Malaysian Statistics on Medicines 2006

Transcription

2006
Sameerah S.A.R.
Lian L.M.
With contributions from
Lim TO, Goh A, Faridah AMY, Nour Hanah O, Rosminah MD, Radzi H,
Menon J, Zainon A, Sharmini, Lim K, Cheng MF, GR Letchumanan, Muruga V, Zanariah H,
Oiyammal C, Lim YS, Goh AS, Chong WP, Wan Azman WA, Hooi LS, Zaki M, Zawawi N, Goh BL, Fadilah O,
Chang BC, Fong AYY, Sim KH, Haarathi C, Rohna R, Asmah J, Roshidah B, Muralitharan G, Tan AL, Malek R,
Lei CM, Masrahayu M, Ngau YY, Lim GC, Wan Ariffin A, M Roslan H, Mary SM, Marzida M, Choy YC, Norliza MA,
Siti Nor Aizah A, Salina AA, Ramli MA, Suarn S, Noor Ratna N, Zariah AA, Hanip R, Raymond AA, Azrinorwaty Z,
Pang YK, Abdol Malek AZ, Aziah AM, Samsinah HH, Shahirah Z, Saraiza AB, Anura M, Noormah MD,
Bethel L, Goh PP, Thiageswari U
A publication of the
Pharmaceutical Services Division and the Clinical Research Centre
Ministry of Health Malaysia
May 2009
© Ministry of Health Malaysia
Published jointly by:
The National Medicines Use Survey
Clinical Research Centre,
Ministry of Health
3rd Floor, MMA House
124, Jalan Pahang
50286 Kuala Lumpur
Malaysia
Tel. : (603) 4043 9300
Fax
: (603) 4043 9500
e-mail : [email protected]
Web site: http://www.crc.gov.my/nmus
and
The National Medicines Use Survey
Pharmaceutical Services Division
Ministry of Health
Lot 36, Jalan Universiti
124, Jalan Pahang
46350 Petaling Jaya
Malaysia
Tel. : (603) 7841 3200
Fax : (603) 7968 2222
This report is copyrighted. However it may be freely reproduced without the permission of the National
Medicines Use Survey. Acknowledgment would be appreciated. Suggested citation is Sameerah S.A.R,
Lian L.M. (Eds). Malaysian Statistics On Medicine 2006. Kuala Lumpur 2009
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: NMUS MRG-CRC-2008-01)
ISSN 1823-8300
9 771823 830006
PREFACE
Ensuring access to quality and affordable medicines is one important objective of Malaysia’s National
Medicines Policy. The National Medicines Use Survey (NMUS) was conducted with the intent to
continuously and systematically collect data on medicines in the hope to further improve its use as well as
providing a tool for better decision making in the allocation of healthcare resources for the Malaysian
population.
NMUS is into its fourth year and we are glad to announce the successful publication of its third report, the
Malaysian Statistics on Medicines (MSOM) 2006. It is worthwhile to note that the first report MSOM 2004
presented results largely from pilot surveys and using test methods basically to demonstrate that such
a project was feasible in a healthcare system such as Malaysia that has many players. In 2005, we
scaled up the survey with larger sample size and wider distribution and also refined data processing and
statistical methods. For MSOM 2006, data collection was on a similar scale; the data processing was
further enhanced to improve quality and the statistical methods reviewed to take into consideration
stratification of hospitals which gives more accurate estimates as hospitals of different sizes may have a drug
use profile. The data processing and complex statistical methods as explained in the methods section of this
publication. Hence results in MSOM 2006, in our opinion are more reliable, more representative and more
robust.
Eleven new chapters are added, bringing in a total of 25 in MSOM 2006 compared to the 14 chapters in MSOM
2005. We are optimistic that more chapters will be reported in future publications of MSOM.
We hope that this MSOM 2006 report will be useful to relevant healthcare professionals serving as a source
of reference and baseline for embarking in future research or clinical audits towards improving rational
prescribing.
We would like to thank all staff who had worked very hard in ensuring the success of the survey, all agencies
and institutions that had helped in providing data, all expert panel members for their enthusiasm and
contributions in completing the chapter reports and each and everyone who have in one way or another contributed
to the success of NMUS and this publication.
Pharmaceutical Services Division
Clinical Research Centre
Ministry of Health Malaysia
i
ACKNOWLEDGEMENTS
The National Medicines Use Survey would like to thank the following for their participation, assistance, support
or contributions:
•
•
•
•
•
•
•
•
•
•
Director General of Health, Ministry of Health Malaysia
Deputy Director General of Health (Research and Technical Support), MOH
Deputy Director General of Health (Medical Services), MOH
Deputy Director General of Health (Public Health), MOH
Senior Director of Pharmaceutical Services Division, MOH
Senior Director of Oral Health Division, MOH
Director, National Pharmaceutical Control Bureau, MOH
Director, Clinical Research Centre, MOH
Principal Assistant Secretary, Procurement Division, MOH
Director, The Office of Electronic Government Application Project (EG-AG), Accountant General’s
Department
• Director, Government Procurement Division, MOH
• Secretary, Information Management Division, MOH
• All medical doctors, pharmacists and support personnel who participated in the NMUS surveys
• All participating public and private hospitals which provided or allowed access to their medicines
procurement
• Members of the NMUS Expert Panels who contributed to writing this report
• Universiti Malaysia Medical Centre, Hospital Universiti Kebangsaan, Hospital Universiti Sains
Malaysia, Lumut Armed Forces Hospital, Terendak Armed Forces Hospital
• Association of Private Hospitals Malaysia, Malaysian Organisation of Pharmaceutical Industries (MOPI)
and Pharmaceutical Association of Malaysia (PhAMA)
• Malaysian Medical Council, Malaysian Medical Association, Malaysian Pharmaceutical Society, The
Academy of Family Physicians, Primary Care Doctors Association Malaysia, Malaysian Dental
Association, Malaysian Private Dental Practitioners Association
• Pharmaniaga Logistik Sdn. Bhd. and Forte Tech Solutions Sdn. Bhd.
• All who have in one way or another supported and/or contributed to the success of the NMUS and this
report
Mr. Mohd. Hatta bin Ahmad
Chairman
Dr. Lim Teck Onn
Co-Chairman
National Medicines Use Survey, Ministry of Health Malaysia
iii
ABOUT THE NATIONAL MEDICINES USE SURVEY
The National Medicines Survey (NMUS) is a project 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 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.
The NMUS is jointly sponsored by:
• Pharmaceutical Services Division, Ministry of Health
• Clinical Research Centre, Ministry of Health
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
utilisation at various level of our health care system, whether national, regional, local or institutional.
Routinely compiled statistics on medicines utilisation have many uses, such as to:
1. Estimate the number of medicines 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 estimatethe 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 healt
care 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.
iv
NMUS STEERING COMMITTEE
Chairman
Mr. Mohd. Hatta bin Ahmad, Deputy Director (Pharmacy Practice),
Pharmaceutical Services Division, Ministry of Health Malaysia
Co-Chairman
Dr. Lim Teck Onn,
Director, Clinical Research Centre, Ministry of Health Malaysia
Members
Ms. Sameerah Shaikh Abd. Rahman, Senior Principal Assistant Director,
Dr. Faridah Aryani bt. Md. Yusof, Head, Pharmaceutical Research Unit,
Clinical Research Centre, Ministry of Health Malaysia
Dr. Lian Lu Ming, Pharmacist Grade U52,
Clinical Research Centre, Ministry of Health Malaysia
Ms. Siti Fauziah bt. Abu, Senior Assistant Director,
Ms. Sarah a/p Nagalingam, Senior Assistant Director,
v
NMUS PROJECT TEAM
Chairman
Mr. Mohd. Hatta bin Ahmad
Co-Chairman
Dr. Lim Teck Onn
NMUS Project Staff
NMUS Project Coordinator
Ms. Sameerah binti Shaikh Abdul Rahman
NMUS Project Manager
Dr. Lim Chiao Mei
Dr. Lian Lu Ming
Pharmacist Liaison Officer
Ms. Siti Fauziah bt. Abu
Ms. Sarah Nagalingam
Technical Support Staff
Pharmaco-Epidemiologist
Dr. Faridah Aryani bt. Md Yusof
Dr. Nour Hanah bt. Othman
Ms. Rosminah bt. Md Din
NMUS Survey Co-ordinator
Ms. Lee Kim Tin
Economist
Mr. Adrian Goh
Statistician
Dr. Hoo Ling Ping
Ms. Norhafizah bt. Ab. Manan
IT Manager
Ms. Celine Tsai Pao Chien
Database Developer/ Administrator
Ms. Tang Roh Yu
Ms. Lim Jie Ying
Ms. Nor Afirdaus Zainal Abidin
Network Administrator
Kevin Ng Hong Heng
Mr. Adlan Ab. Rahman
Desktop Publisher
Ms. Azizah Alimat
Webmaster
Mr. Patrick Lum See Kai
vi
MEMBERS OF NMUS EXPERT PANELS
Expert Panel
1. Antihypertensives, Steroid & Immunosuppressive, Renal Therapeutics
Members
Dato Dr. Zaki Morad Mohd. Zaher (Chairperson)
Dr. Lim Teck Onn
Dr. Zawawi bin Nordin
Dr. Hooi Lai Seong
Dr. Goh Bak Leong
Datin Fadilah bt. Othman
Ms. Manjulaa Devi a/p Subramaniam
Ms. Puteri Juanita bt. Zamri
Ms. Nur Salima bt. Shamsudin
Ms. Zarina bt. Abdul Ghafir
Institution
International Medical University
Clinical Research Centre, MOH
Medical Department, Sultanah Nur Zahirah
Hospital, Kuala Terengganu
Nephrology Dept., Sultanah Aminah Hospital,
Johor Bahru
Nephrology Dept., Serdang Hospital
Pharmacy, Selayang Hospital
Pharmacy, Kuala Lumpur Hospital
2. Antidiabetics, Endocrine and Metabolic Therapeutics
Members
Dr. G.R. Letchumanan a/l Ramanathan (Chairperson)
Dr. Muruga Vadivale
Dr. Zanariah Hussein
Dr. Sharmini Selvarajah
Dr. Ariza Zakaria
Ms. Cheng Mei Fen
Ms. Oiyammal Chelliah
Mr. Lim Kelvin
Mr. Mohd. Nazri Md. Dazali
Institution
Medical Department, Taiping Hospital
Sanofi Aventis
Medical Department, Putrajaya Hospital
Xepa-Soul Pattinson (M) Sdn. Bhd.
Pharmacy, Sungai Bakap Hospital, Penang
Pharmacy, Penang Hospital
Pharmacy, Tampin Health Clinic
3. Antilipidaemia and Cardiovascular Therapeutics
Members
Dr. Chang Boon Cheng (Chairperson)
Prof. Dr. Sim Kui Hian
Dr. Alan Fong Yean Yip
Dr. Chong Wei Peng
Ms. Haarathi a/p Chandriah
Ms. Nirmala a/p Jagan
Ms. Yap Yih Jun
Ms. Long Mei Sim
Institution
Cardiology Dept., Sarawak General Hospital
University Malaya Medical Centre
Pharmacy, TAR Klang Hospital
vii
Expert Panel
4. Antineoplastic, Oncology
Members
Ms. Lim Yeok Siew (Chairperson)
Prof. Wan Ariffin Abdullah
Dr. Gerard Lim Chin Chye
Dr. Mohd. Roslan b. Haron
Dr. Goh Ai Sim
Ms. Yuzlina bt. Muhamad Yunus
Ms. Kamarun Neasa Begam bt. Mohd. Kassim
Institution
Paediatric Oncology Dept., University Malaya
Medical Centre
Radiotherapy & Oncology Dept., Kuala Lumpur
Hospital
Oncology Dept., Sultan Ismail Hospital, Johor Bahru
Haematology Unit, Medical Department, Pulau
Pinang Hospital
Pharmacy, Putrajaya Hospital
5. Antiinfectives
Members
Ms. Sameerah bt. S.A. Rahman (Chairperson)
Dr. Ngau Yen Yew
Ms. Thong Kah Shuen
Ms. Masrahayu bt. Moydin
Ms. Rahela bt. Ambaras Khan
Ms. Jacqueline Lai
Institution
Pharmaceutical Services Division, MOH
Medical Dept., Kuala Lumpur Hospital
Pharmacy, Raja Permaisuri Bainun Hospital, Ipoh
Tawau Hospital, Sabah
6. Musculo-skeletal Therapeutics
Members
Dato’ Dr. Ramanathan a/l Ramaiah (Chairperson)
Dr. Ahmad Tajuddin b. Abdullah
Dr. Chew Chin Seong
Dr. Ling How Tieng
Ms. Aizura bt. Abdul Rahman
Institution
Orthopaedics Dept., Raja Permaisuri Bainun
Hospital, Ipoh
Orthopaedics Dept., Sultanah Nur Zahirah
Hospital, Ipoh
Hospital, Ipoh
Pharmacy, Raja Permaisuri Bainun Hospital, Ipoh
7. Analgesic and Anaesthetics
Members
Dr. Mary S. Cardosa (Chairperson)
Prof. Dr. Marzida bt. Mansor
Institution
Anaesthesiology Dept., Selayang Hospital
University of Malaya Medical Centre
viii
Expert Panel
7. Analgesic and Anaesthetics
Members
Clinical Assoc. Prof. Dr. Choy Yin Choy
Ms. Faizah bt. Abdul Rahman
Ms. Norliza bt. Mat Ariffin
Institution
Universiti Kebangsaan Malaysia Medical Centre
8. Psychiatric Therapeutics
Members
Dr. Siti Nor Aizah bt. Ahmad (Chairperson)
Dato’ Dr. Suarn Singh a/l Jasmit Singh
Dr. Ramli b. Ali
Dr. Salina bt. Abdul Aziz
Dr. Nor Hayati bt. Ali
Ms. Mariam Bintarty bt. Rushdi
Mr. Syed Fadzli b. Syed Sailuddin
Ms. Noor Ratna bt. Naharuddin
Ms. Shamini a/p Rama
Institution
Psychiatry Dept., Kuala Lumpur Hospital
Bahagia Hospital, Tanjung Rambutan
Psychiatry Dept., Selayang Hospital
Psychiatry Dept., Kuala Lumpur Hospital
Psychiatry Dept., Kajang Hospital
Pharmacy, Permai Hospital, Johor Bahru
Pharmacy, Bahagia Hospital, Tanjung Rambutan
9. Respiratory Therapeutics
Members
Datin Dr. Aziah bt. Ahmad Mahayiddin (Chairperson)
Assoc. Prof. Dr. Samsinah bt. Haji Hussain
Assoc. Prof. Dr. Pang Yong Kek
Dr. Norhaya Mohd. Razali
Dr. Mat Zuki b. Mat Jaeb
Mr. Abdol Malek b. Abd. Aziz
Ms. Joanne Liew
Ms. Shahirah bt. Zainudi
Institution
Institute of Respiratory Medicine, Kuala
Lumpur Hospital
Dept. of Pharmacy, University Malaya
University of Malaya Medical Centre
Medical Dept., Sultanah Nur Zahirah Hospital,
Kuala Terengganu
Medical Dept., Raja Perempuan Zainab II
Hospital, Kota Bharu
Pharmacy, Malacca Hospital
10. Gastrointestinal Therapeutics
Members
Dr. Jayaram Menon (Chairperson)
Dato’ Dr. Muhammad Radzi b. Abu Hassan
Ms. Zainon bt. Abudin
Ms. Azuana bt. Ramli
Institution
Medical Dept., Queen Elizabeth Hospital, Sabah
Sultanah Bahiyah Hospital, Alor Star
Pharmacy, Serdang Hospital
ix
Expert Panel
11. Neurology
Members
Dr. Zariah bt. Abdul Aziz (Chairperson)
Institution
Neurology Dept., Sultanah Nur Zahirah
Neurology Dept., Kuala Lumpur Hospital
Medical Faculty, UKM Medical Centre
Pharmacy, Sultanah Nur Zahirah
Dato’ Dr. Mohd. Hanip b. Rafia
Prof. Dr. Raymond Azman Ali
Ms. Norhasyimah bt. Abdul Rahman
Ms. Azinorwaty bt. Zakaria
12. Obstetrics & Gynaecology
Members
Dr. Muralitharan Ganesalingam (Chairperson)
Institution
Obstetrics & Gynaecology Dept., Kuala Lumpur
Hospital
Primary Care Doctors Organisation Malaysia
Ms. Tan Ai Leen
Dr. Molly Cheah
13. Otorhinolaryngology Audiology
Members
Dr. Saraiza bt. Abu Bakar (Chairperson)
Dr. Anura Michelle Manual
Institution
Otorhinolaryngology Dept., Serdang Hospital
Otorhinolaryngology Dept., University of
Malaya Medical Centre
Medical Development Division, MOH
Ms. Normah bt. Mohd. Darus
14. Dermatology
Members
Dr. Rohna bt. Ridzwan (Chairperson)
Dr. Asmah bt. Johar
Dr. Roshidah bt. Baba
Institution
Dermatology Dept., Selayang Hospital
Dermatology Dept., Kuala Lumpur Hospital
Dermatology Dept., Malacca Hospital
15. Nephrology Urology
Members
Dr. Rohan Malek Johan Thambu (Chairperson)
Dr. Clarence Lei Chang Moh Normah
Dr. Suresh Sabaratnam
Ms. Siti Syarihan bt. Abdullah
Institution
Urology Dept., Selayang Hospital
Hospital, Kuching
Urology Dept., Selayang Hospital
x
Expert Panel
16. Ophthalmology Optometry
Members
Dr. Bethel Livingstone (Chairperson)
Dr. Goh Pik Pin
Dr. C.U. Thiageswari
Dr. Thayaniti a/p Sandragesu
Dr. Vivian Gong Hee Ming
Datin Fadilah bt. Othman
Ms. Choong Chiau Ling
Institution
Ophthalmology Dept., Tuanku Jaafar Hospital,
Seremban
Ophthalmology Dept., Selayang Hospital
Ophthalmology Dept., Kuala Lumpur Hospital
Opthalmology Dept., Tengku Ampuan Rahimah
Hospital, Klang
Ophthalmology Dept., Raja Permaisuri
Bainun Hospital, Ipoh
17. Haematology
Members
Ms. Lim Yeok Siew (Chairperson)
Dr. Goh Ai Sim
Institution
Medical Dept., Pulau Pinang Hospital
18. Pharmacoeconomics
Members
Dr. Nour Hanah bt. Othman (Chairperson)
Dr. Faridah Aryani bt. Md. Yusof
Ms. Rosminah bt. Mohd. Din
Ms. Fatimah bt. Abdul Rahim
Ms. Nadia Fareeda bt. Muhammad Gowdh
Mr. Adrian Goh
Institution
xi
CONTENTS
PREFACE………………………………………………………………………………………...
ACKNOWLEDGEMENTS……………………………………………………………….…….
ABOUT THE NATIONAL MEDICINES USE SURVEY………………………………....….
NMUS STEERING COMMITTEE………………………………………………………...….
NMUS PROJECT TEAM………………………………………………………………...….....
MEMBERS OF NMUS EXPERT PANELS………………………………………………...…
CONTENTS……………………………………………………………………………………...
METHODS……………………………………………………………………………………….
ABBREVIATIONS……………………………………………………………………….……..
i
iii
iv
v
vi
vii
xii
xiii
xxiii
Chapter 1: Use of Medicines in Malaysia ................................................................................…...............
Chapter 2: Expenditure on Medicines in Malaysia ................................................................….................
Chapter 3: Use of Medicines for Acid Related Disorders .........................................................................
Chapter 4: Use of Antiobesity Medicines …………................................................................…...............
Chapter 5: Use of Antidiabetics ..............................................................................................……………
Chapter 6: Use of Antianaemic Medicines…………...................................................................................
Chapter 7: Use of Antihaemorrhagic Medicines…………...........................................................................
Chapter 8: Use of Medicines for Cardiovascular Disorders .....................................................................
Chapter 9: Use of Antihypertensives ......................................................................................………….…
Chapter 10: Use of Lipid Lowering Medicines ........................................................................……..…….
Chapter 11: Use of Dermatologicals ………….......................................................................……………
Chapter 12: Use of Gynaecologicals, Sex Hormones and Hormonal Contraceptives ...........…………….
Chapter 13: Use of Urologicals ..............................................................................……………………….
Chapter 14: Use of Medicines for Endocrine Disorders ............................................................…………
Chapter 15: Use of Antiinfectives ...........................................................................................…................
Chapter 16: Use of Antineoplastic Agents, including Endocrine Therapy ………………….....................
Chapter 17: Use of Systemic Corticosteroids and Immunosuppressive Agents......................……………
Chapter 18: Use of Medicines for Rheumatological and Bone Disorders …............................................
Chapter 19: Use of Opioid Analgesics … ………….. ..................................................………………….
Chapter 20: Use of Medicines for Neurological Disorders …….............................................……………
Chapter 21: Use of Medicines for Psychiatric Disorders ..........................................................................
Chapter 22: Use of Medicines for Obstructive Airway Diseases ..............................................................
Chapter 23: Use of Antihistamines & Nasal Decongesants ...……......................................…………….
Chapter 24: Use of Ophthalmologicals …………..................................................................…………….
Chapter 25: Use of Otologicals ...............................................................................………………………
1
5
9
13
15
19
21
25
31
39
43
51
57
61
65
77
83
89
93
95
103
111
115
119
127
Appendix 1: Participants of the National Medicines Use Survey
xii
METHODS
Authors:
Lian LM1, Lim CM1, Tang RY2, Lim JY2, Hoo LP3, Faridah AMY1, Goh A, Lim TO1
1. Clinical Research Centre MOH, 2. Datamed Sdn. Bhd., 3. Clin Research Sdn. Bhd.
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 capitalise on early successes.
Fig. 1 Medicines supply & distribution
system and Sources of data
Manufacturer/Importer
Distributor/Wholesaler
Primary care/GP
Hospital
Pharmacy
Consumer/Patients
12
Hence, the statistics on medicines use and expenditure in this report are estimated from 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
nation-wide 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.
xiii
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, comments on
data inclusion in this report are summarised in the table below.
#
1.0
1.1
1.2
2.0
2.1
3.0
3.1
3.2
3.3
3.4
3.5
4.0
4.1
4.2
4.3
4.4
5.0
5.1
5.2
6.0
6.1
Data sources and Surveys
Year data
available
Medicines import or production data
Medicines import data from Royal Malaysian Customs
Local pharmaceutical manufacture
Domestic sales data
Domestic sales data from local pharmaceutical
companies
Medicines pr ocurement data
Public hospitals medicines procurement data from
several sources:
a.
MOH procurement through central tender (APPL)
b.
MOH individual hospital local purchase (NonAPPL)
c.
University and Armed Forces ho spitals procurement
Private hospitals procurement
Private GPs procurement
Private specialist practice procurement
Private pharmacies procurement
Medicines prescription data
Public (MOH) primary care practice prescription
Private GP prescription
Private specialist practice prescription of highly
specialised medicines.
Pilot survey limited to Nephrology practices and
dialysis facilities only
Hospital practice prescription
Medicines dispensing data
Public hospital pharmacy dispensing
Private free -standing pharmacy dispensing
Household medicines consumption data
Household survey on medicines consumption
xiv
Inclusion
in present
report
2004, 2005, 2006
Data not collected
No
No
Data not collected
No
2001 to 2006
2001 to 2006
2004, 2005, 2006
2000 to 2006
Data not collected
Data not collected
Data not collected
Yes
Yes
Yes
Yes
No
No
No
Limited availability
2005, 2006
Data not collected
No
Yes
No
2001-2004
No
Data not collected
No
Data not collect ed
2005, 2006
Not done
No
Yes
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 hospital medicines procurement
and prescription/dispensing.
•
Collection of prescription data is limited to general clinic practices, while hospital prescription is assumed
to be included in hospital procurement data.
•
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 the latter only. Given
that private medical practitioners in Malaysia retain dispensing rights, prescription is a far more important
source of data than dispensing, unlike say in Australia.
•
Many private medical specialists may self-procure and dispense, rather than use hospital pharmacy
dispensing service. Thus, in so far that prescription of highly specialised medicines for a
particular condition is concentrated in private ambulatory specialist practices (which are unlikely as
most such drugs are probably prescribed in hospital setting), they will be under-estimated in this report.
Separate procurement and prescription surveys on such highly specialised medicines (if any) are required.
•
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 and sales data from pharmaceutical companies, where available, are not used for
statistical estimation, but are used for reference only, and 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 2006, its survey population and sampling unit, sample size and the survey
response or coverage rates are summarized in the table below.
#
Surveys
1.
MOH
Pharmaceutical
procurement
Private hospitals
pharmaceutical
procurement
University and
Armed Forces
hospitals
pharmaceutical
procurement
Private GP
prescription
Private pharmacy
dispensing
2.
3.
4.
5.
Survey population and
sampling unit
133 MOH hos pitals
i. APPL
ii. Non APPL
114 Private hospitals
Sample size
Coverage or response
rate, and completeness
133
99
34
100% for APPL
75% for NonAPPL
30 %
3 University hospitals
2 Armed Forces h ospitals
1 University
2 Armed
Forces
67% for University
100% for Armed Forces
4459
599
13 %
466
23
5%
xv
Data collection
The surveys conducted by NMUS collected data either by
1. Download from existing databases
2. Primary data collection
These are described below.
#
1.
Surveys
MOH Pharmaceutical procurement
2.
4.
Private hospitals’ pharmaceutical
procurement
University and Armed Forces
hospitals pharmaceutical
procurement
Private GP prescription
5.
Private Pharmacy dispensing
3.
Data download from existing databases
Pharmaniaga pharmaceutical procurement
databases, central database as well as individual
hospitals’ local purchase databases.
Individual hospitals’ pharmaceutical
procurement databases
Individual hospitals’ pharmaceutical
procurement databases
A sample of GPs collected prescription data in a
randomly selected week. The sample being
distributed over 3 four - monthly cycle
A sample of pharmacies with resident
pharmacist collected dispensing data in a
randomly selected week. The sample being
distributed over 3 four - monthly cycle
Data management
The collected data, whether in databases or in paper or electronic data collection form, is compiled
into a single database, appropriately processed and coded prior to statistical analysis.
The NMUS database was created in Ms SQL Server 2000. The application has 3 modules: Contact
Management, Data Entry and Data Processing.
•
Contact Management module is used to collect the establishments’ survey details, log and track all the
corespondence 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 using paper CRF or
prescription booklets.
•
Data Processing module is used to clean, manage and process the medicines data prior to statistical
analysis. The automated data processing functionalities include ATC coding, DDD Assignment, Total
Dosage Calculation and Unit Conversions.
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.
xvi
The data processing steps are as follows:
#
1.
2.
3.
4.
5.
#
1.
2.
3.
4.
Data processing for downloaded database
Data were downloaded from the existing database of the following data sources
MOH APPL Procurement
MOH Non - APPL Procurement
Private Hospital Procurement
University Hospital Procurement
Armed Forces Hospital Procurement
GP Prescription
Private Pharmacy Dispensing
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.
The structure of each of the downloaded database/data file would be studied
and analysed to identify the required data fields/variables.
The required variables are 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. The extracted data
would then be normalised by separating into multiple, related tables in a single compiled
database.
Some of the data would require aggregation, e.g. total a few transactions on the same
drug into 1 record, to speed up subsequent query performance
The data would then be linked to the respective SDP in the main contact table.
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 application 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.
Personnel were supervised while doing the first few entries to make sure they know how to do
it correctly.
A standard document on steps/precautions for 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 spelling of drugs when the writing is less legible.
Edit checks
Survey forms are cross - checked against the database.
Selection of survey form is by data entry personnel, randomly by survey date. If number of
drug entries for selected date is not sufficient, more survey dates are included.
Items to check:
Number of patients are same in survey form and database
Number of drug entry/drug prescribed is same in survey form and database.
Age, sex of patient is entered correctly.
Drug particulars are entered correctly.
Calculations and Derived variables
Dose per day is obtained by Dosage* frequency
Dose per visit is obtained by Dosage* frequency * duration
Visual review and manual assessment of entries if there are misspellings.
xvii
#
1.
2.
Common data processing steps
Registered Product List
An estimated 7000 ‘scheduled poison’ products registered with Drug Control Authority were
manually coded to ATC INN (Level 5). The coded Drug Control Authority drug list would
serve as an internal drug dictionary for medicines data coding later.
Data Parsing by programming
The variables ‘Drug description’ and ‘Packaging Description’ in medicines
(procurement/prescription/dispensing) data are parsed into smaller parts using specially written
computer program. Parsing facilitates the auto-coding process and dosage calculation later.
The variable ‘Drug description’ will be parsed into ‘Brand’, ‘INN’, ‘Dosage’, ‘Unit’ and
‘Route’
e.g. Zocor Tab 80 mg
Brand – Zocor
INN – none
Dosage – 80
Unit – mg
Route – Tab
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
3.
4.
5.
6.
ATC Coding
The parsed ‘Brand’ would then be linked to the coded registered 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.
Drug Description Dosage and Unit
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.
Packaging Description Dosage
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.
Total Dosage Calculation
Total Dosage = Total Drug Description Dosage* Total Packaging Description Dosage*
Quantity procured.
Total Dosage Unit = Total Drug Description Unit.
xviii
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 utilisation 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
1
2
3
4
5
Group and subgroups
Anatomical main group. There are 14 of these, eg C cardiovascular,
M musculo-skeletal, R respiratory, etc
Therapeutic main group
Therapeutic subgroup
Chemical or Therapeutic subgroup
Drug chemical substance
An example should make this clear. Simvastatin is coded C10AA01. The structure of its code is as follows:
Level
1
2
3
4
5
Code
C
C10
C10A
C10AA
C10AA01
Group and subgroups
Cardiovascular system
Serum lipid reducing agents
Cholesterol or triglyceride reducers
HMG CoA reductase inhibitors
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.
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 utilisation; 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 are 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.
xix
For anti-infectives (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 utilisation is
equivalent to the treatment of every inhabitant with a 5-days course in the year.
In interpreting drug utilisation statistics using DDD, as in this report, readers are cautioned 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, prescribed or dispensed, as presented here, may not necessarily be consumed.
• DDD may be difficult to assign or not assigned at all for certain medicines, for example medicines with
multiple ingredients, topical products, anti-neoplastic 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 NMUS report, 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:
DDDs/1000 inhabitants/year =
DDDs/1000 inhabitants/year =
Tˆ *1000
DDD * P *365
Tˆ *1000
ddd * P
Where
Tˆ is an estimate of the total quantity of the drug utilised 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,
365 refers to the 365 days in a year
In either case, an estimate of the total quantity of the drug being utilised in the year is required, and this must be
expressed in the same unit as the DDD assigned for the drug.
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.
#
1
Surveys
MOH Pharmaceutical
procurement: APPL
Estimation procedure
No sampling was employed in the survey due to full
response.Therefore the total is the sum of all the quantities
of the drug procured in all procurement records in the year.
The total is Tˆ =
I
∑T
i
i =1
where
T i is the value of the quantity of drug procured of the ith
hospital in the year.
2.
i) MOH Pharmaceutical
procurement: Non
APPL
Data were available for only a sample of hospitals.
The total is estimated by Tˆ =
Ij
4
∑∑ w T
j i
i =1 j =1
xx
#
Surveys
Estimation procedure
(#
'#$%)
# #$ $!%$ Ti $%'& %"&%%) #&!# &# %i% $!%
!#&%
%)#
!# &#%
j$%#% #% $%#% % $!%
j$%#%
#'% $!%$
j$%#%
!#&%
j
$%#%
!# &#%
j$%#%
$!(% $%#%
Bj
wj =
bj
j
Bj$% %&# $ # $!%$%
! !&% bj $% %&# $%$! #$%#%j
#'%-
!#$#!% #'%!#)
$!$
,%(# % ) #$! - #!#) #
#$! %% % ) #$! )$
)#*( #.)$ )
% %$$%%) T/ =
I
+
∑∑ w T
i ij i = j =
(#
Tij $%'& %"&%%) #&!#$#)%it- #
!#) %j%)
$!(% %i%- #!#)
N D
wi = ×
n di
(#N$% %&# - #!#)%! !&% n$
&# #$! - #!#)*$!D $%% %
&# ( #.)$)# d i $%&# $&#'))$ i%- #!#))#
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.
xxi
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 non-responding units that may influence drug utilisation, such as bed strength, staff strength, scope of
services for hospitals etc.
Expenditure estimation methodology
Study Population
The MSOM encompasses private & public healthcare providers in Malaysia consisting of 1. The public health sector which consists of hospitals and primary care clinics of the Ministry of Health,
University Hospitals under the Ministry of Higher Education and Military Hospitals under the Ministry of
Defence.
2. The Private health sector consisting of private hospitals and general practitioners in Malaysia.
3. Private sector retail pharmacies.
Methodology
The expenditure on a particular drug in a given year is the quantity of drug used in that year multiplied by the
price of the drug.
Total expenditure = Quantity of drug utilisation * Price of drug.
Quantity of drug utilisation is determined from the drug utilisation data presented elsewhere in this report.
Median prices were determined for each drug chemical substance (5th level ATC classification) and
denominated in Daily Defined Doses (DDD) for the public and private sectors taking into account the
availability of price data and analytical considerations. Thus there are two prices (i.e. public sector and
private sector median price) for each drug chemical substance.
The expenditure for each procurement item is then calculated as Ei = p50i * DDDi where p50 is the
median price, DDD is the quantity of utilisation and “i” refers to the drug chemical substance.
The total expenditure on a drug chemical substance in a particular sector is the sum of all procurement,
prescription and dispensing of the item items in that sector. The total expenditure for the country is the sum
of total expenditure in all the sectors.
Prices were determined for the public sector from procurement data of MOH, University and Armed Forces
health establishments surveyed by NMUS while private sector prices were determined from procurement
data of private hospitals surveyed by NMUS. As the GP prescription & retail pharmacy dispensing data
obtained by NMUS did not contain any data usable for calculating prices, the prices estimated from private
hospitals were applied to GP and Pharmacy data as well.
xxii
ABBREVIATIONS
ACEI
AF
APPL
ARB
ASR
ATC
BCF
BPFK
CCB
CCF
COAD
CPG
CTZ
DALYs
DDD
Dept
FDA
GERD
GP
HCTZ
HDL
HMG CoA
H2RA
ICU
INN
ISAAC
KL
LDL
LMWH
MOH
NCC
NCI
NMP
NMUS
NPCB
NSAIDs
OTC
PCDOM
PPI
RE
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
Chlorothiazide
Disability Life Years
Defined Daily Dose
Department
Food And Drug Administration
Gastroesophageal Reflux Disease
General Practitioner
Hydrochlorothiazide
High Density Lipoprotein
3-hydroxy-3-methylglutaryl coenzyme A
H2 Receptor Antagonist
Intensive Care Unit
International Nonproprietary Name
International Study of Asthma and Allergies in Childhood
Kuala Lumpur
Lipoprotein Levels
Low Molecular Weight Heparin
Ministry of Health
National Cancer Centre
National Cancer Institute
National Medicines Policy
National Medicines Use Survey
National Pharmaceutical Control Bureau
Non Steroidal Anti- Inflammatory Drugs
Over-the-Counter
Primary Care Doctors Organisation Malaysia
Proton Pump Inhibitors
Reflux Esophagitis
Source Data Producer
Selective Estrogen Receptor Modulator
Stock Keeping Unit
Serotonin Selective Reuptake Inhibitor
Unit of Measurement
Upper Respiratory Tract Infection
World Health Organisation
Wilayah Persekutuan
xxiii
CHAPTER 1
USE OF MEDICINES MALAYSIA
Edited by:
Lim TO1, Nadia Fareeda MG1, Lian LM1, Sameerah SAR2, Mohd. Hatta A2, Faridah AMY1
1. Clinical Research Centre MOH 2. Pharmaceutical Services Division MOH
In this chapter, we report an overview of the national estimates for the use of medicines in Malaysia. It
describes the most commonly used medicines by therapeutic groups and by specific drugs. The scope of the
National Medicines Use Survey (NMUS) was deliberately limited to prescription medicines only and
excluded Over-the-Counter (OTC) medicines, traditional or herbal products and food supplements.
