Jul-Sep, 2012 - Indian Journal of Pharmacy Practice
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Jul-Sep, 2012 - Indian Journal of Pharmacy Practice

Jul-Sep, 2012 - Indian Journal of Pharmacy Practice Jul-Sep, 2012 - Indian Journal of Pharmacy Practice

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Mohammed Saleem TK - Assessment of Drug Prescribing Patterns in Dermatology Outpatient Department in a Tertiary Care Hospital, Malabar, Keralaavailability of medicines, overwork of health personnel,inappropriate promotion of medicines and profit motivesfrom selling medicines. The study of prescribing patternsseeks to monitor, evaluate and if necessary, suggestmodifications in the prescribing behavior of medical7,practitioners to make medical care rational and cost effective8.To monitor, standardize and afford Comparability of results,WHO in collaboration with the International Network for theRational Use of Drug (INRUD) developed core indicators for9assessing drug use . This study utilized these drug-use coreindicators to describe patterns of drug use at dermatologydepartment in a tertiary care hospital to provide feedback tothe prescriber and to create awareness among them aboutrational use of medicines. In this study an attempt was made toassess the drug prescribing patterns in dermatology outpatientdepartment in a tertiary care hospital and to obtaininformation on demographic characteristics of the patientsselected for analysis. Also an attempt was made to describethe patterns of prescribing practices by using WHO/INRUDdrug-use core indicators likeŸ To evaluate average number of drugs per encounterŸ To determine percentage of drugs prescribed by genericnameŸ To determine percentage of encounter with an antibioticprescribedŸ To determine percentage of drugs prescribed from WHOessential drug listŸ To determine percentage of fixed drug combination fromWHO essential drug listMETHODOLOGYA prospective study was carried out over six months (August2010-January 2011) in the Dermatology outpatientdepartment of tertiary care referral hospital in Malabar regionof Kerala after obtaining requisite permission. Hospital catersthe treatment requirement to the people from all over northKerala. Ethical approval for the study was obtained from thehospital ethical committee. Confidentiality and anonymity ofthe patients were maintained during the study. Allprescriptions issued to patients attending the dermatologyoutpatient department during this period following each day'sconsultation were copied out from the case files and recordedin data collection forms adapted from WHO guidelines on9how to investigate drug use in health facilities . Data wasobtained from a total of 500 prescriptions which includes ageand gender of the patients, the diagnosis, the drugs prescribed,their strength, frequency, route of administration and durationof treatment and the prescriptions were subjected tomeasuring the appropriateness of prescription. Misuse of anyone of these parameters was taken as indication of a problemprescription.The Prescriptions were subjected to critical evaluation usingWHO prescribing indicators.a) Average number of drugs per encounter was calculated bydividing the total number of different drug productsprescribed by the number of encounters surveyed.b) Percentage of drugs prescribed by generic name wasdetermined by dividing the number of drugs prescribed bygeneric name by the total number of drugs prescribed,multiplied by 100.c) Percentage of encounters with an antibiotic prescribedwere calculated by dividing the number of patient encountersduring which an antibiotic was prescribed by the totalnumber of encounters surveyed, multiplied by 100.d) Percentage of drugs prescribed from essential druge) Percentage of fixed-dose combination prescribedAll the findings were recorded, compiled, tabulated andanalyzed. The analyzed data were expressed in percentage.RESULTSA total of 500 cases were analyzed. The catchment area of ourhospital is Malabar region of Kerala; Fig 1 & 2 provides thegender distribution & age wise distribution of patient indermatology OPD, respectively. 