Malaysian Statistics On Medicine 2004

Transcription

Malaysian
STATISTICS ON MEDICINE
2004
A02B A02
C03A A03
J01C R02
ATC R06A E07
A10B B01R03B A02
C02C A01
C07A B03R06A D02
A10B A02C03B A11
C01E B15
C07A B02C09C
A01
C08C A05R03D A04
C10A A01J01A A02
R03B B04
C08C A01C09A A03
R03A C02M04A A01
A10A B01
C09A A01
C09A A02
H02A B06
A02B A02
C03A A03
J01C R02
R06A E07
R03B A02
C02C A01
R06A D02
C03B A11
C01E B15
C09C A01
Ranitidine
3.1843
Hydrochlorothiazide
3.0603
Amoxicillin+enzyme inhibitor
2.9569
2.6469
DrugsCetirizine
DDD/1000
population/day
Budesonide
2.5996 14.4913
Glibenclamide
Prazosin
2.4520
Atenolol
Promethazine
2.2757 13.0782
Indapamide
2.1897 11.7436
Metformin
Trimetazidine
2.0636
Metoprolol
10.9895
Losartan
1.9803
Nifedipine
9.8874
R06A
B04
Chlorphenamine
Theophylline
1.8599
Doxycycline
1.7350
Simvastatin
7.9016
A10B
B09
Gliclazide
Tiotropium bromide
1.7158
Amlodipine
6.5788
R03C C02
Salbutamol
Lisinopril
1.6354
Allopurinol
1.5786
Salbutamol
6.3364
M01A
B05
Diclofenac
Insulin, fast-acting ( human)
1.4590
R06A B04
A10B
B09
Captopril
R03C
C02
Enalapril
M01A B05
Prednisolone
Chlorphenamine
M01A G01
Gliclazide
3.8928
R06A
X13
Salbutamol
3.8315
C03C
A01
Diclofenac
3.5837
Ranitidine
Hydrochlorothiazide
Amoxicillin+enzyme inhibitor
Cetirizine
Budesonide
Prazosin
Promethazine
Indapamide
Trimetazidine
Losartan
2.0636
1.9803
C03A
A04
3.1843
C10A
A02
3.0603
2.9569
J01C
A04
2.6469
C09A
A04
2.5996
C10A
A05
2.4520
C09A
A01
2.2757
C09A
A02
2.1897
5.7326
Mefenamic acid
Loratadine 5.6477
5.4231
Furosemide
5.3498
Chlorothiazide
Lovastatin
Amoxicillin
Perindopril
Atorvastatin
Captopril
Enalapril
5.7326
5.6477
5.4231
5.3498
4.7901
4.6098
4.4716
4.0854
4.0799
4.0243
4.0141
3.9146
3.8928
3.8315
Edited by:
Sarojini Sivanandam
Lim T.O.
With contributions from:
Shanthi V, Goh A, Lee KK, Leong KC, Rosminah MS, Letchuman Ramanathan,
Yap PK, Muruga Vadivale, Tamil Selvan M, Sim KH, Khoo KL, Zaki Morad, Rozina Ghazalli, Tan KK,
Lim YS, Beena Devi, R. Ramanathan, Lee CK, Manmohan Singh, Suraya Yusoff,
Suarn Singh, Syed Fadzli SS, Norzila MZ, Molly Cheah
A publication of the
Pharmaceutical Services Division and the Clinical Research Centre
Ministry of Health Malaysia
1
2
Malaysian
Statistics On Medicine
2004
Edited by:
Sarojini Sivanandam
Lim T.O.
With contributions from
Shanthi V, Goh A, Lee KK, Leong KC, Rosminah MS, Letchuman Ramanathan,
Yap PK, Muruga Vadivale, Tamil Selvan M, Sim KH, Khoo KL, Zaki Morad, Rozina Ghazalli, Tan KK,
Lim YS, Beena Devi, R. Ramanathan, Lee CK, Manmohan Singh, Suraya Yusoff,
Suarn Singh, Syed Fadzli SS, Norzila MZ, Molly Cheah
A publication of the
Pharmaceutical Services Division and the Clinical Research Centre
Malaysian Statistics On Medicine 2004
April 2006
© Ministry of Health Malaysia
Published by:
The National Medicines Use Survey
3rd Floor, MMA House
124, Jalan Pahang
53000 Kuala Lumpur
Malaysia
Tel.
: (603) 40439 300
Fax
: (603) 40439400
e-mail : [email protected]
Web site : http://www.crc.gov.my/nmus
This report is copyrighted. However it may be freely reproduced without the permission of the National Medicines
Use Survey. Acknowledgement would be appreciated. Suggested citation is: Sarojini S, Lim T.O. (Eds). Malaysian
Statistics On Medicine 2004. Kuala Lumpur 2006
This report is also published electronically on the website of the National Medicines Use Survey at:
http://www.crc.gov.my/nmus
Funding:
The National Medicines Use Survey is funded by a grant from the Ministry of Health Malaysia (MRG Grant
Number 00311)
FOREWORD
The Ministry of Health Malaysia has embarked on a landmark project, The National Medicines Use Survey
(NMUS), to capture data on the use of medicines in both the government and private sectors in Malaysia and this
report is a culmination of the project.
This NMUS report is very relevant in the present environment of ever increasing expenditure on medicines in
the government sector, which is likely to be similar in the private sector. While we have some data on the use of
medicines in the government sector, there is a lack of information from the private sector. This publication will
help in some ways to rectify the situation.
I am confident this publication will be a very useful reference to the government, the industry and the public and
I must congratulate those who are involved in the survey for successfully completing the project. I am looking
forward to see that the data are regularly updated through follow-up surveys.
DATUK DR HAJI MOHD ISMAIL MERICAN
Director General of Health Malaysia
i
FOREWORD
In tandem with the advancement of the healthcare delivery system and increasing drug expenditure, there is a need
to ensure optimisation and quality use of resources. Since medicines are critical and essential for health sustenance
and improvement, quality use of medicines by healthcare providers and consumers which can contribute towards
quality care and cost-effective therapy remains to be an important component of any healthcare system and the
proposed Malaysia’s National Medicines Policy clearly addresses this.
Promoting rational prescribing by prescribers and appropriate use of medicines by consumers can be achieved
through various strategies including training, education, provision of evidence based drug information and
development of standard treatment guidelines. However, in order to translate strategies into outcomes, data on
the use of medicines in the country need to be collected to provide a general view and description of the pattern
of medicines used by various sectors. The National Medicines Use Survey (NMUS) was conducted with the
intent to continuously and systematically collect these data to improve its use, especially on the aspect of rational
prescribing, as well as providing a tool for better decision making in the allocation of healthcare resources for the
population. Apart from that, Malaysian drug use data will certainly be useful for comparing prescribing patterns
with other developed countries.
The conduct of NMUS required meticulous planning and hard work and I would like to express my deepest thanks
to each and every individual who had contributed to the success of the survey. The Pharmaceutical Services
Division appreciates the tremendous effort and commitment by the Clinical Research Centre to drive this project
which had resulted in the first publication of the preliminary findings of the survey.
I must also congratulate all doctors and pharmacists from the various expert panel groups who had selflessly
contributed towards analysing the data, providing useful input on limitations of the survey so that corrective
actions can be taken for subsequent surveys, and for successfully completing the reports on time to enable this
first publication. This survey had also paved the way for a healthy working partnership between doctors and
pharmacists from the public and private sectors for the common aim of promoting quality use of medicines.
Thank you
DATO’ CHE MOHD ZIN BIN CHE AWANG
Director
Pharmaceutical Services Division
Ministry of Health Malaysia.
ii
PREFACE
Data on the utilization of medicines in a country is important as it provides a picture of the state of the quality
use of medicines.
Drug utilization in a country could be different from other countries or even between areas within that country.
These differences could be because of several factors, such as demographic differences, differences in epidemiology
of disease, difference in medical approach or differences in economic conditions. This type of information allows
for better decision-making in the allocation of resources and in the listing of medicines in the country’s formulary.
The use of this information can enhance appropriate use of medicines for better health outcomes.
There has not been a large survey on the utilization of medicines in Malaysia so far and this aptly called National
Medicines Use Survey [NMUS] is believed to be the first of its kind. However in carrying out this survey, in a
country like Malaysia that does not have one central database of sales or prescriptions or dispensing of medicines,
the task of compiling data on utilization of medicines was huge and fraught with problems. Data needed to be
collected from multiple sources and some of these sources were less than forthcoming in providing data due to
apprehension on the actual or possible use of the data or possibly, some sources were too busy to be able or want
to provide the data needed.
After the hurdle of data collection was surmounted, the next problem was data analysis. There was a need for
intelligent and expert analysis to distill credible information out of all these data as the data from various sources
were not always complete or clean or in the format or depth that was wanted. Under such conditions, therefore it
is not surprising that the target publication of end of 2005 for NMUS has not been met.
However, these experiences will stand us well in the future as this present report of NMUS will not mean the
end of NMUS. NMUS will continue to be an ongoing activity to track the utilization of medicines, which will
change with time. These changes may be due to various reasons such as ageing population, the entrance of new
medicines, the changing life style of the population or the shifting of population from the rural to the urban. With
continuous monitoring, the changing utilization of medicines in the country will be clear.
We would like to thank all staff who has worked so hard in this survey.
We would also like to thank all agencies and institutions who have helped in providing data and who have helped
in one way or another.
Dr. Zaki Morad bin Mohd Zaher
Mr. Lai Lim Swee
Chairman
Co-Chairman
National Medicines Use Survey
iii
ACKNOWLEDGEMENTS
The National Medicines Use Survey would like to thank the following:
All the medical doctors, pharmacists and pharmacist assistants who participated in NMUS surveys
The Association of Private Hospitals Malaysia, Malaysian Organisation of Pharmaceutical Industries and
Pharmaceutical Association of Malaysia for encouraging their members to contribute data to the NMUS
Participating private hospitals for allowing access their medicines procurement data
Pharmaniaga Sdn Bnd for assistance in downloading MOH procurement data
The National Pharmaceutical Control Bureau, Primary Care Division, Procurement Division, all of the MOH,
for valuable assistance
The Malaysian Royal Custom Service for permission to download pharmaceutical import data
The Malaysian Medical Council, Malaysian Medical Association, The Academy of Family Physicians, Primary
Care Doctors Association Malaysia, Malaysian Dental Association, Malaysian Private Dental Practitioner’s
Association, and the Malaysian Pharmaceutical Society, University Malaya Medical Centre, Hospital University
Kebangsaan and Hospital Universiti Sains for supporting this project.
&
All who have in one way or another supported and/or contributed to the success of the NMUS and this report
Dr. Zaki Morad
Chairman
Mr. Lai Lim Swee
Co-Chairman
iv
v
PARTICIPANTS OF THE NATIONAL MEDICINES USE SURVEY
Hospitals participating in NMUS survey
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47.
MOH Hospitals
Hospital Daerah Lundu
Hospital Alor Gajah
Hospital Alor Setar
Hospital Ampang
Hospital Bahagia
Hospital Balik Pulau
Hospital Baling
Hospital Banting
Hospital Batu Gajah
Hospital Batu Pahat
Hospital Bau
Hospital Beaufort
Hospital Beluran
Hospital Bentong
Hospital Besar Sultanah Aminah
Hospital Besut
Hospital Betong
Hospital Bintulu
Hospital Bukit Mertajam
Hospital Changkat Melintang
Hospital Daerah Lawas
Hospital Daro
Hospital Dungun
Hospital Gerik
Hospital Gua Musang
Hospital Hulu Terengganu
Hospital Ipoh
Hospital Jasin
Hospital Jelebu
Hospital Jeli
Hospital Jengka
Hospital Jerantut
Hospital Jitra
Hospital Kajang
Hospital Kampar
Hospital Kanowit
Hospital Kapit
Hospital Kemaman
Hospital Keningau
Hospital Kepala Batas
Hospital Kinabatangan
Hospital Kluang
Hospital Kota Belud
Hospital Kota Marudu
Hospital Kota Tinggi
Hospital Kuala Kangsar
Hospital Kuala Krai
48.
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Hospital Kuala Kubu Bharu
Hospital Kuala Lipis
Hospital Kuala Lumpur
Hospital Kuala Nerang
Hospital Kuala Pilah
Hospital Kuala Terengganu
Hospital Kudat
Hospital Kulim
Hospital Lahad Datu
Hospital Langkawi
Hospital Likas
Hospital Limbang
Hospital Machang
Hospital Marudi
Hospital Melaka
Hospital Mersing
Hospital Mesra
Hospital Miri
Hospital Muadzam Shah
Hospital Muar
Hospital Mukah
Hospital Pakar Sultanah Fatimah
Hospital Papar
Hospital Parit Buntar
Hospital Pasir Mas
Hospital Pekan
Hospital Permai
Hospital Pontian
Hospital Port Dickson
Hospital Pulau Pinang
Hospital Putrajaya
Hospital Queen Elizabeth
Hospital Raja Perempuan Zainab (Hospital
Kota Bahru)
Hospital Ranau
Hospital Raub
Hospital Sandakan(Hospital Duchess of Kent)
Hospital Saratok
Hospital Sarikei
Hospital Seberang Jaya
Hospital Segamat
Hospital Selama
Hospital Selayang
Hospital Semporna
Hospital Sentosa
Hospital Serdang
Hospital Seremban
Hospitals participating in NMUS survey
#
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MOH Hospitals
Hospital Seri Manjung
Hospital Serian
Hospital Setiu
Hospital Sibu
Hospital Sik
Hospital Simunjan
Hospital Sipitang
Hospital Slim River
Hospital Sri Aman
Hospital Sungai Bakap
Hospital Sungai Buluh
Hospital Sungai Petani
Hospital Sungai Siput
Hospital Taiping
Hospital Tambunan
Hospital Tampin
Hospital Tangkak
Hospital Tanjung Karang
Hospital Tapah
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Hospital Tawau
Hospital Teluk Intan
Hospital Temenggung Seri Maharaja Tun
Ibrahim
Hospital Temerloh
Hospital Tengku Ampuan Afzan ( Hospital
Kuantan)
Hospital Tengku Ampuan Jemaah Sabak
Bernam
Hospital Tengku Ampuan Rahimah Klang
Hospital Tengku Anis, Pasir Putih
Hospital Tenom
Hospital Tuanku Fauziah
Hospital Tumpat
Hospital W.P Labuan
Hospital Yan
Institut Perubatan Respiratori
Rajah Charles Brooke Memorial Hospital
Sarawak General Hospital
University Hospitals
Hospital Universiti Kebangsaan Malaysia
University Malaya Medical Centre
Hospital Universiti Sains Malaysia
Armed Forces Hospitals
Lumut Armed Forces Hospital
Terendak Armed Forces Hospital
Private Hospitals
16.
17.
18.
19.
Johor Specialist Hospital
Puteri Specialist Hospital
Medical Specialist Centre (JB) SB
Putra Medical Centre
Hospital Pantai Ayer Keroh
Columbia Asia Medical Centre
Hospital Pantai Mutiara
Gleneagles Medical Centre
Island Hospital
Lam Wah Ee Hospital
Penang Adventist Hospital
Tanjung Medical Centre
Kuantan Medical Centre
Kuantan Specialist Hospital
Hospital Pantai-Putri
20.
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Sabah Medical Centre
Timberland Medical Centre
Columbia Asia Medical Centre
Pantai Klang Specialist Medical Centre Sdn
Bhd
Damansara Specialist Hospital
Sunway Medical Centre
Darul Ehsan Medical Centre
Subang Jaya Medical Centre
Hospital Pantai Indah
Institut Jantung Negara Sdn Bhd
Pantai Cheras Medical Centre
Pantai Medical Centre
Hospital Pusrawi Sdn. Bhd
Taman Desa Medical Centre
Primary Care Clinics participating in NMUS survey
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MOH Clinics
Klinik Kesihatan Kuala Lumpur
Poliklinik Komuniti Petaling Bahagia
Poliklinik Komuniti Sungai Besi
Poliklinik Komuniti Jinjang
Poliklinik Komuniti Dato Keramat
Poliklinik Komuniti Kampung Pandan
Poliklinik Komuniti Cheras Baru
Poliklinik Komuniti Cheras
Poliklinik Komuniti Tanglin
Poliklinik Komuniti Pantai
Poliklinik Komuniti Putrajaya
Poliklinik Komuniti Bandar Tun Razak
Poliklinik Komuniti Setapak
Poliklinik Komuniti Sentul
Poliklinik Komuniti Batu
KK Bagan
Klinik Pesakit Luar Johor Bahru, Jln
Mahmoodiah
Poliklinik Komuniti Taman Tun Aminah
Poliklinik Komuniti Pasir Gudang
Poliklinik Komuniti Simpang Renggam
Poliklinik Komuniti Layang-Layang
Poliklinik Komuniti Bandar Mas
Poliklinik Komuniti Sening
Poliklinik Komuniti Bandar Penawar
Poliklinik Komuniti Pagoh
Klinik Kesihatan Bakri
Poliklinik Komuniti Parit Ismail
Poliklinik Komuniti Bekok
Poliklinik Komuniti Guar Chempedak
Poliklinik Komuniti Banai
Poliklinik Komuniti Serdang
Poliklinik Komuniti Lunas
Jabatan Peasakit Luar Hospital Alor Setar
Poliklinik Komuniti Sungai Tiang
Poliklinik Komuniti Jeniang
Poliklinik Komuniti Cabang 3 Perol
Poliklinik Komuniti Kubang Kerian
Poliklinik Komuniti Balai
Poliklinik Komuniti Kemendore
Poliklinik Komuniti Peringgit
Poliklinik Komuniti Ujong Pasir
Klinik Kesihatan Simpang Empat, Alor Gajah
Poliklinik Komuniti Pertang
Poliklinik Komuniti Palong 7&8 (Felda)
Poliklinik Komuniti Seri Jempol
Poliklinik Komuniti Pedas
Poliklinik Komuniti Kuala Tembeling
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Klinik Pesakit Luar Jalan Lim Hoe Leck,
Kuantan
Poliklinik Komuniti Beserah
Poliklinik Komuniti Jaya Gading
Poliklinik Komuniti Bandar Tun Abdul Razak
Poliklinik Komuniti Kemayan
Poliklinik Komuniti Bayan Lepas
Poliklinik Komuniti Butterworth
Poliklinik Komuniti Kepala Batas
Poliklinik Komuniti Penaga
Klinik Kesihatan Nibong Tebal
Poliklinik Komuniti Jalan Damai Tapah
Poliklinik Komuniti Bagan Datoh
Poliklinik Komuniti Lenggong
Poliklinik Komuniti Lawin
Poliklinik Komuniti Kuala Kurau
Poliklinik Komuniti Kuala Kangsar
Poliklinik Komuniti Manong
Poliklinik Komuniti Lintang
Poliklinik Komuniti Taiping
Poliklinik Komuniti Kuala Sepetang
Poliklinik Komuniti Kangar
Poliklinik Komuniti Weston
Poliklinik Komuniti Sunsuron
Klinik Kesihatan Luyang
Poliklinik Komuniti Sikuati
Poliklinik Komuniti Kuala Sapi
Poliklinik Komuniti Tuaran Jabatan Pesakit
Luar
Poliklinik Komuniti Tatau
Poliklinik Komuniti Jalan Masjid Kuching
Poliklinik Komuniti Kota Sentosa
Poliklinik Komuniti Long Lama
Poliklinik Komuniti Betanak
Poliklinik Komuniti Julau
Poliklinik Komuniti Batu Arang
Poliklinik Komuniti Kajang
Poliklinik Komuniti Ampang
Poliklinik Komuniti Bandar Baru Bangi
Poliklinik Komuniti Rasa
Poliklinik Komuniti Telok Datok
Poliklinik Komuniti Bandar
Jabatan Pesakit Luar Tanjung Karang
Poliklinik Komuniti Kuala Selangor
Poliklinik Komuniti Seri Kembangan
Poliklinik Komuniti Puchong
Poliklinik Komuniti Shah Alam
Poliklinik Komuniti Sungai Besar
Poliklinik Komuniti Sungai Pelek
#
MOH Clinics
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Poliklinik Komuniti Jerteh
Poliklinik Komuniti Kg. Raja Besut
Poliklinik Komuniti Kuala Berang
Poliklinik Komuniti OPD Hospital Kuala Terengganu
Poliklinik Komuniti Hiliran
Poliklinik Komuniti Jengka 22
Klinik Kesihatan Cinta Sayang
Private Clinics
39.
40.
41.
42.
43.
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45.
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47.
48.
49.
Klinik J.D.
Dr Amir Abbas-Kma Sdn Bhd
Ing Insurance Berhad In-House Clinic
Klinik Harun
ASP Medical Clinic
Drs Abraham George & Partners
Drs Young Newton & Partners
Klinik Aishah
Klinik Baba
Klinik Bandar Raya
Klinik K J Lim, Off Jln Genting Kelang
Klinik K J Lim, Gombak
Klinik Leow
Klinik Everlasting Sdn Bhd
Klinik Thean
Klinik Wong
Drs Young Newton & Rakan Rakan, Jalan
Ampang
Kelinik Thurai
Klinik Ahmad Nizam & Surgeri
Klinik Desa Jaya
Klinik Gunn
MAA In House Clinic
Vaithiyanathan Clinic
Klinik Imbi
Klinik Bakti
Healthcare Medical Centre
Klinik Sri Permaisuri
Medi-Klinik Lee, Goh & Rakan Rakan
Klinik dan Surgeri Ng
Klinik Desa
Klinik Hsu Dan Ng
Chye Clinic
Horeb Sdn Bhd, Jalan Ampang
Horeb Sdn Bhd, Leboh Ampang
Klinik Kucai
Klinik Dr Hamid
Poliklinik Chew & Rakan - Rakan
Klinik Catterall Khoo
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Poliklinik Dr Norliza
Klinik K I P Sdn Bhd
Klinik Mediviron Sri Damansara
Klinik Chang
Klinik Maniraj
Klinik Leong
Reddy Klinik
Jose Clinic & Surgery
Dispensary Martin Dan Lalitha
Klinik Ramabai & Surgeri Sdn Bhd
Drs Young Newton & Rakan-Rakan, Jalan
Stesen Sentral
Klinik Shafi
Klinik & Surgeri Uni-Sentul
Klinik T.A.R.