Generally, the measurement unit for medicines use adopted in this report is the DDD [1] which 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 utilisation; it does not necessarily agree with the recommended or prescribed daily
dose.
In this chapter, the utilisation data are presented only for drugs that have assigned DDDs, and the estimates
are expressed as number of DDDs per 1000 population per day; medicines without DDDs are excluded.
However, in other chapters of this publication, utilisation of some medicines of interest that do not have
DDDs are also discussed. In those chapters, the statistics are presented in terms of weight of active
ingredient/1000 population per day (Anti-neoplastic drugs), or weight or volume of drug preparations per
1000 population per day (Dermatologicals, Ophthalmologicals and Otologicals).
Among the therapeutic groups, drugs used in diabetes (A10) ranked highest in terms of utilisation in Malaysia
for the year 2006 (Table 1.1). An estimated 4.0% of the Malaysian population was on this group of drugs in
2006 of which glibenclamide (1.6% of the population) and metformin (1.3% of population) were most used.
Other commonly used diabetic drugs include gliclazide and Insulins and analogues, intermediate-acting
combined with fast-acting (human) with each ranking 9th and 37th among the top 40 drugs by utilisation. The
utilisation of these drugs was heavily skewed towards the public sector with utilisation of more than four
times that of the private sector, suggesting an imbalance in the disease burden borne. (Table 1.2)
Of the top 40 drugs listed by utilisation, 18 were drugs used for cardiovascular diseases (ATC group C and
acetylsalicylic acid B01A C06). Drugs used for the treatment of hypertension were among the highest in
terms of utilisation. Collectively 6.8% of the population were on at least one of these drugs which include
beta-blocking agents (2.6% of population), calcium channel blockers (1.9% of population)), agents acting on
the renin-angiotensin system (2% of population) and antihypertensives (0.3% of population). Prevalence of
hypertension among Malaysians aged 30 years and above in 2006 was estimated to be 42.6% and among them
only 31.4% were on current treatment [2]. A study conducted by Rampal et al in 2004 estimated that only
34.6% of the study participants with hypertension were aware of their condition and on pharmacotherapy, and
of these only 26.6% had adequate blood pressure control [3]. Although utilisation of medicines for the
treatment of hypertension seemed high, poor awareness and under treatment of this disease are issues that
need to be addressed. (Table 1.2)
Lipid modifying agents ranked 5th for therapeutic groups by utilisation, with 1.7% of the population
prescribed these drugs. Simvastatin, lovastatin and atorvastatin constituted 41%, 30% and 18% of the total use
respectively. Utilisation of lovastatin was approximately 8 times more in the public sector compared to the
private sector, and conversely the use of atorvastatin in the private sector was more than twice the utilisation
in the public sector. This suggested a difference in prescribing preference and trend between these parallel
healthcare providers in the country which was very much influenced by cost. Australian data showed that
atorvastatin was the most used lipid modifying agent compared to simvastatin and lovastatin. Atorvastatin
was the top drug ranked by DDD whereas simvastatin ranked 2nd and lovastatin was not among the top 10 [4].
Given the expected trends of increasing serum cholesterol and coronary heart disease in most Asian countries,
utilisation of this group of drugs are expected to increase in the future [5].
1
CHAPTER 1
Drugs used for obstructive airway diseases (R03) ranked 6th by utilisation with inhaled salbutamol
(R03AC02) being the commonest drug used (0.4% of population). Chlorpheniramine and prednisolone were
clearly drugs of choice as their utilisation were highest in their groups, antihistamines for systemic use (R02)
and steroids for systemic use (H02) respectively. Among the antiinflammatory and antirheumatic products
(M01), utilisation of diclofenac (M01A B05) was highest (0.4% of population).
Interestingly, although the prevalence of psychiatric morbidity estimated by NHMS III was 11.2%,
psycholeptics (N05) and psychoanaleptics (N06) only ranked 15th and 20th among therapeutic groups listed
by utilisation and none of the individual drugs in the N05 or N06 groups were in the top 40 drugs listed by
utilisation.
Detailed discussions on the specific therapeutic groups can be found in the respective chapters.
The NMUS, amongst other objectives, is designed to support the implementation of the National Medicines
Policy. Hence it is pertinent to note that 36 (90%) of the top 40 most utilised drugs were in the Malaysian
National Essential Drugs List (NEDL) [5]. Of these 36 drugs, 6 of them were listed under the NEDL
Supplementary List, which lists drugs that are designated as those used by specialists for tertiary level
treatment. This indicated good accessibility to essential drugs generally, with reasonable availability and
utilisation of higher-end drugs for specialists care.
Of the four drugs in the top 40 which were not in the NEDL, two of them were the statins i.e. Lovastatin
(C10A A02) and Atorvastatin (C10A A05), and the other two being Cetirizine (R06A E07), an antihistamine,
and Losartan (C09C A01), a cardiovascular drug acting on the renin-angiotensin system. There are alternative
drugs from the NEDL which are in the top 40 for these groups of drugs, and it may be interesting to study
in greater detail the utilisation of these four drugs compared to their corresponding alternatives listed in the
NEDL.
Table 1.1: Top 30 Therapeutic groups by Utilisation in DDD/1000 population/day 2006
NO.
ATC
THERAPEUTIC GROUP
PUBLIC
PRIVATE
TOTAL
1
2
3
A10
C07
C09
32.792
21.3322
13.8264
7.5037
4.4021
5.7554
40.2957
25.7343
19.5818
4
5
C08
C10
DRUGS USED IN DIABETES
BETA BLOCKING AGENTS
AGENTS ACTING ON THE RENIN-ANGIOTENSIN
SYSTEM
CALCIUM CHANNEL BLOCKERS
LIPID MODIFYING AGENTS
15.941
8.639
3.4246
8.5206
19.3656
17.1599
6
R03
DRUGS FOR OBSTRUCTIVE AIRWAY DISEASES
9.8198
6.6997
16.5194
7
8
9
C03
R06
M01
11.775
5.1758
3.9519
2.8894
6.9945
6.0516
14.6643
12.1703
10.0035
10
11
12
13
14
15
16
17
18
19
20
B01
J01
A02
C01
H02
N05
C02
H03
M04
N03
N06
DIURETICS
ANTIHISTAMINES FOR SYSTEMIC USE
ANTIINFLAMMATORY AND ANTIRHEUMATIC
PRODUCTS
ANTITHROMBOTIC AGENTS
ANTIBACTERIALS FOR SYSTEMIC USE
DRUGS FOR ACID RELATED DISORDERS
CARDIAC THERAPY
CORTICOSTEROIDS FOR SYSTEMIC USE
PSYCHOLEPTICS
ANTIHYPERTENSIVES
THYROID THERAPY
ANTIGOUT PREPARATIONS
ANTIEPILEPTICS
PSYCHOANALEPTICS
5.8947
3.8147
2.5009
2.7994
1.9061
3.0503
2.9987
1.4486
1.0294
1.3457
0.8941
3.9402
5.1222
2.656
1.8969
2.5407
0.9951
0.2328
0.5478
0.5053
0.1535
0.4223
9.835
8.9369
5.1568
4.6961
4.4467
4.0454
3.2315
1.9964
1.5347
1.4992
1.3163
2
CHAPTER 1
NO.
ATC
THERAPEUTIC GROUP
PUBLIC
PRIVATE
TOTAL
21
22
23
24
25
26
27
28
29
30
J04
N07
N04
N02
M03
J05
M05
J02
L02
P01
ANTIMYCOBACTERIALS
OTHER NERVOUS SYSTEM DRUGS
ANTI-PARKINSON DRUGS
ANALGESICS
MUSCLE RELAXANTS
ANTIVIRALS FOR SYSTEMIC USE
DRUGS FOR TREATMENT OF BONE DISEASES
ANTIMYCOTICS FOR SYSTEMIC USE
ENDOCRINE THERAPY
ANTIPROTOZOALS
0.9993
0.4341
0.8293
0.382
0.0658
0.495
0.2633
0.0519
0.1937
0.1787
0.0997
0.6421
0.0527
0.4137
0.5474
0.0688
0.1767
0.2735
0.0906
0.1013
1.099
1.0762
0.882
0.7957
0.6131
0.5638
0.4399
0.3253
0.2844
0.28
Table 1.2: Top 40 Drugs by Utilisation in DDD/1000 population/day 2006
NO.
ATC
THERAPEUTIC GROUP
PUBLIC
PRIVATE
TOTAL
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
A10B B01
A10B A02
C07A B02
C07A B03
C08C A05
B01A C06
C10A A01
C03A A04
A10B B09
C08C A01
C03C A01
C09A A04
C10A A02
C09A A02
R03A C02
C09A A01
R06A B04
M01A B05
C10A A05
R03C C03
M01A G01
H02A B06
R03C C02
C02C A01
R06A X13
J01C A04
C08C A02
R03B A02
R06A E07
A02B A02
R03D A04
A02B C01
C01E B15
R06A B02
C01D A08
C03A A03
Glibenclamide
Metformin
Metoprolol
Atenolol
Nifedipine
Acetylsalicylic acid
Simvastatin
Chlorothiazide
Gliclazide
Amlodipine
Furosemide
Perindopril
Lovastatin
Enalapril
Salbutamol
Captopril
Chlorpheniramine
Diclofenac
Atorvastatin
Terbutaline
Mefenamic acid
Prednisolone
Salbutamol
Prazosin
Loratadine
Amoxicillin
Felodipine
Budesonide
Cetirizine
Ranitidine
Theophylline
Omeprazole
Trimetazidine
Dexchlorpheniramine
Isosorbide dinitrate
Hydrochlorothiazide and potassium-sparing
agents
14.0329
11.1397
11.7536
9.077
10.9355
4.8358
2.6378
6.2441
4.593
3.2803
3.9301
4.3301
4.0507
3.5113
4.024
4.1067
2.5619
1.4652
0.786
0.1697
1.2609
1.1766
0.6566
2.234
0.7417
0.698
1.3805
1.5432
0.2259
1.1741
1.1004
0.5889
0.6345
0.0486
1.2768
1.0077
1.5023
2.0109
0.5828
2.9516
0.6772
2.5826
3.9287
0.0355
1.3678
1.9924
0.9588
0.3811
0.5157
0.9827
0.3237
0.1984
1.3908
2.1248
2.537
2.8792
0.284
1.3428
1.8439
0.0961
1.436
1.4018
0.4422
0.1962
1.5065
0.539
0.4886
0.9111
0.804
1.3559
0.0932
0.3358
15.5352
13.1506
12.3365
12.0287
11.6127
7.4184
6.5665
6.2796
5.9608
5.2728
4.8889
4.7113
4.5664
4.4939
4.3477
4.3051
3.9527
3.59
3.323
3.049
1.545
2.5194
2.5005
2.3301
2.1777
2.0998
1.8227
1.7393
1.7324
1.7131
1.589
1.5
1.4386
1.4045
1.3699
1.3434
3
CHAPTER 1
NO.
ATC
THERAPEUTIC GROUP
PUBLIC
PRIVATE
TOTAL
37
A10A D01
1.1299
0.1955
1.3255
38
39
40
M04A A01
R06A D02
C09C A01
Insulins and analogues, intermediate-acting
combined with fast-acting (human)
Allopurinol
Promethazine
Losartan
0.9627
0.8492
0.5202
0.3601
0.4305
0.5978
1.3277
1.2797
1.1179
References:
1. Complete ATC/DDD Index and Guidelines for ATC Classification and DDD Assignment (WHO
Collaborating
Centre for Drug Statistics Methodology 2007; www.whocc.no)
2. Institute of Public Health (IPH) 2008. The Third National Health and Morbidity Survey (NHMS III) 2006,
Vol 1. Ministry of Health, Malaysia.
3. L Rampal, S Rampal, MZ Azhar, AR Rahman. Prevalence, awareness, treatment and control of hypertension
in Malaysia: A national study of 16 440 subjects. Public Health. 2008 Jan; 122 (1):11-18;
4. Commonwealth of Australia 2008. Australian Statistics on Medicines 2006 Online ISBN:
1-74186-516-6 Available from http://www.health.gov.au/internet/main/ publishing.nsf/Content/health-pbsgeneral-pubs asm.htm
5. Khoo KL, Tan H, Liew YM, Deslypere JP, Janus E. Lipids and coronary heart disease in Asia.
Atherosclerosis. 2003 Jul; 169(1):1-10;
6. The National Essential Drug List (Malaysian)
(http://www.pharmacy.gov.my/html/pharma_care_nedl_f.htm as at 18 March 2009)
4
CHAPTER 2
EXPENDITURE ON MEDICINES IN MALAYSIA
Edited by:
Faridah AMY1, Nour Hanah O2, Rosminah MD2, Fatimah AR2, Nadia Fareeda MG1, Goh A3
1. Clinical Research Centre MOH, 2. Pharmaceutical Services Division, MOH, 3. ClinResearch Sdn. Bhd.
In this section we looked at the estimated drug expenditure in Malaysia in 2006. As expected, the highest
expenditure recorded that year was for amlodipine (C08C C01). This drug was also among the top 10 drugs
utilised in 2006, reflecting the high prevalence of hypertension in the Malaysian population (42.6% for adults aged
30 years and above). The highest expenditure incurred in the public and private sectors were for metoprolol (C07A
B02) and atorvastatin (C10A A05) respectively.
The pattern of drug expenditure differed between the public and private sectors as shown in Table 2.1 and Table
2.3. Private sector expenditure was inclined towards newer and therefore more costly drugs, such as atorvastatin
and clopidogrel (B01A C04).
When compared by therapeutic groups, the highest expenditure was incurred for drugs used in diabetes (A10)
as shown in Table 2.2. This correlated to the high prevalence of diabetes mellitus in the country (14.9% for
adults aged 30 years and above). When compared by sector, the public sector expenditure was concentrated on
drugs used in diabetes whereas lipid modifying agents (C10) topped the list for the private sector as shown in
Table 2.4.
Looking at the Australian expenditure statistics for 2006, atorvastatin, simvastatin (C10A A01) and esomeprazole
(A02B C05) were the top 3 drugs by expenditure as shown in Table 2.3 with lipid modifying agents being the
highest expenditure therapeutic group as shown in Table 2.4.
The analysis in this chapter was conducted on the top 150 drugs by utilisation only. Therefore drugs that were
costly but very low in utilisation were not included in the analysis. Certain drugs under the antineoplastic and immuno
modulating agents’ anatomical main group (L) may have appeared in the top 50 by expenditure if the group was
included.
Table 2.1: Top 50 Drugs by Expenditure in RM ‘000
Rank
ATC
Drugs
Public
Private
Total
1
C08C A01
Amlodipine
20,870
9,913
30,783
2
C10A A05
Atorvastatin
6,691
19,876
26,568
3
C07A B02
Metoprolol
22,406
2,676
25,082
4
C10A A01
Simvastatin
7,143
14,647
21,790
5
J01D C02
Cefuroxime
13,910
7,654
21,564
6
A10B A02
Metformin
14,558
6,091
20,649
7
A10B B09
Gliclazide
12,636
6,790
19,426
8
N05A X08
Risperidone
18,622
190
18,812
9
C07A B03
Atenolol
7,785
10,683
18,468
10
C09A A01
Captopril
11
C09A A02
Enalapril
17,010
1,120
18,130
12
B01A C04
Clopidogrel
15,455
2,277
17,732
13
B03X A01
Erythropoietin
2,288
14,374
16,662
14
J01C R02
Amoxicillin and enzyme inhibitor
9,347
6,331
15,678
15
M01A B05
Diclofenac
5,755
9,459
15,214
16
A02B C01
Omeprazole
668
14,502
15,171
5
CHAPTER 2
Rank
ATC
Drugs
Public
Private
Total
17
A10A D01
4,429
10,209
14,639
18
C08C A05
combined with fast-acting (human)
Nifedipine
11,520
1,721
13,241
19
C08C A02
Felodipine
8,750
4,165
12,916
20
R03B A01
Beclometasone
10,526
2,218
12,744
21
C09A A04
Perindopril
8,394
3,276
11,670
22
A02B A02
Ranitidine
8,212
1,861
10,073
23
C09C A01
Losartan
4,511
5,310
9,821
24
A10B F01
Acarbose
5,728
3,919
9,647
25
B01A C05
Ticlopidine
8,163
965
9,128
26
A10A B01
Insulins and analogues, fast-acting (human)
2,849
5,691
8,539
27
R06A E07
Cetirizine
5,831
2,511
8,341
28
A10A C01
(human)
197
8,052
8,249
29
J01F A01
Erythromycin
6,080
1,950
8,030
30
R03A C02
Salbutamol
5,550
2,461
8,011
31
C07A A05
Propranolol
6,613
1,001
7,614
32
R03B A02
Budesonide
129
7,480
7,609
33
M05B A04
Alendronic acid
6,097
1,038
7,136
34
A10B B01
Glibenclamide
5,659
1,384
7,043
35
R03A K06
2,513
4,294
6,807
36
R03A C13
Salmeterol and other drugs for obstructive airway
diseases
Formoterol
2,150
4,473
6,623
37
N03A G01
Valproic acid
6,363
61
6,424
38
J01C F02
Cloxacillin
5,663
717
6,380
39
R03C C02
Salbutamol
5,417
769
6,185
40
R06A A02
Diphenhydramine
539
5,502
6,041
41
R03C C03
Terbutaline
5,316
609
5,925
42
K07R03A
399
5,192
5,590
43
J01C A04
Formoterol and other drugs for obstructive airway
diseases
Amoxicillin
2,054
3,243
5,298
44
A10B G02
Rosiglitazone
1,140
4,066
5,206
45
M01A H01
Celecoxib
2,767
2,438
5,205
46
C02C A01
Prazosin
4,530
620
5,150
47
R06A X13
Loratadine
423
4,696
5,119
48
C10A B04
Gemfibrozil
4,742
83
4,825
49
M01A H05
Etoricoxib
463
4,218
4,681
50
C01E B15
Trimetazidine
1,331
3,291
4,622
Total Top 50 drugs by Expenditure
334,317
237,381
571,698
Total Top 150 drugs by Expenditure
442,837
341,550
765,356
6
CHAPTER 2
Table 2.2: Top 10 Therapeutic Groups by Expenditure in RM ‘000
Rank
ATC
Therapeutic Group
Public
Private
Total
1
A10
Drugs Used in Diabetes
62,752
33,317
96,069
2
C09
Agents Acting on Renin-Angiotensin System
54,523
25,405
79,928
3
J01
Antibacterials for Systemic Use
42,343
35,267
77,610
4
C10
Lipid Modifying Agents
22,516
48,120
70,636
5
R03
Drugs for Obstructive Airway Diseases
38,629
23,776
63,374
6
C07
Beta Blocking Agents
35,705
24,449
60,154
7
C08
41,462
17,549
59,011
8
A02
Drugs For Acid Related Disorders
12,604
24,650
37,254
9
M01
Antiinflammatory and Antirheumatic Products
6,945
28,019
34,964
10
B01
Antithrombotic Agents
8,538
22,724
31,262
Table 2.3: Top 10 Drugs Ranked by Expenditure
Rank
Malaysia
Australia
Public Expenditure
Private
Expenditure
Total
Expenditure
Total Expenditure
1
Metoprolol
Atorvastatin
Amlodipine
Atorvastatin
2
Amlodipine
Simvastatin
Atorvastatin
Simvastatin
3
Risperidone
Diclofenac
Metoprolol
Esomeprazole
4
Captopril
Clopidogrel
Simvastatin
Salmeterol and Fluticasone
5
Enalapril
Atenolol
Cefuroxime
Clopidogrel
6
Metformin
Omeprazole
Metformin
Olanzapine
7
Cefuroxime
Amlodipine
Gliclazide
Omeprazole
8
Gliclazide
Amoxicillin and
enzyme inhibitor
Risperidone
Vanlafaxine
9
Insulins and analogues,
intermediate-acting
combined with fast-acting
(human)
Felodipine
Cetirizine
Atenolol
Pantoprazole
Cefuroxime
Captopril
Alendronic Acid
10
Table 2.4: Top 10 Therapeutic Groups Ranked by Expenditure
Rank
Malaysia
Australia
Public Expenditure
Private
Expenditure
Total
Expenditure
Total Expenditure
(A10)
Agents Acting on ReninAngiotensin System (C09)
(C10)
Antibacterials for
Systemic Use (J01)
Lipid Modifying Agents (C10)
3
Antibacterials for Systemic
Use (J01)
Drugs Used in
Diabetes (A10)
4
(C08)
Anti-inflammatory and
Antirheumatic Products
(M01)
Drugs Used in
Diabetes (A10)
Agents Acting on
Renin-Angiotensin
System(C09)
Antibacterials for
Systemic Use
(J01)
Lipid Modifying
Agents (C10)
1
2
7
Drugs For Acid Related
Disorders (A02)
Agents Acting on ReninAngiotensin System (C09)
Psychoanaleptics (N06)
CHAPTER 2
Rank
Malaysia
Australia
Public Expenditure
Private
Expenditure
Total
Expenditure
Total Expenditure
5
Drugs for Obstructive Airway
Diseases (R03)
Beta Blocking Agents (C07)
Drugs for
Obstructive Airway
Diseases (R03)
Beta Blocking
Agents (C07)
Drugs for Obstructive Airway
Diseases (R03)
6
Agents Acting on
Renin-Angiotensin
System (C09)
Disorders (A02)
7
Psycholeptics (N05)
Beta Blocking Agents
(C07)
Calcium Channel
Blockers (C08)
(A10)
8
(C10)
Drugs for Obstructive
Airway Diseases (R03)
Antineoplastic Agents (L01)
9
Disorders (A02)
Antithrombotic Agents
(B01)
Drugs For Acid
Related Disorders
(A02)
Antiinflammatory
and Antirheumatic
Products (M01)
Psycholeptics (N05)
Antithrombotic Agents (B01)
References:
1. Institute of Public Health (IPH) 2008. The Third National Health and Morbidity Survey (NHMS III)
2006, Vol 1. Ministry of Health, Malaysia.
2. Commonwealth of Australia 2008. Australian Statistics on Medicines 2006 Online ISBN:
1-74186-516-6. Available from http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pbs
general-pubs asm.htm
3. Commonwealth of Australia 2006. Pharmaceutical Benefits Pricing Authority Annual Report for the year
ended 30 June 2006. Online ISBN: 1 74186 119 5. available from: http://www.health.gov.au/internet/wcms
publishing.nsf/Content/health-pbs-general-pricing-pbparpt.htm
8
CHAPTER 3
USE OF MEDICINES FOR ACID RELATED DISORDERS
Edited by:
Radzi H1, Menon J2, Zainon A3, Azuana R4
1. Alor Star Hospital, 2. Queen Elizabeth Hospital, 3. Selayang Hospital, 4. Serdang Hospital
The common causes of acid related disorders include non-ulcer dyspepsia, peptic ulcer disease and
gastroesophageal reflux disease (GERD). Prevalence of acid related disorders in Asian countries is low at under
10% compared to the more developed nations which can range between 10%-40% depending on the definition
being used [2]. In studies using upper abdominal pain as definition, the lowest prevalence of 8% is seen in
Singapore [3]. Slightly higher rates are seen amongst the Scandinavians at 14.5% to 18.4%. Prevalence rates of
23-25.8% are reported in the US [4].
In this survey, the total utilisation of drugs for acid related disorders in 2006 is 5.15685 DDD/1000
population/day, similar to the previous year’s finding of 5.1619DDD/1000 population/day. Concurring to
the prevalence rate, utilisation of this group of drugs was relatively small compared to consumption in
developed countries. The consumption in the Nordic Countries in 2003 for example ranged from 18.3DDD/1000
population/day in Greenland to 56.5DDD/1000 population/day in Iceland [1], which is far greater than
utilisation reported here. In Australia, consumption for acid related disorder stands at a whopping 64.99 DDD/1000
population/day [7].
In addition to the low prevalence of acid related disorders in our population, another contributory factor
to the low overall consumption could also be the omission of antacid and alginates from this report. These
compounds are largely used as first line treatment for symptoms of acid related disorders. Self medicating
in many patients with this disorder may have also resulted in under reporting of the actual usage. Additionally,
drugs for acid related disorders are usually used for treatments of short durations. Thus, utilisation of
drugs for acid related disorder is relatively small when compared to therapeutic groups. In the NMUS 2005
report, utilisation of acid related disorder drugs was at number 14 among the 30 therapeutics groups under
study. Drugs used for diabetes top the list at 35.86DDD/1000 population/day, seven times more than utilisation
reported for acid related disorders group.
Overall, among the major drug classes for acid related disorders, H2 Receptor Antagonist (H2RA)
tops the list with usage of 2.94DDD/1000 population/day (56.9%) in 2006, trailed closely by Proton
Pump Inhibitors (PPI) at 2.21DDD/1000 population/day (42.9%). This pattern is somewhat inconsistent
with other countries where usage of PPIs is usually more dominant compared to H2RA. For example in
Nordic Countries, PPI was the largest group of drugs used for acid related disorders taking the share of 60-80%
of the AO2 group consumption. In Finland, the usage of PPIs was about five times higher at 22.5DDD/1000
population/day compared to usage of H2RA of only 4.1DDD/1000 population/day. On the other hand, in this
study, for private practice where prescribing is not restricted by formulary, this common trend is observed
whereby PPI consumption was about 14% higher (1.42DDD/1000 population/day and 1.23 DDD/1000
population/day for private and public sectors respectively).
Among all available agents for acid related disorders, ranitidine was utilised the most in 2006 at 1.71DDD/1000
population/day (33.2%) followed by omeprazole at 1.5DDD/1000 population/day (29.1%). In the H2RA
drug class, utilisation of cimetidine is second after ranitidine representing 30.4 % of all H2RAs. Famotidine
(11.3% of H2RAs) and nizatidine (0.01%) were mainly used in private practice. Omeprazole dominated the
PPI drug class making up for 67.8% of all agents in this group. This was followed by esomeprazole
(13.5%), lansoprazole (9.3%), pantoprazole (6.4%) and rabeprazole (3%). In 2006, omeprazole was the only
PPI in generic formulation available in Malaysia. In Australia, omeprazole was also the most used acid
reducing agent at 18.6DDD/1000 population/day (31.9% of all PPIs) [7].
Currently, the driving force behind the utilisation trend observed in this study was mainly the prescribing
restrictions enforced through formularies, generic availability and costs. In the public sector the prescribing of
PPIs are limited to specialist clinics and hospitals whilst H2RA are readily available in most primary clinics
and health care centres. Availability of omeprazole in generic form has significantly reduced costs and
consequently making it more accessible.
9
CHAPTER 3
In developed countries, there is an apparent consensus among physicians on using PPIs as
first line treatment for GERD as it is more potent, effective and generally possess good safety
profile [6]. Usage of PPIs is foreseen to eventually surpass H2RA following the trend in the western
population. Based on the changing trend of prevalence locally, partly due to changing lifestyle and
dietary habits, the overall utilisation trend of drugs for acid related disorders is expected escalate.
Table 2.1: Top 50 Drugs by Expenditure in RM ‘000
ATC
Drug Class
2006
A02B A
H2-receptor antagonists
2.9354
A02B B
A02B C
A02B D
A02B X
Prostaglandins
Proton pump inhibitors
Combinations for eradication of Helicobacter Pylori
Other drugs for peptic ulcer and gastro-oesophageal reflux disease (GORD)
0.0016
2.2125
0.0067
0.0006
Table 3.2: Use of Medicines for Acid Related Disorders by Drug Class and Agents, in DDD/1000
population/day 2006
ATC
Drug Class and Agents
A02B A
H2-receptor antagonists
A02B A01
Cimetidine
A02B A02
Ranitidine
A02B A03
Famotidine
A02B A04
Nizatidine
A02B B
A02B B01
Prostaglandins
Misoprostol
A02B C
A02B C01
Proton pump inhibitors
Omeprazole
A02B C02
Pantoprazole
A02B C03
Lansoprazole
A02B C04
Rabeprazole
A02B C05
Esomep razole
2006
10
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.515
0.3763
0.8913
1.1741
0.539
1.7131
0.0202
0.3104
0.3306
0.0004
0.0004
Public
Private
Total
<0.0001
0.0016
0.0016
Public
Private
Total
0.5889
0.9111
1.5
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0471
0.0952
0.1423
0.1271
0.0775
0.2046
0.0094
0.0565
0.0659
0.019
0.2807
0.2997
CHAPTER 3
ATC
2006
A02B D04
Pantoprazole, amoxicillin and clarithromycin
0.0067
0.0067
A02B X
A02B X05
Public
Private
Total
Other drugs for peptic ulcer and gastro-oesophageal reflux disease (GORD)
Bismuth subcitrate
Public
Private
Total
0.0006
0.0006
References:
1. Committee NM-S, (NOMESCO). Medicines Consumption in the Nordic Countries 1999-2003.
2. HB El-Serag NJT. The prevalence and clinical course of functional dyspepsia. Alimentary Pharmacology &
Therapeutics. 2004; 19(6):643-54.
3. Ho KY, Cheung TK, Wong BC. Gastroesophageal reflux disease in Asian countries: disorder of nature or
nurture? J Gastroenterol Hepatol. 2006 Sep; 21(9):1362-5.
4. Mahadeva S, Goh KL. Epidemiology of functional dyspepsia: a global perspective. World J Gastroenterol.
2006 May 7; 12(17):2661-6.
5. Mahadeva S, Raman MC, Ford AC, Follows M, Axon AT, Goh KL, et al. Gastro-oesophageal reflux is more
prevalent in Western dyspeptics: a prospective comparison of British and South-East Asian patients with
dyspepsia. Aliment Pharmacol Ther. 2005 Jun 15; 21(12):1483-90.
6. Modlin IM, Moss SF, Kidd M, Lye KD. Gastroesophageal reflux disease: then and now. J Clin Gastroenterol.
2004 May-Jun; 38(5):390-402.
7. Australian Government Department of Health and Ageing. Australian Statistics on Medicines. 2006 12th
Edition.
11
CHAPTER 4
USE OF ANTIOBESITY MEDICINES
Edited by:
Sharmini S1, Ariza Z1, Oiyammal C2, Lim K3, Cheng MF4, Nazri D5
1.Clinical Research Centre, MOH 2.Sungai Bakap Hospital, 3.Penang Hospital, 4.Xepa-Soul Pattinson
5. Tampin Health Clinic
The total consumption of anti-obesity drugs in Malaysia for 2006 was 0.72 DDD/1000 population/day.
Centrally acting anti-obesity drugs were most commonly prescribed representing 94.3 percent of drugs used.
Among the centrally acting agents used, phentermine was the favored choice (67%).
Of the anti-obesity medicines utilised, consumption in the public sector was practically negligible. The
private sector utilisation captured a market share of 97.8 percent. This was actually an under represented value
considering private sector response rates were much lower than the public sector. The differing utilisation rates
could be an influence of cost and availability of drugs.
In Australia, the consumption of anti-obesity drugs is almost three fold higher; probably due to the higher
prevalence of obesity.
Table 4.1: Use of antiobesity medicine by Drug Class, in DDD/1000 population/day 2006
ATC
Drug Class
A08A
A08A A
A08A B
ANTIOBESITY PREPARATIONS, EXCL. DIET PRODUCTS
Centrally acting antiobesity products
Peripherally acting antiobesity products
2006
0.7187
0.678
0.0408
Table 4.2: Use of antiobesity medicine by Drug Class and Agents, in DDD/1000 population/day 2006
ATC
2006
A08A A
Centrally acting an tiobesity products
A08A A01
Phentermine
A08A A10
Sibutramine
A08A B
Peripherally acting antiobesity products
A08A B01
Orlistat
Public
Private
Total
Public
Private
Total
0.0019
0.4521
0.4541
0.0112
0.2127
0.2239
Public
Private
Total
0.003
0.037 7
0.0408
References:
1. Australian Statistics on Medicine 2006. Commonwealth Department of Health and Ageing Australia.
13
CHAPTER 5
USE OF ANTIDIABETICS
Edited by:
GR Letchumanan R1, Muruga V2, Sharmini S3, Ariza Z3, Oiyammal C4, Lim K5, Cheng MF6,
Nazri D7
1. Taiping Hospital, 2. Sanofi Aventis, 3. Clinical Research Centre, MOH 4. Sungai Bakap Hospital, 5. Penang
Hospital 6. Xepa-Soul Pattinson, 7. Tampin Health Clinic
The total consumption of anti-diabetic drugs in Malaysia for 2006 was 40.3DDD/1000 population/day. This
figure presented a rough estimation for Malaysian diabetic prevalence of four percent. This is lower than the
National Health and Morbidity Survey 2006 findings of 9.5 percent known diabetes and 14.9 percent total
diabetes prevalence [1]. When adult population values was used (aged 30 and above), the new anti-diabetic
drug consumption was 98.7DDD/1000 population/day indicating a diabetes prevalence of 9.87 percent which is
consistent with the National Health and Morbidity Survey 2006. Among the antidiabetic drugs, the most utilised
were sulphonylureas (54.8%), followed by biguanides (32.6%), insulin (8.2%) and combination drugs (2.7%).
The total anti-diabetic drug utilisation for Australia was 44.8 DDD/1000 population/day, most common being
biguanides (34.0%), followed by insulin (32.5%), sulphonylureas (27.8%) and thiazolidinediones (5.2%) [2].
Among the oral hypoglycaemic drugs, sulphonylureas (22.1DDD/1000 population/day) were the most
commonly consumed followed by metformin (13.2DDD/1000 population/day). Metformin usage was
disappointingly lower than sulphonylurea. Similar usage pattern of metformin was also reported in MSOM
2005 and this was in contrast with current guidelines. When compared to Malaysian drug utilisation,
sulphonylurea use in Australia was almost half (12.5DDD/1000 population/day) whilst metformin use was
comparable (15.2DDD/1000 population/day). Alpha glucosidase inhibitors consumption in Malaysia
(0.46DDD/1000 population/day) was almost doubled to that of Australian usage (0.2DDD/1000 population/
day). Thiazolidinediones use was very low (0.2DDD/1000 population/day) in Malaysia. Australia’s use was
more than 10 fold (2.3DDD/1000 population/day). The reason for the extremely low consumption of
thiazolidinediones may be due to its accessibility; high cost, and it being a List A drug requiring a specialist
prescription in public hospitals. Private hospitals and private specialist clinics which may prescribe these drugs
are underrepresented in this survey.
Insulins and its analogues are underutilised in the country, representing only 8.2 percent of
anti-diabetic drugs used versus 32.5 for Australia. This was only 25 percent of Australian insulin coverage. This
was very low but expected because of the Malaysian culture of reluctance to use injectable drugs. This is an
area which we must improve to ensure better management of diabetes in the country. The pattern of prescribing
insulin, however, was consistent to that in Australia with the most preferred type of insulin being the combined
intermediate/fast acting insulin, followed by fast-acting, intermediate-acting and lastly long-acting insulin.
In general, anti-diabetic drug utilisation was greater in the public sector compared to the private; suggesting
a disproportionate burden of disease within our health care system.
Table 5.1: Use of Anti-Diabetics by Drug Class, in DDD/1000 population/day 2006
ATC
Drug Class
A10A
A10B A
A10B B
A10B D
A10B F
A10B G
A10B X
INSULINS AND ANALOGUES
Biguanides
Sulfonamides, urea derivatives
Combinations of oral blood glucose lowering drugs
Alpha glucosidase inhibitors
Thiazolidinediones
Other blood glucose lowering drugs, excl. insulins
15
2006
3.295
13.1506
22.0883
1.0687
0.4507
0.2057
0.0367
CHAPTER 5
Table 5.2: Use of Anti-Diabetics by Drug Class and Agents, in DDD/1000 population/day 2006
ATC
A10A B
Insulins and analogues for injection, fast-acting
A10A B01
Insulins and analogues, fast-acting (human)
A10A B04
A10A B05
Insulins and analogues, fast-acting; insulin lispro
Insulins and analogues, fast-acting; Insulin aspart
A10A C
Insulins and analogues for injection, intermediate-acting
A10A C01
Insulins and analogues, intermediate-acting (human)
2006
Public
0.6717
Private
0.283
Total
0.9547
Public
0.001
Private
0.001
Total
0.002
Public
0.0065
Private
0.0029
Total
0.0094
Public
0.7004
Private
0.2216
Total
0.922
A10A D
Insulins and analogues for injection, intermediate-acting combined with fast-act
A10A D01
Insulins and analogues, intermediate-acting combined with
fast-acting (human)
A10A D05
Insulins and analogues, intermediate-acting combined with fast-acting
Insulin aspart
A10A E
Insulins and analogues for injection, long-acting
A10A E04
Insulins and analogues, long-acting; Insulin glargine
A10B A
Biguanides
A10B A02
Metformin
A10B B
Sulfonamides, urea derivatives
A10B B01
Glibenclamide
A10B B02
A10B B07
A10B B09
A10B B12
Chlorpropamide
Glipizide
Gliclazide
Glimepiride
16
Public
1.1299
Private
0.1955
Total
1.3255
Public
0.0003
Private
0.0288
Total
0.0291
Public
0.0119
Private
0.0404
Total
0.0523
Public
11.1397
Total
13.1506
Private
2.0109
Public
14.0329
Private
1.5023
Total
15.5352
Public
0.0238
Private
0.0251
Total
0.0488
Public
0.0255
Private
0.0721
Total
0.0975
Public
4.593
Private
1.3678
Total
5.9608
Public
0.0261
Private
0.4199
Total
0.446
CHAPTER 5
ATC
A10B D
Combinations of oral blood glucose lowering drugs
A10B D02
Metformin and sulfonamides
A10B D03
Alpha glucosidase inhibitors
A10B F01
Acarbose
A10B G
Thiazolidinediones
A10B G02
Rosiglitazone
A10B G03
Public
Metformin and rosiglitazone
A10B F
Pioglitazone
A10B X
Other blood glucose lowering drugs, excl. insulins
A10B X02
Repaglinide
A10B X03
2006
Nateglinide
0.0113
Private
1.0128
Total
1.02 41
Public
0.0014
Private
0.0431
Total
0.0446
Public
0.3652
Private
0.0856
Total
0.4507
Public
0.040 6
Private
0.1635
Total
0.2041
Public
-
Private
0.0016
Total
0.0016
Public
0.0099
Private
0.015
Total
0.0249
Publ ic
0.0009
Private
0.0109
Total
0.0118
References:
1. The National Health Morbidity Survey 3, Institute of Public Health, Ministry of Health Malaysia 2007.
2. Australian Statistics on Medicines 2006. Commonwealth Department of Health and Ageing Australia.
3. David M. Nathan, MD et al. Management of Hyperglycemia in Type 2 Diabetes: Consensus Algorithm for
the Initiation and Adjustment of Therapy. A consensus statement from the American Diabetes Association
and the European Association for the Study of Diabetes. DIABETES CARE, Volume 29, No. 8, August 2006;
1963-1972.
4. Malaysian Statistics of Medicines 2005, Ministry of Health Malaysia.
17
CHAPTER 6
USE OF ANTIANAEMIC MEDICINES
Edited by:
Lim YS 1, Goh AS2
1. Kuala Lumpur Hospital, 2. Pulau Pinang Hospital
In this chapter only two antianaemic preparations were described namely parenteral iron and erythropoietin.
There was no procurement data captured on oral iron preparations though Oncology, Obstetric and
Gynaecology as well as General Medicine uses quite a fair amount for anaemia. Erythropoeitin is also known as
recombinant human erythropoietin (rHuEPO) which is a protein hormone produced by specialised cells in the kidneys.
When there are few red blood cells as in anaemia, erythropoietin would be released to stimulate the bone
marrow to produce more red blood cells. Where the production of endogenous erythropoietin is defective as
in multiple myeloma or non-Hodgkin Lymphoma, erythropoietin could ameliorate the anaemia but users
are cautioned of its use with chemotherapy that are thrombogenic or in cancer patients who are at risk of
thromboembolism. Haematology and Oncology hardly use any erythropoietin. In Malaysia, erythropoietin
was the standard of care for many patients with end-stage renal disease (ESRD) except for those who develop
antibodies to the erythropoietin, who develop pure red cell aplasia or who develop arterial hypertension.
When the hidden costs of the complications of blood transfusion were taken into account, erythropoietin
would be a potential and cost effective alternative to transfusion. In some cases intravenous iron without
erythropoietin was just as effective in treating the anaemia.
