ACCP8-Poster TB · mixture of Rifampicin-Isoniazid-Pyrazinamid as they observed during their...
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BAMBANG SIDHARTA 1, 2 , VICKY PUSPITASARI 2 , DIANA LYRAWATI 1, 2 BAMBANG SIDHARTA , VICKY PUSPITASARI , DIANA LYRAWATI 1 Laboratory of Pharmacy, Faculty of Medicine, Brawijaya University, Malang, Indonesia 2 Department of Pharmacy, dr. Saiful Anwar General Hospital, Malang, Indonesia Tuberculosis is one of the leading mortality causes in Indonesia. Failure of tuberculosis treatment due to non-adherence to the medication contributes to high mortality rate. Prescribing of multiple drug regimens and dosing schedules may underlie such non- adherence. Th Mi i t f H lth f Id i bli h d ti l Box 1. Schematic educational program of “Simplifying antituberculotic Box 1. Schematic educational program of “Simplifying antituberculotic prescription” prescription” Explanation of the benefits of 1-mixed powdered of antituberculotic medication to the junior paeditricians. Di i ld b th h it ith dit i i The Ministry of Health of Indonesia published a new national guidelines for management of tuberculosis in 2007. According to the guidelines, unless there is any drug resistance or intolerance, antituberculotic agents are to be given in combination. For children, the recommended antituberculotic agents are Rifampicin (R), Isoniazid (H) and Pyrazinamide (Z), consumed daily for 6-12 months. In the Paediatrics Ward of our hospital, the antituberculotic agents are prescribed mostly by junior paeditricians. The common regimens were Rifampicin once daily, Isoniazid-Pyriydoxin once daily, and Pyrazinamide twice daily; in total 4-capsules a day to be taken in different time. Our previous study, conducted in Dr. Saiful Anwar Malang during the year 2003-2004, found that in 76% of all cases were due to non-adherence owing to difficulties following the different d i hdl f h ib d i b l i Discussion led by thepharmacist with paeditricians Individual communication between pharmacists and the physicians who prescribe the antituberculotic agents during actual daily practice. Monitoring and motivating paediatricians in the ward to prescribe antituberculotic agents as 1-mixed powdered drug. During the discussions, it was revealed that the paeditricians concern about the stability of the mixture of Rifampicin-Isoniazid-Pyrazinamid as they observed during their previous work in primary health centers that such mixture prepared by technician (with no background of pharmacy) was unstable. Another concern is that there is no official policy or guideline from the hospital or Department of Paediatrics specifically which recommend what so called “simple prescription of antituberculatic agents for children” dosing schedules of the prescribed antituberculotic agents. The overall goal of this project is to enhance patients compliance to antituberculotic medication in the Pediatrics Ward. Such better adherence may be gained through simplifying dosing schedule or regimens by using combination products, facilitating patients or their carers to improve their organizational skills. This study compares the pattern of prescriptions of antituberculotic medication in Pediatrics Ward to evaluate the implementation of prescribing simpler regimen of antituberculotic agents. Period Period Percentage (number) of Antituberculotic Prescriptions for Percentage (number) of Antituberculotic Prescriptions for Rifampicin + Rifampicin mixed with Rifampicin, prescription of antituberculatic agents for children . Thus, we demonstrated the dispensing and the subsequent stability analysis of the 1-mixed powdered antituberculotic drugs to the paeditricians, including Senior Pulmonologist and Head of Department of Paediatrics. These in turn led to the amendment and endorsement of the guidelines of antituberculosis prescribing in the Department of Paediatrics (Hospital Policy No. t442/38/211.2300/2008). This effects on the prescription pattern in the following months. Prescribing of Rifampicin-Isoniazid-Pyrazinamide as one powdered mixture gradually increased, up to 36% in current month (Table 1). Table 1. Pattern of antituberculotic prescriptions Table 1. Pattern of antituberculotic prescriptions Our prior study demonstrated that the stability and bioavailability of 1-mixed powdered antituberculotic agents were comparable with that of single drugs (Abiyoso, 2004). Thus, our next attempt was to socialize such results to pediatricians and to foster the prescribing of antituberculosis agents into 1-capsule or 1-mixed powdered drugs, instead of 4-capsule therapy as commonly practiced. An educational program offered by pharmacists focusing on interprofessional discussion on 1-capsule/powder of mixed Rifampicin-Isoniazid-Pyrazinamid for children was conducted in the Pediatrics Ward. Two group interprofessional discussions (pediatricians-pharmacists) led by the pharmacists as well as Isoniazid + Pyrazinamide (R+H+Z) Isoniazid + Pyrazynamide (RH+Z) Isoniazid and Pyrazinamide in one mixture (RHZ) Before discussion of antituberculotic prescribing January-March 2008 100% (837/837) 0% (0/837) 0% (0/837) After discussion of