|Year : 2014 | Volume
| Issue : 1 | Page : 32-36
Drug use pattern in sickle cell disease in a hematology unit of a teaching hospital in North-Western Nigeria
Abdulgafar Olayiwola Jimoh1, Iyabo Mobolawa Adebisi2, Mohammed Alhaji Ndakotsu3
1 Department of Pharmacology and Therapeutics, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
2 Department of Pharmacology and Toxicology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
3 Department of Heamatology and Blood Transfusion, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
|Date of Web Publication||18-Sep-2014|
Iyabo Mobolawa Adebisi
Department of Pharmacology and Toxicology, Usmanu Danfodiyo University, Sokoto
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Sickle cell disease (SCD) is an important public health problem in Nigeria, with a prevalence of about 20/1000 births, and with up to 24% of the general population carrying the trait. Globally, drugs account for about 60% of nonpersonnel cost of healthcare and about 50% of medications are presumed to be inappropriately prescribed, dispensed, or sold. This leads in part to increased cost of healthcare and emergence of drug resistance.
Aim: The aim of the study was to assess the drug prescribing pattern in the management of SCD patients in a hematology unit of Usmanu Danfodiyo University Teaching Hospital in Sokoto, North-West Nigeria; and assess conformity to World Health Organization (WHO) specification.
Materials and Methods: This was a cross-sectional retrospective study involving the review of 272 prescriptions from the case notes of SCD patients seen in the hematology clinic of Usmanu Danfodiyo University Teaching Hospital, Sokoto, a Tertiary Health Care Center in North-West Nigeria from June 2009 to July 2011. Data were collected from case notes of patients and were analyzed using descriptive statistics.
Result: The mean age of SCD patients was 19.6 ± 4.5 years and 54.4% of the patients were male. A total of 1230 drugs was prescribed with an average of 4.5 drugs per prescription. Analgesics, antimalarials, vitamins, and antibiotics, accounted for 30.1%, 28.7%, 23.1%, and 8.7%, of the total prescriptions, respectively. Of the analgesics prescribed, acetaminophen accounted for 24.8%, nonsteroidal anti-inflammatory drugs (32.2%), and narcotics 43%. Artemisilin-based combination therapy was used in the management of malaria, and 73% of SCD patients had prophylactic antimalarial (proguanil). Penicillins accounted for over 60% of antibiotics used.
Conclusion: Drug prescription in SCD patients is high, and thus it is recommended that WHO/International Network on Rational Drug Use standard and core prescribing indicators be adhered to.
Keywords: Prescribing pattern, sickle cell disease, Sokoto-Nigeria
|How to cite this article:|
Jimoh AO, Adebisi IM, Ndakotsu MA. Drug use pattern in sickle cell disease in a hematology unit of a teaching hospital in North-Western Nigeria. Ann Nigerian Med 2014;8:32-6
|How to cite this URL:|
Jimoh AO, Adebisi IM, Ndakotsu MA. Drug use pattern in sickle cell disease in a hematology unit of a teaching hospital in North-Western Nigeria. Ann Nigerian Med [serial online] 2014 [cited 2021 Apr 18];8:32-6. Available from: https://www.anmjournal.com/text.asp?2014/8/1/32/141027
| Introduction|| |
Assessment of drug use patterns with World Health Organization (WHO) drug use indicators is becoming increasingly necessary toward promoting rational drug use in developing countries.  The introduction of the manual "How to investigate drug use in health facilities" following the collaborative work of the International Network for the Rational Use of Drugs (INRUD) and the WHO Essential Drugs and Medicines Policy Department provided useful tools for objective and reproducible measurements of the effectiveness and efficiency of drug use. 
Inappropriate drug prescribing is a global problem.  Misuse of drugs occur in all countries and irrational practices are especially common and costly in developing countries.  Such practices include polypharmacy, the use of wrong or ineffective drugs, underuse or incorrect use of effective drugs, use of combination products which are often more costly and offer no advantage over single compounds, and common overuse of antimicrobials and injections.  Some studies in Nigeria have revealed that appreciable gaps in knowledge exist with respect to rational drug use among health care professionals. , Tamuno,  in a study in Kano highlighted polypharmacy, overuse of antibiotics and injections, and low rate of generic prescribing as practices among private health facilities. This is similar to the report of Okoh in a study among public tertiary hospitals in Edo.  Another study among elderly patients in a Nigerian rural tertiary hospital in Southwest Nigeria found that up to 25.5% of all patients had a potentially inappropriate medication prescribed. 
