Journal of Research in Pharmacy Practice

Abstract Objective: As chief prescribers, physicians could have a key role in rational drug use. Core 
prescribing indicators of all physicians have been evaluated in the Islamic Republic of Iran 
for several years, but no study has assessed the effects of academic status of doctors on 
their prescribing behaviors. We aimed to compare prescribing indicators of two groups of 
academic and non-academic specialist physicians working in Urmia, Iran.
Methods: In this cross-sectional study, prescribing indicators of the total number of 37 
academic and 104 non-academic specialist physicians in six medical specialties (infectious 
diseases, psychiatry, otorhinolaryngology, gynecology, pediatrics and general surgery) were 
studied during 2012 using Rx‑analyzer, a dedicated computer application. A set of five quality 
indicators was used based on the World Health Organization and International Network 
for Rational Use of Drugs recommendations.
Findings: Totally, 709,771 medications in 269,660 prescriptions were studied. For academic 
and non-academic specialist physicians, the average number of medications per prescription 
was 2.26 and 2.65, respectively. Similarly, patients’ encounters with injectable pharmaceuticals 
were 17.37% and 26.76%, respectively. The corresponding figures for antimicrobial agents 
were 33.12% and 45.46%, respectively. The average costs of every prescription were 6.53 and 
3.30 United States Dollar for academic and non-academic specialist physicians, respectively. 
All the above‑mentioned differences were statistically significant.
Conclusion: Better prescribing patterns were observed in academic specialist physicians. 
However, they prescribed medications that were more expensive, while the reason was not 
investigated in this study. Further studies may reveal the exact causes of these differences.

Abstract Objective: In this study, we aimed to assess comparative productivity of 21 pharmaceutical 
companies in Iran during 2000–2013.
Methods: To evaluate the productivity trend of pharmaceutical companies in Iran, we used 
data envelopment analysis‑based Malmquist index. “Total assets” and “capital stock” as inputs 
and “net sales” and “net profit” as outputs extracted from Tehran stock exchange, were 
selected to be included in the analysis. This method provides the possibility for analyzing the 
performance of each company in term of productivity changes over time. We also used an 
estimation generalized least square panel data model to identify the factors that might affect 
productivity of pharmaceutical companies in Iran using EViews 7 and Deep 2.1 software.
Findings: The mean total productivity during all years of the study was 0.9829, which 
indicates the improvement in their overall productivity. The results, over the 13-year 
period, indicated that the range of productivity changes in pharmaceutical companies, that 
were included in this study, was between 0.884 and 1.098. Panel data model indicated that 
age of company could positively (t = 4.765978, P < 0.001) and being located in cities other 
than Tehran (the capital) could negatively (t = −5.369549, P < 0.001) affect the productivity 
of pharmaceutical companies. The analysis showed the new policy (brand-generic scheme) 
and also the type of ownership did not have a significant effect on the productivity of 
pharmaceutical companies.
Conclusion: In this study, pharmaceutical productivity trends were fluctuated that could be 
due to the sub-optimal attention of policy makers and managers of pharmaceutical companies 
toward long-term strategic planning, focusing on productivity improvement.

Abstract Objective: Pruritus is a common and disturbing side effect of neuraxial opioids after 
cesarean section. The purpose of this study was to compare the efficacy of intravenous 
ondansetron and sub-hypnotic dose of propofol in control and treatment of intrathecal 
sufentanil induced pruritus in cesarean surgery.
Methods: Totally, 90 parturient with American Society of Anesthesiology physical status 
grade I-II, undergoing spinal anesthesia with 2.5 µg sufentanil and 10 mg bupivacaine 0.5% were 
enrolled to this randomized, prospective, double-blind study. The women were randomly 
assigned to two groups who received 8 mg ondansetron or 10 mg propofol to treat pruritus 
grade ≥3. The patient was evaluated after 5 min and in the lack of successful treatment, 
the doses of two drugs repeated and if the pruritus is on-going, the exact treatment with 
naloxone was done.
Findings: The incidence of pruritus was 69.3%. Both groups were well-matched. The 
peak time pruritus was 30–75 min after injection. The percentage of individuals consumed 
naloxone were 6.8% and 15.9% in ondansetron and propofol groups, respectively (P = 0.18). 
The mean score of satisfaction (according to visual analog scale criteria) was 9.09 ± 1.1 in 
ondansetron group and 9.3 ± 1.07 in the propofol group (P = 0.39).
Conclusion: Ondansetrone and sub-hypnotic dose of propofol are both safe and 
well‑tolerated. Due to their same efficacy in the treatment of intrathecal sufentanil‑induced 
pruritus, they can be widely used in clinical practice.

