Overview, Challenges and Future Prospects of Drug Information Services in Nepal: A Reflective Commentary

Advancing opioid stewardship in low-middle-income countries: challenges and opportunities

The increased utilization of opioids in low- and middle-income countries (LMICs) presents a growing threat of opioid-related abuse, misuse and diversion. Pharmacists, as integral members of healthcare teams, are responsible for dispensing and monitoring opioid use and hold a pivotal role in opioid stewardship within LMICs. This commentary describes the potential and multifaceted roles of pharmacists in opioid stewardship in resource-constrained settings and highlights appropriate strategies for promoting responsible opioid utilization. Opioid stewardship involves prioritising evidence-based prescribing, management and practices for pain management. It includes measures such as incorporating prescription drug monitoring programmes for appropriate opioid prescription, implementing safe disposal through drug take-back programmes, promoting non-opioid pain management, addressing the opioid addiction stigma, tapering opioid dose, educating patients and caregivers, establishing drug information centers, providing rehabilitative services and integrating collaboration with communities and experts. The combined difficulties of restricted access to healthcare resources and services coupled with low levels of literacy worsen the susceptibility to opioid abuse, misuse, and diversion in LMICs. Early detection, assessment and implementation of interventions to optimise opioid use are imperative for ensuring safe and effective opioid utilization, thereby mitigating the risks of overdose and addiction. The involvement of pharmacists in promoting safe and effective opioid utilization through education, monitoring, collaboration, and policy advocacy serves as a critical component in bridging existing gaps in opioid stewardship within LMICs.

Pattern of Adverse Drug Reactions Associated with the Use of Anticancer Drugs in an Oncology-Based Hospital of Nepal

INTRODUCTION

Adverse drug reactions (ADRs) are among the leading causes of morbidity and mortality worldwide. ADRs of anticancer drugs are ubiquitous. However, in Nepal, studies on chemotherapy-induced ADRs are scarce. Thus, this study aimed to assess the ADRs associated with the use of anticancer drugs and their management along with causality assessment and severity of ADRs.

METHODS

A prospective cross-sectional observational and single-center study was conducted at Bhaktapur Cancer Hospital, Nepal, for 6 months. All the patients who fulfilled the study criteria were analyzed to identify ADRs occurring daily. In addition, all collected data were recorded and analyzed using descriptive statistics.

RESULTS

A total of 861 ADRs were detected among 102 cancer patients. The mean ± S.D. age of the patients was 49.93 ± 14.27 years, and each enrolled patient experienced one or more ADRs with a mean ± S.D. of 8.44 ± 3.27. The common ADRs observed were fatigue, anorexia, alopecia, constipation, nausea, vomiting, and neuropathy. Cyclophosphamide, either alone or in combination with other chemotherapeutic agents, was responsible for most ADRs. According to Naranjo's causality assessment algorithm, most of the ADRs belonged to the probable (47.1%) category. Majority (54.9%) of the ADRs were moderate in their severity. Proton pump inhibitors, antiemetic, mouth gargle, protein powders, iron tablets, and multivitamin and mineral tablets were commonly used for ADR management.

CONCLUSIONS

The occurrence of chemotherapy-related ADRs in each enrolled patient is a crucial concern. The present study highlights the need for active monitoring of the patients to identify and manage ADRs promptly.

A nationwide exploratory survey assessing perception, practice, and barriers toward pharmaceutical care provision among hospital pharmacists in Nepal