The acute and painful vaso-occlusive crisis is the number-one cause of hospital admissions in patients with sickle cell disease (SCD).  The frequency and severity of these painful episodes are highly variable among patients, some having pain daily while others only occasionally. , Pain from a vaso-occlusive crisis is often undertreated because of concerns about narcotic tolerance, addiction, sedation and respiratory depression. 
Pain management should follow the three-step "analgesic ladder" recommended by the WHO.  The choice of analgesics and the dosage used should be based on the severity of pain in an individual patient. Patients with mild pain can often be treated at home with oral fluids and non-narcotic analgesics. , Patients can also be started on acetaminophen with or without codeine or oxycodone (Roxicodone), depending on pain severity. Nonsteroidal anti-inflammatory drugs (NSAID) can be used unless they are specifically contraindicated, such as in peptic ulcer disease, renal disease, or hepatic dysfunction. Narcotic analgesics can be used in patients with moderate to severe pain; a mild opioid used for moderate pain and strong opioids sometimes administered by the parenteral route for severe pain. ,,
Hydroxyurea (HU) therapy is been used as prophylactic treatment because it decreases the frequency and severity of acute painful episodes and acute chest syndrome by nearly half in homozygous SCD (HbSS). , A 2008 consensus conference acknowledged the efficacy of HU in adults and encouraged its use in children.  Other prophylactic measures such as daily oral penicillin  and pneumococcal vaccination,  have also been known to reduce the frequency and severity of acute pain episodes in SCD.
According to the WHO report, inadequate management, absence of national control programs, and basic facilities to manage the patients remain a challenge in most countries where SCD is a major public health concern.  It was, therefore, thought necessary to evaluate the prescribing pattern in this category of patients.
This study was carried out to assess the drug prescribing pattern in the management of SCD patients in a Hematology Unit of Usmanu Danfodiyo University Teaching Hospital in Sokoto, North-West Nigeria; and assess conformity to WHO specifications.
| Materials and Methods|| |
This was a cross-sectional retrospective review of the hospital records of 272 SCD patients managed at the Hematology Unit of Usmanu Danfodiyo University Teaching Hospital, Sokoto, North-West Nigeria. The patients were treated between June 2009 and July 2011.
The study involved retrieval of the case notes of all SCD patients seen in the hematology unit. The following data were retrieved: Bio-data, types, and classes of drugs used and the WHO/INRUD core prescribing indicators. The WHO/INRUD methods of determining core prescribing indicators were employed. The average number of medicine per encounter was calculated by dividing the total number of drugs by the number of encounters. Percentage encounter with a generic name, percentage encounter with antibiotics, and percentage encounter with injections were determined by dividing the number of occurrence by the total number of events respectively, and multiplying by 100.
The data collected were entered into a spread sheet and analyzed by descriptive statistics using the Statistical Package for Social Sciences (SPSS) version 20 (IBM Corporation, Armonk, New York 10504). The results were presented using frequency tables and percentages for all categorical variables.
| Results|| |
The mean age of the SCD patients was 19.6 ± 4.5 years, with 54.4% of the patients being male and 86.8% being students. A total of 1230 drugs was prescribed with an average of 4.5 drugs per prescription, 76.3% of prescriptions were by generic name. Prescription for antibiotics and injections were 8.7 and 12.1%, respectively [Table 1].
|Table 1: WHO core prescription indicators among SCD patient prescriptions|
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Analgesics, antimalarials, and vitamins accounted for 30.1%, 28.7%, and 23.1% of the total prescriptions, respectively [Table 2].
|Table 2: Drug count of all drugs prescribed among SCD patients prescriptions|
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Of the analgesics prescribed, acetaminophen, NSAIDs, and narcotics accounted for 24.8%, 32.2%, and 43%, respectively, and of the anti-malarials used, artemisinin-based combination therapy (ACT) accounted for 34.3%, while 56.7% were given as prophylactic antimalarials [Table 3].
