E-drug: Underdosing for tuberculosis in Uganda, how is it in your
country?
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Dear E-drug Users,
Are the packs of medicines for tuberculosis in your countries delivering
the correct doses for your patients with the disease? There is a problem
with treatment of tuberculosis in my country.
The dose of rifampicin in the fixed dose preparation for treating the
disease is inadequate. Rifampicin is one of the key medicines for
treating the disease. Also the amounts of isoniazid, pyrazinamide in
the fixed dose combinations are inadequate to treat tuberculous
meningitis. Tuberculous meningitis is common in Uganda.
The fixed dose product branded as Infez, Combipack contains rifampicin;
isoniazid; pyrazinamide; and ethambutol. A company, Plethico
Pharmaceuticals Ltd, A.B. Road, Manglia-453771, Ndore (MP), based in
India, manufactures it. The Ministry of Health sanctioned use of the
product in my country.
A day's dose of combipack, Infez, contains two red tablets, and one
white tablet. Each of the two red tablets contains rifampicin 225mg;
isoniazid 150mg; pyrazinamide 750mg. The white tablet contains 800mg of
ethambutol. This makes the dose of isoniazid 300mg; ethambutol 800mg;
and pyrazinamide 1.5g daily for pulmonary tuberculosis. But from the
two red tablets, the dose of rifampicin of 450mg daily isn't enough.
The recommended dose of rifampicin is such that an adult is supposed to
receive 600mg daily-according to the British National Formulary. Most
adults with tuberculosis are of weight, and need this dose. So with the
combipack, Infez, adults are receiving 150mg less per day for 9months.
This is not only a serious under dose in it self, but also patients are
told to take the combination with food.
Food reduces the absorption of rifampicin by 30%, so when patient take
their therapy with food, they actually receive only 70% of 450mg of
rifampicin. In any case at a rate of 150mg less than the correct dose
per day makes a total of 40,500mg(40.5g) less than what is needed
throughout the course of treatment. This is phenomenal.
In another related diagnosis such as tuberculous meningitis, the
recommended doses of isoniazid, pyrazinamide are higher than what can be
obtained from the fixed dose packs. At the same time there are no plain
tablets of isoniazid, pyrazinamide in the country to effect topping up
of doses whenever needed so that we end up using under doses in
tuberculous meningitis as well. We have had thinking that presence of
plain substances on the market results in misuse, and that the germs of
tuberculosis will develop resistance to available medicines because of
this. This sounds plausible.
However, denying people the right doses has caused (and will aid) faster
development of resistance than rightly having plain forms on the market.
True, whoever coined to have fixed dose combinations produced a tool to
compliance. But a bid to comply should never result in giving less than
adequate. The best way therefore is to have both fixed dose combinations
and loose forms in order to effect correct dosing, and then educate both
health professionals and the general public on correct dosing.
For the current fixed dose pack in my country, isn't it possible to add
a tablet of pyridoxine, as well as another of 150mg of rifampicin so as
to give the correct doses for pulmonary tuberculosis? Are the packs in
your countries delivering the correct doses for your patients with
tuberculosis? And when you hear of rapid development of multi-drug
resistant tuberculosis, why do we get surprised after we have
institutionalized under doses of key medicines?
George Kibumba, MPS.,
Teaching Assistant, Clinical Pharmacy,
Dept of Pharmacy, Makerere University,
P.O BOX 7072, Kampala, Uganda.
Private: P.O BOX 33543, Kampala, Uganda.
E-mail: kibumba@yahoo.com
Mobile: 256-78-430 080
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