MalaysiaStatisticsonMedicine - pharmacy.gov.my · iii ACKNOWLEDGEMENTS The National Medicines Use...

Sameerah S.A.R.Lian L.M.

2006

With contributions fromLim TO, Goh A, Faridah AMY, Nour Hanah O, Rosminah MD, Radzi H,

Menon J, Zainon A, Sharmini, Lim K, Cheng MF, GR Letchumanan, Muruga V, Zanariah H,Oiyammal C, Lim YS, Goh AS, Chong WP, Wan Azman WA, Hooi LS, Zaki M, Zawawi N, Goh BL, Fadilah O,Chang BC, Fong AYY, Sim KH, Haarathi C, Rohna R, Asmah J, Roshidah B, Muralitharan G, Tan AL, Malek R,

Lei CM, Masrahayu M, Ngau YY, Lim GC, Wan Ariffin A, M Roslan H, Mary SM, Marzida M, Choy YC, Norliza MA, Siti Nor Aizah A, Salina AA, Ramli MA, Suarn S, Noor Ratna N, Zariah AA, Hanip R, Raymond AA, Azrinorwaty Z,

Pang YK, Abdol Malek AZ, Aziah AM, Samsinah HH, Shahirah Z, Saraiza AB, Anura M, Noormah MD, Bethel L, Goh PP, Thiageswari U

A publication of thePharmaceutical Services Division and the Clinical Research Centre

Ministry of Health Malaysia

May 2009© Ministry of Health Malaysia

Published jointly by:

The National Medicines Use Survey and The National Medicines Use Survey Clinical Research Centre, Pharmaceutical Services DivisionMinistry of Health Ministry of Health3rd Floor, MMA House Lot 36, Jalan Universiti 124, Jalan Pahang 124, Jalan Pahang50286 Kuala Lumpur 46350 Petaling JayaMalaysia Malaysia Tel. : (603) 4043 9300 Tel. : (603) 7841 3200Fax : (603) 4043 9500 Fax : (603) 7968 2222e-mail : [email protected] site: http://www.crc.gov.my/nmus

This report is copyrighted. However it may be freely reproduced without the permission of the National Medicines Use Survey. Acknowledgment would be appreciated. Suggested citation is Sameerah S.A.R, Lian L.M. (Eds). Malaysian Statistics On Medicine 2006. Kuala Lumpur 2009

This report is also published electronically on the website of the National Medicines Use Survey at: http://www.crc.gov.my/nmus

Funding:The National Medicines Use Survey is funded by a grant from the Ministry of Health Malaysia (MRGGrant Number: NMUS MRG-CRC-2008-01)

9 771823 830006

ISSN 1823-8300

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PREFACE

Ensuring access to quality and affordable medicines is one important objective of Malaysia’s NationalMedicines Policy. The National Medicines Use Survey (NMUS) was conducted with the intent tocontinuously and systematically collect data on medicines in the hope to further improve its use as well asproviding a tool for better decision making in the allocation of healthcare resources for the Malaysian population.

NMUS is into its fourth year and we are glad to announce the successful publication of its third report, the Malaysian Statistics on Medicines (MSOM) 2006. It is worthwhile to note that the first report MSOM 2004 presented results largely from pilot surveys and using test methods basically to demonstrate that such a project was feasible in a healthcare system such as Malaysia that has many players. In 2005, we scaled up the survey with larger sample size and wider distribution and also refined data processing and statistical methods. For MSOM 2006, data collection was on a similar scale; the data processing was further enhanced to improve quality and the statistical methods reviewed to take into consideration stratification of hospitals which gives more accurate estimates as hospitals of different sizes may have a drug use profile. The data processing and complex statistical methods as explained in the methods section of this publication. Hence results in MSOM 2006, in our opinion are more reliable, more representative and more robust.

Eleven new chapters are added, bringing in a total of 25 in MSOM 2006 compared to the 14 chapters in MSOM 2005. We are optimistic that more chapters will be reported in future publications of MSOM.

We hope that this MSOM 2006 report will be useful to relevant healthcare professionals serving as a source of reference and baseline for embarking in future research or clinical audits towards improving rational prescribing.

We would like to thank all staff who had worked very hard in ensuring the success of the survey, all agencies and institutions that had helped in providing data, all expert panel members for their enthusiasm and contributions in completing the chapter reports and each and everyone who have in one way or another contributed to the success of NMUS and this publication.

Pharmaceutical Services DivisionClinical Research Centre Ministry of Health Malaysia

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ACKNOWLEDGEMENTS

The National Medicines Use Survey would like to thank the following for their participation, assistance, support or contributions:

• Director General of Health, Ministry of Health Malaysia• Deputy Director General of Health (Research and Technical Support), MOH• Deputy Director General of Health (Medical Services), MOH• Deputy Director General of Health (Public Health), MOH• Senior Director of Pharmaceutical Services Division, MOH• Senior Director of Oral Health Division, MOH• Director, National Pharmaceutical Control Bureau, MOH• Director, Clinical Research Centre, MOH • Principal Assistant Secretary, Procurement Division, MOH• Director, The Office of Electronic Government Application Project (EG-AG), Accountant General’s Department• Director, Government Procurement Division, MOH• Secretary, Information Management Division, MOH

• All medical doctors, pharmacists and support personnel who participated in the NMUS surveys

• All participating public and private hospitals which provided or allowed access to their medicines procurement

• Members of the NMUS Expert Panels who contributed to writing this report

• Universiti Malaysia Medical Centre, Hospital Universiti Kebangsaan, Hospital Universiti Sains Malaysia, Lumut Armed Forces Hospital, Terendak Armed Forces Hospital

• Association of Private Hospitals Malaysia, Malaysian Organisation of Pharmaceutical Industries (MOPI) and Pharmaceutical Association of Malaysia (PhAMA)

• Malaysian Medical Council, Malaysian Medical Association, Malaysian Pharmaceutical Society, The Academy of Family Physicians, Primary Care Doctors Association Malaysia, Malaysian Dental Association, Malaysian Private Dental Practitioners Association

• Pharmaniaga Logistik Sdn. Bhd. and Forte Tech Solutions Sdn. Bhd.

• All who have in one way or another supported and/or contributed to the success of the NMUS and this report

Mr. Mohd. Hatta bin Ahmad Chairman Dr. Lim Teck Onn Co-Chairman

National Medicines Use Survey, Ministry of Health Malaysia

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ABOUT THE NATIONAL MEDICINES USE SURVEY

The National Medicines Survey (NMUS) is a project initiated and supported by the Ministry of Health (MOH) to collect information on the supply, procurement, prescription, dispensing and use of drugs in Malaysia. The NMUS is designed to support the implementation of our National Medicines Policy (NMP). The objectives of NMP are to ensure only safe, efficacious and good quality medicines are available for use in Malaysia, as well as to promote equitable access to, rational and cost-effective use of these medicines,ultimately leading to improved health for all Malaysians. In supporting this, the NMUS provides the functional capacity for the collection, analysis, reporting and dissemination of data on drug utilisation in Malaysia.

The NMUS is jointly sponsored by:• Pharmaceutical Services Division, Ministry of Health• Clinical Research Centre, Ministry of Health

Purpose of the NMUSThe availability of high quality, reliable and timely information on medicines use is crucial for any discussion on improving the use of medicines in Malaysia.The objective of the NMUS is therefore to quantify the present state and time trends of medicines utilisation at various level of our health care system, whether national, regional, local or institutional.

Routinely compiled statistics on medicines utilisation have many uses, such as to:1. Estimate the number of medicines users overall, by age, sex and geography and over time. 2. Estimate on the basis of known disease epidemiology to what extent medicines are under or over-used. 3. Describe pattern of medicines use through assessing which alternative drugs are being used for particular conditions and to what extent.4. Relate the number of adverse drug reactions reported to our pharmacovigilance system to the number of people exposed to the drug in order to assess the magnitude of the problem, or to estimatethe degree of under-reporting of adverse events.5. Provide a crude estimate of disease prevalence based on its prescription rate.6. Estimate expenditure on pharmaceuticals, which constitutes a significant proportion of our healt care expenditure. 7. Monitor and evaluate the effects of interventions to improve the use of medicines. These interventions may be educational effort, promotional campaign, formulary restriction, medicines reimbursement scheme or regulatory measures.

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NMUS STEERING COMMITTEE Chairman Mr. Mohd. Hatta bin Ahmad, Deputy Director (Pharmacy Practice), Pharmaceutical Services Division, Ministry of Health Malaysia Co-Chairman Dr. Lim Teck Onn, Director, Clinical Research Centre, Ministry of Health Malaysia Members Ms. Sameerah Shaikh Abd. Rahman, Senior Principal Assistant Director, Pharmaceutical Services Division, Ministry of Health Malaysia

Dr. Faridah Aryani bt. Md. Yusof, Head, Pharmaceutical Research Unit, Clinical Research Centre, Ministry of Health Malaysia

Dr. Lian Lu Ming, Pharmacist Grade U52, Clinical Research Centre, Ministry of Health Malaysia

Ms. Siti Fauziah bt. Abu, Senior Assistant Director, Pharmaceutical Services Division, Ministry of Health Malaysia

Ms. Sarah a/p Nagalingam, Senior Assistant Director, Pharmaceutical Services Division, Ministry of Health Malaysia

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NMUS PROJECT TEAM

Chairman Mr. Mohd. Hatta bin Ahmad

Co-Chairman Dr. Lim Teck Onn

NMUS Project Staff

NMUS Project Coordinator Ms. Sameerah binti Shaikh Abdul Rahman

NMUS Project Manager Dr. Lim Chiao Mei Dr. Lian Lu Ming

Pharmacist Liaison Officer Ms. Siti Fauziah bt. Abu Ms. Sarah Nagalingam Technical Support Staff Pharmaco-Epidemiologist Dr. Faridah Aryani bt. Md Yusof Dr. Nour Hanah bt. Othman Ms. Rosminah bt. Md Din

NMUS Survey Co-ordinator Ms. Lee Kim Tin

Economist Mr. Adrian Goh

Statistician Dr. Hoo Ling Ping Ms. Norhafizah bt. Ab. Manan

IT Manager Ms. Celine Tsai Pao Chien

Database Developer/ Administrator Ms. Tang Roh Yu Ms. Lim Jie Ying Ms. Nor Afirdaus Zainal Abidin

Network Administrator Kevin Ng Hong Heng Mr. Adlan Ab. Rahman

Desktop Publisher Ms. Azizah Alimat

Webmaster Mr. Patrick Lum See Kai

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MEMBERS OF NMUS EXPERT PANELS

Expert Panel1. Antihypertensives, Steroid & Immunosuppressive, Renal Therapeutics

Members InstitutionDato Dr. Zaki Morad Mohd. Zaher (Chairperson) International Medical UniversityDr. Lim Teck Onn Clinical Research Centre, MOHDr. Zawawi bin Nordin Medical Department, Sultanah Nur Zahirah Hospital, Kuala TerengganuDr. Hooi Lai Seong Nephrology Dept., Sultanah Aminah Hospital, Johor BahruDr. Goh Bak Leong Nephrology Dept., Serdang HospitalDatin Fadilah bt. Othman Pharmacy, Selayang Hospital Ms. Manjulaa Devi a/p Subramaniam Pharmacy, Kuala Lumpur HospitalMs. Puteri Juanita bt. Zamri Pharmacy, Selayang HospitalMs. Nur Salima bt. Shamsudin Pharmacy, Selayang HospitalMs. Zarina bt. Abdul Ghafir Pharmacy, Selayang Hospital

2. Antidiabetics, Endocrine and Metabolic Therapeutics

Members InstitutionDr. G.R. Letchumanan a/l Ramanathan (Chairperson) Medical Department, Taiping HospitalDr. Muruga Vadivale Sanofi AventisDr. Zanariah Hussein Medical Department, Putrajaya HospitalDr. Sharmini Selvarajah Clinical Research Centre, MOHDr. Ariza Zakaria Clinical Research Centre, MOHMs. Cheng Mei Fen Xepa-Soul Pattinson (M) Sdn. Bhd.Ms. Oiyammal Chelliah Pharmacy, Sungai Bakap Hospital, PenangMr. Lim Kelvin Pharmacy, Penang HospitalMr. Mohd. Nazri Md. Dazali Pharmacy, Tampin Health Clinic

3. Antilipidaemia and Cardiovascular Therapeutics

Members InstitutionDr. Chang Boon Cheng (Chairperson) Cardiology Dept., Sarawak General HospitalProf. Dr. Sim Kui Hian Cardiology Dept., Sarawak General HospitalDr. Alan Fong Yean Yip Cardiology Dept., Sarawak General HospitalDr. Chong Wei Peng University Malaya Medical CentreMs. Haarathi a/p Chandriah Pharmacy, TAR Klang HospitalMs. Nirmala a/p Jagan Pharmacy, Kuala Lumpur HospitalMs. Yap Yih Jun Pharmacy, Kuala Lumpur HospitalMs. Long Mei Sim Pharmacy, Selayang Hospital

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Expert Panel4. Antineoplastic, Oncology

Members InstitutionMs. Lim Yeok Siew (Chairperson) Pharmacy, Kuala Lumpur HospitalProf. Wan Ariffin Abdullah Paediatric Oncology Dept., University Malaya Medical CentreDr. Gerard Lim Chin Chye Radiotherapy & Oncology Dept., Kuala Lumpur HospitalDr. Mohd. Roslan b. Haron Oncology Dept., Sultan Ismail Hospital, Johor BahruDr. Goh Ai Sim Haematology Unit, Medical Department, Pulau Pinang HospitalMs. Yuzlina bt. Muhamad Yunus Pharmacy, Putrajaya HospitalMs. Kamarun Neasa Begam bt. Mohd. Kassim Pharmacy, Kuala Lumpur Hospital

5. Antiinfectives

Members InstitutionMs. Sameerah bt. S.A. Rahman (Chairperson) Pharmaceutical Services Division, MOHDr. Ngau Yen Yew Medical Dept., Kuala Lumpur HospitalMs. Thong Kah Shuen Pharmacy, Raja Permaisuri Bainun Hospital, IpohMs. Masrahayu bt. Moydin Pharmacy, Selayang HospitalMs. Rahela bt. Ambaras Khan Pharmaceutical Services Division, MOHMs. Jacqueline Lai Tawau Hospital, Sabah

6. Musculo-skeletal Therapeutics

Members InstitutionDato’ Dr. Ramanathan a/l Ramaiah (Chairperson) Orthopaedics Dept., Raja Permaisuri Bainun Hospital, IpohDr. Ahmad Tajuddin b. Abdullah Orthopaedics Dept., Sultanah Nur Zahirah Hospital, Kuala TerengganuDr. Chew Chin Seong Orthopaedics Dept., Raja Permaisuri Bainun Hospital, IpohDr. Ling How Tieng Orthopaedics Dept., Raja Permaisuri Bainun Hospital, IpohMs. Aizura bt. Abdul Rahman Pharmacy, Raja Permaisuri Bainun Hospital, Ipoh

7. Analgesic and Anaesthetics Members InstitutionDr. Mary S. Cardosa (Chairperson) Anaesthesiology Dept., Selayang HospitalProf. Dr. Marzida bt. Mansor University of Malaya Medical Centre

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Expert Panel7. Analgesic and Anaesthetics

Members InstitutionClinical Assoc. Prof. Dr. Choy Yin Choy Universiti Kebangsaan Malaysia Medical CentreMs. Faizah bt. Abdul Rahman Pharmacy, Selayang HospitalMs. Norliza bt. Mat Ariffin Pharmacy, Selayang Hospital

8. Psychiatric Therapeutics

Members InstitutionDr. Siti Nor Aizah bt. Ahmad (Chairperson) Psychiatry Dept., Kuala Lumpur HospitalDato’ Dr. Suarn Singh a/l Jasmit Singh Bahagia Hospital, Tanjung RambutanDr. Ramli b. Ali Psychiatry Dept., Selayang HospitalDr. Salina bt. Abdul Aziz Psychiatry Dept., Kuala Lumpur HospitalDr. Nor Hayati bt. Ali Psychiatry Dept., Kajang HospitalMs. Mariam Bintarty bt. Rushdi Pharmacy, Kuala Lumpur HospitalMr. Syed Fadzli b. Syed Sailuddin Pharmaceutical Services Division, MOHMs. Noor Ratna bt. Naharuddin Pharmacy, Permai Hospital, Johor BahruMs. Shamini a/p Rama Pharmacy, Bahagia Hospital, Tanjung Rambutan

9. Respiratory Therapeutics

Members InstitutionDatin Dr. Aziah bt. Ahmad Mahayiddin (Chairperson) Institute of Respiratory Medicine, Kuala Lumpur HospitalAssoc. Prof. Dr. Samsinah bt. Haji Hussain Dept. of Pharmacy, University MalayaAssoc. Prof. Dr. Pang Yong Kek University of Malaya Medical CentreDr. Norhaya Mohd. Razali Medical Dept., Sultanah Nur Zahirah Hospital, Kuala TerengganuDr. Mat Zuki b. Mat Jaeb Medical Dept., Raja Perempuan Zainab II Hospital, Kota BharuMr. Abdol Malek b. Abd. Aziz Pharmacy, Malacca HospitalMs. Joanne Liew Pharmacy, Kuala Lumpur HospitalMs. Shahirah bt. Zainudi Pharmacy, Selayang Hospital 10. Gastrointestinal Therapeutics

Members InstitutionDr. Jayaram Menon (Chairperson) Medical Dept., Queen Elizabeth Hospital, SabahDato’ Dr. Muhammad Radzi b. Abu Hassan Sultanah Bahiyah Hospital, Alor StarMs. Zainon bt. Abudin Pharmacy, Selayang HospitalMs. Azuana bt. Ramli Pharmacy, Serdang Hospital

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Expert Panel11. Neurology

Members Institution Dr. Zariah bt. Abdul Aziz (Chairperson) Neurology Dept., Sultanah Nur Zahirah Hospital, Kuala TerengganuDato’ Dr. Mohd. Hanip b. Rafia Neurology Dept., Kuala Lumpur HospitalProf. Dr. Raymond Azman Ali Medical Faculty, UKM Medical Centre Ms. Norhasyimah bt. Abdul Rahman Pharmacy, Sultanah Nur Zahirah Hospital, Kuala TerengganuMs. Azinorwaty bt. Zakaria Pharmacy, Kuala Lumpur Hospital

12. Obstetrics & Gynaecology

Members Institution Dr. Muralitharan Ganesalingam (Chairperson) Obstetrics & Gynaecology Dept., Kuala Lumpur HospitalMs. Tan Ai Leen Pharmacy, Kuala Lumpur HospitalDr. Molly Cheah Primary Care Doctors Organisation Malaysia

13. Otorhinolaryngology Audiology

Members Institution Dr. Saraiza bt. Abu Bakar (Chairperson) Otorhinolaryngology Dept., Serdang Hospital Dr. Anura Michelle Manual Otorhinolaryngology Dept., University of Malaya Medical CentreMs. Normah bt. Mohd. Darus Medical Development Division, MOH

14. Dermatology

Members Institution Dr. Rohna bt. Ridzwan (Chairperson) Dermatology Dept., Selayang HospitalDr. Asmah bt. Johar Dermatology Dept., Kuala Lumpur HospitalDr. Roshidah bt. Baba Dermatology Dept., Malacca Hospital

15. Nephrology Urology

Members Institution Dr. Rohan Malek Johan Thambu (Chairperson) Urology Dept., Selayang HospitalDr. Clarence Lei Chang Moh Normah Hospital, KuchingDr. Suresh Sabaratnam Urology Dept., Selayang HospitalMs. Siti Syarihan bt. Abdullah Pharmacy, Selayang Hospital

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Expert Panel16. Ophthalmology Optometry

Members InstitutionDr. Bethel Livingstone (Chairperson) Ophthalmology Dept., Tuanku Jaafar Hospital, SerembanDr. Goh Pik Pin Ophthalmology Dept., Selayang HospitalDr. C.U. Thiageswari Ophthalmology Dept., Kuala Lumpur HospitalDr. Thayaniti a/p Sandragesu Opthalmology Dept., Tengku Ampuan Rahimah Hospital, KlangDr. Vivian Gong Hee Ming Ophthalmology Dept., Raja Permaisuri Bainun Hospital, IpohDatin Fadilah bt. Othman Pharmacy, Selayang Hospital Ms. Choong Chiau Ling Pharmacy, Selayang Hospital

17. Haematology

Members InstitutionMs. Lim Yeok Siew (Chairperson) Pharmacy, Kuala Lumpur HospitalDr. Goh Ai Sim Medical Dept., Pulau Pinang Hospital

18. Pharmacoeconomics

Members Institution Dr. Nour Hanah bt. Othman (Chairperson) Pharmaceutical Services Division, MOH Dr. Faridah Aryani bt. Md. Yusof Clinical Research Centre, MOH Ms. Rosminah bt. Mohd. Din Pharmaceutical Services Division, MOH Ms. Fatimah bt. Abdul Rahim Pharmaceutical Services Division, MOH Ms. Nadia Fareeda bt. Muhammad Gowdh Clinical Research Centre, MOH Mr. Adrian Goh Clinical Research Centre, MOH

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CONTENTS

PREFACE………………………………………………………………………………………...ACKNOWLEDGEMENTS……………………………………………………………….…….ABOUT THE NATIONAL MEDICINES USE SURVEY………………………………....….NMUS STEERING COMMITTEE………………………………………………………...….NMUS PROJECT TEAM………………………………………………………………...….....MEMBERS OF NMUS EXPERT PANELS………………………………………………...…CONTENTS……………………………………………………………………………………...METHODS……………………………………………………………………………………….ABBREVIATIONS……………………………………………………………………….……..

Chapter 1: Use of Medicines in Malaysia ................................................................................…...............Chapter 2: Expenditure on Medicines in Malaysia ................................................................….................Chapter 3: Use of Medicines for Acid Related Disorders .........................................................................Chapter 4: Use of Antiobesity Medicines …………................................................................…...............Chapter 5: Use of Antidiabetics ..............................................................................................……………Chapter 6: Use of Antianaemic Medicines…………...................................................................................Chapter 7: Use of Antihaemorrhagic Medicines…………...........................................................................Chapter 8: Use of Medicines for Cardiovascular Disorders .....................................................................Chapter 9: Use of Antihypertensives ......................................................................................………….…Chapter 10: Use of Lipid Lowering Medicines ........................................................................……..…….Chapter 11: Use of Dermatologicals ………….......................................................................……………Chapter 12: Use of Gynaecologicals, Sex Hormones and Hormonal Contraceptives ...........……………. Chapter 13: Use of Urologicals ..............................................................................……………………….Chapter 14: Use of Medicines for Endocrine Disorders ............................................................…………Chapter 15: Use of Antiinfectives ...........................................................................................…................Chapter 16: Use of Antineoplastic Agents, including Endocrine Therapy ………………….....................Chapter 17: Use of Systemic Corticosteroids and Immunosuppressive Agents......................……………Chapter 18: Use of Medicines for Rheumatological and Bone Disorders …............................................Chapter 19: Use of Opioid Analgesics … ………….. ..................................................………………….Chapter 20: Use of Medicines for Neurological Disorders …….............................................……………Chapter 21: Use of Medicines for Psychiatric Disorders ..........................................................................Chapter 22: Use of Medicines for Obstructive Airway Diseases ..............................................................Chapter 23: Use of Antihistamines & Nasal Decongesants ...……......................................…………….Chapter 24: Use of Ophthalmologicals …………..................................................................…………….Chapter 25: Use of Otologicals ...............................................................................………………………

Appendix 1: Participants of the National Medicines Use Survey

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1591315192125313943515761657783899395103111115119127

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METHODS

Authors:Lian LM1, Lim CM1, Tang RY2, Lim JY2, Hoo LP3, Faridah AMY1, Goh A, Lim TO1

1. Clinical Research Centre MOH, 2. Datamed Sdn. Bhd., 3. Clin Research Sdn. Bhd.

Introduction

The NMUS is designed, broadly speaking, to estimate the quantity and pattern of use of medicines in Malaysia, as well as to estimate our expenditure on pharmaceutical. This is an ambitious project, which requires multiple surveys at the various levels of the medicines supply and distribution chain in the country (Figure 1) in order to capture all the required data to meet its purpose. Clearly, all these could not be accomplished overnight, and of necessity must be undertaken in phases. We had realistically targeted data sources that are absolutely critical and/or accessible initially, while piloting less accessible ones, and leaving the most inaccessible data sources for the future, hoping to build on the foundation laid by earlier surveys as well as to capitalise on early successes.

Hence, the statistics on medicines use and expenditure in this report are estimated from data from only a limited number of surveys (though they were the critical ones) that could be successfully completed nation-wide or on a more local pilot basis. The scope was also deliberately limited to prescription only medicines (obviously the pharmaceuticals of greatest interest) and excludes Over-the-Counter (OTC) medicines, traditional or herbal products and food supplements. No doubt, the NMUS will mature over time as coverage of existing nation-wide surveys broaden, local pilot surveys are rolled out nation-wide, and presently less accessible data sources become available. Over time, we should be able to provide more accurate and reliable estimates, as well as more informative and detailed analyses.

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Consumer/Patients

Fig. 1 Medicines supply & distributionsystem and Sources of data

Distributor/Wholesaler

HospitalPrimary care/GP Pharmacy

Manufacturer/Importer

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NMUS Surveys

The NMUS conducts several surveys in order to capture data at the various levels of the medicines supply and distribution system in the country. The sources of data, surveys to collect the data, data availability, comments on data inclusion in this report are summarised in the table below.

# Data sources and Surveys Year data available

Inclusion in present report

1.0 Medicines import or production data 1.1 Medicines import data from Royal Malaysian Customs 2004, 2005, 2006 No 1.2 Local pharmaceutical manufacture Data not collected No 2.0 Domestic sales data 2.1 Domestic sales data from local pharmaceutical

companies Data not collected No

3.0 Medicines pr ocurement data 3.1 Public hospitals medicines procurement data from

several sources:

a. MOH procurement through central tender (APPL) 2001 to 2006 Yes b. MOH individual hospital local purchase (NonAPPL) 2001 to 2006 Yes c. University and Armed Forces ho spitals procurement 2004, 2005, 2006 Yes 3.2 Private hospitals procurement 2000 to 2006 Yes 3.3 Private GPs procurement Data not collected No 3.4 Private specialist practice procurement Data not collected No 3.5 Private pharmacies procurement Data not collected No 4.0 Medicines prescription data 4.1 Public (MOH) primary care practice prescription Limited availability No 4.2 Private GP prescription 2005, 2006 Yes 4.3 Private specialist practice prescription of highly

specialised medicines. Data not collected No

Pilot survey limited to Nephrology practices and dialysis facilities only

2001-2004 No

4.4 Hospital practice prescription Data not collected No 5.0 Medicines dispensing data 5.1 Public hospital pharmacy dispensing Data not collect ed No 5.2 Private free -standing pharmacy dispensing 2005, 2006 Yes 6.0 6.1

Household medicines consumption data Household survey on medicines consumption

Not done No

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Thus, the statistics presented in this report are derived from only a limited number of data sources. As shown above:• Of the 6 theoretical data sources, NMUS primarily targeted data sources on hospital medicines procurement and prescription/dispensing. • Collection of prescription data is limited to general clinic practices, while hospital prescription is assumed to be included in hospital procurement data.• Similarly, hospital dispensing data are assumed to be included in hospital procurement data, except of course for private free-standing pharmacies. Dispensing survey is therefore limited to the latter only. Given that private medical practitioners in Malaysia retain dispensing rights, prescription is a far more important source of data than dispensing, unlike say in Australia. • Many private medical specialists may self-procure and dispense, rather than use hospital pharmacy dispensing service. Thus, in so far that prescription of highly specialised medicines for a particular condition is concentrated in private ambulatory specialist practices (which are unlikely as most such drugs are probably prescribed in hospital setting), they will be under-estimated in this report. Separate procurement and prescription surveys on such highly specialised medicines (if any) are required.• It is well known that consumers do access medicines through both formal as well as informal channels. Household survey will be required to obtain information on such use of medicine in the community.• Finally, medicines import and sales data from pharmaceutical companies, where available, are not used for statistical estimation, but are used for reference only, and for cross-checking the reliability of results estimated from the other data sources.

Survey population, sampling and response or coverage rateThe surveys conducted by NMUS 2006, its survey population and sampling unit, sample size and the survey response or coverage rates are summarized in the table below.

# Surveys Survey population and sampling unit

Sample size Coverage or response rate, and completeness

1. MOH Pharmaceutical procurement

133 MOH hos pitals i. APPL ii. Non APPL

133 99

100% for APPL 75% for NonAPPL

2. Private hospitals pharmaceutical procurement

114 Private hospitals 34 30 %

3. University and Armed Forces hospitals pharmaceutical procurement

3 University hospitals 2 Armed Forces h ospitals

1 University 2 Armed Forces

67% for University 100% for Armed Forces

4. Private GP prescription

4459 599 13 %

5. Private pharmacy dispensing

466 23 5%

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Data collectionThe surveys conducted by NMUS collected data either by1. Download from existing databases2. Primary data collection

These are described below.

Data managementThe collected data, whether in databases or in paper or electronic data collection form, is compiled into a single database, appropriately processed and coded prior to statistical analysis.

The NMUS database was created in Ms SQL Server 2000. The application has 3 modules: Contact Management, Data Entry and Data Processing. • Contact Management module is used to collect the establishments’ survey details, log and track all the corespondence documents with SDP, and forecast, plan and schedule the conduct of the survey.• Data Entry module is used to collect the data submitted by the SDP in paper form. It has been designed to collect data from GP prescription survey and pharmacy dispensing survey using paper CRF or prescription booklets.• Data Processing module is used to clean, manage and process the medicines data prior to statistical analysis. The automated data processing functionalities include ATC coding, DDD Assignment, Total Dosage Calculation and Unit Conversions.

The database server is running on Windows 2000 Server. The server environment is Intel Xeon 2.4 Mhz, with a total of 2GB RAM memory and 67.8GP Raid5 Hard disk.

# Surveys Data download from existing databases1. MOH Pharmaceutical procurement

2. Private hospitals’ pharmaceuticalprocurement

Individual hospitals’ pharmaceutical procurement databasesIndividual hospitals’ pharmaceutical procurement databases

3. University and Armed Forces

hospitals pharmaceuticalprocurement

4. Private GP prescription A sample of GPs collected prescription data in a randomly selected week. The sample being distributed over 3 four - monthly cycle

5. Private Pharmacy dispensing A sample of pharmacies with residentpharmacist collected dispensing data in arandomly selected week. The sample beingdistributed over 3 four - monthly cycle

Pharmaniaga pharmaceutical procurement databases, central database as well as individual hospitals’ local purchase databases.

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The data processing steps are as follows:

# Data processing for downloaded database1. Data were downloaded from the existing database of the following data sources

MOH APPL ProcurementMOH Non - APPL ProcurementPrivate Hospital ProcurementUniversity Hospital ProcurementArmed Forces Hospital Procurement GP PrescriptionPrivate Pharmacy Dispensing The data downloaded could be in flat file format, e.g. TXT/XLS and etc, or database files such as Access/Oracle/SQL and etc.

2. The structure of each of the downloaded database/data file would be studiedand analysed to identify the required data fields/variables.The required variables are registration number, drug description, packagingdescription, supplier name, value procured, quantity procured, year procured and etc.

3. Next, the required fields/variables would be extracted using SQL queries. The extracted data would then be normalised by separating into multiple, related tables in a single compiled database.

4. Some of the data would require aggregation, e.g. total a few transactions on the samedrug into 1 record, to speed up subsequent query performance

5. The data would then be linked to the respective SDP in the main contact table.

# Data processing for primary survey data1. Data entry

Data is entered into the Data Entry module of the database.Prior to data entry, data entry personnel are briefed on how to use the application and enter the data. Necessary precautions were given verbally, for example, to check each clinic by office id and name, as they are clinics with many branches of the same name.A demonstration was done on data entry during the briefing.Personnel were supervised while doing the first few entries to make sure they know how to doit correctly. A standard document on steps/precautions for data entry would be mailed to each personnel.They are also given a softcopy of the list of pharmaceutical products (scheduled poison and non-scheduled poison) obtained from National Pharmaceutical Control Bureau, to cross check the spelling of drugs when the writing is less legible.

2. Edit checksSurvey forms are cross - checked against the database.Selection of survey form is by data entry personnel, randomly by survey date. If number of drug entries for selected date is not sufficient, more survey dates are included.Items to check:Number of patients are same in survey form and databaseNumber of drug entry/drug prescribed is same in survey form and database.Age, sex of patient is entered correctly.Drug particulars are entered correctly.

3. Calculations and Derived variablesDose per day is obtained by Dosage* frequency Dose per visit is obtained by Dosage* frequency * duration

4. Visual review and manual assessment of entries if there are misspellings.

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# Common data processing steps1. Registered Product List

An estimated 7000 ‘scheduled poison’ products registered with Drug Control Authority were manually coded to ATC INN (Level 5). The coded Drug Control Authority drug list would serve as an internal drug dictionary for medicines data coding later.

2. Data Parsing by programmingThe variables ‘Drug description’ and ‘Packaging Description’ in medicines (procurement/prescription/dispensing) data are parsed into smaller parts using specially written computer program. Parsing facilitates the auto-coding process and dosage calculation later.The variable ‘Drug description’ will be parsed into ‘Brand’, ‘INN’, ‘Dosage’, ‘Unit’ and ‘Route’ e.g. Zocor Tab 80 mgBrand – Zocor INN – none Dosage – 80 Unit – mg Route – Tab The variable ‘Packaging Description’ will be parsed into ‘Big Unit’, ‘Small Unit’ and ‘Factor’e.g. Pack of 10 tabsBig Unit – Pack Small Unit – tabsFactor – 10

3. ATC Coding The parsed ‘Brand’ would then be linked to the coded registered drug list to obtain the ATC INN and DDD. However, if a certain brand has more than 1 DDD, the administration route has to be considered when assigning the DDD. On the other hand, the parsed ‘INN’ would be linked to the ATC Level 5 to obtain the INN and DDD. Similarly, if a certain INN has more than 1 DDD, the administration route has to be considered when assigning the DDD. Visual review and manual coding of residual medicines data to ATC; most of these residual data are due to incomplete or inconsistent data.

4. Drug Description Dosage and UnitThe Drug Description Dosage and Unit would be the parsed ‘Dosage’ and ‘Unit’ unless more than 1 dosage exists, e.g. 2MG/ML 100ML. This kind of data would require further processing.The results of this step are ‘Total Drug Description Dosage’ and ‘Total Drug Description Unit’.Remaining residual has been handled manually.

5. Packaging Description DosageThe packaging description dosage would be taking the parsed ‘Factor’ and calculated with reference to the ‘SKU’ or ‘UOM’. The result of this step is the ‘Total Packaging Description Dosage’.Remaining residual has been handled manually.

6. Total Dosage CalculationTotal Dosage = Total Drug Description Dosage* Total Packaging Description Dosage* Quantity procured.Total Dosage Unit = Total Drug Description Unit.

xix

Statistical reportThis statistics on use of medicines in this report are presented using the Anatomical Therapeutic Chemical (ATC) classification system, and the unit of measurement is expressed in Defined Daily Dose (DDD). This is recommended by the WHO to be used for drug utilisation research and for purpose of comparisons of drug consumption statistics between countries, between regions or population groups within country and to evaluate trends in drug use over time.

Structure of the ATC Classification systemIn this system, medicines are divided into different groups according to the organ or system on which they act, and on their chemical, pharmacological and therapeutic properties.

Medicines are classified in groups at 5 different levels as follows:

An example should make this clear. Simvastatin is coded C10AA01. The structure of its code is as follows:

Refer to the publication Guidelines for ATC Classification and DDD Assignment (WHO Collaborating Centre for Drug Statistics Methodology 2003; www.whocc.no) for details.

Concept of the Defined Daily Dose (DDD)

The measurement unit for medicines use adopted in this report is the DDD. The DDD is the assumed average maintenance dose per day for a drug used for its main indication in adults. The DDD is simply a technical measure of drug utilisation; it does not necessarily agree with the recommended or prescribed daily dose. Doses for individual patients and patient groups will often differ from the DDD. The DDD is often a compromise based on review of the available information about doses used in various countries. The DDD may even be a dose rarely prescribed because it is an average of two or more commonly used doses.

Medicines use statistics in this report are presented for most drugs as numbers of DDDs per 1000 inhabitants per day. Some interpretative notes are as follows:• The DDDs/1000 inhabitants/day provides a rough estimate of the proportion of population treated daily with certain drugs. For example, the figure 10 DDDs/1000 inhabitants/day indicates that 1% (10/1000) of the population on average might get a certain drug or group of drugs every day in the year. • The DDDs/1000 inhabitants/day is most useful for drugs used in the treatment of chronic diseases and especially when there is a good agreement between the average prescribed daily dose and the DDD. • For most drugs, their DDDs/1000 inhabitants/day are calculated for the total population including all age and sex groups. Where a drug use is limited to particular age or sex groups, then it will be more meaningful to express the figure for the relevant age-sex groups only. For example DDDs/1000 children age<12/day, or DDDs/1000 women in reproductive age groups/day.

Level Group and subgroups 1 Anatomical main group. There are 14 of these, eg C cardiovascular,

M musculo-skeletal, R respiratory, etc

2 Therapeutic main group 3 Therapeutic subgroup 4 Chemical or Therapeutic subgroup 5 Drug chemical substance

Level 1 2 3 4 5

Group and subgroups Cardiovascular system

Serum lipid reducing agents Cholesterol or triglyceride reducers

HMG CoA reductase inhibitors

CodeCC10C10AC10AAC10AA01 Simvastatin

For anti-infectives (or other drugs normally used in short duration), the medicine use statistics are presented as DDD per inhabitant per year. This gives an estimate of the number of days for which each inhabitant is, on average, treated annually. For example, 5 DDDs/inhabitant/year indicates that the utilisation is equivalent to the treatment of every inhabitant with a 5-days course in the year.

In interpreting drug utilisation statistics using DDD, as in this report, readers are cautioned to bear in mind the following limitations:• A medicine may have several indications while the DDD is based on the main indication in adults.• Medicines procured, prescribed or dispensed, as presented here, may not necessarily be consumed.• DDD may be difficult to assign or not assigned at all for certain medicines, for example medicines with multiple ingredients, topical products, anti-neoplastic drugs and anaesthetic agents.• Medicines newly introduced into the market may yet have ATC and DDD assigned to it.• The DDD assigned to a drug is primarily based on other countries’ experience and may not reflect the commonly prescribed adult dose in Malaysia.

Statistical MethodsIn NMUS report, the quantity of use of a medicine is expressed as, depending on the type of medicine, thenumber of DDDs per 1000 inhabitants per day or DDDs per inhabitants per year. These statistics are calculated as follows:

DDDs/1000 inhabitants/year =

DDDs/1000 inhabitants/year =

Where is an estimate of the total quantity of the drug utilised in the year under consideration,DDD is the DDD assigned for the drug according to the ATC/DDD system,P is the mid-year population of Malaysia, 365 refers to the 365 days in a year

In either case, an estimate of the total quantity of the drug being utilised in the year is required, and this must be expressed in the same unit as the DDD assigned for the drug. The statistical estimation of the totals varies depending on the survey method and the sampling design employed to collect the data, and if necessary with adjustment for incomplete data. These are described below.

ˆ *1000* *365

TDDD Pˆ *1000

*Tddd P

T̂

2. i) MOH Pharmaceutical procurement: Non APPL

Data were available for only a sample of hospitals.

The total is estimated by T̂ = ∑∑= =

jI

i jijTw

1

4

1

# Surveys Estimation procedure 1 MOH Pharmaceutical

procurement: APPL No sampling was employed in the survey due to full response.Therefore the total is the sum of all the quantities of the drug procured in all procurement records in the year.

The total is ∑=

=I

iiTT

1

ˆ

where iT is the value of the quantity of drug procured of the ith

hospital in the year.

xx

xxi

Where there is sampling or where response rate of the survey was less than 100%, the procedures described above incorporate the sampling weight of the sampling unit in the estimation of total.

# Surveys Estimation procedure

iT i

jjjjj

j

jj b

Bw =

j Bjbj j

∑∑= =

=I

i jijiTwT

ijT it

j i

ii d

DnN

w ×=

N nD

idi

xxii

The sampling weight for each sampling unit or unit of analysis has the following components:

1. Probability of selection. The basic weight is obtained by multiplying the reciprocals of the probability of selection at each step of sampling design. Example, for GP prescription survey, this is GP practice and prescription day.

2. Adjustment for non-response.The response rate was less than 100% for some surveys; an adjustment to the sampling weight is required. The non-response adjustment weight is a ratio with the number of units in the population as the numerator and the number of responding sampling units as the denominator. The adjustment reduces the bias in anestimate to the extent that non-responding units have same characteristics as responding units. Where this isunlikely, some adjustments took into account differences in some relevant characteristics between responding and non-responding units that may influence drug utilisation, such as bed strength, staff strength, scope of services for hospitals etc.

Expenditure estimation methodologyStudy PopulationThe MSOM encompasses private & public healthcare providers in Malaysia consisting of -1. The public health sector which consists of hospitals and primary care clinics of the Ministry of Health, University Hospitals under the Ministry of Higher Education and Military Hospitals under the Ministry of Defence. 2. The Private health sector consisting of private hospitals and general practitioners in Malaysia.3. Private sector retail pharmacies.

MethodologyThe expenditure on a particular drug in a given year is the quantity of drug used in that year multiplied by the price of the drug.

Total expenditure = Quantity of drug utilisation * Price of drug.

Quantity of drug utilisation is determined from the drug utilisation data presented elsewhere in this report.

Median prices were determined for each drug chemical substance (5th level ATC classification) and denominated in Daily Defined Doses (DDD) for the public and private sectors taking into account the availability of price data and analytical considerations. Thus there are two prices (i.e. public sector and private sector median price) for each drug chemical substance.

The expenditure for each procurement item is then calculated as Ei = p50i * DDDi where p50 is themedian price, DDD is the quantity of utilisation and “i” refers to the drug chemical substance. The total expenditure on a drug chemical substance in a particular sector is the sum of all procurement, prescription and dispensing of the item items in that sector. The total expenditure for the country is the sum of total expenditure in all the sectors.