With regards to prophylactic treatment, 73.4% and 77% of the patients were prescribed proguanil (antimalarial prophylasis) and folic acid, respectively. Penicillins accounted for over 60% of antibiotics. HU in crises prevention was not employed. Data on co-morbidity profile showed a total of 12 different co-morbids in 158 patients with some patients reporting more than one of these. Malaria was the most common (58.9%), followed by upper respiratory tract infections (22.2%) [Table 4].
| Discussion|| |
This study showed that more males (54.4%) were treated at the study center during the study period. Although SCD is known to affect males and females equally,  significant gender differences in morbidity and mortality have been reported in adults with SCD.  Baum et al. reported a striking increase in veno-occlusive after age of 15 years, with a greater rate of pain attacks in males than females.  In a study in Virginia, men with the SS genotype reported a higher percentage of days with crisis (18.5% vs. 11.6%) and heath care utilization (5.1% vs. 2.7%) than women with the SS genotype.  It is believed that men who have the disease experience worse symptoms than women. A possible reason for this is the role of estrogen which help to stimulate the production of nitric oxide, a vasodilator which gives the sickle shaped cells more room to pass through the vessels, preventing blockages which is the cause of sickle cell crisis. 
This study revealed that analgesics were the most prescribed drugs among SCD patients. This was followed by antimalarials, vitamins, and micronutrients. This is in agreement with some previous reports that the acute pain episode is the number-one cause of hospital admissions among patients with SCD. 
The type of analgesics prescribed revealed that narcotics (mild opioids) accounts for 43% of prescribed analgesia. Even though the chronic daily use of opioids in SCD patients with frequent severe painful episodes is controversial, many clinicians report that patients improved and function better after treatment with opioid analgesics.  Others are concerned about the symptoms of withdrawal, along with exacerbation or lack of recognition of interacting factors such as depression, anxiety, or intolerable life stresses. Physicians have been identified to greatly over-estimate the incidence of addiction in patients with SCD. 
The finding of a reasonable percentage of prescriptions of prescriptions and NSAIDs may suggest that clinicians are adhering to the three step "analgesic ladder" recommended by WHO at Usmanu Danfodiyo University Teaching Hospital, Sokoto; although a record of the severity of pain in patients at the time of hospital visit which would have helped in making such a conclusion, but this was not within the scope of this study.
On anti-malarial use, 56.7% of prescriptions were for proguanil (prophylactic anti-malarial) and 34.3% for ACTs (therapeutic anti-malarial). A total of 73% of all patients were placed on anti-malaria prophylaxis. It has been advocated that anti-malarial prophylaxis be prescribed to all patients, as malaria has been associated with severe anemia in patients with HbSS.  This is supported by the result of the co-morbidity profile, where malaria was identified as the most common co-morbid condition. Folic acid is another prophylactic drug that is also advocated for all patients, and our result showed 77% use among SCD patients. Although, in a double blind controlled trial of folate supplementation in children with SCD, it was observed that there was no significant difference in hematology, bone/abdominal pain or growth between the control and test groups, and the authors called for a critical review of the policy of folate supplementation in children with SCD.  Penicillins accounted for over 60% of all antibiotics used in SCD patients.
Attested prophylactic measures such as pneumococcal vaccination,  and daily oral HU,  have been known to reduce the frequency and severity of acute pain episodes in SCD. These have not been used in Usmanu Danfodiyo University Teaching Hospital, Sokoto. Probably due to unavailability and cost implications as reported by Akinyanju et al.  A survey of HU use in community based practices revealed that almost half of the physicians indicated that they prescribed HU to less 10% of their patients, with only 16% indicating that they prescribed hyroxyurea to 60% or more of the SCD patients. 
An assessment of the WHO core prescribing indicators showed that the average number of drugs per prescription was 4.5. This is higher than the WHO standard of 1.6-1.8.  This is not unexpected in the management of SCD as prophylactic treatments e.g., anti-malaria prophylaxis, and folic acid may contribute to increased number of drugs per prescription when added to the regimen used in the management of acute painful vaso-occlusive crises. Furthermore, about 76.3% of drugs in our study were generic prescriptions. This is lower than the standard (100%) stipulated by WHO. However, this is still higher than those in previous studies on the general prescribing pattern in other places where percentage generic prescriptions ranged from 24.4%, 32.6% 46.2%, and 47.7%. ,,, The percentage encounter with antibiotics was low in this study compared to the WHO standard of 20-26.8%.  This is not unexpected as acute pain episodes are common in patients with SCD. Also, prescription of parenterally administered drugs in our study was low. This may suggest the adherence to the WHO "analgesics ladder" where parenteral opioids are restricted to severe pain.
