestinganeffectthatisspecifictoclarithromycin.

Thisstudyhighlightsthefactthatclarithromycinandotherantibioticsshouldonlybeusedwhenabsolutelynecessarytoreducerisksassociatedwithsuchseveresideeffects.

Global antibiotics consumptionVan Boeckel et al, The lancet Infectious Diseases, August 2014A study published in the Lancet infectiousDiseaseshasshownanincreaseof36%intheconsumptionofantibioticsbetweentheyears2000and2010.Thestudyanalyseddatafromhospitalandretailpharmaciesin71countriesfromacross theglobe.Brazil,Russia, India,China,andSouthAfricaaccountedfor76%ofthisincrease.Themostalarmingfindingwastheincreaseintheuseoflastresortdrugssuchascarbapenems(increasedby45%)andpolymixins(increasedby13%).

Alyaa F. AL-Mahdi 1

1. Head of clinical pharmacy services, Radiation and Isotope Centre Khartoum


19SudanJornalofRationalUseofMedicine Focus

Doctors’ Advancement ProgramKeeping Abreast in Medicine and Pharmacy

Focus


Ahmad Al Safi1

17

1. Member of SMC, and chairperson of SMC Doctors’ Advancement Committee, [email protected]

BackgroundSudanMedicalCouncil (SMC) isdedicatedtothepromotionofexcellenceinhealthcaredelivery,medical education, and research.It recognizes its responsibility to promotelifelong learning through the provision ofeducationalexperiencesforalldoctors(medicaldoctors,dentists,andpharmacists)andalliedhealthcare professionals. Awide range oflearningopportunitiesfordoctorsviaaccreditedContinuingMedical Education (CME) andContinuingProfessionalDevelopment(CPD)activitieshadbeenrecognized.Development of the Specialist RegisterBasedon this report,SMCpassedbylawsforSpecialistRegistration,andaSpecialistRegisterwasestablishedin1986.ThisRegister,however, recognizedone levelofspecialistwithnodifferentiationon levelsor typesofspecialization.Documentation of CPD/CME activitiesThe ladder of progression in the doctors’advancementpathwaystartswithspecialist,goesuptoseniorspecialistandendswithconsultant.Tomove fromspecialist toseniorspecialistadoctormustattain600creditpointsinthreeyears,andfromseniorspecialisttoconsultantmustattain1000creditpointsin5years.ThisiswhyalldoctorsregisteredinSMCarerequiredtomaintainarecordoftheirparticipationintheDoctorsAdvancementProgrammeactivitiesinaportfolio(Logbook).ThisportfoliowillenablethemtokeepallthedocumentationrelatedtotheCME/CPDactivitiesinwhichtheyengageintheiractivelife.SMC renamed the Continuing MedicalEducationCommitteeto“DoctorsAdvancementCommittee” and gave it the mandate tofinalize,fine-tuneandimplementthedoctors’advancementprogramme.

Advantages and impact of the Doctors’ Advancement ProgrammeInadditiontoplacingmedicaldoctors,dentistsandpharmacistintheirrightfulcareerpositions,TheProgrammeisstructuredsothathealthcareprofessionalsareappropriately trained tobecompetenttodealwiththehealthchallengesofthe21stcentury.Thisshouldreflectdirectlyandimmediatelyonthequalityofhealthcareservicesthataredeliveredtopatients.TheprogrammeprovidesUniformedForces,Universi t ies, and even private pract icecorporations with yardstick or template onwhichtheycanequatetheranksofthemedicalprofessionals in their roster.Whenmovingacrossborders,thesystemhopefullyequatesorcomparestocurrentinternationalsystems.Tocarryoutitsdutiesefficiently,theProgrammefirstrecognizesthecentresinwhichthetrainingactivitiesarecarriedoutandaccreditsthemasauthorizedproviders.Accreditation of CME/CPD activitiesBeforesubmittinganactivityforaccreditation,theactivityprovidersneed tomakesure thatthe activity aim atmaintaining professionalcompetence,notjustscoringpointsfortheirownsake.PostscriptTheProgramhasbeenannouncedthroughallofficialchannels.Thecutoffdate,however, inwhichcandidatesareexemptediftheysatisfytheyearslimit,isApril2012.ThisimpliesthatallyoungspecialistandseniorspecialistsshouldapplyforthisProgrammeandregisterassoonaspossible.

References1. Sudan Medical Council, Continuing Medical Education

Points Registration Logbook, Personal Data, 2011, 24 pages.

Useful Tips18


Tips on How to Use Accuhaler

Accuhalerisadry-powderinhaler(DPI)availableinaneasy-to-useformat.Itisbreathactivated;thismeanswhen inhaled, theaccuhalerautomatically releasesthemedication.Whenusedproperly, theaccuhalercandelivermedicationdeepintothelungstocontrolsymptomsofasthma.Patients tousesuch typeofmedicationshouldbeselectedcarefullyandinformedaboutthedifferencesbetweenDPIandMeteredDoseInhalers(MDI).Thefollowingstepsshouldbeclearlyexplainedtothepatient.Makesurethatpatientsareabletodemonstratethefollowingstepsproperlybeforeleavingthepharmacyorclinic.Checkperformanceonthenextvisit.1. Holding your Accuhaler in one hand, place the

thumbofyourotherhandonthethumbgrip.2. Open your Accuhaler by pushing the thumb grip

right around until it clicks, themouthpiece shouldnowbefullyvisible(You’llalsoseethelever).

3. Hold the mouthpiece towards you and push theleverawayfromyouuntilitstops.

4. Breatheoutasmuchaspossible.5. Placemouthpiecebetweenteethwithoutbitingand

closelipstoformagoodseal.6. Breathe in steadily through your Accuhaler (not

throughyournose).7. Remove yourAccuhaler and hold your breath for

about10seconds.8. Breatheoutslowly.9. Rinse your mouth with water after using your

Accuhalerandspitit.10.CloseyourAccuhalerbyslidingthethumbgripback

to theoriginalposition, thismakesyourAccuhalerreadytouseagainforthenexttime.

