Background/Purpose:

African countries with a low Human Development Index (LHDI) based on life expectancy, education and income per capita, face competing social, economic, health and poverty related issues that distract from the treatment of chronic conditions such as Rheumatoid Arthritis (RA). Methotrexate (MTX) is standard of care for RA and used for other rheumatic diseases. We sought to determine MTX availability and MTX dispensing practices of pharmacy providers (PP) in Ethiopia, an LHDI country, in order to inform the development of culturally appropriate guidelines for using MTX to treat rheumatic diseases.

Methods:

The Ecumenical Pharmaceutical Network and the Ethiopian Catholic – Social and Development commission (ECC-SDCO) is the second largest health institution in Ethiopia (next to the public health system) and oversees 83 health institutions of which 52 have a pharmacy department (includes 4 hospitals, 16 health centers and 32 clinics). In September 2016, PP attending the Essentials of Pharmacy Practice course provided by ECC-SDCO were invited to participate in an anonymous survey regarding their experience with dispensing MTX for the treatment of rheumatic conditions. We also conducted a 45 minute semi-structured interview for pharmacists serving the country’s sole public rheumatology clinic in Ethiopia. Descriptive statistics are reported from the survey and interview notes.

Results:

Twenty-three PP (18 pharmacy technicians; 5 pharmacists) from hospitals and health centers of 9 regional states and 2 chartered cities of Ethiopia completed the survey (18/23 were located outside Addis). Seven (32%) worked in a hospital based pharmacy, 12 (55%) in a health centre pharmacy and 3 (14%) in other areas (i.e. clinic pharmacy). The number of years of practice (median (range)) was less for pharmacy technicians compared to pharmacists (4 (1-8) vs 10(6-15) p<0.0001). Methotrexate was available in only 3/23 pharmacies (2 were hospital pharmacies) and was only available as oral tablets. Five PP reported that MTX was available in the hospital pharmacy of their region. Only 2/23 PP had dispensed MTX and in both cases it was not for rheumatic conditions. Only 3(13%) PP reported feeling comfortable educating patients on how to take methotrexate, (2 had counseled on MTX, 1 had not, 1 counselled but without confidence). Counselling included need for blood work (n=3), folic acid (n=3) and alcohol intake (n=1). No PP counselled on contraception. While interviewed pharmacists were confident regarding counselling patients on MTX, contraception was not consistently discussed. Additional barriers to prescribing MTX identified by interviewed PP included inconsistent supply and prioritizing use of MTX for non-rheumatologic conditions.

Conclusion:

Bridging the gap of RA treatment between developed and emerging countries is both a need and a responsibility. The survey and interview identified two key aspects limiting the use of MTX in Ethiopia: a) availability of the drug in pharmacies, and b) confidence of designated pharmacists in supplying and counseling patients for methotrexate. Improved MTX access and recommendations for counselling are needed to increase the confidence of pharmacists in dispensing MTX.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/barriers-to-the-use-of-methotrexate-in-ethiopia-survey-of-pharmacy-providers/