248 patients (49.6%) werefound to be female followed by male, 252 patients (50.4%).The age group 20-29 yrs was accounted for the highestnumber of 125(25%) of patients. Total number of drugs in500 prescriptions was found to be 1230. Number of drugs perprescription varied from 1 to 7 with average of 2.46(Fig 3).Most of the prescription consists of minimum of 3 drugs(185prescription, 37%). Only 1% drugs were prescribed ingeneric name. Fig 4 shows the appropriateness of theprescription which indicates the good rational prescriptionhabit of the doctors. Injectables were found to be rarelyprescribed in this OPD (1 out of 1230drugs). The mostcommonly prescribed systemic agents were antihistamine(294) followed by antibiotics (181) & antifungal agents (49).The most commonly prescribed topical agents were topicalsteroids & its combination (236) followed by topicalantifungal agents (124). All systemic agents were given orallyexcept (Inj.kenacort; triamcinolone for treatment of alopeciaAreata). Major therapeutic agent found among the drugcategory is presented in Fig 6, results reveal that levocetrizinewas found to be the major drug among the antihistaminegroup, Fluconazole among antifungal, Clobetasole amongsteroidal agent and Roxithromycin was found among theantibiotic agent. Analysis of steroids revealed that 262patients require steroids and its combination with antibiotics.Out of 262 patients, 125 used very potent topical steroids(clobetasole). 86 patients got steroid combination withantibiotics. Only 25 patients got systemic steroidal therapyIndian Journal of Pharmacy Practice Volume 5 Issue 3 Jul - Sep, 2012 63

Mohammed Saleem TK - Assessment of Drug Prescribing Patterns in Dermatology Outpatient Department in a Tertiary Care Hospital, Malabar, Kerala(omnacortil) (Fig7), and efficacies of these steroids arepresented in Fig 8, which shows that most of the prescriptionscome under high potency steroidal agent. Among the topicalsteroidal agent 91% of the patient got high potency steroidalagent (clobetasole). Analysis of antifungal group (Fig 9)revealed that out of 173 patients requiring an antifungal, 43patients received one topical and one oral antifungal. While14 patients got topical antifungal combination with steroids,20 patients received one topical and one oral and 90 patientsgot only topical antifungal agent, 29 patients received onlysystemic antifungal agents. Fluconazole was most commonlyprescribed because its monthly dose provides cost effectivetreatment and decrease propensity for adverse effect. FromFig 11, it can be seen that antibiotics were prescribed in 287prescriptions out of the total 500 patients, among that mostprescribed drug was Roxithromycin. Only 15 patientsreceived antibiotic combination with steroids. Most of theantibiotic prescriptions were used in case of dermatitis,Eczema, pyoderma condition. Analysis showed that about58.8 % (294 out of 500) patients received at least oneantihistamine, the two antihistamines were prescribedtogether on 4 occasions (Fig 10). Present study shows thatvitamins are usually recommended in the case ofpigmentation disorder like vitiligo, melasma etc and Vit.Acontaining topical agent were used in case of acne &ichthyosis. Among astringent category, calamine was themost commonly prescribed products. The miscellaneouscategory included NSAIDS, proton pump inhibitors,analgesic, Antiviral and antiparasitic agent agents (Fig12).study reveals that Fungal infection were the largest groupof disorder among which T.versicolor was most observedinfection agent. High incidences of Dermatitis andhypersensitivity disorder were found in our study, among thatseborrheic dermatitis was most frequently found. About 9.6%of patients reported with pigmentation disorder. Incidence ofviral infection (0.8%), parasitic skin infection (1.6%) wasrelatively low. Among the non infective skin disorder,Eczema emerged as the single largest disorder (10.0%) (Fig14).WHO/INRUD rational drug-use indicatorsWHO prescribing indicators are given in Fig 13, result revealsthat out of the total 1230 individual drugs prescribed, 13 (1%)were prescribed by generic names and about 18.78% of thedrugs were prescribed from the WHO essential drug list. Atotal of 1230 individual drugs were prescribed in 500encounters. Overall, the average number of drugs perencounter was 2.46. Analyzing for antibiotic prescriptionshowed that 287 individual antibiotics were prescribed for500 patients. Some patients had received more than oneantibiotic, as a systemic preparation in combination witheither a topical application or another systemic preparation.None of the patients received triple antibiotics. Overall, theproportions of encounters with at least one antibioticprescribed shows 23.3%. Present study shows that total of9.75 % drugs prescribed as fixed drug combination, amongthat only 0.2% accounting as essential one.DISCUSSIONIn the present study, even though the sample size was not verylarge, it gave a cross-section of patients and the diseases forwhich they reported for