Khalid A. J. Al Khaja

Evaluation of the Knowledge, Attitude and Practice of Self-Medication among First-Year Medical Students

Objective: This study was undertaken to determine the knowledge, attitude and practice of self-medication among first-year medical students of the Arabian Gulf University, Bahrain. Subjects and Methods: This was an anonymous, questionnaire-based, descriptive study. A prevalidated questionnaire, containing open-ended and close-ended questions, was administered to the subjects. Data were analyzed using SPSS version 12 and the results expressed as counts and percentages. Results: Out of the 134 respondents, 43 (32.1%) were males and 91 (67.9%) were females; their mean age in years ± SD was 18.01 ± 0.78. The respondents’ knowledge about appropriate self-medication was poor, but knowledge of the benefits and risks of self-medication was adequate. The respondents found self-medication to be time-saving, economical, convenient and providing quick relief in common illnesses. Important disadvantages of self-medication mentioned were the risk of making a wrong diagnosis, inappropriate drug use and adverse effects. The majority (76.9%) of the respondents had a positive attitude favoring self-medication. Self-medication was practiced by 44.8% of the subjects. The most common indications for self-medication were to relieve the symptoms of headache (70.9%), cough, cold and sore throat (53.7%), stomachache (32.8%) and fever (29.9%). Analgesics (81.3%) were the most common drugs used for self-medication. The practice of self-medication was appropriate in only 14.2% of cases. Conclusion: Knowledge about appropriate self-medication was poor, attitude towards self-medication was positive, and the practice of self-medication was common and often inappropriate.

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.

Prescribing Patterns and Therapeutic Implications for Diabetic Hypertension in Bahrain

OBJECTIVE: To determine drug prescription patterns and the extent of conformity with World Health Organization/International Society of Hypertension (WHO/ISH) guidelines in diabetic hypertension. DESIGN: Retrospective prescription-based survey. SETTING: Seven primary-care health centers, comprising approximately one-third of primary-care health centers in Bahrain. PATIENTS: Patients with type 2 diabetes and hypertension. MAIN OUTCOME MEASURE: The prescribing pattern of antihypertensive and antidiabetic drugs. RESULTS: Among a study sample of 1463 patients with type 2 diabetes and hypertension, antidiabetic agents were prescribed as monotherapy in the following descending order: glyburide, gliclazide, insulin, and metformin. As combinations, sulfonylureas plus metformin was most popular, followed by metformin plus insulin, and sulfonylureas plus insulin. Sulfonylurea and metformin with insulin was rarely used. There was no significant difference in prescribing of glyburide and metformin between the elderly and young middle-aged diabetic patients; many patients older than 65 years were treated with a β-blocker along with a long-acting sulfonylurea. Both as monotherapy and in overall use, β-blockers, angiotensin-converting enzyme (ACE) inhibitors, and calcium-channel blockers were most often prescribed. Among 35.5% patients treated with antihypertensive combinations, various two- and three-drug combinations of β-blockers, ACE inhibitors, calcium-channel blockers, and diuretics were often used. The proportion of patients taking atenolol 100 mg/d was higher with combination regimens. Hydrochlorothiazide 25 mg or equivalent thiazide diuretics were extensively used. CONCLUSIONS: The prescribing pattern of antihypertensives in diabetic hypertension differs in many instances from WHO/ISH guidelines, especially regarding the choice of antihypertensive drugs and their combinations. The appropriateness of antidiabetic drug choice is questionable in relation to the antihypertensive used.

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.

Effectiveness of an Educational Intervention on Prescription Writing Skill of Preclerkship Medical Students in a Problem‐Based Learning Curriculum

Medical school training for students in pharmacotherapy is suboptimal and junior doctors are not confident to prescribe drugs. This study evaluated the effectiveness of an optional educational intervention on prescribing skill of pre‐clerkship medical students in a problem‐based learning (PBL) program. Performance was assessed in seven end‐unit objective structured practical examinations (OSPE). Physician‐related prescription components (PRCs) and drug‐related prescription components (DRCs) were assessed. The performance of students who attended the intervention sessions (attendees) and non‐attendees was compared. Approximately half of the students attended the sessions. PRCs were written appropriately by most of the students. DRCs were written less competently by both attendees and non‐attendees, specifically the dosage form, quantity to be dispensed and directions. Performance on individual DRCs was significantly better for attendees compared to non‐attendees. The mean total score for all prescription components of attendees was significantly greater than that of non‐attendees. The percentage of high achievers was significantly greater for attendees. A positive correlation was found between student attendance and the total score. An optional educational intervention during the preclerkship phase is an important determinant of prescribing performance of medical students.

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.

Effective use of real-life events as tools for teaching-learning clinical pharmacology in a problem-based learning curriculum

Aim: This paper describes how in a problem-based learning (PBL) medical curriculum, having identified the learning outcomes, problems can be developed from real-life events for teaching-learning clinical pharmacology topics for which PBL cases might be inadequate. Such problems can be very interesting and educational. Methodology: Using the story of the development and withdrawal of rofecoxib (Vioxx®), we developed a problem for undergraduate medical students to address important issues related to clinical pharmacology and therapeutics such as new drug development, preclinical testing, clinical trials, adverse drug reactions, professionalism, and critical appraisal of literature. These topics would otherwise be difficult to address in patient-based problems. Results: The evaluation of the problem based on pooled feedback from 57 tutorial groups, each comprising 8–10 students, collected over 5 years, supported the effectiveness of the problem. Conclusion: A systematic approach described in this paper can be used for the development and validation of educational material for introducing focal topics of pharmacology/clinical pharmacology integrated with other disciplines in innovative medical (and other health profession) curricula.