GenMed 010: a one day workshop on generic medicines.

This report outlines the content of a one-day workshop on Generic Medicines that was held at KIST Medical College, Lalitpur, Nepal on 13(th) December 2010, which was attended by 32 delegates from different institutions in Nepal, including pharmacists, pharmacologists and medical doctors. Right medicine, right patient, right dose, right frequency and duration, right information and right monitoring are conditions to be fulfilled for the rational use of medicine (RUM). The World Health Organization (WHO) defines generic medicine as 'a pharmaceutical product, usually intended to be interchangeable with the innovator product, marketed after the expiry of patent or other exclusivity rights'. Economic factors, supportive legislation and regulation, public and professional acceptance and quality assurance are key enabling factors promoting use of generics. Increased patent protection for medicines and removing process patents is a key feature of new trade agreements and newer medicines for diseases like HIV/AIDS, tuberculosis and infectious diseases are likely to be more expensive. The Medicine and Therapeutics Committee (MTC) can play a key role in promoting generic medicine use in institutions.Nepal being among the Least Developed Countries (LDCs) need not provide patent protection for medicines until 31(st) December 2015. Only a few 'true' generics are available in Nepal and there is huge cost variation in the price of different branded generics. Clinicians have concerns about the quality of medicines in general, substitution of poor quality brands by pharmacists and about therapeutic substitution. Generics have to meet the same regulatory requirements and be bioequivalent to reference preparations assuring their quality.

Drug utilisation among older inpatients in a teaching hospital in Western Nepal.

INTRODUCTION: The proportion of the elderly population in Nepal, though low, is steadily increasing. Studies on drug utilisation among geriatric patients in Western Nepal, a region with the highest proportion of the elderly in all of Nepal, are lacking. The present study was carried out at the Manipal Teaching Hospital, a 700-bed teaching hospital in Pokhara, Western Nepal. METHODS: The study was carried out from June 1, 2005 to May 31, 2006 using case records of discharged patients aged 60 years and older. This was an observational study that utilised a retrospective case notes review methodology. The microorganisms isolated on culture and their antibiotic sensitivity patterns were studied. Drug consumption was measured by the defined daily dose (DDD) per 100 bed-days. The mean cost of the drugs was calculated. The percentage of drugs prescribed by generic name and the percentages of fixed-dose combinations used were noted. The basic demographic information of older inpatients, drug utilisation patterns, drug consumption using DDD, organisms isolated and their antibiotic sensitivity patterns, and the mean cost of the drugs were studied. RESULTS: A total of 548 patients were admitted. Hypertension, acute exacerbation of chronic obstructive pulmonary disease and cancer were the most common illnesses among the patients. The mean number of drugs consumed by each patient was 7.73. Escherichia coli and Pseudomonas aeruginosa were the most common microorganisms isolated. Ranitidine, multivitamins, amlodipine, ipratropium and dextrose normal saline were most commonly prescribed. The DDD per 100 bed-days of ranitidine and omeprazole (highest values) was 33.48 and 3.51, respectively. The mean cost of drugs was USD26.6, and antibiotics accounted for around 40 percent of the cost. CONCLUSION: The use of a high number of drugs, and of parenteral drugs and intravenous fluids, is a common problem. The prescription of generic drugs is low. Guidelines for the use of drugs in the elderly are required and further studies are needed on this issue.

Science attitudes and knowledge among preclinical medical students in Pokhara, Nepal.

