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Risks of Self-Medication Practices
Risks of Self-Medication Practices
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Received : 09/17/2009
Revised : 10/14/2009
Accepted : 11/09/2009
ABSTRACT
1
INTRODUCTION
Self-medication involves the use of medicinal products by the patient to treat self-
recognized disorders or symptoms [1]. It also includes the selection of a medication for
a chronic or recurrent condition by the patient, after an initial diagnosis and prescription
products to family members, specially infants, children or the elderly [1] (see
medicinal products for conditions that are easily self-diagnosed or for recurrent
conditions that have been previously diagnosed by a physician [2]. World Health
Organization points out that responsible self-medication requires the medicinal product
to be supported with information describing how to take the medicine, possible side-
effects, monitoring, possible interactions, warnings, duration of use, etc. It should also
be noted that since herbal medicines are regulated as over-the-counter (OTC) medicinal
health food in most countries [3], the use of herbal medicines also constitutes a potential
case of responsible-self medication, provided that they are supported by the appropriate,
There are many individual and social benefits linked to self-medication practices
[1,4,5]. It facilitates prompt access to medication providing faster relief to the patient,
which is a particularly important issue in those countries with congested (private and/or
2
problematical. This is a very important argument in favor of self-medication when
delays in access to the medication could endanger the patient or jeopardize the efficacy
of the treatment (e.g. contraception pills or asthma treatments). Thus, easy access to
medication can also provide psychological support to chronic patients, reducing anxiety
related to the possibility of running out of medication and helping to develop self-
management of minor health conditions, which is in line with the modern ideal of a
medication saves scarce medical resources from being wasted in minor conditions;
public expenditure in health may then be redirected to more severe disorders. It also
helps better use of physicians’ and pharmacists’ skills. From an economic perspective,
disadvantage depending on the social scenario) and reduces absenteeism from work due
However, self-medication is also linked to several risks for the self-medicated patient
and, in some cases, for the community [1,4,5]. Many of these risks are not limited to
self-medication and may also occur in the prescription situation (although they are often
less likely if correct medical protocols are observed by the physician). Other risks
constitute particular dangers of the self-medication practice. Among the dangers of self-
health condition and consequent failure to seek medical advice promptly; rare but severe
adverse effects; failure to recognize contraindications and potential drug-drug and drug
3
–food interactions; incorrect route or manner of administration; inadequate dosage; risk
In this short review we will attend three of the most important dangers connected to
self-medication practices, namely: multiple drug use and risk of drug interactions; OTC
drug abuse and; misdiagnosis and incorrect choice of therapy. We will concentrate on
recent literature on these issues and we will discuss general and particular solutions to
these subjects.
A drug interaction is defined as the modification of the effect (therapeutic effect and/or
Because of several reasons of physiological nature, the elderly are particularly exposed
to potential drug interactions. Firstly, since a larger number of co-morbid conditions are
present in this age group, the number of medications taken by older persons tends to be
large (see figure 1) [9,10]. Secondly, reduced renal drug elimination, decreased hepatic
drug clearance, reduction of the body water content and increment of body fat content
make drug interactions more likely at old age [11]. As a result, adverse drug reactions
occur two to three times more frequently in patients over 65, and when taking 10
4
interaction [11,12,13]. As we may note in several of the studies cited below this
paragraph, OTC medications (including OTC herbal medicines and dietary supplements
containing herbal drugs) are frequently implicated in drug-drug interactions and tend to
increase the mean number of medications administered to old patients, raising the
Fig.1. The prevalence of one or more (DP ≥ 1) and five or more (DP ≥ 5) dispensed drugs
related to gender and age groups in Sweden, 2006. Note how the proportion of polymedicated
patients increases with age (graph taken from Hovstadius et al., 2009).
While observation of advice on package inserts and labels contributes to the safe use of
OTC medicines and even though labels and package inserts clearly refer potential drug
and food interactions and advise against long-term intake of OTC drugs, impairment of
elderly is an additional factor that makes this particular group vulnerable to adverse
interactions due to misinformation [9]. Furthermore, old people tend to have lower
general and health literacy skills, which increases the probability of an old person not
reading, understanding or remembering the advice of the label or insert [14-17]. Lay
5
beliefs about OTC medications can also influence the level of disclosure regarding OTC
drugs consumption between the patient and the physician. A cross-sectional study
American adults revealed that OTC medications are frequently wrongly regarded as too
weak to cause health problems [18]. Sleath et al. taped 414 primary care medical visits
and found out that only half the patients that had used OTC analgesics (the most used
OTC medications) 30 days before the visit reported it to the physician, while physicians
inquired about OTC medication consumption in only 37% of the visits [19]. The level
medicines can be expected to be similar or even lower [20-22], preventing the physician
measures. We may add that most of the studies cited here took place in developed
countries; the situation regarding polypharmacy1 in emergent countries, where drug use
the Universitary Hospital of the Catholic University at Brasilia (Brazil) [23]. From 218
1
There is no clear definition of polypharmacy or multiple medication. Depending on the author,
polypharmacy may be defined as the concomitant consumption of three, four, five or more drugs.
