RESUMEN
BACKGROUND: Combined oral contraceptive (COC) use is the most commonly used reversible method of birth control. The incorrect use of COCs is frequent and one of the most common causes of unintended pregnancies. Community pharmacists (CPs) are in a strategic position to improve COC use because they are the last health professional to interact with patients before drug use. OBJECTIVE: To evaluate the COC dispensing practices of CPs in a developing country. METHOD: A cross-sectional study was conducted in community pharmacies of Assis and Ourinhos microregions, Brazil, between June 1, 2012, and October 30, 2012. Four simulated patients (SPs) (with counseled audio recording) visited community pharmacies with a prescription for Ciclo 21(®) (a COC containing ethinyl estradiol 30 mcg + levonorgestrel 15 mcg). The audio recording of every SP visit was listened to independently by 3 researchers to evaluate the COC dispensing practice. The percentage of CPs who performed a screening for safe use of COCs (i.e., taking of patients' medical and family history, and measuring of blood pressure) and provided counseling, as well as the quality of the screening and counseling, were evaluated. RESULTS: Of the 185 CPs contacted, 41 (22.2%) agreed to participate in the study and finished the study protocol. Only 3 CPs asked the SP a question (1 question asked by each professional), and all of the questions were closed-ended, viz., "do you smoke?" (n = 2) and "what is your age?" (n = 1). None of the CPs measured the patient's blood pressure. Six CPs provided counseling when dispensing COCs (drug dosing, 5 CPs; possible adverse effects, 2 CPs), and one CP provided counseling regarding both aspects. CONCLUSION: The CPs evaluated did not dispense COC appropriately and could influence in the occurrence of negatives therapeutic outcomes such as adverse effects and treatment failure.
Asunto(s)
Anticonceptivos Orales Combinados/provisión & distribución , Etinilestradiol/provisión & distribución , Conocimientos, Actitudes y Práctica en Salud , Levonorgestrel/provisión & distribución , Farmacéuticos/ética , Adulto , Brasil , Competencia Clínica/estadística & datos numéricos , Anticoncepción/estadística & datos numéricos , Consejo/ética , Femenino , Humanos , Masculino , Simulación de Paciente , Farmacéuticos/psicologíaRESUMEN
BACKGROUND: Emergency contraception (EC) can potentially reduce unwanted pregnancies and abortions. However, these agents are underused due to lack of awareness and barriers to utilization. While earlier economic evaluations have indicated that use of EC is potentially cost-effective, recent evidence of a lower risk of pregnancy following unprotected intercourse than previously reported suggest prior studies may have over-estimated cost savings. OBJECTIVES: To model cost savings and pregnancy-related outcomes associated with the policy change authorizing pharmacist provision of EC in British Columbia, and to estimate the costs of initiatives to further women's awareness and utilization of EC that would result. METHODS: Three decision analytic models were developed evaluating current EC utilization (physician-only), EC utilization following pharmacist provision and potential expanded EC awareness and utilization following a public awareness initiative. Models were developed from the Ministry of Health perspective for 2001 using cost and event data from the Ministry supplemented by data from the literature. RESULTS: Current EC utilization saved the Ministry $2.20 million (95% CR: $0.15 million, $4.90 million) in medical costs the first year, and incremental savings from pharmacist provision was $0.64 million (95% CR: $0.24 million, $1.28 million). A public awareness initiative costing less than $2.57 million (95% CR: $0.22 million, $5.75 million) annually is potentially cost saving. CONCLUSIONS: Pharmacist provision of EC was cost saving to the Ministry, even when the estimated risk of pregnancy in the population is less than assumed in previous studies. Increasing EC availability directly from pharmacists and increasing EC awareness have the potential to reduce health care costs.