Poliklinik Central & Surgeri Sdn Bhd
Poliklinik Sg. Besi
Klinik Ian Ong
Klinik Low
Klinik Dan Surgeri Sri Damansara
Poliklinik Ludher
Dr Leela Ratos Dan Rakan - Rakan (Pudu)
Sdn Bhd
Klinik Care Poliklinik Dan Surgeri
Poliklinik Seri Mas
Poliklinik East Asia
Klinik Bukit Maluri & Surgeri
Klinik Medisquare
Klinik Tan
Klinik TA
Bakti Healthcare - NSTP
Klinik Medimetro
Drs Fateh, Mydin Dan Rakan-Rakan
Poliklinik & Surgeri
Klinik Primecare
Klinik Setapak & Surgeri
Klinik Medi Al-Hilmi
Klinik Chew
#
74.
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
91.
92.
93.
94.
95.
96.
97.
98.
99.
100.
101.
102.
103.
104.
105.
106.
107.
108.
109.
110.
111.
112.
113.
114.
115.
116.
117.
118.
119.
Private Clinics
Klinik Shankar Sdn Bhd
Klinik Perkasa
Klinik Kaulsay
Jaya Clinic
Klinik Reddy
Klinik Senan
Poliklinik Central & Surgeri
The KL Clinic
Poliklinik Kong
Klinik Setia
Poliklinik Lai
Poliklinik Kumpulan City
Klinik Medic Bestari
Klinik Sharani
Klinik Dr Shashikala Sdn Bhd
Care Clinic Pudu
Medi-Klinik Lee, Goh & Rakan -Rakan
Kumpulan Medi-Systems Sdn Bhd
Klinik Catterall, Khoo And Raja Malek
Klinik Medi-Pro
Klinikah Sdn Bhd
Klinik Mediviron(Sentul Raya)
Klinik Raja
Klinik Mitter Dan Rakan -Rakan
Klinik Aminah
Leela Ratos Dan Rakan-Rakan
Poliklinik Meranti
Drs Young Newton & Rakan-Rakan, Pusat
Bandar Damansara
Klinik Arun
Klinik Hamidah
Klinik Famili Wangsa Melawati
Klinik Khairat
Klinik Oziar Darus
Klinik Pakatan Medik
Klinik Fateh Mohd & Rakan-Rakan
Klinik Choo
Dr Mohamed Mydin & Rakan-Rakan Sdn
Bhd
Klinik Alam Medic - Oug
Klinik Family TTDI
Klinik Lee dan Chia
Klinik Leong
Klinik Reddy Pudu
Klinik S K Leong
Klinik Zain & Zakaria
Poliklinik Siti Fatimah
Pusat Rawatan Islam - MAIS
120.
121.
122.
123.
124.
125.
126.
127.
128.
129.
130.
131.
132.
133.
134.
135.
136.
137.
138.
139.
140.
141.
142.
143.
144.
145.
146.
147.
148.
149.
150.
151.
152.
153.
154.
155.
156.
157.
158.
159.
160.
161.
162.
163.
164.
165.
166.
x
Klinik Faiza Woon
Dr Oorloff, Rajakumar & Partners
Klinik Al Ikhwan
Klinik Boon
Klinik Idzham
Klinik Jayaraman
Klinik Keluarga Dr. Hj Mohd Khadzali
Klinik Maamor
Klinik Nathan
Klinik Segara
Klinik Tan & Appaduray
Clinic Wellness Lab
Klinik Setapak Dan Surgeri
Klinik Bakti
Poliklinik Subasari Dan Gan
Poliklinik Dan Surgeri Ren-Ai
Klinik Dr Rahim Omar & Rakan-Rakan
Global Doctors (Malaysia) Sdn Bhd
Klinik City
Klinik Indah
Sundaram Dispensary
Klinik Anthony
Kiara Medical Clinic
Horeb Sdn Bhd, Jln P Ramlee
WCL Medical Associates Sdn Bhd
Klinik Medicare
Poliklinik Dan Surgeri Khor
Klinik Ludher S/B
Klinik Idzham Sdn Bhd
Klinik Raj & Rakan-Rakan
Poliklinik Dan Surgeri Di-G
Pusat Rawatan Desa Pandan
Poliklinik Central
Klinik Reddy Setapak
Klinik Setiajaya
Klinik Idzham Sdn Bhd
Klinik Sannasees
Klinik Rahman
Poliklinik Soo & Tan
Klinik Rakyat
Yuli Poliklinik & Surgeri Sdn Bhd
Klinik Tan See Kin
Klinik Templer
Klinik Mediviron Sri Hartamas
Klinik Raj dan Rakan Rakan
Klinik Fauziah dan Rakan-Rakan
Poliklinik Yazmeen & Mahanum
#
167.
168.
169.
170.
171.
172.
173.
174.
175.
176.
177.
178.
Private Clinics
Poliklinik Rani
Klinik Akashah
Poliklinik Medics
Klinik Sundram
Poly Klinik dan Surgery Kampung Pandan
Aman Putri Dispensary
Klinik Primecare
Klinik Utama
Klinik Murugasu
Klinik Meena
Kumpulan Medic Brickfields
Dr Mohamed Mydin & Rakan-Rakan Sdn
Bhd.
179.
180.
181.
182.
183.
184.
185.
186.
187.
188.
Poliklinik Healthsense
Kelinik S Suren
Klinik & Surgeri Gill
Klinik Medi-Pro
Klinik Kok dan Segeri
Dispensari Sharil
Klinik K. H. Ong
Klinik Keluarga
Klinik Mediviron Brickfields
Klinik Medi Pembangunan
19.
20.
Guardian Kepong, Kuala Lumpur, Kepong
Guardian Lot 10 Shopping Centre,
Jalan Sultan Ismail
Guardian Lucky Garden, Bangsar, Lucky
Garden, Bangsar
Guardian Maju Junction Shopping Centre,
Jalan Sultan Ismail
Guardian Mid Point Pandan Indah, Pandan
Indah
Guardian OUG Plaza, Kuala Lumpur,
Old Klang Road
Guardian Pearl Point Shopping Mall,
Old Klang Road, KL
Guardian Suria KLCC, Kuala Lumpur,
Jalan Ampang
Guardian Taman Danau Desa, Jln 3/109F,
Taman Danau Desa
Guardian Taman Permata, Ulu Klang , Ulu
Kelang
Guardian Taman Tun Dr Ismail, Kuala
Lumpur
Guardian The Weld, Kuala Lumpur,
Jalan Raja Chulan
Guardian University Hospital, Kuala Lumpur,
Lembah Pantai
Farmasi Komuniti UKM
Pharmacies participating in NMUS survey
#
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Private Pharmacies
Farmasi Abc Sdn Bhd, Taman Maluri,
Kuala Lumpur
Farmasi Abc Sdn Bhd, Pandan Indah,
Kuala Lumpur
Farmasi Kepong
Farmasi Maxheal Sdn. Bhd
Farmasi Vitacare Sdn Bhd-Tmw
Plaza Pharmacy Sdn Bhd
Pharmway Sdn Bhd Sdn Bhd
Guardian Alpha Angle, Kuala Lumpur,
Wangsa Maju
Guardian Ampang Park Shopping Centre,
Jalan Ampang
Guardian Bandar Sri Damansara,
Kuala Lumpur , Bandar Sri Damansara
Guardian Bangsar Baru, Kuala Lumpur,
Jalan Telawi 5, Bangsar Baru
Guardian BB Plaza, Kuala Lumpur,
Jalan Bukit Bintang
Guardian Carrefour Wangsa Maju, Wangsa
Maju
Guardian Desa Sri Hartamas, Desa Sri
Hartamas
Guardian Endah Parade, Kuala Lumpur,
Sri Petaling
Guardian Great Eastern Mall , Jalan Ampang
Guardian Jalan Tun Perak, Kuala Lumpur
Guardian Jusco Metro Prima Kepong, Kepong
xi
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
ABOUT THE NATIONAL MEDICINES USE SURVEY
The National Medicines Survey (NMUS) is a service initiated and supported by the Ministry of Health (MOH) to
collect information on the supply, procurement, prescription, dispensing and use of drugs in Malaysia. The NMUS
is designed to support the implementation of our proposed National Medicines Policy (NMP). The objectives of
NMP are to ensure only safe, efficacious and good quality medicines are available for use in Malaysia, as well as
to promote equitable access to, rational and cost-effective use of these medicines, ultimately leading to improved
health for all Malaysians. In supporting this, the NMUS provides the functional capacity for the collection,
analysis, reporting and dissemination of data on drug utilisation in Malaysia
Sponsors and Governance of the NMUS
The NMUS is jointly sponsored by Pharmaceutical Services Division and the Clinical Research Centre, Ministry
of Health.
A Governance Board is established to oversee the operations of the NMUS. Governance via a Board is necessary
to ensure that the NMUS meets the needs and expectations of all interested parties, and thereby to assure the
continuing relevance and justification of the NMUS. All major groups involved in pharmaceutical issues in
Malaysia such as the MOH, Universities, professional bodies, private healthcare providers and the pharmaceutical
industry are represented on this board. The board also works as a consultative forum and provide advice on issues
pertaining to the NMUS and other aspects of the quality use of medicines.
Purpose of the NMUS
The availability of high quality, reliable and timely information on medicines use is crucial for any discussion on
improving the use of medicines in Malaysia.
The objective of the NMUS is therefore to quantify the present state and time trends of medicines utilization at
various level of our health care system, whether national, regional, local or institutional.
Routinely compiled statistics on medicines utilization have many uses, such as to:
1.
Estimate the number of medicine users overall, by age, sex and geography and over time
2.
Estimate on the basis of known disease epidemiology to what extent medicines are under or over-used.
3.
Describe pattern of medicines use through assessing which alternative drugs are being used for particular
conditions and to what extent.
4.
Relate the number of adverse drug reactions reported to our pharmacovigilance system to the number of
people exposed to the drug in order to assess the magnitude of the problem, or to estimate the degree of
under-reporting of adverse events
5.
Provide a crude estimate of disease prevalence based on its prescription rate.
6.
Estimate expenditure on pharmaceuticals, which constitutes a significant proportion of our healthcare
expenditure.
7.
Monitor and evaluate the effects of interventions to improve the use of medicines. These interventions may
be educational effort, promotional campaign, formulary restriction, medicines reimbursement scheme or
regulatory measures.
xii
NMUS GOVERNANCE BOARD
CHAIRMAN:
Dato’ Dr Zaki Morad b Mohd Zaher
CO- CHAIRMAN:
Mr Lai Lim Swee
MEMBERS
Medical services of the MOH
Dato’ Dr Zaki Morad b Mohd Zaher
Pharmaceutical services MOH
Mr Lai Lim Swee
Drug Control Authority
Ms Eishah bt Abd Rahman
Clinical Research Centre
Dr Lim Teck Onn
Primary Care Division
Ms Sahidah Said
Procurement Division
Mr Abdullah Abdul Rahman
Malaysian Medical Council
Prof Dr Raymond Ali
Malaysian Pharmaceutical Society
Ms Usha Rajasingam
The Academy of Family Physicians of Malaysia
Dr Mohd Husni B Jamal
Primary Care Doctors Organisation Malaysia
Dr Molly Cheah
Malaysian Medical Association
Dr M. Ponnusamy A/L Muthaya
Malaysian Dental Association
Dr Shubon Sinha Roy
Malaysian Private Dental Practitioner’s Association
Dr Nedunchelian Vengu
Association of Private Hospitals Malaysia
Dr T. Mahadevan
Malaysian Organisation of Pharmaceutical Industries
Mr Jimmy Piong
Pharmaceutical Association of Malaysia
Mr Tom Hart
University Malaya Medical Centre
Prof Liam Chong Kin
Hospital University Kebangsaan Malaysia
Prof Dr Mohammad Abdul Razak
Hospital Universiti Sains Malaysia
Dr Zaidun Kamari
Universiti Sains Malaysia
Prof Madya Dr Mohamed Izham b Mohamed Ibrahim
xiii
MEMBERS OF NMUS EXPERT PANELS
Expert Panel
1
Anti- Hypertensives, Steroid & Immunosuppressive, Renal Therapeutics
Members
Institution
Dato Dr Zaki Morad (Chairman)
Department of Nephrology,
Kuala Lumpur Hospital
2
3.
4
Dr Lim Teck Onn
CRC, Kuala Lumpur Hospital
Dr Rozina Ghazalli
Medical Department, Penang Hospital
Ms Sahida bt Said
Primary Health Care Division MOH
Ms Siti Shahida Md. Shariffudin
Pharmacy, Kuala Lumpur Hospital
Anti- Diabetics, Endocrine therapeutics
Members
Institution
Dr G. R. Letchuman Ramanathan (Chairman)
Medical Department, Ipoh Hospital
Ms Ernieda bt. Md Hatah
Pharmacy, Putrajaya Hospital
Dr Muruga Vadivale
Sanofi Aventis
Prof Dr.S.P.Chan
Faculty of Medicine, University Malaya
Dr Selva Malar Rasiah
Out Patient Clinic, Kuantan
Dr Zanariah Hussein
Medical Department, Putrajaya Hospital
Ms Loh Kiaw Moi
Xepa-Soul Pattinson
Dr Ariza Zakaria
Dr Yap Piang Kian
Subang Jaya Medical Centre
Ms Oiyammal Chelliah
Pharmacy, Penang Hospital
Dr Badrulnizam
Medical Department, Putrajaya Hospital
Anti-Lipidaemia and Cardiovascular therapeutics
Members
Institution
Dato Dr Khoo Kah Lin (Chairman)
Klinik Dr Khoo Kah Lin
Dr Tamil Selvan Muthusamy
Damansara Specialist Hospital
Prof Dr Sim Kui Hian
Dept of Cardiology, Sarawak General Hospital
Ms Chai Swee Chin
Dr Selvarajah Sathaya
Klinik Prime Care
Dr. Mohd Husni B Jamal
Governance Board
Ms Noraini bt. Mohamad
Pharmacy, Putrajaya Hospital
Dr David Quek Kwang Leng
Dr Quek Specialist Heart Clinic
Antineoplastic, Oncology
Members
Institution
Ms Lim Yeok Siew (Chairman)
Pharmacy Division Kuala Lumpur Hospital
Dr Beena Devi
Dept of Radiotherapy & Oncology,
Sarawak General Hospital
xiv
4
Expert Panel
Antineoplastic, Oncology
Members
Institution
Ms Kamarun Neasa Begam
Ms Nik Nuradlina Nik Adnan
Ms Sujatha Suthandiram
Pharmacy, Tengku Ampuan Rahimah Hospital,
Klang
5.
6.
7
Ms Tajunisah bt. M. Eusoff
Ms Yuzlina Muhamad Yunus
Dr Kananathan Ratnavelu
NCI Cancer Hospital
Dr S. Visalachy PuruShotaman
Hematology Dept, Kuala Lumpur Hospital
Dr Gucharan Singh
Damansara Specialist Centre
Antiinfectives
Members
Institution
Dr Tan Kah Kee (Chairman )
Dept of Paediatrics, Seremban Hospital
Ms Sameerah bt. Shaikh Abdul Rahman
Pharmaceutical Services Division MOH
Ms Rahela Ambaras Khan
Dr Victor Chuang Tuan Giam
Pharmacy, University Kebangsaan Malaysia
Ms Usha Rajasingam
Bio Collagen Tech Sdn Bhd
Ms Zuhaila bt. Muhamad Ikbar
Dr Sharmini Selvarajah
University of Malaya
Ms Rohaizan bt Mohd Hanafiah
Ms Yuen Shalyn
Musculo-skeletal therapeutics
Members
Institution
Dato’ Dr Ramanathan A/L Ramaiah (Chairman)
Orthopaedics Dept, Ipoh Hospital
Dr Lee Chee Kuan
Dr Manmohan Singh
Ms Jennifer Tan
Farmasi Alychem
Ms Suhadah Ahad
Pharmacy, Melaka Hospital
Analgesic and Anaesthetics
Members
Institution
Dr Mary S.Cardosa (Chairman)
Dept of Anaesthesiology, Selayang Hospital
xv
8
9.
10
Expert Panel
Psychiatric therapeutics
Members
Institution
Dr Suraya Yusoff (Chairman)
Psychiatric Dept, Sultanah Aminah Hospital JB
Mr Syed Fadzli bin Syed Sailuddin
Phamaceutical Services Division MOH
Ms Noor Ratna bt. Naharuddin
Pharmacy, Permai Hospital JB
Ms Mariam Bintarty Rushdi
Pharmacy, Hospital Kuala Lumpur
Ms Tengku Malini Tg.Mohd.Noor Izam
Pharmacy, Hospital Kuala Lumpur
Dr Ahmad Hatim Sulaiman
Dept of Psychological Medicine UM
Dr Benjamin Chan Teck Ming
Permai Hospital
Dr Suarn Singh A/L Jasmit Singh
Hospital Bahagia
Dr Zoriah bt. Aziz
Pharmacy UM
Respiratory therapeutics
Members
Institution
Dr Norzila Zainuddin (Chairman)
Department of Paediatric, Kuala Lumpur Hospital
Dr Molly Cheah
Governance Board (PCDOM)
Ms Nurdita bt. Hisham
Pharmacy, Seremban Hospital
Ms Rahayu bt. Shahperi
Ms Sarina Anim bt. Mohd. Hidzir
Outpatient Department Sg Buluh
Datin Dr Aziah Ahmad Mahayiddin
Institute of Respiratory Medicine
Pharmaco-economics
Members
Institution
Dr Shanthi Varatharajan (Chairman)
Institute for Health Management
Dr Lim Teck Onn
Ms Rosminah bt. Mohd. Din
Adrian Goh
Dr Leong Kwok Chi
Klinik Leong
Dr Nour Hanah bt. Othman
Planning and Development Division MOH
En Chua Kee Long
Planning and Development Division MOH
Lee Kin Kok
xvi
NMUS STAFF
NMUS Project Staff
Project Leader
Dr Sarojini Sivanandam
Clinical Research Manager
Dr Lim Chiao Mei
Pharmacist Liaison
Mr Syed Fadzli Syed Sailuddin
Clinical Research Coordinator
Ms Esther Yong
Ms Ang Swee Ling
Ms Lee Kim Tin
Research Assistants
Ms Raihan bt Mohd Raimee
Ms Aida Baharuddin
Technical Support Staff
Pharmaco-Epidemiologist
Dr Sharmini Selvarajah
Ms Yuen Shalyn
Ms Chai Swee Chin
Ms Sameerah binti Sheik Abdul Rahman
Dr Nour Hanah binti Othman
Ms Rosminah binti Md Din
Ms Hasnizan binti Hazan
Ms Zaiton Kamaruddin
Economist
Mr Adrian Goh
Statistician
Ms Teh Poh Geok
Ms Raja’ah binti Meor Yahyauddin
IT Manager
Ms Celine Tsai Pao Chien
Database Developer/ Administrator
Ms Tang Roh Yu
Mr Patrick Lum See Kai
Ms Lim Jie Ying
Mr Sebastian Thoo
Network Administrator
Mr Kevin Ng Hong Heng
Mr Adlan Ab Rahman
Desktop Publisher
Ms Azizah Alimat
Webmaster
Mr Patrick Lum See Kai
xvii
CONTENTS
FOREWORDS ....................................................................................................................... i
PREFACE .............................................................................................................................. iii
ACKNOWLEDGEMENTS ................................................................................................ iv
PARTICIPANTS OF THE NATIONAL MEDICINES USE SURVEY .................... vi
ABOUT THE NATIONAL MEDICINES USE SURVEY ............................................ xii
NMUS GOVERNANCE BOARD ...................................................................................... xiii
MEMBERS OF NMUS EXPERT PANELS .................................................................... xiv
NMUS STAFF ......................................................................................................................... xvi i
CONTENTS ............................................................................................................................ xviii
METHODS .............................................................................................................................. xix
ABBREVIATIONS ................................................................................................................ xxvii
Chapter 1: Use of Medicines in Malaysia ..................................................................................
Chapter 2: Expenditure on Medicines in Malaysia ....................................................................
Chapter 3: Use of Drugs for Acid Related Disorders [Reserve] ................................................
Chapter 4: Use of Antiobesity Medicines [Reserve] ..................................................................
Chapter 5: Use of Antidiabetics .................................................................................................
Chapter 6: Use of Antianaemic Drugs [Reserve] .......................................................................
Chapter 7: Use of Antihaemorrhagic Drugs [Reserve] ..............................................................
Chapter 8: Use of Drugs for Cardiovascular Disorders .............................................................
Chapter 9: Use of Antihypertensives .........................................................................................
Chapter 10: Use of Lipid Lowering Medicines ..........................................................................
Chapter 11: Use of Dermatologicals [Reserve] ..........................................................................
Chapter 12: Use of Gynaecologicals, Sex Hormones and Hormonal Contraceptives [Reserve]
Chapter 13: Use of Urologicals [Reserve] .................................................................................
Chapter 14: Use of Drugs for Endocrine Disorders [Reserve] ..................................................
Chapter 15: Use of Antiinfectives ..............................................................................................
Chapter 16: Use of Antineoplastic Agents .................................................................................
Chapter 17: Use of Systemic Corticosteroids and Immunosuppressive Agents [Reserve] ........
Chapter 18: Use of Drugs for Rheumatological and Bone Disorders ........................................
Chapter 19: Use of Analgesics and Anaesthetics [Reserve] .......................................................
Chapter 20: Use of Drugs for Neurological Disorders [Reserve] ..............................................
Chapter 21: Use of Drugs for Psychiatric Disorders ..................................................................
Chapter 22: Use of Drugs for Obstructive Airway Diseases ......................................................
Chapter 23: Use of Antihistamines & Nasal Decongesants [Reserve] .......................................
Chapter 24: Use of Ophthalmologicals [Reserve] ......................................................................
