[e-drug] Compounding and dispensing problems in Indonesia

e-drug
1

E-DRUG: Compounding and dispensing problems in Indonesia
------------------------------------------------------------------------

Dear Members,

I am a pediatrician (gastrohepatologist) and since 2002 I have been working in community health care, promoting the rational use of medicine, in particular in pediatrics. I am concerned about overmedicalization in pediatric practice. For upper respiratory tract infections, Indonesian pediatricians frequently prescribe an antibiotic plus a mixture of pseudoephedrin/ephedrin, antihistamin, mucolytic, triamnicolone, phenobarb, and other drugs (called "puyer", after the Dutch word for "powder"). The ingredients are put in a bowl, crushed and the resulting powder is divided into equal parts in small sachets (usually 15 sachets to be used over the course of 5 days). Some pediatricians add this "puyer" to a syrup (e.g. thyme syrup and even ranitidine or amoxycillin syrups).

One example of a puyer prescription:

A 15 month old girl with fever and coryza was given:

1. SYRUP: Bufect (Ibuprophen) 60 ml
2. PUYER:
   Nalgestan (PPA 15 mg, chlorpheniramine maletae 2 mg) - 10 tab
   Luminal (phenobarbitone) 50 mg - 6 tab
   Mucohexin 8 mg - 10 tab
   Kenacort 4 mg (trianicolone) - 10 tab
   Codein 20 mg - 3 tab
   Lasal (salbutamol) 4 mg - 4 tab
   Etaphylline 250 mg - 3 tab
   Equal neo tablet refill
3. PUYER:
   Lapicef (cefadroxil) 500 mg capsul - 4 caps
   Equal
4. PUYER:
   Curvit emulsion 175 ml
5. PUYER
   Pankreoflat - 10 TAB
   Cobazym 1000 mcg - 10 tab
   Heptasan (cyproheptadine) - 10 tab
   Lysagor (Pizotifen, here used as an appetite stimulant) - 10 tab
   Equal

I am conducting 2 studies, of which the first one is finished and I am writing out the results. I found:

1. Polypharmacy (median number of drugs per prescription for URIs is 5)
2. Overuse of antibiotics
3. Overuse of steroids (branded trianicolone)
4. Symptomatic prescribing
5. Prescriptions of supplements, herbal, multivitamine, "appetite stimulants"
6. Brandname prescribing

I have been trying to change this practice since 1996, but met with strong resistance from my colleagues who believe that a "puyer" is good for Indonesians. Other stated reasons are that the "puyer" is cheap. I said that prescriptions for URI is very expensive; always more than a day wage (in Indonesia medicines are mainly paid out of pocket). Second, does a child really need so many medicines?

I have educated parents on rational use, giving the message to avoid "puyers". We tell parents to count the number of lines in the prescription .... if more than 2 lines, do not buy it: call us. However, many parents reported back that doctors became upset with them. Doctors said they are giving the best for the children by prescribing a "puyer."

In summary, despite my work to educate health consumers (mailing list, web, parenting classes, radio talk shows, publications, and studies of prescribing pattern, children continue to be given inappropriate "puyers".

I am finalising my study report, and am asked by my overseas colleagues to look for information on similar practices in other countries. I want to ask you whether this practice exists in other countries; how providers can be convinced that such practice is not recommended; and what are the potential problems from a pharmacological and pharmacotherapeutic point of view? I really need scientific bases to argue about such practice, and I hope you can help me.

Thanks,

Wati

Purnamawati Pujiarto (Wati)
Indonesia
E-mail: purnamawati.spak@cbn.net.id

2

E-DRUG: Compounding and dispensing problems in Indonesia (2)
---------------------------------------------------------------------------

Dear colleagues,

This is an old ingrained habit of prescribing and compounding; it seems
that the problems remain widespread despite awareness of rational use of
medicines. There is a kind of misconception and people often called this
habit the "art of compounding", while actually it is more appropriate to
call it "the misart of compounding". A WHO mission to the country in
1987 already reported this concern. In the past there was often a strong
belief among the teachers in pharmacy regarding this 'misart of
compounding." Looking forward to seeing the results of study by Wati.

Budiono

Budiono Santoso MD PhD
Regional Adviser in Pharmaceuticals
World Health Organization, Western Pacific Regional Office,
Po Box 2932, United Nations Avenue, Manila 1000,
Philippines
Phone : (632) 528 9846 (direct)
        (632) 528 8001 (general)
Fax : (632) 521 1036
E-mail: SANTOSOB@wpro.who.int

3

E-DRUG: Compounding and dispensing problems in Indonesia (3)
---------------------------------------------------------------------------

One way I would recommend is to conduct prescription
surveys i.e. collect random samples of prescriptions from
the hospital pharmacy, say over a period of one month.
Photocopy them and tabulate the findings such as number of
drugs per prescription, no of antibiotics, and etc. you
may then present the findings to the prescribers including
the cost to the patients for buying such medicines. It may
help for them to see the results themselves.

Secondly, you may want to start ADR reporting or I am sure
Indonesia already has one. Such prescribing parctice, as
you have mentioned, may have caused unwanted side effects
in patients or other drug related problems. If you can
link the cause and effect, it might help.

Hope this helps.

Manusika Rai
Essential Drugs Programme Bhutan
E-mail: edp@druknet.bt

4

E-DRUG: Compounding and dispensing problems in Indonesia (4)
---------------------------------------------------------------------------

Dear Wati,

Many of us that have been associated with the Indonesian healthcare system will recognise the scenario that you have described. I believe you will get similar observations from a number of countries, as this irrational practice remains, sadly, a worldwide phenomenon. Your efforts should be commended for your tirelessly trying to address the problem. May I ask what in 2008 is the position of the Department of Health over this practice? As in other countries, the weak regulatory, or weak enforcement of professional advice also contributes to these problems. As long as policy on practice is left to individuals or groups to translate into action, with no oversight, these practices will remain. I do know that there is a strong and influential physcian group in Indonesia that you're facing, and indeed these practices may not be easily changed in the absence of strong enforcement of recommendations, the legal / regulatory issues, etc.rds,

Regards,

Bonnie

Bonface Fundafunda PhD., MBA., B.Pharm
Manager, Drug Supply Budget Line
Ministry of Health,
P.O. Box 30205,
Ndeke House,
Lusaka,
Zambia
Tel: +260 211 25 59 11
Fax: +260 211 25 14 04
Mobile: + 260 979 25 29 00
Email: bcfunda@hotmail.com

5

E-DRUG: Compounding and dispensing problems in Indonesia (5)
--------------------------------------------------------------------------

Hi,

You may need to do some serious work of identifying
each item on the puyer list and find out the side
effects, contraindication and the correct dosage. You
will now compare what you have in the puyer with what
the standards are and use this information to butress
your point on irrationality of puyer and the immediate
and long time effect of this irrationality on
children.

Dr Mrs B.A. Aina
Dept of Clinical Pharmacy and Biopharmacy
Faculty of Pharmacy
University of Lagos, CMUL Campus,
Idi Araba, Lagos
NIGERIA
E-mail: bolajokoaina@yahoo.com