title: Pattern of drug utilization for treatment of uncomplicated malaria in urban Ghana following national treatment policy change to artemisinin-combination therapy.
abstract: BACKGROUND
  Change of first-line treatment of uncomplicated malaria to artemisinin-combination therapy (ACT) is widespread in Africa. To expand knowledge of safety profiles of ACT, pharmacovigilance activities are included in the implementation process of therapy changes. Ghana implemented first-line therapy of artesunate-amodiaquine in 2005. Drug utilization data is an important component of determining drug safety, and this paper describes how anti-malarials were prescribed within a prospective pharmacovigilance study in Ghana following anti-malarial treatment policy change.
  
  
  METHODS
  Patients with diagnosis of uncomplicated malaria were recruited from pharmacies of health facilities throughout Accra in a cohort-event monitoring study. The main drug utilization outcomes were the relation of patient age, gender, type of facility attended, mode of diagnosis and concomitant treatments to the anti-malarial regimen prescribed. Logistic regression was used to predict prescription of nationally recommended first-line therapy and concomitant prescription of antibiotics.
  
  
  RESULTS
  The cohort comprised 2,831 patients. Curative regimens containing an artemisinin derivative were given to 90.8% (n = 2,574) of patients, although 33% (n = 936) of patients received an artemisinin-based monotherapy. Predictors of first-line therapy were laboratory-confirmed diagnosis, age >5 years, and attending a government facility. Analgesics and antibiotics were the most commonly prescribed concomitant medications, with a median of two co-prescriptions per patient (range 1-9). Patients above 12 years were significantly less likely to have antibiotics co-prescribed than patients under five years; those prescribed non-artemisinin monotherapies were more likely to receive antibiotics. A dihydroartemisinin-amodiaquine combination was the most used therapy for children under five years of age (29.0%, n = 177).
  
  
  CONCLUSIONS
  This study shows that though first-line therapy recommendations may change, clinical practice may still be affected by factors other than the decision or ability to diagnose malaria. Age, diagnostic confirmation and suspected concurrent conditions lead to benefit:risk assessments for individual patients by clinicians as to which anti-malarial treatment to prescribe. This has implications for adherence to policy changes aiming to implement effective use of ACT. These results should inform education of health professionals and rational drug use policies to reduce poly-pharmacy, and also suggest a potential positive impact of increased access to testing for malaria both within health facilities and in homes.
authors.affiliation: Centre for Tropical Clinical Pharmacology & Therapeutics, University of Ghana Medical School, P,O, Box KB 4236, Accra, Ghana. alexooo@yahoo.com
authors.forename: Alexander N O
authors.initials: AN
authors.lastname: Dodoo
authors.forename: Carole
authors.initials: C
authors.lastname: Fogg
authors.forename: Alex
authors.initials: A
authors.lastname: Asiimwe
authors.forename: Edmund T
authors.initials: ET
authors.lastname: Nartey
authors.forename: Augustina
authors.initials: A
authors.lastname: Kodua
authors.forename: Ofori
authors.initials: O
authors.lastname: Tenkorang
authors.forename: David
authors.initials: D
authors.lastname: Ofori-Adjei
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000655:Amodiaquine / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D000818:Animals; D000962:Antimalarials / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D037621:Artemisinins / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D004359:Drug Therapy, Combination; D004363:Drug Utilization / Q000706:statistics & numerical data*; D005260:Female; D005869:Ghana; D006801:Humans; D007880:Legislation, Drug; D016015:Logistic Models; D008288:Malaria / Q000188:drug therapy* / Q000469:parasitology; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010961:Plasmodium / Q000187:drug effects* / Q000254:growth & development; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D011446:Prospective Studies; D016896:Treatment Outcome
chemical_list: D000962:Antimalarials; D037621:Artemisinins; D000655:Amodiaquine