Community Pharmacy Dispensing Practice. by Pharmacists and Pharmacy Assistants in Manila City

Community Pharmacy Dispensing Practice of Non-steroidal Anti inflammatory drugs by Pharmacists and Pharmacy Assistants in Manila City De Los Santos, S.K.M.; Go, J.K.C.; Hung, K.S.; Medina, I.C.L.; Ong, S.J.O.; Carigma, A.Q. Faculty of Pharmacy, University of Santo Tomas Espana, Manila Philippines

BACKGROUND OF THE STUDY Dispensing Practice Pharmacists Pharmacy Assistants Over-the-Counter most popular treatment of choice for common illnesses (American College of Preventive Medicine, 2011) safe and effective when used as directed inevitable that some people use them incorrectly

BACKGROUND OF THE STUDY Non-Steroidal Anti-Inflammatory t Drugs (DOH) Over the Counter NSAIDS Aspirin Ibuprofen Ketoprofen Naproxen Mefenamic Acid OTC bi i OTC combination preparations Prescribed NSAIDS Indomethacin Diclofenac Celecoxib

BACKGROUND OF THE STUDY Risks of ADRs Gastrointestinal irritations Vomiting, nausea, dizziness Constipation, diarrhea Thrombotic risks Hepatotoxicity Nephrotoxicity Allergic reactions Cardiovascular risk, heart attack, stroke

THEORETICAL FRAMEWORK Healthcare Provision Quality Figure 1: Diagram on The Factors Affecting Decision Making on Giving Recommendation for NSAIDs Usage

OBJECTIVES OF THE STUDY To be able to determine the extent and limitations of the knowledge of pharmacists and pharmacy assistants on Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) factors and variables which influence the community pharmacists and pharmacy assistants in recommending the use of NSAIDs the attitudes that are practiced in dispensing

SIGNIFICANCE OF THE STUDY Provide data on the current practice of dispensing NSAIDs in the community pharmacy setting acquire reflective data on the factors and attitudes affecting the clinical decision-making of community pharmacists and pharmacy assistants in the over-the-counter use of NSAIDs

RESEARCH METHODS

Figure 2: Schematic Diagram of the General Flow of the Study

STUDY POPULATION One pharmacist and one pharmacy assistant per drugstore Community pharmacies in Manila City registered in FDA database

SAMPLING DESIGN AND TECHNIQUE Cluster sampling 90% confidence interval and 10% margin of error a sample size of 90 drugstores.

945 drugstores located in Manila City registered in FDA database 90 sample size 6 Districts of Manila City District 1 15 drugstores District 2 15 drugstores District 3 15 drugstores District i t 4 District i 5 District i t 6 15 drugstores 15 drugstores 15 drugstores Figure 3: A Diagram on Cluster Sampling

Figure 4: Map of the 6 Congressional Districts of Manila City

Table 1: The Six (6) Districts of Manila City and the Areas with Registered Drugstores in the Philippine Food and Drug Administration Congressional District Number Covered Area Area with Registered Drugstores in Phil. FDA Number of Drugstores 1 West Tondo West Tondo 15 2 East Tondo East Tondo 15 Binondo, Binondo, 3 Quiapo, San Nicolas, Quiapo, Sta. Cruz 15 Sta. Cruz 4 Sampaloc Sampaloc 15 5 Ermita, Intramuros, Malate, Paco, Port Area, San Andres Ermita, Malate, 15 Paco 6 San Miguel, Pandacan, Sta. Ana, Sta. Mesa Sta. Ana, Sta. Mesa 15

FORMULATION OF SURVEY TOOL Questionnaire English and Filipino Two (2) parts: Part 1: knowledge assessment Part 2: dispensing practices

CONTENT OF THE SURVEY Knowledge Dispensing Practice Factor Attitude Self - Assessment

CONDUCTING OF SURVEY interview-administered survey or guided 90 drugstores -> 15 drugstores for each congressional district on Manila City

STATISTICAL TREATMENT Mean / Average Table 2: Likert Scale Point System Question Type Always Frequently Often Seldom Never Positively formulated Negatively formulated 5 points 4 points 3 points 2 points 1 point 1 point 2 points 3 points 4 points 5 points

STATISTICAL TREATMENT Mean / Average Table 3: Score Range Category Score Range Interpretation 3.68 5.00 High 2.34 3.67 Moderate 100 1.00 233 2.33 Poor

RESULTS AND DISCUSSION

KNOWLEDGE ASSESSMENT

Pharmacists VS Pharmacy Assistants The Accepted Indications for Non - Steroidal Anti - Inflammatory Drugs (NSAIDs) Scores 6.00 ssistants Indicatio on Scores by Pharmacists an nd pharmacy a 5.00 4.00 3.00 2.00 100 1.00 0.00 3.00 2.83 5.00 450 4.50 3.00 3.00 4.17 4.00 4.83 4.17 3.50 2.83 267 2.67 267 2.67 3.17 3.00 2.83 2.83 2.50 3.00 The Possible Indications for Non - Steroidal Anti - Inflammatory Drugs (NSAIDs) Figure 5 : Scores of Pharmacist and Pharmacy Assistants on the Indication of NSAIDs

