E-DRUG: Compounding and dispensing problems in Indonesia

I am a pediatrician (gastrohepatologist) and since 2002 I have been working in  community health care, promoting the rational use of medicine, in particular in pediatrics.  I am concerned about overmedicalization in pediatric practice.  For upper respiratory tract infections, Indonesian pediatricians frequently prescribe an antibiotic plus a mixture of pseudoephedrin/ephedrin, antihistamin, mucolytic, triamnicolone, phenobarb, and other drugs (called "puyer", after the Dutch word for "powder").

The ingredients are put in a bowl, crushed and the resulting powder is divided into equal parts in small sachets (usually 15 sachets to be used over the course of 5 days). Some pediatricians add this "puyer" to a syrup (e.g. thyme syrup and even ranitidine or amoxycillin syrups)

One example of a puyer prescription:
A 15 month old girl with fever and coryza was given:

1. SYRUP: Bufect (Ibuprophen) 60 ml

2. PUYER:

• Nalgestan (PPA 15 mg, chlorpheniramine maletae 2 mg)
• Luminal (phenobarbitone) 50 mg - 6 tablet
• Mucohexin 8 mg - 10 tablet
• Kenacort (trianicolone) 4 mg - 10 tablet
• Codein 20 mg - 3 tab
• Lasal (salbutamol) 4 mg - 4 tablet
• Etaphylline 250 mg - 3 tablet
• Equal neo tablet refill

3. PUYER:

• Lapicef (cefadroxil) 500 mg/ capsul - 4 capsul
• Equal

4. PUYER:

• Curvit emulsion 175 ml

5. PUYER

• Pankreoflat - 10 tablet
• Cobazym 1000 mcg - 10 tablet
• Heptasan (cyproheptadine) - 10 tablet
• Lysagor (Pizotifen, here used as an appetite stimulant) - 10 tablet
• Equal

I am conducting two studies, of which the first one is finished and I am writing out the results. I found:

1. Poly pharmacy (median number of drugs per prescription for URIs is 5)
2. Overuse of antibiotics
3. Overuse of steroids (branded trianicolone)
4. Symptomatic prescribing
5. Prescriptions of supplements, herbal, multivitamin, "appetite stimulants"
6. Brand name prescribing

I have been trying to change this practice since 1996, but met with strong resistance from my colleagues who believe that a "puyer" is good for Indonesians. Other stated reasons are that the "puyer" is cheap.

I said that prescriptions for URI is very expensive; always more than a day wage
(in Indonesia medicines are mainly paid out of pocket). Second, does a child really
need so many medicines?

I have educated parents on rational use, giving the message to avoid "puyers".
We tell parents to count the number of lines in the prescription ... if more than two lines,
do not buy it: call us. However, many parents reported back that doctors became upset with them. Doctors said they are giving the best for the children by prescribing a "puyer."

In summary, despite my work to educate health consumers (mailing list, web, parenting classes, radio talk shows, publications, and studies of prescribing pattern, children continue to be given inappropriate "puyers".

I am finalizing my study report, and I am asked by my overseas colleagues to look for information on similar practices in other countries.
I want to ask you whether this practice exists in other countries; how providers can be convinced that such practice is not recommended; and what are the potential problems from a pharmacological and pharmacotherapeutic point of view?
I really need scientific bases to argue about such practice, and I hope you can help me.

Thanks,

Purnamawati Pujiarto (Wati)
Indonesia