However, most of the current literature agrees that five is an adequate threshold value to refer
polypharmacy (see the work from Viktil et al., Br J Clin Pharmacol 2007; 63: 187-95).
6
gastrointestinal tract medications, vitamin or mineral supplements, cardiac medications
and antialergics. Potential severe drug-drug interactions were identified with the help of
WHO Model Formulary [24]. The potential risk of administering certain medications to
the elderly was assessed through Fick and collaborators’ update to Beers’ criteria [25-
26]. From 10 interactions found involving OTC medications; 5 were classified as highly
severe and 1 was classified as moderately severe. 9 of the drugs used in self-medication
Porto Alegre, Brazil [27]. The study comprised men and women aged 60 and more.
From a sample of 215 subjects, 33% admitted having consumed medications without
medical advice. The average number of medications taken per person was 3.2 (SD=2.5).
In another cross-sectional descriptive study involving 14 rural health settings and 143
immobile patients above 64 years old from the district of Guadalquivir, Spain, Gavilán
Moral et al. reviewed the medicine cabinet of the participants and inquired about the
origin of the prescription of each drug [28]. According to the patients’ reports, a very
low proportion (1.5%) of the medications found had not been prescribed by a physician
This is quiet lower than the rest of the studies analyzed here, but this difference might
be related with the fact that participants in this study were immobile and therefore their
autonomy was deeply diminished. A mean of 6.8 (SD=3.4) medications per patient was
criteria.
7
Yoon applied the Herbal Information Questionnaire developed by him to investigate
CAUSES SOLUTIONS
Fig.2. Causes of and some of the potential solutions to the increased probability of drug-drug
interactions due to consumption of OTC medications.
potential drug-drug interactions among 65 year old women residing in Florida [29].
From a total sample of 143 patients, he identified 58 women that reported concomitant
use of at least one herbal medication and at least one OTC or prescription drug. A mean
of 8.7 (SD=3.9) medications per patient was found. The mean number of prescription,
OTC and herbal medicines per patient were, in that order, 2.8 (SD=2.1), 3.7 (SD=2.0)
and 2.2 (SD=1.8). Note that according to this study, the mean number of OTC
8
medications consumed by those patients taking an herbal medication is quite above the
participants, 136 interactions were found. 52% (71) of those interactions involved OTC
drugs. 56 interactions were categorized high risk; from those, only 4 involved two
prescription drugs. These results seem to indicate that high risk interactions appear to be
more frequent, in the population studied, when self-medication is practiced. The general
percentage of identified interactions taking into account prescription, OTC and herbal
medications were also significantly higher than in previous studies that only considered
NSAIDs are a major concern among the elderly due to the higher incidence of severe
Neafsey et al. examined a sample of 51 adults aged 60 and older taking antihypertensive
medication and attending a blood pressure clinic [33]. Assessment of knowledge and
antihypertensives and OTC drugs and alcohol was performed to previously developed
and validated instruments [34]. The participants developed a rather low to moderate
performance in the tests: they obtained a mean of 2.0 points (SD=0.8) (40%) out of a 5
point scale in the self-efficacy test, while a mean of 43.1% (SD=15.4) was obtained in
between the performances in both tests, i.e. the participants that were more confident are
9
not those that attained the best scores in the knowledge tests. In other words, those who
think they had a better knowledge on interactions between alcohol and OTC
medications and antihypertensive medications are not the ones that actually have it. No
correlation was found between the performance in the knowledge test and the level of
education; apparently, the level of education is not necessarily correlated with health
literacy. Only 53% of the participants selected acetaminophen as the best analgesic for a
hypertensive patient and only 51% knew that administration of NSAIDs could raise
blood pressure. Only 25% manifested that an OTC analgesic could damage the kidney.
Barat et al. studied the consumption of drugs of 75-year old individuals living in their
homes in the municipality of Aarhus, Denmark [35]. 492 people participate in the study.
Subjects were interviewed at home and their drug storage was examined. Drug
interactions of major and moderate clinical significance were identified. 32.6% of the
total drugs stored corresponded to OTC medications. The mean number of medications
in use was 5.4 (range 1 to 24, SD not reported); the mean number of OTC agents in use
per person was 2.5 (range 1 to 16, SD not informed). The general practitioners were
these drugs unknown to the general practitioner were prescribed by another doctor and a
use of three or more drugs) and number of prescriptors (p=0.01). 72% of the
participants of the Barat et al study had OTC drugs and 40% were using alternative
medicines and dietary supplements. 113 potential drug interactions were found in 15.4%
of the subjects.
