RESULTS AND DISCUSSION
Fifty-eight questionnaires were delivered to 29 pharmacists from the
Public Health Units of Vitória and 29 pharmacists from randomly selected
Private Pharmacies. Three pharmacists from the Public Health Units and
two from Private Pharmacies declined to participate in the survey. Thus
based on the inclusion criterion initially established in the study, 26
questionnaires were analyzed from 26 pharmacists in the Public Health
Units of Vitória and 27 questionnaires from 27 pharmacists from the
Private Pharmacies.
The main results are shown in table 1.In the group of private
pharmaciesthe majority of pharmacistswere in the range of 18-30 years
old and in the other group were in the range of 31-42 years old. In the
Private Pharmacies group, there were no pharmacists over 42 years old,
exhibiting that this pharmacies have professionals younger than the
Public Health Units group.Oliveira19also found a
similar demographic profile,when analyzing the age range of pharmacists
in Brazil. The authors identified that the majority of participating
professionals were 30 years of age, constituting a young group of
pharmacists, trained for a maximum of five years in private college.
In general, the public services there was a higher number of female
professionals compared to men, while in private pharmacies the number of
women and men was similar. Oliveira19 also observed
the prevalence of women in the profession while investigating the
sociodemographic profile of pharmacists in public and private
establishments. In terms of time spent in the pharmacist profession, the
majority of Public Health Unit professionals had 11 to 15 years of
professional practice, whereas individuals employed by private
pharmacies possessed less than a year to 5 years of practice.
In relation to their professional practice, when the pharmacists in the
sample were questioned about their knowledge of the phytotherapeutic
properties of H. perforatum and their indication, the majority of
the Public Health Units professionals responded positively to both
questions.The pharmacists in the Private Pharmacies group displayed the
same results as the Public Health Units group. Considering that the
number of samples for each group was nearly the same, with observing
only the relative frequencies of each response to the questionnaire, it
was observed that the number of participants who possessed limited
knowledge of the phytotherapeutic properties of H. perforatum was
smaller in the Public Health Units group versus the Private Pharmacies
group. ( x² = 22.7985, p = 0.000001) (Table 1).
The pharmacists of Public Health Units reported knowledge of dosage size
and care in the use of H. perforatum . In the Private Pharmacies
group less than half of the sample reported knowledge of proper dosage
and an even smaller percentage reported possessing knowledge about the
care in use of H. perforatum . In relation to the pattern observed
in the previous responses, professionals in the public sector
demonstrateda more advanced knowledge of the utilization and proper
dosage of herbal medicines.
Public Health Units participants mentioned several precautions to
consider when using H. perforatum for medicinal purposes, with
several similar warnings being mentioned in more than one questionnaire
response. The precautions that were mentioned by at least one
interviewee were not to use alcohol, inform the doctor of any adverse
reaction, do not exceed the allotted dose of three times a day, do not
use for severe depression, do not use during lactation and gestation,
and do not mix with another antidepressant. The precautions that were
mentioned at least two times were use sunscreen, and do not take
continuously. The precautions which was mentioned at least six times was
avoid sun exposure and the precaution which was mentioned seven times
was precaution of interactions with other drugs. The Private Pharmacies
group mentioned at least one precaution of being aware of potential drug
interactions. Reducing sun exposure while taking H. perforatumwas the most frequent precaution mentioned by the Private Pharmacies
group. Finally, concomitant use of another antidepressant, a restriction
for diabetics, pregnant women and people using anticonvulsants during
the utilization of H. perforatum were mentioned at least once in
the responses of the private pharmacies group.
In regard to the principle that all pharmacists should be continuously
updating their knowledge of pharmaceutical
practices18, the following question in the
questionnaire was related to the professional’s knowledge about
interactions H. perforatum preforms with other drugs. For the
Public Health Unit group (n= 25), all participants stated that they had
knowledge about the interaction potential of H. perforatum. Among
the Private Pharmacies group (n = 20), only 25% reported knowledge of
interaction potential. (with a x2= 111.2139, p value=
0.00000007) (Table 1).
Concerning the related research on the risks of the use of H.
perforatum concomitant with other drugs, it is important to note that
several authors have described the risks in the use of H.
perforatum concomitant with other medications, food and other
substances12,13,14, 21,20,22. In regards to which
drugs interact with the herbal medicine , the majority of Private
Pharmacies did not respond to the question. Pharmacists from the Public
Health Units and Private Pharmacies suggested more than one drug has the
potential to interact with H. perforatum , with the following
cited: immunosuppressors, medicines to treat heart failure,
antiretrovirals, antibiotics, antihypertensives, antidiabetics,with five
mentions each, anticoagulants, anticonvulsants with six mentions each,
and antidepressants and contraceptives with nine mentions each. (Table
1).