| Conclusion|| |
The management of SCD patients conforms to standard. Analgesics were the most commonly prescribed medications, with no prescription for prophylactic HU. Optimization of adherence to WHO/INRUD standard reference guide is advocated to improve patient care.
| References|| |
|1.||Enwere OO, Falade CO, Salako BL. Drug prescribing pattern at the medical outpatient clinic of a tertiary hospital in southwestern Nigeria. Pharmacoepidemiol Drug Saf 2007;16:1244-9. |
|2.||Hogerzeil HV, Bimo, Ross-Degnan D, Laing RO, Ofori-Adjei D, Santoso B, et al. Field tests for rational drug use in twelve developing countries. Lancet 1993;342:1408-10. |
|3.||Ghimire S, Nepal S, Bhandari S, Nepal P, Palaian S. A prospective surveillance of drug prescribing and dispensing in a teaching hospital in western Nepal. J Pak Med Assoc 2009;59:726-31. |
|4.||Blum NL. Drug information development. A case study Nepal rational pharmaceutical management project. United States Pharmacopoeia (online) 2000. Available from: http://www.usp.org/pdf/EN/dqi/nepalcasestudy.pdf. [Last accessed on 2014 Jun 18]. |
|5.||Chukwuani CM, Onifade M, Sumonu K. Survey of drug use practices and antibiotic prescribing pattern at a general hospital in Nigeria. Pharm World Sci 2002;24:188-95. |
|6.||Okoh A. An assessment of rational drug use in public tertiary hospital in Edo state. Nigeria. Geneva Health Forum, GHF, Research Project; 2012. |
|7.||Tamuno I. Prescription pattern of clinicians in private health facilities in Kano, North Western Nigeria. Asian Pac J Trop Dis 2011;1:235-8. |
|8.||Fadare JO, Agboola SM, Opeke OA, Alabi RA. Prescription pattern and prevalence of potentially inappropriate medications among elderly patients in a Nigerian rural tertiary hospital. Ther Clin Risk Manag 2013;6:115-20. |
|9.||Ballas SK, Lusardi M. Hospital readmission for adult acute sickle cell painful episodes: Frequency, etiology, and prognostic significance. Am J Hematol 2005;79:17-25. |
|10.||Shapiro BS, Dinges DF, Orne EC, Bauer N, Reilly LB, Whitehouse WG, et al. Home management of sickle cell-related pain in children and adolescents: Natural history and impact on school attendance. Pain 1995;61:139-44. |
|11.||Vichinsky EP, Johnson R, Lubin BH. Multidisciplinary approach to pain management in sickle cell disease. Am J Pediatr Hematol Oncol 1982;4:328-33. |
|12.||Ballis SK, Carlos TM, Dampier C, Guidelines Committee. Guidelines for Standard of Care of Acute Painful Episodes in Patients with Sickle Cell Disease. Harrisburg, PA: Commonwealth of Pennsylvania Department of Health; 1996. |
|13.||World Health Organization. Cancer Pain Relief. Geneva: WHO; 1986. |
|14.||Ballas SK. Management of sickle pain. Curr Opin Hematol 1997;4:104-11. |
|15.||Shapiro B, editor. Proceedings of the Conference on Sickle Cell Related Pain: Assessment and Management. Framingham, MA: New England Regional Genetics Group and Maternal and Child Health Bureau; 1993. |
|16.||Carr D, Jacox A, editors. Acute Pain Management: Operative or Medical Procedures and Trauma. AHCPR Publication No. 92-0032. Rockville, MD: AHCPR; 1992. |
|17.||Max MB, Payne R. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain. 3 rd ed. Skokie, IL: American Pain Society; 1992. |
|18.||Charache S, Terrin ML, Moore RD, Dover GJ, Barton FB, Eckert SV, et al. Effect of hydroxyurea on the frequency of painful crises in sickle cell anemia. Investigators of the multicenter study of hydroxyurea in sickle cell anemia. N Engl J Med 1995;332:1317-22. |