For erythropoietin to be effective, it should be supplemented with iron. Parenteral iron was more effective
than oral iron. However there was no data on iron dextran nor on ferric sucrose but on trivalent parenteral
iron namely saccharated iron oxide. Less than 0.0001 DDD/1000 population/ day and only the private sector
used this. Hence less than 0.00001% of the population was using this daily. Australia used Iron Polymaltose
Complex as the trivalent parenteral iron compound in the amount of 0.023DDD/1000 population/day and
was more or less constant throughout the three years surveyed from 2001 till 2003. This was under their
pharmaceutical benefits scheme. By comparison Malaysia used much less parenteral iron.
Erythropoietin use in Australia in 2006 was 0.044DDD/1000 population/day and consumption of
darbepoetin alpha was more favoured with use of nearly 4 times higher (0.17DDD/1000 population/day). In Malaysia,
erythropoietin utilisation in 2006 was 0.178 DDD/1000 population/day and this meant that 0.018% of the
population used erythropoietin on a daily basis. Usage in the government sector was 1.6 times higher than the
private sector. Access to this antianaemic which was considered expensive therapy had been made possible to
haemodialysis patients and other ESRD cases through the Nephrology budget.
This consumption data was based on assumption that all the erythropoietin purchased were consumed and that
the prescribed daily dose was the same as the defined daily dose. However neither the erythropoietin nor
the trivalent parenteral iron was used every day of the year. If supplementary information was available such
as the average duration of treatment rather than assuming that the medication was taken every day of the
year, drug utilisation could be reported in terms of number of patients treated during the year.
Table 6.1: Use of Antianaemic, in DDD/1000 population/day 2006
ATC
Drug Class
2006
B03
ANTIANAEMIC PREPARATIONS
0.178
Table 6.2: Use of Antianaemic by Drug Class, in DDD/1000 population/day 2006
ATC
Drug Class
2006
B03A
B03A C
B03X
B03X A
IRON PREPARATIONS
Iron trivalent, parenteral preparations
OTHER ANTIANAEMIC PREPARATIONS
Other antianaemic preparations
<0.0001
<0.0001
0.178
0.178
19
CHAPTER 6
USE OF ANTIANAEMIC MEDICINES
Table 6.3: Use of Antianaemic by Drug Class and Agents, in DDD/1000 population/day 2006
ATC
B03A C
Iron trivalent, parenteral preparations
B03A C02
Saccharated iron oxide
B03X A
Other antianaemic preparations
B03X A01
Erythropoietin
2006
Public
Private
Total
<0.0001
<0.0001
Public
Private
Total
0.1094
0.0686
0.178
References:
1. Australia Department of Heath and Ageing, Australian Statistics On Medicine 2003.
2. Statistics on Drug use in Australia 2006.
20
CHAPTER 7
USE OF ANTIHAEMORRHAGIC MEDICINES
Edited by:
Lim YS 1, Goh AS2
1. Kuala Lumpur Hospital, 2. Pulau Pinang Hospital
Concerns for the safety of blood transfusions are partly the cause for the development of a range of
interventions to minimise blood loss during major surgeries. One of the interventions is the widespread
use of anti-fibrinolytic agents especially in cardiac surgeries where they are found to reduce blood loss and
decrease the need for red cell transfusions.
Tranexamic acid is a synthetic derivative which exerts its anti-fibrinolytic effect through reversible blockade
of lysine binding sites on plasminogen molecules. It was the most commonly prescribed anti-haemorrhagic
agent in 2006 (0.068DDD/1000 population/day). Tranexamic acid is effective in reducing postoperative blood
loss in patients undergoing cardiac surgeries with statistically significant reductions in transfusion requirements.
In comparison, the usage of aprotinin was rather low (<0.0006DDD/1000 population/day) and was mainly used
therapeutically in open heart surgeries and cardiopulmonary bypass surgeries. Interestingly the usage of
aprotinin was more than 6 times higher in the private institutions reflecting that a higher number of cardiac surgeries
were being done in the private sector. Aprotinin is a proteinase inhibitor from bovine organs and can only be
given intravenously. The loading dose of aprotinin is 15,000 to 20,000 kallikrein inhibitory units (kiu)/kg
body weight as short intravenous infusions followed by 50,000 kiu/hour by continuous infusion. On the
other hand, tranexamic acid can be given orally since it is readily absorbed from gastrointestinal tract and
excreted in its active form in the urine. With short plasma half-life of 80 minutes, tranexamic acid side effects are
transient mainly manifesting as nausea or diarrhoea.
The main indications for tranexamic acid are to prevent excessive bleeding after prostatic surgery, liver
transplant, tonsillectomy, cervical conisation, primary and intrauterine device-induced menorrhagia, from gastric
and intestinal sites, from epistaxis and ocular trauma, after tooth extraction in haemophilia and hereditary
angioneurotic edema. It is also used in controlling bleeding in pregnancy. Tranexamic acid could be
administered intravenously at a dose of 0.5–1g (10-15mg/kg body weight) two to three times a day or
administered orally at 1-1.5 g three to four times daily. In renal insufficiency, this dose needs to be
reduced. Tranexamic acid was reported to be more effective than mefenamic acid and norethisterone but
less effective than intrauterine administration of levonorgestrel in reduction of menstrual blood loss in
clinical trials. However the high incidence of amenorrhoea and adverse events such as intermenstrual
bleeding reported with some hormonal therapy may be unacceptable to patients in which case tranexamic
acid would be particularly useful. Hence tranexamic acid remains as the first line therapy for initial
management of idiopathic menorrhagia for three to four days cycle over two to three cycles to reduce menstrual
blood loss.
Factor VIII and IX concentrates are used to treat bleeding episodes in haemophilia A and haemophilia B
respectively. In Malaysia, patients are given factor concentrates as “on-demand therapy” without charge
in government hospitals. Furthermore haemophilia is a congenital disorder so the patients are not eligible
for insurance coverage. Hence, most hemophiliacs seek treatment in government hospitals and the usage of
factor concentrates is very low in the private sector.
Recombinant factor VIIa or Eptacog alfa (activated) has been licensed for treatment of haemophilia A and B
with inhibitors in Europe since 1996 and in North America since 1999. Overall 1.5 million doses had been
administered. It is indicated as an intravenous haemostatic agent in hemophilia patients with inhibitors to
coagulation factors VIII and IX. On-demand therapy with Eptacog alfa was effective in controlling episodes
of mild to moderate bleeding. Prophylactic treatment was also effective in maintaining haemostasis in
haemophiliacs undergoing orthopaedic surgeries and it is reported that the acquisition costs of Eptacog alfa
are offset by cost savings resulting from the reduction in the episodes of joint-related bleeds. The data had shown
that Eptacog alfa (activated) was as sparingly used in the private as in the government sector.
21
CHAPTER 7
There was no data available for the use of Vitamin K or phytomenadione as a haemostatic agent even though
our Malaysian hospitals do administer the vitamin intramuscularly for prophylactic use in haemorrhagic
disease of the newborn. In life threatening bleeding, Vitamin K may be used therapeutically by the intravenous
route together with fresh frozen plasma or factor concentrates.
Table 7.1: Use of Antihaemorrhagics in DDD/1000 population/day 2006
ATC
Drug Class
B02
2006
ANTI HAEMORRHAGICS
0.0713
Table 7.2: Use of Antianaemics by Drug Class, in DDD/1000 population/day 2006
ATC
Drug Class
B02A
B02A A
B02A B
B02B
B02B A
B02B D
ANTIFIBRINOLYTICS
Amino acids
Proteinase inhibitors
VITAMIN K AND OTHER HEMOSTATICS
Vitamin K
Blood coagulation factors
2006
0.0695
0.0688
0.0006
0.0018
0.0018
Table 7.3: Use of Antihaemorrhagics by Drug Class and Agents, in DDD/1000 population/day 2006
ATC
2006
B02A A
Amino acids
B02A A02
Tranexamic acid
B02A B
Proteinase inhibitors
B02A B01
Aprotinin
B02B A
Vitamin K
B02B A01
Phytomenadione
B02B D
Blood coagulation factors
B02B D02
Coagulation factor VIII
B02B D04
Coagulation factor IX
B02B D08
Eptacog alfa (activated)
Public
Private
Total
0.0524
0.0165
0.0688
Public
Private
Total
<0.0001
0.0006
0.0006
Public
Private
Total
-
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0007
<0.0001
0.0007
0.0011
0.0011
<0.0001
<0.0001
<0.0001
References:
1. Srivasta A, Chuansumrit A, Chandy M, Duraisamy G, Karagus C. Management of haemophilia in the
developing world. Hemophilia 1998 Jul; 4(4):474-80.
2. Srivasta A, You SK, Ayob Y, Chuansumrit A, de Bosch N, Perez Bianco R, Ala F Hemophilia treatment in
developing countries: products and protocols. Semin. Thromb. Hemost. 2005 Nov; 31(5): 495-500.
3. Stonebraker JS, Amand RE, Nagle AJ; A country-by-country comparison of FVIII concentrate consumption
and economic capacity for the global hemophilia community Hemophilia Vol 9 (3) May 2003; 245-250(6).
22
CHAPTER 7
4. Panicker J et al; The overall effectiveness of prophylaxis in severe haemophilia Haemophilia Vol 9, No. 3
May 2003 : 272-278.
5. Lyseng-Williamson KA, Plosker GL Recombinant factor VIIa (Eptacog alfa) a pharmacoeconomic review of
its use in haemophilia in patients with inhibitors to clotting factors VIII and IX. Pharmacoeconomics
2007 : 25 (12) pgs 1007-29.
6. Puckett RM, Offringa M, Department of Paediatrics, Amsterdam. Prophylactic Vitamin K for Vitamin K
deficiency bleeding in neonates. Cochrane Database Systematic Review 2000; (4): CD 002776.
23
CHAPTER 8
USE OF MEDICINES FOR CARDIOVASCULAR DISORDERS
Edited by:
Chong WP1, Wan Azman WA1
1. University Malaya Medical Centre
With contributions from:
Nirmala J2, Yap YJ2, Haarathi C3, Long MS4
1. Sarawak General Hospital, 2. Kuala Lumpur Hospital, 3. Tengku Ampuan Rahimah Hospital, Klang,
4. Selayang Hospital
The most commonly used antithrombotic agents in 2006 were the platelet aggregation inhibitors (9.22DDD/1000
population/day), and among these, acetylsalicylic acid or aspirin accounted for slightly over 80% of the
total usage. The other less frequently used platelet aggregation inhibitors included ticlopidine (0.99DDD/1000
population/day) and clopidogrel (0.74DDD/1000-population/day). Ticlopidine was used more in the
public health services while the private sector utilised more clopidogrel. The role of these drugs in the treatment
and prevention (primary as well as secondary) of cardiovascular diseases is well established and accepted.
But they were probably under utilised in view of the fact that 27% of adults who were 30 years or older had
multiple cardiovascular risk factors in the National Health and Morbidity Survey in 1996. In Australia, the total
community use of aspirin alone was 19.3DDD/1000 population/day in 2005. This was almost 3 times the usage
of aspirin in Malaysia.
Warfarin had a DDD rate of 0.3755, placing it as the 4th most commonly used antithrombotic agent in 2006.
The other antithrombotic drugs such as heparin, different types of low molecular weight heparin,
fibrinolytic agents (classified as enzymes in the table) and glycoprotein IIb/IIIa receptor antagonists (abciximab,
eptifibatide and tirofiban) had very low DDD rates as they were normally administered over a short period of
time for the treatment of acute coronary syndromes.
Isosorbide dinitrate and trimetazidine were the other 2 cardiac drugs which were fairly frequently used at 1.37 and
1.44DDD/1000 population/day respectively. Both are indicated in the treatment of chronic stable angina.
As a group, diuretics had a DDD rate of 14.66. The top 3 diuretics used in 2006 were chlorothiazide (6.28),
furosemide (4.89) and hydrochlorothiazide and potassium-sparing agents in combination (1.34). In contrast,
furosemide (or frusemide in some countries) had a DDD rate of 19.6 in Australia in 2005. This drug is used
predominantly in the acute and long term management of heart failure. It is also used to treat fluid retention
in other conditions.
On the other hand, chlorothiazide and hydrochlorothiazide with potassium-sparing agents in combination
are antihypertensive medications. Their rate of usage simply reflected the high prevalence of hypertension
among Malaysian population and probably the availability of the drugs in the government formulary.
Table 8.1: Use of Drugs for Cardiovascular disorders, in DDD/1000 population/day 2006
ATC
Drug Class
B01
C01A
C01B
C01C
C01D
C01E
C03
C04
ANTITHROMBOTIC AGENTS
CARDIAC GLYCOSIDES
ANTIARRHYTHMICS, CLASS I AND III
CARDIAC STIMULANTS EXCL. CARDIAC GLYCOSIDES
VASODILATORS USED IN CARDIAC DISEASES
OTHER CARDIAC PREPARATIONS
DIURETICS
PERIPHERAL VASODILATORS
25
2006
9.835
0.6509
0.1483
0.2538
2.2033
1.4398
14.6643
0.0745
CHAPTER 8
Table 8.2.1: Use of Anti-Thrombotic drugs by Drug Class, in DDD/1000 population/day 2006
ATC
Drug Class
2006
B01A A
B01A B
B01A C
B01A D
B01A X
Vitamin K antagonists
Heparin group
Platelet aggregation inhibitors excl. heparin
Enzymes
Other antithrombotic agents
0.3755
0.2365
9.2219
0.0009
0.0003
Table 8.2.2: Use of Anti-Thrombotic drugs by Drug Class and Agents, in DDD/1000 population/day 2006
ATC
2006
B01A A
Vitamin K antagonists
B01A A03
Warfarin
B01A B
Heparin group
B01A B01
Heparin
B01A B05
Enoxaparin
B01A B06
Nadroparin
B01A B10
Tinzaparin
B01A B11
Sulodexide
B01A C
Platelet aggregation inhibitors excl. heparin
B01A C04
Clopidogrel
B01A C05
Ticlopidine
B01A C06
Acetylsalicylic acid
B01A C07
Dipyridamole
B01A C11
Iloprost
B01A C13
Abciximab
26
Public
Private
Total
0.2582
0.11 73
0.3755
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0403
0.0626
0.1029
0.0701
0.0297
0.0998
0.0035
0.0018
0.0054
0.0005
0.0019
0.0024
<0.0001
0.0259
0.026
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0678
0.6682
0.7361
0.5478
0.4434
0.9912
4.8358
2.5826
7.4184
0.0697
0.0062
0.0759
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
CHAPTER 8
ATC
B01A C16
Eptifibatide
B01A C17
Tirofiban
B01A D
Enzymes
B01A D0 1
Streptokinase
B01A D02
Alteplase
B01A D04
Urokinase
B01A D10
Drotrecogin alfa (activated)
B01A D11
Tenecteplase
B01A X
Other antithrombotic agents
B01A X05
Fondaparinux
2006
Public
Private
Total
Public
Private
Total
<0.0001
<0.0001
<0.0001
<0.0001
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Tota l
Public
Private
Total
0.0007
0.0001
0.0009
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
Public
Private
Total
<0.0001
0.0002
0.0003
Table 8.3.1: Use of Cardiac Glycosides by Drug Class, in DDD/1000 population/day 2006
ATC
C01A
CARDIAC GLYCOSIDES
C01A A05
Digoxin
Public
Private
Total
Table 8.4.1: Use of Anti-Arrhythmics by Drug Class, in DDD/1000 population/day 2006
ATC
C01B B
Antiarrhythmics, class Ib
C01B B01
Lidocaine
C01B B02
Mexiletine
C01B C
Antiarrhythmics, class Ic
C01B C03
Propafenone
C01B C04
Flecainide
27
2006
0.4195
0.2314
0.6509
2006
Public
Private
Total
Public
Private
Total
0.0013
0.0005
0.0018
-
Public
Private
Total
Public
Private
Total
0.0006
0.0056
0.0062
0.002
0.0093
0.0113
CHAPTER 8
ATC
C01B D
Antiarrhythmics, class III
C01B D01
Amiodarone
2006
Public
Private
Total
Table 8.5.1: Use of Cardiac stimulants by Drug Class, in DDD/1000 population/day 2006
ATC
C01C A
Adrenergic and dopaminergic agents
C01C A02
Isoprenaline
C01C A03
Norepinephrine
C01C A04
Dopamine
C01C A06
Phenylephrine
C01C A07
Dobutamine
C01C A24
Epinephrine
C01C E
Phosphodiesterase inhibitors
C01C E02
Milrinone
C01C X
Other cardiac stimulants
C01C X08
Levosimendan
0.0318
0.0972
0.129
2006
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
<0.0001
<0.0001
<0.0001
0.0206
0.0029
0.0235
0.0055
0.0053
0.0108
0.0045
0.0033
0.0077
0.0115
0.0018
0.0133
0.1495
0.0436
0.193 1
Public
Private
Total
<0.0001
0.0053
0.0053
Public
Private
Total
<0.0001
<0.0001
Table 8.6.1: Use of Vasodilators in Cardiac diseases by Drug Class, in DDD/1000 population/day 2006
ATC
2006
C01D A
Organic nitrates
C01D A02
Glyceryl trinitrate
C01D A05
Pentaerithrityl tetranitrate
C01D A08
Isosorbide dinitrate
C01D A14
Isosorbide mononitrate
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
28
0.1188
0.0517
0.1705
0.0024
0.0024
1.2768
0.0932
1.3699
0.1214
0.5391
0.6605
CHAPTER 8
Table 8.6.2: Use of other cardiac preparations in Cardiac diseases by Drug Class, in DDD/1000
population/day 2006
ATC
2006
C01E A
Prostaglandins
C01E A01
Alprostadil
C01E B
Other cardiac preparations
C01E B10
Adenosine
C01E B15
Trimetazidine
Public
Private
Total
<0.0001
<0.0001
<0.0001
Public
Private
Total
Public
Private
Total
0.0009
0.0002
0.0011
0.6345
0.804
1.4386
Table 8.7.1: Use of Diuretics by Drug Class, in DDD/1000 population/day 2006
ATC
C03A
LOW-CEILING DIURETICS, THIAZIDES
C03A A03
Hydrochlorot hiazide
C03A A04
Chlorothiazide
2006
Public
Private
Total
Public
Private
Total
0.2597
0.8344
1.0942
6.2441
0.0355
6.2796
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0212
0.0212
0.0017
0.0017
0.0557
0.5507
0.6064
Public
Private
Total
Public
Private
Total
3.9301
0.9588
4.8889
0.0219
0.0172
0.0391
Public
Private
Total
Public
Private
Total
0.2517
0.1286
0.3803
0.0024
0.0071
0.0095
C03B
LOW-CEILING DIURETICS, EXCL. THIAZIDES
C03B A04
Chlortalidone
C03B A08
Metolazone
C03B A11
Indapamide
C03C
HIGH-CEILING DIURETICS
C03C A01
Furosemide
C03C A02
Bumetanide
C03D
POTASSIUM-SPARING AGENTS
C03D A01
Spironolactone
C03D B01
Amiloride
C03E
DIURETICS AND POTASSIUM-SPARING AGENTS IN COMBINATION
Public
Hydrochlorothiazide and potassium-sparing agents
C03E A01
Private
Total
29
1.0077
0.3358
1.3434
CHAPTER 8
Table 8.8.1: Use of Peripheral vasodilators by Drug Class, in DDD/1000 population/day 2006
ATC
2006
C04A D
Purine derivatives
C04A D03
Pentoxifylline
C04A E
Ergot alkaloids
C04A E01
Ergoloid mesylates
C04A X02
Phenoxybenzamine
Public
Private
Total
0.0485
0.0136
0.0622
Public
Private
Total
Public
Private
Total
0.0123
0.0123
<0.0 001
<0.0001
References:
1. The National Health Morbidity Survey 2, Institute of Public Health, Ministry of Health Malaysia 1996.
2. Statistics on drug use in Australia 2006, Australian Institute of Health and Welfare 2007.
30
CHAPTER 9
USE OF ANTIHYPERTENSIVES
Edited by:
Hooi LS1, Zaki M2, Lim TO3, Zawawi N4, Goh BL5, Fadilah O6, Nur Salima S6, Puteri JZ6, Zarina AG6,
Manjulaa DS7
1. Sultanah Aminah Hospital, Johor Bahru, 2. International Medical University, 3. Clinical Research
Centre MOH, 4. Sultanah Nur Zahirah Hospital, Terengganu, 5. Serdang Hospital, 6. Selayang Hospital,
7. Kuala Lumpur Hospital
Beta blockers were the most commonly prescribed antihypertensive medication (25.7DDD/1000
population/day) in 2006 followed by the calcium channel blockers (19.4). ACE inhibitors (15.3), diuretics (8.0)
and angiotensin II antagonists (4.3) were also commonly used. Usage of alpha blockers and centrally acting drugs
was low.
In the category of beta blockers there was a small amount which was prescribed in combination with diuretics.
The second largest category was the drugs antagonising the renin-angiotensin system (ACEIs and ARBs)
some of which were in combination with diuretics (total 19.6DDD/1000 population/day). The calcium channel
blockers (CCBs) included those with vascular effects (e.g. amlodipine and nifedipine) and those with cardiac
effects (e.g. diltiazem). Diuretics were prescribed alone (8.0) or in combination with other drugs (beta blocker
or ACEI or ARB or potassium sparing agents) in the same tablet (3.1) which made its overall usage quite
high (total 11.1 DDD/1000 population/day).
There were 3 drugs whose contribution each made up more than 10% of total utilization – metoprolol
(12.3DDD/1000 population/day), atenolol (12.0) and nifedipine (11.6). Of these, two were beta blockers and
one a CCB. These 3 drugs were used mainly in the public sector (88%).
Overall, 80% of all antihypertensives were utilised in the public sector and 20% in the private sector.
The most popular drugs in the private sector were atenolol (3.0DDD/1000 population/day), amlodipine
(2.0) and enalapril (1.0). There was a tendency to use more expensive drugs in the private sector. The
use of antihypertensives should be encouraged in the private sector to reduce the burden of prescribing in the
public sector. Economic considerations about treating a chronic disease in the private sector may be a
deterring factor. Hypertension is a silent disease (killer) and without counseling and education the public may
not be willing to pay for its long term control. Generic drugs which are efficacious should be the ones of
choice. Drug prescribing may have been unduly influenced by aggressive marketing by the pharmaceutical
industry.
Among the beta blockers, the most popular were metoprolol and atenolol. They were favoured over the
older generation beta blocker propranolol. Among the ACEIs, perindopril was the most commonly used
followed by enalapril and captopril. Perindopril is relatively cheap and its daily dosing is an advantage.
The use of ACEIs should be encouraged as they have cardio-and renoprotective effects. The incidence of
diabetes mellitus in new patients with end-stage renal failure (ESRF) was 58% in 2006 in Malaysia (1).
In the early stages of diabetic nephropathy ACEIs and ARBs may help to prevent progression to ESRF. The
most commonly used ARB (with or without combination diuretics) was losartan followed by valsartan,
irbesartan and telmisartan. These drugs are expensive. Among the CCBs nifedipine and amlodipine were the
most commonly used. Nifedipine was extensively used, 94% in the public sector. Amlodipine was popular
in both the public and private sector in spite of its high cost. Its daily dosing is an advantage for patient
compliance over the three times a day dosing of nifedipine. It is a long acting dihydropryridine CCB and is
not contraindicated in cardiovascular disease unlike the short acting nifedipine. Among the diuretics
chlorothiazide (CTZ) and HCTZ were the most commonly prescribed. The former was used by the public
sector while HCTZ was used by the private sector. Their usage was low considering that they are the
recommended first line drugs for hypertension.
The alpha antagonists were not popular although they may be useful in hypertensive men with prostatic
hypertrophy who are not at high risk of heart failure. The use of centrally acting agents was low and this may
be due to their unpleasant side-effects. They are still useful as a third line drug and methyldopa is used in
hypertension during pregnancy. Hydralazine should not be removed from the drug formulary as it is useful
31
CHAPTER 9
in severe hypertension during pregnancy. Minoxidil is a third line drug that sometimes controls severe
hypertension although it was used sparingly as there are side-effects. Nitroprusside is an intravenous drug which
was used only in ICUs to control blood pressure temporarily.
The total utilisation of antihypertensives was 77.3DDD/1000 population/day. From general practice
prescription data, we estimated a patient with hypertension was prescribed a median of only one antihypertensive
medication. That is, the vast majority of patients (81%) in Malaysia were on mono-therapy. Thus, the
utilisation statistic of 77.5DDD/1000 population/day suggested that about 6 to 7% of the population were
on drug treatment for hypertension. About 40% of the population was aged > 30 years in 2006. This means
that about 16% of the population aged 30 and above was taking an antihypertensive drug in 2006. There is a
high prevalence of hypertension in Malaysia (43% in 2006) and a substantial number of patients were not
on drug therapy or had undiagnosed hypertension (2). People with hypertension in Malaysia may need more
drug treatment as less than half of those who are hypertensive were on antihypertensives. This shortfall
may be greater than stated as many on treatment need more than one category of drug to control their blood
pressure to the recommended target.
Overall, compared to the Nordic countries (3) the use of beta blockers, agents acting on the
renin-angiotensin system, calcium channel blockers and diuretics was low in Malaysia. Beta blocker use in 2003
ranged from 13.9DDD/1000 population/day in Greenland to 65.8 in Finland in 2003. For drugs acting on
the renin-angiotensin system, the usage ranged from 30.7DDD/1000 population/day in Greenland to 107.8
in Finland. For calcium channel blockers the range was 15.6 in Greenland to 45.3 in Norway. The use of
thiazides alone or in combination with potassium-sparing agents ranged from 10.9DDD/1000 population/day
in Norway to 50.5 in Denmark in 2003.
The local Clinical Practice Guideline (CPG) on hypertension (4) recommends beta blockers or diuretics as
drugs of first choice for control of uncomplicated hypertension. The utilisation pattern for 2006 was not
consistent with the CPG as antagonists of the renin-angiotensin system were second to beta blockers
followed by the calcium channel blockers. Diuretics lagged behind in fourth place. Many of the drugs in all
4 categories except the ARBs are generic and the order of preference may reflect economic considerations.
The ACEIs and ARBs are weak antihypertensives but have effects beyond blood pressure lowering. These
include cardioprotection post myocardial infarction, reduction of proteinuria and renoprotection in diabetic
and non-diabetic renal disease. The incidence of diabetes mellitus in Malaysia is high (14.9% in 2006) (2)
and many diabetics are hypertensive. This may have some bearing when physicians in Malaysia
choose an antihypertensive drug for their diabetic patients (4,5). The calcium channel blockers have few
side-effects and are efficacious. Diuretics may be less used inspite of their extremely low cost because of
marketing of other (more expensive) drugs by the pharmaceutical industry or the belief that they have
side-effects.
Table 9.1: Use of Antihypertensives by Drug Class, in DDD/1000 population/day 2006
ATC
Drug Class
C02A
C02C A
C02D
C02K
C03A
C03B
C03E
C07
C08
C09A
C09B
C09C
C09D
ANTIADRENERGIC AGENTS, CENTRALLY ACTING
ALPHA-ADRENORECEPTOR ANTAGONISTS
ARTERIOLAR SMOOTH MUSCLE, AGENTS ACTING ON
OTHER ANTIHYPERTENSIVES
CALCIUM CHANNEL BLOCKERS
ACE INHIBITORS, PLAIN
ACE INHIBITORS, COMBINATIONS
ANGIOTENSIN II ANTAGONISTS, PLAIN
ANGIOTENSIN II ANTAGONISTS, COMBINATIONS
32
2006
0.6553
2.5693
0.0063
0.0006
7.3738
0.6293
1.3434
25.7343
19.3656
15.2135
0.0738
2.7293
1.5652
CHAPTER 9
Table 9.2: Use of Antihypertensives by Drug Class and Agents, in DDD/1000 population/day 2006
ATC
2006
C02A
ANTIADRENERGIC AGENTS, CENTRALLY ACTING
C02A B01
Methyldopa (levorotatory)
C02A C01
Clonidine
C02A C05
Moxonidine
C02C A
Alpha-adrenoreceptor antagonists
C02C A01
Prazosin
C02C A04
Doxazosin
C02D
ARTERIOLAR SMOOTH MUSCLE, AGENTS
C02D B01
Dihydralazine
C02D B02
Hydralazine
C02D C01
Minoxidil
C02D D01
Nitroprusside
C02K
OTHER ANTIHYPERTENSIVES
C02K X01
Bosentan
C03A
C03A A03
Hydrochlorothiazide
C03A A04
Chlorothiazide
C03B
C03B A04
Chlortalidone
C03B A08
Metolazone
33
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.5827
0.018
0.6007
<0.000 1
<0.0001
0.0002
0.0544
0.0545
Public
Private
Total
Public
Private
Total
2.234
0.0961
2.3301
0.1764
0.0628
0.2393
Public
0.0004
Private
-
Total
0.0004
Public
Private
Total
Public
Private
Total
Public
Private
Total
<0.0001
<0.0001
0.0047
0.0002
0.0049
0.0001
0.0008
0.001
Public
Private
Total
<0.0001
0.0006
0.0006
Public
Private
Total
Public
Private
Total
0.2597
0.8344
1.0942
6.2441
0.0355
6.2796
Public
Private
Total
Public
Private
Total
0.0212
0.0212
0.0017
0.0017
CHAPTER 9
ATC
C03B A11
Indapamide
2006
C03E
C03E A01
Hydrochlorothiazide and potassium-sparing agents
C07A
C07A A05
Propranolol
C07A A07
Sotalol
C07A B02
Metoprolol
C07A B03
Atenolol
C07A B04
Acebutolol
C07A B05
Betaxolol
C07A B07
Bisoprolol
C07A B09
Esmolol
C07A G01
Labetalol
C07A G02
Carvedilol
C07C
BETA BLOCKING AGENTS AND OTHER DIURETICS
C07C A03
Pindolol and other diuretics
C07C B02
Metoprolol and other diuretics
C07C B03
Atenolol and other diuretics
34
Public
Private
Total
0.0557
0.5507
0.6064
Public
Private
Total
1.0077
0.3358
1.3434
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.255
0.1815
0.4364
0.0146
0.0146
11.7536
0.5828
12.3365
9.077
2.9516
12.0287
0.0019
0.0019
0.0004
0.0703
0.0708
0.0349
0.1517
0.1866
<0.0001
<0.0001
<0.0001
0.1303
0.019
0.1493
0.0808
0.2633
0.3441
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0021
0.0021
0.0167
0.0167
<0.0001
0.1466
0.1467
CHAPTER 9
ATC
C08C
SELECTIVE CALCIUM CHANNEL BLOCKERS WITH MAINLY
VASCULAR EFFECTS
C08C A01
Amlodipine
C08C A02
Felodipine
C08C A03
Isradipine
C08C A04
Nicardipine
C08C A05
Nifedipine
C08C A06
Nimodipine
C08C A09
Lacidipine
C08C A13
Lercanidipine
C08C
SELECTIVE CALCIUM CHANNEL BLOCKERS WITH DIRECT
CARDIAC EFFECTS
C08D A01
Verapamil
C08D B01
Diltiazem
C09A
ACE INHIBITORS, PLAIN
C09A A01
Captopril
C09A A02
Enalapril
C09A A03
Lisinopril
C09A A04
Perindopril
C09A A05
Ramipril
35
2006
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
3.2803
1.9924
5.2728
1.3805
0.4422
1.8227
0.0067
0.0067
<0.0001
0.005
0.005
10.9355
0.6772
11.6127
0.0005
0.0002
0.0007
0.014
0.014
0.0679
0.0679
Public
Private
Total
Public
Private
Total
0.0378
0.0442
0.0821
0.3064
0.1747
0.4811
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
4.1067
0.1984
4.3051
3.5113
0.9827
4.4939
0.1591
0.5872
0.7463
4.3301
0.3811
4.7113
0.3409
0.5856
0.9264
CHAPTER 9
ATC
C09A A06
Quinapril
C09A A09
Fosinopril
C09A A16
Imidapril
C09B
ACE INHIBITORS, COMBINATIONS
C09B A04
Perindopril and diuretics
2006
C09C
ANGIOTENSIN II AN TAGONISTS, PLAIN
C09C A01
Losartan
C09C A03
Valsartan
C09C A04
Irbesartan
C09C A06
Candesartan
C09C A07
Telmisartan
C09C A08
Olmesartan medoxomil
C09D
ANGIOTENSIN II ANTAGONISTS, COMBINATIONS
C09D A01
Losartan and diuretics
C09D A03
Valsartan and diuretics
C09D A04
Irbesartan and diuretics
C09D A06
Candesartan and diuretics
C09D A07
Telmisartan and diuretics
36
Public
Private
Total
Publ ic
Private
Total
Public
Private
Total
0.0014
0.0014
0.0009
0.0058
0.0067
0.0012
0.0211
0.0223
Public
Private
Total
0.0066
0.0672
0.0738
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.5202
0.5978
1.1179
0.1537
0.2183
0.372
0.1987
0.364
0.5627
0.2164
0.2164
0.2038
0.2069
0.4107
0.0496
0.0496
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.1154
0.405
0.5204
0.0891
0.4154
0.5045
0.0686
0.2336
0.3022
0.0006
0.1233
0.1239
0.0195
0.0947
0.1142
CHAPTER 9
References:
1. Lim YN, Lim TO (eds). Fifteenth report of the Malaysian Dialysis and Transplant Registry 2007,
Kuala Lumpur 2008. http://www.msn.org.my/nrr/report2007.htm (accessed on 1 January 2009).
2. Institute for Public Health (IPH) 2008. The Third National Health and Morbidity Survey
(NHMSIII) 2006, Volume 2, page 210 and 253. Ministry of Health Malaysia. ISBN 978-983-3887-30-9.
3. Nordic Medico Statistical Committee. Medicines Consumption in the Nordic Countries 1999-2003.
Copenhagen 2004. ISBN 87-89702-52-2.
4. Academy of Medicine Malaysia, Ministry of Health Malaysia. Clinical practice guidelines on management of
hypertension, 2002. http://www.acadmed.org.my/html/index.shtml (accessed on 10 June 2007).
5. Academy of Medicine Malaysia, Ministry of Health Malaysia. Clinical practice guidelines on diabetic
nephropathy, 2004. http://www.acadmed.org.my/html/index.shtml (accessed on 10 June 20
37
CHAPTER 10
USE OF LIPID LOWERING MEDICINES
Edited by:
Chang BC1, Fong AYY1, Sim KH1
Chong WP2, Nirmala J3, Yap YJ3, Haarathi C4, Long MS5
1. Sarawak General Hospital, 2. Universiti Malaya Medical Centre, 3. Kuala Lumpur Hospital,
4. Tengku Ampuan Rahimah Hospital, Klang, 5. Selayang Hospital
The HMG Co A reductase, or more commonly known as statins, is the mainstay of treatment of
hyperlipidaemia in Malaysia. It has a good safety profile and a proven track record in reducing myocardial
infarction, stroke and cardiovascular death from numerous well conducted multinational trials [1,2]. Indeed,
more recent evidence points towards increasingly lower LDL treatment endpoint [3] and new indications
(eg: patients with high hsCRP) [4] for using stains are emerging. Therefore the usage of statins is likely to
become more widespread in the next few years.
The most popular statin prescribed in the public sector was lovastatin (4.05DDD/1000 population/day);
for the most part related to its lower cost. Simvastatin remained the most popular statin among the private
health sector followed by atorvastatin. Rosuvastatin, the most potent statin around at the moment was not
commonly prescribed (0.225DDD/1000 population/day). With the advent of lower cost generic products, it
is expected this picture to change gradually and the ‘higher end’ statins made more affordable throughout
Malaysia.
Ezetimibe, which inhibits cholesterol absorption at intestinal brush borders, had gained some traction among
Malaysian prescribers (0.42DDD/1000 population/day) despite being a relatively newcomer. It is primarily used
as an adjunct to statins rather than a first line drug. Despite its effectiveness in LDL lowering, evidence
of ezetimibe’s clinical benefits are still pending, awaiting studies such as IMPROVE-IT [5].
The fibrates, despite being in use for a long time and having good clinical trial data [6], were still not
commonly prescribed in Malaysia (1.39DDD/1000 population/day). This could be related to the fact that
increasing HDL and lowering triglyceride is still not viewed as imperative as lowering LDL cholesterol by most
clinicians.
Overall, Malaysia still has low utilisation of lipid lowering agent compared with other developed
countries. For example, Australia with a prevalence of hypercholesterolemia of about 51% [7] (similar
to Malaysia – 53.5%) [8] had a statin usage of 196.23DDD/1000 population/day in 2006 [9]
compared to 15.68DDD/1000 population/day in Malaysia. This seems to indicate that we still have room for
improvement in the treatment of hyperlipidaemia, for both primary and secondary prevention purposes. With
our country’s expanding aged population, this is vital in reducing our cardiovascular health burden and
healthcare cost in future.
Table 10.1: Use of Lipid Lowering Medicines by Drug Class, in DDD/1000 population/day 2006
ATC
Drug Class
2006
C10A A
C10A B
C10A C
C10A X
C10B A
Fibrates
Bile acid sequestrants
Other lipid modifying agents
HMG CoA reductase inhibitors in combination with other lipid
modifying agents
15.3216
1.3854
0.0019
0.0917
0.3593
39
CHAPTER 10
Table 10.2: Use of Lipid Lowering Medicines by Drug Class and Agents, in DDD/1000
population/day 2006
ATC
C10A A
C10A A01
Simvastatin
C10A A0 2
Lovastatin
C10A A03
Pravastatin
C10A A04
Fluvastatin
C10A A05
Atorvastatin
C10A A07
Rosuvastatin
C10A B
Fibrates
C10A B01
Clofibrate
C10A B02
Bezafibrate
C10A B04
Gemfibrozil
C10A B05
Fenofibrate
C10A B08
Ciprofibrate
C10A C
Bile acid sequestrants
C10A C01
Colestyramine
C10A X
Other lipid modifying agents
C10A X04
Benfluorex
C10A X09
Ezetimibe
2006
40
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Tota l
Public
Private
Total
2.6378
3.9287
6.5665
4.0507
0.5157
4.5664
0.1956
0.2534
0.4489
0.1862
0.1862
0.786
2.537
3.323
0.0062
0.2244
0.2306
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0002
0.0002
0.0002
0.0002
0.7413
0.0285
0.7698
0.199
0.3695
0.5684
0.0122
0.0346
0.0468
Public
Private
Total
0.0005
0.0014
0.0019
Public
Private
Total
Public
Private
Total
0.0195
0.0195
0.0077
0.0645
0.0722
CHAPTER 10
ATC
C10B A
2006
HMG CoA reductase inhibitors in combination with other lipid modifying agents
C10B A02
Simvastatin and ezetimibe
Public
Private
Total
0.0021
0.3571
0.3593
References:
1. Shepherd J, Cobbe SM, Ford I, et al. for the West of Scotland Coronary Prevention Group. Prevention of