Chapter 25: Use of Otologicals [Reserve] ..................................................................................
xviii
1
5
7
7
9
13
13
15
21
27
31
31
31
31
33
45
47
49
55
55
57
65
69
69
69
METHODS
Introduction
The NMUS is designed, broadly speaking, to estimate the quantity and pattern of use of medicines in Malaysia,
as well as to estimate our expenditure on pharmaceutical. This is an ambitious project, which requires multiple
surveys at the various levels of the medicines supply and distribution chain in the country (Figure 1) in order
to capture all the required data to meet its purpose. Clearly, all these could not be accomplished overnight, and
of necessity must be undertaken in phases. We had realistically targeted data sources that are absolutely critical
and/or accessible initially, while piloting less accessible ones, and leaving the most inaccessible data sources for
the future, hoping to build on the foundation laid by earlier surveys as well as to capitalize on early successes.
Figure 1: Medicines supply & distribution system and Sources of
medicines data
Manufacturer/ Importer
Distributor
Purchaser
Hospital
Primary care/ GP
Pharmacy
Consumer
Hence, the statistics on medicines use and expenditure in this report are estimated based on data from only a
limited number of surveys (though they were the critical ones) that could be successfully completed nation-wide
or on a more local pilot basis. The scope was also deliberately limited to prescription only medicines (obviously
the pharmaceuticals of greatest interest) and excludes Over-the-Counter (OTC) medicines, traditional or herbal
products and food supplements. No doubt, the NMUS will mature over time as coverage of existing nationwide surveys broaden, local pilot surveys are rolled out nation-wide, and presently less accessible data sources
become available. Over time, we should be able to provide more accurate and reliable estimates, as well as more
informative and detailed analyses.
xix
NMUS Surveys
The NMUS conducts several surveys in order to capture data at the various levels of the medicines supply and
distribution system in the country. The sources of data, surveys to collect the data, data availability, comment on
data inclusion in this report are summarized in the table below.
# Data sources and Surveys
Year data
Inclusion in
available
present report
1. Medicines import or production data
1.1 Medicines import data from Royal Malaysian Custom
2004, 2005
No
1.2 Local pharmaceutical manufacture
Data not collected
No
2. Domestic sales data
2.1 Domestic sales data from local pharmaceutical Failed to collect
No
companies
the data
3. Medicines procurement data
3.1 Public hospitals’ medicines procurement data from
several sources:
a. MOH procurement through central tender
2001 to 2005
Yes
b. MOH individual hospitals’ local purchase
2001 to 2005
Yes
c. University and Armed forces hospitals’ procurement
2004
Yes
3.2 Private hospitals procurement
2000 to 2004
Yes
3.3 Private GPs procurement
Not done yet
No
3.4 Private specialist practice procurement
Not done yet
No
3.5 Private pharmacies’ procurement
Not done yet
No
4. Medicines prescription data
4.1 Public (MOH) primary care practice prescription
2005
Yes
Pilot survey limited to WP only
4.2 Private GP prescription
2005
Yes
4.3 Private specialist practice prescription of highly
Not done yet
No
specialized medicines
4.4 Hospital practice prescription
Data not collected
No
5. Medicines dispensing data
5.1 Public hospital pharmacy dispensing
Data not collected
No
5.2 Private free-standing retail pharmacy dispensing
2005
Yes
6. Household medicines consumption data
6.1 Household survey on medicines consumption
Not done yet
No
Thus, the statistics presented in this report are derived from only a limited number of data sources. As shown
above:
• Of the 6 theoretical data sources, NMUS primarily targeted data sources on medicines procurement and
prescription.
• Collection of prescription data is limited to clinic practices, while hospital prescription is assumed to be
included in hospital procurement data
• Many private medical specialists however may self-procure and dispense, rather than use hospital pharmacy
dispensing service. Hence, separate procurement and prescription survey on highly specialized medicines
are required, and are being piloted. Thus in so far that prescription of highly specialized medicines for a
particular condition is concentrated in private ambulatory specialist practices (unlikely as most are probably
prescribed in hospital setting), they will be under-estimated in this report
• Similarly, hospital dispensing data are assumed to be included in hospital procurement data, except of course
for private free-standing pharmacies. Dispensing survey is therefore limited to this only.
xx
•
It is well known that consumers do access medicines through both formal as well as informal channels.
Household survey will be required to obtain information on such use of medicine in the community.
Finally, medicines import data while not used for statistical estimation, are however used for cross-checking
the reliability of results estimated from the other data sources.
•
Survey population, sampling and response or coverage rate
The surveys conducted by NMUS, its survey population, its sampling unit and sample size, and the survey
response or coverage rates are summarized in the table below.
# Surveys
Survey population
Sample size
Coverage or response rate,
and sampling unit
and completeness
1. MOH Pharmaceutical
128 MOH hospitals
128 hospitals
100% for APPL
procurement
77 hospitals
60% for non-APPL
2. Private hospitals’
123 Private Hospitals
29 hospitals
23.6%
pharmaceutical
procurement
33% for University
3. University and Armed
3 University hospitals
1 University
Forces’ hospital
3 Armed Forces’
2 Armed Forces’
66% for Armed Forces
hospital
pharmaceutical
hospitals
procurement
4. MOH primary care
15 clinics in WP KL
15 clinics
100%
practice prescription
5. Private GP prescription 622 clinics in WP KL
188
30.2%
6. Private pharmacy
72 pharmacies in WP
32
44%
dispensing
KL
Data collection
The surveys conducted by NMUS collected the data either by
1. Download from existing databases
2. Primary data collection
These are described below.
# Surveys
Data download from existing databases
1. MOH Pharmaceutical procurement
Pharmaniaga pharmaceutical procurement databases,
central database as well as local individual hospitals’
databases.
2. Private hospitals’ pharmaceutical procurement Individual hospitals’ pharmaceutical procurement
databases
3. University and Armed Forces hospital Individual hospitals’ pharmaceutical procurement
pharmaceutical procurement
databases
# Surveys
4. MOH primary care practice prescription
5.
Private GP prescription
6. Specialist practice prescription
7.
Private pharmacy dispensing
Primary data collection
All MOH clinics in WP collected prescription data in a
randomly selected week half yearly
A sample of GPs collected prescription data in a randomly
selected week. The sample being distributed over two half
yearly cycle
All dialysis facilities collected data on prescription of
certain highly specialized medicines for all patients in
their facility at the end of each year
A sample of pharmacies with resident pharmacist collected
dispensing data in a randomly selected week. The sample
being distributed over two half yearly cycle.
xxi
Data management
The collected data, whether in downloaded databases or in paper or electronic data collection form must be
compiled into a single database, appropriately processed and coded prior to statistical analysis.
The NMUS database was created in Ms Access 2000. The application has 2 modules: Contact Management and
Data Entry.
• Contact Management module is used to collect the establishment survey details, log and track all the
correspondence documents with SDP, and forecast, plan and schedule the conduct of the survey.
• Data Entry module is used to collect the data submitted by the SDP in paper form. It has been designed to
collect data from GP prescription survey and pharmacy dispensing survey.
The database server is running on Windows 2000 Server. The server environment is Intel Xeon 2.4 Mhz, with a
total of 2GB RAM memory and 67.8GP Raid5 Hard disk
The data processing steps are as follows:
# Data processing for downloaded database
1. Data were downloaded from the existing database of the following data sources
• MOH APPL Procurement
• MOH non APPL Procurement
• Private Hospital
• GP Prescription
The data downloaded could be in flat file format, e.g. TXT/ XLS and etc, or database files such as Access/
Oracle/ SQL and etc.
2. The structure of each of the downloaded database/ data file would be studied and analyzed to identify the
required data fields/ variables. Sometimes the project team might have to consult the SDP to get a better
understanding of the data provided.
3.
Some of the required variables are drug registration number, drug description, packaging description,
supplier name, value procured, quantity procured, year procured and etc.
Next, the required fields/ variables would be extracted using SQL queries based on the understanding of
the database structure.
The extracted data each of the downloaded database/ data file would then be normalized by separating into
multiple, related tables in a single compiled database.
4. Data from some of the sources would require aggregation, e.g. total a few transactions on the same drug
into 1 record, to speed up subsequent query performance
5. The data would then be linked to the respective SDP in the main contact table.
#
1.
Data processing for primary survey data
Data entry
Data is entered into the Data Entry module of the database.
Prior to data entry, data entry personnel are briefed on how to use the database and enter the data. Necessary
precautions were given verbally for example to check each clinic by office id and name, as they are clinics
with many branches of the same name.
A demonstration was done on data entry during the briefing.
Personnels were supervised while doing the first few entries to make sure they know how to do it
correctly.
A standard document on steps/ precautions of data entry would be mailed to each personnel.
They are also given a softcopy of the list of pharmaceutical products (scheduled poison and non-scheduled
poison) obtained from National Pharmaceutical Control Bureau, to cross check the spellings of drugs when
the writing is less legible.
xxii
# Data processing for primary survey data
2. Edit checks
Survey forms are crosschecked against the database.
Selection of survey form is as follows:
a.
By data entry personnel: volume is 5% of total days entered by each individual
b.
Selection of which day and which SDP is random
c.
First five pages of the selected day are then checked.
Items to check:
a.
Number of patients are same in survey form and database
b.
Number of drug entry/ drug prescribed is same in survey form and database.
c.
Age, sex of patient is entered correctly.
d.
Drug particulars are entered correctly.
3. Calculations and Derived variables
• Dose per day is obtained by Dosage*frequency
• Dose per visit is obtained by Dosage*frequency* duration
4. Visual review and manual assessment of entries if they are misspellings.
#
1.
ATC Coding and Total Dosage Calculation
BPFK Registered Product List
An estimated 7000 poison products registered with NPCB were manually coded to 2005 ATC INN (Level
5). The coded NPCB drug list would serve as an internal drug dictionary for medicines data coding later.
2. Data Parsing and Standardization by programming
The variables ‘Drug description’ and ‘Packaging Description’ in medicines (procurement/ prescription/
dispensing) data are parsed and standardized into smaller parts using specially written computer program.
Parsing and standardization help facilitating auto coding process and dosage calculation later.
The variable ‘Drug description’ will be parsed and standardized into ‘Brand’, ‘INN’, ‘Dosage’, ‘Unit’ and
‘Route’
e.g. Zocor Tab 80 mg
Brand – Zocor
Inn – none
Dosage – 80
Unit- mg
Route – Oral (Tab)
3.
The variable ‘Packaging Description’ will be parsed into ‘Big Unit’, ‘Small Unit’ and ‘Factor’
e.g. Pack of 10 tabs
Big Unit – Pack
Small Unit – tabs
Factor – 10
ATC Coding by programming
• Drugs were automatically coded to ATC using specially written computer program
• The parsed ‘Brand’ would then be linked to the coded BPFK drug list to obtain the ATC INN and DDD.
However, if a certain brand has more than 1 DDD, the administration route has to be considered when
assigning the DDD.
• On the other hand, the parsed ‘INN’ would be linked to the ATC Level 5 to obtain the INN and DDD.
Similarly, if a certain INN has more than 1 DDD, the administration route has to be considered when
assigning the DDD.
• Visual review and manual coding of residual medicines data to ATC; most of these residual data are due
to incomplete or inconsistent data.
xxiii
# ATC Coding and Total Dosage Calculation
4. Drug Description Dosage and Unit Calculation by programming
The Drug Description Dosage and Unit would be the parsed ‘Dosage’ and ‘Unit’ unless more than 1 dosage
exists, e.g. 2MG/ML 100ML. This kind of data would require further processing.
The results of this step are ‘Total Drug Description Dosage’ and ‘Total Drug Description Unit’.
Remaining residual has been handled manually
5. Packaging Description Dosage Calculation by programming
The packaging description dosage would be taking the parsed ‘Factor’ and calculated with reference to the
‘SKU’ or ‘UOM’.
The result of this step is the ‘Total Packaging Description Dosage’
Remaining residual has been handled manually
6. Total Dosage Calculation by programming
Total Dosage = Total Drug Description Dosage * Total Packaging Description Dosage * Quantity
procured
Total Dosage Unit = Total Drug Description Unit
Statistical report
This statistics on use of medicines in this report are presented using the Anatomical Therapeutic Chemical
(ATC) classification system, and the unit of measurement is expressed in defined daily dose (DDD). This is
recommended by the WHO to be used for drug utilization research and for purpose of comparisons of drug
consumption statistics between countries, between regions or population groups within country and to evaluate
trends in drug use over time.
Structure of the ATC Classification system
In this system, medicines are divided into different groups according to the organ or system on which they act,
and on their chemical, pharmacological and therapeutic properties.
Medicines are classified in groups at 5 different levels as follows:
Level
Group and subgroups
1.
Anatomical main group. There are 14 of these, eg C cardiovascular, M musculo-skeletal, R respiratory,
etc
2.
Therapeutic main group
3.
Therapeutic subgroup
4.
Chemical or Therapeutic subgroup
5.
Drug chemical substance
An example should make this clear. Simvastatin is coded C10AA01. The structure of its code is as follows:
Level
Code
Group and subgroups
1.
C
Cardiovascular system
2.
C10
Serum lipid reducing agents
3.
C10A
Cholesterol or triglyceride reducers
4.
C10AA
HMG CoA reductase inhibitors
5.
C10AA01
Simvastatin
Refer to the publication Guidelines for ATC Classification and DDD Assignment (WHO Collaborating Centre for
Drug Statistics Methodology 2003; www.whocc.no) for details.
xxiv
Concept of the Defined Daily Dose (DDD)
The measurement unit for medicines use adopted in this report is the DDD.
The DDD is the assumed average maintenance dose per day for a drug used for its main indication in adults. The
DDD is simply a technical measure of drug utilization; it does not necessarily agree with the recommended or
prescribed daily dose. Doses for individual patients and patient groups will often differ from the DDD. The DDD
is often a compromise based on review of the available information about doses used in various countries. The
DDD may even be a dose rarely prescribed because it is an average of two or more commonly used doses.
Medicines use statistics in this report are presented for most drugs as numbers of DDDs per 1000 inhabitants per
day. Some interpretative notes as follows:
• The DDDs/1000 inhabitants/day provides a rough estimate of the proportion of population treated daily
with certain drugs. For example, the figure 10 DDDs/1000 inhabitants/day indicates that 1% (10/1000) of the
population on average might get a certain drug or group of drugs every day in the year.
• The DDDs/1000 inhabitants/day is most useful for drugs used in the treatment of chronic diseases and
especially when there is a good agreement between the average prescribed daily dose and the DDD.
• For most drugs, their DDDs/1000 inhabitants/day are calculated for the total population including all age
and sex groups. Where a drug use is limited to particular age or sex groups, then it will be more meaningful
to express the figure for the relevant age-sex groups only. For example DDDs/1000 children age<12 /day, or
DDDs/1000 women in reproductive age groups/day.
For antiinfectives (or other drugs normally used in short duration), the medicine use statistics are presented
as DDD per inhabitant per year. This gives an estimate of the number of days for which each inhabitant is, on
average, treated annually. For example, 5 DDDs/inhabitant/year indicates that the utilization is equivalent to the
treatment of every inhabitant with a 5-days course in the year.
In interpreting drug utilization statistics expressed using DDD as in this report, readers are caution to bear in
mind the following limitations:
• A medicine may have several indications while the DDD is based on the main indication in adults.
• Medicines procured or prescribed or dispensed, as presented here, may not necessarily be consumed
• DDD may be difficult to assign or not assign at all for certain medicines, for examples medicines with
multiple ingredients, topical products, antineoplastic drugs and anaesthetic agents.
• Medicines newly introduced into the market may yet have ATC and DDD assigned to it.
• The DDD assigned to a drug is primarily based on other countries’ experience and may not reflect the
commonly prescribed adult dose in Malaysia.
Statistical methods
In this report, as explained above, the quantity of use of a medicine is expressed as, depending on the type of
medicine, the number of DDDs per 1000 inhabitants per day or DDDs per inhabitants per year. These statistics
are calculated as follows:
T*1000
DDDs/1000 inhabitants/day =
DDD* P*365
T
DDDs/inhabitant/year =
DDD* P
Where
T is an estimate of the total quantity of the drug utilized in the year under consideration
DDD is the DDD assigned for the drug according to the ATC/DDD system
P is the mid-year population of Malaysia or the relevant area where the survey was conducted
365 refers to the 365 days in a year
In either case, an estimate of the total quantity of the drug being utilized in the year is required, and this must be
expressed in the same unit as the DDD assigned for the drug.
xxv
The statistical estimation of the totals varies depending on the survey method and the sampling design employed
to collect the data, and if necessary with adjustment for incomplete data. These are described below.
#
Surveys
Estimation procedure
1.
MOH
No sampling was employed in the survey.
Pharmaceutical
The total is therefore simply estimated by the sum of all the quantities of the drug
procurement
procured in all procurement records in the year.
Adjustment is made for the 51 hospitals with incomplete procurement records.
2. Private hospitals’ Data were available for only a sample of hospitals.
pharmaceutical
The total is estimated by T =
Wi Ti
procurement
Where;
Wi is the sampling weight of the ith hospital
Ti is the value of the quantity of drug procured of the ith hospital in the year
Since, large hospitals as measured by bed strength was overrepresented in the sample,
a bias correction factor (BCF) was applied to the estimate.
BCF = B / b * Wi
Where B is total number of beds in the population, b the number in the sample and
Wi is the sampling weight of the ith hospital
Data were available for only a sample of hospitals.
3. University
and Armed
Wi Ti
Forces’ hospital
Where;
pharmaceutical
Wi is the sampling weight of the ith hospital adjusted for non-response
procurement
Ti is the value of the quantity of drug procured of the ith hospital in the year
4. Private GP
Data were collected only for a sample of GPs and for each respondent, data collected
prescription
only for a sample of days in a year (working days only).
Wi jTij
Where;
Wij is the sampling weight for the ith day of the jth GP
Tij is the value of the quantity of drug prescribed by the jth GP on the ith day
5. Private specialist No sampling was employed in the survey.
The total is therefore simply estimated by the sum of all the quantities of the drug
practice
prescribed for all patients dialyzing in the facility.
prescription
(Nephrology and
dialysis practices
only)
6. Private pharmacy Data were collected only for a sample of pharmacies and for each respondent, data
dispensing
collected only for a sample of days in a year (working days only).
The total is estimated by T = Wi jTij
Where;
Wij is the sampling weight for the ith day of the jth Pharmacy
Tij is the value of the quantity of drug dispensed by the jth Pharmacy on the ith day
Where there is sampling or where response rate of the survey was less than 100%, the procedures described above
incorporate the sampling weight of the sampling unit in the estimation of total.
The sampling weight for each sampling unit or unit of analysis has the following components:
1. Probability of selection.
The basic weight is obtained by multiplying the reciprocals of the probability of selection at each step of sampling
design. Example, for GP prescription survey, this is GP practice and prescription day.
2. Adjustment for non-response.
The response rate was less than 100% for some surveys; an adjustment to the sampling weight is required. The
non-response adjustment weight is a ratio with the number of units in the population as the numerator and the
number of responding sampling units as the denominator. The adjustment reduces the bias in an estimate to
the extent that non-responding units have same characteristics as responding units. Where this is unlikely,
some adjustments took into account differences in some relevant characteristics between responding and nonresponding units that may influence drug utilization, such as bed strength, staff strength, scope of services for
hospitals etc.
xxvi
ABBREVIATIONS
ACEI
AF
APPL
ARB
ASR
ATC
BCF
BPFK
CCB
CCF
COAD
CPG
DALYs
DDD
Dept
FDA
GP
HMG CoA
INN
ISAAC
KL
LMWH
MOH
NCC
NCI
NMP
NMUS
NPCB
NSAID
OTC
PCDOM
SDP
SERM
SKU
SSRI
UOM
URTI
WHO
WP
Angiotensin Converting Enzyme Inhibitors
Atrial Fibrillation
Approved Product Price List
Angiotensin II Antagonists/ Angiotensin Receptor Blocker
Age Standardized Rate
Anatomical Therapeutic Chemical
Bias Correction Factor
Biro Pengawalan Farmaseutikal Kebangsaan
Calcium Channel Blockers
Congestive Cardiac failure
Chronic Obstructive Airway Disease
Clinical Practice Guidelines
Disability Life Years
Defined Daily Dose
Department
Food And Drug Administration
General Practitioner
3-hydroxy-3-methylglutaryl coenzyme A
International Nonproprietary Name
International Study of Asthma and Allergies in Chilldhood
Kuala Lumpur
Low Molecular Weight Heparin
Ministry of Health
National Cancer Centre
National Cancer Institute
National Medicines Policy
National Pharmaceutical Control Bureau
Non Steroidal Anti- Inflammatory Drugs
Over-the-Counter
Primary Care Doctors Organisation Malaysia
Source Data Producer
Selective Estrogen Receptor Modulator
Stock Keeping Unit
Serotonin Selective Reuptake Inhibitor
Unit of Measurement
Upper Respiratory Tract Infection
World Health Organization
Wilayah Persekutuan
xxvii
CHAPTER 1
USE OF MEDICINES IN MALAYSIA
Malaysian Statistics on Medicine 2004
Edited by:
Sarojini S1, C.M. Lim1, T.O. Lim1, L.S. Lai2, Zaki Morad1
1 Clinical Research Centre MOH, 2 Pharmaceutical Services Division MOH
For the first time in Malaysia, we are able to report national estimates of the use of medicines. This chapter
describes the commonly used medicines by therapeutic groups and by specific drugs. Certain medicines however
were deliberately excluded in this chapter for various reasons as follows:
1. OTC medicines, health supplements and traditional complementary medicines are outside the scope of the
NMUS
2. Medicines without DDD assignment such as antineoplastic drugs, anaesthetic agents
3. Predominantly topical medicines (Dermatologicals, Ophthalmologicals, Otologicals, Gynaecologicals, Nasal
and Throat preparations, Stomologicals)
The most commonly used medicines in 2004 in Malaysia were antidiabetic medications (4% of the population were
on this), of which glibenclamide (1.4% of population) and metformin were the most commonly used drugs.