Prices were determined for the public sector from procurement data of MOH, University and Armed Forces health establishments surveyed by NMUS while private sector prices were determined from procurement data of private hospitals surveyed by NMUS. As the GP prescription & retail pharmacy dispensing data obtained by NMUS did not contain any data usable for calculating prices, the prices estimated from private hospitals were applied to GP and Pharmacy data as well.

xxiii

ABBREVIATIONS

ACEI Angiotensin Converting Enzyme InhibitorsAF Atrial FibrillationAPPL Approved Product Price ListARB Angiotensin II Antagonists/Angiotensin Receptor BlockerASR Age Standardized RateATC Anatomical Therapeutic ChemicalBCF Bias Correction FactorBPFK Biro Pengawalan Farmaseutikal KebangsaanCCB Calcium Channel BlockersCCF Congestive Cardiac FailureCOAD Chronic Obstructive Airway DiseaseCPG Clinical Practice GuidelinesCTZ ChlorothiazideDALYs Disability Life YearsDDD Defined Daily DoseDept DepartmentFDA Food And Drug AdministrationGERD Gastroesophageal Reflux DiseaseGP General PractitionerHCTZ HydrochlorothiazideHDL High Density LipoproteinHMG CoA 3-hydroxy-3-methylglutaryl coenzyme AH2RA H2 Receptor AntagonistICU Intensive Care UnitINN International Nonproprietary NameISAAC International Study of Asthma and Allergies in ChildhoodKL Kuala LumpurLDL Lipoprotein LevelsLMWH Low Molecular Weight HeparinMOH Ministry of HealthNCC National Cancer CentreNCI National Cancer InstituteNMP National Medicines PolicyNMUS National Medicines Use SurveyNPCB National Pharmaceutical Control BureauNSAIDs Non Steroidal Anti- Inflammatory DrugsOTC Over-the-CounterPCDOM Primary Care Doctors Organisation MalaysiaPPI Proton Pump InhibitorsRE Reflux EsophagitisSDP Source Data ProducerSERM Selective Estrogen Receptor ModulatorSKU Stock Keeping UnitSSRI Serotonin Selective Reuptake InhibitorUOM Unit of MeasurementURTI Upper Respiratory Tract InfectionWHO World Health OrganisationWP Wilayah Persekutuan

CHAPTER 1USE OF MEDICINES MALAYSIA Malaysian Statistics on Medicines 2006

1

Edited by:Lim TO1, Nadia Fareeda MG1, Lian LM1, Sameerah SAR2, Mohd. Hatta A2, Faridah AMY1

1. Clinical Research Centre MOH 2. Pharmaceutical Services Division MOH

In this chapter, we report an overview of the national estimates for the use of medicines in Malaysia. It describes the most commonly used medicines by therapeutic groups and by specific drugs. The scope of the National Medicines Use Survey (NMUS) was deliberately limited to prescription medicines only and excluded Over-the-Counter (OTC) medicines, traditional or herbal products and food supplements.

Generally, the measurement unit for medicines use adopted in this report is the DDD [1] which is the assumed average maintenance dose per day for a drug used for its main indication in adults. The DDD is simply a technical measure of drug utilisation; it does not necessarily agree with the recommended or prescribed daily dose.

In this chapter, the utilisation data are presented only for drugs that have assigned DDDs, and the estimatesare expressed as number of DDDs per 1000 population per day; medicines without DDDs are excluded.

However, in other chapters of this publication, utilisation of some medicines of interest that do not have DDDs are also discussed. In those chapters, the statistics are presented in terms of weight of active ingredient/1000 population per day (Anti-neoplastic drugs), or weight or volume of drug preparations per 1000 population per day (Dermatologicals, Ophthalmologicals and Otologicals).

Among the therapeutic groups, drugs used in diabetes (A10) ranked highest in terms of utilisation in Malaysiafor the year 2006 (Table 1.1). An estimated 4.0% of the Malaysian population was on this group of drugs in 2006 of which glibenclamide (1.6% of the population) and metformin (1.3% of population) were most used. Other commonly used diabetic drugs include gliclazide and Insulins and analogues, intermediate-actingcombined with fast-acting (human) with each ranking 9th and 37th among the top 40 drugs by utilisation. Theutilisation of these drugs was heavily skewed towards the public sector with utilisation of more than fourtimes that of the private sector, suggesting an imbalance in the disease burden borne. (Table 1.2)

Of the top 40 drugs listed by utilisation, 18 were drugs used for cardiovascular diseases (ATC group C and acetylsalicylic acid B01A C06). Drugs used for the treatment of hypertension were among the highest in terms of utilisation. Collectively 6.8% of the population were on at least one of these drugs which include beta-blocking agents (2.6% of population), calcium channel blockers (1.9% of population)), agents acting on the renin-angiotensin system (2% of population) and antihypertensives (0.3% of population). Prevalence of hypertension among Malaysians aged 30 years and above in 2006 was estimated to be 42.6% and among them only 31.4% were on current treatment [2]. A study conducted by Rampal et al in 2004 estimated that only 34.6% of the study participants with hypertension were aware of their condition and on pharmacotherapy, and of these only 26.6% had adequate blood pressure control [3]. Although utilisation of medicines for the treatment of hypertension seemed high, poor awareness and under treatment of this disease are issues that need to be addressed. (Table 1.2)

Lipid modifying agents ranked 5th for therapeutic groups by utilisation, with 1.7% of the population prescribed these drugs. Simvastatin, lovastatin and atorvastatin constituted 41%, 30% and 18% of the total use respectively. Utilisation of lovastatin was approximately 8 times more in the public sector compared to the private sector, and conversely the use of atorvastatin in the private sector was more than twice the utilisation in the public sector. This suggested a difference in prescribing preference and trend between these parallel healthcare providers in the country which was very much influenced by cost. Australian data showed that atorvastatin was the most used lipid modifying agent compared to simvastatin and lovastatin. Atorvastatin was the top drug ranked by DDD whereas simvastatin ranked 2nd and lovastatin was not among the top 10 [4]. Given the expected trends of increasing serum cholesterol and coronary heart disease in most Asian countries, utilisation of this group of drugs are expected to increase in the future [5].



2

Drugs used for obstructive airway diseases (R03) ranked 6th by utilisation with inhaled salbutamol (R03AC02) being the commonest drug used (0.4% of population). Chlorpheniramine and prednisolone wereclearly drugs of choice as their utilisation were highest in their groups, antihistamines for systemic use (R02) and steroids for systemic use (H02) respectively. Among the antiinflammatory and antirheumatic products (M01), utilisation of diclofenac (M01A B05) was highest (0.4% of population).

Interestingly, although the prevalence of psychiatric morbidity estimated by NHMS III was 11.2%, psycholeptics (N05) and psychoanaleptics (N06) only ranked 15th and 20th among therapeutic groups listed by utilisation and none of the individual drugs in the N05 or N06 groups were in the top 40 drugs listed by utilisation.

Detailed discussions on the specific therapeutic groups can be found in the respective chapters.

The NMUS, amongst other objectives, is designed to support the implementation of the National Medicines Policy. Hence it is pertinent to note that 36 (90%) of the top 40 most utilised drugs were in the Malaysian National Essential Drugs List (NEDL) [5]. Of these 36 drugs, 6 of them were listed under the NEDL Supplementary List, which lists drugs that are designated as those used by specialists for tertiary level treatment. This indicated good accessibility to essential drugs generally, with reasonable availability and utilisation of higher-end drugs for specialists care.

Of the four drugs in the top 40 which were not in the NEDL, two of them were the statins i.e. Lovastatin (C10A A02) and Atorvastatin (C10A A05), and the other two being Cetirizine (R06A E07), an antihistamine, and Losartan (C09C A01), a cardiovascular drug acting on the renin-angiotensin system. There are alternative drugs from the NEDL which are in the top 40 for these groups of drugs, and it may be interesting to study in greater detail the utilisation of these four drugs compared to their corresponding alternatives listed in the NEDL.

Table 1.1: Top 30 Therapeutic groups by Utilisation in DDD/1000 population/day 2006NO. ATC THERAPEUTIC GROUP PUBLIC PRIVATE TOTAL 1 A10 DRUGS USED IN DIABETES 32.792 7.5037 40.2957

2 C07 BETA BLOCKING AGENTS 21.3322 4.4021 25.7343 3

C09

AGENTS ACTING ON THE RENIN-ANGIOTENSIN SYSTEM

4 C08 CALCIUM CHANNEL BLOCKERS 15.941 3.4246 19.3656

5 C10 LIPID MODIFYING AGENTS 8.639 8.5206 17.1599

6 R03 DRUGS FOR OBSTRUCTIVE AIRWAY DISEASES

7 C03 DIURETICS 11.775 2.8894 14.6643

8 R06 ANTIHISTAMINES FOR SYSTEMIC USE 5.1758 6.9945 12.1703 9

M01

ANTIINFLAMMATORY AND ANTIRHEUMATIC PRODUCTS

3.9519

6.0516

10.0035

10 B01 ANTITHROMBOTIC AGENTS 5.8947 3.9402 9.835

11 J01 ANTIBACTERIALS FOR SYSTEMIC USE 3.8147 5.1222 8.9369

12 A02 DRUGS FOR ACID RELATED DISORDERS 2.5009 2.656 5.1568

13 C01 CARDIAC THERAPY 2.7994 1.8969 4.6961

14 H02 CORTICOSTEROIDS FOR SYSTEMIC USE 1.9061 2.5407 4.4467

15 N05 PSYCHOLEPTICS 3.0503 0.9951 4.0454

16 C02 ANTIHYPERTENSIVES 2.9987 0.2328 3.2315

17 H03 THYROID THERAPY 1.4486 0.5478 1.9964

18 M04 ANTIGOUT PREPARATIONS 1.0294 0.5053 1.5347

19 N03 ANTIEPILEPTICS 1.3457 0.1535 1.4992

20 N06 PSYCHOANALEPTICS 0.8941 0.4223 1.3163

13.8264 5.7554 19.5818

9.8198 6.6997 16.5194


3

NO. ATC THERAPEUTIC GROUP PUBLIC PRIVATE TOTAL 21 J04 ANTIMYCOBACTERIALS 0.9993 0.0997 1.099

22 N07 OTHER NERVOUS SYSTEM DRUGS 0.4341 0.6421 1.0762

23 N04 ANTI-PARKINSON DRUGS 0.8293 0.0527 0.882

24 N02 ANALGESICS 0.382 0.4137 0.7957

25 M03 MUSCLE RELAXANTS 0.0658 0.5474 0.6131

26 J05 ANTIVIRALS FOR SYSTEMIC USE 0.495 0.0688 0.5638

27 M05 DRUGS FOR TREATMENT OF BONE DISEASES 0.2633 0.1767 0.4399

28 J02 ANTIMYCOTICS FOR SYSTEMIC USE 0.0519 0.2735 0.3253

29 L02 ENDOCRINE THERAPY 0.1937 0.0906 0.2844

30 P01 ANTIPROTOZOALS 0.1787 0.1013 0.28

Table 1.2: Top 40 Drugs by Utilisation in DDD/1000 population/day 2006NO. ATC THERAPEUTIC GROUP PUBLIC PRIVATE TOTAL 1 A10B B01 Glibenclamide 14.0329 1.5023 15.5352

2 A10B A02 Metformin 11.1397 2.0109 13.1506

3 C07A B02 Metoprolol 11.7536 0.5828 12.3365

4 C07A B03 Atenolol 9.077 2.9516 12.0287

5 C08C A05 Nifedipine 10.9355 0.6772 11.6127

6 B01A C06 Acetylsalicylic acid 4.8358 2.5826 7.4184

7 C10A A01 Simvastatin 2.6378 3.9287 6.5665

8 C03A A04 Chlorothiazide 6.2441 0.0355 6.2796

9 A10B B09 Gliclazide 4.593 1.3678 5.9608

10 C08C A01 Amlodipine 3.2803 1.9924 5.2728

11 C03C A01 Furosemide 3.9301 0.9588 4.8889

12 C09A A04 Perindopril 4.3301 0.3811 4.7113

13 C10A A02 Lovastatin 4.0507 0.5157 4.5664

14 C09A A02 Enalapril 3.5113 0.9827 4.4939

15 R03A C02 Salbutamol 4.024 0.3237 4.3477

16 C09A A01 Captopril 4.1067 0.1984 4.3051

17 R06A B04 Chlorpheniramine 2.5619 1.3908 3.9527

18 M01A B05 Diclofenac 1.4652 2.1248 3.59

19 C10A A05 Atorvastatin 0.786 2.537 3.323

20 R03C C03 Terbutaline 0.1697 2.8792 3.049

21 M01A G01 Mefenamic acid 1.2609 0.284 1.545

22 H02A B06 Prednisolone 1.1766 1.3428 2.5194

23 R03C C02 Salbutamol 0.6566 1.8439 2.5005

24 C02C A01 Prazosin 2.234 0.0961 2.3301

25 R06A X13 Loratadine 0.7417 1.436 2.1777

26 J01C A04 Amoxicillin 0.698 1.4018 2.0998

27 C08C A02 Felodipine 1.3805 0.4422 1.8227

28 R03B A02 Budesonide 1.5432 0.1962 1.7393

29 R06A E07 Cetirizine 0.2259 1.5065 1.7324

30 A02B A02 Ranitidine 1.1741 0.539 1.7131

31 R03D A04 Theophylline 1.1004 0.4886 1.589

32 A02B C01 Omeprazole 0.5889 0.9111 1.5

33 C01E B15 Trimetazidine 0.6345 0.804 1.4386

34 R06A B02 Dexchlorpheniramine 0.0486 1.3559 1.4045

35 C01D A08 Isosorbide dinitrate 1.2768 0.0932 1.3699 36

C03A A03 Hydrochlorothiazide and potassium-sparing agents

1.0077

0.3358

1.3434


4

NO. ATC THERAPEUTIC GROUP PUBLIC PRIVATE TOTAL 37

A10A D01

Insulins and analogues, intermediate-acting combined with fast-acting (human)

1.1299

0.1955

1.3255

38 M04A A01 Allopurinol 0.9627 0.3601 1.3277

39 R06A D02 Promethazine 0.8492 0.4305 1.2797

40 C09C A01 Losartan 0.5202 0.5978 1.1179

References:1. Complete ATC/DDD Index and Guidelines for ATC Classification and DDD Assignment (WHO Collaborating Centre for Drug Statistics Methodology 2007; www.whocc.no)2. Institute of Public Health (IPH) 2008. The Third National Health and Morbidity Survey (NHMS III) 2006, Vol 1. Ministry of Health, Malaysia.3. L Rampal, S Rampal, MZ Azhar, AR Rahman. Prevalence, awareness, treatment and control of hypertension in Malaysia: A national study of 16 440 subjects. Public Health. 2008 Jan; 122 (1):11-18; 4. Commonwealth of Australia 2008. Australian Statistics on Medicines 2006 Online ISBN: 1-74186-516-6 Available from http://www.health.gov.au/internet/main/ publishing.nsf/Content/health-pbs- general-pubs asm.htm5. Khoo KL, Tan H, Liew YM, Deslypere JP, Janus E. Lipids and coronary heart disease in Asia. Atherosclerosis. 2003 Jul; 169(1):1-10;6. The National Essential Drug List (Malaysian) (http://www.pharmacy.gov.my/html/pharma_care_nedl_f.htm as at 18 March 2009)

CHAPTER 2EXPENDITURE ON MEDICINES IN MALAYSIA Malaysian Statistics on Medicines 2006

5


Edited by:Faridah AMY1, Nour Hanah O2, Rosminah MD2, Fatimah AR2, Nadia Fareeda MG1, Goh A3

1. Clinical Research Centre MOH, 2. Pharmaceutical Services Division, MOH, 3. ClinResearch Sdn. Bhd.

In this section we looked at the estimated drug expenditure in Malaysia in 2006. As expected, the highest expenditure recorded that year was for amlodipine (C08C C01). This drug was also among the top 10 drugs utilised in 2006, reflecting the high prevalence of hypertension in the Malaysian population (42.6% for adults aged 30 years and above). The highest expenditure incurred in the public and private sectors were for metoprolol (C07A B02) and atorvastatin (C10A A05) respectively. The pattern of drug expenditure differed between the public and private sectors as shown in Table 2.1 and Table 2.3. Private sector expenditure was inclined towards newer and therefore more costly drugs, such as atorvastatin and clopidogrel (B01A C04).

When compared by therapeutic groups, the highest expenditure was incurred for drugs used in diabetes (A10) as shown in Table 2.2. This correlated to the high prevalence of diabetes mellitus in the country (14.9% for adults aged 30 years and above). When compared by sector, the public sector expenditure was concentrated on drugs used in diabetes whereas lipid modifying agents (C10) topped the list for the private sector as shown in Table 2.4.

Looking at the Australian expenditure statistics for 2006, atorvastatin, simvastatin (C10A A01) and esomeprazole (A02B C05) were the top 3 drugs by expenditure as shown in Table 2.3 with lipid modifying agents being the highest expenditure therapeutic group as shown in Table 2.4.

The analysis in this chapter was conducted on the top 150 drugs by utilisation only. Therefore drugs that were costly but very low in utilisation were not included in the analysis. Certain drugs under the antineoplastic and immunomodulating agents’ anatomical main group (L) may have appeared in the top 50 by expenditure if the group was included.

Table 2.1: Top 50 Drugs by Expenditure in RM ‘000

Rank ATC Drugs Public Private Total 1 C08C A01 Amlodipine 20,870 9,913 30,783

2 C10A A05 Atorvastatin 6,691 19,876 26,568

3 C07A B02 Metoprolol 22,406 2,676 25,082

4 C10A A01 Simvastatin 7,143 14,647 21,790

5 J01D C02 Cefuroxime 13,910 7,654 21,564

6 A10B A02 Metformin 14,558 6,091 20,649

7 A10B B09 Gliclazide 12,636 6,790 19,426

8 N05A X08 Risperidone 18,622 190 18,812

9 C07A B03 Atenolol 7,785 10,683 18,468

10 C09A A01 Captopril

11 C09A A02 Enalapril 17,010 1,120 18,130

12 B01A C04 Clopidogrel 15,455 2,277 17,732

13 B03X A01 Erythropoietin 2,288 14,374 16,662

14 J01C R02 Amoxicillin and enzyme inhibitor 9,347 6,331 15,678

15 M01A B05 Diclofenac 5,755 9,459 15,214

16 A02B C01 Omeprazole 668 14,502 15,171


6

Rank ATC Drugs Public Private Total 17 A10A D01 Insulins and analogues, intermediate-acting

combined with fast-acting (human) 4,429 10,209 14,639

18 C08C A05 Nifedipine 11,520 1,721 13,241

19 C08C A02 Felodipine 8,750 4,165 12,916

20 R03B A01 Beclometasone 10,526 2,218 12,744

21 C09A A04 Perindopril 8,394 3,276 11,670

22 A02B A02 Ranitidine 8,212 1,861 10,073

23 C09C A01 Losartan 4,511 5,310 9,821

24 A10B F01 Acarbose 5,728 3,919 9,647

25 B01A C05 Ticlopidine 8,163 965 9,128

26 A10A B01 Insulins and analogues, fast-acting (human) 2,849 5,691 8,539

27 R06A E07 Cetirizine 5,831 2,511 8,341

28 A10A C01 Insulins and analogues, intermediate-acting (human)

197 8,052 8,249

29 J01F A01 Erythromycin 6,080 1,950 8,030

30 R03A C02 Salbutamol 5,550 2,461 8,011

31 C07A A05 Propranolol 6,613 1,001 7,614

32 R03B A02 Budesonide 129 7,480 7,609

33 M05B A04 Alendronic acid 6,097 1,038 7,136

34 A10B B01 Glibenclamide 5,659 1,384 7,043

35 R03A K06 Salmeterol and other drugs for obstructive airway diseases

2,513 4,294 6,807

36 R03A C13 Formoterol 2,150 4,473 6,623

37 N03A G01 Valproic acid 6,363 61 6,424

38 J01C F02 Cloxacillin 5,663 717 6,380

39 R03C C02 Salbutamol 5,417 769 6,185

40 R06A A02 Diphenhydramine 539 5,502 6,041

41 R03C C03 Terbutaline 5,316 609 5,925

42 K07R03A Formoterol and other drugs for obstructive airway diseases

399 5,192 5,590

43 J01C A04 Amoxicillin 2,054 3,243 5,298

44 A10B G02 Rosiglitazone 1,140 4,066 5,206

45 M01A H01 Celecoxib 2,767 2,438 5,205

46 C02C A01 Prazosin 4,530 620 5,150

47 R06A X13 Loratadine 423 4,696 5,119

48 C10A B04 Gemfibrozil 4,742 83 4,825

49 M01A H05 Etoricoxib 463 4,218 4,681

50 C01E B15 Trimetazidine 1,331 3,291 4,622

Total Top 50 drugs by Expenditure 334,317 237,381 571,698

Total Top 150 drugs by Expenditure 442,837 341,550 765,356


7

Table 2.2: Top 10 Therapeutic Groups by Expenditure in RM ‘000

Table 2.3: Top 10 Drugs Ranked by Expenditure

Table 2.4: Top 10 Therapeutic Groups Ranked by Expenditure

Rank ATC Therapeutic Group Public Private Total

1 A10 Drugs Used in Diabetes 62,752 33,317 96,069

2 C09 Agents Acting on Renin-Angiotensin System 54,523 25,405 79,928

3 J01 Antibacterials for Systemic Use 42,343 35,267 77,610

4 C10 Lipid Modifying Agents 22,516 48,120 70,636

5 R03 Drugs for Obstructive Airway Diseases 38,629 23,776 63,374

6 C07 Beta Blocking Agents 35,705 24,449 60,154

7 C08 Calcium Channel Blockers 41,462 17,549 59,011

8 A02 Drugs For Acid Related Disorders 12,604 24,650 37,254

9 M01 Antiinflammatory and Antirheumatic Products 6,945 28,019 34,964

10 B01 Antithrombotic Agents 8,538 22,724 31,262

Rank Malaysia

Australia

Public Expenditure Private Expenditure

Total Expenditure

Total Expenditure

1 Metoprolol Atorvastatin Amlodipine Atorvastatin

2 Amlodipine Simvastatin Atorvastatin Simvastatin

3 Risperidone Diclofenac Metoprolol Esomeprazole

4 Captopril Clopidogrel Simvastatin Salmeterol and Fluticasone

5 Enalapril Atenolol Cefuroxime Clopidogrel

6 Metformin Omeprazole Metformin Olanzapine

7 Cefuroxime Amlodipine Gliclazide Omeprazole

8 Gliclazide Amoxici llin and enzyme inhibitor

Risperidone Vanlafaxine

9 Insulins and analogues, intermediate-acting combined with fast-acting (human)

Cetirizine Atenolol Pantoprazole

10 Felodipine Cefuroxime Captopril Alendronic Acid

Rank Malaysia

Australia


Total Expenditure

Total Expenditure

1 Drugs Used in Diabetes (A10)

Lipid Modifying Agents (C10)

Drugs Used in Diabetes (A10)


2 Agents Acting on Renin-Angiotensin System (C09)

Antibacterials for Systemic Use (J01)

Agents Acting on Renin-Angiotensin System(C09)

Drugs For Acid Related Disorders (A02)

3 Antibacterials for Systemic Use (J01)


Antibacterials for Systemic Use (J01)

Agents Acting on Renin-Angiotensin System (C09)

4 Calcium Channel Blockers (C08)

Anti-inflammatory and Antirheumatic Products (M01)


Psychoanaleptics (N06)


8

Rank Malaysia

Australia


Total Expenditure

Total Expenditure

5 Drugs for Obstructive Airway Diseases (R03)

Agents Acting on Renin-Angiotensin System (C09)

Drugs for Obstructive Airway Diseases (R03)


6 Beta Blocking Agents (C07) Drugs For Acid Related Disorders (A02)

Beta Blocking Agents (C07)

Psycholeptics (N05)

7 Psycholeptics (N05) Beta Blocking Agents (C07)

Calcium Channel Blockers (C08)


8 Lipid Modifying Agents (C10)


Drugs For Acid Related Disorders (A02)

Antineoplastic Agents (L01)

9 Drugs For Acid Related Disorders (A02)

Antithrombotic Agents (B01)

Antiinflammatory and Antirheumatic Products (M01)

Antithrombotic Agents (B01)

References:1. Institute of Public Health (IPH) 2008. The Third National Health and Morbidity Survey (NHMS III) 2006, Vol 1. Ministry of Health, Malaysia.2. Commonwealth of Australia 2008. Australian Statistics on Medicines 2006 Online ISBN: 1-74186-516-6. Available from http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pbs general-pubs asm.htm3. Commonwealth of Australia 2006. Pharmaceutical Benefits Pricing Authority Annual Report for the year ended 30 June 2006. Online ISBN: 1 74186 119 5. available from: http://www.health.gov.au/internet/wcms publishing.nsf/Content/health-pbs-general-pricing-pbparpt.htm

CHAPTER 3USE OF MEDICINES FOR ACID RELATED DISORDERS Malaysian Statistics on Medicines 2006

9

Edited by:Radzi H1, Menon J2, Zainon A3, Azuana R4

1. Alor Star Hospital, 2. Queen Elizabeth Hospital, 3. Selayang Hospital, 4. Serdang Hospital

The common causes of acid related disorders include non-ulcer dyspepsia, peptic ulcer disease and gastroesophageal reflux disease (GERD). Prevalence of acid related disorders in Asian countries is low at under 10% compared to the more developed nations which can range between 10%-40% depending on the definition being used [2]. In studies using upper abdominal pain as definition, the lowest prevalence of 8% is seen inSingapore [3]. Slightly higher rates are seen amongst the Scandinavians at 14.5% to 18.4%. Prevalence rates of 23-25.8% are reported in the US [4].

In this survey, the total utilisation of drugs for acid related disorders in 2006 is 5.15685 DDD/1000 population/day, similar to the previous year’s finding of 5.1619DDD/1000 population/day. Concurring to the prevalence rate, utilisation of this group of drugs was relatively small compared to consumption in developed countries. The consumption in the Nordic Countries in 2003 for example ranged from 18.3DDD/1000 population/day in Greenland to 56.5DDD/1000 population/day in Iceland [1], which is far greater than utilisation reported here. In Australia, consumption for acid related disorder stands at a whopping 64.99 DDD/1000 population/day [7].

In addition to the low prevalence of acid related disorders in our population, another contributory factor to the low overall consumption could also be the omission of antacid and alginates from this report. These compounds are largely used as first line treatment for symptoms of acid related disorders. Self medicating in many patients with this disorder may have also resulted in under reporting of the actual usage. Additionally, drugs for acid related disorders are usually used for treatments of short durations. Thus, utilisation of drugs for acid related disorder is relatively small when compared to therapeutic groups. In the NMUS 2005report, utilisation of acid related disorder drugs was at number 14 among the 30 therapeutics groups under study. Drugs used for diabetes top the list at 35.86DDD/1000 population/day, seven times more than utilisation reported for acid related disorders group.

Overall, among the major drug classes for acid related disorders, H2 Receptor Antagonist (H2RA) tops the list with usage of 2.94DDD/1000 population/day (56.9%) in 2006, trailed closely by Proton Pump Inhibitors (PPI) at 2.21DDD/1000 population/day (42.9%). This pattern is somewhat inconsistentwith other countries where usage of PPIs is usually more dominant compared to H2RA. For example in Nordic Countries, PPI was the largest group of drugs used for acid related disorders taking the share of 60-80% of the AO2 group consumption. In Finland, the usage of PPIs was about five times higher at 22.5DDD/1000 population/day compared to usage of H2RA of only 4.1DDD/1000 population/day. On the other hand, in this study, for private practice where prescribing is not restricted by formulary, this common trend is observed whereby PPI consumption was about 14% higher (1.42DDD/1000 population/day and 1.23 DDD/1000 population/day for private and public sectors respectively).

Among all available agents for acid related disorders, ranitidine was utilised the most in 2006 at 1.71DDD/1000 population/day (33.2%) followed by omeprazole at 1.5DDD/1000 population/day (29.1%). In the H2RA drug class, utilisation of cimetidine is second after ranitidine representing 30.4 % of all H2RAs. Famotidine (11.3% of H2RAs) and nizatidine (0.01%) were mainly used in private practice. Omeprazole dominated the PPI drug class making up for 67.8% of all agents in this group. This was followed by esomeprazole (13.5%), lansoprazole (9.3%), pantoprazole (6.4%) and rabeprazole (3%). In 2006, omeprazole was the onlyPPI in generic formulation available in Malaysia. In Australia, omeprazole was also the most used acidreducing agent at 18.6DDD/1000 population/day (31.9% of all PPIs) [7].

Currently, the driving force behind the utilisation trend observed in this study was mainly the prescribing restrictions enforced through formularies, generic availability and costs. In the public sector the prescribing of PPIs are limited to specialist clinics and hospitals whilst H2RA are readily available in most primary clinics and health care centres. Availability of omeprazole in generic form has significantly reduced costs andconsequently making it more accessible.


CHAPTER 3USE OF MEDICINES FOR ACID RELATED DISORDERSMalaysian Statistics on Medicines 2006

10

In developed countries, there is an apparent consensus among physicians on using PPIs as first line treatment for GERD as it is more potent, effective and generally possess good safety profile [6]. Usage of PPIs is foreseen to eventually surpass H2RA following the trend in the western population. Based on the changing trend of prevalence locally, partly due to changing lifestyle and dietary habits, the overall utilisation trend of drugs for acid related disorders is expected escalate.

Table 2.1: Top 50 Drugs by Expenditure in RM ‘000

Table 3.2: Use of Medicines for Acid Related Disorders by Drug Class and Agents, in DDD/1000population/day 2006

ATC Drug Class 2006 A02B A H2-receptor antagonists 2.9354

A02B B Prostaglandins 0.0016

A02B C Proton pump inhibitors 2.2125

A02B D Combinations for eradication of Helicobacter Pylori 0.0067 A02B X Other drugs for peptic ulcer and gastro-oesophageal reflux disease (GORD) 0.0006

ATC Drug Class and Agents 2006 A02B A H2-receptor antagonists

A02B A01 Cimetidine Public 0.515

Private 0.3763

Total 0.8913

A02B A02 Ranitidine Public 1.1741

Private 0.539

Total 1.7131

A02B A03 Famotidine Public 0.0202

Private 0.3104

Total 0.3306

A02B A04 Nizatidine Public -

Private 0.0004

Total 0.0004

A02B B Prostaglandins

A02B B01 Misoprostol Public <0.0001

Private 0.0016

Total 0.0016

A02B C Proton pump inhibitors

A02B C01 Omeprazole Public 0.5889

Private 0.9111

Total 1.5 A02B C02 Pantoprazole Public 0.0471

Private 0.0952

Total 0.1423

A02B C03 Lansoprazole Public 0.1271

Private 0.0775

Total 0.2046

A02B C04 Rabeprazole Public 0.0094

Private 0.0565

Total 0.0659

A02B C05 Esomeprazole Public 0.019

Private 0.2807

Total 0.2997


11

ATC Drug Class and Agents 2006 A02B D04 Pantoprazole, amoxicillin and clarithromycin Public -

Private 0.0067

Total 0.0067

A02B X Other drugs for peptic ulcer and gastro-oesophageal reflux disease (GORD)

A02B X05 Bismuth subcitrate Public -

Private 0.0006

Total 0.0006

References:1. Committee NM-S, (NOMESCO). Medicines Consumption in the Nordic Countries 1999-2003.2. HB El-Serag NJT. The prevalence and clinical course of functional dyspepsia. Alimentary Pharmacology & Therapeutics. 2004; 19(6):643-54.3. Ho KY, Cheung TK, Wong BC. Gastroesophageal reflux disease in Asian countries: disorder of nature or nurture? J Gastroenterol Hepatol. 2006 Sep; 21(9):1362-5.4. Mahadeva S, Goh KL. Epidemiology of functional dyspepsia: a global perspective. World J Gastroenterol. 2006 May 7; 12(17):2661-6. 5. Mahadeva S, Raman MC, Ford AC, Follows M, Axon AT, Goh KL, et al. Gastro-oesophageal reflux is more prevalent in Western dyspeptics: a prospective comparison of British and South-East Asian patients with dyspepsia. Aliment Pharmacol Ther. 2005 Jun 15; 21(12):1483-90.6. Modlin IM, Moss SF, Kidd M, Lye KD. Gastroesophageal reflux disease: then and now. J Clin Gastroenterol. 2004 May-Jun; 38(5):390-402.7. Australian Government Department of Health and Ageing. Australian Statistics on Medicines. 2006 12th Edition.

CHAPTER 4USE OF ANTIOBESITY MEDICINES Malaysian Statistics on Medicines 2006

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Edited by:Sharmini S1, Ariza Z1, Oiyammal C2, Lim K3, Cheng MF4, Nazri D5

1.Clinical Research Centre, MOH 2.Sungai Bakap Hospital, 3.Penang Hospital, 4.Xepa-Soul Pattinson 5. Tampin Health Clinic

The total consumption of anti-obesity drugs in Malaysia for 2006 was 0.72 DDD/1000 population/day. Centrally acting anti-obesity drugs were most commonly prescribed representing 94.3 percent of drugs used. Among the centrally acting agents used, phentermine was the favored choice (67%).

Of the anti-obesity medicines utilised, consumption in the public sector was practically negligible. The private sector utilisation captured a market share of 97.8 percent. This was actually an under represented value considering private sector response rates were much lower than the public sector. The differing utilisation rates could be an influence of cost and availability of drugs.

In Australia, the consumption of anti-obesity drugs is almost three fold higher; probably due to the higher prevalence of obesity.

Table 4.1: Use of antiobesity medicine by Drug Class, in DDD/1000 population/day 2006

Table 4.2: Use of antiobesity medicine by Drug Class and Agents, in DDD/1000 population/day 2006

References: 1. Australian Statistics on Medicine 2006. Commonwealth Department of Health and Ageing Australia.

CHAPTER 4USE OF ANTIOBESITY MEDICINES Malaysian Statistics on Medicines 2006

ATC Drug Class 2006 A08A ANTIOBESITY PREPARATIONS, EXCL. DIET PRODUCTS 0.7187

A08A A Centrally acting antiobesity products 0.678

A08A B Peripherally acting antiobesity products 0.0408

ATC Drug Class and Agents 2006 A08A A Centrally acting an tiobesity products A08A A01 Phentermine Public 0.0019

Private 0.4521

Total 0.4541

A08A A10 Sibutramine Public 0.0112

Private 0.2127

Total 0.2239

A08A B Peripherally acting antiobesity products A08A B01 Orlistat Public 0.003

Private 0.0377

Total 0.0408

CHAPTER 5USE OF ANTIDIABETICS Malaysian Statistics on Medicines 2006

15


Edited by:GR Letchumanan R1, Muruga V2, Sharmini S3, Ariza Z3, Oiyammal C4, Lim K5, Cheng MF6,Nazri D7

1. Taiping Hospital, 2. Sanofi Aventis, 3. Clinical Research Centre, MOH 4. Sungai Bakap Hospital, 5. Penang Hospital 6. Xepa-Soul Pattinson, 7. Tampin Health Clinic

The total consumption of anti-diabetic drugs in Malaysia for 2006 was 40.3DDD/1000 population/day. This figure presented a rough estimation for Malaysian diabetic prevalence of four percent. This is lower than the National Health and Morbidity Survey 2006 findings of 9.5 percent known diabetes and 14.9 percent total diabetes prevalence [1]. When adult population values was used (aged 30 and above), the new anti-diabetic drug consumption was 98.7DDD/1000 population/day indicating a diabetes prevalence of 9.87 percent which isconsistent with the National Health and Morbidity Survey 2006. Among the antidiabetic drugs, the most utilised were sulphonylureas (54.8%), followed by biguanides (32.6%), insulin (8.2%) and combination drugs (2.7%). The total anti-diabetic drug utilisation for Australia was 44.8 DDD/1000 population/day, most common being biguanides (34.0%), followed by insulin (32.5%), sulphonylureas (27.8%) and thiazolidinediones (5.2%) [2].

Among the oral hypoglycaemic drugs, sulphonylureas (22.1DDD/1000 population/day) were the most commonly consumed followed by metformin (13.2DDD/1000 population/day). Metformin usage was disappointingly lower than sulphonylurea. Similar usage pattern of metformin was also reported in MSOM 2005 and this was in contrast with current guidelines. When compared to Malaysian drug utilisation, sulphonylurea use in Australia was almost half (12.5DDD/1000 population/day) whilst metformin use was comparable (15.2DDD/1000 population/day). Alpha glucosidase inhibitors consumption in Malaysia (0.46DDD/1000 population/day) was almost doubled to that of Australian usage (0.2DDD/1000 population/day). Thiazolidinediones use was very low (0.2DDD/1000 population/day) in Malaysia. Australia’s use was more than 10 fold (2.3DDD/1000 population/day). The reason for the extremely low consumption of thiazolidinediones may be due to its accessibility; high cost, and it being a List A drug requiring a specialist prescription in public hospitals. Private hospitals and private specialist clinics which may prescribe these drugs are underrepresented in this survey.

Insulins and its analogues are underutilised in the country, representing only 8.2 percent of anti-diabetic drugs used versus 32.5 for Australia. This was only 25 percent of Australian insulin coverage. This was very low but expected because of the Malaysian culture of reluctance to use injectable drugs. This is an area which we must improve to ensure better management of diabetes in the country. The pattern of prescribing insulin, however, was consistent to that in Australia with the most preferred type of insulin being the combined intermediate/fast acting insulin, followed by fast-acting, intermediate-acting and lastly long-acting insulin.

In general, anti-diabetic drug utilisation was greater in the public sector compared to the private; suggesting a disproportionate burden of disease within our health care system.

Table 5.1: Use of Anti-Diabetics by Drug Class, in DDD/1000 population/day 2006ATC Drug Class 2006 A10A INSULINS AND ANALOGUES 3.295

A10B A Biguanides 13.1506

A10B B Sulfonamides, urea derivatives 22.0883

A10B D Combinations of oral blood glucose lowering drugs 1.0687

A10B F Alpha glucosidase inhibitors 0.4507

A10B G Thiazolidinediones 0.2057

A10B X Other blood glucose lowering drugs, excl. insulins 0.0367

CHAPTER 5USE OF ANTIDIABETICSMalaysian Statistics on Medicines 2006

Table 5.2: Use of Anti-Diabetics by Drug Class and Agents, in DDD/1000 population/day 2006

16

ATC Drug Class and Agents 2006 A10A B Insulins and analogues for injection, fast-acting A10A B01 Insulins and analogues, fast-acting (human) Public 0.6717

Private 0.283

Total 0.9547

A10A B04 Insulins and analogues, fast-acting; insulin lispro Public 0.001

Private 0.001

Total 0.002

A10A B05 Insulins and analogues, fast-acting; Insulin aspart Public 0.0065

Private 0.0029

Total 0.0094 A10A C Insulins and analogues for injection, intermediate-acting A10A C01 Insulins and analogues, intermediate-acting (human) Public 0.7004

Private 0.2216

Total 0.922 A10A D Insulins and analogues for injection, intermediate-acting combined with fast-act A10A D01 Insulins and analogues, intermediate-acting combined with

fast-acting (human) Public 1.1299

Private 0.1955

Total 1.3255 A10A D05 Insulins and analogues, intermediate-acting combined with fast-acting

Insulin aspart Public 0.0003

Private 0.0288

Total 0.0291 A10A E Insulins and analogues for injection, long-acting A10A E04 Insulins and analogues, long-acting; Insulin glargine Public 0.0119

Private 0.0404

Total 0.0523 A10B A Biguanides

A10B A02 Metformin Public 11.1397

Total 13.1506

Private 2.0109 A10B B Sulfonamides, urea derivatives A10B B01 Glibenclamide Public 14.0329

Private 1.5023

Total 15.5352

A10B B02 Chlorpropamide Public 0.0238

Private 0.0251

Total 0.0488

A10B B07 Glipizide Public 0.0255

Private 0.0721

Total 0.0975

A10B B09 Gliclazide Public 4.593

Private 1.3678

Total 5.9608

A10B B12 Glimepiride Public 0.0261

Private 0.4199

Total 0.446


17

ATC Drug Class and Agents 2006 A10B D Combinations of oral blood glucose lowering drugs A10B D02 Metformin and sulfonamides Public 0.0113

Private 1.0128

Total 1.0241

A10B F Alpha glucosidase inhibitors

A10B G Thiazolidinediones

A10B X Other blood glucose lowering drugs, excl. insulins

A10B D03 Metformin and rosiglitazone Public 0.0014

Private 0.0431

Total 0.0446

A10B F01 Acarbose Public 0.3652

Private 0.0856

Total 0.4507

A10B G02 Rosiglitazone Public 0.040 6

Private 0.1635

Total 0.2041

A10B G03 Pioglitazone Public -

Private 0.0016

Total 0.0016

A10B X02 Repaglinide Public 0.0099

Private 0.015

Total 0.0249

A10B X03 Nateglinide Publ ic 0.0009

Private 0.0109

Total 0.0118

References: 1. The National Health Morbidity Survey 3, Institute of Public Health, Ministry of Health Malaysia 2007.2. Australian Statistics on Medicines 2006. Commonwealth Department of Health and Ageing Australia.3. David M. Nathan, MD et al. Management of Hyperglycemia in Type 2 Diabetes: Consensus Algorithm for the Initiation and Adjustment of Therapy. A consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes. DIABETES CARE, Volume 29, No. 8, August 2006; 1963-1972.4. Malaysian Statistics of Medicines 2005, Ministry of Health Malaysia.

CHAPTER 6USE OF ANTIANAEMIC MEDICINES Malaysian Statistics on Medicines 2006

19

CHAPTER 6USE OF ANTIANAEMIC MEDICINES Malaysian Statistics on Medicines 2006

Edited by:Lim YS 1, Goh AS2

1. Kuala Lumpur Hospital, 2. Pulau Pinang Hospital

In this chapter only two antianaemic preparations were described namely parenteral iron and erythropoietin. There was no procurement data captured on oral iron preparations though Oncology, Obstetric and Gynaecology as well as General Medicine uses quite a fair amount for anaemia. Erythropoeitin is also known as recombinant human erythropoietin (rHuEPO) which is a protein hormone produced by specialised cells in the kidneys. When there are few red blood cells as in anaemia, erythropoietin would be released to stimulate the bone marrow to produce more red blood cells. Where the production of endogenous erythropoietin is defective as in multiple myeloma or non-Hodgkin Lymphoma, erythropoietin could ameliorate the anaemia but users are cautioned of its use with chemotherapy that are thrombogenic or in cancer patients who are at risk of thromboembolism. Haematology and Oncology hardly use any erythropoietin. In Malaysia, erythropoietin was the standard of care for many patients with end-stage renal disease (ESRD) except for those who develop antibodies to the erythropoietin, who develop pure red cell aplasia or who develop arterial hypertension. When the hidden costs of the complications of blood transfusion were taken into account, erythropoietin would be a potential and cost effective alternative to transfusion. In some cases intravenous iron without erythropoietin was just as effective in treating the anaemia.

For erythropoietin to be effective, it should be supplemented with iron. Parenteral iron was more effective than oral iron. However there was no data on iron dextran nor on ferric sucrose but on trivalent parenteraliron namely saccharated iron oxide. Less than 0.0001 DDD/1000 population/ day and only the private sector used this. Hence less than 0.00001% of the population was using this daily. Australia used Iron Polymaltose Complex as the trivalent parenteral iron compound in the amount of 0.023DDD/1000 population/day and was more or less constant throughout the three years surveyed from 2001 till 2003. This was under theirpharmaceutical benefits scheme. By comparison Malaysia used much less parenteral iron.

Erythropoietin use in Australia in 2006 was 0.044DDD/1000 population/day and consumption of darbepoetin alpha was more favoured with use of nearly 4 times higher (0.17DDD/1000 population/day). In Malaysia, erythropoietin utilisation in 2006 was 0.178 DDD/1000 population/day and this meant that 0.018% of the population used erythropoietin on a daily basis. Usage in the government sector was 1.6 times higher than the private sector. Access to this antianaemic which was considered expensive therapy had been made possible to haemodialysis patients and other ESRD cases through the Nephrology budget.

This consumption data was based on assumption that all the erythropoietin purchased were consumed and that the prescribed daily dose was the same as the defined daily dose. However neither the erythropoietin nor the trivalent parenteral iron was used every day of the year. If supplementary information was available such as the average duration of treatment rather than assuming that the medication was taken every day of the year, drug utilisation could be reported in terms of number of patients treated during the year.