treatment. The disease profiledescribed in this study corresponds well with the healthstatistics from the Indian dermatology department (fungiinfection, dermatitis) accounting for most morbidity reportedfrom the dermatology outpatient department. The number ofmale patients was more than females and the ratio was more. 11than that expected from the sex ratio of other studies It isimportant to choose the right medicine(s) for a patient and inan appropriate manner in order to achieve the best results ofmedicine therapy. In our study it is heartening to note thatmore than 90 percentage of medicines, recorded route ofadministration, dose, frequency of administration andduration of treatment. This positive observation would be asign of good prescribing patterns in this dermatologyoutpatient department. The irrational use of drugs is acommon occurrence throughout the world. Average numberof drugs per prescription is an important index of prescriptionaudit. In our study the mean number of drugs per prescriptionwas found to be 2.46, it was lower than what had been12previously reported in other studies in Western Nepal and. 13other parts of India It is preferable to keep the number ofdrugs per prescription as low as possible since higher figureslead to increase risk of drug interaction, adverse effect andincreased cost to the patient. Our study reports that only 1% ofdrugs were prescribed by generic name. Our value is less than14, 15 .that reported in other studies The decreasing percentageof drugs prescribed by generic names in our hospital is amatter of concern and the reasons for these should beinvestigated. Prescribing by brand name may be an evidenceof dangerous promotional strategy by pharma companies.Our study revealed that the percentage of drugs prescribedfrom WHO essential drug list was only 20.16%, which islower compare to that of the study conducted in North India10(75-95%) . The possible reason for this lower value could bethe prescribers lacking the understanding and importance ofessential drug concept. The low rate of prescribing fromWHO essential drug list may be contributed by excessive useof antihistamines (cetrizine), antibiotics (Roxithromycin,fusidic acid) and several topical steroidal preparation whichare not included in WHO essential drug list. In the presentstudy total of 9.75% fixed drug combination were prescribed,among that only 0.2% could be considered as essential whichis much lower than what have been previously reported (39%)Indian Journal of Pharmacy Practice Volume 5 Issue 3 Jul - Sep, 2012 64

Mohammed Saleem TK - Assessment <strong>of</strong> Drug Prescribing Patterns in Dermatology Outpatient Department in a Tertiary Care Hospital, Malabar, Keralaavailability <strong>of</strong> medicines, overwork <strong>of</strong> health personnel,inappropriate promotion <strong>of</strong> medicines and pr<strong>of</strong>it motivesfrom selling medicines. The study <strong>of</strong> prescribing patternsseeks to monitor, evaluate and if necessary, suggestmodifications in the prescribing behavior <strong>of</strong> medical7,practitioners to make medical care rational and cost effective8.To monitor, standardize and afford Comparability <strong>of</strong> results,WHO in collaboration with the International Network for theRational Use <strong>of</strong> Drug (INRUD) developed core indicators for9assessing drug use . This study utilized these drug-use coreindicators to describe patterns <strong>of</strong> drug use at dermatologydepartment in a tertiary care hospital to provide feedback tothe prescriber and to create awareness among them aboutrational use <strong>of</strong> medicines. In this study an attempt was made toassess the drug prescribing patterns in dermatology outpatientdepartment in a tertiary care hospital and to obtaininformation on demographic characteristics <strong>of</strong> the patientsselected for analysis. Also an attempt was made to describethe patterns <strong>of</strong> prescribing practices by using WHO/INRUDdrug-use core indicators likeŸ To evaluate average number <strong>of</strong> drugs per encounterŸ To determine percentage <strong>of</strong> drugs prescribed by genericnameŸ To determine percentage <strong>of</strong> encounter with an antibioticprescribedŸ To determine percentage <strong>of</strong> drugs prescribed from WHOessential drug listŸ To determine percentage <strong>of</strong> fixed drug combination fromWHO essential drug listMETHODOLOGYA prospective study was carried out over six months (August2010-January 2011) in the Dermatology outpatientdepartment <strong>of</strong> tertiary care referral hospital in Malabar region<strong>of</strong> Kerala after obtaining requisite permission. Hospital catersthe treatment requirement to the people from all over northKerala. Ethical approval for the study was obtained from thehospital ethical committee. Confidentiality and anonymity <strong>of</strong>the patients were maintained during the study. Allprescriptions issued to patients attending the dermatologyoutpatient department during this period following each day'sconsultation were copied out from the case files and recordedin data collection forms adapted from WHO guidelines on9how to investigate drug use in health facilities . Data wasobtained from a total <strong>of</strong> 500 prescriptions which includes ageand gender <strong>of</strong> the patients, the diagnosis, the drugs prescribed,their strength, frequency, route <strong>of</strong> administration and duration<strong>of</strong> treatment and the prescriptions were subjected tomeasuring the appropriateness <strong>of</strong> prescription. Misuse <strong>of</strong> anyone <strong>of</strong> these parameters was taken as indication <strong>of</strong> a problemprescription.The Prescriptions were subjected to critical evaluation usingWHO prescribing indicators.a) Average number <strong>of</strong> drugs per encounter was calculated bydividing the total number <strong>of</strong> different drug productsprescribed by the number <strong>of</strong> encounters surveyed.b) Percentage <strong>of</strong> drugs prescribed by generic name wasdetermined by dividing the number <strong>of</strong> drugs prescribed bygeneric name by the total number <strong>of</strong> drugs prescribed,multiplied by 100.c) Percentage <strong>of</strong> encounters with an antibiotic prescribedwere calculated by dividing the number <strong>of</strong> patient encountersduring which an antibiotic was prescribed by the totalnumber <strong>of</strong> encounters surveyed, multiplied by 100.d) Percentage <strong>of</strong> drugs prescribed from essential druge) Percentage <strong>of</strong> fixed-dose combination prescribedAll the findings were recorded, compiled, tabulated andanalyzed. The analyzed data were expressed in percentage.RESULTSA total <strong>of</strong> 500 cases were analyzed. The catchment area <strong>of</strong> ourhospital is Malabar region <strong>of</strong> Kerala; Fig 1 & 2 provides thegender distribution & age wise distribution <strong>of</strong> patient indermatology OPD, respectively. 248 patients (49.6%) werefound to be female followed by male, 252 patients (50.4%).The age group 20-29 yrs was accounted for the highestnumber <strong>of</strong> 125(25%) <strong>of</strong> patients. Total number <strong>of</strong> drugs in500 prescriptions was found to be 1230. Number <strong>of</strong> drugs perprescription varied from 1 to 7 with average <strong>of</strong> 2.46(Fig 3).Most <strong>of</strong> the prescription consists <strong>of</strong> minimum <strong>of</strong> 3 drugs(185prescription, 37%). Only 1% drugs were prescribed ingeneric name. Fig 4 shows the appropriateness <strong>of</strong> theprescription which indicates the good rational prescriptionhabit <strong>of</strong> the doctors. Injectables were found to be rarelyprescribed in this OPD (1 out <strong>of</strong> 1230drugs). The mostcommonly prescribed systemic agents were antihistamine(294) followed by antibiotics (181) & antifungal agents (49).The most commonly prescribed topical agents were topicalsteroids & its combination (236) followed by topicalantifungal agents (124). All systemic agents were given orallyexcept (Inj.kenacort; triamcinolone for treatment <strong>of</strong> alopeciaAreata). Major therapeutic agent found among the drugcategory is presented in Fig 6, results reveal that levocetrizinewas found to be the major drug among the antihistaminegroup, Fluconazole among antifungal, Clobetasole amongsteroidal agent and Roxithromycin was found among theantibiotic agent. Analysis <strong>of</strong> steroids revealed that 262patients require steroids and its combination with antibiotics.Out <strong>of</strong> 262 patients, 125 used very potent topical steroids(clobetasole). 86 patients got steroid combination withantibiotics. Only 25 patients got systemic steroidal therapy<strong>Indian</strong> <strong>Journal</strong> <strong>of</strong> <strong>Pharmacy</strong> <strong>Practice</strong> Volume 5 Issue 3 <strong>Jul</strong> - <strong>Sep</strong>, <strong>2012</strong> 63

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