IPDR Position Statement on the Pathology of Haemorrhoids

December 25, 2012 § Leave a comment

Haemorrhoids are a common affliction among the adult population worldwide. The lay public and physicians alike have a tendency to associate every ailment involving the anorectal region with haemorrhoids, including nonspecific signs and symptoms such as anorectal pain, bleeding, lumps, and itching. For this and other reasons objective data are not available to enable the characterization of the actual epidemiology of haemorrhoids among populations. In the United States tentative estimates have put the incidence of haemorrhoids in the population at 4.4%.

 

Traditionally, gastroenterologists have classified haemorrhoids into four(4) grades on the basis of severity. Haemorrhoids are diagnosed with a combination of visual inspection and proctosigmoidoscopy. Medical treatment with widely available medications, mainly suppositories including locally active allopathic or herbal drug substances, has been recommended for first grade haemorrhoids. Second grade and third grade haemorrhoids are treated with one of several nonoperative procedures which are selected dependent on physician preference and expertise. Such include injection sclerotherapy, cryotherapy, rubber band ligation, diathermy coagulation, bipolar coagulation, and infrared photocoagulation. The recommended treatment for fourth grade haemorrhoids is surgery.

 

The IPDR affirms that the proper diagnostic procedures for haemorrhoids are visual examination in combination with ano-proctosigmoidoscopy. IPDR recognizes that medical treatment in comparison with surgical treatment offers an easier approach to treating diseases, which treatment option may sometimes be administered by the affected patients themselves. The organization further recognizes, however, that current practice sparsely employs medicinal substances in the treatment of haemorrhoids. This the IPDR identifies is due to the fact that no aetiological foundation has been laid down for the disease.

 

This paper is intended to make a statement on the pathology of haemorrhoids. IPDR identifies haemorrhoids among the autoimmune complex, so that the organization identifies haemorrhoids as one of the manifestations of autoimmune disorders. To put the disease into this aetiological perspective will be an important contribution to its treatment as to determine which treatment modalities are appropriate. Further, the position of the IPDR is that haemorrhoids could be successfully treated medically with the therapeutic agents used for treating other autoimmune diseases, namely the antiinflammatory agents, immunoregulatory agents, cytoregulatory agents, antiviral drugs, and the phlebotonic agents. Special mention needs be made of the employment of the antiinflammatory effects of NSAIDs in the treatment of haemorrhoids. IPDR recommends the local application of the NSAIDs, either alone or together with therapeutic agents from the other useful drug classes mentioned above, in the treatment of haemorrhoids. Such medications may be applied as a therapy or prophylaxis and, as these may be administered by patients themselves, are considered preferred to the currently existing treatment procedures of the disease.

Advertisements

Sheabutter – Uncovering the antiinflammatory properties of a botanical

December 25, 2012 § Leave a comment

The solid fat which is extracted from the nuts of the tropical tree Vitellaria paradoxa (alias Butyrospermum parkii) Fam. Sapotaceae, named sheabutter, is put to several culinary and cosmetical applications in Ghana. I became deeply interested in this botanical product when I successfully used it to eradicate a severe acneiform disease from my face. The condition was the pustular and inflammatory type and had persisted for more than a decade, and haven resisted most conventional treatments for acne it seemed intractable. Within a few weeks of application of sheabutter the pustular lesions discharged their contents, inflammations were completely resolved, and the black spots had cleared. It was a complete cure.

I therefore proceeded to try the product on other inflammatory conditions of the skin, such as swellings as a result of trauma, inflamed spots from insect stings, and other inflammations of uncertain aetiologies. I have also briefly tried the product on open wounds. The findings have always been remarkable. Sheabutter exerts potent analgesic and antiinflammatory properties. Inflammations arising from all aetiologies quickly resolve within a few hours under the action of sheabutter. Wounds heal rapidly without leaving a scar.

This discovery has cast some light on the medicinal potential of sheabutter and informs us that this product merits our close study and attention. I suspect that sheabutter would eventually prove very useful in dermatological practice, and effective in the therapy of autoimmune diseases and other rheumatological disorders.

