Drug treatment and prevention of malaria in pregnancy: a critical review of the guidelines.

BACKGROUND: Malaria caused by Plasmodium falciparum in pregnancy can result in adverse maternal and fetal sequelae. This review evaluated the adherence of the national guidelines drawn from World Health Organization (WHO) regions, Africa, Eastern Mediterranean, Southeast Asia, and Western Pacific, to the WHO recommendations on drug treatment and prevention of chloroquine-resistant falciparum malaria in pregnant women. METHODS: Thirty-five updated national guidelines and the President's Malaria Initiative (PMI), available in English language, were reviewed. The primary outcome measures were the first-line anti-malarial treatment protocols adopted by national guidelines for uncomplicated and complicated falciparum malaria infections in early (first) and late (second and third) trimesters of pregnancy. The strategy of intermittent preventive treatment of malaria in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) was also addressed. RESULTS: This review evaluated the treatment and prevention of falciparum malaria in pregnancy in 35 national guidelines/PMI-Malaria Operational Plans (MOP) reports out of 95 malaria-endemic countries. Of the 35 national guidelines, 10 (28.6%) recommend oral quinine plus clindamycin as first-line treatment for uncomplicated malaria in the first trimester. As the first-line option, artemether-lumefantrine, an artemisinin-based combination therapy, is adopted by 26 (74.3%) of the guidelines for treating uncomplicated or complicated malaria in the second and third trimesters. Intravenous artesunate is approved by 18 (51.4%) and 31 (88.6%) guidelines for treating complicated malaria during early and late pregnancy, respectively. Of the 23 national guidelines that recommend IPTp-SP strategy, 8 (34.8%) are not explicit about directly observed therapy requirements, and three-quarters, 17 (73.9%), do not specify contra-indication of SP in human immunodeficiency virus (HIV)-infected pregnant women receiving cotrimoxazole prophylaxis. Most of the guidelines (18/23; 78.3%) state the recommended folic acid dose. CONCLUSION: Several national guidelines and PMI reports require update revisions to harmonize with international guidelines and emergent trends in managing falciparum malaria in pregnancy. National guidelines and those of donor agencies should comply with those of WHO guideline recommendations although local conditions and delayed guideline updates may call for deviations from WHO evidence-based guidelines.

Potentially Inappropriate Prescribing in Older Adults with Hypertension or Diabetes Mellitus and Hypertension in a Primary Care Setting in Bahrain.

OBJECTIVES: The aims of this study were to evaluate: (1) the prevalence and types of potentially inappropriate prescribing in older adults with hypertension or diabetes mellitus and hypertension, and (2) whether or not differences in the training of primary care physicians were associated with potentially inappropriate prescribing. MATERIALS AND METHODS: Primary care prescriptions issued by family physicians and general practitioners were audited using Screening Tool of Older Persons' Prescriptions criteria (version 1), with 18 out of 65 applicable criteria. Descriptive statistics were used to test the difference between proportions, and two-tailed t test was used for continuous variables. RESULTS: A total of 2,090 outpatient prescriptions were written during the study period; of these, 712 (34.1%) were potentially inappropriate. The mean number of drugs per patient was 6.03 (±2.5). Of the 712 prescriptions, 543 (76.3%) were used for the treatment of acute medical illnesses. The most common examples of potentially inappropriate prescribing were: orphenadrine (n = 174; 8.33%), long-term nonsteroidal anti-inflammatory drugs for > 3 months (n = 150; 7.18%), proton pump inhibitors for > 8 weeks (n = 135; 6.46%), antihypertensive therapy duplication (n = 59; 2.82%), long-acting glyburide (n = 48; 2.29%), and chlordiazepoxide for > 1 month (n = 44; 2.11%). Family physicians showed a greater tendency toward potentially inappropriate prescribing compared to general practitioners, but the difference was nonsignificant (n = 514 [34.75%] vs. n = 162 [31.3%]; p = 0.16). CONCLUSIONS: The prevalence of potentially inappropriate prescribing (i.e., 34.1%) was within the spectrum reported worldwide and unrelated to the training backgrounds of physicians. Most of the identified potentially inappropriate prescribing (76.3%) in older adults was associated with medications for acute medical illnesses and hence inappropriate polypharmacy should be discouraged.

