Letters to the Editor
References 1. 2. 3.
Chickering AW, Gamson ZF. Seven Principles for Good Practice in Undergraduate Education. 1987. p. 3. Prince M. Does Active Learning Work? A Review of the Research. J Eng Educ 2004;93:223-31. Vernon DT, Blake RL. Does problem-based learning work? A meta-analysis of
4. 5.
evaluative research. Acad Med 1993;68:550-63. McParland M, Noble LM, Livingston G. The effectiveness of problem-based learning compared to traditional teaching in undergraduate psychiatry. Med Educ 2004;38:859-67. Goss B, Reid K, Dodds A, McColl G. Comparison of medical students’ diagnostic reasoning skills in a traditional and a problem based learning curriculum. Int J Med Educ 2011;2:87-93.
Pharmaceutical waste from hospitals and homes: Need for better strategies Access this article online Website: www.ijp-online.com
Quick Response Code:
DOI: 10.4103/0253-7613.135969
Sir, It has become clear now that the ever-increasing use of pharmaceuticals in clinical and veterinary practice can have adverse influence on the environment, which is probably best exemplified by the association between the use of diclofenac for treatment in livestock and decline in number of vultures in the Indian subcontinent.[1] Consequently, the concept of ecopharmacovigilance (defined as science and activities concerning detection, assessment, understanding, and prevention of adverse effects or other problems related to the presence of pharmaceuticals in the environment, which affect human and other animal species) is gaining momentum.[2] Leftover, unwanted medication from hospitals and homes are one of the major source of pharmaceutical waste, and its safe disposal has become more important than ever. Pharmaceutical waste in hospital wards could be generated through partially used or unused dosage forms, patient’s personal medications, outdated drugs, etc. Besides, expired drugs may accumulate, though albeit slowly, in dispensaries and drug stores of hospitals due to inappropriate donations or inadequacies in stock management and distribution. In healthcare facilities purchasing drugs through rate contract system, it is not uncommon to come across substandard or misbranded drugs. All these factors contribute to increase in pharmaceutical waste in hospitals. Substantial waste, similarly, can be generated from leftover medicines from households and other places in society ranging from workplaces to zoos and cruise ships. Because these products are frequently purchased in excess or are not fully consumed as directed (due to patient non-compliance, physician-altered treatment, intolerable effects, etc.), widespread accumulation of unwanted leftover drugs can occur eventually leading to need for disposal.[3] The question is how is this pharmaceutical waste disposed? A study assessing pharmaceutical waste management at selected hospitals and homes in Ghana showed that four out of five hospitals do not have any separate collection and disposal
program for pharmaceutical waste. Half of the population surveyed confirmed having unused, leftover, or expired medicines at home, and over 75% population disposed them through the normal waste bins, which end up in the landfills or dump sites.[4] A questionnaire survey in dental students from North India showed that 70% of students possessed up to five expired medications at home, and the predominant method adopted for disposal was via household trash.[5] In India, rules and regulations regarding handling and management of various types of wastes are applicable to six main categories of waste: Municipal solid waste, hazardous waste, bio-medical waste (BMW), plastic waste, e-waste, and batteries.[6] All healthcare establishments, irrespective of the quantum of waste generated, come under BMW rules.[7] These rules classify discarded, contaminated, or outdated medicines and cytotoxic drugs into category five and recommend their disposal by incineration. Deep burial can be an option only in rural areas with no access to centralized treatment facility, with prior approval from prescribed authority. However, hardly anything is known about actual practices followed by healthcare facilities. The authorities concerned with disposal of these pharmaceuticals also need to be extra cautious to ensure security from scavenging and pilferage. Anti-neoplastics or cytotoxic drugs must be handled with extreme care as they have the ability to kill or stop growth of living cells and can have extremely serious effects, such as interfering with reproductive processes in various life forms.[8] It is noteworthy that the current BMW guidelines are not applicable to radioactive waste or hazardous chemicals. Some of the pharmaceutical waste (e.g. unused discarded nicotine patches[9]) meets the definition of hazardous waste by the Resource Conservation and Recovery Act (RCRA), U.S. Proper management of hazardous waste is highly complex and needs methods different from those used for disposal of biomedical waste. Presently, those who handle drugs (pharmacists and nurses) in hospitals do not receive appropriate training in hazardous waste management during their academic studies, and those who do receive such training (environment personnel) may not be familiar with active ingredients in various pharmaceutical formulations. All this confusion stresses the need to formulate specific guidelines that would include all aspects of pharmaceutical waste management for hospitals and homes and to implement appropriate programs for collection and disposal of unwanted medications from these sources. As pharmaceutical waste not only poses threat to the environment Indian Journal of Pharmacology | August 2014 | Vol 46 | Issue 4 459
Letters to the Editor
but also indicates wastage of valuable resources, measures to minimize pharmaceutical waste generation are equally important. Shraddha M. Pore Department of Pharmacology, Government Medical College, Miraj, Maharashtra, India Correspondence to: Dr. Shraddha M. Pore, E-mail: [email protected]
3.
