ASSESSMENT AND EVALUATION OF POLYPHARMACY RELATED ISSUES IN PAKISTAN.

1. Assessment and evaluation of poly pharmacy associating factors including antibiotics
and nutritional supplements in hospital and community pharmacy.
Abstract:
This study aimed to estimate the prevalence of poly pharmacy, the use of antibiotics and
nutritional supplements and to determine the factors affecting poly pharmacy in different age
limits of patients. The study of pharmacoeconomics and evaluation of the safety and efficacy
parameters including drug/drug interactions.
 A retrospective cross sectional study of prescriptions of hospitalized and community
pharmacy patients were carried out in Lahore and Faisal Abad.
 100 prescriptions were collected (43% were female patients and 57% male patients). The
prevalence of poly pharmacy (patients who take ≥5 medications) at hospitals and community
pharmacy was 40%.
 19% patients were reported taking nutritional supplements. The % of the community
pharmacy prescriptions was 75% and hospital admitted prescriptions were 25%.
 17% drug-drug interactions were reported.
 The% of drug interactions of each pharmacological classes were (NSAIDs (34%),
(Antihypertensive (34%), antibiotics (10%), antifungal (8%), ant diabetics (8%)
Supplements 5%).The cost of therapy per prescription/day was 174.70/PKR.
 About half of elderly patients are exposed to poly pharmacy. A portion of geriatrics used
nutritional supplements. The factors that were associated with patients exposure to poly
pharmacy were different diseases including diabetes, hypertension
Heart Diseases, Joint pains and GIT infections. Pharmacoeconomic analysis shows that in
60% patients medications were according to international standard while in 40% patients
were irrational.

2. 1) NO: OF MALE AND FEMALE PATIENTS IN DIFFERENT AGE GROUPS:
Age limits No: of patients No:of female patients No: of male patients
30-34 9 4 5
35-38 16 8 8
39-42 12 5 7
43-46 18 8 10
47-50 20 9 11
51-54 6 2 4
55-58 4 1 3
59-62 5 2 3
63-66 2 1 1
67-70 8 3 5
TOTAL 100 43 57
2) AVERAGE NO: OF DRUGS PRESCRIBED= 420/100 = 4.20
% OF MALE
PATIENTS
57%
% OF FEMALE
PATIENTS
43%
% OF MALE AND FEMALE PATIENTS

3. 3) % of the antibiotic classes used in all age limits:
AGE LIMITS NAME OF
ANTIBIOTICS
ANTIBIOTIC CLASS
30-34 VIBRAMYCIN Tetracycline
CEFIXIME 3rd generation cephalosporin
LEVOFLOXCACINE 2nd generation
flouroquinolone
CLINDAMYCINE Lincomycin class
SULFAMETHOXAZOL Protein synthesis inhibitor
TRIMETHOPRIM Protein synthesis inhibitor
AZITHROMYCINE Macrolide
FLAGYL Metronidazole
35-38 CEFUROXIME 2nd
generation cephalosporin
FLAGYL Metronidazole
CIPROFLOXACINE 2nd generation
flouroquinolone
LEVOFLOXACINE 3rd generation
flouroquinolone
TOBRAMYCIN penicillin antibiotic
MOXIFLOXACINE 4th generation cephalosporin
CEFTRIAXONE 3rd generation cephalosporin
AMOXICILLINE penicillin antibiotic
CEFIXIME 3rd generation cephalosporin
FLAGYL METRONIDAZOL
39-42 CEFTRIAXONE 3rd generation cephalosporin
AMOXICILLINE penicillin antibiotic
FLAGYL METRONIDAZOL
43-46 AMOXICILLINE penicillin antibiotic
OFLOXACINE 2nd generation
flouroquinolone
CIPROFLOXACINE 2nd generation
flouroquinolone
FLAGYL METRONIDAZOL
CLARITHROMYCINE Macrolide
CEFACLOR 2nd generation cephalosporin
47-50 CEFTRIAXONE 3rd generation cephalosporin
FLAGYL METRONIDAZOL
CEFUROXIME 2nd
generation cephalosporin
FLAGYL METRONIDAZOL
51-54 CIPROFLOXACINE 2nd generation