coronary heart disease with pravastatin in men with hypercholesterolaemia. N Eng J Med 1995; 333:1301-7
2. Scandinavian Simvastatin Survival Study Group. Randomised trial in cholesterol lowering in 4444 patients
with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994; 344:1383-9.
3. LaRosa JC, Grundy SM, Waters DD, et al. Intensive lipid lowering with atorvastatin in patients with stable
coronary disease. N Eng J Med 2005.
4. Ridker PM, Eleanor Danielson, Fonseca F, et al. Rosuvastatin to Prevent Vascular Events in Men and Women
with Elevated C-Reactive Protein (JUPITER). N Eng J Med Nov. 2008.
5. Cannon CP, Guigliano RP, et al. Rationale and design of IMPROVE-IT (IMProved Reduction of Outcomes:
Vytorin Efficacy International Trial): comparison of ezetimbe/simvastatin versus simvastatin monotherapy on
cardiovascular outcomes in patients with acute coronary syndromes. Am Heart J. Nov. 2008.
6. Helsinki Heart Study: primary-prevention trial with gemfibrozil in middle-aged men with dyslipidemia.
Safety of treatment, changes in risk factors, and incidence of coronary heart disease. Frick MH - N Eng J
Med Nov. 1987.
7. Australian Diabetes, Obesity and Lifestyle Study (AusDiab). 2001 Report.
8. Non-communicable Disease Surveillance Programme, Malaysia, 2006.
9. Australian Statistics on Medicine 2006. Department of Health and Aging, Australian Government.
41
CHAPTER 11
USE OF DERMATOLOGICALS
Edited by:
Rohna R1, Asmah J2, Roshidah B3
1. Selayang Hospital, 2. Kuala Lumpur Hospital, 3. Melaka Hospital
The topical dermatological medicaments included in this study were antifungals, anti-psoriatics, antibiotics,
antivirals, corticosteroids, anti-acne agents, hair growth stimulants, depigmenting agents, calcineurin inhibitors
and metronidazole. Topical dermatological medicament is the major therapeutic modality used in treating patients
with skin disorders. Utilisation is measured as total dose of topical medicament in g/ml/1000 population/day.
There is a disparity in the utilisation of dermatological medicaments by public and private health care providers
with the latter having access to a larger variety of topical medicaments (Table A). Prescribing only
medicaments that are available in the Ministry of Health (MOH) drug formulary by healthcare
providers in the public sector is one possible explanation for the disparity. The list of medicaments
(Table A) that were utilised only by private healthcare providers was not available in the MOH drug
formulary. In the public sector, prescribing of certain dermatological medicaments (e.g. topical anti-acne agents)
is only by trained dermatologists and they are few in number. In private sector, the non-dermatologists have access
to clindamycin and various other topical anti-acne agents such as adapalene and azelaic acid.
The lower usage of the newer but expensive medicaments (e.g. tacrolimus, pimecrolimus, imiquimod and
metronidazole) in government healthcare facilities was because of the availability of their cheap and effective
equivalents in the MOH drug formulary. In special cases of drug resistance or contraindication, prescribing
of dermatological medicaments not in the MOH formulary is permissible after seeking approval from the
Director General of Health, Malaysia.
In government healthcare facilities, procurement of dermatological medicaments for acute (acute cutaneous
infections) and chronic skin diseases (eczema and psoriasis) took preference over hair growth stimulants
(minoxidil, finasteride) and depigmentation agents8-10(hydroquinone) which are perceived as more for cosmetic
benefits.
Medications (acitretin and methoxalen) that require vigilant long term monitoring was utilised less in the
private sector because patients requiring these agents were often referred to government hospitals for
management.
There was a high usage of the moderately potent and very potent topical steroids1-7 by private health
care providers. The appropriateness of these prescriptions and monitoring of their side effects1-7 need further
study. Similarly the usage of topical antibiotics was more in the private sector as compared to public sector.
Here again, the appropriateness of topical antibiotic prescriptions and the drug resistance pattern need
further study. Healthcare providers need to be aware of untoward events1-11 that can occur with inappropriate
drug usage.
43
CHAPTER 11
Table A: Utilisation of Medicament by Health Care Providers 2006
Increased medicament usage
Increased medicament usage
in Public Health Facilities
in Private Health Facilities
Topical Anti-fungal medicaments
Nystatin, Miconazole
Ketoconazole
Isoconazole, Econazole,
Terbinafine, Fluconazole
Anti-psoriatic therapy
Acitretin, Methoxalen
Antibiotic & Antiseptics
Neomycin, Silver sulfadiazine
Antiviral
Corticosteroids
Hydrocortisone
Combination Topical steroid and
Antibiotic (AB)/antifungal
Hydrocortisone plus AB
Medicament used in Private
Health Facilities only
Calcipotriol combination therapy
Tetracycline, Fusidic acid,
Gentamicin, Mupirocin
Topical aciclovir
Clobetasone, Triamcinolone
Betametasone, Mometasone
Hydrocortisone aceponate,
clobetasol
Bethamethasone AB combination
Bethamethasone plus other
combination
Anti-acne
Adapalene, clindamycin,
Azelaic acid
Hair growth stimulants
Depigmenting agent
Calcineurin inhibitors
Acne rosacea therapy
Finasteride
Hydroquinone
Tacrolimus and pimecrolimus
Tromantadine, Imiquimod
Aclometasone, Dexamethasone
Fluocinolone acetonide,
Fluticasone
Prednisolone plus AB,
Triamcinolone/dexamethasone plus AB,
Fluocinolone acetonide/clobetasol
plus AB,
Hydrocortisone plus other combination
Topical isotretinoin
Topical erythromycin and
erythromycin combination
Topical minoxidil
Topical metronidazole
Table 11.1: Use of Dermatological by Drug Class and Agents, in total dosage/1000 population/day 2006
ATC
D01A A
Antibiotics
Unit
D01A A01
Nystatin
g/ml/cc
D01A C
Imidazole and triazole derivatives
D01A C01
Clotrimazole
D01A C02
D01 A C03
D01A C05
D01A C07
D01A C08
g/ml/cc
Miconazole
g/ml/cc
Econazole
g/ml/cc
Isoconazole
g/ml/cc
Tioconazole
g/ml/cc
Ketoconazole
g/ml/cc
44
2006
Public
0.1064
Private
0.0089
Total
0.1153
Public
0.1469
Private
0.3403
Total
0.4872
Public
1.3178
Private
0.6315
Total
1.9493
Public
-
Private
0.0434
Total
0.0434
Public
-
Private
0.0003
Total
0.0003
Public
0.0007
Private
0.0059
Total
0.0066
Public
0.0608
Private
0.3199
Total
0.3808
CHAPTER 11
ATC
Unit
D01A C15
Fluconazole
g/ml/cc
D01A C20
D01A C52
Combinations
Miconazole, combinations
D01A E
Other antifungals for topical use
D01A E13
Selenium sulfide
D01A E15
D01A E16
g/ml/cc
g/ml/cc
g/ml/cc
Terbinafine
g/ml/cc
Amorolfine
g/ml/cc
2006
Public
-
Private
0.0002
Total
0.0002
Public
0.0051
Private
1.7155
Total
1.7207
Public
-
Private
0.0229
Total
0.0229
Public
0.032
Private
0.0388
Total
0.0707
Public
-
Private
0.0277
Total
0.0277
Public
0.0001
Private
<0.0001
Total
0.0002
Table 11.2: Use of Dermatological by Drug Class and Agents, in DDD/1000 population/day 2006
ATC
2006
D01B A
Antifungals for systemic use
D01B A01
D01B A02
Griseofulvin
Terbinafine
Public
0.1525
Private
0.231
Total
0.3835
Public
0.0048
Private
0.0081
Total
0.0128
Table 11.3: Use of Dermatological by Drug Class and Agents, in total dosage/1000 population/day
ATC
D05A D
Psoralens for topical use
Unit
D05A D02
Methoxsalen
g/ml/cc
D05A X
Other antipsoriatics for topical use
D05A X02
Calcipotriol
D05A X52
g/ml/cc
Calcipotriol, combinations
g/ml/cc
45
2006
Public
0.0003
Private
0.0001
Total
0.0004
Public
0.0465
Private
0.0124
Total
0.0589
Public
-
Private
0.0064
Total
0.0064
CHAPTER 11
ATC
2006
D05B A
Psoralens for systemic use
D05B A02
Methoxsalen
D05B B
Retinoids for treatment of psoriasis
D05B B01
Etretinate
D05B B02
Acitretin
Public
0.0012
Private
0.0007
Total
0.002
Public
-
Private
-
Total
-
Public
0.006
Private
0.0004
Total
0.0064
ATC
D06A A
Tetracycline and derivatives
Unit
D06A A04
Tetracy cline
g/ml/cc
D06A X
Other antibiotics for topical use
D06A X01
Fusidic acid
D06A X04
D06A X07
D06A X09
g/ml/cc
Neomycin
g/ml/cc
Gentamicin
g/ml/cc
Mupirocin
g/ml/cc
2006
Public
-
Private
0.0041
Total
0.0041
Public
0.0303
Private
0.2682
Total
0.2985
Public
0.8132
Private
0.2511
Total
1.0644
Public
0.0116
Private
0.2203
Total
0.2319
Public
0.0255
Private
0.0896
Total
0.1151
ATC
D06B A
Sulfonamides
Unit
D06B A01
Silver sulfadiazine
g/ml/cc
D06B B
Antivirals
D06B B02
Tromantadine
D06B A
Sulfonamides
D06B B03
Aciclovir
g/ml/cc
g/ml/cc
46
2006
Public
0.1782
Private
0.0919
Total
0.2701
Public
-
Private
0.0054
Total
0.0054
Public
0.002
Private
0.0588
Total
0.0608
CHAPTER 11
ATC
Unit
D06B B10
Imiquimod
g/ml/cc
D06B X
Other chemotherapeutics
D06B X01
Metronidazole
g/ml/cc
2006
Public
-
Private
0.0003
Total
0.0003
Public
-
Private
0.0113
Total
0.0113
ATC
D07A A
Corticosteroids, weak (group I)
Unit
D07A A02
Hydrocortisone
g/ml/cc
D07A B
Corticosteroids, moderately potent (group II)
D07A B01
Clobetasone
D07A B03
D07A B09
D07A B10
D07A B19
Flumetasone
g/ml/cc
Alclometasone
g/ml/cc
Dexamethasone
Corticosteroids, potent (group III)
D07A C01
Betamethasone
g/ml/cc
g/ml/cc
Fluocinolone acetonide
D07A C
Corticosteroids, potent (group III)
D07A C13
Mometasone
D07A C16
g/ml/cc
Triamcinolone
D07A C
D07A C04
g/ml/cc
g/ml/cc
g/ml/cc
Hydrocortisone aceponate
g/ml/cc
47
2006
Public
1.0887
Private
0.6583
Total
1.747
Public
0.0491
Private
0.0622
Total
0.1113
Public
0.0002
Private
-
Total
0.0002
Public
0.0013
Private
0.085
Total
0.0863
Public
-
Private
0.0001
Total
0.0001
Public
-
Private
0.0005
Total
0.0005
Public
0.8813
Private
1.3885
Total
2.2698
Public
-
Private
0.0276
Total
0.0276
Public
0.0168
Private
0.0951
Total
0.1119
Public
0.0005
Private
0.0083
Total
0.0088
CHAPTER 11
ATC
Unit
D07A C17
Fluticasone
g/ml/cc
D07A D
Corticosteroids, very potent (group IV)
D07A D01
Clobetasol
g/ml/cc
2006
Public
-
Private
0.0182
Total
0.0182
Public
0.0583
Private
0.5533
Total
0.6116
ATC
D07C A
Unit
Corticosteroids, weak, combinations with antibiotics
D07C A01
Hydrocortisone and antibiotics
D07C A03
g/ml/cc
Prednisolone and antibiotics
g/ml/cc
2006
Public
0.0573
Private
0.0407
Total
0.0981
Public
-
Private
0.0006
Total
0.0006
D07C B
Corticosteroids, moderately potent, combinations with antibiotics
D07C B01
Triamcinolone and antibiotics
D07C B04
g/ml/cc
Dexamethasone and antibiotics
g/ml/cc
D07C C
Corticosteroids, potent, combinations with antibiotics
D07C C01
Betamethasone and antibiotics
D07C C02
D07C D01
g/ml/cc
Fluocinolone acetonide and antibiotics
g/ml/cc
Clobetasol and antibiotics
g/ml/cc
Public
-
Private
0.049
Total
0.049
Public
-
Private
0.0015
Total
0.0015
Public
0.0198
Private
0.6038
Total
0.6235
Public
-
Private
0.0016
Total
0.0016
Public
-
Private
0.0013
Total
0.0013
ATC
D07X A
Corticosteroids, weak, other combinations
Unit
D07X A01
Hydrocortisone
g/ml/cc
Public
Private
Total
0.0313
0.0313
D07X C
Corticosteroids, potent, other combinations
D07X C01
Betamethasone
g/ml/cc
Public
Private
Total
0.004
0.1847
0.1887
48
2006
CHAPTER 11
ATC
D10A D
Retinoids for topical use in acne
Unit
D10A D01
Tretinoin
g/ml/cc
D10A D03
Adapalene
g/ml/cc
D10A D04
Isotretinoin
g/ml/cc
D10A E01
Benzoyl peroxide
g/ml/cc
D10A F
Antiinfectives for treatment of acne
D10A F01
Clindamycin
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0358
0.035
0.0708
0.0002
0.0357
0.0359
0.0031
0.00 31
0.0002
0.0002
g/ml/cc
Public
Private
Total
0.0002
0.0894
0.0896
Public
Private
Total
Public
Private
Total
0.0384
0.0384
0.0029
0.0029
Public
Private
Total
0.0007
0.012
0.0128
D10A F
Antiinfectives for treatment of acne
D10A F02
Erythromycin
g/ml/cc
D10A F52
Erythromycin, combinations
g/ml/cc
D10A X
Other anti-acne preparations for topical use
D10A X03
Azelaic acid
2006
g/ml/cc
ATC
D10B A
Retinoids for treatment of acne
D10B A0 1
Isotretinoin
2006
Public
Private
Total
0.01
0.0073
0.0173
Table 11.13: Use of Dermatological by Drug Class and Agents, in total dosage/1000population/day 2006
ATC
D11A C
Medicated shampoos
Unit
D11A C03
Selenium compounds
g/ml/cc
Public
Private
Total
0.0604
0.1091
0.1695
D11A X
Other dermatologicals
D11A X01
Minoxidil
g/ml/cc
D11A X10
Finasteride
mg
Public
Private
Total
Public
Private
Total
0.0231
0.0231
0.0012
0.0989
0.1001
49
2006
CHAPTER 11
ATC
Unit
D11A X11
Hydroquinone
g/ml/cc
D11A X14
Tacrolimus
g/ml/cc
D11A X
Other dermatologicals
D11A X15
Pimecrolimus
g/ml/cc
2006
Public
Private
Total
Public
Private
Total
<0.0001
0.0119
0.012
0.0005
0.0098
0.0103
Public
Private
Total
<0.0001
0.0019
0.002
References:
1. Rajesh B et al. Factors affecting prescription of ultra-high potency topical corticosteroids in skin
disease: an analysis of US national practice data Journal of Drugs of Dermatology, Nov.-Dec. 2005.
2. MA Al-Dhalimi and, N. Aljawahiry. Misuse of topical corticosteroids: a clinical study in an Iraqi
hospital Eastern Mediterranean Health Journal Volume 12 No 6 November 2006 Griffiths WAD, Wilkinson
JD. Topical therapy. In: Champion RH et al. Textbook of dermatology, vol. 4. 6th ed. Oxford, Blackwell
Science, 1998:3547-52.
3. Sulzberger MB, Witten VH. The effect of topically applied compound F in selected dermatoses. Journal of
investigative dermatology, 1952, 19(2):101-2.
4. Lagos B, Maibach H. Frequency of application of topical corticosteroids: an overview. British journal of
dermatology, 1998, 139(5):763-6.
5. Brodkin RH, Janniger CK. The artful use of topical steroids. Cutis, 1998, 61(3):125-6.
6. Keane FM et al. Unregulated use of clobetasol propionate. British journal of dermatology, 2001,
144(5):1095-6.
7. Fleischer AB Jr, Ford PG. How to prevent side-effects of topical corticosteroids. Skin and aging, 1998,
February: 54-65.
8. Mahe A et al. Skin diseases associated with the cosmetic use of bleaching products in women from
Dakar, Senegal. British journal of dermatology, 2003, 148(3):493-500. Arnold J, Anthonioz P, Marchand
JP. Depigmenting action of corticosteroids. Dermatologica, 1975, 151(5):274-80.
9. Del Giudice P, Pinier Y. The widespread use of skin lightening creams in Senegal: a persistent health
problem in West Africa. International journal of dermatology, 2002, 41(2):69-72.
10. Hammarstrom et al. Pharmaceutical care for patients with skin diseases: a campaign year at Swedish
pharmacies. Journal of Clinical Pharmacy and Therapeutics, 1995, 20(6):327-334.
50
CHAPTER 12: USE OF GYNAECOLOGICALS,
SEX HORMONES AND HORMONAL CONTRACEPTIVES
Edited by:
Muralitharan G1, Tan AL2
1. Ampang Hospital, 2. Kuala Lumpur Hospital
There has been very little review on the use of gynaecological, hormone and hormonal contraceptive drugs
in Malaysian literature. Obstetrics and Gynaecology have altered their pharmacotherapeutic usage in recent
times. This is due to various factors. Firstly, what was thought to be first line management is currently
not effective therapeutically and has therefore been abandoned and newer drugs introduced. Secondly, newer
therapies have been introduced for common Obstetric and Gynaecological problems which are not addressed
in Table 12.1. Thirdly, hormonal therapies have changed with newer hormonal drugs where the hormones
are more closely associated with the biochemical nature of natural hormones.
In the management of preterm labour, the drug of choice as a tocolytic agent has changed recently
to ritodrine. However there is level A evidence that Atosiban and Nifedipine appear to be preferable as they
have fewer adverse effects and comparable effectiveness. [1] These drugs will need to be looked into in
future reviews. Antenatal corticosteroid therapy is an established evidence based therapy which has been
associated with reduction in respiratory distress syndrome of the newborn. [2] Corticosteroids for this indication
have also not been addressed in Table 12.1. Similarly, the diagnosis of preterm rupture of membranes
is often difficult to ascertain. There are various new tools that are available that have not been evaluated
in Malaysia and are therefore not widely used. Amniosure, a device that is FDA approved and which claims
sensitivity and specificity of more than 90% will need to be evaluated for usage in Malaysia. Actin Prom and
Actin Partus, devices that are widely used in first world countries in the diagnosis of preterm labour and
labour need to be evaluated in future for use in Malaysia.
In the management of hypertensive disease complicating pregnancy and eclampsia, the use of Magnesium
Sulphate is now an integral component. [3] This needs to be addressed in future reviews of this nature.
Similarly thoromboprophylactic drugs both low molecular weight heparin and conventional heparin is now
widely utilised in Obstetric and Gynaecological practice. They need to be evaluated in future undertakings of this
nature.
Metformin therapy is now encouraged in the management of polycystic ovarian syndrome. [4] This needs
to be addressed in Chapter 12. Similarly, pelvic inflammatory disease is an increasing problem in the
community today. Chlamydia is an organism associated with pelvic inflammatory disease and Azithromycin
is the drug of choice. Similarly, with the current increase in assisted reproductive techniques, the use of
ovulatory drugs ranging from GnRH analogues and purified FSH derivatives to conventional therapy such
as Clomiphene Citrate and Tamoxifen need to be addressed in future reviews. Surgical management
of subfertile patients is now supplemented with the use of substances which aid in preventing adhesions which
is an important cause of subfertility. Drug therapy for the management of endometriosis and subfertility
is now closely associated and drugs used for the first condition are often supplemented with drugs for
the subfertility. [5]
Review of Table 12.2.2 reveals that there are drugs where there is a disparity in its usage in the public and
private sector. The disparity is largely in the use of drugs which are expensive. There is also evidence that
synthetic hormonal therapy and selective estrogen receptor modulators for menopausal women is underutilised
within the public sector.
In conclusion, there is a need to relook at drugs categorised under gynaecological and hormonal usage.
A lot of the drugs are now not commonly used by practicing gynaecologists and have been replaced by
newer drugs. The next review will need to update the use of these drugs and will need to look at medical devices
that are now part of daily Obstetrics and Gynaecology practice.
51
Table 12.1: Use of Gynaecologicals, Sex Hormones and Hormonal Contraceptives, in DDD/1000
population/day 2006
ATC
Drug Class
2006
G01
G02
G03
GYNECOLOGICAL ANTIINFECTIVES AND ANTISEPTICS
OTHER GYNECOLOGICALS
SEX HORMONES AND MODULATORS OF THE GENITAL SYSTEM
0.2119
0.0947
10.7433
Table 12.2.1: Use of Gynaecologicals, Sex Hormones and Hormonal Contraceptives by Drug Class, in
DDD/1000 population/day 2006
ATC
2006
G01A
G01A A
G01A F
G02A
G02A B
G02A D
G02C
G02C A
G02C B
G0 2C X
G03A
G03A A
G03A B
G03A C
G03B
G03B A
G03B B
G03C
G03C A
G03D
G03D A
G03D B
G03D C
G03F
G03F A
G03F B
G03G
G03G A
G03G B
G03H
G03H A
G03H B
G03X
G03X A
G03X C
ANTIINFECTIVES AND ANTISEPTICS, EXCL. COMBINATIONS WITH
CORTICOSTEROIDS
Antibiotics
Imidazole derivatives
OXYTOCICS
Ergot alkaloids
Prostaglandins
OTHER GYNECOLOGICALS
Sympathomimetics, labour repressants
Prolactine inhibitors
Other gynecologicals
HORMONAL CONTRACEPTIVES FOR SYSTEMIC USE
Progestogens and estrogens, fixed combinations
Progestogens and estrogens, sequential preparations
Progestogens
ANDROGENS
3-oxoandrosten (4) derivatives
5-androstanon (3) derivatives
ESTROGENS
Natural and semisynthetic estrogens, plain
PROGESTOGENS
Pregnen (4) derivatives
Pregnadien derivatives
Estren derivatives
PROGESTOGENS AND ESTROGENS IN COMBINATION
GONADOTROPINS AND OTHER OVULATION STIMULANTS
Gonadotropins
Ovulation stimulants, synthetic
ANTIANDROGENS
Antiandrogens, plain
Antiandrogens and estrogens
OTHER SEX HORMONES AND MODULATORS OF THE GENITAL SYSTEM
Antigonadotropins and similar agents
Selective estrogen receptor modulators
52
0.2119
0.0648
0.147
0.0515
0.0059
0.0457
0.0431
0.0218
0.0213
<0.0001
8.7254
3.9443
0.0388
4.7423
0.0267
0.0245
0.0022
0.1336
0.1336
1.0514
0.367
0.1996
0.4848
0.1935
0.0794
0.1141
0.3619
0.0342
0.3277
0.0964
0.013
0.0834
0.1544
0.0251
0.1293
Table 12.2.2: Use of Gynaecologicals, Sex Hormones and Hormonal Contraceptives by Drug Class and
Agents, in DDD/1000 population/day 2006
ATC
2006
G01A A
G01A A01
Antibiotics
Nystatin
G01A A03
Amphotericin B
G01A A10
Clindamycin
G01A F
G01A F01
Metronidazole
G01A F02
Clotrimazole
G01A F04
Miconazole
G01A F05
Econazole
G01A F08
Tioconazole
G01A F11
Ketoconazole
G02A B
G02A B01
Ergot alkaloids
Methylergometrine
G02A B03
Ergometrine
G03D C02
Norethisterone
G03D C05
Tibolone
G03F A
G03F A01
Norethisterone and estrogen
G03F A12
Medroxyprogesterone and estrogen
53
Public
Private
Total
Public
Private
Total
Public
Priva te
Total
0.0596
0.004
0.0636
0.0012
0.0012
<0.0001
<0.0001
Public
Private
Total
Public
Private
Total
Public
Private
Tota l
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0539
0.0003
0.0543
0.0216
0.0579
0.0795
0.0035
0.0035
0.0069
0.0069
0.0024
0.0024
0.0004
0.0004
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0025
0.0025
0.003
0.0004
0.0034
0.0223
0.2787
0.301
0.1063
0.0705
0.1768
Public
Private
Total
Public
Private
Total
0.0135
0.0183
0.0318
0.0279
0.0023
0.0302
ATC
G03F A14
Dydrogesterone and estrogen
2006
G03F B
G03F B01
Norgestrel and estrogen
G03F B05
Norethisterone and estrogen
G03F B06
Medroxyprogesterone and estrogen
G03F B07
Medrogestone and estrogen
G03F B08
Dydrogesterone and estrogen
G03G A
G03G A01
Gonadotropins
Chorionic gonadotrophin
G03G A02
Human menopausal gonadotrophin
G03G A05
Follitropin alfa
G03G A06
Follitropin beta
G03G A07
Lutropin alfa
G03G A08
Choriogonadotropin alfa
G03G B
G03G B02
Ovulation stimulants, synthetic
Clomifene
G03H A
G03H A01
Antiandrogens, plain
Cyproterone
G03H B
G03H B0 1
Antiandrogens and estrogens
Cyproterone and estrogen
54
Public
Private
Total
0.0103
0.007
0.0173
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0709
0.0155
0.0864
<0.0001
0.0014
0.0014
0.0244
0.0003
0.0247
0.0006
0.0006
0.001
0.001
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0122
0.0183
0.0305
0.0003
0.0003
0.0009
0.0008
0.0018
0.0007
0.0009
0.0016
<0.0001
<0.0001
<0.0001
<0.0001
Public
Private
Total
0.1178
0.2098
0.3277
Public
Private
Total
0.0111
0.0019
0.013
Public
Private
Total
0.0116
0.0718
0.0834
ATC
G03X A
G03X A01
Antigonadotropins and similar agents
Danazol
G03X A02
Gestrinone
G03X C
G03X C01
Raloxifene
2006
Public
Private
Total
Public
Private
Total
0.0156
0.008
0.0237
0.0012
0.0003
0.0014
Public
Private
Total
0.0646
0.0647
0.1293
References:
1. Royal College of Obstetricians and Gynaecologists. Tocolytic Drugs For Women in Preterm Labour. Clinical
Guideline No. 1 (B) October 2002.
2. Royal College of Obstetricians and Gynaecologists. Antenatal Corticosteroids To Prevent Respiratory
Distress Syndrom. Guideline No. 7 Revised February 2004.
3. Royal College of Obstetricians and Gynaecologists. The Management of Severe Pre-Eclampsia/Eclampsia.
Guideline No. 10 (A) March 2006.
4. Royal College of Obstetricians and Gynaecologists. Long-Term Consequences of Polycystic Ovary
Syndrome. Green-top Guideline No. 33 December 2007.
5. Royal College of Obstetricians and Gynaecologists. The Investigation and Management of Endometriosis.
Green-top Guideline No. 24 October 2006.
55
CHAPTER 13
USE OF UROLOGICALS
Edited by:
Malek R1, Lei CM2, Subaratnam S1, Syarihan S1
1. Selayang Hospital 2. Normah Hospital, Kuching
Although urology started as a surgical specialty, medicines play an expanding role in the management of
urological disease.
Medicines in urology may be discussed under the following drug class:
(a) Drugs used for overactive bladder, OAB: The oldest drug is Flavoxate, with rather non specific and weak
anti-cholinergic action. The anti-cholinergic of choice is currently Tolterodine, reflected in its increased
usage. However, there are newer anti-cholinergics with less side effects of dry mouth. When the newer
agents are duly registered, it is likely to increase in usage, as seen in other countries.
(b) Drugs used in erectile dysfunction: The oral prostagladin type 5 inhibitors, namely Sildenafil, Tadalafil and
Vardenafil are introduced at different stages in Malaysia. It is therefore not unexpected the earlier drug,
namely, Sildenafil has a bigger usage. Experience in other countries showed that the 3 drugs have almost an
equal share.
Alprostadil is actually an injectable although put in the same group. The usage is reported as very low.
Nevertheless, this has more or less replaced Papaverine as the first line intracorporeal injection for penile
erection. Alprostadil have a small but definite role in the treatment of erectile dysfunction.
(c) Alpha-adrenoreceptor antagonists: There are 3 main drugs in this group used for relief of bladder outlet
obstruction. Only the extended release (XL) form of Alfuzosin is available. For Doxazosin, both the extended
release (XL) as well as the rapid release lower dosage is available. For Terazosin, only the rapid release
incremental dosages (1, 2, 5 mg) are available. It is likely that the drug usage reported refers to the optimal
dosage and not the starting dosage of this alpha-adrenoreceptor antagonist.
(d) 5-alpha reductase inhibitors: There are currently 2 drugs in this class, namely, Finasteride and Dutasteride.
Finasteride has been in use for more than 10 years and currently, the generic forms are available. Therefore,
it is not surprising that usage of Finasteride is more than that of Dutasteride.
(e) Gonadotrophin releasing hormone analogues: In urology, these drugs are used to inhibit the production
of testosterone by the testes, as a treatment for advanced prostate cancer. This includes Buserelin,
Leuprorelin, Goserelin and Triptorelin. Again, they are short acting as well as depot versions (with
action ranging from 3 to 12 months). They are also used by the gynaecologists and the total usage probably
covers both usages.
(f) Anti-estrogens: These include Flutamide, Bicalutamide and Cyproterone Acetate. For some patients with
prostate cancer, anti-androgens are added onto the gonadotrophin release hormone analogues for maximal
androgen blockage (MAB). This is to block the action of hormones from the adrenal glands.
(g) Selective immunosuppressive agents for metastatic kidney cancer: This new group of drugs includes
Etanercept, Infliximab, Leflunomide, Efalizumab. These are new drugs which have shown some efficacy
for metastatic renal cancer. They are often used by the urologists together with the medical oncologists.
In view of the high cost, it is probable that the reported usage from the present survey is an underestimate
as they are likely to be used in the private hospitals.
(h) Testosterone: Testosterone is increasing used in the field of men’s health. A recent survey showed that
there is a 20% incidence of testosterone deficient syndrome in patients with metabolic syndrome. Again,
these drugs are likely to be given by private specialists.
57
CHAPTER 13
USE OF UROLOGICALS
(i) Anti-diuretic hormone: The commercial preparation of this is Desmopressin (Minirin). It is used mainly
to treat nocturnal polyuria which is seen in paediatric patients with enuresis and in some elderly men.
Table 13.1: Use of Urological, in DDD/1000 population/day 2006
ATC
2006
G04
UROLOGICALS
0.7232
Table 13.2.1: Use of Urological by Drug Class, in DDD/1000 population/day 2006
ATC
2006
G04B
G04C
OTHER UROLOGICALS, INCL. ANTISPASMODICS
DRUGS USED IN BENIGN PROSTATIC HYPERTROPHY
0.2018
0.5214
Table 13.2.2: Use of Gynecological, Sex Hormones and Hormonal Contraceptives by Drug Class and
Agents, in DDD/1000 population/day 2006
ATC
G04B D
Urinary antispasmodics
2006
G04B D02
Flavoxate
G04B D04
Oxybutynin
G04B D07
Tolterodine
G04B E
Drugs used in erectile dysfunction
G04B E01
Alprostadil
G04B E03
Sildenafil
G04B E08
Tadalafil
G04B E09
Vardenafil
G04C A
Alpha-adrenoreceptor antagonists
G04C A01
Alfuzosin
G04C A03
Terazosin
C02CA04
Doxazosin
58
Public
Private
Total
Public
Private
Tota l
Public
Private
Total
0.0002
0.0149
0.0151
0.0029
0.0003
0.0032
0.0159
0.006
0.0219
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
<0.0001
<0.0001
<0.0001
0.0011
0.1173
0.1184
0.0023
0.0364
0.0387
0.0001
0.0044
0.0045
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.048
0.0506
0.0986
0.2885
0.0706
0.359
0.1764
0.0628
0.2393
CHAPTER 13
USE OF UROLOGICALS
ATC
G04C B
Testosterone-5-alpha reductase inhibitors
G04C B01
Finasteride
G04C B02
Dutasteride
2006
Public
Private
Total
Public
Private
Total
0.03
0.0039
0.0339
0.0151
0.0148
0.0299
Table 13.2.3: Use of Urologicals listed in other chapters, Gonadotropin releasing hormone analogues,
anti-androgens, selective immunosuppressive agents, hormones
ATC
L02A E
Gonadotropin releasing hormone analogues
L02A E01
Buserelin
L02A E02
Leuprorelin
L02A E03
Goserelin
L02A E04
Triptorelin
L02B A
Anti-oxoandrosten (4) derivatives
L02B B01
Flutamide
L02B B03
Bicalutamide
Cyproterone acetate
L04A A
Selective immunosuppressive agents
L04A A11
Etanercept
L04A A12
Infliximab
L04A A13
Leflunomide
L04A A21
Efalizumab
59
2006
Public
Private
Total
Public
Private
Total
Public
Private
Tota l
Public
Private
Total
<0.0001
<0.0001
<0.0001
0.0024
0.0085
0.0109
0.0038
0.0021
0.0059
0.0011
0.0003
0.0015
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0018
0.0007
0.0025
0.0053
0.001
0.0063
0.0111
0.0919
0.3277
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
<0.0001
0.0009
0.001
<0.0001
0.0036
0.0037
0.0077
0.0069
0.0146
<0.0001
<0.0001
CHAPTER 13
USE OF UROLOGICALS
ATC
G03
G03B A
Sex Hormones
3-oxoandrosten (4) derivatives
2006
G03B A03
Testosterone
H01B
H01B A
POSTERIOR PITUITARY LOBE HORMONES
Vasopressin and analogues
H01B A02
Desmopressin
Public
Private
Total
0.0112
0.0133
0.0245
Public
Private
Total
0.0122
0.0037
0.0159
References:
1. “Prevalence of Symptomatic BPE Among Malaysian Men Aged 50 and Above Attending Screening During
Prostate Health Awareness Campaign”. GC Teh, RM Sahabudin, TC Lim, WL Chong, S Woo, M Mohan, A
Khairullah, P Abrams, Institute of Urology, Kuala Lumpur Hospital, Malaysia, Bristol Urological Institute,
Southmead Hospital, Bristol, UK.
2. “Impotence Clinic in a Developing Country”. CCM Lei, V Manivannan, PKK Mah, PEP. Ng, A Khairullah
International J Impotence Research (1994) 6, Suppl. 1, P113.
3. “Asian Sildenafil Efficacy and Safety Study (Assess-1): a double-blind, placebo-controlled, flexible-dose
study of oral Sildenafil in Malaysian, Singaporean, and Filipino men with erectile dysfunction”. Tan HM,
Lei CCM, Mendoza JB et al. Urology 56 (4): 635-640, 2000.
4. “Efficacy and tolerability of Vardenafil, an oral phosphodiesterase type-5 inhibitor, in Asian men with
erectile dysfunction”. HM Tan, CM Chin, CB Chua, E Gatchalian, A Kongkanand, CCM Lei, FC Ng, K
Ratana-Olarn, D Serrano, A Taher, I Tambi, A Tantiwong, M Wong, AWC Yip , Asian J Andrology 2008;
10(3) 495-502.
60
CHAPTER 14
USE OF MEDICINES FOR ENDOCRINE DISORDERS
Edited by:
Zanariah H1
Oiyammal C2, Nazri D3
1. Putrajaya Hospital, 2. Sungai Bakap Hospital, 3. Tampin Health Clinic
The total consumption of endocrine related drugs in Malaysia for 2006 was 2.11DDD/1000 population/day.
Among the endocrine related drugs, the most utilised were thyroid-related drugs (94.4%), followed by pituitary
and hypothalamic hormone and analogues (5.3%) and drugs for calcium homeostasis (0.3%). In comparison, there
was very much higher utilisation of endocrine-related drugs in Australia for 2006 at a level of 17.0DDD/1000
population/day, with a similar trend, the most common being thyroid related drugs (98.1%), followed by pituitary
and hypothalamic hormone and analogues (1.87%) and drugs for calcium homeostasis (0.01%).
Thyroid therapy consisted of drugs utilised for hypothyroidism and hyperthyroidism. For treatment of
hypothyroidism, thyroid hormone replacement was almost entirely (99.99%) with Levothyroxine (T4)
sodium at 0.93DDD/1000 population/day in comparison to a much higher consumption in Australia at
15.87DDD/1000 population/day. Use of Liothyronine (T3) Sodium in Australia was minimal at 0.05DDD/1000
population/day, consisting 0.3% of thyroid hormone replacement therapy. This thyroid hormone formulation
was hardly utilised in Malaysia. Thyroid hormone consumption with Levothyroxine Sodium was more than
10-fold higher in Australia compared to Malaysia suggesting a higher prevalence of hypothyroidism,
possibly related to better screening, diagnosis and treatment among the elderly population.
For treatment of hyperthyroidism, consumption of anti-thyroid preparations were higher in Malaysia
(1.06DDD/1000 population/day) compared to Australia (0.77DDD/1000 population/day) in 2006. The most
utilised anti-thyroid preparation in Malaysia was Carbimazole (84.2%) followed by Propylthiouracil (15.8%).
The higher anti-thyroid drug utilisation in Malaysia is probably related to a preference for first-line medical
therapy in hyperthyroidism, often continued over the long-term as radioactive iodine facilities for treatment
of hyperthyroidism is currently still limited in accessibility and usually placed as second-line therapy. The
higher consumption of carbimazole is most probably due to the convenience of daily dosing as opposed to
divided dosing for Propylthiouracil.
Drug utilisation of pituitary and hypothalamic hormones and analogues were generally low in Malaysia
at 0.11DDD/1000 population/day and similarly in Australia at 0.32DDD/1000 population/day.
Consumption of drugs for calcium homeostasis was also low in Malaysia at 0.006DDD/1000 population/day
and Australia at 0.001DDD/1000 population/day. These drugs include parathyroid hormone and analogues
such as Teriparatide (0.0006DDD/1000 population/day) and Calcitonin preparations (0.006DDD/1000
population/day). There was a higher consumption of Calcitonin preparations in Malaysia compared to Australia
(0.001DDD/1000 population/ day).
Table 14.1: Use of Drug for Endocrine Disorders, in DDD/1000 population/day 2006
ATC
2006
H01
PIT UITARY AND HYPOTHALAMIC HORMONES AND ANALOGUES
THYROID THERAPY
PANCREATIC HORMONES
CALCIUM HOMEOSTASIS
0.1128
H03
H04
H05
61
1.9964
<0.0001
0.0064
CHAPTER 14
Table 14.2: Use of Pituitary and Hypothalamic Hormones and Analogues by Drug Class, in DDD/1000
population/day 2006
ATC
2006
H01A
H01A A
H01A B
H01A C
H01B
H01B A
H01B B
H01C
H01C B
H01C C
ANTERIOR PITUITARY LOBE HORMONES AND ANALOGUES
ACTH
Thyrotropin
Somatropin and somatropin agonists
POSTERIOR PITUITARY LOBE HORMONES
Vaso pressin and analogues
Oxytocin and analogues
HYPOTHALAMIC HORMONES
Antigrowth hormone
Anti -gonadotropin-releasing hormones
0.009
0.0045
<0.0001
0.0045
0.1025
0.0191
0.0834
0.0013
0.0012
<0.0001
Table 14.3.1: Use of Thyroid Therapy by Drug Class, in DDD/1000 population/day 2006
ATC
H03A
H03A A
H03B
H03B A
H03B B
THYROID PREPARATIONS
Thyroid hormones
ANTITHYROID PREPARATIONS
Thiouracils
Sulfur-containing imidazole derivatives
2006
0.9344
0.9344
1.062
0.1679
0.8941
Table 14.3.2: Use of Thyroid Therapy by Drug Class and Agents, in DDD/1000 population/day 2006
ATC
2006
H03A A
Thyroid hormones
H03A A01
Levothyroxine sodium
H03A A02
Liothyronine sodium
H03B A
Thiouracils
H03B A02
Propylthiouracil
H03B B
Sulfur-containing imidazole derivatives
H03B B01
Carbimazole
Public
Private
Total
Public
Private
Total
0.7504
0.1839
0.9343
<0.0001
<0.0001
<0.0001
Public
Private
Total
0.0872
0.0808
0.1679
Public
Private
Total
0.611
0.2831
0.8941
Table 14.4.1: Use of Calcium Homeostasis by Drug Class, in DDD/1000 population/day 2006
ATC
H05A
H05A A
H05B
H05B A
PARATHYROID HORMONES AND ANALOGUES
Parathyroid hormones and analogues
ANTI-PARATHYROID AGENTS
Calcitonin preparations
62
2006
0.0006