Asunto(s)
Anticonceptivos Poscoito/economía , Anticonceptivos Poscoito/provisión & distribución , Técnicas de Apoyo para la Decisión , Utilización de Medicamentos/economía , Evaluación de Resultado en la Atención de Salud , Servicios Farmacéuticos/economía , Pautas de la Práctica en Medicina/economía , Colombia Británica , Ahorro de Costo/estadística & datos numéricos , Árboles de Decisión , Utilización de Medicamentos/estadística & datos numéricos , Etinilestradiol/economía , Etinilestradiol/provisión & distribución , Femenino , Educación en Salud/economía , Conocimientos, Actitudes y Práctica en Salud , Accesibilidad a los Servicios de Salud/economía , Humanos , Levonorgestrel/economía , Levonorgestrel/provisión & distribución , Norgestrel/economía , Norgestrel/provisión & distribución , Servicios Farmacéuticos/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Embarazo , Embarazo no DeseadoRESUMEN
The European Society of Contraception developed a survey to examine birth control methods in the 12 countries++ of the European Community. Responses to those questions relating to prescribing++ practices of oral contraceptives (OCs) are presented herein. The survey was sent to 400 physicians. One hundred two responded, most from France, Belgium, and the United Kingdom. The responses revealed that the most popular OCs are modern combined formulations containing low doses of ethinyl estradiol and progestogens such as norgestimate, desogestrel, gestodene, and levonorgestrel. More than half of physicians prescribe a particular formulation because of its tolerability and 20% because of its hormonal content. More than 90% prescribe OCs to healthy, nonsmoking women over 40. However, three fourths will not prescribe OCs to smokers over 35. Half of physicians recommend mammography for their older OC patients. Half also recommend cholesterol screening, but 8% only for women over 30. Most physicians are no longer reluctant to prescribe OCs to their diabetic patients: 61% prescribe OCs for women with non-insulin-dependent diabetes, 56% for those with insulin-dependent diabetes, and 85% for those with a history of gestational diabetes. Despite recent studies showing no relation between past OC use and cardiovascular disease, 42% of physicians said that their greatest OC-related health concern is cardiovascular disease. One third cited noncompliance as their greatest concern. These results reveal inhomogeneous prescribing practices for OCs among European physicians. ¿Over-screening¿--not prescribing the pill because of perceived (but not necessarily real) health risks--may be depriving many women of the contraceptive and noncontraceptive benefits of OCs. Complete and accurate information--as promoted by the European Society of Contraception--is one way to combat such overscreening.
PIP: Findings are presented from the 1993 European Society of Contraception Oral Contraceptive Survey conducted in 12 member countries among 102 physicians. Findings are considered suggestive because of the low response rate of 25% to the mailed questionnaire to 400 physicians. The aim is to determine the prescribing practices of oral contraceptives. Over 50% of physicians prescribed the following modern, low-dose combined formulations: Marvelon, Mercilon, Minulet, Gynera, Cilest, and Femodene. 66% of physicians prescribed monophasic pills containing 20-30 mcg of ethinyl estradiol and low doses of desogestrel, gestodene, levonorgestrel, or norgestimate. 58% preferred oral pills because of their tolerability. Other desirable features were the cost, hormonal content, and other factors. 94% prescribed oral pills for women aged over 40 years who were healthy and did not smoke. 75% would not prescribe oral pills to women who were over the age of 35 years and who smoked. Over 50% of physicians recommended mammograms for women aged over 35 years who used oral pills. 45% routinely performed lipoprotein screening of oral pill users. 8% did so only for patients aged over 30 years. 42 physicians out of the 102 responding had a protocol based on the total cholesterol level. 61% prescribed oral pills for women with non-insulin-dependent diabetes. The majority prescribed oral pills for women with insulin-dependent diabetes. 38% of physicians who prescribed oral pills for women with diabetes prescribed very-low-dose monophasic oral contraceptives. 85% prescribed oral pills for women with gestational diabetes. 42% were concerned about patient risk of cardiovascular disease. The study revealed a range of practices among physicians.