Clinical Pharmacy: A Theoretical Framework For Practice

August 2, 2012 § Leave a comment

The assurance of quality of any system is not possible without adequate supervision. A quality assured healthcare system should not be composed of only the prescriber and patient; it must also include a supervisor. Thus, three roleplays are critical to every efficient healthcare system, namely, the provider, the receiver, and the supervisor. To illustrate this position, given the circumstances that the receiver most likely would be naïve to the technicalities and procedures of healthcare, and that the provider is an imperfect being who is also susceptible to errors, negligence and opportunism, who then is to ensure that the care provided is of standard quality and efficiency? The supervisor of course. Presently this vital role of supervision within the healthcare system is left unfilled worldwide. Consequently healthcare resources are wasted and treatments are mainly ineffective and uneconomical.

We live in the conception stage of the clinical pharmacy profession, and very typical of the time, there is no consensus as regards the function and structure of this noble profession. There is now much debate in both academic and practice fields as to what particular role the clinical pharmacist should fill within the healthcare structure. The support seems to be stronger on the side of those who argue that clinical pharmacists ought to be accorded with some measure of authority to be able to prescribe treatments. This I think is a duplication of role much as the role of a prescriber is already sufficiently filled by other health professions. This statement by no means expresses sufficiency in terms of numbers of those professionals but the identity. My personal candid opinion on this issue is that we do not need more health professions to serve as prescribers any more. We as pharmacists are already suitably positioned both by law and education to authoritatively vet the treatments which are being discharged by the existing prescriber-professions, and with the proper orientation, we are the best suited among the health professions to provide supervision in the healthcare system. I posit that the clinical pharmacy profession should fill this supervisory role which remains vacant up to this present time. In the succeeding sections I undertake to define a theoretical basis for this position and illustrate how it could be put into practice.

Tripartite Model Of The Healthcare Team

Let it be invented as the basis of our noble profession a certain tripartite model of the healthcare team. This constitutes a radical departure from the current model of the healthcare team wherein the doctor occupies a commanding position among a team of other health professions, including pharmacists. The whole development process of the clinical pharmacy profession consists in agitations for the general acceptance and fixation of this tripartite model of the healthcare team into the health system. The latter may be illustrated with the following diagram.

We depict the healthcare team as equilateral triangular relationship of three distinct roles which are of equal and complementary importance, namely: the provider of healthcare, the receiver, and the quality assurance specialist. The medical doctor functions as the provider of healthcare services at the head of other health professions who for the purposes of this model I would describe as the allied health professions. The patient functions as the receiver of healthcare services and two reasons may be adduced to explain the inclusion of the patient in the healthcare team. Firstly, the patient is the ultimate decision maker in any properly administered health system; another facet of sharp contradiction between the current model of the healthcare team and the tripartite model we are now discussing. It is incontrovertible that the authority belongs to the patient both to seek healthcare services and to choose a particular treatment option, and that healthcare professionals should only function to guide the patient to choose and then deliver the selected treatment. The patient should never be considered as an unquestioning recipient of healthcare services. Secondly, the success of every healthcare effort is totally dependent on the cooperation of the patient. If the patient is made to appreciate his/her vital role as team-player in healthcare there is the higher prospect of maximum cooperation and adherence to the instructions of healthcare professionals.

In this model the clinical pharmacist functions as the quality assurance specialist. Someone offered a useful word to describe this role, namely; umpire. The idea of umpire is deemed very appropriate in comparison to the word referee which carries similar connotations in that there is some bias in the work of the former. The clinical pharmacist necessarily should exist to function for the benefit of the patient and in the interest of the healthcare system. As medical practice is made up of much technical language and procedures of which the patient most likely would be ignorant, it is very necessary for there to be an agency who may function somewhat as the patient’s advocate to stand by the patient, carry the latter through the healthcare process, and to ensure that good quality and economical care is provided. This is the professional function we propose for the clinical pharmacist.

The allied health professions include all other known professions besides the medical profession and clinical pharmacy. To mention a few, allied health professionals as per this model under consideration include nurses, radiologists, biomedical scientists, laboratory technicians, ultrasonographers, dieticians, physiotherapists, and anaesthetists. Notably, pharmacists who practice the traditional pharmacy profession which is in current general acceptance are included among allied health professionals. As these professionals mainly perform in response to the instructions of the medical practitioner we consider that these interact with the patient in an indirect manner. This explains why in the tripartite model the allied health professions are placed only tangential to the medical profession and not in direct relationship to the patient. In contrast to the traditional pharmacist who follows the instructions of the medical practitioner the clinical pharmacist functions in an independent capacity and is not subject to the medical practitioner. The latter two are both hires of the patient.

