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In this work, Christopher Chen examines and compares the regulation of over-the-counter derivatives in Hong Kong and Singapore, the two largest international financial centres in Asia Pacific. Chen analyses current or proposed regulations on trade reporting, centralised clearing and mandatory exchange trading mandates regarding OTC derivatives against the backdrop of reforms of international financial regulatory structure after the global financial crisis. The article also relates the reforms in Asia to development in major Western markets such as the US, the UK or the European Union. Apart from technical comparison and dissecting of content of rules from different angles, his work also examines the rationale behind those reforms and policy concerns behind Asian adoption of the regulatory mandates prescribed by G20 as well as potential policy concerns (such as competition and extraterritoriality) in a market that is dominated by Western banks.

Objectives To compare the efficacy and safety of single versus combination non-prescription oral analgesics in community-derived people aged 40 years and older with chronic knee pain. Methods A randomised, double-blind, four-arm, parallel-group, active controlled trial investigating short-term (day 10) and long-term (week 13) benefits and side-effects of four regimens, each taken three times a day: ibuprofen (400 mg); paracetamol (1000 mg); one fixed-dose combination tablet (ibuprofen 200 mg/paracetamol 500 mg); two fixed-dose combination tablets (ibuprofen 400 mg/paracetamol 1000 mg). Results There were 892 participants (mean age 60.6, range 40–84 years); 63% had radiographic knee osteoarthritis and 85% fulfilled American College of Rheumatology criteria for osteoarthritis. At day 10, two combination tablets were superior to paracetamol (p<0.01) for pain relief (determined by mean change from baseline in WOMAC pain; n=786). At 13 weeks, significantly more participants taking one or two combination tablets rated their treatment as excellent/good compared with paracetamol (p=0.015, p=0.0002, respectively; n=615). The frequency of adverse events was comparable between groups. However, by 13 weeks, decreases in haemoglobin (≥1 g/dl) were observed in some participants in all groups. Twice as many participants taking two combination tablets had this decrease compared with those on monotherapy (p<0.001; paracetamol, 20.3%; ibuprofen, 19.6%; one or two combination tablets, 24.1%, 38.4%, respectively). Conclusions Ibuprofen/paracetamol combination analgesia, at non-prescription doses, confers modest short-term benefits for knee pain/osteoarthritis. However, in this population, paracetamol 3 g/day may cause similar degrees of blood loss as ibuprofen 1200 mg/day, and the combination of the two appears to be additive. Study no ISRCTN77199439

Adult acne vulgaris affects up to 43–51% of individuals. While there are numerous treatment options for acne including topical, oral, and energy-based approaches, benzoyl peroxide (BPO) is a popular over the counter (OTC) treatment. Although BPO monotherapy has a long history of efficacy and safety, it suffers from several disadvantages, most notably, skin irritation, particularly for treatment naïve patients. In this prospective, randomized, controlled, split-face study, we evaluated the comparative efficacy, safety, and tolerability of a novel 3-step azelaic acid, salicylic acid, and graduated retinol regimen versus a common OTC BPO-based regimen over 12 weeks. A total of 37 adult subjects with self-reported mild to moderate acne vulgaris were recruited. A total of 21 subjects underwent a 2-week washout period and completed the full study with 3 dropping out due to product irritation from the BPO routine, and 13 being lost to follow-up. Detailed tolerability surveys were conducted at Week 4. Additional surveys on tolerability and product preferences were collected monthly, at Week 4, Week 8, and Week 12. A blinded board-certified dermatologist objectively scored the presence and type of acne lesions (open or closed comedones, papules, pustules, nodules, and cysts) at baseline, Week 4, Week 8, and Week 12. Patients photographed themselves and uploaded the images using personal mobile phones. Detailed Week 4 survey results showed across 25 domains of user-assessed product performance, the novel routine outperformed the BPO routine in 19 (76%) which included domains in preference (e.g. “I would use this in the future) and performance (“my skin improved” and “helped my acne clear up faster”). Users of the novel routine reported less facial redness, itching, and burning, though differences did not reach statistical significance. In terms of efficacy, both products performed similarly, reducing total acne lesions by 36% (novel routine) and 40% (BPO routine) by Week 12. Overall, accounting for user preferences and tolerability the novel routine was more preferred than the BPO routine in 79% of domains (22/28). Differences in objective acne lesion reduction were not statistically significant (p = 0.97). In a randomized split-face study, a 3-step azelaic acid, salicylic acid, and graduated retinol regimen delivered similar acne lesion reduction, fewer user dropouts, greater user tolerability, and higher use preference compared to a 3-step BPO routine based in a cohort of participants with mild-to-moderate acne vulgaris.

