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4.

2 ASCITES

Table 4.2a: FREQUENCY & PERCENTAGE WISE


DISTRIBUTION OF MEDICATIONS IN MEDICATION
HISTORIES OF ASCITES

DRUG CATEGORY GENERIC DRUGS FREQUENCY PERCENTAGE

ANTIBIOTICS
CEPHALOSPORIN Cefotaxime 4(40% of all AB) 9
Ceftriaxone 1(10% of all AB) 2
QUINOLONES Ciprofloxacin 1(10% of all AB) 2
Levofloxacin 1(10% of all AB) 2
ANTI AMEOBICS metronidazole 3(30% of all AB) 7
DIURETICS
Potassium sparing spironolactone 7 16
diuretics frusemide 5 11
Loop diuretics
H2-BLOCKER ranitidine 2 4
PROTON PUMP Omeprazole 1 2
INHIBITOR
Pantoprazole 1 2
LAXATIVE Lactulose 5 11
ANTI-DOPAMINERGIC Metoclopramide 2 4
BETA BLOCKER propranolol 2 4
ANTI HEOMRRAGHIC Vitamin k 1 2
BLOOD PLASMA haemaccel 2 4
SUBSTITUE
DIGESTIVE ENZYMES Eplazyme 2 4
MULTIVITAMINS 3 7
MISCELLENIOUS Tramadol 1 2
Antacid 1 2
TOTAL DRUGS=45

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Figure 4.2a: PERCENTAGE WISE PRESENTATION OF MEDICATIONS IN
MEDICATION HISTORIES OF ASCITES

Antacid
Tramadol 2% Cefotaxime
2% 9%
Ceftriaxone
multivitamin 2%
7%

Ciprofloxacin
Eplazyme 2%
4%
Levofloxacin
2%
Haemaccel
4%
Metronidazole
7%
Vitamin k
2%

propranolol
4%

Metoclopramide
4%
Spironolactone
16%

Lactulose
11%

Pantoprazole Frusemide
2% 11%
Ranitidine
Omeprazole 4%
2%

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DISSCUSSION OF PHARMACOTHERAPY

Among 7 reported cases of ascites 5 cases (66% of all cases) were of cirrhotic ascites
and 2 (33% of all cases) of malignant ascites. The total number of antibiotics used in
all ascites cases were 10, among which most common antibiotic used were
cefotaxime 4 (40% of all antibiotics used), ceftriaxone 1(10% of all antibiotics),
Levofloxacin 1(10% of all antibiotics), ciprofloxacin 1(10% of all antibiotics) and
metronidazole 3(30% of all antibiotics). Cefotaxime percentage in ascites is much
higher because In Third-generation cephalosporin, cefotaxime is the treatment of
choice for SBP in ascites as it provides good activity against the usual pathogens
encountered in SBP and high penetration into ascitic fluid. (Garcia-Tsao G, Lim
Joseph .2009)
In ascites cases most common diuretics used were potassium sparing diuretic
spironolactone 7(16% of all drugs used) and loop diuretic frusemide 5(11% of all
drugs used). The ratio of these diuretics is higher because Sodium restriction together
with spironolactone and frusemide is the choice of therapy for ascites. (Timm EG,
Stragand JJ.2005)
The other agents use for symptomatic relief were ranitine 4% of all drugs used,
Omeprazole 2%,pantaprazole 2%,propranolol 4%,Lactulose 11%, metoclopramide
2% and vitamin K 2%. Multivitmain used in ascites cases were 7%, plasma substitute
4% and digestives enzymes 4% of all drugs used.

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Table 4.2b:
ETIOLOGY FREQUENCY %AGE
CIRRHOTIC ASCITIES 5 66%
MALIGNANT ASCITIES 2 33%
TOTAL CASES 7
FREQUENCY & PERCENTAGE WISE DISTRIBUTION OF
ETIOLOGY IN MEDICATION HISTORIES OF ASCITES

Table 4.2c:
FREQUENCY & PERCENTAGE WISE DISTRIBUTION OF
DRPs IN MEDICATION HISTORIES OF ASCITES

DRUG RELATED PROBLEM FREQUENCY PRCENTAGE

Untreated condition 2 7

Excessive dosage 3 10

Drug interaction 1 3
Requiring dose adjustment in 3 10
hepatic impairment

Cost related problem 13 46

Miscellaneous problem 7 24

Total problems=29

Figure 4.2b:

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PERCENTAGE WISE PRESENTATION OF DRPs IN MEDICATION
HISTORIES OF ASCITES

Untreated conditions
Miscellaneous 7%
problems Excessive dosage
24% 10%

Drug interactions
3%

Requiring dose
adjustment in hepatic
impairment
10%

Cost related problems


46%

DISSCUSSION OF DRPs

Among 7 reported cases of Ascites total 29 drug related problems were identified.
The major drug related problem was cost related problem that were 13 (46% of
DRPs). Status of alternative cost effective efficacious drugs should be considered
according to patient socio economic status to resolve such problems.
Problems requiring dose adjustment in hepatic impairment were 3 (10 % of DRPs)
and excessive dosage problems were 3(10% of DRPs).In cirrhotic patients
Metronidazole dose should reduced to one third and from TDS to OD and
Omeprazole/Esomeprazole dose to 20mgOD.
In ascites cases untreated conditions were 2 (7% of DRPs) and drug interactions
reported 1(3% of DRPs). Between Levofloxacin and antacid of significant rating 2
and rapid onset with moderate severity & probable documentation. The management
includes avoiding of concurrent use but if can not be avoided give antacid before or 2
hours after the quinolone.
Miscellaneous problems were 7(24% of DRPs) that include lack of RFT monitoring
in case of diuretic therapy and non Counselling in case of quinolone administration
and milk intake. As ciprofloxacin has interaction with milk of significant rating-
2(onset rapid, severity moderate and suspected documentation. Management include
avoiding milk intake but if milk can not be avoided lengthen the intake of milk and
drug as much as possible.

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