0.0006
0.0058
0.0058
CHAPTER 14
Table 14.4.2: Use of Thyroid Therapy by Drug Class, in DDD/1000 population/day 2006
ATC
H05A A
Parathyroid hormones and analogues
H05A A02
Teriparatide
H05B A
H05B A01
Calcitonin (salmon synthetic)
2006
Public
Private
Total
<0.0001
0.0005
0.0006
Public
Private
Total
0.0044
0.0013
0.0058
References:
1. Australian Statistics on Medicine 2006. Commonwealth Department of Health and Ageing Australia.
63
CHAPTER 15
USE OF ANTIINFECTIVES
Edited by:
Masrahayu M1, Ngau YY2, Thong KS3, Sameerah SAR4, Jacqueline L5, Rahela AK4
1. Selayang Hospital, 2. Kuala Lumpur Hospital, 3. Raja Permaisuri Bainun Hospital, Ipoh, 4. Pharmaceutical
Services Division, MOH, 5. Tawau Hospital
The most commonly prescribed antiinfectives in 2006 were Antibacterials (8.94DDD/1000population/day),
followed by Antimycobacterials (1.10), Antivirals for systemic use (0.56), Antimycotic for systemic use (0.33)
and Antimalarials (0.08). Among the classes of antibacterials prescribed, Penicillins were most commonly
used constituting 47.1% of total use of antibacterials, followed by Macrolides, Lincosamides and
Streptogramins group (15.5%), Tetracyclines (12.3%), other Beta-lactam Antibacterials (10.7%), Sulfonamide
and Trimethoprim (8.6%), Quinolones (4.3%), other antibacterial (0.85%), Aminoglycoside (0.51%) and
Amphenicol (0.05%).
Among the penicillin class, penicillins with extended spectrum were most commonly prescribed (2.52DDD/1000
population/day) constituting 59.7% of total use. Beta-lactamase resistant penicillins, penicillin combinations
with beta-lactamase inhibitors and beta-lactamase sensitive penicillin constituted 19.2%, 15.9% and 5.2% of
penicillin use respectively. Results also showed that Amoxicillin was the highest antibiotic used in the penicillin
group for both public (0.7) and private (1.4) sectors.
Cephalosporins constituted 8.8% of total antibacterial use. The first and second generation cephalosporins
were the most used and use between both groups were comparable with 0.42 and 0.43DDD/1000
population/day respectively. The first-generation group constituted 44.6% of total cephalosporin use followed
by the second-generation group (45.2%), the 3rd generation (8.1%) and 4th generation (2.0%). Cefalexin
(0.37DDD/1000 population/day) was the most widely prescribed cephalosporin followed by cefuroxime (0.36)
and cefadroxil (0.05). Ceftriaxone was the most widely prescribed third-generation cephalosporin with
0.04DDD/1000 population/day.
The Carbapenems constituted 0.17% of total antibacterial use. Meropenem use (44.3%) was near equal
proportion in use with imipenem (43.8%). Ertapenem was the least prescribed carbapenem but its consumption
was predominantly in the private sector.
Sulphonamides and trimethoprim constituted 8.6% of antibacterial use and the combination Sulfamethoxazole
and trimethoprim was the highest used in this group (66.2%). For Macrolides, erythromycin was most widely
prescribed (0.94), followed by clarithromycin (0.19) and roxithromycin (0.12). For tetracyclines, doxycycline
(0.92) was most commonly prescribed, followed by tetracycline (0.15) and minocycline (0.03). For quinolones,
ciprofloxacin (0.14) was the most commonly prescribed, followed by ofloxacin (0.11) and norfloxacin (0.08).
Vancomycin was the most frequently prescribed glycopeptide antibiotic, almost ten-fold higher than teicoplanin.
Vancomycin consumption was higher in the public sector.
Among the antifungals, ketoconazole (0.24DDD/1000 population/day) was the most frequently prescribed,
followed by itraconazole (0.05) and fluconazole (0.03). Amphotericin B was rarely prescribed and so was
flucytosine, caspofungin and voriconazole. Ketoconazole (95%) and fluconazole (58%) was more frequently
prescribed in the private sector, amphotericin B (93%) mainly by the public sector while itraconazole
consumption was almost equal in both the public and private sectors.
Among the anti-mycobacterials, isoniazid (0.46DDD/1000 population/day)) was the most frequently
prescribed followed by rifampicin (0.3), pyrazinamide (0.12) and ethambutol (0.11). Usage of these drugs was
predominantly in the public sector. Usage of second-line anti-mycobacterial drugs was relatively infrequent.
Aminoquinolones were the most commonly prescribed anti-protozoal drugs (0.06DDD/1000 population/day),
of which primaquine was the most frequently prescribed agent (52%) followed by hydroxychloroquine (28%).
For the antivirals, nucleoside and nucleotide reverse transcriptase inhibitors (0.18DDD/1000 population/day)
were the most commonly prescribed agents (36.4% of total drugs used), followed by neuraminidase
inhibitors (0.15). Oseltamivir (0.125) was the most commonly prescribed antiviral, followed by lamivudine (0.116)
65
CHAPTER 15
and aciclovir (0.047). While Oseltamivir was predominantly prescribed by the public sector, lamivudine was more
commonly used in the private sector.
Antibacterial use in Malaysia (8.94DDD/1000 population/day)) is lower when compared to the United
States (24.92), Europe (19.04) and British Columbia (17.9) [1,2]. It is however comparable to countries with
relatively lower antibiotic consumption such as Austria (12.5), Latvia (11.7) and the Netherlands (9.78).
Antibiotic use in Malaysia was also lower than Greece (31.4), France (28.97), Luxembourg (27.34),
Hungary (19.63) and Slovenia (17.1) [3]. The most frequently prescribed class of antibacterials in Malaysia was
penicillins (J01C) and this was also the case for the United States and Europe. However, consumption
of penicillins was twice as much in the United States (9.70) and Europe (8.71) as compared to Malaysia (4.21).
Among the penicillin subclasses, penicillins with extended spectrum (2.51) were the most frequently prescribed
in Malaysia, similar to the United States (5.68) and Europe (4.49) [2]. Amoxicillin was the most commonly
prescribed antibacterial agent in Malaysia (2.10) and this was also similar to the United States (5.59) and Europe
(4.26). However, amoxicillin consumption in Malaysia was lower than the lowest DDD in Europe, the
Netherlands (3.76).
The second most common antibacterial agent prescribed in Malaysia was erythromycin (0.94DDD/1000
population/day)) as compared to co-amoxiclav which was the second most commonly prescribed
antibacterial agent in the United States and Europe. The third most common antibacterial agent prescribed
in Malaysia was doxycycline (0.92), which was similar to United States and Europe. Erythromycin was the
most common macrolide prescribed in Malaysia while in the United States and Europe, azithromycin was
the more popular macrolide. Cloxacillin (0.8DDD/1000 population/day) was the fourth most common
antibacterial agent prescribed in Malaysia. For the fluroquinolone group, levofloxacin was most commonly
prescribed in the United States and Europe, while ciprofloxacin was the most commonly prescribed quinolone in
Malaysia.
The use of antimicrobial agents particularly its overuse and misuse, is the major driver of antimicrobial
resistance (4). Information on the trends and patterns of antibiotic consumption is essential to formulate control
measures on antibiotic prescribing, although this is mainly feasible in the public sector. The National
Antibiotic Guideline 2008 a publication of the Ministry of Health Malaysia will serve as an important tool
towards rational prescribing of antibiotics. Antimicrobial stewardship programs in concert with aggressive
infection control efforts represent the best chance for control of resistant pathogens. Stopping antibacterials when they
are not needed, switching to more narrow spectrum drug regimens, and optimal dosing using pharmacokinetic and
pharmacodynamic principles are critical (5, 6).
In conclusion, antibacterial agents were the most commonly prescribed antiinfective agent in Malaysia and
amoxicillin was the most frequently prescribed antibiotic. There were significant prescribing differences
between the government and private sectors, with the private sector consuming more beta-lactam/beta-lactamase
combinations, roxithromycin, clarythromycin and cefalexin.
Table 15.1: Use of Anti-Infectives, in DDD/1000 population/day 2006 and DD/population/year
ATC
2006
2006
(DDDs/population/ year)
J01
J02
J04
J05
P01B
ANTIBACTERIALS FOR SYSTEMIC USE
ANTIMYCOTICS FOR SYSTEMIC USE
ANTIMYCOBACTERIALS
ANTIVIRALS FOR SYSTEMIC USE
ANTIMALARIALS
8.9369
0.3253
1.099
0.5638
0.0807
3.262
0.1187
0.4011
0.2058
0.0295
66
CHAPTER 15
Table 15.2.1: Use of Anti-Bacterials by Drug Class, in DDD/1000 population/day 2006
ATC
2006
2006
(DDDs/population/year)
J01A
J01B
J01C
J01D
J01E
J01F
J01G
J01M
J01X
TETRACYCLINES
AMPHENICOLS
BETA -LACTAM ANTIBACTERIALS, PENICILLINS
OTHER BETA-LACTAM ANTIBACTERIALS
SULFONAMIDES AND TRIMETHOPRIM
MACROLIDES, LINCOSAMIDES AND
STREPTOGRAMINS
AMINOGLYCOSIDE ANTIBACTERIALS
QUINOLONE ANTIBACTERIALS
OTHER ANTIBACTERIALS
1.1032
0.0045
4.2079
0.9589
0.4027
0.0017
1.5359
0.35
0.7657
1.3867
0.2795
0.5062
0.046
0.3877
0.0762
0.0168
0.1415
0.0278
Table 15.2.2: Use of Anti-Bacterials by Drug Class and Agents, in DDD/1000 population/day 2006
ATC
J01A A
Tetracyclines
J01A A02
Doxycycline
J01A A06
Oxytetracycline
J01A A07
Tetracycline
J01A A08
Minocycline
J01B A
Amphenicols
J01B A01
Chloramphen icol
J01C A
Penicillins with extended spectrum
J01C A01
Ampicillin
J01C A04
Amoxicillin
J01C A06
Bacampicillin
J01C A12
Piperacillin
2006
J01C E
Beta-lactamase sensitive penicillins
J01C E01
Benzylpenicillin
2006
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.2688
0.6527
0.9215
<0.0001
<0.0001
<0.0001
0.0585
0.0885
0.147
0.0004
0.0343
0.0347
0.0981
0.2382
0.3363
<0.0001
<0.0001
<0.0001
0.0214
0.0323
0.0537
0.0001
0.0125
0.0127
Public
Private
Total
0.0027
0.0019
0.0045
0.001
0.0007
0.0017
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0692
0.0565
0.1257
0.698
1.4018
2.0998
0.2145
0.0648
0.2793
0.0002
0.0002
0.0252
0.0206
0.0459
0.2548
0.5117
0.7664
0.0783
0.0237
0.102
<0.0001
<0.0001
Public
Private
Total
0.0182
0.0013
0.0195
0.0067
0.0005
0.0071
67
CHAPTER 15
ATC
J01C E02
Phenoxymethylpenicillin
J01C E08
Benzathine benzylpenicillin
J01C E09
Procaine benzylpenicillin
2006
2006
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.1706
0.0173
0.188
0.0018
0.0004
0.0022
0.0077
0.0002
0.0079
0.0623
0.0063
0.0686
0.0007
0.0001
0.0008
0.0028
<0.0001
0.0029
Public
Private
Total
Public
Private
Total
0.6363
0.1638
0.8002
0.0014
0.0112
0.0126
0.2323
0.0598
0.2921
0.0005
0.0041
0.0046
J01C F
Beta-lactamase resistant penicillins
J01C F02
Cloxacillin
J01C F05
Flucloxacillin
J01C R
Combinations of penicillins, incl. beta-lactamase inhibitors
J01C R01
Ampicillin and enzyme inhibitor
J01C R02
Amoxicillin and enzyme
inhibitor
J01C R04
Sultamicillin
J01C R05
Piperacillin and enzyme
inhibitor
J01D B
First-generation cephalosporins
J01D B01
Cefalexin
J01D B04
Cefazolin
J01D B05
Cefadroxil
J01D B09
Cefradine
J01D C
Second-generation cephalosporins
J01D C02
Cefuroxime
J01D C04
Cefaclor
Publi c
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0181
0.0124
0.0306
0.1484
0.4491
0.5974
0.0113
0.0289
0.0402
0.003
0.0014
0.0044
0.0066
0.0045
0.0112
0.0542
0.1639
0.2181
0.0041
0.0105
0.0147
0.0011
0.0005
0.0016
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0607
0.306
0.3667
<0.0001
0.0031
0.0031
0.0489
0.0489
0.0008
0.0008
0.0222
0.1117
0.1339
<0.0001
0.0011
0.0011
0.0178
0.0178
0.0003
0.0003
Public
Private
Total
Public
Private
Total
0.1619
0.2013
0.3631
0.0019
0.0462
0.0481
0.0591
0.0735
0.1325
0.0007
0.0169
0.0176
68
CHAPTER 15
ATC
J01D C10
Cefprozil
J01D D
Third-generation cephalosporins
J01D D01
Cefotaxime
J01D D02
Ceftazidime
J01D D04
Ceftriaxone
J01D D12
Cefoperazone
J01D D14
Ceftibuten
J01D E
Fourth-generation cephalosporins
J01D E01
Cefepime
J01D H
Carbapenems
J01D H02
Meropenem
J01D H03
Ertapenem
J01D H51
Imipenem and enzyme inhibitor
J01E A
Trimethoprim and derivatives
J01E A01
Trimethoprim
J01E B04
Sulfapyridine
2006
2006
Public
Private
Total
0.0004
0.0135
0.014
0.0001
0.0049
0.0051
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.004
0.0005
0.0046
0.0078
0.0027
0.0104
0.0163
0.0221
0.0384
0.0091
0.0006
0.0098
0.0134
0.01 34
0.0015
0.0002
0.0017
0.0028
0.001
0.0038
0.0059
0.0081
0.014
0.0033
0.0002
0.0036
0.0049
0.0049
Public
Private
Total
0.0105
0.0086
0.0191
0.0038
0.0031
0.007
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0055
0.0027
0.0082
<0.0001
0.0021
0.0022
0.0058
0.0023
0.0081
0.002
0.001
0.003
<0.0001
0.0008
0.0008
0.0021
0.0008
0.0029
Public
Private
Total
Public
Private
Total
0.0178
0.0051
0.0229
0.2112
0.2112
0.0065
0.0018
0.0083
0.0771
0.0771
J01E E
Combinations of sulfonamides and trimethoprim, incl. derivatives
J01E E01
Sulfamethoxazole and
trimethoprim
J01E E02
Sulfadiazine and trimethoprim
Publi c
Private
Total
Public
Private
Total
69
0.2487
0.2585
0.5072
0.0245
0.0245
0.0908
0.0944
0.1851
0.0089
0.0089
CHAPTER 15
ATC
J01F A
Macrolides
J01F A01
Erythromycin
J01F A02
Spiramycin
J01F A06
Roxithromycin
J01F A09
Clarithromycin
J01F A10
Azithromycin
J01F F
Lincosamides
J01F F01
Clindamycin
J01F F 02
Lincomycin
J01G A
Streptomycins
J01G A01
Streptomycin
J01G B
Other aminoglycosides
J01G B03
Gentamicin
J01G B04
Kanamycin
J01G B06
Amikacin
J01G B07
Netilm icin
J01M A
Fluoroquinolones
J01M A01
Ofloxacin
J01M A02
Ciprofloxacin
J01M A03
Pefloxacin
2006
2006
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.5574
0.38 4
0.9414
<0.0001
0.0015
0.0015
0.1182
0.1182
0.0191
0.1745
0.1936
0.0119
0.0998
0.1117
0.2035
0.1401
0.3436
<0.0001
0.0005
0.0006
0.0431
0.0431
0.007
0.0637
0.0707
0.0044
0.0364
0.0408
Public
Private
Total
Public
Private
Total
0.0057
0.0082
0.0139
0.0064
0.0064
0.0021
0.003
0.0051
0.0023
0.0023
Public
Private
Total
0.0243
0.0007
0.025
0.0089
0.0003
0.0091
Publi c
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.006
0.0077
0.0136
0.0002
0.0004
0.0007
0.0032
0.0014
0.0046
0.0009
0.0012
0.0021
0.0022
0.0028
0.005
<0.0001
0.0002
0.0002
0.0012
0.0005
0.0017
0.0003
0.0005
0.0008
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.013
0.0935
0.1066
0.0226
0.1179
0.1405
0.0022
0.0065
0.0087
0.0047
0.0341
0.0389
0.0082
0.04 3
0.0513
0.0008
0.0024
0.0032
70
CHAPTER 15
ATC
J01M A06
Norfloxacin
J01M A12
Levofloxacin
J01M A14
Moxifloxacin
J01M A16
Gatifloxacin
J01M B
Other quinolones
J01M B02
Nalidixic acid
J01M B04
Pipemidic acid
J01M B07
Flumequine
J01X A
Glycopeptide antibacterials
J01X A01
Vancomycin
J01X A02
Teicoplanin
J01X B
Polymyxins
J01X B01
Colistin
J01X B02
Polymyxin B
J01X C
Steroid antibacterials
J01X C01
Fusidic acid
J01X D
J01X D01
Metronidazole
J01X D02
Tinidazole
2006
2006
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
<0.0001
0.0818
0.0818
0.001
0.0195
0.0205
0.0002
0.0163
0.0165
0.0003
0.0043
0.0046
<0.0001
0.0299
0.0299
0.0004
0.0071
0.0075
<0.0001
0.0059
0.006
0.0001
0.0016
0.0017
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0085
0.0085
<0.0001
<0.0001
0.0031
0.0031
<0.0001
<0.0001
Public
Private
Total
Public
Private
Total
0.0035
0.0013
0.0048
0.0002
0.0004
0.0005
0.0013
0.0005
0.0018
<0.0001
0.0001
0.0002
Public
Private
Total
Public
Private
Total
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
Public
Private
Total
0.0089
0.0016
0.013
0.0032
0.0006
0.0038
Public
Private
Total
Public
Private
Total
0.0358
0.0128
0.0486
-
0.0131
0.0047
0.0177
-
71
CHAPTER 15
ATC
J01X E
Nitrofuran derivatives
J01X E01
Nitrofurantoin
J01X X
Other antibacterials
J01X X01
Fosfomycin
J01X X04
Spectinomycin
J01X X08
Linezolid
2006
2006
Publ ic
Private
Total
0.0064
0.0022
0.0086
0.0023
0.0008
0.0031
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0016
0.0016
<0.0001
<0.0001
0.001
0.0004
0.0014
0.0006
0.0006
<0.0001
<0.0001
0.0004
0.0001
0.0005
Table 15.3.1: Use of Anti-Mycotics by Drug Class, in DDD/1000 population/day 2006
ATC
2006
2006
J02A A
J02A B
J02A C
J02A X
Antibiotics
Triazole derivatives
Other antimycotics for systemic use
0.0028
0.2352
0.0872
0.0001
0.001
0.0859
0.0318
<0.0001
Table 15.3.2: Use of Anti-Mycotics by Drug Class and Agents, in DDD/1000 population/day 2006
ATC
2006
2006
J02A A
Antibiotics
J02A A01
Amphotericin B
J02A B
J02A B02
Ketoconazole
J02A C
Triazole derivatives
J02A C01
Fluconazole
J02A C02
Itraconazole
J02A C03
Voriconazole
J02A X
Other antimycotics for systemic use
J02A X01
Flucytosine
J02A X04
Caspofungin
Public
Private
Total
0.0026
0.0002
0.0028
0.001
<0.0001
0.001
Public
Private
Total
0.0117
0.2235
0.2352
0.0043
0.0816
0.0859
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0146
0.0203
0.035
0.0227
0.0294
0.0521
0.0002
0.0002
0.0053
0.0074
0.0128
0.0083
0.0107
0.019
<0.0001
<0.0001
Public
Private
Total
Public
Private
Total
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.000
1
<0.0001
<0.0001
72
CHAPTER 15
Table 15.4.1: Use of Anti-Mycobacterials by Drug Class, in DDD/1000 population/day 2006
ATC
J04A B
Antibiotics
J04A B01
Cycloserine
J04A B02
Rifampicin
2006
2006
Public
Private
Total
Public
Private
Total
0.0016
0.0016
0.256
0.0228
0.2788
0.0006
0.0006
0.0934
0.0083
0.1018
Public
Private
Total
Public
Private
Total
0.4356
0.0242
0.4598
<0.0001
<0.0001
0.159
0.0088
0.1678
<0.0001
<0.0001
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.1084
0.0143
0.1226
0.0891
0.0174
0.1065
0.0143
0.0143
0.0065
0.0065
0.0001
0.0001
0.0395
0.0052
0.0448
0.0325
0.0064
0.0389
0.0052
0.0052
0.0024
0.0024
<0.0001
<0.0001
Public
Private
Total
Public
Private
Total
0.004
0.004
0.1047
<0.0001
0.1047
0.0015
0.0015
0.0382
<0.0001
0.0382
J04A C
Hydrazides
J04A C01
Isoniazid
J04A D03
Ethionamide
J04A K
Other drugs for treatment of tuberculosis
J04A K01
Pyrazinamide
J04A K02
Ethambutol
J04A M02
Rifampicin and isoniazid
J04A M05
Rifampicin, pyrazinamide
and isoniazid
J04A M06
Rifampicin, pyrazinamide,
ethambutol and isoniazid
J04B A
Drugs for treatment of lepra
J04B A01
Clofazimine
J04B A02
Dapsone
Table 15.5.1: Use of Anti-Malarials by Drug Class, in DDD/1000 population/day 2006
ATC
Drug Class
2006
2006
P01A
P01B A
P01B B
P01B C
P01B D
AGENTS AGAINST AMOEBIASIS AND OTHER
PRO TOZOAL DISEASES
Aminoquinolines
Biguanides
Methanolquinolines
Diaminopyrimidines
73
0.1992
0.0727
0.0648
<0.0001
0.0049
0.011
0.0236
<0.0001
0.0018
0.004
CHAPTER 15
Table 15.5.2: Use of Anti-Malarials by Drug Class and Agents, in DDD/1000 population/day 2006
ATC
P01A
2006
AGENTS AGAINST AMOEBIASIS AND OTHER PROTOZOAL DISEASES
P01A B01
Metronidazole
P01A B02
Tinidazole
P01B A
Aminoquinolines
P01B A01
Chloroquine
P01B A02
Hydroxychloroquine
P01B A03
Primaquine
P01B B
Biguanides
P01B B51
Proguanil, combinations
P01B C
Methanolquinolines
P01B C01
Quinine
P01B C02
Mefloquine
P01B D
Diaminopyrimidines
P01B D01
Pyrimethamine
P01B D51
Pyrimethamine, combinations
2006
Public
Private
Total
Public
Private
Total
0.1108
0.0839
0.1947
0.0045
0.0045
0.0404
0.0306
0.0711
0.0016
0.0016
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0082
0.0048
0.013
0.0158
0.0025
0.0183
0.031
0.0024
0.0334
0.003
0.0018
0.0048
0.0058
0.0009
0.0067
0.0113
0.0009
0.0122
Public
Private
Total
<0.0001
<0.0001
<0.0001
<0.0001
Public
Private
Total
Public
Private
Total
0.0035
0.0013
0.0048
<0.0001
<0.0001
0.0013
0.0005
0.0018
<0.0001
<0.0001
Public
Priva te
Total
Public
Private
Total
0.0002
<0.0001
0.0003
0.0091
0.0017
0.0108
<0.0001
<0.0001
0.0001
0.0033
0.0006
0.0039
Table 15.6.1: Use of Anti-Virals by Drug Class, in DDD/1000 population/day 2006
ATC
Drug Class
2006
2006
J05A B
Nucleosides and nucleotides excl. reverse
transcriptase inhibitors
Protease inhibitors
Nucleoside and nucleotide reverse
transcriptase inhibitors
Non-nucleoside reverse transcriptase
inhibitors
Neuraminidase inhibitors
0.0519
0.0189
0.0109
0.177
0.004
0.0646
0.092
0.0336
0.1544
0.0563
J05A E
J05A F
J05A G
J05A H
74
CHAPTER 15
Table 15.6.2: Use of Anti-Virals by Drug Class and Agents, in DDD/1000 population/day 2006
ATC
2006
J05A B
2006
Nucleosides and nucleotides excl. reverse transcriptase inhibitors
J05A B01
Aciclovir
J05A B04
Ribavirin
J05A B06
Ganciclovir
J05A B09
Famciclovir
J05A B11
Valaciclovir
J05A B14
Valganciclovir
J05A D01
Foscarnet
J05A E
Protease inhibitors
J05A E01
Saquinavir
0.0063
0.0406
0.047
0.0026
0.0005
0.0031
0.0004
<0.0001
0.0004
<0.0001
0.0012
0.0013
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
0.0023
0.0148
0.0171
0.0009
0.0002
0.0011
0.0001
<0.0001
0.0001
<0.0001
0.0004
0.0005
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
0.0023
0.0001
0.0024
0.0008
0.0008
<0.0001
<0.0001
0.0008
0.0008
J05A F
Public
Private
<0.0001
Total
<0.0001
Indinavir
Public
0.0063
Private
0.0003
Total
0.0066
Ritonavir
Public
0.0021
Private
Total
0.0021
Nelfinavir
Public
<0.0001
Private
Total
<0.0001
Lopinavir
Public
0.0022
Private
Total
0.0022
Nucleoside and nucleotide reverse transcriptase inhibitors
J05A F01
Zidovudine
J05A F02
Didanosine
J05A F04
Stavudine
J05A E02
J05A E03
J05A E04
J05A E06
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
75
0.0033
0.0033
0.0089
0.0011
0.01
0.0337
0.0012
0.0349
0.0012
0.0012
0.0032
0.0004
0.0036
0.0123
0.0004
0.0128
CHAPTER 15
ATC
J05A F05
Lamivudine
J05A F08
Adefovir dipivoxil
J05A F10
Entecavir
2006
2006
0.1096
0.0064
0.116
0.0038
0.0061
0.0099
0.0028
0.0028
0.04
0.0023
0.0423
0.0014
0.0022
0.0036
0.001
0.001
Public
Private
Total
Public
Private
Total
0.0616
0.0001
0.0618
0.0285
0.0017
0.0302
0.0225
<0.0001
0.0225
0.0104
0.0006
0.011
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0299
0.0299
0.1204
0.004
0.1245
0.0751
0.0025
0.0776
0.0109
0.0109
0.044
0.0015
0.0454
0.0274
0.0009
0.0283
Public
Private
Total
Public
Private
Total
Public
Private
Total
J05A G
Non-nucleoside reverse transcriptase inhibitors
J05A G01
Nevirapine
J05A G03
Efavirenz
J05A H
Neuraminidase inhibitors
J05A H01
Zanamivir
J05A H02
Oseltamivir
J05A R01
Zidovudine and lamivudine
References:
1. Patrick DM, Marra F , Hutchinson J , et al. Per capita antibiotic consumption: How does a North
American Jurisdiction compare with Europe? Clin Infect Dis. 2004; 39:11-7.
2. Goossens H, Ferech M, Coenen S et al. Comparison of outpatient systemic antibacterial use in 2004 in the
Unitd States & 27 European countries. Clin Infect Dis. 2007; 44: 1091-5.
3. Ferech M, Coenen S, Kumar SM et al. European Surveillance of Antimicrobial Consumption (ESAC):
outpatient antibiotic use in Europe. J Antimicrob Chemother 2006; 58:401-7.
4. Health Protection Agency. Antimicrobial Resistance and Prescribing in England, Wales and Northern Ireland,
2008. London.
5. Pakyz AL, MacDougall C, Oinonen M, Polk RE. Trends in Antibacterial Use in US Academic Health Centers
2002 to 2006. Arch Intern Med. 2008; 168(20):2254-2260.
6. Avorn JL, Barrett JF, Davey PG, McEwen SA, O’Brien TF and Levy SB. 2001. Antibiotic resistance:
synthesis of recommendations by expert policy groups Alliance for the Prudent Use of Antibiotics United
States of America World Health Organization.
76
CHAPTER 16: USE OF ANTINEOPLASTIC AGENTS
INCLUDING ENDOCRINE THERAPY
Edited by:
Lim YS1, Lim GC1, Goh AS㪉, Wan Ariffin A3, M Roslan H4, Kamarun Neasa BMK1, Yuzlina MY5
1. Kuala Lumpur Hospital, 2. Pulau Pinang
Johor Bahru, 5. Putrajaya Hospital
Hospital, 3. Universiti Malaya, 4. Sultan Ismail Hospital,
Systemic therapy is part of the treatment for many cancer patients and for some malignancies they may be the
only option. Systemic therapy in cancer is particularly complex and antineoplastic drugs are used either as
monotherapy or in combination in different regimes. Antineoplastics can be used in first line or as treatment
for relapse of disease.
Some of the antineoplastics have been around since 6 decades ago. Taxanes came in use in 1992 followed
by the molecular targeted agents such as Imatinib Mesylate in early 2000’s. Bevacizumab was the first clinically
proven antiangiogenic agent for the treatment of colon cancer in 2004.
The top ten antineoplastics in terms of expenditure in 2006 by public hospitals were Epirubicin (RM5.3 million),
Docetaxel (RM5.2 million), Oxaliplatin (RM2.8 million), Rituximab (RM2.5 million), Gemcitabine (RM2.1
million), Irinotecan (RM2.0 million), Methotrexate (RM1.3 million), Paclitaxel (RM 1.2 million), Fluorouracil
(RM1.1 million) and Capecitabine (RM1.0 million). Prices were quoted according to Hospital Kuala Lumpur
catalog of drug prices for 2006.
Epirubicin was used mainly for breast cancer as in the FEC regime which was a combination therapy with
Flurouracil and Cyclophosphamide. Docetaxel was used mainly in breast cancer for salvage therapy. This
taxane was also used in Non-Small Cell Lung Cancer (NSCLC). Another taxane, Paclitaxel was used in ovarian
cancer and NSCLC in combination with Carboplatin or Cisplatin. Then in 2006, government hospitals started
using Paclitaxel for a new indication in Ministry of Health (MOH) Formulary in combination with
Gemcitabine for breast cancer. The earlier indication of Gemcitabine that was approved by the Drug Control
Authority (DCA) was for pancreatic cancer. Furthermore Gemcitabine was widely used for NSCLC in combination
with Cisplatin, a platinum compound.
Irinotecan was frequently used for colorectal cancer. On the other hand, Methotrexate, a folic acid analog
was used for breast cancer in combination with Cyclophosphamide and Fluorouracil. This is the popularly
known CMF regime which was the first line therapy in many breast cancer patients. Fluorouracil was mainly
used for colorectal cancer, breast cancer, nasopharyngeal cancer, stomach and pancreatic cancer.
Capecitabine is an antimetabolite of pyrimidine analog. Capecitabine initially was used in public hospitals
for colorectal cancer only, but not long afterwards was also indicated for breast cancer in metastatic setting.
Tegafur was used in private hospitals exceeding ten fold more than in public hospitals. Tegafur was on case
by case approval by Director General of Health until 2008 when it was indicated for NSCLC. However
Tegafur found many more uses in private hospitals in addition to NSCLC such as head and neck cancer and breast
cancer. Hence the disparity between quantum of Tegafur used in private compared to public hospitals. The tyrosine
kinase inhibitor Imatinib was included in the MOH Formulary in 2007. Imatinib was used for CML as well as for
gastro-intestinal stromal tumour (GIST) which had been incompletely resected or unresectable. The usage of
Imatinib was actually higher than captured in these procurement data due to the Glivec International Assistance
Program (GIPAP) in CML and GIST in Malaysia.
The other molecular targeted therapy were the monoclonal antibodies Rituzimab and Trastuzumab. While
Rituzimab was already in MOH Formulary since 2004, Trastuzumab was used on a named-patient basis
in 2006. This accounted for the relatively low expenditure for Trastuzumab. In haematological malignancies,
Rituximab and the proteosome inhibitor, Bortezomib are making real impact on patient survival and remission
rates. Rituximab was already in the MOH Formulary in 2004 for Rituximab enhanced regime of
Cyclophosphamide, Adriamycin, Vincristine and Prednisolone (R-CHOP) in Non-Hodgkin’s Lymphoma whereas
Bortezomib was not in the MOH Formulary until 2008. However, improvement in survival comes at a cost and
the soaring price of new cancer regimes are adding to the financial burden of cancer patients and causing a strain
to public hospitals’ budget.
77
Due to the exorbitant price of the newer drugs, only a selected number of patients may have access to these
novel targeted agents. The newer drugs that are being focused on in government hospitals are those in
whom overall survival benefit have been proven in published randomised controlled trials. Patients depend largely
on insurance coverage in the private hospitals and adequacy of budget in individual government hospitals.
The usage of Rituximab was more in public than in private hospitals. The usage of Bortezomib was low in
government, university hospitals and private hospitals. Many patients would go to public hospitals if they
could get the monoclonal antibodies there since they would not need to worry about the exorbitant prices of
the drugs that were heavily subsidised. Other non-formulary drugs such as anagrelide and arsenic trioxide
were little used in public hospitals and even less so in private hospitals.
Table 16.1: Use of Antineoplastic Agents by Drug Class and Agents, in total dosage/1000 population/day
2006
ATC
Unit
2006
L01A A
Nitrogen mustard analogues
L01A A01
L01 A A02
L01A A03
L01A A06
mg
Melphalan
g
Ifosfamide
Alkyl sulfonates
L01A B01
Busulfan
L01A C
Ethylene imines
L01A C01
Thiotepa
L01A D
Nitrosoureas
L01A D01
Carmustine
mg
mg
mg
mg
Lomustine
L01A X
Other alkylating agents
L01A X03
Temozolomide
L01A X04
mg
Chlorambucil
L01A B
L01A D0 2
mg
Cyclophosphamide
mg
mg
Dacarbazine
78
Public
2.2612
Private
0.6601
Total
2.9212
Public
0.0062
Private
0.0009
Total
0.0071
Public
0.0036
Private
<0.0001
Total
0.0036
Public
0.0009
Private
0.0001
Total
0.0011
Public
0.0093
Private
<0.0001
Total
0.0095
Public
-
Private
<0.0001
Total
<0.0001
Public
0.003
Private
<0.0001
Total
0.003
Public
0.0008
Private
0.0003
Total
0.001
Public
0.0045
Private
0.022
Total
0.0265
Public
0.0631
Private
0.0198
Total
0.0829
Table 16.2: Use of Antineoplastic Agents by Drug Class, in total dosage/1000population/day 2006
ATC
L01B A
Folic acid analogues
Unit
L01B A01
Methotrexate
mg
L01B A04
Pemetrexed
mg
L01B B
Purine analogues
L01B B02
Mercaptopurine
mg
L01B B03
Tioguanine
mg
L01B B04
Cladribine
mg
L01B B05
Fludarabine
mg
L01B C
Pyrimidine analogues
L01B C01
Cytarabine
mg
L01B C02
Fluorouracil
mg
L01B C05
Gemcitabine
mg
L01B C06
Capecitabine
mg
L01B C53
Tegafur, combinations
mg
2006
Public
Private
Total
Public
Private
Total
0.6852
0.1102
0.7954
0.0055
0.0055
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.6879
0.0103
0.6982
0.0133
0.0002
0.0135
<0.0 001
<0.0001
0.001
0.0018
0.0028
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.7999
0.0436
0.8435
4.8107
1.4858
6.2965
0.2908
0.121
0.4118
7.5826
8.9727
16.5553
0.0272
0.326
0.3533
2006
ATC
Unit
2006
L01C A
Vinca alkaloids and analogues
L01C A01
Vinblastine
mg
L01C A02
Vincristine
mg
L01C A04
Vinorelbine
mg
79
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0011
0.0003
0.0014
0.0018
0.0002
0.002
0.0062
0.0051
0.0113
ATC
L01C B
Podophyllotoxin derivatives
Unit
L01C B01
Etop oside
mg
L01C B02
Teniposide
mg
L01C D
Taxanes
L01C D01
Paclitaxel
mg
L01C D02
Docetaxel
mg
2006
Public
Private
Total
Public
Private
Total
0.1511
0.0293
0.1804
0.0015
<0.0001
0.0015
Public
Private
Total
Public
Private
Total
0.0687
0.0464
0.1151
0.0152
0.0158
0.031
Table 16.4: Use of Antineoplastic Agents by Drug Class, in total dosage/1000 population/day 2006
ATC
L01D A
Actinomycines
Unit
L01D A01
Dactinomycin
mg
Public
Private
Total
<0.0001
<0.0001
<0.0001
L01D B
Anthracyclines and related substances
L01D B01
Doxorubicin
mg
L01D B02
Daunorubicin
mg
L01D B03
Epirubicin
mg
L01D B06
Idarubicin
mg
L01D B07
Mitoxantrone
mg
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0426
0.0274
0.0701
0.0085
0.0008
0.0093
0.0771
0.0123
0.0893
0.0008
<0.0001
0.0009
0.0003
0.0001
0.0004
Public
Private
Total
Public
Private
Total
0.0074
0.0031
0.0105
0.002
0.001
0.003
L01D C
Other cytotoxic antibiotics
L01D C01
Bleomycin
mg
L01D C03
Mitomycin
mg
80
2006
2006
ATC
L01X A
Platinum compounds
Unit
L01X A01
Cisplatin
mg
L01X A02
Carboplatin
mg
L01X A03
Oxaliplatin
mg
L01X B
Methylhydrazines
L01X B01
Procarbazine
L01X C
Monoclonal antibodies
L01X C02
2006
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0817
0.0462
0.1278
0.3832
0.1088
0.4919
0.0123
0.0281
0.0404
mg
Public
Private
Total
0.0269
<0.0001
0.0269
Rituximab
mg
L01X C0 3
Trastuzumab
mg
L01X C06
Cetuximab
mg
L01X C07
Bevacizumab
mg
L01X E01
Imatinib
mg
L01X E02
Gefitinib
mg
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0377
0.0242
0.0619
0.0008
0.0058
0.0065
0.0017
0.0335
0.0352
0.0128
0.0128
0.0942
0.2025
0.2966
0.0086
0.1336
0.1422
L01X X
Other antineoplastic agents
L01X X02
Asparaginase
mg
L01X X05
Hydroxycarbamide
mg
L01X X11
Estramustine
mg
L01X X14
Tretinoin
mg
L01X X17
Topotecan
mg
Public
Private
Total
Publ ic
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
5.2422
0.2473
5.4895
23.5787
5.4791
29.0578
<0.0001
<0.0001
0.0301
0.0046
0.0347
-
81
ATC
Unit
L01 X X19
Irinotecan
mg
L01X X27
Arsenic trioxide
mg
L01X X32
Bortezomib
mg
L01X X35
Anagrelide
mg
2006
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
References:
1. Australia Department of Health and Ageing, Australian Statistics On Medicine 2003.
2. Statistics on Drug use in Australia 2006.
82
0.0202
0.0097
0.03
0.0007
0.0007
<0.0001
<0.0001
<0.0001
0.0037
0.0005
0.0042
CHAPTER 17: USE OF SYSTEMIC CORTICOSTEROIDS
AND IMMUNOSUPPRESIVE AGENTS
Edited by:
Hooi LS1, Zaki M2, Lim TO3, Zawawi N4, Goh BL5, Fadilah O6, Nur Salima S6, Puteri JZ6, Zarina AG6,
Manjulaa DS7
1. Sultanah Aminah Hospital, Johor Bharu, 2. International Medical University, 3. Clinical Research
Centre, MOH, 4. Sultanah Nur Zahirah Hospital, Terengganu, 5. Serdang Hospital, 6. Selayang Hospital,
7. Kuala Lumpur Hospital
The list of drugs in this chapter include steroids, progestogens, gonadotropin releasing hormone (GnRH)
analogues, tamoxifen, anti-androgens, enzyme inhibitors, granulocyte colony stimulating factor, interferons
and immunosuppressants like calcineurin inhibitors, mycophenolate acid, sirolimus, etanercept, infliximab,
azathioprine, thalidomide and methotrexate.
The main drug in this chapter is prednisolone. Systemic glucocorticoids have non-specific anti-inflammatory
and immunosuppressant properties but the side-effects are protean. The usage in 0.4% of the general
population in 2006 is high. This amounts to 118,000 people on glucocorticoids daily assuming the population
of Malaysia was 26.6 million in 2006 (table 17.1). About 67,000 people per day were on prednisolone (table 17.2).
This may suggest overuse or even abuse of steroids, which warrants further investigation.
There were a total of 490 patients treated with GnRH analogues (for cancer of the prostate), 6,000 on
tamoxifen (for cancer of the breast), 230 on the anti-androgens (for cancer of the prostate) and 600 on the enzyme
inhibitors (for cancer of the breast). Granulocyte colony stimulating factor was used very little (70 per day)
and interferon usage was surprisingly low in view of the large numbers of patients with hepatitis B
and hepatitis C in Malaysia. Multiple sclerosis is a rare disease here and the use of interferon beta-1a is
low. The total usage of all classes of interferons was 480 people per day. There may be under-usage of these
drugs for their justified indications but this may reflect their high cost.
There were about 1,460 people on ciclosporin, 135 on tacrolimus and 540 on mycophenolic acid from
the data available. From the National Transplant Registry of 2006 there were 1,120 patients with functioning
kidney transplants on ciclosporin in 2006 [1]. It is used mainly in the public sector as there is a specific
allocation for its use for renal transplantation. There were 254 renal transplant patients on tacrolimus in 2006
and 705 on mycophenolate mofetil (MMF) [1]. DDD/1000 population/day for MMF is 2g which is the
standard when used in combination with cyclosporine. In combination with tacrolimus the dose of MMF is
usually halved to 1 g/day. This may explain the lower figures reported here compared to NTR figures for
mycophenolic acid.
There were a negligible number of people on sirolimus, etanercept and infliximab. The last 2 mainly for
rheumatoid arthritis are very costly. About 2,500 patients were on azathioprine and there were 100 people on
methotrexate.
Table 17.1: Use of Systemic Corticosteroids and Immunosuppressive Agents by Drug Class, in DDD/1000
population/day 2006
ATC
Drug Class
2006
H02A A
H02A B
Mineralocorticoids
Glucocorticoids
