Objectives The persistence pattern of anti-migraine drugs’ use among migraineurs is very low in the United States and different European countries. However, the cost and persistence of antimigraine drugs in Asian countries have not been well-studied. Hence, the present study aimed to evaluate the treatment cost and persistence among migraineurs in Pakistan. Methods Data from prescriptions collected from migraineurs who visited the Outpatient Department (OPD) of different public and private sector tertiary-care hospitals of Karachi, Pakistan were used to conduct this retrospective cohort study from 2017 to 2019. The minimum follow up period for each migraineur was about 12 months for persistence analysis while dropped-out patients data were also included in survival analysis as right censored data. Pairwise comparisons from Cox regression/hazards ratio were used to assess the predictors of persistence with the reference category of non-binary variables i.e. hazard ratio = 1 for low frequency migraineurs and NSAIDs users. Persistence with anti-migraine drugs was estimated using the Kaplan-Meier curve along with the Log Rank test. Results A total of 1597 patients were included in this study, 729 (45.6%) were male and 868 (54.3%) were female. Non-steroidal anti-inflammatory drugs (NSAIDs) were the most prescribed class of drug initially for all classes of migraineurs (26.1%). Of them, 57.3% of migraineurs discontinued their treatment, 28.5% continued while 14.8% were switched to other treatment approaches. Persistence with initial treatment was more profound in female (58.8%) patients compared to males while the median age of continuers was 31 years. The total cost of migraine treatment in the entire study cohort was 297532.5 Pakistani Rupees ($1901.1). By estimating the hazard ratios (HR) using the Cox regression analysis, it can be observed that patients with high frequency (HR, 1.628; 95%CI, 1.221–2.179; p<0.0001) migraine, depression (HR, 1.268; 95%CI, 1.084–1.458; p<0.0001), increasing age (HR, 1.293; 95%CI, 1.092–1.458; p<0.0001), combination analgesics (HR, 1.817; 95%CI, 0.841–2.725; p = 0.0004) and prophylaxis drugs (HR, 1.314; 95%CI, 0.958–1.424; p<0.0001) users were at a higher risk of treatment discontinuation. However, patients with chronic migraine (HR, 0.881; 95%CI, 0.762–0.912; p = 0.0002), epileptic seizure (HR, 0.922; 95%CI, 0.654–1.206; p = 0.0002), other comorbidities (HR, 0.671; 95%CI, 0.352–1.011; p = 0.0003) and users of triptan(s) (HR, 0.701; 95%CI, 0.182–1.414; p = 0.0005) and triptan(s) with NSAIDs (HR, 0.758; 95%CI, 0.501–1.289; p<0.0001) had more chances to continue their initial therapy. Conclusion Similar to western countries, the majority of migraineurs exhibited poor persistence to migraine treatments. Various factors of improved persistence were identified in this study.

Background: Drug stores in Pakistan are run by dispensers with varied knowledge, qualification, and experience. The current study was sought to explore the knowledge, qualification, experience, and dispensing practices among dispensers working in drugstores in South Karachi, Pakistan. Methods: A cross-sectional survey was carried out using a structured questionnaire. Data were collected from medical stores in South Karachi which were then categorized, coded, and analyzed using SPSS version 23. Relationship among different study variables with pharmacist’s availability and personal experience was assessed using statistical non-parametric Chi-square test. A total of 385 samples obtained using a simple random sampling method were included in the study. However, only 210 responses on questionnaire were complete which were then selected for study analysis between October and December 2018. Results: Of the 210 surveyed drugstores, 9% of their staff had studied only till primary school, 5.7% till the eighth grade, 25.2% up to secondary school level, 26.7% till higher secondary school level, 15.7% had non-professional education, and 8.1% were professional graduate. Only 9% of them had a degree in Pharm. D or B. Pharm, while 0.5% had a post-graduation qualification. Furthermore, 44.8% of pharmacies had a valid pharmacy license but the pharmacist was physically absent in 91% of the drugstores. Majority of pharmacies did not maintain appropriate temperature (refrigerator and/or room temperature). Majority of dispensers did not review prescription particulars before dispensing medications and also dispensed medications on older prescriptions as well as without prescription. Conclusion: In conclusion, the overall knowledge and practices of dispensers working in drugstores was poor. However, the presence of pharmacist was associated with good dispensing practices to a certain extent.

