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J Indian Acad Forensic Med. October- December 2011, Vol. 33, No. 4 ISSN 0971-0973 Original Research Paper A Study of rational use of Drugs among the Ophthalmic-in- Patients of a Government Teaching Hospital In View of Forensic Pharmacology *Kanchan Kumar Mondal, **Supreeti Biswas, ***Rajat Kanti Biswas, ****Anjan Adhikari, *****Biswajit Sukul, ******Saibendu Kumar Lahiri, *******Krishnangshu Ray Abstract: Inappropriate, irrational and cost-ineffective practices of pharmaceuticals are worldwide phenomena. A retrospective study was conducted among the Ophthalmic-in-patients to investigate the nature of utilization of drugs in respect of rationality correlating the clinical and forensic pharmacology. Prescriptions in the Bed Head Tickets were the study samples which were analyzed according to the WHO/INRUD Indicators. Incurred cost per day per prescription was calculated. Commonly prescribed drugs were also studied. Result revealed that proportion of drugs from Essential Medicines List (EML) was 51.62%, while 54.05% was prescribed by generic names. Most commonly prescribed drugs were antibiotics (100%), analgesic-anti-inflammatory agents (100%) and mydriatic-cycloplegic agents (91.98%). Average number of drugs per prescription was 4.03±1.5 and average cost per day per prescription was 99.22 INR (Indian Rupees). Injectables were prescribed in 97.36% cases, and 10.81% of total drugs (37) prescribed. Prescribing practices were not always in accordance with the WHO criteria for rational use of drugs. It is suggested that there is a felt need to provide more inputs to the Ophthalmologists to promote rational use of drugs. Key Words: Essential medicine, Fluoroquinolones, INRUD indicators, Mydriatics, Polypharmacy Introduction: A number of interfaces exist between drugs, medical practice, and the law. It is essential in modern society that every individual involved in the health care system have at least a cursory exposure to those aspects of the law that are intimately involved with the practice of medicaltherapeutics.‖[1] Forensic Pharmacology offers a unique and comprehensible account of pharmacological methods and knowledge dealing with illicit drug use, poisoning and toxicology, and the relevant aspects of prescription writing. [1, 2] Corresponding Author: * Asso. Prof. Ophthalmology, RGKMC, Kolkata. Email: kanchan.kr.mondal@gmail.com **Prof. & HOD, Pharmacology, BMC, Burdwan ***Demonstrator, Pharmacology, RGKMC, Kolkata. ****Asst. Prof. Pharmacology, RGKMC, Kolkata *****Asso. Prof., FMT, NRSMC, Kolkata ******Prof. & Head, PSM, RGKMC, Kolkata *******Prof., Deptt of Clinical & Experimental Pharmacology, & Director, Calcutta School of Tropical Medicine, Kolkata 324 It focuses on the detection, analysis, and consultation pertaining to the negligence in prescribing and administering drugs, and adverse drug effects that result in harm, criminal activity, or death. [1, 3] Drug utilization research, part of clinical pharmacology, explores the links between pharmacotherapeutics and forensic science (forgery of prescriptions). Inappropriate and cost-ineffective uses of pharmaceuticals are worldwide phenomena especially in the developing countries. [4] Drug utilization research may provide insights into different aspects of drug prescribing including pattern, determinants, outcomes of drug use and quality control cycle (signals of irrational use and interventions to improve drug use). [4] Rational use of drugs should be one which meets up patients‘ clinical needs in doses that meet their own individual requirements for an adequate period of time at the lowest cost to them and their community. [5] In spite of extensive programs on rational use of drugs and the Essential Medicine List (EML) of WHO, [6] prescribing behavior has not been changed significantly. In the legal and ethical context special care needs to be taken, when treating institutionalized populations. [7] Several studies of drug utilization pattern for varieties of morbid
