How Mary Waithera, 67, ended up popping 17 pills a day is a cautionary tale on overprescription in Kenya. And her case is not the worst.
In 2015, a year after she was diagnosed with high blood pressure, she moved from taking two pills to manage her condition to 10 pills every day. She also ballooned from about 75 to 90kg.
Having retired from teaching a few years earlier, Waithera had always enjoyed taking care of her cows and tending crops at her farm in Kinangop. But soon, this became impossible. Her knees were swollen and she would pant heavily after walking short distances.
In a visit to her doctor at a mission hospital in Nyeri, Waithera was prescribed more pills, known as diuretics, to take at night to manage her knees problem.
“While the swelling reduced, I began to feel extremely fatigued and I lacked sleep. Most of the time I just sat in the house,” she says.
The fatigue was successfully managed with two daily pills. But now every day after eating, she would develop stomach discomforts. “This persistent sensation of wanting to vomit,” she says.
She received more pills in the next hospital visit.
“But this was killing me; all I did was take medicine. It was a difficult schedule because some were to be taken once a day, others twice, others thrice,” she says.
“One Sunday, I limped to church but in the wrong direction for about 30 minutes, until people who knew me were puzzled when I said I was headed to our local church.”
“When I think about taking all these drugs, I feel like dying,” Gatundu farmer Willliam Njoroge, 65, who popped 19 pills a day before a review found he only needed six
TIME TO SEEK HELP
Waithera was on the verge of giving up hope when her daughter, alarmed, took her to a professional doctor of pharmacy in December 2017.
“When we poured out all the medications she was taking in a day, the pills literally covered my table,” says Dr Joseph Kathare, a professional medication therapy management (MTM) pharmacist employed by the Kiambu government at Igegania Hospital.
Waithera was popping 17 different pills every day. She spent Sh30,000 every month to buy the drugs because most are not available in government facilities.
“I did a comprehensive medication review. This means looking at her medical records and trying to justify each drug,” Dr Kathare says.
“For this, I developed a personal medication list, personal medication problems and pharmacoeconomics of each drug. I also looked at the side-effects or adverse effects associated with each medication presently and in the future.” The entire process is called medication therapy management.
Dr Kathare shared his report with the medics who had prescribed the medicines. He then reduced Waither’s prescription to just 10 drugs and later to only two, which she takes to manage her blood pressure.
“There is a tendency by prescribers and other non-pharmacists to prescribe medication for every symptom,”Dr Joseph Kathare
Dr Kathare says situations where a single patient takes a multitude of medicines — called polypharmacy — are rampant in almost all Kenyan health facilities.
Most victims are children and patients above 50 years, with at least one chronic condition like high blood pressure or diabetes.
“Many of them are being killed by the risks associated with the many drugs they are taking, rather than the disease itself,” he says.
Dr Kathare discovered the mental disorientation, dizziness, joint pains, nausea and memory loss that Waithera suffered were not a progression of hypertension or another underlying condition but the result of inappropriate drugs and drug interactions.
“There is a tendency by prescribers and other non-pharmacists to prescribe medication for every symptom, and yet not every symptom requires a medication,” he says.
He explains that all drugs have side-effects, but these are often misinterpreted as a new disease problem, triggering more prescriptions.
The World Health Organisation says whenever a patient exceeds five daily drugs, that prescription must be evaluated by a qualified pharmacist.
A 2016 study by the University of London showed over a third of all medicines in Kenya are prescribed, dispensed or sold inappropriately, with many of them harming patients.
“Most of this harm is preventable,” says the WHO in its latest Medication Safety in Polypharmacy 2019 report.
“Adverse events (from drugs) are now estimated to be the 14th leading cause of morbidity and mortality in the world, putting patient harm in the same league as tuberculosis and malaria.”
WHO says polypharmacy harms patients through drug-drug interactions, increases the risk of medical errors and poor adherence by patients, reducing the quality of life and sometimes leading to death.
“Medication safety should start with appropriate prescribing and a thorough risk-benefit analysis of each medicine is often the first step,” says the WHO report.
DICLOFENAC SIDE-EFFECTS
It triggers multiple side-effects such as nausea, constipation, headache, dizziness, and drowsiness.