The Accepted Indications for Non - Steroidal Anti - Inflammatory Drugs (NSAIDs) Overall Scores Pharmacists and Pharmacy Assistants from July 2014 to September 2014 Treatment of Allergy Pain Relief Indication Score es 4.75 4.5 4.5 4.25 4 39 3.9 3.7 3.75 3.5 3.25 3 2.9 2.9 3 3 Constipation 27 2.7 Reduction of Fever Treatment of Inflammation Treatment of Anemia Lowering of Stomach Acidity Lowering of Blood Pressure Correction of Blood Sugar Prevention of Blood Clotting 2.75 27 2.7 2.6 2.5 2.25 2 1.75 1.5 1.25 1 0.75 05 0.5 0.25 0 The Possible Indications for Non - Steroidal Anti - Inflammatory Drugs (NSAIDs) Figure 6 : Overall Scores on the Indication of NSAIDs

9 Pharmacists VS Pharmacy Assistants Non - Steroidal Anti - Inflammatory Drugs (NSAIDs) Possible Adverse Drug Reactions (ADRs) Overall Mean Rankings 8 7.83 Adverse Drug Reaction Rank king 7 6 5 4 3 2 1 3.33 4.00 683 6.83 683 6.83 6.33 6.17 6.00 5.50 7.00 5.67 5.17 6.83 6.17 4.5 5.33 4.33 5.00 2.67 4.00 0 Possible Adverse Drug Reactions (ADRs) of NSAIDs Figure 7 : Ranking mean score of Pharmacist and Pharmacist Assistant on the Adverse Drug Reaction of NSAIDs

Non - Steroidal Anti - Inflammatory Drugs (NSAIDs) Possible Adverse Drug Reactions (ADRs) Overall Mean Rankings Pharmacists and Pharmacy Assistants from July 2014 to September 2014 7.5 7 7 6.5 64 6.4 6.3 6 6 5.8 5.5 5.3 5 4.9 4.7 4.5 4 3.9 3.5 3.5 3 2 1.5 1 0.5 0 Allergy Bleeding Constipation Diarrhea Edema Headache 2.5 Hepatotoxicity Nausea and Vomiting Peptic Ulcer Stomach ache Figure 8 : Overall Ranking Scores on the Adverse Drug Reaction of NSAIDs

DISPENSING PRACTICE : FACTORS

Pharmacists VS Pharmacy Assistants Factors Affecting Pharmacist and Pharmacy Assistant Dispensing of Non - Steroidal Anti - Inflammatory Drugs (NSAIDs) 5.00 4.50 4.00 3.50 3.00 4.50 4.50 4.50 4.50 4.33 4.17 4.17 4.17 4.33 4.17 3.50 4.00 3.00 3.83 3.67 3.67 333 3.33 3.17 2.50 2.00 1.50 1.00 0.50 0.00 Figure 9 : Mean score of Pharmacist and Pharmacist Assistant on Dispensing Factors of NSAIDs

Factors Affecting Pharmacist and Pharmacy Assistant Dispensing of Non - Steroidal Anti - Inflammatory Drugs (NSAIDs) from July 2014 to September 2014 4.75 4.5 4.32 4.3 4.23 4.15 4.18 4.25 4 3.8 3.75 3.63 3.5 3.4 3.22 3.25 3 2.75 2.5 2.25 2 1.75 1.5 1.25 1 0.75 05 0.5 0.25 0 Brand Familiarity Drug Efficacy Drug Safety Easy Administration Cost/ Price of Drug Drug Advertisements Drug Promos/ Freebies Drug Product Presentation MedRep Influence Figure 10 : Overall Scores for NSAIDs Dispensing Factor

DISPENSING PRACTICE : ATTITUDES

Pharmacists vs Pharmacy Assistants Non - Steroidal Anti - Inflammatory Drugs (NSAIDs) Dispensing Practices Dispenser provides information based on his 3.83 4.33 Patients asked how drug will be taken. 3.17 3.5 Inquires if the meds were taken before and 3.67 3.83 Dis spensing Pract tices Patients asked for intended drug use. Dispense medicines with no additionals info. Patients asked for other prevailing conditions. Patients look for information on specific No verbal information given but gives print 3 2.67 2.5 2.5 2.83 2.5 3.83 3.83 4.17 4.17 Dispenser reads package insert aloud. 2.5 2.83 Patients read package insert on their own. 25 2.5 3.17 0 1 2 3 4 5 Dispensing Frequency Figure 11 : Mean score of Pharmacist and Pharmacist Assistant Attitude in Dispensing of NSAIDs

Non - Steroidal Anti - Inflammatory Drugs (NSAIDs) Dispensing Practices of Pharmacists and Pharmacy Assistants from July 2014 to September 2014 Dispenser provides information based on his knowledge. 3.98 Patients asked how drug will be taken. 3.48 Dispe ensing Practices Inquires if the meds were taken before and experienced Aes. Patients asked for intended drug use. Dispense medicines with no additionals info. Patients asked for other prevailing conditions. Patients look for information on specific sites. No verbal information given but gives print materials. 2.76 2.45 2.62 3.75 3.67 4.11 Dispenser reads package insert aloud. 2.64 Patients read package insert on their own. 2.93 Figure 12 : Overall Scores on the Attitude in Dispensing of NSAIDs 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 Dispensing Frequency