Table 6.1: Use of Antianaemic, in DDD/1000 population/day 2006

Table 6.2: Use of Antianaemic by Drug Class, in DDD/1000 population/day 2006

ATC Drug Class 2006 B03 ANTIANAEMIC PREPARATIONS 0.178

ATC Drug Class 2006 B03A IRON PREPARATIONS <0.0001

B03A C Iron trivalent, parenteral preparations <0.0001

B03X OTHER ANTIANAEMIC PREPARATIONS 0.178

B03X A Other antianaemic preparations 0.178

CHAPTER 6USE OF ANTIANAEMIC MEDICINESMalaysian Statistics on Medicines 2006

Table 6.3: Use of Antianaemic by Drug Class and Agents, in DDD/1000 population/day 2006

20

ATC Drug Class and Agents 2006B03A C Iron trivalent, parenteral preparations

B03X A Other antianaemic preparations

B03A C02 Saccharated iron oxide Public -

Private <0.0001

Total <0.0001

B03X A01 Erythropoietin Public 0.1094

Private 0.0686

Total 0.178

References:1. Australia Department of Heath and Ageing, Australian Statistics On Medicine 2003.2. Statistics on Drug use in Australia 2006.

CHAPTER 7USE OF ANTIHAEMORRHAGIC MEDICINES Malaysian Statistics on Medicines 2006

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Edited by:Lim YS 1, Goh AS2

1. Kuala Lumpur Hospital, 2. Pulau Pinang Hospital

Concerns for the safety of blood transfusions are partly the cause for the development of a range of interventions to minimise blood loss during major surgeries. One of the interventions is the widespread use of anti-fibrinolytic agents especially in cardiac surgeries where they are found to reduce blood loss and decrease the need for red cell transfusions.

Tranexamic acid is a synthetic derivative which exerts its anti-fibrinolytic effect through reversible blockade of lysine binding sites on plasminogen molecules. It was the most commonly prescribed anti-haemorrhagic agent in 2006 (0.068DDD/1000 population/day). Tranexamic acid is effective in reducing postoperative blood loss in patients undergoing cardiac surgeries with statistically significant reductions in transfusion requirements. In comparison, the usage of aprotinin was rather low (<0.0006DDD/1000 population/day) and was mainly used therapeutically in open heart surgeries and cardiopulmonary bypass surgeries. Interestingly the usage of aprotinin was more than 6 times higher in the private institutions reflecting that a higher number of cardiac surgeries were being done in the private sector. Aprotinin is a proteinase inhibitor from bovine organs and can only be given intravenously. The loading dose of aprotinin is 15,000 to 20,000 kallikrein inhibitory units (kiu)/kg body weight as short intravenous infusions followed by 50,000 kiu/hour by continuous infusion. On the other hand, tranexamic acid can be given orally since it is readily absorbed from gastrointestinal tract and excreted in its active form in the urine. With short plasma half-life of 80 minutes, tranexamic acid side effects are transient mainly manifesting as nausea or diarrhoea.

The main indications for tranexamic acid are to prevent excessive bleeding after prostatic surgery, liver transplant, tonsillectomy, cervical conisation, primary and intrauterine device-induced menorrhagia, from gastric and intestinal sites, from epistaxis and ocular trauma, after tooth extraction in haemophilia and hereditary angioneurotic edema. It is also used in controlling bleeding in pregnancy. Tranexamic acid could be administered intravenously at a dose of 0.5–1g (10-15mg/kg body weight) two to three times a day or administered orally at 1-1.5 g three to four times daily. In renal insufficiency, this dose needs to be reduced. Tranexamic acid was reported to be more effective than mefenamic acid and norethisterone but less effective than intrauterine administration of levonorgestrel in reduction of menstrual blood loss in clinical trials. However the high incidence of amenorrhoea and adverse events such as intermenstrual bleeding reported with some hormonal therapy may be unacceptable to patients in which case tranexamic acid would be particularly useful. Hence tranexamic acid remains as the first line therapy for initial management of idiopathic menorrhagia for three to four days cycle over two to three cycles to reduce menstrual blood loss.

Factor VIII and IX concentrates are used to treat bleeding episodes in haemophilia A and haemophilia Brespectively. In Malaysia, patients are given factor concentrates as “on-demand therapy” without charge in government hospitals. Furthermore haemophilia is a congenital disorder so the patients are not eligible for insurance coverage. Hence, most hemophiliacs seek treatment in government hospitals and the usage of factor concentrates is very low in the private sector.

Recombinant factor VIIa or Eptacog alfa (activated) has been licensed for treatment of haemophilia A and B with inhibitors in Europe since 1996 and in North America since 1999. Overall 1.5 million doses had beenadministered. It is indicated as an intravenous haemostatic agent in hemophilia patients with inhibitors to coagulation factors VIII and IX. On-demand therapy with Eptacog alfa was effective in controlling episodes of mild to moderate bleeding. Prophylactic treatment was also effective in maintaining haemostasis in haemophiliacs undergoing orthopaedic surgeries and it is reported that the acquisition costs of Eptacog alfaare offset by cost savings resulting from the reduction in the episodes of joint-related bleeds. The data had shown that Eptacog alfa (activated) was as sparingly used in the private as in the government sector.

CHAPTER 7USE OF ANTIHAEMORRHAGIC MEDICINESMalaysian Statistics on Medicines 2006

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There was no data available for the use of Vitamin K or phytomenadione as a haemostatic agent even though our Malaysian hospitals do administer the vitamin intramuscularly for prophylactic use in haemorrhagic disease of the newborn. In life threatening bleeding, Vitamin K may be used therapeutically by the intravenous route together with fresh frozen plasma or factor concentrates.

Table 7.1: Use of Antihaemorrhagics in DDD/1000 population/day 2006

Table 7.2: Use of Antianaemics by Drug Class, in DDD/1000 population/day 2006

Table 7.3: Use of Antihaemorrhagics by Drug Class and Agents, in DDD/1000 population/day 2006

References: 1. Srivasta A, Chuansumrit A, Chandy M, Duraisamy G, Karagus C. Management of haemophilia in the developing world. Hemophilia 1998 Jul; 4(4):474-80.2. Srivasta A, You SK, Ayob Y, Chuansumrit A, de Bosch N, Perez Bianco R, Ala F Hemophilia treatment in developing countries: products and protocols. Semin. Thromb. Hemost. 2005 Nov; 31(5): 495-500.3. Stonebraker JS, Amand RE, Nagle AJ; A country-by-country comparison of FVIII concentrate consumption and economic capacity for the global hemophilia community Hemophilia Vol 9 (3) May 2003; 245-250(6).

ATC Drug Class 2006 B02 ANTI HAEMORRHAGICS 0.0713

ATC Drug Class 2006 B02A ANTIFIBRINOLYTICS 0.0695

B02A A Amino acids 0.0688

B02A B Proteinase inhibitors 0.0006

B02B VITAMIN K AND OTHER HEMOSTATICS 0.0018

B02B A Vitamin K -

B02B D Blood coagulation factors 0.0018

ATC Drug Class and Agents 2006 B02A A Amino acids B02A A02 Tranexamic acid Public 0.0524

Private 0.0165

Total 0.0688

B02A B Proteinase inhibitors B02A B01 Aprotinin Public <0.0001

Private 0.0006

Total 0.0006

B02B A Vitamin K B02B A01 Phytomenadione Public -

Private -

Total -

B02B D Blood coagulation factors B02B D02 Coagulation factor VIII Public 0.0007

Private <0.0001

Total 0.0007

B02B D04 Coagulation factor IX Public 0.0011

Private -

Total 0.0011

B02B D08 Eptacog alfa (activated) Public <0.0001

Private <0.0001

Total <0.0001


23

4. Panicker J et al; The overall effectiveness of prophylaxis in severe haemophilia Haemophilia Vol 9, No. 3 May 2003 : 272-278.5. Lyseng-Williamson KA, Plosker GL Recombinant factor VIIa (Eptacog alfa) a pharmacoeconomic review of its use in haemophilia in patients with inhibitors to clotting factors VIII and IX. Pharmacoeconomics 2007 : 25 (12) pgs 1007-29.6. Puckett RM, Offringa M, Department of Paediatrics, Amsterdam. Prophylactic Vitamin K for Vitamin K deficiency bleeding in neonates. Cochrane Database Systematic Review 2000; (4): CD 002776.

CHAPTER 8USE OF MEDICINES FOR CARDIOVASCULAR DISORDERS Malaysian Statistics on Medicines 2006

25


Edited by:Chong WP1, Wan Azman WA1

1. University Malaya Medical Centre

With contributions from:Nirmala J2, Yap YJ2, Haarathi C3, Long MS4

1. Sarawak General Hospital, 2. Kuala Lumpur Hospital, 3. Tengku Ampuan Rahimah Hospital, Klang, 4. Selayang Hospital

The most commonly used antithrombotic agents in 2006 were the platelet aggregation inhibitors (9.22DDD/1000 population/day), and among these, acetylsalicylic acid or aspirin accounted for slightly over 80% of the total usage. The other less frequently used platelet aggregation inhibitors included ticlopidine (0.99DDD/1000 population/day) and clopidogrel (0.74DDD/1000-population/day). Ticlopidine was used more in the public health services while the private sector utilised more clopidogrel. The role of these drugs in the treatment and prevention (primary as well as secondary) of cardiovascular diseases is well established and accepted. But they were probably under utilised in view of the fact that 27% of adults who were 30 years or older had multiple cardiovascular risk factors in the National Health and Morbidity Survey in 1996. In Australia, the total community use of aspirin alone was 19.3DDD/1000 population/day in 2005. This was almost 3 times the usage of aspirin in Malaysia.

Warfarin had a DDD rate of 0.3755, placing it as the 4th most commonly used antithrombotic agent in 2006. The other antithrombotic drugs such as heparin, different types of low molecular weight heparin, fibrinolytic agents (classified as enzymes in the table) and glycoprotein IIb/IIIa receptor antagonists (abciximab, eptifibatide and tirofiban) had very low DDD rates as they were normally administered over a short period of time for the treatment of acute coronary syndromes.

Isosorbide dinitrate and trimetazidine were the other 2 cardiac drugs which were fairly frequently used at 1.37 and 1.44DDD/1000 population/day respectively. Both are indicated in the treatment of chronic stable angina.

As a group, diuretics had a DDD rate of 14.66. The top 3 diuretics used in 2006 were chlorothiazide (6.28),furosemide (4.89) and hydrochlorothiazide and potassium-sparing agents in combination (1.34). In contrast,furosemide (or frusemide in some countries) had a DDD rate of 19.6 in Australia in 2005. This drug is usedpredominantly in the acute and long term management of heart failure. It is also used to treat fluid retention in other conditions.

On the other hand, chlorothiazide and hydrochlorothiazide with potassium-sparing agents in combination are antihypertensive medications. Their rate of usage simply reflected the high prevalence of hypertension among Malaysian population and probably the availability of the drugs in the government formulary.

Table 8.1: Use of Drugs for Cardiovascular disorders, in DDD/1000 population/day 2006 ATC Drug Class 2006 B01 ANTITHROMBOTIC AGENTS 9.835

C01A CARDIAC GLYCOSIDES 0.6509

C01B ANTIARRHYTHMICS, CLASS I AND III 0.1483

C01C CARDIAC STIMULANTS EXCL. CARDIAC GLYCOSIDES 0.2538

C01D VASODILATORS USED IN CARDIAC DISEASES 2.2033

C01E OTHER CARDIAC PREPARATIONS 1.4398

C03 DIURETICS 14.6643

C04 PERIPHERAL VASODILATORS 0.0745

CHAPTER 8USE OF MEDICINES FOR CARDIOVASCULAR DISORDERSMalaysian Statistics on Medicines 2006

Table 8.2.1: Use of Anti-Thrombotic drugs by Drug Class, in DDD/1000 population/day 2006

Table 8.2.2: Use of Anti-Thrombotic drugs by Drug Class and Agents, in DDD/1000 population/day 2006

26

ATC Drug Class 2006 B01A A Vitamin K antagonists 0.3755

B01A B Heparin group 0.2365

B01A C Platelet aggregation inhibitors excl. heparin 9.2219

B01A D Enzymes 0.0009

B01A X Other antithrombotic agents 0.0003

ATC Drug Class and Agents 2006 B01A A Vitamin K antagonists B01A A03 Warfarin Public 0.2582

Private 0.1173

Total 0.3755

B01A B Heparin group B01A B01 Heparin Public 0.0403

Private 0.0626

Total 0.1029

B01A B05 Enoxaparin Public 0.0701

Private 0.0297

Total 0.0998

B01A B06 Nadroparin Public 0.0035

Private 0.0018

Total 0.0054

B01A B10 Tinzaparin Public 0.0005

Private 0.0019

Total 0.0024

B01A B11 Sulodexide Public <0.0001

Private 0.0259

Total 0.026

B01A C Platelet aggregation inhibitors excl. heparin B01A C04 Clopidogrel Public 0.0678

Private 0.6682

Total 0.7361

B01A C05 Ticlopidine Public 0.5478

Private 0.4434

Total 0.9912

B01A C06 Acetylsalicylic acid Public 4.8358

Private 2.5826

Total 7.4184

B01A C07 Dipyridamole Public 0.0697

Private 0.0062

Total 0.0759

B01A C11 Iloprost Public <0.0001

Private <0.0001

Total <0.0001

B01A C13 Abciximab Public -

Private <0.0001

Total <0.0001


27

Table 8.3.1: Use of Cardiac Glycosides by Drug Class, in DDD/1000 population/day 2006

Table 8.4.1: Use of Anti-Arrhythmics by Drug Class, in DDD/1000 population/day 2006ATC Drug Class and Agents 2006 C01B B Antiarrhythmics, class Ib

C01B B01 Lidocaine Public 0.0013

Private 0.0005

Total 0.0018

C01B B02 Mexiletine Public -

Private -

Total -

C01B C Antiarrhythmics, class Ic C01B C03 Propafenone Public 0.0006

Private 0.0056

Total 0.0062

C01B C04 Flecainide Public 0.002

Private 0.0093

Total 0.0113

ATC Drug Class and Agents 2006 C01A CARDIAC GLYCOSIDES C01A A05 Digoxin Public 0.4195

Private 0.2314

Total 0.6509

ATC 2006

B01A D B01A D0 1 Public 0.0007

Private 0.0001

Total 0.0009

B01A D02 Public -

Private -

Total -

B01A D04 Public <0.0001

Private <0.0001

Total <0.0001

B01A D10 Public -

Private -

Tota l -

B01A D11 Public -

Private <0.0001

Total <0.0001

B01A X B01A X05 Public <0.0001

Private 0.0002

Total 0.0003

B01A C16 Public -

Private <0.0001

Total <0.0001

B01A C17

Drug Class and Agents

EnzymesStreptokinase

Alteplase

Urokinase

Drotrecogin alfa (activated)

Tenecteplase

Other antithrombotic agentsFondaparinux

Eptifibatide

Tirofiban Public -

Private <0.0001 Total <0.0001


28

ATC Drug Class and Agents 2006 C01B D Antiarrhythmics, class III C01B D01 Amiodarone Public 0.0318

Private 0.0972

Total 0.129

Table 8.5.1: Use of Cardiac stimulants by Drug Class, in DDD/1000 population/day 2006

Table 8.6.1: Use of Vasodilators in Cardiac diseases by Drug Class, in DDD/1000 population/day 2006

ATC Drug Class and Agents 2006 C01C A Adrenergic and dopaminergic agents C01C A02 Isoprenaline Public <0.0001

Private <0.0001

Total <0.0001

C01C A03 Norepinephrine Public 0.0206

Private 0.0029

Total 0.0235

C01C A04 Dopamine Public 0.0055

Private 0.0053

Total 0.0108

C01C A06 Phenylephrine Public 0.0045

Private 0.0033

Total 0.0077

C01C A07 Dobutamine Public 0.0115

Private 0.0018

Total 0.0133

C01C A24 Epinephrine Public 0.1495

Private 0.0436

Total 0.193 1

C01C E Phosphodiesterase inhibitors C01C E02 Milrinone Public <0.0001

Private 0.0053

Total 0.0053

C01C X Other cardiac stimulants C01C X08 Levosimendan Public -

Private <0.0001

Total <0.0001

ATC Drug Class and Agents 2006 C01D A Organic nitrates C01D A02 Glyceryl trinitrate Public 0.1188

Private 0.0517

Total 0.1705

C01D A05 Pentaerithrityl tetranitrate Public -

Private 0.0024

Total 0.0024

C01D A08 Isosorbide dinitrate Public 1.2768

Private 0.0932

Total 1.3699

C01D A14 Isosorbide mononitrate Public 0.1214

Private 0.5391

Total 0.6605


Table 8.6.2: Use of other cardiac preparations in Cardiac diseases by Drug Class, in DDD/1000 population/day 2006

29

ATC Drug Class and Agents 2006 C01E A Prostaglandins C01E A01 Alprostadil Public <0.0001

Private <0.0001

Total <0.0001

C01E B Other cardiac preparations C01E B10 Adenosine Public 0.0009

Private 0.0002

Total 0.0011

C01E B15 Trimetazidine Public 0.6345

Private 0.804

Total 1.4386

Table 8.7.1: Use of Diuretics by Drug Class, in DDD/1000 population/day 2006ATC Drug Class and Agents 2006 C03A LOW-CEILING DIURETICS, THIAZIDES C03A A03 Hydrochlorot hiazide Public 0.2597

Private 0.8344

Total 1.0942

C03A A04 Chlorothiazide Public 6.2441

Private 0.0355

Total 6.2796

C03B LOW-CEILING DIURETICS, EXCL. THIAZIDES C03B A04 Chlortalidone Public -

Private 0.0212

Total 0.0212

C03B A08 Metolazone Public 0.0017

Private -

Total 0.0017

C03B A11 Indapamide Public 0.0557

Private 0.5507

Total 0.6064

C03C HIGH-CEILING DIURETICS C03C A01 Furosemide Public 3.9301

Private 0.9588

Total 4.8889

C03C A02 Bumetanide Public 0.0219

Private 0.0172

Total 0.0391

C03D POTASSIUM-SPARING AGENTS C03D A01 Spironolactone Public 0.2517

Private 0.1286

Total 0.3803

C03D B01 Amiloride Public 0.0024

Private 0.0071

Total 0.0095

C03E DIURETICS AND POTASSIUM-SPARING AGENTS IN COMBINATION C03E A01 Public 1.0077

Private 0.3358

Hydrochlorothiazide and potassium-sparing agents

Total 1.3434


30

Table 8.8.1: Use of Peripheral vasodilators by Drug Class, in DDD/1000 population/day 2006

References:1. The National Health Morbidity Survey 2, Institute of Public Health, Ministry of Health Malaysia 1996.2. Statistics on drug use in Australia 2006, Australian Institute of Health and Welfare 2007.

ATC Drug Class and Agents 2006 C04A D Purine derivatives C04A D03 Pentoxifylline Public 0.0485

Private 0.0136

Total 0.0622

C04A E Ergot alkaloids C04A E01 Ergoloid mesylates Public -

Private 0.0123

Total 0.0123

C04A X02 Phenoxybenzamine Public <0.0001

Private -

Total <0.0001

CHAPTER 9USE OF ANTIHYPERTENSIVES Malaysian Statistics on Medicines 2006

31


Edited by:Hooi LS1, Zaki M2, Lim TO3, Zawawi N4, Goh BL5, Fadilah O6, Nur Salima S6, Puteri JZ6, Zarina AG6, Manjulaa DS7

1. Sultanah Aminah Hospital, Johor Bahru, 2. International Medical University, 3. Clinical Research Centre MOH, 4. Sultanah Nur Zahirah Hospital, Terengganu, 5. Serdang Hospital, 6. Selayang Hospital, 7. Kuala Lumpur Hospital

Beta blockers were the most commonly prescribed antihypertensive medication (25.7DDD/1000 population/day) in 2006 followed by the calcium channel blockers (19.4). ACE inhibitors (15.3), diuretics (8.0) and angiotensin II antagonists (4.3) were also commonly used. Usage of alpha blockers and centrally acting drugs was low.

In the category of beta blockers there was a small amount which was prescribed in combination with diuretics.The second largest category was the drugs antagonising the renin-angiotensin system (ACEIs and ARBs) some of which were in combination with diuretics (total 19.6DDD/1000 population/day). The calcium channel blockers (CCBs) included those with vascular effects (e.g. amlodipine and nifedipine) and those with cardiaceffects (e.g. diltiazem). Diuretics were prescribed alone (8.0) or in combination with other drugs (beta blocker or ACEI or ARB or potassium sparing agents) in the same tablet (3.1) which made its overall usage quite high (total 11.1 DDD/1000 population/day).

There were 3 drugs whose contribution each made up more than 10% of total utilization – metoprolol (12.3DDD/1000 population/day), atenolol (12.0) and nifedipine (11.6). Of these, two were beta blockers and one a CCB. These 3 drugs were used mainly in the public sector (88%).

Overall, 80% of all antihypertensives were utilised in the public sector and 20% in the private sector. The most popular drugs in the private sector were atenolol (3.0DDD/1000 population/day), amlodipine (2.0) and enalapril (1.0). There was a tendency to use more expensive drugs in the private sector. The use of antihypertensives should be encouraged in the private sector to reduce the burden of prescribing in the public sector. Economic considerations about treating a chronic disease in the private sector may be a deterring factor. Hypertension is a silent disease (killer) and without counseling and education the public may not be willing to pay for its long term control. Generic drugs which are efficacious should be the ones of choice. Drug prescribing may have been unduly influenced by aggressive marketing by the pharmaceutical industry.

Among the beta blockers, the most popular were metoprolol and atenolol. They were favoured over the older generation beta blocker propranolol. Among the ACEIs, perindopril was the most commonly used followed by enalapril and captopril. Perindopril is relatively cheap and its daily dosing is an advantage. The use of ACEIs should be encouraged as they have cardio-and renoprotective effects. The incidence of diabetes mellitus in new patients with end-stage renal failure (ESRF) was 58% in 2006 in Malaysia (1). In the early stages of diabetic nephropathy ACEIs and ARBs may help to prevent progression to ESRF. The most commonly used ARB (with or without combination diuretics) was losartan followed by valsartan, irbesartan and telmisartan. These drugs are expensive. Among the CCBs nifedipine and amlodipine were the most commonly used. Nifedipine was extensively used, 94% in the public sector. Amlodipine was popular in both the public and private sector in spite of its high cost. Its daily dosing is an advantage for patient compliance over the three times a day dosing of nifedipine. It is a long acting dihydropryridine CCB and is not contraindicated in cardiovascular disease unlike the short acting nifedipine. Among the diuretics chlorothiazide (CTZ) and HCTZ were the most commonly prescribed. The former was used by the public sector while HCTZ was used by the private sector. Their usage was low considering that they are the recommended first line drugs for hypertension.

The alpha antagonists were not popular although they may be useful in hypertensive men with prostatic hypertrophy who are not at high risk of heart failure. The use of centrally acting agents was low and this may be due to their unpleasant side-effects. They are still useful as a third line drug and methyldopa is used in hypertension during pregnancy. Hydralazine should not be removed from the drug formulary as it is useful

CHAPTER 9USE OF ANTIHYPERTENSIVESMalaysian Statistics on Medicines 2006

32

in severe hypertension during pregnancy. Minoxidil is a third line drug that sometimes controls severe hypertension although it was used sparingly as there are side-effects. Nitroprusside is an intravenous drug which was used only in ICUs to control blood pressure temporarily.

The total utilisation of antihypertensives was 77.3DDD/1000 population/day. From general practice prescription data, we estimated a patient with hypertension was prescribed a median of only one antihypertensive medication. That is, the vast majority of patients (81%) in Malaysia were on mono-therapy. Thus, the utilisation statistic of 77.5DDD/1000 population/day suggested that about 6 to 7% of the population were on drug treatment for hypertension. About 40% of the population was aged > 30 years in 2006. This means that about 16% of the population aged 30 and above was taking an antihypertensive drug in 2006. There is a high prevalence of hypertension in Malaysia (43% in 2006) and a substantial number of patients were not on drug therapy or had undiagnosed hypertension (2). People with hypertension in Malaysia may need more drug treatment as less than half of those who are hypertensive were on antihypertensives. This shortfall may be greater than stated as many on treatment need more than one category of drug to control their blood pressure to the recommended target.

Overall, compared to the Nordic countries (3) the use of beta blockers, agents acting on the renin-angiotensin system, calcium channel blockers and diuretics was low in Malaysia. Beta blocker use in 2003 ranged from 13.9DDD/1000 population/day in Greenland to 65.8 in Finland in 2003. For drugs acting on the renin-angiotensin system, the usage ranged from 30.7DDD/1000 population/day in Greenland to 107.8 in Finland. For calcium channel blockers the range was 15.6 in Greenland to 45.3 in Norway. The use of thiazides alone or in combination with potassium-sparing agents ranged from 10.9DDD/1000 population/day in Norway to 50.5 in Denmark in 2003.

The local Clinical Practice Guideline (CPG) on hypertension (4) recommends beta blockers or diuretics as drugs of first choice for control of uncomplicated hypertension. The utilisation pattern for 2006 was not consistent with the CPG as antagonists of the renin-angiotensin system were second to beta blockers followed by the calcium channel blockers. Diuretics lagged behind in fourth place. Many of the drugs in all 4 categories except the ARBs are generic and the order of preference may reflect economic considerations. The ACEIs and ARBs are weak antihypertensives but have effects beyond blood pressure lowering. These include cardioprotection post myocardial infarction, reduction of proteinuria and renoprotection in diabetic and non-diabetic renal disease. The incidence of diabetes mellitus in Malaysia is high (14.9% in 2006) (2) and many diabetics are hypertensive. This may have some bearing when physicians in Malaysia choose an antihypertensive drug for their diabetic patients (4,5). The calcium channel blockers have few side-effects and are efficacious. Diuretics may be less used inspite of their extremely low cost because of marketing of other (more expensive) drugs by the pharmaceutical industry or the belief that they have side-effects.

Table 9.1: Use of Antihypertensives by Drug Class, in DDD/1000 population/day 2006ATC Drug Class 2006 C02A ANTIADRENERGIC AGENTS, CENTRALLY ACTING 0.6553

C02C A ALPHA-ADRENORECEPTOR ANTAGONISTS 2.5693

C02D ARTERIOLAR SMOOTH MUSCLE, AGENTS ACTING ON 0.0063

C02K OTHER ANTIHYPERTENSIVES 0.0006

C03A LOW-CEILING DIURETICS, THIAZIDES 7.3738

C03B LOW-CEILING DIURETICS, EXCL. THIAZIDES 0.6293

C03E DIURETICS AND POTASSIUM-SPARING AGENTS IN COMBINATION 1.3434

C07 BETA BLOCKING AGENTS 25.7343

C08 CALCIUM CHANNEL BLOCKERS 19.3656

C09A ACE INHIBITORS, PLAIN 15.2135

C09B ACE INHIBITORS, COMBINATIONS 0.0738

C09C ANGIOTENSIN II ANTAGONISTS, PLAIN 2.7293

C09D ANGIOTENSIN II ANTAGONISTS, COMBINATIONS 1.5652


33

Table 9.2: Use of Antihypertensives by Drug Class and Agents, in DDD/1000 population/day 2006ATC Drug Class and Agents 2006 C02A ANTIADRENERGIC AGENTS, CENTRALLY ACTING C02A B01 Methyldopa (levorotatory) Public 0.5827

Private 0.018

Total 0.6007

C02A C01 Clonidine Public <0.000 1

Private -

Total <0.0001

C02A C05 Moxonidine Public 0.0002

Private 0.0544

Total 0.0545

C02C A Alpha-adrenoreceptor antagonists C02C A01 Prazosin Public 2.234

Private 0.0961

Total 2.3301

C02C A04 Doxazosin Public 0.1764

Private 0.0628

Total 0.2393

C02D ARTERIOLAR SMOOTH MUSCLE, AGENTS C02D B01 Dihydralazine Public 0.0004

Private -

Total 0.0004

C02D B02 Hydralazine Public -

Private <0.0001

Total <0.0001

C02D C01 Minoxidil Public 0.0047

Private 0.0002

Total 0.0049

C02D D01 Nitroprusside Public 0.0001

Private 0.0008

Total 0.001

C02K OTHER ANTIHYPERTENSIVES C02K X01 Bosentan Public <0.0001

Private 0.0006

Total 0.0006

C03A LOW-CEILING DIURETICS, THIAZIDES C03A A03 Hydrochlorothiazide Public 0.2597

Private 0.8344

Total 1.0942

C03A A04 Chlorothiazide Public 6.2441

Private 0.0355

Total 6.2796

C03B LOW-CEILING DIURETICS, EXCL. THIAZIDES C03B A04 Chlortalidone Public -

Private 0.0212

Total 0.0212

C03B A08 Metolazone Public 0.0017

Private -

Total 0.0017


34

ATC Drug Class and Agents 2006 C03B A11 Indapamide Public 0.0557

Private 0.5507

Total 0.6064

C03E DIURETICS AND POTASSIUM-SPARING AGENTS IN COMBINATION C03E A01 Hydrochlorothiazide and potassium-sparing agents Public 1.0077

Private 0.3358

Total 1.3434

C07A BETA BLOCKING AGENTS

Public 0.255

Private 0.1815

C07A A05 Propranolol

Total 0.4364

C07A A07 Sotalol Public -

Private 0.0146

Total 0.0146

C07A B02 Metoprolol Public 11.7536

Private 0.5828

Total 12.3365

C07A B03 Atenolol Public 9.077

Private 2.9516

Total 12.0287

C07A B04 Acebutolol Public -

Private 0.0019

Total 0.0019

C07A B05 Betaxolol Public 0.0004

Private 0.0703

Total 0.0708

C07A B07 Bisoprolol Public 0.0349

Private 0.1517

Total 0.1866

C07A B09 Esmolol Public <0.0001

Private <0.0001

Total <0.0001

C07A G01 Labetalol Public 0.1303

Private 0.019

Total 0.1493

C07A G02 Carvedilol Public 0.0808

Private 0.2633

Total 0.3441

C07C BETA BLOCKING AGENTS AND OTHER DIURETICS C07C A03 Pindolol and other diuretics Public -

Private 0.0021

Total 0.0021

C07C B02 Metoprolol and other diuretics Public -

Private 0.0167

Total 0.0167

C07C B03 Atenolol and other diuretics Public <0.0001

Private 0.1466

Total 0.1467


35

ATC Drug Class and Agents 2006C08C SELECTIVE CALCIUM CHANNEL BLOCKERS WITH MAINLY VASCULAR EFFECTS C08C A01 Amlodipine Public 3.2803

Private 1.9924

Total 5.2728

Public 1.3805

Private 0.4422

C08C A02 Felodipine

Total 1.8227

C08C A03 Isradipine Public -

Private 0.0067

Total 0.0067

C08C A04 Nicardipine Public <0.0001

Private 0.005

Total 0.005

C08C A05 Nifedipine Public 10.9355

Private 0.6772

Total 11.6127

C08C A06 Nimodipine Public 0.0005

Private 0.0002

Total 0.0007

C08C A09 Lacidipine Public -

Private 0.014

Total 0.014

C08C A13 Lercanidipine Public -

Private 0.0679

Total 0.0679

C08C SELECTIVE CALCIUM CHANNEL BLOCKERS WITH DIRECT CARDIAC EFFECTS C08D A01 Verapamil Public 0.0378

Private 0.0442

Total 0.0821

C08D B01 Dilt iazem Public 0.3064

Private 0.1747

Total 0.4811

C09A ACE INHIBITORS, PLAIN C09A A01 Captopril Public 4.1067

Private 0.1984

Total 4.3051

C09A A02 Enalapril Public 3.5113

Private 0.9827

Total 4.4939

C09A A03 Lisinopril Public 0.1591

Private 0.5872

Total 0.7463

C09A A04 Perindopril Public 4.3301

Private 0.3811

Total 4.7113

C09A A05 Ramipril Public 0.3409

Private 0.5856

Total 0.9264


36

ATC Drug Class and Agents 2006C09A A06 Quinapril Public -

Private 0.0014

Total 0.0014

C09A A09 Fosinopril Publ ic 0.0009

Private 0.0058

Total 0.0067

C09A A16 Imidapril Public 0.0012

Private 0.0211

Total 0.0223

C09B ACE INHIBITORS, COMBINATIONS

C09B A04 Perindopril and diuretics Public 0.0066

Private 0.0672

Total 0.0738

C09C ANGIOTENSIN II AN TAGONISTS, PLAIN

C09C A01 Losartan Public 0.5202

Private 0.5978

Total 1.1179

C09C A03 Valsartan Public 0.1537

Private 0.2183

Total 0.372

C09C A04 Irbesartan Public 0.1987

Private 0.364

Total 0.5627

C09C A06 Candesartan Public -

Private 0.2164

Total 0.2164

C09C A07 Telmisartan Public 0.2038

Private 0.2069

Total 0.4107

C09C A08 Olmesartan medoxomil Public -

Private 0.0496

Total 0.0496

C09D ANGIOTENSIN II ANTAGONISTS, COMBINATIONS C09D A01 Losartan and diuretics Public 0.1154

Private 0.405

Total 0.5204

C09D A03 Valsartan and diuretics Public 0.0891

Private 0.4154

Total 0.5045

C09D A04 Irbesartan and diuretics Public 0.0686

Private 0.2336

Total 0.3022

C09D A06 Candesartan and diuretics Public 0.0006

Private 0.1233

Total 0.1239

C09D A07 Telmisartan and diuretics Public 0.0195

Private 0.0947

Total 0.1142


37

References:1. Lim YN, Lim TO (eds). Fifteenth report of the Malaysian Dialysis and Transplant Registry 2007, Kuala Lumpur 2008. http://www.msn.org.my/nrr/report2007.htm (accessed on 1 January 2009).2. Institute for Public Health (IPH) 2008. The Third National Health and Morbidity Survey (NHMSIII) 2006, Volume 2, page 210 and 253. Ministry of Health Malaysia. ISBN 978-983-3887-30-9.3. Nordic Medico Statistical Committee. Medicines Consumption in the Nordic Countries 1999-2003. Copenhagen 2004. ISBN 87-89702-52-2.4. Academy of Medicine Malaysia, Ministry of Health Malaysia. Clinical practice guidelines on management of hypertension, 2002. http://www.acadmed.org.my/html/index.shtml (accessed on 10 June 2007).5. Academy of Medicine Malaysia, Ministry of Health Malaysia. Clinical practice guidelines on diabetic nephropathy, 2004. http://www.acadmed.org.my/html/index.shtml (accessed on 10 June 20

CHAPTER 10USE OF LIPID LOWERING MEDICINES Malaysian Statistics on Medicines 2006

39


Edited by: Chang BC1, Fong AYY1, Sim KH1

With contributions from:Chong WP2, Nirmala J3, Yap YJ3, Haarathi C4, Long MS5

1. Sarawak General Hospital, 2. Universiti Malaya Medical Centre, 3. Kuala Lumpur Hospital, 4. Tengku Ampuan Rahimah Hospital, Klang, 5. Selayang Hospital

The HMG Co A reductase, or more commonly known as statins, is the mainstay of treatment of hyperlipidaemia in Malaysia. It has a good safety profile and a proven track record in reducing myocardial infarction, stroke and cardiovascular death from numerous well conducted multinational trials [1,2]. Indeed, more recent evidence points towards increasingly lower LDL treatment endpoint [3] and new indications (eg: patients with high hsCRP) [4] for using stains are emerging. Therefore the usage of statins is likely to become more widespread in the next few years.

The most popular statin prescribed in the public sector was lovastatin (4.05DDD/1000 population/day); for the most part related to its lower cost. Simvastatin remained the most popular statin among the private health sector followed by atorvastatin. Rosuvastatin, the most potent statin around at the moment was not commonly prescribed (0.225DDD/1000 population/day). With the advent of lower cost generic products, it is expected this picture to change gradually and the ‘higher end’ statins made more affordable throughout Malaysia.

Ezetimibe, which inhibits cholesterol absorption at intestinal brush borders, had gained some traction among Malaysian prescribers (0.42DDD/1000 population/day) despite being a relatively newcomer. It is primarily used as an adjunct to statins rather than a first line drug. Despite its effectiveness in LDL lowering, evidence of ezetimibe’s clinical benefits are still pending, awaiting studies such as IMPROVE-IT [5].

The fibrates, despite being in use for a long time and having good clinical trial data [6], were still not commonly prescribed in Malaysia (1.39DDD/1000 population/day). This could be related to the fact that increasing HDL and lowering triglyceride is still not viewed as imperative as lowering LDL cholesterol by most clinicians.

Overall, Malaysia still has low utilisation of lipid lowering agent compared with other developed countries. For example, Australia with a prevalence of hypercholesterolemia of about 51% [7] (similar to Malaysia – 53.5%) [8] had a statin usage of 196.23DDD/1000 population/day in 2006 [9] compared to 15.68DDD/1000 population/day in Malaysia. This seems to indicate that we still have room for improvement in the treatment of hyperlipidaemia, for both primary and secondary prevention purposes. With our country’s expanding aged population, this is vital in reducing our cardiovascular health burden and healthcare cost in future.

Table 10.1: Use of Lipid Lowering Medicines by Drug Class, in DDD/1000 population/day 2006 ATC Drug Class 2006

C10A A HMG CoA reductase inhibitors 15.3216

C10A B Fibrates 1.3854

C10A C Bile acid sequestrants 0.0019

C10A X Other lipid modifying agents 0.0917

C10B A HMG CoA reductase inhibitors in combination with other lipid 0.3593

modifying agents

CHAPTER 10USE OF LIPID LOWERING MEDICINESMalaysian Statistics on Medicines 2006

40

Table 10.2: Use of Lipid Lowering Medicines by Drug Class and Agents, in DDD/1000population/day 2006

ATC Drug Class and Agents 2006 C10A A HMG CoA reductase inhibitors C10A A01 Simvastatin Public 2.6378

Private 3.9287

Total 6.5665

C10A A0 2 Lovastatin Public 4.0507

Private 0.5157

Total 4.5664

C10A A03 Pravastatin Public 0.1956

Private 0.2534

Total 0.4489

C10A A04 Fluvastatin Public -

Private 0.1862

Total 0.1862

C10A A05 Atorvastatin Public 0.786

Private 2.537

Tota l 3.323

C10A A07 Rosuvastatin Public 0.0062

Private 0.2244

Total 0.2306

C10A B Fibrates C10A B01 Clofibrate Public -

Private 0.0002

Total 0.0002

C10A B02 Bezafibrate Public -

Private 0.0002

Total 0.0002

C10A B04 Gemfibrozil Public 0.7413

Private 0.0285

Total 0.7698

C10A B05 Fenofibrate Public 0.199

Private 0.3695

Total 0.5684

C10A B08 Ciprofibrate Public 0.0122

Private 0.0346

Total 0.0468

C10A C Bile acid sequestrants C10A C01 Colestyramine Public 0.0005

Private 0.0014

Total 0.0019

C10A X Other lipid modifying agents C10A X04 Benfluorex Public -

Private 0.0195

Total 0.0195

C10A X09 Ezetimibe Public 0.0077

Private 0.0645

Total 0.0722


41

ATC Drug Class and Agents 2006 C10B A HMG CoA reductase inhibitors in combination with other lipid modifying agents C10B A02 Simvastatin and ezetimibe Public 0.0021

Private 0.3571

Total 0.3593

References:1. Shepherd J, Cobbe SM, Ford I, et al. for the West of Scotland Coronary Prevention Group. Prevention of coronary heart disease with pravastatin in men with hypercholesterolaemia. N Eng J Med 1995; 333:1301-72. Scandinavian Simvastatin Survival Study Group. Randomised trial in cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994; 344:1383-9.3. LaRosa JC, Grundy SM, Waters DD, et al. Intensive lipid lowering with atorvastatin in patients with stable coronary disease. N Eng J Med 2005.4. Ridker PM, Eleanor Danielson, Fonseca F, et al. Rosuvastatin to Prevent Vascular Events in Men and Women with Elevated C-Reactive Protein (JUPITER). N Eng J Med Nov. 2008.5. Cannon CP, Guigliano RP, et al. Rationale and design of IMPROVE-IT (IMProved Reduction of Outcomes: Vytorin Efficacy International Trial): comparison of ezetimbe/simvastatin versus simvastatin monotherapy on cardiovascular outcomes in patients with acute coronary syndromes. Am Heart J. Nov. 2008.6. Helsinki Heart Study: primary-prevention trial with gemfibrozil in middle-aged men with dyslipidemia. Safety of treatment, changes in risk factors, and incidence of coronary heart disease. Frick MH - N Eng J Med Nov. 1987.7. Australian Diabetes, Obesity and Lifestyle Study (AusDiab). 2001 Report.8. Non-communicable Disease Surveillance Programme, Malaysia, 2006.9. Australian Statistics on Medicine 2006. Department of Health and Aging, Australian Government.

CHAPTER 11USE OF DERMATOLOGICALS Malaysian Statistics on Medicines 2006

43


Edited by:Rohna R1, Asmah J2, Roshidah B3

1. Selayang Hospital, 2. Kuala Lumpur Hospital, 3. Melaka Hospital

The topical dermatological medicaments included in this study were antifungals, anti-psoriatics, antibiotics, antivirals, corticosteroids, anti-acne agents, hair growth stimulants, depigmenting agents, calcineurin inhibitors and metronidazole. Topical dermatological medicament is the major therapeutic modality used in treating patients with skin disorders. Utilisation is measured as total dose of topical medicament in g/ml/1000 population/day.

There is a disparity in the utilisation of dermatological medicaments by public and private health care providers with the latter having access to a larger variety of topical medicaments (Table A). Prescribing only medicaments that are available in the Ministry of Health (MOH) drug formulary by healthcare providers in the public sector is one possible explanation for the disparity. The list of medicaments (Table A) that were utilised only by private healthcare providers was not available in the MOH drug formulary. In the public sector, prescribing of certain dermatological medicaments (e.g. topical anti-acne agents) is only by trained dermatologists and they are few in number. In private sector, the non-dermatologists have access to clindamycin and various other topical anti-acne agents such as adapalene and azelaic acid.

The lower usage of the newer but expensive medicaments (e.g. tacrolimus, pimecrolimus, imiquimod and metronidazole) in government healthcare facilities was because of the availability of their cheap and effective equivalents in the MOH drug formulary. In special cases of drug resistance or contraindication, prescribing of dermatological medicaments not in the MOH formulary is permissible after seeking approval from the Director General of Health, Malaysia.

In government healthcare facilities, procurement of dermatological medicaments for acute (acute cutaneousinfections) and chronic skin diseases (eczema and psoriasis) took preference over hair growth stimulants (minoxidil, finasteride) and depigmentation agents8-10(hydroquinone) which are perceived as more for cosmetic benefits.

Medications (acitretin and methoxalen) that require vigilant long term monitoring was utilised less in the private sector because patients requiring these agents were often referred to government hospitals for management.

There was a high usage of the moderately potent and very potent topical steroids1-7 by private health care providers. The appropriateness of these prescriptions and monitoring of their side effects1-7 need further study. Similarly the usage of topical antibiotics was more in the private sector as compared to public sector. Here again, the appropriateness of topical antibiotic prescriptions and the drug resistance pattern need further study. Healthcare providers need to be aware of untoward events1-11 that can occur with inappropriate drug usage.