Note: The dose counter on the top of the Accuhaler shows how many doses are left to use.Advice on how to clean the Accuhaler device 1. Mouthpieceshouldbecleanedbyadrytissueorcloth,

twoorthreetimesaweekorasneeded,andNEVERbewashed.Ifitgetswet,itwillnotworkproperly.

2. Ifpowdersticksinthehole,itshouldbebrushedout.

Sarra I. Rashid 1

1. Medicines’ Information Center and Reference Library, Directorate General of Pharmacy, Federal Ministry of Health

Holdyouraccuhalerawayfromyourlips,breathoutasfarasitiscomfort.

Placethemouthpiecebetweenyourlips,breathinquicklyanddeeply.

Closeyouraccuhalerbyslidingtheoutercasebacktowardyou.

Removetheaccuhaerfromyourmouth,holdyourbreathfor10seconds,breathoutslowly.

Holdtheoutercaseinonehand,placethethumpofotherhandinthethumpgrip,slideawaytillitclicks.


Q. What is meant by Adherence to (or compliance with) a medication regimen?A. Adherence to (or compliance with) amedicationregimen isgenerallydefinedastheextenttowhichpatientstakemedicationsas prescribed/advised by their physician/pharmacist . The word “adherence” isPREFERREDbymanyphysicians/pharmacists,because“compliance”suggeststhatthepatientisnotpositivelyinvolvedinhisowntherapeuticplan.Q. Why patient adherence to a medication regimen is important?A.Becausethefullbenefitofthemedicationswill onlybeachieved if patients follow theprescribedtreatmentregimenscarefully.

Q. What are the major complications related to poor patient adherence? A. Pooradherencetomedicationregimenscontributestoincreasemorbidity,worseningofdisease,mortality,andincreasedhealthcarecosts.Q. How adherence rate is estimated?A. Ratesofadherenceforindividualpatientsareusuallyreportedasthepercentageoftheprescribeddosesofthemedicationactuallytakenbythepatientoveraspecifiedperiod.Q. What are the major predictors that increase potential for patients' poor adherence to medications?A. Patients may be non-compliant withtheirprescribed regimen,when theyhave;asymptomaticdisease (e.g.hypertension),reduced cognitive abilities (forgetfulness),annoyingmedications'adverse-effects,patientlack on believe of benefits of treatment,psychological problems, complexity oftreatment,inadequatefollow-upordischargeplanning,orcostofmedication.

Q&A Q. What are the system's barriers to patients' adherence to treatment?A. Thoserelatedtohealthcaresystem;poorhealthcaresystem,incompetentstaff,orhighmedicationcost.Barriersrelatedtohealthcareproviders;lowlevelofjobsatisfactionandtheirinteractionwiththehealthcaresystemse.g.poorknowledgeaboutdrugcostandinsurancecoverageofdrugs.Q. How can we improve patients' adherence to their treatment regimens?A. Methodstoimproveadherencemustinvolvecombinationsofbehavioralinterventions;• Reinforcingandincreasing

convenienceofcare.• Providingeducationtopatientsabout

healthconditionsandimportanceoftreatments.

Methodscanbegrouped into fourgeneralcategories:• Patienteducationinvolvingpatients

families.• Improvingdosingschedules.• Extendingclinicsworkinghoursto

reducewaitingtime.• Improvingcommunicationbetween

physiciansandpatients.

Q. What is the role of practitioners in enhancing patient non adherence?Practitionersarerequiredtopaymoreattentiontodetectpooradherence,informingpatientsabout importanceof treatment, simplifyingprescribedregimensasmuchaspossibleandcustomizingthergimentothepatients'lifestyle.A simple strategy is to ask patients howtheytaketheirmedicationsto identifypooradherence,ifany.Pooradherentpatientsmayneedmore intensivestrategies to improvetheircompliancewithtreatmentschedulebyadoptingoneoftheinnovativemeasuresformanagingchronicdiseases.

Questions and Answers19

Sawsan E. Ahmed1

1. Medicines’ Information Center pharmacist, Omdurman Maternity Hospital


Success Stories20

South Darfur State Medicines Information Center (SDSMIC): A Success Story

Since2007agroupofpharmacistinSouthDarfurStatetriedtoestablishMedicinesInformationCenter(MIC)inNyalacity.TheyheldnumberofmeetingswiththegeneralmanagerofNyalaTeachingHospitalatthattime.

InOctober2012,aworkshopentitled:RationalUseofMedicineswasheldatSouthDarfurStateinNyalaCity,bythelecturers(Prof.AbdallaElkhawad,ProfElrasheidAhmed,Dr.KamalAlomda).ThemainworkshoprecommendationwastheestablishmentofthefirstMIConthestatelevel,undertheGeneralDirectorateofPharmacy-SouthDarfurState.In2012

pharmacistunioninSouthDarfurStateatNyalacitysetoneofthemostimportantgoalsoftheunionastheestablishmentoftheMIC.ThismeetingwasorganizedbytheGeneralStateMinisterofHealth,theGeneralManagerofNyalaTeachingHospitalandGeneralDirectorofPharmacywiththeresultofestablishmentoftheMICinemergencydepartmentofNyalaTeachingHospital.TheGeneralDirectoryofPharmacyprovidesthecenterwithtwodesktopcomputer,printerandtwopharmacistsweresenttobeattachedforamonthintheNationalMedicinesInformationCenterandReferenceLibrary(NMICRL).

PresentlytheMICisanintegralpartofthePharmacyDepartmentandrespondstorequestsfromallhospitalstaffbutmostcommonlyreceivequestionsfromphysicians,pharmacists,pharmacytechnicians,nursesandpublic.MICprovidesdrugsinformationandeducationalmaterials.