Background: Medication errors are of primary concern in hospitals of Pakistan but only few are reported. Prevalence and type of medication errors are essential for estimating the appropriateness of therapy. Pharmacist is key in improving therapy effectiveness and decreasing medication errors. Objective: To assess the prevalence, type of medication errors and pharmacist interventions. Methodology: An interventional study on prescriptions of inpatients was conducted at Liaquat University of Medical and Health Sciences (LUMHS) Hyderabad. Five hundred and fifteen prescriptions were collected randomly from medicine, gynecology and obstetrics and urology department during one year from 01-09-2017 to 31-08-2018. Medications errors were identified by Pharmacist by comparing the prescriptions with standard of British National Formulary (BNF) (edition 73) and informing physician for resolving medication errors. Data was analyzed with statistical package for social sciences version 25.0. Results: Out of 515 inpatients prescriptions, male patients were 248 (48.2%) and female were 267 (51.8%) with male to female ratio of 1:1.08 and mean age of 37.7 ± 11.6 (18-60) years. 427 medication errors were reported in 303 (59.4%) prescriptions including; omission error 64 (15.0%), unauthorized drug error 41 (9.6%), wrong dose error 67 (15.7%), wrong time error 74 (17.3%), wrong dosage form error 27 (6.3%), wrong route error 23 (5.4%), wrong drug preparation 44 (10.3%), wrong rate error 56 (13.1%) and incorrect administration technique 31 (7.3%). 172 (40.3%) interventions of pharmacists were accepted by physicians. Conclusion: Rate of medication errors in inpatients prescriptions are high with possible errors of dose, time, omission, rate, drug preparation and others. Pharmacist effectively intervening the prescriptions and playing active role in decreasing medication errors.

Objective: To find out the frequency of anemia, agranulocytosis and thrombocytopenia in hyperthyroid patients after the use of propylthiouracil. Study Design: Cross sectional study. Place and Duration of Study: Out Door Patients Department and Pathology Laboratory in Liaquat University Medical & Health Sciences, Hospital Hyderabad/Jamshoro, from May 2016 to Apr 2017. Methodology: Two hundred cases, comprising of adult patients were categorized into five groups, age group 15-30 years 79 (39.5%) patients presenting the highest out of total, age group 31-45 years 68 (34%) patients, age group 46-60 years 36 (18%), age group 61-75 years 14 (7%) patients, age group >75 years 3 (1.5) patients. Complete blood count was analyzed on Sysmex Kx21 and thyroid profiles were analyzed on Elecysis 2010 from the Pathology Department. SPSS version 22 was used for data analysis. Result: Out of total patients, 32 (16%) were males and 168 (84%) were females with mean age of 37.44 ± 14.82 years. Majority of patients 68 (34%) were anemic, while 4 (2%) had agranulocytosis and 11 (5.5%) had thrombocytopenia. Headache was reported in 111 (55.5%), exophthalmos in 106 (53%), sore throat in 172 (86%), fever in 136 (68%) and weight loss in 95 (47.5%) patients. Conclusion: Propylthiouracil causes defective hematopoiesis in hyperthyroid patients because propylthiouracil has adverse suppressive effects on bone marrow.

ABSTRACT… Introduction: Drug-drug interaction refers to an altered or impaired response of drug as a resultant of the other drug's activity. However, recently advancement in field of therapeutics has leaded the therapy toward more rational and logical trend in order to improve the patients' health with respect to cost effectiveness. Objective: To assess the various levels of DDIs in Prescriptions at public sector teaching hospital of Hyderabad, Pakistan. Study Design and Settings/Methodology: A descriptive observational questionnaire based study has been conducted by collecting initially 250 random prescriptions of various patients prescribed with multiple drugs. Tertiary care hospital OPD and In-patient wards were visited for a period of 06 months. The Prescriptions (℞) so collected were analyzed and assessed individually for drug interactions using Standard drug interaction software i.e.. Lexi-comp's Lexi-Interact, Drug Information Handbook, Hansten and Horn's drug interactions. Results: For this study, a total 250 Prescriptions were collected. It was observed that 30 (12%) prescriptions contained with single medication, 10 (4%) prescriptions were unreadable, 210 (84%) prescriptions were contained more than one medication. Moreover, 210 (84%) poly-pharmacy prescriptions focused keenly. Subsequently, 51 (24%) prescriptions ensured the prevalence of DDIs and 159 (76%) were NonDDIs prescriptions. Similarly, 13 ℞ contained four or more than four drugs, 32 ℞ contained three drugs and 06 prescriptions contained two drugs correspondingly. Conclusion: It was clearly concluded that the most potential reason of DDIs are Poly pharmacy. So it is of utmost need to enhance the health care policies in overall healthcare system in order to antagonize DDIs associated morbidity and mortality among society.

