Awatif H. H. Damanhori

Drug treatment of hypertension in pregnancy: a critical review of adult guideline recommendations.

This review evaluates the guideline recommendations for the management of hypertension in pregnancy as presented by 25 national/international guidelines developed for the management of arterial hypertension in adults. There is a general consensus that oral &agr;-methyldopa and parenteral labetalol are the drugs of choice for nonsevere and severe hypertension in pregnancy, respectively. Long-acting nifedipine is recommended by various guidelines as an alternative for first-line and second-line therapy in nonsevere and severe hypertension. The safety of &bgr;-blockers, atenolol in particular, in early and late stages of pregnancy is unresolved; their use is contraindicated according to several guidelines. Diuretic-associated harmful effects on maternal and fetal outcomes are controversial: their use is discouraged in pregnancy. It is important to develop specific guidelines for treating hypertension in special groups such as adult females of childbearing age and sexually active female adolescents to minimize the risk of adverse effects of drugs on the fetus. In several guidelines, the antihypertensive classes, recommended drug(s), intended drug formulation, and route of administration are not explicit. These omissions should be addressed in future guideline revisions in order to enhance the guidelines’ utility and credibility in clinical practice.

Prescription writing skills of residents in a family practice residency programme in Bahrain

Purpose of the study: To evaluate the prescription writing skill of final year residents in a family practice residency programme (FPRP) in Bahrain, and to compare skill of residents who have graduated from medical schools with problem based learning (PBL) versus traditional (non-PBL) curricula. Study design: Prescriptions issued by the residents were prospectively collected for two consecutive cohorts in May 2004 and May 2005. Prescription errors were classified as errors of omission (minor and major), commission (incorrect information) and integration (drug–drug interactions). Results: In 69.6% of medications with major omission errors, dosage form (39.4%) and length of treatment (18.5%) were not specified. In 24.7% of medications with commission errors, dosing frequency (19.9%) and incorrect strength/dose (2.2%) were the most common errors. Integration errors comprised 5.7% of all prescribing errors. No significant differences were observed between PBL and non-PBL graduates with regard to the total number of prescriptions with errors, drugs per prescription, polypharmacy, and the total number of drugs with errors. The proportion of prescriptions with a potential for drug–drug interactions was comparable between PBL and non-PBL graduates. PBL graduates prescribed medications using brand names at a rate greater than non-PBL, whereas non-PBL graduates prescribed medications on inappropriate “as required” basis, and injections at a rate greater than PBL residents. Conclusions: Prescription writing skill of the final year residents in an FPRP programme was suboptimal for both PBL and non-PBL graduates. Integration of prescription writing skill and a rational pharmacotherapeutic programme into the FPRP curriculum is recommended.

Antihypertensive Drugs and Male Sexual Dysfunction: A Review of Adult Hypertension Guideline Recommendations.

Background: Published clinical practice guidelines have addressed antihypertensive therapy and sexual dysfunction (SD) in many different ways. Objective: In this systematic review, we evaluated guidelines that address antihypertensive drug-associated SD, guideline recommendations, and recent guideline trends. Methods: Thirty sets of guidelines for hypertension management in adults that had been published in the English language since 2000 were reviewed. The primary outcome measure was antihypertensive-associated SD potential, which was independently evaluated using specific questions by 2 authors in a nonblinded standardized manner. Results: Sexual dysfunctions associated with thiazide-class diuretics, β-blockers, and centrally acting sympathoplegics were addressed by half of the guidelines reviewed. There is no clarity on β-blockers and thiazide-class diuretics because one-third of the guidelines are vague about individual β-blockers and diuretics, and there is no statement on third-generation β-blockers and thiazide-like diuretics that can improve erectile function. The revised guidelines never use terms such as loss of libido, ejaculatory dysfunction, lack of orgasm, and priapism. Summary versions of guidelines are inadequate to reflect the key interpretation of the primary guidelines on SD associated with antihypertensives, even in the major guidelines that were updated recently. Therapeutic issues such as exploring SD in clinical history, assessing SD prior to and during treatment with antihypertensives, substituting the offending agents with alternatives that possess a better safety profile, intervening with phosphodiesterase-5 inhibitors, and avoiding the concomitant use of nitrovasodilators are superficially addressed by most guidelines, with the exception of 2013 European Society of Hypertension/European Society of Cardiology and Seventh Joint National Committee recommendations. Conclusion: Future guideline revisions, including both full and summary reports, should provide a balanced perspective on antihypertensive-related SD issues to improve the impact of hypertension treatment guidelines on patient care and quality of life.