Asia M. Zareiba1, Ahmed D. Ahmed2

1. Medicine supply fund , South Darfur Ministry of Health , South Darfur State 2. Revolving Drug Fund (RDF), Ministry of Health, Nyala, South Darfur State


Success Stories21

Pharmacistsinchargearetrainedininformationretrievalandanalysisandusearangeofinformationsourcesincludingspecialisttexts,informationdatabases,referencesandprimaryjournals.Publiceducationhasbeendemonstratedthroughthelocalmedia(radioandTV)whichwascoveringtheopeningceremonyofthecenter.

Onthe2ndofNovember2014thecentercommenceditsactivitiesasthefirstcenterintheregionbyprovidingservicestothepublic.

Thecenternowbroadcastaseriesofradioprogramsforthelocalpubliconweeklybases.AspartofthecentersactivitiesaworkshopwasconductedontherationaluseofmedicinesinNyalaUniversityonFebruarythisyear.

Acknowledgements ThecenterstaffwishestothankallmedicalagenciesandcommunitypharmaciesinNyala,southDarfurstate;fortheirgreatsupport.


Patient Medication Adherence

DefinitionsAdherence has been defined as the active,voluntary, and collaborative involvement ofthe patient in a mutually acceptable courseofbehaviortoproduceatherapeuticresult.Itdenoteschoiceandmutuality ingoalsetting,treatmentplanning,andimplementationoftheregimen.Complianceis"theextenttowhichaperson'sbehavior coincides with medical advice".Noncompliance then essentially means thatpatients disobey the advice of their healthcareproviders.Theconceptofnoncompliancenotonlyassumesanegativeattitude towardpatients,butalsoplacespatientsinapassive,unequal role in relationship to their careproviders.Concordanceis"anagreementreachedafternegotiation between a patient and a healthcareprofessionalthatrespectsthebeliefsandwishesofthepatientindeterminingwhether,when and howmedicines are to be taken ".Recentlythefocusofconcordancehasshifted

22

tomeansimilaritybetweendoctorandpatientingender,race,andlanguage.Causes of non-adherenceTheWorldHealthOrganizationproposesthatadherenceisaffectedbythefollowingfactors(Figure1):

• Healthcaresystemorprovider-patientrelationshipfactors.

• Diseaseandtreatmentfactors.• Patientrelatedfactors.• Socio-economicfactors.

Health care system or provider-patient relationship factor:Thequalityofthepatient-doctorrelationshipinawellorganizedhealthcaresystemisaveryimportantdeterminantofregimenadherence.Researchhasdemonstratedthatpatientswhoaresatisfiedwiththeirrelationshipwiththeirhealthcareprovidershavebetteradherence.Socialsupportprovidedbynurseshasbeenshowntopromoteadherence.

Continuous Medical Education

Nuha M. Agabna 1

Figure 1: Causes of non-adherence


Diseaseandtreatments

factors

Causeofnon

adherence

Healthcaresystem

factors

Patientrelatedfactors

Socio-economicfactors


23 Continuous Medical Education

Disease and treatment related factors:Research has generally shown that lowerregimenadherencecanbeexpectedincaseswhenahealthconditionischronic,whenthecourseofsymptomsvariesorwhensymptomsarenotapparent,whena regimen ismorecomplex, and when a treatment regimenrequireslifestylechanges.

Patient related factors:Patientnoncomplianceisattributedtopersonalqualitiesofthepatients,suchasforgetfulness,lackofwillpowerormotivation,orlowlevelofeducation.Higherlevelsofstressandmal-adaptivecopinghavebeenassociatedwithmoreadherenceproblems.Psychologicalproblemssuchasanxiety,depression,andfearofgastrointestinaladverseeffectshavealsobeen linkedwithworsediseasemanagement.

The socioeconomic factors which thought to influence compliance are identified as:

• un-affordabilityandun-availabilityofmedications.

• Shortageofhealthinsurancecoverage.• Greaterlevelsofsocialsupport,

particularlydisease-relatedsupportfromspousesandotherfamilymembersareassociatedwithbetterregimenadherence.Studieshaveshownthatlowlevelsoffamilyconflict,highlevelsofcohesionandorganizationandgoodcommunicationpatternsareassociatedwithbetterregimenadherence.

• Healthbeliefs,misconceptionandattitudes:Appropriatehealthbeliefs,suchasperceivedseriousnessofdisease,vulnerabilitytocomplications,andtheefficacyoftreatment,canpredictbetteradherence.Generallypatientsadherewellwhenthetreatmentregimenmakessensetothem,whenitseemseffective.

InterventionsThecomplianceinterventionswereclassifiedbytheoreticalfocusintoeducation,behavior,and affect ive categories within which

specific interventionstrategieswerefurtherdistinguished.Nosinglestrategyorprogrammaticfocusshowedanyclearadvantagecomparedwithanother.Comprehensive interventionscombiningcognitive,behavioral,andaffectivecomponentsweremoreeffectivethansingle-focusinterventions.

Effective behavioral interventions: Severalspecificstrategiescanhelppatientswithbehaviorchange.

• Firstistheestablishmentofrapport,conveyinggenuineinterestinpatients.

• Buildingthepatientconfidenceinhealthcaresystem.

• Goodcommunicationisacriticalpartofthebehavior-changeprocess.However,knowledgewillnotguaranteethatbehaviorchangewilloccur.

Finally,effectivebehavioralconsultationwithprovidersencouragespatientstoexpresstheirconcernsanduseactivelisteningtechniques,suchasopen-endedquestions,clarifications,reflectivestatements,andsummarystatements.

ReferencesAronson. Time to abandon the term ‘patient concordance. British journal of clinical pharmacology. 2007, 64(5) 711-713.

Cameron C. Patient compliance: recognition of factors involved and suggestions for promoting compliance with therapeutic regimens. Journal of Advanced Nursing. 24(2): 244–250,

Roter et al., Effectiveness of Interventions to Improve Patient Compliance: A Meta-Analysis Medical Care. 1998, 36(8) 1138-1161.

