Evaluation of medication package inserts in Saudi Arabia

A Cross-Sectional Evaluation of Knowledge of Medicine Safety and Frequency of Reading Medication Leaflets and Its Predictors - Insights from Saudi Adults in Riyadh, Saudi Arabia

Background and Aim

On the other hand, patient safety, is of the utmost importance, in addition to health care providers' counseling and advice, patient information leaflets (PILs) also have a significant impact on health outcomes. This study aimed to assess the Knowledge of medicine safety and Frequency of reading medication Leaflets and their predictors among the Saudi population in Riyadh Saudi Arabia.

Methods and Materials

This cross-sectional study was conducted over three months in 2023 using online structured self-administered questionnaires, on the adults of Saudi Arabia, admitted to provide informed consent, aged ≥18 years, able to complete the questionnaires, being Saudi nationals, and currently living in the country. The data analysis was performed using the Statistical Package for Social Science (SPSS) version 27.

Results

In this study, 23.6% (n=123) of respondents always read the PILs, while 14.6% (n=76) of them never read the PILs. In addition, 22.6% (n=118) of them find it difficult to understand the PILs. In this study, 53.9% of them revealed that ADRs are unexpected reactions after taking the normal dose and 15.4% of them do not know what ADRs are. The respondents gender (B= 0.164; SE=0.075; 95CI = 0.017-0.310; p = 0.029), Social status (B = 0.251; SE = 0.079; 95CI = 0.096-0.406; p = 0.002) and monthly income (B= 0.136; SE = 0.021; 95CI = 0.095-0.178; p < 0.001) was the predictor of reading PILs.

Conclusion

In this study, two-thirds of participants took medication and knew why they were taking it. However, only a few of them took the medicine after seeing a doctor, suggesting self-medication practice. In addition, 22.1% of them find it difficult to understand the PILS, and a small number of them would rather read it. Highlighting the significance of seeking medical advice from healthcare professionals before using a medication.

A Comparative Evaluation of Drug Information Leaflets of Over-the-Counter Medicines in Palestine

Our study aims to conduct an evaluation and comparison between the leaflets of local and imported oral solid over-the-counter medications (OTC) found in the Palestinian markets. Forty-nine leaflets were evaluated using a scoring method and depending on the appearance of 31 headings, along with the use of manual word counting to assess the amount of information within 23 topics of all 31. None of the evaluated PIs, local or imported, completed all 31 criteria. Remarkably, the imported product leaflets achieved higher scores than their local leaflets in 19 out of 31 topics, whereas the local products achieved better scores than the imported agents in only 2 items, and 10 criteria were equally scored between them. None of the PIs mentioned pharmacokinetic information, instructions for converting tablets or capsules into liquid forms, or shelf life. In general, imported leaflets give more detailed information than their local counterparts. The lowest value of the fold difference in mean rank was 0.85 times for the direction of use, and the highest value was 2.43-fold for adverse drug reactions. The results showed a deficiency in the information provided in the local package inserts compared to the imported versions of oral solid OTC medications available in Palestine. These findings encourage the Palestinian Ministry of Health to provide full criteria for pharmaceutical companies to ensure that the leaflets contain sufficient and updated information and ensure that the patients use their drugs safely and effectively.

Utility of patient information leaflet and perceived impact of its use on medication adherence

BACKGROUND

Although patients frequently use patient information leaflets (PILs) to obtain information about medicine, their confidence in using it may be diminished after reading it. This study aimed to assess the public perception of PIL's quality and the perceived impact of its use on medication adherence.

METHODS

A community-based cross-sectional study of 1,138 adult individuals in Saudi Arabia, April-May 2020, was conducted via Survey Monkey using an anonymous validated e-questionnaire. Data were collected on personal characteristics, PIL readership and preferences, perception towards PIL quality and impact of its use on taking medication, and reasons for not reading PIL. In addition, logistic regression analysis was performed to identify the significant predictors of reading PIL. Significance was considered at p < 0.05.

RESULTS

Nearly all participants (91.1%) reported reading PIL. The more read PIL's sections were directions of use (52.7%) and side effects (30.3%). Female gender (OR = 5.64, 95%CI: 3.53,9.02), age over 40 years (OR = 2.80, 95%CI: 1.69,4.64), and secondary education or more (OR = 1.74, 95%CI: 1.06,2.85) were the significant predictors of reading PIL. The majority of PIL readers reported their preference for verbal information (65.8%), hard copy presentation (77%), adding graphics (71.1%), and concise content of PIL (68.8%). In addition, most participants reported PIL always/usually adds to their knowledge of medicines (70.6%) and said that PIL reading positively impacted their medication adherence (64.9%). For only 8.8%, PIL reading negatively impacted their adherence, primarily because of reading information on medicine's side effects and complications (74.4%). More than one-half of participants perceived the PIL quality as good/excellent in terms of; font size (51.3%), language comprehensiveness (64.9%), paper quality (68.0%), and general appearance (64.9%). Getting sufficient information from doctors and pharmacists was the main reason for not reading the PIL (59.2%). Most participants (92.5%) agreed on standardizing how information is displayed in the PIL among all PILs of all companies.

CONCLUSION

PIL is read by nearly all the study sample, especially females, older, and educated subjects. It was perceived as beneficial in upgrading medication adherence. Effective designing of PILs should focus on patients' literacy level and age. Standardization of the PIL structure in all pharmaceutical companies is recommended.

Evaluation of Medicine Information Leaflets for Omeprazole, Safety Knowledge, and Perceptions of Taking the Medication in Thailand

PURPOSE

This study aimed to compare package inserts and patient information leaflets for omeprazole in terms of the quality of and satisfaction with the written medicine information, medication safety knowledge, and perceived benefits and risks.