CHAPTER 11USE OF DERMATOLOGICALSMalaysian Statistics on Medicines 2006

44

Table A: Utilisation of Medicament by Health Care Providers 2006

Table 11.1: Use of Dermatological by Drug Class and Agents, in total dosage/1000 population/day 2006

Increased medicament usage in Public Health Facilities

Increased medicament usage in Private Health Facilities

Medicament used in Private Health Facilities only

Topical Anti-fungal medicaments Nystatin, Miconazole

Ketoconazole

Anti-psoriatic therapy Acitretin, Methoxalen

Calcipotriol combination therapy

Antibiotic & Antiseptics Neomycin, Silver sulfadiazine

Tetracycline, Fusidic acid, Gentamicin, Mupirocin

Antiviral Topical aciclovir Tromantadine, Imiquimod Corticosteroids Hydrocortisone

Clobetasone, Triamcinolone Betametasone, Mometasone Hydrocortisone aceponate, clobetasol

Aclometasone, Dexamethasone Fluocinolone acetonide, Fluticasone

Combination Topical steroid and Antibiotic (AB)/antifungal Hydrocortisone plus AB

Bethamethasone AB combination Bethamethasone plus other

Prednisolone plus AB, Triamcinolone/dexamethasone plus AB,

Anti-acne Adapalene, clindamycin,

Azelaic acid Topical isotretinoin Topical erythromycin and erythromycin combination

Hair growth stimulants Finasteride Topical minoxidil Depigmenting agent Hydroquinone Calcineurin inhibitors Tacrolimus and pimecrolimus Acne rosacea therapy Topical metronidazole

Isoconazole, Econazole,Terbinafine, Fluconazole

Fluocinolone acetonide/clobetasol plus AB, Hydrocortisone plus other combination

combination

ATC Drug Class and Agents Unit 2006 D01A A Antibiotics

D01A A01 Nystatin g/ml/cc Public 0.1064

Private 0.0089

Total 0.1153

D01A C Imidazole and triazole derivatives D01A C01 Clotrimazole g/ml/cc Public 0.1469

Private 0.3403

Total 0.4872

D01A C02 Miconazole g/ml/cc Public 1.3178

Private 0.6315

Total 1.9493

D01A C03 Econazole g/ml/cc Public -

Private 0.0434

Total 0.0434

D01A C05 Isoconazole g/ml/cc Public -

Private 0.0003

Total 0.0003

D01A C07 Tioconazole g/ml/cc Public 0.0007

Private 0.0059

Total 0.0066

D01A C08 Ketoconazole g/ml/cc Public 0.0608

Private 0.3199

Total 0.3808


45

ATC Drug Class and Agents Unit 2006 D01A C15 Fluconazole g/ml/cc Public -

Private 0.0002

Total 0.0002

D01A C20 Combinations g/ml/cc Public 0.0051

Private 1.7155

Total 1.7207

D01A C52 Miconazole, combinations g/ml/cc Public -

Private 0.0229

Total 0.0229

D01A E Other antifungals for topical use D01A E13 Selenium sulfide g/ml/cc Public 0.032

Private 0.0388

Total 0.0707

D01A E15 Terbinafine g/ml/cc Public -

Private 0.0277

Total 0.0277

D01A E16 Amorolfine g/ml/cc Public 0.0001

Private <0.0001

Total 0.0002

Table 11.2: Use of Dermatological by Drug Class and Agents, in DDD/1000 population/day 2006ATC Drug Class and Agents 2006 D01B A Antifungals for systemic use D01B A01 Griseofulvin Public 0.1525

Private 0.231

Total 0.3835

D01B A02 Terbinafine Public 0.0048

Private 0.0081

Total 0.0128

Table 11.3: Use of Dermatological by Drug Class and Agents, in total dosage/1000 population/dayATC Drug Class and Agents Unit 2006 D05A D Psoralens for topical use

D05A D02 Methoxsalen g/ml/cc Public 0.0003

Private 0.0001

Total 0.0004

D05A X Other antipsoriatics for topical use D05A X02 Calcipotriol g/ml/cc Public 0.0465

Private 0.0124

Total 0.0589

D05A X52 Calcipotriol, combinations g/ml/cc Public -

Private 0.0064

Total 0.0064


46

Table 11.4: Use of Dermatological by Drug Class and Agents, in DDD/1000 population/day 2006ATC Drug Class and Agents 2006 D05B A Psoralens for systemic use D05B A02 Methoxsalen Public 0.0012

Private 0.0007

Total 0.002

D05B B Retinoids for treatment of psoriasis

D05B B01 Etretinate Public -

Private

Total

-

-

D05B B02 Acitretin Public 0.006

Private 0.0004

Total 0.0064

Table 11.5: Use of Dermatological by Drug Class and Agents, in total dosage/1000 population/day 2006ATC Drug Class and Agents Unit 2006 D06A A Tetracycline and derivatives

D06A A04 Tetracy cline g/ml/cc Public -

Private 0.0041

Total 0.0041

D06A X Other antibiotics for topical use D06A X01 Fusidic acid g/ml/cc Public 0.0303

Private 0.2682

Total 0.2985

D06A X04 Neomycin g/ml/cc Public 0.8132

Private 0.2511

Total 1.0644

D06A X07 Gentamicin g/ml/cc Public 0.0116

Private 0.2203

Total 0.2319

D06A X09 Mupirocin g/ml/cc Public 0.0255

Private 0.0896

Total 0.1151

Table 11.6: Use of Dermatological by Drug Class and Agents, in total dosage/1000 population/day 2006ATC Drug Class and Agents Unit 2006 D06B A Sulfonamides

D06B A01 Silver sulfadiazine g/ml/cc Public 0.1782

Private 0.0919

Total 0.2701

D06B B Antivirals D06B B02 Tromantadine g/ml/cc Public -

Private 0.0054

Total 0.0054

D06B A Sulfonamides

D06B B03 Aciclovir g/ml/cc Public 0.002

Private 0.0588

Total 0.0608


47

Table 11.7: Use of Dermatological by Drug Class and Agents, in total dosage/1000 population/day 2006ATC Drug Class and Agents Unit 2006 D07A A Corticosteroids, weak (group I) D07A A02 Hydrocortisone g/ml/cc Public 1.0887

Private 0.6583

Total 1.747

D07A B Corticosteroids, moderately potent (group II) D07A B01 Clobetasone g/ml/cc Public 0.0491

Private 0.0622

Total 0.1113

D07A B03 Flumetasone g/ml/cc Public 0.0002

Private -

Total 0.0002

D07A B09 Triamcinolone g/ml/cc Public 0.0013

Private 0.085

Total 0.0863

D07A B10 Alclometasone g/ml/cc Public -

Private 0.0001

Total 0.0001

D07A B19 Dexamethasone g/ml/cc Public -

Private 0.0005

Total 0.0005 D07A C Corticosteroids, potent (group III) D07A C01 Betamethasone g/ml/cc Public 0.8813

Private 1.3885

Total 2.2698 D07A C04 Fluocinolone acetonide g/ml/cc Public -

Private 0.0276

Total 0.0276

D07A C Corticosteroids, potent (group III) D07A C13 Mometasone g/ml/cc Public 0.0168

Private 0.0951

Total 0.1119

D07A C16 Hydrocortisone aceponate g/ml/cc Public 0.0005

Private 0.0083

Total 0.0088

ATC Drug Class and Agents Unit 2006 D06B B10 Imiquimod g/ml/cc Public -

Private 0.0003

Total 0.0003

D06B X Other chemotherapeutics

D06B X01 Metronidazole g/ml/cc Public -

Private 0.0113

Total 0.0113


48

ATC Drug Class and Agents Unit 2006 D07A C17 Fluticasone g/ml/cc Public -

Private 0.0182

Total 0.0182

D07A D Corticosteroids, very potent (group IV) D07A D01 Clobetasol g/ml/cc Public 0.0583

Private 0.5533

Total 0.6116

Table 11.8: Use of Dermatological by Drug Class and Agents, in total dosage/1000 population/day 2006ATC Drug Class and Agents Unit 2006 D07C A Corticosteroids, weak, combinations with antibiotics D07C A01 Hydrocortisone and antibiotics g/ml/cc Public 0.0573

Private 0.0407

Total 0.0981

D07C A03 Prednisolone and antibiotics g/ml/cc Public -

Private 0.0006

Total 0.0006

D07C B Corticosteroids, moderately potent, combinations with antibiotics D07C B01 Triamcinolone and antibiotics g/ml/cc Public -

Private 0.049

Total 0.049

D07C B04 Dexamethasone and antibiotics g/ml/cc Public -

Private 0.0015

Total 0.0015

D07C C Corticosteroids, potent, combinations with antibiotics D07C C01 Betamethasone and antibiotics g/ml/cc Public 0.0198

Private 0.6038

Total 0.6235

D07C C02 Fluocinolone acetonide and antibiotics g/ml/cc Public -

Private 0.0016

Total 0.0016

D07C D01 Clobetasol and antibiotics g/ml/cc Public -

Private 0.0013

Total 0.0013

Table 11.9: Use of Dermatological by Drug Class and Agents, in total dosage/1000 population/day 2006ATC Drug Class and Agents Unit 2006 D07X A Corticosteroids, weak, other combinations D07X A01 Hydrocortisone g/ml/cc Public -

Private 0.0313

Total 0.0313

D07X C Corticosteroids, potent, other combinations D07X C01 Betamethasone g/ml/cc Public 0.004

Private 0.1847

Total 0.1887


49

Table 11.11: Use of Dermatological by Drug Class and Agents, in total dosage/1000 population/day 2006ATC Drug Class and Agents Unit 2006 D10A D Retinoids for topical use in acne D10A D01 Tretinoin g/ml/cc Public 0.0358

Private 0.035

Total 0.0708

D10A D03 Adapalene g/ml/cc Public 0.0002

Private 0.0357

Total 0.0359

D10A D04 Isotretinoin g/ml/cc Public -

Private 0.0031

Total 0.00 31

D10A E01 Benzoyl peroxide g/ml/cc Public -

Private 0.0002

Total 0.0002

D10A F Antiinfectives for treatment of acne D10A F01 Clindamycin g/ml/cc Public 0.0002

Private 0.0894

Total 0.0896

D10A F Antiinfectives for treatment of acne

D10A F02 Erythromycin g/ml/cc Public -

Private 0.0384

Total 0.0384

D10A F52 Erythromycin, combinations g/ml/cc Public -

Private 0.0029

Total 0.0029

D10A X Other anti-acne preparations for topical use D10A X03 Azelaic acid g/ml/cc Public 0.0007

Private 0.012

Total 0.0128

Table 11.12: Use of Dermatological by Drug Class and Agents, in DDD/1000 population/day 2006

Table 11.13: Use of Dermatological by Drug Class and Agents, in total dosage/1000population/day 2006

ATC Drug Class and Agents 2006 D10B A Retinoids for treatment of acne D10B A0 1 Isotretinoin Public 0.01

Private 0.0073

Total 0.0173

ATC Drug Class and Agents Unit 2006 D11A C Medicated shampoos

D11A C03 Selenium compounds g/ml/cc Public 0.0604

Private 0.1091

Total 0.1695

D11A X Other dermatologicals

D11A X01 Minoxidil g/ml/cc Public -

Private 0.0231

Total 0.0231

D11A X10 Finasteride mg Public 0.0012

Private 0.0989

Total 0.1001


50

ATC Drug Class and Agents Unit 2006 D11A X11 Hydroquinone g/ml/cc Public <0.0001

Private 0.0119

Total 0.012

D11A X14 Tacrolimus g/ml/cc Public 0.0005

Private 0.0098

Total 0.0103

D11A X Other dermatologicals

D11A X15 Pimecrolimus g/ml/cc Public <0.0001

Private 0.0019

Total 0.002

References:1. Rajesh B et al. Factors affecting prescription of ultra-high potency topical corticosteroids in skin disease: an analysis of US national practice data Journal of Drugs of Dermatology, Nov.-Dec. 2005.2. MA Al-Dhalimi and, N. Aljawahiry. Misuse of topical corticosteroids: a clinical study in an Iraqi hospital Eastern Mediterranean Health Journal Volume 12 No 6 November 2006 Griffiths WAD, Wilkinson JD. Topical therapy. In: Champion RH et al. Textbook of dermatology, vol. 4. 6th ed. Oxford, Blackwell Science, 1998:3547-52. 3. Sulzberger MB, Witten VH. The effect of topically applied compound F in selected dermatoses. Journal of investigative dermatology, 1952, 19(2):101-2. 4. Lagos B, Maibach H. Frequency of application of topical corticosteroids: an overview. British journal of dermatology, 1998, 139(5):763-6. 5. Brodkin RH, Janniger CK. The artful use of topical steroids. Cutis, 1998, 61(3):125-6. 6. Keane FM et al. Unregulated use of clobetasol propionate. British journal of dermatology, 2001, 144(5):1095-6. 7. Fleischer AB Jr, Ford PG. How to prevent side-effects of topical corticosteroids. Skin and aging, 1998, February: 54-65. 8. Mahe A et al. Skin diseases associated with the cosmetic use of bleaching products in women from Dakar, Senegal. British journal of dermatology, 2003, 148(3):493-500. Arnold J, Anthonioz P, Marchand JP. Depigmenting action of corticosteroids. Dermatologica, 1975, 151(5):274-80. 9. Del Giudice P, Pinier Y. The widespread use of skin lightening creams in Senegal: a persistent health problem in West Africa. International journal of dermatology, 2002, 41(2):69-72. 10. Hammarstrom et al. Pharmaceutical care for patients with skin diseases: a campaign year at Swedish pharmacies. Journal of Clinical Pharmacy and Therapeutics, 1995, 20(6):327-334.

CHAPTER 12: USE OF GYNAECOLOGICALS, SEX HORMONES AND HORMONAL CONTRACEPTIVES Malaysian Statistics on Medicines 2006

51


Edited by:Muralitharan G1, Tan AL2

1. Ampang Hospital, 2. Kuala Lumpur Hospital

There has been very little review on the use of gynaecological, hormone and hormonal contraceptive drugs in Malaysian literature. Obstetrics and Gynaecology have altered their pharmacotherapeutic usage in recenttimes. This is due to various factors. Firstly, what was thought to be first line management is currently not effective therapeutically and has therefore been abandoned and newer drugs introduced. Secondly, newer therapies have been introduced for common Obstetric and Gynaecological problems which are not addressedin Table 12.1. Thirdly, hormonal therapies have changed with newer hormonal drugs where the hormones are more closely associated with the biochemical nature of natural hormones.

In the management of preterm labour, the drug of choice as a tocolytic agent has changed recently to ritodrine. However there is level A evidence that Atosiban and Nifedipine appear to be preferable as they have fewer adverse effects and comparable effectiveness. [1] These drugs will need to be looked into in future reviews. Antenatal corticosteroid therapy is an established evidence based therapy which has been associated with reduction in respiratory distress syndrome of the newborn. [2] Corticosteroids for this indication have also not been addressed in Table 12.1. Similarly, the diagnosis of preterm rupture of membranes is often difficult to ascertain. There are various new tools that are available that have not been evaluated in Malaysia and are therefore not widely used. Amniosure, a device that is FDA approved and which claims sensitivity and specificity of more than 90% will need to be evaluated for usage in Malaysia. Actin Prom and Actin Partus, devices that are widely used in first world countries in the diagnosis of preterm labour and labour need to be evaluated in future for use in Malaysia.

In the management of hypertensive disease complicating pregnancy and eclampsia, the use of Magnesium Sulphate is now an integral component. [3] This needs to be addressed in future reviews of this nature. Similarly thoromboprophylactic drugs both low molecular weight heparin and conventional heparin is now widely utilised in Obstetric and Gynaecological practice. They need to be evaluated in future undertakings of this nature.

Metformin therapy is now encouraged in the management of polycystic ovarian syndrome. [4] This needs to be addressed in Chapter 12. Similarly, pelvic inflammatory disease is an increasing problem in the community today. Chlamydia is an organism associated with pelvic inflammatory disease and Azithromycin is the drug of choice. Similarly, with the current increase in assisted reproductive techniques, the use of ovulatory drugs ranging from GnRH analogues and purified FSH derivatives to conventional therapy such as Clomiphene Citrate and Tamoxifen need to be addressed in future reviews. Surgical management of subfertile patients is now supplemented with the use of substances which aid in preventing adhesions which is an important cause of subfertility. Drug therapy for the management of endometriosis and subfertility is now closely associated and drugs used for the first condition are often supplemented with drugs for the subfertility. [5]

Review of Table 12.2.2 reveals that there are drugs where there is a disparity in its usage in the public and private sector. The disparity is largely in the use of drugs which are expensive. There is also evidence that synthetic hormonal therapy and selective estrogen receptor modulators for menopausal women is underutilised within the public sector.

In conclusion, there is a need to relook at drugs categorised under gynaecological and hormonal usage. A lot of the drugs are now not commonly used by practicing gynaecologists and have been replaced by newer drugs. The next review will need to update the use of these drugs and will need to look at medical devices that are now part of daily Obstetrics and Gynaecology practice.


52

ATC Drug Class 2006 G01 GYNECOLOGICAL ANTIINFECTIVES AND ANTISEPTICS 0.2119

G02 OTHER GYNECOLOGICALS 0.0947

G03 SEX HORMONES AND MODULATORS OF THE GENITAL SYSTEM 10.7433

Table 12.1: Use of Gynaecologicals, Sex Hormones and Hormonal Contraceptives, in DDD/1000 population/day 2006

Table 12.2.1: Use of Gynaecologicals, Sex Hormones and Hormonal Contraceptives by Drug Class, in DDD/1000 population/day 2006

ATC Drug Class and Agents 2006 G01A ANTIINFECTIVES AND ANTISEPTICS, EXCL. COMBINATIONS WITH

CORTICOSTEROIDS 0.2119

G01A A Antibiotics 0.0648

G01A F Imidazole derivatives 0.147

G02A OXYTOCICS 0.0515

G02A B Ergot alkaloids 0.0059

G02A D Prostaglandins 0.0457

G02C OTHER GYNECOLOGICALS 0.0431

G02C A Sympathomimetics, labour repressants 0.0218

G02C B Prolactine inhibitors 0.0213

G02C X Other gynecologicals <0.0001

G03A HORMONAL CONTRACEPTIVES FOR SYSTEMIC USE 8.7254

G03A A Progestogens and estrogens, fixed combinations 3.9443

G03A B Progestogens and estrogens, sequential preparations 0.0388

G03A C Progestogens 4.7423

G03B ANDROGENS 0.0267

G03B A 3-oxoandrosten (4) derivatives 0.0245

G03B B 5-androstanon (3) derivatives 0.0022

G03C ESTROGENS 0.1336

G03C A Natural and semisynthetic estrogens, plain 0.1336

G03D PROGESTOGENS 1.0514

G03D A Pregnen (4) derivatives 0.367

G03D B Pregnadien derivatives 0.1996

G03D C Estren derivatives 0.4848

G03F PROGESTOGENS AND ESTROGENS IN COMBINATION 0.1935

G03F A Progestogens and estrogens, fixed combinations 0.0794

G03F B Progestogens and estrogens, sequential preparations 0.1141

G03G GONADOTROPINS AND OTHER OVULATION STIMULANTS 0.3619

G03G A Gonadotropins 0.0342

G03G B Ovulation stimulants, synthetic 0.3277

G03H ANTIANDROGENS 0.0964

G03H A Antiandrogens, plain 0.013

G03H B Antiandrogens and estrogens 0.0834 G03X OTHER SEX HORMONES AND MODULATORS OF THE GENITAL SYSTEM 0.1544

G03X A Antigonadotropins and similar agents 0.0251

G03X C Selective estrogen receptor modulators 0.1293


53

Table 12.2.2: Use of Gynaecologicals, Sex Hormones and Hormonal Contraceptives by Drug Class and Agents, in DDD/1000 population/day 2006

ATC Drug Class and Agents 2006 G01A A Antibiotics

G01A A01 Nystatin Public 0.0596

Private 0.004

Total 0.0636

G01A A03 Amphotericin B Public -

Private 0.0012

Total 0.0012

G01A A10 Clindamycin Public -

Priva te <0.0001

Total <0.0001

G01A F Imidazole derivatives

G01A F01 Metronidazole Public 0.0539

Private 0.0003

Total 0.0543

G01A F02 Clotrimazole Public 0.0216

Private 0.0579

Total 0.0795

G01A F04 Miconazole Public -

Private 0.0035

Tota l 0.0035

G01A F05 Econazole Public -

Private 0.0069

Total 0.0069

G01A F08 Tioconazole Public -

Private 0.0024

Total 0.0024

G01A F11 Ketoconazole Public -

Private 0.0004

Total 0.0004

G02A B Ergot alkaloids

G02A B01 Methylergometrine Public -

Private 0.0025

Total 0.0025

G02A B03 Ergometrine Public 0.003

Private 0.0004

Total 0.0034

G03D C02 Norethisterone Public 0.0223

Private 0.2787

Total 0.301

G03D C05 Tibolone Public 0.1063

Private 0.0705

Total 0.1768

G03F A Progestogens and estrogens, fixed combinations

G03F A01 Norethisterone and estrogen Public 0.0135

Private 0.0183

Total 0.0318

G03F A12 Medroxyprogesterone and estrogen Public 0.0279

Private 0.0023

Total 0.0302


54

G03F A14 Dydrogesterone and estrogen Public 0.0103

Private 0.007

Total 0.0173

G03F B Progestogens and estrogens, sequential preparations

G03F B01 Norgestrel and estrogen Public 0.0709

Private 0.0155

Total 0.0864

G03F B05 Norethisterone and estrogen Public <0.0001

Private 0.0014

Total 0.0014

G03F B06 Medroxyprogesterone and estrogen Public 0.0244

Private 0.0003

Total 0.0247

G03F B07 Medrogestone and estrogen Public 0.0006

Private -

Total 0.0006

G03F B08 Dydrogesterone and estrogen Public 0.001

Private -

Total 0.001

G03G A Gonadotropins

G03G A01 Chorionic gonadotrophin Public 0.0122

Private 0.0183

Total 0.0305

G03G A02 Human menopausal gonadotrophin Public -

Private 0.0003

Total 0.0003

G03G A05 Follitropin alfa Public 0.0009

Private 0.0008

Total 0.0018

G03G A06 Follitropin beta Public 0.0007

Private 0.0009

Total 0.0016

ATC Drug Class and Agents 2006

G03G A07 Lutropin alfa Public -

Private <0.0001

Total <0.0001

G03G A08 Choriogonadotropin alfa Public -

Private <0.0001

Total <0.0001

G03G B Ovulation stimulants, synthetic

G03G B02 Clomifene Public 0.1178

Private 0.2098

Total 0.3277

G03H A Antiandrogens, plain

G03H A01 Cyproterone Public 0.0111

Private 0.0019

Total 0.013

G03H B Antiandrogens and estrogens

G03H B0 1 Cyproterone and estrogen Public 0.0116

Private 0.0718

Total 0.0834


55

ATC Drug Class and Agents 2006 G03X A Antigonadotropins and similar agents

G03X A01 Danazol Public 0.0156

Private 0.008

Total 0.0237

G03X A02 Gestrinone Public 0.0012

Private 0.0003

Total 0.0014

G03X C Selective estrogen receptor modulators

G03X C01 Raloxifene Public 0.0646

Private 0.0647

Total 0.1293

References:1. Royal College of Obstetricians and Gynaecologists. Tocolytic Drugs For Women in Preterm Labour. Clinical Guideline No. 1 (B) October 2002.2. Royal College of Obstetricians and Gynaecologists. Antenatal Corticosteroids To Prevent Respiratory Distress Syndrom. Guideline No. 7 Revised February 2004.3. Royal College of Obstetricians and Gynaecologists. The Management of Severe Pre-Eclampsia/Eclampsia. Guideline No. 10 (A) March 2006.4. Royal College of Obstetricians and Gynaecologists. Long-Term Consequences of Polycystic Ovary Syndrome. Green-top Guideline No. 33 December 2007.5. Royal College of Obstetricians and Gynaecologists. The Investigation and Management of Endometriosis. Green-top Guideline No. 24 October 2006.

CHAPTER 13USE OF UROLOGICALS Malaysian Statistics on Medicines 2006

57


Edited by:Malek R1, Lei CM2, Subaratnam S1, Syarihan S1

1. Selayang Hospital 2. Normah Hospital, Kuching

Although urology started as a surgical specialty, medicines play an expanding role in the management of urological disease.

Medicines in urology may be discussed under the following drug class:

(a) Drugs used for overactive bladder, OAB: The oldest drug is Flavoxate, with rather non specific and weak anti-cholinergic action. The anti-cholinergic of choice is currently Tolterodine, reflected in its increased usage. However, there are newer anti-cholinergics with less side effects of dry mouth. When the newer agents are duly registered, it is likely to increase in usage, as seen in other countries.

(b) Drugs used in erectile dysfunction: The oral prostagladin type 5 inhibitors, namely Sildenafil, Tadalafil and Vardenafil are introduced at different stages in Malaysia. It is therefore not unexpected the earlier drug, namely, Sildenafil has a bigger usage. Experience in other countries showed that the 3 drugs have almost an equal share.

Alprostadil is actually an injectable although put in the same group. The usage is reported as very low. Nevertheless, this has more or less replaced Papaverine as the first line intracorporeal injection for penile erection. Alprostadil have a small but definite role in the treatment of erectile dysfunction.

(c) Alpha-adrenoreceptor antagonists: There are 3 main drugs in this group used for relief of bladder outlet obstruction. Only the extended release (XL) form of Alfuzosin is available. For Doxazosin, both the extended release (XL) as well as the rapid release lower dosage is available. For Terazosin, only the rapid release incremental dosages (1, 2, 5 mg) are available. It is likely that the drug usage reported refers to the optimal dosage and not the starting dosage of this alpha-adrenoreceptor antagonist.

(d) 5-alpha reductase inhibitors: There are currently 2 drugs in this class, namely, Finasteride and Dutasteride. Finasteride has been in use for more than 10 years and currently, the generic forms are available. Therefore, it is not surprising that usage of Finasteride is more than that of Dutasteride.

(e) Gonadotrophin releasing hormone analogues: In urology, these drugs are used to inhibit the production of testosterone by the testes, as a treatment for advanced prostate cancer. This includes Buserelin, Leuprorelin, Goserelin and Triptorelin. Again, they are short acting as well as depot versions (with action ranging from 3 to 12 months). They are also used by the gynaecologists and the total usage probably covers both usages.

(f) Anti-estrogens: These include Flutamide, Bicalutamide and Cyproterone Acetate. For some patients with prostate cancer, anti-androgens are added onto the gonadotrophin release hormone analogues for maximal androgen blockage (MAB). This is to block the action of hormones from the adrenal glands.

(g) Selective immunosuppressive agents for metastatic kidney cancer: This new group of drugs includes Etanercept, Infliximab, Leflunomide, Efalizumab. These are new drugs which have shown some efficacy for metastatic renal cancer. They are often used by the urologists together with the medical oncologists. In view of the high cost, it is probable that the reported usage from the present survey is an underestimate as they are likely to be used in the private hospitals.

(h) Testosterone: Testosterone is increasing used in the field of men’s health. A recent survey showed that there is a 20% incidence of testosterone deficient syndrome in patients with metabolic syndrome. Again, these drugs are likely to be given by private specialists.

CHAPTER 13USE OF UROLOGICALSMalaysian Statistics on Medicines 2006

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(i) Anti-diuretic hormone: The commercial preparation of this is Desmopressin (Minirin). It is used mainly to treat nocturnal polyuria which is seen in paediatric patients with enuresis and in some elderly men.

Table 13.1: Use of Urological, in DDD/1000 population/day 2006 ATC Drug Class and Agents 2006 G04 UROLOGICALS 0.7232

Table 13.2.1: Use of Urological by Drug Class, in DDD/1000 population/day 2006ATC Drug Class and Agents 2006 G04B OTHER UROLOGICALS, INCL. ANTISPASMODICS 0.2018

G04C DRUGS USED IN BENIGN PROSTATIC HYPERTROPHY 0.5214

Table 13.2.2: Use of Gynecological, Sex Hormones and Hormonal Contraceptives by Drug Class and Agents, in DDD/1000 population/day 2006

ATC Drug Class and Agents 2006 G04B D Urinary antispasmodics G04B D02 Flavoxate Public 0.0002

Private 0.0149

Total 0.0151

G04B D04 Oxybutynin Public 0.0029

Private 0.0003

Tota l 0.0032

G04B D07 Tolterodine Public 0.0159

Private 0.006

Total 0.0219

G04B E Drugs used in erectile dysfunction G04B E01 Alprostadil Public <0.0001

Private <0.0001

Total <0.0001

G04B E03 Sildenafil Public 0.0011

Private 0.1173

Total 0.1184

G04B E08 Tadalafil Public 0.0023

Private 0.0364

Total 0.0387

G04B E09 Vardenafil Public 0.0001

Private 0.0044

Total 0.0045

G04C A Alpha-adrenoreceptor antagonists G04C A01 Alfuzosin Public 0.048

Private 0.0506

Total 0.0986

G04C A03 Terazosin Public 0.2885

Private 0.0706

Total 0.359

C02CA04 Doxazosin Public 0.1764

Private 0.0628

Total 0.2393


59

ATC Drug Class and Agents 2006 G04C B Testosterone-5-alpha reductase inhibitors G04C B01 Finasteride Public 0.03

Private 0.0039

Total 0.0339

G04C B02 Dutasteride Public 0.0151

Private 0.0148

Total 0.0299

Table 13.2.3: Use of Urologicals listed in other chapters, Gonadotropin releasing hormone analogues, anti-androgens, selective immunosuppressive agents, hormones

ATC Drug Class and Agents 2006 L02A E Gonadotropin releasing hormone analogues L02A E01 Buserelin Public <0.0001

Private <0.0001

Total <0.0001

L02A E02 Leuprorelin Public 0.0024

Private 0.0085

Total 0.0109

L02A E03 Goserelin Public 0.0038

Private 0.0021

Tota l 0.0059

L02A E04 Triptorelin Public 0.0011

Private 0.0003

Total 0.0015

L02B A Anti-oxoandrosten (4) derivatives

L02B B01 Flutamide Public 0.0018

Private 0.0007

Total 0.0025

L02B B03 Bicalutamide Public 0.0053

Private 0.001

Total 0.0063

Cyproterone acetate Public 0.0111

Private 0.0919

Total 0.3277

L04A A Selective immunosuppressive agents

L04A A11 Etanercept Public <0.0001

Private 0.0009

Total 0.001

L04A A12 Infliximab Public <0.0001

Private 0.0036

Total 0.0037

L04A A13 Leflunomide Public 0.0077

Private 0.0069

Total 0.0146

L04A A21 Efalizumab Public -

Private <0.0001

Total <0.0001

CHAPTER 13USE OF UROLOGICALSMalaysian Statistics on Medicines 2006

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ATC Drug Class and Agents 2006 G03 Sex Hormones

G03B A 3-oxoandrosten (4) derivatives

G03B A03 Testosterone Public 0.0112

Private 0.0133

Total 0.0245 H01B POSTERIOR PITUITARY LOBE HORMONES

H01B A Vasopressin and analogues

H01B A02 Desmopressin Public 0.0122

Private 0.0037

Total 0.0159

References:1. “Prevalence of Symptomatic BPE Among Malaysian Men Aged 50 and Above Attending Screening During Prostate Health Awareness Campaign”. GC Teh, RM Sahabudin, TC Lim, WL Chong, S Woo, M Mohan, A Khairullah, P Abrams, Institute of Urology, Kuala Lumpur Hospital, Malaysia, Bristol Urological Institute, Southmead Hospital, Bristol, UK.2. “Impotence Clinic in a Developing Country”. CCM Lei, V Manivannan, PKK Mah, PEP. Ng, A Khairullah International J Impotence Research (1994) 6, Suppl. 1, P113.3. “Asian Sildenafil Efficacy and Safety Study (Assess-1): a double-blind, placebo-controlled, flexible-dose study of oral Sildenafil in Malaysian, Singaporean, and Filipino men with erectile dysfunction”. Tan HM, Lei CCM, Mendoza JB et al. Urology 56 (4): 635-640, 2000.4. “Efficacy and tolerability of Vardenafil, an oral phosphodiesterase type-5 inhibitor, in Asian men with erectile dysfunction”. HM Tan, CM Chin, CB Chua, E Gatchalian, A Kongkanand, CCM Lei, FC Ng, K Ratana-Olarn, D Serrano, A Taher, I Tambi, A Tantiwong, M Wong, AWC Yip , Asian J Andrology 2008; 10(3) 495-502.

CHAPTER 14USE OF MEDICINES FOR ENDOCRINE DISORDERS Malaysian Statistics on Medicines 2006

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Edited by:Zanariah H1

With contributions from:Oiyammal C2, Nazri D3

1. Putrajaya Hospital, 2. Sungai Bakap Hospital, 3. Tampin Health Clinic

The total consumption of endocrine related drugs in Malaysia for 2006 was 2.11DDD/1000 population/day. Among the endocrine related drugs, the most utilised were thyroid-related drugs (94.4%), followed by pituitary and hypothalamic hormone and analogues (5.3%) and drugs for calcium homeostasis (0.3%). In comparison, there was very much higher utilisation of endocrine-related drugs in Australia for 2006 at a level of 17.0DDD/1000 population/day, with a similar trend, the most common being thyroid related drugs (98.1%), followed by pituitary and hypothalamic hormone and analogues (1.87%) and drugs for calcium homeostasis (0.01%).

Thyroid therapy consisted of drugs utilised for hypothyroidism and hyperthyroidism. For treatment of hypothyroidism, thyroid hormone replacement was almost entirely (99.99%) with Levothyroxine (T4) sodium at 0.93DDD/1000 population/day in comparison to a much higher consumption in Australia at 15.87DDD/1000 population/day. Use of Liothyronine (T3) Sodium in Australia was minimal at 0.05DDD/1000 population/day, consisting 0.3% of thyroid hormone replacement therapy. This thyroid hormone formulation was hardly utilised in Malaysia. Thyroid hormone consumption with Levothyroxine Sodium was more than 10-fold higher in Australia compared to Malaysia suggesting a higher prevalence of hypothyroidism, possibly related to better screening, diagnosis and treatment among the elderly population.

For treatment of hyperthyroidism, consumption of anti-thyroid preparations were higher in Malaysia (1.06DDD/1000 population/day) compared to Australia (0.77DDD/1000 population/day) in 2006. The most utilised anti-thyroid preparation in Malaysia was Carbimazole (84.2%) followed by Propylthiouracil (15.8%). The higher anti-thyroid drug utilisation in Malaysia is probably related to a preference for first-line medical therapy in hyperthyroidism, often continued over the long-term as radioactive iodine facilities for treatment of hyperthyroidism is currently still limited in accessibility and usually placed as second-line therapy. The higher consumption of carbimazole is most probably due to the convenience of daily dosing as opposed to divided dosing for Propylthiouracil.

Drug utilisation of pituitary and hypothalamic hormones and analogues were generally low in Malaysia at 0.11DDD/1000 population/day and similarly in Australia at 0.32DDD/1000 population/day.

Consumption of drugs for calcium homeostasis was also low in Malaysia at 0.006DDD/1000 population/day and Australia at 0.001DDD/1000 population/day. These drugs include parathyroid hormone and analogues such as Teriparatide (0.0006DDD/1000 population/day) and Calcitonin preparations (0.006DDD/1000 population/day). There was a higher consumption of Calcitonin preparations in Malaysia compared to Australia (0.001DDD/1000 population/ day).

ATC Drug Class and Agents 2006 H01 PITUITARY AND HYPOTHALAMIC HORMONES AND ANALOGUES 0.1128

H03 THYROID THERAPY 1.9964

H04 PANCREATIC HORMONES <0.0001

H05 CALCIUM HOMEOSTASIS 0.0064

Table 14.1: Use of Drug for Endocrine Disorders, in DDD/1000 population/day 2006

CHAPTER 14USE OF MEDICINES FOR ENDOCRINE DISORDERSMalaysian Statistics on Medicines 2006

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ATC Drug Class and Agents 2006 H01A ANTERIOR PITUITARY LOBE HORMONES AND ANALOGUES 0.009

H01A A ACTH 0.0045

H01A B Thyrotropin <0.0001

H01A C Somatropin and somatropin agonists 0.0045

H01B POSTERIOR PITUITARY LOBE HORMONES 0.1025

H01B A Vaso pressin and analogues 0.0191

H01B B Oxytocin and analogues 0.0834

H01C HYPOTHALAMIC HORMONES 0.0013

H01C B Antigrowth hormone 0.0012

H01C C Anti -gonadotropin-releasing hormones <0.0001

Table 14.2: Use of Pituitary and Hypothalamic Hormones and Analogues by Drug Class, in DDD/1000 population/day 2006

Table 14.3.1: Use of Thyroid Therapy by Drug Class, in DDD/1000 population/day 2006

Table 14.3.2: Use of Thyroid Therapy by Drug Class and Agents, in DDD/1000 population/day 2006

Table 14.4.1: Use of Calcium Homeostasis by Drug Class, in DDD/1000 population/day 2006

ANTI-PARATHYROID AGENTS

ATC Drug Class and Agents 2006 H05A PARATHYROID HORMONES AND ANALOGUES 0.0006

H05A A Parathyroid hormones and analogues 0.0006

H05B 0.0058

H05B A Calcitonin preparations 0.0058

ATC Drug Class and Agents 2006 H03A THYROID PREPARATIONS 0.9344

H03A A Thyroid hormones 0.9344

H03B ANTITHYROID PREPARATIONS 1.062

H03B A Thiouracils 0.1679

H03B B Sulfur-containing imidazole derivatives 0.8941

ATC Drug Class and Agents 2006 H03A A Thyroid hormones

H03A A01 Levothyroxine sodium Public 0.7504

Private 0.1839

Total 0.9343

H03A A02 Liothyronine sodium Public <0.0001

Private <0.0001

Total <0.0001

H03B A Thiouracils

H03B A02 Propylthiouracil Public 0.0872

Private 0.0808

Total 0.1679

H03B B Sulfur-containing imidazole derivatives H03B B01 Carbimazole Public 0.611

Private 0.2831

Total 0.8941


63

Table 14.4.2: Use of Thyroid Therapy by Drug Class, in DDD/1000 population/day 2006

References:1. Australian Statistics on Medicine 2006. Commonwealth Department of Health and Ageing Australia.

ATC Drug Class and Agents 2006 H05A A Parathyroid hormones and analogues H05A A02 Teriparatide Public <0.0001

Private 0.0005

Total 0.0006

H05B A Calcitonin preparations H05B A01 Calcitonin (salmon synthetic) Public 0.0044

Private 0.0013

Total 0.0058

CHAPTER 15USE OF ANTIINFECTIVES Malaysian Statistics on Medicines 2006

65


Edited by:Masrahayu M1, Ngau YY2, Thong KS3, Sameerah SAR4, Jacqueline L5, Rahela AK4

1. Selayang Hospital, 2. Kuala Lumpur Hospital, 3. Raja Permaisuri Bainun Hospital, Ipoh, 4. Pharmaceutical Services Division, MOH, 5. Tawau Hospital

The most commonly prescribed antiinfectives in 2006 were Antibacterials (8.94DDD/1000population/day),followed by Antimycobacterials (1.10), Antivirals for systemic use (0.56), Antimycotic for systemic use (0.33) and Antimalarials (0.08). Among the classes of antibacterials prescribed, Penicillins were most commonly used constituting 47.1% of total use of antibacterials, followed by Macrolides, Lincosamides and Streptogramins group (15.5%), Tetracyclines (12.3%), other Beta-lactam Antibacterials (10.7%), Sulfonamide and Trimethoprim (8.6%), Quinolones (4.3%), other antibacterial (0.85%), Aminoglycoside (0.51%) and Amphenicol (0.05%).

Among the penicillin class, penicillins with extended spectrum were most commonly prescribed (2.52DDD/1000 population/day) constituting 59.7% of total use. Beta-lactamase resistant penicillins, penicillin combinations with beta-lactamase inhibitors and beta-lactamase sensitive penicillin constituted 19.2%, 15.9% and 5.2% of penicillin use respectively. Results also showed that Amoxicillin was the highest antibiotic used in the penicillin group for both public (0.7) and private (1.4) sectors.

Cephalosporins constituted 8.8% of total antibacterial use. The first and second generation cephalosporins were the most used and use between both groups were comparable with 0.42 and 0.43DDD/1000 population/day respectively. The first-generation group constituted 44.6% of total cephalosporin use followed by the second-generation group (45.2%), the 3rd generation (8.1%) and 4th generation (2.0%). Cefalexin (0.37DDD/1000 population/day) was the most widely prescribed cephalosporin followed by cefuroxime (0.36)and cefadroxil (0.05). Ceftriaxone was the most widely prescribed third-generation cephalosporin with0.04DDD/1000 population/day.

The Carbapenems constituted 0.17% of total antibacterial use. Meropenem use (44.3%) was near equalproportion in use with imipenem (43.8%). Ertapenem was the least prescribed carbapenem but its consumption was predominantly in the private sector.

Sulphonamides and trimethoprim constituted 8.6% of antibacterial use and the combination Sulfamethoxazole and trimethoprim was the highest used in this group (66.2%). For Macrolides, erythromycin was most widely prescribed (0.94), followed by clarithromycin (0.19) and roxithromycin (0.12). For tetracyclines, doxycycline (0.92) was most commonly prescribed, followed by tetracycline (0.15) and minocycline (0.03). For quinolones, ciprofloxacin (0.14) was the most commonly prescribed, followed by ofloxacin (0.11) and norfloxacin (0.08). Vancomycin was the most frequently prescribed glycopeptide antibiotic, almost ten-fold higher than teicoplanin. Vancomycin consumption was higher in the public sector.

Among the antifungals, ketoconazole (0.24DDD/1000 population/day) was the most frequently prescribed, followed by itraconazole (0.05) and fluconazole (0.03). Amphotericin B was rarely prescribed and so wasflucytosine, caspofungin and voriconazole. Ketoconazole (95%) and fluconazole (58%) was more frequentlyprescribed in the private sector, amphotericin B (93%) mainly by the public sector while itraconazole consumption was almost equal in both the public and private sectors.

Among the anti-mycobacterials, isoniazid (0.46DDD/1000 population/day)) was the most frequently prescribed followed by rifampicin (0.3), pyrazinamide (0.12) and ethambutol (0.11). Usage of these drugs was predominantly in the public sector. Usage of second-line anti-mycobacterial drugs was relatively infrequent. Aminoquinolones were the most commonly prescribed anti-protozoal drugs (0.06DDD/1000 population/day), of which primaquine was the most frequently prescribed agent (52%) followed by hydroxychloroquine (28%).

For the antivirals, nucleoside and nucleotide reverse transcriptase inhibitors (0.18DDD/1000 population/day)were the most commonly prescribed agents (36.4% of total drugs used), followed by neuraminidase inhibitors (0.15). Oseltamivir (0.125) was the most commonly prescribed antiviral, followed by lamivudine (0.116)

CHAPTER 15USE OF ANTIINFECTIVESMalaysian Statistics on Medicines 2006

66

and aciclovir (0.047). While Oseltamivir was predominantly prescribed by the public sector, lamivudine was more commonly used in the private sector.