10
In a retrospective study on 833 patients over 64 years old discharged from home care
(returned to self-care or care of the family, or hospitalized), Flaherty et al. found a mean
of 6.6 (SD=3.9) and 5.7 (SD=3.4) drugs per patient (including both prescription and
respectively [36]. Five of the top 10 medications used by the participants were OTC
while it rose to 27% in the self-care/care of the family group (the criteria used to
geriatric pharmacology).
As a part of the Medical Research Council Cognitive Function and Ageing Study, Chen
Nottingham, Oxford) and two rural (Cambridgeshire, Gwynedd) centers in England and
North Wales [37]. 12489 people aged 65 and over were interviewed. The mean number
of drugs taken by participants 65-74 years old was 2.03 (SD=1.95); among the
participants ≥75 years old, the mean value was 2.47 (SD=2.02). Fairly consistent with
some of the reports previously described, the most frequently used drug categories were
drugs.
over (the first in 1990-91, N=1131; the second in 1998-99, N=1197) from the
municipality of Lieto, Finland [38]. The most commonly used medications were , again,
11
cardiovascular and central nervous system agents. The mean number of medications per
person increased from 3.1 (SD=2.8) to 3.8 (SD=3.1) during this period and
Table 1 summarizes some of the described reports. Some general conclusions may be
drawn from the reviewed literature. Due to physiological reasons, older adults are more
sensitive to drug-drug interactions. Simultaneously, due to the fact that old age is
polypharmacy is more common in this age group. The mean number of medications in
this age group ranges from 2 to 9, depending on the study and considering results from
different locations [9,27-29,35-40]. Many of the most used medications among the
elderly are OTC medications (including herbal medicines and dietary supplements).
OTC medications are frequently involved in sever drug-drug interactions. OTC NSAIDs
appear among the most frequently used medications among the elderly. These drugs,
alone or associated to other drugs and/or health conditions (hypertension, impaired renal
function) are well known to elicit severe adverse drug reactions such as gastrointestinal
physician on OTC and herbal drugs consumption prevents the physician from designing
Table 1. Summary of the reviewed studies on drug consumption among the elderly.
Average
Most consumed
Type of study number of
Authors Participants therapeutic
(instrument) medications per
categories
patient (SD)
Chagas Bortolon 218 women Cross-sectional Not reported Analgesics,
12
et al [23] from Brasilia (semi-structured gastrointestinal,
(Brazil), ≥60 personal survey) dietary
years old supplements,
cardiovascular,
antialergics
Analgesics,
215 men and
Cross-sectional gastrointestinal,
women from
(personal metabolics
Flores et al [27] Porto Alegre 3.2 (2.5)
structured (including dietary
(Brazil), ≥60
interview) supplements),
years old
cardiovascular
Cross-sectional
143 immobile
(reviewing of
men and women Analgesics,
medicine cabinet
Gavilán Moral et from antiacids,
and non- 6.8 (3.4)
al. [28] Guadalquivir antihypertensives,
structured
(Spain), ≥65 NSAIDs
personal
years old
interview)
58 women from
Florida (USA)
Data extracted
concomitantly
from two
consuming at
different cross-
least one herbal
Yoon [29] sectional studies 8.7 (3.9) Not reported
drug and one
(personal
OTC or
structured
prescription
interviews)
drug, 65 years
old
Cardiovascular,
492 men and Cross-sectional
central Nervous
women from (reviewing of
5.4 (not System,
Barat et al [35] Aarhus drug storage and
reported) gastrointestinal,
(Denmark), 75 personal
alternative
years old interview)
medicine
833 men and 6.6 (3.9) Cardiovascular,
women from (hospitalized analgesics,
Flaherty et al Missouri (USA) Retrospective patients) gastrointestinal
[36] discharged from chart review 5.7 (3.4) (self- (antiacids,
home care, ≥65 care/care of the laxatives), dietary
years old family) supplements
Cardiovascular,
12489 men and
central nervous
women from
Cross-sectional 2.03 (1.95) (≤ 74 system (includes
three urban and
(personal years old) non-narcotic
Chen et al [37] two rural centers
structured- 2.47 (2.02) (≥75 analgesics),
from England
interview) years old) gastrointestinal,
and Wales, ≥65
musculoskeletal,
years old
dietetic
1197 men and Cross-sectional
Cardiovascular,
Linjakumpu et al women from (personal
3.8 (3.1) central nervous
[38] Lieto (Findland), structured-
system
≥64 years old interview)
13
Several measures can be proposed to manage this problematic. Most authors agree that
educational interventions to either (or both) the patients and the health providers are one
of the best options to deal with the problematic of multiple medications [9,41-44]. In
light of the conclusions, it is fundamental to inform the patient that OTC status is not
pharmacists) is a key strategy to help designing rational and safe medication schemes.