antituberculotic prescribing April 2008 69% (215/302) 31%(87/302) 0%(0/302) After policy/guideline of antituberculotic prescribing in Paediatrics Ward was rectified and endorsed May 2008 64%(191/298) 17%(50/295) 19%(57/295) June 2008 48%(151/314) 16%(49/314) 36%(114/314) individual communication during the actual prescribing daily were conducted for one month (see Box 1). These attempts were followed by formal meetings between the pharmacists in Pediatrics Ward with the Senior Pulmonologist and Head of Department of Pediatrics to produce new hospital policy about prescribing and regimens of antituberculotic medication. Subsequently, we compared the pattern of prescriptions of antituberculotic medication for in-patient and out- patients collected in our Pharmacy outlet in the Paediatrics Ward. Our results revealed that during January and March 2008 -before the discussions took place, of 837 prescriptions all were of 4-capsule Despite prescription of 1-mixed drug products have not been fully achieved, the progress so far was encouraging. We expect that prescribing of simpler regimen of antituberculotic agent will continue to increase in the following months. Further collaboration between pharmacists and the paediatricians, also with patients or their carers are to pursue to effect better outcomes in tuberculosis management. These approaches may be used as a model implemented for adults patients in other Departments in the hospital. Abijoso, 2004. Sediaan Tunggal Obat Anti Tuberkulosis Program DOTS Berbasis Pilihan Penderita, Surabaya : Program Pascasarjana Universitas Airlangga Surabaya. therapy, to be consumed separately, i.e Rifampicin once daily; Isoniazid-Pyridoxin once daily; and Pyrazinamide twice daily. Following our interprofessional discussions, evaluation of prescription collected in April 2008 showed that prescription of antibtuberculotic agents changed. Among 302 prescriptions, 31% were of two combinations i.e mixture of Rifampisin-Isoniazid- Pyridoxin once daily and Pyrazinamid twice daily (Tabel 1). Department of Health Republic of Indonesia, 2007. National Guideline for Tuberculosis Management, Jakarta: Provincial Health Office East Java. This study was funded by UK (School of Pharmacy, University of London)-Indonesia (Faculty of Medicine, Brawijaya University) Delphe Project, DFID, British Council-United Kingdom.
Transcript of ACCP8-Poster TB · mixture of Rifampicin-Isoniazid-Pyrazinamid as they observed during their...
9/1/2008
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BAMBANG SIDHARTA1, 2, VICKY PUSPITASARI 2, DIANA LYRAWATI 1, 2BAMBANG SIDHARTA , VICKY PUSPITASARI , DIANA LYRAWATI 1 Laboratory of Pharmacy, Faculty of Medicine, Brawijaya University, Malang, Indonesia
2Department of Pharmacy, dr. Saiful Anwar General Hospital, Malang, Indonesia
Tuberculosis is one of the leading mortality causes in Indonesia.Failure of tuberculosis treatment due to non-adherence to themedication contributes to high mortality rate. Prescribing of multipledrug regimens and dosing schedules may underlie such non-adherence.
Th Mi i t f H lth f I d i bli h d ti l
Box 1. Schematic educational program of “Simplifying antituberculotic Box 1. Schematic educational program of “Simplifying antituberculotic prescription”prescription”
Explanation of the benefits of 1-mixed powdered of antituberculoticmedication to the junior paeditricians.Di i l d b th h i t ith dit i iThe Ministry of Health of Indonesia published a new national
guidelines for management of tuberculosis in 2007. According to theguidelines, unless there is any drug resistance or intolerance,antituberculotic agents are to be given in combination. For children,the recommended antituberculotic agents are Rifampicin (R),Isoniazid (H) and Pyrazinamide (Z), consumed daily for 6-12 months.
In the Paediatrics Ward of our hospital, the antituberculotic agents areprescribed mostly by junior paeditricians. The common regimenswere Rifampicin once daily, Isoniazid-Pyriydoxin once daily, andPyrazinamide twice daily; in total 4-capsules a day to be taken indifferent time. Our previous study, conducted in Dr. Saiful AnwarMalang during the year 2003-2004, found that in 76% of all cases weredue to non-adherence owing to difficulties following the differentd i h d l f h ib d i b l i
Discussion led by the pharmacist with paeditriciansIndividual communication between pharmacists and the physicians whoprescribe the antituberculotic agents during actual daily practice.Monitoring and motivating paediatricians in the ward to prescribeantituberculotic agents as 1-mixed powdered drug.
During the discussions, it was revealed that the paeditricians concern about the stability of themixture of Rifampicin-Isoniazid-Pyrazinamid as they observed during their previous work inprimary health centers that such mixture prepared by technician (with no background ofpharmacy) was unstable. Another concern is that there is no official policy or guideline from thehospital or Department of Paediatrics specifically which recommend what so called “simpleprescription of antituberculatic agents for children”dosing schedules of the prescribed antituberculotic agents.