Elements Of Pharmacoprudence

Let it be introduced into the lexicon of healthcare the term “pharmacoprudence” to describe the job function of the clinical pharmacist. It emanates from the realization that the role which we seek to establish for the clinical pharmacist is very much similar to that of the legal practitioner. And as is jurisprudence so is pharmacoprudence. In very few words I may define pharmacoprudence as the science and practice of the rational, efficient, efficacious and economical utilization of therapeutic agents. We associate pharmacoprudence with the broader coverage of all therapeutic agents in contrast to the limited focus of drugs alone. Further to the point pharmacoprudence is the professional domain of the clinical pharmacist.

The profession of clinical pharmacy may be practised both within the hospital setting and the private sector, although there is the business facet as well in the latter case. But in whatever field of practice wherein the clinical pharmacist may be found there should be uncompromising autonomy of practice. That is, the clinical pharmacist does not perform by the instructions of any other health profession. I have the opinion that so as to avoid attrition at the workplace clinical pharmacy is best practised in a private business office.

Pharmacoprudence, the job function of the clinical pharmacist, embodies several interrelated activities which include the following:

  1. Pharmacoeconomic evaluation of therapeutic agents. The clinical pharmacist follows the global scholarly biomedical literature in the medical field(s) of his/her specialization. The objective is to keep updated with the emerging trends in the diagnosis and treatment, as well as the issues in the field(s) of his/her specialization. At predetermined intervals the clinical pharmacist prepares a review literature to be circulated among the healthcare facilities he/she works with.
  2. Maintenance of managed health records (MHRs) for individual clients. The clinical pharmacist should maintain MHRs for his/her clients. These are electronic forms of patients’ medical folders which are organized and stored in a manner as to enable faster information retrieval. It is a difficult task to access pertinent information from the conventional patients medical folders in which documents vital information are scattered in chronological order. In the MHRs such pieces of information are stored in a classified structure. The breadth of coverage of the MHR should be wide enough for it to serve as a comprehensive health record of the client.
  3. Performance of clinical audits on population-wide and individual basis. Clinical auditing is the process of measuring the degree of compliance between any prescribed treatment and generally accepted treatment protocols. Clinical audits are the main instruments for quality assurance of the healthcare system. Although international protocols are often employed local protocols may be developed through the leadership of the clinical pharmacist and are then submitted for peer review. As a result of clinical auditing the clinical pharmacist institutes corrective measures to address the points of deviation of the prescribed treatment from the standard protocols.
  4. Execution of clinical trials. The clinical pharmacist is also a research scientist and would frequently have to initiate or participate in clinical trials. The quest for superior therapeutic agents is ever imperative and necessitates that the clinical pharmacist should be ready to experiment with therapeutic agents to determine new ways of treating diseases.
  5. Training and education of other healthcare staff and the general public. The clinical pharmacist is a health educator and trainer. A regular program should be developed whereby the clinical pharmacist may disseminate the knowledge acquired through his/her own studies to other healthcare professions, the academic community, and the general public. The practice office of the clinical pharmacist could serve as a platform for apprenticeship and training of other people in pharmacoprudence. A clinical pharmacist could very successfully establish a continuous succession of clinical pharmacy practice by using this approach.

History Of Professions

I should point out that no existing profession is of a natural origin; they all began as the conceptions of men, were inaugurated, and thereafter nurtured to maturity. This is the tortuous trajectory which our noble profession would have to follow. A few discussions I have had with colleague pharmacists have hinted to me that the theoretical framework discussed here would meet with pessimistic reception from the very people it is meant to stimulate. There is uncertainty whether the tripartite model would be acceptable to the other health professions. Some advised that we pursue the approach of dialogue with other stakeholders of the healthcare system to reach consensus. But do we have to beg for permission from other people to practice our profession? Must we seek the approval of other health professions to practice clinical pharmacy in the best way that we think it should be practised? It is a plain fact that clinical pharmacy is our own profession and we alone, and none other, have the ethical authority to determine its identity and course to follow. The professions are conceived by ideas, born by the fellowship of people, and are nurtured through practice. This theoretical framework has been conceived for the clinical pharmacy profession. The next important step is the organization of all colleagues who subscribe to these propositions. We would not beg the established system to accept our model; we would fix the model into it.

