Barriers to the use of methotrexate in Ethiopia for rheumatic diseases: Insights from pharmacy providers

Objectives: African countries with a Low Human Development Index (LHDI) face competing social, economic, and health priorities that distract from the treatment of chronic conditions like Rheumatoid Arthritis (RA). Methotrexate (MTX) is standard of care for RA. We sought to determine MTX availability and dispensing practices of Pharmacy Providers (PP) in Ethiopia, an LHDI country.Methods: Pharmacy Providers (PP) from across Ethiopia completed a survey regarding their experience with dispensing MTX for the treatment of rheumatic conditions. In addition, a semistructured interview was conducted with two pharmacists serving the country’s sole public rheumatology clinic. We report descriptive statistics from the survey and thematic analysis of the interview.Results: Twenty-three PP working in hospital and community pharmacies completed the survey. Oral MTX was available in 13% of pharmacies and dispensed by two PP for rheumatic conditions. Only three PP felt comfortable educating patients taking MTX. Interviewed pharmacists identified barriers to MTX use including inconsistent availability for rheumatic diseases, and sub-optimal patient acceptance due to low health literacy combined with social and cultural determinants of non-adherence. Identified needs included specialty specific tools and recommendations for prescribing, monitoring, and counselling patients regarding MTX that are appropriate to the local health and social environment.Conclusion: We identified key factors limiting the use of MTX among Ethiopian patients with rheumatic conditions including drug availability, confidence of pharmacists counselling on MTX, and patient confidence in the drug. Enhancing access to MTX and promoting training of health care professionals in patient counselling could optimize the treatment of rheumatic patients in LHDI.Keywords: Methotrexate, Pharmacists, Low Human Development Index, Africa, ILAR, Rheumatoid arthritis