4. % of the antibiotic classes used in all age limits:
ANTIBIOTIC
CLASSES
CEPHALOSPORINS FLUROQUINOLONES MACROLIDES PENICILLINS TETRACYCLINE FOLICACID SYNTHESIS
INHIBITOR
METRONIDAZOL
% USED 32 18 5 15 2 5 23
% OF ANTIBIOTICS USED IN AGE LIMITS
CEPHALOSPORINS (32%)
METRONIDAZOL (23%)
FLOUROQUINOLONES (18%)
PENICILLINS (15%)
FOLIC ACID SYNTHESIS INHIBITOR
(5%)
TETRACYCLINES (2%)
flouroquinolone
FLAGYL METRONIDAZOL
AMOXICILLINE penicillin antibiotic
CEFTRIAXONE 3rd generation cephalosporin
55-58 GENTAMYCIN nitro imidazoleantibiotic
CLARITHROMYCIN
FLAGYL METRONIDAZOL
59-62 CIPROFLOXACIN 3rd generation cephalosporin
METRONIDAZOL nitro imidazole antibiotic
63-66 AMOXICILLINE penicillin antibiotic
CIPROFLOXACINE Flouroquinolones
67-70 LEVOFLOXACINE Flouroquinolones
AMOXICILLINE penicillin antibiotic
MOXIFLOCACINE 4th
generation cephalosporin
CEFTRIAXONE 3rd generation cephalosporin
FLAGYL METRONIDAZOL

5. 4)Names of the supplements used in patients:
Sr no: Name of
supplement
Active ingredients
1 VITAMINK1 phytonadione
2 FEFOL FOLICACID+CALCIUM
3 alpha keto acid Histidine, L-Tyrosine, L-lysine, nitrogen & calcium.
4 Surbex-z Nicotinamide:100mg, Riboflavin(VitaminB2):15mg, Thiamine HCl
(VitaminB1):15mg, Tocopherol (VitaminE):30IU, Zinc
Oxide:22.5mg, AscorbicAcid:500mg,Cyanocobalamin:12mcg, Folic
Acid:150mcg, Pyridoxine:20mg]
5 Polybion-z Nicotinamide:50mg, Riboflavin(VitaminB2):15mg, Thiamine HCl
(VitaminB1):15mg, Ascorbic
Acid:300mg,Cyanocobalamin:10mcg,Pyridoxine:10mg
6 INDROP-D VITAMIN D
7 Iberetfolic Ferrous Sulphate:525mg,Nicotinamide:30mg, Riboflavin (Vitamin
B2):6mg, Thiamine HCl (Vitamin B1):6mg, Ascorbic
Acid:500mg, Calcium
Pantothenate:10mg,Cyanocobalamin:25mcg, Folic
Acid:0.8mg, Pyridoxine:5mg
8 Maltofer syrup Iron Hydroxide PolyMaltose Complex:50mg/5ml
9 Osteo d Alfacalcidol 0.5mg
10 Avemar Silicon dioxide, maltodextrin,fructose,sodium chloride
11 Myfol Folic acid
12 Ferfix- Folic Acid:0.35mg, Iron Hydroxide Poly Maltose Complex:100mg
13 Divasas Nicotinic Acid:20mg, Retinol (VitaminA):5000IU, Riboflavin(Vitamin
B2):1.7mg, Thiamine HCl (Vitamin B1):1.5mg, Tocopherol (Vitamin E):30mg, Ascorbic
Acid:60mg, Calciferol:400IU,Cyanocobalamin:6mcg, Iron
Salts:18mg, Iodine:150mcg,Magnesium Oxidesand
Hydroxides:100mg,Pyridoxine:2mg,
14 QALSAN-D CalciumCarbonate:1250mg,Cholecalciferol:125IU
15 Bevidox Thiamine HCl (Vitamin
B1):100mg/3ml,Cyanocobalamin:1000mcg/3ml,Pyridoxine:100mg/3ml]
16 cremafinn Paraffin:1.25ml/5ml, MagnesiumOxidesandHydroxides:3.5ml/5m
17 Sangbion Manganese:0.2mg,Cyanocobalamin:7.5mcg, Folic
Acid:1mg, Copper:0.2mg
18 CAL-C CalciumLactate,AscorbicAcid:,CalciumCarbonate:
19 Trihemic Tocopherol (Vitamin E):30IU,Ascorbic Acid:600mg,Cyanocobalamin:25mcg,
Folic Acid:1mg, Ferrous Fumarate:350mg