0.0034
4.4433
Table 17.2: Use of Systemic Corticosteroids and Immunosuppressive Agents by Drug Class and Agents,
in DDD/1000 population/day 2006
ATC
H02A A
Mineralocorticoids
H02A A02
Fludrocortisone
2006
Public
Private
Total
83
0.0023
0.0011
0.0034
ATC
H02A B
Glucocorticoids
H02A B01
Betamethasone
H02A B02
Dexamethasone
H02A B04
Methylprednisolone
H02A B06
Predni solone
H02A B08
Triamcinolone
H02A B09
Hydrocortisone
2006
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.429
0.429
0.32
0.274
0.594
0.0866
0.0561
0.1427
1.1766
1.3428
2.5194
0.0133
0.1086
0.1219
0.3073
0.3291
0.6364
Table 17.3: Use of Systemic Corticosteroids and Immunosuppressive Agents by Drug Class, in
ATC
Drug Class
2006
L02
L03
L04
ENDOCRINE THERAPY
IMMUNOSTIMULANTS
IMMUNOSUPPRESSIVE AGENTS
0.2844
6.149
0.2001
Table 17.4: Use of Systemic Corticosteroids and Immunosuppressive Agents by Drug Class, in
ATC
L02A B
Progestogens
2006
L02A B01
Megestrol
L02A B02
Medroxyprogesterone
L02A E
Gonad otropin releasing hormone analogues
L02A E01
Buserelin
L02A E02
Leuprorelin
L02A E03
Goserelin
L02A E04
Triptorelin
84
Public
Private
Total
Public
Private
Total
0.0067
0.0067
<0.0001
<0.0001
0.0001
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
<0.0001
<0.0001
<0.0001
0.0024
0.0085
0.0109
0.0038
0.0021
0.0059
0.0011
0.0003
0.0015
ATC
L02B A
Anti-estrogens
L02B A01
Tamoxifen
L02B B
L02B B01
Anti -androgens
Flutamide
L02B B03
Bicalutamide
L02B G
Enzyme inhibitors
L02B G03
Anastrozole
L02B G04
Letrozole
L02B G06
Exemestane
L03A A
Colony stimulating factors
L03A A02
Filgrastim
L03A A10
Lenograstim
L03A B
Interferons
L03A B04
Interferon alfa-2a
L03A B05
Interferon alfa-2b
L03A B07
Interferon beta-1a
L03A B08
Interferon beta-1b
L03A B10
Peginterferon alfa-2b
L03A B11
Peginterferon alfa-2a
2006
85
Public
Private
Total
0.1664
0.0613
0.2277
Public
Private
Total
Public
Private
Total
0.0018
0.0007
0.0025
0.0053
0.001
0.0063
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0067
0.0043
0.011
0.0055
0.0051
0.0106
0.0006
0.0005
0.0011
Public
Private
Total
Public
Private
Total
0.0018
0.0006
0.0024
0.0001
<0.0001
0.0002
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0005
<0.0001
0.0005
0.0043
<0.0001
0.0044
0.0042
0.0042
<0.0001
<0.0001
<0.0001
0.0016
0.0013
0.0029
0.0023
0.0036
0.0059
ATC
L03A X
Other cytokines and immunomodulators
L03A X03
BCG vaccine
L04A A
Selective immunosuppressive agents
L04A A01
Ciclosporin
L04A A02
Muromonab-CD3
L04A A05
Tacrolimus
L04A A06
Mycophenolic acid
L04A A08
Daclizumab
L04A A09
Basiliximab
L04A A10
Sirolimus
L04A A11
Etanercept
L04A A12
Infliximab
L04A A13
Leflunomide
L04A A21
Efali zumab
L04A X
Other immunosuppressive agents
L04A X01
Azathioprine
L04A X02
Thalidomide
L04A X03
Methotrexate
86
2006
Public
Private
Total
5.3237
0.8046
6.1283
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0519
0.003
0.0549
0.0049
0.0002
0.0051
0.0157
0.0046
0.0203
<0.0001
<0.0001
<0.0001
0.0009
0.001
<0.0001
0.0036
0.0037
0.0077
0.0069
0.0146
<0.0001
<0.0001
Public
Private
Total
Public
Private
Total
Public
Private
0.0856
0.0084
0.0939
0.0015
0.0012
0.0028
0.0036
References:
1. Hooi LS, Lela Yasmin Mansor (eds). 3rd report of the National Transplant Registry Malaysia 2006.
Kuala Lumpur 2007. Chapter 5. Renal Transplantation from http://www.mstorg.my/ntrSite
publications_3rdReport2006.htm accessed on 3 January 2009.
87
CHAPTER 18: USE OF MEDICINES FOR
RHEUMATOLOGICAL AND BONE DISORDERS
Edited by:
Ramanathan R1, Ahmad TA2, Ling HT1, Chew CS1, Aizura AR1
1. Raja Permaisuri Bainun Hospital, Ipoh, 2. Sultanah Nur Zahirah Hospital, Kuala Terengganu
Antiinflammatory and antirheumatic products ranked 9th place as the most used drugs by therapeutic
group in Malaysia in 2006 (10DDD/1000 population/day) with estimated 1% population utilising them.
The acetic acid derivatives and related substances were the most used NSAIDs by drug class (4.05DDD/1000
population/day) followed by the Fenamates (2.68), Coxibs (1.27) and Oxicams (1.06). Diclofenac acid
was the most consumed NSAID (1.47 and 2.12DDD/1000 population/day, public and private sectors
respectively). The second commonest NSAID used was mefenamic acid (total DDD 2.68). The newer group,
called Coxibs (DDD 1.265) with supposedly less side effects such as Etoricoxib (DDD 0.67) was mainly used
by private hospitals (91%) while Celecoxib was equally used in the private and public hospitals. In Australia,
Oxicams (DDD 8.679) were the highest prescribed, followed closely by Coxibs (DDD 7.250) and acetic
acid derivatives (DDD 6.224). [1] Better GIT profile is probably why Cox-2 selective inhibitors are popular
nowadays.
Anti-Rheumatic Nimesulide was withdrawn from public hospitals due to the side effects of liver failure.
Newer DMARD’S had reduced the use of Penicillamine by 50%.
Muscle relaxants were prescribed 10 fold more by the private sector (examples: Chlorzoxazone and
Orphenadrine), probably to supplement the action of NSAIDs. The public hospitals used Baclofen more so
to treat non-inflammatory muscle spasms eg, in celebral palsy. Dantrolene, although a muscle relaxant, was
reserved for malignant hyperthermia and is rarely used in Malaysia. Gout was treated with allopurinol (DDD 1.32)
with 73% use by the public sector and caution regarding its gastric side effects and worsening of symptoms during
acute phase use, need to be emphasised.
Greater demand in usage of anti-osteoporosis drugs is expected with increasing lifespan. The three commonest
drugs used in 2006 were the bisphosphonates, followed by Selective Estrogen Receptor Modulators (SERMs)
and calcitonin groups. The weekly or monthly dosing of bisphophonates had made their usage popular.
Strontium and parathyroid hormone have emerged as newer drugs for this condition. Bisphophonates are said
to remain in the body forever. Long term studies may show its safety profile in time to come.
Table 18.1: Use of Drugs for Rheumatological and Bone disorders, in DDD/1000 population/day 2006
ATC
Drug Class
2006
G03X C
H05B A
M01
M03
M04
M05
ANTIINFLAMMATORY AND ANTIR HEUMATIC PRODUCTS
MUSCLE RELAXANTS
0.1293
0.0058
10.0035
0.6131
1.5347
0.4399
Table 18.2.1: Use of Non-Steroidal Anti-Inflammatory drugs by Drug Class, in DDD/1000 population/day
2006
ATC
2006
M01A B
M01A C
M01A E
M01A G
M01A H
M01A X
M01C C
Acetic acid derivatives and related substances
Oxicams
Propionic acid derivatives
Fenamates
Coxibs
Other antiinflammatory and antirheumatic agents, non-steroids
Penicillamine and similar agents
89
4.0492
1.0649
0.8283
2.6834
1.265
0.1078
0.005
Table 18.2.2: Use of Non-Steroidal Anti-Inflammatory drugs by Drug Class and Agents, in DDD/1000
population/day 2006
ATC
M01A B
Acetic acid derivatives and related substances
M01A B01
Indometacin
M01A B02
Sulindac
M01A B05
Diclofenac
M01A B15
Ketorolac
M01A C
Oxicams
M01A C01
Piroxicam
M01A C02
Tenoxicam
M01A C06
Meloxicam
M01A E
Propionic acid derivatives
M01A E01
Ibuprofen
M01A E02
Naproxen
M01A E03
Ketoprofen
M01A G
Fenamates
M01A G01
Mefenamic acid
M01A H
Coxibs
M01A H01
Celecoxib
M01A H02
Rofecoxib
M01A H03
Valdecoxib
90
2006
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.3642
0.0897
0.4539
<0.0001
<0.0001
1.4652
2.1248
3.59
0.0007
0.0045
0.0052
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0538
0.4298
0.4836
0.0001
0.0372
0.0373
0.1999
0.3441
0.5441
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.1589
0.2338
0.3927
0.0981
0.3202
0.4184
0.0106
0.0066
0.0172
Public
Private
Total
1.2609
1.4224
2.6834
Public
Private
Total
Public
Private
Total
Publ ic
Private
Total
0.2733
0.3152
0.5885
0.0014
0.0014
ATC
2006
M01A H04
Parecoxib
0.0008
0.0038
0.0046
0.0604
0.6101
0.6705
M01A X
Public
Private
Total
Etoricoxib
Public
Private
Total
Other antiinflammatory and antirheumatic agents, non-steroids
M01A X17
Nimesulide
Public
Private
Total
0.1078
0.1078
Public
Private
Total
0.0048
0.0002
0.005
M01A H05
M01C C
Penicillamine and similar agents
M01C C01
Penicillamine
Table 18.3.1: Use of Muscle relaxants by Drug Class and Agents, in DDD/1000 population/day 2006
ATC
2006
M03B
MUSCLE RELAXANTS, CENTRALLY ACTING AGENTS
M03B B52
Chlormezanone, combinations excl. psycholeptics
M03B B53
Chlorzoxazone, combinations excl. psycholeptics
M03B C01
Orphenadrine (citrate)
M03B X01
Baclofen
M03C
MUSCLE RELAXANTS, DIRECTLY ACTING AGENTS
M03C A01
Dantrolene
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.056
0.056
0.4021
0.4021
0.0153
0.0848
0.1001
0.0504
0.0044
0.0548
Public
Private
Total
-
Table 18.4.1: Use of Anti-Gout preparations by Drug Class, in DDD/1000 population/day 2006
ATC
M04A
M04A A01
Allopurinol
M04A B 01
Probenecid
M04A C01
Colchicine
2006
Public
Private
Total
Public
Private
Total
Public
Private
Total
91
0.9627
0.3601
1.3227
0.0004
0.0031
0.0036
0.0664
0.1421
0.2084
Table 18.5.1: Use of Bone diseases therapy by Drug Class, in DDD/1000 population/day 2006
ATC
2006
M05
M05B A01
Etidronic acid
M05B A02
Clodronic acid
M05B A03
Pamidronic acid
M05B A04
Alendronic acid
M05B A06
Ibandronic acid
M05B A07
Risedronic acid
M05B A08
Zoledronic acid
M05B B03
Alendronic acid and cholecalciferol
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
0.0005
0.0005
0.0018
0.002
0.0038
0.0003
<0.0001
0.0004
0.257
0.1148
0.3718
<0.0001
<0.0001
0.0036
0.0211
0.0247
<0.00 01
<0.0001
Total
0.0002
Public
Private
Total
0.0004
0.038
0.0385
Table 18.6.1: Use of Selective Estrogen Receptor Modulators by Drug Class, in DDD/1000 population/day
2006
ATC
2006
G03
SEX HORMONES AND MODULATORS OF THE GENITAL SYSTEM
G03X C01
Raloxifene
Public
Private
Total
0.0646
0.0647
0.1293
Table 18.7.1: Use Calcitonin preparations of by Drug Class, in DDD/1000 population/day 2006
ATC
H05
CALCIUM HOMEOSTASIS
H05B A01
Calcitonin (salmon synthetic)
2006
Public
Private
Total
References:
1. National Health Survey: Use of Medications, Australia 2006.
2. Malaysian Statistics on Medicines 2005.
92
0.0044
0.0013
0.0058
CHAPTER 19
USE OF OPIOID ANALGESICS
Edited by:
Mary SC1, Marzida M2, Choy YC3, Faizah AR1, Norliza MA1
1. Selayang Hospital, 2. University of Malaya Medical Centre, 3. Universiti Kebangsaan Malaysia Medical Centre
Drugs used for pain control belong to the following subgroups of the ATC classification: anti-inflammatory
products, opioids, analgesics and antipyretics. This chapter covers only opioid analgesics.
The total opioid consumption in Malaysia in 2006 was 0.7268DDD/1000 population/day. This figure is very
much lower than the opioid consumption in the Nordic countries [1], which ranged from 14.0DDD/1000
population/day in Finland to 21.8DDD/1000 population /day in Sweden.
Weak opioids were more commonly used than strong opioids. Of the weak opioids, tramadol was the most
common, followed closely by codeine and its combinations. The most commonly used strong opioid was
morphine, which had much higher use than pethidine, fentanyl and oxycodone.
The combined DDD/1000 population/day of the weak opioids (dihydrocodeine, codeine, tramadol and
tramadol combinations) was 0.5164, which is more than double that of the strong opioids (morphine, oxycodone,
pethidine and fentanyl) which totaled to 0.2084. This pattern is different from the Nordic countries [1] where
the total consumption of strong opioids was higher than that of weak opioids. In Malaysia, tramadol, tramadol
combinations and codeine combinations comprise the main bulk of the weak opioids that were consumed. These
drugs are not controlled under the Dangerous Drugs Act (DDA), and have lower risk of respiratory depression and
addiction, thus accounting for their popularity compared to the other opioids.
Data from the International Narcotics Control Board (INCB) [2] for opioid consumption in Malaysia showed
that in the 1990s there was an increasing trend in morphine consumption which showed plateau after the year
2000, when the newer opioids like fentanyl and oxycodone became available; the consumption of these new
opioids is still increasing. This overall increased consumption in opioids probably reflects an increased awareness
regarding the use of opioids to control chronic cancer pain. This is supported by the data obtained from
this study, as the DDD/1000 population/day of the oral form of morphine (usually used for chronic and cancer
pain) is 5 times that of the DDD for the parenteral form (used for anaesthesia and acute pain). Fentanyl is much
less used than morphine, and this data only includes the transdermal form, thus reflecting only its use for chronic
cancer pain.
The use of morphine in the public sector is more than 10 times that in the private sector - this probably
reflects the fact that the majority of patients with advanced cancer are treated in the public sector, where oral
morphine is used as the mainstay of analgesia for chronic cancer pain.
Table 19.1: Use of Analgesics by Drug Class, in DDD/1000 population/day 2006
ATC
Drug Class
N02A
OPIOIDS
2006
0.7268
Table 19.1.2: Use of Analgesics by Drug Class, in DDD/1000 population/day 2006
ATC
Drug Class
2006
N02A A
N02A B
N02A D
N02A F
N02A X
Natural Opium alkaloids
Phenylpiperidine derivatives
Benzomorphone derivatives
Morphinan derivatives
Other opioids
0.4139
0.0226
<0.0001
0.0019
0.2883
93
CHAPTER 19
USE OF OPIOID ANALGESICS
Table 19.2: Use of Opioid Analgesics by Drug Class, agents and Administration Route, in
DDD/1000population/day 2006
ATC
Year
AdmRCodeO
AdmRCodeP
N02A A
Natural opium alkaloids
N02A A01
Morphine
N02A A05
Oxycodone
N02A A08
Dihydrocodeine
N02A A59
Codeine, combinations excl.
psycholeptics
N02A B
Phenylpiperidine derivatives
N02A B02
Pethidine
N02A B03
Fentanyl
N02A D
Benzomorphan derivatives
N02A D01
Pentazocine
N02A F
Morphinan derivatives
N02A F02
Nalbuphine
N02A X
Other opioids
N02A X02
Tramadol
N02A X52
Tramadol, combinations
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
0.1474
0.0032
0.1506
0.0004
0.0004
0.0008
0.0161
0.0187
0.0348
-
0.0283
0.0062
0.0345
-
0.1757
0.0094
0.185
0.0004
0.0004
0.0008
0.0161
0.0187
0.0348
-
Private
Total
0.1933
0.1933
-
0.1933
0.1933
Public
Private
Total
Public
-
0.0085
0.0088
0.0173
Private
Total
-
0.0085
0.0088
0.0173
AdmRCodeTD
0.0048
0.0005
0.0053
Public
Private
Total
-
AdmRCodeP
<0.0001
<0.0001
<0.0001
<0.0001
Public
Private
Total
-
0.0013
0.0006
0.0019
0.0013
0.0006
0.0019
Public
Private
Total
Public
Private
Total
0.146
0.0399
0.1859
0.0003
0.0907
0.091
0.0084
0.003
0.0114
-
0.1544
0.0429
0.1973
0.0003
0.0907
0.091
0.0048
0.0005
0.0053
References:
1. Medicines consumption in the Nordic countries 1999-2003. Nordic Medico Statistical Committee 2004;
2004:Copenhagen.
2. International Narcotics Control Board; United Nations population data (Malaysia), by Pain & Policy Studies
Group, University of Wisconsin/WHO Collaborating Center, 2008.
94
CHAPTER 20
USE OF MEDICINES FOR NEUROLOGICAL DISORDERS
Edited by:
Zariah AA1, Hanip R2, Raymond AA3, Norhasyimah AR1, Azrinorwaty Z2
1. Sultanah Nur Zahirah Hospital, Kuala Terengganu, 2. Kuala Lumpur Hospital, 3. Universiti Kebangsaan
Malaysia Medical Centre
There were 4 main categories of neurological drug groups being analysed for the year 2006. These included
the anticonvulsants, drugs for Parkinson’s disease, drugs for dementia and the anti-migraine preparations.
The largest category consisted of the anticonvulsants with the total utilisation at 1.5DDD/1000
population/day. This translated to a rough estimate of about 0.15% of our population having epilepsy.
This estimated data is slightly lower compared to data from developed countries which gave a range between
0.5% and 1%.
The most commonly prescribed drugs for both public and private hospitals were phenytoin (0.5DDD/1000
population/day), sodium valproate (0.4) and carbamazepine (0.3). The first three drugs have
traditionally been used as first line drugs for generalised tonic clonic seizures. Although phenytoin has
not been a popular drug for many clinicians worldwide, surprisingly it is still commonly prescribed by both
the public and private sector doctors in our country. Its usage has been minimal especially in developed
countries like the UK and Scandinavia, due to its very narrow toxicity range and its hideous side
effects of hirsutism in females. In the local consensus guidelines on the management of epilepsy, phenytoin
is recommended as the second and not first choice for generalised seizure due to similar reason. The most
probable reasons for its relatively high usage locally are likely due to its cost, availability and partly
contributed by the wide use in the elderly with post stroke epilepsy. It also has a major role in the treatment of status
epilepticus.
Sodium valproate being a versatile drug is the treatment of choice as monotherapy or adjunctive therapy in
both partial and generalised seizures. Carbamazepine despite of having its greatest risk of causing
Steven-Johnsons syndrome, was almost as popular, being one of the treatment of choice for women of child
bearing age due to its comparatively lower risk of teratogenecity.
Use of phenobarbitone (0.1), clonazepam (0.04), and primidone (0.001) was limited most likely related to
its sedative side effect particularly with clonazepam. Benzodiazepines however, have a particularly prominent
role in myoclonus and movement disorders.
Among the newer anticonvulsants, lamotrigine (0.04), gabapentin (0.03) and levetiracetam (0.01) were more
commonly used compared to others like topiramate (0.006), oxcarbazepine (0.003) and vigabatrin (0.0004).
Gabapentin usage is more related to neuropathic pain rather than as an anticonvulsant. Vigabatrin unlike
Lamotrigine, Levetiracetam, Topiramate and Oxcarbazepine is currently indicated for second line use in patients
with refractory partial epilepsy. Overall usage for the newer AEDs is low due to their higher cost and specialist
level prescribing rights.
Anticonvulsant usage in private practice is very much lower with both the traditional as well as the newer
drugs. This probably reflects the populations’ preference in seeking treatment at public hospitals. The most
likely reason for this would have to be the high cost of these medications.
The trend in prescribing AED in Australia is similar (see Table 20.7) whereby there is a higher usage of the
conventional/older AED like valproic acid (3.6) and carbamazepine (1.89) and there was lower usage of
phenytoin (1.65). In descending order of frequency, the most commonly used newer anticonvulsants were
lamotrigine (0.98), followed by gabapentin (0.48), levetiracetam (0.4), topiramate (0.27), oxcarbazepine (0.06)
and vigabatrin (0.054).
In the group, drugs used for Parkinson’s disease, there were 5 main classes of drugs available. They were the
levodopa (+ peripheral dopa decarboxylase inhibitors), dopamine agonists, anticholinergics/antimuscarinics,
amantadine and the enzyme inhibitors (monoamine oxidase type B inhibitors, catechol-o-methyl transferase
95
CHAPTER 20
inhibitors. Artane was the most commonly prescribed drug with a DDD/1000 population/day of 0.6. Its
popularity was likely due to its availability, cost, usefulness in reducing tremor and rigidity and served as
an alternative to reduce risk of development of motor complications associated with levodopa therapy.
Levodopa (+ peripheral dopa decarboxylase inhibitors) although is the gold standard and the most effective
drug therapy in Parkinson’s disease came second in its usage at 0.16 DDD/1000 population/day. Stalevo, a
3-in-one preparation with levodopa, carbidopa and entacapone showed very little usage at 0.0017DDD/1000
population/day. It is currently not available in the Ministry of Health (public sector)
Among the dopamine agonists, the commonly used drugs in descending order of frequency were; piribedil
(0.009), bromocriptine (0.006), ropinirole (0.001) and pramipexole (0.0003). Bromocriptine and piribedil
both ergot derived DA had been in the market longer than the other newer dopamine agonists. Pramipexole
was only made available in Malaysia in June 2006. Hence in spite of the current practice of using DA as
first choice in de novo and young parkinsonian patients and with possible neuroprotective effects, the non
availability and cost were the likely factors for their low usage.
Amantadine (0.007), a tricyclic amine was used previously as an antiviral. It was mainly used in levodopa
induced dyskinesias and hence has a limited role in PD therapy.
Among the enzyme inhibitors, selegiline (0.06) had been available in Malaysia for many years and usually
used in the early stage of PD, whereas comtan (0.012) was a relatively newer addition, used in combination with
levodopa.
The prescribing practice in Australia differed slightly (see Table 20.8), with the levodopa group (1.43)
having the higher usage compared to the anticholinergics. Among the anticholinergic, unlike in
Malaysia where benzhexol was very popular, benzatropine (0.49) had a higher usage. The dopamine
agonists both older and newer ones together with amantadine showed the lowest ratings (0.02 for bromocriptine,
ropinirole, pramipexole and 0.003 for amantadine). Their use of comtan (0.1) and stalevo (0.05) were much
higher.
In dementia, drugs available for cognitive improvement were the cholinesterase inhibitors, usage at 0.02DDD/1000
population/day and the NMDA receptor antagonist, memantine usage at 0.001DDD/1000 population/day.
In 2006 and till currently memantine and galantamine are still unavailable in the public sector. Although
an estimated 5 to 10% of the adult population age 65 years and older is affected by a dementia disorder,
lack of awareness by both the public and health care professionals could explain the least usage of
these drugs (0.02) among the four subgroup neurological disorders surveyed. No data from Australia was
available for comparison.
The total use of anti-migraine preparations in 2006 in Malaysia was 0.0689DDD/1000 population/day. The most
utilised class of drug was ergot alkaloid (0.0337DDD/1000 population/day), followed by pizotifen (0.0265DDD/1000
population/day) and selective serotonin (5HT1) agonist, sumatriptan (0.0087DDD/1000 population/day).
Ergot alkaloids constituted 48.9% by drug class with the breakdown of ergotamine combinations excluding
psycholeptics (94%), ergotamine combinations with psycholeptics (5.6%) and ergotamine (0.4%). Ergot
alkaloid had not been approved and was unavailable in public hospitals hence its low usage in acute
migraine attack. However, it had its usage in private practice despite the alarming side effects with
chronic use. The only available ergot combination in Malaysia in 2006 was Cafergot® which contained
ergotamine and caffeine. Sumatriptan used in acute attacks showed a usage of 0.009 DDD/1000
population/day, being used more in the private practice (0.006) compared to public hospitals (0.002). There was no
survey made on other drugs for acute attacks like paracetamol, cox-2 inhibitors, NSAIDs, opioids or
corticosteroids. In Australia, sumatriptan showed the highest usage amongst the drugs for aborting acute
attacks, followed by the ergot alkaloid methysergide (0.03), the newer triptans, zolmitriptans (0.03) and
naratriptan (0.02).
Pizotifen used as migraine prophylaxis was the only prophylaxis surveyed with usage of 0.002DDD/1000
population/day. It would be interesting to look at the results of other migraine prophylaxis which was not
96
CHAPTER 20
surveyed, including the newer anticonvulsants like topiramate, levetiracetam as well as the conventional
choices like beta blockers and calcium channel blockers. As such, analyses as to the practice of use of
antimigraine drugs are rather limited due to the restricted choices of drugs surveyed.
Table 20.1: Use of Drugs for Neurological Disorder, in DDD/1000 population/day 2006
ATC
Drug Class
2006
N02C
N03
N04
N06D
N07
ANTIMIGRAINE PREPARATIONS
ANTIEPILEPTICS
ANTIPARKINSON DRUGS
ANTIDEMENTIA DRUGS
0.0689
1.4992
0.882
0.0258
0.9054
Table 20.2.1: Use of Analgesics by Drug Class, in DDD/1000 population/day 2006
ATC
Drug Class
2006
N02C
N02C A
N02C C
N02C X
ANTIMIGRAINE PREPARATIONS
Ergot alkaloids
Selective serotonin (5HT1) agonists
Other antimigraine preparations
0.0689
0.0337
0.0087
0.0265
Table 20.2.2: Use of Analgesics by Drug Class and Agents, in DDD/1000 population/day 2006
ATC
N02C A
Ergot alkaloids
2006
N02C A02
Ergotamine
N02C A52
Ergotamine, combinations excl. psycholeptics
N02C A72
Ergotamine, combinations with psycholeptics
N02C C
Selective serotonin (5HT1) agonists
N02C C01
Sumatriptan
N02C X
Other antimigraine preparations
N02C X01
Pizotifen
Public
Private
Total
Pub lic
Private
Total
Public
Private
Total
0.0001
0.0001
0.0003
0.0314
0.0317
0.0019
0.0019
Public
Private
Total
0.002
0.0067
0.0087
Public
Private
Total
0.0183
0.0082
0.0265
Table 20.3.1: Use of Anti-Epileptics by Drug Class, in DDD/1000 population/day 2006
ATC
Drug Class
2006
N03A
N03A A
N03A B
N03A D
N03A E
N03A F
N03A G
N03A X
ANTIEPILEPTICS
Barbiturates and derivatives
Hydantoin derivatives
Succinimide derivatives
Benzodiazepine derivatives
Carboxamide derivatives
Fatty acid derivatives
Other antiepileptics
1.4992
0.1231
0.5077
0.0483
0.3172
0.3985
0.1044
97
CHAPTER 20
Table 20.3.2: Use of Antiepileptics by Drug Class and Agents, in DDD/1000 population/day 2006
ATC
N03A A
Barbiturates and derivatives
N03A A02
Phenobarbital
N03A A03
Primidone
N03A B
Hydantoin derivatives
N03A B02
Phenytoin
N03A D
Succinimide derivatives
N03A D01
Ethosuximide
N03A E
N03A E01
Clonazepam
N03A F
Carboxamide derivatives
N03A F01
Carbamazepine
N03A F02
Oxcarbazepine
N03A G
Fatty acid derivatives
N03A G01
Valproic acid
N03A G04
Vigabatrin
N03A X
Other antiepileptics
N03A X0 9
Lamotrigine
N03A X11
Topiramate
N03A X12
Gabapentin
N03A X14
Levetiracetam
2006
98
Public
Private
Total
Public
Private
Total
0.1062
0.0153
0.1215
0.0013
0.0002
0.0015
Public
Private
Total
0.4641
0.0436
0.5077
Public
Private
Total
-
Public
Private
Total
0.0399
0.0085
0.0483
Public
Private
Total
Public
Private
Total
0.2905
0.0236
0.3142
0.0002
0.0027
0.003
Public
Private
Total
Public
Private
Total
0.3673
0.0308
0.3981
0.0001
0.0003
0.0004
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.038
0.0033
0.0412
0.0058
0.0003
0.0061
0.0221
0.0159
0.038
0.0101
0.0089
0.0191
CHAPTER 20
Table 20.4.1: Use of Antiparkinson by Drug Class, in DDD/1000 population/day 2006
ATC
Drug Class
N04A
N04A A
N04A B
N04A C
N04B
N04B A
N04B B
N04B C
N04B D
N04B X
ANTICHOLINERGIC AGENTS
Tertiary amines
Ethers chemically close to antihistamines
Ethers of tropine or tropine derivatives
DOPAMINERGIC AGENTS
Dopa and dopa derivatives
Adamantane derivatives
Dopamine agonists
Monoamine oxidase B inhibitors
Other dopaminergic agents
2006
0.6121
0.6094
0.0004
0.0023
0.2698
0.1739
0.0066
0.0171
0.0604
0.0118
Table 20.4.2: Use of Antiparkinson by Drug Class and Agents, in DDD/1000 population/day 2006
ATC
2006
N04A A
Tertiary amines
N04A A01
Trihexyphenidyl
N04A A04
Procyclidine
N04A B
Ethers chemically close to antihistamines
N04A B02
Orphenadrine (chloride)
N04A C
Ethers of tropine or tropine derivatives
N04A C01
Benzatropine
N04B A
Dopa and dopa derivatives
N04B A02
Levodopa and decarboxylase inhibitor
N04B A03
Levodopa, decarboxylase inhibitor and COMT inhibitor
N04B B
Adamantane derivatives
N04B B01
Amantadine
N04B C
Dopamine agonists
N04B C01
Bromocriptine
N04B C04
Ropinirole
N04B C05
Pramipexole
99
Public
Private
Total
Public
Private
Total
0.5887
0.0204
0.6091
0.0003
<0.0001
0.0003
Public
Private
Total
0.0004
0.0004
Public
Private
Total
0.002
0.0003
0.0023
Public
Private
Total
Public
Private
Total
0.1549
0.0173
0.1722
0.0008
0.0009
0.0017
Public
Private
Total
0.0029
0.0036
0.0066
Public
Private
Total
Publ ic
Private
Total
Public
Private
Total
0.0061
0.0003
0.0063
0.0006
0.0006
0.0012
0.0003
0.0003
CHAPTER 20
ATC
N04B C08
Piribedil
N04B D
Monoamine oxidase B inhibitors
N04B D01
Selegiline
N04B X02
Entacapone
2006
Public
Private
Total
0.0082
0.0011
0.0093
Public
Private
Total
Public
Private
Total
0.054
0.0065
0.0604
0.0109
0.0009
0.0118
Table 20.5.1: Use of Antidementia Drugs by Drugs Class, in DDD/1000 population/day 2006
ATC
2006
N06D
N06D A
N06D X
ANTIDEMENTIA DRUGS
Anticholinesterases
Other anti-dementia drugs
0.0258
0.0247
0.0011
Table 20.5.2: Use of Antidementia Drugs by Drugs Class and Agents, in DDD/1000 population/day 2006
ATC
N06D A
Anticholinesterases
N06D A02
Donepezil
N06D A03
Rivastigmine
N06D A04
Galantamine
N06D X
Other antidementia drugs
N06D X01
Memantine
2006
Publi c
Private
Total
Public
Private
Total
Public
Private
Total
0.0102
0.0032
0.0134
0.006
0.0006
0.0066
0.0047
0.0047
Public
Private
Total
0.0009
0.0001
0.0011
Table 20.6.1: Use of Other Nervous System Drugs by Drug Class, in DDD/1000 population/day 2006
ATC
2006
N07A
N07A A
N07C
N07C A
N07X
N07X X
PARASYMPATHOMIMETICS
Anticholinesterases
ANTIVERTIGO PREPARATIONS
Antivertigo preparations
Other nervous system drugs
0.1268
0.1268
0.778 6
0.7786
<0.0001
<0.0001
100
CHAPTER 20
Table 20.6.2: Use of Other Nervous System Drugs by Drug Class and Agents, in DDD/1000 population/day
2006
ATC
2006
N07A A
Anticholinesterases
N07A A01
Neostigmine
N07A A02
Pyridostigmine
N07A A03
Distigmine
N07C A
A ntivertigo preparations
N07C A01
Betahistine
N07C A02
Cinnarizine
N07C A03
Flunarizine
N07X X
Other nervous system drugs
N07X X02
Riluzole
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0294
0.0213
0.0507
0.0704
0.0056
0.0761
<0.0001
<0.0001
Public
Private
Total
Public
Private
Total
Public
Private
Tota l
0.1257
0.242
0.3677
0.1156
0.2004
0.316
0.0183
0.0766
0.0949
Public
Private
Total
<0.0001
<0.0001
Table 20.7: Use of drugs for epilepsy in DDD/1000 population/day comparing use in Malaysia and
Australia for the year 2006
Drug
Malaysia
Australia
Phenobarbitone
Primidone
Clonazepam
Carbamazepine
Oxcarbazepine
Valproic Acid
Vigabatrin
Lamotrigine
Public/Subsidized
Private/Survey
TOTAL
Public/Subsidized
Private/Survey
TOTAL
Public/Subsidized
Private/S urvey
TOTAL
Public/Subsidized
Private/Survey
TOTAL
Public/Subsidized
Private/Survey
TOTAL
Public/Subsidized
Private/Survey
TOTAL
Public/Subsidized
Private/Survey
TOTAL
Public/Subsidized
Private/Survey
TOTAL
0.1062
0.0153
0.1215
0.0013
0.0002
0.0015
0.0399
0.0085
0.0484
0.2905
0.0236
0.3141
0.0002
0.0027
0.0029
0.3673
0.0308
0.3981
0.0001
0.0003
0.0004
0.038
0.0033
0.0413
101
0.110
0.020
0.130
0.092
0.001
0.093
0.163
0.205
0.368
1.838
0.048
1.886
0.058
0.000
0.058
3.603
0.039
3.642
0.054
0.000
0.054
0.792
0.18 8
0.980
CHAPTER 20
Drug
Topiramate
Gabapentin
Levetiracetam
Public/Subsidized
Private/Survey
TOTAL
Public/Subsidized
Private/Survey
TOTAL
Public/Subsidized
Private/Survey
TOTAL
Malaysia
Australia
0.0058
0.0003
0.0061
0.0221
0.0159
0.0380
0.010 1
0.0089
0.02
0.259
0.010
0.269
0.302
0.176
0.478
0.392
0.003
0.4
Table 20.8: Use of drugs for Parkinson’s disease in DDD/1000 population/day comparing use in
Malaysia and Australia for the year 2006
Drug
Malaysia
Australia
Artane
Procyclidine
Ophenadrine
Benzatropine
Levodopa &
Decarboxylase
Inhibitor
Stalevo
Amantadine
Bromocriptine
Ropinirole
Pramipexole
Piribedil
Selegiline
Comtan
Public/Subsidized
Private/Survey
Total
Public/Subsidized
Private/Survey
Total
Public/Subsidized
Private/Survey
Total
Public/Subsidiz ed
Private/Survey
Total
Public/Subsidized
0.59
0.02
0.61
0.0003
<0.0001
0.13
0.008
0.13
-
0.0004
0.0004
0.002
0.0003
-
Private/Survey
Total
Public/Subsidized
Private/Survey
Total
Public/Subsidized
Private/Survey
Total
Public/Subsidized
Private/Survey
Total
Public/Subsidized
Private/Survey
Total
Public/Subsidized
Private/Survey
Total
Public/Subsidized
Private/Survey
Total
Public/Subsidized
Private/Survey
Total
Public/Subsidized
Private/Survey
Total
0.017
0.172
0.0008
0.0009
0.0017
0.003
0.004
0.007
0.006
0.0003
0.0063
0.0006
0.0006
0.0012
0.0003
0.0003
0.008
0.001
0.009
0.054
0.0065
0.06
0.011
0.0009
0.012
0.155
References:
1. Malaysian consensus guidelines on the management of epilepsy 2005.
2. British National Formulary September 2007.
3. Malaysian consensus on Parkinson’s disease.
4. Malaysian guidelines on the management of dementia 2003.
5. Malaysian consensus guidelines on the management of headache 2005.
6. Australian statistics on medicine 2006.
102
0.465
0.03
0.49
(Madopar)
0.56
0.002
0.56
0.054
0.000
0.054
0.0
0.003
0.003
0.02
0.000
0.002
0.002
0.002
-
0.102
0.00
0.102
0.097
0.00
0.097
Sinemet
0.87
0.006
0.87
CHAPTER 21
USE OF DRUGS FOR PSYCHIATRIC DISORDERS
Edited by:
Siti Nor Aizah A1, Salina AA1, Ramli MA2, Suarn S3, Nor Hayati A4, Shamini R3, Noor Ratna N5,
Mariam Bintarty R,1 Syed Fadzli SS6
1. Kuala Lumpur Hospital, 2. Selayang Hospital, 3. Bahagia Hospital, Tanjung Rambutan 4. Kajang Hospital,
5. Permai Hospital, Johor Bahru, 6. Pharmaceutical Services Division, MOH.
The impact of mental and behavioural disorders does not only affect the individual concerned but extend onto
the families and communities. In 2000, it was estimated that neuropsychiatric disorders accounted for 12.3%
of Disability Adjusted Life Years (DALYs) [1].
Pharmacotherapy is one of the important treatment modalities in the holistic management of the various
psychiatric disorders. Antipsychotics was the group of drugs most consumed, comprising 53%,
followed by antidepressants (22%), anxiolytics, hypnotics and sedatives (21%) and drugs used in addictive
disorders (4%). In some of the Nordic countries, the hypnotics were among the top 10 most consumed medicines
in 2003 [2]. In the same publication, it was notable that the 1999-2003 drug consumption trends indicated that
the antipsychotic use was increased by 4-23%; whereas the antidepressants use escalated between 43-66%.
Eighty seven percent (87%) of typical antipsychotics were prescribed compared with 13% of atypical
antipsychotics. This pattern did not vary much from previous year’s data [3] and the prescribing practice was
the reverse in Australia [4]. The use of atypical antipsychotics was higher in the private sector (26%) as
compared to the public sector (13%). Although its use is recommended as first line treatment in a number of different
psychotic conditions [5, 6], the low usage of atypical antipsychotics locally might be due to its high cost.
The Selective Serotonin Reuptake Inhibitors (SSRI) was the highest consumed antidepressant (67%), followed
by Non-Selective Monoamine Reuptake Inhibitors (24.30%). The wide discrepancy between the SSRIs and
the use of other antidepressants could be due to its favourable safety profile and its approval for indications
for not only mood disorders but for anxiety disorders as well [7]. The prescription of the newer antidepressants
such as Mirtazapine, Venlafaxine and Duloxetine, among others, categorised under the Other Antidepressants
were much lower (7%).
The anxiolytics, sedatives and hypnotics were much more widely used in the private sector (69%) comparative
to the public sector (31%). This discrepancy could be explained by tendency of patients with anxiety [8]
and sleep disorders [9] to seek medical consultations from primary healthcare practitioners. In both facilities,
Alprazolam was the most commonly prescribed anxiolytic (N05B); 27% in private and 21% in public. Among
the hypnotics and sedatives (N05C); the benzodiazepine derivatives Midazolam was prescribed more in the
private sector, whereas usage of benzodiazepine related drug such as Zolpidem was comparable in both
sectors.
The use of drugs for addictive disorders was slightly higher in the private sector i.e. 56.3%. Drugs used for
opioid dependence, Methadone (56%) and Buprenorphine (42%) were widely prescribed. Drugs used for
alcohol dependence, Naltrexone; and for nicotine dependence, Nicotine; each only comprised of 1% usage.
The low consumption of nicotine (0.0017DDD/1000 population/day) was of concern in up scaling the smoking
cessation services considering the prevalence of established smokers in 2006 were 21.5%, of which 23.6%