Antibacterial use in Malaysia (8.94DDD/1000 population/day)) is lower when compared to the United States (24.92), Europe (19.04) and British Columbia (17.9) [1,2]. It is however comparable to countries with relatively lower antibiotic consumption such as Austria (12.5), Latvia (11.7) and the Netherlands (9.78). Antibiotic use in Malaysia was also lower than Greece (31.4), France (28.97), Luxembourg (27.34), Hungary (19.63) and Slovenia (17.1) [3]. The most frequently prescribed class of antibacterials in Malaysia was penicillins (J01C) and this was also the case for the United States and Europe. However, consumption of penicillins was twice as much in the United States (9.70) and Europe (8.71) as compared to Malaysia (4.21). Among the penicillin subclasses, penicillins with extended spectrum (2.51) were the most frequently prescribed in Malaysia, similar to the United States (5.68) and Europe (4.49) [2]. Amoxicillin was the most commonly prescribed antibacterial agent in Malaysia (2.10) and this was also similar to the United States (5.59) and Europe (4.26). However, amoxicillin consumption in Malaysia was lower than the lowest DDD in Europe, the Netherlands (3.76).

The second most common antibacterial agent prescribed in Malaysia was erythromycin (0.94DDD/1000 population/day)) as compared to co-amoxiclav which was the second most commonly prescribed antibacterial agent in the United States and Europe. The third most common antibacterial agent prescribed in Malaysia was doxycycline (0.92), which was similar to United States and Europe. Erythromycin was the most common macrolide prescribed in Malaysia while in the United States and Europe, azithromycin was the more popular macrolide. Cloxacillin (0.8DDD/1000 population/day) was the fourth most common antibacterial agent prescribed in Malaysia. For the fluroquinolone group, levofloxacin was most commonly prescribed in the United States and Europe, while ciprofloxacin was the most commonly prescribed quinolone in Malaysia.

The use of antimicrobial agents particularly its overuse and misuse, is the major driver of antimicrobial resistance (4). Information on the trends and patterns of antibiotic consumption is essential to formulate control measures on antibiotic prescribing, although this is mainly feasible in the public sector. The National Antibiotic Guideline 2008 a publication of the Ministry of Health Malaysia will serve as an important tool towards rational prescribing of antibiotics. Antimicrobial stewardship programs in concert with aggressive infection control efforts represent the best chance for control of resistant pathogens. Stopping antibacterials when they are not needed, switching to more narrow spectrum drug regimens, and optimal dosing using pharmacokinetic and pharmacodynamic principles are critical (5, 6).

In conclusion, antibacterial agents were the most commonly prescribed antiinfective agent in Malaysia and amoxicillin was the most frequently prescribed antibiotic. There were significant prescribing differences between the government and private sectors, with the private sector consuming more beta-lactam/beta-lactamase combinations, roxithromycin, clarythromycin and cefalexin.

ATC Drug Class and Agents 2006 2006 (DDDs/population/ year)

J01 ANTIBACTERIALS FOR SYSTEMIC USE 8.9369 3.262

J02 ANTIMYCOTICS FOR SYSTEMIC USE 0.3253 0.1187

J04 ANTIMYCOBACTERIALS 1.099 0.4011

J05 ANTIVIRALS FOR SYSTEMIC USE 0.5638 0.2058

P01B ANTIMALARIALS 0.0807 0.0295

Table 15.1: Use of Anti-Infectives, in DDD/1000 population/day 2006 and DD/population/year


67

ATC Drug Class and Agents 2006 2006 (DDDs/population/year)

J01A TETRACYCLINES 1.1032 0.4027

J01B AMPHENICOLS 0.0045 0.0017 J01C BETA-LACTAM ANTIBACTERIALS, PENICILLINS 4.2079 1.5359

J01D OTHER BETA-LACTAM ANTIBACTERIALS 0.9589 0.35

J01E SULFONAMIDES AND TRIMETHOPRIM 0.7657 0.2795

J01F MACROLIDES, LINCOSAMIDES AND 1.3867 0.5062

STREPTOGRAMINS

J01G AMINOGLYCOSIDE ANTIBACTERIALS 0.046 0.0168

J01M QUINOLONE ANTIBACTERIALS 0.3877 0.1415

J01X OTHER ANTIBACTERIALS 0.0762 0.0278

Table 15.2.1: Use of Anti-Bacterials by Drug Class, in DDD/1000 population/day 2006


J01A A Tetracyclines

J01A A02 Doxycycline Public 0.2688 0.0981

Private 0.6527 0.2382

Total 0.9215 0.3363

J01A A06 Oxytetracycline Public <0.0001 <0.0001

Private <0.0001 <0.0001

Total <0.0001 <0.0001

J01A A07 Tetracycline Public 0.0585 0.0214

Private 0.0885 0.0323

Total 0.147 0.0537

J01A A08 Minocycline Public 0.0004 0.0001

Private 0.0343 0.0125

Total 0.0347 0.0127

J01B A Amphenicols

J01B A01 Chloramphen icol Public 0.0027 0.001

Private 0.0019 0.0007

Total 0.0045 0.0017

J01C A Penicillins with extended spectrum J01C A01 Ampicillin Public 0.0692 0.0252

Private 0.0565 0.0206

Total 0.1257 0.0459

J01C A04 Amoxicillin Public 0.698 0.2548

Private 1.4018 0.5117

Total 2.0998 0.7664

J01C A06 Bacampicillin Public 0.2145 0.0783

Private 0.0648 0.0237

Total 0.2793 0.102

J01C A12 Piperacillin Public 0.0002 <0.0001

Private - -

Total 0.0002 <0.0001

J01C E Beta-lactamase sensitive penicillins

J01C E01 Benzylpenicillin Public 0.0182 0.0067

Private 0.0013 0.0005

Total 0.0195 0.0071

Table 15.2.2: Use of Anti-Bacterials by Drug Class and Agents, in DDD/1000 population/day 2006


68

ATC Drug Class and Agents 2006 (DDDs/population/year)

J01C E02 Phenoxymethylpenicillin Public 0.0623

Private 0.0063

Total 0.0686

J01C E08 Benzathine benzylpenicillin Public 0.0007

Private 0.0001

Total 0.0008

J01C E09 Procaine benzylpenicillin Public 0.0028

Private <0.0001

Total 0.0029

J01C F Beta-lactamase resistant penicillins J01C F02 Cloxacillin Public 0.2323

Private 0.0598

Total 0.2921

J01C F05 Flucloxacillin Public 0.0005

Private 0.0041

Total 0.0046

J01C R Combinations of penicillins, incl. beta-lactamase inhibitorsJ01C R01 Ampicillin and enzyme inhibitor Public 0.0066

Private 0.0045

Total 0.0112

J01C R02 Amoxicillin and enzyme Public 0.0542

inhibitor Private 0.1639

Total 0.2181

J01C R04 Sultamicillin Public 0.0041

Private 0.0105

Total 0.0147

J01C R05 Piperacillin and enzyme Public 0.0011

inhibitor Private 0.0005

Total 0.0016

J01D B First-generation cephalosporins J01D B01 Cefalexin Public 0.0222

Private 0.1117

Total 0.1339

J01D B04 Cefazolin Public <0.0001

Private 0.0011

Total 0.0011

J01D B05 Cefadroxil Public -

Private 0.0178

Total 0.0178

J01D B09 Cefradine Public -

Private 0.0003

Total 0.0003

J01D C Second-generation cephalosporins J01D C02 Cefuroxime Public 0.0591

Private 0.0735

Total 0.1325

J01D C04 Cefaclor Public 0.0007

Private 0.0169

Total 0.0176

2006

0.1706

0.0173

0.188

0.0018

0.0004

0.0022

0.0077

0.0002

0.0079

0.6363

0.1638

0.8002

0.0014

0.0112

0.0126

0.0181

0.0124

0.0306

0.1484

0.4491

0.5974

0.0113

0.0289

0.0402

0.003

0.0014

0.0044

0.0607

0.306

0.3667

<0.0001

0.0031

0.0031

-

0.0489

0.0489

-

0.0008

0.0008

0.1619

0.2013

0.3631

0.0019

0.0462

0.0481


69

J01E A Trimethoprim and derivatives

J01E E Combinations of sulfonamides and trimethoprim, incl. derivatives

J01D C10 Cefprozil Public 0.0004 0.0001

Private 0.0135 0.0049

Total 0.014 0.0051

J01D D Third-generation cephalosporins J01D D01 Cefotaxime Public 0.004 0.0015

Private 0.0005 0.0002

Total 0.0046 0.0017

J01D D02 Ceftazidime Public 0.0078 0.0028

Private 0.0027 0.001

Total 0.0104 0.0038

J01D D04 Ceftriaxone Public 0.0163 0.0059

Private 0.0221 0.0081

Total 0.0384 0.014

J01D D12 Cefoperazone Public 0.0091 0.0033

Private 0.0006 0.0002

Total 0.0098 0.0036

J01D D14 Ceftibuten Public - -

Private 0.0134 0.0049

Total 0.0134 0.0049

J01D E Fourth-generation cephalosporins J01D E01 Cefepime Public 0.0105 0.0038

Private 0.0086 0.0031

Total 0.0191 0.007

J01D H Carbapenems

J01D H02 Meropenem Public 0.0055 0.002

Private 0.0027 0.001

Total 0.0082 0.003

J01D H03 Ertapenem Public <0.0001 <0.0001

Private 0.0021 0.0008

Total 0.0022 0.0008


J01D H51 Imipenem and enzyme inhibitor Public 0.0058 0.0021

Private 0.0023 0.0008

Total 0.0081 0.0029

J01E A01 Trimethoprim Public 0.0178 0.0065

Private 0.0051 0.0018

Total 0.0229 0.0083

J01E B04 Sulfapyridine Public 0.2112 0.0771

Private - -

Total 0.2112 0.0771

J01E E01 Sulfamethoxazole and Public 0.2487 0.0908

trimethoprim Private 0.2585 0.0944

Total 0.5072 0.1851

J01E E02 Sulfadiazine and trimethoprim Public - -

Private 0.0245 0.0089

Total 0.0245 0.0089


70


J01F A Macrolides

J01F A01 Erythromycin Public 0.5574 0.2035

Private 0.38 4 0.1401

Total 0.9414 0.3436

J01F A02 Spiramycin Public <0.0001 <0.0001

Private 0.0015 0.0005

Total 0.0015 0.0006

J01F A06 Roxithromycin Public - -

Private 0.1182 0.0431

Total 0.1182 0.0431

J01F A09 Clarithromycin Public 0.0191 0.007

Private 0.1745 0.0637

Total 0.1936 0.0707

J01F A10 Azithromycin Public 0.0119 0.0044

Private 0.0998 0.0364

Total 0.1117 0.0408

J01F F Lincosamides

J01F F01 Clindamycin Public 0.0057 0.0021

Private 0.0082 0.003

Total 0.0139 0.0051

J01F F 02 Lincomycin Public - -

Private 0.0064 0.0023

Total 0.0064 0.0023

J01G A Streptomycins

J01G A01 Streptomycin Public 0.0243 0.0089

Private 0.0007 0.0003

Total 0.025 0.0091

J01G B Other aminoglycosides

J01G B03 Gentamicin Public 0.006 0.0022

Private 0.0077 0.0028

Total 0.0136 0.005

J01G B04 Kanamycin Public 0.0002 <0.0001

Private 0.0004 0.0002

Total 0.0007 0.0002

J01G B06 Amikacin Public 0.0032 0.0012

Private 0.0014 0.0005

Total 0.0046 0.0017

J01G B07 Netilm icin Public 0.0009 0.0003

Private 0.0012 0.0005

Total 0.0021 0.0008

J01M A Fluoroquinolones

J01M A01 Ofloxacin Public 0.013 0.0047

Private 0.0935 0.0341

Total 0.1066 0.0389

J01M A02 Ciprofloxacin Public 0.0226 0.0082

Private 0.1179 0.043

Total 0.1405 0.0513

J01M A03 Pefloxacin Public 0.0022 0.0008

Private 0.0065 0.0024

Total 0.0087 0.0032


71


J01M A06 Norfloxacin Public <0.0001 <0.0001

Private 0.0818 0.0299

Total 0.0818 0.0299

J01M A12 Levofloxacin Public 0.001 0.0004

Private 0.0195 0.0071

Total 0.0205 0.0075

J01M A14 Moxifloxacin Public 0.0002 <0.0001

Private 0.0163 0.0059

Total 0.0165 0.006

J01M A16 Gatifloxacin Public 0.0003 0.0001

Private 0.0043 0.0016

Total 0.0046 0.0017

J01M B Other quinolones

J01M B02 Nalidixic acid Public - -

Private - -

Total - -

J01M B04 Pipemidic acid Public - -

Private 0.0085 0.0031

Total 0.0085 0.0031

J01M B07 Flumequine Public - -

Private <0.0001 <0.0001

Total <0.0001 <0.0001

J01X A Glycopeptide antibacterials

J01X A01 Vancomycin Public 0.0035 0.0013

Private 0.0013 0.0005

Total 0.0048 0.0018

J01X A02 Teicoplanin Public 0.0002 <0.0001

Private 0.0004 0.0001

Total 0.0005 0.0002

J01X B Polymyxins

J01X B01 Colistin Public <0.0001 <0.0001

Private - -

Total <0.0001 <0.0001

J01X B02 Polymyxin B Public <0.0001 <0.0001

Private <0.0001 <0.0001

Total <0.0001 <0.0001

J01X C Steroid antibacterials

J01X C01 Fusidic acid Public 0.0089 0.0032

Private 0.0016 0.0006

Total 0.013 0.0038

J01X D Imidazole derivatives

J01X D01 Metronidazole Public 0.0358 0.0131

Private 0.0128 0.0047

Total 0.0486 0.0177

J01X D02 Tinidazole Public - -

Private - -

Total - -


72


J01X E Nitrofuran derivatives

J01X E01 Nitrofurantoin Publ ic 0.0064 0.0023

Private 0.0022 0.0008

Total 0.0086 0.0031

J01X X Other antibacterials

J01X X01 Fosfomycin Public - -

Private 0.0016 0.0006

Total 0.0016 0.0006

J01X X04 Spectinomycin Public <0.0001 <0.0001

Private - -

Total <0.0001 <0.0001

J01X X08 Linezolid Public 0.001 0.0004

Private 0.0004 0.0001

Total 0.0014 0.0005

Table 15.3.1: Use of Anti-Mycotics by Drug Class, in DDD/1000 population/day 2006

Table 15.3.2: Use of Anti-Mycotics by Drug Class and Agents, in DDD/1000 population/day 2006


J02A A Antibiotics 0.0028 0.001

J02A B Imidazole derivatives 0.2352 0.0859

J02A C Triazole derivatives 0.0872 0.0318

J02A X Other antimycotics for systemic use 0.0001 <0.0001


J02A A Antibiotics

J02A A01 Amphotericin B Public 0.0026

Private 0.0002

Total 0.0028

J02A B Imidazole derivatives J02A B02 Ketoconazole Public 0.0117

Private 0.2235

Total 0.2352

J02A C Triazole derivatives J02A C01 Fluconazole Public 0.0146

Private 0.0203

Total 0.035

J02A C02 Itraconazole Public 0.0227

Private 0.0294

Total 0.0521

J02A C03 Voriconazole Public 0.0002

Private -

Total 0.0002

J02A X Other antimycotics for systemic use J02A X01 Flucytosine Public <0.0001

Private -

Total <0.0001

J02A X04 Caspofungin Public <0.0001

Private <0.0001

Total <0.0001

2006 (DDDs/population/year)

0.001

<0.0001

0.001

0.0043

0.0816

0.0859

0.0053

0.0074

0.0128

0.0083

0.0107

0.019

<0.0001

-

<0.0001

<0.0001

-

<0.0001

<0.0001

<0.0001

<0.0001


73

Table 15.4.1: Use of Anti-Mycobacterials by Drug Class, in DDD/1000 population/day 2006ATC Drug Class and Agents 2006 2006

(DDDs/population/year) J04A B Antibiotics

J04A B01 Cycloserine Public 0.0016 0.0006

Private - -

Total 0.0016 0.0006

J04A B02 Rifampicin Public 0.256 0.0934

Private 0.0228 0.0083

Total 0.2788 0.1018

J04A C Hydrazides

J04A C01 Isoniazid Public 0.4356 0.159

Private 0.0242 0.0088

Total 0.4598 0.1678

J04A D03 Ethionamide Public <0.0001 <0.0001

Private - -

Total <0.0001 <0.0001

J04A K Other drugs for treatment of tuberculosis J04A K01 Pyrazinamide Public 0.1084 0.0395

Private 0.0143 0.0052

Total 0.1226 0.0448

J04A K02 Ethambutol Public 0.0891 0.0325

Private 0.0174 0.0064

Total 0.1065 0.0389

J04A M02 Rifampicin and isoniazid Public - -

Private 0.0143 0.0052

Total 0.0143 0.0052

J04A M05 Rifampicin, pyrazinamide Public - -

and isoniazid Private 0.0065 0.0024

Total 0.0065 0.0024 J04A M06 Public - -

Private 0.0001 <0.0001

Rifampicin, pyrazinamide, ethambutol and isoniazid

Total 0.0001 <0.0001

J04B A Drugs for treatment of lepra

J04B A01 Clofazimine Public 0.004 0.0015

Private - -

Total 0.004 0.0015

J04B A02 Dapsone Public 0.1047 0.0382

Private <0.0001 <0.0001

Total 0.1047 0.0382

Table 15.5.1: Use of Anti-Malarials by Drug Class, in DDD/1000 population/day 2006ATC Drug Class 2006 2006

(DDDs/population/year) P01A AGENTS AGAINST AMOEBIASIS AND OTHER

PROTOZOAL DISEASES 0.1992 0.0727

P01B A Aminoquinolines 0.0648 0.0236

P01B B Biguanides <0.0001 <0.0001

P01B C Methanolquinolines 0.0049 0.0018

P01B D Diaminopyrimidines 0.011 0.004


74


P01A AGENTS AGAINST AMOEBIASIS AND OTHER PROTOZOAL DISEASES P01A B01 Metronidazole Public 0.1108 0.0404

Private 0.0839 0.0306

Total 0.1947 0.0711

P01A B02 Tinidazole Public - -

Private 0.0045 0.0016

Total 0.0045 0.0016

P01B A Aminoquinolines

P01B A01 Chloroquine Public 0.0082 0.003

Private 0.0048 0.0018

Total 0.013 0.0048

P01B A02 Hydroxychloroquine Public 0.0158 0.0058

Private 0.0025 0.0009

Total 0.0183 0.0067

P01B A03 Primaquine Public 0.031 0.0113

Private 0.0024 0.0009

Total 0.0334 0.0122

P01B B Biguanides

P01B B51 Proguanil, combinations Public - -

Private <0.0001 <0.0001

Total <0.0001 <0.0001

P01B C Methanolquinolines

P01B C01 Quinine Public 0.0035 0.0013

Private 0.0013 0.0005

Total 0.0048 0.0018

P01B C02 Mefloquine Public - -

Private <0.0001 <0.0001

Total <0.0001 <0.0001

P01B D Diaminopyrimidines

P01B D01 Pyrimethamine Public 0.0002 <0.0001

Priva te <0.0001 <0.0001

Total 0.0003 0.0001

P01B D51 Pyrimethamine, combinations Public 0.0091 0.0033

Private 0.0017 0.0006

Total 0.0108 0.0039

Table 15.5.2: Use of Anti-Malarials by Drug Class and Agents, in DDD/1000 population/day 2006

ATC Drug Class 2006 2006 (DDDs/population/year)

J05A B Nucleosides and nucleotides excl. reverse transcriptase inhibitors

0.0519 0.0189

J05A E Protease inhibitors 0.0109 0.004

J05A F Nucleoside and nucleotide reverse 0.177 0.0646

transcriptase inhibitors

J05A G Non-nucleoside reverse transcriptase 0.092 0.0336

inhibitors J05A H

Neuraminidase inhibitors

0.1544 0.0563

Table 15.6.1: Use of Anti-Virals by Drug Class, in DDD/1000 population/day 2006


75

Table 15.6.2: Use of Anti-Virals by Drug Class and Agents, in DDD/1000 population/day 2006ATC Drug Class and Agents 2006 2006

(DDDs/population/year) J05A B Nucleosides and nucleotides excl. reverse transcriptase inhibitors J05A B01 Aciclovir Public 0.0063 0.0023

Private 0.0406 0.0148

Total 0.047 0.0171

J05A B04 Ribavirin Public 0.0026 0.0009

Private 0.0005 0.0002

Total 0.0031 0.0011

J05A B06 Ganciclovir Public 0.0004 0.0001

Private <0.0001 <0.0001

Total 0.0004 0.0001

J05A B09 Famciclovir Public - -

Private - -

Total - -

J05A B11 Valaciclovir Public <0.0001 <0.0001

Private 0.0012 0.0004

Total 0.0013 0.0005

J05A B14 Valganciclovir Public <0.0001 <0.0001

Private <0.0001 <0.0001

Total <0.0001 <0.0001

J05A D01 Foscarnet Public <0.0001 <0.0001

Private - -

Total <0.0001 <0.0001

J05A E Protease inhibitors

J05A E01 Saquinavir Public - -

Private <0.0001 <0.0001

Total <0.0001 <0.0001

J05A E02 Indinavir Public 0.0063 0.0023

Private 0.0003 0.0001

Total 0.0066 0.0024

J05A E03 Ritonavir Public 0.0021 0.0008

Private - -

Total 0.0021 0.0008

J05A E04 Nelfinavir Public <0.0001 <0.0001

Private - -

Total <0.0001 <0.0001

J05A E06 Lopinavir Public 0.0022 0.0008

Private - -

Total 0.0022 0.0008

J05A F Nucleoside and nucleotide reverse transcriptase inhibitors J05A F01 Zidovudine Public 0.0033 0.0012

Private - -

Total 0.0033 0.0012

J05A F02 Didanosine Public 0.0089 0.0032

Private 0.0011 0.0004

Total 0.01 0.0036

J05A F04 Stavudine Public 0.0337 0.0123

Private 0.0012 0.0004

Total 0.0349 0.0128


76


J05A F05 Lamivudine Public 0.1096 0.04

Private 0.0064 0.0023

Total 0.116 0.0423

J05A F08 Adefovir dipivoxil Public 0.0038 0.0014

Private 0.0061 0.0022

Total 0.0099 0.0036

J05A F10 Entecavir Public - -

Private 0.0028 0.001

Total 0.0028 0.001

J05A G Non-nucleoside reverse transcriptase inhibitors

J05A G01 Nevirapine Public 0.0616 0.0225

Private 0.0001 <0.0001

Total 0.0618 0.0225

J05A G03 Efavirenz Public 0.0285 0.0104 Private 0.0017 0.0006

Total 0.0302 0.011

J05A H Neuraminidase inhibitors

J05A H01 Zanamivir Public 0.0299 0.0109

Private - -

Total 0.0299 0.0109

J05A H02 Oseltamivir Public 0.1204 0.044

Private 0.004 0.0015

Total 0.1245 0.0454

J05A R01 Zidovudine and lamivudine Public 0.0751 0.0274

Private 0.0025 0.0009

Total 0.0776 0.0283

References:1. Patrick DM, Marra F , Hutchinson J , et al. Per capita antibiotic consumption: How does a North American Jurisdiction compare with Europe? Clin Infect Dis. 2004; 39:11-7.2. Goossens H, Ferech M, Coenen S et al. Comparison of outpatient systemic antibacterial use in 2004 in the Unitd States & 27 European countries. Clin Infect Dis. 2007; 44: 1091-5.3. Ferech M, Coenen S, Kumar SM et al. European Surveillance of Antimicrobial Consumption (ESAC): outpatient antibiotic use in Europe. J Antimicrob Chemother 2006; 58:401-7.4. Health Protection Agency. Antimicrobial Resistance and Prescribing in England, Wales and Northern Ireland, 2008. London.5. Pakyz AL, MacDougall C, Oinonen M, Polk RE. Trends in Antibacterial Use in US Academic Health Centers 2002 to 2006. Arch Intern Med. 2008; 168(20):2254-2260.6. Avorn JL, Barrett JF, Davey PG, McEwen SA, O’Brien TF and Levy SB. 2001. Antibiotic resistance: synthesis of recommendations by expert policy groups Alliance for the Prudent Use of Antibiotics United States of America World Health Organization.

CHAPTER 16: USE OF ANTINEOPLASTIC AGENTSINCLUDING ENDOCRINE THERAPY Malaysian Statistics on Medicines 2006

77


Edited by: Lim YS1, Lim GC1, Goh AS , Wan Ariffin A3, M Roslan H4, Kamarun Neasa BMK1, Yuzlina MY5

1. Kuala Lumpur Hospital, 2. Pulau Pinang Hospital, 3. Universiti Malaya, 4. Sultan Ismail Hospital,Johor Bahru, 5. Putrajaya Hospital

Systemic therapy is part of the treatment for many cancer patients and for some malignancies they may be theonly option. Systemic therapy in cancer is particularly complex and antineoplastic drugs are used either as monotherapy or in combination in different regimes. Antineoplastics can be used in first line or as treatment for relapse of disease.

Some of the antineoplastics have been around since 6 decades ago. Taxanes came in use in 1992 followedby the molecular targeted agents such as Imatinib Mesylate in early 2000’s. Bevacizumab was the first clinically proven antiangiogenic agent for the treatment of colon cancer in 2004.

The top ten antineoplastics in terms of expenditure in 2006 by public hospitals were Epirubicin (RM5.3 million), Docetaxel (RM5.2 million), Oxaliplatin (RM2.8 million), Rituximab (RM2.5 million), Gemcitabine (RM2.1 million), Irinotecan (RM2.0 million), Methotrexate (RM1.3 million), Paclitaxel (RM 1.2 million), Fluorouracil (RM1.1 million) and Capecitabine (RM1.0 million). Prices were quoted according to Hospital Kuala Lumpur catalog of drug prices for 2006.

Epirubicin was used mainly for breast cancer as in the FEC regime which was a combination therapy withFlurouracil and Cyclophosphamide. Docetaxel was used mainly in breast cancer for salvage therapy. Thistaxane was also used in Non-Small Cell Lung Cancer (NSCLC). Another taxane, Paclitaxel was used in ovariancancer and NSCLC in combination with Carboplatin or Cisplatin. Then in 2006, government hospitals startedusing Paclitaxel for a new indication in Ministry of Health (MOH) Formulary in combination with Gemcitabine for breast cancer. The earlier indication of Gemcitabine that was approved by the Drug Control Authority (DCA) was for pancreatic cancer. Furthermore Gemcitabine was widely used for NSCLC in combination with Cisplatin, a platinum compound.

Irinotecan was frequently used for colorectal cancer. On the other hand, Methotrexate, a folic acid analogwas used for breast cancer in combination with Cyclophosphamide and Fluorouracil. This is the popularlyknown CMF regime which was the first line therapy in many breast cancer patients. Fluorouracil was mainlyused for colorectal cancer, breast cancer, nasopharyngeal cancer, stomach and pancreatic cancer.

Capecitabine is an antimetabolite of pyrimidine analog. Capecitabine initially was used in public hospitalsfor colorectal cancer only, but not long afterwards was also indicated for breast cancer in metastatic setting.Tegafur was used in private hospitals exceeding ten fold more than in public hospitals. Tegafur was on case by case approval by Director General of Health until 2008 when it was indicated for NSCLC. However Tegafur found many more uses in private hospitals in addition to NSCLC such as head and neck cancer and breast cancer. Hence the disparity between quantum of Tegafur used in private compared to public hospitals. The tyrosine kinase inhibitor Imatinib was included in the MOH Formulary in 2007. Imatinib was used for CML as well as for gastro-intestinal stromal tumour (GIST) which had been incompletely resected or unresectable. The usage of Imatinib was actually higher than captured in these procurement data due to the Glivec International Assistance Program (GIPAP) in CML and GIST in Malaysia.

The other molecular targeted therapy were the monoclonal antibodies Rituzimab and Trastuzumab. While Rituzimab was already in MOH Formulary since 2004, Trastuzumab was used on a named-patient basis in 2006. This accounted for the relatively low expenditure for Trastuzumab. In haematological malignancies, Rituximab and the proteosome inhibitor, Bortezomib are making real impact on patient survival and remission rates. Rituximab was already in the MOH Formulary in 2004 for Rituximab enhanced regime of Cyclophosphamide, Adriamycin, Vincristine and Prednisolone (R-CHOP) in Non-Hodgkin’s Lymphoma whereas Bortezomib was not in the MOH Formulary until 2008. However, improvement in survival comes at a cost and the soaring price of new cancer regimes are adding to the financial burden of cancer patients and causing a strain to public hospitals’ budget.

CHAPTER 16: USE OF ANTINEOPLASTIC AGENTSINCLUDING ENDOCRINE THERAPYMalaysian Statistics on Medicines 2006

78

Due to the exorbitant price of the newer drugs, only a selected number of patients may have access to these novel targeted agents. The newer drugs that are being focused on in government hospitals are those in whom overall survival benefit have been proven in published randomised controlled trials. Patients depend largely on insurance coverage in the private hospitals and adequacy of budget in individual government hospitals.

The usage of Rituximab was more in public than in private hospitals. The usage of Bortezomib was low in government, university hospitals and private hospitals. Many patients would go to public hospitals if they could get the monoclonal antibodies there since they would not need to worry about the exorbitant prices of the drugs that were heavily subsidised. Other non-formulary drugs such as anagrelide and arsenic trioxide were little used in public hospitals and even less so in private hospitals.

Table 16.1: Use of Antineoplastic Agents by Drug Class and Agents, in total dosage/1000 population/day 2006

ATC Drug Class and Agents Unit 2006 L01A A Nitrogen mustard analogues L01A A01 Cyclophosphamide Public 2.2612

Private 0.6601

mg

Total 2.9212

L01A A02 Chlorambucil Public 0.0062

Private 0.0009

mg

Total 0.0071

L01A A03 Melphalan Public 0.0036

Private <0.0001

mg

Total 0.0036

L01A A06 Ifosfamide Public 0.0009

Private 0.0001

g

Total 0.0011

L01A B Alkyl sulfonates

L01A B01 Busulfan Public 0.0093

Private <0.0001

mg

Total 0.0095

L01A C Ethylene imines

L01A C01 Thiotepa Public -

Private <0.0001

mg

Total <0.0001

L01A D Nitrosoureas

L01A D01 Carmustine Public 0.003

Private <0.0001

mg

Total 0.003

L01A D0 2 Lomustine Public 0.0008

Private 0.0003

mg

Total 0.001

L01A X Other alkylating agents

L01A X03 Temozolomide Public 0.0045

Private 0.022

mg

Total 0.0265

L01A X04 Dacarbazine Public 0.0631

Private 0.0198

mg

Total 0.0829


79

Table 16.2: Use of Antineoplastic Agents by Drug Class, in total dosage/1000population/day 2006ATC Drug Class and Agents Unit 2006 L01B A Folic acid analogues

L01B A01 Methotrexate Public 0.6852

Private 0.1102

mg

Total 0.7954

L01B A04 Pemetrexed Public -

Private 0.0055

mg

Total 0.0055

L01B B Purine analogues

L01B B02 Mercaptopurine Public 0.6879

Private 0.0103

mg

Total 0.6982

L01B B03 Tioguanine Public 0.0133

Private 0.0002

mg

Total 0.0135

L01B B04 Cladribine Public <0.0001

Private -

mg

Total <0.0001

L01B B05 Fludarabine Public 0.001

Private 0.0018

mg

Total 0.0028

L01B C Pyrimidine analogues

L01B C01 Cytarabine Public 0.7999

Private 0.0436

mg

Total 0.8435

L01B C02 Fluorouracil Public 4.8107

Private 1.4858

mg

Total 6.2965

L01B C05 Gemcitabine Public 0.2908

Private 0.121

mg

Total 0.4118

L01B C06 Capecitabine Public 7.5826

Private 8.9727

mg

Total 16.5553

L01B C53 Tegafur, combinations Public 0.0272

Private 0.326

mg

Total 0.3533


ATC Drug Class and Agents Unit 2006 L01C A Vinca alkaloids and analogues L01C A01 Vinblastine Public 0.0011

Private 0.0003

mg

Total 0.0014

L01C A02 Vincristine Public 0.0018

Private 0.0002

mg

Total 0.002

L01C A04 Vinorelbine Public 0.0062

Private 0.0051

mg

Total 0.0113


80

ATC Drug Class and Agents Unit 2006 L01C B Podophyllotoxin derivatives

L01C B01 Etoposide Public 0.1511

Private 0.0293

mg

Total 0.1804

L01C B02 Teniposide Public 0.0015

Private <0.0001

mg

Total 0.0015

L01C D Taxanes

L01C D01 Paclitaxel Public 0.0687

Private 0.0464

mg

Total 0.1151

L01C D02 Docetaxel Public 0.0152

Private 0.0158

mg

Total 0.031

ATC Drug Class and Agents Unit 2006 L01D A Actinomycines

L01D A01 Dactinomycin Public <0.0001

Private <0.0001

mg

Total <0.0001

L01D B Anthracyclines and related substances

L01D B01 Doxorubicin Public 0.0426

Private 0.0274

mg

Total 0.0701

L01D B02 Daunorubicin Public 0.0085

Private 0.0008

mg

Total 0.0093

L01D B03 Epirubicin Public 0.0771

Private 0.0123

mg

Total 0.0893

L01D B06 Idarubicin Public 0.0008

Private <0.0001

mg

Total 0.0009

L01D B07 Mitoxantrone Public 0.0003

Private 0.0001

mg

Total 0.0004

L01D C Other cytotoxic antibiotics

L01D C01 Bleomycin Public 0.0074

Private 0.0031

mg

Total 0.0105

L01D C03 Mitomycin Public 0.002

Private 0.001

mg

Total 0.003

Table 16.4: Use of Antineoplastic Agents by Drug Class, in total dosage/1000 population/day 2006


81


ATC Drug Class and Agents Unit 2006 L01X A Platinum compounds

L01X A01 Cisplatin Public 0.0817

Private 0.0462

mg

Total 0.1278

L01X A02 Carboplatin Public 0.3832

Private 0.1088

mg

Total 0.4919

L01X A03 Oxaliplatin Public 0.0123

Private 0.0281

mg

Total 0.0404

L01X B Methylhydrazines

L01X B01 Procarbazine Public 0.0269

Private <0.0001

mg

Total 0.0269

L01X C Monoclonal antibodies

L01X C02 Rituximab Public 0.0377

Private 0.0242

mg

Total 0.0619

L01X C0 3 Trastuzumab Public 0.0008

Private 0.0058

mg

Total 0.0065

L01X C06 Cetuximab Public 0.0017 Private 0.0335

mg

Total 0.0352

L01X C07 Bevacizumab Public -

Private 0.0128

mg

Total 0.0128

Imatinib Public 0.0942

Private 0.2025

L01X E01

mg

Total 0.2966

L01X E02 Gefitinib Public 0.0086

Private 0.1336

mg

Total 0.1422

L01X X Other antineoplastic agents

L01X X02 Asparaginase Public 5.2422

Private 0.2473

mg

Total 5.4895

L01X X05 Hydroxycarbamide Publ ic 23.5787

Private 5.4791

mg

Total 29.0578

L01X X11 Estramustine Public -

Private <0.0001

mg

Total <0.0001

L01X X14 Tretinoin Public 0.0301

Private 0.0046

mg

Total 0.0347

L01X X17 Topotecan Public -

Private -

mg

Total -


82

References:1. Australia Department of Health and Ageing, Australian Statistics On Medicine 2003.2. Statistics on Drug use in Australia 2006.

ATC Drug Class and Agents Unit 2006 L01X X19 Irinotecan Public 0.0202

Private 0.0097

mg

Total 0.03

L01X X27 Arsenic trioxide Public 0.0007

Private -

mg

Total 0.0007

L01X X32 Bortezomib Public <0.0001

Private <0.0001

mg

Total <0.0001

L01X X35 Anagrelide Public 0.0037

Private 0.0005

mg

Total 0.0042

CHAPTER 17: USE OF SYSTEMIC CORTICOSTEROIDSAND IMMUNOSUPPRESIVE AGENTS Malaysian Statistics on Medicines 2006

83


Edited by:Hooi LS1, Zaki M2, Lim TO3, Zawawi N4, Goh BL5, Fadilah O6, Nur Salima S6, Puteri JZ6, Zarina AG6, Manjulaa DS7

1. Sultanah Aminah Hospital, Johor Bharu, 2. International Medical University, 3. Clinical Research Centre, MOH, 4. Sultanah Nur Zahirah Hospital, Terengganu, 5. Serdang Hospital, 6. Selayang Hospital, 7. Kuala Lumpur Hospital

The list of drugs in this chapter include steroids, progestogens, gonadotropin releasing hormone (GnRH)analogues, tamoxifen, anti-androgens, enzyme inhibitors, granulocyte colony stimulating factor, interferons and immunosuppressants like calcineurin inhibitors, mycophenolate acid, sirolimus, etanercept, infliximab, azathioprine, thalidomide and methotrexate.

The main drug in this chapter is prednisolone. Systemic glucocorticoids have non-specific anti-inflammatory and immunosuppressant properties but the side-effects are protean. The usage in 0.4% of the general population in 2006 is high. This amounts to 118,000 people on glucocorticoids daily assuming the population of Malaysia was 26.6 million in 2006 (table 17.1). About 67,000 people per day were on prednisolone (table 17.2). This may suggest overuse or even abuse of steroids, which warrants further investigation.

There were a total of 490 patients treated with GnRH analogues (for cancer of the prostate), 6,000 on tamoxifen (for cancer of the breast), 230 on the anti-androgens (for cancer of the prostate) and 600 on the enzyme inhibitors (for cancer of the breast). Granulocyte colony stimulating factor was used very little (70 per day) and interferon usage was surprisingly low in view of the large numbers of patients with hepatitis B and hepatitis C in Malaysia. Multiple sclerosis is a rare disease here and the use of interferon beta-1a is low. The total usage of all classes of interferons was 480 people per day. There may be under-usage of these drugs for their justified indications but this may reflect their high cost.

There were about 1,460 people on ciclosporin, 135 on tacrolimus and 540 on mycophenolic acid from the data available. From the National Transplant Registry of 2006 there were 1,120 patients with functioning kidney transplants on ciclosporin in 2006 [1]. It is used mainly in the public sector as there is a specific allocation for its use for renal transplantation. There were 254 renal transplant patients on tacrolimus in 2006 and 705 on mycophenolate mofetil (MMF) [1]. DDD/1000 population/day for MMF is 2g which is the standard when used in combination with cyclosporine. In combination with tacrolimus the dose of MMF is usually halved to 1 g/day. This may explain the lower figures reported here compared to NTR figures for mycophenolic acid.

There were a negligible number of people on sirolimus, etanercept and infliximab. The last 2 mainly for rheumatoid arthritis are very costly. About 2,500 patients were on azathioprine and there were 100 people on methotrexate.

Table 17.1: Use of Systemic Corticosteroids and Immunosuppressive Agents by Drug Class, in DDD/1000 population/day 2006

Table 17.2: Use of Systemic Corticosteroids and Immunosuppressive Agents by Drug Class and Agents, in DDD/1000 population/day 2006

ATC Drug Class 2006 H02A A Mineralocorticoids 0.0034

H02A B Glucocorticoids 4.4433

ATC Drug Class and Agents 2006 H02A A Mineralocorticoids

H02A A02 Fludrocortisone Public 0.0023

Private 0.0011

Total 0.0034

CHAPTER 17: USE OF SYSTEMIC CORTICOSTEROIDSAND IMMUNOSUPPRESIVE AGENTSMalaysian Statistics on Medicines 2006

84

ATC Drug Class and Agents 2006 H02A B Glucocorticoids

H02A B01 Betamethasone Public -

Private 0.429

Total 0.429

H02A B02 Dexamethasone Public 0.32

Private 0.274

Total 0.594

H02A B04 Methylprednisolone Public 0.0866

Private 0.0561

Total 0.1427

H02A B06 Predni solone Public 1.1766

Private 1.3428

Total 2.5194

H02A B08 Triamcinolone Public 0.0133

Private 0.1086

Total 0.1219

H02A B09 Hydrocortisone Public 0.3073

Private 0.3291

Total 0.6364

ATC Drug Class 2006 L02 ENDOCRINE THERAPY 0.2844

L03 IMMUNOSTIMULANTS 6.149

L04 IMMUNOSUPPRESSIVE AGENTS 0.2001



ATC Drug Class and Agents 2006L02A B Progestogens

L02A B01 Megestrol Public -

Private 0.0067

Total 0.0067

L02A B02 Medroxyprogesterone Public <0.0001

Private <0.0001

Total 0.0001

L02A E Gonad otropin releasing hormone analogues L02A E01 Buserelin Public <0.0001

Private <0.0001

Total <0.0001

L02A E02 Leuprorelin Public 0.0024

Private 0.0085

Total 0.0109

L02A E03 Goserelin Public 0.0038

Private 0.0021

Total 0.0059

L02A E04 Triptorelin Public 0.0011

Private 0.0003

Total 0.0015


85

ATC Drug Class and Agents 2006 L02B A Anti-estrogens

L02B A01 Tamoxifen Public 0.1664

Private 0.0613

Total 0.2277

L02B B Anti -androgens

L02B B01 Flutamide Public 0.0018

Private 0.0007

Total 0.0025

L02B B03 Bicalutamide Public 0.0053

Private 0.001

Total 0.0063

L02B G Enzyme inhibitors

L02B G03 Anastrozole Public 0.0067

Private 0.0043

Total 0.011

L02B G04 Letrozole Public 0.0055

Private 0.0051

Total 0.0106

L02B G06 Exemestane Public 0.0006

Private 0.0005

Total 0.0011

L03A A Colony stimulating factors

L03A A02 Filgrastim Public 0.0018

Private 0.0006

Total 0.0024

L03A A10 Lenograstim Public 0.0001

Private <0.0001

Total 0.0002

L03A B Interferons

L03A B04 Interferon alfa-2a Public 0.0005

Private <0.0001

Total 0.0005

L03A B05 Interferon alfa-2b Public 0.0043

Private <0.0001

Total 0.0044

L03A B07 Interferon beta-1a Public 0.0042

Private -

Total 0.0042

L03A B08 Interferon beta-1b Public <0.0001

Private <0.0001

Total <0.0001

L03A B10 Peginterferon alfa-2b Public 0.0016

Private 0.0013

Total 0.0029

L03A B11 Peginterferon alfa-2a Public 0.0023

Private 0.0036

Total 0.0059

CHAPTER 17: USE OF SYSTEMIC CORTICOSTEROIDSAND IMMUNOSUPPRESIVE AGENTSMalaysian Statistics on Medicines 2006

86

L03A X Other cytokines and immunomodulators L03A X03 BCG vaccine Public 5.3237

Private 0.8046

Total 6.1283

L04A A Selective immunosuppressive agents L04A A01 Ciclosporin Public 0.0519

Private 0.003

Total 0.0549

L04A A02 Muromonab-CD3 Public -

Private -

Total -

L04A A05 Tacrolimus Public 0.0049

Private 0.0002

Total 0.0051

L04A A06 Mycophenolic acid Public 0.0157

Private 0.0046

Total 0.0203

L04A A08 Daclizumab Public -

Private -

Total -

L04A A09 Basiliximab Public -

Private -

Total -

Public <0.0001

Private -

L04A A10 Sirolimus

Total <0.0001

L04A A11 Etanercept Public <0.0001

Private 0.0009

Total 0.001

L04A A12 Infliximab Public <0.0001

Private 0.0036

Total 0.0037

L04A A13 Leflunomide Public 0.0077

Private 0.0069

Total 0.0146

L04A A21 Efali zumab Public -

Private <0.0001

Total <0.0001

L04A X Other immunosuppressive agents L04A X01 Azathioprine Public 0.0856

Private 0.0084

Total 0.0939

L04A X02 Thalidomide Public 0.0015

Private 0.0012

Total 0.0028

Public - L04A X03 Methotrexate

Private 0.0036



87

References:1. Hooi LS, Lela Yasmin Mansor (eds). 3rd report of the National Transplant Registry Malaysia 2006. Kuala Lumpur 2007. Chapter 5. Renal Transplantation from http://www.mstorg.my/ntrSite publications_3rdReport2006.htm accessed on 3 January 2009.

