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The guidelines in EDLIZ have always reflected the consensus of local experts and takes into consideration factors such as the Zimbabwean setting prevailing economic climate practical experience as well as evidence based therapeutics This new EDLIZ has taken into account the dynamic changes in the
EDLIZ 2015,Printed by, EDLIZ 2015,EDLIZ 7TH EDITION 2015. PUBLISHED BY , The National Medicine and Therapeutics Policy. Advisory Committee NMTPAC , Ministry of Health Child Care. Republic of Zimbabwe, Further copies may be obtained through the relevant Provincial Medical. Directorate City Health Directorate the NMTPAC Ministry of Health . Child Care MoHCC PO Box CY 1122 Causeway Harare Zimbabwe . or the MoHCC website www mohcc gov zw Copies of the text may be. obtained on soft copy if required for teaching purposes from email. address dps mohcc gov zw or nmtpac gmail com EDLIZ was. prepared using Microsoft Word , The information presented in these guidelines conforms to current. medical nursing and pharmaceutical practice It is provided in good. faith Whilst every effort was made to ensure that medicine doses are. correct no responsibility can be taken for errors and omissions . EDLIZ Review Co ordinator, No part of this publication may be reproduced by any process without. the written permission of the copyright holder exception being made for. the purpose of private study research criticism or review or for. teaching but not for sale or other commercial use . Original Cover Design Regina Gapa and Charon Lessing. Cover redesign Layout Kim Hoppenworth,Cover redesign and layout 2015 Newman B Madzikwa. Copyright June 2015 Ministry of Health Child Care. EDLIZ 2015,EDLIZ REVIEW COMMITTEE,Apollo Tsitsi Samukange Emma. Borok Margaret Mujuru Hilda,Chakanyuka Christine C Mushavi Angela. Hove Ropafadzai Madzikwa Newman B ,Mungwadzi Godfrey Ndhlovu Chiratidzo E . Bakasa Clemenciana Sifeku Florah N ,Mudzimu Forward Wellington Maureen. Torongo Mabel Vuragu Davison N ,Nyamayaro Raphael Maunganidze Aspect. Khoza Star Basopo Victor,Madziyire Mugove G Chidakwa Claitos. Bara Wilfred,ACKNOWLEDGEMENTS, We would like to thank all the individuals who made contributions. through colleagues or discussion forums or by communicating through. electronic mail We are grateful to all who made this edition a national. guide that serves as the standard for Zimbabwe Thank you to all the. healthcare workers for your support , The following attended our review workshops as well as being. instrumental in current chapter reviews , Akinjide Obonyo Akindele P Dr Maunga Simbarashe Dr. Apollo Tsitsi Dr Maunganidze Aspect Dr,Bakasa Clemenciana Ms Mbuzi Tonnie Mr. Bare Blessing Mhazo Tichatyei Mr,Basopo Victor Mr Mhembere Josephine Dr. Bepe Tafadzwa Dr Midzi Stanley Dr,Borok Margaret Dr Misihairambwi Silence Ms. Burutsa Patricia Ms Mlilo Lindiwe Dr,Bwakura Tapiwanashe Dr Moyo Dothan Mr. Cakana Andrew Prof Moyo Mluleki Mr,Chakanyuka Artmore Dr Moyo Sifiso Mr. Chakanyuka Christine C Dr Mudombi Wisdom Dr,Chari Godfrey Mudzimu Forward Mr. Charimari Lincoln Dr Mujuru Hilda A Dr,Chemhuru Milton Dr Mungwadzi Godfrey Dr. Chikanya Sonia Irene Ms Munjanja Stephen P Prof,Chimhini Gwendoline Dr Mushavi Angela Dr. EDLIZ 2015,Chirenje Mike Z Prof Musiya N Dr,Chiro Erick Mr Musungwa Alexio Mr. Cowan Frances M Prof Musvipa Mary Ms,Deda Petunia Ms Mutsvairo Sitembile Ms. Dliwayo Thokozile Ms Mwaramba Charles Mr, Dube Siphathisiwe Noreen Mrs Mwonzora Muchaneta Mrs. Dube Tirivashoma Mr Nathoo Kusum J Prof ,Fana Golden Dr Ncube Phumuzile Ms. Gambanga Pauline Dr Ndamukwa Pikirai Mr,Glavintcheva Iskra L Dr Ndhlovu Chiratidzo E Prof. Gunguwo Hillary Dr Ndlovu Misheck Mr,Gwanzura Lovemore Prof Ndowa Francis Dr. Gwata Beatrice Mrs Nembiri Tinashe Ms,Hove Ropafadzai Mrs Ngwende Gift W Dr. Kambarani Rose Prof Nkala Lee Mr,Kandawasvika Petronella Dr Nyadzayo Tasiana K Mr. Khoza Star Dr Nyakabau Anna M Dr,Khumalo Brian Mr Nyamayaro Raphael Dr. Khumalo Mhlawempi Nyaruwanga Albert Mr,Kufa Tarisai Dr Pasi Christopher Dr. Kusemwa Muyambi Preetyosa Ms Phiri Isaac Dr,Latif AS Prof Reid Andrew Dr. Machisa Vimbainashe Ms Rimai Ruth Ms,Madhombiro Munyaradzi Dr Samukange Emma Mrs. Madzikwa Newman B Mr Sandy Charles Dr,Magombeyi Rudo Ms Sanyanga Arthur Mr. Magunda Farai Shumba Godfrey Mr,Mandimika Florence Sibanda Elopy N Prof. Mandire Joice Ms Sifeku Florah N Mrs,Mangezi Walter Dr Sithole Dorcas Ms. Mangoma Tariro Ms Tagwirei Dexter Prof,Mangwiro John C Dr Takaruza Kelvin Mr. Masanganise Rangarirai Prof Tambudze Gaundencia Ms. Masendu Maureen Dr Tekasala Lumbu Jerry Mr,Mashinge Farayi Mr Ticklay Ismail Dr. Mashoko Tsungai Ms Vuragu