were defined as heavy smokers [10].
103
CHAPTER 21
Table 21.1.1: Use of Anti-Psychotics by Drug Class, in DDD/1000 population/day 2006
ATC
N05A A
N05A B
N05A C
N05A D
N05A E
N05A F
N05A H
N05A K
N05A L
N05A N
N05A X
Phenothiazines with aliphatic side-chain
Phenothiazines with piperazine structure
Phenothiazines with piperidine structure
Butyr ophenone derivatives
Indole derivatives
Thioxanthene derivatives
Diazepines, oxazepines and thiazepines
Neuroleptics, in tardive dyskinesia
Benzamides
Lithium
Other antipsychotics
2006
0.4881
0.8033
0.0007
0.6728
0.0013
0.0693
0.136
<0.0001
0.31
0.029
0.2061
Table 21.1.2: Use of Anti-Psychotics by Drug Class and Agents, in DDD/1000 population/day 2006
ATC
2006
N05A A
Phenothiazines with aliphatic side-chain
N05A A01
Chlorpromazine
N05A B
Phenothiazines with piperazine structure
N05A B02
Fluphenazine
N05A B03
Perphenazine
N05A B04
Prochlorperazine
N05A B06
Trifluoperazine
N05A C
Phenothiazines with piperidine structure
N05A C02
Thioridazine
N05A D
Butyrophenone derivatives
N05A D01
Haloperidol
N05A E
Indole derivatives
N05A E04
Ziprasidone
N05A F
Thioxanthene derivatives
N05A F01
Flupentixol
N05A F05
Zuclopenthixol
104
Public
Private
Total
0.4835
0.0046
0.4881
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.5418
0.0115
0.5534
0.0224
0.0026
0.025
0.0818
0.0318
0.1136
0.1106
0.0009
0.1115
Public
Private
Total
<0.0001
0.0006
0.0007
Public
Private
Total
0.66
0.0128
0.6728
Public
Private
Total
0.0003
0.001
0.0013
Public
Private
Total
Public
Private
Total
0.0205
0.0015
0.022
0.0459
0.0014
0.0473
CHAPTER 21
ATC
N05A H
Diazepines, oxazepines and thiazepines
N05A H02
Clozapine
N05A H03
Olanzapine
N05A H04
Quetiapine
N05A K
Neuroleptics, in tardive dyskinesia
N05A K01
Tetrabenazine
N05A L
Benzamides
N05A L01
Sulpiride
N05A N
Lithium
N05A N01
Lithium
N05A X
Other antipsychotics
N05A X08
Risperidone
N05A X12
Aripiprazole
2006
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0887
0.0003
0.089
0.0296
0.0011
0.0307
0.0149
0.0014
0.0163
Public
Private
Total
<0.0001
<0.0001
Public
Private
Total
0.307
0.003
0.31
Public
Private
Total
0.0275
0.0014
0.029
Public
Private
Total
Public
Private
Total
0.2009
0.0034
0.2043
0.0002
0.0017
0.0018
Table 21.2.1: Use of Anti-Depressants by Drug Class, in DDD/1000 population/day 2006
ATC
N06A A
N06A B
N06A F
N06A G
N06A X
Non-selective monoamine reuptake inhibitors
Selective serotonin reuptake inhibitors
Monoamine oxidase inhibitors, non-selective
Monoamine oxidase A inhibitors
Other antidepressants
2006
0.2723
0.7504
<0.0001
0.018
0.0792
Table 21.2.2: Use of Anti-Depressants by Drug Class and Agents, in DDD/1000 population/day 2006
ATC
2006
N06A A
Non-selective monoamine reuptake inhibitors
N06A A02
Imipramine
N06A A04
Clomipramine
N06A A09
Amitriptyline
Public
Private
Total
Public
Private
Total
Public
Private
Total
105
0.029
0.0046
0.0336
0.0175
0.0011
0.0186
0.0906
0.0479
0.1384
CHAPTER 21
ATC
2006
N06A A10
Nortriptyline
N06A A16
Dosulepin
N06A A21
Maprotiline
N06A B
Selective serotonin reuptake inhibitors
N06A B03
Fluoxetine
N06A B04
Citalopram
N06A B05
Paroxetine
N06A B06
Sertraline
N06A B08
Fluvoxamine
N06A B10
Escitalopram
N06A F
Monoamine oxidase inhibitors, non-selective
N06A F04
Tranylcypromine
N06A G
Monoamine oxidase A inhibitors
N06A G02
Moclobemide
N06A X
Other antidepressants
N06A X03
Mianserin
N06A X06
Nefazodone
N06A X11
Mirtazapine
N06A X14
Tianeptine
106
Public
Private
Total
Public
Private
Total
Public
Private
Total
<0.0001
<0.0001
0.0626
0.0156
0.0782
0.0018
0.0016
0.0034
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.1119
0.028
0.1399
0.001
0.023
0.024
0.004
0.0073
0.0112
0.2392
0.0526
0.2918
0.1854
0.0276
0.213
0.0425
0.028
0.0705
Public
Private
Total
<0.0001
<0.0001
Public
Private
Total
0.0171
0.0009
0.018
Public
Private
Tota l
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0091
0.0038
0.0129
0.0171
0.0168
0.0339
0.0003
0.0065
0.0068
CHAPTER 21
ATC
N06A X16
Venlafaxine
N06A X21
Duloxetine
2006
Public
Private
Total
Public
Private
Total
0.0191
0.0047
0.0238
0.0002
0.0016
0.0018
Table 21.3.1: Use of Anxiolytics, Hypnotics and Sedatives by Drug Class, in DDD/1000 population/day
2006
ATC
Drug Class
2006
N05B A
N05B B
N05C C
N05C D
N05C F
N05C M
Diphenylmethane derivatives
Aldehydes and derivatives
Benzodiazepine related drugs
Other hypnotics and sedatives
0.7978
0.1404
0.0139
0.2149
0.1617
<0.0001
Table 21.3.2: Use of Anxiolytics, Hypnotics and Sedatives by Drug Class and Agents, in DDD/1000
population/day 2006
ATC
2006
N05B A
N05B A01
Diazepam
N05B A02
Chlordiazepoxide
N05B A05
Potassium clorazepate
N05B A06
Lorazepam
N05B A08
Bromazepam
N05B A09
Clobazam
N05B A12
Alprazolam
N05B B
Diphenylmethane derivatives
N05B B01
Hydroxyzine
N05C C
Aldehydes and derivatives
N05C C01
Chloral hydrate
107
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0656
0.1552
0.2209
0.0061
0.0061
0.0195
0.0195
0.0834
0.0939
0.1773
0.0063
0.0219
0.0282
0.0013
0.0128
0.0141
0.0856
0.2461
0.3317
Public
Private
Total
0.0522
0.0882
0.1404
Public
Private
Total
0.006
0.008
0.0139
ATC
N05C C05
Paraldehyde
N05C D
N05C D01
Flurazepam
N05C D02
Nitrazepam
N05C D05
Triazolam
N05C D08
Midazolam
N05C F
Benzodiazepine related drugs
N05C F01
Zopiclone
N05C F02
CHAPTER 21
2006
Zolpidem
N05C M
Other hypnotics and sedatives
N05C M05
Scopolamine
Public
Private
Total
<0.0001
<0.0001
<0.0001
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0004
0.0004
0.0019
0.0169
0.0189
0.0192
0.0192
0.0524
0.1241
0.1764
Public
-
Private
0.0292
Total
0.0292
Public
Private
Total
0.0601
0.0725
0.1325
Public
Private
Total
<0.0001
<0.0001
<0.0001
Table 21.4.1: Use of Drugs used in Additive Disorder by Drug Class, in DDD/1000 population/day 2006
ATC
2006
N07B
N07B A
N07B B
N07B C
DRUGS USED IN ADDICTIVE DISORDERS
Drugs used in nicotine dependence
Drugs used in alcohol dependence
Drugs use d in opioid dependence
0.1708
0.0017
0.0014
0.1678
Table 21.4.2: Use of Drugs used in Additive Disorder by Drug Class and Agents, in DDD/1000 population/
day 2006
ATC
N07B A
Drugs used in nicotine dependence
N07B A01
Nicotine
N07B B
Drugs used in alcohol dependence
N07B B04
Naltrexone
N07B C
Drugs used in opioid dependence
N07B C01
Buprenorphine
108
2006
Public
Private
Total
0.0005
0.0011
0.0017
Public
Private
Total
0.001
0.0004
0.0014
Public
Private
Total
0.0018
0.0695
0.0713
CHAPTER 21
ATC
N07B C 02
Methadone
N07B C51
Buprenorphine, combinations
2006
Public
Private
Total
Public
Private
Total
0.0713
0.0251
0.0964
<0.0001
<0.0001
References:
1. World Health Report 2001.
2. Nordic Medico Statistico Committee 2004. Medicines Consumption in The Nordic Countries 1999-2003.
3. Pharmaceutical Services Division and the Clinical Research Centre, Ministry of Health, Malaysia 2007.
Malaysian Statistics on Medicine 2005.
4. Commonwealth of Australia 2008. Australian Statistics on Medicine 2006.
5. Kane JM, Leucht S, Carpenter D, et al, The Expert Consensus Guideline Series: Optimising pharmacologic
treatment of psychotic disorders. J Clin Psychiatry 2003; 64 (Suppl 12):1-100.
6. Weiden PJ, Preskorn SH, Fahnestock PA, et al. Translating the psychopharmacology of antipsychotics to
individualized treatment for severe mental illness: A roadmap. J Clin Psychiatry 2006; 68 (Suppl 7):1-46.
7. Stein DJ. Serotonergic Neurocircuitry in Mood and Anxiety Disorders. London, UK. Martin Dunitz Ltd.
2003.
8. Sartorius N, Ustun TB, Lecrubier Y, Wittchen HU. Depression comorbid with anxiety: Results from the
WHO study on psychological disorders in primary health care. Br J Psychiatry 1996; 168(Suppl 30):38-43.
9. G Hajak. Insomnia in Primary Care. Sleep 2000; 23 (Suppl 3): S54-S63.
10. Institute for Public Health (IPH) 2008. The Third National Health and Morbidity Survey (NHMS III) 2006,
Vol 2, Ministry of Health Malaysia.
109
CHAPTER 22: USE OF MEDICINES FOR OBSTRUCTIVE
AIRWAY DISEASES
Edited by:
Pang YK1, Abdol Malek AZ2, Aziah AM3, Samsinah HH4, Joanne L5, Mat Zuki MJ6, Norhaya R7, Shahirah Z8
1. University of Malaya Medical Centre, 2. Pharmacy, Melaka Hospital, 3. Institute of Respiratory
Medicine, Kuala Lumpur Hospital, 4. Department of Pharmacy, University Malaya, 5. Pharmacy, Kuala Lumpur
Hospital, 6. Raja Perempuan Zainab II Hospital, Kota Bharu, 7. Sultanah Nur Zahirah Hospital, Kuala Terengganu,
7. Pharmacy, Selayang Hospital
In clinical practice, asthma and chronic obstructive pulmonary disease (COPD), classified under obstructive
airway diseases, are considered the two common diseases. Many of the drugs used in these diseases are
quite similar, although the indications and the effects of drugs may differ considerably between the two. Data
reported in this survey were based on the statistics of drug procurement and hence did not differentiate between
those used in asthma from those used in COPD. To gain more insight into the prescribing trend and behaviour, it
would be more appropriate in the future to separate the usage of drugs for asthma and COPD into the two
different diseases.
In asthma, inhaled glucocorticoids used as monotherapy or in combination with long-acting ß2 agonist
are indicated for maintenance therapy. Use of long-acting ß2 agonists may prevent the need to increase
the inhaled dose of glucocorticoids. Inhaled glucocorticoids and long-acting ß2 agonist are also used in
patients with COPD, particularly in those with frequent exacerbations and those whose spirometry show
significant FEV1 reversibility. On the other hand, short acting ß2 agonists (termed as “rescue” agents) are
indicated for relief of acute reversible airway obstruction in patients with asthma and COPD. Based on
these recommendations, one would expect that the usage of inhaled glucocorticoids should far exceed
that of ß2 agonists; however, in this survey, the usage of ß2 agonists (4.6693) was still higher than that
of glucocorticoids (2.3883). This seems to suggest that inhaled glucocorticoids are underused in the treatment
of asthma and this might have resulted in many patients with uncontrolled asthma and increase usage of
rescue ß2 agonists.
Based on this survey, of the various inhaled glucocorticoids, budesonide was the most popular agent used. The
usage of ciclesonide was still low as it was a new agent in this group. The latter is used in a small number
of patients in government hospitals with specialists. Inhaled salbutamol on the other hand was the most popular
ß2 agonist used to relieve symptoms.
The use of oral ß2 agonists was still alarmingly high (5.5604). Although the oral route has the advantage of
ease and simplicity of administration, in terms of clinical effects this is not the preferred route. This showed
that the move to encourage doctors to change the prescription of reliever drugs from oral route to the inhaled
method has not yet been very successful. This trend seems to be more deeply entrenched for those in the private
sector.
Leukotriene receptor antagonists (e.g. montelukast) are recommended for those who have mild to moderate
asthma as a monotherapy or used as an add-on for those whose asthma are still not well control despite
receiving other agents. This drug is also particularly useful in controlling asthma resulting from certain
triggers such as exercise-induced asthma, aspirin-induced asthma and allergen-induced asthma. It is easy to take
(oral tablet once at night) but is still quite costly. The survey showed that the private sector tend to use it more
often than the public sector. This may be that patients in the private sector could better afford this treatment.
The use of montelukast in the public hospitals is restricted by the number of patients allowed to be prescribed the
drug.
The use of Seretide® (accuhaler) is higher than Symbicort® (turbohaler) which is reflective of current practice.
Both these drugs are costly and due to their unique presentation, the patients’ therapeutic outcomes are monitored,
either in the ward or, in some government hospitals, during consultation at the Medication Therapy Adherence
Clinics (MTAC) by the pharmacists. The new drug for asthma management, omalizumab (an anti-Ig E antibody)
was not included in this report as it was not yet available in 2006 in Malaysia.
111
AIRWAY DISEASES
Table 22.1: Use of Medicines for Obstructive Airway Diseases by Drug Class, in DDD/1000 population/day
2006
ATC
2006
R03A C
R03A K
R03B A
R03B B
R03B C
R03C A
R03C C
R03D A
R03D C
Selective beta-2-adrenoreceptor
agonists
Adrenergics and other drugs for obstructive airway diseases
Glucocorticoids
Anticholinergics
Antiallergic agents, excl. corticosteroids
Alpha-and beta-adrenoreceptor agonists
Selective beta-2-adrenoreceptor agonists
Xanthines
Leukotriene receptor antagonists
4.6693
1.6081
2.3883
0.5069
0.0496
5.5604
1.5931
0.1436
Table 22.2: Use of Medicines for Obstructive Airway Diseases by Drug Class and Agents, in DDD/1000
population/day 2006
ATC
R03A C
R03A C02
Salbutamol
R03A C03
Terbutaline
R03A C04
Fenoterol
R03A C12
Salmeterol
R03A C13
Formoterol
R03A K
Adrenergics and other drugs for obstructive airway diseases
R03A K03
Fenoterol and other drugs for obstructive airway diseases
R03A K04
Salbutamol and other drugs for obstructive airway diseases
R03A K06
Salmeterol and other drugs for obstructive airway diseases
R03A K07
Formoterol and other drugs for obstructive airway diseases
R03B A
Glucocorticoids
R03B A01
Beclometasone
112
2006
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
4.024
0.3237
4.3477
0.016 2
0.0274
0.0436
0.0073
0.001
0.0083
0.0084
0.0002
0.0086
0.2551
0.006
0.2611
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0226
0.0226
0.3962
0.1024
0.4986
0.2208
0.4593
0.6801
0.3086
0.0983
0.406 9
Public
Private
Total
0.5753
0.0277
0.6029
AIRWAY DISEASES
ATC
2006
R03B A02
Budesonide
Public
Private
Total
1.5432
0.1962
1.7393
R03B A05
Fluticasone
R03B A08
Ciclesonide
Public
Private
Total
Public
Private
Total
0.0189
<0.0001
0.019
<0.0001
0.027
0.0271
R03B B
Anticholinergics
R03B B01
Ipratropium bromide
R03B B04
Tiotropium bromide
Public
Private
Total
Public
Private
Total
0.4182
0.0527
0.4709
0.0165
0.0195
0.036
Public
Private
Total
-
Public
Private
Total
0.0445
0.0051
0.0496
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.6566
1.8439
2.5005
0.1697
2.8792
3.049
0.0016
0.0016
0.0064
0.0064
0.003
0.003
Public
Private
Total
Public
Private
Total
1.1004
0.4886
1.589
0.0028
0.0014
0.0042
Public
Private
Total
0.0372
0.1064
0.1436
R03B C
R03B C01
Cromoglicic acid
R03C A
Alpha-and beta-adrenoreceptor agonists
R03C A02
Ephedrine
R03C C
R03C C02
Salbutamol
R03C C03
Terbutaline
R03C C04
Fenoterol
R03C C08
Procaterol
R03C C12
Bambuterol
R03D A
Xanthines
R03D A04
Theophylline
R03D A05
Aminophylline
R03D C
Leukotriene receptor antagonists
R03D C03
Montelukast
113
AIRWAY DISEASES
References:
1. Global Strategy for Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease
(Updated 2008).
114
CHAPTER 23: USE OF ANTIHISTAMINES
AND NASAL DECONGESANTS
Edited by:
Saraiza AB1, Anura M2, Noormah MD3
1. Serdang Hospital, 2. University Malaya Medical Centre, 3. Medical Development Division, MOH
Nasal decongestants and antihistamines are commonly used drugs for allergy and nasal symptoms in
Otorhinolaryngology clinics in Malaysia. The 2006 survey showed usage of 0.9592DDD/population/year and
the usage of anti-histamines for systemic use was 4.4422 DDDs/population/year.
In the present survey, the drugs were classified into several types which include nasal decongestants for
topical use and systemic use. For local applications it was divided into plain sympathomimetics, anti-allergic without
corticosteroid and corticosteroids. The nasal decongestant for systemic use was mainly sympatomimetics.
The most utilised nasal decongestants were corticosteroid based nasal decongestants. Its usage was very high
compared to other topical decongestants. Newer generation corticosteroids usage was much higher in the
private sector. Generic corticosteroids such as beclomethasone and budesonide had lost popularity in the private
sector but not the public sector. Some plain topical decongestants especially oxymetazoline were persistently used
in both private and public healthcare sectors. Pseudoephedrine combinations were widely used systemic nasal
decongestants in both sectors.
Antihistamines can be divided into several subgroups that is sedative and non sedative. Non sedative
antihistamines are gaining popularity especially the newer generation groups. There was broad use of
sedative antihistamines in the private sector but less in numbers compared to public sector. Some drugs listed were
not available for use in the public sector. Usage of second and third generation antihistamines especially
cetirizine, loratadine and desloratadine were frequent in public and private sectors but the usage in private was
much higher. This factor may be attributed to the availability and the prescription that does not require specialist
countersignature.
Comparing our systemic antihistamine usage in 2006 with the Australian statistics on medicines, we found that
the Australians had lower usage of antihistamines. Usage of topical nasal decongestants was comparatively
lower in Malaysia then Australia. Usage of steroid based decongestant especially mometasone was high in
Australia. Use of other drugs was fairly the same in both countries.
Table 23.1: Use of Anti-Histamines and Nasal Decongestants, in DDD/1000 population /day 2006 and DDD/
population/year
ATC
2006
2006
(DDDs/population/year
R01
R06
NASAL PREPARATIONS
2.6279
12.1703
0.9592
4.4422
Table 23.2.1: Use of Nasal Decongestants by Drug Class, in DDD/1000 population/day 2006
ATC
2006
2006
R01A
DECONGES TANTS AND OTHER NASAL
PREPARATIONS FOR TOPICAL USE
Sympathomimetics, plain
Corticosteroids
NASAL DECONGESTANTS FOR SYSTEMIC USE
Sympathomimetics
1.2602
0.46
0.2781
<0.0001
0.982
1.3677
0.1015
<0.0001
0.3584
0.4992
1.3677
0.4992
R01A A
R01A C
R01A D
R01B
R01B A
115
Table 23.2.2: Use of Nasal Decongestants by Drug Class and Agents, in DDD/1000 population/day 2006
2006
ATC
2006
R01A A
Sympathomimetics, plain
R01A A03
Ephedrine
R01A A05
Oxymetazoline
R01A A07
Xylometazoline
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0007
0.0002
0.0008
0.0516
0.2145
0.2661
0.0112
0.0112
0.0003
<0.0001
0.0003
0.0188
0.0783
0.0971
0.0041
0.0041
Public
Private
Total
<0.0001
<0.0001
<0.0001
<0.0001
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0637
0.0113
0.075
0.406
0.0923
0.4983
0.0003
0.1214
0.1217
0.1204
0.1337
0.2542
<0.0001
0.0328
0.0329
0.0233
0.0041
0.027 4
0.1482
0.0337
0.1819
0.0001
0.0443
0.0444
0.044
0.0488
0.0928
<0.0001
0.012
0.012
Public
Private
Total
Public
Private
Total
0.0147
0.0147
0.4097
0.9432
1.353
0.0054
0.0054
0.1496
0.3443
0.4938
R01A C
R01A C01
Cromoglicic acid
R01A D
Corticosteroids
R01A D01
Beclometasone
R01A D05
Budesonide
R01A D08
Fluticasone
R01A D09
Mometasone
R01A D11
Triamcinolone
R01B A
Sympathomimetics
R01B A02
Pseudoephedrine
R01B A52
Pseudoephedrine,
combinations
Table 23.3.1: Use of Anti-Histamines by Drug Class, in DDD/1000 population/day 2006
ATC
2006
2006
R06A
R06A A
R06A B
R06A D
R06A E
R06A X
Aminoalkyl ethers
Substituted alkylamines
Phenothiazine derivatives
Piperazine derivatives
Other antihistamines for systemic use
12.1704
0.7964
5.3686
1.2842
1.858
2.8631
116
4.4422
0.2907
1.9596
0.4687
0.6782
1.045
Table 23.3.2: Use of Anti-Histamines by Drug Class and Agents, in DDD/1000 population/day 2006
ATC
2006
2006
R06A A
Aminoalkyl ethers
R06A A02
Diphenhydramine
R06A A04
Clemastine
R06A A08
Carbinoxamine
R06A B
Substituted alkylamines
R06A B01
Brompheniramine
R06A B02
Dexchlorpheniramine
R06A B04
Chlorphenamine
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.6028
0.1772
0.78
0.0086
0.0086
0.0078
0.0078
0.22
0.0647
0.2847
0.0032
0.0032
0.0028
0.0028
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0114
0.0114
0.0486
1.3559
1.4045
2.5619
1.3908
3.9527
0.0042
0.0042
0.0177
0.4949
0.5126
0.9351
0.5076
1.4427
Public
Private
Total
Public
Private
Total
0.8492
0.4305
1.2797
0.0045
0.0045
0.31
0.1571
0.4671
0.0017
0.0017
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0004
0.0306
0.031
0.0002
0.0041
0.0044
0.2259
1.5065
1.7324
0.0005
0.0897
0.0903
0.0001
0.0112
0.0113
<0.0001
0.0015
0.0016
0.0824
0.5499
0.6323
0.0002
0.0328
0.0329
0.0904
0.0173
0.1077
0.0014
0.0014
0.033
0.0063
0.0393
0.0005
0.0005
R06A D
Phenothiazine derivatives
R06A D02
Promethazine
R06A D07
Mequitazine
R06A E
Piperazine derivatives
R06A E01
Buclizine
R06A E05
Meclozine
R06A E07
Cetirizine
R06A E09
Levocetir izine
R06A X
Other antihistamines for systemic use
R06A X07
Triprolidine
R06A X09
Azatadine
Public
Private
Total
Public
Private
Total
117
ATC
R06A X12
Terfenadine
R06A X13
Loratadine
R06A X17
Ketotifen
R06A X18
Acrivastine
R06A X26
Fexofenadine
R06A X27
Desloratadine
2006
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0014
0.0014
0.7417
1.436
2.1777
0.2121
0.2121
0.0019
0.0019
0.008
0.1455
0.1535
0.0463
0.1611
0.2074
2006
0.0005
0.0005
0.2707
0.5241
0.7949
0.0774
0.0774
0.0007
0.0007
0.0029
0.0531
0.056
0.0169
0.0588
0.0757
References:
1. Vernacchio L, Kelly JP, Kaufman DW, Mitchell AA, Pseudoephedrine use among US children, 1999-2006:
results from the Slone survey. Pediatrics. 2008 Dec; 122(6):1299-304.
2. Ryan T, Brewer M, Small L, Over-the-counter cough and cold medication use in young children. Pediatric
Nur 2008 Mar-Apr; 34(2):174-80, 184.
3. Coleman C, Moore M. Decongestants and antihistamines for acute otitis media in children. Cochrane
Database Syst Rev. 2008 Jul 16; (3):CD001727.
118
CHAPTER 24
USE OF OPHTHALMOLOGICALS
Edited by:
Bethel L1, Goh PP2, Thiageswari U3, Thayanitu S4, Gong VHM5, Fadilah O2, Choong CL2
1. Tunku Jaafar Hospital, Seremban, 2. Selayang Hospital, 3. Kuala Lumpur Hospital, 4. TAR Hospital, Klang,
5. Raja Permaisuri Bainun Hospital, Ipoh
The National Medicine Use Survey 2006 had results on common ophthalmological agents used in Malaysia.
These include anti-infectives for the treatment of ocular infections, steroidals and steroidal and anti-infective
combinations for inflammatory eye conditions and eyes following surgery, i ntraocular pressure (IOP)
reducing agents for glaucoma, anticholinergic or sympathomimetic mydriatics, sympathomimetics for decongestion,
antiallergics for allergic conjunctivitis, topical anaesthesia used as adjunct or as single anaesthesia during
ocular surgery and antineovascularisation agents in the treatment of various retinal vascular conditions such as
proliferative diabetic retinopathy and age related macular degeneration. The survey participants were mainly
public health care providers (MOH and University), private hospitals and private general practitioners. It did not
include individual private practice ophthalmologists.
Drug utilisation statistics are generally expressed as defined daily dose (DDD), the assumed average dose per day
of a drug used for its main indication by adults, as the standard unit for reference. However, except for
anti-glaucoma agents, no DDD have been assigned yet by the WHO for the ophthalmologicals. Thus, for the
purpose of this report on Malaysian statistics on drug utilisation, the total usage in this chapter for drugs, other
than anti-glaucoma agents, is expressed in gram or ml or cc, per 1000 population (pop) per day, irrespective of the
strength of the preparations.
The commonest topical antibiotic used in both public and private sector for 2006 was chloramphenicol
(1.12DDD/1000 population/day), followed by gentamicin (0.089), fusidic acid (0.032) and ciprofloxacin (0.019).
Chloramphenicol was the commonest prescribed topical antiinfective because it is readily available, can be
prescribed by all categories of medical practitioners and primary care doctors, and is affordable. Being broad spectrum,
it is prescribed for the treatment of conjunctivitis, the most common eye condition presenting to primary care centres. 1,2
Among anti-inflammatory steroidal eye drops, betamethasone (0.023DDD/1000 population/day) and
dexamethasone (0.022) were commonly used. Prednisolone and fluromethalone were sparingly used in the
public sector as it is not freely available. Among anti-inflammatory non-steroidal eye drops, ketorolac, was more
commonly used (0.0068DDD) as compared to diclofenac and indometacin.
Among steroidal and anti-infective combination, dexamethasone and anti-infective combination was the
commonest used (0.133DDD/1000 population/day). Steroidal and anti-infective combinations were prescribed
more than plain steroidal agents because of their wider indication including post-operative prophylaxis, ocular
infection and ocular trauma.
Glaucoma is the second leading cause of blindness worldwide. Based on population-based studies in Singapore,
the age and sex specific prevalence of glaucoma in Malays was 3.4%3, and Chinese was 3.2% 4. Prevalence
of glaucoma increases with age. Most patients are treated medically and often lifelong. Some of them need more
than one drug to control disease progression, and above all, anti-glaucoma agents are costly. The 2006 survey
have results on 11 anti-glaucoma agents. Among them, timolol was the most commonly used (0.552DDD/1000
population/day), followed by latanoprost (0.284), dorzolamide (0.105), betaxolol (0.094). The other less
commonly used anti glaucoma agents were: brimonidine (0.049), pilocarpine (0.045), brinzolamide (0.041),
travoprost (0.014) and bimatoprost (0.013). The 4 most commonly prescribed anti–glaucoma agents derive from
3 pharmacologic classes, namely beta blocker (timolol and betaxolol), prostaglandin analogue (latanoprost) and
carbonic anhydrase inhibitors (dorzolamide). Clinical practice guidelines on management of primary open angle
glaucoma recommend that topical beta blockers and prostaglandin analogues are the most cost-effective IOP
lowering agents5. The findings in this survey indicated that the prescribing pattern among ophthalmologists appear
to be in compliance with the recommendation. Findings from the MOH Ophthalmology Service Census in 2007
showed that MOH Ophthalmology departments spent more than 50% of their drug allocation on anti-glaucoma
agents. The expenditure on anti-glaucoma drugs will continue to rise due to increasing aging population.
119
CHAPTER 24
The commonest anti-allergic agent was cromoglicic acid and commonest local anaesthetic was proxymetacaine.
Among the anti-neovascularization agents, verteporfin was the commonest used in 2006.
Table 24.1: Use of Ophthalmological by Drug Class and Agents, in total dosage/1000 population/day 2006
ATC
Unit
2006
S01A A
Antibiotics
S01A A01
Chloramphenicol
g/ml/cc
S01A A02
Chlortetr acycline
g/ml/cc
S01A A03
Neomycin
g/ml/cc
S01A A09
Tetracycline
g/ml/cc
S01A A10
Natamycin
g/ml/cc
S01A A11
Gentamicin
g/ml/cc
S01A A12
Tobramycin
g/ml/cc
S01A A13
Fusidic acid
g/ml/cc
S01A A17
Erythromycin
g/ml/cc
S01A A18
Polymyxin B
g/ml/cc
S01A A20
Antibiotics in combination with other drugs
g/ml/cc
S01A A30
Combinations of different antibiotics
g/ml/cc
S01A B04
Sulfacetamide
g/ml/cc
S01A D
Antivirals
S01A D03
Aciclovir
g/ml/cc
S01A D05
Interferon
g/ml/cc
120
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.8457
0.2754
1.1211
0.0005
0.0012
0.0017
0.0002
0.0002
0.0009
0.0009
0.0005
0.0002
0.0007
0.0168
0.0725
0.0893
0.0001
0.005
0.0051
0.0087
0.023 1
0.0318
0.001
0.001
<0.0001
<0.0001
0.001
0.001
0.0012
0.0211
0.0222
0.003
0.003
Public
Private
Total
Public
Private
Total
0.002
0.0009
0.0029
<0.0001
<0.0001
CHAPTER 24
ATC
S01A X
Other antiinfectives
Unit
S01A X11
Ofloxacin
g/ml/cc
S01A X12
Norfloxacin
g/ml /cc
S01A X13
Ciprofloxacin
g/ml/cc
S01A X17
Lomefloxacin
g/ml/cc
S01A X19
Levofloxacin
g/ml/cc
S01A X22
Moxifloxacin
g/ml/cc
2006
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0015
0.0002
0.0016
0.0006
0.0066
0.0071
0.0104
0.009
0.0194
0.0019
0.0019
<0.0001
0.0005
0.0005
0.0003
0.0003
Table 24.2: Use of Ophthalmological by Drug Class and Agents, in total dosage/1000 population/day
2006
ATC
Unit
2006
S01B A
Corticosteroids, plain
S01B A01
Dexamethasone
g/ml/cc
S01B A04
Prednisolone
g/ml/cc
S01B A06
Betamethasone
g/ml/cc
S01B A07
Fluorometholone
g/ml/cc
S01B C
Antiinflammatory agents, non-steroids
S01B C01
Indometacin
g/ml/cc
S01B C03
Diclofenac
g/ml/cc
S01B C05
Ketorolac
g/ml/cc
121
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0191
0.003
0.0221
0.0006
0.0117
0.0123
0.0223
0.0011
0.0234
0.0023
0.0071
0.0094
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0004
0.0004
0.0002
0.0002
0.0025
0.0043
0.0068
CHAPTER 24
2006
ATC
Unit
2006
S01C A
Corticosteroids and antiinfectives in combination
S01C A01
Dexamethasone and antiinfectives
g/ml/cc
S01C A05
Betamethasone and antiinfectives
g/ml/c c
S01C A07
Fluorometholone and antiinfectives
g/ml/cc
S01C B04
Betamethasone
g/ml/cc
S01C C01
Diclofenac and anti infectives
g/ml/cc
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0292
0.1038
0.133
0.0083
0.0062
0.0145
0.0011
0.0011
0.0006
0.0006
0.0084
0.0084
Table 24.4.1: Use of Ophthalmological by Drug Class and Agents, in DDD/1000 population/day 2006
ATC
S01E A
Sympathomimetics in glaucoma therapy
S01E A05
Brimonidine
S01E B
Parasympathomimetics
S01E B01
Pilocarpine
S01E B02
Carbachol
S01E C
Carbonic anhydrase inhibitors
S01E C01
Acetazolamide
S01E C03
Dorzolamide
S01E C04
Brinzolamide
S01E D
Beta blocking agents
S01E D01
Timolol
S01E D02
Betaxolol
122
2006
Public
Private
Total
0.0309
0.0181
0.0489
Public
Private
Total
Public
Private
Total
0.0374
0.0075
0.0449
0.0039
0.0011
0.005
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0214
0.0058
0.0273
0.1007
0.0046
0.1052
0.0356
0.0055
0.041
Public
Private
Total
Public
Private
Total
0.4858
0.0665
0.5522
0.0683
0.0257
0.094
CHAPTER 24
ATC
S01E D03
Levobunolol
S01E E
Prostaglandin analogues
S01E E01
Latanoprost
S01E E03
Bimatoprost
S01E E04
Travoprost
2006
Public
Private
Total
0.0012
0.0012
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.2684
0.0153
0.2837
<0.0001
0.0129
0.0129
0.006
0.0075
0.0135
Table 24.4.2: Use of Ophthalmological by Drug Class and Agents, in total dosage/1000 population/day
2006
ATC
S01E D
Beta blocking agents
Unit
S01E D51
Timolol, combinations
g/ml/cc
2006
Public
Private
Total
0.0002
0.0016
0.0018
2006
ATC
S01F A
Anticholinergics
Unit
S01F A01
Atropine
g/ml/cc
S01F A04
Cyclopentolate
g/ml/cc
S01F A05
Homatropine
g/ml/cc
S01F A06
Tropicamide
g/ml/cc
S01F B
Sympathomimetics excl. antiglaucoma preparations
S01F B0 1
Phenylephrine
g/ml/cc
123
2006
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0063
0.001
0.0073
0.0042
0.0024
0.0066
0.0108
0.0027
0.0136
0.0202
0.0057
0.026
Public
Private
Total
0.009
0.0026
0.0116
CHAPTER 24
2006
ATC
Unit
2006
S01G A
Sympathomimetics used as decongestants
S01G A01
Naphazoline
g/ml/cc
S01G A02
Tetryzoline
g/ml/cc
S01G A51
Naphazoline, combinations
g/ml/cc
S01G A52
Tetryzoline, combinations
g/ml/cc
S01G A55
Phenylephrine, combinations
g/ml/cc
S01G X
Other antiallergics
S01G X01
Cromoglicic acid
g/ml/cc
S01G X05
Lodoxamide
g/ml/cc
S01G X06
Emedastine
g/ml/cc
S01G X09
Olopatadine
g/m l/cc
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0073
0.0073
0.0228
0.0228
0.0072
0.0072
0.0082
0.0165
0.0247
0.0004
0.0018
0.0021
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0308
0.0284
0.0592
0.0029
0.0029
0.0026
0.0026
0.0007
0.006
0.0068
2006
ATC
S01H A
Local anaesthetics
Unit
S01H A02
Oxybuprocaine
g/ml/cc
S01H A03
Tetracaine
g/ml/cc
S01H A04
Proxymetacaine
g/ml/cc
124
2006
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0003
0.0002
0.0006
0.0006
0.0001
0.0007
0.0167
0.006
0.0227
CHAPTER 24
2006
ATC
Unit
2006
S01L A
Antineovascularisation agents
S01L A01
Verteporfin
mg
S01L A03
Pegaptanib
g/ml/cc
S01L A04
Ranibizumab
g/ml/cc
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0003
0.0003
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
ATC
Unit
2006
S01X A
Other ophthalmologicals
S01X A13
Alteplase
g/ml/cc
Public
Private
Total
<0.0001
<0.0001
ATC
S03A A
Antiin fectives
Unit
S03A A06
Gentamicin
g/ml/cc
S03A A08
Chloramphenicol
g/ml/cc
2006
Public
Private
Total
Public
Private
Total
0.0022
0.0136
0.0158
0.0005
0.0005
ATC
S03B A
Corticosteroids
Unit
S03B A03
Betamethasone
g/ml/cc
2006
Public
Private
Total
0.0022
0.0012
0.0033
ATC
S03C A
Unit
Corticosteroids and antiinfectives in combination
S03C A01
Dexamethasone and antiinfectives
g/ml/cc
S03C A06
Betamethasone and antiinfectives
g/ml/cc
125
2006
Public
Private
Total
Public
Private
Total
<0.0001
0.1409
0.141
0.0028
0.0096
0.0124
CHAPTER 24
References:
1. Dart, JK. Eye disease at a community health centre. Br Med J (Clin Res Ed) 1986; 293:1477.
2. Leibowitz, HM. The red eye. N Engl J Med 2000; 343:345.
3. Sunny Y Shen, Tien Y Wong, Paul J Foster, et al. The Prevalence and Types of Glaucoma in Malay People:
The Singapore Malay Eye Study. IOVS 2008 (in print).
4. Poster PJ, Oen FT, Machin D, et al. The prevalence of glaucoma in Chinese residents of Singapore: a cro
sectional population survey of the Tanjong Pagar district. Arch Ophthalmol 2000; 118:1105-11.
5. Clinical Practice Guidelines on Management of Primary Open Angle Glaucoma. MOH Publication. MOH/P
PAK/159.O8 (GU) Feb 2008.
126
CHAPTER 25
USE OF OTOLOGICALS
Edited by:
Saraiza AB1, Anura M2, Noormah MD3
1. Serdang Hospital, 2. University Malaya Medical Centre, 3. Medical Development Division MOH
Drug utilisation statistics are generally expressed as defined daily dose (DDD), the assumed average dose per
day of a drug used for its main indication by adults, as the standard unit for reference. However, no DDD
have been assigned yet by the WHO for the otologicals. Thus, for the purpose of this chapter report, the total
usage for otological drugs is expressed in gram or ml or cc, per 1000 population (pop) per day, irrespective of
the strength of the preparations.
Otological preparations used in Malaysia are classified into local antibiotic ear drops, local steroid ear drops
and combination antibiotic and steroid ear drops. The 2006 national survey showed that the private sector used
a wider variety of otological drugs compared to the public sector. The use of combination antibiotic and steroid
ear drops were much higher in the private sector, 3.5 times more than the amount used in public hospitals;
while antibiotic preparations alone were more commonly used in public hospitals, 2.7 times more than the
private sector. Steroid alone preparations were used only in the public hospitals. The total usage of otological
preparations were 0.2725g/ml per 1000 population per day.
Table 25: Use of Otologicals by Drug Class and Agents, in total dosage/1000 population/day 2006
ATC
S02A A
Antiinfectives
Unit
S02A A01
Chloramphenicol
g/ml/cc
S02A A07
Neomycin
g/ml /cc
S02A A11
Polymyxin B
g/ml/cc
S02A A14
Gentamicin
g/ml/cc
2006
Public
Private
Total
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.1605
0.0507
0.2112
0.0007
0.0007
0.0067
0.0067
0.0014
0.0014
Table 25.2: Use of Otologicals by Drug Class and Agents, in total dosage/1000 population/day 2006
ATC
S02B A
Corticosteroids
Unit
S02B A07
Betamethasone
g/ml/cc
127
2006
Public
Private
Total
0.0017
0.0017
CHAPTER 25
USE OF OTOLOGICALS
Table 25.3: Use of Otologicals by Drug Class and Agents, in total dosage/1000 population/day 2006
ATC
S02C A
Unit
Corticosteroids and antiinfectives incombination
S02 C A03
Hydrocortisone and antiinfectives
g/ml/cc
S02C A04
Triamcinolone and antiinfectives
g/ml/cc
S02C A06
Dexameth asone and antiinfectives
g/ml/cc
2006
Public
Private
Total
Public
Private
Total
Public
Private
Total
0.0013
0.0091
0.0104
0.0083
0.0055
0.0138
0.0259
0.0007
0.0266
References:
1. Poetker DM, Lindstrom DR, Patel NJ, Conley SF, Flanary VA, Link TR, Kerschner JE, Ofloxacin otic drops
vs neomycin-polymyxin B otic drops as prophylaxis against early postoperative tympanostomy tube
otorrhea: Arch Otolaryngol Head Neck Surg. 2006 Dec; 132(12):1294-8.