Polypharmacy is associated with reduced health-related quality of life (HRQoL). This study explores the association between prescription and non-prescription medication pill burdens, independent of underlying morbidity, on HRQoL in an older adult population. Data from the final intervention year of the ASPirin in Reducing Events in the Elderly (ASPREE) randomized trial in older adults from Australia and the USA, were analyzed cross-sectionally. Participants reported daily prescription and non-prescription pill counts at the final trial visit. HRQoL was assessed using the 12-Item Short-Form instrument (SF-12) and summarized into the physical component summary (PCS) score and mental component summary (MCS) score, where lower scores reflect poorer HRQoL. Multivariable regression, adjusted for covariates, was used to examine the relationships of categorized prescription and non-prescription pill counts with PCS and MCS separately. 15,165 participants responded to the question about prescription use and 15,727 for non-prescriptions (mean age = 80 years). Compared with non-users of prescription medications, lower mean PCS scores and larger reductions in scores were seen as prescription medication pill burden increased from 1-3, 4-6, 7-9, to ≥ 10 pills (- 1.7, - 4.5, - 7.6, and - 10.9, respectively, p < 0.001). A similar relationship, but of lesser magnitude, was observed with non-prescription medication pill burden, where the mean PCS was lower by - 0.2 for 1-3 pills (p = 0.494), - 1.8 for 4-6 (p < 0.001), and - 1.9 for ≥ 7 pills (p < 0.001), compared with non-users. No significant association was observed between prescription or non-prescription medication pill burdens and MCS. Prescription and non-prescription medication pill burdens are independently associated with reduced physical, but not mental, HRQoL in older adults.

Background Antimicrobial self-medication is common in most low and middle income countries (LMICs). However there has been no systematic review on non-prescription antimicrobial use in these settings. This review thus intended to establish the burden, risk factors and effects of antimicrobial self-medication in Low and Middle Income Countries. Methods In 2012, we registered a systematic review protocol in PROSPERO (CRD42012002508). We searched PubMed, Medline, Scopus, and Embase databases using the following terms; “self-medication”, “non-prescription”, ‘self-treatment’, “antimicrobial”, “antimalarial”, “antibiotic”, “antibacterial” “2002-2012” and combining them using Boolean operators. We performed independent and duplicate screening and abstraction of study administrative data, prevalence, determinants, type of antimicrobial agent, source, disease conditions, inappropriate use, drug adverse events and clinical outcomes of antibiotic self-medication where possible. We performed a Random Effects Meta-analysis. Results A total of thirty four (34) studies involving 31,340 participants were included in the review. The overall prevalence of antimicrobial self-medication was 38.8 % (95 % CI: 29.5-48.1). Most studies assessed non-prescription use of antibacterial (17/34: 50 %) and antimalarial (5/34: 14.7 %) agents. The common disease symptoms managed were, respiratory (50 %), fever (47 %) and gastrointestinal (45 %). The major sources of antimicrobials included, pharmacies (65.5 %), leftover drugs (50 %) and drug shops (37.5 %). Twelve (12) studies reported inappropriate drug use; not completing dose (6/12) and sharing of medicines (4/12). The main determinants of antimicrobial self-medication include, level of education, age, gender, past successful use, severity of illness and income. Reported negative outcomes of antimicrobial self-medication included, allergies (2/34: 5.9 %), lack of cure (4/34: 11.8 %) and causing death (2/34: 5.9 %). The commonly reported positive outcome was recovery from illness (4/34: 11.8 %). Conclusion The prevalence of antimicrobial self-medication is high and varies in different communities as well as by social determinants of health and is frequently associated with inappropriate drug use.

