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COMPOUNDING

POLYPHARMACYPRESCRIPTION IN

INDONESIA

Purnamawati Pudjiarto;Arifianto, Arifianto;

Farian Sakinah;

Yulianto Kurniawan

Concern & Caring ParentsFoundation

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ABSTRACTCompounding Polypharmacy Prescription In Indonesia

Pudjiarto, Purnamawati Sujud; Arifianto, Arifianto; Sakinah, Farian; Kurniawan, Yulianto

Problems: The WHO-EML stated that “The custom in some places is to treat sick childrenwith a mixture of several medicines ("puyer"), not necessarily all appropriate to their

needs. Adult solid dosages forms are mixed together, ground to a powder, and the

powder divided into assumed pediatric doses then dispensed for administration to the

child. The Committee recommended that this irrational practice should not be used.”

However, resistance to change is very strong.

Objective: To study the “puyer” prescribing for children diagnosed with 4 viral infections (do

not need antibiotic) URI, fever, acute cough (without fever and signs of URI), acute GE;

and to see the change of “puyer” and types of medicine consumed after beingeducated.

Method: Intervention (done by doctors-trainers): written materials, FGD (6 months,3 weekly

meeting), “boosters” through the mailing list. Pre intervention, participants submit

prescriptions, data of illness-consumption of puyer, questioner.

Setting: Jakarta, 2004-2006.

Study Population: members of our mailing list from Indonesia.

Results: 160 eligible e-mails. Pre-post intervention, puyer prescribed 67.4%-24.7% andconsumed 65.4%vs4%, respectively. The most prescribed were antibiotic, steroid,

antipyretic, antihistamines; which changed significantly post intervention.

URI: median of medicines was 5, maximum 8, puyer 77.4%.

Fever: Median 4, maximum 8 medicines, puyer 72.6%.

Diarrhea: median 3, maximum 7 medicines, puyer 55.4%.

Cough: median 4, maximum 11 medicines, puyer 87.0%. Generic for URI, Fever,

acute GE and acute cough 16.9, 9.7, 3.6, and 18.4% respectively.Pre-post intervention, types of medicine: (1) antibiotic for URI 64.6%vs3.8%; GE

40.9%vs1.7%; fever 87.3%vs6.4%; coughs 46.3% vs 5.2%; (2) ORS for GE 4.6%vs68.7%.

(3) antitussive-mucolytic 86.9%vs21.2%. Knowledge 7.4vs96.2%. Seeking information

23.2%vs96.4%.

Conclusion: Puyer opens a window toward irrational polypharmacy that are potentially

harmful and costly. Consumer education is important to reduce irrational polypharmacy

puyer and to improve patient safety.

Funding sources: Concern & Caring Parent Foundation

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INTRODUCTION

• Irrational use of medicine problems :

– In Indonesia, a survey in Denpasar, Bali, showedthat 84,4% of pediatric prescriptions contain

more than 4 active ingredients. In West

Sumatera, the average medicines perscribed for

children with URI is 3.69 medicines. A study

under the MOH, Indonesia found that theaverage number of medications for each patient

is 3,49.

– In some areas of West Sumatera, Indonesia, the

rate of antibiotic use is more than 90%.

– Data from our mailing list

([email protected]) showed that 73%

reported of having been given antibiotics.

– The highest expenditure is for antibiotics (63% of

expenditure in URI), followed by cough-cold

remedies, analgesics.

– The cost of medications for diarrhea and URI is

68% of the total cost of health care for the

under-fives and 38% for above 5 years and 36%

of total health expenditure for drugs.

mailto:[email protected]:[email protected]

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OBJECTIVES

To understand the prescribing pattern in pediatrics

• Specific objectives

– Data on polypharmacy for children with URI, fever,

coughs, acute gastroenteritis.

– Data on the prescribed medications and number

of medications for those four ailments.

– Data on the rate of antibiotic use for those 4

health conditions.

– Data on generic use in those 4 conditions.

– Data on compliance to the standard treatment

guideline.

Fig 1. Processing compounding medicines or

PUYER (clockwise)

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METHOD

• Sample Population

– Members of [email protected] mailing list

• Data collection (2004-2006) – Emailed prescriptions or prescription’s

copy for children with URI, fever, coughs

acute GE; sent by parents before and afterintervention

• Inclusion criteria:

– Emails should contain chronologicalproblems (symptoms and signs),

– Emails should mention the age and weightof the child

– Emails should report the prescriptions,the name of all the medications, clearlyand or prescriptions are sent asattachments.

• Exclusion criteria:

– Do not provide clear or complete reportsmentioned above and or

– Did not write clearly/correctly the nameof all the drugs or only mentioned someof the drugs being given for their children

– Drop out

mailto:[email protected]:[email protected]:[email protected]:[email protected]

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RESULTSTable 1. Overall picture of the prescribing pattern

URI

(55)

Fever

(43)

Diarrhea

(27)