Prevalence of drugs with constipation-inducing potential and laxatives in community-dwelling older adults in Bahrain: therapeutic implications.

OBJECTIVES: This study evaluated the prevalence of prescribing drugs with constipation-inducing potential and the prophylactic use of laxatives in community-dwelling older adults. METHOD: An audit of outpatient prescriptions ordered for older adults aged ≥65 years with one or more chronic morbidities in 24 governmental primary healthcare centres in Bahrain. The prescriptions were collected by pharmacist-in-charge of each health centre between December 2015 and June 2016. The proportion of prescriptions with constipation-inducing drugs and co-prescribed laxatives was determined. KEY FINDINGS: The overall prevalence of prescribing drugs with the potential to cause constipation was 30.5% (642/2106). Prescriptions with at least one anticholinergic/drug with anticholinergic potential (DAP) were 22.5% (473/2106): single medication in 16.6% (350/2106) and two or more combinations in 5.9% (124/2106). A combination of two or more anticholinergics/DAP accounted for 2.9% (61/2106) prescriptions. Constipation-inducing drugs other than anticholinergics such as multivalent cation preparations and non-dihydropyridine calcium channel blockers were prescribed in 8.0% (168/2106) of cases. Orphenadrine and first-generation antihistamines, both with high anticholinergic drug burden, were the frequently prescribed medications, either alone or combined. The rate of prescribed laxatives was 2.96% (19/642), mostly for those on constipation-inducing drug monotherapy. CONCLUSION: Approximately a third of prescriptions for older adults had constipation-inducing medications, typically a single DAP. Prescribing laxatives were uncommon and did not correlate with the prevalence of prescribing drugs with constipation potential. Physicians' awareness about anticholinergic drugs and their potential risks, and the prophylactic use of laxatives to mitigate iatrogenic constipation are to be included in continuing professional programmes.

Evaluation of drug utilization and prescribing errors in infants: a primary care prescription-based study.

The purpose of this study is to evaluate the drug utilization trends and to describe the prevalence and type of medication-related prescribing errors in infants treated at primary care health centers in Bahrain. Prescriptions issued for infants were collected over a 2-week period in May 2004 from 20 health centers. Prescribing errors were classified as omission (minor and major), commission (incorrect information) and integration errors. Medications were classified according to the British National Formulary. In infants with a mean age of 6.5 months (+/-3.1) drugs per prescription were 2.52 (+/-1.1). Paracetamol and sodium chloride nasal drops were the topmost prescribed systemic and topical drugs, respectively. In 2282 prescriptions, 2066 (90.5%) were with omission (major), commission, and integration errors. In 54.1% of prescriptions with omission errors, length of therapy was not specified in 27.7%, and in 12.8% the dosage form was not stated. In 43.5% of prescriptions with errors of commission, dosing frequency (20.8%) and dose/strength (17.7%)-related errors were most common. Errors of integration such as potential drug-drug interaction comprised 2.4% of all prescribing errors. The proportion of drugs prescribed irrationally were: contraindicated medications, notably chlorpheniramine, promethazine, and corticosteroids (16.1%); medications prescribed on a p.r.n. basis (13.3%); missed information regarding strength of medications (2.8%); medications prescribed over extended periods (2.7%); low dosing frequency (2.6%); supratherapeutic doses (2.3%); excessive dosing frequency (0.8%). Irrational drug therapy in infants, with prescribing errors were apparent in primary care practice, which may be related to a lack of drug information, pharmacovigilance programme, and nonadherence to basic principles of prescribing. Establishing a national drug policy and pharmacovigilance programme for promoting rational drug use are to be considered. There is also a need to evaluate the effectiveness of interventions by measuring the outcomes.

Physician gender and antihypertensive prescription pattern in primary care.