PATIENTS AND METHODS

A cross-sectional, comparative study was conducted at a university hospital in Thailand. Outpatients visiting the pharmacy departments prescribed omeprazole were randomly selected to receive either a package insert or a patient information leaflet. Medication safety knowledge was measured using a set of eight questions. The quality of the written medicine information was measured by the Consumer Information Rating Form. Perceived benefits and risks of the medication were rated using a visual analog scale. Linear regression was used to determine factors associated with perceived benefits and risks.

RESULTS

Of the 645 patients, 293 agreed to answer the questionnaire. 157 and 136 patients were given patient information leaflets and package inserts, respectively. Most respondents were female (65.6%), over half had a degree (56.2%). Patients reading the patient information leaflets had slightly higher overall safety knowledge scores than those reading the package inserts (5.88 ± 2.25 vs 5.25 ± 1.84, p=0.01). Using the Consumer Information Rating Form, the patient information leaflets were given significantly higher scores compared to the package inserts for comprehensibility (19.34±3.92 vs 17.32±3.52, p<0.001) and design quality (29.25 ± 5.00 vs 23.81 ± 5.16, p<0.001). After reading the leaflets, patients receiving the patient information leaflets had significantly higher satisfaction with the information provided (p=0.003). In contrast, those receiving the package inserts rated the risks of omeprazole higher (p=0.007).

CONCLUSION

Demonstrable differences were found from the patient perspective between a package insert and a patient information leaflet for the same medicine, mostly in favour of patient information leaflets. Medicine safety knowledge after reading PI and PIL was similar. However, receiving package inserts provided higher perceived risks from taking the medicine.

Evaluation of patient comprehension and quality of consumer medicine information

Background

Consumer medicine information (CMI) is voluntarily produced by pharmaceutical manufacturers in Thailand, but quality assessment of Thai-CMI is not routinely performed.

Objective

This study aimed to evaluate the content and design quality of CMI available in Thailand and assess patient understanding of the medicine information provided.

Methods

A cross-sectional study that consisted of two phases. Phase 1 was expert assessment of CMI using 15-item content checklists. Phase 2 was patient assessment of CMI by user-testing and the Consumer Information Rating Form. Participants (n=130) were outpatients aged 18 years or older with an educational level of less than grade 12. Self-administered questionnaires were distributed to patients at two university-affiliated hospitals in Thailand.

Results

A total of 60 CMI produced by 13 Thai pharmaceutical manufacturers were included in the study. Most of the CMI contained essential information about the medicines, but lacked information about serious adverse effects, maximum dose, warnings, and use in specific patient groups. Of 13 CMI selected for user-testing, none met the passing criteria with only 40.8% - 70.0% of answers found in the correct position and answered correctly. The mean values of patients' rating the CMI were between 2.5 (SD=0.8) and 3.7 (SD=0.5) for utility on a 4-point scale, and 2.3 (SD=0.7) to 4.0 (SD=0.8) for comprehensibility and 2.0 (SD=1.2) to 4.9 (SD=0.3) for design quality on a 5-point scale. Eight CMI were rated as poor (less than 3.0) for font size.

Conclusion

More safety information about medications should be included in Thai CMI and the design quality must be improved. CMI needs to be evaluated before distribution to consumers.

Assessment of the Quality of Saudi Patient Information Leaflets (PILs) Based on the Accuracy of Physical Description and Frequency of Solid Dosage Forms

The physical description of dosage forms is one of the most important considerations in avoiding patient confusion and minimizing medication errors. This study aimed to determine the quality and accuracy of the physical descriptions in patient information leaflets (PILs). This cross-sectional study constituted a total of 200 drugs and PILs that were randomly selected, by pharmacy students, from Al-Dawaa community pharmacies in the Hail region of Saudi Arabia, from January 2021 to July 2021. The drugs and PILs were thoroughly evaluated in accordance with the Gulf Cooperation Council (GCC) guidelines for PILs. The accuracy screening of the total solid dosage forms (capsules + tablets) revealed that 45% showed complete accuracy and compliance, 1.5% showed poor accuracy and compliance, and 53% showed no accuracy and no compliance with the GCC guidelines and the Saudi Food and Drug Authority (SFDA) guidelines. In the frequency test, color, shape, and imprints accounted for 95.6%, 79.1%, and 73.6%, respectively. However, the size of the dosage form was the least (2.2%) used physical description feature. These findings recommend pharmaceutical companies to pay more attention to the written physical description in their PILs. Additionally, the process of PIL approval should be optimized, evaluated, and updated systematically to ensure that they contain the essential information.

The impact of using pictorial aids in caregivers’ understanding of patient information leaflets of pediatric pain medications: A quasi-experimental study

Introduction

Patient information leaflets (PILs) are one of the main sources of information for over-the-counter medications (OTCs). This study aimed to assess caregivers' understanding of instructions in PILs provided with paracetamol medications and the impact of pictograms use.

Methods

A quasi-experimental study was conducted among caregivers of children aged < 13 years recruited in pediatric outpatient clinics at University Medical City in Riyadh. The calculated sample size was 128; at least 64 participants were needed in each group (the text-only group and the text-plus pictograms group). Caregivers' health literacy was assessed using a validated Arabic version of the Newest Vital Sign scale. Participants’ understanding of PILs instructions was assessed using eight questions on the route of administration, minimal hours between doses, max daily dose, shake medication before use, storage, and reporting adverse events; and was rated based on the number of questions correctly understood. Characteristics of participants were compared by Pearson X² and t-test was used to assess the significance of mean score differences between groups.

