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Table of Contents
Year : 2014  |  Volume : 8  |  Issue : 1  |  Page : 32-36

Drug use pattern in sickle cell disease in a hematology unit of a teaching hospital in North-Western Nigeria

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 Publication18-Sep-2014

Correspondence Address:
Iyabo Mobolawa Adebisi
Department of Pharmacology and Toxicology, Usmanu Danfodiyo University, Sokoto
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0331-3131.141027

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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 Top

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. [1] 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. [2]

Inappropriate drug prescribing is a global problem. [1] Misuse of drugs occur in all countries and irrational practices are especially common and costly in developing countries. [3] 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. [4] Some studies in Nigeria have revealed that appreciable gaps in knowledge exist with respect to rational drug use among health care professionals. [5],[6] Tamuno, [7] 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. [6] 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. [8]

The acute and painful vaso-occlusive crisis is the number-one cause of hospital admissions in patients with sickle cell disease (SCD). [9] The frequency and severity of these painful episodes are highly variable among patients, some having pain daily while others only occasionally. [10],[11] Pain from a vaso-occlusive crisis is often undertreated because of concerns about narcotic tolerance, addiction, sedation and respiratory depression. [12]

Pain management should follow the three-step "analgesic ladder" recommended by the WHO. [13] 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. [12],[14] 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. [15],[16],[17]

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). [18],[19] A 2008 consensus conference acknowledged the efficacy of HU in adults and encouraged its use in children. [20] Other prophylactic measures such as daily oral penicillin [21] and pneumococcal vaccination, [22] 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. [23] 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 Top

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 Top

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].
Table 3: Antimalarial used among SCD patients

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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].
Table 4: Co-morbidity profi le among patients with sickle cell disease

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   Discussion Top

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, [24] significant gender differences in morbidity and mortality have been reported in adults with SCD. [25] 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. [26] 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. [27] 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. [28]

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. [9]

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. [29] 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. [30]

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. [30] 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. [31] Penicillins accounted for over 60% of all antibiotics used in SCD patients.

Attested prophylactic measures such as pneumococcal vaccination, [22] and daily oral HU, [18] 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. [32] 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. [33]

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. [34] 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%. [35],[36],[37],[38] The percentage encounter with antibiotics was low in this study compared to the WHO standard of 20-26.8%. [34] 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 Top

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 Top

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  [Table 1], [Table 2], [Table 3], [Table 4]


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