4. 5. 6. 7. 8.
References 1. 2.
Oaks JL, Gilbert M, Virani MZ, Watson RT, Meteyer CU, Rideout BA, et al. Diclofenac residues as the cause of vulture population decline in Pakistan. Nature 2004;427:630-3. Medhi B, Sewal RK. Ecopharmacovigilance: An issue urgently to be addressed.
9.
Indian J Pharmacol 2012;44:547-9. Daughton CG, Ruhoy IS. Accumulation and disposal of left over medications: A key aspect of pharmacovigilance. In: Rahman SZ, Shahid M, Gupta V, editors. An Introduction to Environmental Pharmacology. 1st ed. Aligarh: Ibn Sina Academy; 2008. p. 101-7. Sasu S, Kümmerer K, Kranert M. Assessment of pharmaceutical waste management at selected hospitals and homes in Ghana. Waste Manag Res 2012;30:625-30. Aditya S. Safe medication disposal: Need to sensitize undergraduate students. Int J Pharm Life Sci 2013;4:2475-80. Available from: http://www.cpcb.nic.in [Last accessed on 2014 Apr 02]. The Gazette of India (Extraordinary) Part II-Section 3-Subsection (ii) No 1626. New Delhi, Wednesday, August 24, 2011. World Health Organization. Guidelines for Safe Disposal of Unwanted Pharmaceuticals in and after Emergencies1999. Available from: http://www.who. int/water_sanitation_health/medicalwaste/unwantpharm.pdf [Last accessed on 2014 Feb 01]. Unused discarded nicotine patches, gum and lozenges are P075; used discarded nicotine patches are not P075. Guidance Memos and Letters. Available from: http://www.epa.gov/osw/hazard/generation/pharmaceuticals.htm [Last accessed on 2014 Mar 21].
Comment: Comparison of efficacy, safety and cost-effectiveness of various statins in dyslipidemic diabetic patients Correspondence to: Dr. Sanjay Hadigal, E-mail: [email protected]
Access this article online Website: www.ijp-online.com
Quick Response Code:
DOI: 10.4103/0253-7613.135970
References 1. 2.
Sir, I read with interest the above mentioned article.[1] However, I had a few comments to make regarding the same. The method used to arrive at the particular sample size was not mentioned and neither was the power of the study. Some of the data mentioned in the written content did not correlate with the data that was mentioned in the graph. The authors mentioned that atorvastatin reduced LDL-C the most at a dose of 40 mg (15.9%). However, Table 3 clearly mentions that atorvastatin at a dose of 20 mg reduced LDL-C the most (21.2%). In Figure 1b, the footnote of the graph wrongly mentions microalbuminia instead of microalbuminuria. As the authors had used the term cost-effectiveness in the study title, it would have been better if they had shed more light on the pharmacoeconomic analysis.[2] They have solely mentioned the acquisition cost of rosuvastatin when compared to atorvastatin. A cost-effective analysis with the calculation of the Incremental Cost Effectiveness Ratio would have been more appropriate and insightful. Sanjay Hadigal, Ashok Shenoy K. Department of Pharmacology, Kasturba Medical College, Mangalore, Karnataka, India
460 Indian Journal of Pharmacology | August 2014 | Vol 46 | Issue 4
Bener A, Dogan M, barakat L, Al-Hamaq AO. Comparison of efficacy, safety, and cost-effectiveness of various statins in dyslipidemic diabetic patients. Indian J Pharmacol 2014;46:88-93. Lisa AS. Pharmacoeconomics: Principles, Methods and Applications In: Joseph TD, Robert LT, Gary CY, Barbara GW, Michael L, editors. Pharmacotherapy: A Pathophysiological Approach. 7th ed. New Delhi: McGraw-Hill; 2008. p. 1-14.
Author’s Reply Madam, We would like to thank reader for his/her valuabale comments. Meanwhile, I would like to clarify and reply to the reader point-by-point as given below: 1. This study is a cohort observational population-based study conducted at Hamad Medical Hospital and PHC Centre.[1] A total of 1,542 consecutive diabetes patients who were diagnosed with dyslipidemia and prescribed any of the indicated statins between January 2007 and September 2013 were included in the study. Since the study is based on cohort time interval and subjects who met and satisfied inclusion and exclusion criteria, there is no need for the sample size 2. We do agree with the reader that there are typographical errors in the Results section. The third paragraph should read as: “Atorvastatin reduced LDL-C the most at a dose of 40 mg (15.9%) and atorvastatin reduced LDL-C the most at a dose of 20 mg (21.2%),” which is very clear and
Copyright of Indian Journal of Pharmacology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
References 1. 2. 3.
