C hildren are more vulnerable to the
various adverse events related to use of drugs(1). It is, therefore,
important to study drug use patterns in pediatric population in order to
optimize the pharmacotherapy. With the help of WHO prescribed drug use
indicators(2) and concept of defined daily doses(3), it is possible to
compare drug utilization patterns between different settings. The aim of
this study was to evaluate the drug utilization in the out patient
pediatric setting of a public tertiary care teaching hospital.
Methods
The study was carried out in the pediatric out-patient
clinic of a tertiary care teaching hospital in Northern India over a
period of three months (September to November, 2006). Children attending
for vaccination and if advised hospitalization, were excluded. Baseline
data record included patients’ demographics, diagnosis, dosage, dosage
form and route of administration of drugs prescribed. The patients were
selected by convenience sampling.
The data were analyzed for the WHO recommended
prescribing indicators(4). The prescribing and utilization pattern of the
medicines was carried out with reference to National List of Essential
Medicines (NLEM) India, 2003(5). The results are presented as mean±SEM
and percentages, as applicable.
Results
Of 254 patients, 172 were male. The average age of the
patients was 3.9±0.2
years. The prescribing indicators were calculated for all patients and
studied in five age groups to identify possible differences (Table
I).
TABLE I
Prescribing Indicators in Different Age Groups
|
0-1 yr |
1-4 yr |
4-8 yr |
8-12yr |
>12yr |
Total |
Number of patients (%) |
69 (27.2) |
97 (38.2) |
59 (23.2) |
27 (10.6) |
2 (0.79) |
254 (100) |
Average no of drugs per prescription |
2.3 |
2.4 |
2.2 |
2.2 |
1.5 |
2.3 |
% Drugs prescribed from NLEM |
39.2 |
42.5 |
47.7 |
65.6 |
33.3 |
45 |
% Drugs prescribed with generic names |
4.4 |
7.23 |
6.15 |
3.27 |
0 |
5.8 |
% Encounter with an antibiotic prescribed |
33.3 |
33 |
17 |
30 |
50 |
29 |
% Encounter with an injection prescribed |
0 |
1.03 |
3.3 |
0 |
0 |
1.2 |
The average number of medicines prescribed was 2.31±0.58.
It was found that in most of the prescriptions (44.1%), two drugs were
prescribed; this was followed by three drugs in one prescription in 27.2%
of the total prescriptions. Five drugs were prescribed in only 2% of the
prescriptions. Out of 587 medicines, 264 (45%) medicines were prescribed
from the NLEM. The prescribing from NLEM was highest for age group 8-12
years (65.6%). Paracetamol, amoxicillin, salbutamol, albendazole and
antacid preparations containing aluminium and magnesium hydroxide
contributed to the majority (76%) of drugs prescribed from the NLEM. There
was a poor tendency of prescribing by generic name; only 34 medicines were
prescribed by generic name. Albendazole, paracetamol, amoxicillin and
vitamin K were the most common medicines prescribed by their generic name.
The percentage encounter with an antibiotic prescribed
was found to be 29.1%. All the antibiotics were targeted for upper and
lower respiratory tract infections (URI and LRTI). Children less than 4
years received a larger proportion of antibiotics. The use of injections
was very low (1.2%). Paracetamol was the most frequently prescribed
medicine (83 cases) followed by paracetamol combinations, decongestants
and antiallergics, and amoxicillin. Of the antimicrobial agents,
amoxicillin was most commonly prescribed accounting for more than 50% of
all cases prescribed with an antimicrobial agent. This was followed by
azithromycin and co-trimoxazole.
72% of medicines were prescribed as syrup followed by
tablet (16.1%). All others dosage forms comprised only 5.8%. The dosage
was defined as teaspoonful (TSF). For 271 out of 425 liquid preparations,
dosages were mentioned as TSF. Most of the patients had single diagnosis;
URI was the most common diagnosis followed by LRTI and anemia. The
diagnosis was illegible or not available in 50 cases.
Discussion
The results confirmed that average number of drugs
(2.31) is slightly higher than the recommended value of 2(6). However,
this is smaller than earlier Indian reports(7,8). The average number of
drugs in this study matches those previously reported(9,10,12,13) while
values under 1.4 have been reported from Sweden(9), Italy(11) and
Barcelona(12).
Prescribing by generic name is known to reduce the cost
of drug treatment and rationalizing drug therapy. This varies from
13.3-93% across the globe (10,13,14). The results of work conducted in
India report this as 73.4% (8) which does not compare very well with the
figure of 5.8% found in this study. This needs further investigation. It
should be noted that this study is only a preliminary one and is ongoing.
One of the reasons for poor prescribing by generic name is the
non-availability of the pediatric formulations in the hospital pharmacy.
Hence, clinicians often prefer to prescribe by trade names, with which
they are familiar and the patients find it easier to procure. There was
fair prescribing from NLEM but it is less than that reported
earlier(8,13). This is another important area with a scope of improvement.
The household administration of liquid dosage form has
been identified as one of the important factor contributing to medication
error in pediatric patients(15). It has been reported that dosage
prescribed on TSF basis can lead to underdosing because while the quantity
defined as ‘a teaspoonful’ is equivalent to 80 grains or 5.2g of water and
the teaspoons available at home vary in size(16). Because 72% medications
were prescribed as syrups, this is an area of major concern. Prescribing
dosage as mL and use of syringe or graduated caps to measure accurate
amount should be strongly advocated in pediatric setting.
To conclude, this study provides few insights into the
drug use patterns in a pediatric out patient department of a tertiary care
teaching hospital. The prescribing from NLEM was fair, the use of
injections was low and there is a scope for improvement in case of
medicines prescribed by generic name.
Acknowledgment
The authors acknowledge the kind support of the
Director Principal, Government Medical College and Hospital, Chandigarh on
this work.
Contributors: PT was involved in designing the
study and preparation of manuscript and he will act as guarantor of the
study. SD was involved in data collection and review of literature. SB has
helped in manuscript writing. VRP, SB. SD and PT were involved in analysis
and interpretation of the data.
Funding: None.
Competing interests: None stated.
What This Study Adds?
• Prescribing from the National List of Essential
Medicines was fair and use of injections was low in this study.
|
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