Coughs

(41) Total medicines 260 186 83 186

Median 5 4 3 4

Max 8 9 7 11

% Puyer 77.4 72.6 55.4 87

% Antibiotics(% generics) 54.5 7 86.4 0 74.1 5 46.3 10.5

% Generics 16.9 9.7 3.6 19.4

% medicines

-Steroid

-Anti Histamine

-Anti Convulsion

-Anti Pyretics

-Supplement

61.8

50.9

16.4 36.4

21.8

41.9

53.5

55.8 79.1

34.9

44.4

18.5

11.1 29.6

51.9

60.9

36.6

14.6 17.1

2.4

Figure 2. Examples

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Table 2. Miscellaneous “medications” for URI,

fever, coughs, diarrhea

URI FEVER COUGHS DIARRHEA

Isoprinosine Isoprinosine Vit B6 Anti fever

Nonflamin

Vit B complex Ketotifen Anti

histamine

Vit B

complex

Mycostatine Isoniazide Vit V complex

Vit B6 Cobazim Cimetidine Colostrum

Nicotinamide Imboost

Colostrum

bovine

Digestive

enzyme

Becombion Cariamyl Cariamyl

Low lactose

milk

Cobazim Toplexil syr

Stimuno Polysylane

Lactobacillus Echinaceae

Transpulmin

balsam

ImboostKetotifen

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PRESCRIBING PATTERN

010

2030405060708090

100

P e r c e n t ( % )

Medicines for Fever

Generic

Branded

Medicines for URI

0

10

20

3040

50

60

70

M u c o l y

t i c s

C o r t i c o s t e

r o i d s

A n t i b i o t i c s

D e c o n g e s t a n t s

A n t i h i s t a m

i n e s

B r o n c h o d i l a t o r s

A n t i p y r e t i c s

O t h e r

A n t i c o n

v u l s a

n t s

A n t i t u s s i v

e s

A n t i e m e t i c s

P e r c e n t

( % )

Generic

Branded

Medicines for Diarrhea

01020304050607080

O R S

A n t i b i o t i c s

P r o b i o t i c s

A n t i e

m e t i c s O

t h e r

A n t i h i s t a m i n e

A n t i c

o n v u

l s a n t s

A d s o r b e n t s

A n t i m

o t i l i t y

A n t i p y r e t i c s

E n z y m e

S u p p l e m e n t

P e r c e n t ( % )

Generic

Branded

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PRESCRIBING PATTERN (2)Medicines for Cough

0102030405060708090

100

B r o n c h o

d i l a t o r s

M u c o l y t i c

s

C o r t i c o s t e

r o i d s

A n t i b i o t i c

s

A n t i h i s

t a m i n e

s

D e c o n g e s t a n t s O t h e

r

A

n t i p y

r e t i c

s

A n t i c o n v u l s a

n t s

A n t i t u

s s i v e

s

A n t i e m

e t i c s

P e r c e n t ( % )

Generic

Branded

0

10

2030

40

50

P e r c e n t ( % )

Bronchodilators for Cough

Generic

Branded

Steroids for Cough

0

10

20

30

40

50

60

B e t a

m e t h a

s o n e

D e x a

m e t h a

s o n e

M e t h y

l p r e d n i s o

l o n e

P r e d

n i s o n e

T r i a

m c i n

o l o n

P e r c e n t ( % )

Generic

Branded

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ANTIBIOTIC PRESCRIBING PATTERN

Antibiotics for Fever

0

5

10

15

20

25

A m o x i c i l l i

n e

A z i t h

r o m y c i n

C e p h a

d r o x y l

C e p h r

a d i n e

C e p h y

x i m

C h l

o r a m

p h e n i c

o l

C l a

r i t h r

o m y c i n

C o t r i m

o x a z

o l e

E r y t h r

o m y c i n

S p i r a

m y c i n

P e r c e n t ( % )

Generic

Branded

Antibiotics for Diarrhea

05

101520253035

C e p h a d

r o x y l

C h l o

r a m p h e

n i c o l

C e p h r a

d i n e

C o t r i

m o x a z o l e

M e t r o n i d a

z o l e

P o l y m

y x y n

C l o x a c i l l i n

N i f u

r o x a z i d

e

M y c o s

t a t i n

P e r c e n t ( % )

Generic

Branded

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ANTIBIOTIC PRESCRIBING PATTERN (2)

Antibiotics for Cough

0

5

10

15

20

25

A m o x i c i l l i n

e

A z i t h

r o m y c i n

C e p h

a d r o x y l

C e p h

r a d i n e

C e p h

y x i m

C e p h

a c l o

r

C l a r i t h

r o m y c i n

C o t r i

m o x

a z o l e

E r y t h r

o m y c i n

S p i r a

m y c i n

P e r c e n t ( % )

Generic

Branded

Antibiotics is the third most frequent

drug for URI (54.54%) such as:

Amoxycillin :(27,27%; mostly non

generic), followed by

cefadroxil, cefradine, spyramicine (all

together are 15,15%).

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PRESCRIBING PATTERN

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

URI GE Fever Coughs

Antibiotic Use

Pre

Post

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

ORS Antitussive

Changes of drug use

Pre

Post

Puyer consumed

65.40%

4%

Pre

Post

Puyer prescription

67.40%

24.70%P re

Post

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CONCLUSIONS

Overprescribing of symptomatic medicines

(antitussive, antiemetic, adsorbents, antipyretic) Overprescribing of antibiotics;

Overprescribing (abusive use) of steroids;

Overprescribing of none guideline related

medicines e.g antihistamines, bronchodilators,

anticonvulsants;

Overprescribing of unnecessary medicines e.g

mucolytic, decongestants (never proven to be

effective yet already banned for under 6 years)

Overprescribing of multivitamin, supplements

(e.g. immunomodulators, “appetite stimulants”)

The above-mentioned data showed that

(1) Doctors often prescribe medicines that have not

yet been proven to be effective for those 4

conditions;(2)Doctors often prescribe “strong” medicines which

harm outweigh the benefit;

(3)Doctors often prescribe supplements and

products that are not needed by these children

(4)Further study need to be conducted to convince

related parties the importance of improving

prescribing practice particularly for children

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