Chickering AW, Gamson ZF. Seven Principles for Good Practice in Undergraduate Education. 1987. p. 3. Prince M. Does Active Learning Work? A Review of the Research. J Eng Educ 2004;93:223-31. Vernon DT, Blake RL. Does problem-based learning work? A meta-analysis of
4. 5.
evaluative research. Acad Med 1993;68:550-63. McParland M, Noble LM, Livingston G. The effectiveness of problem-based learning compared to traditional teaching in undergraduate psychiatry. Med Educ 2004;38:859-67. Goss B, Reid K, Dodds A, McColl G. Comparison of medical students’ diagnostic reasoning skills in a traditional and a problem based learning curriculum. Int J Med Educ 2011;2:87-93.
Pharmaceutical waste from hospitals and homes: Need for better strategies Access this article online Website: www.ijp-online.com
Quick Response Code:
DOI: 10.4103/0253-7613.135969
Sir, It has become clear now that the ever-increasing use of pharmaceuticals in clinical and veterinary practice can have adverse influence on the environment, which is probably best exemplified by the association between the use of diclofenac for treatment in livestock and decline in number of vultures in the Indian subcontinent.[1] Consequently, the concept of ecopharmacovigilance (defined as science and activities concerning detection, assessment, understanding, and prevention of adverse effects or other problems related to the presence of pharmaceuticals in the environment, which affect human and other animal species) is gaining momentum.[2] Leftover, unwanted medication from hospitals and homes are one of the major source of pharmaceutical waste, and its safe disposal has become more important than ever. Pharmaceutical waste in hospital wards could be generated through partially used or unused dosage forms, patient’s personal medications, outdated drugs, etc. Besides, expired drugs may accumulate, though albeit slowly, in dispensaries and drug stores of hospitals due to inappropriate donations or inadequacies in stock management and distribution. In healthcare facilities purchasing drugs through rate contract system, it is not uncommon to come across substandard or misbranded drugs. All these factors contribute to increase in pharmaceutical waste in hospitals. Substantial waste, similarly, can be generated from leftover medicines from households and other places in society ranging from workplaces to zoos and cruise ships. Because these products are frequently purchased in excess or are not fully consumed as directed (due to patient non-compliance, physician-altered treatment, intolerable effects, etc.), widespread accumulation of unwanted leftover drugs can occur eventually leading to need for disposal.[3] The question is how is this pharmaceutical waste disposed? A study assessing pharmaceutical waste management at selected hospitals and homes in Ghana showed that four out of five hospitals do not have any separate collection and disposal
program for pharmaceutical waste. Half of the population surveyed confirmed having unused, leftover, or expired medicines at home, and over 75% population disposed them through the normal waste bins, which end up in the landfills or dump sites.[4] A questionnaire survey in dental students from North India showed that 70% of students possessed up to five expired medications at home, and the predominant method adopted for disposal was via household trash.[5] In India, rules and regulations regarding handling and management of various types of wastes are applicable to six main categories of waste: Municipal solid waste, hazardous waste, bio-medical waste (BMW), plastic waste, e-waste, and batteries.[6] All healthcare establishments, irrespective of the quantum of waste generated, come under BMW rules.[7] These rules classify discarded, contaminated, or outdated medicines and cytotoxic drugs into category five and recommend their disposal by incineration. Deep burial can be an option only in rural areas with no access to centralized treatment facility, with prior approval from prescribed authority. However, hardly anything is known about actual practices followed by healthcare facilities. The authorities concerned with disposal of these pharmaceuticals also need to be extra cautious to ensure security from scavenging and pilferage. Anti-neoplastics or cytotoxic drugs must be handled with extreme care as they have the ability to kill or stop growth of living cells and can have extremely serious effects, such as interfering with reproductive processes in various life forms.[8] It is noteworthy that the current BMW guidelines are not applicable to radioactive waste or hazardous chemicals. Some of the pharmaceutical waste (e.g. unused discarded nicotine patches[9]) meets the definition of hazardous waste by the Resource Conservation and Recovery Act (RCRA), U.S. Proper management of hazardous waste is highly complex and needs methods different from those used for disposal of biomedical waste. Presently, those who handle drugs (pharmacists and nurses) in hospitals do not receive appropriate training in hazardous waste management during their academic studies, and those who do receive such training (environment personnel) may not be familiar with active ingredients in various pharmaceutical formulations. All this confusion stresses the need to formulate specific guidelines that would include all aspects of pharmaceutical waste management for hospitals and homes and to implement appropriate programs for collection and disposal of unwanted medications from these sources. As pharmaceutical waste not only poses threat to the environment Indian Journal of Pharmacology | August 2014 | Vol 46 | Issue 4 459
Letters to the Editor
but also indicates wastage of valuable resources, measures to minimize pharmaceutical waste generation are equally important. Shraddha M. Pore Department of Pharmacology, Government Medical College, Miraj, Maharashtra, India Correspondence to: Dr. Shraddha M. Pore, E-mail: [email protected]
3.