should proactively inquire about OTC consumption, and they should also adopt an
open, receptive attitude towards the information shared by the patient (particularly,
possible should be prescribed to the patient, above all to the old patient, considering his
developed. Online systems providing 24-hour access to update medical records could be
improved management of older adults’ medication have been developed [45]; they
inappropriate prescribing. Finally, it has been suggested that the use of alternative
methods of information display in labels and package inserts could lead to more
2
This is not always true: depending on the country (or even the state) OTC medicines can be purchased
without any health professional’s surveillance. Some countries or states allow selling drugs in commercial
circuits that exclude pharmacists or physicians. Internet drug sales are often unregulated. Herbal drugs
and dietary supplements are often under-regulated. All this provides a complex scenario; anyway,
pharmacists’ involvement in medical record updating could be a step towards improvement of the
polypharmacy problematic.
14
adequate interpretation of risk and proper manner of use of medications in patients,
which is particularly important in the case of patients with impaired cognitive functions
or vision or poor literacy (and health literacy) skills [9,46-48]. Graphical displays,
pictograms, the use of larger print, clearer identification of the active ingredient and
Drug abuse has been defined as (persistent or sporadic) excessive drug use inconsistent
with or unrelated to acceptable medical practice. The intentional use of excessive doses
or the intentional use of therapeutic doses but for purposes other than the indication of
the drug constitute drug abuse [49]. We will review recent literature and reports on OTC
drug abuse. Since the purpose of this review is to describe risks connected to self-
medication, we will not focus on abuse of OTC medications by patients with a story of
illicit drug dependence or abuse that resort to OTC drugs when their drug of choice is
not available. This is a consequence of the availability of OTC medications and may
trigger a discussion on the need to revise the OTC status of certain drugs, but is not a
non-medical use (e.g. recreational use or use as ergogenics or anabolics) of OTC drugs
here. For an extensive description of abuse of prescription and OTC drugs for non-
medical purposes the reader may refer to the recent review from Lessenger & Feinberg
[50].
15
Table 2. Summary of studies on abuse of OTC medications.
16
multiple drug use.
Myers et al. Prescription and Analysis of data collected by 23 specialist substance
[59] OTC drugs abuse treatment centers in Cape Town (South Africa). A
standardized one-page form is completed on each person
treated. 710 forms collected during 1998-2000 referred to
abuse of prescription and OTC medications. 33.7% used
medications as primary drug of abuse. 107 patients (15%)
abuse of analgesics; 2.3% corresponded to codeine-
containing OTC preparations.
Goniewicz OTC nicotine Analysis of current studies reveals 0.4-17% of patients
et al. [60] replacement use the NRT for more time than recommended. Research
therapy (NRT) to assess particular dependence symptoms (subjective
sense of dependence, occurrence of withdrawal
symptoms, difficulties in ceasing using therapy) does not
reveal them.
Hughes et OTC NRT Two cross-sectional study based on telephone surveys to
al. [61] smokers recruited through newspaper ads. Study 1
(N=266) revealed that among long term users (≥90 days)
20% attributed their use to addiction. Study 2 (on 100
smokers or ex-smokers that reported addiction to nicotine
gum) showed that 66% met DSM-IV and 74% met ICD-
10 criteria for dependence.
Schiffman et OTC NRT Analysis of OTC NRT purchase patterns in data from a
al. [62] population based panel of 40000 US households that
electronically scanned all household purchases between
1997-2000. 2690 households recorded NRTs. Among 805
households that purchased nicotine gum, 5.2% of new
purchase incidents led to continuous monthly purchase of
gum for ≥3 months, and 2.3% ≥6 months. For nicotine
patches (2050 households) these percentages were 2.9 and
0.9%. Allowing one month gaps within a "continuous"
purchase run resulted in increased estimates (for gum:
11.2% ≥3 months and 6.7% ≥ 6 months; for patch: 5.7%
and 1.7%, in that order).
However, table 2 seems to indicate that several OTC preparations can lead to abuse
and/or dependence. It should be noted that some of the case-reports and studies on OTC
medication abuse (eating disorders, depression). Abuse and/or dependence of NRT may
the smoker subjected to the treatment. Nevertheless, a revision of OTC status may be
necessary in the case of some drugs object of abuse for either medical or non-medical
17
reasons. Among them we may mention orlistat, OTC sleep aids and OTC cough and flu
medications. Lessenger and Feinberg have discussed some general strategies that the
physicians may adopt to reduce medications abuse [50], among them inquiring about
prescription, OTC and herbal drug use at the initial examination. A cross-sectional
study developed in North Ireland reveals the inconsistent fact that, although 80% of the
surveyed population agree or strongly agree that some OTC medicines can cause
dependence if used for a long period of time, more than 47% of the sample indicated
that non-prescription medicines are totally safe to use3 [64]. This inconsistent risk
perspectives on OTC medications might be the most important approach to handle the
Treatment of minor, non-specific symptoms with OTC medications can mask a severe,
underlying disease (especially when the treatment is taken for a longer period than
recommended in the label or package insert) and delay an appointment with the
physician. Misdiagnosis is also a very common and important issue in the case of
infectious diseases, which can have different causes (bacteria, virus, fungus, parasites)
3
It is worth mention that analgesics are among the most liable for abuse drugs according to the surveyed
population.