More serious reactions include stroke, high blood pressure and heart attack.
BAG FULL OF MEDICINE
Gatundu farmer Willliam Njoroge, 65, began with a few medicines to manage arthritis and hypertension.
In a year’s time, he suffered insomnia, had hallucinations and developed ankle oedema or swelling.
“What I think is killing me is this paper bag I am carrying,” Njoroge said when he visited Dr Kathare for a medication review in January last year.
“When I think about taking all these drugs, I feel like dying.” He took 19 different pills every day.
Dr Kathare, a well-known MTM champion, says 10 of those pills had the same active ingredient. Three other pills of different brands contained diclofenac to treat inflation and arthritis.
Dr Kathare says due to lack of patient education on the medicines they are taking, some end up buying different brands of drugs from different chemists, yet they contain the same active constituent.
Diclofenac triggers multiple side-effects like nausea, constipation, headache, dizziness and drowsiness. More serious reactions include stroke, high blood pressure and heart attack.
“His hypertension had developed from the drugs he was taking for arthritis,” says Dr Kathare.
“So I evaluated all the drugs and developed a report to show a justification. Out of 19 pills, he was left with only six. I also developed a target medication review meant to be shared with the patients’ physician.”
Dr Kathare says professionally, every prescription must be reviewed by a Mediation Therapy Management pharmacist to guide the prescriber on whether the patient is comfortable with the regimen, can afford the cost of those medicines and will adhere to the treatment.
In some instances, polypharmacy is inevitable, especially when managing multiple disease conditions.
“If there’s likely to be a drug interaction or potential dangerous adverse effect with the prescription, the MTM pharmacist in collaboration with the prescriber will change the prescription,” he says.
But this review rarely happens due to lack of collaborative practice between the doctors of pharmacy and the prescribers, who may include medical doctors and other clinicians.
There’s also the influence of the pharmaceutical industry, whose sales agents offer various kickbacks to medics who prescribe their medicines in large volumes.
“Today everyone is prescribing, including student interns under no supervision, which should not happen, and these prescriptions are never evaluated by professional pharmacists.”
The Kenya Pharmacy and Poisons Board has registered about 3,000 qualified pharmacists in Kenya, the majority working in county hospitals.
Polypharmacy is also perpetuated by patients through self-medication by buying over-the-counter medicines and nutritional supplements.
Dr Kathare advises patients to keep a careful record of which drugs they’re taking— including over-the-counter medications, family planning drugs, dietary supplements and herbal concoctions — and bring that list to every doctor visit.
WHO says when a patient’s drugs are reviewed and reduced, the quality of life improves within 30 days.
The Medication in Polypharmacy Report 2019 says the process is not just about stopping some medicines but encompasses minimisation of dosage, number of tablets taken and frequency of administration times.
WHO advises countries to create national guidelines to control polypharmacy and promote medication therapy.
In 2016, researchers from the University of London evaluated prescriptions in primary health facilities in Kenya and 10 other African countries and found that patients are given an average of three different drugs per hospital visit, unnecessarily, instead of the WHO-recommended two.
The study was published in the BMC Public Health journal under the title, “Prescribing indicators at primary health care centres within the WHO African region: a systematic analysis ( 1995–2015 )”.
“A generally high number of medicines prescribed per patient exceeding WHO reference value may point to polypharmacy as an increasing problem in Africa,” says the study.
The researchers said the problem will worsen as people live longer and people suffer multiple non-communicable diseases in their old age.
IT SAVES LIFE AND MONEY
Dr Kathare makes a strong economic case for medication therapy management.
“Think of a quack prescriber putting 10 patients on 10 pills a day, each pill costing Sh500, for six months or for one year. What do you think will be the economic impact on the patient and the nation at large? But if this patient can access MTM services before he religiously starts taking these medicines, a lot of interventions can help,” he says.
“MTM services are the solution for the nations’ escalating health care budget.”
In Kinangop, Waithera says she would spend Sh30,000 to buy medicines every month (about 500 pills every month). This took away all her earnings from dairy farming.
After the pills were reduced to two every day, she now spends only Sh1,500 per month.
“Now I’m back to my old self. I can work comfortably in the shamba and walk long distances. The confusion, nausea, fatigue are gone,” she says.