Treatment of Hypertension in Bahrain

Objective To evaluate the adequacy of blood pressure (BP) control and therapeutic appropriateness of antihypertensive drug(s) prescribed, taking into consideration laboratory parameters and the presence of comorbidities, in hypertensive patients. Methods Therapeutic audit of medical records of hypertensive patients from 9 primary care health centers in Bahrain using World Health Organization/International Society of Hypertension guidelines criteria. Results The recommended target BP <140/<90 mm Hg was achieved in 37 (16.5%) patients with a mean BP of 126 ± 6 / 80 ± 5 mm Hg. Groups with inadequate BP control were 15 (6.7%) with normal systolic BP (SBP) and high diastolic BP (DBP), 59 (26.3%) with high SBP and normal DBP, and 113 (50.4%) with high SBP and high DBP. Pulse pressure of the controlled group was 46.3 ± 5.9, whereas pulse pressures of the inadequately controlled groups with BP cutoffs <140/≥90, ≥140/<90, and ≥140/≥90 mm Hg were 37.4 ± 6.1, 72.7 ± 13.5, and 59.7 ± 13.6 mm Hg, respectively. Of the 281 treated hypertensive patients, 56.6% were on monotherapy; BP of patients on combination therapy versus monotherapy did not differ. The choice of antihypertensives in relation to comorbidities and laboratory findings revealed that many hypertensive patients with dyslipidemia were on β-blockers and diuretics, 39.3% of patients with ischemic heart disease were on β-blockers, approximately 20% of patients with hyperuricemia were on diuretics, and 27.6% and 10.4% of patients with isolated systolic hypertension were on diuretics and calcium-channel blockers, respectively. Conclusions BP control was achieved in 1 of 6 treated patients. In several instances, metabolic abnormalities and comorbidities were apparently not considered while prescribing antihypertensives. A rational drug therapy approach is needed in treating hypertension to achieve better control rates.

Medication prescribing errors pertaining to cardiovascular/antidiabetic medications: a prescription audit in primary care

This study was carried out to identify the medication prescribing errors (MPEs) pertaining to cardiovascular/antidiabetic medications in prescriptions issued to hypertensive and diabetic hypertensive patients. A retrospective, nationwide audit of prescriptions (n = 2773) issued by primary care physicians (n = 194) of 20 health centres in Bahrain was carried out. Approximately one‐quarter of prescriptions ordered by two‐thirds of primary care physicians had errors. No significant differences with respect to overall errors were evident in prescriptions ordered by the family physicians and general practitioners. The most common error (in 8.0% of prescriptions) was prescribing β‐blockers or diuretics (thiazide) or their combinations to patients on lipid‐lowering drugs. Prescribing multiple antihypertensives, often with a similar mechanism, accounted for 2.2% errors: approximately half of these (1.45%) were two angiotensin‐converting enzyme inhibitors (ACEIs) co‐prescribed and/or ACEIs plus angiotensin‐II receptor blockers. In 0.7% of prescriptions, β‐blockers were ordered to patients on salbutamol treatment. High‐dose metformin (3 g/day) was prescribed to approximately 4% diabetic hypertensives; of these, many were elderly patients. Prescribing high‐dose glibenclamide (median dose 15 mg) to the elderly accounted for 3.6% of the overall errors. Polypharmacy, such as aspirin along with an immediate‐release dipyridamole, was prescribed occasionally (0.25%), particularly by the general practitioners (P = 0.0139). MPEs are common in primary care, in Bahrain. Some of these prescribing errors have the potential to harm patients. Effective measures to detect and prevent such errors are needed to improve the quality of health care. Standard treatment guidelines and educational interventions are important strategies to achieve these goals.

Antimicrobial prescribing trends in primary care: implications for health policy in Bahrain.

To evaluate antimicrobial prescribing pattern by primary care physicians.

Topical corticosteroids in infants: prescribing pattern and prescribing errors in Bahrain

ObjectiveA nationwide, primary care-based prescription audit in infants to determine the prescribing pattern and prescribing errors of topical corticosteroid preparations in Bahrain.MethodPrescriptions dispensed for infants were collected for two successive weeks from 20 primary-care health centres.ResultsAmong 2282 out of 102,084 prescriptions (2.2%) dispensed for infants, 296 (13.0%) had corticosteroids for topical application to the skin, eye and ear. Plain corticosteroids comprised 6.7%, whereas corticosteroids with antiinfectives accounted for 6.3% of topical corticosteroid preparations. Based on potency the proportions of corticosteroids prescribed were: mild (6.7%), moderately potent (2.6%) and potent (3.7%). The frequency of dosing and length of therapy were not stated in 21.6% and 43.6% of prescriptions, respectively. Base cream as a dilutional vehicle was prescribed in 11.2% (11/98) and 32.4% (12/37) prescriptions containing hydrocortisone acetate 1% cream and betamethasone valerate 0.1%, respectively. In few instances two corticosteroids were concomitantly prescribed.ConclusionPrescribing moderate-to-potent topical preparations in approximately half of the infants, co-prescription of multiple corticosteroid preparations, omission of important components of prescription, and resorting to the controversial vehicle diluting technique suggest that topical corticosteroid therapy is sub-optimal. In infants, topical corticosteroids should be rationally prescribed. Establishing the treatment guidelines, pharmacovigilance programme and revision of the primary care essential drug list are needed in Bahrain.