18
disease can aggravate the health condition of the patient and help to spread resistant
After clinical diagnosis, Ferris and collaborators found that, from 95 women who
purchased and presented with an OTC medication for vulvovaginal candidasis (VVC),
only 33.7% were actually diagnosed VVC. The remaining women presented bacterial
[65]. Women with a previous clinically based diagnosis were not more accurate in
diagnosing VVC. Neither were those who read the label compared to those who did not.
In another study from Ferris et al. 552 women completed a 63-question survey
instrument designed to assess their knowledge of the symptoms and signs of pelvic
diagnosis of VVC (N=365) was accurate in diagnosis VVC, compared to 11% of the
participants that had not received a previous diagnosis (N=154) and 83.7% of a control
group of 49 medically-trained women [66]. In Africa, over 70% of malaria cases do not
present initially to health facilities but diagnose and manage it at home with traditional
the onset of the disease [67]. Several current studies from both developed and emergent
treatment of non-specific upper respiratory tract symptoms (which are often of viral
origin) [68-75]. Table 3 summarizes these articles. Since oral antibiotics are prescription
drugs, self-medication with these therapeutic agents come from leftover from previous
exact number of doses for a prescribed treatment and enforcement of current laws are
19
therefore proposed as solutions to self-medication with antibacterials. Evidence-based
guidelines for the self-diagnosis of infectious diseases (e.g. VVC) and educational
20
Myers et al. Prescription and Analysis of data collected by 23 specialist substance
[59] OTC drugs abuse treatment centers in Cape Town (South Africa).
A standardized one-page form is completed on each
person treated. 710 forms collected during 1998-2000
referred to abuse of prescription and OTC
medications. 33.7% used medications as primary drug
of abuse. 107 patients (15%) abuse of analgesics;
2.3% corresponded to codeine-containing OTC
preparations.
Goniewicz et OTC nicotine Analysis of current studies reveals 0.4-17% of patients
al. [60] replacement therapy use the NRT for more time than recommended.
(NRT) Research to assess particular dependence symptoms
(subjective sense of dependence, occurrence of
withdrawal symptoms, difficulties in ceasing using
therapy) does not reveal them.
Hughes et al. OTC NRT Cross-sectional study based on two telephone surveys
[61] to smokers recruited through newspaper ads. Study 1
(N=266) revealed that among long term users (≥90
days) 20% attributed their use to addiction. Study 2
(on 100 smokers or ex-smokers that reported addiction
to nicotine gum) showed that 66% met DSM-IV and
74% met ICD-10 criteria for dependence.
Schiffman et OTC NRT Analysis of OTC NRT purchase patterns in data from
al. [62] a population based panel of 40000 US households that
electronically scanned all household purchases
between 1997-2000. 2690 households recorded NRTs.
Among 805 households that purchased nicotine gum,
5.2% of new purchase incidents led to continuous
monthly purchase of gum for ≥3 months, and 2.3% ≥6
months. For nicotine patches (2050 households) these
percentages were 2.9 and 0.9%. Allowing one month
gaps within a "continuous" purchase run resulted in
increased estimates (for gum: 11.2% ≥3 months and
6.7% ≥ 6 months; for patch: 5.7% and 1.7%, in that
order).
FINAL CONCLUSIONS
always involves some degree of danger to the consumer. This is especially true in the
case of those patients that do not follow the instructions given by the label of package
insert. Educational interventions aimed to make the patients conscious of potential risks
of OTC medications and the importance of disclosing OTC and alternative medicines
21
consumption to the physician and/or pharmacist are among the most popular measures
also educate lay people on the importance of observing label or inserts instructions on
case of symptoms persistence. Improving the understanding of the label and inserts by
the patient (true pictograms, graphs, larger typography, simpler instructions) and
professionals are other possible strategies towards safe self-medication, particularly for
old or low literate patients having difficulties when dealing with the label written
instructions.
REFERENCES
1. World Health Organization. Guidelines for the regulatory assessment of medicinal products
for use in self-medication. 2000.
2. World Health Organization. The role of the Pharmacist in self-care and self-medication.
1998.
3. World Health Organization. National Policy on traditional Medicine and regulation of
herbal medicines - Report of a WHO Global Survey. 2005.
4. Hughes CM, McElnay JC, Fleming GF. Benefits and risks of self-medication. Drug Saf
2001; 24:1027-37.
