COMPOUNDING

POLYPHARMACY
PRESCRIPTION IN
INDONESIA

Purnamawati Pudjiarto;
Arifianto, Arifianto;
Farian Sakinah;
Yulianto Kurniawan

Concern & Caring Parents

Foundation

ABSTRACT
Compounding Polypharmacy Prescription In Indonesia
Pudjiarto, Purnamawati Sujud; Arifianto, Arifianto; Sakinah, Farian; Kurniawan, Yulianto
Problems: The WHO-EML stated that The custom in some places is to treat sick children
with a mixture of several medicines ("puyer"), not necessarily all appropriate to their
needs. Adult solid dosages forms are mixed together, ground to a powder, and the
powder divided into assumed pediatric doses then dispensed for administration to the
child. The Committee recommended that this irrational practice should not be used.
However, resistance to change is very strong.
Objective: To study the puyer prescribing for children diagnosed with 4 viral infections (do
not need antibiotic) URI, fever, acute cough (without fever and signs of URI), acute GE;
and to see the change of puyer and types of medicine consumed after being
educated.
Method: Intervention (done by doctors-trainers): written materials, FGD (6 months,3 weekly
meeting), boosters through the mailing list. Pre intervention, participants submit
prescriptions, data of illness-consumption of puyer, questioner.
Setting: Jakarta, 2004-2006.
Study Population: members of our mailing list from Indonesia.
Results: 160 eligible e-mails. Pre-post intervention, puyer prescribed 67.4%-24.7% and
consumed 65.4%vs4%, respectively. The most prescribed were antibiotic, steroid,
antipyretic, antihistamines; which changed significantly post intervention.
URI: median of medicines was 5, maximum 8, puyer 77.4%.
Fever: Median 4, maximum 8 medicines, puyer 72.6%.
Diarrhea: median 3, maximum 7 medicines, puyer 55.4%.
Cough: median 4, maximum 11 medicines, puyer 87.0%. Generic for URI, Fever,
acute GE and acute cough 16.9, 9.7, 3.6, and 18.4% respectively.
Pre-post intervention, types of medicine: (1) antibiotic for URI 64.6%vs3.8%; GE
40.9%vs1.7%; fever 87.3%vs6.4%; coughs 46.3% vs 5.2%; (2) ORS for GE 4.6%vs68.7%.
(3) antitussive-mucolytic 86.9%vs21.2%. Knowledge 7.4vs96.2%. Seeking information
23.2%vs96.4%.
Conclusion: Puyer opens a window toward irrational polypharmacy that are potentially
harmful and costly. Consumer education is important to reduce irrational polypharmacy
puyer and to improve patient safety.
Funding sources: Concern & Caring Parent Foundation

INTRODUCTION

Irrational use of medicine problems :

In Indonesia, a survey in Denpasar, Bali, showed
that 84,4% of pediatric prescriptions contain
more than 4 active ingredients. In West
Sumatera, the average medicines perscribed for
children with URI is 3.69 medicines. A study
under the MOH, Indonesia found that the
average number of medications for each patient
is 3,49.
In some areas of West Sumatera, Indonesia, the
rate of antibiotic use is more than 90%.
Data from our mailing list
(sehat@yahoogroups.com) showed that 73%
reported of having been given antibiotics.
The highest expenditure is for antibiotics (63% of
expenditure in URI), followed by cough-cold
remedies, analgesics.
The cost of medications for diarrhea and URI is
68% of the total cost of health care for the
under-fives and 38% for above 5 years and 36%
of total health expenditure for drugs.

OBJECTIVES
To understand the prescribing pattern in pediatrics
Specific objectives
Data on polypharmacy for children with URI, fever,
coughs, acute gastroenteritis.
Data on the prescribed medications and number
of medications for those four ailments.
Data on the rate of antibiotic use for those 4
health conditions.
Data on generic use in those 4 conditions.
Data on compliance to the standard treatment
guideline.

Fig 1. Processing compounding medicines or

PUYER (clockwise)

METHOD
Sample Population
Members of
mailing list

sehat@yahoogroups.com

Data collection (2004-2006)

Emailed prescriptions or prescriptions
copy for children with URI, fever, coughs
acute GE; sent by parents before and after
intervention

Inclusion criteria:
Emails should contain chronological
problems (symptoms and signs),
Emails should mention the age and weight
of the child
Emails should report the prescriptions,
the name of all the medications, clearly
and or prescriptions are sent as
attachments.

Exclusion criteria:
Do not provide clear or complete reports
mentioned above and or
Did not write clearly/correctly the name
of all the drugs or only mentioned some
of the drugs being given for their children
Drop out

RESULTS
Table 1. Overall picture of the prescribing pattern
Total medicines
Median
Max
% Puyer
% Antibiotics
(% generics)
% Generics
% medicines
-Steroid
-Anti Histamine
-Anti Convulsion
-Anti Pyretics
-Supplement

URI
(55)
260
5
8
77.4
54.5
7
16.9

Fever
(43)
186
4
9
72.6
86.4
0
9.7

Diarrhea
(27)
83
3
7
55.4
74.1
5
3.6

Coughs
(41)
186
4
11
87
46.3
10.5
19.4

61.8
50.9
16.4
36.4
21.8

41.9
53.5
55.8
79.1
34.9

44.4
18.5
11.1
29.6
51.9

60.9
36.6
14.6
17.1
2.4

Figure 2. Examples

Table 2. Miscellaneous medications for URI,

fever, coughs, diarrhea
FEVER
URI
Isoprinosine Isoprinosine
Vit B complex
Nonflamin
Vit B
Mycostatine
complex
Cobazim
Vit B6