Results

A total of 130 caregivers participated in the study; almost half of them were mothers (47%, [n = 61]) and 43% (n = 56) have “a possibility of limited health literacy”. The mean number of correct answers to questions assessing the understanding of PILs instructions was significantly higher among the text-plus pictograms group compared to the text-only group (5.25 ± 1.85 vs. 4.38 ± 1.27; p < 0.001). When results were controlled for age and gender, better health literacy was found to be associated with a better understanding of instructions (B = 0.39, 95 %CI 0.23–0.54).

Conclusion

Limited comprehension of medications instructions was observed; adding pictorial aids to PILs might enhance the comprehension. Differences in health literacy levels of caregivers should be considered when designing PILs.

Evaluation of Medication Package Inserts in Ethiopia

Background

Patients require accurate and reliable information to help them use their medications safely and effectively. Inadequate patient knowledge may contribute to medication nonadherence which could negatively affect treatment outcomes. The purpose of this study was to evaluate the presentation and completeness of medication package inserts (MPIs) which are available in the Ethiopian market.

Methods

A cross-sectional document review was performed in February and March of 2019. All MPIs which were authorized by EFDA to sell in the Ethiopian market and available during the data collection period were considered.

Results

The mean overall completeness score of 200 MPIs was 18.39 ± 4.30. Of the 200 MPIs, only 20% were from domestic pharmaceutical companies. Antimicrobials represented 24% of the total MPIs. Topical preparations, cardiovascular drugs, gastrointestinal drugs, and nonsteroidal anti-inflammatory drugs, accounted for 12.5%,12.5%, 11%, and 9% of the MPIs, respectively. The majority of the MPIs presented information about the drug's use during pregnancy and lactation, 77.0% and 74.0%, respectively. However, only half of the MPIs, 49.5%, gave information about special warnings and precautions. Only a few of the MPIs provided information about instructions to convert tablets or capsules into liquid forms and the possibility of tablet splitting, 4.8% and 8.7%, respectively. Furthermore, only 1.0% had local language translation.

Conclusion

The MPIs available in Ethiopia provide inadequate information including about the safety of drug products and local language translation. Regulatory authorities should implement stringent regulations to ensure the provision of vital information which extends beyond checking the mere presence of an MPI. They should also act to the possible standardization of MPIs.

Investigation of the effects of different beverages on the disintegration time of over-the-counter medications in Saudi Arabia

Full disintegration of Oral solid dosage forms is critically important to achieve reliable clinical performance of the drug. Tablets/capsules are supposed to be taken with a full glass of water; however, many patients do not follow this recommendation as they administer their medications with beverages other than water. This study aims to assess the impact of different commonly consumed beverages in Saudi Arabia on the disintegration times of common over-the-counter (OTC) medication tablets and capsules in the Kingdom of Saudi Arabia. Five immediate release OTC drugs were chosen: Fevadol®, Solpadeine®, Ralaxon®, Artiz ®, and Brufen®. The disintegration times of these medications were assessed using a disintegration test in five beverages: Coca-cola, arabic coffee, orange juice, buttermilk and an energy drink. Times were compared to the disintegration time in water under two temperature conditions (37 °C and 5 °C). All beverages significantly increased the disintegration times of fevadol, solpadeine, and relaxon in comparison with water. The same was found for burfen, except that arabic coffee did not significantly increase disintegration time (p > 0.05). The disintegration time of artiz tablets was also significantly influenced by all beverages, except for Coca-cola and the energy drink, which had no significant impact on the disintegration time. The tested beverages should not be used as substitutes for water when ingesting medications. Patients should be advised to avoid consuming beverages other than water with therapeutic products. Increasing public awareness of drug-beverage interactions is needed.

Provision and Need for Medicine Information in Asia and Africa: A Scoping Review of the Literature

Published reviews of written medicine information (WMI) have mainly drawn on studies published in high-income countries, including very few Asian or African studies. We therefore set out to scope the research literature to determine the extent and type of studies concerning WMI for patients/consumers across these two continents. We sought empirical studies published between January 2004 and December 2019, conducted in any Asian or African country, as defined by the United Nations, in English or with an English abstract. The majority of the 923 papers identified were from high-income countries. We retained 26 papers from Africa and 99 from Asia. Most African studies (n = 20) involved patients in the development of PILs, in the assessment of the effectiveness of PILs or in surveys. In contrast, the highest proportion of Asian studies concerned the content of WMI (n = 42). WMI is desired, but needs to be in local languages, and there needs to be more use made of pre-tested pictograms. Existing WMI frequently does not meet local regulatory requirements, particularly locally manufactured products. A number of studies reported potentially positive impacts of providing WMI on knowledge and medicine use behaviours. Provision of medicine information is essential for safe use of medicines in all countries. Internationally agreed guidelines, incorporating good design principles, are needed to ensure the optimal content and design of WMI. The World Health Organization should support African and Asian regulatory bodies to share best practice in relation to WMI for patients/consumers and to develop and implement pan-continental guidelines that take into account consumer needs and preferences.

Evaluation of the community pharmacists' performance in the screening of non-steroidal anti-inflmmatory drugs risks in Saudi Arabia

OBJECTIVES

To assess community pharmacists' knowledge and practices regarding screening risk factors and providing safety information about the use of non- steroidal anti-in ammatory drugs (NSAIDs) to patients.

METHODS

Cross-sectional and a self-administered questionnaire-based study was conducted over a 4-month period (May-August 2019) with selected community pharmacies in Jeddah, Saudi Arabia. The questionnaire composed of demographic data and the pharmacist's role in supplying NSAIDs.