5. World Health Organization. Self-care in the context of primary health care. 2009.
6. Secoli SR. Drugs interactions: fundamental aspects for clinical practice nursing. Rev Esc
Enf USP 2001; 35:28-34.
7. Cadieux RL. Drug interactions in the elderly. How multiple drug use increases riks
exponentially. Postgrad Med 1989; 86: 179-86.
8. Köhler GI, Bode-Böger SM, Busse R, Hoopman M, Welte T, Böger RH. Drug-drug
interactions in medical patients: effects of in-hospital treatment and relation to multiple drug
use. Int J Clin Pharmacol Ther 2000; 38:504-13.
22
9. Roumie CL, Griffins MR. Over-the-counter analgesics in older adults. A call for improved
labeling and consumer education. Drugs Aging 2004; 21:485-98.
10. Hovstadius B, Åstrand B, Petersson G. Dispensed drugs and multiple medications in the
Swedish: an individual-based register study. BMC Clin Pharmacol 2009, 9:11.
11. Turnheim K. Drug dosage in the elderly: is it rational? Drugs Aging 1998; 13:357-79.
12. Nolan L, O’Malley K. Prescribing for the elderly. Part 1. Sensitivity of the elderly to
adverse drug reactions. J Am Geriatr Soc 1988; 36:142-9.
13. Colt HG, Shapiro AP. Drug-induced illness as a cause for admission to a community
hospital. . J Am Geriatr Soc 1989; 37:323-26.
14. Gazmararian JA, Baker DW, Williams MV, Parker RM, Scott TL, Green DC, Fehrenbach
SN, Ren J, Koplan JP. Health literacy among Medicare enrollees in a managed care
organization. JAMA 1999; 281: 545-51
15. Brown H, Prisuta R, Jacobs B, Campbell A. Literacy of older adults in America. Results
from the National Adults Literacy Survey, NCES 97-576. US Department of Education.
National Center for Education Statistics. Washington DC, 1996.
16. Federman AD, Sano M, Wolf MS, Siu AL, Halm EA. Health literacy and cognitive
performance in older adults. J Am Geriatr Soc 2009; 57: 1475-80.
17. Baker DW, Gazmararian JA, Sudano J, Patterson M. The association between age and
health literacy among elderly persons. J Gerontol B Psychol Sci Soc Sci 2000; 55: S368-74.
18. National Council on Patient Information and Education. Attitudes and beliefs about the use
of over-the-counter medicines: a dose of reality. 2002.
19. Sleath B, Rubin RH, Campbell W, Gwyther L, Clark T, Cecil G. Physician-patient
communication about over-the-counter medications. Soc Sci Med 2001; 53: 359-67.
20. Chao MT, Wade C, Kronenberg F. Disclosure of Complementary and Alternative Medicine
to Conventional Medical Providers: Variation by Race/Ethnicity and Type of CAM. J Natl
Med Assoc 2008; 100: 1341-9.
21. Barraco D, Valencia G, Riba AL, Nareddy S, Draus CBSN, Schwartz SM. Complementary
and alternative medicine (CAM) use patterns and disclosure to physicians in acute coronary
syndromes patients. Complement Ther Med 2005; 13: 34-40.
22. Bruno JJ, Ellis JJ. Herbal use among US elderly: 2002 National Health Survey. Ann
Pharmacother 2005; 39:643-8.
23. Chagas Bortolon P, Ferreira de Medeiros EF, Silva Naves JO, Gomes de Oliveira
Karnikowski M, de Tolêdo Nóbrega O. Analysis of the self-medication pattern among
Brazilian elderly women. Ciênc. saúde coletiva 2008; 13:1219-26.
24. World Health Organization. WHO Model Formularr. 2004.
25. Berrs MH. Explicit criteria for determining potentially inappropriate medication use by the
elderly. Arch. Intern. Med. 1997; 157:1531-6.
23
26. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers
criteria for potentially inappropriate medication use in older adults: results of a US
consensus panel of experts. Arch. Intern. Med. 2003; 163:2716-24.
27. Flores LM, Mengue SS. Drug use by the elderly in Southern Brazil. Rev Saúde Pública
2005; 39:1-6.
28. Gavilán Moral E, Morales Suárez-Varela MT, Hoyos Esteban JA, Pérez Suanes AM.
Inappropriate multiple medication and prescribing of drugs in immobile elderly patients
living in the community. Aten Primaria 2006; 38: 476-82
29. Yoon SL. Herbal, prescribed and over-the-counter drug use in older women: prevalence of
drug interactions. Geriatr Nurs 2006; 27:118-29.
30. Solberg LI, Hurley JS, Roberts MH, Nelson WW, Frost FJ, Crain AL, Gunter MJ, Young
LR. Measuring patient safety in ambulatory care: potential for identifying medical group
drug-drug interaction rates using claims data. Am J Manag Care 2004; 10:753-9.
