Pandemic of drugs overuse

A new mother in Kathmandu took her two-month-old baby to hospital to treat an infection. The doctor diagnosed upper respiratory infection (URI) and prescribed half a dozen medications, including the cough syrup Dextromethorphan.

Dextromethorphan is not recommended for children under four by the US Food and Drug Administration (FDA) since 2008 after studies showed it to be ineffective for colds and causes damage to the central nervous system.

In Saptari, a 14-month-old boy with chronic cough was taken to a private clinic multiple times. In each visit, the doctor there prescribed Dextromethorphan and Beclomethasone, a corticosteroid.

The child’s skin became swollen and sore, and he was brought to Om Hospital in Kathmandu. Doctors concluded that his nervous system was affected by overdose of Dextromethorphan, and referred the baby to AIIMS Hospital in New Delhi. The baby died during treatment.

A paper titled Adverse Events Associated with Pediatric Exposure to Dextromethorphan published in the medical journal Clinical Toxicology had already concluded that the cough syrup should only be given to children above four, and only for the most serious cases.

Sixty percent of the 1,716 children under four in this study who were prescribed Dextromethorphan were found to have side effects ranging from vomiting, breathing problems, and effects on the nervous system. Other studies have noted that the drug can cause the respiratory system of children to slow down severely, leading to suffocation.

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A four-year-old boy in Bhaktapur suffering from cough and constipation was taken to a nearby private hospital. The doctor diagnosed common cold and prescribed six types of medicines including a nasal drug with the generic name Oxymetazoline, commonly used to treat nasal polyps.

Oxymetazoline has also been prohibited for use in children under six by the FDA and other regulatory bodies. Doctors at the Bhaktapur hospital have been found to be prescribing this medicine to children to treat colds. Overuse of oxymetazoline can eventually cause inflammation of the nasal cavity, affecting breathing.

As more and more Nepalis, especially children and the elderly, suffer from respiratory infections due to increasing air pollution, the misuse and overuse of drugs by an over-commercialised medical and pharmaceutical sector is also increasing.

Doctors have also been found to be prescribing Montelukast, usually given only to patients with complications like asthma and rhinitis, to treat the common cold, sore throat, rashes or arthritis in children.

FDA studies have shown that Montelukast in children and adolescents can cause behavioural and psychological side effects, including suicidal ideation. The drug has a black box warning, the FDA’s strictest alert to warn the public about its side effects, to be used only in cases where its benefit outweighs its harm. 

The Global Initiative for Asthma (GINA) guidelines also mention that parents must be made fully aware of the possible side effects of Montelukast before it is prescribed to children with asthma.

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Medical Sector on Steroids

Doctors in Nepal also over-prescribe steroids, usually recommended to treat cancer, arthritis, vasculitis, asthma, muscular dystrophy, and arrhythmia, for children suffering colds and coughs. Steroids suppress the body's immune system, which is why doctors might prescribe them to address short-term health problems. The random prescription of such powerful medication can have long-term effects on health.

At a clinic in Jhapa, doctors prescribed a one-year-old with a common cold, the steroid Prednisolone. When the cold persisted, the boy’s parents eventually began to buy the medicine over the counter whenever their son got sick. This went on for three and a half years until the child was unable to walk.

When he was brought to a hospital in Kathmandu, doctors discovered that he had cataracts in both eyes as well as myopathy, a rare condition that causes the muscles of the legs to deteriorate. The child had to undergo cataract surgery, usually performed on elderly patients over 60. But there was no treatment for his myopathy.

A study published in the British Medical Journal found that the prescription of steroids in children causes complications including obesity, diabetes, increased blood pressure, cataracts, weakened bones and muscles, as well as excessive body hair growth.

Immunology and paediatric rheumatologist Dharmagat Bhattarai has seen many patients with disabilities and other lifelong health complications caused by the prescription of steroids to treat common colds. 