The various antihypertensive medications also figured very high on the top 30 list; beta-blockers was second
(2.5% of population on this), followed by agents acting on the renin-angiotensin system (third on list, 2.2%),
calcium channel blockers (seventh on list, 1.8%) and diuretics (tenth on list, 1.5%; though this include high
ceiling diuretics not used for hypertension). Collectively, these antihypertensive medicines were more commonly
used than antidiabetics. Hypertension and diabetes mellitus are the two most prevalent chronic disorders in the
country. In 1996, the prevalence of hypertension was 33% [1] and diabetes mellitus 8% [2]; thus in the light
of known disease epidemiology, such high medicines utilization rates for these conditions are to be expected.
Indeed one may question whether they were sufficiently high to ensure all in need of therapy were on treatment
and properly controlled.
This utilization pattern is in sharp contrast to Australia (the only country in the region with available medicine
use statistics [3]), where lipid reducers (top) and antiasthmatics (second on list) dominated its top-10 drug list
in year 2000. The latter only ranked fourth on Malaysian top-10 list, which is to be expected considering the
difference in disease prevalence between the 2 countries [4], while the relatively lower use of lipid reducers
(only 2% of population compared with 7% or higher in Australia) definitely suggests under-utilization of lipid
reducers, even if past survey has shown lower prevalence of hypercholesterolaemia in Malaysia [5]. Another
interesting contrast is simvastatin (sixth on our list) and lovastatin (twentieth on list) are commonly used here,
while atorvastatin topped the Australian list.
A surprisingly highly used medicine is antihistamines for systemic use (2% of population), mostly chlorpheniramine
and loratadine, which deserve further investigation.
Antibacterial medicines not surprisingly were widely used, amoxicillin, amoxicillin+ enzyme inhibitor,
doxycycline were the most popular items in the group. Similarly, antirheumatic medicines were also commonly
used (1.6% of population; the common drugs were diclofenac and mefenamic acid) and analgesics (1%). Refer to
individual chapters for detailed discussion on these specific therapeutic groups.
Certain perhaps surprising levels of medicine utilization observed (in terms of % of population on), whether
expectedly or unexpectedly high or low, were:
•
Drugs for acid related disorders such as peptic ulcers 0.7%
•
Systemic corticosteroids 0.5%
•
Psycholeptics 0.5%
•
Antiepileptics 0.2%
•
Antigout medicines, 0.2%
•
Thyroid therapy (thyroxine and antithyroid medicines) 0.2%
1
CHAPTER 1
For the disorders for which these medicines are indicated, little is known about their epidemiology and treatment
in this country to aid interpretation of these medicines use statistics. They deserve further investigation. Refer to
individual chapters for further discussion on some of these specific therapeutic groups.
Table 1.1: Top 30 Therapeutic groups by Utilization in DDD/1000 population/day 2004
#
ATC
Therapeutic group
Public
Private
1.
A10
DRUGS USED IN DIABETES
26.7887
15.1461
2.
C07
BETA BLOCKING AGENTS
17.0781
8.5554
3.
C09
AGENTS ACTING ON THE RENIN9.3489
12.8611
ANGIOTENSIN SYSTEM
4.
R03
DRUGS FOR OBSTRUCTIVE AIRWAY
11.6735
10.3845
DISEASES
5.
R06
ANTIHISTAMINES FOR SYSTEMIC USE
4.9574
14.6639
6.
C10
SERUM LIPID REDUCING AGENTS
5.0703
14.1665
7.
C08
CALCIUM CHANNEL BLOCKERS
12.3461
6.2281
8.
J01
ANTIBACTERIALS FOR SYSTEMIC USE
3.8749
13.8439
9.
M01
ANTIINFLAMMATORY AND
4.0256
11.9142
ANTIRHEUMATIC PRODUCTS
10. C03
DIURETICS
8.1171
7.7100
11.
N02
ANALGESICS
4.2168
5.4568
12. A02
DRUGS FOR ACID RELATED DISORDERS
2.3643
4.6592
13. C01
CARDIAC THERAPY
2.9101
2.6040
14.
N05
PSYCHOLEPTICS
3.2487
1.8760
15. H02
CORTICOSTEROIDS FOR SYSTEMIC USE
1.4101
3.4475
16. C02
OTHER ANTIHYPERTENSIVES
2.9638
0.3169
17.
B01
ANTITHROMBOTIC AGENTS
2.1520
1.1157
18. N03
ANTIEPILEPTICS
1.8314
0.4358
19.
M04
ANTIGOUT PREPARATIONS
1.0003
1.1924
20. H03
THYROID THERAPY
1.2360
0.8220
21.
N06
PSYCHOANALEPTICS
0.5030
0.8226
22. N07
OTHER NERVOUS SYSTEM DRUGS
0.4089
0.7186
23. M05
DRUGS FOR TREATMENT OF BONE
0.6809
0.3762
DISEASES
24. J02
ANTIMYCOTICS FOR SYSTEMIC USE
0.0371
0.9775
25. J04
ANTIMYCOBACTERIALS
0.8336
0.1419
26. N04
ANTI-PARKINSON DRUGS
0.7094
0.0368
27.
M03
MUSCLE RELAXANTS
0.0406
0.5911
28. L02
ENDOCRINE THERAPY
0.1697
0.0827
29. P01
ANTIPROTOZOALS
0.1981
0.0231
30. J05
ANTIVIRALS FOR SYSTEMIC USE
0.1151
0.0875
2
Total
41.9348
25.6335
22.2100
22.0580
19.6212
19.2368
18.5742
17.7188
15.9397
15.8271
9.6736
7.0235
5.5141
5.1247
4.8576
3.2808
3.2676
2.2672
2.1927
2.0580
1.3256
1.1274
1.0571
1.0146
0.9755
0.7462
0.6318
0.2524
0.2213
0.2026
CHAPTER 1
Table 1.2: Top 40 Drugs by Utilization in DDD/1000 population/day 2004
#
ATC
Drugs
Public
1.
A10B B01
GLIBENCLAMIDE
10.9606
2.
C07A B03
ATENOLOL
6.3664
3.
A10B A02
METFORMIN
7.7235
4.
C07A B02
METOPROLOL
10.1242
5.
C08C A05
NIFEDIPINE
8.8336
6.
C10A A01
SIMVASTATIN
1.0938
7.
C08C A01
AMLODIPINE
2.8030
8.
R03A C02
SALBUTAMOL
5.3490
9.
R06A B04
CHLORPHENIRAMINE
2.4555
10. A10B B09
GLICLAZIDE
2.7913
11.
R03C C02
SALBUTAMOL
0.6634
12. M01A B05
DICLOFENAC
1.2021
13. M01A G01
MEFENAMIC ACID
1.4452
14.
R06A X13
LORATADINE
0.5986
15. C03C A01
FUROSEMIDE
3.3840
16. A10A DINSULINS AND ANALOGUES
2.9303
(INTERMEDIATE-ACTING COMBINED
WITH FAST-ACTING)
17.
C03A A04
CHLOROTHIAZIDE
4.0569
18. C10A A02
LOVASTATIN
2.9441
19.
J01C A04
AMOXICILLIN
0.7732
20. C09A A04
PERINDOPRIL
3.0035
21.
C10A A05
ATORVASTATIN
0.4129
22. C09A A01
CAPTOPRIL
3.6115
23. C09A A02
ENALAPRIL
1.8020
24. H02A B06
PREDNISOLONE
0.9587
25. A02B A02
RANITIDINE
1.0864
26. C03A A03
HYDROCHLOROTHIAZIDE
0.0007
27.
J01C R02
AMOXICILLIN+ENZYME INHIBITOR 0.0984
28. R06A E07
CETIRIZINE
0.0941
29. R03B A02
BUDESONIDE
1.7225
30. C02C A01
PRAZOSIN
2.3022
31.
R06A D02
PROMETHAZINE
0.9011
32. C03B A11
INDAPAMIDE
0.0925
33. C01E B15
TRIMETAZIDINE
0.8007
34. C09C A01
LOSARTAN
0.3466
35. R03D A04
THEOPHYLLINE
1.2720
36. A10A BINSULINS AND ANALOGUES (FAST1.0116
ACTING)
37.
J01A A02
DOXYCYCLINE
0.1970
38. R03B B04
TIOTROPIUM BROMIDE
0.7026
39.
C09A A03
LISINOPRIL
0.0001
40. M04A A01
ALLOPURINOL
0.6952
3
Private
3.5307
6.7118
4.0201
0.8652
1.0538
6.8078
3.7759
0.9874
3.2771
2.8564
4.7596
4.1477
3.3449
4.0112
1.0876
1.5073
Total
14.4913
13.0782
11.7436
10.9895
9.8874
7.9016
6.5788
6.3364
5.7326
5.6477
5.4231
5.3498
4.7901
4.6098
4.4716
4.4376
0.0284
1.1358
3.2511
1.0106
3.5017
0.2813
2.0296
2.6250
2.0978
3.0596
2.8586
2.5528
0.8771
0.1498
1.3746
2.0972
1.2629
1.6337
0.5879
0.7592
4.0854
4.0799
4.0243
4.0141
3.9146
3.8928
3.8315
3.5837
3.1843
3.0603
2.9569
2.6469
2.5996
2.4520
2.2757
2.1897
2.0636
1.9803
1.8599
1.7708
1.5380
1.0132
1.6353
0.8834
1.7350
1.7158
1.6354
1.5786
CHAPTER 1
References
1. Lim TO, Zaki M, Maimunah AH, Rozita H, Ding LM. Prevalence, awareness, treatment and control of
Hypertension in Malaysian adult population. Singapore Medical Journal 2004;45:20-27
2. Lim TO, Ding LM, Zaki M, Suleiman AB et al. Distribution of blood glucose in a national sample of
Malaysian adults. Med J Malaysia 2000;55:65-77
3. Australian Statistics on Medicine 1999-2000.Commonwealth Department of health and ageing Australia
2003
4. International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide
variations in the prevalence of asthma symptoms: the International Study of Asthma and Allergies in
Childhood (ISAAC) Eur Respir J. 1998; 12:315-35
5. Lim TO, Ding LM, Zaki M, Suleiman AB et al. Distribution of blood total cholesterol in a national sample
of Malaysian adults. Med J Malaysia 2000;55:78-89
4
CHAPTER 2
EXPENDITURE ON MEDICINES IN MALAYSIA
Edited by:
Shanthi V1, A. Goh2 , KK Lee2, Leong KC4, Rosminah Mohd Din3, Lim TO2
Nour Hanah Othman3, Chua KL5
1 Institute for Health Management, 2 Clinical Research Centre MOH, 3 Pharmaceutical Services Division MOH,
4 Klinik Leong, 5 Planning & Development Division MOH
Considering the common chronic diseases in the country, the cost estimates of the commonly used drugs were
not surprising. In the top-10 list by cost, antihypertensive medications took the first, second, sixth and tenth
ranks, while the statins were in the third and fourth rank, and an oral antidiabetics was ranked seventh.
The Malaysian healthcare sector spent about RM 145 million on antihypertensive medicines alone in year 2004.
Among these medicines, losartan, a drug acting on the renin-angiotensin system, tops the list with estimated
expenditure of RM 46.9 million. The private sector alone spent about RM 32 million on losartan in year 2004.
Amlodipine a calcium channel blocker, is the close second with a cost of RM 33 million.
The widely used statins, atorvastatin and simvastatin ranked third and fourth in the list with a 3.9 and 7.9 DDD/1000
population/day presented with a total cost of RM 74 million. Out of which the private sector accounted for RM 63
million. This is similiar to the Australian Statistics on Medicine wherein the statins are ranked first and second.
This is expected in reference to their high utilization for hypercholesterolaemias in both countries.
Diabetes being one of the most prevalent chronic disorders in the country accounted for a total of RM 39 million
in drug expenditure. Presently gliclazide, the more commonly used oral antidiabetic drug in the private sector
is ranked seventh in the list with a cost of RM 16.5 million. The other commonly used oral antidiabetic drugs,
metformin, glibenclamide and insulin, had a total cost of RM 22.7 million.
Estimated Cost of the Top 40 Utilized Drugs, 2004
#
ATC
Drugs
1.
2.
3.
4.
5.
C09C A01
C08C A01
C10A A05
C10A A01
J01C R02
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
C09D A01
A10B B09
R03A C02
M01A B05
C09A A04
B01A C05
C07A B02
A10B A02
A02B C01
C10A B05
C08C A05
LOSARTAN
AMLODIPINE
ATORVASTATIN
SIMVASTATIN
AMOXICILLIN+ENZYME
INHIBITOR
LOSARTAN AND DIURETICS
GLICLAZIDE
SALBUTAMOL (INHALANT)
DICLOFENAC
PERINDOPRIL
TICLOPIDINE
METOPROLOL
METFORMIN
OMEPRAZOLE
FENOFIBRATE
NIFEDIPINE
5
Public Cost/
Year (RM)
14,370,813
28,330,855
4,368,009
2,910,660
849,856
PrivateCost/
Year (RM)
32,541,686
4,759,518
26,428,830
27,269,223
20,387,523
Total Cost/
year (RM)
46,912,499
33,090,373
30,796,838
30,179,883
21,237,380
902,534
8,157,546
11,447,111
2,864,376
8,693,567
6,828,453
9,636,382
9,807,577
888,512
117,373
7,052,004
16,837,071
8,347,800
2,113,082
9,883,180
2,925,160
3,873,663
823,512
12,463
7,232,717
7,991,129
856,024
17,739,605
16,505,346
13,560,193
12,747,555
11,618,727
10,702,116
10,459,894
9,820,041
8,121,229
8,108,503
7,908,028
CHAPTER 2
EXPENDITURE ON MEDICINES IN MALAYSIA
Estimated Cost of the Top 40 Utilized Drugs, 2004
#
ATC
Drugs
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
C01E B15
R06A E07
R06A X13
C08C A02
R03B A02
C09A A01
J01F A01
C10A A02
C03B A11
A10A D01
C07A B03
A10B B01
A10A B01
R06A B04
R03D A04
H02A B06
C09A A03
C02C A01
A02B A02
C09A A02
C03A A04
M04A A01
J01C A04
R03C C02
Public Cost/
Year (RM)
2,563,485
131,792
335,349
2,079,655
6,467,952
5,563,912
2,934,642
3,809,996
587,731
3,064,353
2,229,122
1,842,110
2,402,741
1,506,309
442,003
447,570
28,317
2,303,985
2,525,793
1,236,661
2,500,040
689,874
2,165,817
21,162
TRIMETAZIDINE
CETIRIZINE
LORATADINE
FELODIPINE
BUDESONIDE
CAPTOPRIL
ERYTHROMYCIN
LOVASTATIN
INDAPAMIDE
INSULIN
ATENOLOL
GLIBENCLAMIDE
INSULIN
CHLORPHENAMINE
THEOPHYLLINE
PREDNISOLONE
LISINOPRIL
PRAZOSIN
RANITIDINE
ENALAPRIL
CHLOROTHIAZIDE
ALLOPURINOL
AMOXICILLIN
SALBUTAMOL (SYSTEMIC)
6
PrivateCost/
Year (RM)
5,188,363
7,198,341
6,891,295
4,792,226
8,517
433,374
2,631,479
1,463,490
4,405,864
1,576,255
2,350,060
2,614,223
1,423,701
2,010,313
2,860,405
2,843,125
2,862,908
449,748
104,008
1,392,857
18,695
1,512,194
9,107
2,096,135
Total Cost/
year (RM)
7,751,848
7,330,133
7,226,643
6,871,881
6,476,469
5,997,285
5,566,121
5,273,485
4,993,595
4,640,608
4,579,182
4,456,333
3,826,442
3,516,622
3,302,408
3,290,696
2,891,225
2,753,733
2,629,801
2,629,518
2,518,734
2,202,068
2,174,924
2,117,297
CHAPTER 3:
USE OF DRUGS FOR ACID RELATED DISORDERS [RESERVE]
CHAPTER 4:
USE OF ANTIOBESITY MEDICINES [RESERVE]
7
CHAPTER 5
USE OF ANTIDIABETICS
Edited by:
G.R. Letchuman Ramanathan1, Yap Piang Kian2, Muruga Vadivale3, SP Chan10 , Oiyammal Chelliah4, Loh Kiaw
Moi5, Ariza Zakaria6, Ernieda Md Hatah7
Selva Malar8, Zanariah Hussein7, Badrulnizam7
1 Ipoh Hospital MOH, 2 Subang Jaya Medical Centre, 3 Sanofi Aventis Group, 4 Penang Hospital MOH, 5 XepaSoul Pattinson, 6 Clinical Research Centre MOH, 7 Putrajaya Hospital MOH, 8 Kuantan Health Clinic MOH, 10
Faculty of Medicine, University Malaya
Among antidiabetic medicines, the sulfonylureas were the most widely used (21.157 DDD/1000 population/day),
followed by biguanides, insulin, thiazolidinediones and alpha-glucosidase inhibitors. 2.1% of the population was
on sulfonylureas, translating to about 5% of population aged 30 and above (about 40% of population was aged
>=30 in 2004). This is consistent with the known high prevalence of diabetes in Malaysia (prevalence of 8.3% in
1996), taking into account substantial number of patients were not on drug therapy or had undiagnosed diabetes
[1,2].
The most popular sulphonylurea was glibenclamide. Chlorpropamide usage was low. This is rightly so as it tends
to cause serious prolonged hypoglycaemia. The Australian data (2000) showed that the use of chlorpropamide in
Australia was almost non-existent [3]. The use of chlorpropamide locally should also be discouraged.
The biguanides only accounted for 11.7436 DDD/1000 population/day in 2004. Metformin has been recommended
in recent guidelines to be first line therapy for most type 2 patients. It is also cheap and hence cost effective.
The other oral agents, the alpha-glucosidase inhibitors and thiazolidinediones had lower usage. This was probably
because of their prohibitive cost.
The fixed-dose combination drugs were new on the market in 2004 and hence thier observed low usage. We
expect a rise in the use of these drugs in the future because of their cost advantage. It is anticipated that fixed
dose combinations will also improve compliance. As expected, the newer oral agents like glipizide, gliclazide,
glimepiride, rosiglitazone, repaglinide and nateglinide were more commonly used in the private sector as these
drugs were either not available in the Government formulary or their usage was only limited to specialists
(gliclazide, rosiglitazone and repaglinide).
It is a fact that most patients with type 2 diabetes will eventually require insulin for optimal glycaemic control.
Intermediate-acting insulin combined with fast-acting insulin seems to be the preferred regime. Although three
injections pre-meal of a fast-acting insulin and a basal dose of either an intermediate-acting insulin or longacting insulin(glargine) is more physiological; patients and doctors in general prefer the less intensive regime
using combinations (usually 30% short-acting and 70% long-acting) requiring only two injections a day. In
terms of public/private use, the only category where the DDD was higher in the private category was the longacting insulins. This is probably due to the fact that the new insulin analogue (glargine) was not available in the
Government formulary in 2004.
Comparing insulin use in Australia (2000), Finland (2002) and Malaysia (2004), the figures were 10.58, 18.62
and 7.78 DDD/1000 persons respectively [3,4]. Even if we take into consideration the lower prevalence of type
1 diabetes in Malaysia, the overall usage of insulin in Malaysia was low. The need for more stringent diabetic
control in type 2 diabetics (and hence the use of insulin when beta-cell failure ensues) has to be emphasised.
9
CHAPTER 5
Table 5.1: Use of Antidiabetics by Drug Class, in DDD/1000 population/day 2004
#
Drug Class
A10A
INSULIN AND ANALOGUES
A10B A
BIGUANIDES
A10B B
SULFONAMIDES, UREA DERIVATIVES
A10B D
COMBINATIONS OF ORAL BLOOD GLUCOSE LOWERING
DRUGS
A10B F
ALPHA GLUCOSIDASE INHIBITORS
A10B G
THIAZOLIDINEDIONES
A10B X
OTHER ORAL BLOOD GLUCOSE LOWERING DRUGS
2004
7.7762
11.7436
21.1569
0.0545
0.3861
0.5741
0.2433
Table 5.2: Use of Antidiabetics by Drug Class and Agents, in DDD/1000 population/day 2004
ATC
Drug Class and Agents
2004
A10A
INSULIN AND ANALOGUES
A10A B
INSULINS AND ANALOGUES, FAST-ACTING Total
1.7708
Public
1.0116
Private
0.7592
A10A C
INSULINS AND ANALOGUES,
Total
0.9099
INTERMEDIATE-ACTING
Public
0.8
Private
0.1099
A10A D
INSULINS AND ANALOGUES,
Total
4.4376
INTERMEDIATE-ACTING COMBINED WITH
Public
2.9303
FAST-ACTING
Private
1.5073
A10A E
INSULINS AND ANALOGUES, LONG-ACTING Total
0.6579
Public
0.1327
Private
0.5251
A10B A
BIGUANIDES
A10B A02
METFORMIN
Total
11.7436
Public
7.7235
Private
4.0201
A10B B
SULFONAMIDES, UREA DERIVATIVES
A10B B01
GLIBENCLAMIDE
Total
14.4913
Public
10.9606
Private
3.5307
A10B B02
CHLORPROPAMIDE
Total
0.0448
Public
0.0225
Private
0.0223
A10B B07
GLIPIZIDE
Total
0.1075
Public
0.0013
Private
0.1062
A10B B09
GLICLAZIDE
Total
5.6477
Public
2.7913
Private
2.8564
A10B B12
GLIMEPIRIDE
Total
0.8657
Public
0.0607
Private
0.805
10
CHAPTER 5
Table 5.2: Use of Antidiabetics by Drug Class and Agents, in DDD/1000 population/day 2004
ATC
2004
A10B D
COMBINATIONS OF ORAL BLOOD GLUCOSE
LOWERING DRUGS
A10B D03
METFORMIN AND ROSIGLITAZONE
Total
0.0545
Public
Private
0.0545
A10B F
A10B F01
ALPHA GLUCOSIDASE INHIBITORS
ACARBOSE
A10B G
A10B G02
THIAZILIDINEDIONES
ROSIGLITAZONE
A10B X
A10B X02
A10B X03
Total
Public
Private
0.3861
0.2456
0.1404
Total
Public
Private
0.5741
0.0176
0.5565
OTHER ORAL BLOOD GLUCOSE LOWERING
DRUGS
REPAGLINIDE
Total
Public
Private
NATEGLINIDE
Total
Public
Private
0.2186
0.0818
0.1368
0.0247
0.0091
0.0157
References
1. The National Health Morbidity Survey 1, Institute of Public Health, Ministry of Health Malaysia 1985.
2. The National Health Morbidity Survey 2, Institute of Public Health, Ministry of Health Malaysia 1996.
3. Australian Statistics on Medicine 1999-2000. Commonwealth Department of Health and Ageing Australia
2003
4. Medicines consumption in the Nordic countries 1999-2003. Nordic Medico Statistical Committee 2004;
2004: Copenhagen
11
CHAPTER 6:
USE OF ANTIANAEMIC DRUGS [RESERVE]
CHAPTER 7:
USE OF ANTIHAEMORRHAGIC DRUGS [RESERVE]
13
CHAPTER 8
USE OF DRUGS FOR CARDIOVASCULAR DISORDERS
Edited by:
Tamil Selvan Muthusamy1, Sim Kui Hian2 , Khoo Kah Lin3
Mohd. Husni B Jamal4, Chai Swee Chin5, David KL Quek6, Noraini bt. Mohamad7
1 Damansara Specialist Hospital, 2 Sarawak General Hospital MOH, 3 Klinik Dr Khoo Kah Lin, 4 Governance
Board, 5 Clinical Research Centre, 6 D Quek Specialist Heart Clinic, 7 Putra Jaya Hospital MOH
The only Vitamin K antagonist used in the country is warfarin. Warfarin is used by 0.0033 % of the population
everyday in a year (or a DDD of 0.33). The common indications for warfarin use are: for stroke prevention among
patients with Atrial Fibrillation (AF); valvular heart disease especially those with valve replacements; venous
thrombosis-embolism; intra-cardiac thrombi [1]. It is well-known that the incidence of AF increases with age;
therefore increased warfarin use in this subset should confer benefit among the elderly. 2.5% of the population
of Malaysia are above 70 years of age [2], therefore approximately 0.25% of the population are in AF (10 % of
population above 70 years of age are in AF). In comparison, the DDD for warfarin in Australia for the year 2003
is 4.840. Based on this, there appears to be gross underuse of the drug in Malaysia.