The overall goal of this project is to enhance patients compliance toantituberculotic medication in the Pediatrics Ward. Such betteradherence may be gained through simplifying dosing schedule orregimens by using combination products, facilitating patients or theircarers to improve their organizational skills.
This study compares the pattern of prescriptions of antituberculoticmedication in Pediatrics Ward to evaluate the implementation ofprescribing simpler regimen of antituberculotic agents. PeriodPeriod Percentage (number) of Antituberculotic Prescriptions for Percentage (number) of Antituberculotic Prescriptions for
Rifampicin + Rifampicin mixed with Rifampicin,
prescription of antituberculatic agents for children .
Thus, we demonstrated the dispensing and the subsequent stability analysis of the 1-mixedpowdered antituberculotic drugs to the paeditricians, including Senior Pulmonologist and Headof Department of Paediatrics. These in turn led to the amendment and endorsement of theguidelines of antituberculosis prescribing in the Department of Paediatrics (Hospital Policy No.t442/38/211.2300/2008). This effects on the prescription pattern in the following months.Prescribing of Rifampicin-Isoniazid-Pyrazinamide as one powdered mixture gradually increased,up to 36% in current month (Table 1).
Table 1. Pattern of antituberculotic prescriptionsTable 1. Pattern of antituberculotic prescriptions
Our prior study demonstrated that the stability and bioavailability of1-mixed powdered antituberculotic agents were comparable with thatof single drugs (Abiyoso, 2004). Thus, our next attempt was tosocialize such results to pediatricians and to foster the prescribing ofantituberculosis agents into 1-capsule or 1-mixed powdered drugs,instead of 4-capsule therapy as commonly practiced.
An educational program offered by pharmacists focusing oninterprofessional discussion on 1-capsule/powder of mixedRifampicin-Isoniazid-Pyrazinamid for children was conducted in thePediatrics Ward. Two group interprofessional discussions(pediatricians-pharmacists) led by the pharmacists as well as
Isoniazid + Pyrazinamide
(R+H+Z)
Isoniazid + Pyrazynamide
(RH+Z)
Isoniazid and Pyrazinamide in one
mixture (RHZ)Before discussion of antituberculotic prescribing
January-March 2008 100% (837/837) 0% (0/837) 0% (0/837)After discussion of antituberculotic prescribing
April 2008 69% (215/302) 31%(87/302) 0%(0/302)After policy/guideline of antituberculotic prescribing in Paediatrics Ward was rectified and endorsed
May 2008 64%(191/298) 17%(50/295) 19%(57/295)June 2008 48%(151/314) 16%(49/314) 36%(114/314)
(pediatricians pharmacists) led by the pharmacists as well asindividual communication during the actual prescribing daily wereconducted for one month (see Box 1). These attempts were followedby formal meetings between the pharmacists in Pediatrics Ward withthe Senior Pulmonologist and Head of Department of Pediatrics toproduce new hospital policy about prescribing and regimens ofantituberculotic medication. Subsequently, we compared the patternof prescriptions of antituberculotic medication for in-patient and out-patients collected in our Pharmacy outlet in the Paediatrics Ward.
Our results revealed that during January and March 2008 -before thediscussions took place, of 837 prescriptions all were of 4-capsule
Despite prescription of 1-mixed drug products have not been fully achieved, the progress so far wasencouraging. We expect that prescribing of simpler regimen of antituberculotic agent will continueto increase in the following months. Further collaboration between pharmacists and thepaediatricians, also with patients or their carers are to pursue to effect better outcomes intuberculosis management. These approaches may be used as a model implemented for adultspatients in other Departments in the hospital.
Abijoso, 2004. Sediaan Tunggal Obat Anti Tuberkulosis Program DOTS Berbasis Pilihan Penderita, Surabaya : Program Pascasarjana Universitas Airlangga Surabaya.
therapy, to be consumed separately, i.e Rifampicin once daily;Isoniazid-Pyridoxin once daily; and Pyrazinamide twice daily.Following our interprofessional discussions, evaluation ofprescription collected in April 2008 showed that prescription ofantibtuberculotic agents changed. Among 302 prescriptions, 31%were of two combinations i.e mixture of Rifampisin-Isoniazid-Pyridoxin once daily and Pyrazinamid twice daily (Tabel 1).
, y g j gg yDepartment of Health Republic of Indonesia, 2007. National Guideline for Tuberculosis
Management, Jakarta: Provincial Health Office East Java.
This study was funded by UK (School of Pharmacy, University of London)-Indonesia (Faculty ofMedicine, Brawijaya University) Delphe Project, DFID, British Council-United Kingdom.