Pharmaceutical care (PC) services reduce medication errors, improve the use of medicines, and optimize the cost of treatment. It can detect medication-related problems and improve patient medication adherence. However, PC services are not commonly provided in hospital pharmacies in Nepal. Therefore, the present study was done to determine the situation of PC in hospital pharmacies and explore the perception, practice, and barriers (and their determinants) encountered by hospital pharmacists while providing PC. A descriptive online cross-sectional study was conducted from 25th March to 25th October 2021 among pharmacists with a bachelor’s degree and above working in hospital pharmacies using non-probability quota sampling. The questionnaire in English addressed perception and practice regarding PC, and barriers encountered and were validated by experts and pre-tested among 23 pharmacists. Descriptive statistics were used to describe the data. Kendall’s correlation was used to explore the correlations among various perception and practice constructs. The scores were also compared among subgroups of respondents using the Mann–Whitney test for subgroups with two categories and Kruskal–Wallis test for greater than two categories. A total of 144 pharmacists participated in the study. Majority of the participants were male, between 22 and 31 years of age, and had work experience between 10 and 20 years. Over 50% had received no training in PC. The perception scores were higher among those with more work experience and the practice scores among those who had received PC training. Participants agreed that there were significant barriers to providing PC, including lack of support from other professionals, lack of demand from patients, absence of guidelines, inadequate training, lack of skills in communication, lack of compensation, problems with access to the patient medical record, lack of remuneration, and problems with accessing objective medicine information sources. A correlation was noted between certain perceptions and practice-related constructs. Hospital pharmacists who participated had a positive perception and practice providing PC. However, PC was not commonly practised in hospital pharmacies. Significant barriers were identified in providing PC. Further studies, especially in the eastern and western provinces, are required. Similar studies may be considered in community pharmacies.

Usefulness of a Drug Information Resources Website (SAGASU-DI) Created Based on Inquiries to Clinical Pharmacists

The use of drug information is increasing as the role of pharmacists expands. However, pharmacists spend a huge amount of time collecting drug information, and there has not been any drug information resource website that aims to improve the efficiency of community pharmacists with regard to drug information operations. The purpose of this study was to evaluate the usefulness of a drug information resources website (SAGASU-DI). SAGASU-DI articles were created based on inquiries to clinical pharmacists. The usage statistics of the SAGASU-DI were monitored using Google Analytics between May and July 2021. In addition, a pop-up questionnaire was used to evaluate the usefulness of the SAGASU-DI in answering the questions of viewers. Statistics showed that our website had 25,447 users and 33,000 page views, with a browsing time of 29 s on average. Visitors accessed the website through desktop (51.9%) and mobile (44.3%) systems. Community pharmacists accounted for 40.2% of the visitors. The pop-up questionnaire showed that 23.2% of the viewers were satisfied with our website, and 1.5% of the viewers were not. Although 65.1% of the viewers refused to answer the questionnaire, the average percentage of the viewers who were satisfied with the site was 94.1%. The SAGASU-DI was found to be a valuable resource website for drug information services, mainly for community pharmacists.

Pharmacist Involvement in Cancer Pain Management: A Systematic Review and Meta-Analysis

This review aimed to critically evaluate the impact of pharmacist involvement in managing pain in cancer patients. Databases (including MEDLINE, Embase and CENTRAL) were searched with a broad search strategy for studies involving pharmacists and cancer pain management until February 10, 2021. The quality of studies and evidence were assessed using standardized tools and GRADE, respectively. A random-effects model was used for meta-analysis. Sixty-four studies were included. Common interventions delivered by the pharmacists were medication review, patient education, adverse drug reactions (ADRs) detection and management, pharmacological recommendations (in dosing and pharmacotherapy choice), and pain assessment. A pooled analysis of 3 randomized control trials showed a significant reduction in pain intensity with a standardized mean difference (SMD) of 0.35 [95% confidence intervals (CI): -0.55, -0.16]. Pooled analyses from nonrandomized studies of interventions also showed significant results in reduction of ADRs with an odds ratio of 0.69 (95% CI: 0.61, 0.79) and improvement in quality of life with SMD of 0.80 (95% CI: 0.29, 1.32). Thus, pharmacists significantly improve the clinical outcomes of cancer patients related to pain. This indicates the involvement of pharmacists directly or in collaboration with healthcare professionals in the oncology team is highly beneficial for the patients. PERSPECTIVES: This systematic review presents a comprehensive evaluation of pharmacist involvement in cancer pain management. This shows the importance of direct involvement of the pharmacist or as an important member of the multidisciplinary oncology team.