Low molecular weight heparin (LMWH) is more commonly used than unfractionated heparin (DDD 0.59563 and
0.1794 respectively). This shows a rapid clinical acceptance and adaptation of use of LMWH as an antithrombotic
in our country. Similar increased use was recorded in Australia in the year 2003 (DDD LMWH 0.612, Heparin
0.035) [3]. Regarding commonly used antithrombotics, there are no data available for the use of aspirin, the
most widely used anti-platelet agent. Because aspirin is the anchor medication for most coronary heart disorders,
its prevalence of use and costs would have been very instructive as to how Malaysian physicians utilize this
important drug. The failure to capture the use of aspirin should be corrected in the next NMUS. Regarding other
antiplatelet drugs, the use of clopidogrel and ticlopidine are comparable. The use of glycoprotein 2B3A receptor
blockers is very small and is likely to be appropriate.
Fibrinolytic agents are a first line therapy for most ST-Elevation Myocardial Infarction in Malaysia (the less
available superior therapy is direct percutaneous coronary intervention or PCI). The use of streptokinase as
thrombolytic agent (for ST-Elevation Myocardial Infarction, and some pulmonary embolism) is 0.0009, which
appears to be low. The use of the more expensive lytic agents is even lower, most likely due to cost-constraints.
Digoxin is mainly used in patients with congestive cardiac failure and Atrial Fibrillation and the DDD figure
of 0.5724 is acceptable. The use should increase in future due to increase in our ageing population resulting in
possibly higher incidence of AF and congestive cardiac failure. However, it should be noted that the dose of
digoxin used in the elderly should be carefully monitored and appropriately lower, based on their renal function
and lower lean body weight. The DDD for digoxin in Australia for example is 5.599, which reflects a larger
prevalence of heart failure problems in that subset of the population.
Antiarrhythmic drugs are generally used in specialized units. Amiodarone is the commonest drug used. The use
of other antiarrhythmic drugs is limited, and mirrors the declining norm as well as international use. Vasodilators
(especially nitrates) are used mainly in the treatment of coronary artery disease. The long acting forms (isorsorbide
mononitrate) are not widely used in public institution due to their cost and lower availability.
Diuretics are very widely used in Malaysia especially in the public sector. Hydrochlorothiazide and chlorothiazide
are widely used antihypertensive drugs (DDD 3.0603 and 4.0854 respectively). Indapamide on the other hand is
a weak diuretic with a potent antihypertensive effect, but with possible significant longer-term adverse events. Its
use is surprisingly wide (DDD 2.1897). A similar pattern is also seen in Australia (DDD 7.535).
Spironolactone (an aldosterone inhibitor) on the other hand appears to be underused, although not totally
unexpected. Previously when first used, its higher doses were associated with potassium retention as well as
15
CHAPTER 8
gynaecomastia, hence it has never been endorsed as a first line diuretic for hypertensive use. Therefore, because
antihypertensive drugs are the most prescribed, its use should be appropriately lower. However, of recent years,
this drug has been shown to reduce mortality in Congestive Cardiac failure (CCF) [4]. The Government hospital
discharge rate for CCF is 41.78 per 100 000 population (0.04178 % of Malaysian population) and the death rate
from CCF is 3.63 per 100 000 population (0.00363% of the population)[5]. Spironolactone DDD in the public
sector is 0.2176 (0.02176% of the population take this drug everyday in a year).
Furosemide is a potent loop-diuretic principally used for correcting water and salt retention. It use as an
antihypertensive is not recommended as it has only a short duration of action and severe metabolic-electrolyte
effects. Furosemide’s DDD is 4.4716; thus it is widely used. (However, furosemide use is less than that of the
thiazides combined (3.0603+4.0854=7.1457). Furosemide is usually and appropriately used in CCF, but it is also
commonly used in renal diseases and perhaps less appropriately in general practice when given rather freely for
short term treatment of episodic water retention in outpatients.
In summary NMUS shows that the cardiovascular drug use in Malaysia appears to be very similar to
international data. The use of some very beneficial drug should increase with wider application of clinical practice
guidelines.
Table 8.1: Use of Drugs for Cardiovascular disorders, in DDD/1000 population/day 2004
#
Drug Class
2004
B01
ANTITHROMBOTIC DRUGS
3.2676
C01A
CARDIAC GLYCOSIDES
0.5724
C01B
ANTIARRHYTHMICS
0.1721
C01C
CARDIAC STIMULANTS
0.2959
C01D
VASODILATORS IN CARDIAC DISEASES
2.3971
C03
DIURETICS
15.8271
C04
PERIPHERAL VASODILATORS
0.0606
Table 8.2.1: Use of Antithrombotic drugs by Drug Class, in DDD/1000 population/day 2004
#
Drug Class
2004
B01AA
VITAMIN K ANTAGONISTS
0.3344
B01AB
HEPARIN GROUP
0.7886
B01AC
PLATELET AGGREGATION INHIBITORS
2.143
B01AD
ENZYMES
0.0016
Table 8.2.2: Use of Antithrombotic drugs by Drug Class and Agents, in DDD/1000 population/day 2004
ATC
2004
B01AA
VITAMIN K ANTAGONISTS
B01A A03
WARFARIN
Total
0.3344
Public
0.2299
Private
0.1045
B01AB
B01A B01
B01A B05
HEPARIN GROUP
HEPARIN
Total
Public
Private
Total
Public
Private
ENOXAPARIN
16
0.1794
0.1392
0.0402
0.5202
0.4825
0.0377
CHAPTER 8
Table 8.2.2: Use of Antithrombotic drugs by Drug Class and Agents, in DDD/1000 population/day 2004
ATC
2004
B01A B06
NADROPARIN
Total
0.0747
Public
0.0709
Private
0.0038
B01A B10
TINZAPARIN
Total
0.0014
Public
0.001
Private
0.0005
B01A B11
SULODEXIDE
Total
0.0129
Public
0.0009
Private
0.012
B01AC
PLATELET AGGREGATION INHIBITORS
B01A C04
CLOPIDOGREL
Total
0.7623
Public
0.3329
Private
0.4293
B01A C05
TICLOPIDINE
Total
1.3231
Public
0.8442
Private
0.4789
B01A C07
DIPYRIDAMOLE
Total
0.0573
Public
0.049
Private
0.0083
B01A C11
ILOPROST
Total
0.0002
Public
<0.0001
Private
0.0002
B01A C13
ABCIXIMAB
Total
0.0001
Public
0.0001
Private
<0.0001
B01A C16
EPTIFIBATIDE
Total
<0.0001
Public
0
Private
<0.0001
B01A C17
TIROFIBAN
Total
0.0001
Public
0
Private
0.0001
B01AD
ENZYMES
B01A D01
STREPTOKINASE
Total
0.001
Public
0.0008
Private
0.0001
B01A D02
ALTEPLASE
Total
0.0006
Public
0.0006
Private
<0.0001
B01A D04
UROKINASE
Total
<0.0001
Public
<0.0001
Private
<0.0001
B01A D10
DROTRECOGIN ALFA (ACTIVATED)
Total
<0.0001
Public
<0.0001
Private
<0.0001
17
CHAPTER 8
Table 8.3.1: Use of Cardiac Glycosides by Drug Class, in DDD/1000 population/day 2004
#
Drug Class
2004
C01A A05
DIGOXIN
Total
0.5724
Public
0.3645
Private
0.2079
Table 8.4.1: Use of Anti-Arrhythmics by Drug Class, in DDD/1000 population/day 2004
#
Drug Class
2004
C01B B01
LIDOCAINE
Total
0.019
Public
0.0157
Private
0.0034
C01B C03
PROPAFENONE
Total
0.0058
Public
0.002
Private
0.0038
C01B C04
FLECAINIDE
Total
0.012
Public
0.0053
Private
0.0068
C01B D01
AMIODARONE
Total
0.1353
Public
0.0427
Private
0.0926
Table 8.5.1: Use of Cardiac stimulants by Drug Class, in DDD/1000 population/day 2004
#
Drug Class
2004
C01C A02
ISOPRENALINE
Total
<0.0001
Public
<0.0001
Private
<0.0001
C01C A03
NOREPINEPHRINE
Total
0.0327
Public
0.0319
Private
0.0008
C01C A04
DOPAMINE
Total
0.007
Public
0.0042
Private
0.0029
C01C A06
PHENYLEPHRINE
Total
0.0057
Public
0.003
Private
0.0026
C01C A07
DOBUTAMINE
Total
0.015
Public
0.013
Private
0.0021
C01C A09
METARAMINOL
Total
0.0001
Public
0.0001
Private
0
C01C A24
EPINEPHRINE
Total
0.2346
Public
0.1257
Private
0.1089
18
CHAPTER 8
Table 8.5.1: Use of Cardiac stimulants by Drug Class, in DDD/1000 population/day 2004
#
Drug Class
2004
C01C E02
MILRINONE
Total
0.0008
Public
0.0004
Private
0.0005
C01C X08
LEVOSIMENDAN
Total
<0.0001
Public
0
Private
<0.0001
Table 8.6.1: Use of Vasodilators in Cardiac diseases by Drug Class, in DDD/1000 population/day 2004
#
Drug Class
2004
C01D A02
GLYCERYL TRINITRATE
Total
0.179
Public
0.1122
Private
0.0669
C01D A08
ISOSORBIDE DINITRATE
Total
1.3881
Public
1.2368
Private
0.1513
C01D A14
ISOSORBIDE MONONITRATE
Total
0.83
Public
0.1392
Private
0.6908
Table 8.7.1: Use of Diuretics by Drug Class, in DDD/1000 population/day 2004
#
Drug Class
C03A A03
HYDROCHLOROTHIAZIDE
Total
Public
Private
C03A A04
CHLOROTHIAZIDE
Total
Public
Private
C03B A04
CHLORTALIDONE
Total
Public
Private
C03B A11
INDAPAMIDE
Total
Public
Private
C03C A01
FUROSEMIDE
Total
Public
Private
C03C A02
BUMETANIDE
Total
Public
Private
C03D A01
SPIRONOLACTONE
Total
Public
Private
19
2004
3.0603
0.0007
3.0596
4.0854
4.0569
0.0284
0.0001
0
0.0001
2.1897
0.0925
2.0972
4.4716
3.384
1.0876
0.0928
0.0785
0.0143
0.3084
0.2176
0.0908
CHAPTER 8
Table 8.7.1: Use of Diuretics by Drug Class, in DDD/1000 population/day 2004
#
Drug Class
C03D B01
AMILORIDE
Total
Public
Private
C03E A01
HYDROCHLOROTHIAZIDE AND POTASSIUM- Total
SPARING AGENTS
Public
Private
2004
0.2857
0.2857
1.3331
0.0011
1.332
Table 8.8.1: Use of Peripheral vasodilators by Drug Class, in DDD/1000 population/day 2004
#
Drug Class
2004
C04A D03
PENTOXIFYLLINE
Total
0.0568
Public
0.0427
Private
0.014
C04A E01
ERGOLOID MESYLATES
Total
0.0038
Public
0.0003
Private
0.0036
References:
1. Ezekowitz, Bridgers, et al Warfarin in the prevention of stroke associated with non rheumatic atrial
fibrillation. N Engl J Med. 327:1406,1992.
2. Vital Statistics Malaysia 2004
3. Australian Statistics on Medicine 1999-2000.Commonwealth Department of Health and Ageing Australia
2003
4. Pitt B, Zannad F, Remme WJ, et al. N Engl J Med 1999; 341: 709-717
5. Petunjuk petunjuk Indicators for Monitoring and Evaluation of Strategy for Health for All. Ministry Of
Health Malaysia – December 2004
20
CHAPTER 9
USE OF ANTIHYPERTENSIVES
Edited by:
Zaki Morad1, Rozina Ghazalli2, Lim TO3
Sahida bt Said4, Siti Shahida Md. Shariffudin1
1 Kuala Lumpur Hospital MOH, 2 Penang Hospital MOH, 3 Clinical Research Centre MOH, 4 Primary Health
Care Division MOH
Beta blockers were the most commonly prescribed antihypertensive medications, followed by Calcium Channel
Blockers (CCB), Angiotensin Converting Enzyme Inhibitors (ACEI), diuretics and Angiotensin II Antagonists
(ARB). In total, utilization of these drugs amounted to about 75 DDD/1000 population/day. That is, about 7.5%
of the population was on antihypertensive (assuming no combination among these classes), which translates into
18.7% of population aged 30 and above (about 40% of population was aged >=30 in 2004). This is consistent with
the known high prevalence of hypertension in Malaysia (prevalence of 33% in 1996), taking into account substantial
number of patients were not on drug therapy or had undiagnosed hypertension [1]. The utilization pattern is also
somewhat consistent with local clinical practice guideline [2], which recommended beta blockers and diuretics
as drugs of first choice for control of uncomplicated hypertension. Diuretics however could be more widely used.
In other Asian countries (Taiwan, China, India), CCBs appear to be the most popular antihypertensives, while in
Australia the ARBs were the most widely used [3].
Among the beta blockers we noted that the most popular are atenolol and metoprolol, They are favoured over the
older generation of beta blockers like esmolol probably due to the single daily dosing. Carvedilol, a relatively new
drug has gained increased usage.
Nifedipine is the most commonly used CCB in the public sector because of its low cost but in the private sector
the more expensive drugs such as amlodipine and felodipine are favoured because of the convenient daily dosing.
In addition the dihydropyridine group appears to be favored. In Australia [3] the dihydropyridine usage also
far outweighs the non-dihydropyridine usage for hypertension perhaps because of usage in cardiac associated
reasons.
Amongst the ACEIs, perindopril leads the way followed by captopril then enalapril. In the public sector, perindopril
is now relatively cheap and because of daily dosing convenience has overtaken captopril as the main prescribed
ACEI. In the private sector enalapril is the most commonly used followed by lisinopril.
The most commonly used ARB is losartan in the public sector and telmisartan in private. However with every
ARB the private sector overtakes the MOH due to the cost factor. In Australia [3] irbesartan was the top ARB
used.
Table 9.1: Use of Antihypertensives by Drug Class, in DDD/1000 population/day
#
Drug Class
C02A
CENTRALLY ACTING ADRENERGIC BLOCKERS
C02C-A
ALPHA BLOCKERS
C02D
ARTERIOLAR SMOOTH MUSCLE RELAXANTS
C02K
C03A
LOW-CEILING DIURETICS, THIAZIDES
C03B
LOW-CEILING DIURETICS, EXCL. THIAZIDES
C07
BETA BLOCKERS
C08
C09A
ANGIOTENSIN CONVERTING ENZYME INHIBITORS,
PLAIN
C09B
ANGIOTENSIN CONVERTING ENZYME INHIBITORS,
COMBINATIONS
C09C
ANGIOTENSIN II ANTAGONISTS, PLAIN
C09D
ANGIOTENSIN II ANTAGONISTS, COMBINATIONS
21
2004
2004
0.6164
2.6571
0.0071
0.0001
7.1457
2.1897
25.6335
18.5742
14.5902
0.0043
4.7457
2.8697
CHAPTER 9
Table 9.2: Use of Antihypertensives by Drug Class and Agents, in DDD/1000 population/day 2004
ATC
2004
C02A
CENTRALLY ACTING ADRENERGIC BLOCKERS
C02A B
METHYLDOPA
Total
0.5865
Public
0.5621
Private
0.0244
C02A C05
MOXONIDINE
Total
0.03
Public
Private
0.03
C02C-A
ALPHA BLOCKERS
C02C A01
PRAZOSIN
Total
2.452
Public
2.3022
Private
0.1498
C02C A04
DOXAZOSIN
Total
0.2052
Public
0.094
Private
0.1111
C02D
ARTERIOLAR SMOOTH MUSCLE RELAXANTS
C02D A01
DIAZOXIDE
Total
0
Public
0
Private
0
C02D B01
DIHYDRALAZINE
Total
0.0034
Public
0.0031
Private
0.0003
C02D B02
HYDRALAZINE
Total
0
Public
0
Private
0
C02D C01
MINOXIDIL
Total
0.0014
Public
0.0008
Private
0.0007
C02D D01
NITROPRUSSIDE
Total
0.0023
Public
0.0017
Private
0.0006
C02K
C02K D01
KETANSERIN
Total
<0.0001
Public
0
Private
<0.0001
C02K X01
BOSENTAN
Total
0.0001
Public
0
Private
0.0001
C03A
LOW-CEILING DIURETICS, THIAZIDES
C03A A03
HYDROCHLOROTHIAZIDE
Total
3.0603
Public
0.0007
Private
3.0596
22
CHAPTER 9
ATC
2004
C03A A04
CHLOROTHIAZIDE
Total
4.0854
Public
4.0569
Private
0.0284
C03B
LOW-CEILING DIURETICS, EXCL. THIAZIDES
C03B A04
CHLORTALIDONE
Total
0.0001
Public
0
Private
0.0001
C03B A11
INDAPAMIDE
Total
2.1897
Public
0.0925
Private
2.0972
C07
BETA BLOCKERS
C07A A05
PROPRANOLOL
Total
0.6566
Public
0.3736
Private
0.2829
C07A A07
SOTALOL
Total
0.0208
Public
0.0002
Private
0.0206
C07A B02
METOPROLOL
Total
10.9895
Public
10.1242
Private
0.8652
C07A B03
ATENOLOL
Total
13.0782
Public
6.3664
Private
6.7118
C07A B04
ACEBUTOLOL
Total
0.0006
Public
Private
0.0006
C07A B05
BETAXOLOL
Total
0.0756
Public
0.0134
Private
0.0622
C07A B07
BISOPROLOL
Total
0.2735
Public
0.0085
Private
0.265
C07A B09
ESMOLOL
Total
<0.0001
Public
<0.0001
Private
<0.0001
C07A G01
LABETALOL
Total
0.1286
Public
0.1163
Private
0.0123
C07A G02
CARVEDILOL
Total
0.4101
Public
0.0753
Private
0.3348
23
CHAPTER 9
ATC
2004
C08
C08C A01
AMLODIPINE
Total
6.5788
Public
2.803
Private
3.7759
C08C A02
FELODIPINE
Total
1.3333
Public
0.4035
Private
0.9298
C08C A03
ISRADIPINE
Total
0.0103
Public
Private
0.0103
C08C A04
NICARDIPINE
Total
0.0089
Public
0
Private
0.0089
C08C A05
NIFEDIPINE
Total
9.8874
Public
8.8336
Private
1.0538
C08C A06
NIMODIPINE
Total
0.0017
Public
0.0005
Private
0.0012
C08C A09
LACIDIPINE
Total
0.0027
Public
<0.0001
Private
0.0027
C08C A13
LERCANIDIPINE
Total
0.1344
Public
Private
0.1344
C08D A01
VERAPAMIL
Total
0.0795
Public
0.0245
Private
0.0551
C08D B01
DILTIAZEM
Total
0.5371
Public
0.2811
Private
0.256
C09A
ANGIOTENSIN CONVERTING ENZYME INHIBITORS, PLAIN
C09A A01
CAPTOPRIL
Total
3.8928
Public
3.6115
Private
0.2813
C09A A02
ENALAPRIL
Total
3.8315
Public
1.802
Private
2.0296
C09A A03
LISINOPRIL
Total
1.6354
Public
0.0001
Private
1.6353
24
CHAPTER 9
ATC
2004
C09A A04
PERINDOPRIL
Total
4.0141
Public
3.0035
Private
1.0106
C09A A05
RAMIPRIL
Total
1.0647
Public
0.1961
Private
0.8686
C09A A06
QUINAPRIL
Total
0.0488
Public
0
Private
0.0488
C09A A09
FOSINOPRIL
Total
0.1028
Public
0.0047
Private
0.0981
C09B
ACE INHIBITORS, COMBINATIONS
C09B A04
PERINDOPRIL AND DIURETICS
Total
0.0043
Public
0.0008
Private
0.0035
C09C
ANGIOTENSIN II ANTAGONISTS, PLAIN
C09C A01
LOSARTAN
Total
1.9803
Public
0.3466
Private
1.6337
C09C A03
VALSARTAN
Total
0.7344
Public
0.1017
Private
0.6327
C09C A04
IRBESARTAN
Total
0.5115
Public
0.074
Private
0.4374
C09C A06
CANDESARTAN
Total
0.3311
Public
0.001
Private
0.3301
C09C A07
TELMISARTAN
Total
1.1884
Public
0.1111
Private
1.0773
C09D
ANGIOTENSIN II ANTAGONISTS, COMBINATIONS
C09D A01
LOSARTAN AND DIURETICS
Total
1.2717
Public
0.0647
Private
1.207
C09D A03
VALSARTAN AND DIURETICS
Total
0.8293
Public
0.0213
Private
0.8081
C09D A04
IRBESARTAN AND DIURETICS
Total
0.343
Public
0.0095
Private
0.3335
25
CHAPTER 9
ATC
2004
C09D A06
CANDESARTAN AND DIURETICS
Total
0.2053
Public
0.0002
Private
0.2051
C09D A07
TELMISARTAN AND DIURETICS
Total
0.2204
Public
0.0001
Private
0.2203
References:
1. Lim TO, Zaki M, Maimunah AH, Rozita H, Ding LM. Prevalence, awareness, treatment and control of
Hypertension in Malaysian adult population. Singapore Medical Journal 2004;45:20-27
2. Clinical Practice Guidelines on management of Hypertension. Available at: http://www.acadmed.org.my/
html/index.shtml
3. Australian Statistics on Medicine 2003.Commonwealth Department of health and ageing Australia 2005
26
CHAPTER 10
USE OF LIPID LOWERING MEDICINES
Edited by:
Sim Kui Hian1, Tamil Selvan Muthusamy2, Khoo Kah Lin3
Mohd. Husni B Jamal4, Chai Swee Chin5, David KL Quek6, Noraini bt. Mohamad7, Selvarajah Sathaya7
1 Sarawak General Hospital MOH, 2 Damansara Specialist Hospital, 3 Klinik Dr Khoo Kah Lin, 4 Governance
Board, 5 Clinical Research Centre, 6 D Quek Specialist Heart Clinic, 7 PutraJaya Hospital MOH, 8 Klinik Prime
Care
Lipid lowering medicines has been proven beyond doubt as one of the most cost effective treatments in the
primary and secondary prevention of coronary artery disease [1].