J Indian Acad Forensic Med. October- December 2011, Vol. 33, No. 4 ISSN 0971-0973 conditions were carried out and published. But a few ocular drug utilization data has been generated, that also upon Out Patient Department, [8-11] and there exists a paucity of reports upon indoor ocular patients. Hence, the present study has been contemplated to ascertain the situation in this sector aiming to focus on drug utilization pattern and to identify the basic defects in rational use of drugs. Materials and Methods: The study was record based, retrospective and cross sectional. Preparatory work was carried out in the Department of Pharmacology. Necessary approval was obtained to handle the records from the Department of Ophthalmology and Medical Record Section (MRS) of the Institution. The study protocol was approved by the Institutional Ethics Committee. Prescriptions from Bed Head Tickets (BHTs) of all discharged patients of Ophthalmology Department between April 2007 and March 2008 were the study material and collected from the MRS. Census method of sampling of data was followed to collect all those BHTs. Data from those BHTs were copied in a structurally designed Case Report Form (Annexure – I) and the process was exercised for a period of 6 months. All collected data were compiled, audited and analyzed according to the WHO/INRUD (International Network for Rational Use of Drugs) indicators [12] for number of drugs per prescription, number of antibiotics per prescription, number of drugs prescribed by generic name, number of drugs prescribed from the WHO Model List of Essential Medicines (EML), [6] and number of injectables per prescription. The cost per day per prescription was calculated in Indian Rupees (INR). Moreover, the commonly prescribed drugs were also looked into. All the data were expressed in standard statistical format. Results: Screening the records of one year from MRS, 948 BHTs were obtained as prescriptions for ophthalmic-in-patients (Table 1). Majority (97.36%) of them was surgical cases (923) including cataract surgery, dacryocystorhinostomy, dacryocystectomy, pterygium excision, repair of corneal rupture, evisceration, enucleation, trabeculectomy, lid mass removal, lid repair, correction of ptosis, squint and entropeon. Medical cases were corneal ulcer, uveitis, hyphaema, endophthalmitis, vitreous hemorrhage, retrobulbar neuritis, acute dacryocystitis and glaucoma. Table 1 shows the pattern of drug 325 utilization for ophthalmic-indoor prescriptions (N = 948), whereas Table 2 describes the prescribing behavior for total drugs (n = 37) prescribed over 948 prescriptions. Among the studied prescriptions, the most common groups of drugs prescribed were antibiotics (100%), analgesic-anti-inflammatory agents (100%) and mydriatic-cycloplegic agents (91.98%). Average number of drugs per day per prescription was 4.03±1.5. Number of antibiotics per prescription was at least one with preponderance of fluoroquinolones. Different members of fluoroquinolone family with preponderance of norfloxacin seconded by ofloxacin were prescribed. In 2.71% cases 2 antibiotics (one topical with one oral) were prescribed. For 948 prescriptions 96.42% was topical fluoroquinolones whereas 3.58% was oral antimicrobial agents out of which mostly fluoroquinolones. Analgesic-anti-inflammatory agents were NSAIDs in majority (95.63%) cases and corticosteroids in few (13.56%) cases. NSAIDs were prescribed in the form of either topical flurbiprofen or oral ibuprofen. Antacid (96.22%) and or H2 blockers (78.18%) were prescribed too often along with ibuprofen. Surgical cases (97.36%) were prescribed with injectables which was 10.81% out of total drugs (37) prescribed over 948 prescriptions. Number of injectables per prescription only for surgical cases was 2±1. Topical and oral NSAIDs were prescribed during pre- and post-operative period respectively. Since there is no Hospital Formulary, the prescription of drugs was studied from the EML. Results showed that proportion of drugs prescribed from EML was 51.62%, and 54.05% was prescribed by generic names. Symptomatic drugs were 56.76 % of total drugs (37) prescribed. Average cost per day per prescription was INR 99.22 ranging between INR 57.95 and INR 140.50. Most commonly prescribed mydriatic-cycloplegic agent was tropicamide (90.56%); in 73.10% cases cyclopentolate and in few cases (1.26%) atropine were prescribed. Prescriptions containing other medications like timolol, acetazolamide, diazepam, alprazolam and tear substitutes were observed in some encounters. Among the surgical cases children (1.3%) received general anaesthesia for the surgery. Local anaesthetic agent (LA) was utilized for the adult or older patients. Lignocaine was the routinely used LA in combination with adrenaline, bupivacaine and hyaluronidase. Patients with raised blood pressure received LA without adrenaline.
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