RESULTS

The majority of participating community pharmacists dispense NSAIDs. However, many did not apply relevantly good communication skills such as seeking information about concomitant drugs (42.5%) or providing advice on managing any adverse side effects of taking NSAIDs (39.1%). Most of the community pharmacists also did not provide relevantly good communication about risk factors. The most common screening risk factors mentioned were a history of pregnancy and breastfeeding (84.2%) followed by being at an older age (74.5%) or a history of a gastrointestinal ulcer (71.5%).

CONCLUSION

Community pharmacists in Saudi Arabia need to appropriately screen their patients for adverse drug reactions and the ectively communicate the risks of using NSAIDs. The Saudi Regulatory Authority could endorse several approaches to apply a good strategy for improving the dispensing practices in community pharmacies, communication and awareness of risk factors especially in high-risk patients who are taking NSAIDs.

Information adequacy of medicine package inserts in India: A critical evaluation

Objectives:

Package inserts (PIs) are used by physicians and other health-care providers as ready source of approved prescribing information. In India, they are subject to statutory regulations that specify the information to be provided under various headings. Uniformity of PIs with optimal level of information is desirable, the absence of which may lead to medication errors. This observational study aimed to evaluate the information adequacy and accuracy of PIs available in the Indian market.

Materials and Methods:

PIs of drugs marketed in India, and approved by United States Food and Drug Administration, were collected from various retail pharmacies through purposive sampling. The adequacy and accuracy of the information in each PI were evaluated with the help of a 25-item checklist prepared as per stipulations mentioned in statutory guidelines. Each required item of information was scored 1 if present and appropriate or 0 if absent or deemed incomplete or inaccurate. A total information adequacy score (IAS), with maximum value 25, was thereby calculated.

Results:

From the total 135 PIs analyzed, the median IAS was 17 (interquartile range 15–19). Deficiencies were observed under important headings. For example, “references” were mentioned in only 6.67% and “date of last updating” in only 19.26% of PIs. Other notable shortcomings were in “disposal” (not mentioned in 92.59%), “effects on ability to drive and use machines” (76.30%), “pharmaceutical incompatibilities” (66.67%), “shelf life” (62.96%), “excipients” (60.00%), and “overdose” (17.78%) information. Information on “generic name,” “composition,” and “indications” were however provided by all (100%) PIs.

Conclusions:

The information provided by PIs in India being inadequate, may not be able to serve as a reliable source of information.

Experiences and Views of Medicine Information Among the General Public in Thailand

PURPOSE

Written and electronic medicine information are important for improving patient knowledge and safe use of medicines. Written medicine information in Thailand is mostly in the form of printed package inserts (PIs), designed for health professionals, with few medicines having patient information leaflets (PILs). The aim of this study was to determine practices, needs and expectations of Thai general public about written and electronic medicine information and attitudes towards PILs.

PATIENTS AND METHODS

Cross-sectional survey, using self-completed questionnaires, was distributed directly to members of the general public in a large city, during January to March 2019. It explored experiences of using information, expectations, needs and attitudes, the latter measured using a 10-item scale. Differences between sub-groups were assessed, applying the Bonferroni correction to determine statistical significance.

RESULTS

Of the total 851 questionnaires distributed, 550 were returned (64.2%). The majority of respondents (88%) had received PIs, but only a quarter (26.2%) had received PILs. Most respondents (78.5%) had seen medicine information in online form. High educational level and income increased the likelihood of receiving PILs and electronic information. The majority of respondents (88.5%) perceived PILs as useful, but 70% considered they would still need information about medicines from health professionals. Indication, drug name and precautions were the most frequently read information in PIs and perceived as needed in PILs. Three-quarters of respondents would read electronic information if it were available, with more who had received a PIL having previously searched for such information compared to those who had not. All respondents had positive overall attitudes towards PILs.

CONCLUSION

Experiences of receiving PILs and electronic medicine information in Thailand are relatively limited. However, the general public considered PILs as a useful source of medicine information. Electronic medicine information was desired and should be developed to be an additional source of information for consumers.

Comparative evaluation of drug information leaflets for non-steroidal anti-inflammatory drugs in Palestine: local versus imported products

BACKGROUND

Drug information leaflets (DILs) are written for patients and health care providers to show how to use the medications safely and effectively, in order to reach the required therapeutics outcomes. This comparative study was conducted to evaluate various DILs of non-steroidal anti-inflammatory drugs (NSAIDs) that are produced in Palestine, along with their imported equivalents.

METHODS

Thirty-five DILs of NSAIDs were analyzed and evaluated in a cross-sectional comparative study. Thirty-one statements were obtained from literature and used; evaluation was performed on basis of both any presence or absence of these statements in the leaflets. 23 of the 31 statements that were available in both local and imported DILs were also evaluated in terms of total word-counts: the median (interquartile range) word-count for each statement was determined separately for the two groups and then compared. For the remaining 8 statements, this was not performed,either because they were not present in any leaflet, or because counting the number of words would not be meaningful.

RESULTS

A total of 35 DILs for nine different active ingredients of NSAIDs were analyzed. In 97% of leaflets, "Instructions to convert medication into liquid forms" were missing and 94% did not provide any information about "Pharmacokinetics". 83% of DILs provided no information about "Mechanism of action" and 74% did not mention any reliable references. 66% of the analyzed inserts did not include any instruction about the possibility of a tablet splitting. And in 63%, the "Date of last revision" was missing. Further, "Duration of using" and "Inactive ingredients" were not found in 51% of leaflets. In terms of word-count, the related sections of the 23 selected criteria were expressed with more words by imported leaflets compared with the local ones, significant differences were found in 12 categories, the highest significance of > 42.4-fold difference was found in "Geriatric considerations" category whereas 1.4-fold difference was found in "Shelf life," being the lowest one.

