Fm Haaijer-Ruskamp

INVESTIGATING DRUG-USE IN PREGNANCY - METHODOLOGICAL PROBLEMS AND PERSPECTIVES

In this study the use of prescribed drugs before, during and after pregnancy is described. The study is based on data obtained from pharmacy records of 1,948 women who delivered a live-born infant. Different measures to evaluate drug exposure are used. During the nine months of pregnancy 86% of the women used on average 4.2 prescriptions. During the course of pregnancy the use of gastro-intestinal and blood-forming drugs increased, whereas the use of cardiovascular, antiphlogistic and central nervous system drugs decreased. Anti-emetics were predominantly used in the first trimester, and antacids in the last trimester, whereas laxatives were especially used after delivery. The percentage of women who used a treatment for vaginal infections increased from 2 to 7 during pregnancy. Most of the women (73%) received one or more iron prescriptions during the course of pregnancy, however, the prescribed daily dose was low (prescribed daily dose/defined daily dose=0.6). At least 1% of the women filled a new prescription for anticonceptives in the first trimester of pregnancy. Most likely, our data reflect the general prescribing pattern for Dutch pregnant women who delivered a live-born baby. Therefore, they form a good and detailed base for further studies, for instance, on the exposure to drugs with known or suspected risks or on the use of drugs in patients with chronic concomitant diseases. Such studies may lead to recommendations that may improve prescribing behaviour.

QUESTIONS ABOUT DRUGS - HOW DO PREGNANT-WOMEN SOLVE THEM

In this study the need for information about drugs among pregnant women and the use of available sources was explored. The women participating in this study were well aware of the risks of the use of drugs. Health professionals were considered to be important sources of information and they should therefore use up-to-date information concerning this topic. Health professionals should also bear in mind in their counseling activities that the beliefs of pregnant women on the safety and need of drugs might lead to reasoned non-compliance.

Polypharmacy in the elderly - a literature review

Background: The increasing number of elderly people in the population is leading to an increase in the amount of treatment prescribed for chronic diseases. As these diseases require treatment with an increasing number of medicines, the problems of polypharmacy are becoming more important. Objectives: By means of an extensive literature review:- to define polypharmacy; to determine the extent and nature of polypharmacy in the elderly; and to discover the problems which may result from polypharmacy in general practice. Method: A Medline search from 1985 to 1998 yielded 1751 references from which we selected 143 articles for review. Results: Qualitative definitions of polypharmacy vary greatly. We recommend defining it simply and quantitatively as the simultaneous use of two or more drugs. In almost every study the use of cardiovascular drugs is high, and in particular diuretics are often used in combination with other drugs. Giving more than one drug to a patient becomes more common over time; this applies especially to ACE inhibitors, calcium channel blockers and analgesics. The extent of the harm done by polypharmacy is not clear, because information is lacking on the clinical relevance of some recognised interactions. Conclusion: The quality of the papers we studied was too poor to allow a systematic review. Pooling of the studies was impossible, because in only nine of the 62 studies standard deviations around averages were mentioned. Many studies could not be compared with each other because different methods were used to measure prevalence. Papers sometimes failed to clarify whether they were referring to prescription drugs only or prescription and non-prescriptions medicines. Some of the populations interviewed were not representative. Therefore, we can draw very few conclusions about the degree of polypharmacy in the different studies or the extent to which it is associated with health problems. There is a need for more standardisation of definitions and improved quality of research in this area. EurJ Gen Pract 2000;6:98–106.

HANDLING OF RISK-BEARING DRUGS DURING PREGNANCY. DO WE CHOOSE LESS RISKY ALTERNATIVES?

The drug use of nearly 2,000 pregnant women was evaluated at the level of the individual patient for the drugs belonging to the Australian risk categories B3, C and D. The pattern of changes in the use of these drugs is studied in terms of women who discontinue (d), continue (c) or begin (b) using the drug during pregnancy. The ratios d/(c+b) and d/b were the highest for the drugs belonging to the high-risk groups and the lowest for drugs from the low-risk categories. This suggests a congruence between theoretical knowledge and daily practice. Patients who had already been using a drug for a long time before pregnancy, more frequently continued using that drug than patients who had been using the drug only incidentally before. The described daily dose for the riskful drugs was approximately 20% lower in patients who started to use a drug during pregnancy compared to those who continued drug use. The data from this analysis indicate that the prescribing physician is generally aware of the possible risks of drug use during pregnancy. The d/(b+c) and d/b ratios are shown to be a good measure of prescribing behaviour in relation to pregnancy and can be used to compare knowledge of theory and daily practice.

A study of drug utilization in pregnancy in the light of known risks: is there room for improvement?

The prescription records of 1948 Dutch women who delivered a live-born infant during an 18 month period in 1987 and 1988 were set against the Australian classification of drugs with respect to the known or suspected risks in pregnancy. During pregnancy the use of drugs with proven or anticipated foetal toxicity proves to decrease, indicating that the medical profession is relatively well aware of these potential side effects. In the case of antibiotics the fall in the use of potentially toxic drugs is due to a shift to relatively less toxic drugs whereas the decreased use of analgesics and some antirheumatic drugs is not accompanied by replacement by others. Prescriptions for hormonal contraceptives were sometimes actually filled in the first trimester of pregnancy, and the figures suggest that exposure to these products in early pregnancy may not be negligible. The present study shows that in spite of the generally favourable trends, 167.8 out of 1000 women received during the course of pregnancy one or more prescriptions from the higher risk categories (D, C or B3) in the Australian system. By combining such utilization studies with data from registries of birth defects one will be able to develop the fund of knowledge and to ensure that the classification of drugs with respect to their risks in pregnancy is as accurate as it can reasonably be.

Information about drugs in family magazines

Family magazines can play an important role in the diffusion of medical information and information regarding drugs to a ‘lay audience’. We describe what kind of drugs are discussed in the family magazines and which information regarding these drugs is given. Furthermore, we look into the information sources for journalists; special attention is paid to the role of the pharmacist: is (s)he recognized by journalists as one of the experts on drugs? Two approaches were used in order to answer the above described research questions: a content analysis of family magazines and indepth interviews of journalists. Gynaecological products as well as drugs for the central nervous system receive much attention in family magazines. The kind of information given about drugs is limited. Only part of the publications pays attention to side-effects. Patients asking questions about drugs in response to publications in family magazines know the name of a drug but are rarely informed about other aspects of the therapy, such as side-effects. In the provision of information physicians and medical specialists play an important role as sources of information for journalists. There is, however, until now no role for the pharmacist as a source of information on drugs in family magazines.