One-day out-patient prescribing patterns at a national referral hospital in Kenya

Background: Poor prescribing habits lead to ineffective and unsafe treatment for patients, exacerbating or prolonging of illness as well as causing distress and harm to them. Drug utilization studies can help identifying gaps in prescribing and feed the results back to prescribers to enhance future rational use of medicines. Objective: Evaluate outpatient prescribing practices and patterns in a leading national Hospital in Kenya. Methods: A sample of 60 prescriptions was selected by quasi-random sampling. Data was abstracted using a pre-designed data collection form, entered into and analyzed using Excel software. Results: The average number of drugs prescribed per prescription was three with a polypharmacy rate (>4 drugs) of 20%. Only two-thirds (65%) of the prescribed drugs were actually dispensed at the hospital pharmacy due to shortages, principally shortages of originators. Slightly more than half (52%) of the drugs were prescribed by generic name. Prescribing by brand names was highest among medical interns (61%). Almost all drugs prescribed (95%) were consistent with the hospital tender list. Conclusions: There is a need to increase the rate of prescribing of generics to save costs as well as reduce stock-out levels. This can be helped by instigating a comprehensive generics policy. There is also a need to strengthen and empower drugs and therapeutic committees (DTCs) to improve selection and availability of quality generics to win the confidence of prescribers. Keywords: Drug utilisation studies, generics, prescribing patterns, prescribing indicators, polypharmacy, WHO indicators, Keny

One-day out-patient prescribing patterns at a national referral hospital in Kenya

Background: Poor prescribing habits lead to ineffective and unsafe treatment for patients, exacerbating or prolonging of illness as well as causing distress and harm to them. Drug utilization studies can help identifying gaps in prescribing and feed the results back to prescribers to enhance future rational use of medicines. Objective: Evaluate outpatient prescribing practices and patterns in a leading national Hospital in Kenya. Methods: A sample of 60 prescriptions was selected by quasi-random sampling. Data was abstracted using a pre-designed data collection form, entered into and analyzed using Excel software. Results: The average number of drugs prescribed per prescription was three with a polypharmacy rate (>4 drugs) of 20%. Only two-thirds (65%) of the prescribed drugs were actually dispensed at the hospital pharmacy due to shortages, principally shortages of originators. Slightly more than half (52%) of the drugs were prescribed by generic name. Prescribing by brand names was highest among medical interns (61%). Almost all drugs prescribed (95%) were consistent with the hospital tender list. Conclusions: There is a need to increase the rate of prescribing of generics to save costs as well as reduce stock-out levels. This can be helped by instigating a comprehensive generics policy. There is also a need to strengthen and empower drugs and therapeutic committees (DTCs) to improve selection and availability of quality generics to win the confidence of prescribers

Patterns and Risk Factors for Alanine Aminotransferase Elevation among HIV Patients on Nevirapine Regimens - Supplementary Information

Background: Elevated levels of serum transaminases are often detected in HIV patients. This has often been attributed to hepatic effects of antiretroviral drugs. Objective: To determine the pattern and risk factors for alanine aminotransferase elevation in HIV patients positive on nevirapine based regimens. Methodology: We conducted a retrospective cohort study of HIV infected patients on nevirapine containing regimens who attended the Kenyatta National Hospital comprehensive care clinic between May and August 2014. We sampled participants by convenient sampling method.  Generalized linear regression was performed to establish patterns and predictors for hepatotoxicity (grade 1-4) which were the primary outcomes of interest. Predictor variables that were included in the analysis include; demographic information, baseline ALT and CD4 levels, ART regimens, co-morbidities and treatment duration. Results: Risk factors for ALT elevation differed by gender.  Predictor variables that were significantly associated with ALT elevation in both sexes included; elevated baseline ALT level [β=10.14 (95%CI 7.34- 12.96); P<0.001], [β=13.52 (95%CI 9.36 –17.68); P < 0.001] and renal disease [β=5.44 (95%CI 2.62 – 8.25); P <0.001], [β=11.52 (95%CI 3.46 – 19.60); P = 0.005] in females and males respectively. Ethnicity had a protective effect in both sexes; [β-6.61(95%CI-9.28, -3.93); P< 0.001] in males and [β-1.20 (95% CI-2.39, -0.01); P= 0.048] in females. Among the different ethnic groups, Nilotes and Cushites had lower ALT levels compared to Bantus. Other factors that were significant included; smoking (P=0.001), concurrent illnesses (P=0.045), previous adverse drug reactions (P=0.040) in females and a longer duration of anti-retroviral therapy [β 1.81(95%CI 0.89 – 2.73); P < 0.001] in males.  Poor adherence had a protective effect [β -1.62(95%CI -3.20, -0.04); P=0.045] among females, whereas initiation on AZT+3TC+NVP had a significant protective effect [β-7.80 (95%CI -13.96, -1.63); P=0.013] in males. Conclusion: Creatinine and transaminase testing should be done routinely to deal with delayed hepatotoxicity in patients with abnormal ALT baseline levels. Key words: Alanine aminotransferase, hepatotoxicity, nevirapine

Patterns and Risk Factors for Alanine Aminotransferase Elevation among HIV Patients on Nevirapine Regimens