Polypharmacy associated with medical tourism: a critique on drug therapy

Medical tourism is the practice of patients seeking health care services from an area outside their home country. In recent years, medical tourism has rapidly grown for the following reasons: (a) inadequate access to health care services at home country; (b) the treatment is not covered by health insurance providers; (c) the service is available at a much lower cost elsewhere; and (d) long waiting period to get access to care as a result of overburden on public healthcare system at home country [1]. Complicated urgent surgeries and elective procedures are the most frequently sought procedures by patients as medical tourists [2]. Polypharmacy is the prescription, administration, or use of more medications than are clinically warranted [3]. Polypharmacy has been shown to predispose patients to drug-drug interactions, adverse drug reactions, and poor patient compliance [4]. We present a case of polypharmacy associated with medical tourism in a middle-aged Bahraini who sought treatment for diabetes mellitus from a well known hospital promoting medical tourism services in a south-east Asian country.

Pediatric iron preparations for infants in Bahrain: some therapeutic concerns.

BACKGROUND Infants and children are at a high risk for medication errors. OBJECTIVES This retrospective study was conducted to determine the type and prevalence of prescribing errors related to pediatric iron preparations prescribed in primary care in Bahrain. METHODS Prescriptions issued for infants and collected at 20 health center pharmacies for 2 weeks were audited, specifically for errors. RESULTS Of 2,282 prescriptions dispensed for infants (mean age 9.14 +/- 0.91 months), 159 (7.0%) included an iron preparation. Iron preparations were mostly prescribed (90.6%) with brand names, several of which were neither listed in the primary care drug list nor were available as pediatric dosage forms. 42 (26.4%) prescriptions were issued without specifying the dosage forms, 14 (8.8%) without the duration of therapy and 4 (2.5%) without dosage. Iron dosage was stated as metric volume (ml) and metric weight (mg elemental iron) units in 78.6% and 9.4% of the prescriptions, respectively. The mean elemental iron (+/- SD) prescribed for treating anemia was 4.5 +/- 1.7 mg/kg body weight. A significant difference was observed between physicians and nurses regarding the amount of elemental iron prescribed for treating anemia. CONCLUSIONS Prescribing of multiple brands of pediatric iron preparations unavailable in the primary care drug list and in pediatric dosage forms, prescribing iron as inconvenient decimal fractions (metric volume units), and omission errors in prescriptions, were common. This may be related to poor communications between the prescribers and the pharmacy services and a lack of information dissemination on newly introduced iron formulations. Moreover, frequent changes in brand availability in primary care may have created confusion for prescribers. The communication between pharmacy services and prescribers should be strengthened, and the procurement of multiple brands should be discouraged. A better management of drug supply and effective policies to minimize prescribing errors are needed in Bahrain.

Pharmacotherapy and blood pressure control in elderly hypertensives in a primary care setting in Bahrain

Background and aims: Antihypertensive treatment in the elderly has important beneficial effects in terms of reduced cardiovascular morbidity and mortality. The aim of this study was to determine, in elderly hypertensives, the adherence of primary care physicians to World Health Organization/International Society of Hypertension (WHOASH) guidelines for the drug management of hypertension and extent of blood pressure (BP) control. Methods: A multicentric therapeutic audit of medical records of elderly hypertensives was performed in nine primary care health centers in the Kingdom of Bahrain. Results: In elderly hypertensives (≥60 years), the WHQ/ISH-1999 recommended BP targets of <140/<90 mmHg and BP<130/85 mmHg were achieved in 11.1% of elderly hypertensives and 4.1% of elderly diabetic hypertensives, respectively. Antihypertensive combination therapy was used in approximately half of the elderly. No significant difference in BP was found in elderly hypertensives treated either with monotherapy or combination therapy. As regards mono- and overall drug utilization, β-blockers were the most frequently prescribed drugs in hypertensives, and angiotensin-converting enzyme (ACE) inhibitors in diabetic hypertensives. Diuretics and calcium channel blockers, the preferred antihypertensives for the elderly, were less often prescribed, particularly in patients with isolated systolic hypertension. Conclusions: Approximately one out of 9 elderly hypertensives and one out of 24 diabetic hypertensives achieved optimal BP control. Although preference for antihypertensives was markedly influenced by comorbidity with diabetes, tailoring of drug therapy was suboptimal and did not adhere to the recommended guidelines in elderly hypertensives. Efforts to improve the drug management of hypertension at primary care level, particularly in the elderly, are required.