CHAPTER 18: USE OF MEDICINES FORRHEUMATOLOGICAL AND BONE DISORDERS Malaysian Statistics on Medicines 2006

89


Edited by: Ramanathan R1, Ahmad TA2, Ling HT1, Chew CS1, Aizura AR1

1. Raja Permaisuri Bainun Hospital, Ipoh, 2. Sultanah Nur Zahirah Hospital, Kuala Terengganu

Antiinflammatory and antirheumatic products ranked 9th place as the most used drugs by therapeutic group in Malaysia in 2006 (10DDD/1000 population/day) with estimated 1% population utilising them. The acetic acid derivatives and related substances were the most used NSAIDs by drug class (4.05DDD/1000 population/day) followed by the Fenamates (2.68), Coxibs (1.27) and Oxicams (1.06). Diclofenac acid was the most consumed NSAID (1.47 and 2.12DDD/1000 population/day, public and private sectors respectively). The second commonest NSAID used was mefenamic acid (total DDD 2.68). The newer group, called Coxibs (DDD 1.265) with supposedly less side effects such as Etoricoxib (DDD 0.67) was mainly used by private hospitals (91%) while Celecoxib was equally used in the private and public hospitals. In Australia, Oxicams (DDD 8.679) were the highest prescribed, followed closely by Coxibs (DDD 7.250) and acetic acid derivatives (DDD 6.224). [1] Better GIT profile is probably why Cox-2 selective inhibitors are popular nowadays.

Anti-Rheumatic Nimesulide was withdrawn from public hospitals due to the side effects of liver failure. Newer DMARD’S had reduced the use of Penicillamine by 50%.

Muscle relaxants were prescribed 10 fold more by the private sector (examples: Chlorzoxazone and Orphenadrine), probably to supplement the action of NSAIDs. The public hospitals used Baclofen more so to treat non-inflammatory muscle spasms eg, in celebral palsy. Dantrolene, although a muscle relaxant, was reserved for malignant hyperthermia and is rarely used in Malaysia. Gout was treated with allopurinol (DDD 1.32) with 73% use by the public sector and caution regarding its gastric side effects and worsening of symptoms during acute phase use, need to be emphasised.

Greater demand in usage of anti-osteoporosis drugs is expected with increasing lifespan. The three commonest drugs used in 2006 were the bisphosphonates, followed by Selective Estrogen Receptor Modulators (SERMs) and calcitonin groups. The weekly or monthly dosing of bisphophonates had made their usage popular. Strontium and parathyroid hormone have emerged as newer drugs for this condition. Bisphophonates are said to remain in the body forever. Long term studies may show its safety profile in time to come.

Table 18.1: Use of Drugs for Rheumatological and Bone disorders, in DDD/1000 population/day 2006

Table 18.2.1: Use of Non-Steroidal Anti-Inflammatory drugs by Drug Class, in DDD/1000 population/day 2006

ATC Drug Class 2006 G03X C Selective estrogen receptor modulators 0.1293

H05B A Calcitonin preparations 0.0058

M01 ANTIINFLAMMATORY AND ANTIR HEUMATIC PRODUCTS 10.0035

M03 MUSCLE RELAXANTS 0.6131

M04 ANTIGOUT PREPARATIONS 1.5347

M05 DRUGS FOR TREATMENT OF BONE DISEASES 0.4399

ATC Drug Class and Agents 2006 M01A B Acetic acid derivatives and related substances 4.0492

M01A C Oxicams 1.0649

M01A E Propionic acid derivatives 0.8283

M01A G Fenamates 2.6834

M01A H Coxibs 1.265

M01A X Other antiinflammatory and antirheumatic agents, non-steroids 0.1078

M01C C Penicillamine and similar agents 0.005

CHAPTER 18: USE OF MEDICINES FORRHEUMATOLOGICAL AND BONE DISORDERSMalaysian Statistics on Medicines 2006

90

ATC Drug Class and Agents 2006 M01A B Acetic acid derivatives and related substances

M01A B01 Indometacin Public 0.3642

Private 0.0897

Total 0.4539

M01A B02 Sulindac Public -

Private <0.0001

Total <0.0001

M01A B05 Diclofenac Public 1.4652

Private 2.1248

Total 3.59

M01A B15 Ketorolac Public 0.0007

Private 0.0045

Total 0.0052

M01A C Oxicams

M01A C01 Piroxicam Public 0.0538

Private 0.4298

Total 0.4836

M01A C02 Tenoxicam Public 0.0001

Private 0.0372

Total 0.0373

M01A C06 Meloxicam Public 0.1999

Private 0.3441

Total 0.5441

M01A E Propionic acid derivatives

M01A E01 Ibuprofen Public 0.1589

Private 0.2338

Total 0.3927

M01A E02 Naproxen Public 0.0981

Private 0.3202

Total 0.4184

M01A E03 Ketoprofen Public 0.0106

Private 0.0066

Total 0.0172

M01A G Fenamates

M01A G01 Mefenamic acid Public 1.2609

Private 1.4224

Total 2.6834

M01A H Coxibs

M01A H01 Celecoxib Public 0.2733

Private 0.3152

Total 0.5885

M01A H02 Rofecoxib Public -

Private -

Total -

M01A H03 Valdecoxib Publ ic -

Private 0.0014

Total 0.0014

Table 18.2.2: Use of Non-Steroidal Anti-Inflammatory drugs by Drug Class and Agents, in DDD/1000 population/day 2006


91

ATC Drug Class and Agents 2006 M01A H04 Parecoxib Public 0.0008

Private 0.0038

Total 0.0046

M01A H05 Etoricoxib Public 0.0604

Private 0.6101

Total 0.6705

M01A X Other antiinflammatory and antirheumatic agents, non-steroids M01A X17 Nimesulide Public -

Private 0.1078

Total 0.1078

M01C C Penicillamine and similar agents M01C C01 Penicillamine Public 0.0048

Private 0.0002

Total 0.005

Table 18.3.1: Use of Muscle relaxants by Drug Class and Agents, in DDD/1000 population/day 2006

Table 18.4.1: Use of Anti-Gout preparations by Drug Class, in DDD/1000 population/day 2006

ATC Drug Class and Agents 2006 M03B MUSCLE RELAXANTS, CENTRALLY ACTING AGENTS M03B B52 Chlormezanone, combinations excl. psycholeptics Public -

Private 0.056

Total 0.056

M03B B53 Chlorzoxazone, combinations excl. psycholeptics Public -

Private 0.4021

Total 0.4021

M03B C01 Orphenadrine (citrate) Public 0.0153

Private 0.0848

Total 0.1001

M03B X01 Baclofen Public 0.0504

Private 0.0044

Total 0.0548

M03C MUSCLE RELAXANTS, DIRECTLY ACTING AGENTS M03C A01 Dantrolene Public -

Private -

Total -

ATC Drug Class and Agents 2006 M04A ANTIGOUT PREPARATIONS M04A A01 Allopurinol Public 0.9627

Private 0.3601

Total 1.3227

M04A B 01 Probenecid Public 0.0004

Private 0.0031

Total 0.0036

M04A C01 Colchicine Public 0.0664

Private 0.1421

Total 0.2084

CHAPTER 18: USE OF MEDICINES FORRHEUMATOLOGICAL AND BONE DISORDERSMalaysian Statistics on Medicines 2006

92

ATC Drug Class and Agents 2006 M05 DRUGS FOR TREATMENT OF BONE DISEASES M05B A01 Etidronic acid Public -

Private 0.0005

Total 0.0005

M05B A02 Clodronic acid Public 0.0018

Private 0.002

Total 0.0038

M05B A03 Pamidronic acid Public 0.0003

Private <0.0001

Total 0.0004

M05B A04 Alendronic acid Public 0.257

Private 0.1148

Total 0.3718

M05B A06 Ibandronic acid Public -

Private <0.0001

Total <0.0001

M05B A07 Risedronic acid Public 0.0036

Private 0.0211

Total 0.0247

M05B A08 Zoledronic acid Public <0.00 01

Private <0.0001 Total 0.0002 M05B B03 Alendronic acid and cholecalciferol Public 0.0004

Private 0.038

Total 0.0385

Table 18.5.1: Use of Bone diseases therapy by Drug Class, in DDD/1000 population/day 2006

Table 18.6.1: Use of Selective Estrogen Receptor Modulators by Drug Class, in DDD/1000 population/day 2006

ATC Drug Class and Agents 2006 G03 SEX HORMONES AND MODULATORS OF THE GENITAL SYSTEM G03X C01 Raloxifene Public 0.0646

Private 0.0647

Total 0.1293

Table 18.7.1: Use Calcitonin preparations of by Drug Class, in DDD/1000 population/day 2006

ATC Drug Class and Agents 2006 H05 CALCIUM HOMEOSTASIS H05B A01 Calcitonin (salmon synthetic) Public 0.0044

Private 0.0013

Total 0.0058

References:1. National Health Survey: Use of Medications, Australia 2006.2. Malaysian Statistics on Medicines 2005.

CHAPTER 19USE OF OPIOID ANALGESICS Malaysian Statistics on Medicines 2006

93

CHAPTER 19USE OF OPIOID ANALGESICS Malaysian Statistics on Medicines 2006

Edited by:Mary SC1, Marzida M2, Choy YC3, Faizah AR1, Norliza MA1

1. Selayang Hospital, 2. University of Malaya Medical Centre, 3. Universiti Kebangsaan Malaysia Medical Centre

Drugs used for pain control belong to the following subgroups of the ATC classification: anti-inflammatory products, opioids, analgesics and antipyretics. This chapter covers only opioid analgesics.

The total opioid consumption in Malaysia in 2006 was 0.7268DDD/1000 population/day. This figure is very much lower than the opioid consumption in the Nordic countries [1], which ranged from 14.0DDD/1000 population/day in Finland to 21.8DDD/1000 population /day in Sweden.

Weak opioids were more commonly used than strong opioids. Of the weak opioids, tramadol was the most common, followed closely by codeine and its combinations. The most commonly used strong opioid was morphine, which had much higher use than pethidine, fentanyl and oxycodone.

The combined DDD/1000 population/day of the weak opioids (dihydrocodeine, codeine, tramadol and tramadol combinations) was 0.5164, which is more than double that of the strong opioids (morphine, oxycodone, pethidine and fentanyl) which totaled to 0.2084. This pattern is different from the Nordic countries [1] where the total consumption of strong opioids was higher than that of weak opioids. In Malaysia, tramadol, tramadol combinations and codeine combinations comprise the main bulk of the weak opioids that were consumed. These drugs are not controlled under the Dangerous Drugs Act (DDA), and have lower risk of respiratory depression and addiction, thus accounting for their popularity compared to the other opioids.

Data from the International Narcotics Control Board (INCB) [2] for opioid consumption in Malaysia showed that in the 1990s there was an increasing trend in morphine consumption which showed plateau after the year 2000, when the newer opioids like fentanyl and oxycodone became available; the consumption of these new opioids is still increasing. This overall increased consumption in opioids probably reflects an increased awareness regarding the use of opioids to control chronic cancer pain. This is supported by the data obtained from this study, as the DDD/1000 population/day of the oral form of morphine (usually used for chronic and cancer pain) is 5 times that of the DDD for the parenteral form (used for anaesthesia and acute pain). Fentanyl is much less used than morphine, and this data only includes the transdermal form, thus reflecting only its use for chronic cancer pain.

The use of morphine in the public sector is more than 10 times that in the private sector - this probably reflects the fact that the majority of patients with advanced cancer are treated in the public sector, where oral morphine is used as the mainstay of analgesia for chronic cancer pain.

Table 19.1: Use of Analgesics by Drug Class, in DDD/1000 population/day 2006

Table 19.1.2: Use of Analgesics by Drug Class, in DDD/1000 population/day 2006

ATC Drug Class 2006 N02A OPIOIDS 0.7268

ATC Drug Class 2006 N02A A Natural Opium alkaloids 0.4139 N02A B Phenylpiperidine derivatives 0.0226 N02A D Benzomorphone derivatives <0.0001 N02A F Morphinan derivatives 0.0019 N02A X Other opioids 0.2883

CHAPTER 19USE OF OPIOID ANALGESICSMalaysian Statistics on Medicines 2006

94

ATC Drug Class and Agents Year AdmRCodeO AdmRCodeP Total N02A A Natural opium alkaloids N02A A01 Morphine Public 0.1474 0.0283 0.1757

Private 0.0032 0.0062 0.0094

Total 0.1506 0.0345 0.185

N02A A05 Oxycodone Public 0.0004 - 0.0004

Private 0.0004 - 0.0004

Total 0.0008 - 0.0008

N02A A08 Dihydrocodeine Public 0.0161 - 0.0161

Private 0.0187 - 0.0187

Total 0.0348 - 0.0348 N02A A59 Codeine, combinations excl.

psycholeptics Public - - -

Private 0.1933 - 0.1933

Total 0.1933 - 0.1933

N02A B Phenylpiperidine derivatives N02A B02 Pethidine Public - 0.0085 0.0085

Private - 0.0088 0.0088

Total - 0.0173 0.0173

N02A B03 Fentanyl Public AdmRCodeTD

- 0.0048 0.0048

Private - 0.0005 0.0005

Total - 0.0053 0.0053

N02A D Benzomorphan derivatives N02A D01 Pentazocine Public - AdmRCodeP -

Private - <0.0001 <0.0001

Total - <0.0001 <0.0001

N02A F Morphinan derivatives

N02A F02 Nalbuphine Public - 0.0013 0.0013

Private - 0.0006 0.0006

Total - 0.0019 0.0019

N02A X Other opioids

N02A X02 Tramadol Public 0.146 0.0084 0.1544

Private 0.0399 0.003 0.0429

Total 0.1859 0.0114 0.1973

N02A X52 Tramadol, combinations Public 0.0003 - 0.0003

Private 0.0907 - 0.0907

Total 0.091 - 0.091

Table 19.2: Use of Opioid Analgesics by Drug Class, agents and Administration Route, inDDD/1000population/day 2006

References:1. Medicines consumption in the Nordic countries 1999-2003. Nordic Medico Statistical Committee 2004; 2004:Copenhagen.2. International Narcotics Control Board; United Nations population data (Malaysia), by Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2008.

CHAPTER 20USE OF MEDICINES FOR NEUROLOGICAL DISORDERS Malaysian Statistics on Medicines 2006

95


Edited by:Zariah AA1, Hanip R2, Raymond AA3, Norhasyimah AR1, Azrinorwaty Z2

1. Sultanah Nur Zahirah Hospital, Kuala Terengganu, 2. Kuala Lumpur Hospital, 3. Universiti Kebangsaan Malaysia Medical Centre

There were 4 main categories of neurological drug groups being analysed for the year 2006. These included the anticonvulsants, drugs for Parkinson’s disease, drugs for dementia and the anti-migraine preparations.

The largest category consisted of the anticonvulsants with the total utilisation at 1.5DDD/1000 population/day. This translated to a rough estimate of about 0.15% of our population having epilepsy. This estimated data is slightly lower compared to data from developed countries which gave a range between 0.5% and 1%.

The most commonly prescribed drugs for both public and private hospitals were phenytoin (0.5DDD/1000population/day), sodium valproate (0.4) and carbamazepine (0.3). The first three drugs have traditionally been used as first line drugs for generalised tonic clonic seizures. Although phenytoin has not been a popular drug for many clinicians worldwide, surprisingly it is still commonly prescribed by both the public and private sector doctors in our country. Its usage has been minimal especially in developed countries like the UK and Scandinavia, due to its very narrow toxicity range and its hideous side effects of hirsutism in females. In the local consensus guidelines on the management of epilepsy, phenytoin is recommended as the second and not first choice for generalised seizure due to similar reason. The most probable reasons for its relatively high usage locally are likely due to its cost, availability and partly contributed by the wide use in the elderly with post stroke epilepsy. It also has a major role in the treatment of status epilepticus.

Sodium valproate being a versatile drug is the treatment of choice as monotherapy or adjunctive therapy inboth partial and generalised seizures. Carbamazepine despite of having its greatest risk of causing Steven-Johnsons syndrome, was almost as popular, being one of the treatment of choice for women of child bearing age due to its comparatively lower risk of teratogenecity.

Use of phenobarbitone (0.1), clonazepam (0.04), and primidone (0.001) was limited most likely related to its sedative side effect particularly with clonazepam. Benzodiazepines however, have a particularly prominent role in myoclonus and movement disorders.

Among the newer anticonvulsants, lamotrigine (0.04), gabapentin (0.03) and levetiracetam (0.01) were more commonly used compared to others like topiramate (0.006), oxcarbazepine (0.003) and vigabatrin (0.0004). Gabapentin usage is more related to neuropathic pain rather than as an anticonvulsant. Vigabatrin unlike Lamotrigine, Levetiracetam, Topiramate and Oxcarbazepine is currently indicated for second line use in patients with refractory partial epilepsy. Overall usage for the newer AEDs is low due to their higher cost and specialist level prescribing rights.

Anticonvulsant usage in private practice is very much lower with both the traditional as well as the newer drugs. This probably reflects the populations’ preference in seeking treatment at public hospitals. The most likely reason for this would have to be the high cost of these medications.

The trend in prescribing AED in Australia is similar (see Table 20.7) whereby there is a higher usage of the conventional/older AED like valproic acid (3.6) and carbamazepine (1.89) and there was lower usage of phenytoin (1.65). In descending order of frequency, the most commonly used newer anticonvulsants were lamotrigine (0.98), followed by gabapentin (0.48), levetiracetam (0.4), topiramate (0.27), oxcarbazepine (0.06) and vigabatrin (0.054).

In the group, drugs used for Parkinson’s disease, there were 5 main classes of drugs available. They were the levodopa (+ peripheral dopa decarboxylase inhibitors), dopamine agonists, anticholinergics/antimuscarinics, amantadine and the enzyme inhibitors (monoamine oxidase type B inhibitors, catechol-o-methyl transferase


96

inhibitors. Artane was the most commonly prescribed drug with a DDD/1000 population/day of 0.6. Its popularity was likely due to its availability, cost, usefulness in reducing tremor and rigidity and served as an alternative to reduce risk of development of motor complications associated with levodopa therapy. Levodopa (+ peripheral dopa decarboxylase inhibitors) although is the gold standard and the most effective drug therapy in Parkinson’s disease came second in its usage at 0.16 DDD/1000 population/day. Stalevo, a 3-in-one preparation with levodopa, carbidopa and entacapone showed very little usage at 0.0017DDD/1000 population/day. It is currently not available in the Ministry of Health (public sector)

Among the dopamine agonists, the commonly used drugs in descending order of frequency were; piribedil (0.009), bromocriptine (0.006), ropinirole (0.001) and pramipexole (0.0003). Bromocriptine and piribedil both ergot derived DA had been in the market longer than the other newer dopamine agonists. Pramipexole was only made available in Malaysia in June 2006. Hence in spite of the current practice of using DA as first choice in de novo and young parkinsonian patients and with possible neuroprotective effects, the non availability and cost were the likely factors for their low usage.

Amantadine (0.007), a tricyclic amine was used previously as an antiviral. It was mainly used in levodopa induced dyskinesias and hence has a limited role in PD therapy.

Among the enzyme inhibitors, selegiline (0.06) had been available in Malaysia for many years and usually used in the early stage of PD, whereas comtan (0.012) was a relatively newer addition, used in combination with levodopa.

The prescribing practice in Australia differed slightly (see Table 20.8), with the levodopa group (1.43) having the higher usage compared to the anticholinergics. Among the anticholinergic, unlike in Malaysia where benzhexol was very popular, benzatropine (0.49) had a higher usage. The dopamine agonists both older and newer ones together with amantadine showed the lowest ratings (0.02 for bromocriptine, ropinirole, pramipexole and 0.003 for amantadine). Their use of comtan (0.1) and stalevo (0.05) were much higher.

In dementia, drugs available for cognitive improvement were the cholinesterase inhibitors, usage at 0.02DDD/1000 population/day and the NMDA receptor antagonist, memantine usage at 0.001DDD/1000 population/day. In 2006 and till currently memantine and galantamine are still unavailable in the public sector. Although an estimated 5 to 10% of the adult population age 65 years and older is affected by a dementia disorder, lack of awareness by both the public and health care professionals could explain the least usage of these drugs (0.02) among the four subgroup neurological disorders surveyed. No data from Australia was available for comparison.

The total use of anti-migraine preparations in 2006 in Malaysia was 0.0689DDD/1000 population/day. The most utilised class of drug was ergot alkaloid (0.0337DDD/1000 population/day), followed by pizotifen (0.0265DDD/1000 population/day) and selective serotonin (5HT1) agonist, sumatriptan (0.0087DDD/1000 population/day).

Ergot alkaloids constituted 48.9% by drug class with the breakdown of ergotamine combinations excluding psycholeptics (94%), ergotamine combinations with psycholeptics (5.6%) and ergotamine (0.4%). Ergot alkaloid had not been approved and was unavailable in public hospitals hence its low usage in acute migraine attack. However, it had its usage in private practice despite the alarming side effects with chronic use. The only available ergot combination in Malaysia in 2006 was Cafergot® which contained ergotamine and caffeine. Sumatriptan used in acute attacks showed a usage of 0.009 DDD/1000 population/day, being used more in the private practice (0.006) compared to public hospitals (0.002). There was no survey made on other drugs for acute attacks like paracetamol, cox-2 inhibitors, NSAIDs, opioids or corticosteroids. In Australia, sumatriptan showed the highest usage amongst the drugs for aborting acute attacks, followed by the ergot alkaloid methysergide (0.03), the newer triptans, zolmitriptans (0.03) and naratriptan (0.02).

Pizotifen used as migraine prophylaxis was the only prophylaxis surveyed with usage of 0.002DDD/1000 population/day. It would be interesting to look at the results of other migraine prophylaxis which was not


97

surveyed, including the newer anticonvulsants like topiramate, levetiracetam as well as the conventional choices like beta blockers and calcium channel blockers. As such, analyses as to the practice of use of antimigraine drugs are rather limited due to the restricted choices of drugs surveyed.

ATC Drug Class 2006 N02C ANTIMIGRAINE PREPARATIONS 0.0689

N03 ANTIEPILEPTICS 1.4992

N04 ANTIPARKINSON DRUGS 0.882

N06D ANTIDEMENTIA DRUGS 0.0258

N07 OTHER NERVOUS SYSTEM DRUGS 0.9054

ATC Drug Class 2006 N02C ANTIMIGRAINE PREPARATIONS 0.0689

N02C A Ergot alkaloids 0.0337

N02C C Selective serotonin (5HT1) agonists 0.0087

N02C X Other antimigraine preparations 0.0265

ATC Drug Class 2006 N03A ANTIEPILEPTICS 1.4992

N03A A Barbiturates and derivatives 0.1231

N03A B Hydantoin derivatives 0.5077

N03A D Succinimide derivatives -

N03A E Benzodiazepine derivatives 0.0483

N03A F Carboxamide derivatives 0.3172

N03A G Fatty acid derivatives 0.3985

N03A X Other antiepileptics 0.1044

Table 20.1: Use of Drugs for Neurological Disorder, in DDD/1000 population/day 2006

Table 20.2.1: Use of Analgesics by Drug Class, in DDD/1000 population/day 2006

Table 20.2.2: Use of Analgesics by Drug Class and Agents, in DDD/1000 population/day 2006

Table 20.3.1: Use of Anti-Epileptics by Drug Class, in DDD/1000 population/day 2006

ATC Drug Class and Agents 2006 N02C A Ergot alkaloids N02C A02 Ergotamine Public -

Private 0.0001

Total 0.0001

N02C A52 Ergotamine, combinations excl. psycholeptics Pub lic 0.0003

Private 0.0314

Total 0.0317

N02C A72 Ergotamine, combinations with psycholeptics Public -

Private 0.0019

Total 0.0019

N02C C Selective serotonin (5HT1) agonists N02C C01 Sumatriptan Public 0.002

Private 0.0067

Total 0.0087

N02C X Other antimigraine preparations N02C X01 Pizotifen Public 0.0183

Private 0.0082

Total 0.0265


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ATC Drug Class and Agents 2006 N03A A Barbiturates and derivatives N03A A02 Phenobarbital Public 0.1062

Private 0.0153

Total 0.1215

N03A A03 Primidone Public 0.0013

Private 0.0002

Total 0.0015

N03A B Hydantoin derivatives

N03A B02 Phenytoin Public 0.4641

Private 0.0436

Total 0.5077

N03A D Succinimide derivatives N03A D01 Ethosuximide Public -

Private -

Total -

N03A E Benzodiazepine derivatives N03A E01 Clonazepam Public 0.0399

Private 0.0085

Total 0.0483

N03A F Carboxamide derivatives N03A F01 Carbamazepine Public 0.2905

Private 0.0236

Total 0.3142

N03A F02 Oxcarbazepine Public 0.0002

Private 0.0027

Total 0.003

N03A G Fatty acid derivatives N03A G01 Valproic acid Public 0.3673

Private 0.0308

Total 0.3981

N03A G04 Vigabatrin Public 0.0001

Private 0.0003

Total 0.0004

N03A X Other antiepileptics N03A X0 9 Lamotrigine Public 0.038

Private 0.0033

Total 0.0412

N03A X11 Topiramate Public 0.0058

Private 0.0003

Total 0.0061

N03A X12 Gabapentin Public 0.0221

Private 0.0159

Total 0.038

N03A X14 Levetiracetam Public 0.0101

Private 0.0089

Total 0.0191

Table 20.3.2: Use of Antiepileptics by Drug Class and Agents, in DDD/1000 population/day 2006


99

ATC Drug Class 2006 N04A ANTICHOLINERGIC AGENTS 0.6121

N04A A Tertiary amines 0.6094

N04A B Ethers chemically close to antihistamines 0.0004

N04A C Ethers of tropine or tropine derivatives 0.0023

N04B DOPAMINERGIC AGENTS 0.2698

N04B A Dopa and dopa derivatives 0.1739

N04B B Adamantane derivatives 0.0066

N04B C Dopamine agonists 0.0171

N04B D Monoamine oxidase B inhibitors 0.0604

N04B X Other dopaminergic agents 0.0118

Table 20.4.1: Use of Antiparkinson by Drug Class, in DDD/1000 population/day 2006

Table 20.4.2: Use of Antiparkinson by Drug Class and Agents, in DDD/1000 population/day 2006ATC Drug Class and Agents 2006 N04A A Tertiary amines N04A A01 Trihexyphenidyl Public 0.5887

Private 0.0204

Total 0.6091

N04A A04 Procyclidine Public 0.0003

Private <0.0001

Total 0.0003

N04A B Ethers chemically close to antihistamines N04A B02 Orphenadrine (chloride) Public -

Private 0.0004

Total 0.0004

N04A C Ethers of tropine or tropine derivatives N04A C01 Benzatropine Public 0.002

Private 0.0003

Total 0.0023

N04B A Dopa and dopa derivatives N04B A02 Levodopa and decarboxylase inhibitor Public 0.1549

Private 0.0173

Total 0.1722

N04B A03 Levodopa, decarboxylase inhibitor and COMT inhibitor Public 0.0008

Private 0.0009

Total 0.0017

N04B B Adamantane derivatives N04B B01 Amantadine Public 0.0029

Private 0.0036

Total 0.0066

N04B C Dopamine agonists

N04B C01 Bromocriptine Public 0.0061

Private 0.0003

Total 0.0063

N04B C04 Ropinirole Publ ic 0.0006

Private 0.0006

Total 0.0012

N04B C05 Pramipexole Public -

Private 0.0003

Total 0.0003


100

ATC Drug Class and Agents 2006 N06D ANTIDEMENTIA DRUGS 0.0258

N06D A Anticholinesterases 0.0247

N06D X Other anti-dementia drugs 0.0011

Table 20.5.1: Use of Antidementia Drugs by Drugs Class, in DDD/1000 population/day 2006

ATC 2006 N06D A N06D A02 Publi c 0.0102

Private 0.0032

Total 0.0134

N06D A03 Public 0.006

Private 0.0006

Total 0.0066

N06D A04 Public -

Private 0.0047

Total 0.0047

N06D X N06D X01

Drug Class and AgentsAnticholinesterasesDonepezil

Rivastigmine

Galantamine

Other antidementia drugsMemantine Public 0.0009

Private 0.0001

Total 0.0011

Table 20.5.2: Use of Antidementia Drugs by Drugs Class and Agents, in DDD/1000 population/day 2006

Table 20.6.1: Use of Other Nervous System Drugs by Drug Class, in DDD/1000 population/day 2006ATC Drug Class and Agents 2006 N07A PARASYMPATHOMIMETICS 0.1268

N07A A Anticholinesterases 0.1268

N07C ANTIVERTIGO PREPARATIONS 0.778 6

N07C A Antivertigo preparations 0.7786

N07X OTHER NERVOUS SYSTEM DRUGS <0.0001

N07X X Other nervous system drugs <0.0001

ATC Drug Class and Agents 2006 N04B C08 Piribedil Public 0.0082

Private 0.0011

Total 0.0093

N04B D Monoamine oxidase B inhibitors N04B D01 Selegiline Public 0.054

Private 0.0065

Total 0.0604

N04B X02 Entacapone Public 0.0109

Private 0.0009

Total 0.0118


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Table 20.6.2: Use of Other Nervous System Drugs by Drug Class and Agents, in DDD/1000 population/day 2006

ATC Drug Class and Agents 2006 N07A A Anticholinesterases N07A A01 Neostigmine Public 0.0294

Private 0.0213

Total 0.0507

N07A A02 Pyridostigmine Public 0.0704

Private 0.0056

Total 0.0761

N07A A03 Distigmine Public -

Private <0.0001

Total <0.0001

N07C A Antivertigo preparations N07C A01 Betahistine Public 0.1257

Private 0.242

Total 0.3677

N07C A02 Cinnarizine Public 0.1156

Private 0.2004

Total 0.316

N07C A03 Flunarizine Public 0.0183

Private 0.0766

Tota l 0.0949

N07X X Other nervous system drugs N07X X02 Riluzole Public -

Private <0.0001

Total <0.0001

Table 20.7: Use of drugs for epilepsy in DDD/1000 population/day comparing use in Malaysia and Australia for the year 2006

Drug Malaysia Australia Phenobarbitone Public/Subsidized 0.1062 0.110 Private/Survey 0.0153 0.020 TOTAL 0.1215 0.130 Primidone Public/Subsidized 0.0013 0.092 Private/Survey 0.0002 0.001 TOTAL 0.0015 0.093 Clonazepam Public/Subsidized 0.0399 0.163 Private/S urvey 0.0085 0.205 TOTAL 0.0484 0.368 Carbamazepine Public/Subsidized 0.2905 1.838 Private/Survey 0.0236 0.048 TOTAL 0.3141 1.886 Oxcarbazepine Public/Subsidized 0.0002 0.058 Private/Survey 0.0027 0.000 TOTAL 0.0029 0.058 Valproic Acid Public/Subsidized 0.3673 3.603 Private/Survey 0.0308 0.039 TOTAL 0.3981 3.642 Vigabatrin Public/Subsidized 0.0001 0.054 Private/Survey 0.0003 0.000 TOTAL 0.0004 0.054 Lamotrigine Public/Subsidized 0.038 0.792 Private/Survey 0.0033 0.188 TOTAL 0.0413 0.980


102

Drug Malaysia Australia Topiramate Public/Subsidized 0.0058 0.259 Private/Survey 0.0003 0.010 TOTAL 0.0061 0.269 Gabapentin Public/Subsidized 0.0221 0.302 Private/Survey 0.0159 0.176 TOTAL 0.0380 0.478 Levetiracetam Public/Subsidized 0.010 1 0.392 Private/Survey 0.0089 0.003 TOTAL 0.02 0.4

Table 20.8: Use of drugs for Parkinson’s disease in DDD/1000 population/day comparing use inMalaysia and Australia for the year 2006

References:1. Malaysian consensus guidelines on the management of epilepsy 2005.2. British National Formulary September 2007.3. Malaysian consensus on Parkinson’s disease.4. Malaysian guidelines on the management of dementia 2003.5. Malaysian consensus guidelines on the management of headache 2005.6. Australian statistics on medicine 2006.

Drug Malaysia Australia Artane Public/Subsidized 0.59 0.13 Private/Survey 0.02 0.008 Total 0.61 0.13 Procyclidine Public/Subsidized 0.0003 - Private/Survey <0.0001 Total Ophenadrine Public/Subsidized - - Private/Survey 0.0004 Total 0.0004 Benzatropine Public/Subsidiz ed 0.002 0.465 Private/Survey 0.0003 0.03 Total 0.49 Levodopa & Public/Subsidized 0.155 (Madopar) Sinemet Decarboxylase 0.56 0.87 Inhibitor Private/Survey 0.017 0.002 0.006 Total 0.172 0.56 0.87 Stalevo Public/Subsidized 0.0008 0.054 Private/Survey 0.0009 0.000 Total 0.0017 0.054 Amantadine Public/Subsidized 0.003 0.0 Private/Survey 0.004 0.003 Total 0.007 0.003 Bromocriptine Public/Subsidized 0.006 0.02 Private/Survey 0.0003 0.000 Total 0.0063 0.002 Ropinirole Public/Subsidized 0.0006 0.002 Private/Survey 0.0006 Total 0.0012 Pramipexole Public/Subsidized - 0.002 Private/Survey 0.0003 Total 0.0003 Piribedil Public/Subsidized 0.008 - Private/Survey 0.001 Total 0.009 Selegiline Public/Subsidized 0.054 0.102 Private/Survey 0.0065 0.00 Total 0.06 0.102 Comtan Public/Subsidized 0.011 0.097 Private/Survey 0.0009 0.00 Total 0.012 0.097

CHAPTER 21USE OF DRUGS FOR PSYCHIATRIC DISORDERS Malaysian Statistics on Medicines 2006

103


Edited by:Siti Nor Aizah A1, Salina AA1, Ramli MA2, Suarn S3, Nor Hayati A4, Shamini R3, Noor Ratna N5, Mariam Bintarty R,1 Syed Fadzli SS6

1. Kuala Lumpur Hospital, 2. Selayang Hospital, 3. Bahagia Hospital, Tanjung Rambutan 4. Kajang Hospital, 5. Permai Hospital, Johor Bahru, 6. Pharmaceutical Services Division, MOH. The impact of mental and behavioural disorders does not only affect the individual concerned but extend onto the families and communities. In 2000, it was estimated that neuropsychiatric disorders accounted for 12.3% of Disability Adjusted Life Years (DALYs) [1].

Pharmacotherapy is one of the important treatment modalities in the holistic management of the various psychiatric disorders. Antipsychotics was the group of drugs most consumed, comprising 53%, followed by antidepressants (22%), anxiolytics, hypnotics and sedatives (21%) and drugs used in addictive disorders (4%). In some of the Nordic countries, the hypnotics were among the top 10 most consumed medicines in 2003 [2]. In the same publication, it was notable that the 1999-2003 drug consumption trends indicated that the antipsychotic use was increased by 4-23%; whereas the antidepressants use escalated between 43-66%.

Eighty seven percent (87%) of typical antipsychotics were prescribed compared with 13% of atypical antipsychotics. This pattern did not vary much from previous year’s data [3] and the prescribing practice was the reverse in Australia [4]. The use of atypical antipsychotics was higher in the private sector (26%) as compared to the public sector (13%). Although its use is recommended as first line treatment in a number of different psychotic conditions [5, 6], the low usage of atypical antipsychotics locally might be due to its high cost.

The Selective Serotonin Reuptake Inhibitors (SSRI) was the highest consumed antidepressant (67%), followed by Non-Selective Monoamine Reuptake Inhibitors (24.30%). The wide discrepancy between the SSRIs and the use of other antidepressants could be due to its favourable safety profile and its approval for indications for not only mood disorders but for anxiety disorders as well [7]. The prescription of the newer antidepressants such as Mirtazapine, Venlafaxine and Duloxetine, among others, categorised under the Other Antidepressants were much lower (7%).

The anxiolytics, sedatives and hypnotics were much more widely used in the private sector (69%) comparative to the public sector (31%). This discrepancy could be explained by tendency of patients with anxiety [8] and sleep disorders [9] to seek medical consultations from primary healthcare practitioners. In both facilities, Alprazolam was the most commonly prescribed anxiolytic (N05B); 27% in private and 21% in public. Among the hypnotics and sedatives (N05C); the benzodiazepine derivatives Midazolam was prescribed more in theprivate sector, whereas usage of benzodiazepine related drug such as Zolpidem was comparable in both sectors.

The use of drugs for addictive disorders was slightly higher in the private sector i.e. 56.3%. Drugs used for opioid dependence, Methadone (56%) and Buprenorphine (42%) were widely prescribed. Drugs used for alcohol dependence, Naltrexone; and for nicotine dependence, Nicotine; each only comprised of 1% usage. The low consumption of nicotine (0.0017DDD/1000 population/day) was of concern in up scaling the smoking cessation services considering the prevalence of established smokers in 2006 were 21.5%, of which 23.6% were defined as heavy smokers [10].

CHAPTER 21USE OF DRUGS FOR PSYCHIATRIC DISORDERSMalaysian Statistics on Medicines 2006

104

ATC Drug Class and Agents 2006 N05A A Phenothiazines with aliphatic side-chain 0.4881

N05A B Phenothiazines with piperazine structure 0.8033

N05A C Phenothiazines with piperidine structure 0.0007

N05A D Butyrophenone derivatives 0.6728

N05A E Indole derivatives 0.0013

N05A F Thioxanthene derivatives 0.0693

N05A H Diazepines, oxazepines and thiazepines 0.136

N05A K Neuroleptics, in tardive dyskinesia <0.0001

N05A L Benzamides 0.31

N05A N Lithium 0.029

N05A X Other antipsychotics 0.2061

Table 21.1.1: Use of Anti-Psychotics by Drug Class, in DDD/1000 population/day 2006

Table 21.1.2: Use of Anti-Psychotics by Drug Class and Agents, in DDD/1000 population/day 2006ATC Drug Class and Agents 2006 N05A A Phenothiazines with aliphatic side-chain N05A A01 Chlorpromazine Public 0.4835

Private 0.0046

Total 0.4881

N05A B Phenothiazines with piperazine structure N05A B02 Fluphenazine Public 0.5418

Private 0.0115

Total 0.5534

N05A B03 Perphenazine Public 0.0224

Private 0.0026

Total 0.025

N05A B04 Prochlorperazine Public 0.0818

Private 0.0318

Total 0.1136

N05A B06 Trifluoperazine Public 0.1106

Private 0.0009

Total 0.1115

N05A C Phenothiazines with piperidine structure N05A C02 Thioridazine Public <0.0001

Private 0.0006

Total 0.0007

N05A D Butyrophenone derivatives N05A D01 Haloperidol Public 0.66

Private 0.0128

Total 0.6728

N05A E Indole derivatives N05A E04 Ziprasidone Public 0.0003

Private 0.001

Total 0.0013

N05A F Thioxanthene derivatives

N05A F01 Flupentixol Public 0.0205

Private 0.0015

Total 0.022

N05A F05 Zuclopenthixol Public 0.0459

Private 0.0014

Total 0.0473


105

ATC Drug Class and Agents 2006 N05A H Diazepines, oxazepines and thiazepines N05A H02 Clozapine Public 0.0887

Private 0.0003

Total 0.089

N05A H03 Olanzapine Public 0.0296

Private 0.0011

Total 0.0307

N05A H04 Quetiapine Public 0.0149

Private 0.0014

Total 0.0163

N05A K Neuroleptics, in tardive dyskinesia N05A K01 Tetrabenazine Public <0.0001

Private -

Total <0.0001

N05A L Benzamides N05A L01 Sulpiride Public 0.307

Private

Total 0.31

N05A N Lithium N05A N01 Lithium Public 0.0275

Private 0.0014

Total 0.029

N05A X Other antipsychotics N05A X08 Risperidone Public 0.2009

Private 0.0034

Total 0.2043

N05A X12 Aripiprazole Public 0.0002

Private 0.0017

Total 0.0018

0.003

Table 21.2.1: Use of Anti-Depressants by Drug Class, in DDD/1000 population/day 2006ATC Drug Class and Agents 2006 N06A A Non-selective monoamine reuptake inhibitors 0.2723

N06A B Selective serotonin reuptake inhibitors 0.7504

N06A F Monoamine oxidase inhibitors, non-selective <0.0001

N06A G Monoamine oxidase A inhibitors 0.018

N06A X Other antidepressants 0.0792

Table 21.2.2: Use of Anti-Depressants by Drug Class and Agents, in DDD/1000 population/day 2006ATC Drug Class and Agents 2006 N06A A Non-selective monoamine reuptake inhibitors N06A A02 Imipramine Public 0.029

Private 0.0046

Total 0.0336

N06A A04 Clomipramine Public 0.0175

Private 0.0011

Total 0.0186

N06A A09 Amitriptyline Public 0.0906

Private 0.0479

Total 0.1384


106

ATC Drug Class and Agents 2006 N06A A10 Nortriptyline Public -

Private <0.0001

Total <0.0001

N06A A16 Dosulepin Public 0.0626

Private 0.0156

Total 0.0782

N06A A21 Maprotiline Public 0.0018

Private 0.0016

Total 0.0034

N06A B Selective serotonin reuptake inhibitors N06A B03 Fluoxetine Public 0.1119

Private 0.028

Total 0.1399

N06A B04 Citalopram Public 0.001

Private 0.023

Total 0.024

N06A B05 Paroxetine Public 0.004

Private 0.0073

Total 0.0112

N06A B06 Sertraline Public 0.2392

Private 0.0526

Total 0.2918

N06A B08 Fluvoxamine Public 0.1854

Private 0.0276

Total 0.213

N06A B10 Escitalopram Public 0.0425

Private 0.028

Total 0.0705

N06A F Monoamine oxidase inhibitors, non-selective N06A F04 Tranylcypromine Public <0.0001

Private -

Total <0.0001

N06A G Monoamine oxidase A inhibitors

N06A G02 Moclobemide Public 0.0171

Private 0.0009

Total 0.018

N06A X Other antidepressants N06A X03 Mianserin Public 0.0091

Private 0.0038

Tota l 0.0129

N06A X06 Nefazodone Public -

Private -

Total -

N06A X11 Mirtazapine Public 0.0171

Private 0.0168

Total 0.0339

N06A X14 Tianeptine Public 0.0003

Private 0.0065

Total 0.0068


107

ATC Drug Class and Agents 2006 N06A X16 Venlafaxine Public 0.0191

Private 0.0047

Total 0.0238

N06A X21 Duloxetine Public 0.0002

Private 0.0016

Total 0.0018

ATC Drug Class 2006 N05B A Benzodiazepine derivatives 0.7978

N05B B Diphenylmethane derivatives 0.1404

N05C C Aldehydes and derivatives 0.0139

N05C D Benzodiazepine derivatives 0.2149

N05C F Benzodiazepine related drugs 0.1617

N05C M Other hypnotics and sedatives <0.0001

Table 21.3.1: Use of Anxiolytics, Hypnotics and Sedatives by Drug Class, in DDD/1000 population/day2006

Table 21.3.2: Use of Anxiolytics, Hypnotics and Sedatives by Drug Class and Agents, in DDD/1000population/day 2006

ATC Drug Class and Agents 2006 N05B A Benzodiazepine derivatives N05B A01 Diazepam Public 0.0656

Private 0.1552

Total 0.2209

N05B A02 Chlordiazepoxide Public -

Private 0.0061

Total 0.0061

N05B A05 Potassium clorazepate Public -

Private 0.0195

Total 0.0195

N05B A06 Lorazepam Public 0.0834

Private 0.0939

Total 0.1773

N05B A08 Bromazepam Public 0.0063

Private 0.0219

Total 0.0282

N05B A09 Clobazam Public 0.0013

Private 0.0128

Total 0.0141

N05B A12 Alprazolam Public 0.0856

Private 0.2461

Total 0.3317

N05B B Diphenylmethane derivatives N05B B01 Hydroxyzine Public 0.0522

Private 0.0882

Total 0.1404

N05C C Aldehydes and derivatives N05C C01 Chloral hydrate Public 0.006

Private 0.008

Total 0.0139


108

ATC Drug Class and Agents 2006 N05C C05 Paraldehyde Public <0.0001

Private <0.0001

Total <0.0001

N05C D Benzodiazepine derivatives N05C D01 Flurazepam Public -

Private 0.0004

Total 0.0004

N05C D02 Nitrazepam Public 0.0019

Private 0.0169

Total 0.0189

N05C D05 Triazolam Public -

Private 0.0192

Total 0.0192

N05C D08 Midazolam Public 0.0524

Private 0.1241

Total 0.1764

N05C F Benzodiazepine related drugs

N05C F02 Zolpidem Public 0.0601

Private 0.0725

Total 0.1325

N05C M Other hypnotics and sedatives

N05C M05 Scopolamine Public <0.0001

Private <0.0001

Total <0.0001

N05C F01 Zopiclone Public -

Private 0.0292

Total 0.0292

Table 21.4.1: Use of Drugs used in Additive Disorder by Drug Class, in DDD/1000 population/day 2006ATC Drug Class and Agents 2006 N07B DRUGS USED IN ADDICTIVE DISORDERS 0.1708

N07B A Drugs used in nicotine dependence 0.0017

N07B B Drugs used in alcohol dependence 0.0014

N07B C Drugs use d in opioid dependence 0.1678

Table 21.4.2: Use of Drugs used in Additive Disorder by Drug Class and Agents, in DDD/1000 population/day 2006

ATC Drug Class and Agents 2006 N07B A Drugs used in nicotine dependence N07B A01 Nicotine Public 0.0005

Private 0.0011

Total 0.0017

N07B B Drugs used in alcohol dependence N07B B04 Naltrexone Public 0.001

Private 0.0004

Total 0.0014

N07B C Drugs used in opioid dependence N07B C01 Buprenorphine Public 0.0018

Private 0.0695

Total 0.0713


109

ATC Drug Class and Agents 2006 N07B C 02 Methadone Public 0.0713

Private 0.0251

Total 0.0964

N07B C51 Buprenorphine, combinations Public -

Private <0.0001

Total <0.0001

References:1. World Health Report 2001.2. Nordic Medico Statistico Committee 2004. Medicines Consumption in The Nordic Countries 1999-2003.3. Pharmaceutical Services Division and the Clinical Research Centre, Ministry of Health, Malaysia 2007. Malaysian Statistics on Medicine 2005. 4. Commonwealth of Australia 2008. Australian Statistics on Medicine 2006. 5. Kane JM, Leucht S, Carpenter D, et al, The Expert Consensus Guideline Series: Optimising pharmacologic treatment of psychotic disorders. J Clin Psychiatry 2003; 64 (Suppl 12):1-100.6. Weiden PJ, Preskorn SH, Fahnestock PA, et al. Translating the psychopharmacology of antipsychotics to individualized treatment for severe mental illness: A roadmap. J Clin Psychiatry 2006; 68 (Suppl 7):1-46.7. Stein DJ. Serotonergic Neurocircuitry in Mood and Anxiety Disorders. London, UK. Martin Dunitz Ltd. 2003.8. Sartorius N, Ustun TB, Lecrubier Y, Wittchen HU. Depression comorbid with anxiety: Results from the WHO study on psychological disorders in primary health care. Br J Psychiatry 1996; 168(Suppl 30):38-43.9. G Hajak. Insomnia in Primary Care. Sleep 2000; 23 (Suppl 3): S54-S63.10. Institute for Public Health (IPH) 2008. The Third National Health and Morbidity Survey (NHMS III) 2006, Vol 2, Ministry of Health Malaysia.

