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Hazardous use of Methotrexate in Afghanistan

by: Dr Khesrow Sangarwal
A number colleagues who have visited Afghanistan over the past few years has expressed concern regarding the careless and often hazardous use of various cytotoxic and disease-modifying agents, by both the healthcare professionals and patients, in Afghanistan. This concern has unfortunately not been raised and documented in a scientific manner, but has always dominated our discussions on healthcare issues in Afghanistan.One of such agents is Methotrexate, a disease-modifying drug that has a wide range of therapeutic indications, ranging from treating dermatological problems to chemotherapy of different malignancies. The agent has significant anti-inflammatory and immunosuppressant effects, and is classified as an antimetabolite cytotoxic drug [1]. These qualities has made methotrexate both a dramatically life-enhancing, and a potentially life-threatening medication.

In Afghanistan, the product is mainly, and liberally used to treat Rheumatoid Arthritis, a potentially disabling musculoskeletal conditions. There are no official guidelines and protocols available to regulate the use of medication in the country. Methotrexate is munificently used by generalists all over the country, all across the age spectrum.

As with all other prescribed medications in Afghanistan, the level of negligence and carelessness on the part of healthcare professionals and clients respectively, is frightening. Methotrexate like any other medication is available over the counter with no limitation. We have observed numerous scenarios where inappropriate use of Methotrexate has lead to dire consequences for patients in Afghanistan. We have a number of case reports available to us that illustrate examples of erroneous prescribing, unprescribed dispensation, and inappropriate administration and use of the drug.

Although, due to the absence of scientifically collected data, these cases are admittedly only of anecdotal importance, the scope of the problem is not of a negligible magnitude. Many colleagues who have travelled to Afghanistan have reported a consistent and identical story of Methotrexate misuse in the country. I went through some of these case reports, and identified the following life-threatening irregularities:

1- Use of Methotrexate as a first line treatment of joint pain, often in absence of a diagnosis of Rheumatoid Arthritis.
2- Failure to do base line, and follow-up blood tests, and absence of monitoring procedures.
3- Self-prescribing of methotrexate by patient, and use of methotrexate without doctor’s recommendation.
4- Absence of regulations to prevent unprescribed dispensation of methotrexate.
5- Prescribing practitioner’s unawareness of indications, interactions, monitoring, side effects of the drug.

The drug monitoring authorities [2], and healthcare regulating bodies worldwide [3], as well as drug manufacturing firms have specific and essential instructions for therapeutic use of methotrexate [1]. These essential recommendations are often ignored in Afghanistan, resulting in grave, and often fatal consequences for patients.

We are encouraging our colleagues to write up the case studies that they have encountered illustrating the hazardous use of Methotrexate and other cytotoxic drugs in Afghanistan. We hope this will illustrate the magnitude of problem, and prompt the healthcare authorities to take action. We believe that misuse of prescribed drugs in Afghanistan is becoming a public health issue for the country.

Moreover, Discourse Afghanistan is currently assessing the feasibility of devising a study to look closer into this problem, and its consequences for patients.

[1]- The electronic Medicines Compendium (eMC). Methotrexate, summary of product characteristics. Uly 2012. Available on line at Accessed on 08/09/2013
[2]- US Food and Drug Administration FDA. Methotrexate Safety Information. December 2011. Avaialable on line at Accessed on 08/09/2013
[3]- National Patient Safety Agency. Towards the safer use of oral Methotrexate. March 2005. Document available on line at Accessed on 08/09/2013.

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