Davison N Mr,Mashumba Azza Dr Wellington Maureen Dr. Maswaure Laucas Zaranyika Trust Dr,Matonhodze Alex Mr. Thank you , Mrs R F Hove Prof C E Ndhlovu, Director of Pharmacy Services NMTPAC Chairperson. EDLIZ 2015, It is the national objective that the health care needs of Zimbabweans. are met through the provision and proper use of essential medicines . Sometimes we do not need to give medicines that is there is not. always a pill for every ill Thus there is need to use medicines. appropriately efficiently and effectively , The guidelines in EDLIZ have always reflected the consensus of local. experts and takes into consideration factors such as the Zimbabwean. setting prevailing economic climate practical experience as well as. evidence based therapeutics , This new EDLIZ has taken into account the dynamic changes in the. Burden of Disease as reflected by the inclusion of antiretroviral. medicines and treatment of other opportunistic infections other than. Tuberculosis TB Many of the therapeutic regimens of the previous. EDLIZ still hold true and remain the same and should reinforce the. confidence of the prescriber in making reliable therapeutic choices . I urge all health workers to familiarise themselves with the revised. guidelines to prescribe within the bounds of this publication and to. recognise the critical importance of providing a quality service to all. health care recipients through the rational use of medicines . EDLIZ REMAINS good medicine Use it , Hon Dr P D Parirenyatwa. Minister of Health Child Care, EDLIZ 2015,THE ESSENTIAL MEDICINES LIST FOR. ZIMBABWE EDLIZ 7TH EDITION, This 7th essential medicines list and standard treatment guidelines for. the most common health conditions in Zimbabwe has been endorsed by. the National Medicine Therapeutics Policy Advisory Committee. NMTPAC It is the product of many years of combined efforts by. hundreds of health workers at all levels of the health care system in. Zimbabwe from the front line health care providers to the providers of. specialist care It has been refined over the years as a result of its. widespread use by our healthcare workers We continue to revise the. standard treatment guidelines and take into account medicine. developments and new healthcare problems Thus this latest edition has. included more essential medicines , The essential medicine list is based on the Essential Medicines. Concept Medicines in EDLIZ are chosen to meet the health care needs. of the majority of the population and should therefore always be. available and accessible at a price that both the patient and the nation. can afford ,Selection of medicines for inclusion, Selection of medicines for inclusion in EDLIZ has been based on the. following criteria with special emphasis on proven evidence for their use. in the Zimbabwean setting , relevance to prevalent diseases. proven efficacy and safety Safe, adequate scientific data in a variety of Efficacious. settings Quality, adequate quality Available, Affordable. favourable cost benefit ratio, Accessible, desirable pharmacokinetics Rationally used. possibilities for local manufacture, available as single ingredient items. GENERIC MEDICINES, Every medicine has a chemical name and a generic name For. example paracetamol its chemical name is N 4 Hydroxyphenol . acetamide and the international non proprietary name INN or generic. name is paracetamol The INN is the medicine s official name. regardless of who manufactures or markets it An additional brand name. EDLIZ 2015, is chosen by the manufacturer to facilitate recognition and association of. the product with a particular manufacturer for marketing purposes . For most common medicines there are several branded products that all. contain the same active ingredient and therefore share the same INN . The use of generic names for medicine procurement as well as. prescribing carries considerations of clarity quality and price . Proponents of generic medicines procurement and prescribing point out. generic names are more informative than brand names and facilitate. purchasing of products from multiple suppliers whether as brand . name or as generic products , generic medicines are generally cheaper than products sold by. brand name this is demonstrated very clearly when it comes to. antiretroviral medicines, generic prescribing also facilitates product substitution whenever. appropriate , Opponents argue that the quality of generic medicines is inferior to that. of brand innovator products However quality assurance and naming of. medicines are completely separate issues Generic medicines from. reliable suppliers are as safe effective and high in quality as