CHAPTER 22: USE OF MEDICINES FOR OBSTRUCTIVEAIRWAY DISEASES Malaysian Statistics on Medicines 2006

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Edited by:Pang YK1, Abdol Malek AZ2, Aziah AM3, Samsinah HH4, Joanne L5, Mat Zuki MJ6, Norhaya R7, Shahirah Z8

1. University of Malaya Medical Centre, 2. Pharmacy, Melaka Hospital, 3. Institute of Respiratory Medicine, Kuala Lumpur Hospital, 4. Department of Pharmacy, University Malaya, 5. Pharmacy, Kuala Lumpur Hospital, 6. Raja Perempuan Zainab II Hospital, Kota Bharu, 7. Sultanah Nur Zahirah Hospital, Kuala Terengganu, 7. Pharmacy, Selayang Hospital In clinical practice, asthma and chronic obstructive pulmonary disease (COPD), classified under obstructive airway diseases, are considered the two common diseases. Many of the drugs used in these diseases are quite similar, although the indications and the effects of drugs may differ considerably between the two. Data reported in this survey were based on the statistics of drug procurement and hence did not differentiate between those used in asthma from those used in COPD. To gain more insight into the prescribing trend and behaviour, it would be more appropriate in the future to separate the usage of drugs for asthma and COPD into the two different diseases. In asthma, inhaled glucocorticoids used as monotherapy or in combination with long-acting ß2 agonist are indicated for maintenance therapy. Use of long-acting ß2 agonists may prevent the need to increase the inhaled dose of glucocorticoids. Inhaled glucocorticoids and long-acting ß2 agonist are also used in patients with COPD, particularly in those with frequent exacerbations and those whose spirometry show significant FEV1 reversibility. On the other hand, short acting ß2 agonists (termed as “rescue” agents) are indicated for relief of acute reversible airway obstruction in patients with asthma and COPD. Based on these recommendations, one would expect that the usage of inhaled glucocorticoids should far exceed that of ß2 agonists; however, in this survey, the usage of ß2 agonists (4.6693) was still higher than that of glucocorticoids (2.3883). This seems to suggest that inhaled glucocorticoids are underused in the treatment of asthma and this might have resulted in many patients with uncontrolled asthma and increase usage of rescue ß2 agonists. Based on this survey, of the various inhaled glucocorticoids, budesonide was the most popular agent used. The usage of ciclesonide was still low as it was a new agent in this group. The latter is used in a small number of patients in government hospitals with specialists. Inhaled salbutamol on the other hand was the most popular ß2 agonist used to relieve symptoms. The use of oral ß2 agonists was still alarmingly high (5.5604). Although the oral route has the advantage of ease and simplicity of administration, in terms of clinical effects this is not the preferred route. This showed that the move to encourage doctors to change the prescription of reliever drugs from oral route to the inhaled method has not yet been very successful. This trend seems to be more deeply entrenched for those in the private sector.

Leukotriene receptor antagonists (e.g. montelukast) are recommended for those who have mild to moderate asthma as a monotherapy or used as an add-on for those whose asthma are still not well control despite receiving other agents. This drug is also particularly useful in controlling asthma resulting from certain triggers such as exercise-induced asthma, aspirin-induced asthma and allergen-induced asthma. It is easy to take (oral tablet once at night) but is still quite costly. The survey showed that the private sector tend to use it more often than the public sector. This may be that patients in the private sector could better afford this treatment. The use of montelukast in the public hospitals is restricted by the number of patients allowed to be prescribed the drug.

The use of Seretide® (accuhaler) is higher than Symbicort® (turbohaler) which is reflective of current practice. Both these drugs are costly and due to their unique presentation, the patients’ therapeutic outcomes are monitored, either in the ward or, in some government hospitals, during consultation at the Medication Therapy Adherence Clinics (MTAC) by the pharmacists. The new drug for asthma management, omalizumab (an anti-Ig E antibody) was not included in this report as it was not yet available in 2006 in Malaysia.


112

ATC Drug Class and Agents 2006 R03A C Selective beta-2-adrenoreceptor agonists- 4.6693

R03A K Adrenergics and other drugs for obstructive airway diseases 1.6081

R03B A Glucocorticoids 2.3883

R03B B Anticholinergics 0.5069

R03B C Antiallergic agents, excl. corticosteroids -

R03C A Alpha-and beta-adrenoreceptor agonists 0.0496

R03C C Selective beta-2-adrenoreceptor agonists 5.5604

R03D A Xanthines 1.5931

R03D C Leukotriene receptor antagonists 0.1436

Table 22.1: Use of Medicines for Obstructive Airway Diseases by Drug Class, in DDD/1000 population/day 2006

Table 22.2: Use of Medicines for Obstructive Airway Diseases by Drug Class and Agents, in DDD/1000 population/day 2006

ATC Drug Class and Agents 2006 R03A C Selective beta-2-adrenoreceptor agonists R03A C02 Salbutamol Public 4.024

Private 0.3237

Total 4.3477

R03A C03 Terbutaline Public 0.016 2

Private 0.0274

Total 0.0436

R03A C04 Fenoterol Public 0.0073

Private 0.001

Total 0.0083

R03A C12 Salmeterol Public 0.0084

Private 0.0002

Total 0.0086

R03A C13 Formoterol Public 0.2551

Private 0.006

Total 0.2611

R03A K Adrenergics and other drugs for obstructive airway diseases R03A K03 Fenoterol and other drugs for obstructive airway diseases Public -

Private 0.0226

Total 0.0226

R03A K04 Salbutamol and other drugs for obstructive airway diseases Public 0.3962

Private 0.1024

Total 0.4986

R03A K06 Salmeterol and other drugs for obstructive airway diseases Public 0.2208

Private 0.4593

Total 0.6801

R03A K07 Formoterol and other drugs for obstructive airway diseases Public 0.3086

Private 0.0983

Total 0.406 9

R03B A Glucocorticoids

R03B A01 Beclometasone Public 0.5753

Private 0.0277

Total 0.6029


113

ATC Drug Class and Agents 2006 R03B A02 Budesonide Public 1.5432

Private 0.1962

Total 1.7393

R03B A05 Fluticasone Public 0.0189

Private <0.0001

Total 0.019

R03B A08 Ciclesonide Public <0.0001

Private 0.027

Total 0.0271

R03B B Anticholinergics R03B B01 Ipratropium bromide Public 0.4182

Private 0.0527

Total 0.4709

R03B B04 Tiotropium bromide Public 0.0165

Private 0.0195

Total 0.036

R03B C Antiallergic agents, excl. corticosteroids R03B C01 Cromoglicic acid Public -

Private -

Total -

R03C A Alpha-and beta-adrenoreceptor agonists R03C A02 Ephedrine Public 0.0445

Private 0.0051

Total 0.0496

R03C C Selective beta-2-adrenoreceptor agonists R03C C02 Salbutamol Public 0.6566

Private 1.8439

Total 2.5005

R03C C03 Terbutaline Public 0.1697

Private 2.8792

Total 3.049

R03C C04 Fenoterol Public -

Private 0.0016

Total 0.0016

R03C C08 Procaterol Public -

Private 0.0064

Total 0.0064

R03C C12 Bambuterol Public -

Private 0.003

Total 0.003

R03D A Xanthines R03D A04 Theophylline Public 1.1004

Private 0.4886

Total 1.589

R03D A05 Aminophylline Public 0.0028

Private 0.0014

Total 0.0042

R03D C Leukotriene receptor antagonists

R03D C03 Montelukast Public 0.0372

Private 0.1064

Total 0.1436


114

References:1. Global Strategy for Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease (Updated 2008).

CHAPTER 23: USE OF ANTIHISTAMINESAND NASAL DECONGESANTS Malaysian Statistics on Medicines 2006

115


Edited by:Saraiza AB1, Anura M2, Noormah MD3

1. Serdang Hospital, 2. University Malaya Medical Centre, 3. Medical Development Division, MOH

Nasal decongestants and antihistamines are commonly used drugs for allergy and nasal symptoms in Otorhinolaryngology clinics in Malaysia. The 2006 survey showed usage of 0.9592DDD/population/year and the usage of anti-histamines for systemic use was 4.4422 DDDs/population/year.

In the present survey, the drugs were classified into several types which include nasal decongestants for topical use and systemic use. For local applications it was divided into plain sympathomimetics, anti-allergic without corticosteroid and corticosteroids. The nasal decongestant for systemic use was mainly sympatomimetics. The most utilised nasal decongestants were corticosteroid based nasal decongestants. Its usage was very highcompared to other topical decongestants. Newer generation corticosteroids usage was much higher in the private sector. Generic corticosteroids such as beclomethasone and budesonide had lost popularity in the private sector but not the public sector. Some plain topical decongestants especially oxymetazoline were persistently used in both private and public healthcare sectors. Pseudoephedrine combinations were widely used systemic nasal decongestants in both sectors.

Antihistamines can be divided into several subgroups that is sedative and non sedative. Non sedative antihistamines are gaining popularity especially the newer generation groups. There was broad use of sedative antihistamines in the private sector but less in numbers compared to public sector. Some drugs listed were not available for use in the public sector. Usage of second and third generation antihistamines especially cetirizine, loratadine and desloratadine were frequent in public and private sectors but the usage in private was much higher. This factor may be attributed to the availability and the prescription that does not require specialist countersignature.

Comparing our systemic antihistamine usage in 2006 with the Australian statistics on medicines, we found that the Australians had lower usage of antihistamines. Usage of topical nasal decongestants was comparatively lower in Malaysia then Australia. Usage of steroid based decongestant especially mometasone was high in Australia. Use of other drugs was fairly the same in both countries.

Table 23.1: Use of Anti-Histamines and Nasal Decongestants, in DDD/1000 population /day 2006 and DDD/population/year

Table 23.2.1: Use of Nasal Decongestants by Drug Class, in DDD/1000 population/day 2006

ATC Drug Class and Agents 2006 2006 (DDDs/population/year

R01 NASAL PREPARATIONS 2.6279 0.9592

R06 ANTIHISTAMINES FOR SYSTEMIC USE 12.1703 4.4422


R01A DECONGES TANTS AND OTHER NASAL PREPARATIONS FOR TOPICAL USE

1.2602 0.46

R01A A Sympathomimetics, plain 0.2781 0.1015

R01A C Antiallergic agents, excl. corticosteroids <0.0001 <0.0001

R01A D Corticosteroids 0.982 0.3584 R01B NASAL DECONGESTANTS FOR SYSTEMIC USE 1.3677 0.4992

R01B A Sympathomimetics 1.3677 0.4992

CHAPTER 23: USE OF ANTIHISTAMINESAND NASAL DECONGESANTSMalaysian Statistics on Medicines 2006

116

combinations Private 0.9432 0.3443


R01A A Sympathomimetics, plain R01A A03 Ephedrine Public 0.0007

0.0002

0.0003

Private <0.0001

Total 0.0008 0.0003

R01A A05 Oxymetazoline Public 0.0516 0.0188

Private 0.2145 0.0783

Total 0.2661 0.0971

R01A A07 Xylometazoline Public - -

Private 0.0112 0.0041

Total 0.0112 0.0041

R01A C Antiallergic agents, excl. corticosteroids R01A C01 Cromoglicic acid Public - -

Private <0.0001 <0.0001

Total <0.0001 <0.0001

R01A D Corticosteroids R01A D01 Beclometasone Public 0.0637 0.0233

Private 0.0113 0.0041

Total 0.075 0.027 4

R01A D05 Budesonide Public 0.406 0.1482

Private 0.0923 0.0337

Total 0.4983 0.1819

R01A D08 Fluticasone Public 0.0003 0.0001

Private 0.1214 0.0443

Total 0.1217 0.0444

R01A D09 Mometasone Public 0.1204 0.044

Private 0.1337 0.0488

Total 0.2542 0.0928

R01A D11 Triamcinolone Public <0.0001 <0.0001

Private 0.0328 0.012

Total 0.0329 0.012

R01B A Sympathomimetics

R01B A02 Pseudoephedrine Public - -

Private 0.0147 0.0054

Total 0.0147 0.0054

R01B A52 Pseudoephedrine, Public 0.4097 0.1496

Total 1.353 0.4938

Table 23.2.2: Use of Nasal Decongestants by Drug Class and Agents, in DDD/1000 population/day 2006


R06A ANTIHISTAMINES FOR SYSTEMIC USE 12.1704 4.4422

R06A A Aminoalkyl ethers 0.7964 0.2907

R06A B Substituted alkylamines 5.3686 1.9596

R06A D Phenothiazine derivatives 1.2842 0.4687

R06A E Piperazine derivatives 1.858 0.6782

R06A X Other antihistamines for systemic use 2.8631 1.045

Table 23.3.1: Use of Anti-Histamines by Drug Class, in DDD/1000 population/day 2006


117

Table 23.3.2: Use of Anti-Histamines by Drug Class and Agents, in DDD/1000 population/day 2006

R06A A02 Diphenhydramine Public 0.22

Private 0.0647

Total 0.2847

R06A A04 Clemastine Public -

Private 0.0032

Total 0.0032

R06A A08 Carbinoxamine Public -

Private 0.0028

Total 0.0028

R06A B01 Brompheniramine Public -

Private 0.0042

Total 0.0042

R06A B02 Dexchlorpheniramine Public 0.0177

Private 0.4949

Total 0.5126

R06A B04 Chlorphenamine Public 0.9351

Private 0.5076

Total 1.4427

R06A D02 Promethazine Public 0.31

Private 0.1571

Total 0.4671

R06A D07 Mequitazine Public -

Private 0.0017

Total 0.0017

R06A E01 Buclizine Public 0.0001

Private 0.0112

Total 0.0113

R06A E05 Meclozine Public <0.0001

Private 0.0015

Total 0.0016

ATC Drug Class and Agents 2006 2006(DDDs/population/year)

R06A A Aminoalkyl ethers

R06A B Substituted alkylamines

R06A D Phenothiazine derivatives

R06A E Piperazine derivatives

R06A E07 Cetirizine Public 0.0824

Private 0.5499

Total 0.6323

R06A E09 Levocetir izine Public 0.0002

Private 0.0328

Total 0.0329

R06A X Other antihistamines for systemic use

R06A X07 Triprolidine Public 0.033

Private 0.0063

Total 0.0393

R06A X09 Azatadine Public -

Private 0.0005

Total 0.0005

0.6028

0.1772

0.78

-

0.0086

0.0086

-

0.0078

0.0078

-

0.0114

0.0114

0.0486

1.3559

1.4045

2.5619

1.3908

3.9527

0.8492

0.4305

1.2797

-

0.0045

0.0045

0.0004

0.0306

0.031

0.0002

0.0041

0.0044

0.2259

1.5065

1.7324

0.0005

0.0897

0.0903

0.0904

0.0173

0.1077

-

0.0014

0.0014

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ATC Drug Class and Agents 2006 2006(DDDs/population/year)

R06A X12 Terfenadine Public - -

Private 0.0014 0.0005

Total 0.0014 0.0005

R06A X13 Loratadine Public 0.7417 0.2707

Private 1.436 0.5241

Total 2.1777 0.7949

R06A X17 Ketotifen Public - -

Private 0.2121 0.0774

Total 0.2121 0.0774

R06A X18 Acrivastine Public - -

Private 0.0019 0.0007

Total 0.0019 0.0007

R06A X26 Fexofenadine Public 0.008 0.0029

Private 0.1455 0.0531

Total 0.1535 0.056

R06A X27 Desloratadine Public 0.0463 0.0169

Private 0.1611 0.0588

Total 0.2074 0.0757

References:1. Vernacchio L, Kelly JP, Kaufman DW, Mitchell AA, Pseudoephedrine use among US children, 1999-2006: results from the Slone survey. Pediatrics. 2008 Dec; 122(6):1299-304.2. Ryan T, Brewer M, Small L, Over-the-counter cough and cold medication use in young children. Pediatric Nur 2008 Mar-Apr; 34(2):174-80, 184.3. Coleman C, Moore M. Decongestants and antihistamines for acute otitis media in children. Cochrane Database Syst Rev. 2008 Jul 16; (3):CD001727.

CHAPTER 24USE OF OPHTHALMOLOGICALS Malaysian Statistics on Medicines 2006

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Edited by:Bethel L1, Goh PP2, Thiageswari U3, Thayanitu S4, Gong VHM5, Fadilah O2, Choong CL2

1. Tunku Jaafar Hospital, Seremban, 2. Selayang Hospital, 3. Kuala Lumpur Hospital, 4. TAR Hospital, Klang, 5. Raja Permaisuri Bainun Hospital, Ipoh

The National Medicine Use Survey 2006 had results on common ophthalmological agents used in Malaysia. These include anti-infectives for the treatment of ocular infections, steroidals and steroidal and anti-infective combinations for inflammatory eye conditions and eyes following surgery, i ntraocular pressure (IOP) reducing agents for glaucoma, anticholinergic or sympathomimetic mydriatics, sympathomimetics for decongestion, antiallergics for allergic conjunctivitis, topical anaesthesia used as adjunct or as single anaesthesia during ocular surgery and antineovascularisation agents in the treatment of various retinal vascular conditions such as proliferative diabetic retinopathy and age related macular degeneration. The survey participants were mainly public health care providers (MOH and University), private hospitals and private general practitioners. It did not include individual private practice ophthalmologists.

Drug utilisation statistics are generally expressed as defined daily dose (DDD), the assumed average dose per day of a drug used for its main indication by adults, as the standard unit for reference. However, except for anti-glaucoma agents, no DDD have been assigned yet by the WHO for the ophthalmologicals. Thus, for the purpose of this report on Malaysian statistics on drug utilisation, the total usage in this chapter for drugs, other than anti-glaucoma agents, is expressed in gram or ml or cc, per 1000 population (pop) per day, irrespective of the strength of the preparations.

The commonest topical antibiotic used in both public and private sector for 2006 was chloramphenicol (1.12DDD/1000 population/day), followed by gentamicin (0.089), fusidic acid (0.032) and ciprofloxacin (0.019). Chloramphenicol was the commonest prescribed topical antiinfective because it is readily available, can be prescribed by all categories of medical practitioners and primary care doctors, and is affordable. Being broad spectrum, it is prescribed for the treatment of conjunctivitis, the most common eye condition presenting to primary care centres. 1,2

Among anti-inflammatory steroidal eye drops, betamethasone (0.023DDD/1000 population/day) and dexamethasone (0.022) were commonly used. Prednisolone and fluromethalone were sparingly used in the public sector as it is not freely available. Among anti-inflammatory non-steroidal eye drops, ketorolac, was more commonly used (0.0068DDD) as compared to diclofenac and indometacin.

Among steroidal and anti-infective combination, dexamethasone and anti-infective combination was the commonest used (0.133DDD/1000 population/day). Steroidal and anti-infective combinations were prescribed more than plain steroidal agents because of their wider indication including post-operative prophylaxis, ocular infection and ocular trauma.

Glaucoma is the second leading cause of blindness worldwide. Based on population-based studies in Singapore, the age and sex specific prevalence of glaucoma in Malays was 3.4%3, and Chinese was 3.2% 4. Prevalence of glaucoma increases with age. Most patients are treated medically and often lifelong. Some of them need more than one drug to control disease progression, and above all, anti-glaucoma agents are costly. The 2006 survey have results on 11 anti-glaucoma agents. Among them, timolol was the most commonly used (0.552DDD/1000 population/day), followed by latanoprost (0.284), dorzolamide (0.105), betaxolol (0.094). The other less commonly used anti glaucoma agents were: brimonidine (0.049), pilocarpine (0.045), brinzolamide (0.041), travoprost (0.014) and bimatoprost (0.013). The 4 most commonly prescribed anti–glaucoma agents derive from 3 pharmacologic classes, namely beta blocker (timolol and betaxolol), prostaglandin analogue (latanoprost) and carbonic anhydrase inhibitors (dorzolamide). Clinical practice guidelines on management of primary open angle glaucoma recommend that topical beta blockers and prostaglandin analogues are the most cost-effective IOP lowering agents5. The findings in this survey indicated that the prescribing pattern among ophthalmologists appear to be in compliance with the recommendation. Findings from the MOH Ophthalmology Service Census in 2007 showed that MOH Ophthalmology departments spent more than 50% of their drug allocation on anti-glaucoma agents. The expenditure on anti-glaucoma drugs will continue to rise due to increasing aging population.

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The commonest anti-allergic agent was cromoglicic acid and commonest local anaesthetic was proxymetacaine. Among the anti-neovascularization agents, verteporfin was the commonest used in 2006.

Table 24.1: Use of Ophthalmological by Drug Class and Agents, in total dosage/1000 population/day 2006ATC Drug Class and Agents Unit 2006 S01A A Antibiotics

S01A A01 Chloramphenicol g/ml/cc Public 0.8457

Private 0.2754

Total 1.1211

S01A A02 Chlortetr acycline g/ml/cc Public 0.0005

Private 0.0012

Total 0.0017

S01A A03 Neomycin g/ml/cc Public -

Private 0.0002

Total 0.0002

S01A A09 Tetracycline g/ml/cc Public -

Private 0.0009

Total 0.0009

S01A A10 Natamycin g/ml/cc Public 0.0005

Private 0.0002

Total 0.0007

S01A A11 Gentamicin g/ml/cc Public 0.0168

Private 0.0725

Total 0.0893

S01A A12 Tobramycin g/ml/cc Public 0.0001

Private 0.005

Total 0.0051

S01A A13 Fusidic acid g/ml/cc Public 0.0087

Private 0.023 1

Total 0.0318

S01A A17 Erythromycin g/ml/cc Public -

Private 0.001

Total 0.001

S01A A18 Polymyxin B g/ml/cc Public -

Private <0.0001

Total <0.0001

S01A A20 Antibiotics in combination with other drugs g/ml/cc Public -

Private 0.001

Total 0.001

S01A A30 Combinations of different antibiotics g/ml/cc Public 0.0012

Private 0.0211

Total 0.0222

S01A B04 Sulfacetamide g/ml/cc Public 0.003

Private -

Total 0.003

S01A D Antivirals

S01A D03 Aciclovir g/ml/cc Public 0.002

Private 0.0009

Total 0.0029

S01A D05 Interferon g/ml/cc Public -

Private <0.0001

Total <0.0001


121

ATC Drug Class and Agents Unit 2006 S01A X Other antiinfectives

S01A X11 Ofloxacin g/ml/cc Public 0.0015

Private 0.0002

Total 0.0016

S01A X12 Norfloxacin g/ml /cc Public 0.0006

Private 0.0066

Total 0.0071

S01A X13 Ciprofloxacin g/ml/cc Public 0.0104

Private 0.009

Total 0.0194

S01A X17 Lomefloxacin g/ml/cc Public -

Private 0.0019

Total 0.0019

S01A X19 Levofloxacin g/ml/cc Public <0.0001

Private 0.0005

Total 0.0005

S01A X22 Moxifloxacin g/ml/cc Public -

Private 0.0003

Total 0.0003

Table 24.2: Use of Ophthalmological by Drug Class and Agents, in total dosage/1000 population/day 2006

ATC Drug Class and Agents Unit 2006 S01B A Corticosteroids, plain

S01B A01 Dexamethasone g/ml/cc Public 0.0191

Private 0.003

Total 0.0221

S01B A04 Prednisolone g/ml/cc Public 0.0006

Private 0.0117

Total 0.0123

S01B A06 Betamethasone g/ml/cc Public 0.0223

Private 0.0011

Total 0.0234

S01B A07 Fluorometholone g/ml/cc Public 0.0023

Private 0.0071

Total 0.0094

S01B C Antiinflammatory agents, non-steroids S01B C01 Indometacin g/ml/cc Public 0.0004

Private -

Total 0.0004

S01B C03 Diclofenac g/ml/cc Public -

Private 0.0002

Total 0.0002

S01B C05 Ketorolac g/ml/cc Public 0.0025

Private 0.0043

Total 0.0068


122


ATC Drug Class and Agents Unit 2006 S01C A Corticosteroids and antiinfectives in combination S01C A01 Dexamethasone and antiinfectives g/ml/cc Public 0.0292

Private 0.1038

Total 0.133

S01C A05 Betamethasone and antiinfectives g/ml/c c Public 0.0083

Private 0.0062

Total 0.0145

S01C A07 Fluorometholone and antiinfectives g/ml/cc Public -

Private 0.0011

Total 0.0011

S01C B04 Betamethasone g/ml/cc Public -

Private 0.0006

Total 0.0006

S01C C01 Diclofenac and anti infectives g/ml/cc Public -

Private 0.0084

Total 0.0084

Table 24.4.1: Use of Ophthalmological by Drug Class and Agents, in DDD/1000 population/day 2006ATC Drug Class and Agents 2006 S01E A Sympathomimetics in glaucoma therapy S01E A05 Brimonidine Public 0.0309

Private 0.0181

Total 0.0489

S01E B Parasympathomimetics S01E B01 Pilocarpine Public 0.0374

Private 0.0075

Total 0.0449

S01E B02 Carbachol Public 0.0039

Private 0.0011

Total 0.005

S01E C Carbonic anhydrase inhibitors S01E C01 Acetazolamide Public 0.0214

Private 0.0058

Total 0.0273

S01E C03 Dorzolamide Public 0.1007

Private 0.0046

Total 0.1052

S01E C04 Brinzolamide Public 0.0356

Private 0.0055

Total 0.041

S01E D Beta blocking agents S01E D01 Timolol Public 0.4858

Private 0.0665

Total 0.5522

S01E D02 Betaxolol Public 0.0683

Private 0.0257

Total 0.094


123

ATC Drug Class and Agents 2006 S01E D03 Levobunolol Public -

Private 0.0012

Total 0.0012

S01E E Prostaglandin analogues S01E E01 Latanoprost Public 0.2684

Private 0.0153

Total 0.2837

S01E E03 Bimatoprost Public <0.0001

Private 0.0129

Total 0.0129

S01E E04 Travoprost Public 0.006

Private 0.0075

Total 0.0135

Table 24.4.2: Use of Ophthalmological by Drug Class and Agents, in total dosage/1000 population/day 2006

ATC Drug Class and Agents Unit 2006 S01E D Beta blocking agents S01E D51 Timolol, combinations g/ml/cc Public 0.0002

Private 0.0016

Total 0.0018


ATC Drug Class and Agents Unit 2006 S01F A Anticholinergics

S01F A01 Atropine g/ml/cc Public 0.0063

Private 0.001

Total 0.0073

S01F A04 Cyclopentolate g/ml/cc Public 0.0042

Private 0.0024

Total 0.0066

S01F A05 Homatropine g/ml/cc Public 0.0108

Private 0.0027

Total 0.0136

S01F A06 Tropicamide g/ml/cc Public 0.0202

Private 0.0057

Total 0.026

S01F B Sympathomimetics excl. antiglaucoma preparations S01F B0 1 Phenylephrine g/ml/cc Public 0.009

Private 0.0026

Total 0.0116


124



ATC Drug Class and Agents Unit 2006 S01G A Sympathomimetics used as decongestants S01G A01 Naphazoline g/ml/cc Public -

Private 0.0073

Total 0.0073

S01G A02 Tetryzoline g/ml/cc Public -

Private 0.0228

Total 0.0228

S01G A51 Naphazoline, combinations g/ml/cc Public -

Private 0.0072

Total 0.0072

S01G A52 Tetryzoline, combinations g/ml/cc Public 0.0082

Private 0.0165

Total 0.0247

S01G A55 Phenylephrine, combinations g/ml/cc Public 0.0004

Private 0.0018

Total 0.0021

S01G X Other antiallergics

S01G X01 Cromoglicic acid g/ml/cc Public 0.0308

Private 0.0284

Total 0.0592

S01G X05 Lodoxamide g/ml/cc Public -

Private 0.0029

Total 0.0029

S01G X06 Emedastine g/ml/cc Public -

Private 0.0026

Total 0.0026

S01G X09 Olopatadine g/ml/cc Public 0.0007

Private 0.006

Total 0.0068

ATC Drug Class and Agents Unit 2006 S01H A Local anaesthetics

S01H A02 Oxybuprocaine g/ml/cc Public 0.0003

Private 0.0002

Total 0.0006

S01H A03 Tetracaine g/ml/cc Public 0.0006

Private 0.0001

Total 0.0007

S01H A04 Proxymetacaine g/ml/cc Public 0.0167

Private 0.006

Total 0.0227


125

ATC Drug Class and Agents Unit 2006 S01L A Antineovascularisation agents

S01L A01 Verteporfin mg Public 0.0003

Private -

Total 0.0003

S01L A03 Pegaptanib g/ml/cc Public <0.0001

Private -

Total <0.0001

S01L A04 Ranibizumab g/ml/cc Public <0.0001

Private <0.0001

Total <0.0001


ATC Drug Class and Agents Unit 2006 S01X A Other ophthalmologicals

S01X A13 Alteplase g/ml/cc Public -

Private <0.0001

Total <0.0001


ATC Drug Class and Agents Unit 2006 S03A A Antiin fectives

S03A A06 Gentamicin g/ml/cc Public 0.0022

Private 0.0136

Total 0.0158

S03A A08 Chloramphenicol g/ml/cc Public -

Private 0.0005

Total 0.0005


ATC Drug Class and Agents Unit 2006 S03B A Corticosteroids

S03B A03 Betamethasone g/ml/cc Public 0.0022

Private 0.0012

Total 0.0033


Table 24.12: Use of Ophthalmological by Drug Class and Agents, in total dosage/1000 population/day 2006ATC Drug Class and Agents Unit 2006 S03C A Corticosteroids and antiinfectives in combination S03C A01 Dexamethasone and antiinfectives g/ml/cc Public <0.0001

Private 0.1409

Total 0.141

S03C A06 Betamethasone and antiinfectives g/ml/cc Public 0.0028

Private 0.0096

Total 0.0124


126

References: 1. Dart, JK. Eye disease at a community health centre. Br Med J (Clin Res Ed) 1986; 293:1477.2. Leibowitz, HM. The red eye. N Engl J Med 2000; 343:345. 3. Sunny Y Shen, Tien Y Wong, Paul J Foster, et al. The Prevalence and Types of Glaucoma in Malay People: The Singapore Malay Eye Study. IOVS 2008 (in print).4. Poster PJ, Oen FT, Machin D, et al. The prevalence of glaucoma in Chinese residents of Singapore: a cro sectional population survey of the Tanjong Pagar district. Arch Ophthalmol 2000; 118:1105-11.5. Clinical Practice Guidelines on Management of Primary Open Angle Glaucoma. MOH Publication. MOH/P PAK/159.O8 (GU) Feb 2008.

CHAPTER 25USE OF OTOLOGICALS Malaysian Statistics on Medicines 2006

127


Edited by:Saraiza AB1, Anura M2, Noormah MD3

1. Serdang Hospital, 2. University Malaya Medical Centre, 3. Medical Development Division MOH

Drug utilisation statistics are generally expressed as defined daily dose (DDD), the assumed average dose per day of a drug used for its main indication by adults, as the standard unit for reference. However, no DDD have been assigned yet by the WHO for the otologicals. Thus, for the purpose of this chapter report, the total usage for otological drugs is expressed in gram or ml or cc, per 1000 population (pop) per day, irrespective of the strength of the preparations.

Otological preparations used in Malaysia are classified into local antibiotic ear drops, local steroid ear drops and combination antibiotic and steroid ear drops. The 2006 national survey showed that the private sector used a wider variety of otological drugs compared to the public sector. The use of combination antibiotic and steroid ear drops were much higher in the private sector, 3.5 times more than the amount used in public hospitals; while antibiotic preparations alone were more commonly used in public hospitals, 2.7 times more than the private sector. Steroid alone preparations were used only in the public hospitals. The total usage of otological preparations were 0.2725g/ml per 1000 population per day.

Table 25: Use of Otologicals by Drug Class and Agents, in total dosage/1000 population/day 2006

ATC Drug Class and Agents Unit 2006 S02A A Antiinfectives S02A A01 Chloramphenicol g/ml/cc Public 0.1605

Private 0.0507

Total 0.2112

S02A A07 Neomycin g/ml /cc Public -

Private 0.0007

Total 0.0007

S02A A11 Polymyxin B g/ml/cc Public -

Private 0.0067

Total 0.0067

S02A A14 Gentamicin g/ml/cc Public -

Private 0.0014

Total 0.0014

ATC Drug Class and Agents Unit 2006 S02B A Corticosteroids S02B A07 Betamethasone g/ml/cc Public 0.0017

Private -

Total 0.0017

Table 25.2: Use of Otologicals by Drug Class and Agents, in total dosage/1000 population/day 2006


128

Table 25.3: Use of Otologicals by Drug Class and Agents, in total dosage/1000 population/day 2006

References:1. Poetker DM, Lindstrom DR, Patel NJ, Conley SF, Flanary VA, Link TR, Kerschner JE, Ofloxacin otic drops vs neomycin-polymyxin B otic drops as prophylaxis against early postoperative tympanostomy tube otorrhea: Arch Otolaryngol Head Neck Surg. 2006 Dec; 132(12):1294-8.2. Coleman C, Moore M. Decongestants and antihistamines for acute otitis media in children. Cochrane Database Syst Rev. 2008 Jul, 16; (3):CD001727.

ATC Drug Class and Agents Unit 2006 S02C A Corticosteroids and antiinfectives incombination

S02C A03 Hydrocortisone and antiinfectives g/ml/cc Public 0.0013

Private 0.0091

Total 0.0104

S02C A04 Triamcinolone and antiinfectives g/ml/cc Public 0.0083

Private 0.0055

Total 0.0138

S02C A06 Dexameth asone and antiinfectives g/ml/cc Public 0.0259

Private 0.0007

Total 0.0266

APPENDIX 1 Malaysian Statistics on Medicines 2006

PARTICIPANTS OF THE NATIONAL MEDICINES USE SURVEY

Hospitals participating in NMUS survey # Ministry of Health Hospitals 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47.

Hospital Alor Gajah Hospital Ampang Hospital Bahagia Ulu Kinta Hospital Balik Pulau Hospital Baling Hospital Banting Hospital Batu Gajah Hospital Batu Pahat Hospital Bau Hospital Beaufort Hospital Beluran Hospital Bentong Hospital Besut Hospital Betong Hospital Bintulu Hospital Bukit Mertajam Hospital Changkat Melintang Hospital Daerah Lawas Hospital Daro Hospital Duchess of Kent, Sandakan Hospital Dungun Hospital Gerik Hospital Gua Musang Hospital Hulu Terengganu Hospital Jasin Hospital Jelebu Hospital Jeli Hospital Jempol Hospital Jengka Hospital Jerantut Hospital Jitra Hospital Kajang Hospital Kampar Hospital Kanowit Hospital Kapit Hospital Kemaman Hospital Keningau Hospital Kepala Batas Hospital Kinabatangan Hospital Kluang Hospital Kota Belud Hospital Kota Marudu Hospital Kota Tinggi Hospital Kuala Kangsar Hospital Kuala Krai Hospital Kuala Kubu Bharu Hospital Kuala Lipis

48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90. 91. 92. 93. 94.

Hospital Kuala Lumpur Hospital Kuala Nerang Hospital Kuala Penyu Hospital Kudat Hospital Kulim Hospital Kunak Hospital Labuan Hospital Lahad Datu Hospital Langkawi Hospital Likas Hospital Limbang Hospital Lundu Hospital Machang Hospital Marudi Hospital Melaka Hospital Mersing Hospital Mesra Bukit Padang Hospital Miri Hospital Muadzam Shah Hospital Mukah Hospital Pakar Sultanah Fatimah, Muar Hospital Papar Hospital Parit Buntar Hospital Pasir Mas Hospital Pekan Hospital Permai Hospital Pitas Hospital Pontian Hospital Port Dickson Hospital Pulau Pinang Hospital Putrajaya Hospital Queen Elizabeth Hospital Raja Perempuan Bainun, Ipoh Hospital Raja Perempuan Zainab II, Kota Bharu Hospital Rajah Charles Brooke Memorial Hospital Ranau Hospital Raub Hospital Sarikei Hospital Seberang Jaya Hospital Segamat Hospital Selama Hospital Selayang Hospital Semporna Hospital Sentosa Hospital Serdang Hospital Seri Manjung Hospital Serian





Hospitals participating in NMUS survey # Ministry of Health Hospitals 95. 96. 97. 98. 99. 100. 101. 102. 103. 104. 105. 106. 107. 108. 109. 110. 111. 112. 113.

Hospital Setiu Hospital Sibu Hospital Sik Hospital Simunjan Hospital Sipitang Hospital Slim River Hospital Sri Aman Hospital Sultan Abdul Halim, Sungai Petani Hospital Sultan Haji Ahmad Shah, Temerloh Hospital Sultan Ismail, Johor Bahru Hospital Sultanah Aminah, Johor Bahru Hospital Sultanah Bahiyah, Alor Setar Hospital Sultanah Nur Zahirah, Kuala Terengganu Hospital Sungai Bakap Hospital Sungai Buloh Hospital Sungai Siput Hospital Taiping Hospital Tambunan Hospital Tampin

114. 115. 116. 117. 118. 119. 120. 121. 122. 123. 124. 125. 126. 127. 128. 129. 130. 131. 132.

Hospital Tanah Merah Hospital Tangkak Hospital Tanjong Karang Hospital Tapah Hospital Tawau Hospital Teluk Intan Hospital Temenggung Seri Maharaja Tun Ibrahim, Kulai Hospital Tengku Ampuan Afzan, Kuantan Hospital Tengku Ampuan Jemaah, Sabak Bernam Hospital Tengku Ampuan Rahimah, Klang Hospital Tengku Anis, Pasir Puteh Hospital Tenom Hospital Tuanku Ampuan Najihah, Kuala Pilah Hospital Tuanku Fauziah, Kangar Hospital Tuanku Ja’afar, Seremban Hospital Tumpat Hospital Umum Sarawak Hospital Yan Hospital Saratok

# University Hospitals 1. 2.

Universiti Kebangsaan Malaysia Medical Centre University Malaya Medical Centre

# Armed Forces Hospitals 1. 2.

Lumut Armed Forces Hospital Terendak Armed Forces Hospital

# Private Hospitals 1. 2. 3. 4. 5. 6. 7.

Amanjaya Specialist Centre Ampang Puteri Specialist Hospital Bukit Mertajam Specialist Hospital Columbia Asia Medical Centre, Sarawak Columbia Asia Medical Centre, Seremban Columbia Asia Nursing and Rehabilitation Centre Damai Service Hospital, Melawati Damansara Specialist Hospital Darul Ehsan Medical Centre

8. 9. 10. 11. 12. 13. 14. 15. 16. 17.

Gleneagles Intan Medical Centre Ipoh Specialist Hospital Island Hospital Johor Specialist Hospital Kajang Specialist Hospital Kampung Baru Medical Centre Kempas Medical Centre Kuantan Medical Centre Kuantan Specialist Hospital Landmark Medical Centre Sdn. Bhd.



165

Hospitals participating in NMUS survey # Ministry of Health Hospitals 18. 19. 20. 21. 22. 23 23. 24. 25. 26. 27. 28. 29. 30. 31. 32

Loh Guan Lye Specialist Centre Medical Specialist Centre (JB) Sdn. Bhd. Metro Specialist Hospital Miri City Medical Centre N.S. Chinese Maternity Hospital and Medical Centre National Heart Institute NCI Cancer Hospital Pantai Ayer Keroh Hospital Sdn. Bhd. Pantai Cheras Medical Centre Pantai Indah Hospital Pantai Klang Specialist Medical Centre Sdn. Bhd. Pantai Mutiara Hospital Pantai Putri Hospital Pantai Utara Hospital Penang Adventist Hospital Perdana Specialist Hospital

33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49.

