Prescribing Pattern For Osteoarthritis In A Tertiary Care Hospital
ULLAL S D , NARENDRANATH S , KAMATH R K, PAI MRSM, KAMATH S U, SAVUR AMARNATH D
*(MD), Department of Pharmacology, Kasturba Medical College, Mangalore;
**(MD), Department of Pharmacology, JJM Medical College, Davanagere;
***(MS), Department of Orthopaedics, Kasturba Medical College, Mangalore;
****(MD), Department of Pharmacology, Kasturba Medical College, Mangalore;
*****( MS), Department of Orthopaedics, Kasturba Medical College, Mangalore;
******( MS), Department of Orthopaedics, Kasturba Medical College, Mangalore.
Dr. Sheetal Dinkar Ullal, Department of Pharmacology, Kasturba Medical College, Light house hill Road, Mangalore. 575001. Ph:9448306242. email:firstname.lastname@example.org
Background: Treatment of osteoarthritis aims at reducing pain and improving mobility. NSAIDs are widely prescribed for symptomatic relief despite well-known adverse effects. Paracetamol with its better safety profile is recommended as the initial analgesic of choice. SYSADOA is a generic term used for symptomatic slow acting drugs for osteoarthitis, and includes glucosamine sulphate and related compounds, chondroitin sulphate, and diacerein. SYSADOA when compared to NSAIDs, are safer, comparable in symptomatic efficacy and better in structure modifying efficacy in osteoarthritis. A drug utilization study is considered to be one of the most effective methods to assess and evaluate the prescribing attitude of physicians. Despite the considerable socio-economic impact of OA, not many studies have established the drug-prescribing trend in India. Hence we decided to study the prescribing pattern of SYSADOA, paracetamol and NSAIDs in OA vis-à-vis the standard recommendations and in the process provide constructive feedback to prescribing clinicians. Methods: Prescriptions for osteoarthritic patients collected cross-sectionally for six months from an orthopaedic outpatient unit in a tertiary care hospital, were analysed. Results: Out of 154 prescriptions analysed, 7% were prescribed glucosamine and chondroitin, while 4% received diacerein. Paracetamol was prescribed in 17% cases. NSAIDs were prescribed in 84%, with 27% receiving two or more NSAIDs simultaneously. Conclusion: SYSADOA and paracetamol were under-prescribed while NSAIDs were probably over-prescribed.
cite this article :
ULLAL S D*, NARENDRANATH S**, KAMATH R K***, PAI MRSM****, KAMATH S U*****, SAVUR AMARNATH D******. PRESCRIBING PATTERN FOR OSTEOARTHRITIS IN A TERTIARY CARE HOSPITAL. Journal of Clinical and Diagnostic Research [serial online] 2010 June [cited: 2013 Dec 6 ]; 4:2421-2426. Available from http://www.jcdr.net/back_issues.asp?issn=0973-709x&year=2010&month=June&volume=4&issue=3&page=2421-2426&id=746
Material and Methods
Methods Prescriptions of patients diagnosed with OA were collected from an orthopaedic outpatient unit in a tertiary care hospital, for a period of six months. Relevant data (including age, sex, duration of disease, drugs prescribed and doses) were recorded and the prescribing pattern of SYSADOA, paracetamol and NSAIDs analyzed. Drugs accounting for drug utilization 90% (DU 90%) segment were noted. DU 90% segment is the number of drugs accounting for 90% of drug use (13). This method is inexpensive, flexible and simple for assessing the quality and quantity of drug use in routine health care. The study was approved by the Institutional Ethics Committee. Descriptive statistical analysis was done.
One hundred and fifty four patients with the diagnosis of OA visited the orthopaedic outpatient unit during the six months in which data was collected. Prescriptions of all 154 patients were analyzed, out of which 66 (43%) were male and 88 (57%) female. (Table/Fig 1) shows the demographic characteristics of the patients. One hundred and fifty three (99%) patients were affected with osteoarthritis of the knee alone, either unilateral or bilateral. In one patient along with the knees, the right wrist was also involved. Thirty nine patients were newly diagnosed cases of OA, 115 were old cases.
(Table/Fig 2) shows the details of the drugs used. Only ten (7%) patients were prescribed glucosamine; nine received a combination of glucosamine and chondroitin while one received glucosamine alone. Six (4%) patients were prescribed diacerein.
A total of 174 NSAIDs were used. Forty two (27%) prescriptions contained more than one NSAID. Twenty four (16%) patients were not prescribed any NSAID. In 5 (3%) patients only topical NSAIDs were prescribed. In 28 (18%) patients both topical and systemic NSAIDs were prescribed simultaneously. Diclofenac, paracetamol, naproxen and aceclofenac accounted for the DU 90% segment. The most common NSAID used was diclofenac, totaling to 68 (44%). Paracetamol was prescribed in 26 (17%) cases, either alone or in combination with NSAIDs. Etoricoxib, the only COX – 2 inhibitor used, was prescribed in 10 (7%) patients. Various gastroprotective agents were used along with the oral NSAIDs in 29 (19%) patients, pantoprazole being the most preferred one.