CONCLUSIONS

This study shows that local products provide less information than imported products, so we recommend that appropriate measurements be taken by both Palestinian authorities and manufacturers to improve both quantity and quality of local DILs.

A comparative evaluation of medicine package inserts for oral antidiabetic agents in Palestine

BACKGROUND

Patient package inserts (PPIs) should provide accurate, sufficient, and clear information for patients as well as health care professionals. The goal of this study was to evaluate and compare the PPIs of local and imported anti-diabetic agents in the Palestinian market.

METHODS

Eighteen leaflets were collected and analysed based on the completeness of 31 criteria using a scoring method, then the quantity of information was assessed by applying word counting of 17 headings and subheadings. Statistical comparisons of the word count for all products were performed using the Mann-Whitney U test with mean ranks. Then the mean ranks for differences in word counts were adjusted to calculate the fold-difference statistic by dividing the higher mean rank by the lower mean rank.

RESULTS

In general, the PPIs of imported agents scored better than local PPIs, but none of the inserts fulfilled the whole criteria. Thirteen out of thirty-one criteria were available in all products. None of these agents had provided any information about duration of use, instructions to convert tablets into liquids forms, pharmacokinetics, or shelf life. Moreover, mechanism of action and maximum dose were deficient in all local PPIs (0.0%), while they were included in 37.5 and 62.5% of imported PPIs, respectively. Furthermore, 90.0% of local PPIs lacked information about drug dose, 80.0% didn't mention any instructions regarding effects on ability to drive or possibility of tablet splitting, and 60.0% didn't involve orders about possibility of tablet crushing. Local PPIs provided inadequate and less detailed instructions regarding many aspects, since the estimated mean rank of local and imported PPIs demonstrated a range of difference from 1.04-fold for missing dose to 2.64-fold for warning and precautions.

CONCLUSIONS

Significant differences were being identified, with excellence being assigned to imported PPIs. So, it is worth suggesting some necessary modifications in PPI topography and sequence structure of local diabetic agents. Experts in Palestinian Ministry of Health should implement regulatory guidelines to improve the quality and quantity of information provided by local PPIs. This optimisation could become a step forward toward optimal health practice in our society.

Knowledge of patients on safe medication use in relation to nonsteroidal anti-inflammatory drugs

INTRODUCTION

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely prescribed and used medications that are used as analgesic, antipyretic, or anti-inflammatory agents, but have a high risk of adverse effects.

OBJECTIVE

The main purpose of this study is to evaluate the knowledge of patients toward the risks and safe usage of NSAIDs.

METHODS

A descriptive cross-sectional study was conducted among patients who attended orthopedic clinics at King Khalid University Hospital in Riyadh, Saudi Arabia, during December 2017 to February 2018. A self-administered questionnaire comprising three sections [sociodemographic information, patients' knowledge of NSAIDs, and the attitude toward receiving information about NSAIDs' adverse drug reactions (ADRs)] was used. The attitude was measured with a 5-point Likert scale.

RESULTS

The mean duration of NSAIDs usage was 7.3 ± 6.9 years. Only 45% of the respondents used NSAIDs daily, while 38% said they only used NSAIDs as needed. Nearly one-quarter of patients (25.5%) were counseled by a healthcare provider on the risks of NSAIDs. Almost 94% and 90.5% of the study subjects agreed that physicians and pharmacists, respectively, should play an essential role in providing information regarding ADRs to their patients. More than half of the respondents claimed that information about ADRs might lead them to discontinue their medicines. More than one-third of respondents stated that their healthcare setting provided them with insufficient knowledge of ADRs.

CONCLUSION

Counseling of patients may diminish potentially inappropriate use and increase risk awareness. Healthcare providers can improve their role in identifying and counseling patients on NSAIDs.

Evaluation of Medication Package Inserts in Iran

Objective:

Package inserts (PIs) provide information for the safe and effective use of medication. There is no study on the evaluation of PIs in Iran. The purpose of this study was to evaluate the completeness of PIs supplied with the 100 top-selling medications in Iran.

Methods:

This cross-sectional observational study was conducted during 3 weeks in January 2017. One hundred medications were chosen from a list supplied by the Iran Food and Drug Administration (IFDA). The PIs were assessed for the presentation and completeness of quality criteria, which was consisted of two parts. The first part was the criteria required by the IFDA, mentioned in Chapter 16 of the Pharmaceutical Regulations and Instructions provided by the IFDA. The second part of the criteria was defined according to the critical comments of clinical and industrial pharmacists.

Findings:

Thirty-seven out of 100 medications included no PIs. None of the PIs met all the criteria required by the IFDA. The highest score for completeness was 18 out of 21 (85.7%). Medication name, description, and adverse reaction were mentioned in all PIs. Other items such as patient counseling information (98%), warnings (95.2%), precautions (95.2%), pregnancy/lactation (95%), and storage condition (90.5%) have been mentioned in a high percentage of PIs.

Conclusion:

PIs have improved in recent years in Iran, but there is an absolute need for more accurate and up-to-date information. The IFDA should supervise pharmaceutical companies more strictly in this regard and should revise its regulations requiring PIs to conform to the FDA regulations.

