Drug utilization review of tramadol hydrochloride in a regional hospital in South Africa; findings and implications

Abstract

Background: Drug utilization reviews (DURs) can be used to promote rational prescribing and ensure compliance with standard treatment guidelines. In recent years, the use of tramadol hydrochloride (HCl) for pain has increased significantly across countries. We sought to determine prescribing patterns and use of tramadol in a Regional Hospital in South Africa to provide future guidance in view of increasing concerns with the prescribing of tramadol. Method: A prospective, quantitative and descriptive study was conducted over two months. Outpatient and inpatient prescriptions and ward requisitions where tramadol HCl was prescribed or ordered were identified, which included outpatients collecting antiretroviral (ARV) treatment. These were reviewed and evaluated to determine the level of compliance to the Standard Treatment Guidelines and Essential Medicines List (STGs/EML) for South Africa as a measure of the quality of prescribing. Quantities issued to the inpatient wards and expenditure incurred by the pharmacy departments were assessed to determine overall usage and total costs. Results: In total, 415 tramadol HCl prescriptions were collected over a 2-month period. Compliance was 70.1% to the STGs/EML. The outpatient pharmacy department had the highest compliance at 76.4% while the ARV pharmacy compliance was 29.1%. Most prescriptions dispensed at the outpatient pharmacy were from the Surgical Outpatient Department (140; 33.7%) and the Orthopaedic Outpatient Department (108; 26.0%). The outpatient pharmacy had the highest tramadol HCl consumption and expenditure at $4,874.13 (R72,054.28), while the inpatient pharmacy's expenditure was $2,526.63 (R37,351.20), and the ARV pharmacy $590.13 (R8,722.75). The hospital's tramadol HCl expenditure increased when compared to previous financial years, from $10,576.04 (R156,326.00) in 2014-2015 to $39,584.00 (R585,088.80) in 2016-2017. Conclusion: This study highlights the need for the implementation of monitoring and evaluation tools to enhance rational prescribing and use of tramadol HCl. These are being implemented and will be evaluated in future projects.

Fixed dose drug combinations – are they pharmacoeconomically sound? Findings and implications especially for lower- and middle-income countries

“…This is seen with the FDC of acetaminophen/ibuprofen in patients with moderate to severe postoperative dental pain where the combination provided greater and more rapid analgesia than comparable doses of either agent alone [56]. Besides this, FDCs of tramadol and paracetamol may be opioid sparing without sacrificing effectiveness, which is seen as important given some of the recent concerns with tramadol especially its potential for abuse [260][261][262][263]. In addition, a tramadol/paracetamol FDC can present a potential alternative to nonsteroidal anti-inflammatory drugs (NSAIDs) in the elderly reducing concerns with possible gastrointestinal side-effects [264].…”

Review of the Current Situation of Postoperative Pain and Causes of Inadequate Pain Management in Africa

“…Relevant research had demonstrated that tramadol, rather than other more powerful opioid medications, can also have some desirable postoperative analgesic effects but with fewer side effects. [102][103][104] The Royal College of Anesthetists claims that 67 mg of tramadol offers the same analgesic effective as 10 mg of morphine. 105 Consequently, tramadol is often utilized in low-and middle-income nations.…”

“…105 Consequently, tramadol is often utilized in low-and middle-income nations. 104 However, the United National Office on Drug and Crime raised the alarm in its annual World Drug Report, stating "… about addiction to tramadol, rates of which are soaring in parts of Africa. This puts further strain on already overburdened healthcare systems".…”

Bridging Old and New in Pain Medicine: An Historical Review

“…As the use of opioids in these nations rises, so does the number of opioid-related deaths; this very much follows the experience of the United States. Problematic and nonmedical use of tramadol has been reported in Egypt [ 33 ], Ghana [ 34 ], South Africa [ 35 ], and other African nations [ 36 ].…”