A study on the prescription pattern of drugs in Jazan general hospital, KSA

Inappropriate drug prescribing is a global problem affecting the healthcare system. This study was performed to assess the drug prescribing pattern in geriatric, paediatric and obstetrics and gynaecology department. Patient's chances of exposure to poly pharmacy are more, therefore, this study was carried out to find out the rational use of prescribed drugs in Jazan general hospital. A prospective cross sectional (descriptive) study was carried out and a total of 3070 prescriptions were collected for the study during November, 2012 to October, 2013. 1034, 1024, and 1012 prescriptions from geriatric, pediatric and obstetrics and gynaecology department respectively were collected. The average numbers of drugs used per patient were 3.1, 7.4 and 3.3 for geriatric, pediatric and obstetrics and gynaecology department patients respectively. Prescription pattern of the drugs for pediatric patients consists of antibiotics, analgesics and antipyretics mainly. For geriatric patients among systemic route, commonly prescribed therapeutic class of medications were antibacterials (70.5%), and among oral route, pantoprazole was the most commonly prescribed medication (61.2%). For obstetrics and gynaecology department patients the most frequently prescribed drugs were oral iron, folic acid preparations, antibiotics and analgesics. There is a high level of exposure to medication in paediatric and geriatric population. In obstetrics and gynaecology department, the average numbers of drugs per prescription were slightly higher compared to the standard set by World Health Organisation (WHO) but majority of the drugs were prescribed as per United State Food and Drugs Administration (USFDA) category A (the safest category during pregnancy).


INTRODUCTION
Rational use of drugs is one of the major problems that health care providers and hospital administrators face nowadays in many countries (Thomas et al., 1997).Various studies have been conducted in developing and developed countries during past few years regarding safe and effective use of drugs.These studies show that irrational drug use is a global phenomenon and only few prescriptions justify rational drug use  agree that this article remain permanently open access under the terms of the Creative Commons Attribution License 4.0 International License Aditya, 2006;Sneha and Mathurak, 2006).
It is well documented that safe and effective drug therapy is possible only when patients are well informed about the medications and their use.The rational use of drugs requires that the patients receive medications to their clinical need in appropriate doses that meet their own individual requirement for an adequate period of time and at the lowest cost to them and their community as per defined by the World Health Organization.The five important criteria for rational drug use are accurate diagnosis, proper prescribing, correct dispensing, suitable packing and patient adherence (Alam et al., 2006).
The prescribers should make an accurate diagnosis and prescribe rationally and the pharmacist should ensure that effective form of the drug reaches the right patient in prescribed dosage and quantity, with clear instructions on its appropriate use (Alam et al., 2006;Lea, 1985).Prescribers need to take into account the way in which the disposition of drugs in children differs from adults both pharmacokinetically and pharmacodynamically (Sutcliffe, 1999).Infants and children suffer from frequent but usually non-serious illnesses and infections.Most of these are self-limiting and are often treated not only inappropriately, but also resorting to polypharmacy (Ghai and Paul, 1998).Unnecessary drugs are sometimes prescribed for example, antibiotics, for patients without evidence of bacterial illness or multivitamins in large quantities for patient without nutritional problems (Andreasen, 1973;Brin, 1968).There are many potential difficulties involved with prescribing to children.There is a paucity of randomised clinical studies designed to test medication use in children (Sutcliffe, 1999).
While prescribing drugs during pregnancy, the benefits to the mother and the risks to the foetus should be carefully considered.Pregnancy is a time which brings profound physiological changes in the body of a woman which challenges the clinicians in managing the disease states and selection of drugs best suited to treat them (Cheney, 2012).Reducing errors in medication and improving safety of the patient are important areas of discussion as the life and health of the unborn child is also at stake and may lead to serious functional and structural side effects during development (Benjamin, 2003).Irrational use of drugs is a huge worldwide problem and extra care should be taken especially in pregnancy, for example unnecessary drugs are sometimes prescribed like multivitamins in large quantities for patient without nutritional problems or antibiotics, for patients without evidence of bacterial illness.
In order to be rational, drug use must be effective, safe, prescribed for the proper therapeutic indication and the correct dosage in an appropriate formulation, easily available and of a reasonable cost (Akhtar, 2012).By keeping all of these issues in mind, a study was carried out in Jazan general hospital, to assess the drug prescribing pattern in geriatric, pediatric and obstetrics and gynaecology department patients as chances of exposure to polypharmacy are more.Gizan is situated on the eastern flank of the Red Sea about 1100 km southwest of Riyadh in the Kingdom of Saudi Arabia.