Sabate E. Adherence to long-term therapies: Evidence for action. Geneva: World Health Organization; 2003.

Seltzer et al,. Effect of patient education on medication compliance. The Canadian Journal of Psychiatry. 1980, 25(8): 638-645.

Strategies to Improve Patient Medication Adherence

Halfofthepatientswithchronicdiseaseswerefoundby theWorldHealthOrganization tobenon-adherentwiththeirprescribedmedications'regimensinthedevelopedworld,whilethoseinthedevelopingworldwere farworse than thispercentage1.A large number of patients don’t follow thetreatment recommendations given to them.Solving non-adherence problem requiresmaking patients more proactive in their ownhealth care and forming closer interpersonalrelationshipswithpatients.

Don’t forget:

►Patientsneedtobesupported,notblamed. ►Theconsequencesofpooradherencetolong-termtherapiesarepoorhealthoutcomesandincreasedhealthcarecosts. ►Improvingadherencealsoenhancespatientsafety. ►Adherenceisanimportantmodifierofhealthsystemeffectiveness. ►Improvingadherencemightbethebestinvestmentfortacklingchronicconditionseffectively.

24

Sarah A. Kareem1

1. Head of Medicines’ Information Center and Reference Library, Directorate General of Pharmacy, Federal Ministry of Health

Figure 1 Integration of IMS model components’ for better adherence



Health care providers can help their patientsfollowprescribedtreatmentsandachievebettertreatment outcomes - particularly in chronicdisease management - by working throughthree components model: the Information-Motivation-Strategy(IMS)Model2.Thismodelwasdevelopedaftersynthesizingfindingsfrommore than 100 large-scale studies andmeta-analysesconductedbetween1948and2009.Researcheshaveshownthatusingmultimodalinterventions is more promising and haveimproved both adherence and treatmentoutcomes3.

TheIMSmodeldemonstratesthat informationis a prerequisite for changing behavior, but

The IMS model can be modified to fit in thehealth care setting of Sudan, illustrating thethree model components with the appropriaterecommendations for healthcare providers toapplythemontheirpatients.1. Information: Allpatientsmustwell

understandtheprovidedhealthinformationtheyreceive.

• Recommendations: Communicateinformationeffectivelytopatients.Buildtrustandencouragepatientstoparticipateindecision-makingandtobepartnersintheirownhealthcare.Askpatientstosharewhyandhowtheywillcarryouttheirtreatmentrecommendations.Listentopatients'concernsandgivethemfullattention.

2. Motivation:Makingpeoplebelieveintheirtreatment,motivatethemtofollowthetreatmentrecommendations.

in itself is insufficient to achieve this change.Motivationisalsoacriticaldeterminantandisindependent of behavior change. Informationandmotivationworkbetterwhencombinedwithstrategy to affect behavior; especially whenthestrategyused is familiaroruncomplicated(Figure1).

Information

Strategy Behavioralchabge

Betteradherance

Motivation


25

References1. Adherence to long-term therapies: evidence for action,

World Health Organization, 2003, ISBN 92 4 154599 2.

2. M. Robin DiMatteo, Kelly Haskard-Zolnierek, Leslie Martin. Improving patient adherence: a three-factor model to guide practice. Health Psychology Review, 2011; DOI: 10.1080/17437199.2010.537592

3. Piette JD, Kraemer FB, Weinberger M, McPhee SJ. Impact of automated calls with nurse follow-up on diabetes treatment outcomes in a Department of Veterans Affairs Health Care System. Diabetes Care. 2001;24:202–208.

4. Putting prevention into practice: the green book, The Royal Australian College of General Practitioners (RACGP), http://www.racgp.org.au/your-practice/guidelines/greenbook/applying-the-framework-strategies,-activities-and-resources/motivational-interviewing-strategies/issues-and-strategies-to-address-patient-adherence/, accessed April 2015.

Continuous Medical Educatio9

• Recommendations:Helppatientstobelieveintheefficacyofthetreatment.Elicit,listentoanddiscussanynegativeattitudestowardtreatment.Determinetheroleofthepatient'ssocialsysteminsupportingorcontradictingelementsoftheregimen.Helpthepatientscommittoadherenceandtobelievethattheyarecapableofdoingit.Beawareofandsensitivetopatient'sculturalbeliefsandpractices,andviewtreatmentthroughaculturallenstomakesurethatrecommendationsdonotconflictwithculturalnorms.

3. Strategy:Concretebarriersrepresentacommonsetofobstaclestoadherence,suchasthecostofmedications,unreliabletransportationtomakeappointments,mentalhealthissues,complicatedstoragerequirementsandcomplextreatmentregimens.Patientsneedapracticalstrategytofollowtreatmentrecommendations.

• Recommendations:Helpovercomepracticalbarriersthatmakeitdifficultforpatientstoeffectivelycarryoutacourseofaction.Identifyindividualswhocanprovideconcreteassistance.Identifyresourcestoprovidefinancialaidordiscounts.Providewritteninstructions/reminders.Offerlinkstosupportgroups.

Health care providers should check what the patient remembers and understands 4

Reinforcekeymessagesby:

►Repetitionandsummary(especiallyattheendoftheconsultation)

►Keepthemessagessimple

►Givehandouts,drawingsandleafletstoaidunderstanding(thesemaybepersonalized)

►Reinforcebehavior

►Linkadherencetoroutineactivities(e.g.meals,prayers,cleaningteeth)

The IMS Model emphasizes the importanceof patient-practitioner relationships throughinforming,motivatingpatientsand focusingonthedeterminedstrategiesintendingtoeliminatebarriers to adherence with the prescribedtreatment. It also is a useful tool for targetingpatientneeds,toindividualizepatientadherenceandultimatelyoptimizehealthoutcomes.