Barriers of healthcare professionals in utilizing the service of drugs and poison information Centre: A cross-sectional study

Background

Health care professionals (HCPs) have been using drugs and poison information centre (DIC) less frequently in recent years. The purpose of this study was to identify the barriers that inhibit HCPs from using the DIC service in a tertiary care hospital, as well as the factors that assist HCPs in using DIC more effectively.

Methods

A cross-sectional study was conducted among HCPs in Sri Ramachandra Institute of Higher Education and Research, Chennai. HCPs were given a semi-structured questionnaire that was developed and validated by a subject expert, a public health expert, and a clinical psychologist, and their barriers and facilitators in accessing drug information services were recorded.

Findings

A total of 405 HCPs responded to the survey. Among the identified barriers, the top 3 were: HCPs found it easier to use mobile internet (31%) and the department's reference library (25%) instead of contacting DIC for any drug/poison information. In addition, 17% of HCPs stated that they were too busy. The factors that may assist HCPs utilize DIC more effectively were more awareness is required to demonstrate the functionalities of DIC (24%), and a mobile application is required (23%).

Conclusion

Today's HCPs have easy access to a variety of drug information resources, and many prefer to do their own drug/poison research. As current generation HCPs find it more convenient to use mobile internet than contacting DIC, the creation of a mobile application for drug information service may enhance the number of questions from HCPs.

Impact of pharmacist services on economic, clinical, and humanistic outcome (ECHO) of South Asian patients: a systematic review

Background

Pharmacists in high-income countries routinely provide efficient pharmacy or pharmaceutical care services that are known to improve clinical, economic, and humanistic outcomes (ECHO) of patients. However, pharmacy services in low- and middle-income countries, mainly South Asia, are still evolving and limited to providing traditional pharmacy services such as dispensing prescription medicines. This systematic review aims to assess and evaluate the impact of pharmacists’ services on the ECHO of patients in South Asian countries.

Methods

We searched PubMed/Medline, Scopus, EMBASE, CINAHL, and Cochrane Library for relevant articles published from inception to 20th September 2021. Original studies (only randomised controlled trials) conducted in South Asian countries (published only in the English language) and investigating the economic, clinical (therapeutic and medication safety), and humanistic impact (health-related quality of life) of pharmacists’ services, from both hospital and community settings, were included.

Results

The electronic search yielded 430 studies, of which 20 relevant ones were included in this review. Most studies were conducted in India (9/20), followed by Pakistan (6/20), Nepal (4/20) and Sri Lanka (1/20). One study showed a low risk of bias (RoB), 12 studies showed some concern, and seven studies showed a high RoB. Follow-up duration ranged from 2 to 36 months. Therapeutic outcomes such as HbA1c value and blood pressure (systolic blood pressure and diastolic blood pressure) studied in fourteen studies were found to be reduced. Seventeen studies reported humanistic outcomes such as medication adherence, knowledge and health-related quality of life, which were found to be improved. One study reported safety and economic outcomes each. Most interventions delivered by the pharmacists were related to education and counselling of patients including disease monitoring, treatment optimisation, medication adherence, diet, nutrition, and lifestyle.

Conclusion

This systematic review suggests that pharmacists have essential roles in improving patients’ ECHO in South Asian countries via patient education and counselling; however, further rigorous studies with appropriate study design with proper randomisation of intervention and control groups are anticipated.

