Miss. Anushree S. Deshpande Mr. Harshitkumar B. Patel Mr. Arvind D. Vasoya

By

Project submitted ToRajiv Gandhi University of Health Sciences,

Bangalore, Karnataka.

Department of Clinical Pharmacy,H.S.K Hospital and Research center &

Hanagal Shri Kumareshwar College of Pharmacy,Bagalkot- 587101, Karnataka, India

2014.

EVALUATION OF ANTIMALARIAL DRUGS USE IN A TERTIARY CARE TEACHING HOSPITAL

Doctor of PharmacyUnder the guidance of

Mr. MALLAPPA H. SHALAVADI M.Pharm, [Ph.D.]

INTRODUCTION

• India has the largest population in the world at risk of

malaria, with 85% living in malarious zones

•Malaria is a tropical disease transmitted by the female

Anopheles mosquito of which Anopheles gambiae is the

most efficient vector.

• It is caused by infection by the protozoan parasite of

the genus plasmodium, is a disease of global

importance.

• Malaria is a major cause of morbidity and mortality

in the developing world.

• It is a public health problem in more than 90

countries.

• Each year, between 300 and 500 million new cases

are reported worldwide.

• Around 1.5 million confirmed cases are reported annually by the

National Vector Borne Disease Control Programme (NVBDCP),

of which about 50% are due to Plasmodium falciparum.

• WHO now recommends that treatment policies for

falciparum malaria in all countries experiencing

resistance to monotherapies such as chloroquine,

sulphadoxine-pyrimethamine and amodiaquine, should

be combination therapies preferably those containing an

artemisinin derivative.

• Artemisinin and its derivatives are a group of drugs 

that possess the most rapid action of all current drugs

against Plasmodium falciparum  malaria.

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• Patient counseling on malaria.

•To identify the potential drug-drug interactions in prescriptions.

•Adjusting doses in appropriate patients (e.g., Patients with

impaired renal or hepatic function).

Role Of Pharmacist

Study Methodology

Study procedure

• The study is approved by Institutional Human

Ethics Committee [Ref: SNMC/PG/2013-

14/2885], S.N.M.C and H.S.K Hospital and

research Centre, Bagalkot.

• The study will be conducted in accordance

with the ethical principles of the ethics

committee guidelines

• This study was conducted in S.N Medical College

and HSK hospital and research center Bagalkot.

• We have taken cases from general medicine and

Pediatric Departments.

• It is a 850 bedded general hospital run by the BVV

Sangha.

Study site

Study criteria

Inclusion criteria

- Patients diagnosed with malaria.

- Patients of all age group of either sex.

- Patients receiving anti-malarial drugs.

Exclusion criteria

- Patients attending outpatient department

Source of data

• Past prescription.

• Patient data collection form, patient case notes

• Lab data reports.

• Treatment charts .

• Drug intervention and interaction form.

• Interviewing patients.

• Discharge cards/advice on discharge.

Methodology

• Personal visit made on daily basis to general medicine ward and

pediatric wards to identify the patients who were diagnosed with

malaria.

•Patient demographic details were collected.

•Clinical data was collected.

•Name of drug, dose, frequency, duration and cost of treatment

noted in patient data collection form.

• Potential drug-drug interactions in the treatment regimen have

to be assessed using Micromedex-2.0.

• The inpatient data collected and created separately in computer

based format, stored and retrieved when they required in MS

office format.

RESULTS

Patients characteristics according to age.

0-2year 2-6year 6-12year 12-18year 18-30year 30-45year 45-60year >60year0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

3.16%2.63%

10.53%

3.16%

10.63%

7.37%

14.21%

8.95%

3.16%

0.00% 0.00%

2.63%

10.00%

14.21%

3.16%

6.30%

MALE

FEMALE

Age group

Perc

enta

ge

Pattern of malaria parasite infection in patient visiting tertiary care hospital

Plasmodium falciparum

Plasmodium vivax

Mixed

Clinical malaria

Complicated malaria

0.00% 20.00% 40.00% 60.00% 80.00%

58.69%

8.69%

6.52%

6.52%

19.50%

Percentage of prescription

Percentage

Number of uncomplicated malaria cases

Plasmodium vivax

Plasmodium falciparum

Pregnant women with plasmodium falciperum

Mixed clinical malaria

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

8.11%

70.27%

2.70%

10.81% 8.11%

Antimalarial drugs prescribed for patient visiting tertiary care hospital

Artesunate

Aretsunate+Pyrimethamine+Sulphadoxine

Artemether/Lumefantrine

Chloroquine phosphate

Doxycycline

Primaquine

Hydroxy chloroquine sulfate

Quinine

0.00% 5.00% 10.00% 15.00% 20.00% 25.00%

14.40%

19.70%

17.42%

12.12%

23.49%

8.33%2.28%2.28%

Percentage of prescription of antimalarial drugs

Antimalarial drugs given in complicatedmalaria cases

Artesunate

Artesunate+sulphadoxine+ Pyrimithamine

Doxycycline

Chloroquine

Artemether & lumefantrine

Primaquine

0 0.5 1 1.5 2 2.5 3 3.5

2

2

3

2

3

2

Number of antimalarial drugs

Artesunate prescribed for patient visiting tertiary care hospital

Antimalarial drug

Malaria cases (n=46)

Non malarial cases (n=52)

Number of prescription

Percentage (%)

Number of prescription

Percentage (%)

Artesunate 25 54.34 17 32.69

Antimalarial drugs prescribed in infectious diseases other than malaria cases.