Similar to worldwide trend, the HMG CoA reductase inhibitors (or statins) were the most commonly used lipid
lowering agents in Malaysia. Compared to Nordic countries (in 2003, Greenland, lowest in the group, had a 29.9
DDD/1000 population/day while Norway, highest in the group, had a 97.8 DDD/1000 population/day) [2], the
usage of HMG CoA reductase inhibitors in Malaysia was only 17.0 DDD/1000 population/day (despite population
adjustment for age). Therefore, given the fact that coronary artery disease was the number one cause of death in
Malaysia during the corresponding period, statin use as a class of drugs, is still severely underutilised despite the
strong recommendation by the Malaysian CPG on the Management of Dyslipidaemia in 2004 [3].
In 2004 in Malaysia, simvastatin was the most commonly used HMG CoA reductase inhibitor with 7.9 DDD/1000
population/day. In an earlier comparable period (in 2000) in Australia, simvastatin was also the most commonly
used HMG CoA reductase inhibitor with 29.7 DDD/1000 population/day [4]. The second most common HMG
CoA reductase inhibitor used in Malaysia, in 2004, was atorvastatin at 3.9 DDD/1000 population/day. In Australia,
in 2003, however, atorvastatin had become the most common HMG CoA reductase inhibitor used [5].
All the HMG CoA reductase inhibitors used in Malaysia in 2004 were more commonly used by the private health
care providers apart from the generic Lovastatin which was the most common HMG CoA reductase inhibitor
used by the public health care providers.
In Malaysia in 2004, fibrates had the same level of utilization as in Australia (in 2002-2003) at around 1.9
DDD/1000 population/day [5]. The public health care providers had greater usage of this class of medicine than
the private sector. Generic gemfibrozil was the most commonly used medicine in this class.
Similar to the Nordic countries and Australia, all the other class of lipid lowering medicines such as bile acid
sequestrants, nicotinic acid derivatives and newer agents such as ezetimibe only had negligible usage in NMUS
Malaysia 2004.
Table 10.1: Use of Lipid Lowering Medicines by Drug Class, in DDD/1000 population/day 2004
#
Drug Class
2004
C10A A
HMG COA REDUCTASE INHIBITORS
17.0099
C10A B
FIBRATES
1.9141
C10A C
BILE ACID SEQUESTRANTS
0.0034
C10A D
NICOTINIC ACID AND DERIVATIVES
0.0001
C10A X
OTHER CHOLESTEROL AND TRIGLYCERIDE REDUCERS 0.3093
27
CHAPTER 10
Table 10.2: Use of Lipid Lowering Medicines by Drug Class and Agents, in DDD/1000 population/day
2004
ATC
2004
C10A A
C10A A01
SIMVASTATIN
Total
7.9016
Public
1.0938
Private
6.8078
C10A A02
LOVASTATIN
Total
4.0799
Public
2.9441
Private
1.1358
C10A A03
PRAVASTATIN
Total
0.5667
Public
0.1032
Private
0.4635
C10A A04
FLUVASTATIN
Total
0.5469
Public
0.0026
Private
0.5443
C10A A05
ATORVASTATIN
Total
3.9146
Public
0.4129
Private
3.5017
C10A A07
ROSUVASTATIN
Total
0.0001
Public
0.0001
Private
C10A B
FIBRATES
C10A B02
BEZAFIBRATE
Total
0.0045
Public
0
Private
0.0045
C10A B04
GEMFIBROZIL
Total
0.5271
Public
0.4671
Private
0.0599
C10A B05
FENOFIBRATE
Total
1.2838
Public
0.0362
Private
1.2476
C10A B08
CIPROFIBRATE
Total
0.0987
Public
0.0093
Private
0.0894
28
CHAPTER 10
Table 10.2: Use of Lipid Lowering Medicines by Drug Class and Agents, in DDD/1000 population/day
2004
ATC
2004
C10A C
C10A C01
COLESTYRAMINE
Total
0.0034
Public
0.0003
Private
0.0032
C10A D
NICOTINIC ACID AND DERIVATIVES
C10A D02
NICOTINIC ACID
Total
<0.0001
Public
<0.0001
Private
0
C10A D06
ACIPIMOX
Total
0.0001
Public
0
Private
0.0001
C10A X
OTHER CHOLESTEROL AND TRIGLYCERIDE REDUCERS
C10A X09
EZETIMIBE
Total
0.3093
Public
0.0006
Private
0.3086
References:
1. Kastelein JJP. Atherosclerosis. 1999;143(suppl 1):S17-S21
2. Medicines consumption in the Nordic countries 1999-2003.Nordic Medico Statistical Committee 2004;
2004: Copenhagen.
3. Third Malaysia CPG on Management of dyslipidaemia 2004.
2003
5. Australian Statistics on Medicine 2003.Commonwealth of Australia 2005.
29
CHAPTER 11: USE OF DERMATOLOGICALS [RESERVE]
CHAPTER 12: USE OF GYNAECOLOGICALS, SEX HORMONES AND HORMONAL
CONTRACEPTIVES [RESERVE]
CHAPTER 13: USE OF UROLOGICALS [RESERVE]
CHAPTER 14: USE OF DRUGS FOR ENDOCRINE DISORDERS [RESERVE]
31
CHAPTER 15
USE OF ANTIINFECTIVES
Edited by:
Tan Kah Kee1
Victor Chuang Tuan Giam2, Sameerah bt Shaikh Abdul Rahman3, Usha Rajasingam4, Rahela bt Ambaras Khan3,
Sharmini Selvarajah5, Zuhaila bt Muhamad Ikbar6, Rohaizan bt Mohd Hanafiah6, Yuen Shalyn5
1 Seremban Hospital MOH, 2 Universiti Kebangsaan Malaysia, 3 Pharmacy Services Division, 4 Bio Collagen
Tech Sdn Bhd, 5 Clinical Research Centre MOH, 6 Penang Hospital MOH
The most commonly used antiinfectives in 2004 were antibacterials, followed by antimycotics, antimycobacterials,
antivirals and antimalarials. Among all classes of antibacterials, penicillins were most used, which was four times
more frequent than macrolides, lincosamides and streptogramins, other beta-lactams such as cephalosporins
and carbapenems, and tetracyclines. Amongst penicillins, usage of amoxicillin was the highest, followed
by amoxicillin and enzyme inhibitor, and cloxacillin. Amoxicillin, amoxicillin and enzyme inhibitor were
predominantly prescribed in the private sector whilst cloxacillin was more commonly prescribed in the public
sector. Heavy consumption of penicillins could be due to widespread usage for common infections such as Upper
Respiratory Tract Infection (URTI) and skin infections.
The most commonly used macrolides were erythromycin and clarithromycin. In the cephalosporin group,
cephalexin was most used followed by cefuroxime. The private sector prescribed mostly cephalexin, while the
public sector used twice as much cefuroxime than private. Among the tetracyclines class, doxycycline was the
most used and predominantly prescribed by the private sector. The private used eight times more doxycycline
than the public sector.
This could be due to widespread usage of doxycycline for the treatment of acne, although no definitive data on
indications for prescription could be obtained to verify it.
More quinolones were being prescribed in the private sector in a range of two fold (ciprofloxacin) to 24 fold
(ofloxacin), while the public sector hardly use norfloxacin. In the use of sulphamethoxazole and trimethoprim,
private sector used two times more (0.4) than the public sector (0.2)
The use of antibacterials in Malaysia (17.7) is higher than Denmark (15.0/1000 inhabitants/day) and Sweden
(16.3), comparable to Norway (17.0) but lower than Finland (22.3) and Iceland (20.3). Pattern of consumption of
the penicillin group (J01 C) is similar to the Nordic countries (1999-2003) where it is the dominant antimicrobial
group in both regions. Consumption of combinations of amoxicillin and enzyme inhibitor (J01C R02) was
significantly higher in Malaysia (15 times more) compared to most Nordic countries. Consumption of macrolides
(2.2) was similar to Norway (1.9) and Denmark (2.2) but far higher than Sweden (0.9). Quinolone consumption
was more frequent in Malaysia compared to Nordic regions, except in Finland, which was higher (2.3 times
more). In contrast, consumption of antibacterial of class sulfonamides and trimethoprim was generally lower in
Malaysia compared to most Nordic countries, except in Finland and Iceland, which was higher (3 times more).
Table 15.1: Use of Antiinfectives, in DDD/1000 population/day 2004
#
Drug Class
J01
ANTIBACTERIALS
J02
ANTIMYCOTICS
J04
ANTIMYCOBACTERIALS
J05
ANTIVIRALS
P01B
ANTIMALARIALS
33
2004
17.7188
1.0146
0.9756
0.2026
0.1203
CHAPTER 15
Table 15.2.1: Use of Antibacterials by Drug Class, in DDD/1000 population/day 2004
#
Drug Class
2004
J01A
TETRACYCLINES
2.0082
J01B
AMPHENICOLS
0.0064
J01C
BETA-LACTAMS, PENICILLINS
8.8538
J01D
OTHER BETA-LACTAMS
2.1925
J01E
SULFONAMIDES AND TRIMETHOPRIM
0.657
J01F
MACROLIDES, LINCOSAMIDES AND STREPTOGRAMINS 2.2027
J01G
AMINOGLYCOSIDES
0.3632
J01M
QUINOLONES
0.6823
J01X
OTHER ANTIBACTERIALS
0.7527
Table 15.2.2: Use of Antibacterials by Drug Class and Agents, in DDD/1000 population/day 2004
ATC
2004
J01A
TETRACYCLINES
J01A A02
DOXYCYCLINE
Total
1.735
Public
0.197
Private
1.538
J01A A06
OXYTETRACYCLINE
Total
0
Public
0
Private
0
J01A A07
TETRACYCLINE
Total
0.2167
Public
0.0561
Private
0.1606
J01A A08
MINOCYCLINE
Total
0.0565
Public
0.0005
Private
0.0559
J01B
ANPHENICOLS
J01B A01
CHLORAMPHENICOL
Total
0.0064
Public
0.0027
Private
0.0037
J01C
BETA-LACTAMS, PENICILLINS
J01C A01
AMPICILLIN
Total
0.1816
Public
0.0717
Private
0.1099
J01C A04
AMOXICILLIN
Total
4.0243
Public
0.7732
Private
3.2511
J01C A06
BACAMPICILLIN
Total
0.3568
Public
0.2211
Private
0.1357
J01C A12
PIPERACILLIN
Total
0.0012
Public
0.0012
Private
0
34
CHAPTER 15
ATC
2004
J01C E01
BENZYLPENICILLIN
Total
0.0282
Public
0.0234
Private
0.0048
J01C E02
PHENOXYMETHYLPENICILLIN
Total
0.1949
Public
0.1707
Private
0.0242
J01C E08
BENZATHINE BENZYLPENICILLIN
Total
0.0013
Public
0.0012
Private
0.0001
J01C E09
PROCAINE BENZYLPENICILLIN
Total
0.0001
Public
0.0001
Private
<0.0001
J01C F02
CLOXACILLIN
Total
0.9678
Public
0.6695
Private
0.2983
J01C F05
FLUCLOXACILLIN
Total
0.0379
Public
0.0008
Private
0.0371
J01C R01
AMPICILLIN AND ENZYME INHIBITOR
Total
0.033
Public
0.0227
Private
0.0103
J01C R02
AMOXICILLIN AND ENZYME INHIBITOR
Total
2.9569
Public
0.0984
Private
2.8586
J01C R03
TICARCILLIN AND ENZYME INHIBITOR
Total
0
Public
Private
0
J01C R04
SULTAMICILLIN
Total
0.0666
Public
0.0305
Private
0.0361
J01C R05
PIPERACILLIN AND ENZYME INHIBITOR
Total
0.0032
Public
0.0025
Private
0.0008
J01D
OTHER BETA-LACTAMS
J01D B01
CEFALEXIN
Total
1.1906
Public
0.0428
Private
1.1478
J01D B04
CEFAZOLIN
Total
0.0028
Public
0
Private
0.0028
35
CHAPTER 15
ATC
2004
J01D B05
CEFADROXIL
Total
0.0569
Public
Private
0.0569
J01D C02
CEFUROXIME
Total
0.3745
Public
0.2545
Private
0.12
J01D C04
CEFACLOR
Total
0.1213
Public
0.0026
Private
0.1187
J01D C10
CEFPROZIL
Total
0.0261
Public
0.0006
Private
0.0255
J01D D01
CEFOTAXIME
Total
0.1007
Public
0.0045
Private
0.0962
J01D D02
CEFTAZIDIME
Total
0.0137
Public
0.0115
Private
0.0022
J01D D04
CEFTRIAXONE
Total
0.0294
Public
0.0205
Private
0.009
J01D D10
CEFETAMET
Total
0
Public
0
Private
0
J01D D12
CEFOPERAZONE
Total
0.0165
Public
0.016
Private
0.0005
J01D D14
CEFTIBUTEN
Total
0.0616
Public
0.0004
Private
0.0612
J01D E01
CEFEPIME
Total
0.0507
Public
0.0467
Private
0.004
J01D H02
MEROPENEM
Total
0.1359
Public
0.011
Private
0.1249
J01D H03
ERTAPENEM
Total
0.0018
Public
0.0006
Private
0.0011
J01D H51
IMIPENEM AND ENZYME INHIBITOR
Total
0.0099
Public
0.0066
Private
0.0034
36
CHAPTER 15
ATC
2004
J01E
SULFONAMIDES AND TRIMETHOPRIM
J01E A01
TRIMETHOPRIM
Total
0.0423
Public
0.0014
Private
0.0409
J01E C01
SULFAMETHOXAZOLE
Total
<0.0001
Public
<0.0001
Private
0
J01E E01
SULFAMETHOXAZOLE AND TRIMETHOPRIM Total
0.6071
Public
0.2032
Private
0.4039
J01E E02
SULFADIAZINE AND TRIMETHOPRIM
Total
0.0076
Public
<0.0001
Private
0.0075
J01F
MACROLIDES, LINCOSAMIDES AND STREPTOGRAMINS
J01F A01
ERYTHROMYCIN
Total
1.3734
Public
0.5767
Private
0.7967
J01F A02
SPIRAMYCIN
Total
0.0007
Public
<0.0001
Private
0.0006
J01F A06
ROXITHROMYCIN
Total
0.2004
Public
0
Private
0.2004
J01F A09
CLARITHROMYCIN
Total
0.3289
Public
0.0397
Private
0.2892
J01F A10
AZITHROMYCIN
Total
0.2446
Public
0.0131
Private
0.2316
J01F A13
DIRITHROMYCIN
Total
0
Public
0
Private
0
J01F F01
CLINDAMYCIN
Total
0.0409
Public
0.0023
Private
0.0386
J01F F02
LINCOMYCIN
Total
0.0138
Public
0
Private
0.0138
J01G
AMINOGLYCOSIDES
J01G A01
STREPTOMYCIN
Total
0.0497
Public
0.0493
Private
0.0004
37
CHAPTER 15
ATC
2004
J01G B03
GENTAMICIN
Total
0.3017
Public
0.0119
Private
0.2898
J01G B04
KANAMYCIN
Total
0.0034
Public
0.0002
Private
0.0032
J01G B06
AMIKACIN
Total
0.0055
Public
0.0048
Private
0.0007
J01G B07
NETILMICIN
Total
0.003
Public
0.0021
Private
0.0009
J01M
QUINOLONES
J01M A01
OFLOXACIN
Total
0.1475
Public
0.0058
Private
0.1417
J01M A02
CIPROFLOXACIN
Total
0.3347
Public
0.1197
Private
0.215
J01M A03
PEFLOXACIN
Total
0.0136
Public
0.0069
Private
0.0067
J01M A04
ENOXACIN
Total
0.0024
Public
0
Private
0.0024
J01M A06
NORFLOXACIN
Total
0.107
Public
<0.0001
Private
0.1069
J01M A12
LEVOFLOXACIN
Total
0.0061
Public
0
Private
0.0061
J01M A14
MOXIFLOXACIN
Total
0.0187
Public
0.0015
Private
0.0172
J01M A16
GATIFLOXACIN
Total
0.0217
Public
0.0007
Private
0.021
J01M B04
PIPEMIDIC ACID
Total
0.0306
Public
<0.0001
Private
0.0306
38
CHAPTER 15
ATC
2004
J01X
OTHER ANTIBACTERIALS
J01X A01
VANCOMYCIN
Total
0.0055
Public
0.0042
Private
0.0012
J01X A02
TEICOPLANIN
Total
0.002
Public
0.0017
Private
0.0003
J01X B02
POLYMYXIN B
Total
0.0001
Public
0.0001
Private
0
J01X C01
FUSIDIC ACID
Total
0.0194
Public
0.0129
Private
0.0065
J01X D01
METRONIDAZOLE
Total
0.7106
Public
0.0464
Private
0.6643
J01X D02
TINIDAZOLE
Total
0.0009
Public
0
Private
0.0009
J01X E01
NITROFURANTOIN
Total
0.0091
Public
0.0086
Private
0.0005
J01X X01
FOSFOMYCIN
Total
0.0003
Public
0
Private
0.0003
J01X X04
SPECTINOMYCIN
Total
0
Public
0
Private
0
J01X X08
LINEZOLID
Total
0.0049
Public
0.0001
Private
0.0048
Table 15.3.1: Use of Antimycotics by Drug Class, in DDD/1000 population/day 2004
#
Drug Class
2004
J02A A
ANTIBIOTICS
0.0036
J02A B
IMIDAZOLE DERIVATIOVES
0.8942
J02A C
TRIAZOLE DERIAVTIVES
0.1168
J02A X
OTHER ANTIMYCOTICS FOR SYSTEMIC USE
0.0001
39
CHAPTER 15
Table 15.3.2: Use of Antimycotics by Drug Class and Agents, in DDD/1000 population/day 2004
ATC
2004
J02A A
ANTIBIOTICS
J02A A01
AMPHOTERICIN B
Total
0.0036
Public
0.0034
Private
0.0001
J02A B
IMIDAZOLE DERIVATIOVES
J02A B01
MICONAZOLE
Total
0.0158
Public
0.0011
Private
0.0147
J02A B02
KETOCONAZOLE
Total
0.8784
Public
0.0073
Private
0.871
J02A C
TRIAZOLE DERIAVTIVES
J02A C01
FLUCONAZOLE
Total
0.0576
Public
0.0142
Private
0.0435
J02A C02
ITRACONAZOLE
Total
0.0591
Public
0.011
Private
0.0481
J02A X
OTHER ANTIMYCOTICS FOR SYSTEMIC USE
J02A X01
FLUCYTOSINE
Total
<0.0001
Public
<0.0001
Private
0
J02A X04
CASPOFUNGIN
Total
0.0001
Public
<0.0001
Private
<0.0001
Table 15.4.1: Use of Antimycobacterials by Drug Class, in DDD/1000 population/day 2004
ATC
2004
J04A B01
CYCLOSERINE
Total
0.0004
Public
0.0004
Private
0
J04A B02
RIFAMPICIN
Total
0.2387
Public
0.1954
Private
0.0433
J04A B30
CAPREOMYCIN
Total
0
Public
0
Private
0
J04A C01
ISONIAZID
Total
0.4357
Public
0.3881
Private
0.0476
40
CHAPTER 15
Table 15.4.1: Use of Antimycobacterials by Drug Class, in DDD/1000 population/day 2004
ATC
2004
J04A D03
ETHIONAMIDE
Total
0
Public
0
Private
0
J04A K01
PYRAZINAMIDE
Total
0.129
Public
0.1043
Private
0.0247
J04A K02
ETHAMBUTOL
Total
0.075
Public
0.0569
Private
0.018
J04A M02
RIFAMPICIN AND ISONIAZID
Total
0.0082
Public
Private
0.0082
J04A M05
RIFAMPICIN, PYRAZINAMIDE AND
Total
0.0001
ISONIAZID
Public
0
Private
0.0001
J04B A01
CLOFAZIMINE
Total
<0.0001
Public
<0.0001
Private
0
J04B A02
DAPSONE
Total
0.0884
Public
0.0884
Private
0
Table 15.5.1: Use of Antimalarials by Drug Class, in DDD/1000 population/day 2004
#
Drug Class
2004
P01B A
AMINOQUINOLINES
0.1143
P01B B
BIGUANIDES
0
P01B C
METHANOLQUINOLINES
0.003
P01B D
DIAMINOPYRIMIDINES
0.003
Table 15.5.2: Use of Antimalarials by Drug Class and Agents, in DDD/1000 population/day 2004
ATC
2004
P01B A
AMINOQUINOLINES
P01B A01
CHLOROQUINE
Total
0.0052
Public
0.0048
Private
0.0004
P01B A02
HYDROXYCHLOROQUINE
Total
0.0434
Public
0.0366
Private
0.0068
P01B A03
PRIMAQUINE
Total
0.0657
Public
0.0653
Private
0.0004
41
CHAPTER 15
Table 15.5.2: Use of Antimalarials by Drug Class and Agents, in DDD/1000 population/day 2004
ATC
2004
P01B B
BIGUANIDES
P01B B01
PROGUANIL
Total
0
Public
0
Private
0
P01B C
METHANOLQUINOLINES
P01B C01
QUININE
Total
0.0029
Public
0.0019
Private
0.0011
P01B C02
MEFLOQUINE
Total
0.0001
Public
<0.0001
Private
<0.0001
P01B D
DIAMINOPYRIMIDINES
P01B D01
PYRIMETHAMINE
Total
0.0001
Public
0
Private
0.0001
P01B D51
PYRIMETHAMINE, COMBINATIONS
Total
0.003
Public
0.0007
Private
0.0023
Table 15.6.1: Use of Antivirals by Drug Class, in DDD/1000 population/day 2004
#
Drug Class
J05A B
NUCLEOSIDES AND NUCLEOTIDES, EXCLUDING
REVERSE TRANSCRIPTASE INHIBITORS
J05A E
PROTEASE INHIBITORS
J05A F
NUCLEOSIDES AND NUCLEOTIDES REVERSE
TRANSCRIPTASE INHIBITORS
J05A G
NON-NUCLEOSIDE REVERSE TRANSCRIPTASE
INHIBITORS
J05A H
NEURAMINIDASE INHIBITORS
2004
0.0664
0.017
0.095
0.0241
<0.0001
Table 15.6.2: Use of Antivirals by Drug Class and Agents, in DDD/1000 population/day 2004
ATC
2004
J05A B
NUCLEOSIDES AND NUCLEOTIDES, EXCLUDING REVERSE
J05A B01
ACICLOVIR
Total
0.0623
Public
0.0043
Private
0.058
J05A B04
RIBAVIRIN
Total
0.002
Public
0.0017
Private
0.0002
J05A B06
GANCICLOVIR
Total
0.0001
Public
0.0001
Private
<0.0001
42
CHAPTER 15
ATC
2004
J05A B09
FAMCICLOVIR
Total
<0.0001
Public
0
Private
<0.0001
J05A B11
VALACICLOVIR
Total
0.002
Public
0
Private
0.002
J05A B14
VALGANCICLOVIR
Total
0.0001
Public
0.0001
Private
0
J05A E
PROTEASE INHIBITORS
J05A E02
INDINAVIR
Total
0.0148
Public
0.0147
Private
0.0001
J05A E03
RITONAVIR
Total
0.0021
Public
0.0021
Private
<0.0001
J05A E04
NELFINAVIR
Total
<0.0001
Public
<0.0001
Private
0
J05A F
NUCLEOSIDES AND NUCLEOTIDES REVERSE
J05A F01
ZIDOVUDINE
Total
0.0145
Public
0.0143
Private
0.0002
J05A F02
DIDANOSINE
Total
0.011
Public
0.0105
Private
0.0005
J05A F03
ZALCITABINE
Total
<0.0001
Public
<0.0001
Private
0
J05A F04
STAVUDINE
Total
0.0113
Public
0.0109
Private
0.0005
J05A F05
LAMIVUDINE
Total
0.0437
Public
0.0233
Private
0.0204
J05A F08
ADEFOVIR DIPIVOXIL
Total
0.0031
Public
0.0001
Private
0.003
J05A F30
COMBINATIONS
Total
0.0114
Public
0.0099
Private
0.0015
43
CHAPTER 15
ATC
2004
J05A G
NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS
J05A G01
NEVIRAPINE
Total
0.0039
Public
0.0038
Private
0.0001
J05A G03
EFAVIRENZ
Total
0.0202
Public
0.0193
Private
0.0009
J05A H
NEURAMINIDASE INHIBITORS
J05A H02
OSELTAMIVIR
Total
<0.0001
Public
<0.0001
Private
0
References:
2004: Copenhagen
2. Monnet DL, Molstad S, Cars O. Defined daily doses of antimicrobials reflect antimicrobial prescriptions in
ambulatory care. Journal of Antimicrobial Chemotherapy 2004; 53: 1109-11
44
CHAPTER 16:
USE OF ANTINEOPLASTIC AGENTS
Edited by:
Lim Yeok Siew1, Beena Devi2
S Visalachy PuruShotaman1, Sujatha Suthandiram3, Kamarun Neasa1, Yuzlina Muhamad Yunus1,
Kananathan Ratnavelu4, Nik Nuradlina Nik Adnan1, Tajunisah Mohamad Eusoff5, Gucharan Singh6