Background: Elevated levels of serum transaminases are often detected in HIV patients. This has often been attributed to hepatic effects of antiretroviral drugs. Objective: To determine the pattern and risk factors for alanine aminotransferase elevation in HIV patients positive on nevirapine based regimens. Methodology: We conducted a retrospective cohort study of HIV infected patients on nevirapine containing regimens who attended the Kenyatta National Hospital comprehensive care clinic between May and August 2014. We sampled participants by convenient sampling method.  Generalized linear regression was performed to establish patterns and predictors for hepatotoxicity (grade 1-4) which were the primary outcomes of interest. Predictor variables that were included in the analysis include; demographic information, baseline ALT and CD4 levels, ART regimens, co-morbidities and treatment duration. Results: Risk factors for ALT elevation differed by gender.  Predictor variables that were significantly associated with ALT elevation in both sexes included; elevated baseline ALT level [β=10.14 (95%CI 7.34- 12.96); P<0.001], [β=13.52 (95%CI 9.36 –17.68); P < 0.001] and renal disease [β=5.44 (95%CI 2.62 – 8.25); P <0.001], [β=11.52 (95%CI 3.46 – 19.60); P = 0.005] in females and males respectively. Ethnicity had a protective effect in both sexes; [β-6.61(95%CI-9.28, -3.93); P< 0.001] in males and [β-1.20 (95% CI-2.39, -0.01); P= 0.048] in females. Among the different ethnic groups, Nilotes and Cushites had lower ALT levels compared to Bantus. Other factors that were significant included; smoking (P=0.001), concurrent illnesses (P=0.045), previous adverse drug reactions (P=0.040) in females and a longer duration of anti-retroviral therapy [β 1.81(95%CI 0.89 – 2.73); P < 0.001] in males.  Poor adherence had a protective effect [β -1.62(95%CI -3.20, -0.04); P=0.045] among females, whereas initiation on AZT+3TC+NVP had a significant protective effect [β-7.80 (95%CI -13.96, -1.63); P=0.013] in males. Conclusion: Creatinine and transaminase testing should be done routinely to deal with delayed hepatotoxicity in patients with abnormal ALT baseline levels. Key words: Alanine aminotransferase, hepatotoxicity, nevirapine

Incidence and Risk Factors of Renal Dysfunction in Patients on Nevirapine-Based Regimens at a Referral Hospital in Kenya

Introduction: Nevirapine-based regimens are the most commonly used ART in Kenya. There is little literature on the renal toxicity of NNRTIS in Kenyan settings. Some studies in Asia have demonstrated an association of NNRTIs and renal toxicity. Given that NNRTIs may cause renal toxicity, clinical studies on their contribution to the same are required. Objectives: To evaluate the incidence and risk factors for renal dysfunction in HIV adult patients on Nevirapine based regimens. Methodology: The design was a descriptive (right censored arm) hospital based retrospective cohort study carried out at a national referral hospital. Ethical approval was obtained. The study population was patients on Nevirapine based regimens seen between May and August, 2014. Convenient sampling was used to recruit 241 patients. Estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease (MDRD) formula. Patients with eGFR < 50ml/min/1.73m2 were considered to have renal dysfunction. Data obtained by the patient interviews and abstraction of patient files and was analyzed using STATA software. Ordered Logistic regression was used to identify covariates that determine the severity of renal dysfunction. Results: The incidence of renal dysfunction was 4.3% (95% C.I, 1.68-6.94).Five (2.1%)   patients had a low eGFR at baseline, while ten (8.3%) patients had elevated serum creatinine (above 120µg/l). None of the patients developed severe renal dysfunction. Seventy (32%) and ten (4.6%) had mild and moderate renal dysfunction respectively. The females had a higher risk of developing renal dysfunction (adjusted O.R 0.48 (95% C.I 0.24-1.04; p=0.04). Alcohol consumption was a significant predictor of renal dysfunction (adjusted O.R 1.84 (95% C.I 1.01-3.29; p=0.04).All fifteen patients with a BMI of over 18.5 had elevated eGFR of below 50ml/min/1.73m.2Patients who had been initiated on stavudine based regimens had the highest incidence of renal dysfunction. Conclusion: Routine eGFR calculations should be done at each clinical visit. Early detection of risk factors and systematic screening should be advocated for improved patient care. Key Words: Body Mass Index, Renal dysfunction, Stavudine, Nevirapin

Effect of Pesticide Exposure on Serum Cholinesterase Levels among Asthmatic Children in Naivasha Sub-County, Kenya

Background: Pesticide exposure is a risk factor for asthma exacerbations in flower farm regions in the world.  Data on levels of serum cholinesterase among asthmatic children exposed to pesticides in Kenya is scanty. Objectives: To compare and identify variables which affect the concentration of serum cholinesterases in children who are exposed and unexposed to pesticides. Methodology: The design was a comparative cross-sectional study that involved exposed and unexposed children.  The study was conducted between May and July, 2014 in Naivasha, Kenya.  Patients were interviewed and serum samples were analysed for cholinesterase levels.  Multi-linear regression was done to identify variables that affected cholinesterase activity. Results: Children who were exposed to pesticides had a lower median ChE activity of 5828 [IQR 4863, 6443] compared to the unexposed arm whose median was 7133 [IQR 6063, 8179].  Five predictor variables were found to be significantly associated with depression of serum cholinesterase levels.  The most important predictor variable for the levels of ChE in children, was not using protective clothing by the parent [adjusted β -1457.0 (95% CI - 2594, 1319.8)].  Others were not using household pesticides [adjusted β 96.3, (95% CI 22.6, 170.0)], female sex [adjusted β -695.7 (95% CI -1296.2, - 95.3)], non school attendance [adjusted β -1676.8 (95% CI -3371.6, 18.1)] and not taking a break after spraying [adjusted β 1105.5 (95% CI (315.0, 1895.2)]. Conclusion: Children who were exposed to pesticides had low cholinesterase levels. Parents should therefore be encouraged to wear protective gear as this conferred protection of children from the effects of pesticide exposure. Key words: asthma, exposure, children, pesticides, cholinesterase