“Steroids should be used according to guidelines only in cases of serious diseases, to prevent amputations and in lifesaving situations,” says Bhattarai. “It cannot be used for general health problems.”

Children under five are more susceptible to viral infections such as the common cold and diarrhoea, for which there is no specific medication. With proper care, such infections clear up on their own within a few days.

An investigation by this paper of prescriptions by doctors in Kathmandu Valley showed that at least 8 out of 10 children who had been diagnosed with cold and cough had been prescribed unnecessary medication.

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Molecular microbiologist Guna Raj Dhungana says: “Uncontrolled use of antibiotics cause pathogens to evolve, and develop the ability to fight the drug.”

Physicians we showed the prescriptions to found that even in cases of viral infections, doctors in various hospitals in Kathmandu had recommended antibiotics like Amoxicillin, Azithromycin, Cefixime, Metronidazole, and Ofloxacin to children.

Antibiotics are designed to fight bacterial infections, and they do not work for viral conditions. Excessive use of antibiotics causes antimicrobial resistance (AMR) which means the drugs will not work against more serious infections. 

The WHO has identified AMR as one of the top global public health threats, warning of as many as 10 million deaths each year by 2050 due prescription drugs failure. 

Infectious disease specialist Prabhat Adhikari estimates that even the stronger antibiotics have stopped working in 80% of patients with bacterial infections at ICUs of major hospitals in Kathmandu.

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“Patients who have had surgery are likely to develop infections, and people with heart failure are at risk of developing pneumonia when intubated,” explains Adhikari. “Antibiotics can be ineffective in treating such infections, causing premature deaths.”

Most parents do not realise that minor conditions like the common cold can clear up in a week and do not require treatment and there is no needfor a trip to the hospital.

Some doctors take advantage of worried parents to make a quick buck on commissions from pharmaceutical companies. “We can require prescriptions for certain drugs, but it all depends on the doctor’s conduct,” says healthcare expert Kiran Raj Pandey.

International regulatory bodies have medical guidelines which are regularly updated. Once there is evidence that a certain drug has negative side effects, its use is restricted. Some doctors have not read those guidelines, and continue to prescribe discontinued medicines.

Just as alarming is the nexus between the drug manufacturers and healthcare institutions in Nepal. Pharmaceutical companies pay as much as 60% of their profit to hospitals and doctors for prescribing their brands. Doctors therefore prescribe expensive and strong antibiotics to patients who can be treated with more affordable alternatives. 

For instance, European countries prescribe patients cheap penicillin-based antibiotics to treat pneumonia, whereas Nepali doctors prescribe expensive and last-resort antibiotics like Linezolid, Vancomycin, Meropenem, and Colistin.

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“Pharmaceutical companies have incentivised doctors to prescribe more drugs with commissions and gifts,” says infectious disease specialist Anup Subedee. “Many doctors do not think in terms of whether their patient will get better but what will earn them more.”

Misuse of prescription drugs is also driving many Nepalis, already overburdened with out of pocket medical costs, into poverty. Medicine makes up for nearly 75% of the total health expenditure of Nepalis.

“Studies have shown that drug purchases can cause three to four percent of people to fall into poverty, and cause financial stress in up to 15% of families of patients,” says health economist Shiva Raj Adhikari.

The mushrooming of private health institutions in Nepal has also created competition in the health sector such that hospitals and clinics try to make money through unnecessary medications and laboratory tests as well as other redundant administrative fees.

In Nepal, the Nepal Medical Council (NMC) administers the licensing examination of doctors and regulates their medical practice. However, it does not monitor the conduct of individual doctors without a complaint. “It is not possible to check on the type and dosage of medication prescribed by an individual doctor, but we will review any complaints,” says NMC’s Satish Kumar Deo.

Infectious disease specialist Subedee says that the NMC should audit prescriptions of doctors to check whether they follow relevant guidelines: “If the council has the professional skills, leadership and sense of accountability to do what is right, this problem can be solved overnight.” 

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