medicines. with brand names At the same time branded medicines from a. manufacturer with inadequate procedures for quality control can be of. poor quality despite the brand name Also although any medicine can. be counterfeited there are more incentives for counterfeiting brand . name medicines than generic medicines Some pharmaceutical. companies also sell their branded products under the generic name for. a much lower price , Bio equivalence is often misused as an argument against the use of. generic equivalents For many medicines the variation in bioavailability. among individual patients is much larger than the variation among. products of different manufacturers In fact bioavailability is clinically. relevant for only a relatively small number of medicines such as. furosemide digoxin levodopa isoniazid theophylline and phenytoin . Zimbabwe has a well understood generic policy which requires that all. prescribing is in the generic name and the dispenser can make generic. substitutions unless bioavailability is an issue in which case the. prescriber should indicate accordingly ,ADVANTAGES OF EDLIZ. The benefits of the selection and use of a limited number of essential. medicines are , Improved medicines supply, More rational prescribing. EDLIZ 2015, Lower costs, Improved patient use,IMPROVED MEDICINES SUPPLY. The regular supply of medicines is difficult in many countries and the. consequent health implications are many Improved medicines. availability should lead to improved clinical outcomes . With fewer essential medicines being,purchased the mechanisms and. logistics for procurement storage easier procurement . distribution will clearly be easier It is storage distribution. not practical for each clinic in lower holding stocks. Zimbabwe to attempt to procure lower losses, transport and warehouse all the better quality assurance. hundreds of items in EDLIZ , Conversely limiting the number of medicines available at the primary. health care level makes a regular supply of medicines more practical. and possible , With an improved supply the possibilities of holding lower quantities. exist This has financial implications as well as reducing the likelihood of. medicines expiring or being damaged during storage . Quality assurance can be better managed when the number of. medicines is limited and quality checks can be performed more. frequently ,MORE RATIONAL focused more effective training. PRESCRIBING more experience with fewer medicines, no irrational treatment alternatives. In the absence of limited available,lists the large variety of. focused medicine information,products available on the. market contributes to better recognition of adverse medicine. inconsistent prescribing and reactions,consequently variation in. clinical practice even within the same health care facility Irrational. prescribing may lead to therapeutic hazards and increased costs . When the number of medicines is limited training can be more focused. and the quality of care enhanced This is especially true when the list. represents a consensus of opinion on first choice of treatment such as. Using EDLIZ enables the prescriber to become more familiar with the. medicines they use and better able to recognise adverse effects . EDLIZ 2015, The use of EDLIZ also eliminates irrational products from being. available for prescribing and allows for more focused medicine. information to be provided on suitable essential medicines . LOWER COSTS,Improved effectiveness and efficiency in. patient treatment leads to lower health care more competition. costs The essential medicines concept is lower prices. increasingly being accepted as a universal,tool to promote both quality of care and cost. Essential medicines are usually available from multiple suppliers With. increased competition more favourable prices can be negotiated . By limiting the number of different medicines that can be used to treat a. particular clinical problem larger quantities of the selected medicine will. be needed with potential opportunities to achieve economies of scale . IMPROVED PATIENT USE, Focusing on fewer medicines can enhance patient education and efforts. to promote the proper use of medicines in both patients and prescribers . Additionally with improved, medicine availability changes focused education efforts. to chronic medication reduced confusion increased, regimens are less likely and adherence to treatment. as a consequence patients, have a better understanding of their disease their medication and the. need for compliance ,IMPLEMENTATION OF EDLIZ AND SETTING UP OF. HOSPITAL MEDICINE AND THERAPEUTICS COMMITTEES, The advantages presented here however do