31. Peng CC, Glassman PA, Marks IR, Fowler C, Castiglione B, Good CB. Retrospective drug
utilization review: incidence of clinically relevant potential drug-drug interactions in a large
ambulatory population. J Manag Care Pharm 2003; 9:513-22.
32. Tarone RE, Blot WJ, McLaughin JK. Nonselective nonaspirin nonsteroidal anti-
inflammatory drugs and gastrointestinal bleeding: relative and absolute risk estimates from
recent epidemiologic studies. Am J Ther 2004; 11:17-25.
33. Neafsey PJ, Shellman J. Misconceptions of older adults with hypertension concerning OTC
medications and alcohol. Home Healthcare Nurse 2002; 20:300-7.
34. Neafsey PJ, Strickler Z, Shellman J, Padula A. Use of touchscreen equipped computers to
deliver health information about self-medication to older adults. J Gerontol Nurs 2001;
27:19-27.
35. Barat I, Andreasen F, Damsgaard EMS. The consumption of drugs by 75-year-old
individuals living in their own homes. Eur J Clin Pharmacol 2000; 56:501-9.
36. Flaherty JH, Perry III HM, Lynchard GS, Morley JE. Polypharmacy and hospitalization
among older home care patients. J. Gerontol: Med Sci 2000; 55A:M554-9.
37. Chen YF, Dewey ME, Avery AJ, Analysis Group of the Medical Research Council
Cognitive Function and Ageing Study. Self-reported medication use for older people in
England and Wales. J Clin Pharm Ther 2001; 26: 129-40
38. Rosenfeld S. Prevalence, associated factors, and misuse of medication in the elderly: a
review. Cad Saúde Pública 2003; 19:717-24.
39. Hanlon JT, Schmader KE, Ruby CM, Weinberger M. Suboptimal prescribing in older
patients and aoutpatients. J Am Geriatr Soc 2001; 49:200-9.
24
40. Olivier P, Bertrand L, Tubery M, Lauque D, Montastruc JL, Lapeyre-Mestre M.
Hospitalizations because of adverse drug reactions in elderly patients admitted through the
emergency department: a prospective survey. Drugs Aging 2009; 26:475-82
41. Queneau P. Pitfalls of polypharmacy, particularly in the elderly. Bull Mem Acad R Med
Belg 2006; 161:408-21.
42. Amoako EP, Richardson-Campbell L, Kennedy-Malone L. Self-medication with over-the-
counter drugs among elderly adults. J Gerontol Nurs 2003; 29:10-5.
43. Berembein DM. Polypharmacy: overdosing on good intentions. Mang Care Q 2002; 10:1-5
44. Colley CA. Polpypharmacy: the cure becomes the disease. J Gen Intern Med 1993; 8:278-
83.
45. Bergman-Evans B. Evidence-based guideline. Improving medication management for older
adult clients. J Gerontol Nurs 2006; 32:6-14.
46. Olson RM, Blank D, Cardinal E, Hopf G, Chalmers RK. Understanding medication-related
needs of low-literacy patients. J Am Pharm Assoc (Wash) 1996; NS36:424-9.
47. Mansoor LE, Dowse R. Effect of pictograms on readability of patient information materials.
Ann Pharmacother 2003; 37:1003-9.
48. Berry DC, Raynor DK, Knapp P, Bersellini E. Patients’ understanding of risk associated
with medication use: impact of European Commission guidelines and other risk scales.
Drug Saf 2003; 26:1-11.
49. World Health Organization. WHO Expert Committee on Drug Dependence 33 rd Report.
2003.
50. Lessenger JE, Feinberg SD. Abuse of prescription and over-the-counter medications. J Am
Board Fam Med 2008; 21:45-54.
51. Hagler Robinson A. Orlistat misuse as purging in a patient with binge-eating disorder.
Psychosomatics 2009; 5:177-8.
52. Fernández-Aranda F, Amor A, Jiménez-Murcia S, Giménez-Martínez L, Turón-Gil V,
Vallejo Ruiloba J. Bulimia nervosa and misuse of orlistat: two case reports. Int J Eat
Disorder 2001; 30: 458-61
53. Cochrane C, Malcolm R. Case report of abuse of orlistat. Eat Behav 2002; 3:167-9.
54. Orriols L, Gaillard J, Lapeyre-Mestre M, Roussin A. Evaluation of abuse and dependence
on drugs used for self-medication: a pharmacoepidemiological pilot study based on
community pharmacies in France. Drug Safety 2009; 32:859-73.
55. Barrington SL, Carroll R, Hewitson M, Munangatire B, Rogers PJ, Wood SM. Use of
diphenhydramine as a non-prescription hypnotic: patients’ experiences. Int J Pharm Pract
2003; 11:R25.