Asunto(s)
Anticoncepción/estadística & datos numéricos , Anticonceptivos Orales/provisión & distribución , Adulto , Envejecimiento/fisiología , Enfermedades Cardiovasculares/epidemiología , Anticoncepción/tendencias , Anticonceptivos Orales/efectos adversos , Recolección de Datos , Desogestrel/efectos adversos , Desogestrel/provisión & distribución , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 2/complicaciones , Congéneres del Estradiol/efectos adversos , Congéneres del Estradiol/provisión & distribución , Etinilestradiol/efectos adversos , Etinilestradiol/provisión & distribución , Europa (Continente)/epidemiología , Femenino , Humanos , Levonorgestrel/efectos adversos , Levonorgestrel/provisión & distribución , Norgestrel/efectos adversos , Norgestrel/análogos & derivados , Norgestrel/provisión & distribución , Norpregnenos/efectos adversos , Norpregnenos/provisión & distribución , Progesterona/efectos adversos , Progesterona/provisión & distribución , Congéneres de la Progesterona/efectos adversos , Congéneres de la Progesterona/provisión & distribución , Factores de Riesgo , Fumar/efectos adversos , Encuestas y CuestionariosRESUMEN
Among the low dose oral contraceptives that is to say less than 50 mcg of ethinylestradiol per pill one must single out the pills made of a third generation progestagen (desogestrel, gestodene, norgestimate) from the others. The contraceptive efficacy (tested on the Pearl index) according to the files of government authorities visa (AMM) is equivalent for all the oral contraceptives whatever their composition (between 0 to 0.07 women year). The clinical tolerance of the low dose pills of the 3rd generation is comparable to that of the other low dose pills. Is there any advantage then in prescribing them? The most important advantage is the decrease of metabolic and vascular effects. The use of so-called third generation progestive, besides the beneficial effects an lipidic and glucidic metabolisms, has mainly enabled the decrease of the estrogen doses of progestagens. The ethinylestradiol is directly implicated in the risk of venous thrombosis: hemostasis the modifications are less important with 30 mcg than with 50, 20 than 30 mcg. Relying on theoretical arguments one could have estimated that minipills would lead to an insufficient ovarian slow down. These hypothesis are contradicted by recent studies from Falsetti and Benagiano who studied the rates of FSH and LH under minipills. This does not include the variability and the individual sensitiveness of the patients and as well the reason following which minipills would favor functional ovarian cysts, lies on the confusion made between a cyst and a 20 mm diameter follicule.(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Anticonceptivos Orales Combinados/uso terapéutico , Etinilestradiol/uso terapéutico , Progestinas/uso terapéutico , Neoplasias de la Mama/inducido químicamente , Neoplasias de la Mama/epidemiología , Ensayos Clínicos como Asunto , Anticonceptivos Orales Combinados/clasificación , Anticonceptivos Orales Combinados/farmacología , Etinilestradiol/clasificación , Etinilestradiol/farmacología , Etinilestradiol/provisión & distribución , Femenino , Hormona Folículo Estimulante/sangre , Glucosa/metabolismo , Humanos , Metabolismo de los Lípidos , Hormona Luteinizante/sangre , Hormona Luteinizante/efectos de los fármacos , Quistes Ováricos/inducido químicamente , Quistes Ováricos/epidemiología , Progestinas/clasificación , Progestinas/farmacología , Progestinas/provisión & distribución , Factores de Riesgo , Tromboflebitis/inducido químicamente , Tromboflebitis/epidemiologíaRESUMEN
The new progestative molecules have allowed to reduce the doses of steroids in the combined pills. They have a reduced androgenic activity allowing the positive effects of ethinyl estradiol to act on lipid metabolisms, which may lead to a reduction of atherogenesis. However these new pills should not be administered if the classical contraindications exist. On the contrary the strong gonadotropic effect of the latest nor-pregnane derivates can be used (the chlormadinone as well) on patients with thromboembolic history on the condition that the still partially experimental aspect of this mode of contraception is taken into consideration.