Freque ency Scores 5 4.5 4 3.5 3 2.5 2 1.5 4.5 4.33 Pharmacist VS Pharmacy Assistants Provided Additional Non - Steroidal Anti - Inflammatory Drugs (NSAIDs) Dispensing Information 4.17 4.17 44.00 4.00 4.00 4 4 3.83 367 3.67 367 3.67 3.67 3.50 3.50 3.33 3.33 3.17 3.17 3.17 3.00 1 05 0.5 0 Additional NSAID Dispensing Information Figure 13 : Dispensing Information of NSAIDs VS Dispensing Frequency mean score of Pharmacist and Pharmacist Assistant graph

Pharmacist and Pharmacy Assistants - Provided Additional Non - Steroidal Anti -Inflammatory Drugs (NSAIDs) Dispensing Information from July 2014 - September 2014 Generic Alternative Dosage/Frequency Medication Use and Application NSAIDs Food Requirements Duration of Treatment Storage Condition Freq quency Scores 475 4.75 4.5 4.25 4 3.75 3.5 3.25 3 2.75 2.5 2.25 2 1.75 1.5 1.25 1 0.75 4.298 3.894 3.923 3.894 3.702 3.485 3.49 3.135 3.019 3.567 3.809 Adverse Effect(s) 05 0.5 0.25 0 Additional NSAID Dispensing Information Figure 14 : Dispensing Information of NSAIDs VS Overall Dispensing Frequency Scores graph

SELF- ASSESSMENT

Pharmacists VS Pharmacy Assistants Self - Assessment on General Non - Steroidal Anti - Inflammatory Drugs (NSAIDs) Knowledge NSAIDs Adverse Effects Knowledge Satisfactory 35 3.5 3.67 NSAIDs Contraindications Knowledge Satisfactory 3.33 3.83 NSAIDs Drug - Drug Interactions Knowledge Satisfactory 3.17 3.5 NSAIDSs Indications Knowledge Satisfactory t 3.5 3.83 NSAIDs General Knowledge Satisfactory 3.83 3.83 0 1 2 3 4 5 Figure 15 : Confidence mean score of Pharmacist and Pharmacist Assistant on Self Assessment Evaluation

3.9 3.8 Pharmacists & Pharmacy Assistants Self - Assessment on General Non - Steroidal Anti - Inflammatory Drugs (NSAIDs) Knowledge from July 2014 - September 2014 3.84 3.75 3.7 NSAIDs General Knowledge 3.6 3.6 Satisfactory NSAIDSs Indications Knowledge Satisfactory 3.5 3.4 3.3 3.2 3.35 3.48 NSAIDs Drug - Drug Interactions Knowledge Satisfactory NSAIDs Contraindications Knowledge Satisfactory NSAIDs Adverse Effects Knowledge Satisfactory 3.1 Figure 16 : Overall Confidence Mean Score on Self Assessment

CONCLUSION KNOWLEDGE ASSESSMENT Both pharmacist and pharmacy assistants, whether accounting for individual or overall scores, are highly knowledgeable about the indications of Non-Steroidal Anti-Inflammatory Drugs NSAID Indication Table 7: Knowledge Assessment Results Pharmacist Score Pharmacy Assistant Score Overall Score Relief of Pain 5.00 4.50 4.5 Treatment of Inflammation Reduction of Fever 4.83 4.17 3.9 4.17 4.00 3.7

Both pharmacist and pharmacy assistants, whether accounting for individual or overall scores, are highly knowledgeable of the ADRs for NSAID use Table 8: Most Common ADRs based on the score of the surveyed Pharmacist and Pharmacist Assistant Possible ADR Pharmacist Score Pharmacy Assistant Overall Score Score Allergy 3.33 4.00 3.9 Peptic Ulcer 4.33 5.00 4.7 Stomachache 2.67 4.00 3.5

DISPENSING PRACTICE : FACTORS Pharmacist and Pharmacy Assistants are influenced by: Factors: Highly influences dispensing practice 1. Brand familiarity (mean = 4.32) 2. Drug Safety (mean = 4.3) 3. Drug Efficacy (mean = 4.23) Attitudes: Most common dispensing practice done 1. What the medication is for (mean = 4.11) 2. Providing information (mean = 3.98) 3. Previous ADR with the medication (mean = 3.75) Information provided: Most common additional information provided 1. Generic alternative (mean = 4.298) 2. Information on how the medication is applied (mean = 3.923) 3. Food requirement (mean = 3.894)

SELF-ASSESSMENT The Participants i showed a high h level l of confidence in the following: o o general knowledge of NSAIDS indications of NSAIDS The Participants showed a moderate level of confidence in the knowledge on the following: o drug-drug interactions of NSAIDS o o contraindications of NSAIDS adverse drug effects of NSAIDS