6. % of prescriptions with and without supplements:
5) % of drug-drug interactions in prescriptions:
% OF PRESCRIPTIONS WITH AND WITHOUT
SUPPLEMENTS
PRESCRIPTIONS WITHOUT
SUPPLEMENTS(81%)
PRESCRIPTIONS WITH
SUPPLEMENTS(19%)
17%
83%
% OF DRUG-DRUG INTERACTIONS IN
PRESCRIPTIONS
PRESCRIPTIONS WITH D-D
INTERACTIONS(17%)
PRESCRIPTIONS WITHOUT
D-D INTERACTIONS(83%)

7. 6) % OF INTERACTIONS OF DIFFERENT PHARMACOLOGICAL CLASSES:
% OF INTERACTIONS OF DIFFERENT
PHARMACOLOGICALCLASSES
NSAIDs(34%)
ANTIHYPERTENSIVE(34%)
ANTIBIOTICS(10)
ANTIFUNGALS(8%)
ANTIDIABETICS(8%)
SUPPLEMENTS(5%)
OTHERS(1%)

8. TABLE OF D-D INTERACTIONS:
Sr
no:
Drug+drug interaction mechanism Significance
level
Out put Management
1 Ciprofloxacin+calcium
supplements
GI absorptionof
QUINOLONES maybe
decreased.
2 Decreased
pharmacologic effects
of QUINOLONES
Concurrent usecannot beavoided.
2 aspirin+glimepiridine Aspirinreduces basal
glucose levels and(↑es
) insulinsecretionalso
inhibition of
prostaglandinsynthesis
mayinhibit insulin
responses to glucose.
2 ↑es hypoglycemic
effect
Monitor the patient's bloodglucose. If
hypoglycemia develops, consider
decreasing the SULFONYLUREAdose
3 ASPIRIN+DICLOFENAC SODIUM Competitive inhibition
of the acetylationsite
of cyclooxygenase in
the platelet.
1 ↓es cadioprotectivity
and ↑es gastric
irritationvia aspirin
SELECTanalgesics thatdo notinterfere
with antiplatelet effect(eg,
acetaminophen).
4 NORTRIPTYLINE+LEVOFLOXACI
N
MECHANISMIS
UNKNOWN
1 may(↑es)torsades
de pointes
Other quinolone antibiotics thatdo
not prolong the QTc interval (USED)
5 ASPIRIN+PROPRANOLOL SALICYLATES may
inhibit biosynthesisof
prostaglandins involved
in the antihypertensive
activity
2
may(↓es)activityof
propranolol
Monitor BP. Ifan interaction is
suspected, consider lowering thedose
ofthe SALICYLATE
6 FLUCONAZOL+STEROIDS Inhibition of
CORTICOSTEROID
metabolism (CYP3A4)
and decrease in
elimination.
2 may↑es toxicityof
steroids
Closely monitor patients for
CORTICOSTEROID adverseeffects.
Adjust doseas needed
7 LOSARTAN+FLUCONAZOL inhibition of
metabolism (CYP2C9) of
LOSARTAN by
FLUCONAZOLE
3 may↑es
antihypertensive
effects
Closely monitor bloodpressure
response toLOSARTAN when
FLUCONAZOLEis started, stopped, or
changed indosage
8 METHOTREXATE+MEFENAMIC
ACID
Reducedrenal
clearance is suspected.
1 may↑es MTX
toxicity
Monitor for renalimpairment that
could predispose toMTX toxicity
9 ASPIRIN+PROPRANOLOL SALICYLATES may
inhibit biosynthesisof
prostaglandins involved
in the antihypertensive
activity
2 may(↓es) activity
of propranolol
Monitor BP. Ifan interaction is
suspected, consider lowering thedose
ofthe SALICYLATE
10 piroxicam and acetaminophen
with (ALENDRONATE)
NSAIDs and
BISPHOSPHONATES
maybe synergistic with
respect to causing
gastric ulcers.
3 ↑es riskof gastric
ulceration
Use cautionwhen co-administering
these agents
11 OMEPRAZOL+CYANOCOBALMI
N
OMEPRAZOLE-induced
hypo hydria or
achlorhydria may
decrease the
absorptionof vitamin
B12.
5 MAY
(↓es)therapeutic
actionof VITAMIN
B12
Ifboth drugs aretobe given
chronically, consider administering
VITAMIN B12 parenterally.
12 ASPIRIN+OMEPRAZOL (PPI) mayincrease in
gastric pH results in a
3 may(↑es)gastric side
effects
Patients atrisk ofserious gastric
disorders dueto therelease of