Guidelines to Improve Medication Orders Adherence26

Tohelphealthcareprovidersbecomemore familiarwithproveninterventionsthatcanenhancepatientadherence,the fol lowing mnemonic"SIMPLE"couldbeused.

Nuha M. Agabna1



Strategies Specific Interventions

Simplifyingregimen

characteristics

Adjustmentoftime,frequency,amount,anddosageMatchtherapytopatients'dailyactivitiesUsingadherenceaids,suchasmedicationboxesandalarms

ImpartingknowledgeDiscussionwithphysician,nurse,orpharmacist.DistributionofwritteninformationorpamphletsAccesstohealth-educationinformationontheWeb

Modifyingpatientbeliefs

Assessmentofperceivedsusceptibility,severity,benefit,andbarriers.Rewarding,tailoring,andcontingencycontracting

Patientandfamily

communication

Activelisteningandprovisionofclear,directmessagesInvolvementofpatientsindecisionsabouttheirowntreatmentsSendingremindersviamail,email,ortelephoneConvenienceofcare,scheduledappointmentHomevisits,familysupport,counseling

Leavingthebias Tailorofpatienteducationtothelevelofunderstanding

Evaluatingadherence Self-reports(mostcommonlyused)

Pillcounting,measuringserumorurinedruglevels

1. Simplifyingregimen characteristics.

2. Impartingknowledge.3. Modifyingpatientbeliefs.4. Patientcommunication.5. Leavingthebias.6. Evaluatingadherence.




1. Simplifying regimen:Manyofthestrategiesusedtosimplifyaregimenhavealreadybecomewell-standardizedpractices.• Prescribemedicinesthatcanbetaken

onceaday.Thiscanbedonewithalongeractingdrug(whereverpossible)orcombinedmedicines.

• Matchadministrationtothepatient'sdailyactivities.Forexample,beforeamealorbeforegoingtosleep.

• Useadherenceaidse.g.medicationboxes,alarms.

2. Imparting Appropriate Knowledge:Patients' understandingabout their conditionsand t reatments is pos i t ive ly re la ted toadherence.Adherence,satisfaction,recall,andunderstandingareallrelatedtotheamountandtypeofinformationgiven.Patientsdonotalwaysunderstandprescription instructionsandoftenforgetconsiderableportionsofwhathealthcarepractitionerstellthem.Effectiveinformationgivingcouldbedoneby:• Limitinginstructionsto3or4majorpoints

duringeachdiscussion.• Usingsimple,everydaylanguage,(only36%

ofpatientscorrectlyinterpretthemeaningof"every6hours"Correctly)

• Strengtheningoraleducationwithwrittenmaterials.

• Involvingthepatient'sfamilymembersandfriends.

• Reinforcingtheconceptsdiscussed.

3. Modifying Beliefs and Human Behavior:For interventions thatarecomplexandrequirelifestylemodificationsitisworthwhiletoaddresspatients'beliefs, intentions,andself-efficacytooptimizechangesinbehaviorandbeliefs.

4. Patient Communication:Communication encompasses interventionsranging fromphysician-patientcommunication,sendingmailortelephonereminders,toinvolvepatients'familiesinthedialogue.Listentopatients.

Askthepatientabouthis/herfeelings,concernsandviewsaboutpsychologicalfactorsontheadherence,thenprovidethemwith informationaboutallareasthat the individual findspertinent,andencouragethemtoparticipateindecisionmakingwhenaplanformanagementisformulated.

5. Leaving the Bias:Noclearrelationshipbetweenadherenceandrace,sex,educationalexperience,intelligence,maritalstatus,occupationalstatus, income,andethnicorculturalbackground.Moreover,an individual'slevelofadherencemayvaryovertimeandbetweendifferentaspectsoftreatmentproves thatdemographic factorsplayaminor role in adherence behavior.Adherencecanbeeffectivelyenhancedbytailoringtheeducationtothepatient'slevelofunderstanding.

6. Evaluating Adherence:Thiscanbedonebyself-reports,pillcounting,andinsomecasesmeasuringserumorurinedrug levels.Of these,self-reportisthemostsimple,practicalandwidely used tool. If a healthcareprofessional is unable to detect nonadherence,itisimpossibleforhimorhertocorrecttheproblem.

Reference

Ashish Atreja, Naresh Bellam, Susan R. Levy. Strategies to Enhance Patient adherence: Making it Simple. MedGenMed. 2005; 7(1):4.



Pharmaceutical Pictograms Can Aid Patients’ AdherenceKamal Addin M. Ahmad 1, Sarah A. Kareem 2

To use their prescribedand/or over-the-counter(O . T.C ) med i c a t i o n ssafely and appropriately,patients need accurate,comprehensive,balanced,clear,easilyunderstandableand pract ica l ly usefu l

medicationinformation.Medicationinformationhastobeconsideredasanintegralpartofthehealthcare.Patientsusuallygettheirneededmedicationinformation,fromtheirhealthcareproviders,inverbal,writtenand/orvisualforms.Failuretounderstandmedicationinformation,may lead topoorpatients' adherenceandmedicationerrors,whichmayincreasetheriskstopatients,andbequitecostlytotheindividualpatientsandthecommunityatlarge.The verbal medication information whichpatientsgetfromtheirhealthcareproviders,mainly thephysiciansandpharmacists, ismostly deficient, suboptimal, inadequate,difficult to understand, and is also easilyforgotten. To be able to adhere to theirmedications,patientsneedtounderstandandrecallthatinformationandbesatisfiedwithit.Highpatients’generalilliteracy,andlowhealthliteracy,asitisthecaseindevelopingcountries,consideredamongmanyother factors, asthemost frequentcausesforpoorpatients’understandingofmedicationinformationanditshighlypossibleensuingrisks.The difficulty of understanding the verbalmedicationinformationprovidedtopatientsbytheirhealthcareproviders,isalsoattributedtotheveryshortdurationoftheencounterwithhealthcareproviders,languagebarriers,typeofmessage,numberofmedicinesprescribed,psychologicalstatusofpatient,age,anxiety,andmedicalandpharmaceutical technicalterms(jargon)used,andthecommunicationskillsoftheprovider1.