More than half of artemisinin combination therapies (ACTs) consumed globally are dispensed in the retail sector, where diagnostic testing is uncommon, leading to overconsumption and poor targeting. In many malaria-endemic countries, ACTs sold over the counter are available at heavily subsidized prices, further contributing to their misuse. Inappropriate use of ACTs can have serious implications for the spread of drug resistance and leads to poor outcomes for nonmalaria patients treated with incorrect drugs. We evaluated the public health impact of an innovative strategy that targets ACT subsidies to confirmed malaria cases by coupling free diagnostic testing with a diagnosis-dependent ACT subsidy. We conducted a cluster-randomized controlled trial in 32 community clusters in western Kenya (population approximately 160,000). Eligible clusters had retail outlets selling ACTs and existing community health worker (CHW) programs and were randomly assigned 1:1 to control and intervention arms. In intervention areas, CHWs were available in their villages to perform malaria rapid diagnostic tests (RDTs) on demand for any individual >1 year of age experiencing a malaria-like illness. Malaria RDT-positive individuals received a voucher for a discount on a quality-assured ACT, redeemable at a participating retail medicine outlet. In control areas, CHWs offered a standard package of health education, prevention, and referral services. We conducted 4 population-based surveys-at baseline, 6 months, 12 months, and 18 months-of a random sample of households with fever in the last 4 weeks to evaluate predefined, individual-level outcomes. The primary outcome was uptake of malaria diagnostic testing at 12 months. The main secondary outcome was rational ACT use, defined as the proportion of ACTs used by test-positive individuals. Analyses followed the intention-to-treat principle using generalized estimating equations (GEEs) to account for clustering with prespecified adjustment for gender, age, education, and wealth. All descriptive statistics and regressions were weighted to account for sampling design. Between July 2015 and May 2017, 32,404 participants were tested for malaria, and 10,870 vouchers were issued. A total of 7,416 randomly selected participants with recent fever from all 32 clusters were surveyed. The majority of recent fevers were in children under 18 years (62.9%, n = 4,653). The gender of enrolled participants was balanced in children (49.8%, n = 2,318 boys versus 50.2%, n = 2,335 girls), but more adult women were enrolled than men (78.0%, n = 2,139 versus 22.0%, n = 604). At baseline, 67.6% (n = 1,362) of participants took an ACT for their illness, and 40.3% (n = 810) of all participants took an ACT purchased from a retail outlet. At 12 months, 50.5% (n = 454) in the intervention arm and 43.4% (n = 389) in the control arm had a malaria diagnostic test for their recent fever (adjusted risk difference [RD] = 9 percentage points [pp]; 95% CI 2-15 pp; p = 0.015; adjusted risk ratio [RR] = 1.20; 95% CI 1.05-1.38; p = 0.015). By 18 months, the ARR had increased to 1.25 (95% CI 1.09-1.44; p = 0.005). Rational use of ACTs in the intervention area increased from 41.7% (n = 279) at baseline to 59.6% (n = 403) and was 40% higher in the intervention arm at 18 months (ARR 1.40; 95% CI 1.19-1.64; p < 0.001). While intervention effects increased between 12 and 18 months, we were not able to estimate longer-term impact of the intervention and could not independently evaluate the effects of the free testing and the voucher on uptake of testing. Diagnosis-dependent ACT subsidies and community-based interventions that include the private sector can have an important impact on diagnostic testing and population-wide rational use of ACTs. Targeting of the ACT subsidy itself to those with a positive malaria diagnostic test may also improve sustainability and reduce the cost of retail-sector ACT subsidies. ClinicalTrials.gov NCT02461628.

More and more elderly people with cancer are treated in oncology clinics worldwide every year, many of whom have comorbid disorders treated with one or more drugs. Moreover, these patients might also take self-prescribed over-the-counter drugs or complementary and alternative medicines, which they might not tell their doctor about. Initiation of chemotherapy with one or more cytotoxic or targeted agents and drugs for treatment of cancer symptoms or toxic effects related to treatment can result in polypharmacy. We examine the clinical implications of polypharmacy. Challenges for the medical teams who treat elderly patients with cancer include identification of what drugs are actually being taken by the patient, avoidance or management of any adverse effects or drug interactions, and reassessing the patient's overall treatment. We address these issues and propose practical recommendations for management of treatment for elderly patients with cancer.