Knowledge of science and the scientific method are important in learning about and using evidence-based medicine in practice. Courses in research methodology have been introduced for both medical students and practicing doctors. In Pokhara, the basic science subjects are taught in an integrated manner during the first four semesters of the undergraduate medical course. Studies on students' attitudes towards and knowledge of science are lacking in medical colleges in Nepal. Hence the study was carried out to obtain information on students' attitude towards and knowledge of science and scientific methodology among preclinical medical students and note the association, if any, of students' attitudes and their demographic characteristics. The study was carried out in March 2005 among the students of the first four semesters at the Manipal College of Medical Sciences, Pokhara, Nepal using a questionnaire developed by Hren and coworkers. Two hundred and twenty students (overall response rate 73.3%) successfully completed the questionnaire. Seventy-five respondents were Nepalese, 115 were Indians, 27 were Sri Lankans and 3 belonged to other nationalities. The X +/- SD total attitude score was 147.4 +/- 10.8 (neutral score 135). The X +/- SD scores on the subscales, value of science to humanity, value of scientific methodology and value of science to medicine were 51.3 +/- 5.4, 39.6 +/- 3.7 and 58.5 +/- 5.9 (neutral scores were 36, 51 and 48 respectively). The knowledge score measured using a set of 8 multiple choice questions was 3.3 +/- 1.4. The attitude scores were lower and the knowledge score was comparable to that reported previously in a study in Croatia but higher than that reported from Southeast Europe.

Can drug utilization help in promoting the more rational use of medicine? Experiences from Western Nepal.

Drug utilization research describes the extent, nature and determinants of drug use in populations and aims to facilitate the more rational use of medicines. The departments of Pharmacology and Clinical Pharmacy at the Manipal College of Medical Sciences, Pokhara, Nepal are committed to promoting the more rational use of medicines. The departments run a Drug Information Center and a Pharmacovigilance Center in the teaching hospital. Over the last eight years, the departments have conducted drug utilization studies in the teaching hospital and the community. A few of these were of the intervention type and drug use was studied before and after the intervention. Members of the departments are on the hospital Drug and Therapeutics Committee. Educational initiatives to improve prescribing have been carried out in a few instances. Restricting the number of brands in the hospital pharmacy and creation of a hospital drug list has been carried out. The impact of these initiatives has been studied only in a few cases. Generic prescribing was found to be low. The educational initiatives to improve prescribing had only limited success. The hospital is in the process of framing antimicrobial use guidelines for various departments. A hospital formulary is under preparation. The influence of drug utilization studies on the prescribing patterns has been low to moderate. The department of Clinical Pharmacy runs a Medication Counseling Center in the hospital and teaches appropriate use of medicines to patients. The studies and initiatives to promote the more rational use of medicines should be continued and strengthened.

Disease mongering.

Convincing healthy people that they are sick and require medicines can enormously expand the market. Disease mongering can turn ordinary ailments like baldness into medical problems, consider risk factors such as hypertension and osteoporosis as diseases and frame prevalence estimates to increase potential markets. In Asia, conditions like erectile dysfunction, male pattern baldness, attention deficit hyperactivity disorder and irritable bowel syndrome, and the drugs to treat them, are widely promoted. Fairness creams and traditional medicines are also widely used. The cost of disease mongering to the individual and the community is expected to be high. Some authors have argued that medicalisation of illnesses may not be a problem and the real problem may be the lack of medicines. Doctors will play a key role in combating disease mongering. Disentanglement from the pharmaceutical industry and development of a capacity for critical analysis are required. Educating patients and empowering them to make decisions are important. Several initiatives have been undertaken to combat disease mongering. Initiatives at the level of the patient and the physician are especially important. Studies on the extent and knowledge of disease mongering among doctors and medical students, and their economic and social consequences are urgently required.

Fluoroquinolone utilization among inpatients in a teaching hospital in western Nepal.