AccordingtotheSudaneseCouncilofMinisters2004,Sudanhaveahighgeneralilliteracyrate(50%)2,alsoSudanisdistinguishedbyitsmultiethnic society. Moreover, small percent ofregisteredmedicinesarelocallyproduced,andthecastingmajorityoftheofficiallyregisteredmedicationsareimported(88.8%)3.Englishareused in the textsofwrittenmedicationinformation,mainlythepackageinserts,morethanArabicwhichistheofficialnativelanguage.This assumption is further backedby thefact that theSudaneseNationalMedicinesandPoisonsBoard(NMPB),whichcurrentlyregulatestheregistrationofpharmaceuticalproducts,mandates in itsarticle13.2, that''The package insert should be at least written in English and or / Arabic languages".Thisstatement,initself,makesitverydifficult,evenforliterateSudaneseindividuals,toreadandcomprehend those texts. Moreover,manystudiesreportedthatthereisquiteconsiderableirrationalprescribing,inSudan,whichmightleadtomedicationerrors.Accordingly, it becomes imperative to usethe visualmedication information form,asrepresentedbypharmaceuticalpictograms,sidebysidetotheverbalandwrittenmedicationinformationforms,tocomplementandreinforcebothofthem,butnottoreplacethem;inanattempt to secure better understanding ofpatientsfortheirmedications’useinstructions,to help them handle their medicationsmoreproperly; thus increasing theirsafety,effectivenessandusefulness.Pictogramsareintendedtoactasstimulustorecallinformationandkeepitforfuturereference.TheInternationalPharmaceuticalFederation(FIP) suggested various formats of themedication instructions to be printed inpictogramsformat.

1. Pharmacy practice and pharmaceutical promotion specialist, [email protected]. Head of Medicines’ Information Center and Reference Library, Directorate General of Pharmacy, Federal Ministry of Health



AmedicationinformationsheetforonemedicationAlabelwithcustomizablesize

AstoryboardofamedicationAprescriptioncalendarthatcombinesallmedicines

Sudanesepeoplehavealonghistoryoffamiliaritywithpictograms;sinceancient,Meroeuseofhieroglyphicsymbolsandtherecentofpictographicsymbolssincethefirstelections1953.Moreover,eventheilliteratecardriversaresmoothlydealingwiththevarioustrafficsignals.Thismayhelppublictoacceptthepharmaceuticalpictograms,whichmayprovemoreconducivetoimprovetheirunderstandinganduseofmedications’information.Belowaresomeexamplesofthepictogramsusedinthestudy.

References1. Awad A I. Himad HA. Drug use practices in teaching hospital of

Khartoum State, Sudan. European Journal of Clinical Pharmacology 2006; 62(12):1087 – 1093.

2. Council of Ministers, Central Bureau of Statistics (2005). Statistical Year Book for the Year 2004. Sudan Currency Printing Press Lmtd. Khartoum: pp. 199 – 255.

3. Yahia AY. Shouna GO. Ali M M. (2009). Sudan Medicine Index: Sudan Currency Printing Press. Khartoum: pp. 272 – 360.

30 Pharmacovigilance Awareness


Partners of the National Pharmacovigilance Program

Pharmacovigilance havepa r tne rs a t d i f f e ren tl eve l s ; i n te rna t i ona l ,national or state leveland pharmacovigilancesentinelsitesatthebottomo f the organ iza t iona ln e two r k . I n v o l v emen t

of pharmacovigilance partners is crucialfor the success of its activities. Partnersshareresponsibilityforthepracticeofdrugsafetymonitoring; anticipate, understandand respond to the continually increasingdemandsandexpectationsofthepublichealthadministrators, policy officials, politiciansand health professionals.These partnersinclude;theUppsalamonitoringcenterattheinternationallevel,nationalpharmacovigilancecenter,and theadvisorycommitteeat thenational level,hospitalsandtheacademia,the pharmaceutical industry, healthcareprofessionalsandthepatientsatthesentinelsites.• Pharmacovigilanceadvisorycommitteeis

amultidisciplinarypanelofclinicalexpertswhodeterminethevalidityandclinicalimportanceofthegeneratedsignals.Membersshouldbecapableoftechnicalassistanceincausalityassessment,risk

Randa A. Almahdi 1

1. Lecturer of pharmacy practice, Faculty of Pharmacy, University of Sciences and Technology

management,caseinvestigationandcrisismanagement.

• Pharmaceuticalindustry:Theprimaryresponsibilityistosupportpost-approvalsurveillanceactivitiesforthesafetyofmedicines.

• Hospitals:Pharmacydepartmentsinhospitalsaroundtheworld,haveimportanteffortsinclinicalpharmacologyandreportingofadversedrugreactions.

• Academia:Expansionofscientificknowledgeindrugsafetyisattributabletogreaterawarenessandacademicinterestinthisfield.

• HealthcareProfessionals:Doctors,pharmacistsandnurseswhohavebeenthemajorprovidersofcasereportsonsuspectedADRs.

• Patients:Observationsandreportsmadebyahealthprofessionalwillbeaninterpretationofadescriptionoriginallyprovidedbythepatient.

• Otherpartnersinclude;FederalandstatesministriesofhealthinSudan,Sudancentralmedicalsupplies,Sudanmedicalcouncil,drugimportingcompanies,thepublichealthinstitutePHI,thesocietyoftheSudaneseclinicalpharmacists,medicalsocieties,privateclinicsandcommunitypharmacies.