2. Coleman C, Moore M. Decongestants and antihistamines for acute otitis media in children. Cochrane
Database Syst Rev. 2008 Jul, 16; (3):CD001727.
128
APPENDIX 1
PARTICIPANTS OF THE NATIONAL MEDICINES USE SURVEY
Hospitals participating in NMUS survey
#
Ministry of Health Hospitals
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
Hospital Alor Gajah
Hospital Ampang
Hospital Bahagia Ulu Kinta
Hospital Balik Pulau
Hospital Baling
Hospital Banting
Hospital Batu Gajah
Hospital Batu Pahat
Hospital Bau
Hospital Beaufort
Hospital Beluran
Hospital Bentong
Hospital Besut
Hospital Betong
Hospital Bintulu
Hospital Bukit Mertajam
Hospital Changkat Melintang
Hospital Daerah Lawas
Hospital Daro
Hospital Duchess of Kent, Sandakan
Hospital Dungun
Hospital Gerik
Hospital Gua Musang
Hospital Hulu Terengganu
Hospital Jasin
Hospital Jelebu
Hospital Jeli
Hospital Jempol
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
Hospital Kuala Kubu Bharu
Hospital Kuala Lipis
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
91.
92.
93.
94.
Hospital Kuala Lumpur
Hospital Kuala Nerang
Hospital Kuala Penyu
Hospital Kudat
Hospital Kulim
Hospital Kunak
Hospital Labuan
Hospital Lahad Datu
Hospital Langkawi
Hospital Likas
Hospital Limbang
Hospital Lundu
Hospital Machang
Hospital Marudi
Hospital Melaka
Hospital Mersing
Hospital Mesra Bukit Padang
Hospital Miri
Hospital Muadzam Shah
Hospital Mukah
Hospital Pakar Sultanah Fatimah, Muar
Hospital Papar
Hospital Parit Buntar
Hospital Pasir Mas
Hospital Pekan
Hospital Permai
Hospital Pitas
Hospital Pontian
Hospital Port Dickson
Hospital Pulau Pinang
Hospital Putrajaya
Hospital Queen Elizabeth
Hospital Raja Perempuan Bainun, Ipoh
Hospital Raja Perempuan Zainab II, Kota Bharu
Hospital Rajah Charles Brooke Memorial
Hospital Ranau
Hospital Raub
Hospital Sarikei
Hospital Seberang Jaya
Hospital Segamat
Hospital Selama
Hospital Selayang
Hospital Semporna
Hospital Sentosa
Hospital Serdang
Hospital Seri Manjung
Hospital Serian
APPENDIX 1
#
95.
96.
97.
98.
99.
100.
101.
102.
103.
104.
105.
106.
107.
108.
109.
110.
111.
112.
113.
#
1.
2.
#
Hospital Setiu
Hospital Sibu
Hospital Sik
Hospital Simunjan
Hospital Sipitang
Hospital Slim River
Hospital Sri Aman
Hospital Sultan Abdul Halim, Sungai Petani
Hospital Sultan Haji Ahmad Shah, Temerloh
Hospital Sultan Ismail, Johor Bahru
Hospital Sultanah Aminah, Johor Bahru
Hospital Sultanah Bahiyah, Alor Setar
Hospital Sultanah Nur Zahirah, Kuala
Terengganu
Hospital Sungai Bakap
Hospital Sungai Buloh
Hospital Sungai Siput
Hospital Taiping
Hospital Tambunan
Hospital Tampin
Universiti Kebangsaan Malaysia Medical Centre
University Malaya Medical Centre
Armed Forces Hospitals
Lumut Armed Forces Hospital
Terendak Armed Forces Hospital
#
Private Hospitals
1.
2.
3.
4.
Amanjaya Specialist Centre
Ampang Puteri Specialist Hospital
Bukit Mertajam Specialist Hospital
Columbia Asia Medical Centre, Sarawak
Columbia Asia Medical Centre, Seremban
Columbia Asia Nursing and Rehabilitation
Centre
Damai Service Hospital, Melawati
Damansara Specialist Hospital
Darul Ehsan Medical Centre
6.
7.
121.
122.
123.
124.
125.
126.
127.
128.
129.
130.
131.
132.
Hospital Tanah Merah
Hospital Tangkak
Hospital Tanjong Karang
Hospital Tapah
Hospital Tawau
Hospital Teluk Intan
Hospital Temenggung Seri Maharaja Tun Ibrahim,
Kulai
Hospital Tengku Ampuan Afzan, Kuantan
Hospital Tengku Ampuan Jemaah, Sabak Bernam
Hospital Tengku Ampuan Rahimah, Klang
Hospital Tengku Anis, Pasir Puteh
Hospital Tenom
Hospital Tuanku Ampuan Najihah, Kuala Pilah
Hospital Tuanku Fauziah, Kangar
Hospital Tuanku Ja’afar, Seremban
Hospital Tumpat
Hospital Umum Sarawak
Hospital Yan
Hospital Saratok
University Hospitals
1.
2.
5.
114.
115.
116.
117.
118.
119.
120.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Gleneagles Intan Medical Centre
Ipoh Specialist Hospital
Island Hospital
Johor Specialist Hospital
Kajang Specialist Hospital
Kampung Baru Medical Centre
Kempas Medical Centre
Kuantan Medical Centre
Kuantan Specialist Hospital
Landmark Medical Centre Sdn. Bhd.
APPENDIX 1
#
18.
19.
20.
21.
22.
23
23.
24.
25.
26.
27.
28.
29.
30.
31.
32
Loh Guan Lye Specialist Centre
Medical Specialist Centre (JB) Sdn. Bhd.
Metro Specialist Hospital
Miri City Medical Centre
N.S. Chinese Maternity Hospital and Medical
Centre
National Heart Institute
NCI Cancer Hospital
Pantai Ayer Keroh Hospital Sdn. Bhd.
Pantai Cheras Medical Centre
Pantai Indah Hospital
Pantai Klang Specialist Medical Centre Sdn.
Bhd.
Pantai Mutiara Hospital
Pantai Putri Hospital
Pantai Utara Hospital
Penang Adventist Hospital
Perdana Specialist Hospital
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
PUSRAWI Hospital Sdn. Bhd.
Puteri Klang Medical Centre
Puteri Specialist Hospital
Putra Medical Centre, Alor Setar
Putra Specialist Hospital (Batu Pahat) Sdn. Bhd.
Putra Specialist Hospital (Melaka) Sdn. Bhd.
Rafflesia Medical Centre Sdn. Bhd.
Sabah Medical Centre
Selangor Medical Centre
Sentosa Medical Centre Sdn. Bhd. KL
Sri Kota Specialist Medical Centre
Subang Jaya Medical Centre
Sunway Medical Centre
Taman Desa Medical Centre
Tanjung Medical Centre
Timberland Medical Centre
Tung Shin Hospital
#
State/ District/Area Health Departments
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
Jabatan Kesihatan Negeri Johor
Jabatan Kesihatan Negeri Kelantan
Jabatan Kesihatan Negeri Perlis
Jabatan Kesihatan Negeri Sabah
Jabatan Kesihatan Negeri Sarawak
Pejabat Kesihatan Daerah Alor Gajah
Pejabat Kesihatan Daerah Bachok
Pejabat Kesihatan Daerah Batu Pahat
Pejabat Kesihatan Daerah Baling
Pejabat Kesihatan Daerah Barat Daya
Pejabat Kesihatan Daerah Batang Padang
Pejabat Kesihatan Daerah Bandar Baharu
Pejabat Kesihatan Daerah Besut
Pejabat Kesihatan Daerah Cameron
Highlands
Pejabat Kesihatan Daerah Dungun
Pejabat Kesihatan Daerah Gombak
Pejabat Kesihatan Daerah Gua Musang
Pejabat Kesihatan Daerah Hilir Perak
Pejabat Kesihatan Daerah Hulu Langat
Pejabat Kesihatan Daerah Hulu Perak
Pejabat Kesihatan Daerah Hulu Selangor
Pejabat Kesihatan Daerah Hulu Terengganu
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
165
Pejabat Kesihatan Daerah Kulim
Pejabat Kesihatan Daerah Langkawi
Pejabat Kesihatan Daerah Larut, Matang dan
Selama
Pejabat Kesihatan Daerah Manjung
Pejabat Kesihatan Daerah Maran
Pejabat Kesihatan Daerah Marang
Pejabat Kesihatan Daerah Melaka Tengah
Pejabat Kesihatan Daerah Muar
Pejabat Kesihatan Daerah Padang Terap
Pejabat Kesihatan Daerah Pasir Mas
Pejabat Kesihatan Daerah Pasir Puteh
Pejabat Kesihatan Daerah Penampang
Pejabat Kesihatan Daerah Pendang
Pejabat Kesihatan Daerah Perak Tengah
Pejabat Kesihatan Daerah Petaling
Pejabat Kesihatan Daerah Pitas
Pejabat Kesihatan Daerah Port Dickson
Pejabat Kesihatan Daerah Putrajaya
Pejabat Kesihatan Daerah Sabak Bernam
Pejabat Kesihatan Daerah Segamat
Pejabat Kesihatan Daerah Seremban
Pejabat Kesihatan Daerah Seberang Perai Selatan
APPENDIX 1
#
State/ District/Area Health Departments
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
91.
92.
93.
94.
95.
96.
Pejabat Kesihatan Daerah Jasin
Pejabat Kesihatan Daerah Jelebu
Pejabat Kesihatan Daerah Jeli
Pejabat Kesihatan Daerah Jempol
Pejabat Kesihatan Daerah Johor Bahru
Pejabat Kesihatan Daerah Kemaman
Pejabat Kesihatan Daerah Keningau
Pejabat Kesihatan Daerah Kerian
Pejabat Kesihatan Daerah Kinta
Pejabat Kesihatan Daerah Klang
Pejabat Kesihatan Daerah Kluang
Pejabat Kesihatan Daerah Kota Bharu
Pejabat Kesihatan Daerah Kota Setar
Pejabat Kesihatan Daerah Kuala Kangsar
Pejabat Kesihatan Daerah Kuala Krai
Pejabat Kesihatan Daerah Kuala Langat
Pejabat Kesihatan Daerah Kuala Muda
Pejabat Kesihatan Daerah Kuala Penyu
Pejabat Kesihatan Daerah Kuala Pilah
Pejabat Kesihatan Daerah Kuala Selangor
Pejabat Kesihatan Daerah Kuala Terengganu
Pejabat Kesihatan Daerah Kuantan
Pejabat Kesihatan Daerah Kubang Pasu
Pejabat Kesihatan Daerah Kudat
Pejabat Kesihatan Daerah Seberang Perai
Tengah
Pejabat Kesihatan Daerah Seberang Perai
Utara
#
Others
1.
2.
Department of Public Health, MOH
Disease Control Division, National Public
Health Laboratory
Vector Borne Disease Control Section, Disease
Control Division, MOH
3.
4.
5.
6.
7.
8.
166
Pejabat Kesihatan Daerah Sepang
Pejabat Kesihatan Daerah Setiu
Pejabat Kesihatan Daerah Sik
Pejabat Kesihatan Daerah Tampin
Pejabat Kesihatan Daerah Tanah Merah
Pejabat Kesihatan Daerah Timur Laut
Pejabat Kesihatan Daerah Tumpat
Pejabat Kesihatan Daerah Yan
Pejabat Kesihatan Kawasan Beaufort
Pejabat Kesihatan Kawasan Beluran
Pejabat Kesihatan Kawasan Kota Kinabalu
Pejabat Kesihatan Kawasan Lahad Datu
Pejabat Kesihatan Kawasan Sandakan
Pejabat Kesihatan Kawasan Tawau
Pejabat Kesihatan Kawasan Tuaran
Pejabat Pergigian Bahagian Kuching
Pejabat Pergigian Bahagian Miri
Pejabat Pergigian Bahagian Samarahan
Pejabat Pergigian Bahagian Sibu
Pejabat Pergigian Bahagian Sri Aman
Pejabat Pergigian Beaufort
Pejabat Pergigian Daerah Petaling
Pejabat Pergigian Daerah Kemaman
Pejabat Pergigian Daerah Seberang Perai Utara
Pejabat Pergigian Sandakan
Pejabat Pergigian Tawau
Ibu Pejabat Tibi/Kusta – Kota Kinabalu
National Leprosy Control Centre
Pegawai Kesihatan Kanan (RKPBV) Perak
Pegawai Pergigian Kanan Pahang
Pegawai Pergigian Kanan Perak
APPENDIX 1
Ministry of Health Institutions participating in NMUS survey
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
College of Allied Health Science, Kuching
College of Community Nursing, Kluang
College of Medical Laboratory Technology
College of Nursing, Ipoh
College of Nursing, Kuala Terengganu
College of Nursing, Kubang Kerian
Institute for Medical Research (IMR)
Institute for Public Health
Kolej Kejururawatan Masyarakat
Kolej Kejururawatan Melaka
Makmal Keselamatan dan Kualiti Makanan,
Pulau Pinang
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
Makmal Perubatan dan Stor Kuching
Makmal Ubat & Stor Kapit
Makmal Ubat & Stor Limbang
Makmal Ubat & Stor Miri
Makmal Ubat & Stor Sarikei
Makmal Ubat & Stor Sibu
Makmal Ubat & Stor Sri Aman
National Blood Centre
Pusat Bekalan Farmasi Negeri Sabah, Kota
Kinabalu
Stor Pergigian Negeri Selangor
Stor Pergigian Pusat Kota Kinabalu
Primary Care Clinics participating in NMUS survey
#
Ministry of Health Clinics
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
Jabatan Pesakit Luar Hospital Baling
Jabatan Pesakit Luar Hospital Bandar Machang
Jabatan Pesakit Luar Hospital Balik Pulau
Jabatan Pesakit Luar Hospital Bukit Mertajam
Jabatan Pesakit Luar, Hospital Mersing
Jabatan Pesakit Luar, Poliklinik Komuniti
Sipitang
Klinik Kesihatan Air Hangat
Klinik Kesihatan Air Itam Pulau Pinang
Klinik Kesihatan Ayer Molek
Klinik Kesihatan Bahau
Klinik Kesihatan Bakar Arang
Klinik Kesihatan Bandar Bachok
Klinik Kesihatan Bandar Baharu
Klinik Kesihatan Bandar 32 Bera
Klinik Kesihatan Bandar Gua Musang
Klinik Kesihatan Bandar Miri
Klinik Kesihatan Bandar Pasir Mas
Klinik Kesihatan Bandar Sungai Petani
Klinik Kesihatan Benta
Klinik Kesihatan Beris Kubor Besar
Klinik Kesihatan Beris Panchor
Klinik Kesihatan Beseri
Klinik Kesihatan Bintangor
Klinik Kesihatan Bintulu
Klinik Kesihatan Bongawan
Klinik Kesihatan Bukit Mendi
Klinik Kesihatan Bukit Minyak
Klinik Kesihatan Beris Panchor
Klinik Kesihatan Bukit Pasir, Muar
Klinik Kesihatan Bukit Tunggal
167
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
Klinik Kesihatan Cheng
Klinik Kesihatan Cheroh
Klinik Kesihatan Chini
Klinik Kesihatan Dabong
Klinik Kesihatan Durian Tunggal
Klinik Kesihatan Dong
Klinik Kesihatan Gambang
Klinik Kesihatan Gual Ipoh
Klinik Kesihatan Hutan Percha
Klinik Kesihatan Ibu dan Anak Gombak Setia
Klinik Kesihatan Ibu dan Anak (Pejabat
Kesihatan Daerah Dungun)
Klinik Kesihatan Ibu dan Anak Kuala Nerang
Klinik Kesihatan Jalan Gereja
Klinik Kesihatan Jalan Masjid Kuching
Klinik Kesihatan Jalan Oya
Klinik Kesihatan Jelapang
Klinik Kesihatan Jelebu
Klinik Kesihatan Jeli
Klinik Kesihatan Juasseh
Klinik Kesihatan Kapit
Klinik Kesihatan Karak
Klinik Kesihatan Kampung Gial
Klinik Kesihatan Kepala Batas
Klinik Kesihatan Kinarut
Klinik Kesihatan Klebang Besar
Klinik Kesihatan Kota Sentosa
Klinik Kesihatan Kuah
Klinik Kesihatan Kuala Penyu
Klinik Kesihatan Kuala Perlis
Klinik Kesihatan Kuala Sanglang
APPENDIX 1
#
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
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.
Klinik Kesihatan Kulim
Klinik Kesihatan Labok
Klinik Kesihatan Lanang
Klinik Kesihatan Lawas
Klinik Kesihatan Lenga, Muar
Klinik Kesihatan Lubok China
Klinik Kesihatan Lubuk Buntar
Klinik Kesihatan Lubuk Merbau
Klinik Kesihatan Lui Muda
Klinik Kesihatan Macap Baru
Klinik Kesihatan Mahligai
Klinik Kesihatan Merlimau
Klinik Kesihatan Menglembu
Klinik Kesihatan Menggatal
Klinik Kesihatan Mempaga (Felda PK Fasa 1)
Klinik Kesihatan Merbau Pulas
Klinik Kesihatan Naka
Klinik Kesihatan Padang Besar
Klinik Kesihatan Padang Matsirat
Klinik Kesihatan Padang Tengku
Klinik Kesihatan Paka
Klinik Kesihatan Parit Raja
Klinik Kesihatan Parit Yaani
Klinik Kesihatan Pengkalan Chepa
Klinik Kesihatan Perai
Klinik Kesihatan Pulai Chondong
Klinik Kesihatan Putatan
Klinik Kesihatan Pokok Assam
Klinik Kesihatan Rantau Panjang
Klinik Kesihatan Rembau
Klinik Kesihatan Sarikei
Klinik Kesihatan Seberang Jaya
Klinik Kesihatan Selangau
Klinik Kesihatan Semerah
Klinik Kesihatan Serting Hilir
Klinik Kesihatan Siburan
Klinik Kesihatan Simpang Bekoh
Klinik Kesihatan Simpang Durian
Klinik Kesihatan Simpang Empat
Klinik Kesihatan Sri Aman
Klinik Kesihatan Sri Medan
Klinik Kesihatan Sungai Acheh
Klinik Kesihatan Sungai Lembing
Klinik Kesihatan Sungai Rambai
Klinik Kesihatan Tanah Puteh
Klinik Kesihatan Tanjung Kling
Klinik Kesihatan Taman Selasih
108.
109.
110.
111.
112.
113.
114.
115.
116.
117.
118.
119.
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.
168
Klinik Kesihatan Teluk Bahang
Klinik Kesihatan Temerloh
Klinik Kesihatan Tersang
Klinik Kesihatan Triang
Klinik Kesihatan Tudan
Klinik Kesihatan Ulu Gali
Klinik Pergigian Banting
Klinik Pergigian Bentong
Klinik Pergigian Bintulu
Klinik Pergigian Besar Baling
Klinik Pergigian Besar Jalan Gambut, Kuantan
Klinik Pergigian Besar Jitra
Klinik Pergigian Besar Kulim
Klinik Pergigian Besar Langkawi
Klinik Pergigian Besar Sungai Petani
Klinik Pergigian Besar Telok Wanjah
Klinik Pergigian Daerah Kerian
Klinik Pergigian Hospital Kuala Kangsar
Klinik Pergigian Hospital Teluk Intan
Klinik Pergigian Hulu Perak
Klinik Pergigian Kelana Jaya
Klinik Pergigian Keningau
Klinik Pergigian Komuniti Tapah
Klinik Pergigian Kinta
Klinik Pergigian Kubang Semang
Klinik Pergigian Kudat
Klinik Pergigian Labuan
Klinik Pergigian Limbang
Klinik Pergigian Mukah
Klinik Pergigian Pakar Hospital Lahad Datu
Klinik Pergigian Pakar Kuching
Klinik Kesihatan Selandar
Klinik Pergigian Perak Tengah
Klinik Pergigian Rompin
Klinik Pergigian Seremban
Klinik Pergigian Seri Manjung
Klinik Pergigian Taiping
Klinik Pergigian Wilayah
Poliklinik Komuniti Ajil
Poliklinik Komuniti Alor Janggus
Poliklinik Komuniti Air Tawar 2
Poliklinik Komuniti AU 2
Poliklinik Komuniti Ayer Baloi
Poliklinik Komuniti Bagan Terap
Poliklinik Komuniti Bandar Permaisuri
Poliklinik Komuniti Bandar Tenggara
Poliklinik Komuniti Batu Rakit
APPENDIX 1
#
155.
156.
157.
158.
159.
160.
161.
162.
163.
164.
165.
166.
167.
168.
169.
170.
171.
172.
173.
174.
175.
176.
177.
178.
179.
180.
181.
Poliklinik Komuniti Bukit Besi
Poliklinik Komuniti Bukit Changgang
Poliklinik Komuniti Bukit Payong
Poliklinik Komuniti Bukit Waha
Poliklinik Komuniti Endau
Poliklinik Komuniti Jabi
Poliklinik Komuniti Jalan Mengkibol
Poliklinik Komuniti Jalan Merbau
Poliklinik Komuniti Ijok
Poliklinik Komuniti Inanam
Poliklinik Komuniti Kahang Batu 22
Poliklinik Komuniti Kahang Timur
Poliklinik Komuniti Kampung Lalang
Poliklinik Komuniti Kampung Majidee
Poliklinik Komuniti Kampung Rahmat
Poliklinik Komuniti Kampung Soeharto
Poliklinik Komuniti Kota Sarang Semut
Poliklinik Komuniti Klang
Poliklinik Komuniti Kuala Ketil
Poliklinik Komuniti Kundasang
Poliklinik Komuniti Kupang
Poliklinik Komuniti Lok Heng
Poliklinik Komuniti Malau
Poliklinik Komuniti Manir
Poliklinik Komuniti Membakut
Poliklinik Komuniti Paloh, Kluang
Poliklinik Komuniti Palong 4,5,6
182.
183.
184.
185.
186.
187.
188
189.
190.
191.
192.
193.
194.
195.
196.
197.
198.
199.
200.
201.
202.
203.
204.
205.
206.
207.
208.
Poliklinik Komuniti Pasir Akar
Poliklinik Komuniti Pekan Air Panas
Poliklinik Komuniti Pekan Nanas
Poliklinik Komuniti Penampang
Poliklinik Komuniti Pengkalan Berangan
Poliklinik Komuniti Pengerang
Poliklinik Komuniti Pokok Sena
Poliklinik Komuniti Pontian
Poliklinik Komuniti Renggam
Poliklinik Komuniti Salak
Poliklinik Komuniti Seberang Takir
Poliklinik Komuniti Sekinchan
Poliklinik Komuniti Simpang Empat
Poliklinik Komuniti Sri Medang/Gong Tok Pek
Poliklinik Komuniti Sungai Air Tawar
Poliklinik Komuniti Sungai Buloh
Poliklinik Komuniti Sungai Selisek
Poliklinik Komuniti Tamparuli
Poliklinik Komuniti Tampoi
Poliklinik Komuniti Tawar
Poliklinik Komuniti Telipok
Poliklinik Komuniti Tenggaroh II (Felda)
Poliklinik Komuniti Tengkawang
Poliklinik Komuniti Tunjang
Poliklinik Komuniti Ulu Tiram
Poliklinik Komuniti Wakaf Tapai
Poliklinik Penambang
#
Private Clinics
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12
24 Jam Poliklinik Yap
Ali Klinik
Asia Clinic
B. Kong’s Clinic
Bina Kelinik
Chan Clinic, Kuching
Chen Dispensary
Chan Clinic, Miri
Cheah & Lim Medical Associates
Chu Hwa Dispensary
City Medical Centre
City Poliklinik
13
14.
15
16
17
18
19.
20.
21.
22.
23.
24.
169
Clinic Ho
Clinic Joseph
Chong’s Clinic
Clinic Wellness Lab, Cheras
Dindings Poliklinik
Ding Polyklinik Dan Surgeri
Dispensary Martin dan Lalita
Dispensary Sharil
Dora Medical Clinic Bhd.
Dr Amir Abbas-KMA Sdn.Bhd.
Dr Jaafar Dan Rakan-Rakan
Dr John Yeo’ Clinic, Batu Niah
APPENDIX 1
#
Private Clinics
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
Dr. Kueh’s Clinic
Dr. Leela Ratos dan Rakan-Rakan Sdn. Bhd.
Jln. Pudu
Dr. Mohamed Mydin & Rakan-Rakan
Sdn. Bhd. Jln. Ampang
Dr. Mohamed Mydin & Rakan-Rakan
Sdn. Bhd. Jln. Tun Razak
Dr. S. Vijayakumar
Dr. Yap’s Clinic
Fateh, Mydin dan Rakan-Rakan
Poliklinik & Surgeri
Drs. Young Newton & Partners
Drs. Young Newton & Rakan-Rakan,
Brickfields
Damansara
Jln. Ampang
Elizabeth Medical Centre Sdn. Bhd.
Gill Medical Centre
Goay Klinik
Goh Clinic
Gul Medical Centre
Healthcare Clinic
Healthcare Medical Centre
Horeb Sdn. Bhd. Jln. Ampang
Horeb Sdn. Bhd. Leboh Ampang
ING Insurance Berhad In-House Clinic Intan
Poliklinik & Surgeri, Tmn. Arowana
Island Klinik, Esplanade
Island Klinik, Island Glades
Jose Clinic & Surgery
Kelinik & Surgeri Templer
Kelinik Ganesan Sdn. Bhd.
Kelinik Gopi, Jln. Market
Kelinik Gopi, Tmn. Desa Permai
Kelinik Liu
Kelinik Ng
Kelinik Poh Soon Sim Sdn. Bhd.
Kelinik Ratna
Kelinik S. Suren
Kelinik Selvam
Kelinik Thurai
Kelinik Woo & Hong
Khong Klinik
Klinik Australia
Klinik & Surgeri Bakti
65.
66.
67.
68.
69.
70.
71.
72.
73.
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.
170
Klinik & Surgeri Delima
Klinik & Surgeri Dorai
Klinik & Surgeri Dr. Harvinder
Klinik & Surgeri Gill
Klinik & Surgeri Lee, Seri Kembangan
Klinik & Surgeri Lee, Taman Ros
Klinik & Surgeri Ong
Klinik & Surgeri Sipitang
Klinik & Surgeri Stanley Chong
Klinik & & Surgeri Guna
Klinik & Surgeri Wisma Bersalin Bhajan
Klinik Aisah
Klinik Al’ Azhim, Klebang
Klinik Al Farabi Jaya Gading
Klinik Al-Azhim Tampin
Klinik Ali
Klinik Al-Insaan
Klinik Alor Setar
Klinik Amal
Klinik Aman, Shah Alam
Klinik Amardev & Surgery
Klinik Aminah, Hulu Kelang
Klinik Aminah, Pelabuhan Kelang
Klinik Anis, Shah Alam
Klinik Anita
Klinik Anthony
Klinik Ariffin
Klinik Arun, Sentul
Klinik Asean
Klinik Asniza, Taman Pandan Permai
Klinik Awana Kijal
Klinik Baba
Klinik Bala, Georgetown
Klinik Bala, Paya Terubong
Klinik Baling
Klinik Ban
Klinik Bandar Baru
Klinik Bandar Raya
Klinik Bandaran Sdn. Bhd. Jln. Bunga Melor
Klinik Bandaran Sdn. Bhd. Section 15
Klinik Bandaran Sdn. Bhd. Section 25
Klinik Baru Jerteh
Klinik Berkat
Klinik Bersatu 16 Jam, Tmn. Chai Leng
Klinik Bersatu Kulim
Klinik Bersatu, Jln. Raja Uda
Klinik Bersatu, Tmn. Ipoh Timur
APPENDIX 1
#
Private Clinics
112.
113.
114.
115.
116.
117.
118.
119.
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.
Klinik Bersatu, Tmn. Seruling
Klinik Bintulu
Klinik Boon
Klinik Bukit Beruang
Klinik Bukit Jambul
Klinik Bukit Maluri & Surgeri
Klinik C.F. Chong
Klinik C.S. Ooi
Klinik Care Poliklinik dan Surgeri
Klinik Catterall, Khoo and Raja Malek,
Bangunan Ming
Klinik Ceria
Klinik Chai
Klinik Chan, Ipoh Garden
Klinik Chang
Klinik Chen
Klinik Cheryan
Klinik Chew
Klinik Chiew
Klinik Chin, Jln. Sultan Idris Shah
Klinik Chon
Klinik Chong, Kota Bharu
Klinik Chong, Seremban
Klinik Choo
Klinik Chua, Ayer Tawar
Klinik Chua, Sitiawan
Klinik Cinta Sayang, Jln. Ibrahim
Klinik Dan Surgeri Dr. Gan
Klinik Dan Surgeri Putra
Klinik Dan Surgeri Raju
Klinik Dan Surgeri Soo
Klinik dan Surgeri Sri Damansara
Klinik Dedap
Klinik Deepa
Klinik Desa, Desa Petaling
Klinik Doktor Wong - Dr. Wong Hua Seh
Klinik Dorai
Klinik Doshi
Klinik Dr. (Mrs) Law
Klinik Dr. Bazlan
Klinik Dr. C.H. Kong
Klinik Dr. Che Ku
Klinik Dr. Cheu Sdn. Bhd.
Klinik Dr. Chew
Klinik Dr. Chin Kon Yoon
Klinik Dr. Elvin Chong & Surgery
Klinik Dr. Hamid
158.
159.
160.
161.
162.
163.
164.
165.
166.
167.
168.
169.
170.
171.
172.
173.
174.
175.
176.
177.
178.
179.
180.
181.
182.
183.
184.
185.
186.
187.
188.
189.
190.
191.
192.
193.
194.
195.
196.
197.
198.
199.
200.
201.
202.
203.
204.
171
Klinik Dr. Husna, Tmn. Ria
Klinik Dr. Kamaludin
Klinik Dr. Karim
Klinik Dr. Lilian Hong
Klinik Dr. Mohamad
Klinik Dr. Najiha
Klinik Dr. Rahim Omar & Rakan-Rakan
Klinik Dr. Ramzi
Klinik Dr. Roslan, Baling
Klinik Dr. Roziah
Klinik Dr. Shashikala Sdn. Bhd.
Klinik Dr. Syed
Klinik Dr. Ting
Klinik Dr. Tuan Yusof
Klinik Dr. Umi
Klinik Dr. Wong & Dr. Lau
Klinik Dr. Yong
Klinik Dr. Aishah Dan Dr. Fisol
Klinik Dr. S. Kumar
Klinik Dr. Zakaria
Klinik Eastern
Klinik Efendi
Klinik Ehsan
Klinik Eirena
Klinik Elizabeth, Tmn. Makmor
Klinik Elopura Sdn. Bhd. - Jln. Tmn. Mawar
Klinik Elopura Sdn. Bhd. - Sedco Complex
Klinik Endau
Klinik Everlasting Sdn. Bhd.
Klinik Faiza Woon
Klinik Famili TTDI
Klinik Fateh Mohd & Rakan-Rakan
Klinik Fauzi
Klinik Fettes Park
Klinik G.S.
Klinik Ganesha Vijayam
Klinik George Jinivon
Klinik Glugor
Klinik Gopeng
Klinik Grace
Klinik Gunn
Klinik Gurdip
Klinik Hafiz
Klinik Halizah
Klinik Hamidah
Klinik Healthcare
Klinik Hee Annandan Sdn. Bhd.
APPENDIX 1
#
Private Clinics
205.
206
207.
208.
209.
210.
211.
212.
213.
214.
215.
216.
217.
218.
219.
220.
221.
222.
223.
224.
225.
226.
227.
228.
229.
230.
231.
232.
233.
234.
235.
234.
235.
236.
237.
238.
239.
240.
241.
242.
243.
244.
245.
246.
247.
248.
249.
Klinik Hemavathy
Klinik Hikmah
Klinik Hisham
Klinik Hj. Ayaz
Klinik Ho, Senai
Klinik Hock-San
Klinik Hon
Klinik Hossana
Klinik Hsu dan Ng
Klinik H.T. Lee
Klinik Husin
Klinik Ian Ong
Klinik Ibu Kota, Satok
Klinik Idaman
Klinik IHM
Klinik Ikhwan & Surgeri
Klinik Iman
Klinik Imbi
Klinik In-House
Klinik Ishak Dan Surgeri
Klinik J.D.
Klinik Jaafar & Partners
Klinik Jalan Templer Sdn. Bhd.
Klinik Jauhar
Klinik Jaya, Subang Jaya
Klinik Jayaraman, Jln. Raja Laut
Klinik Jelebu
Klinik Jo
Klinik Johor, Johor Jaya
Klinik Joseph & Surgeri
Klinik K.G. Mah
Klinik K.I.P. Sdn. Bhd.
Klinik K.J. Lim, Prima Setapak
Klinik Kanta
Klinik Kapar, Jalan Besar Kapar
Klinik Karak
Klinik Kaulsay
Klinik Kayu Ara
Klinik Keluarga
Klinik Keluarga Aishah
Klinik Keluarga Dan Surgeri
Klinik Keluarga Dr. Hj. Mohd. Khadzali
Klinik Khizan
Klinik Koidupan
Klinik Kok
Klinik Kok Dan Surgeri
Klinik Kok Dan Wendy, Klang
250.
251.
252.
253.
254.
255.
256.
257.
258.
259.
260.
261.
262.
263.
264.
265.
266.
267.
268.
269.
270.
271.
272.
273.
274.
275.
276.
277.
278.
279.
280.
281.
282.
283.
284.
285.
286.
287.
288.
289.
290.
291.
292.
293.
294.
295.
296.
172
Klinik Kok Dan Wendy, Subang Jaya
Klinik Kok Wah
Klinik Kok, Jln. 17/1A
Klinik Kok, Jln. USJ 4/1
Klinik Kong
Klinik Kuantan
Klinik Kucai
Klinik Kumpulan Muslimah
Klinik Kwok
Klinik Lahad Datu (Cawangan)
Klinik Langkawi, Pusat Bandar Kuah
Klinik Lau
Klinik Lee, Petaling Jaya
Klinik Leela
Klinik Leong, Puchong
Klinik Leong, Kuala Terengganu
Klinik Leong, Tmn. Maluri
Klinik Leow
Klinik Liew & Surgeri
Klinik Lim, Seremban
Klinik Lim, Kuching
Klinik Lim & Lau
Klinik Lim Chin Chong Sdn Bhd
Klinik Lim, Jln. Amarasegara
Klinik Lin & Chandran
Klinik Ling & Thoo
Klinik Lo
Klinik Low, Setapak
Klinik Ludher, Jln. Kelang Lama
Klinik M. Ghana
Klinik Maamor
Klinik Maharani
Klinik Majid
Klinik K.S. Tan
Klinik K.V. Tan
Klinik K.H. Ong
Klinik Kalai
Klinik Makbul
Klinik Malaysia, Sibu
Klinik Malaysia, Tampoi
Klinik Maniraj
Klinik Mansor
Klinik Maranatha
Klinik Maria, Keningau
Klinik Maria, Seremban
Klinik Mariam
Klinik Masjid Tanah
APPENDIX 1
#
Private Clinics
297.
298.
299.
300.
301.
302.
303.
304.
305.
306.
307.
308.
309.
310.
311.
312.
313.
314.
315.
316.
317.
318.
319.
320.
321.
322.
323.
324.
325.
326.
327.
328.
329.
330.
331.
332.
333.
334.
335.
336.
337.
338.
339.
340.
341.
342.
Klinik Medan Jaya
Klinik Medic Bestari
Klinik Medical Subang HI TEC
Klinik Medicare, Jln. Bangsar
Klinik Medijaya, Century Garden
Klinik Medik 24-7, Bandar Country Homes
Klinik Medimetro
Klinik Melaka
Klinik Melawati
Klinik Mersing
Klinik Mesra
Klinik Mesra, Shah Alam
Klinik Metro Medics, HICOM Industrial
Estate
Klinik Metro, Puchong
Klinik Michael Wong
Klinik Ming
Klinik Mitter dan Rakan-Rakan
Klinik Mogan
Klinik Moorthy
Klinik Muhibbah
Klinik Muhibbah, Alor Setar
Klinik Mutiara Inanam
Klinik Naga
Klinik Nagiah
Klinik Najihah
Klinik Nanda
Klinik Nathan, Bgn. Mas
Klinik Neoh
Klinik Ng & Ng
Klinik Ng, Jln. Kangsar
Klinik Noh
Klinik Noorleza
Klinik Nur Aqila
Klinik Nuraina Poliklinik & Surgeri
Klinik Nuraini
Klinik Ong & Surgeri
Klinik Oziar Darus
Klinik Pakatan Medik, Kuala Lumpur
Klinik Pakatan Medik, Banting
Klinik Panicker
Klinik Pantai, Batu Ferringhi
Klinik Pantai, Rantau
Klinik Pantai, Tmn. Kota Lukut
Klinik Papar Medical Group
Klinik Perdana, Kuantan
Klinik Perdana - Bgn. PKINK
343.
344.
345.
346.
347.
348.
349.
350.
351.
352.
353.
355.
356.
357.
358.
359.
360.
361.
362.
363.
364.
365.
366.
367.
368.
369.
370.
371.
372.
373.
374.
375.
376.
377.
378.
379.
380.
381.
382.
383.
384.
385.
386.
387.
288.
389.
390.
173
Klinik Perdana - Wisma Suara Muda
Klinik Perdana, Islah
Klinik Perdana, Jln. Lubok Stol
Klinik Perdana, Lumut
Klinik Perdana, Pusing
Klinik Perkasa
Klinik Permata
Klinik Pertama, Johor Bahru
Klinik Pertama, Georgetown
Klinik Pertama, Sg. Besi
Klinik Perubatan & Surgeri Dr. Ahmad
Klinik Perubatan Chong
Klinik Perubatan Lita Alis
Klinik Perubatan Ong
Klinik Petaling Jaya
Klinik Poorni
Klinik Prihatin
Klinik Primecare, Phileo Corporate Park
Klinik Public
Klinik Pushpa
Klinik Rabiah
Klinik Radha, Bentong
Klinik Radha Ampang
Klinik Rahim
Klinik Rahimah
Klinik Rahmat
Klinik Raj
Klinik Raj (Jasin) Sdn. Bhd.
Klinik Raj dan Rakan-Rakan, Sentul
Klinik Raja, Ipoh
Klinik Raju
Klinik Rakyat, Gopeng
Klinik Rakyat, Jln. Besar Kepong
Klinik Rakyat, Jln. Telok Wanjah
Klinik Rakyat, Taiping
Klinik Rama
Klinik Ramabai & Surgeri Sdn.Bhd.
Klinik Rawatan Keluarga
Klinik Rawatan Utama
Klinik Razak
Klinik Razana
Klinik Reddy PJ
Klinik Reddy Pudu
Klinik Reddy Setapak
Klinik Rembau
Klinik Ria
Klinik Roberts
APPENDIX 1
#
Private Clinics
391.
392.
393.
394.
395.
396.
397.
398.
399.
400.
401.
402.
403.
404.
405.
406.
407.
408.
409.
410.
411.
412.
413.
414.
415.
416.
417.
418.
419.
420.
421.
422.
423.
424.
425.
426.
427.
428.
429.
430.
431.
432.
433.
434.
435.
436.
Klinik Rohana & Seripah Sdn. Bhd. Tmn. Seri
Intan
Klinik Roslina
Klinik S.K. Leong
Klinik S.K. Lo Sdn. Bhd.
Klinik S.L. Ma
Klinik Sabrina
Klinik Sada
Klinik Sanan
Klinik Sandhu Senai
Klinik Saujana, Melaka Tengah
Klinik Saujana, Selayang
Klinik Saujana, Sungai Buloh
Klinik Segamat
Klinik Segara, Jln. Bangsar
Klinik Sekeluarga Ipoh, Fair Park
Klinik Sekeluarga Ipoh, Tmn. Bukit Merah
Klinik Senan
Klinik Sentosa, Johor Bahru
Klinik Sentosa, Kuala Berang
Klinik Sentosa Sdn. Bhd. Lengkok Dumbar
Klinik Sentosa, Penang Street
Klinik Seremban, Bdr. Seremban Selatan
Klinik Seremban, Senawang Jaya
Klinik Seri Pulau, Jln. P. Ramlee
Klinik Serijasa
Klinik Setapak & Surgeri, Sri Rampai
Klinik Setia
Klinik Setiajaya
Klinik Shafi, Jinjang Utara
Klinik Shankar Sdn. Bhd.
Klinik Shanraj
Klinik Sharani
Klinik Shatin
Klinik Sibu
Klinik Sidhu
Klinik Sihat Putrajaya
Klinik Sihat, Menggatal Oldtownship
Klinik Simee
Klinik Sinar
Klinik Siti Zariah
Klinik Siva & Surgeri
Klinik Soo, Chemor
Klinik Soon, Sibu
Klinik Soon, Puchong
Klinik Soong
Klinik Sri Puteri
437.
438.
439.
440.
441.
442.
443.
444.
445.
446.
447.
448.
449.
450.
451.
452.
453.
454.
455.
456.
457.
458.
459.
460.
461.
462.
463.
464.
465.
466.
467.
468.
469.
470.
471.
472.
473.
474.
475.
476.
477.
478.
479.
480.
481.
482.
483.
174
Klinik Sri Sulong
Klinik Subang Perdana
Klinik Subra Sdn. Bhd.
Klinik Subramaniam
Klinik Suhaini
Klinik Sukimi
Klinik Sulaiman, Jengka
Klinik Sulaiman, Jln. Tahan
Klinik Sulaiman, Kompleks Teruntum
Klinik Sulaiman, Maran
Klinik Sungai Besar
Klinik Syed Salleh & Rakan-Rakan
Klinik Terengganu
Klinik T.A.R.
Klinik TA
Klinik Taipan
Klinik Tampin
Klinik Tan, Melaka
Klinik Tan Cheng Leng
Klinik Tan, Bidor
Klinik Tan, Sg. Petani
Klinik Tawakal, Parit Sulong
Klinik Teck Hoe
Klinik Teh, Petaling Jaya
Klinik Teh, Port Dickson
Klinik Templer
Klinik Tenaga Baru
Klinik Tengku Amir
Klinik Teo, Kota Kinabalu
Klinik Teoh & Chan Sdn. Bhd.
Klinik Ting
Klinik Toh & Lim
Klinik Tujuan
Klinik Ummu Roihan
Klinik Union 16 Jam, Tmn. Tangling
Klinik Union 24 Jam
Klinik Union, Hunza Complex
Klinik Utama, Kepong
Klinik Utama, Petaling Jaya
Klinik Venka
Klinik Vigneshwer
Klinik Voon
Klinik Wan Suhaimi
Klinik Wang
Klinik Wawasan 24 Jam
Klinik Wawasan, Tmn. Sentosa
Klinik Wee
APPENDIX 1
#
Private Clinics
484.
485.
486.
487.
488.
489.
490.
491.
492.
493.
494.
495.
496.
497.
498.
499.
500.
501.
502.
503.
504.
505.
506.
507.
508.
509.
510.
511.
512.
513.
514.
515.
516.
517.
518.
519.
520.
521.
522.
523.
524.
525.
526.
527.
528.
529.
Klinik West Jelutong
Klinik Wira
Klinik Wong, Tawau
Klinik Wong, Petaling Jaya
Klinik Wong Ching Seh
Klinik Y.M. Lo
Klinik Yeoh
Klinik Yii
Klinik Yusof
Klinik Zahar
Klinik Zain & Zakaria, Batu Caves
Klinik Zainab
Klinik Zainiati
Klinik Zaleha
Kumpulan Medic, Shah Alam
Kumpulan Medic, Subang Jaya
Kumpulan Perubatan SMP Sdn. Bhd. (Klinik
Pertama)
LKB Clinic
Loh & Lim Sdn. Bhd.
MAA In House Clinic
Maha Klinik
Medi-Klinik Shahrol
Medic-Klinik Lim
Mediklinik Keluarga, Tmn. Ipoh Jaya Timur
Mediklinik TTDI Jaya
Merican Dispensary
Ooi Kwee Lim Polyclinic
Ophir Clinic
Perak Medical Centre Sdn. Bhd. Kampar
Perdana Polyclinics, Selayang
Perdana Polyclinics Wilayah
Poli Klinik, Jln. P. Ramlee
Poliklinik & Surgeri Batu Gajah
Poliklinik & Surgeri Chew
Poliklinik & Surgeri Gul
Poliklinik & Surgeri Seapark
Poliklinik Al-Bukhari
Poliklinik Al-Haj
Poliklinik Aman
Poliklinik An-Nisa
Poliklinik Bahagia
Poliklinik Bukit Mayang Emas
Poliklinik Central & Surgeri, Jln. Gombak
Poliklinik Chew & Rakan-Rakan
Poliklinik & Surgeri Sentosa
Poliklinik Damai & Surgeri, Tmn. Desa Jaya
530.
531.
532.
533.
534.
535.
536.
537.
538.
539.
540.
541.
542.
543.
544.
545.
546.
547.
548.
549.
550.
551.
552.
553.
554.
555.
556.
557.
558.
559.
560.
561.
562.
563.
564.
565.
567.
568.
568.
569.
570.
571.
572.
573.
574.
575.
576
175
Poliklinik dan Surgeri Ren-Ai
Poliklinik Dinamik, Beranang
Poliklinik Dinamik, Kajang
Poliklinik Dinamik, Semenyih
Poliklinik Dr. Azhar, Jeniang
Poliklinik Dr. Norliza
Poliklinik Family
Poliklinik Fitrah, Bgn. PKNK
Poliklinik Harmoni
Poliklinik Hidayah, Bagan Serai
Poliklinik Hidayah, Jln. Kuala Pilah
Poliklinik Ihsan
Poliklinik Jaya
Poliklinik Kong
Poliklinik Kumpulan City - Capital Square
Poliklinik Kumpulan City - Dataran Templer
Poliklinik Kumpulan City - Jln. Inai
Poliklinik Kumpulan City - Jln. Pahang
Poliklinik Kumpulan City - Tmn. Connaught
Poliklinik Kumpulan City - Tmn. OUG
Poliklinik Lai
Poliklinik Liew
Poliklinik Lim & Leong
Poliklinik Lim & Pusat Rawatan Intan
Poliklinik Mat Top
Poliklinik Medic, Melaka Tengah
Poliklinik Meranti
Poliklinik Mindaku
Poliklinik Murni
Poliklinik Mutiara, Shah Alam
Poliklinik Mutiara, Tmn. Desa Aman
Poliklinik Ng
Poliklinik Ong, Bt. Gajah
Poliklinik Pan-Medic, Farlim
Poliklinik Penawar
Poliklinik Perdana
Poliklinik Pertama
Poliklinik Perubatan Kubang Pasu
Poliklinik Putra, Kulim
Poliklinik Raj
Poliklinik Rajen
Poliklinik Rakyat, Masjid Tanah
Poliklinik Rakyat, Bahau
Poliklinik Rakyat, Jln. Tuanku Munawir
Poliklinik Rakyat, Putatan
Poliklinik Rakyat, Tmn. Tasik Jaya
Poliklinik Rama
APPENDIX 1
#
Private Clinics
577.
578.
579.
580.
581.
582.
583.
584.
585.
586.
587.
588.
589.
590.
591.
592.
593.
594.
595.
596.
Poliklinik Raub & Surgeri
Poliklinik Ravi
Poliklinik S.M. Lee & Rakan-Rakan
Poliklinik S. Naga, Tmn. Kluang Jaya
Poliklinik Salehudin
Poliklinik Samudera, Sitiawan
Poliklinik Sandhu
Poliklinik Sentosa
Poliklinik Seri Mutiara
Poliklinik Sg. Besi
Poliklinik Simpang Pulai, Tmn. Bersatu
Poliklinik Sri Permai
Poliklinik Star Puchong
Poliklinik Sungai Long
Poliklinik Tang
Poliklinik Tan, Lee & Cheong
Poliklinik Teoh & Ding
Poliklinik Zakariya
Poliklinik Zul Dan Rakan-Rakan Sdn. Bhd.
Poly Klinik dan Surgery Kampung Pandan
597.
598.
599.
600.
601.
602.
603.
604.
605.
606.
607.
608.
609.
610.
611.
612.
613.
614.
615.
616.
Polyklinik Rajoo
Pusat Rawatan Desa Pandan
Pusat Rawatan Islam - Mais
Sham Poliklinik Sdn. Bhd.
Shri Senthil Clinic
Sim’s Medical Clinic, Miri
Siva Clinic
Somu Kelinik
Sushila Clinic
Tejani Medical Centre
Teow & Teo Medicare Sdn. Bhd.
The Key Clinic
The People’s Dispensary Sdn. Bhd.
Johor Bahru
Tiram Medical Centre
Uma Klinik
Union Clinic, Bau
Vaithiyanathan Clinic
Victor Medical Practice
Yoong Clinic Sdn. Bhd.
17.
Farmasi Alychem Sdn. Bhd. - Sg. Long,
Kajang
Farmasi Apollo
Farmasi Bakti Sdn. Bhd.
Farmasi Bintang
Farmasi Carrie
Farmasi Chia
Farmasi Gamma
Farmasi Kemuning
Farmasi Komuniti UKM
Farmasi Lim
Farmasi Nazifa
Farmasi Pendang
Farmasi Rantau
Farmasi Ruby
Farmasi S.J. Sdn. Bhd.
Farmasi Teck Hong
Farmasi USJ Sdn. Bhd.
Farmasi Utara Sdn. Bhd.
Pharmacies participating in NMUS survey
#
Private Pharmacies
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Alpro Pharmacy Holdings Sdn. Bhd.
Damansara
Apo’s Pharmacy
Bahau Pharmacy Sdn. Bhd.
Balik Pulau Health-Care
Baling Pharmacy Sdn. Bhd.
C.S. Lo Pharmacy
Carene Pharmacy
CL SU Pharmacy Sdn. Bhd.
Daya Pharma Sdn. Bhd.
Delima Farmasi Sdn. Bhd.
Excelcare Pharmacy
Far East Pharmacy Sdn. Bhd.
Farmasi Al-Nabilah
Farmasi Alychem Sdn. Bhd. - Bdr. Baru Sg.
Buloh
Farmasi Alychem Sdn. Bhd. - Payar Jaras, Sg.
Buloh
Farmasi Alychem Sdn. Bhd. - Selayang, Batu
Caves
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
176
APPENDIX 1
Pharmacies participating in NMUS survey
#
Private Pharmacies
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
Farmasi Voon
Gaya Pharmacy Supplies
GP Pharmacy
Health-Care Pharmacy
Jitra Pharmacy Sdn. Bhd.
Joy Pharmacy
K.H. Hoe Pharmacal Sdn. Bhd.
Karamunsing Pharmacy Sdn. Bhd.
KNL Medicare
Kumpulan Farmasi Vitacare Sdn. Bhd.
Mico Farmasi Sdn. Bhd.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
Others
1.
Ministry of Foreign Affairs.
177
Nori Care Pharmacy
Pahang Pharmacy Sdn. Bhd. - Karak
Pharmachem Labuan Sdn. Bhd.
Pusat Farmasi USM (Kedai Koop)
Remedy Pharmacy
Rheco Pharmacy
Sentosa Pharmacy
Sungai Siput Pharmacy
Yin Woh Tong Medical Supply Sdn. Bhd.
YW Yong Farmasi Sdn. Bhd.
Zuffa Pharmacy Sdn. Bhd. – Jln. Petani

Malaysian Statistics on Medicines 2006

Transcription

Similar documents

Learning Centers in High School? Absolutely!

X - Malaysia Geospatial Forum 2014

primary care - Clinical Research Centre

Call 1-888-4PPA-NOW

IN THEATERS FOR A LIMITED TIME MUVICO THEATERS

Together Rx Access - Colorado Access 2000

Reporting Form - Yellow Card Scheme

WelCome to KliniK hirslanden inFormation For in

Malaysian Statistics On Medicine 2004

EOH3101 Introduction