Additional Information

Principles

The National Drug Policy makes provision for an Essential Drugs Program which is a key component in promoting rational medicines use.

The perspective adopted in the Adult Hospital Level Standard Treatment Guidelines (STGs) is that of a competent medical officer practicing in a public sector hospital. The STGs serve as a standard for practice, but do not replace sound clinical judgment. It is important to remember that the recommended treatments provided in this book are guidelines only and are based on the assumption that prescribers are competent to handle patients with the relevant conditions presenting to their facilities.

All reasonable steps have been taken to align the STGs with Department of Health guidelines that were available at the time of review. Each treatment guideline in the Adult Hospital Level STGs and Essential Medicines List (EML) has been designed as a progression in care from the current Primary Health Care (PHC) STGs and EML. A medicine is included or removed from the EML using an evidence based review of safety and effectiveness, followed by considerations of cost and other relevant practice factors. Where a referral to a tertiary facility is recommended, the relevant medicines have either been reviewed or included in the tertiary level EML, or is in the process of being reviewed. Given that the PHC STGs and EML are reviewed prior to the Adult Hospital Level STGs, there may be a period when the two STGs are not always perfectly aligned.

The dosing regimens provide the recommended doses used in usual circumstances. However, the prescribed dose should take into consideration drug-drug interactions and co-morbid states, notably renal or hepatic failure, critical illness, and morbid obesity.

It is anticipated that each Province will review the EML and prevailing tenders to compile a formulary which:

• Lists formulations and pack sizes that will facilitate care in alignment with the STGs.
• Selects the preferred member of the therapeutic class based on cost.
• Implements formulary restrictions consistent with the local environment.
• Provides information regarding the prices of medicines.

Therapeutic classes are designated in the “Medicine treatment” section of the STGs followed by an example such as, HMGCoA reductase inhibitors (statins) e.g. simvastatin. These therapeutic classes have been designated where none of the members of the class offer a significant benefit over the other registered members of the class. Always consult the local formulary to identify the example from the therapeutic class that has been approved for use in your facility.

Navigating the book

It is important that you become familiar with the contents and layout of the book in order to use the STGs effectively.

The International Classification of Diseases (ICD)-10 number has been included with the conditions to facilitate accurate recording of diagnoses. A brief description and diagnostic criteria are included to assist the medical officer to make a diagnosis. These guidelines also provide guidelines for referral of patients with more complex and uncommon conditions to tertiary facilities with the resources for further investigation and management.

The STGs are arranged into chapters according to the organ systems of the body. Conditions and medicines are cross referenced in two separate indexes of the book. In some therapeutic areas that are not easily amenable to the development of a STG, the section is limited to a list of medicines.

This edition of the Adult Hospital Level STG and EML provides additional information: a quick reference to dosing of antimicrobials for specific indications (Antimicrobial Medicines) and a section providing guidance on special considerations for specific medicines (Prescribing Information for Specific Medicines).

Furthermore, to promote transparency, in this fifth edition, revisions are accompanied by the level of evidence that is cited and hyperlinked accordingly. All evidence is graded according to the Strength Of Recommendation Taxonomy (SORT) (a patient-centered approach to grading evidence in the medical literature), described in detail on here.

The section on Patient Education in Chronic Conditions aims to assist health workers to improve patient adherence and health, generally.

Glossary

Medicines Safety

Provincial and local Pharmaceutical and Therapeutics Committees (PTCs) should develop medicines safety systems to obtain information regarding medication errors, prevalence and importance of adverse medicine events, interactions and medicines quality. These systems should not only support the regulatory pharmacovigilance plan, but should also provide pharmacoepidemiology data that will be required to inform future essential medicines decisions as well as local interventions to improve safety.

In accordance with the Medicines Control Council’s guidance on reporting adverse drug reactions in South Africa, the medical officer with the support of the PTC should report the relevant adverse reactions to the National Adverse Drug Event Monitoring Centre (NADEMC). To facilitate reporting a copy of the form and guidance on its use has been provided at the back of the book.

Feedback

Comments that aim to improve these treatment guidelines will be appreciated.

The submission form and guidelines for completing the form are included in the book. Motivations will only be accepted from the Provincial PTC.