Conformity of package inserts information to regulatory requirements among selected branded and generic medicinal products circulating on the East African market

Background

Availability of correct and adequate information about medicines is an important aspect in ensuring rational use of medicines and hence facilitating safety and expected efficacy of medicines during therapy. Package inserts have proven to be a good source of information to the prescribers and patients whereby they have been useful in highlighting important information pertaining proper use and handling of the medicines. The present study was aimed at establishing the extent to which package inserts of medicines circulating on the markets of the East African Community (EAC) Partner States conform to medicines information requirements as established in the harmonized guidelines as well as national guidelines.

Methods

A total of 99 package inserts from six (6) types of medicines namely Albendazole, Artemether/Lumefantrine (ALu), Ciprofloxacin, Paracetamol, Amoxicillin and Metronidazole were purposefully collected from three EAC Partner States: Kenya, Tanzania and Uganda. The medicines were selected based on their indications as first line treatments, high rates of utilization within the medicines supply system and their positions in treatment of diseases of public importance across EAC Partner States. The inserts were evaluated on the availability of information regarding fifteen (15) parameters as extracted from the EAC harmonized guidelines for registration of medicines. Moreover, comparisons were made between the percentage conformity of the branded versus generic products, markets from which the samples were collected, origin of the manufacturer and type of medicine.

Results

Majority (93.9–100%) of the medicines’ package inserts highly conformed to the inclusion of the information regarding the description and composition of the medications, indications, dosage and methods of administration, warnings and precautions, contraindications and storage conditions. However, the information on handling and disposal, container package description, excipients used, clinical pharmacology of the medicines, and directions regarding overdose ranked the least in conformance with conformity ranging from 13.1–52.5%.

The parameter with the lowest observed percentage conformity among the branded products scored 50% as compared to 10.8% among the generic products. Moreover, there was no significant difference (P<0.05) in the percentage conformity of the package inserts collected from each of the three Partner States as compared to the average from studied medicines. A generally good conformity was observed among medicines manufactured by European based manufacturers as compared to those based in Asia and EAC Partner States. In addition, PIs of Albendazole, Ciprofloxacin, Amoxicillin and Artemether/Lumefantrine did show overall high conformity across most of the product information requirements.

Conclusion

Our study revealed the existence of a significant number of medicinal products circulating on the markets of EAC Partner States without necessary compliance with all product information requirements. We therefore recommend that NMRAs ensure thorough pre-market assessment of product information as well as strengthening their post marketing surveillance to ensure that medicines circulating on the market comply to medicines information requirements at all times. Emphasis should also be given to manufacturers on the importance of inclusion of appropriate and adequate product information for the safety of patients, including advocating for inclusion of patient-friendly and easy to understand medicines information.

Calculating reading ease score of patient package inserts in Iran

Background

The patient package inserts (PPIs), which contain the necessary information about medications intended for patients, need to be expressed in a clear language comprehensible to everyone.

Objective

This study aimed to evaluate the readability and understandability of the drug package inserts for the inexpert people.

Methods

The readability of the 158 PPIs of the 33 drugs, registered and manufactured in Iran, was calculated. The main criterion for selecting PPIs to include in this study was of those top-selling drugs during the year 2015 according to the Social Security Organization in Iran. The PPIs were collected from the pharmacies of the three major cities, namely, Tabriz, Ardabil and Meshgin Shahr. Then, using the Flesch–Dayani readability (FDR) tool adjusted for the Persian language, the average number of the words and syllables was counted to calculate and grade the readability score of the selected PPIs.

Results

This study showed that the average FDR readability score for all the 33 drugs is 52.52, which are graded 10th–11th. Of the PPIs, 70.89% were difficult to read, and on average, the readability of the PPIs was five times difficult than the standard ones. Only 13.92% PPIs were suitable for the 5th–7th grade, and 15.19% of the package inserts ranked in the 8th–9th reading grade.

Conclusion

A considerable number of the PPIs in Iran have low readability level and were not suitable for the inexpert readers. Since the treatment cost is very high, people tend to use medications arbitrarily or simply use old prescriptions. This study suggests the necessity of a major improvement in the readability level of the PPIs in order to ensure the usefulness of the PPIs to the majority of the consumers.

Readability of written medicine information materials in Arabic language: expert and consumer evaluation

BACKGROUND

Written Medicine Information (WMI) is one of the sources that patients use to obtain information concerning medicine. This paper aims to assess the readability of two types of WMIs in Arabic language based on vocabulary use and sentence structure using a panel of experts and consumers.

METHODS

This is a descriptive study. Two different types of materials, including the online text from King Abdullah Bin Abdulaziz Arabic Health Encyclopaedia (KAAHE) and medication leaflets submitted by the manufacturers to the Saudi Food and Drug Authority (SFDA) were evaluated. We selected a group of sentences from each WMI. The readability was assessed by experts (n = 5) and consumers (n = 5). The sentence readability of each measured using a specific criteria and rated as 1 = easy, 2 = intermediate, or 3 = difficult.

RESULTS

A total of 4476 sentences (SFDA 2231; KAHEE 2245) extracted from websites or patient information leaflets on 50 medications and evaluated. The majority of the vocabulary and sentence structure was considered easy by both expert (SFDA: 68%; KAAHE: 76%) and consumer (SFDA: 76%; KAAHE: 84%) groups. The sentences with difficult or intermediate vocabulary and sentence structure are derived primarily from the precautions and side effects sections.

CONCLUSIONS

The SFDA and KAAHE WMIs are easy to read and understand as judged by our study sample. However; there is room for improvement, especially in sections related to the side effects and precautions.

