Malaria Drugs in Nigeria: Policy Change, Prescription Change

An article by Mokuolu et al. in the January 2007 issue of the American Journal of Tropical Medicine and Hygiene, reports on changes in malaria drug sales before and after the issuance of the new national antimalarials drug policy. Data come from doctors’ prescriptions at University of Ilorin Teaching Hospital pharmacy in Kwara State.  The Federal Ministry of Health, with support from WHO conducted two rounds of malaria drug efficacy trials, and based on these a new policy promoting Artemisinin-based Combination Therapy (ACT) was drafted in 2004. The policy was not officially inaugurated until May of 2005.  Data from Ilorin examine both 2004 and 2005.

The hospital pharmacy operates a revolving fund with prices pegged just above cost. Sales of drugs containing artemisinin increased by 300% in just one year.  Also, as a percentage of total malaria drug doses sold, medicines containing artemisinin rose from 18% in 2004 to 49% in 2005.  The proportion of sales of chloroquine, the former first line drug, dropped from 73% to 27% in the same period.  These changes occurred in spite of the fact that the cost of a course of chloroquine tablets was about 12 US cents compared to between US $2.30 and $7.20 for a tablets containing artemisinin.  It appears that prescribers are adopting the new policy, and consumers are paying the price.

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Three issues of concern arise from the findings.  In 2005, over two-thirds of the drugs containing artemisinin were not ACTs, but artemisinin monotherapy formulations (see photo above). WHO has demanded that sales on monotherapy drugs be halted in order to prevent the spread to resistance to artemisinin. The current approach of the Nigerian Agency for Food and Drug Administration (NAFDAC) has taken the approach of not intending to renew the license of monotherapy drugs when these expire, but not in pulling the drugs off the shelves.  A second concern is the fact that a small (~7%) but notable portion of drugs were sold in syrup form which is not only more expensive but also less stable. Child dose packets of ACT tablets are available (see photo below). Finally sulphadoxine-pyramethamine (SP) continues to be a large portion of total sales (23% in 2005) in spite of the fact that SP, according to national policy, should be reserved for Intermittent Preventive Treatment in pregnancy and not used for curative purposes.

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Hopefully the authors will continue to monitor malaria drug prescribing and branch out into the state and local governments as well as into the private sector to learn more about response to the new national ACT policy. Learning about compliance with the new policy in the private sector is crucial, because this is where the bulk of malaria drugs are sold and where the bulk of controversy about drug quality exists. (Note that pictures of malaria medicines herein do NOT constitute an endorsement.)

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