Anti-Microbial Awareness

Part 2: Modes of Antibiotic Resistance Kamal M. Elhag1

The emergences of newmechanisms of antibioticres is tance cont inue toevolve for the last sevendecades and whenevera new ant imicrobia l isintroduced,microorganismsdevelopnewmechanisms

toevadeitsaction.Theexplosionofantibioticusageworldwidewasalwaysfollowedbytheappearanceofclinicalinfectionwithorganismsresistant tocommonlyusedantibiotics.Thishasledtoavastandwideningchasmdividingthenumberofantibiotic resistant infectionsandeffectivedrugstotreatthem.Thisarticledealswiththedifferentmodesofantimicrobialresistanceandtheproblemsoftherapy,focusingonthesituationinSudan.

Modesofantibioticresistancearedifferent,awholebacterialspeciesmaybenaturallyor

intrinsiclyresistanttoanantibioticforexamplePseudomonasaeruginosaisinvariablyresistanttoerythromycin.Amicrobewillbenaturallyresistanttoanantibioticifeitheritdoesnotpossessatargetforitsactionoritsouterstructureisimpermeableto the drug. However, naturally susceptiblemicroorganisms can acquire resistance to avarietyofantibioticsbyselectionof resistantmutants.Inthissituationtheantibioticsuppressessusceptible bacteria and allows resistantmutantsandothersnaturallyinsusceptibletotheantibiotictoovergrowandreplacethesusceptiblebacterialpopulation.Theothermechanism isresistancetransferwherebacteriaacquireextra-chromosomalDNAsegment(plasmid,episomeetc.),thatcontainsresistancegenestoseveralantibiotics.ThisDNAsegment is transferablebetweenbacteria;alsoknownasinfectiousdrugresistance1.Underantibioticpressurebacteriathatpossessresistancegenesmaytransferthem

1. Consultant Microbiologist, Soba University Hospital, Khartoum, [email protected]

31


References1. Denis O, Rodriguez-Villalobos H, Struelens MJ. The problem of resistance. In: Finchh RG, Greenwood D, Norrby SR,

Whitley RJ eds. Antibiotics and chemotherapy 9th ed. Edinburgh: Elsevier;2010:24-48.2. Pallares R, Pujol M, Pena C, Ariza J, Martin R, Gudiol F. Cephalosporins as risk factor for nosocomial Enterococcus

faecalis bacteremia. A matched case-control study. Arch Intern Med 1993; 153:1581–6.8. 3. Dahms RA, Johnson EM, Statz CL, Lee JT, Dunn DL, Beilman GJ. Third-generation cephalosporins and vancomycin as

risk factors for postoperative vancomycin-resistant enterococcus infection. Arch Surg 1998; 133:1343–6. 4. Washio M, Mizoue T, Kajioka T, et al. Risk factors for methicillinresistant Staphylococcus aureus (MRSA) infection in a

Japanese geriatric hospital. Public Health 1997; 111:187–90.5. Landman D, Quale JM, Mayorga D, et al. Citywide clonal outbreak of multiresistant Acinetobacter baumannii and

Pseudomonas aeruginosa in Brooklyn, NY: the preantibiotic era has returned. Arch Intern Med 2002; 162:1515–20.6. Lautenbach E, LaRosa LA, Marr AM, Nachamkin I, Bilker WB, Fishman NO. Changes in the prevalence of vancomycin-

resistant enterococci in response to antimicrobial formulary interventions: impact of progressive restrictions on use of vancomycin and third-generation cephalosporins. Clin Infect Dis 2003; 36:440–6.

7. Lautenbach E, Strom BL, Bilker WB, Patel JB, Edelstein PH, Fishman NO. Epidemiological investigation of fluoroquinolone resistance in infections due to extended-spectrum b-lactamase–producing Escherichia coli and Klebsiella pneumoniae. Clin Infect Dis 2001; 33:1288–94.

8. Paterson DL. “Collateral Damage” from cephalosporins or quinolone antibiotic therapy. Clin Infect Dis 2004;38 (suppl 4): S341-5.

tootherbacteria.Resistanceisexpressedasinactivationof theantibioticby inactivatingenzymes,reducedpermeabilityoftheantibioticintothecell;alterationofthebindingsite,effluxoftheantibioticorthemicroorganismsusesanalternativepathway inmetabolizing thesubstrate1.

Theselectionofdrugresistantorganismsandtheunwanteddevelopmentofcolonizationor infectionwithmulti-resistant organismsisknownascollateraldamage,which isaterm used to refer to ecological adverseeffectsofantibiotictherapy.Thirdgenerationcephalosporin as well as quinolone usehas been linked to subsequent infectionwithmulti-resistantGramnegativebacteria,methicillin-resistantStaphylococcusaureus(MRSA)andvancomycin-resistantenterococci(VRE)2-7.Therefore,neitherthirdgenerationcephalosporinsnorfluoroquinolonesappearsuitable for sustained use in hospitals asroutineantibiotictherapy8.

Microorganismsareseveralstepsaheadofus.Wemustvalueandconservewhateverantibioticswe have and should use themwiselyandjudiciously.

Inourhospitalssettings,themaincausefortherisingantibioticresistanceisthatantibiotics

thatcausecollateraldamageare routinelyusedfortreatmentofcommoninfections,whilestandard,moreeffectiveandsafeantibioticsare excluded. This will undoubtedly leadto treatment failure and increasepatientsmorbidityandmortality,infectionwithmulti-resistantorganisms isknownascollateraldamage,which is a termused to refer toecologicaladverseeffectsofantibiotictherapy.Thirdgenerationcephalosporinaswellasquinoloneusehasbeenlinkedtosubsequentinfectionwithmulti-resistantGramnegativebacteria,methicillin-resistantStaphylococcusaureus (MRSA)and vancomycin-resistantenterococci (VRE) 2-5. Therefore, neitherth i rd generat ion cephalospor ins norfluoroquinolonesappearsuitableforsustaineduseinhospitalsasroutineantibiotictherapy6.