METHODOLOGY
A prospective cross sectional (descriptive) study was undertaken in the department of geriatrics, paediatrics, obstetrics and gynaecology of Jazan General hospital in Gizan City.The study was designed to obtain information regarding the prescribing pattern of drugs by the medical prescribers and also to analyze the basic information on the prescription for the elderly, paediatrics and obstetrics and gynaecology patients.Duration of study period was one year (November, 2012to October, 2013).A total of 3070 prescriptions were collected from the hospital's pharmacy located in the hospital.1034 files belonging to the hospitalized elderly patients (age >65 years), 1024 files of pediatric patients (age < 6) and 1012 files from obstetrics and gynaecology patients were collected for the study.
Parameters present on the prescription such as patient information (name, age, gender, nationality and file no.diagnosis, co-morbid condition/s, medication history and duration of hospitalization), information of hospital (name, department, unit), identity of the prescriber (name and signature), consultant-incharge and the date, disease diagnosed and drugs prescribed to each patient were studied.The others indicators assessed during the current study were average number of drugs per prescription, percentage of types of drugs prescribed to individual patients, percentage of category of drugs prescribed as per WHO core indicator and USFDA, percentage of patient prescribed with injectables and percentage of patient prescribed with antibiotics.
All of the patient and hospital information (variables) present on the prescriptions were calculated by dividing the total no. of variables by total no. of prescriptions and multiplying it by 100.The average number of drugs prescribed per patient was calculated by dividing the total number of drugs by the number of patients.Percentage of patient with injections, and percentage of patients with antibiotics were determined by dividing the number of times the drug was prescribed by the total number of patients respectively and finally multiplied by 100.The drug prescribing pattern was evaluated as per WHO prescribing indicators, and potentially inappropriate drug prescription patterns were evaluated as per Beer's criteria.

RESULTS
The demographic characteristics of geriatric patients are shown in Table 1.Out of 1034 prescriptions studied, 648 (62.67%) belonged to males and the rest 386 (37.33%) to female patients, giving a male to female ratio of 1:0.59.Most of the patients were in the age group of 65 to 70years (57.83%) and least were in more than 90 years age group (1.45%).Based on Beers criteria, 870 (84.14%) patients received potentially appropriate prescriptions and 164 (15.86%) were prescribed inappropriately.In the later case, 126 (34.62%) were of male patients and 38(10.44%) of female patients.
According to the WHO core drug use indicator pattern, average number of drugs prescribed per encounter was 7.09.The average number of diseases present was 4+1.Generic prescriptions were recorded with a very low figure of 7.24% which may not be in favor of the patients.Antibiotics were prescribed to 12.05%, while injections were prescribed to 28.45%.The percentage of drugs prescribed from national essential drugs list was 97.28% suggesting a good supply of the drugs in the hospital which is an impressive finding of the study as shown in Table 3.
The study shows the prevalence of some missing items in the prescriptions.The major missing items were the date of the consultation and sex of the patient.In contrary, almost all physicians mentioned frequency and duration of medication.Missing items included family health record number (5.4%), name of the patient (1.2%), age of the patient (18.43%), sex of the patient (22.12%), nationality of the patient (2.4%), name of physician (0.2%), date of the consultation (25.54%) and diagnosis of the disease (18.3%) (Table 4).
In obstetrics and gynaecology department, the average number of drugs per patient was found to be 3.30 (range 1 to 10).Fifty-four different types of medicines and a total number of 3340 medicines were prescribed for the entire period.Table 7 shows the WHO prescribing indicators that were evaluated.The most frequently prescribed drugs were oral iron, preparations of folic acid, antibiotics and analgesics.Prescription pattern among the obstetrics and gynaecology patients observed was like minerals/vitamins 45.2%, antibiotics 19.86%, analgesics 15.61%, steroidal progestin 3.55%, antacids 3.26%, antiallergens 2.66%, antifungals 1.58%, anthelmintics 1.08%, antihypertensives 0.88%, expectorants 0.49%, antiemetics 0.49% and others 11.06%.
Paracetamol 265 (53.86%) was the most frequently prescribed analgesic and other analgesics included in the prescriptions were aspirin 91(18.50%),Diclofenac Sodium 65 (13.30%),Indomethacine 44 (8.94%) and Ranitidine, Indomethacin and Salbutamol.Category D drugs in which there is evidence of risk to human foetus, but potential benefits may be acceptable despite potential risks were 1.33%, mainly Aspirin and Category X drugs in which animal/human studies show foetal abnormalities, but risks involved clearly outweigh benefits were 0.00%(none).Prescribing of Category X drugs during pregnancy were not seen, Category B and C drugs were common and category A drugs were maximum as shown in Table 9.Most common antibiotic prescribed was Cefalexin.Most common antacid prescribed was Ranitidine hydrochloride.The dose and duration of drug usage was clearly mentioned.Nearly all of the prescribed drugs were from the essential drug list of the hospital.Missing items included family health record number(7.81%),legible name of the patient (0.79%), age of the patient (16.70%), sex of the patient (19.66%), nationality of the patient (2.47%), name of the physician (7.41%), date of the consultation (36.07%) and diagnosis (12.55%) as shown in Table 10.