4. 5. 6. 7. 8.
References 1. 2.
Oaks JL, Gilbert M, Virani MZ, Watson RT, Meteyer CU, Rideout BA, et al. Diclofenac residues as the cause of vulture population decline in Pakistan. Nature 2004;427:630-3. Medhi B, Sewal RK. Ecopharmacovigilance: An issue urgently to be addressed.
9.
Indian J Pharmacol 2012;44:547-9. Daughton CG, Ruhoy IS. Accumulation and disposal of left over medications: A key aspect of pharmacovigilance. In: Rahman SZ, Shahid M, Gupta V, editors. An Introduction to Environmental Pharmacology. 1st ed. Aligarh: Ibn Sina Academy; 2008. p. 101-7. Sasu S, Kümmerer K, Kranert M. Assessment of pharmaceutical waste management at selected hospitals and homes in Ghana. Waste Manag Res 2012;30:625-30. Aditya S. Safe medication disposal: Need to sensitize undergraduate students. Int J Pharm Life Sci 2013;4:2475-80. Available from: http://www.cpcb.nic.in [Last accessed on 2014 Apr 02]. The Gazette of India (Extraordinary) Part II-Section 3-Subsection (ii) No 1626. New Delhi, Wednesday, August 24, 2011. World Health Organization. Guidelines for Safe Disposal of Unwanted Pharmaceuticals in and after Emergencies1999. Available from: http://www.who. int/water_sanitation_health/medicalwaste/unwantpharm.pdf [Last accessed on 2014 Feb 01]. Unused discarded nicotine patches, gum and lozenges are P075; used discarded nicotine patches are not P075. Guidance Memos and Letters. Available from: http://www.epa.gov/osw/hazard/generation/pharmaceuticals.htm [Last accessed on 2014 Mar 21].
Comment: Comparison of efficacy, safety and cost-effectiveness of various statins in dyslipidemic diabetic patients Correspondence to: Dr. Sanjay Hadigal, E-mail: [email protected]
Access this article online Website: www.ijp-online.com
Quick Response Code:
DOI: 10.4103/0253-7613.135970
References 1. 2.
Sir, I read with interest the above mentioned article.[1] However, I had a few comments to make regarding the same. The method used to arrive at the particular sample size was not mentioned and neither was the power of the study. Some of the data mentioned in the written content did not correlate with the data that was mentioned in the graph. The authors mentioned that atorvastatin reduced LDL-C the most at a dose of 40 mg (15.9%). However, Table 3 clearly mentions that atorvastatin at a dose of 20 mg reduced LDL-C the most (21.2%). In Figure 1b, the footnote of the graph wrongly mentions microalbuminia instead of microalbuminuria. As the authors had used the term cost-effectiveness in the study title, it would have been better if they had shed more light on the pharmacoeconomic analysis.[2] They have solely mentioned the acquisition cost of rosuvastatin when compared to atorvastatin. A cost-effective analysis with the calculation of the Incremental Cost Effectiveness Ratio would have been more appropriate and insightful. Sanjay Hadigal, Ashok Shenoy K. Department of Pharmacology, Kasturba Medical College, Mangalore, Karnataka, India
460 Indian Journal of Pharmacology | August 2014 | Vol 46 | Issue 4
Bener A, Dogan M, barakat L, Al-Hamaq AO. Comparison of efficacy, safety, and cost-effectiveness of various statins in dyslipidemic diabetic patients. Indian J Pharmacol 2014;46:88-93. Lisa AS. Pharmacoeconomics: Principles, Methods and Applications In: Joseph TD, Robert LT, Gary CY, Barbara GW, Michael L, editors. Pharmacotherapy: A Pathophysiological Approach. 7th ed. New Delhi: McGraw-Hill; 2008. p. 1-14.
Author’s Reply Madam, We would like to thank reader for his/her valuabale comments. Meanwhile, I would like to clarify and reply to the reader point-by-point as given below: 1. This study is a cohort observational population-based study conducted at Hamad Medical Hospital and PHC Centre.[1] A total of 1,542 consecutive diabetes patients who were diagnosed with dyslipidemia and prescribed any of the indicated statins between January 2007 and September 2013 were included in the study. Since the study is based on cohort time interval and subjects who met and satisfied inclusion and exclusion criteria, there is no need for the sample size 2. We do agree with the reader that there are typographical errors in the Results section. The third paragraph should read as: “Atorvastatin reduced LDL-C the most at a dose of 40 mg (15.9%) and atorvastatin reduced LDL-C the most at a dose of 20 mg (21.2%),” which is very clear and
Copyright of Indian Journal of Pharmacology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