not just happen EDLIZ. itself will not ensure rational prescribing or facilitate good procurement. or quality assurance Educational regulatory financial or managerial. strategies on their own are less effective in promoting the rational use of. medicines than combined strategies The production of EDLIZ is one. such regulatory strategy but further steps such as training and re . training patient education and the establishment and effective. functioning of hospital medicine and therapeutic committees HMTCs . have to be taken to ensure cost effective prescribing and patient care It. is therefore necessary for every hospital to have a forum where. medicine issues can be discussed Ideally a separate hospital medicine. EDLIZ 2015, and therapeutics committee HMTC should be formed Given the. current manpower constraints we encourage hospitals to exploit every. opportunity such as the regular divisional meetings held in Central. Hospitals to discuss and address medicine related problems The. NMTPAC is available to assist those hospitals that are ready to set up. an HMTC A technical guideline to set up a HMTC developed by the. NMTPAC is available ,EXPLANATIONS CHANGES FROM THE PREVIOUS. This edition is essentially the same in format and layout categorisation. as the last edition You will need to read it carefully to note changes in. recommendations that apply to your areas of interest Extra bulletins will. be sent out where drastic changes in medicine recommendations have. All medicines in EDLIZ are categorised firstly by level of availability. ABCS in the health care system and secondly according to priority. VEN Hence in the example below amoxicillin is available at primary. health care facility C level and is ranked vital V . Medicine Codes Adult dose Frequency Duration, amoxicillin po C V 500mg 3 times a day 7 days. LEVEL OF AVAILABILITY, C medicines are those required at primary health care level and should. be available at all levels of care , B medicines are found at district hospital level or secondary and higher. levels of care Some B medicines may be held at primary health care. facilities on a named patient basis for example in the management. and follow up of chronic illnesses , A medicines are prescribed at provincial or central hospital levels . S medicines specialist only have been brought back into this edition . These are medicines that require special expertise and or diagnostic. tests before being prescribed ,VEN CLASSIFICATION, All medicines are also classified according to their priority This is mostly. a tool to assist in giving priority to medicines based on economic. considerations Thus V medicines are vital they are considered. EDLIZ 2015, lifesaving or their unavailability would cause serious harm and efforts. should always be aimed at making them 100 available . E medicines are essential and are given second priority Without E. medicines there would be major discomfort or irreversible harm And N. medicines are still necessary but are lower in priority than V and E. medicines , This edition of EDLIZ has been produced as a result of a highly. consultative process and represents both the practical nature of the. input from health care workers and the changing nature of medicine. especially over the recent years It has adopted an evidence based. approach wherever possible and has balanced this with the resources. available to the health care system , The NMTPAC is a standing committee that reviews the therapeutic. guidelines in EDLIZ on a continual basis and always looks forward to. feedback from the providers of health care in Zimbabwe Contact the. NMTPAC through Directorate of Pharmacy Services on. dps mohcc gov zw or nmtpac gmail com with your comments . Brigadier General Dr G Gwinji, Permanent Secretary. Ministry of Health Child Care, Republic of Zimbabwe. EDLIZ 2015,MAJOR HIGHLIGHTS IN THE LATEST, The major changes in this latest edition of EDLIZ will be highlighted here. so that you are aware of recommendations that you need to consider in. your medicine management or supply issues Ideally each hospital should. create its own local medicine formulary which shows which medicines are. considered very useful in that setting so that you do not have to order. medicines that your doctors will not prescribe or use For instance you. should not keep specialist medicines if there is no specialist to prescribe. them Hospital Medicine and Therapeutics Committees should select. medicines for use in their hospital using the EDLIZ . New chapter, There is one new chapter Overview of Surgical Conditions We welcome. any comments on the utility of this chapter Your comments will be used in. future