Artesunate

Artesunate+Sulphadoxine+Pyrimithamine

Doxycycline

Chloroquine

Hydroxy chloroquine

Artemether/lumefentrine

0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20%

13%

8%

19%

11%

3%

11%

Numbers of patients

Pattern of drugs regimen prescribed for patients

1 Drug therapy

2 Drugs therapy

3 Drugs therapy

4 drugs therapy

5 Drugs therapy

0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 35.00%

26.84%

24.48%

30.61%

9.18%

1.02%Percentage

Percentage

Drug interaction found in prescriptions.

Major Moderate Minor Contraindicated0.00%5.00%

10.00%15.00%20.00%25.00%30.00%35.00%40.00%45.00%50.00%

43.24%

32.43%

18.92%

8.11%

Percantage

Drug-drug interaction of artemisinin derivatives with other drugs in malaria and nonmalarial cases.

Infection Drug-drug interactions Percentage

Malarial cases(n=46) 1 2.17%

Non malarial

cases(n=52)

7 13.46%

Assessment of rationality of antimalarial drugs prescribed for patient according to guidelines.

plasmodium vivax

plasmodium falciparum

mixed

clinical malaria

complicated malaria

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00%

12.00%

52.00%

12.00%

12.00%

12.00%

4.76%

66.67%

0.00%

0.00%

28.57%irrational

rational

Clinical outcome

Outcome Number of patients Percentage

Improved 22 47.83%

Cured 24 52.17%

Worsened 00 00.00%

Expired 00 00.00%

Total 46 100%

Drug use evaluation of antimalarial drugs prescribed for patients with help of prescribing indicator.

Indicator Data

Average no of drug 1.42

I.V. injection(percentage) 44.89%

Cost of antimalarial drug prescribed for patient visiting tertiary care hospital.

Indicator Data

Average drug cost 1085.22 Rs

Percentage drug cost on injection 86.51 %

Discussion

• Drug use indicator has provided easy & convenient

measures to assess optimal drug used in health facilities.

• In our study, we collected total 98 cases prescribed with

antimalarial drugs amongst them 60.5% were male and

39.49% female, which was also seen in previous studies

conducted in various areas

• Out of 46 malarial cases, 78.78% were positive for

plasmodium falciparum and 21.22% were positive for vivax

and mixed type. This indicate Plasmodium falciparum is

more common in this area of Karnataka for malarial

infection.

• Major prescription of antimalarials were 19.70% of artesunate +

sulfadoxine + pyrimethamine, 17.42% of artemether +

lumifantrine, artesunate 14.4%.

• Prescribing artesunate alone leads to development of resistance

according to NVBDCP. Artesunate should be given in

combination with Sulfadoxine/Pyrimethamine or lumefantrine.

• Three drug combination was more prescribed i.e 30.61%. Almost

all combination contain artemisinin derivatives which was in

accord with guidelines.

• In malarial cases, we found 45.65% of irrational prescription and

82.69% of non malarial cases.

• More irrational procreation arise for patients suffering with

plasmodium falciparum malaria this will shows our hospital

clinicians are not adhered to guidelines to treat the malarial cases.

• Prescribing indicators shows 44.879% of I.V. injections were

prescribed, this will increase cost of the prescriptions as injections

are costlier than oral therapy.

• The cost of injections was found 86.51% out of total cost. This

because I.V. preparations were used more and are much more

expensive.

Conclusion Our study shows that inappropriate use of antimalarial drugs was high

among patient with plasmodium falciparum and nonmalarial patients.

Irrational prescriptions are high which indicate non adherence to

guidelines. Cost of therapy is very high thus it contribute economic

burden on patients.

Bagalkot is endemic for Plasmodium falciparum & Plasmodium vivax

malaria and there is requirement of rational prescriptions for

betterment of therapy for malaria.

This result should inform education of health professional and rational

drug use policy and to reduce the cost of prescription.

Recommendation

This study has to be conducted in other hospital of Baglakot district.

Annexure

Antimalarial drug cost documentation form

Name of drug

Cost of drug

1 2 3 4 5 6 7 8 9 10 Cost per day

Total[Total Day × cost per day]

Total

Name of the Staff Incharge : Signature of staff Incharge : Remarks of the staff Incharge :

Acknowledgement

• With great pleasure and pride we express our deepest thanks to our guide,

Mr. Mallappa H. Shalavadi, Department of Pharmacy Practice, H. S. K

College of Pharmacy, Bagalkot.

• It is our privilege to extend our cordial and humble thanks to Dr. I. S.

Muchchandi, principal, and Dr.Chandrasekhar. V. M Professor and HOD,

H. S. K College of Pharmacy, Bagalkot.

• We also express our humble thanks to Dr. Ashok. Mallapur Principal and

Dr. Chandrashekar T M. Dean, S. N Medical College & HSK Hospital and

Research Centre, Bagalkot.