PUSRAWI Hospital Sdn. Bhd. Puteri Klang Medical Centre Puteri Specialist Hospital Putra Medical Centre, Alor Setar Putra Specialist Hospital (Batu Pahat) Sdn. Bhd. Putra Specialist Hospital (Melaka) Sdn. Bhd. Rafflesia Medical Centre Sdn. Bhd. Sabah Medical Centre Selangor Medical Centre Sentosa Medical Centre Sdn. Bhd. KL Sri Kota Specialist Medical Centre Subang Jaya Medical Centre Sunway Medical Centre Taman Desa Medical Centre Tanjung Medical Centre Timberland Medical Centre Tung Shin Hospital

Hospitals participating in NMUS survey # State/ District/Area Health Departments 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.

Jabatan Kesihatan Negeri Johor Jabatan Kesihatan Negeri Kelantan Jabatan Kesihatan Negeri Perlis Jabatan Kesihatan Negeri Sabah Jabatan Kesihatan Negeri Sarawak Pejabat Kesihatan Daerah Alor Gajah Pejabat Kesihatan Daerah Bachok Pejabat Kesihatan Daerah Batu Pahat Pejabat Kesihatan Daerah Baling Pejabat Kesihatan Daerah Barat Daya Pejabat Kesihatan Daerah Batang Padang Pejabat Kesihatan Daerah Bandar Baharu Pejabat Kesihatan Daerah Besut Pejabat Kesihatan Daerah Cameron Highlands Pejabat Kesihatan Daerah Dungun Pejabat Kesihatan Daerah Gombak Pejabat Kesihatan Daerah Gua Musang Pejabat Kesihatan Daerah Hilir Perak Pejabat Kesihatan Daerah Hulu Langat Pejabat Kesihatan Daerah Hulu Perak Pejabat Kesihatan Daerah Hulu Selangor Pejabat Kesihatan Daerah Hulu Terengganu

23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44.

Pejabat Kesihatan Daerah Kulim Pejabat Kesihatan Daerah Langkawi Pejabat Kesihatan Daerah Larut, Matang dan Selama Pejabat Kesihatan Daerah Manjung Pejabat Kesihatan Daerah Maran Pejabat Kesihatan Daerah Marang Pejabat Kesihatan Daerah Melaka Tengah Pejabat Kesihatan Daerah Muar Pejabat Kesihatan Daerah Padang Terap Pejabat Kesihatan Daerah Pasir Mas Pejabat Kesihatan Daerah Pasir Puteh Pejabat Kesihatan Daerah Penampang Pejabat Kesihatan Daerah Pendang Pejabat Kesihatan Daerah Perak Tengah Pejabat Kesihatan Daerah Petaling Pejabat Kesihatan Daerah Pitas Pejabat Kesihatan Daerah Port Dickson Pejabat Kesihatan Daerah Putrajaya Pejabat Kesihatan Daerah Sabak Bernam Pejabat Kesihatan Daerah Segamat Pejabat Kesihatan Daerah Seremban Pejabat Kesihatan Daerah Seberang Perai Selatan



166

Hospitals participating in NMUS survey # State/ District/Area Health Departments 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70.

Pejabat Kesihatan Daerah Jasin Pejabat Kesihatan Daerah Jelebu Pejabat Kesihatan Daerah Jeli Pejabat Kesihatan Daerah Jempol Pejabat Kesihatan Daerah Johor Bahru Pejabat Kesihatan Daerah Kemaman Pejabat Kesihatan Daerah Keningau Pejabat Kesihatan Daerah Kerian Pejabat Kesihatan Daerah Kinta Pejabat Kesihatan Daerah Klang Pejabat Kesihatan Daerah Kluang Pejabat Kesihatan Daerah Kota Bharu Pejabat Kesihatan Daerah Kota Setar Pejabat Kesihatan Daerah Kuala Kangsar Pejabat Kesihatan Daerah Kuala Krai Pejabat Kesihatan Daerah Kuala Langat Pejabat Kesihatan Daerah Kuala Muda Pejabat Kesihatan Daerah Kuala Penyu Pejabat Kesihatan Daerah Kuala Pilah Pejabat Kesihatan Daerah Kuala Selangor Pejabat Kesihatan Daerah Kuala Terengganu Pejabat Kesihatan Daerah Kuantan Pejabat Kesihatan Daerah Kubang Pasu Pejabat Kesihatan Daerah Kudat Pejabat Kesihatan Daerah Seberang Perai Tengah Pejabat Kesihatan Daerah Seberang Perai Utara

71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90. 91. 92. 93. 94. 95. 96.

Pejabat Kesihatan Daerah Sepang Pejabat Kesihatan Daerah Setiu Pejabat Kesihatan Daerah Sik Pejabat Kesihatan Daerah Tampin Pejabat Kesihatan Daerah Tanah Merah Pejabat Kesihatan Daerah Timur Laut Pejabat Kesihatan Daerah Tumpat Pejabat Kesihatan Daerah Yan Pejabat Kesihatan Kawasan Beaufort Pejabat Kesihatan Kawasan Beluran Pejabat Kesihatan Kawasan Kota Kinabalu Pejabat Kesihatan Kawasan Lahad Datu Pejabat Kesihatan Kawasan Sandakan Pejabat Kesihatan Kawasan Tawau Pejabat Kesihatan Kawasan Tuaran Pejabat Pergigian Bahagian Kuching Pejabat Pergigian Bahagian Miri Pejabat Pergigian Bahagian Samarahan Pejabat Pergigian Bahagian Sibu Pejabat Pergigian Bahagian Sri Aman Pejabat Pergigian Beaufort Pejabat Pergigian Daerah Petaling Pejabat Pergigian Daerah Kemaman Pejabat Pergigian Daerah Seberang Perai Utara Pejabat Pergigian Sandakan Pejabat Pergigian Tawau

# Others 1. 2. 3.

Department of Public Health, MOH Disease Control Division, National Public Health Laboratory Vector Borne Disease Control Section, Disease Control Division, MOH

4. 5. 6. 7. 8.

Ibu Pejabat Tibi/Kusta – Kota Kinabalu National Leprosy Control Centre Pegawai Kesihatan Kanan (RKPBV) Perak Pegawai Pergigian Kanan Pahang Pegawai Pergigian Kanan Perak



167

Ministry of Health Institutions participating in NMUS survey 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

College of Allied Health Science, Kuching College of Community Nursing, Kluang College of Medical Laboratory Technology College of Nursing, Ipoh College of Nursing, Kuala Terengganu College of Nursing, Kubang Kerian Institute for Medical Research (IMR) Institute for Public Health Kolej Kejururawatan Masyarakat Kolej Kejururawatan Melaka Makmal Keselamatan dan Kualiti Makanan, Pulau Pinang

12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.

Makmal Perubatan dan Stor Kuching Makmal Ubat & Stor Kapit Makmal Ubat & Stor Limbang Makmal Ubat & Stor Miri Makmal Ubat & Stor Sarikei Makmal Ubat & Stor Sibu Makmal Ubat & Stor Sri Aman National Blood Centre Pusat Bekalan Farmasi Negeri Sabah, Kota Kinabalu Stor Pergigian Negeri Selangor Stor Pergigian Pusat Kota Kinabalu

Primary Care Clinics participating in NMUS survey # Ministry of Health Clinics 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.

Jabatan Pesakit Luar Hospital Baling Jabatan Pesakit Luar Hospital Bandar Machang Jabatan Pesakit Luar Hospital Balik Pulau Jabatan Pesakit Luar Hospital Bukit Mertajam Jabatan Pesakit Luar, Hospital Mersing

Jabatan Pesakit Luar, Poliklinik Komuniti Sipitang Klinik Kesihatan Air Hangat Klinik Kesihatan Air Itam Pulau Pinang Klinik Kesihatan Ayer Molek Klinik Kesihatan Bahau Klinik Kesihatan Bakar Arang Klinik Kesihatan Bandar Bachok Klinik Kesihatan Bandar Baharu Klinik Kesihatan Bandar 32 Bera Klinik Kesihatan Bandar Gua Musang Klinik Kesihatan Bandar Miri Klinik Kesihatan Bandar Pasir Mas Klinik Kesihatan Bandar Sungai Petani Klinik Kesihatan Benta Klinik Kesihatan Beris Kubor Besar Klinik Kesihatan Beris Panchor Klinik Kesihatan Beseri Klinik Kesihatan Bintangor Klinik Kesihatan Bintulu Klinik Kesihatan Bongawan Klinik Kesihatan Bukit Mendi Klinik Kesihatan Bukit Minyak Klinik Kesihatan Beris Panchor Klinik Kesihatan Bukit Pasir, Muar Klinik Kesihatan Bukit Tunggal

31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41.

42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60.

Klinik Kesihatan Cheng Klinik Kesihatan Cheroh Klinik Kesihatan Chini Klinik Kesihatan Dabong Klinik Kesihatan Durian Tunggal Klinik Kesihatan Dong Klinik Kesihatan Gambang Klinik Kesihatan Gual Ipoh Klinik Kesihatan Hutan Percha Klinik Kesihatan Ibu dan Anak Gombak Setia Klinik Kesihatan Ibu dan Anak (Pejabat Kesihatan Daerah Dungun) Klinik Kesihatan Ibu dan Anak Kuala Nerang Klinik Kesihatan Jalan Gereja Klinik Kesihatan Jalan Masjid Kuching Klinik Kesihatan Jalan Oya Klinik Kesihatan Jelapang Klinik Kesihatan Jelebu Klinik Kesihatan Jeli Klinik Kesihatan Juasseh Klinik Kesihatan Kapit Klinik Kesihatan Karak Klinik Kesihatan Kampung Gial Klinik Kesihatan Kepala Batas Klinik Kesihatan Kinarut Klinik Kesihatan Klebang Besar Klinik Kesihatan Kota Sentosa Klinik Kesihatan Kuah Klinik Kesihatan Kuala Penyu Klinik Kesihatan Kuala Perlis Klinik Kesihatan Kuala Sanglang



168

Primary Care Clinics participating in NMUS survey # Ministry of Health Clinics 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90. 91. 92. 93. 94 95. 96. 97. 98. 99. 100. 101. 102. 103. 104. 105. 106. 107.

Klinik Kesihatan Kulim Klinik Kesihatan Labok Klinik Kesihatan Lanang Klinik Kesihatan Lawas Klinik Kesihatan Lenga, Muar Klinik Kesihatan Lubok China Klinik Kesihatan Lubuk Buntar Klinik Kesihatan Lubuk Merbau Klinik Kesihatan Lui Muda Klinik Kesihatan Macap Baru Klinik Kesihatan Mahligai Klinik Kesihatan Merlimau Klinik Kesihatan Menglembu Klinik Kesihatan Menggatal Klinik Kesihatan Mempaga (Felda PK Fasa 1) Klinik Kesihatan Merbau Pulas Klinik Kesihatan Naka Klinik Kesihatan Padang Besar Klinik Kesihatan Padang Matsirat Klinik Kesihatan Padang Tengku Klinik Kesihatan Paka Klinik Kesihatan Parit Raja Klinik Kesihatan Parit Yaani Klinik Kesihatan Pengkalan Chepa Klinik Kesihatan Perai Klinik Kesihatan Pulai Chondong Klinik Kesihatan Putatan Klinik Kesihatan Pokok Assam Klinik Kesihatan Rantau Panjang Klinik Kesihatan Rembau Klinik Kesihatan Sarikei Klinik Kesihatan Seberang Jaya Klinik Kesihatan Selangau Klinik Kesihatan Semerah Klinik Kesihatan Serting Hilir Klinik Kesihatan Siburan Klinik Kesihatan Simpang Bekoh Klinik Kesihatan Simpang Durian Klinik Kesihatan Simpang Empat Klinik Kesihatan Sri Aman Klinik Kesihatan Sri Medan Klinik Kesihatan Sungai Acheh Klinik Kesihatan Sungai Lembing Klinik Kesihatan Sungai Rambai Klinik Kesihatan Tanah Puteh Klinik Kesihatan Tanjung Kling Klinik Kesihatan Taman Selasih

108. 109. 110. 111. 112. 113. 114. 115. 116. 117. 118. 119. 120. 121. 122. 123. 124. 125. 126. 127. 128. 129. 130. 131. 132. 133. 134. 135. 136. 137. 138. 139. 140. 141. 142. 143. 144. 145. 146. 147. 148. 149. 150. 151. 152. 153. 154.

Klinik Kesihatan Teluk Bahang Klinik Kesihatan Temerloh Klinik Kesihatan Tersang Klinik Kesihatan Triang Klinik Kesihatan Tudan Klinik Kesihatan Ulu Gali Klinik Pergigian Banting Klinik Pergigian Bentong Klinik Pergigian Bintulu Klinik Pergigian Besar Baling Klinik Pergigian Besar Jalan Gambut, Kuantan Klinik Pergigian Besar Jitra Klinik Pergigian Besar Kulim Klinik Pergigian Besar Langkawi Klinik Pergigian Besar Sungai Petani Klinik Pergigian Besar Telok Wanjah Klinik Pergigian Daerah Kerian Klinik Pergigian Hospital Kuala Kangsar Klinik Pergigian Hospital Teluk Intan Klinik Pergigian Hulu Perak Klinik Pergigian Kelana Jaya Klinik Pergigian Keningau Klinik Pergigian Komuniti Tapah Klinik Pergigian Kinta Klinik Pergigian Kubang Semang Klinik Pergigian Kudat Klinik Pergigian Labuan Klinik Pergigian Limbang Klinik Pergigian Mukah Klinik Pergigian Pakar Hospital Lahad Datu Klinik Pergigian Pakar Kuching Klinik Kesihatan Selandar Klinik Pergigian Perak Tengah Klinik Pergigian Rompin Klinik Pergigian Seremban Klinik Pergigian Seri Manjung Klinik Pergigian Taiping Klinik Pergigian Wilayah Poliklinik Komuniti Ajil Poliklinik Komuniti Alor Janggus Poliklinik Komuniti Air Tawar 2 Poliklinik Komuniti AU 2 Poliklinik Komuniti Ayer Baloi Poliklinik Komuniti Bagan Terap Poliklinik Komuniti Bandar Permaisuri Poliklinik Komuniti Bandar Tenggara Poliklinik Komuniti Batu Rakit



169

Primary Care Clinics participating in NMUS survey # Ministry of Health Clinics 155. 156. 157. 158. 159. 160. 161. 162. 163. 164. 165. 166. 167. 168. 169. 170. 171. 172. 173. 174. 175. 176. 177. 178. 179. 180. 181.

Poliklinik Komuniti Bukit Besi Poliklinik Komuniti Bukit Changgang Poliklinik Komuniti Bukit Payong Poliklinik Komuniti Bukit Waha Poliklinik Komuniti Endau Poliklinik Komuniti Jabi Poliklinik Komuniti Jalan Mengkibol Poliklinik Komuniti Jalan Merbau Poliklinik Komuniti Ijok Poliklinik Komuniti Inanam Poliklinik Komuniti Kahang Batu 22 Poliklinik Komuniti Kahang Timur Poliklinik Komuniti Kampung Lalang Poliklinik Komuniti Kampung Majidee Poliklinik Komuniti Kampung Rahmat Poliklinik Komuniti Kampung Soeharto Poliklinik Komuniti Kota Sarang Semut Poliklinik Komuniti Klang Poliklinik Komuniti Kuala Ketil Poliklinik Komuniti Kundasang Poliklinik Komuniti Kupang Poliklinik Komuniti Lok Heng Poliklinik Komuniti Malau Poliklinik Komuniti Manir Poliklinik Komuniti Membakut Poliklinik Komuniti Paloh, Kluang Poliklinik Komuniti Palong 4,5,6

182. 183. 184. 185. 186. 187. 188 189. 190. 191. 192. 193. 194. 195. 196. 197. 198. 199. 200. 201. 202. 203. 204. 205. 206. 207. 208.

Poliklinik Komuniti Pasir Akar Poliklinik Komuniti Pekan Air Panas Poliklinik Komuniti Pekan Nanas Poliklinik Komuniti Penampang Poliklinik Komuniti Pengkalan Berangan Poliklinik Komuniti Pengerang Poliklinik Komuniti Pokok Sena Poliklinik Komuniti Pontian Poliklinik Komuniti Renggam Poliklinik Komuniti Salak Poliklinik Komuniti Seberang Takir Poliklinik Komuniti Sekinchan Poliklinik Komuniti Simpang Empat Poliklinik Komuniti Sri Medang/Gong Tok Pek Poliklinik Komuniti Sungai Air Tawar Poliklinik Komuniti Sungai Buloh Poliklinik Komuniti Sungai Selisek Poliklinik Komuniti Tamparuli Poliklinik Komuniti Tampoi Poliklinik Komuniti Tawar Poliklinik Komuniti Telipok Poliklinik Komuniti Tenggaroh II (Felda) Poliklinik Komuniti Tengkawang Poliklinik Komuniti Tunjang Poliklinik Komuniti Ulu Tiram Poliklinik Komuniti Wakaf Tapai Poliklinik Penambang

Primary Care Clinics participating in NMUS survey # Private Clinics 1. 24 Jam Poliklinik Yap 13 Clinic Ho 2. Ali Klinik 14. Clinic Joseph 3. Asia Clinic 15 Chong’s Clinic 4. B. Kong’s Clinic 16 Clinic Wellness Lab, Cheras 5. Bina Kelinik 17 Dindings Poliklinik 6. Chan Clinic, Kuching 18 Ding Polyklinik Dan Surgeri 7. Chen Dispensary 19. Dispensary Martin dan Lalita 8. Chan Clinic, Miri 20. Dispensary Sharil 9. Cheah & Lim Medical Associates 21. Dora Medical Clinic Bhd. 10. Chu Hwa Dispensary 22. Dr Amir Abbas-KMA Sdn.Bhd. 11. City Medical Centre 23. Dr Jaafar Dan Rakan-Rakan 12 City Poliklinik 24. Dr John Yeo’ Clinic, Batu Niah



170

Primary Care Clinics participating in NMUS survey # Private Clinics

25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64.

Dr. Kueh’s Clinic Dr. Leela Ratos dan Rakan-Rakan Sdn. Bhd. Jln. Pudu Dr. Mohamed Mydin & Rakan-Rakan Sdn. Bhd. Jln. Ampang Dr. Mohamed Mydin & Rakan-Rakan Sdn. Bhd. Jln. Tun Razak Dr. S. Vijayakumar Dr. Yap’s Clinic Fateh, Mydin dan Rakan-Rakan

Poliklinik & Surgeri Drs. Young Newton & Partners Drs. Young Newton & Rakan-Rakan, Brickfields Drs. Young Newton & Rakan-Rakan, Damansara Drs. Young Newton & Rakan-Rakan, Jln. Ampang Elizabeth Medical Centre Sdn. Bhd. Gill Medical Centre Goay Klinik Goh Clinic Gul Medical Centre Healthcare Clinic Healthcare Medical Centre Horeb Sdn. Bhd. Jln. Ampang Horeb Sdn. Bhd. Leboh Ampang ING Insurance Berhad In-House Clinic Intan Poliklinik & Surgeri, Tmn. Arowana Island Klinik, Esplanade Island Klinik, Island Glades Jose Clinic & Surgery Kelinik & Surgeri Templer Kelinik Ganesan Sdn. Bhd. Kelinik Gopi, Jln. Market Kelinik Gopi, Tmn. Desa Permai Kelinik Liu Kelinik Ng Kelinik Poh Soon Sim Sdn. Bhd. Kelinik Ratna Kelinik S. Suren Kelinik Selvam Kelinik Thurai Kelinik Woo & Hong Khong Klinik Klinik Australia Klinik & Surgeri Bakti

65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90. 91. 92. 93. 94 95. 96. 97. 98. 99. 100. 101. 102. 103. 104. 105. 106. 107. 108. 109. 110. 111.

Klinik & Surgeri Delima Klinik & Surgeri Dorai Klinik & Surgeri Dr. Harvinder Klinik & Surgeri Gill Klinik & Surgeri Lee, Seri Kembangan Klinik & Surgeri Lee, Taman Ros Klinik & Surgeri Ong Klinik & Surgeri Sipitang Klinik & Surgeri Stanley Chong

Klinik & & Surgeri Guna Klinik & Surgeri Wisma Bersalin Bhajan Klinik Aisah Klinik Al’ Azhim, Klebang Klinik Al Farabi Jaya Gading Klinik Al-Azhim Tampin Klinik Ali Klinik Al-Insaan Klinik Alor Setar Klinik Amal Klinik Aman, Shah Alam Klinik Amardev & Surgery Klinik Aminah, Hulu Kelang Klinik Aminah, Pelabuhan Kelang Klinik Anis, Shah Alam Klinik Anita Klinik Anthony Klinik Ariffin Klinik Arun, Sentul Klinik Asean Klinik Asniza, Taman Pandan Permai Klinik Awana Kijal Klinik Baba Klinik Bala, Georgetown Klinik Bala, Paya Terubong Klinik Baling Klinik Ban Klinik Bandar Baru Klinik Bandar Raya Klinik Bandaran Sdn. Bhd. Jln. Bunga Melor Klinik Bandaran Sdn. Bhd. Section 15 Klinik Bandaran Sdn. Bhd. Section 25 Klinik Baru Jerteh Klinik Berkat Klinik Bersatu 16 Jam, Tmn. Chai Leng Klinik Bersatu Kulim Klinik Bersatu, Jln. Raja Uda Klinik Bersatu, Tmn. Ipoh Timur



171

Primary Care Clinics participating in NMUS survey # Private Clinics 112. 113. 114. 115. 116. 117. 118. 119. 120. 121. 122. 123. 124. 125. 126. 127. 128. 129. 130. 131. 132. 133. 134. 135. 136. 137. 138. 139. 140. 141. 142. 143. 144. 145. 146. 147. 148. 149. 150. 151. 152. 153. 154. 155. 156. 157.

Klinik Bersatu, Tmn. Seruling Klinik Bintulu Klinik Boon Klinik Bukit Beruang Klinik Bukit Jambul Klinik Bukit Maluri & Surgeri Klinik C.F. Chong Klinik C.S. Ooi Klinik Care Poliklinik dan Surgeri Klinik Catterall, Khoo and Raja Malek, Bangunan Ming Klinik Ceria Klinik Chai Klinik Chan, Ipoh Garden Klinik Chang Klinik Chen Klinik Cheryan Klinik Chew Klinik Chiew Klinik Chin, Jln. Sultan Idris Shah Klinik Chon Klinik Chong, Kota Bharu Klinik Chong, Seremban Klinik Choo Klinik Chua, Ayer Tawar Klinik Chua, Sitiawan Klinik Cinta Sayang, Jln. Ibrahim Klinik Dan Surgeri Dr. Gan Klinik Dan Surgeri Putra Klinik Dan Surgeri Raju Klinik Dan Surgeri Soo Klinik dan Surgeri Sri Damansara Klinik Dedap Klinik Deepa Klinik Desa, Desa Petaling Klinik Doktor Wong - Dr. Wong Hua Seh Klinik Dorai Klinik Doshi Klinik Dr. (Mrs) Law Klinik Dr. Bazlan Klinik Dr. C.H. Kong Klinik Dr. Che Ku Klinik Dr. Cheu Sdn. Bhd. Klinik Dr. Chew Klinik Dr. Chin Kon Yoon Klinik Dr. Elvin Chong & Surgery Klinik Dr. Hamid

158. 159. 160. 161. 162. 163. 164. 165. 166. 167. 168. 169. 170. 171. 172. 173. 174. 175. 176. 177. 178. 179. 180. 181. 182. 183. 184. 185. 186. 187. 188. 189. 190. 191. 192. 193. 194. 195. 196. 197. 198. 199. 200. 201. 202. 203. 204.

Klinik Dr. Husna, Tmn. Ria Klinik Dr. Kamaludin Klinik Dr. Karim Klinik Dr. Lilian Hong Klinik Dr. Mohamad Klinik Dr. Najiha Klinik Dr. Rahim Omar & Rakan-Rakan Klinik Dr. Ramzi Klinik Dr. Roslan, Baling Klinik Dr. Roziah Klinik Dr. Shashikala Sdn. Bhd. Klinik Dr. Syed Klinik Dr. Ting Klinik Dr. Tuan Yusof Klinik Dr. Umi Klinik Dr. Wong & Dr. Lau Klinik Dr. Yong Klinik Dr. Aishah Dan Dr. Fisol Klinik Dr. S. Kumar Klinik Dr. Zakaria Klinik Eastern Klinik Efendi Klinik Ehsan Klinik Eirena Klinik Elizabeth, Tmn. Makmor Klinik Elopura Sdn. Bhd. - Jln. Tmn. Mawar Klinik Elopura Sdn. Bhd. - Sedco Complex Klinik Endau Klinik Everlasting Sdn. Bhd. Klinik Faiza Woon Klinik Famili TTDI Klinik Fateh Mohd & Rakan-Rakan Klinik Fauzi Klinik Fettes Park Klinik G.S. Klinik Ganesha Vijayam Klinik George Jinivon Klinik Glugor Klinik Gopeng Klinik Grace Klinik Gunn Klinik Gurdip Klinik Hafiz Klinik Halizah Klinik Hamidah Klinik Healthcare Klinik Hee Annandan Sdn. Bhd.



172

Primary Care Clinics participating in NMUS survey # Private Clinics 205. 206 207. 208. 209. 210. 211. 212. 213. 214. 215. 216. 217. 218. 219. 220. 221. 222. 223. 224. 225. 226. 227. 228. 229. 230. 231. 232. 233. 234. 235. 234. 235. 236. 237. 238. 239. 240. 241. 242. 243. 244. 245. 246. 247. 248. 249.

Klinik Hemavathy Klinik Hikmah Klinik Hisham Klinik Hj. Ayaz Klinik Ho, Senai Klinik Hock-San Klinik Hon Klinik Hossana Klinik Hsu dan Ng Klinik H.T. Lee Klinik Husin Klinik Ian Ong Klinik Ibu Kota, Satok Klinik Idaman Klinik IHM Klinik Ikhwan & Surgeri Klinik Iman Klinik Imbi Klinik In-House Klinik Ishak Dan Surgeri Klinik J.D. Klinik Jaafar & Partners Klinik Jalan Templer Sdn. Bhd. Klinik Jauhar Klinik Jaya, Subang Jaya Klinik Jayaraman, Jln. Raja Laut Klinik Jelebu Klinik Jo Klinik Johor, Johor Jaya Klinik Joseph & Surgeri Klinik K.G. Mah Klinik K.I.P. Sdn. Bhd. Klinik K.J. Lim, Prima Setapak Klinik Kanta Klinik Kapar, Jalan Besar Kapar Klinik Karak Klinik Kaulsay Klinik Kayu Ara Klinik Keluarga Klinik Keluarga Aishah Klinik Keluarga Dan Surgeri Klinik Keluarga Dr. Hj. Mohd. Khadzali Klinik Khizan Klinik Koidupan Klinik Kok Klinik Kok Dan Surgeri Klinik Kok Dan Wendy, Klang

250. 251. 252. 253. 254. 255. 256. 257. 258. 259. 260. 261. 262. 263. 264. 265. 266. 267. 268. 269. 270. 271. 272. 273. 274. 275. 276. 277. 278. 279. 280. 281. 282. 283. 284. 285. 286. 287. 288. 289. 290. 291. 292. 293. 294. 295. 296.

Klinik Kok Dan Wendy, Subang Jaya Klinik Kok Wah Klinik Kok, Jln. 17/1A Klinik Kok, Jln. USJ 4/1 Klinik Kong Klinik Kuantan Klinik Kucai Klinik Kumpulan Muslimah Klinik Kwok Klinik Lahad Datu (Cawangan) Klinik Langkawi, Pusat Bandar Kuah Klinik Lau Klinik Lee, Petaling Jaya Klinik Leela Klinik Leong, Puchong Klinik Leong, Kuala Terengganu Klinik Leong, Tmn. Maluri Klinik Leow Klinik Liew & Surgeri Klinik Lim, Seremban Klinik Lim, Kuching Klinik Lim & Lau Klinik Lim Chin Chong Sdn Bhd Klinik Lim, Jln. Amarasegara Klinik Lin & Chandran Klinik Ling & Thoo Klinik Lo Klinik Low, Setapak Klinik Ludher, Jln. Kelang Lama Klinik M. Ghana Klinik Maamor Klinik Maharani Klinik Majid Klinik K.S. Tan Klinik K.V. Tan Klinik K.H. Ong Klinik Kalai Klinik Makbul Klinik Malaysia, Sibu Klinik Malaysia, Tampoi Klinik Maniraj Klinik Mansor Klinik Maranatha Klinik Maria, Keningau Klinik Maria, Seremban Klinik Mariam Klinik Masjid Tanah



173


Klinik Medan Jaya Klinik Medic Bestari Klinik Medical Subang HI TEC Klinik Medicare, Jln. Bangsar Klinik Medijaya, Century Garden Klinik Medik 24-7, Bandar Country Homes Klinik Medimetro Klinik Melaka Klinik Melawati Klinik Mersing Klinik Mesra Klinik Mesra, Shah Alam Klinik Metro Medics, HICOM Industrial Estate Klinik Metro, Puchong Klinik Michael Wong Klinik Ming Klinik Mitter dan Rakan-Rakan Klinik Mogan Klinik Moorthy Klinik Muhibbah Klinik Muhibbah, Alor Setar Klinik Mutiara Inanam Klinik Naga Klinik Nagiah Klinik Najihah Klinik Nanda Klinik Nathan, Bgn. Mas Klinik Neoh Klinik Ng & Ng Klinik Ng, Jln. Kangsar Klinik Noh Klinik Noorleza Klinik Nur Aqila Klinik Nuraina Poliklinik & Surgeri Klinik Nuraini Klinik Ong & Surgeri Klinik Oziar Darus Klinik Pakatan Medik, Kuala Lumpur Klinik Pakatan Medik, Banting Klinik Panicker Klinik Pantai, Batu Ferringhi Klinik Pantai, Rantau Klinik Pantai, Tmn. Kota Lukut Klinik Papar Medical Group Klinik Perdana, Kuantan Klinik Perdana - Bgn. PKINK

343. 344. 345. 346. 347. 348. 349. 350. 351. 352. 353. 355. 356. 357. 358. 359. 360. 361. 362. 363. 364. 365. 366. 367. 368. 369. 370. 371. 372. 373. 374. 375. 376. 377. 378. 379. 380. 381. 382. 383. 384. 385. 386. 387. 288. 389. 390.

Klinik Perdana - Wisma Suara Muda Klinik Perdana, Islah Klinik Perdana, Jln. Lubok Stol Klinik Perdana, Lumut Klinik Perdana, Pusing Klinik Perkasa Klinik Permata Klinik Pertama, Johor Bahru Klinik Pertama, Georgetown Klinik Pertama, Sg. Besi Klinik Perubatan & Surgeri Dr. Ahmad Klinik Perubatan Chong Klinik Perubatan Lita Alis Klinik Perubatan Ong Klinik Petaling Jaya Klinik Poorni Klinik Prihatin Klinik Primecare, Phileo Corporate Park Klinik Public Klinik Pushpa Klinik Rabiah Klinik Radha, Bentong Klinik Radha Ampang Klinik Rahim Klinik Rahimah Klinik Rahmat Klinik Raj Klinik Raj (Jasin) Sdn. Bhd. Klinik Raj dan Rakan-Rakan, Sentul Klinik Raja, Ipoh Klinik Raju Klinik Rakyat, Gopeng Klinik Rakyat, Jln. Besar Kepong Klinik Rakyat, Jln. Telok Wanjah Klinik Rakyat, Taiping Klinik Rama Klinik Ramabai & Surgeri Sdn.Bhd. Klinik Rawatan Keluarga Klinik Rawatan Utama Klinik Razak Klinik Razana Klinik Reddy PJ Klinik Reddy Pudu Klinik Reddy Setapak Klinik Rembau Klinik Ria Klinik Roberts



174


Klinik Rohana & Seripah Sdn. Bhd. Tmn. Seri Intan Klinik Roslina Klinik S.K. Leong Klinik S.K. Lo Sdn. Bhd. Klinik S.L. Ma Klinik Sabrina Klinik Sada Klinik Sanan Klinik Sandhu Senai Klinik Saujana, Melaka Tengah Klinik Saujana, Selayang Klinik Saujana, Sungai Buloh Klinik Segamat Klinik Segara, Jln. Bangsar Klinik Sekeluarga Ipoh, Fair Park Klinik Sekeluarga Ipoh, Tmn. Bukit Merah Klinik Senan Klinik Sentosa, Johor Bahru Klinik Sentosa, Kuala Berang Klinik Sentosa Sdn. Bhd. Lengkok Dumbar Klinik Sentosa, Penang Street Klinik Seremban, Bdr. Seremban Selatan Klinik Seremban, Senawang Jaya Klinik Seri Pulau, Jln. P. Ramlee Klinik Serijasa Klinik Setapak & Surgeri, Sri Rampai Klinik Setia Klinik Setiajaya Klinik Shafi, Jinjang Utara Klinik Shankar Sdn. Bhd. Klinik Shanraj Klinik Sharani Klinik Shatin Klinik Sibu Klinik Sidhu Klinik Sihat Putrajaya Klinik Sihat, Menggatal Oldtownship Klinik Simee Klinik Sinar Klinik Siti Zariah Klinik Siva & Surgeri Klinik Soo, Chemor Klinik Soon, Sibu Klinik Soon, Puchong Klinik Soong Klinik Sri Puteri

437. 438. 439. 440. 441. 442. 443. 444. 445. 446. 447. 448. 449. 450. 451. 452. 453. 454. 455. 456. 457. 458. 459. 460. 461. 462. 463. 464. 465. 466. 467. 468. 469. 470. 471. 472. 473. 474. 475. 476. 477. 478. 479. 480. 481. 482. 483.

Klinik Sri Sulong Klinik Subang Perdana Klinik Subra Sdn. Bhd. Klinik Subramaniam Klinik Suhaini Klinik Sukimi Klinik Sulaiman, Jengka Klinik Sulaiman, Jln. Tahan Klinik Sulaiman, Kompleks Teruntum Klinik Sulaiman, Maran Klinik Sungai Besar Klinik Syed Salleh & Rakan-Rakan Klinik Terengganu Klinik T.A.R. Klinik TA Klinik Taipan Klinik Tampin Klinik Tan, Melaka Klinik Tan Cheng Leng Klinik Tan, Bidor Klinik Tan, Sg. Petani Klinik Tawakal, Parit Sulong Klinik Teck Hoe Klinik Teh, Petaling Jaya Klinik Teh, Port Dickson Klinik Templer Klinik Tenaga Baru Klinik Tengku Amir Klinik Teo, Kota Kinabalu Klinik Teoh & Chan Sdn. Bhd. Klinik Ting Klinik Toh & Lim Klinik Tujuan Klinik Ummu Roihan Klinik Union 16 Jam, Tmn. Tangling Klinik Union 24 Jam Klinik Union, Hunza Complex Klinik Utama, Kepong Klinik Utama, Petaling Jaya Klinik Venka Klinik Vigneshwer Klinik Voon Klinik Wan Suhaimi Klinik Wang Klinik Wawasan 24 Jam Klinik Wawasan, Tmn. Sentosa Klinik Wee



175


Klinik West Jelutong Klinik Wira Klinik Wong, Tawau Klinik Wong, Petaling Jaya Klinik Wong Ching Seh Klinik Y.M. Lo Klinik Yeoh Klinik Yii Klinik Yusof Klinik Zahar Klinik Zain & Zakaria, Batu Caves Klinik Zainab Klinik Zainiati Klinik Zaleha Kumpulan Medic, Shah Alam Kumpulan Medic, Subang Jaya Kumpulan Perubatan SMP Sdn. Bhd. (Klinik Pertama) LKB Clinic Loh & Lim Sdn. Bhd. MAA In House Clinic Maha Klinik Medi-Klinik Shahrol Medic-Klinik Lim Mediklinik Keluarga, Tmn. Ipoh Jaya Timur Mediklinik TTDI Jaya Merican Dispensary Ooi Kwee Lim Polyclinic Ophir Clinic Perak Medical Centre Sdn. Bhd. Kampar Perdana Polyclinics, Selayang Perdana Polyclinics Wilayah Poli Klinik, Jln. P. Ramlee Poliklinik & Surgeri Batu Gajah Poliklinik & Surgeri Chew Poliklinik & Surgeri Gul Poliklinik & Surgeri Seapark Poliklinik Al-Bukhari Poliklinik Al-Haj Poliklinik Aman Poliklinik An-Nisa Poliklinik Bahagia Poliklinik Bukit Mayang Emas Poliklinik Central & Surgeri, Jln. Gombak Poliklinik Chew & Rakan-Rakan Poliklinik & Surgeri Sentosa Poliklinik Damai & Surgeri, Tmn. Desa Jaya

530. 531. 532. 533. 534. 535. 536. 537. 538. 539. 540. 541. 542. 543. 544. 545. 546. 547. 548. 549. 550. 551. 552. 553. 554. 555. 556. 557. 558. 559. 560. 561. 562. 563. 564. 565. 567. 568. 568. 569. 570. 571. 572. 573. 574. 575. 576

Poliklinik dan Surgeri Ren-Ai Poliklinik Dinamik, Beranang Poliklinik Dinamik, Kajang Poliklinik Dinamik, Semenyih Poliklinik Dr. Azhar, Jeniang Poliklinik Dr. Norliza Poliklinik Family Poliklinik Fitrah, Bgn. PKNK Poliklinik Harmoni Poliklinik Hidayah, Bagan Serai Poliklinik Hidayah, Jln. Kuala Pilah Poliklinik Ihsan Poliklinik Jaya Poliklinik Kong Poliklinik Kumpulan City - Capital Square Poliklinik Kumpulan City - Dataran Templer Poliklinik Kumpulan City - Jln. Inai Poliklinik Kumpulan City - Jln. Pahang Poliklinik Kumpulan City - Tmn. Connaught Poliklinik Kumpulan City - Tmn. OUG Poliklinik Lai Poliklinik Liew Poliklinik Lim & Leong Poliklinik Lim & Pusat Rawatan Intan Poliklinik Mat Top Poliklinik Medic, Melaka Tengah Poliklinik Meranti Poliklinik Mindaku Poliklinik Murni Poliklinik Mutiara, Shah Alam Poliklinik Mutiara, Tmn. Desa Aman Poliklinik Ng Poliklinik Ong, Bt. Gajah Poliklinik Pan-Medic, Farlim Poliklinik Penawar Poliklinik Perdana Poliklinik Pertama Poliklinik Perubatan Kubang Pasu Poliklinik Putra, Kulim Poliklinik Raj Poliklinik Rajen Poliklinik Rakyat, Masjid Tanah Poliklinik Rakyat, Bahau Poliklinik Rakyat, Jln. Tuanku Munawir Poliklinik Rakyat, Putatan Poliklinik Rakyat, Tmn. Tasik Jaya Poliklinik Rama



176

Primary Care Clinics participating in NMUS survey # Private Clinics 577. 578. 579. 580. 581. 582. 583. 584. 585. 586. 587. 588. 589. 590. 591. 592. 593. 594. 595. 596.

Poliklinik Raub & Surgeri Poliklinik Ravi Poliklinik S.M. Lee & Rakan-Rakan Poliklinik S. Naga, Tmn. Kluang Jaya Poliklinik Salehudin Poliklinik Samudera, Sitiawan Poliklinik Sandhu Poliklinik Sentosa Poliklinik Seri Mutiara Poliklinik Sg. Besi Poliklinik Simpang Pulai, Tmn. Bersatu Poliklinik Sri Permai Poliklinik Star Puchong Poliklinik Sungai Long Poliklinik Tang Poliklinik Tan, Lee & Cheong Poliklinik Teoh & Ding Poliklinik Zakariya Poliklinik Zul Dan Rakan-Rakan Sdn. Bhd. Poly Klinik dan Surgery Kampung Pandan

597. 598. 599. 600. 601. 602. 603. 604. 605. 606. 607. 608. 609. 610. 611. 612. 613. 614. 615. 616.

Polyklinik Rajoo Pusat Rawatan Desa Pandan Pusat Rawatan Islam - Mais Sham Poliklinik Sdn. Bhd. Shri Senthil Clinic Sim’s Medical Clinic, Miri Siva Clinic Somu Kelinik Sushila Clinic Tejani Medical Centre Teow & Teo Medicare Sdn. Bhd. The Key Clinic The People’s Dispensary Sdn. Bhd. Johor Bahru Tiram Medical Centre Uma Klinik Union Clinic, Bau Vaithiyanathan Clinic Victor Medical Practice Yoong Clinic Sdn. Bhd.

Pharmacies participating in NMUS survey # Private Pharmacies 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

Alpro Pharmacy Holdings Sdn. Bhd. Damansara Apo’s Pharmacy Bahau Pharmacy Sdn. Bhd. Balik Pulau Health-Care Baling Pharmacy Sdn. Bhd. C.S. Lo Pharmacy Carene Pharmacy CL SU Pharmacy Sdn. Bhd. Daya Pharma Sdn. Bhd. Delima Farmasi Sdn. Bhd. Excelcare Pharmacy Far East Pharmacy Sdn. Bhd. Farmasi Al-Nabilah Farmasi Alychem Sdn. Bhd. - Bdr. Baru Sg. Buloh Farmasi Alychem Sdn. Bhd. - Payar Jaras, Sg. Buloh Farmasi Alychem Sdn. Bhd. - Selayang, Batu Caves

17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34.

Farmasi Alychem Sdn. Bhd. - Sg. Long, Kajang Farmasi Apollo Farmasi Bakti Sdn. Bhd. Farmasi Bintang Farmasi Carrie Farmasi Chia Farmasi Gamma Farmasi Kemuning Farmasi Komuniti UKM Farmasi Lim Farmasi Nazifa Farmasi Pendang Farmasi Rantau Farmasi Ruby Farmasi S.J. Sdn. Bhd. Farmasi Teck Hong Farmasi USJ Sdn. Bhd. Farmasi Utara Sdn. Bhd.



177

Pharmacies participating in NMUS survey # Private Pharmacies 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45.

Farmasi Voon Gaya Pharmacy Supplies GP Pharmacy Health-Care Pharmacy Jitra Pharmacy Sdn. Bhd. Joy Pharmacy K.H. Hoe Pharmacal Sdn. Bhd. Karamunsing Pharmacy Sdn. Bhd. KNL Medicare Kumpulan Farmasi Vitacare Sdn. Bhd. Mico Farmasi Sdn. Bhd.

46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56.

Nori Care Pharmacy Pahang Pharmacy Sdn. Bhd. - Karak Pharmachem Labuan Sdn. Bhd. Pusat Farmasi USM (Kedai Koop) Remedy Pharmacy Rheco Pharmacy Sentosa Pharmacy Sungai Siput Pharmacy Yin Woh Tong Medical Supply Sdn. Bhd. YW Yong Farmasi Sdn. Bhd. Zuffa Pharmacy Sdn. Bhd. – Jln. Petani

Others 1. Ministry of Foreign Affairs.

MalaysiaStatisticsonMedicine - pharmacy.gov.my · iii ACKNOWLEDGEMENTS The National Medicines Use...

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