OBJECTIVE: To obtain information on the prescribing patterns of fluoroquinolones among hospitalized patients, other antibiotics and drugs co-prescribed, calculate fluoroquinolone utilization using defined daily dose (DDD), calculate mean cost of drugs and detail the sensitivity patterns of isolated microorganisms. METHODS: The study was carried out over a five-month period (1st November 2003 to 31st March 2004) at the Manipal Teaching Hospital, Pokhara, Nepal. Demographic details and duration of hospitalization was noted. The percentage of patients prescribed parenteral antibiotics and fluoroquinolones were recorded. The cost of drugs was determined using the price list supplied by the pharmacy. Fluoroquinolone utilization was measured in DDD/100 bed-days. RESULTS: Fluoroquinolones were prescribed to 263 patients during the study period; 160 females and 103 males. Mean +/- SD number of drugs prescribed and duration of hospitalization were 6.5 +/- 3.3 and 6.2 +/- 5.4 days respectively. Fluoroquinolone utilization was 7.76 DDD/100 bed-days. Ciprofloxacin was the most commonly prescribed drug (6.83 DDD/100 bed-days). Fluoroquinolones were used for prophylaxis in 110 patients (41.8%). Other indications were urinary tract infections and acute gastroenteritis. E.coli, S.aureus and P. aeruginosa were common organisms isolated. The mean cost of drugs was 13.1 U.S. $ and fluoroquinolones contributed to 36.7% of the total drug costs. CONCLUSION: The use of fluoroquinolones was high compared to that reported previously.

Pattern of potential drug-drug interactions in diabetic out-patients in a tertiary care teaching hospital in Nepal.

A prospective study was conducted at Manipal Teaching Hospital, Pokhara, Nepal to identify and analyze the pattern of the potential DDIs (drug-drug interaction) in diabetes patients. A total of 182 patients who were prescribed 685 drugs (average, 3.76 drugs per prescription) were enrolled. Patients 51 to 60 years of age had a higher risk [43 patients, or (23.6%)] of developing DDIs. It was found that 174 (92.1%) of the potential DDIs were of "moderate" severity. Cardiovascular drugs carried a risk of DDIs (187 drugs, or 49.5%). The most common potential DDI observed was between metformin and enalapril (n = 64).

Attitudes of first-year medical students towards the doctor patient relationship.

In recent years, medical schools all over the world have instituted a variety of curricula to teach communication skills, professional values and ethics to medical students. Studies on the student attitudes towards doctor-patient relationships are lacking in Nepal. The present study was carried out to obtain information on the sharing and caring dimensions of the doctor-patient relationship and note any association of the dimensions with the demographic characteristics of the respondents. The study was carried out among first year students of the Manipal College of Medical Sciences, Pokhara, Nepal in August 2003 using the patient-practitioner orientation scale. One hundred and sixty-five students participated. The mean +/- SD total, caring and sharing scores were 3.71 +/- 0.48, 3.51 +/- 0.55 and 3.91 +/- 0.62 respectively. Students whose first degree relative was a doctor had higher sharing score compared to those without doctor relatives. Female students had higher scores. Students had a positive attitude towards the doctor-patient relationship. Our scores were lower than those reported previously. Further studies are required and the results obtained will be helpful in designing a doctor-patient relationship course for Nepal.

Prescribing patterns among paediatric inpatients in a teaching hospital in western Nepal.

INTRODUCTION: Infants and children constitute a large proportion of the population in developing countries. In Nepal, studies on drug use patterns in the paediatric age group are lacking in hospitals in the western region. The present study was carried out to obtain demographical information and information on the prescribing patterns of drugs. The antibiotic sensitivity patterns of commonly-isolated micro-organisms and the mean cost of drugs were obtained. METHODS: The study was carried out over a four-month period (December 1, 2003 to March 31, 2004) at the Manipal Teaching Hospital, a tertiary care hospital in Pokhara, western Nepal. The case records of patients discharged from the paediatrics ward during the study period were analysed. Mean number of drugs prescribed was calculated. The percentage of admissions that were prescribed antibiotics was determined. RESULTS: 356 patients were admitted during the study period, of which 228 were male. The median duration of hospitalisation was four days. The mean number of drugs prescribed per admission was 4.5. 789 drugs (48.9 percent) were prescribed by the parenteral route. Antibiotics were prescribed in 249 admissions (69.9 percent). Staphylococcus aureus, Escherichia coli, and Acinetobacter species were the common organisms isolated, and were resistant in some cases to the commonly-used antibiotics. The mean (+/- standard deviation) cost of drugs per admission was 5.4 (+/-1.6) US dollars. CONCLUSION: Prescribing by generic name should be encouraged. Use of parenteral antibiotics was high and route conversion programmes should be instituted. Use of antibiotics for predominantly viral infections should be reduced. Treatment guidelines for common conditions should be formulated.