1 Kuala Lumpur Hospital MOH, 2 Sarawak General Hospital MOH, 3 Hospital Tengku Ampuan Rahimah MOH,
4 NCI cancer Hoapital, 5 Penang Hospital MOH, 6 Damansara Specialist Centre.
Antineoplastics are agents used in the treatment of cancer. Treatment of cancer using antineoplastic agents is
complex and is usually under the care of oncologists. Cancer is still a major problem in Malaysia causing high
morbidity and mortality. In 2003 there were 21,464 cancer cases diagnosed in West Malaysia. The cumulative
lifetime risk of cancer in the Malaysian population is 1:4. The age-standardized rate (ASR) for overall cancer
incidence in West Malaysia in 2003 is 143.2 per 100,000. Malaysia has a population of 25 million in 2004.
The top 5 cancers are breast cancer, lung cancer, colorectal, cervix and leukemia. According to the report
prepared by Dr G. Lim on NCC, it states that there are 5 government hospitals and 14 private centres treating
cancer cases and Malaysia has 1 oncologist per 800,000 population (NCC report). Based on the recommendation
given by the Royal College of Radiologists in 1998, the norm for UK is 1:250,000. Funding for antineoplastic
agents for Government hospitals comes from Ministry of Health (MOH) and in the 23 private hospitals, the drug
cost is borne by patients themselves. 54% of the total cancer patients are seen in Government hospitals while
46% are seen in private hospitals.
The National Medicine Use Survey (NMUS) identified 44 antineoplastic drugs used in Malaysia. The top 15
antineoplastics are as in table 1. The top 5 antineoplastic agents used for solid tumours and hematological cancers
are shown in table 2 .The low usage drugs are gemtuzumab, cladribine, alemtuzumab, thiotepa and topotecan.
Usage of trastuzumab for breast cancer in the country was 0.05 mg/1000 population. Usage of imatinib for
chronic myeloid leukemia and gastro-intestinal stromal tumour was 23.297 mg/1000 population. Gefitinib was
used for lung cancer as much as 26.24 mg/1000 population. Temozolomide usage for glioblastoma multiforme
was 4.28 mg/1000 population .
This is the first attempt at preparing a report which is descriptive in nature on antineoplastic agents used nationwide
and hence should not be interpreted as being wholly conclusive. In addition to the government hospitals which
participated in this study, only 29 private hospitals contributed their data. There are limitations in our data
presentation because of the following reasons:
1. Other classes of drugs such as antibacterials can be in daily defined dose (DDD) but antineoplastic agents can
not be calculated (DDD) even for study purposes. The reason for this is because some antineoplastic agents
are used for different types of cancers at varying doses and even for the same indication there are different
treatment regimes using different doses in mg/m2.
2. Note that the indications for the drugs were not captured in the present format of data collection.
In order to have meaningful interpretation of the usage of antineoplastic agents nationwide, we recommend that
there is more information of indications of the usage, the number of patients who had been on those agents, the
number of trained personnel and facilties. With additional information, we hope to be able to produce a report
which would help policy makers to be able to make the right decisions that would help cancer patients in the country.
In addiction in future, we will be able to produce reports, which can be made comparable internationally.
45
CHAPTER 16
USE OF ANTINEOPLASTIC AGENTS
Table 1: Use of Antineoplastic Drugs in total dosage/1000 population 2004
ATC
Drug Name
Unit
Route
L01X X05 HYDROXYCARBAMIDE
MG
o
L01B C02 FLUOROURACIL
MG
p
L01B C06 CAPECITABINE
MG
o
L01X X24 PEGASPARGASE
U
p
L01X X02 ASPARAGINASE
U
p
L01B C01 CYTARABINE
MG
p
L01A A01 CYCLOPHOSPHAMIDE
MG
p
L01A A06 IFOSFAMIDE
MG
p
L01B B02 MERCAPTOPURINE
MG
o
L01B C05 GEMCITABINE
MG
p
L01C B01 ETOPOSIDE
MG
p
L01B A01 METHOTREXATE
MG
p
L01A X04 DACARBAZINE
MG
p
L01X A02 CARBOPLATIN
MG
p
L01B C02 FLUOROURACIL
MG
o
2004
5236.53
3077.589
1004.578
994.8829
899.4993
872.9756
681.2297
447.4823
297.6244
153.169
123.4749
120.5313
116.9271
83.3364
67.8944
Table 2. Top 5 Antineoplastic drugs for solid tumours and hematological malignancies
No
ANTINEOPLASTICS USED IN
ANTINEOPLASTICS USED IN HEMATOLOGICAL
SOLID TUMOURS
MALIGNANCIES
1.
FLUROURACIL INJECTION
HYDROXYCARBAMIDE ORAL
2.
CAPECITABINE ORAL
PEGASPARGASE INJECTION
3.
CYCLOPHOSPHAMIDE INJECTION
ASPARAGINASE INJECTION
4.
IFOSFAMIDE INJECTION
CYTARABINE INJECTION
5.
GEMCITABINE INJECTION
MERCAPTOPURINE ORAL
References
1. First Databank. Min/Max Dosing Modules. 2005
2. GLCC. Presentations for RMK 9. 2005
3. Katherine Blake. UK Government moves to tackle lottery of cancer drugs. BMJ 2004
4. Manitoba Centre for Health Policy. Dose Intensity. May 2004
5. Norwegian Institute of Public Health WHO collaborating Centre for Drug Statistics Methodology Norway.
Guidelines for ATC classification and DDD assignment 2005
6. Variations in usage of cancer drugs approved by NICE Report of the Review undertaken by the National
Cancer Director.
46
CHAPTER 17: USE OF SYSTEMIC CORTICOSTEROIDS AND IMMUNOSUPPRESSIVE
AGENTS [RESERVE]
47
CHAPTER 18: USE OF DRUGS FOR
RHEUMATOLOGICAL AND BONE DISORDERS
Edited by:
R. Ramanathan1, Lee Chee Kuan1, Manmohan Singh1, Jennifer Tan2, Suhadah Ahad3
1 Ipoh Hospital MOH, 2 Farmasi Alychem, 3 Melaka Hospital MOH
In the year 2004, diclofenec in all its forms was the most commonly used Non Steroidal Anti Inflammatory
Drugs (NSAID) in public and private sectors in Malaysia. This is followed by mefenamic acid, coxibs, propionic
acid derivatives, oxicams and others in that order. Diclofenac is available in oral, parental, and as suppository.
The reason for its high usage is likely due to its cost effectiveness and easy availability. In the public sector, its
prescription does not need to be countersigned by a specialist. It is also sold widely by the private clinics and
pharmacies. Comparing our usage to that in Australia and Finland, their most used NSAID is ibuprofen [1,2].
These NSAIDs must be used with great caution as they can cause severe gastric side effects on prolonged and
uncontrolled usage.
Mefenamic acid is the second most commonly used NSAID. This drug is also widely used by gynaecologists to
treat dysfunction uterine bleeding and dysmenorrhoea.
COX-2 inhibitors made their appearance in our market in the late 90’s and gradually become a popular medication
to treat pain. COX-2 inhibitors have gastric protective function, hence can be used with less caution in patients
with history of gastric ulcer. Nevertheless the usage is still low due to its high cost. This is also the main reason
why this drug is used more in the private sector. The most commonly used coxib is etoricoxib followed by
celecoxib, valdecoxib, rofecoxib, and parecoxib. Rofecoxib was withdrawn from the world market in the second
half of 2004 because it was found to be associated with higher incidence of cardic events and transient increase in
blood pressure. Injectable valdecoxib was also withdrawn in early 2005 due to it side effect; skin allergy reaction.
Nevertheless the other coxibs still need to be used with great caution as large-scale studies are underway to
determine the safety of these coxibs.
In the propionic acid group, ibuprofen has the highest usage in Malaysia and it seems to be the most popular
propionic derivative used in Finland and Australia also. The other members of this group is ketoprofen which is
not commonly used orally or parenteraly but usually applied topically.
Nimesulide was banned by FDA since 1985 but is still being used in our private sector. The sales may be from
the GP clinics or the pharmacies. In view of the severe side effects, this drug should be withdrawn from our
market.
The antigout preparations used are mainly allopurinol for chronic gout control and colchicines in the treatment
of acute gout attacks. This trend is similar to the Finland and Australian studies but their usage is much higher
compared to ours. This may be due to lack of awareness in our population that gout can be treated with this
medication.
Osteoporosis is the commonest bone disease treated in our clinical practice. Alendronate acid is the most
commonly used bisphosphanate in the management of bone disease in Malaysia. This is due to the fact that
alendronte can prevent a second vertebral and non-vertebral fractures in 50 % of individuals with osteoporotic
bones [3,4,5].
The other bisphosphonates are not widely used due to cost and availability. We would like to see other classes of
anti osteoporotic agents such as alfacalcidiol, SERMs, parathyroid hormones and the latest, strontium, be used
too.
49
Table 18.1: Use of Drugs for Rheumatological and Bone disorders, in DDD/1000 population/day 2004
#
Drug Class
2004
M01
NON-STEROIDAL ANTIINFLAMMATORY AGENTS
15.9397
M03
MUSCLE RELAXANTS
0.6318
M04
ANTIGOUT PREPARATIONS
2.1927
M05
BONE DISEASES THERAPY
1.0571
Table 18.2.1: Use of Non-Steroidal Antiinflammatory drugs by Drug Class, in DDD/1000 population/day
2004
#
Drug Class
2004
M01A A
BUTYLPYRAZOLIDINES
0
M01A B
ACETIC ACID DERIVATIVES
6.0663
M01A C
OXICAMS
1.1485
M01A E
PROPIONIC ACID DERIVATIVES
1.4998
M01A G
FENAMATES
4.7901
M01A H
COXIBS
2.3982
M01A X
OTHER NON-STEROIDAL ANTI-INFLAMMATORY
0.0332
AGENTS
M01C C
PENICILLAMINE
0.0037
Table 18.2.2: Use of Non-Steroidal Antiinflammatory drugs by Drug Class and Agents, in DDD/1000
population/day 2004
ATC
2004
M01A A
BUTYLPYRAZOLIDINES
M01A A01
PHENYLBUTAZONE
Total
0
Public
0
Private
M01A B
ACETIC ACID DERIVATIVES
M01A B01
INDOMETACIN
Total
0.6929
Public
0.4138
Private
0.2791
M01A B02
SULINDAC
Total
0.0187
Public
Private
0.0187
M01A B05
DICLOFENAC
Total
5.3498
Public
1.2021
Private
4.1477
M01A B15
KETOROLAC
Total
0.0049
Public
0.0045
Private
0.0003
M01A C
OXICAMS
M01A C01
PIROXICAM
Total
0.3457
Public
0.0557
Private
0.29
50
population/day 2004
ATC
2004
M01A C02
TENOXICAM
Total
0.0336
Public
Private
0.0336
M01A C06
MELOXICAM
Total
0.7692
Public
0.2765
Private
0.4927
M01A E
PROPIONIC ACID DERIVATIVES
M01A E01
IBUPROFEN
Total
0.9071
Public
0.1955
Private
0.7116
M01A E02
NAPROXEN
Total
0.5771
Public
0.0505
Private
0.5266
M01A E03
KETOPROFEN
Total
0.0156
Public
0.0058
Private
0.0098
M01A G
FENAMATES
M01A G01
MEFENAMIC ACID
Total
4.7901
Public
1.4452
Private
3.3449
M01A H
COXIBS
M01A H01
CELECOXIB
Total
0.6874
Public
0.2245
Private
0.4629
M01A H02
ROFECOXIB
Total
0.3498
Public
0.1369
Private
0.2129
M01A H03
VALDECOXIB
Total
0.3884
Public
0.0061
Private
0.3823
M01A H04
PARECOXIB
Total
0.0008
Public
0.0001
Private
0.0007
M01A H05
ETORICOXIB
Total
0.9718
Public
0.0047
Private
0.9671
M01A X
OTHER NON-STEROIDAL ANTIINFLAMMATORY AGENTS
M01A X17
NIMESULIDE
Total
0.0332
Public
Private
0.0332
51
population/day 2004
ATC
2004
M01C C
PENICILLAMINE
M01C C01
PENICILLAMINE
Total
0.0037
Public
0.0036
Private
0.0001
Table 18.3.1: Use of Muscle relaxants by Drug Class, in DDD/1000 population/day 2004
#
2004
M03B C01
ORPHENADRINE (CITRATE)
Total
0.2289
Public
0.0056
Private
0.2233
M03B C51
ORPHENADRINE, COMBINATIONS
Total
0.3652
Public
Private
0.3652
M03B X01
BACLOFEN
Total
0.0377
Public
0.035
Private
0.0027
Table 18.4.1: Use of Antigout preparations by Drug Class, in DDD/1000 population/day 2004
#
2004
M04A A01
ALLOPURINOL
Total
1.5786
Public
0.6952
Private
0.8834
M04A B01
PROBENECID
Total
0.0032
Public
0
Private
0.0032
M04A C01
COLCHICINE
Total
0.6108
Public
0.3051
Private
0.3058
52
Table 18.5.1: Use of Bone diseases therapy by Drug Class, in DDD/1000 population/day 2004
#
2004
M05B A02
CLODRONIC ACID
Total
0.0041
Public
0.002
Private
0.0022
M05B A03
PAMIDRONIC ACID
Total
0.0012
Public
0.0012
Private
0.0001
M05B A04
ALENDRONIC ACID
Total
1.0433
Public
0.6693
Private
0.3739
M05B A07
RISEDRONIC ACID
Total
0.0083
Public
0.0083
Private
M05B A08
ZOLEDRONIC ACID
Total
0.0002
Public
0.0001
Private
0.0001
References:
2004: Copenhagen
2. Australian Statistics on Medicine 1999-2000.Commonwealth Department of health and ageing Australia
2003
3. Black DM, Thompson De, Bauer DC et al, for the FIT Research group. Fracture risk reduction with alendronate
in women with osteoporosis; The Fracture Intervention Trial. J Clin Endocrinol Metab 2000:85(11):41184124.
4. Quandt S, Thompson D, Hocberg M. Consistency of effect of alendronate on reduction in risk of hip and
forearm fractures: A meta-analysis. Poster presented at: 5th Workshop on Bisphosphonates; April 5-7 2000;
Dayos Switzerland.
5. Lees B, Garland SW, Walton C et al. Role of oral pamidronate in prevention of bone loss in postmenopausal
women. Osteoporos Int 1996;6(6):480-485
53
CHAPTER 19: USE OF ANALGESICS AND ANAESTHETICS [RESERVE]
CHAPTER 20: USE OF DRUGS FOR NEUROLOGICAL DISORDERS [RESERVE]
55
CHAPTER 21
USE OF DRUGS FOR PSYCHIATRIC DISORDERS
Edited by:
Suraya Yusoff1, Suarn Singh2, Syed Fadzli Syed Sailuddin3
Benjamin Chan Teck Ming4, Ahmad Hatim Sulaiman5, Zoriah bt Aziz6, Tg Malini Tg Mohd Noor Izam7, Noor
Ratna Naharuddin4, Mariam Bintarty Rushdi7
1 Sultanah Aminah Hospital MOH, 2 Bahagia Hospital MOH, 3 Pharmaceutical Services Division MOH, 4
Permai Hospital MOH, 5 Department of Psychological Medicine, Faculty of Medicine,University of Malaya, 6
Department of Pharmacy Faculty of Medicine,University of Malaya, 7 Kuala Lumpur Hospital MOH
The prevalence of mental health disorders in Malaysia is about 10.7% [1] and was responsible for 8.6% of the
total Disability Life Years (DALYs). Mental disorders ranked fourth as the leading cause of burden of disease by
disease categories and unipolar major depression accounts for 45% of this burden [2]. The biopsychosocial model
is used in the management of mental disorder. However psychopharmacology still remains one of the mainstay
of treatment of most mental disorders. The cost of psychiatric medications however, has increased over the years
with the introduction of newer generation of both antipsychotic and antidepressant medications.
Among the psychiatric medications, antipsychotics form 37.9% of consumption, antidepressants 32.1%, followed
by anxiolytics, sedatives and hypnotics 30%. This may be because the majority of patients with psychotic
symptoms are treated at the public facilities.