The public is the ultimate authority in every enterprise; it is that which the public would accept that matters and not the preferences of other health professions. By embarking on robust social marketing campaigns we are sure to lead the public to appreciate the merits and benefits of the clinical pharmacy profession.

Our Opportunity

A dichotomy could still be maintained between traditional pharmacy practice and clinical pharmacy. It would serve no useful purpose to clinical pharmacy to dissolve traditional hospital pharmacy profession. As allied health profession traditional hospital pharmacy practice should continue to perform its current functions such as pharmaceutical stock management, dispensing of medicines, preparations of admixtures and extemporaneous products, et cetera. A person who seeks to pursue a career in pharmacy practice should have the option between traditional hospital pharmacy and clinical pharmacy.

A somewhat queer pair of factors combine to produce an ironic advantage for our course. On one hand the pharmacist is in possession of a very extensive knowledge on the applications of therapeutic agents; on the other hand we are not giving the legal mandate to prescribe treatments. These two seemingly opposing factors place the pharmacist in a unique position among the health professions. The pharmacist is the best qualified professional to vet the treatments that are prescribed by the prescriber-professions. This I think constitutes a very good opportunity for launching the clinical pharmacy profession. Instead of arguing for authority as prescribers we should express optimism and make the available provisions work to our advantage.

 

Announcement: Establishment of IPDR

July 22, 2012 § Leave a comment

It is being announced for the information of all and sundry the establishment of the Institute of Pharmacoprudence and Drugs Research (IPDR). This is a nonprofit organization which has been formed to provide leadership in the emerging field of clinical pharmacy.

All colleagues who are interested in the profession of clinical pharmacy are warmly welcome to join this all-important collaboration. For further information click to download the information brochure which appears here below. You may also contact pharm.2278@hotmail.com for further information.

BROCHURE

Ginger as antiemetic drug

February 18, 2012 § Leave a comment

Ginger, the fresh or dried rhizomes of the plant Zingiber officinale Roscoe (Fam. Zingiberaceae), has gained official recognition for use both in foods and pharmaceuticals. Monographs on ginger now appear in the European, USP and all the major pharmacopoeias. In the Martindale1 ginger has been listed among the established antiemetic drugs. The different pharmacologic groups of drugs which are currently being used as antiemetics include, firstly, the prokinetic dopamine antagonists such as domperidone and metoclopramide; secondly, the serotonin antagonists such as ondansetron and granisetron; and thirdly, the anticholinergic drugs such as promethazine, prochlorperazine, droperidol, doxylamine, and dimenhydrinate. High cost and greater incidence of adverse effects are two disadvantages which preclude the routine use of these established antiemetic drugs. Besides the anticholinergic drugs, which otherwise are relatively cheaper, are mostly sedating and are not suitable for daytime cases. Ginger compares favourably to each of these drugs. The strengths of ginger as alternative antiemetic drug are that it is a cheaper option, suitable for use in both adults and paediatric cases, applicable throughout the day, and a better safety profile. Moreover ginger has the most rapid onset of action so that evidence of antiemetic action becomes manifest shortly after taking a dose. Also ginger presents the broadest spectrum of activity with additional actions that are beneficial to the impaired gastrointestinal system.

Ginger has been screened for biological activity through the years and the volume of reported findings keeps on expanding. Ali and colleagues2 reviewed the research on ginger up to 2007 and their report provides an important source of information about the herb. Several important pharmacologic actions have been identified but the focus here is being placed on its antiemetic actions. The alcoholic extracts of ginger were found to be effective for blocking experimentally-induced emesis in animal models. At the pharmacologic level anticholinergic and antiserotonergic actions were revealed and associated with the antiemetic actions of these extracts. Moreover the extracts were found to stimulate the transit of a test meal through the rat intestines. On the basis of these findings ginger is presumed to exert antiemetic action by a broad pharmacologic basis which includes stimulation of gastrointestinal transit(prokinetic), anticholinergic and antiserotonergic actions. It appears that ginger has a rapid GIT action as well as a delayed CNS action.