56. Phelan M, Akram G, Lewis M, Blenkinsopp A, Millson D, Croft P. A community
pharmacy-based survey of users of over-the-counter sleep aids. Pharm J 2002; 269:287-90.
25
57. Lagerløv P, Holager T, Helseth S, Rosvold EO. Self-medication with over-the-counter
analgesics among 15-16 year-old teenagers. Tidsskr Nor Laegeforen 2009; 129:1447-50.
58. Mäntyselkä P, Ahonen R, Viinamäki H, Takala J, Kumpusalo E. Drug use by patients
visiting primary care physicians due to noncaute musculoskeletal pain. Eur J Pharm Sci
2002; 17:201-6.
59. Myers B, Siegfried N, Parry CDH. Over-the-counter and prescription medicine misuse in
Cape Town – findings from specialist treatment centres. South Af Med J 2003; 93:367-70.
60. Goniewicz ML Zymełka A, Czogała J, Koszowski B. Problems of abuse of and dependence
on Nicotine Replacement Therapy (NRT). Przegl Lek 2006; 63:1119-22.
61. Hughes J, Pillitteri JL, Callas PW, Callahan R, Kenny M. Misuse and dependence on over-
the counter nicotine gum in a volunteer sample. Nicotin Tob Res 2004; 6:79-84.
62. Shiffman S, Hughes J, Pillitieri J, Burton S. Persistent use of nicotine replacement therapy:
an analysis of actual purchase patterns in a population based sample. Tob Control 2003;
12:310-16.
63. Akram G. Over-the-counter medication: an emerging and neglected drug abuse? J Subst
Use 2000; 5:136-42.
64. Wazaify M, Shields E, Hughes CM, McElnay JC. Societal perspectives on over-the-counter
(OTC) medicines. Fam Pract 2005; 22:170-6.
65. Ferris DG, Nyirjesy P, Sobel JD, Soper D, Pavletic A, Litaker MS. Over-the-counter
antifungal drug misuse associated with patient-diagnosed vulvovaginal candidasis. Obstet
Gynecol 2002; 99:419-25.
66. Ferris DG, Dekle C, Litaker MS. Women’s use of over-the-counter antifungal medications
for gynecologic symptoms. J Fam Pract 1996; 42:595-600.
67. Amexo M, Tolhurst R, Barnish G, Bates I. Malaria misdiagnosis: effects on the poor and
vulnerable. Lancet 2004; 364:1896-8
68. Dreser A, Wirtz VJ, Corbett KK, Echániz G. Antibiotic use in Mexico: review of problems
and policies. Salud Publica Mex 2008;50 suppl 4:S480-S487.
69. Basualdo W, Allende I, Gamarra G, Desagracia G, Kubiak B, Sánchez M, Sosa A.
Determinants of antibiotics consumption in Asunción, Great Asunción and Ciudad del Este,
Paraguay. Rev Panam Infectol 2008; 10 (Supl. 1):S160-2.
70. Grigoryan L, Haaijer-Ruskamp FM, Burgerhof JGM, Mechtler R, Deschepper R, Tambic-
Andrasevic A, Andrajati R, Monnet DL, Cunney R, Di Matteo A, Edelstein H,
Valinteliene R, Alkerwi A, Scicluna EA, Grzesiowski P, Bara AC, Tesar T, Cizman M,
Campos J, Stålsby Lundborg C, Birkin J. Self-medication with antimicrobial drugs in
Europe. Emerg Infect Dis 2006; 12:452-9.
71. Sarahroodi S, Arzi A. Self-medication with antibiotics: is it a problem among Iranian
college students in Tehran? J Biol Sci 2009; 9:829-32.
26
72. Richman PB, Garra G, Eskin B, Nashed AH, Cody R. Oral antibiotic use without
consulting a physician: a survey of ED patients. Am J Emerg Med 2001; 19:57-60.
73. Raz R, Edelstein H, Grigoryan LL, Haaijer-Ruskamp FM. Self-medication with antibiotics
by a population in northern Israel. Israel Med Assoc J 2005; 7:722-5.
74. Papaioannidou P, Tsanakalis F, Akritopoulos P. Antibiotic use by general population:
attitudes, beliefs and behavior. Epitheorese Klinikes Farmakologias kai Farmakokinetikes
2009; 27:74-7.
75. Nounou B, Cattáneo ME, Salmón R, Palasezze L, Boccaleri J, Cestona E, Bedecarrás F,
Ranieri F, Talevi A, Muñoz SM. A Study Regarding Consumption and Self-medication
with Antibiotics in the City of La Plata (Buenos Aires, Argentina). Lat Am J Pharm 2009;
4:544-51.
76. Bond CM, Watson MC, Grampian Evidence Based Community Pharmacy Guidelines
Group. The development of evidence-based guidelines for over-th-counter treatment of
vulvovaginal candidiasis. Pharm World Sci 2003; 25:177-81.
27