Objective: To assess the adverse drug reactions due to anti hypertensive therapy among hypertensive patients at teaching hospital of Hyderabad, Sindh, Pakistan. Methodology: The current study was performed in a teaching hospital of Hyderabad, Sindh, Pakistan. A cross sectional study was conceded in medicine and cardiac outpatient department during the period of study. A total of 1271 hypertensive patients were enrolled during the period of 2 years by purposive sampling procedure. A series of questions were asked by the hypertensive patients. The questionnaire contains the demographic details of the patients, prescribing trend and various ADRs found in patients due to antihypertensive therapy. The written consent was also taken from the health care professionals as well as patients. Results: Out of 1271 patients, 57.99% belong to male gender, 79.78% to urban areas, 69.16% enrolled from cardiac OPD, 32.33% were aged between 49-58 years of age, 21.40% had 1 parent positive history of hypertension and 44.22% had 3-5 years duration of hypertension. Maximum patients were on dual therapy i.e. 42.64% and the most common combination therapy was valsartan+amlodipine i.e. 11.99%. Moreover the most common combination therapy that caused maximum ADRs was telmisartan+hydrochlorothiazide i.e. 17.54%. Conclusion: The existing passive pharmacovigilance department should be active again under Drug regulatory authority of Pakistan. A council will create under the Drug regulatory authority of Pakistan that helps to communicate with international organizations such as Uppsala monitoring center under World Health Organization, Food and Drug Administration etc. Moreover council will also establish a system of ADRs reporting throughout the country and then data will share with all stake holders.

Prescription is an order for medications issued by a physician, veterinarian, dentist or other properly licensed medical practitioner to pharmacist. Incorrect prescription writing habits may lead to substandard therapeutic goals and even can cause drug induced injuries. Non-steroidal anti-inflammatory (NSAIDs) drugs are used in various inflammatory diseases such as arthritis. The missed or wrong information regarding NSAIDs in prescription may lead to irrational drug use and can cause gastrointestinal, cardiovascular and other problems. The present study was carried out to evaluate the prescribing errors in NSAIDs containing prescriptions. We collected a total of 2712 prescriptions by randomly visiting the pharmacies located beside outpatient clinical settings in various towns of Karachi city, Pakistan. Among the omission errors, the absence of prescriber's registration number (94.5%), prescriber's qualification (93.7%), drug's generic name (86.5%), patient's diagnosis (86%) and patient's weight (83.90%) were the most frequent errors. Regarding the commission errors the error of writing an ambiguous order (77.7%) was the most common followed by the use of non-standard or abbreviated drug names (37.6%), wrong dose (26.9%) and wrong dosage form (23.2%). Overall a low compliance to the standards of prescription writing was observed which may cause serious or fatal NSAIDs induced injuries. Implementation of electronic prescribing systems, educational programs on prescription writing and proper reviewing of the orders by pharmacists may be valuable to reduce the errors.

Background: Propylthiouracil (PTU) is a thyro-suppressive medication commonly used for the treatment of hyperthyroidism, but may cause agranulocytosis, which rises the mortality of patients. Objective: To evaluate the prevalence of agranulocytosis in hyperthyroid patients after the use of Propylthiouracil. The aim of the current research is to access the drug utilization and investigation of PTU which aids in accessing rational therapy and other aspects related to the patient’s safety. Methodology: A cross- sectional study conducted from May 2016 to April 2017 at Liaquat University of Medical and Health Sciences, Hospital Hyderabad/ Jamshoro. 150 prescriptions were collected by non-probability consecutive sampling technique from the adults with Hyperthyroidism patients using Propylthiouracil. Thyroid function tests were conducted using Immunoassay Elecysis 2010. The blood profile tests were evaluated on Sysmex kx21. The collected data was evaluated using the Statistical Package for Social Sciences (SPSS). Results: The data revealed that the propylthiouracil-induced agranulocytosis in 4 hyperthyroid patients (n=2 males, n=2 females) and the prevalence of Propylthiouracil-induced agranulocytosis was 2.7%. Conclusion: It was observed that Propylthiouracil damages the hematopoietic stem cells and precursors of granulocytes in bone marrow can cause agranulocytosis.