The consumption of antipsychotic medication is still low in Malaysia compared to other countries. It may indicate
that a proportion of population with schizophrenia did not come forward for treatment due to the stigma of
the illness. It may also mean that default rate is high. Most of the consumption is at public facilities (54.3%).
Among the conventional antipsychotic medication, phenothiazines showed the highest consumption followed by
the thioxanthenes. We can safely imply from the data that the usage of depot medication is about 28.7%. Atypical
antipsychotics form only 10.3% of consumption. In Australia, it contributes to 35% of consumption in 2002 [3].
The main reason may be due to the high cost of the atypical. Among the atypicals, risperidone (6%) shows the
highest consumption, at both the private and public facilities.
Lithium is coded among the antipsychotic medication group. However its use in psychiatry is as a mood
stabilizer, and so should not be in this group. Spain actually excluded lithium from the total DDD calculations for
antipsychotic medication [4].
The consumption of antidepressant is still low compared to other countries. Depression is probably underdiagnosed and under-treated. Among the antidepressant groups, the Serotonin Selective Reuptake Inhibitor
(SSRI), non-selective monoamine reuptake inhibitors and other antidepressant group are used in equal amount.
The use of SSRI in other countries far exceeds that of other types of antidepressants. The non-selective monoamine
reuptake inhibitors are still highly used despite the recommendation in the guidelines. The private facilities are
the main consumers of antidepressant. It is encouraging to see that most depressed patients prefer to see private
practitioners.
Anxiolytics, sedative and hypnotics use are still very low in Malaysia. Like Australia, the use of benzodiazepines
related hypnotics is much lower compared to the benzodiazepine derivatives [5]. Of the anxiolytics, the
benzodiazepines were the most commonly used, forming 83.5% of the total consumption. Among the hypnotics,
the benzodiazepine derivatives are more commonly used when compared to the benzodiazepines related group,
62.4% and 37.48% respectively. The consumption of these 2 groups of drugs is much higher in the private
facilities (66.3% versus 33.7%). This is expected as most patients with anxiety and insomnia seek treatment from
private practitioners first.
The anti-dementia medication consumption in Malaysia is still very low. They are mainly used in the public
facilities. The consumption in other countries is equally low.
57
CHAPTER 21
Table 21.1.1: Use of Antipsychotics by Drug Class, in DDD/1000 population/day 2004
#
Drug Class
2004
N05A A/B/C
PHENOTHIAZINES
1.4295
N05A D
BUTYROPHENONE DERIVATIVES
0.615
N05A E
INDOLE DERIVATIVES
0.0017
N05A F
THIOXANTHENE DERIVATIVES
0.1896
N05A H
DIAZEPINES, OXAZEPINES AND THIAZEPINES
0.1217
N05A K
NEUROLEPTICS, IN TARDIVE DYSKINESIA
0
N05A L
BENZAMIDES
0.2661
N05A N
LITHIUM
0.03
N05A X
OTHER ANTI-PSYCHOTICS
0.1722
Table 21.1.2: Use of Antipsychotics by Drug Class and Agents, in DDD/1000 population/day 2004
ATC
2004
N05A A/B/C
PHENOTHIAZINES
N05A A01
CHLORPROMAZINE
Total
0.5486
Public
0.5273
Private
0.0213
N05A B02
FLUPHENAZINE
Total
0.6028
Public
0.5905
Private
0.0123
N05A B03
PERPHENAZINE
Total
0.0634
Public
0.0119
Private
0.0515
N05A B04
PROCHLORPERAZINE
Total
0.0604
Public
0.0578
Private
0.0027
N05A B06
TRIFLUOPERAZINE
Total
0.1311
Public
0.1266
Private
0.0045
N05A C02
THIORIDAZINE
Total
0.0231
Public
0.0205
Private
0.0026
N05A D
BUTYROPHENONE DERIVATIVES
N05A D01
HALOPERIDOL
Total
0.615
Public
0.611
Private
0.004
N05A E
INDOLE DERIVATIVES
N05A E04
ZIPRASIDONE
Total
0.0017
Public
0.0003
Private
0.0014
58
CHAPTER 21
Table 21.1.2: Use of Antipsychotics by Drug Class and Agents, in DDD/1000 population/day 2004
ATC
2004
N05A F
THIOXANTHENE DERIVATIVES
N05A F01
FLUPENTIXOL
Total
0.1521
Public
0.1232
Private
0.029
N05A F02
CLOPENTHIXOL
Total
0.0078
Public
0.0078
Private
N05A F05
ZUCLOPENTHIXOL
Total
0.0297
Public
0.0291
Private
0.0006
N05A H
DIAZEPINES, OXAZEPINES AND THIAZEPINES
N05A H02
CLOZAPINE
Total
0.031
Public
0.0306
Private
0.0004
N05A H03
OLANZAPINE
Total
0.0829
Public
0.0747
Private
0.0083
N05A H04
QUETIAPINE
Total
0.0077
Public
0.0072
Private
0.0006
N05A K
NEUROLEPTICS, IN TARDIVE DYSKINESIA
N05A K01
TETRABENAZINE
Total
0
Public
0
Private
N05A L
BENZAMIDES
N05A L01
SULPIRIDE
Total
0.2661
Public
0.2628
Private
0.0033
N05A N
LITHIUM
N05A N01
LITHIUM
Total
0.03
Public
0.0257
Private
0.0043
N05A X
OTHER ANTIPSYCHOTICS
N05A X08
RISPERIDONE
Total
0.1722
Public
0.1498
Private
0.0225
59
CHAPTER 21
Table 21.2.1: Use of Antidepressants by Drug Class, in DDD/1000 population/day 2004
#
Drug Class
2004
N06A A
NON-SELECTIVE MONOAMINE REUPTAKE INHIBITORS 0.5696
N06A B
SELECTIVE SEROTONIN REUPTAKE INHIBITORS
0.4654
N06A G
MONOAMINE OXIDASE A INHIBITORS
0.0229
N06A X
OTHER ANTIDEPRESSANTS
0.114
Table 21.2.2: Use of Antidepressants by Drug Class and Agents, in DDD/1000 population/day 2004
ATC
2004
N06A A
NON-SELECTIVE MONOAMINE REUPTAKE INHIBITORS
N06A A02
IMIPRAMINE
Total
0.0415
Public
0.0256
Private
0.0159
N06A A04
CLOMIPRAMINE
Total
0.0114
Public
0.0091
Private
0.0023
N06A A09
AMITRIPTYLINE
Total
0.0966
Public
0.0349
Private
0.0617
N06A A16
DOSULEPIN
Total
0.4108
Public
0.0476
Private
0.3632
N06A A21
MAPROTILINE
Total
0.0093
Public
0.0056
Private
0.0038
N06A B
SELECTIVE SEROTONIN REUPTAKE INHIBITORS
N06A B03
FLUOXETINE
Total
0.1004
Public
0.0609
Private
0.0395
N06A B04
CITALOPRAM
Total
0.0186
Public
0.0044
Private
0.0141
N06A B05
PAROXETINE
Total
0.0272
Public
0.0021
Private
0.0251
N06A B06
SERTRALINE
Total
0.1528
Public
0.105
Private
0.0478
N06A B08
FLUVOXAMINE
Total
0.1659
Public
0.1156
Private
0.0504
N06A B10
ESCITALOPRAM
Total
0.0004
Public
0.0004
Private
60
CHAPTER 21
Table 21.2.2: Use of Antidepressants by Drug Class and Agents, in DDD/1000 population/day 2004
ATC
2004
N06A G
MONOAMINE OXIDASE A INHIBITORS
N06A G02
MOCLOBEMIDE
Total
0.0229
Public
0.0133
Private
0.0097
N06A X
OTHER ANTIDEPRESSANTS
N06A X03
MIANSERIN
Total
0.0201
Public
0.0199
Private
0.0002
N06A X06
NEFAZODONE
Total
0.0007
Public
0.0007
Private
N06A X11
MIRTAZAPINE
Total
0.0775
Public
0.0093
Private
0.0682
N06A X14
TIANEPTINE
Total
0
Public
0
Private
0
N06A X16
VENLAFAXINE
Total
0.0158
Public
0.0041
Private
0.0117
Table 21.3.1: Use of Anxiolytics, Hypnotics and Sedatives by Drug Class, in DDD/1000 population/day
2004
#
Drug Class
2004
N05B A, N05C D
BENZODIAZEPINE DERIVATIVES
1.6085
N05B B
DIPHENYLMETHANE DERIVATIVES
0.2861
N05C C
ALDEHYDES AND DERIVATIVES
<0.0001
N05C F
BENZODIAZEPINE RELATED DRUGS
0.3966
N05C M
OTHER HYNOPTICS AND SEDATIVES
0.0077
61
CHAPTER 21
Table 21.3.2: Use of Anxiolytics, Hypnotics and Sedatives by Drug Class and Agents, in DDD/1000
population/day 2004
ATC
2004
N05B A, N05C D
BENZODIAZEPINE DERIVATIVES
N05B A01
DIAZEPAM
Total
0.3126
Public
0.0565
Private
0.2561
N05B A02
CHLORDIAZEPOXIDE
Total
0.0057
Public
Private
0.0057
N05B A05
POTASSIUM CLORAZEPATE
Total
0.0063
Public
Private
0.0063
N05B A06
LORAZEPAM
Total
0.1794
Public
0.0159
Private
0.1634
N05B A08
BROMAZEPAM
Total
0.0241
Public
0.005
Private
0.0192
N05B A09
CLOBAZAM
Total
0.0388
Public
0.0003
Private
0.0385
N05B A12
ALPRAZOLAM
Total
0.3976
Public
0.0888
Private
0.3088
N05C D02
NITRAZEPAM
Total
0.0046
Public
0.0002
Private
0.0044
N05C D05
TRIAZOLAM
Total
0.2315
Public
Private
0.2315
N05C D08
MIDAZOLAM
Total
0.4079
Public
0.184
Private
0.2239
N05B B
DIPHENYLMETHANE DERIVATIVES
N05B B01
HYDROXYZINE
Total
0.2861
Public
0.0295
Private
0.2565
N05C C
ALDEHYDES AND DERIVATIVES
N05C C05
PARALDEHYDE
Total
<0.0001
Public
<0.0001
Private
0
62
CHAPTER 21
Table 21.3.2: Use of Anxiolytics, Hypnotics and Sedatives by Drug Class and Agents, in DDD/1000
population/day 2004
ATC
2004
N05C F
BENZODIAZEPINE RELATED DRUGS
N05C F01
ZOPICLONE
Total
0.0699
Public
Private
0.0699
N05C F02
ZOLPIDEM
Total
0.3266
Public
0.2119
Private
0.1147
N05C M
OTHER HYNOPTICS AND SEDATIVES
N05C M05
SCOPOLAMINE
Total
0.0077
Public
Private
0.0077
Table 21.4.1: Use of Anti-Dementia by Drug Class, in DDD/1000 population/day 2004
#
Drug Class
2004
N06D
ANTI-DEMENTIA DRUGS
0.0274
Table 21.4.2: Use of Anti-Dementia by Drug Class and Agents, in DDD/1000 population/day 2004
ATC
2004
N06D
ANTI-DEMENTIA DRUGS
N06D A02
DONEPEZIL
Total
0.0114
Public
0.0087
Private
0.0028
N06D A03
RIVASTIGMINE
Total
0.0155
Public
0.0152
Private
0.0003
N06D A04
GALANTAMINE
Total
0.0004
Public
0.0001
Private
0.0003
References:
1. The National Health Morbidity Survey, 1996.
2. Division of Burden of Disease Institute for Public Health, Malaysian Burden of Disease and Injury Study, in
Health Prioritization: Burden of Disease Approach. 2004, Ministry of Health Malaysia.
3. Martin BG, Stephen Miller L, Icotzan JA, Antipsychotic prescription use and costs for persons with
schizophrenia in the 1990’s: current trends and 5 year time series forecasts, Schizophrenia Research 47(2001):
281-292.
4. Santamaria B, Perez M, Montero D, Madurga M, de Abajo FJ. Use of antipsychotic agents in Spain through
1985-2000. Europsychiatry 2002: 17: 471-476.
2003
63
CHAPTER 22
USE OF DRUGS FOR OBSTRUCTIVE AIRWAY DISEASES
Edited by:
Norzila Mohamed Zainudin1, Molly Cheah2
Aziah Ahmad Mahayiddin1, Rahayu Shahperi1, Nurdita Hisham3, Sarina Anim bt. Mohd Hidzir4
1 Kuala Lumpur Hospital MOH, 2 NMUS Governance Board (PCDOM), 3 Seremban Hospital MOH, 4 Sungei
Buluh Health Clinic MOH
The drugs used in treating asthma are divided into two groups; the first being corticosteroids which is used for
basic treatment of airway inflammation. The other group is the bronchodilating agents, which are used for acute
symptoms. The bronchodilating agents include the beta-2 adrenoreceptors, the anticholinergics and xanthines.
However in the late 90s two more new drugs were introduced into asthma management therapy. These are the
combination of inhaled glucocorticoids with long acting beta 2 agonists and the antileukotrienes, which is an oral
medication. Both medications are used as antiinflammatory and for asthma prophylaxis.
The prevalence of asthma in children in Malaysia is 10%[1]. While in the adult population the prevalence of
asthma is 5 % from the National Health Morbidity Survey[2]. Based on the Malaysian Consensus Guidelines on
Asthma[3,4], the mainstay therapy of inhaled corticosteroids. However the combination therapy is advocated in
the moderate to severe persistent asthmatic. Antileukotrienes however can be prescribed as a first line therapy in
mild persistent group.
The data shows that the usage of inhaled beta-2 agonists is very high, 6 times more commonly used as compared
to inhaled glucocorticoids alone. Specifically, the usage of inhaled salbutamol is 5 times higher than inhaled
budesonide. In Australia the use of salbutamol is only 1.7 times higher compared to budesonide in 2000. These
findings supported the community survey in Malaysia, which showed there is an underutilization of inhaled
steroids [5]. Only one third of chronic asthmatics were on inhaled steroids.
The consensus recommended the use of bronchodilator in powdered or aerosol formulation as these are delivered
directly to the lung and the required dosages were smaller and with less side effects. The data showed that the oral
forms are more commonly used compared to the inhalational agents. Reasons may be due to the easy delivery
[6]. Inhalational therapy requires longer time spent by the doctor due to the need of teaching patients the way of
using it. Oral bronchodilator is cheaper compared to inhalational agents.
In terms of steroids prophylaxis, fluticasone is much more prescribed in the private practice. Both budesonide and
beclomethasone are listed as B drugs in the public while fluticasone is a list A drug that can only be prescribed
by a specialist.
Antileukotrienes are more commonly prescribed in the private practice. Again this drug is an A list drug in
public hospitals. Its usage is limited to the mild persistent asthma or as an add-on therapy if asthma is not well
controlled on inhaled corticosteroids. Since it is an oral medication, it is being used more in the private sector
although it is more expensive compared to inhalational glucorticosteroids.
The anticholinergics are commonly used for COAD. The newer agent tiatropium bromide is much more commonly
used than compared to iatropium bromide. The tiotropium bromide is a long acting anti-cholinergic prescribed
for severe COAD.
Compared to the Australian and the Nordic countries, the prescription of inhaled bronchodilators and inhaled
steroids are higher than in Malaysia [7,8]. The reasons may be due to that Australia has a higher prevalence of
asthma than in Malaysia. The other reason is that there may be more awareness among medical practitioners
about asthma management as well as an active Australia Asthma Foundation.
65
CHAPTER 22
Table 22.1: Use of Medicines for Obstructive Airway Diseases by Drug Class, in DDD/1000 population/
day 2004
#
Drug Class
2004
R03A C INHALATIONAL SELECTIVE BETA-2-ADRENORECEPTOR AGONISTS
6.8083
R03A K ADRENERGICS AND OTHER DRUGS FOR OBSTRUCTIVE AIRWAY
0.8801
DISEASES
R03B A INHALATIONAL GLUCOCORTICOIDS
3.2641
R03B B INHALATIONAL ANTICHOLINERGICS
2.2498
R03B C INHALATIONAL ANTIALLERGIC AGENTS, EXCLUDING
0.0001
CORTICOSTEROIDS
R03C A ALPHA- AND BETA-ADRENORECEPTOR AGONISTS FOR SYSTEMIC USE
0.0073
R03C C SELECTIVE BETA-2-ADRENORECEPTOR AGONISTS FOR SYSTEMIC USE
6.7596
R03D A XANTHINES
1.869
R03D C LEUKOTRIENE RECEPTOR ANTAGONISTS
0.2197
Table 22.2: Use of Medicines for Obstructive Airway Diseases by Drug Class and Agents, in DDD/1000
population/day 2004
ATC
2004
R03A C
INHALATIONAL SELECTIVE BETA-2-ADRENORECEPTOR
AGONISTS
R03A C02
SALBUTAMOL
Total
6.3364
Public
5.349
Private
0.9874
R03A C03
TERBUTALINE
Total
0.0125
Public
0.0014
Private
0.0111
R03A C04
FENOTEROL
Total
0.0017
Public
0
Private
0.0017
R03A C12
SALMETEROL
Total
0.1029
Public
0.1017
Private
0.0012
R03A C13
FORMOTEROL
Total
0.3549
Public
0.1957
Private
0.1592
R03A K
ADRENERGICS AND OTHER DRUGS FOR OBSTRUCTIVE
AIRWAY DISEASES
R03A K03
FENOTEROL AND OTHER DRUGS FOR Total
0.0213
OBSTRUCTIVE AIRWAY DISEASES
Public
0
Private
0.0213
R03A K04
SALBUTAMOL AND OTHER DRUGS FOR Total
0.466
Public
0.4197
Private
0.0464
R03A K06
SALMETEROL AND OTHER DRUGS FOR Total
0.3182
Public
0.1725
Private
0.1457
66
CHAPTER 22
population/day 2004
ATC
2004
R03A K07
FORMOTEROL AND OTHER DRUGS FOR Total
0.0745
Public
0.019
Private
0.0555
R03B A
INHALATIONAL GLUCOCORTICOIDS
R03B A01
BECLOMETASONE
Total
0.422
Public
0.3875
Private
0.0345
R03B A02
BUDESONIDE
Total
2.5996
Public
1.7225
Private
0.8771
R03B A05
FLUTICASONE
Total
0.2425
Public
0.0273
Private
0.2152
R03B B
INHALATIONAL ANTICHOLINERGICS
R03B B01
IPRATROPIUM BROMIDE
Total
0.5339
Public
0.29
Private
0.2439
R03B B04
TIOTROPIUM BROMIDE
Total
1.7158
Public
0.7026
Private
1.0132
R03B C
INHALATIONAL ANTIALLERGIC AGENTS, EXCLUDING
CORTICOSTEROIDS
R03B C01
CROMOGLICIC ACID
Total
0.0001
Public
0.0001
Private
0
R03C A
ALPHA- AND BETA-ADRENORECEPTOR AGONISTS FOR
SYSTEMIC USE
R03C A02
EPHEDRINE
Total
0.0073
Public
0.0059
Private
0.0014
R03C C
SELECTIVE BETA-2-ADRENORECEPTOR AGONISTS FOR
SYSTEMIC USE
R03C C02
SALBUTAMOL
Total
5.4231
Public
0.6634
Private
4.7596
R03C C03
TERBUTALINE
Total
0.532
Public
0.3095
Private
0.2225
R03C C04
FENOTEROL
Total
0.79
Public
0
Private
0.79
67
CHAPTER 22
population/day 2004
ATC
2004
R03C C08
PROCATEROL
Total
0.0099
Public
0
Private
0.0099
R03C C12
BAMBUTEROL
Total
0.0047
Public
0
Private
0.0047
R03D A
XANTHINES
R03D A04
THEOPHYLLINE
Total
1.8599
Public
1.272
Private
0.5879
R03D A05
AMINOPHYLLINE
Total
0.0091
Public
0.0047
Private
0.0044
R03D C
LEUKOTRIENE RECEPTOR ANTAGONISTS
R03D C03
MONTELUKAST
Total
0.2197
Public
0.0289
Private
0.1908
References:
1. International Study of Asthma and Allergies in Chilldhood (ISAAC) Steering Committee. Worldwide
variations in the prevalence of asthma symptoms: the International Study of Asthma and Allergies in
Childhood (ISAAC) Eur Respir J. 1998; 12:315-35
2. Rugayah B. Public Health Institute. Ministry Of Health Malaysia. Report on Second National Health and
Morbidity survey 1997; 11:94-8.
3. Guidelines for the management of childhood asthma. A Consensus Statement prepared for the Academy of
Medicine of Malaysia 2004.
4. Clinical Practice Guidelines for Management of Adult Asthma. A joint statement of the Malaysian Thoracic
Society, Ministry of Health Malaysia., Academy Of Medicine Malaysia 2002.
5. Lai CK, De Guia TS, Kim YY Kiuo SH, Mukhodpadhyyay A, Soriano JB, Trung PL, Zhong NS, Zainudin
N, Zainudin BM. The asthma insights and reality in Asia Pacific Steering committee. Asthma Control in the
Asia Pacific Region: the Asthma Insights and Reality in Asia-Pacific Study. J Allergy Clin Immunol 2003
111: 263-8.
6. Chan PWK, Norzila MZ. Prescribing pattern for childhood asthma treatment in general practice Med Journal
Malaysia 2003;58:475-81.
7. Australian Statistics on Medicine 1999-2000. Commonwealth Department of Health and Ageing Australia
2003
8. Medicines consumption in the Nordic countries 1999-2003. Nordic Medico Statistical Committee 2004;
2004: Copenhagen
68
CHAPTER 23: USE OF ANTIHISTAMINES & NASAL DECONGESANTS [RESERVE]
CHAPTER 24: USE OF OPHTHALMOLOGICALS [RESERVE]
CHAPTER 25: USE OF OTOLOGICALS [RESERVE]
69
71
Malaysian Statistics On Medicine
2004
A publication of the Pharmaceutical Services Division and the Clinical Research Centre
72

Malaysian Statistics On Medicine 2004

Transcription

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