As has been reported in the existing medical literature, (14), (15) in this study too, OA was found to be overwhelmingly more common in the knee than in other joints and was more common in females than in males. Despite the huge international hype and claims of recent increase in consumption of drugs like glucosamine in OA (16), this study found that SYSADOA (glucosamine, chondroitin and diacerein) have been used sparingly, despite these drugs being very safe and so far the only ones having both symptom modifying and structure modifying effects in OA. Many reports including the recent EULAR and OARSI recommendations have favoured their use (3), (4),[ 7], (8), (9), (10), especially in early OA. Their under-prescription probably reflects the lack of faith in the clinical effectiveness and cost effectiveness of these drugs. Large scale randomized clinical trials are needed to clear the air regarding the benefits of using these drugs. In the meantime, SYSADOA should be welcomed if the patient can afford them, even if they only marginally delay the progression of this chronic disabling disease while safely improving the symptoms.
Paracetamol has been recommended as the oral analgesic to be used first and if effective, for long durations owing to its gastrointestinal safety. Analgesic efficacy of paracetamol has been found to be comparable to that of ibuprofen and naproxen (17), (18). NSAIDs are to be started only if the patient is unresponsive to paracetamol. However, paracetamol too was under-prescribed, with only 17% patients receiving it, and only 3% receiving it as monotherapy. This could be because the symptom-modifying efficacy of paracetamol in OA is suspect, as found in some studies (19), and as perceived by most physicians.
As against the use of SYSADOA and paracetamol, NSAIDs were prescribed in 84% of patients, with 27% patients receiving two or more NSAIDs at the same time. Simultaneous use of two or more NSAIDs, which essentially act by the same mechanism, defies logic. Inspite of the disturbing statistics of the adverse effects of oral NSAIDs and their limited disease modifying efficacy, these drugs have been found to be the most preferred. Diclofenac was the most common NSAID used (44%). Though ibuprofen has been rated as the safest conventional NSAID (20), only two prescriptions contained it. Selective COX-2 inhibitors (used in 7% patients) seem to have lost the race, probably owing to reports of associated cardiovascular risks. Topical NSAIDs were used in only 21% of patients, either alone or in combination with systemic NSAIDs. There is growing evidence that topical and oral NSAIDs have equivalent efficacy; moreover, topical NSAIDs display better gastrointestinal safety than their systemic counterparts (21). With doubts about the analgesic efficacy of paracetamol in OA, and concerns about cardiovascular effects of selective COX-2 inhibitors, topical NSAIDs should be used more often for symptomatic relief in OA. However, this study found that in patients with gastrointestinal risk, conventional NSAIDs combined with gastroprotective agents (19%), mainly proton pump inhibitors were preferred instead. Results of similar drug utilization studies in OA have been tabulated in (Table/Fig 3). Only one study (25) found the management of OA being followed was satisfactorily close to the standard guidelines.
In conclusion, this study has found that in the treatment of osteoarthritis NSAIDs, especially oral diclofenac is the most preferred drug. Paracetamol, SYSADOA and topical NSAIDs are being under-prescribed.
• The prescribing pattern for osteoarthritis in the study setup differs from the guidelines recommended by the Osteoarthritis Research International and European League against Rheumatism. • Gastrointestinal adverse effects of NSAIDs requiring the use of gastro-protectives can be minimized by increasing the use of paracetamol and SYSADOA
Jordan KM, Arden NK, Doherty M, et al. EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Ann Rheum Dis 2003; 62:1145-1155.
Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. 2008; 16(2):137-62.
Pavelka K, Trc T, Karpas K, et al. The efficacy and safety of diacerein in the treatment of painful osteoarthritis of the knee: a randomized, multicenter, double-blind, placebo-controlled study with primary end points at two months after the end of a three-month treatment period. Arthritis Rheum 2007; 56(12): 4055-64.
Yuen YH, Chang S, Chong CK, Lee SC, Critchlev JA, Chan JC. Drug utilization in a hospital general medical outpatient clinic with particular reference to antihypertensive and antidiabetic drugs. J Clin Pharm Ther 1998; 23:287-94.
Bradley JD, Brandt KD, Katz BP, Kalasinski LA, Ryan SI. Treatment of knee osteoarthritis: relationship of clinical features of joint inflammation to the response to a nonsteroidal antiinflammatory drug or pure analgesic. J Rheumatol 1992; 19: 1950–4.
Pincus T, Koch GG, Sokka T, et al. A randomized, double blind, crossover clinical trial of diclofenac plus misoprostol versus acetaminophen in patients with osteoarthritis of the hip or knee. Arthritis Rheum 2001; 14: 1587-98.
Henry D, Lim LLY, Rodriguez LAG, et al. Variability in risk of gastrointestinal complications with individual non-steroidal anti-inflammatory drugs: results of a collaborative meta-analysis. British Medical Journal 1996; 312:1563-1566.
PS Tugwell, Wells GA, Shainhouse JZ, et al. Equivalence study of a topical diclofenac solution (PENNSAID) compared with oral diclofenac in the symptomatic treatment of osteoarthritis of the knee: a randomized controlled study. Journal of Rheumatology 2004; 31: 2002-2012.
Rosemann T, Laux G, Szecsenvi J. Osteoarthritis: quality of life, comorbidities, medication and health service utilization assessed in a large sample of primary care patients. J Orthop Surg Res 2007; 2: 12.
Bishnoi M, Kumar A, Kulkarni SK. Prescription monitoring of management pattern of osteoarthritis with non-steroidal antiinflammatory drugs at PUHC, Chandigarh in India. Indian J Pharm Sci 2006;68:525-7
Janhsen K, Thiem U, Engin E, Pientka L. Are clinical practice guidelines adequately considered in drug treatment of osteoarthritis patients? Results from the HERAS survey. In: 16. Jahrestagung der Gesellschaft für Arzneimittelanwendungsforschung und Arzneimittelepidemiologie. Berlin, 19.-20.11.2009.