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It is developed in concordance with the standard treatment guidelines keeping in mind the healthcare needs of the majority of the population paroxetine 10 mg without a prescription. Careful selection of a limited range of essential medicines results in a higher quality of care order paroxetine 10 mg line, better management of medicines and more cost-effective use of health resources discount paroxetine 10 mg amex. The list of essential medicines guides the hospital drug policies, procurement and supply of medicines in public sector, medicine cost reimbursement and medicine donations. The list serves as a reference document for correct dosage form and strength for prescribing. Preference is given to single drug formulations as opposed to fixed dose combinations where appropriate. Such rational use of medicines, especially antimicrobial drugs, reduces development of drug resistance. The list also serves as a reference for assessing the healthcare access of the populace. Melphalan T Tablet 2 mg, 5 mg Tablet 50 mg Mercaptopurine T Injection 100 mg / ml Tablet 2. P) Dilute 34 ml of Formaldehyde formaldehyde solution P, S, T Solution Solution with water to produce 100 ml (As per I. P) Glutaraldehyde S,T Solution 2% Potassium P, S, T Crystals for solution Permanganate Page 58 of 123 Section: 16 –Diuretics Route of Administration/ Medicines Category Strengths Dosage Form Injection 10 mg/ ml Furosemide P,S,T Tablets 40mg Hydrochlorothia 25 mg, P,S,T Tablets zide 50 mg Mannitol P,S,T Injection 10%, 20% Spironolactone P,S,T Tablets 25 mg Page 59 of 123 Section: 17 – Gastrointestinal medicines 17. Colchicin Page 77 of 123 Alphabetical List of Medicines – Therapeutic area wise 5. Desferrioxamine mesylate Page 78 of 123 Alphabetical List of Medicines – Therapeutic area wise 5. Amphotericin B Page 79 of 123 Alphabetical List of Medicines – Therapeutic area wise 7. Fluconazole Page 80 of 123 Alphabetical List of Medicines – Therapeutic area wise 32. Sodium Stibogluconate Page 81 of 123 Alphabetical List of Medicines – Therapeutic area wise 57. Cyclophosphamide Page 82 of 123 Alphabetical List of Medicines – Therapeutic area wise 12. Procarbazine Page 83 of 123 Alphabetical List of Medicines – Therapeutic area wise 37. Losartan Potassium Page 85 of 123 Alphabetical List of Medicines – Therapeutic area wise 20. Anti-D immunoglobin (human) Page 89 of 123 Alphabetical List of Medicines – Therapeutic area wise 2. Gentamicin Page 90 of 123 Alphabetical List of Medicines – Therapeutic area wise 7. Chlorpromazine hydrochloride Page 91 of 123 Alphabetical List of Medicines – Therapeutic area wise 4. Artesunate (To be used only in combination with Sulfadoxine + Pyrimethamine) P,S,T 14. Zidovudine+ Lamivudine+ Nevirapine S,T Total Medicines under Category S,T - 106 1. Vincristine T Total Medicines Category P,S,T 181 Category S,T 106 Category T 61 Total 348 Page 123 of 123 . Surveys suggest that up to 1/4 of all prescriptions in palliative care come into this category. It is important for prescribers to understand that marketing authorization for drugs regulates the marketing activities of pharmaceutical companies, and not the prescriber’s clinical practice. Even so, off-label use does have implications for prescribers, and these are discussed in this section. The situation has become more complicated now that mixing two or more licensed drugs in a syringe for administration by continuous infusion is officially considered to produce an unlicensed preparation. However, such use in palliative care is often appropriate and will generally represent standard practice. New drugs will have relatively limited safety information and the pharmaceutical company is generally required to outline a risk management plan. Restrictions are imposed if evidence of safety and efficacy is unavailable in particular patient groups, e. The considerable expense of this, perhaps coupled with a small market for a new indication, often means that a revised application is not made. These prescriptions can be dispensed by pharmacists8 and administered by nurses or midwives. Current legislation on mixing does not extend to controlled drugs, although amendments are under consideration. Meanwhile, existing good practice arrangements should be followed in relation to mixing controlled drugs. It is possible to draw a hierarchy of degrees of reasonableness relating to off-label and unlicensed drug use (Figure 1). The more dangerous the medicine and the more flimsy the evidence the more difficult it is to justify its prescription. Thus, it is important that prescribers (or those authorizing treatment on their behalf) provide sufficient information to patients about the drug’s expected benefits and potential risks (undesirable effects, drug interactions, etc. For off-label prescribing, monitoring can be delegated to another doctor, but not if the drug is completely unlicensed. When current practice supports the use of a drug in this way, it may not be necessary to draw attention to the licence when recommending it. However, it is good practice to give as much information as patients or those authorizing treatment on their behalf, require or which they may see as significant. When patients, or their carers express concern, you should also explain in broad terms the reasons why the drug is not licensed for its proposed use. However, you must explain the reasons for prescribing a drug that is unlicensed or being used off-label when there is little research or other evidence of current practice to support its use, or when the use of the drug is innovative. In palliative care, off-label drug use is so widespread that concerns have been expressed that a detailed explanation on every occasion is impractical, would be burdensome for the patient and increase anxiety, and could result in the refusal of beneficial treatment. However, in situations where there is little evidence and limited clinical experience to support a drug’s off-label use, these figures change to 57% and 7% respectively. A position statement has also been produced by the Association for Palliative Medicine and the Pain Society (Box D). The licence (or marketing authorization) specifies the conditions and patient groups for which the medicine should be used, and how it should be given. In palliative care, medicines are commonly used for conditions or in ways that are not specified on the licence. Your doctor will use medicines beyond the licence only when there is research and experience to back up such use. Medicines used very successfully beyond the licence include some antidepressants and anti- epileptics (anti-seizure drugs) when given to relieve some types of pain. Also, instead of injecting into a vein or muscle, medicines are often given subcutaneously (under the skin) because this is more comfortable and convenient. The information needs of carers and other health professionals involved in the care of the patient should also be considered and met as appropriate. Anti-competitive strategies used by some drug manufacturers, such as “evergreening” and “product hopping,” restrict access to less costly, high-value generics and therapeutic alternatives. Health plans have developed a number of innovative strategies to address unsustainable increases in the prices of specialty drugs. Addressing these cost trends is critical to ensuring a sustainable health care system and achieving affordability for businesses and consumers. While some of these drugs have been groundbreaking in the treatment of cancer, rheumatoid arthritis, multiple sclerosis, and other chronic conditions, the cost of treating a patient with specialty drugs can exceed tens of thousands of dollars a year. The treatment regimen for some of the most expensive specialty drugs can cost $750,000 per year. Historically these drugs have targeted diseases affecting very small populations—sometimes as few as a thousand individuals nationally. But over time and with breakthroughs in the understanding of disease and clinical pathways, these drugs are now used to treat chronic conditions affecting tens of millions of patients.

Long-term results after operatively treated Achilles tendon rupture: fibrin glue versus suture discount paroxetine 10 mg mastercard. Isokinetic strength and strength endurance of the lower limb musculature ten years after achilles tendon repair order paroxetine 20mg amex. Long-term results after functional nonoperative treatment of achilles tendon rupture order paroxetine 10 mg fast delivery. Surgical repair followed by functional rehabilitation for acute and chronic achilles tendon injuries: excellent functional results, patient satisfaction and no reruptures. Repair of acute rupture of the Achilles tendon: a new technique using polyester tape without external splintage. Immediate, full weightbearing cast treatment of acute Achilles tendon ruptures: a long-term follow-up study. Acute achilles tendon rupture postoperative treatment with a below knee cast the ankle in neutral position compared to early restricted motion of the ankle. Elongation of the Achilles tendon after rupture repair occurred slightly less with postoperative early motion than with postoperative immobilization. Comparison of surgical and no surgical treatment of Achilles tendon rupture in athletes. Recovering motor performance of the foot after Achilles rupture repair: a randomized clinical study about early functional treatment vs. Partial rupture of the proximal Achilles tendon: a differential diagnostic problem in ultrasound imaging. Scripta Medica Facultatis Medicae Universitatis Brunensis Masarykianae 2006;79(2):75-84. Cumulative incidence of achilles tendon rupture and tendinopathy in male former elite athletes. Local flap coverage for soft tissue defects following open repair of Achilles tendon rupture. Prolonged thromboprophylaxis with dalteparin after surgical treatment of achilles tendon rupture: a randomized, placebo-controlled study. Optimizing Achilles tendon repair: effect of epitendinous suture augmentation on the strength of achilles tendon repairs. Reconstruction for neglected Achilles tendon rupture: the modified Bosworth technique. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a quantitative review. Favorable Outcome of Percutaneous Repair of Achilles Tendon Ruptures in the Elderly. Acute Achilles tendon rupture: minimally invasive surgery versus non operative treatment, with immediate full weight bearing. Acute Achilles tendon rupture: minimally invasive surgery versus nonoperative treatment with immediate full weightbearing--a randomized controlled trial. Early motion of the ankle after operative treatment of a rupture of the Achilles tendon. Separation of tendon ends after Achilles tendon repair: a prospective, randomized, multicenter study. Early mobilisation of operatively treated achilles tendon ruptures: 1 to 2 years follow-up [abstract]. The increasing incidence and difference in sex distribution of Achilles tendon rupture in Finland in 1987-1999. Ultrasonography in the differential diagnosis of Achilles tendon injuries and related disorders. Technique tip: a new technique for augmentation of repair of chronic Achilles tendon rupture. Residual functional problems after non- operative treatment of Achilles tendon rupture. Primary repair without augmentation for early neglected Achilles tendon ruptures in the recreational athlete. Operative treatment of acute Achilles tendon rupture: Open end-to-end-reconstruction versus reconstruction with Mitek-anchors. Use of fluroquinolone and risk of Achilles tendon rupture: A population-based cohort study. Comparison of functional ability following percutaneous and open surgical repairs of acutely ruptured Achilles tendons. The influence of early weight bearing compared with non-weight bearing after surgical repair of the Achilles tendon. Spontaneous atraumatic Achilles tendon rupture in healthy individuals: Biomechanical aspect. Loss of bone mineral of the hip and proximal tibia following rupture of the Achilles tendon. Operative versus conservative functional treatment of acute achilles tendon rupture. Achilles tendon rupture: rising incidence in New Zealand follows international trends. Increased risk of achilles tendon rupture with quinolone antibacterial use, especially in elderly patients taking oral corticosteroids. Nonoperative treatment of acute rupture of the achilles tendon: results of a new protocol and comparison with operative treatment. Quantitative review of operative and nonoperative management of achilles tendon ruptures. Bi-pedicled V-Y gastrocnemius myocutaneous flap for repairing Achilles tendon and overlying skin defect: The anatomic basis and clinical application. These guidelines are a working document that refects the state of the feld at the time of publication. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. Address correspondence to American Association of Clinical with endocrine and metabolic disorders. Many of the endocrinology training programs in the United States lack a dedicated nutrition 2. As a result, nutritional counseling and man- healthy eating for the prevention and treatment of meta- agement for our patients is often delegated to other health bolic and endocrine diseases in adults. Recommendations recently approved counseling for obesity, most overweight are assigned Grade levels based on the supporting clini- patients or patients with obesity, dyslipidemia, polycystic cal evidence and subjective factors. In addition, all primary writers are from this important component of health care. Recommendation grades are based • the relative scarcity and increased expense of on four intuitive levels: (grades A [strong], B [intermedi- healthy foods, ate], and C [weak]) or expert opinion when there is a lack • the easy accessibility, low cost, and palatability of of conclusive clinical evidence (grade D). There are also four intuitive levels quate and/or ineffective food policies, of evidence: 1 = strong, 2 = intermediate, 3 = weak, and • the perishability of foods, increased need for 4 = no evidence. Comments may be appended to recom- preservatives, and decreased awareness of food mendations regarding relevant subjective factors that may safety, have infuenced the grading process. The consensus level • the variability of nutrient-gene interactions of experts for each recommendation may also be explicitly (nutrigenomics and nutrigenetics), and provided in appropriate instances. Thus, the process lead- • transcultural factors, including religious, social, ing to a fnal recommendation and grade is not dogmatic ethnic, and economic factors, as well as individ- but rather incorporates a complex expert integration of ual food preferences, culinary styles, and belief objective and subjective factors meant to refect optimal systems. Essential macronutrients and micronutrients, (15 to 35% of calories depending on total intake) fber, and water should be provided by well-cho- can replace a portion of saturated fat and/or refned sen foods and beverages that can be enjoyed and carbohydrates in the meal plan to help improve constitute a healthy eating pattern. The weight-loss goal for overweight or obese patients with vitamin B12 defciency can gener- patients is 5 to 10% of current body weight over ally be treated with oral vitamin B12 (1,000 μg per the ensuing 6 to 12 months. When subjective factors have a strong impact, then recommendation grades may be adjusted up (“positive” impact) or down (“negative” impact). Sustained behavior modifcation must be the use of dietary supplements to meet nutrient achieved for long-term success with weight man- requirements should be implemented (Grade D, agement. When frst treating a patient with over- nutritional supplementation and medical moni- weight or obesity, emphasis should be placed on toring for complications, including electrolyte 8 Clinical Practice Guidelines for Healthy Eating, Endocr Pract. What Nutritional Recommendations are weight is recommended to prevent and treat hyper- Appropriate for Cardiovascular Health?

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Therefore cheap paroxetine 40 mg visa, test results must be read only within the time specified by the manufacturer order paroxetine 30mg with visa. C T Negative Results: One line ‘C’ appears in the result window Positive Results: P purchase paroxetine 10 mg without prescription. Test is positive even if the test line is faint Invalid Results: No ‘C’ line appears in the results window. This means that, in patients with suspected malaria, a confirmed diagnosis is recommended, wherever possible, before giving anti-malaria treatment. On the basis of clinical judgement, these patients may be treated for malaria in addition to any other cause of fever. Treatment failure may be due to drug resistance, poor adherence to treatment, poor quality of drugs, unusual pharmacokinetic properties in that individual, or misdiagnosis. The development of malarial symptoms and signs 28 days or more after the initiation of malaria therapy is considered as indicative of a new infection, and requires appropriate investigation. In all patients with suspected severe/complicated malaria with or without fever or history of fever, the use of a confirmatory blood slide is recommended, so that parasitaemia can be quantified. Note that, high parasitaemia is not always present in severe disease and initial blood slide examination may be negative. When effective malaria prevention strategies are in place, the number of children with fever due to malaria may markedly reduce. This information will be used to determine the need for change in national diagnostic guidelines. In patients with non-severe symptoms and signs, anti-malaria treatment may be withheld if the diagnostic test is negative, and the patient carefully observed. In patients with severe symptoms and signs, anti-malaria treatment should be offered if the malaria test results are negative, and repeat blood film examination is recommended to confirm the diagnosis. Although clinicians may treat patients for malaria even if the test results are negative, they must note that, in all cases, fever may have another cause. Apart from preventive measures, early diagnosis and complete treatment are the important modalities that have been adopted to contain the disease. In view of widespread chloroquine resistance in Plasmodium falciparum infection, and other recent developments, the national policy has been revised to meet these challenges. These guidelines are the collaborative effort of National Vector Borne Disease Control Programme, National Institute of Malaria Research and experts from different parts of the country. The aim of this endeavour is to guide the medical professionals on the current methods of diagnosis and treatment based on the national drug policy (2008). This manual deals with the treatment of uncomplicated malaria and specific antimalarials for severe disease. The general management should be carried out according to the clinical condition of the patient and judgement of the treating physician. The warning signs of severe malaria have been listed so as to recognize the condition and give the initial treatment correctly before referring them to a higher facility. It is hoped that these guidelines will be useful for doctors involved in the management of malaria. Prompt and effective treatment is also important for controlling the transmission of malaria. The continued treatment of such cases with chloroquine is probably one of the factors responsible for increased proportion of P. A revised National Drug Policy on Malaria has been adopted by the Ministry of Health and Family Welfare in 2008 and these guidelines have therefore been prepared for clinicians involved in the treatment of malaria. The fever is often accompanied by headache, myalgia, arthralgia, anorexia, nausea and vomiting. The symptoms of malaria can be non-specific and mimic other diseases like viral infections, enteric fever etc. Malaria should be suspected in patients residing in endemic areas and presenting with above symptoms. It should also be suspected in those patients who have recently visited an endemic area. The user’s manual should always be read properly and instructions followed meticulously. It is the responsibility of the clinician or technician doing a rapid test for malaria to ensure that the kit is within its expiry date and has been transported and stored under recommended conditions. Early diagnosis and treatment of cases of malaria aims at: • Complete cure • Prevention of progression of uncomplicated malaria to severe disease • Prevention of deaths • Interruption of transmission • Minimizing risk of selection and spread of drug resistant parasites. Patient should be advised to stop primaquine immediately if he develops symptoms like dark coloured urine, yellow conjunctiva, bluish discolouration of lips, abdominal pain, nausea, vomiting etc. Presently, Artemether + Lumefantrine fixed dose combination and blister pack of artesunate + mefloquine are also available in the country. Artemisinin derivatives must never be administered as monotherapy for uncomplicated malaria. These rapidly acting drugs, if used alone, can lead to development of parasite resistance. If a slide result is obtained later, the treatment should be adjusted according to species. The algorithm for diagnosis and treatment is as follows: Where microscopy result is available within 24 hours Clinically suspected malaria case Take slide for microscopy P. Microscopic evidence may be negative for asexual parasites in patients with severe infections due to sequestration and partial treatment. However, if the symptoms clearly point to severe malaria and there is no alternative explanation, such a case should be treated accordingly. Loading dose of 20 mg/kg should not be given, if the patient has already received quinine. If parenteral quinine therapy needs to be continued beyond 48 hours, dose should be reduced to 7 mg/kg 8 hourly. Note: • Once the patient can take oral therapy, the further follow-up treatment should be as below: n Patients receiving parenteral quinine should be treated with oral quinine 10 mg/kg three times a day to complete a course of 7 days, along with doxycycline 3 mg/kg per day for 7 days. However, if quinine is not available, artemisinin derivatives may be given to save the life of mother. In recent years, increased attention has been drawn to severe malaria caused by P. Some cases have been reported in India, and there is reason to fear that this problem will become more common in the coming years. Chemoprophylaxis Chemoprophylaxis is recommended for travellers, migrant labourers and military personnel exposed to malaria in highly endemic areas. Use of personal protection measures like insecticide-treated bednets should be encouraged for pregnant women and other vulnerable populations. The drug should be started 2 days before travel and continued for 4 weeks after leaving the malarious area. Note: Doxycycline is contraindicated in pregnant women and children less than 8 years. Note: Mefloquine is contraindicated in cases with history of convulsions, neuropsychiatric problems and cardiac conditions. Recommended reading Malaria in India and guidelines for its control including case management Website of National Vector Borne Disease Control Programme http://www. Anup Anvikar, Scientist D National Institute of Malaria Research, Delhi e-mail: anvikar@rediffmail. Usha Arora, Deputy Director National Vector Borne Disease Control Programme, Delhi e-mail: uarora2006@yahoo. Dhillon, Director National Vector Borne Disease Control Programme, Delhi e-mail: drgpsdhillon@hotmail. Dua, Officer-in-Charge National Institute of Malaria Research, Delhi e-mail: vkdua51@gmail. Sanjib Mohanty, Joint Director Ispat General Hospital, Rourkela e-mail: sanjibmalaria@rediffmail. Sonal, Joint Director National Vector Borne Disease Control Programme, Delhi e-mail: gssnvbdcp@gmail. Neena Valecha, Scientist F National Institute of Malaria Research, Delhi e-mail: neenavalecha@gmail. Neena Valecha Scientist F National Institute of Malaria Research Sector 8, Dwarka New Delhi – 110 077 E-mail: neenavalecha@gmail. Children under five years of age and pregnant women are at risk of serious illness, but malaria affects all levels of society. The Ministry of Health (MoH) is absolutely dedicated to ensuring that this disease is addressed at all levels and on all fronts.

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Patch and may manifest as acute urticaria paroxetine 10 mg without a prescription, angio-oedema and ana- test with proton pump inhibitors at 10–50% of the drug in phylaxis (58) discount paroxetine 20mg fast delivery. Although very rare paroxetine 30 mg discount, vaccine components, that petrolatum is nonirritant (moderate/weak). In individuals with a history of serious systemic tests have been described in some case reports. Patch tests reaction to egg and the vaccine needed by the patient is with calcium channels blockers and beta-blockers of 1–30% derived by yolk sac culture (e. Discussion Skin tests have the potential to locally reproduce in vivo an Additives IgE-mediated or T-cell-mediated drug allergy. Interpreted in Several cases of anaphylaxis to additives such as polysorbate the clinical context, skin tests using nonirritant drug concen- 80, carboxymethylcellulose and macrogols/polyethylene gly- trations can confirm or exclude the diagnosis of drug allergy. Although uncommon, hypersensi- In vitro laboratory tests may not be available, restricted in tivity should be considered, if a patient shows reaction to repertoire, not well validated or of research nature. Drug different unrelated drugs containing the same additive (high/ provocation tests are time-consuming, associated with appre- strong). However, we have by 10 mg/ml carboxymethylcellulose have been reported to be consensus been able to agree and recommend test concentra- nonirritant (weak/low). Published by John Wiley & Sons Ltd 709 Skin test concentrations for drugs Brockow et al. Table 4 Drugs for which the value of skin tests has not adequately skin tests, drug allergy cannot be excluded and a drug provo- been demonstrated cation test has to be considered. Hormones, corticosteroids and insulins In addition to standardizing skin test concentration, there Nonbetalactam antibiotics is a need to be able to reproduce test results not only in a Nonplatinum chemotherapeutics single but amongst different centres. Other published techniques and protocols are For many drugs, where the literature is confined to small available in the online Table S1, for example, the multicentre case series, case reports, personal experience or nonexistent, French study on perioperative drugs (34). Studies are in pro- no specific recommendation is made or should be regarded gress in Europe to validate and further standardize the as tentative until further review. Drug reactions may be due to its establish nonirritant test concentration and determine test metabolites, and testing using drug metabolites should be an sensitivity and specificity. The recommendations will need Skin prick test is relatively simple to perform and shows regular review and standardization. In specialized centres, we acceptable specificity for most of the reviewed drugs with the recommend testing all patients with a suggestive history of exception of drugs with irritant or histamine-releasing prop- drug allergy with the concentrations listed in Tables 1–3as erties such as quinolones and opioids (high/strong). Intradermal test has a high sensitiv- ity, but also a higher risk of inducing irritant reactions and Author contributions false-positive results. When nonirritant concentrations are used, skin tests in Additional Supporting Information may be found in the drug hypersensitivity are generally characterized by a rela- online version of this article: tively low sensitivity and a high specificity (high/strong). Relevant literature data on reported skin test this review, we aimed to select skin test concentrations with concentrations to systemically applied drugs with information the highest possible specificity (>95%) and thus a high posi- on the test preparation, number of patients and controls, test tive predictive value. Update dures in the diagnosis of drug hypersensitiv- interest group on drug hypersensitivity. Reducing the risk of anaphylaxis dur- Non-immediate reactions to beta-lactams: nol 2011;128:366–373. Management of hypersensitivity reactions to Diagnostic evaluation of a large group of Allergy 2011;66:955–960. Danish anaesthesia allergy centre – tion, diagnosis and management: review of diagnosis of beta-lactam hypersensitivity. J Allergy Clin Immunol quality of evidence and strength of recom- Pharm Des 2006;12:3313–3326. Immediate hypersensitivity to quinol- the patient with a history of local anesthetic Bircher A. Nonir- allergic reactions to dipyrone: value of baso- specificity for protamine allergy. Anesth ritating concentration for skin testing with phil activation test in the identification of Analg 1996;82:386–389. Macias E, Ruiz A, Moreno E, Laffond E, dictive value of skin tests in investigating Diagnosing nonimmediate reactions to ceph- Davila I, Lorente F. J Allergy Clin Immunol mal test and patch test in the diagnosis of Contact Dermatitis 2004;50:359–366. Anaphylaxis to dyes during the peri- of minor determinants of amoxicillin in the oral provocation. Contact allergy and respiratory/muco- ity syndrome: cross-reactivity with tricyclic value of including amoxicillin as a determi- sal complaints from heroin (diacetylmorphine). General- hypersensitivity: flare-up reactions, cross- anic acid can be the component in amoxicil- ized dermatitis due to codeine. Utility of patch testing in patients with Allergy 68 (2013) 702–712 © 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 711 Skin test concentrations for drugs Brockow et al. Cutaneous project: the diversity of diagnostic proce- corticosteroids in a series of 315 patients: adverse drug reactions caused by delayed dures for drug allergy around Europe. D19380 Access to medicines for multiple sclerosis February 2014 Charles River Associates Table of contents Executive Summary. The symptoms vary from patient to patient but include fatigue, vision problems, difficulties walking or speaking, memory problems and depression. The symptoms often appear periodically – known as relapses – which may last for a few hours, or many months. This looked at available evidence on prevalence, the costs to society and difference in access across European countries and discussed the determinants of patient access. The result of this is that whereas Kobelt found a range of 6% to 58% for the set of countries, we find a range from 13% to 69% as illustrated in Figure 1. In some countries, studies exist that have looked at the level of access for different sub-populations. Final Report Page 4 Access to medicines for multiple sclerosis February 2014 Charles River Associates Another picture emerges if we look at the composition of the products being used. There are significant differences between European countries in terms of access to innovative treatments when we compare existing first line treatments to more recent second line treatments (Natalizumab & Fingolimod)2. Scandinavian countries provide better access to innovative second line treatments in Europe (Norway 39%, Sweden 31. Access to a neurologist is seen as particularly problematic in some member states. More broadly, there is also considerable variation in specialised neurology and neurological rehabilitation services. In addition to assisting in the management of the disease, nurses are also important as they encourage the use of new treatments. We have also reviewed the clinical guidelines that have been used in different European member states. Although there are differences in clinical guidelines, these do not seem to explain much of the variation. There are, however some countries (such as the Czech Republic) with low access and restrictive guidelines where this appears an important barrier to access. Final Report Page 5 Access to medicines for multiple sclerosis February 2014 Charles River Associates Although in most countries all first line products are reimbursed, there are restrictions imposed on the use of the medicines. The biggest impact appears to be in the delays that these reimbursement restrictions cause to patient access. We would expect that countries with a higher income pay higher prices, but access could depend on the affordability of medicines (and associated medical costs). In terms of affordability, we do find a relationship between affordability and improved access. These are seen as key tools in disease management, allowing disease characteristics in 3 Nine O’Clock (2013), “6000 to 8000 Romanians diagnosed with multiple sclerosis”, available at http://www. Addressing this requires greater investment in healthcare infrastructure devoted to treating and managing the disease. It is also important that clinical guidelines are kept up to date and more importantly that they are actually used in practice.

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