Inourhospitalssettings,themaincausefortherisingantibioticresistanceisthatantibioticsthatcausecollateraldamageare routinelyusedfortreatmentofcommoninfections,whilestandard,moreeffectiveandsafeantibioticsare excluded. This will undoubtedly leadto treatment failure and increasepatientsmorbidityandmortality.

32Anti-Microbial Awareness

Guide for authorsScope of the journal:Rationaluseofmedicines(RUM)issuesdirectedtohealthcareprovidersandmedicalstudents.Suitability of publication:All topics related to thedifferentaspectsofRUMwillbeevaluatedbytheeditorialboard.Prospectiveauthorswithasubject(s)orquestionsaboutthesuitabilityoftheirpapersormaterialsareinvitedtorequestanopinionfromtheEditorialBoard.([email protected]).Avoid plagiarismHow to submit materials:ManuscriptscanbehandedoverdirectlytotheDirectorateGeneralofPharmacyassoftcopyorbye-mail([email protected]).Types of manuscripts:1.Researchpapers.2.Casereports.3.Thematictopics.4.Successstories.

Preparation of manuscripts AllmanuscriptsmustbetypedinArialfontsize12,with1.5linespacing.ManuscriptsmustbeinWord.Pagemarginsonallsidesmustbeatleast2.5cmwide.YoucanuseeitherEnglishorAmericanspellingbutnotbothonthesamemanuscript.1. Research papersOriginal research will have the priority ofpublications.Author(s)nameandaffiliationsshould be clearly written. Contact person,telephonenumberande-mailaddressshouldbeincluded.Totalwordscountshouldnotexceed800wordsincludingreferences,tables,tablecaptions,figurelegends,andfootnotes.Maximumofthreetablesandfiguresareaccepted.Themanuscriptshouldbedividedintosections.Eachsectionshouldhaveaseparateheading.Subheadingstaketheformofparagraphlead-ins(shouldbeboldcase),indentedandruninwith

thetext,separatedbyaperiod.Introduction:This sectionshouldprovide thereaderwithsufficientbackgroundinformationtoevaluatetheresultsoftheresearch.Anextensivereviewoftheliteratureisnotneededinthissection.Itshouldalsogivetherationaleforandobjectivesofthestudythatisbeingreported.Methods:Sufficientinformationmustbeprovidedsothatthereaderwillunderstandthemethodologyandbeabletorepeattheexperiment.Results:Theresultssectionshouldbewritteninsuchamannertoprovideinformationbymeansoftext,tablesandfigures.Resultsanddiscussionmaybecombinedortheremaybeaseparatediscussionsection. Ifadiscussionsection isincluded,placeextensiveinterpretationsofresultsinthissection.Donotrepeattheresults.Givenumberstofiguresandtablesintheorderinwhichtheyarementionedinthetext.Allfiguresandtablesmustbecitedinthetext.Conclusionsandrecommendations:Acknowledgepersonal,financialandinstitutionalassistanceattheendofthissection.References:UsetheVancouverreferencesystem.Cite6referencesmaximum.Ethicalclearanceisarequirementforallresearchesfrom2012onward.2. Case reportsAnycasethatisrelatedtoRUMwillbeconsidered.Themanuscriptshouldincludethefollowingsetting:completedescriptionofthecase,consequencesandoutcomeandfinallyfollowupifapplicable.Suggestionsforsolutionsshouldbe included.Wordscountshouldnotexceed400words.3. Thematic topicsAny topic related to rationalmedicineuse isconsidered.Themanuscriptshouldnotexceed400words.4. Success storiesAnystorythatreflectsrationaluseofmedicineandpositivechangestowardsrationalmedicinesuseiswelcomed.Themanuscriptshouldnotexceed400words.NOTE: Acceptedmanuscriptsmaybesubjectedtominor/appropriatechangespriortopublishing.Pleasecheckthewebsiteforpreviousissuesandupdateswww.sjrum.sd

S J

SudanJornalofRationalUseofMedicine

RepublicofSudanFederalMinistryofHealthDirectorateGeneralofPharmacyNationalMedicinesInformationCentreandReferenceLibraryAlgamaStreetTel.0183749255,0183772843Fax:0183749256Website:www.nmicrl.sd www.sjrum.sdEmail:[email protected] B.Pharm,M.Pharm,MBABadreldinSaidHagnour B.Pharm,FPSMNuhaHajAli B.Pharm,MCPEslamA.Mohammed B.Pharm,FPSM

©AllRightReservedforGDoP2014

J

AspartofactivitiestargetedtoimprovetheRationalUseofMedicinesattheDirectorateGeneralofPharmacy-FederalMinistryofHealth-

Sudan,theSudanNationalStandardTreatmentGuidelines2014havebeenpublishedandarecurrentlyinthe

processofdissemination.

StandardTreatmentGuidelines areinvaluable in resource-constrained

environmentswith thehighburdenofdisease, toensureequitableaccess to

medicines.Theobjectivesare toprovidequality, safe, and efficacious essential

medicinesataffordablecosttotheSudanesepeople and also ensure the rational use of

thesemedicines.ForthegrowingNationalHealthInsuranceFund,astandardtreatmentguidelineis

s e en a s acostcontainmenttooltoensurethatinefficiencies,fraudandirresponsiblepoly-pharmacyareminimized.

Byapplyingtheseguidelines,wewillhaveastandardapproachtomanagethepriorityandcommonmedicalconditionsinSudan.Itisenvisionedthatthisdocumentwillalsobeusedinpre-servicetrainingofhealthcareworkersand,assuch,willbeofbenefittostudentsinmedicaltraininginstitutions.

Sudan Standard Treatment Guidelines

Documents

Sudan Journal of Rational Use of Medicine - WHOapps.who.int/medicinedocs/documents/s22198en/s22198en.pdf · Nuha Mohamed A. Agabna B. Pharm, M. Pharm , Ph.D ... Sudan Journal of Rational