Comparative analysis of package inserts of local and imported antihypertensive medications in Palestine

BACKGROUND

Package inserts (PIs) as a reliable reference for patients and health care providers should provide accurate, complete and up-to-date information. The purpose of the current study is to assess and compare the PIs of antihypertensive agents locally produced in Palestine and their imported counterparts.

METHODS

Thirty-five PIs were assessed for the presence of 31 information statements using a scoring method. Word counting of 20 headings and subheadings was used to evaluate and compare local and imported PIs for information quantity.

RESULTS

None of the analysed PIs fulfilled the criteria. All of them included the brand name, active ingredients, indications, directions for use, adverse drug reactions, drug-drug interactions, pregnancy and lactation considerations, and storage. Whereas none of them, either local or imported PIs, included the shelf life and instructions to convert tablets or capsules into liquid forms. Additionally, only one (5%) imported and no (0%) local PIs mentioned the duration of therapy. Moreover, 93.4% of local PIs were deficient in areas regarding the inactive ingredients and date of last revision, and 86.7% did not mention the drug dose and possibility of tablet splitting. Furthermore, the maximum dose was not indicated in 90% of imported and 86.7% of local PIs. In general, imported PIs contained more detailed information than their local counterparts, where the range of differences in medians between the local and imported PIs was from 1.5-fold for pregnancy considerations to >42.00-fold for the effect on the ability to drive and use machines.

CONCLUSIONS

The findings of this study revealed the superiority of imported over local PIs in both quality and quantity of information provided. This emphasises the need for appropriate measures to be taken by the Ministry of Health and local manufacturers to ensure efficiency of local PIs in providing accurate, complete and up-to-date information.

Readability and Comprehensibility of Patient Information Leaflets for Antidiabetic Medications in Qatar

Background:The readability and comprehensibility of the patient information leaflets (PILs) provided with antidiabetic medications are of questionable standards; this issue negatively affects adherence to drug therapy, especially in patients with limited literacy skills. Objective: To evaluate the readability and comprehensibility of PILs supplied with medications used for the treatment of type 2 diabetes mellitus in Qatar. Methods: All PILs of the antidiabetic medications in Qatar were evaluated using the Flesch Reading Ease (FRE) score for readability. The Flesch-Kincaid Grade Level, Gunning-Fog Index, and SMOG Grading were used to estimate the comprehensibility of PILs in terms of school grade levels. Results: A total of 45 PILs were evaluated: 32 (71.1%) PILs of brand-name products and 13 (28.9%) for generics. Nine (20%) of the PILs were in English only; 8 (17.8%) were in English, Arabic, and French; and 28 (62.2%) were in English and Arabic. The mean FRE score was 37.71 (±15.85), and the most readable PIL had FRE score of 62. The mean scores for the comprehensibility evaluations were 10.96 (±2.67), 15.02 (±2.52), and 11.41 (±1.6) for the Flesch-Kincaid Grade Level, Gunning-Fog Index, and SMOG Grading, respectively. The most commonly used antidiabetic medication was metformin with 1372.9 (±552.9) as PILs' mean number of words. Conclusion: Only 2.2% of PILs had acceptable readability scores. All PILs could be comprehended by at least an 11th grade student, which exceeds the recommended grade level for health-related materials. Approximately 20% of these PILs were in English only and were not readable by most patients.

An evaluation of the completeness of drug-drug interaction-related information in package inserts

PURPOSE

The project aimed to evaluate the completeness of drug-drug interaction (DDI)-related information in package inserts (PIs) and develop a systematic approach to conduct the evaluation.

METHODS

DDI-related information in the branded PIs of statins, macrolides, protease inhibitors and selected drugs of narrow therapeutic index (DNTI) were evaluated against the criteria distilled from the Food and Drug Administration (FDA) labelling recommendation guidance document. Decision trees were crafted and employed in the evaluation process. Scores were computed to give each PI an overall completeness score and individual criterion completeness score. The Kruskal-Wallis test and Dunn's multiple comparison test were used to assess the differences in the completeness scores.

RESULTS

The mean overall completeness score of the 21 PIs was 35.7 ± 13.4 % (range 12.2-62 %). Eight out of the 11 individual evaluation criterion had a mean completeness score below 50 %. A subclass analysis conducted revealed that PIs from the different drug classes differed in the type of DDI-related information, such that they are more complete or less complete.

CONCLUSION

The completeness score of DDI-related information in the PIs varied extensively amongst and within drug classes. A consensus between the authorities and drug companies on the type and quality of DDI-related information to be included could improve their completeness in PIs and make PIs a valuable source of DDI reference. Decision trees, albeit not validated yet, lay the groundwork for a valuable tool to evaluate DDI-related or other drug information.

Patient Evaluation of Medication Package Leaflets in Al Kharj City, Saudi Arabia

OBJECTIVE

The purpose of this study was to determine how well patients could correctly recognize and comprehend the various information items in over-the-counter (OTC) medications package leaflets in Saudi Arabia.

METHODS

Leaflets from 20 most commonly sold OTC medications were examined by experts to evaluate the leaflet layout, language, and content. The same leaflets were also evaluated by patients who had their medicines dispensed at 2 hospitals and 8 community pharmacies in Al Kharj, Saudi Arabia. A questionnaire was used for the patients' examination.

RESULTS

A total of 479 questionnaires were included in the study. Each package leaflet was examined by at least 20 participants. The results indicate poor comprehensibility, for many items, particularly items regarding "drug interactions" and "contraindications."

CONCLUSION

The participants had some difficulty recognizing and comprehending certain information items in the package leaflets that are supplied with OTC medications in Saudi Arabia.