OBJECTIVES: To determine: (i) the gender-based differences of physicians in prescribing antihypertensive drugs in the management of hypertension; (ii) the influence of patient comorbidity such as diabetes mellitus on the gender-based pattern of antihypertensive prescription, and (iii) gender-based prescription patterns among family physicians (FPs) and general practitioners (GPs). METHODS: A survey study was carried out at 15 out of 20 health centres in Bahrain during May and June 2000. A total of 3971 prescriptions, issued to 2705 patients with uncomplicated hypertension and 1266 patients with diabetic hypertension by 77 FPs (female = 54, male = 23) and 41 GPs (female = 11, male = 30), were analysed. RESULTS: As monotherapy, female physicians preferred ACE inhibitors (OR: 0.82, CI: 0.68-0.98, P = 0.033). In terms of overall drug utilization (monotherapy + combination therapy): (i) male physicians preferred beta blockers (OR: 1.17, CI: 1.03-1.31, P = 0.014) and diuretics (OR: 1.15, CI: 1.00-1.32, P = 0.047), while female physicians preferred methyldopa (OR: 0.73, CI: 0.56-0.94, P = 0.019); (ii) in uncomplicated hypertension, female physicians preferred calcium channel blockers (OR: 0.83, CI: 0.69-0.99, P = 0.038) and methyldopa (OR: 0.69, CI: 0.49-0.98, P = 0.042), and (iii) in diabetic hypertension, male physicians preferred beta blockers (OR: 1.26, CI: 1.00-1.57, P = 0.047). While female FPs prescribed methyldopa more extensively (OR: 0.66, CI: 0.47-0.92, P = 0.018), male GPs prescribed beta blockers (OR: 1.28, CI: 1.00-1.62, P = 0.046). CONCLUSIONS: Within the same practice setting, gender-based differences in the prescription of antihypertensive drugs were seen. Such preference for a particular class of antihypertensives was also influenced by the presence of comorbidity in patients and, to a limited extent, by the training level of primary care physicians.

Prescribing pattern of antihypertensive drugs by family physicians and general practitioners in the primary care setting in Bahrain.

The aim was to determine whether there are differences among family physicians (FPs) and general practitioners (GPs) in terms of their preference for different classes of antihypertensives, either alone or in combinations, in uncomplicated cases of hypertension and to determine the extent of adherence to WHO/ISH guidelines. We have analysed prescribing of antihypertensives by qualified family physicians (FPs) (n=77) and compared this with that of general practitioners (GPs) (n =41) by auditing 1791 prescriptions of FPs and 914 prescriptions of GPs, issued to patients with uncomplicated hypertension, at 15 out of 20 health centres in Bahrain. The choice of antihypertensive(s) by FPs and GPs was comparable and conformed with the WHO/ISH guidelines as regards preference for: (i) beta-blockers, angiotensin converting enzyme (ACE) inhibitors and calcium channel blockers (CCBs) as monotherapy; (ii) two-drug combinations (diuretic-beta-blocker; beta-blocker-CCB); (iii) three-drug combinations (diuretic-beta-blocker-CCB; diuretic-beta-blocker-ACE inhibitor; beta-blocker- ACE inhibitor-CCBs), and (iv) choice of drug used for the elderly either alone (CCBs) or as combinations (diuretic-beta-blocker; beta-blocker-CCB and diuretic-beta-blocker-ACE inhibitor; diuretic-beta-blocker-CCB). In several instances prescribing by both FPs and GPs was not in accordance with the WHO/ISH guidelines: reluctance to prescribe diuretics as monotherapy; use of suboptimal combinations (beta-blocker-ACE inhibitor); and extensive use of beta-blockers and irrational use of immediate-release nifedipine in elderly. A statistically significant prescribing difference between FPs and GPs was evident in the following: beta-blockers as monotherapy (P =0.01), diuretic-CCB (P=0.046), and diuretic-CCB-methyldopa (P=0.01) combination, and immediate-release nifedipine monotherapy in the elderly (P=0.027), were prescribed more often by the GPs. However, beta-blocker-ACE inhibitor-CCB combination was more often prescribed by FPs (P=0.046). Remarkable differences in prescribing pattern of antihypertensives between the FPs and GPs were evident. Although the general pattern supported a superior prescribing profile of the FPs as expected, there is a need for improved prescribing by both GPs and FPs. Educational programmes, both graduate and residency training, and continuing professional education, should specifically address these deficiencies in order to assure quality primary health care.

Topical corticosteroids in infants: prescribing pattern and prescribing errors in Bahrain.