revisions ,Antibiotics, A new cephalosporin Cefixime has been added to the treatment of. sexually transmitted illnesses Azithromycin has also been added for the. treatment of gonococcus ,Immunisation, Rotavirus immunisation has now become routinely available Human. Papilloma Virus HPV vaccination is currently being used in a limited. setting but it is hoped that it will be rolled out nationally in 2016 . Asthma Treatment, Given that salbutamol inhalers are more accessible oral salbutamol has. been phased out completely You will need to ensure that your patients. are aware of this change Use of steroids as an inhaler should be. encouraged in place of regular oral Salbutamol Health care workers will. need to always check that their clients can use the inhalers appropriately . ART Guidelines use latest ART guidelines , Stavudine containing regimens are being phased out and will not be. available except for a limited number of patients who will still need them . For first line therapy tenofovir lamivudine and efavirenz will be used in. most instances for adults adolescents and children as well as pregnant. Third line antiretroviral medicines will be available in selected hospitals . These third line medicines will include raltegravir and darunavir Please. EDLIZ 2015, familiarise yourself with the dosing of these new medicines and the. algorithm for their use ,Malaria Treatment, The malaria medicines have also been revised The first line therapy. remains the same as before i e Artemether Lumefantrine AL . However where oral quinine would have been used we now recommend. oral artesunate and amodiaquine as a combined medicine For pre . referral use rectal artesunate will be used instead of IM quinine This new. combination of antimalarial therapy is given orally and should simplify the. management of patients with severe malaria Instead of using parenteral. quinine for complicated malaria intravenous artesunate will be used . Unlike with IV quinine use there will be no need to worry about. hypoglycaemic effects with the use of artesunate ,Tropical Diseases. You will need to familiarize yourself with the recognition and management. of Ebola which is currently causing a huge epidemic in West Africa . Hence our healthcare delivery centres are on the lookout for such Ebola. infections ,TB recommendations use latest TB guidelines . Isoniazid prophylaxis has been adopted and hence you should familiarise. yourself with the protocol for its use Isoniazid INH like any other. medicines can cause side effects Look out for gastrointestinal symptoms . hepatitis skins reactions and peripheral neuropathy Stopping the INH as. soon as possible will help to save lives Thus patients will need to be. informed about the need to look out for these adverse events Some of the. adverse events are rather idiosyncratic and hence not dose related Use. the usual adverse medicines reporting forms and send forms through to. the Pharmacovigilance and Clinical Trials PVCT Unit at the Medicine. Control Authority of Zimbabwe MCAZ offices ,Metabolic and Endocrine Conditions. The use of the Basal Bolus regimen has been introduced and we hope to. phase out the reference to using Sliding Scale insulin The Basal Bolus. Regimen is more physiological as it uses an underlying intermediate or. long acting dose of insulin once a day as well as pre meal prandial bolus . short acting or rapid acting insulin doses By checking pre meal glucose . extra correctional doses can be added to the calculated prandial doses of. insulin Thus you will need to read and familiarize yourself with these new. recommendations for diabetes therapy , EDLIZ 2015, TABLE OF CONTENTS. EDLIZ 7TH EDITION 2015 III,ACKNOWLEDGEMENTS IV,FOREWORD VI. THE ESSENTIAL MEDICINES LIST FOR ZIMBABWE EDLIZ 7TH EDITION VII. MAJOR HIGHLIGHTS IN THE LATEST EDLIZ XIII,TABLE OF CONTENTS XV. GUIDELINES ON ANTIMICROBIAL TREATMENT AND PROPHYLAXIS 1. BASIC INFECTION PREVENTION AND CONTROL MEASURES 7,PAEDIATRIC CONDITIONS 14. IMMUNISATION 59,OBSTETRIC AND GYNAECOLOGICAL CONDITIONS 66. SEXUALLY TRANSMITTED INFECTIONS 88,HIV RELATED DISEASE 101. ANTIRETROVIRAL THERAPY 117, USE OF ARVS FOR PREVENTION OF MOTHER TO CHILD TRANSMISSION. OF HIV PMTCT 135,TUBERCULOSIS 139,TROPICAL DISEASES 151. MALARIA 167,RESPIRATORY CONDITIONS 183,CARDIOVASCULAR DISEASE 196. GASTROINTESTINAL CONDITIONS 210,RENAL TRACT CONDITIONS 223. RHEUMATOLOGICAL AND JOINT CONDITIONS 232,METABOLIC ENDOCRINE CONDITIONS 238. NEUROLOGICAL CONDITIONS 257,MENTAL HEALTH 269,COMMON EYE CONDITIONS 280. COMMON ORAL CONDITIONS 292,EAR NOSE AND THROAT DISORDERS 296. SKIN CONDITIONS 307,BURNS 317,PAIN MANAGEMENT CARE OF THE TERMINALLY ILL 326.