Nicotinamide Imboost
Becombion
Cobazim
Stimuno
Lactobacillus
Transpulmin
balsam
Imboost
Ketotifen

Cariamyl
Toplexil syr
Polysylane
Echinaceae

COUGHS
Vit B6
Ketotifen
Isoniazide

Cimetidine
Colostrum
bovine
Cariamyl

DIARRHEA
Anti fever
Anti
histamine
Vit V complex

Colostrum
Digestive
enzyme
Low lactose
milk

A OR
nt
ib S
i
P otic
ro s
A bio
nt tic
ie
m s
et
ic
s
A
nt O
A ihis t he
nt ta r
ic
on mi
vu ne
A lsa
ds n
or ts
b
A en
nt t s
im
A ot
nt ili
ip ty
yr
et
E ics
S nz
up ym
pl
em e
en
t

Percent (%)

Percent (%)

O
An
th
t ic
er
on
vu
ls
an
ts
An
t it
us
si
ve
s
An
t ie
m
et
ic
s

M
uc
ol
yt
C
ic
or
s
tic
os
te
ro
id
s
An
t ib
io
D
tic
ec
s
on
ge
st
an
An
ts
t ih
is
ta
m
Br
in
es
on
ch
od
i la
to
rs
An
t ip
yr
et
ic
s

Percent (%)

PRESCRIBING PATTERN
Medicines for URI

70
60
50
40
30
20
10
0
Generic

Branded

Medicines for Fever

100
90
80
70
60
50
40
30
20
10
0
Generic

Branded

M edicines for Diarrhea

80
70
60
50
40
30
20
10
0

Generic

Branded

B
et
am
et
ha
D
so
ex
ne
am
et
M
ha
et
so
h
yl
ne
p
re
d
ni
so
lo
ne
P
re
dn
is
on
T
e
ria
m
ci
no
lo
n

Percent (%)

Percent (%)
nc
h

od
ila
C Mu to
or c rs
t ic ol
os yti
te cs
ro
A An ids
nt tib
i
D his ioti
ec ta cs
o n mi
ge ne
st s
an
ts
A O
A nt t h
nt ip e
ic yr r
on e
v tic
A uls s
nt a
itu nt
A ss s
nt iv
ie es
m
et
ic
s

B
ro

Percent (%)

PRESCRIBING PATTERN (2)

M e dicine s for Cough

100
90
80
70
60
50
40
30
20
10
0
Generic

Branded

Bronchodilators for Cough

50
40
30
20
10
0
Generic

Branded

Ste roids for Cough

60
50
40
30
20
10
0

Generic

Branded

Ce
ph
Ch
ad
ro
lo
xy
ra
m
l
ph
en
Ce
i co
ph
l
ra
Co
di
tri
ne
m
ox
M
az
et
ole
ro
ni
da
zo
Po
l
l ym e
yx
yn
Cl
ox
ac
Ni
il li
fu
n
ro
xa
z id
M
e
yc
os
ta
ti n

Percent (%)

m
ox
A icil
zi
th line
ro
m
C
ep yc
ha i n
C dr o
ep xy
hr
l
ad
in
C
C
hl ep e
or
h
am yx
im
p
C
he
la
rit nic
hr
ol
C
o
m
ot
rim yc
in
o
E xaz
ry
th ole
ro
S myc
pi
r a in
m
yc
in

Percent (%)

ANTIBIOTIC PRESCRIBING PATTERN

Antibiotics for Fever

25

20

15

10
Generic
Branded

Antibiotics for Diarrhea

35
30
25
20
15
10
5
0

Generic

Branded

ANTIBIOTIC PRESCRIBING PATTERN (2)

25
20
15
10
5
0

Generic
Branded

Am
Az oxi
ith ci lli
Ce rom ne
ph y c
ad i n
Ce ro
ph x y
ra l
Ce di
ph ne
C y
Cl ep xi m
a r ha
i
Co thro c lo r
tri my
m
c
Er o x in
y t az
hr ol
e
o
Sp my
i ra c in
m
yc
in

Percent (%)

Antibiotics for Cough

Antibiotics is the third most frequent

drug for URI (54.54%) such as:
Amoxycillin :(27,27%; mostly non
generic), followed by
cefadroxil, cefradine, spyramicine (all
together are 15,15%).

PRESCRIBING PATTERN
Puyer prescription
24.70%

P re
Puyer consumed

P os t

4%

67.40%

Pre
Post
65.40%

Antibiotic Use
100.00%
80.00%
60.00%

Pre

40.00%

Post

20.00%
0.00%
URI

GE

Fever

Coughs

Changes of drug use

100.00%
80.00%
60.00%

Pre

40.00%

Post

20.00%
0.00%
ORS

Antitussive

CONCLUSIONS
Overprescribing of symptomatic medicines
(antitussive, antiemetic, adsorbents, antipyretic)
Overprescribing of antibiotics;
Overprescribing (abusive use) of steroids;
Overprescribing of none guideline related
medicines e.g antihistamines, bronchodilators,
anticonvulsants;
Overprescribing of unnecessary medicines e.g
mucolytic, decongestants (never proven to be
effective yet already banned for under 6 years)
Overprescribing of multivitamin, supplements
(e.g. immunomodulators, appetite stimulants)
The above-mentioned data showed that
(1) Doctors often prescribe medicines that have not
yet been proven to be effective for those 4
conditions;
(2) Doctors often prescribe strong medicines which
harm outweigh the benefit;
(3) Doctors often prescribe supplements and
products that are not needed by these children
(4) Further study need to be conducted to convince
related parties the importance of improving
prescribing practice particularly for children