Continuing Pharmacy Education: Exploring the Status and Future Prospects in Nepal

Continuing pharmacy education (CPE) is an educational way for pharmacy professionals to develop competency in providing quality pharmaceutical care to patients. The CPE program helps maintain up-to-date knowledge and skills, increase the professionalism of pharmacists, and positively impact patient health outcomes. However, the concept and practice of CPE are still in their infancy in Nepal. Nepal's conventional pharmacy education system involves didactic lectures focusing more on theoretical learning than practical and experiential approaches, leading to the generation of pharmacists theoretically knowledgeable but practically non-competent to deliver pharmaceutical care services in independent practice settings. Additionally, in the absence of CPE, the professionals might miss updated information on new therapies, technologies, and approaches in patient management. The community and hospital pharmacies in Nepal are often business-oriented rather than service, and may not even be staffed by pharmacists, so the CPE programs are rarely conducted for the pharmacy professionals. Hence, the present commentary aimed to explore the status of CPE and its barriers or challenges in implementation and to suggest solutions in Nepal.

Generic Medicine and Generic Prescribing in Nepal: An Implication for Policymakers

Generic medicines are being promoted in many countries for their added benefits over branded drugs, such as reduced price, therapeutic equivalence, and convenience to the patients. However, generic prescribing is still not up to the optimum level in Nepal to assure access to cost-effective, quality medicines to the public and to reduce the overall economic burden and practice-related errors of medications. This review aimed to discuss the current scenario of generic medicine, generic prescribing, hurdles on the one hand, and potentials ways in promoting generic medicine usage and generic prescribing in Nepal on the other. Extensive literature on generic medicine usage and generic prescribing practice in Nepal was reviewed. This review found some of the major challenges to be addressed for the proper implementation of generic medicine prescribing, and utilization. These challenges include lack of facilities and competency to assure therapeutic equivalence of different brand-name medicines, lack of understanding about generic medicines among health care providers (HCPs) and the public, and lack of stringent regulation towards promoting generic medicines. Rational pharmaceutical promotion and awareness about generic medication to the medical students are also inevitable towards promoting the practice of generic medicines. The practice of generic medicine and generic prescribing is not possible without the assurance of therapeutically equivalent generic alternatives. The study recommended the prompt effort of the regulatory authority to enforce the generic prescribing and generic substitution policy through strengthening policies, procedures and laboratory testing to assure citizens’ right to access to cost-effective, and affordable quality medicine, as the Nepal’s National Health and Drug Policy mandated.

Reintroduction of Post-Baccalaureate Doctor of Pharmacy (PharmD, Post-Bac) Program in Nepal: Exploration of the Obstacles and Solutions to Move Forward

This commentary article highlights the status of clinical pharmacy education in Nepal, explores the challenges and solutions in sustainably reintroducing Post-Baccalaureate Doctor of Pharmacy (PharmD, Post-Bac) in Nepal, as was previously launched by Kathmandu University (KU) Department of Pharmacy in 2010, and suggests a few prospects forward. Clinical pharmacy practice has remained on the sidelines and subordinate to physicians in Nepal. KU launched the PharmD (Post-Bac.) as a postgraduate program to establish the professional identity of clinical pharmacists in the country. However, despite unremitting efforts, the program did not thrive long and held since 2014. This paper aimed to explore challenges that remained at the forefront of the program and provide possible solutions for its reintroduction. The KU produced three batches of PharmD Post-Bac. graduates and now the revival of the program is crucial. Undoubtedly, a well-trained clinical preceptor can bring significant changes in the quality and competency of the PharmD graduates. Advocacy programs to foster the role of clinical pharmacists in the patient care services and revisiting of Bachelor of Pharmacy (BPharm) curriculum to complement the necessity of the PharmD program are needed. The non-sustenance of the PharmD program is emblematic of the dire mosaic that the clinical pharmacists are facing while delivering patient-oriented services in the country. Hence, strategies need to be formulated for the revival and sustainability of the program.

Knowledge, awareness and preparedness regarding coronavirus disease 2019 pandemic among community pharmacy practitioners working in Kathmandu, Nepal: A pilot study

Good knowledge, awareness and preparedness regarding coronavirus disease 2019, among community pharmacy practitioners (CPPs), will enable them to provide correct information and support to patients, convey instructions from the public health authorities and protect their own health.