Medicine information leaflets for non-steroidal anti-inflammatory drugs in Thailand

BACKGROUND

The importance of promoting the use of patient-oriented medicines leaflets is recognized in many countries. Leaflets should include basic information plus specific warnings, and be provided with all medicines, but there is little attempt at enforcement of these requirements in Thailand.

OBJECTIVE

To determine content and availability of Thai information leaflets for nonsteroidal anti-inflammatory drugs (NSAIDs).

METHODS

Leaflets for all NSAIDs available for purchase from 34 pharmacies in a large city were evaluated against a checklist and number of leaflets assessed against number of medicine packs available in each pharmacy.

RESULTS

Of the 76 leaflets for ten different NSAIDs, 67 (88 %) were for locally manufactured products. Only 22 % of 76 leaflets were sufficient in number for distribution with medicines, while only 4 % had patient-oriented leaflets. No leaflet covered all topics in the checklist. Less than half included safety information, such as contraindications (46 %), precautions (47 %), and adverse drug reactions (34 %). Locally-produced leaflets provided less information than those for originator products and no leaflet included all the warnings required by Thai regulations.

CONCLUSION

This study illustrates the variable availability and quality of NSAID information leaflets. The lack of accessible essential information about medicines in Thailand requires urgent attention to enable patients to minimise adverse reactions.

How (not) to inform patients about drug use: use and effects of negations in Dutch patient information leaflets

PURPOSE

Under EU regulations, patient information leaflets (PILs) are required to be clear and understandable. Negations (e.g., not, no) are a linguistic aspect that may impact PIL comprehension, yet go unmentioned in these regulations. We conducted two studies to determine (1) how negations are used in Dutch PILs (study 1) and (2) the effects of negations on readers (study 2).

METHODS

Study 1 was a content analysis of 30 PILs of different brands of pollinosis drugs, half of which were freely available in drugstores and half only by physician prescription. We mapped negation use in PIL sections on 'proper usage' and 'potential side effects'. Study 2 was an experiment in which participants (N = 80, Mage  = 33.19 years, SDage  = 13.66; 76.3% female) were presented with one of two PIL texts on proper drug usage. Texts were identical except for the use of negations. After reading, participants answered questions about comprehension, PIL appreciation and medical adherence intentions.

RESULTS

Study 1 demonstrates that negations are often used in PILs as 21.0% of clauses contain at least one negation. This number is higher in sections related to potential side effects than proper usage. Study 2 demonstrates that negations decrease both actual and subjective comprehension. Negations also decrease PIL appreciation and medical adherence intentions. The reduction in medical adherence intentions is driven by the decrease of subjective and not actual comprehension.

CONCLUSIONS

In general, participants prefer PILs that contain clear and comprehensible language. To increase comprehensibility, PIL designers should refrain from using negations as much as possible.

A study of package inserts in southern India

INTRODUCTION

Package insert is an officially approved document that accompanies a drug. It is intended to provide information for the safe and effective use of a drug and contains information based on regulatory guidelines. Sometimes, information provided in the package inserts is suboptimal which can led to medication errors. This study was undertaken to assess the presentation and completeness of clinical information provided in the currently available package inserts for anti-diabetic, anti-hypertensive and hypolipedemic drugs in India.

MATERIAL AND METHODS

Around 130 package inserts were collected from pharmacies located at different areas of Bangalore. They were analyzed based on criteria mentioned in Schedule D of Drug and Cosmetic act 1945.

RESULTS AND OBSERVATIONS

Out of 134 package inserts, 64 were anti-diabetics, 40 anti-hypertensives, and 30 hypolipedemics. Out of them, 31 (23.14%) belonged to Grade 'A' (including all injectable preparations) and remaining 76.86% to Grade 'B'. None of the PIs belonged to Grade 'C'. The inserts were inadequate in many aspects; for example, they had unclear instructions about generic name of other ingredients used, about handling, undesirable effects, pediatric and geriatric use, and guidelines for use of the drugs.

CONCLUSION

This study indicated that information relevant to the safe and effective use of medication was not mentioned in the analyzed package inserts. It is, therefore, recommended to update the existing package inserts based on criteria mentioned in the Schedule D of Drug and Cosmetic Act, 1945.

Saudi young patient understanding of information about side effects: Verbal versus numerical expression

OBJECTIVE

To determine the effect of providing different formats about side effect information (verbal versus numerical) to acne patients in Saudi Arabia that are newly prescribed Roaccutane.

DESIGN

A prospective study assessing patients' degree of estimation about side effect information.

PARTICIPANTS

One hundred and forty-one acne patients newly prescribed Roaccutane.

SETTINGS

Four dermatology clinics in Riyadh. Two in tertiary hospitals and the other two in private clinics.

INTERVENTION

Each patient received information about two different side effects for Roaccutane. The side effect provided was supplemented with the probability of occurrence, which was written either in words or in numbers. (Dry eye "very common" or "30%"; Loss of hair "rare" or "0.01%").

MAIN OUTCOME MEASURES

Patient's estimation of side effect occurrence. Other outcomes were the likelihood of experiencing the side effect, the severity of the side effect, their perception of risk of the side effects to their general health, their satisfaction with the information provided and, whether the information provided will influence their decision to take the medicine.

RESULT

The mean estimate for side effect occurrence for the dry eyes was 46% in the verbal group and 41% in the numerical group (p = 0.5); for loss of hair it was 50% in the verbal group and 39% in the numerical group (p = 0.03). There are no significant differences between verbal and numerical groups regarding the remaining measures.

CONCLUSION

Patients overestimate the probability of occurrence of side effect. Verbal format of probability of occurrence is associated with higher estimation than the numerical format.