Regarding the usual therapeutic indication and dosage, the Public Health
Unit group answered that H. perforatum acts as an antidepressant
and should be administered three times a day and the Private Pharmacies
group reported the plant’s performance as sedative, antidepressant, and
for use in the treatment of symptoms related to menopause. Among the
related medicinal properties, the antidepressant effect of this herbal
medicine has been of particular interest to the scientific
community9, 11 22, 23, 24. For example, clinical
studies have suggested that aqueous extracts of H. perforatum are
as effective as synthetic antidepressants and cause fewer side
effects7. Linde25 further claimed
that such extracts are comparable to the other forms of antidepressants
used in the treatment of mild to moderate depression. The indications
and dosages reported by the Public Health Unit group aligned with those
referenced in the scientific literature.The indications described by the
Private Pharmacies group display that despite the statement that the
indication of the herbal medicine is known, respondents stated thatH. perforatum is utilized in menopausal therapy, which is not in
accordance with the official indications presented for the medicinal
product.
In the public Health Units, at least half of pharmacists interviewed did
not know the indicated dose for this phytotherapic. Similar results were
observed in the Private Pharmacies group when pharmacists were
questioned about the dosage and indication of the medicine.
The efficacy and tolerance of H. perforatum was compared with
fluoxetine and placebo for treatment of depression in a double-blind
clinical trial lasting over a period of 4 weeks. A demonstrated
remission rate was significant for both H. perforatum and
fluoxetine compared to placebo (H. perforatum 24%, fluoxetine
28% and placebo 7%). Phytotherapy was more tolerated than fluoxetine
and both medicines were equally effective in short-term
treatment23. Another study comparing H.
perforatum fluoxetine, and a placebo sought to evaluate the efficacy of
herbal medicine in patients with Major Depressive Disorder, through
exploratory analyzes from a double-blind study. The researchers
concluded that H. perforatum also showed a trend towards greater
efficacy compared to fluoxetine and the placebo24.
However, it was noted in the study that the use of H. perforatummight cause adverse side effects.
The European Medicines Agency Committee on Herbal Medicinal
Products21 reported H. perforatum drug
interactions with benzodiazepines, oral contraceptives, antidepressants,
voriconazole, methadone, digoxin, theophylline, cyclosporine and
finasteride. A study by Mao &Gubili 201712 warned of
the interactions between H. perforatum, chemotherapeutics, and
antidepressants, which resulted in their reduced efficacy. There are
studies that relate drug interaction with a reduction of plasma levels
and interaction with cytochrome P45012, 14, 21, 22,
26, . Interactions have been reported particularly with drugs, which
are a substrate of cytochrome P450 (CYP), which are enzymes that are
common sites of drug interactions in humans,and P-glycoprotein which is
one of the most clinically important transmembrane transporters in
humans. Clinical studies suggest that H. perforatum may modulate
CYP activity and has been shown to lower plasma concentration of
well-known P-glycoprotein substrates, including digoxin, fexofenadine,
and talinolol14.
The result found in the textual analysis with the calculation of
frequency of words is shown in figure 1
In relation to knowledge of the adverse side effects ofH.
perforatum , the Public Health Unit professionals reported not knowing
of any adverse effects but suggested at least one of the
following:dizziness,dry mouth, increased pressure and skin blemishes,
allergic reactions, gastrointestinal irritations, and photosensitivity.
In the Private Pharmacies group, the majority did not respond and a
percentage suggested at least one of the following adverse effects:
dizziness, dry mouth, nausea, fatigue, swelling in the legs, drowsiness,
intoxication, allergic reactions, and, gastrointestinal irritations.
Comparing the adverse effects mentioned by both groups, no adverse
effects of H. perforatum use were found in the literature. As
described by Henderson et al. 200215, the known
adverse effects are gastrointestinal symptoms, allergies, dry mouth,
mental confusion, fatigue, dizziness, and sedation with each adverse
effect existing in the mild to moderate, or even transient range. Such
scientific descriptions corroborate with that described by both sample
groups. The analysis of the response from both sample groups suggests
that knowledge of the adverse effects of H. perforatum use is
still low. According to a review by the European Medicines Agency
(2009)21, the adverse side effects of H.
perforatum are nausea, headache, dizziness, pain, melancholia, heart
palpitation, abdominal pain, insomnia, diarrhea, acute deterioration,
dry mouth, allergic reaction to sunlight, asthenia, sweating, somatic
disorder, cerebral hemorrhage, autonomic nervous system disorder, skin
and appendage disorders, sleep disturbance, sexual problems,
forgetfulness, ear and labyrinth disorders, frequent urination, blurred
vision, tremor muscle spasms, muscle joint stiffness, lack of appetite,
fatigue, bronchitis, influenza-like symptoms, cough, infection,
drowsiness, constipation, pruritus, restlessness, tremor, and
gastrointestinal disorders. Among these listed side effects, at least
five were mentioned by five of the interviewees in this study.