Asunto(s)
Anticonceptivos Orales Combinados/uso terapéutico , Etinilestradiol/uso terapéutico , Congéneres de la Progesterona/uso terapéutico , Arteriosclerosis/inducido químicamente , Ensayos Clínicos como Asunto , Anticonceptivos Orales Combinados/farmacología , Anticonceptivos Orales Combinados/provisión & distribución , Etinilestradiol/farmacología , Etinilestradiol/provisión & distribución , Humanos , Congéneres de la Progesterona/farmacología , Congéneres de la Progesterona/provisión & distribución , Tromboembolia/inducido químicamenteRESUMEN
A large number of publications on oral contraceptives (OC) can be found in the medical literature. These reports deal not only with mode of action or efficacy of OCs but also with side effects. Adverse drug reactions (ADR) are not accepted nor acceptable from a population of young women free of disease who expect from their mode of contraception to be fully efficient and devoid from side effects. In most instances, side effects observed with OCs as well as their efficacy are related to the total dose of steroïds contained in the combination, to the balance between the estrogen and the progestin content and to the specific characteristics of the molecules. Cardiovascular morbidity and mortality reported in OC users have been related firstly to the ethinylestradiol (EE) and as a first step, the estrogen dose has been reduced in the OCs synthesized in the 70s. Later on, cardiovascular risk has been correlated to lipid profile changes and progestins with androgenic properties have been made responsible for cardiovascular events reported in OC users. In order to minimize the incidence of ADRs and to induce beneficial changes in lipid patterns, new progestational molecules devoid of androgenic properties have been recently synthesized. Three compounds called "third generation" progestins, derived from levonorgestrel are presently available in Europe. These three gonane progestins demonstrate affinity for the androgenic receptor, but when administered together with EE do not oppose the estrogenic effect observed on protein markers such as the Sex Hormone Binding Globulin (SHBG) or the High Density Lipoprotein (HDL).(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Anticonceptivos Orales Combinados/efectos adversos , Etinilestradiol/efectos adversos , Congéneres de la Progesterona/efectos adversos , Coagulación Sanguínea/efectos de los fármacos , Enfermedades Cardiovasculares/sangre , Enfermedades Cardiovasculares/inducido químicamente , Enfermedades Cardiovasculares/epidemiología , Anticonceptivos Orales Combinados/química , Anticonceptivos Orales Combinados/provisión & distribución , Etinilestradiol/química , Etinilestradiol/provisión & distribución , Femenino , Humanos , Aceptación de la Atención de Salud , Congéneres de la Progesterona/química , Congéneres de la Progesterona/provisión & distribución , Factores de Riesgo , Triglicéridos/sangreRESUMEN
Purchasers of a low-cost oral contraceptive were intercepted and interviewed in a sample of Santo Domingo pharmacies that represented the highest sales of the product, yet also reflected the socioeconomic profile of the city's entire population. Users of the contraceptive were later interviewed in greater depth in their homes. The survey of users showed that the Dominican Republic's social marketing program, implemented by PROFAMILIA, was reaching an appropriate target market--that is, younger, lower-middle-class women of low parity. The program was, in addition, successful in attracting first-time adopters, and it was also expanding the overall commercial market for all contraceptives. The marketing campaign was successful in part because a mass audience was reached, through brief television spots. Program impact on contraceptive prevalence can be assessed from sales data.
PIP: Purchasers of a low-cost oral contraceptive were intercepted and interviewed (449 pharmacy interviews in a sample of pharmacies in Santo Domingo, Dominican Republic, that represented the highest sales of the product, yet also reflected the socioeconomic profile of the city's entire population. Contraceptive users were later interviewed in greater depth in 252 home interviews. The survey showed that the Dominican Republic's social marketing program, implemented by PROFAMILIA, was reaching appropriate target market, that is, younger, lower middle class women of low parity. The program was also successful in attracting 1-time contraceptive users, and it was expanding the overall commercial market for all contraceptives. The marketing campaign was successful in part because a mass audience was reached with brief television spots. It is concluded that program impact on contraceptive prevalence can be assessed from sales data.