|19.||Lanzkron S, Strouse JJ, Wilson R, Beach MC, Haywood C, Park H, et al. Systematic review: Hydroxyurea for the treatment of adults with sickle cell disease. Ann Intern Med 2008;148:939-55. |
|20.||Brawley OW, Cornelius LJ, Edwards LR, Gamble VN, Green BL, Inturrisi C, et al. National institutes of health consensus development conference statement: Hydroxyurea treatment for sickle cell disease. Ann Intern Med 2008;148:932-8. |
|21.||World Health Organization. WHO African Region Ministerial Consultation on Noncommunicable Diseases. Brazzaville, Congo: WHO Regional Office for Africa; 2011. p. 4-6. |
|22.||Ilesanmi OO. Gender differences in sickle cell crises: Implication for genetic counselling and psychotherapy. J Psychol Psychother 2013;3:123. |
|23.||Kamble M, Chatruvedi P. Epidemiology of sickle cell disease in a rural hospital of central India. Indian Pediatr 2000;37:391-6. |
|24.||Reiter CD, Gladwin MT. An emerging role for nitric oxide in sickle cell disease vascular homeostasis and therapy. Curr Opin Hematol 2003;10:99-107. |
|25.||Brookoff D, Polomano R. Treating sickle cell pain like cancer pain. Ann Intern Med 1992;116:364-8. |
|26.||Baum KF, Dunn DT, Maude GH, Serjeant GR. The painful crisis of homozygous sickle cell disease. A study of the risk factors. Arch Intern Med 1987;147:1231-4. |
|27.||McClish DK, Levenson JL, Penberthy LT, Roseff SD, Bovbjerg VE, Roberts JD, et al. Gender differences in pain and healthcare utilization for adult sickle cell patients: The PiSCES Project. J Womens Health (Larchmt) 2006;15:146-54s. |
|28.||Schechter NL, Berrien FB, Katz SM. The use of patient-controlled analgesia in adolescents with sickle cell pain crisis: A preliminary report. J Pain Symptom Manage 1988;3:109-13. |
|29.||Akinyanju O, Johnson AO. Acute illness in Nigerian children with sickle cell anaemia. Ann Trop Paediatr 1987;7:181-6. |
|30.||Gaston MH, Verter JI, Woods G, Pegelow C, Kelleher J, Presbury G, et al. Prophylaxis with oral penicillin in children with sickle cell anemia. A randomized trial. N Engl J Med 1986;314:1593-9. |
|31.||Rabb LM, Grandison Y, Mason K, Hayes RJ, Serjeant B, Serjeant GR. A trial of folate supplementation in children with homozygous sickle cell disease. Br J Haematol 1983;54:589-94. |
|32.||Akinyanju OO, Otaigbe AI, Ibidapo MO. Outcome of holistic care in Nigerian patients with sickle cell anaemia. Clin Lab Haematol 2005;27:195-9. |
|33.||Zumberg MS, Reddy S, Boyette RL, Schwartz RJ, Konrad TR, Lottenberg R. Hydroxyurea therapy for sickle cell disease in community-based practices: A survey of Florida and North Carolina hematologists/oncologists. Am J Hematol 2005;79:107-13. |
|34.||Isah AO, Laing R, Quick J, Mabadeje AF, Hogerzeil H, Ross-Degnan D. The development of reference values for the WHO health facility core prescribing indicators. West Afr J Pharmacol Drug Res 2002;18: 6-11. |
|35.||Akande TM, Ologe MO. Prescription pattern at a secondary health care facility in Ilorin, Nigeria. Ann Afr Med 2007;6:186-9. |
|36.||Enato EF, Sounyo AA, Madadi P. Assessment of disease profiles and drug prescribing patents of health care facilities in Edo State. Niger J Public Health Africa 2012;l3:101-6. |
|37.||Ravi Shankar P, Partha P, Nagesh S. Prescribing patterns in medical outpatients. Int J Clin Pract 2002;56:549-51. |
|38.||Ghosh R, Neogi JN, Srivastava BS, Sen P. Prescribing trends in a teaching hospital in Nepal. JNMA J Nepal Med Assoc 2003;42:346-9. |
[Table 1], [Table 2], [Table 3], [Table 4]