Access to medicines without prescription is a major contributing factor for self-medication practices. This study was designed to examine the ratio of non-prescribed medicines sales and self-medication practices in Punjab, Pakistan. This study also evaluates the reasons for self-medication within its communities. An observational study was conducted in 272 systemically selected pharmacies to analyze medicines-related sales, with or without prescription. A cross-sectional survey was performed between June 2015 and November 2016. Consumers were interviewed about their self-medication practices. Of the pharmacies surveyed, 65.3% participated in the study. A total of 4348 medicines were purchased for self-medication by 3037 consumers (15.2% of all study participants), of which 873 (28.7%) participated in an interview. Majority (81.2%) medicine purchaser, (90.9%) interview participants, and (59.4%) drug users were male. On average, each community pharmacy sold 7.9 medicines without prescription each day, to an average of 5.5 customers. Many participants (28.9%) had matriculation in their formal education. The medicines most often sold for self-medication were analgesics and antipyretics(39.4%). More than 25% of participants reported fever symptoms and 47.8% assumed their illness was too trivial to consult a doctor. Media advertisements were the most common source of information for participants (46.7%). Many types of medicines were often sold without prescription from community pharmacies. Self-medication was common practice for a wide range of illnesses. Pakistan also needs effective implementation of policies to monitor medication sales. Public education about rational medication and limits to advertising medicine are very necessary.

In much of the world antimicrobial drugs are sold without prescription or oversight by health-care professionals. The scale and effect of this practice is unknown. We systematically reviewed published works about non-prescription antimicrobials from 1970–2009, identifying 117 relevant articles. 35 community surveys from five continents showed that non-prescription use occurred worldwide and accounted for 19–100% of antimicrobial use outside of northern Europe and North America. Safety issues associated with non-prescription use included adverse drug reactions and masking of underlying infectious processes. Non-prescription use was common for non-bacterial disease, and antituberculosis drugs were available in many areas. Antimicrobial-resistant bacteria are common in communities with frequent non-prescription use. In a few settings, control efforts that included regulation decreased antimicrobial use and resistance. Non-prescription antimicrobial and antituberculosis use is common outside of North America and northern Europe and must be accounted for in public health efforts to reduce antimicrobial resistance.

Background Although over the counter (OTC) drugs are believed to be relatively safe, their inappropriate use could have serious implications. The aim of the study was to assess the practice of self-medication, prevalence of risky practice and its associated factors in pharmacy outlets of Asmara, Eritrea. Methods A descriptive cross-sectional study was conducted among 609 customers in 20 pharmacy outlets in Asmara between August and September, 2017. Two-stage cluster sampling was employed and data were collected using a structured questionnaire through face to face exit interviews. Descriptive statistics and multivariate logistic regression were performed using SPSS (version 22). Results Of the 609 customers, 93.7% had practiced self-medication with OTC drugs; of which 81.8% were at risky practice. On average, each participant was using OTC drugs at least once a month (Median = 1, IQR = 3.67). Educational level ( p  < 0.0001), religion ( p  = 0.047), occupation ( p  = 0.027) and knowledge regarding OTC drugs ( p  = 0.019) were significantly associated with risky practice. Respondents with elementary and below educational level were fifteen times (AOR = 15.49, CI: 1.97, 121.80) at higher risk compared to those with higher education, and students were almost three times (AOR = 2.96, CI: 1.13, 7.73) at higher risk than governmental employees. Furthermore, respondents with below average score in knowledge were more likely to be engaged in risky practice (AOR = 1.83, CI: 1.11, 3.04) compared to those with above average score. The most frequently preferred OTC drug group was analgesics (34.3%) followed by antipyretics (15.7%) and cough and cold preparations (14.2%). About 14% of the respondents admitted that they had taken more than the recommended dose and 6.9% had experienced drug related problems following the consumption of OTC drugs. Always, 35% of the respondents read package insert(s) and 73.9% check expiry dates while purchasing OTC drugs. Refrigerating OTC drugs, where it is not recommended, was also one of the prominent risky practices. Conclusions This study revealed that inappropriate self-medication practice with OTC drugs was prevalent requiring early intervention to minimize the risks.