9. more rapiddissolution
and release of
SALICYLATE.
SALICYLATES in the stomach should
avoid concurrent useoftheseagents.
13
Aspirin+captopril
DUE TO Inhibitionof
prostaglandinsynthesis
MAY
(↓es)hypotensive
and vasodilator
effects of the ACE
INHIBITOR
Adjust ASPIRIN dosageto less than
100 mg/day; convertto non-aspirin
antiplateletagent; or continueASPIRIN
and convert patient fromACE
INHIBITOR to angiotensin-receptor
blocker.
14 Aspirin+insulin The serum glucose-
lowering actionof
INSULIN maybe
potentiated.
2 acute INSULIN
response to a glucose
loadis enhanced
Monitor blood glucoseconcentrations
and tailor the INSULIN regimen as
needed.
15 ASPIRIN+RINGER LACTATE Urine alkalinization
leads to increasedrenal
clearance andreduced
serum levels of
SALICYLATES
3 Renal clearance of
SALICYLATES
increases
dramaticallyabove
urine pH7.
The patient receiving concurrent
URINARY ALKALINIZER and anti-
inflammatory SALICYLATEtherapy may
require higher thanexpected
SALICYLATEdoses
16 CLARITHROMYCIN+OMEPRAZOL CLARITHROMYCIN may
inhibit the metabolism
(cytochrome P450 3A4
and 2C19) of
OMEPRAZOLE,
3 MAY(↑es)
concentrations of
CLARITHROMYCIN
and OMEPRAZOLE
no specialaction is needed.Co -
administration oftheseagents maybe
beneficialin thetreatmentof
Helicobacterpylori
17 ATENOLOL+AMINOPHYLINE Pharmacologic antagonism.
BETA-BLOCKERS may reduce
demethylation of
THEOPHYLLINE.
2 MAY (↓es)
eliminationof
THEOPHYLLINE
Monitor plasma THEOPHYLLINElevels
when a BETA-BLOCKER is added or
deletedfrom a regimen
Average Costof 100 prescriptions =17468/100=174.70
COST/PRESCRIPTION/day =174.70

10. 8) % OF PRESCRIPTIONS:
% of community pharmacy prescription % of hospital admitted prescriptions
75 25
% OF TYPES OF PRESCRIPTIONS:
COMMUNITY PHARMACY
PRESCRIPTIONS(75%)
HOSPITAL ADMITTED
PRESCRIPTIONS(25%)