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close this bookEssential Drugs - Practical Guidelines (Médecins Sans Frontières)
View the document(introductory text...)
View the documentAcknowledgeements
View the documentPreface
View the documentPart one: drugs, infusions, vaccines
View the documentOral drugs
View the documentInjectable drugs
View the documentInfusion solutions and Electrolytes
View the documentVaccines and sera
View the documentDrugs for external use and Disinfectants
View the documentPart two
View the documentOrganization and management of a pharmacy
View the documentPreservation and quality of the drugs
View the documentPrescription, cost, compliance
View the documentUse of antibiotics in precarious situations
View the documentAntiseptics and disinfectants
View the documentThe New Emergency HeaIth Kit (WHO)
View the documentBibliography
View the documentPharmaco-therapeutical index WHO essential drug list (7th list, 1992)
View the documentAlphabetical index (with indicative prices)

Prescription, cost, compliance

SOME SUGGESTIONS FOR
Reducing costs - Facilitating control - Reducing risks

Limiting the use of injectable drugs
Limiting the use of syrups and other drinkable solutions
Looking at other regimens of treatment
Considering the prescription of non-essential drugs and placebos
Using the traditional pharmacopoeia as a supplement to essential drugs

A more effective, safe and economical use of drugs can result from carefully choosing treatment protocols and the corresponding list of drugs.

Limiting the use of injectable drugs

Many patients ask to be treated by means of injection because they imagine it to be more effective. There are also prescribers who attach greater value and effectiveness to injections and transfusions.

Treatment by injection is always more costly than oral treatment. The price of the drug is higher for an equal dose of effective, active substance. More over, treatment by injection requires the strict sterilization of injection material or even the use of expensive disposable material. It may also expose the patient to complications due to poorly tolerated products (e.g. abscess, gangrene as a result of quinine injections, transfused antibiotics). Complications may arise when the injection technique is performed badly (overdose symptoms following an IV injection administered too quickly, paralysis of the sciatic nerve). If sterilization does not meet optimum standards, there may also be a risk of bacterial or viral contamination (tetanus, hepatitis, AIDS...).

If the drug required also exists in the form of tablets or capsules, injections should not be administered except in emergency cases when the patient's digestive system would not tolerate any other treatment or when he or she is incapable of taking the drug orally.

In such a case, treatment by means of oral drugs should replace treatment by injection as soon as possible (antimalarials, antibiotics, diuretics...).

Limiting the use of syrups and other drinkable solutions

It is often easier to take drugs in liquid form, especially for children who like the nice-smelling sweetened solutions. There are however numerous reasons to avoid the use of such syrups:

- Risk of incorrect usage

Away from controlled hospital conditions, people with little medical understanding may often take a dangerous dose of the drug. Spoons are never of a standard size (there are spoons used for soup, coffee, tea...). Solutions have to be prepared in advance, using an exact measure of clean boiled water and should be shaken before use. There is therefore a high chance of an under- or overdose.

Solutions can only be stored for a few days and carry the risk of contamination or fermentation.
In many countries, syrups are thought of as cough mixtures. This may account for much confusion between such cough mixtures and antibiotic syrups or solutions.

- Economic considerations

Compared with the price of tablets or capsules, the price of syrups and drinkable solutions is substantially higher. Even if used in the form of a powder for subsequent preparation, costs may be between 2 and 7 times higher than for an equivalent active dose. This is because of the drug bottle itself and the higher transportation costs caused by weight and volume.

Looking at other regimens of treatment

The initial choice of a particular treatment will often determine compliance and its medium-term cost. It is preferable to choose those treatments that are as short as possible and require fewest doses (once or twice a day). Obviously, treatment with a single dose daily is the ideal. In this respect, the following cases are good examples:

- An "instant" treatment using a single dose is often preferable, even if such a treatment is sometimes less effective from a pharmacological point of view. For instance, the treatment of amoebiasis with a single dose of 8 tablets of 250 mg metronidazole may be preferred to a dassic 7-day treatment.
- The combination of pyrimethamine-sulfadoxine for treating malaria should not be given as a first choice treatment in those zones where chloroquine is effective. But a single dose which may be taken immediately may be preferable for those patients who may not be very disciplined.
- A short-course anti-tuberculosis chemotherapy including rifampicin may seem a costly treatment. Those costs might be even higher if poorly monitored treatment is interrupted, followed by relapse or reinfection.

Considering the prescription of non-essential drugs and placebos

Psychosomatic illnesses occur frequently in developing countries, just as they do in industrialised ones. It is not always possible to prescribe a specific therapy in order to overcome these complaints. Is it really possible and desirable to send those patients home without giving them a symptomatic drug or a placebo ? And what kind of placebo should be used ?

When local medication rules are quite strict and do not allow the use of any placebo or non-essential symptomatic medication, we often see an abuse of other products (chloroquine, acetyl salicylic acid, diazepam and even antibiotics).

On the other hand, you may sometimes run the risk of using a placebo when genuinely effective and necessary medication should be prescribed. This happens, but not very frequently. Therefore, the introduction of a placebo on the drug list may be justified. Multivitamins may, for example, act as a harmless and relatively cheap placebo. Their composition is generally that necessary to prevent vitamin deficiencies and they have no contra-indications.

Many specialized pharmaceutical products (tonics, liver treatments presented as drinkable ampoules) have no real therapeutic justification and, as they cost more, they should not be used as placebos.

Using the traditional pharmacopoeia as a supplement to essential drugs

Effective traditional medication, usually intended for the treatment of symptoms, still exists nearly everywhere in the world. Prepared from local plants and used for generations, these remedies often have all the advantages and half the cost of industrially-prepared drugs for the same indications.

This may be the case for laxatives, cough mixtures, anti-diarrhoea, cholagogue and dermatological preparations. They may be administered in the form of infusions, decoctions or various other mixtures and they can be prepared at health care facilities.

Medical personnel should of course be aware of the existence of these treatments and suggest their use to patients as a complement to the therapeutic treatment that has already been chosen.
Nevertheless, the patient must understand the limits of traditional remedies when it comes to serious illnesses such as tuberculosis,meningitis... In these cases, there is no effective treatment other than "modern" drugs.