Objective

The aim of this study was to determine knowledge, awareness and preparedness regarding coronavirus disease 2019 among CPPs working in Kathmandu, Nepal.

Methods

A cross-sectional study was conducted using a convenience sampling method from 10 February to 25 March 2020. Data were analysed descriptively, and one-sample independent t-test and one-way analysis of variance were used to compare scores among different subgroups of respondents (p < 0.05). Post hoc analyses (following analysis of variance) were done using the Bonferroni test.

Results

A total of 81 CPPs participated. Mean ± standard deviation age was 26.70 ± 5.29 years. Majority of the respondents were male (64.2%). Many CPPs (40.7%) had work experience between 1 and 5 years. Almost half (45.7%) had an educational qualification of Diploma in Pharmacy. Significant differences in knowledge (p = 0.022) and preparedness (p < 0.001) were found among individuals with differing levels of work experience. Similarly, a significant difference was found between knowledge-preparedness and work experience (p = 0.022 and p < 0.001), location of pharmacy (p < 0.001) and educational qualification (p = 0.031). Awareness (p < 0.001) and preparedness scores (p = 0.049) were different among community pharmacies with the different number of medicines available.

Conclusion

Knowledge was found to be higher in CPPs with a work experience of more than 5 years. CPPs working at larger community pharmacies were more aware and prepared. CPPs' knowledge, awareness and preparedness should be evaluated more widely and strengthened.

Clinical Pharmacy Education and Practice in Nepal: A Glimpse into Present Challenges and Potential Solutions

This commentary article highlights the challenges in providing clinical pharmacy education in Nepal and suggests a few ways forward. Contrary to other health care professions, clinical pharmacy practice is a new healthcare discipline in the country which is currently undergoing transition. The existing pharmacy curriculum and training in the country can provide competencies needed for pharmacists in industrial settings. Considering the importance of clinical pharmacists in patient care, the Government of Nepal has implemented a policy recommending the recruitment of clinical pharmacists in hospitals. However, the education and training for pharmacists provided in the country are not sufficient enough for optimum patient care and for delivering clinical pharmacy services. International collaborations in terms of faculty and student exchanges, preceptor training, and accreditation by international organizations such as Accreditation Council for Pharmacy Education (ACPE), establishment of need-based curriculum, incorporating clinical pharmacy department under the organizational structure of hospitals, etc., may be the right approaches to improve the current status of clinical pharmacy education in the country.

Paradigm shift of drug information centers during the COVID-19 pandemic

The novel coronavirus disease 2019 (COVID-19) pandemic is a major global threat affecting millions of lives throughout the world physically and psychologically. With the asymptomatic presentation of COVID-19 in many patients and the similarity of its symptoms with the common cold and influenza, the need for accurate information on the disease is very important for its identification and proper management. Accurate information on the disease, its prevention and treatment can be disseminated through drug information centers (DICs). DICs are usually staffed by pharmacists and/or clinical pharmacists/pharmacologists. DICs are a reliable source of current and unbiased information on COVID-19 and its associated complications, including management options for healthcare professionals and the public. In addition to health and drug information, pharmacists working in the DICs can be involved in the management of the patients' health by providing information on home care and safety, medication management of patients with chronic comorbid illnesses, and psychological advice. This article explores the possible additional roles DICs can play, besides providing drug information within the hospital or in the community.

Pharmacy Patronage: Identifying the Roles of Nepalese Pharmacists in Tacking COVID-19

Coronavirus disease (COVID-19) pandemic is one of the dire issues currently worldwide. With increasing death tolls every day and with new information regarding disease every minute, it is very important to disseminate the updated and reliable information to the public. Along with other health care professionals, the pharmacists’ role is crucial in preventing the spread and management of the disease. The involvement of pharmacists from clinical trials, drug evaluation to providing pharmaceutical care and other basic pharmacy services in the frontline in this health emergency is undeniable. This commentary focuses on the role of pharmacists in different settings of the health care system and the degree of recognition of the work in Nepal.