Ernst and Pittler (2000) reviewed the evidence for the usefulness of ginger against nausea and vomiting from six clinical studies; three studies evaluated the efficacy of prior ginger treatment in preventing postoperative nausea and vomiting; one each on the efficacy of ginger for sea sickness, morning sickness and chemotherapy-induced nausea and vomiting. The conclusions were that ginger was superior to placebo and at least as equally effective as metoclopramide which was used as the standard antiemetic drug. The dose of ginger used in these studies was one(1) gram statim or in divided doses; where results were unconvincing the explanation has been that the doses of ginger that were employed were too low.

Phytochemical analysis4 of ginger have identified the presence of active principles such as saponins, flavonoids, amines, alkaloids, and terpenoids. The oleoresin of ginger is the antiemetic product of the herb and it is available in excess of 4.5% by weight of the fresh material. A ginger elixir may be prepared extemporaneously using the following formula.

Ginger Elixir

Ginger tincture 100mL

Citric acid monohydrate 6g

Sodium benzoate 1.2g

Purified water to make 1000mL

The ginger elixir is suitable for both paediatric and adult patients, it is very cheap, and would enable prescribers to give an effective but cheap antiemetic drug to their patients.

Safety profile

No adverse effects of ginger have been reported; occasional untoward gastrointestinal effects include heartburns and irritation. Ginger may potentiate the actions of drugs such as antiplatelets, antidiabetics, antihypertensives, anticoagulants, and cardiodepressants. Precaution is necessary in using ginger concomitantly with these drugs. Safety studies of use of ginger in pregnant rats have produced mixed results; whilst ginger was found not to be teratogenic its use in pregnancy has been associated with increased incidence of foetal death and heavy birth weights in those foetuses which survived loss. In the absence of further research, therefore, it is generally considered that avoidance of ginger and ginger-based formulations during pregnancy is prudent.

1. Martindale: the complete drug reference, 36th edition(2009). Pharmaceutical press, UK. P1732

2. Ali, B.H., Blunden, G., Tanira, M.O., Nemmar, A., 2008. Some phytochemical, pharmacological and toxicological properties of ginger(Zingiber officinale Roscoe): a review of recent research. Food Chem. Toxicol. 46, 409 – 420.

3. Ernst, E., Pittler, M.H., 2000. Efficacy of ginger for nausea and vomiting: a systematic review of randomized clinical trials. Br. J. Anaesth. 84, 367 – 371.

4. Ghayur, M.N., Gilani, A.H., Afridi, M.B., Houghton, P.J., 2005. Cardiovascular effects of ginger aqueous extract and its phenolic constituents are mediated through multiple pathways. Vascul. Pharmacol. 43, 234 – 241.

Pharmacoprudence defined

May 31, 2011 § 1 Comment

In keeping with my adopted tradition of comparing clinical pharmacy to the legal profession I have coined and now introduce the term “pharmacoprudence” into the lexicon of healthcare. Akin to the term “jurisprudence” as for when the affairs of the law are concerned. Pharmacoprudence may be defined in simple terms as the operation of systems for the rational utilization of drugs as well as nonpharmacological interventions in the delivery of healthcare.

Advocacy for the use of evidence-based and economical methods in healthcare is now prevalent round the world. The concept of rational use of drugs and other medical resources has been around for many years although this very term (pharmacoprudence) has not been used before to describe it. Now we are making an attempt to establish pharmacoprudence as an identified and important aspect of healthcare delivery.

As would be discussed later pharmacoprudence is the subject matter of the clinical pharmacy profession. Therefore although these two terms are not interchangeable the clinical pharmacist may so succinctly describe his/her function or role in healthcare as that of pharmacoprudence. This embodies among other things the following activities.

  • Initiation and participation in locally-relevant clinical trials or research
  • Surveillance of the global medical scholarly literature and review of research findings
  • Clinical auditing on both patient and population-wide basis
  • Training and information service to the medical community
%d bloggers like this: