Endocrinology & Metabolic Syndrome
Open Access

Drug Therapy Problems and Determinants among Ambulatory Type 2 Diabetes Mellitus Patients: Pharmacists’ Intervention in South-East Ethiopia

Author info »

Introduction

Diabetes mellitus is a serious, chronic metabolic disorders that characterized by high sugar level either when the pancreas does not produce enough insulin, or when the body cannot effectively use insulin [1]. Type 2 diabetes mellitus (T2DM) accounts about 90% of all diagnosed cases of diabetes among adults [2].

The prevalence of diabetes mellitus (DM) is 8.8% globally and 7.1% in Africa region among the adult population. It has been gradually increasing for the past three decades and is growing most rapidly in low and middle-income countries [3,4].

The four major groups of antidiabetic agents are: Biguanides which reduce gluconeogenesis in the liver include metformin, Insulin secretagogues which stimulate the pancreas to secrete insulin such as sulfonylureas, Insulin sensitizers which improve sensitivity of peripheral tissues to insulin such as thiazolidinediones and Insulin analogues which provide insulin exogenously [2].

In the absence of contraindication metformin is the first and most widely used pharmacological treatment. It lowers blood sugar levels and help to reduce cardiovascular risk without increased risk of hypoglycaemia and weight gain [5,6].

Cardiovascular risk preventives (statins, antiplatelets) and antihypertensive agents significantly improve the outcome of T2DM. Rennin angiotensin aldosterone system blockers are encouraged to control blood pressure in DM patients with proteinuria or microalbuminuria [7].

Pharmacotherapy has a potential to delay onset of diabetes and its complication, despite these medications are available for the management of diabetes often goal not achieved, because of a failure of to initiate, to stick with a therapy [8].

Drug therapy problem(DTP) is any undesirable event experienced by a patient that involves, or is suspected to involve, drug therapy, and that interferes with achieving the desired goals of therapy and requires professional judgment to resolve [9]. Drug therapy problems(DTPs) may arise at all stages of the medication process from prescription to follow up of the treatment [10].

About fourteen different classifications on DTPs were found published with a different focus. To date there is no consensus and uniform methods of classification of DTPs [11,12]. However, according to Robert J. Cipolle all DTPs can be categorized in to seven types. These are needs additional drug therapy, unnecessary drug therapy, dose too low, ineffective drug therapy, dose too high, adverse drug reaction and non-compliance [13].

Drug therapy problems are significant public health problems worldwide and have been significantly increased over the past few decades [14]. It was estimated that around 5–10% of hospital admissions were due to drug related problems, in which 50% of them are avoidable [15,16]. Approximately 25% of patient’s drug related hospitalizations in Canadian hospital over 70% of these causes were preventable [17]. Each year in Australia, medicationrelated problems account for an estimated 140,000 admissions to hospital annually and an estimated annual economic burden of $380 million [18].

Drug therapy problem in T2DM is one of the factors which affect the outcome of therapy and safety medical care. It is a clinical problem, unless intervention done on the spot of the problems occurrence and it must be identified and resolved in a manner similar to other clinical problems [14]. DTP in diabetes mellitus patients cannot be resolved or prevented unless the cause of the problem is clearly understood [19].

Objective

• To assess the prevalence of drug therapy problems among T2DM patients at ambulatory follow up clinic

• To determine clinical pharmacist’s intervention and the acceptance rate among T2DM patients attending ambulatory follow up clinic

• To identify determinants of drug therapy problems among T2DM patients at ambulatory clinic of the hospital.

Study Method and Population

Hospital based prospective cross sectional study was employed at the outpatient chronic illness follow up clinic in Madda Walabu University Goba Referral Hospital (MWUGRH) from April 1, 2017 to June 30, 2017. A total of 216 T2DM participants were included in the study.

Inclusion criteria

Type 2 diabetes mellitus

Patients who had received at least one antdiabetic drug

Patients who provided informed consent

Patients who were greater than 18 years’ old

Exclusion criteria

Patients with incomplete medical records

Critically ill patients

Study variables

Dependent variable

Drug therapy problems

Independent variable

Socio demographic characteristics, disease related variables, medication related variables

Data collection instrument and procedure

Data was collected by interviewing participants and reviewing patient medical records. Data was collected by two Pharmacists, two Nurses with bachelor degree and one master science in clinical pharmacy. Drug related problems were identified by evaluating the appropriateness of medication orders in terms of indication, dosage, safety and effectiveness. The existence of DTPs was identified using Ethiopian treatment guide line and ADA guidelines of DM treatment [1,20]. The identified DTPs were classified as unnecessary drug therapy, needs additional drug therapy, ineffective drug, dosage too low, adverse drug reaction, dosage too high and noncompliance.

The nurses involved in the vital sign measurement and data collection from the chart. The pharmacists were involved in identification of drug therapy problems and patient counselling for adherence. The master holder clinical pharmacist approved the identified problems and intervention was made by discussion with the responsible physician working in the outpatient clinic. The change made for pharmacist interventions were documented in patient chart.

Data quality management and analysis

The principal investigator had provided training to data collectors. Data was entered into Epi-Data version 4.0.2.101 and exported to the SPSS version 22 (SPSS Inc., Chicago, IL, USA) for analysis. Descriptive statistics was performed to determine the proportion of drug therapy problems by its category. Bivariate and multivariate logistic regression analysis were performed to identify determinants associated with DTPs. Statistical analyses were performed with a p value of less than 0.05 which is considered as significant.

Ethical consideration

Ethical clearance and approval of the study was obtained from Jimma University ethical review board, Institute of Health before starting the actual data collection. Subsequent permission was granted from MWUGRH to access data and interview patients. Each participant was asked to sign a written informed consent before data collection.

Operational definitions

Drug therapy problem: Any undesirable event experienced by a patient which involves, or is suspected to involve, drug therapy, and that interferes with achieving the desired goals of therapy [9].

Polypharmacy: When greater than or equal to 5 drugs are prescribed for the patient [21].

Glycaemic control: Regulation and maintenance blood glucose levels within normal ranges.

Good control: When the average FBS is 70-130 gm/dl, whereas >130 mg/dl is poor [20].

Intervention: When pharmaceutical care plan designed, communicated and the identified problems suggested to be solved

Pharmacist intervention: A recommendation suggested by clinical pharmacist for changing in the patients’ therapeutic management [22].

Accepted: When the suggested problems were recognized and solved.

Intervention accepted but not implemented: When the suggested problems were recognized, but the problems not solved during intervention.

Result

Socio-demographic characteristics of the study participants

A total of 216 participants were included in the study, of these more than half of them (52.8%) were males. The mean age of study participants was 57.07 ± 13.126 years with range of 30-96 years. About 25.9% of patients were overweight. Among the participants 81.5% were married. 29.6% of the participants had no formal education and 22.2% of them were farmers. Equal number of participant (94.9%) not used tobacco as well as not chews chat, but 9.7% of participants were alcohol drinkers (Table 1).

Table 1: Socio demographic characteristics of T2DM patients in Madda Walabu University Goba Referral Hospital South-East east Ethiopia,2017.

Disease related characteristics

More than half (63%) of participants had hospital admission and 38.4% had family history of diabetes mellitus. The mean duration of DM was 6.02 ± 4.879 years ranging from 1-27 year. Among participants 67.1% had at least one co-morbid disease. Complication was reported in 20.3% cases. From the participants’ poor glacemic control, uncontrolled blood pressure and dyslipedemia reported in 70.4%, 29.6% and 9.7% patients respectively (Table 2).

Table 2: Disease related variables among T2DM patients in Madda Walabu University Goba Referral Hospital South-East East Ethiopia, 2017.

Medication related characteristics

Among the participants, 25% had taken two medications and 24.5% participants received single medication. Of the total participants 24.1% taking more than or equal to five medications per day, the mean number of medication was 2.89 ± 1.6 and ranging from one to seven medications. Metformin with Glibenclamide were the most frequently prescribed antidiabetic medication (40.3%), insulin was the most frequent prescribed (27.8%) single medication. Out of patients received antihypertensive medication, 53.1% of them had on enalapril. Of the total participants 36% had received lipid lowering medication, simvastatin was the commonly prescribed lipid lowering medication (83.3%) and 35.6% patients received aspirin as antiplatelet. Among concurrently prescribed medications other than anti-diabetics, antihypertensive, statin and antiplatelet, GIT drugs were 21.4 % (Table 3).

Table 3: Medication related variables among T2DM patients in Madda Walabu University Goba Referral Hospital, South-East East Ethiopia, 2017.

Drug therapy problems

Among the participants, 88% had at least one drug therapy problem, with the mean number of 2.06 ± 0.861; the maximum numbers of DTPs were four but half of the participants (50%) had two DTPs. A total number of 446 DTPs were identified across the seven categories. Need additional drug therapy were the highest (50.2%), followed by non-compliance to medication (21.7%). Dose too low, ineffective drug therapy and adverse drug reaction accounted 12.3%, 6.3% and 5% respectively. Unnecessary drug therapy and Dose too high were the least involved categories of DTPs. 3.6% and 0.7% percent respectively (Figure 1).

Figure 1. Drug therapy problems among ambulatory T2DM patients at Madda Walabu University Goba Referral Hospital, 2017

Causes of drug therapy problems

Requirement of preventive drug therapy was the leading cause for needs additional drug category (65.5%) and lack of understanding of the instruction (37.1%) was the frequent causes of problems for non-compliance drug therapy problems (Table 4).

Table 4: Causes of DTPs among T2DM patients in Madda Walabu University Goba Referral Hospital, South-East East Ethiopia, 2017.

Medications involved as the cause of DTPs

For the total 446 causes of DTPs, different class of medicines involved 455 times. Of the mediation indicated for T2DM and co existing conditions statin and metformin were the most frequently involved as the cause of DTPs, 33.6% and 20% respectively. Glibenclamide was the single least involved drug as the cause of DTPs (7%). Other drugs than the group of antidiabetic, antihypertensive, cholesterol lowering and blood thinners were the least (4.3%) (Table 5).

Table 5: Common drugs involved in each category of DTPs among T2DM patients in Madda Walabu University Goba Referral Hospital, South-East East Ethiopia, 2017.

Pharmacists’ recommendations and interventions acceptance rate

Among the total 446 DTPs identified 94% intervention was done by pharmacists. The remaining (6%) of the identified DTPs were solved by the other health care teams before the intervention of the pharmacists. Half of the suggestions provided were addition of new drugs, followed by pharmaceutical counseling for adherence and dose adjustment 21.7% and 13% respectively (Figure 2). Of the interventions done for the problems, the acceptance rate was 72.6%, unknown status of acceptance 11.7% and not accepted for the interventions done were 15.7% (Table 6).

Figure 2. Frequent Interventions done among T2DM patients at Madda Walabu University Goba Referral Hospital, 2017.

Table 6: Intervention and acceptance rate of DTPs among T2DM patients in Madda Walabu University Goba Referral Hospital, South-East East Ethiopia, 2017.

Determinants associated with DTPs in logistic regressions

Even if five variables were associated with DTPs, only age group and hypertension were significant independent predictors on multivariable logistic regression analysis. Accordingly, it was found that the likely hood of having DTPs increases as the age of the patient increases. Patients with the age group of 46-59 years old were 3.5 times more likely to have DTPs [AOR, 3.537; 95% CI, 1.207-10.364; p=0.021], whereas those above 60 years old were 5.467 times more likely to have DTPs when compared to those less than 45 years old [AOR, 5.467; 95% CI, 1.599-18.693; p=0.007]. Similarly, patients with hypertensive disease were seven times more likely to experience drug therapy problems than their counter parts [AOR, 7.349; 95% CI, 2.020-26.735; p=0.002].

However, it also found that patients with medication greater than or equal to five were association to have DTPs, but not statistically significant [AOR, 1.306; 95% CI, 0.115-14.899; p=0.083] compared to those less than five medications per day (Table 7).

Table 7: Logistic regression analysis of the association between independent variables and DTPs among T2DM patients at South-East Ethiopia, 2017.

Discussion

Among the study participants, 88% encountered at least one or more drug therapy problems. From the seven categories, a total of 446 DTPs were identified. The result of this study is relatively similar with the Huri et al., studies (90.5% and 90%) which had at least one drug therapy problem [23,24]. Similarly, Rao et al., study of Australia sample (90%) of participants had drug therapy problems [25].

The result of this study is higher number of DTPs than Al-Taani et al. [26] 81.2%, Minnesota [25] 70% and Cipolle et al. [27] 84% had at least one DTPs. The difference might be due to these studies were done in multicentre setting, large sample population were used and Participants who received atleast two glycemic control drugs included. Participants included in this study were those who had atleast one antidiabetic drugs. Good glycemic control and for further prevention of diabetic related risks more than one drug might be required, for example participants on insulin only needs metformin additionally for synergetic and extra benefit. Likewise, in the study unit the comprensive pharmaceutical care was not implemented previously to minimise the existence of drug therapy problems. This contributes for higher DTPs in our setting.

On the other hand, the result of this study is lower than Ogbonna et al. [28] 94% and the study in Switzerland almost all (100%) participants had at least one DTPs [29]. The discrepancies exist that would be attributed to a retrospective study method was used and participants who had took four or more drug therapy were the inclusion criteria in the above studies: those patients receiving complex drug regimen vulnerable for the existence medication related problems and would have more DTPs. Study settings, study populations and drug therapy problems classification methods variations also had a cause for the discrepancy.

From the seven classes of DTPs, half percent (50.2%) were under need additional drug therapy category. This was in line with the study by Cipolle et al. [27] which reported needs additional drugs as the most frequent problem (33%) [27]. Similarly, the study done in Australia and Minnesota sample reported needs additional drug was the most frequent problems [25].

In the Minnesota sample 59% the cause for needs additional drug therapy were indicated to prevent the onset of new medical conditions, however in this study around two third (65.5%) from those needs additional drug therapy the cause was requirement of preventive drug therapy [25]. The variation could be due to the utilization of risk preventative drugs, like statin, anti-platelet, antihypertensive and optimum utilization of metformin for control of diabetes and cardiovascular risk prevention was low in the study setting.

The second most common drug therapy problem in this study was non-compliance accounting 27% of the total DTPs, which is nearly similar result with the study done in Nigeria (26.1%) had compliance problem [30]. Non adherence to medication helps to cause complication and poor glycemic control. Study done at Tripoli, medication adherence accounts (36.1%) for poor glycaemic control [31]. Unnecessary drug therapy (4.5%) and dose too high (0.8%) was the least frequently involved categories DTPs.

The most frequent prescribed drug was glibenclimade with metformin (40.3%) followed by insulin injection (27.8%). Unlike this Ogbonna et al., study and Onah et al. study in Nigeria, Metformin was the most commonly prescribed antidiabetics agent [28-30]. The discrepancy might be the utilization of metformin not optimized according to the guide line in the study setting. Among the class of medication involved in DTPs the premier was statin (33.6%) and metformin (20%) followed by antihypertensive (14.8%). This was related with the study done in Malaysia, this could be the use of statin for cardiovascular risk prevention not to the optimum and not based on the intensity of the statin [24]. Likewise, the use of antihypertensive per the guide line as recommended for the diabetes mellitus patients not well practiced.

Among the DTPs identified pharmacists’ intervention was done for 94%, the rest six percent of the problems were solved by the other health care team before pharmacist recommendation. This was nearly similar to the study done in Chua et al (87.3%) recommendations were done by pharmacists [32]. Likewise, study done in India, almost all interventions were addressed by clinical pharmacists [22].

The most frequent suggestion given in this study was addition of new medicine (50.2%), it was different from studies done by Shareef et al. [22] in which clinical pharmacist frequent suggestion were on cessation of drug (17.98%) and clinical pharmacist interventions in India, 25.17% of frequent suggestion were cessation of drug [33]. These studies were the same prospective study design but the variation was due to the sample population difference included in the study, in the above studies admitted T2DM participants were included in the study. Patients admitted in the ward might be exposed unnecessary drug and pharmacists’ suggestions for termination of the problems might be higher than participants in the outpatient setting. Ambulatory patients visit the clinic for refill of previous diagnosis; lack of further investigation during each facility visit patients might not receive the medication for new diagnosis as well as for the prophylaxis therapy.

The overall physicians’ acceptance rates for suggestions given was 72.6% of the total recommendations, 11.7% of the intervention unknown status of acceptance and intervention not accepted were 15.7%. This finding was virtually similar to Chua et al., study in which 77.9% of changes recommended by the pharmacists were accepted [32]. The result of this study higher than the study by Shareef et al. [22] which only 58.20% of the recommendations was accepted.

Likewise, the study done in India, the acceptance rate of suggestions and the changes in drug therapy was 52.38% [33]. The disagreement might be resulted from these two studies were undergone in ward patients, patients were at critical and unstable conditions the acceptance rate of regimen change might not be noticeable.

Age group and hypertension were remained as independent determinants of drug related problems on logistic regression. Accordingly, the likely hood of occurrence of DTPs was increasing as age of the respondent increases. Participants found within the age group of 45-59 years about three times more likely to have DTPs than those below 44 years old [AOR, 3.537; 95% CI, 1.207- 10.364; p=0.021], whereas the factor increased to five times for elderly patients age greater than 60 years [AOR, 5.467; 95% CI, 1.599-18.693; p=0.007]. Association of advanced age with DTPs has agreed with scientific ground as it results in multiple disease conditions requiring additional drug for the prophylaxis and being forgetfulness prone for poor adherence and to have DTPs. This finding was in line with a study done in Florida, and in Jordan, but the study done in Malaysia Correspondingly, prevalence of hypertension had independent predictor of DTPs with significance of p value<0.002 levels [23,34,35]. The likely hood to had DTPs was seven times higher than patients who did not had hypertension [AOR, 7.349; 95% CI, 2.020-26.735; p=0.002]. Different studies were reported hypertension was the most prevalent co-morbid condition responsible DTPs [24-27]. This might be due to problem of selecting antihypertensive drug compiling to diabetes mellitus to the optimum dose, complex drug taking schedule which contribute non-compliance, adverse effect and cardiovascular risk that necessitate need of additional drug therapy which collectively result in increasing the chance of DTPs occurrence.

The major limitation of this study was, it is limited by chance of recall bias in adherence assessment as it was based on respondent’s self-report, missing of some data by chart review and lack of adequate organ function tests, only one study center and short study period of time had some of the limitations.

Conclusion

This study showed that majority of type 2 diabetes mellitus included in the study had at least one drug related problem showing optimal medication management in type 2 diabetes mellitus patients was a major challenge in clinical practice. Metformin with glibenclimide was the frequent prescribed drug for the participants. Need additional drug therapy due to underutilization of statin, metformin and antihypertensive for optimum utilization and cardiovascular risk prevention, the health care team working in DM clinic should be optimized underutilized medicines based on the guide line. Noncompliance and dose too low were the most common categories of drug related problems identified. Advanced age and hypertensive co morbidity were independently determining the occurrence of drug therapy problems. The study highlights the impact of clinical pharmacist in multidisciplinary health care team, which demonstrated that pharmacist interventions resulted in greater improvements in many drug therapy problems to achieve diabetes mellitus treatment goal.

Competing Interests

The authors declared that they have no competing interests

Authors Contributions

The authors’ responsibilities were as follows. AM Participated in the design of the study, writing of results and discussion, performed the statistical analysis, drafting the manuscript and wrote the paper. TT performed analysis and interpretation of data as well as manuscript drafting. BB Participated in the design of the study, performed the statistical analysis and has been involved drafting of the manuscript. All authors read and approved the final manuscript.

Acknowledgements

The authors would like to thank Jimma University for approval of ethical clearance and technical and financial support for this study. The authors’ truthfully gratitude also go to, Madda Walabu University Goba Referral Hospital staffs, all data collectors and supervisors for actively participating during data collection and entire time.

References

1. Marathe PH, Gao HX, Close KL. American Diabetes Association Standards of Medical Care in Diabetes. J Diabetes. 2017;40(1):1-142.
2. Kaul K, Tarr JM, Ahmad SI, Kohner EM, Chibber R. Introduction to diabetes mellitus. Adv Exp Med Biol. 2012; 771:1-11.
3. Dunning T, Sinclair A, Colagiuri S. New International Diabetes Federation (IDF) Guideline for managing type 2 diabetes in older people. Diabetes Res Clin Pract. 2014;103(3):538-540.
4. Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M, et al. Management of hyperglycaemia in type 2 diabetes, 2015: a patient-centred approach. Update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetologia. 2015;58(3):429-442.
5. Marín-Peñalver JJ, Martín-Timón I, Sevillano-Collantes C, del Cañizo-Gómez FJ. Update on the treatment of type 2 diabetes mellitus. World J Diabetes. 2016;7(17):354-395.
6. Paneni F. 2013 ESC/EASD guidelines on the management of diabetes and cardiovascular disease: Established knowledge and evidence gaps. Diab Vasc Dis Res. 2014;11(1):5-10.
7. Samson SL, Garber AJ. Prevention of type 2 Diabetes Mellitus: Potential of pharmacological agents. Best Pract Res Clin Endocrinol Metab. 2016;30(3):357-371.
8. Cipolle RJ, Strand LM, Morley PC. Pharmaceutical care practice: the patient-centered approach to medication management: McGraw-Hill Medical New York; 2012;pp:1093–1097.
9. Dahal P, Venkataraman R, Fuloria PC. Assessment of clinical pharmacist intervention in tertiary care teaching hospital of Southern India. Asian J Pharm Clin Res. 2013;6(2):258-61.
10. Adusumilli P, Adepu R. Drug Related Problems: An Over View of Various Classification Systems. Asian J Pharm Clin Res. 2014;7(4):7-10.
11. van Mil JF, Westerlund LT, Hersberger KE, Schaefer MA. Drug-related problem classification systems. Annals of pharmacotherapy. Ann Pharmacother 2004;38(5):859-67.
12. Cipolle R, Strand L, Morley PC. Drug therapy problems. Pharmaceutical Care Practice: The Clinician’s Guide. 2012;2.
13. Gangwar SS, Monisha N, Nachiya J, Narasingarao K, Parimalakrishnan S, Singh SP. Impact of medication and psychological behaviour assessment by community pharmacists in type 2 diabetes mellitus patients after hospital stay. Afr Health Sci. 2014;14(3):539-550.
14. Nivya K, Kiran VSS, Ragoo N, Jayaprakash B, Sekhar MS. Systemic review on drug related hospital admissions–A pubmed based search. Saudi Pharm J. 2015;23(1):1-8.
15. Somers A, Robays H, Vander Stichele R, Van Maele G, Bogaert M, Petrovic M. Contribution of drug related problems to hospital admission in the elderly. J Nutr Health Aging. 2010;14(6):477-482.
16. Samoy LJ, Zed PJ, Wilbur K, Balen RM, Abu-Laban RB, Roberts M. Drug-Related Hospitalizations in a Tertiary Care Internal Medicine Service of a Canadian Hospital: A Prospective Study. Pharmacotherapy. 2006;26(11):1578-1586.
17. Platt C. Medication-related problems occurring in people with diabetes during an admission to an adult teaching hospital: A retrospective cohort study. Diabetes Res Clin Pract. 2012;97(2): 223-230.
18. Cipolle RJ, Strand LM, Morley PC. Pharmaceutical care practice: McGraw-Hill; 1998.
19. FMHACA. EthiopiaStandard Treatment Guidelines For General Hospital. 2014;pp:69-76.
20. Nobili A, Marengoni A, Tettamanti M, Salerno F, Pasina L, Franchi C, et al. Association between clusters of diseases and polypharmacy in hospitalized elderly patients: Results from the REPOSI study. Eur J Intern Med. 2011;22(6):597–602.
21. Shareef J, Fernandes J, Samaga L. Assessment of clinical pharmacist interventions in drug therapy in patients with diabetes mellitus in a tertiary care teaching hospital. Diabetes Metab Syndr. 2016;10(2):82-87.
22. Huri HZ, Ling LC. Drug-related problems in type 2 diabetes mellitus patients with dyslipidemia. BMC Public Health. 2013;13(1):1192.
23. Huri HZ, Wee HF. Drug related problems in type 2 diabetes patients with hypertension: a cross-sectional retrospective study. BMC Endocr Disord. 2013;13(1):2.
24. Rao D, Gilbert A, Strand LM, Cipolle RJ. Drug therapy problems found in ambulatory patient populations in Minnesota and South Australia. Pharm World Sci. 2007;29(6):647-654.
25. Al-Taani GM, Al-Azzam SI, Alzoubi KH, Elhajji FWD, Scott MG, Alfahel H, et al. Prediction of drug-related problems in diabetic outpatients in a number of hospitals, using a modelling approach. Drug Healthc Patient Saf. 2017;9:65-70.
26. Cipolle R, Strand L, Frakes M. Diabetes: co-morbidities and drug therapy problems in patients with diabetes. Medication Management Systems, Inc. 2013;pp:1-10.
27. Ogbonna B, Ezenduka CC, Opara C, Ahara LG. Drug Therapy Problems in Patients with Type-2 Diabetes in a Tertiary Hospital in Nigeria. International Journal of Innovative Research and Development. 2014;3(1).
28. Eichenberger PM, Haschke M, Lampert ML, Hersberger KE. Drug-related problems in diabetes and transplant patients: an observational study with home visits. Int J Clin Pharm. 2011;33(5):815-823.
29. Onah OP, Adamu S. Assessment of Drug Therapy Problems In Patients with Diabetes Melitus Type II In A Nigerian Tertiary Hospital. World Journal of Pharmaceutical Research. 2014;5(9):82-92.
30. Ashur ST, Shah SA, Bosseri S, Fah TS, Shamsuddin K. Glycaemic control status among type 2 diabetic patients and the role of their diabetes coping behaviours: a clinic-based study in Tripoli, Libya. Libyan J Med. 2016;11(1):31086.
31. Chua SS, Kok LC, Yusof FAM, Tang GH, Lee SWH, Efendie B, et al. Pharmaceutical care issues identified by pharmacists in patients with diabetes, hypertension or hyperlipidaemia in primary care settings. BMC Health Serv Res. 2012;12(1):388.
32. Shareef J, Fernandes J, Samaga L. Clinical Pharmacist Interventions in Drug Therapy in Patients with Diabetes Mellitus And Hypertension In A University Teaching Hospital. Int J pharm sci Res 2015;6(10):4424.
33. Bain KT, Weschules DJ, Tillotson P. Prevalence and predictors of medication-related problems. Pharmacotherapy. 2006;2:4.
34. AbuRuz SM, Bulatova NR, Yousef A-MM, Al-Ghazawi MA, Alawwa IA, Al-Saleh A. Comprehensive assessment of treatment related problems in hospitalized medicine patients in Jordan. Int J Clin Pharm. 2011;33(3):501-511.