Affordability, Effectivity, and the Importance in Patient’s Compliance

In the current economic state of the world today, we all struggle to find solutions to make our daily lives adaptable & sustainable. The crisis brought about by the COVID-19 pandemic, especially in a third-world country like the Philippines affected all walks of life, more so Filipinos in the marginalized sector of the society. As a practitioner in the ever-changing landscape of Obstetrics and Gynecology regarding sexually transmitted infections (STI), I find it daunting to find affordable, yet effective alternatives compared to the pricey ones. In a community wherein most of the patients that I serve and attend to belong to the middle working, lower-middle, and mostly from the poorest sector of the society (receiving referrals from neighboring town’s District hospitals & Rural Health Units (RHU), I find it disheartening that most of them could not afford to complete a 7-day cycle of anti-infectives. And all physicians know that to get the desired effect of a certain medication, the required days, or weeks to get a successful treatment plan should be completed. As an Obstetrician-Gynecologist trained in a government hospital, I saw all kinds of depressing scenarios of patients not getting well sooner due to a lack of funds to be able to complete a treatment plan. So as soon as I finished my training and went back to my roots to serve my community, I obligated myself to become a doctor who is empathic about not only my patients’ well-being but also their financial capacity to afford what I prescribe.

In my everyday practice as an Ob-Gyn, I see a lot of patients who came in with complaints of a vaginal discharge described as whitish to greyish with a “fishy” odor which is common in women with Bacterial Vaginosis (BV). This common infection happens when some bacteria found in the normal flora in the vagina “overgrow” causing bacterial imbalance (defined by Cleveland Clinic.Org). Bacterial vaginosis is associated with poor obstetrics and gynecologic outcomes such as preterm delivery, and infections after surgeries such as hysterectomies and may make women more susceptible to sexually transmitted infections, especially HIV. Although it is not sexually transmitted, bacterial vaginosis is linked with sexual activity.

Bacterial Vaginosis (BV) is the most prevalent cause of symptomatic vaginitis in the Philippines. Prevalence of BV is at 28.16%. The mainstay of treatment of BV is Metronidazole. Although antibiotic treatment has been shown to eliminate BV-associated organisms, there is a high recurrence rate (according to the article in the Philippine Journal of Obstetrics and Gynecology by R.R. Munoz-Cruz, MD, J.T. Co MD, FPOGS L. Reyes MD, FPOGS - FEU-NRMF Hospital). In another study done in SPMC-JHCS in November 2015, it was also stated that BV is the most common female genital infection caused by an imbalance of vaginal microflora, accounting for 28.56% prevalence rate in the Philippines among women aged 17 to 49 years old.

Why am I stressing about bacterial vaginosis? As an ObGyn, I deal with pregnant and non-pregnant women who are suffering from BV. Emphasizing on my pregnant women, it is a challenging task to recognize and treat BV immediately because of the implications it has on pregnancy. It causes preterm labor and early delivery, early miscarriage, postpartum endometritis, and low birth weight. This is where the choice of treatment comes in. It is hard to find an affordable Metronidazole in the market that is equally effective as the expensive ones. With Dymetrazole 500 mg tablet, I found an ally in treating my patients with BV (especially pregnant women - Metronidazole is Category B in FDA - meaning it has no teratogenic effects on pregnant animal studies but has no extensive studies on humans). It is not only highly effective in my patients but also very affordable compared to its branded and expensive counterpart. Affordability is key to better compliance with the medications prescribed. And compliance is key to a successful treatment for any disease or infection.

On the other hand, as an anti-protozoal Metronidazole is also highly effective for Trichomonas vaginalis and for Amoebiasis. In women with Trichomoniasis, which is a highly contagious sexually transmitted infection, it is recommended to also treat their sexual partners. Again, affordability plays a major role in the compliance of both the patients & their partners. In pregnant women with Trichomoniasis, a Category B drug-like Metronidazole is fairly used. Metronidazole is the drug of choice (which is a Category B drug by US and Philippine FDA - meaning there are no teratogenic effects on animal study but there are no studies done in humans) that is why the risks and benefits are carefully weighed by the clinicians extensively. Trichomoniasis causes increased preterm delivery and low birth weights when not treated. Metronidazole 500 mg/tablet at 1 tablet 2 x a day for 1 week is highly effective against Trichomonas vaginalis. Again, compliance cannot be over-emphasized in the success of the treatment and affordability plays an important role.

In Amoebiasis during pregnancy, in my years of practice as an Obstetrician, it is known to be more severe than in non-pregnant women. In the present study, women with amoebiasis infection had a two-fold increase in odds of preterm delivery compared to the reference group (Prevalence of Parasitic Infections and Associations with Pregnancy, February 13, 2016). Metronidazole is the drug of choice for pregnant women weighing all the risks and benefits that it comes with it. Again, I also will stress that it is important to treat amoebiasis in pregnant women because pregnancy has been described as a risk factor for the development of invasive amoebiasis and the management of these patients is especially complex. Metronidazole as a Category B drug by US and Philippine FDA is well tolerated and although it crosses the placenta, it seems to have no significant embryotoxic effects. {ROE FJ Toxicologic Evaluation of Metronidazole with Particular reference to Carcinogenic, Mutagenic, and Teratogenic Potential. Surgery 198; 93 (CH2: 158-64- CAS Published)}

Affordable Metronidazole that is safe and effective in the market is a daunting task. That is why when I came across Dymetrazole which is cost-effective, it was such a relief that for less than 200 PHP per treatment, compliance is achieved for a better response to managing ObGyn infections in a scenario of the economic crisis brought about by the pandemic.