In order for pharmacists to be able to guide the use and care ofH. perforatum , it is necessary for pharmacists to obtain and
maintain knowledge about the drug, including knowledge of the adverse
side effects and interactions. From the Public Health Unit group, most
professionals affirmed having learned about H. perforatum in
continuing education training and most of Private Pharmacies reported
having learned about the H. perforatum drug through family
tradition, an educational training course, popular knowledge, and
academic knowledge.
In the Public Health Units group the greatest source of information was
in the form of an educational training course.In the Private Pharmacies
group, the majority stated that the academic medium and popular
knowledge as sources of information about H. perforatum . Popular
wisdom is commonly used to obtain information on indications of use,
efficacy, and safety of medicinal plants and herbal
medicines27. However, randomized, double-blind, and
controlled clinical trials conducted with herbal medicines provide new
insights and are recent reliable sources of information with
methodological standards that can reduce risks and
uncertainties27. Access to this information is
provided through training courses, which are unfortunately becoming
increasingly scarce. Oliveira17 observed that the
percentage of interviewed pharmacists who received training was nearly
equivalent to those who rarely received formal training. It is clear
that professionals working in public pharmacies receive continuing
education in service, while professionals working in private pharmacies
rely on familial and popular knowledge, but still seek extension courses
to update themselves, and a percentage reported having received the
knowledge during the training period of their occupation.
Pharmacists were also asked to keep up to date on the innovations and
recent events in the field of herbal medicines. Pharmacists in thePublic
Health Units group mentioned at least one of the following sources to
remain current in the field of herbal medicine: popular journals and
magazines, educational courses, continuing education, and academic
journals. The Private Pharmacies professionals cited at least one of the
following sources: educational courses, permanent education, newspapers,
and popular magazines and journals (Table 1).
Heckler28, when analyzing the profile of 20
pharmacists, suggested that they used books, information from suppliers,
and the internet as a sources of information about herbal medicines.
However, it is important to note that the books mentioned are national
and often package inserts and manuals that contain a restricted
information about the medicine and cannot be supported by the
pharmacist. Rates29 affirmed that the prevalence of
this type of reading has been considered a determinant for the poor
quality of information provided to the user of the herbal medicine.
The basic elements of primary and pharmaceutical care are similar and
both fields include care centered around the patient, knowledge about
the treatment of acute and chronic disorders, prevention of injuries,
effective documentation service delivery, universal access, ongoing care
and systematically integrality of care, the responsibility for
treatment, including correct guidance with follow up of the user
treatment, and promotion of education and health30.
The professionals from both groups affirmed that they did not follow up
with users during their treatment with the medicine H.
perforatum, but pharmacists from both groups provided information to
users about the mode of use, interactions, and side effects. According
to Kirby31 patients’ knowledge of their condition and
disease improves adherence to treatment and are among the strategies to
promote the rational use of medicines, with pharmaceutical counseling
being one of these measures. Glaeser32 stated that
pharmacists are the most available health professionals for the general
population and are as relevant to patient care as the services provided
by other less available health professionals. When asked about what
makes the users’ orientation difficult, the majority of pharmacists
indicated the lack of pharmacy structure and the lack of user knowledge.
In a general evaluation, respecting the limit of the research and the
sample number obtained, greater knowledge about the herbal medicineH. perofatum by the pharmacists in Public Health Units was
evident with a p value< 0.05. Silva et al.33emphasized that little attention is given to the development of
communication skills, a fundamental point for this practice within
pharmacies, however, they concluded that it is possible to develop them
continuously, through lifelong education or in-service training. Based
on data similar to Silva et al.33 Vitoria’s
authorities implemented a course of continuing education for the
pharmacists from Public Health Units. It is possible that the policies
implemented by the municipality may be responsible for the current level
of knowledge about H.perforatum in the Public Health Units group.
The results suggest that pharmacists in Public Health Units receive more
information and obligatorily follow protocols for dispensing, whereas in
private pharmacies the pharmacist must obtain knowledge through
extension courses or postgraduate courses, contrary to pharmacists in
Public Health Units who receive continuing education in service.