OBJECTIVE: A nationwide, primary care-based prescription audit in infants to determine the prescribing pattern and prescribing errors of topical corticosteroid preparations in Bahrain. METHOD: Prescriptions dispensed for infants were collected for two successive weeks from 20 primary-care health centres. RESULTS: Among 2282 out of 102,084 prescriptions (2.2%) dispensed for infants, 296 (13.0%) had corticosteroids for topical application to the skin, eye and ear. Plain corticosteroids comprised 6.7%, whereas corticosteroids with antiinfectives accounted for 6.3% of topical corticosteroid preparations. Based on potency the proportions of corticosteroids prescribed were: mild (6.7%), moderately potent (2.6%) and potent (3.7%). The frequency of dosing and length of therapy were not stated in 21.6% and 43.6% of prescriptions, respectively. Base cream as a dilutional vehicle was prescribed in 11.2% (11/98) and 32.4% (12/37) prescriptions containing hydrocortisone acetate 1% cream and betamethasone valerate 0.1%, respectively. In few instances two corticosteroids were concomitantly prescribed. CONCLUSION: Prescribing moderate-to-potent topical preparations in approximately half of the infants, co-prescription of multiple corticosteroid preparations, omission of important components of prescription, and resorting to the controversial vehicle diluting technique suggest that topical corticosteroid therapy is sub-optimal. In infants, topical corticosteroids should be rationally prescribed. Establishing the treatment guidelines, pharmacovigilance programme and revision of the primary care essential drug list are needed in Bahrain.

Rational use of antimicrobials in infants in primary care of Bahrain.

This nationwide prescription-based study was undertaken to evaluate antimicrobial prescribing for infants, and to identify prescribing errors in infants in 20 primary care health centres of Bahrain. Data was collected on a daily basis by pharmacists in May 2004. Antimicrobials ranked the 5th most common drugs prescribed in infants; beta-lactams, notably amoxycillin and cephalexin, comprised 81.6% of overall prescribed antimicrobials. Antimicrobials were prescribed to approximately one out of four infants (23.8%), prescribed more often to infants aged 9-12 months of age. Approximately one-fifth (22%) of infants received antimicrobials at subtherapeutic daily doses. The prescribing errors were related to dosage (39.2%), strength/doses (26.4%), frequency of dosing (19.2%), and duration of therapy (4.5%). Antimicrobial dosage prescribed in relation to infants' age revealed a positive correlation for amoxycillin (r = 0.264; p < 0.0001), cephalexin (r = 0.223; p = 0.029), erythromycin (r = 0.127; p = 0.284), and a negative correlation for metronidazole (r = -0.183; p = 0.415). Overt use of antimicrobials in infants, and prescription-writing errors (in dosages and frequency of dosing) were common in primary care. Dosage adjustment in relation to developmental stages of infants has received inadequate attention. Effective strategies to improve prescription writing skills are urgently required.

Pharmacotherapy and blood pressure control in elderly hypertensives in a primary care setting in Bahrain.

BACKGROUND AND AIMS: Antihypertensive treatment in the elderly has important beneficial effects in terms of reduced cardiovascular morbidity and mortality. The aim of this study was to determine, in elderly hypertensives, the adherence of primary care physicians to World Health Organization/International Society of Hypertension (WHO/ISH) guidelines for the drug management of hypertension and extent of blood pressure (BP) control. METHODS: A multicentric therapeutic audit of medical records of elderly hypertensives was performed in nine primary care health centers in the Kingdom of Bahrain. RESULTS: In elderly hypertensives (> or =60 years), the WHO/ISH-1999 recommended BP targets of <140/<90 mmHg and BP<130/85 mmHg were achieved in 11.1% of elderly hypertensives and 4.1% of elderly diabetic hypertensives, respectively. Antihypertensive combination therapy was used in approximately half of the elderly. No significant difference in BP was found in elderly hypertensives treated either with monotherapy or combination therapy. As regards mono- and overall drug utilization, beta-blockers were the most frequently prescribed drugs in hypertensives, and angiotensin-converting enzyme (ACE) inhibitors in diabetic hypertensives. Diuretics and calcium channel blockers, the preferred antihypertensives for the elderly, were less often prescribed, particularly in patients with isolated systolic hypertension. CONCLUSIONS: Approximately one out of 9 elderly hypertensives and one out of 24 diabetic hypertensives achieved optimal BP control. Although preference for antihypertensives was markedly influenced by comorbidity with diabetes, tailoring of drug therapy was suboptimal and did not adhere to the recommended guidelines in elderly hypertensives. Efforts to improve the drug management of hypertension at primary care level, particularly in the elderly, are required.