title: Prescription practices and availability of artemisinin monotherapy in India: where do we stand?
abstract: BACKGROUND
  The World Health Organization has urged all member states to deploy artemisinin-based combination therapy and progressively withdraw oral artemisinin monotherapies from the market due to their high recrudescence rates and to reduce the risk of drug resistance. Prescription practices by physicians and the availability of oral artemisinin monotherapies with pharmacists directly affect the pattern of their use. Thus, treatment practices for malaria, with special reference to artemisinin monotherapy prescription, in selected states of India were evaluated.
  
  
  METHODS
  Structured, tested questionnaires were used to conduct convenience surveys of physicians and pharmacists in eleven purposively selected districts across six states in 2008. In addition, exit interviews of patients with a diagnosis of uncomplicated malaria or a prescription for an anti-malarial drug were also performed. Logistic regression was used to determine patient clinical care, and institutional factors associated with artemisinin monotherapy prescription.
  
  
  RESULTS
  Five hundred and eleven physicians from 196 health facilities, 530 pharmacists, and 1,832 patients were interviewed. Artemisinin monotherapy was available in 72.6% of pharmacies and was prescribed by physicians for uncomplicated malaria in all study states. Exit interviews among patients confirmed the high rate of use of artemisinin monotherapy with 14.8% receiving such a prescription. Case management, i.e. method of diagnosis and overall treatment, varied by state and public or private sector. Treatment in the private sector (OR 8.0, 95%CI: 3.8, 17) was the strongest predictor of artemisinin monotherapy prescription when accounting for other factors. Use of the combination therapy recommended by the national drug policy, artesunate + sulphadoxine-pyrimethamine, was minimal (4.9%), with the exception of one state.
  
  
  CONCLUSIONS
  Artemisinin monotherapy use was widespread across India in 2008. The accessible sale of oral artemisinin monotherapy in retail market and an inadequate supply of recommended drugs in the public sector health facilities promoted its prescription. This study resulted in notifications to all state drug controllers in India to withdraw the oral artemisinin formulations from the market. In 2010, artesunate + sulphadoxine-pyrimethamine became the universal first-line treatment for confirmed Plasmodium falciparum malaria and was deployed at full scale.
authors.affiliation: National Institute of Malaria Research, Indian Council of Medical Research, Dwarka, New Delhi 110 077, India.
authors.forename: Neelima
authors.initials: N
authors.lastname: Mishra
authors.forename: Anupkumar R
authors.initials: AR
authors.lastname: Anvikar
authors.forename: Naman K
authors.initials: NK
authors.lastname: Shah
authors.forename: Vineet Kumar
authors.initials: VK
authors.lastname: Kamal
authors.forename: Surya Kant
authors.initials: SK
authors.lastname: Sharma
authors.forename: Harish Chandra
authors.initials: HC
authors.lastname: Srivastava
authors.forename: Manoj Kumar
authors.initials: MK
authors.lastname: Das
authors.forename: Khageswar
authors.initials: K
authors.lastname: Pradhan
authors.forename: Hemant
authors.initials: H
authors.lastname: Kumar
authors.forename: Yogendra K
authors.initials: YK
authors.lastname: Gupta
authors.forename: Pooja
authors.initials: P
authors.lastname: Gupta
authors.forename: Aditya Prasad
authors.initials: AP
authors.lastname: Dash
authors.forename: Neena
authors.initials: N
authors.lastname: Valecha
mesh_terms: D000962:Antimalarials / Q000008:administration & dosage / Q000600:supply & distribution* / Q000627:therapeutic use; D037621:Artemisinins / Q000008:administration & dosage / Q000600:supply & distribution* / Q000627:therapeutic use; D003430:Cross-Sectional Studies; D004338:Drug Combinations; D004351:Drug Resistance; D006268:Health Facilities / Q000706:statistics & numerical data; D006801:Humans; D057970:Inappropriate Prescribing / Q000517:prevention & control* / Q000706:statistics & numerical data; D007194:India / Q000453:epidemiology; D016015:Logistic Models; D008288:Malaria / Q000188:drug therapy* / Q000453:epidemiology; D010595:Pharmacists; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011331:Private Practice; D017150:Public Sector; D011739:Pyrimethamine / Q000008:administration & dosage / Q000600:supply & distribution / Q000627:therapeutic use; D013413:Sulfadoxine / Q000008:administration & dosage / Q000600:supply & distribution / Q000627:therapeutic use; D011795:Surveys and Questionnaires
chemical_list: D000962:Antimalarials; D037621:Artemisinins; D004338:Drug Combinations; C001205:fanasil, pyrimethamine drug combination; D013413:Sulfadoxine; D011739:Pyrimethamine