Initiating and strengthening medical student research: time to take up the gauntlet.

Self-directed learning and evidence-based medicine are becoming increasingly important in medical education. Medical student research projects can enable students to learn research methodologies and critical analysis skills. Medical schools in developed countries have introduced research programmes for medical students. A few medical colleges in developing countries have initiated student research programmes. South Asia has a huge population and massive health problems and research may be helpful in finding solutions. Student research can contribute to the published output of institutions. Research projects can help students to develop critical analysis skills, teach them to write for peer-reviewed publications and can foster student-faculty interaction. In Nepal, opportunities and funding for research are limited. Principles of scientific research should be taught to students. A community research project should be made compulsory. Funding for research should be boosted and infrastructure strengthened. Faculty members actively involved in research can serve as powerful 'role models'. Marks should be allotted for research projects and students must be encouraged to publish their findings. Publications and projects should be considered during admission to postgraduate courses. Student research should be initiated, actively pursued and strengthened.

Learning styles of preclinical students in a medical college in western Nepal.

OBJECTIVES: Information on the learning styles of medical students are lacking in medical colleges in Nepal. Learning styles may be associated with student understanding and may predict success in examination. The present study was carried out to obtain information on learning styles and preferences for teaching of fourth semester medical students and note the association, if any, between respondents' personal characteristics and preferences for learning styles and types of teaching. The correlation between preferences for learning styles and types of teaching and performance in the second year university examination was also explored. METHODS: The study was carried out during October 2003 at the Manipal College of Medical Sciences, Pokhara, Nepal using the Approaches and Study Skills Inventory (ASSIST) instrument. Information on the respondents' personal characteristics was collected. Respondents had to indicate their degree of agreement with a set of statements using a modified Likert-type scale. The statements were grouped into three main learning styles and two types of teaching. The median scores among different subgroups of respondents were compared using appropriate non-parametric tests (p<0.05). RESULTS: Ninety-two students (92%) participated; fifty-six were male. Thirty-one respondents were Nepalese, 48 were Indians. Majority were educated in English medium schools. The median scores for deep and surface learning styles were 64 and 49 respectively (maximum score=80). The scores for strategic learning was 75.5 (maximum score=100). There was no clear preference for any particular type of teaching. Indian students used more surface apathetic learning strategies compared to others. There was a negative correlation between surface learning and marks obtained in the final examination. CONCLUSIONS: The students mainly used deep and strategic learning styles. Differences in preference for learning styles and types of teaching were noted according the respondents' personal characteristics. This was a preliminary study and further studies are required.

Medication counseling center in a teaching hospital.

Patient compliance is often not achieved during drug therapy. Many reasons including lack of patients' understanding regarding medication and disease, poor socioeconomic pattern, unavailability of drugs are attributed to this situation. Providing counseling to patients can improve their understanding regarding medication, disease and life style modifications which in turn improves compliance. Medication counseling centers are one of the means to counsel the patients. The study was conducted to analyze the performance of such a center at Manipal Teaching Hospital, a teaching hospital in Western Nepal. Patients were counseled as per the Omnibus Budget Reconciliation Act-1990 guidelines and data were collected from the documentation form of the center and analyzed. Results indicated that 84.5% of the patients were directed to the medication counseling center by the pharmacists. Nearly one quarter of the population was either asthmatic or chronic obstructive pulmonary disease patients. Bronchodilators were found to be the major therapeutic category of drugs and were found in 26.7% of the patients. Among the various counseling aids, placebo inhalers were used in 45.1% of the patients. The counseling pharmacists dedicated an average time period of 6-10 minutes in about 42.1% of the patients. Language was found to be the major barrier while counseling 16.5% of the patients. The study concluded that the medication counseling center can play a definite role in enhancing patients' understanding about medications and disease pattern, which in turn may improve patient compliance.