DISCUSSION
Use of five or more medications is considered as  (Mirza et al., 2009).The average number of drugs per elderly patient was found to be 7.09 which demonstrate high prevalence of polypharmacy (67.02%).Similar data was found in some other studies in Nepal (Joshi et al., 1997) and in India (Veena et al., 2012), where the incidence was 73 and 88.67%, respectively.In this study, a total of 7336 drug formulations were prescribed to 1034 patients for different diseases.To evaluate the appropriateness prescribing for geriatric patients, Beers criteria was first developed in 1991 and was recently updated in 2012.
In the present study, according to Beers criteria, it was revealed that 15.6% of total drugs prescribed were inappropriate.These findings are not significantly different from that found in a study from India (Zaveri et al., 2010;Shah et al., 2011) and Japan (Niwata et al., 2006) in which use of at least one or more inappropriate medicine was used per prescriptions.This suggests that drugs 'to be avoided in elderly' are among the most frequently inappropriately prescribed drugs.The common morbidities included respiratory tract infections followed by GIT disorders.Higher incidence of these respiratory tract infections may be due to the high percentage of airborne Amaranthus pollen in Jazan which potentially causes allergic respiratory diseases as reported by Hasnain et al. (2007).
In paediatrics department, an average prescription rate of 3+1 per consulting child was seen.This high rate of prescribing may be a reflection of increased vulnerability of children to various illnesses.Prescribing for children was from a limited formulary of medications, which is consistent with evidence found in other countries (Sanz and Boada, 1998).The most frequently prescribed medications were antibiotics, analgesics and antipyretics, and nasal decongestants.In discriminate or prolonged prophylactic use of new antibiotics has been shown to contribute to the emergence of multi-resistant hosocomiat strains in the hospital setting (Sande and Scheld, 1980).As with antibiotics, it is difficult to justify the use of analgesics on such a large scale, taking into account that prolonged and excessive use of analgesic compounds may be potential hazards (Bulger and Sherris, 1968).Hence, there is a strong call for studies into how medicines are being prescribed to children in various settings and populations (Sanz, 1998).Studies that have investigated prescribing in paediatric populations have found high prescribing rates, although a limited formulary of medications is used (Straand et al., 1998).
The average number of drugs per prescription in this study (3.30) was higher than the range of the standard set by WHO (1.6 to 1.8) but percentage of patients prescribed with injection was 5.18%, which is low as compared with the range of the standard set by WHO.The most frequently prescribed drugs, was in accordance with earlier studies done in the other countries like Ethiopia (Mereke et al., 2013), India (Rathod et al., 2012;Jayawardhani et al., 2012), Finland (Heikkila et al., 1994) and Australia (Maats et al., 2002).
The prescribing indicators also showed that the percentage of prescribed antibiotic was in the range of the standard set by WHO.This is also encouraging, since antibiotics are routine drugs used for most bacterial infections and this could help to minimize drug resistance problems that could be promoted with over usage of antibiotics.The results revealed that the majority of thedrugs were from category A, there were no drugs prescribed from the category X.This type of pattern of category wise prescription was reported from similar studies conducted in other countries like India, Netherland, Finland etc. (Joshi et al., 2012;Bakker et al., 2006).

Conclusion
This study helped in evaluating the existing pattern of use of drugs in geriatrics, paediatrics, obstetrics and gynaecology department of Jazan general hospital, Jazan.High level of exposure to medication was seen in paediatrics and geriatrics population whereas in obstetrics and gynaecology department, the average number of drugs was slightly higher compared to the standard set by WHO.Drug therapy can be improved by introducing appropriate intervention programs for medical prescribers for better health care outcomes.This can be considered as an effort to improve the quality of life.

Table 1 .
Gender distribution of elderly patients.

Table 2 .
Age distribution of inappropriate prescriptions in elderly patients.

Table 3 .
WHO core drug indicator for drug prescribing pattern in elderly patients.

Table 4 .
Missing item prevalence in prescriptions of elderly patients.

Table 5 .
Major diseases present in the paediatric patients.

Table 6 .
Drug category used in the paediatric age group.

Table 7 .
Drug prescribing indicators (as per WHO) in the paediatric age group.

Table 8 .
Frequency distribution of the medicines prescribed in the obstetrics and gynaecology patients.

Table 9 .
Percentage of drugs used in different categories in the obstetrics and gynaecology patients.

Table 10 .
Missing information on the prescription in the obstetrics and gynaecology patients.