Abstract Objective: Through manual review of clinical notes for patients with type 2 diabetes 
mellitus attending a Danish diabetes center, the aim of the study was to identify adverse drug 
reactions(ADRs) associated with three classes of glucose‑lowering medicines: “Combinations 
of oral blood‑glucose lowering medicines” (A10BD), “dipeptidyl peptidase‑4 (DDP‑4) 
inhibitors” (A10BH), and “other blood glucose lowering medicines” (A10BX). Specifically, 
we aimed to describe the potential of clinical notes to identify new ADRs and to evaluate 
if sufficient information can be obtained for causality assessment.
Methods: For observed adverse events (AEs) we extracted time to onset, outcome, and 
suspected medicine(s). AEs were assessed according to World Health Organization-Uppsala 
Monitoring Centre causality criteria and analyzed with respect to suspected medicines, type 
of ADR (system organ class), seriousness and labeling status.
Findings: A total of 207 patients were included in the study leading to the identification 
of 163 AEs. 14% were categorized as certain, 60% as probable/likely, and 26% as possible. 
15 (9%) ADRs were unlabeled of which two were serious: peripheral edema associated with 
sitagliptin and stomach ulcer associated with liraglutide. Of the unlabeled ADRs, 13 (87%) 
were associated with “other blood glucose lowering medications,” the remaining 2 (13%) 
with “DDP‑4 inhibitors.”
Conclusion: Clinical notes could potentially reveal unlabeled ADRs associated with 
prescribed medicines and sufficient information is generally available for causality assessment. 
However, manual review of clinical notes is too time-consuming for routine use and hence 
there is a need for developing information technology (IT) tools for automatic screening 
of patient records with the purpose to detect information about potentially serious and 
unlabeled ADRs.

Abstract Objective: Thrombocytopenia is a common problem in cardiovascular surgery patients. 
However, heparin-induced thrombocytopenia (HIT) is a rare but life-threatening complication 
of prophylaxis or treatment with heparin. Prompt management of HIT with an alternative 
anticoagulant is necessary due to the extreme risk of thrombotic complications. Therefore, 
we evaluated the effects of danaparoid in the treatment of HIT in patients with cardiac 
surgery who are at moderate to high risk of HIT.
Methods: A prospective observational study involving 418 postcardiac surgery patients 
who received unfractionated heparin and low-molecular weight heparin was conducted 
in an educational tertiary cardiac care hospital in Iran. All patients were assessed for HIT 
type II based on thrombocytopenia and pretest clinical scoring system, the “4T’s” score. HIT 
patients were treated with 1500–2500 units intravenous bolus danaparoid sodium followed 
by 200–400 units/h for a mean of 5 days. Successful response to danaparoid therapy, defined 
as augmentation in platelet count and improvement of thrombotic events was assessed in 
all patients treated with danaparoid.
Findings: According to pretest clinical score (4T’s), the probability of HIT was high in 
14 (3.3%) patients and intermediate in three ones (0.7%). 15 patients with HIT were 
treated with danaparoid. One death occurred in danaparoid-treated group due to persistent 
thrombocytopenia. The rest of patients were treated successfully with danaparoid without 
any major thrombotic complication.
Conclusion: According to our data and the previous studies’, HIT can be managed 
prosperously with danaparoid in postcardiac surgery patients. However, with the absence of 
any increase in platelet count after 3–5 days of danaparoid therapy and/or the occurrence 
of a new thrombotic event, danaparoid cross-reactivity with heparin should be suspected.

Abstract Objective: Laryngoscopy and intratracheal intubation may cause acute hemodynamic 
instabilities due to catecholamine release. Magnesium sulfate (MgSO4
) prevents catecholamine 
release and results in bradycardia and vasodilatation, so can be used to diminish complications 
of laryngoscopy and intubation in doses > 50 mg/kg. The aim of this study was to compare 
the different doses of MgSO4
 used to improve cardiovascular instabilities due to laryngoscopy 
and intratracheal intubation.
Methods: In this double-blind randomized controlled trial, 120 patients undergoing elective 
surgery were divided equally into four groups (n = 30) and received different doses of 
MgSO4
 as case groups (Group I: 30 mg/kg, Group II: 40 mg/kg, Group III: 50 mg/kg) or the 
equal volume of normal saline as a control group. The patients’ hemodynamic status was 
recorded at baseline, before laryngoscopy and in 1, 3, 5, and 10 minutes after laryngoscopy. 
Bradycardia, tachycardia, hypertension, hypotension, ST-T changes, arrhythmias, and duration 
of extubation and laryngoscopy were also recorded.
Findings: There was no significant difference in heart rate between four groups(Pbaseline = 0.46, 
Ppreoperation = 0.55, P1 min = 0.86, P3 min = 0.30, P5 min = 0.63, P10 min = 0.74). Systolic, diastolic and 
mean arterial pressures were statistically significant less at 1, 3, and 5 minutes after intubation 
in comparison with other times of following-up in the three groups received MgSO4
 than 
the control group.
Conclusion: The use of MgSO4
 in doses less than 50 mg/kg can be effective to reduce 
cardiovascular instability related to laryngoscopy and tracheal intubation.

