Anti-inflammatory drugs; A closer look at the risks in Somaliland



Self-medication has been defined in various ways as the act of procurement and consumption of pharmaceuticals without consulting medical practitioner. Self-medication trends in different regions of the world are high like in India it is 31% and 59% in Nepal, and 62 % in Somaliland according to my estimations as there is no currently relevant data that shows the use of Nsaids in Somaliland .And it is alarming despite the efforts made to control this problem it decreases day by day.

In general, once a drug is on the market the threshold for removing it is fairly high. For example, Paracetamol, a drug if taken in overdose can cause liver failure and is the leading cause of liver transplants . The daily recommended use of Paracetamol is 6 tablets per day.

Acetylcysteine, which is mucolytic and antidote for paracetomol overdose can treat liver failure if taken in the appropriate time. Acetylcysteine which is available on the Somaliland market as (ASIST) is imported by Mubarak Pharmaceutical Company. Paracetamol is an effective pain reliever and safe at appropriate doses.


NSAIDs are among the most widely used drugs, starting in infancy for pain and fever, right through to the elderly where they are standards for treating osteoarthritis and other muscle and skeletal conditions. NSAIDs all work in the same way, blocking the cyclooxygenase (COX) enzyme, responsible for the production of prostaglandin messenger substances that cause pain, inflammation and fever. The mechanism of action is also responsible for the extensive side effect list, a consequence of COX enzymes being distributed throughout the body. Ulcers are the most well-known effect and hospitalization secondary to gastrointestinal bleeding from NSAIDs is common. Fortunately these side effects can be prevented with drugs like proton pump inhibitors. The other well-known side effect is cardiovascular disease, and NSAIDs seem to increase the risks of heart attacks and strokes. There are two main subtypes of COX enzymes (conveniently, COX-1 and COX-2) and the affinity of a particular NSAID for the different COX enzymes seems to be the main factor influencing the degree of cardiovascular risk.

Now in a world that responds quickly to new evidence we’d expect to see a shift away from the NSAIDs with the worst side effect profiles and towards more use of those with the best side effect profiles. After all, no NSAID has been shown to be clinically more effective than another in trials, although individual responses can vary. But the most toxic NSAIDs are still used widely, as was noted recently in a paper published in PLoS Medicine, entitled, Use of Non-Steroidal Anti-Inflammatory Drugs That Elevate Cardiovascular Risk: An Examination of Sales and Essential Medicines Lists in Low-, Middle-, and High-Income Countries by Patricia McGettigan and David Henry. NPR’s headline was perhaps a more succinct summary of the key finding, which was World’s Most Popular Painkiller Raises Heart Attack Risk. It’s important to note that this paper doesn’t present any previously unpublished information about NSAID safety, but it does an effective job of illustrating the disconnect between medical evidence and medical practice.

All NSAIDS can cause side effects if not taking in the appropriate way and these side effects include:

  • indigestion
  • stomach ulcer (a sore in the lining of the stomach)
  • increased blood pressure
  • gastrointestinal bleeding – internal bleeding within the digestive system
  • anemia – where blood is unable to carry enough oxygen around your body which can cause shortness of breath and tiredness
  • gastrointestinal perforation – where a hole occurs in the wall of your stomach or intestines

Rare side effects include:

  • heart failure – the heart is having trouble pumping enough blood around the body
  • heart attack
  • hypertension (high blood pressure that needs treatment)
  • stroke
  • making pre-existing inflammatory bowel disease (IBD) worse




Ways to improve Drug use in Somaliland

  1. Maintain an accurate medication and medical history: Identify all medications, including any over the counter (OTC) therapies. Having a complete list of medications can deter a provider from adding on an additional therapy. Further, knowledge of a specific medication being used may explain a patient-specific symptom or complaint. For example, knowing a patient is on an opiod analgesic may explain why he or she has constipation. A complete history of the patient’s medical condition also is important. Identifying the patient medical history allows the pharmacist to identify inappropriately prescribed medications. For instance, metformin is not appropriate for patients with end-stage kidney disease.
  2. Link each prescribed medication to a disease state: Each medication should match a patient’s diagnosis. Any medication that does not match a diagnosis is potentially unnecessary, and an attempt to discontinue the medication should be made.
  3. Identify medications that are treating side effects: The use of multiple medications leads to a higher risk of side effects. When side effects occur, additional medications can be initiated to treat the side effect. A common example includes the use of laxatives to treat the medication side effect of constipation. Other examples include, Aricept (donepezil) to treat cognitive impairment caused by obybutynin, tolterodine, antihistamines, opiods and benzodiazepines. Discontinuing one drug that is causing a side effect can often lead to the discontinuation of several drugs.
  4. Giving necessary training to the pharmacists and also creating community awareness through media, universities and etc.
  5. Taking preventions during prescription: The appropriateness of the medication for the patient and the potential for side effects must be considered. Any drug that is unnecessary, inappropriate, or has a high likelihood for causing side effects that would require additional therapy should be avoided.
  6. Last but not least, Never take NSAIDS on empty stomach as they can cause stomach bleeding and ulcer.



The prevalence of self-medication practice is remarkably high in the Somaliland and is nearly despite the fact that majority of the people may not know it is risky. On this basis it can be assumed worse situation in smaller cities and villages where there is low literacy rate. This calls for proper awareness training programs nationwide, restricting unnecessary drugs’ advertisements, check and balance on pharmacies regarding OTC products and prescription only drugs and ensuring access of common man to essential drugs.


Written By:

Mustafe Khalid Mohamed

PhD candidate



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