Abstract Objective: The objective was to assess the frequency of polypharmacy and potential 
complications among local seniors.
Methods: A cross-sectional convenience sample of 59 adults aged above 65 years was 
interviewed at Cuyahoga county (U.S. state of Ohio) senior programs. Polypharmacy was 
defined as more than five prescribed medications. Primary outcomes were frequent missed 
doses, one or more duplicate drug/s, and equal or more than one contraindicated drug 
combinations.
Findings: Among seniors with the mean age of 76.9 years (25.4% male), 40.6% used multiple 
pharmacies and 35.6% had polypharmacy. Of all seniors with polypharmacy, about 57% had 
contraindicated drug combinations. Polypharmacy was associated with duplication (P = 0.02), 
but not frequent missed doses (P = 0.20).
Conclusion: As shown by this study, polypharmacy was associated with duplicated therapy 
and contraindicated drug combinations. Improved communications among seniors, physicians, 
and pharmacists is necessary to minimize adverse consequences of polypharmacy

Abstract Objective: Ketamine administration is known to induce hemodynamic pressor response 
and psychomimetic effects which could be attenuated by appropriate premedication. The 
present study was designed to evaluate the effect of midazolam on hemodynamic stability 
and postoperative emergence phenomenon following ketamine anesthesia.
Methods: This was a prospective observational study including 30 adult patients with 
American Society of Anesthesiologists physical grades I and II scheduled for elective 
short surgeries under ketamine anesthesia. Patients were premedicated with midazolam 
(0.02 mg/kg intravenously) before the ketamine induction (1 mg/kg intravenously). 
Demographic data and hemodynamic variables were observed during the perioperative 
period. Pain score by visual analog scale score and psychomimetic effects were recorded 
postoperatively.
Findings: The mean ± standard deviation of heart rate, systolic blood pressure, diastolic 
blood pressure, and respiratory rate were decreased postoperatively (85.3 ± 11.4, 120.7 ± 8.2, 
79.2 ± 5.5, 13.5 ± 1.8, respectively) compared to intraoperative period (88.53 ± 14.1, 
123.83 ± 13.8, 83 ± 9.1, 14.13 ± 2.0, respectively). There was statistically significant decrease 
in systolic (P = 0.03) and diastolic (P = 0.002) blood pressure, but not with heart rate and 
respiratory rate. Eighty percent of patients had no pain at ½ hour and 1 hour, while this 
increased to 90% at 2 hours postoperatively. Mild emergence delirium was noted in 13.3% and 
16.7% at ½ hour and 1 hour, respectively, which decreased to 13.3% at 2 hours. Dreams were 
noticed in 20%, 27% and 10% of patients at ½ hour, 1 and 2 hours after surgery, respectively.
Conclusion: Midazolam premedication in ketamine anesthesia effectively attenuated 
the hemodynamic pressor response and postoperative emergence phenomenon. Hence, 
the combination of midazolam with ketamine can be safely used for short surgical painful 
procedures in adults.

Abstract Objective: This study aimed to assess the knowledge, awareness, and perception of 
contraception among senior pharmacy students of a public sector university in Malaysia.
Methods: A cross‑sectional, questionnaire‑based study was conducted among senior 
pharmacy students. The pretested questionnaire was used to collect data from the 
participants over the period of 1‑month. The questionnaire was divided into four sections, for 
gathering the information about students’ demographic data, and their knowledge, attitudes, 
and perception toward contraception. Data were statistically analyzed using SPSS version 20.
Findings: The response rate was 68.6%. The results showed that the contraceptive knowledge 
was comparatively higher in year four students (P < 0.001), married respondents (P < 0.001) 
and those taking elective courses (P = 0.022) as compared to their respective counterparts. 
Majority of the students were well aware and had a positive perception about contraception.
Conclusion: Overall findings reflect that the majority of the students had good knowledge, 
perception, and awareness about contraception. The study recommends future studies to 
be conducted covering different pharmacy schools across the country to further establish 
the results.

Abstract Multiple sclerosis (MS) is a chronic and debilitating inflammatory autoimmune disorder of the 
central nervous system. MS patients may experience severe local inflammatory skin reactions 
during disease-modifying therapy with subcutaneously injected interferon-beta-1b (IFN-β). 
We report the case of a 49-year-old woman with relapsing-remitting MS, who developed 
multiple cutaneous necrotic ulcers on both arms and thighs after 3 months of treatment with 
subcutaneous IFN-β-1b. The biopsy specimens showed skin and subcutaneous tissue necrosis. 
We diagnosed the skin lesions as cutaneous necrotic ulcerations associated with IFN-β-1b 
injection. The treatment included ending the use of subcutaneously injected IFN-β-1b and 
switching to intramuscularly injected IFN-β-1a because of the multiple cutaneous necrotic 
ulcers. The injection of IFN-β-1b in the areas with lesions was stopped, and the patient’s 
clinical condition improved with the addition of routine wound care, surgical debridement, 
and skin grafting. This report is intended to raise awareness about severe adverse skin 
reactions which may rarely occur with subcutaneous IFN-β-1b injection. Early recognition 
and correction of the injection technique and switching to other forms of interferon can 
help to prevent these complications.