Introduction

The term "arthritis" is a broad one used to describe joint inflammation. The prevalence of this joint illness ranges from 22% to 39% in India, making it the second most prevalent rheumatologic condition. Osteoarthritis is described as a Degenerative joint condition (also known as osteoarthrosis). It is characterised by a gradual decline and loss of articular cartilage, which leads to the development of osteophytes, discomfort, mobility restriction, deformity, and eventual impairment. The main symptom is a localised, intense, throbbing pain that is connected to the injured joint. As people age, OA becomes more common and more severe. Age, gender, hormone status, genetics, obesity, occupational or recreational activity, and local environmental factors are some potential risk factors (e.g., injury, overloading of joints, muscle weakness, or joint deformity). Pain management is a primary goal of drug therapy for OA. Because OA frequently affects older people who also have other health issues. Acetaminophen, NSAIDS like aspirin and diclofenac, as well as dietary supplements glucosamine and chondroitin have all been shown to stimulate the synthesis of proteoglycan from articular cartilage in vitro. These medications are typically prescribed to reduce symptoms. Monitoring of prescriptions can analyse the current trend of prescription patterns, identify the issues, and give feedback to prescribers in order to raise awareness about inappropriate drug usage.

Material And Methods

Study design, study setting, and source of data

In December 2020 we conducted an Observational Study in Orthopedic departments (inpatient and outpatient) of The Oxford Medical College, Hospital and Research Centre to evaluate prescription patterns of NSAIDS in Osteoarthritis patients using WHO prescribing indicators.

Sampling Size and Technique

The study was carried out for 12 months among in-patients and outpatients treated for Osteoarthritis through a collection of data from the patient's medical records.

The sample size of 100 was calculated using the following sample size equations

Patients who are above 18 years of both genders were recruited into the study.

Methods of Data Analysis

Data Collection

Step 1: Designing the study protocol for obtaining Ethical approval from the Institutional Ethics Committee of The Oxford Medical College and Research Centre, Bangalore

Step 2: Collection of demographics of the patient (Name, Age, Sex, etc.) and the details regarding family history, past medical history, pregnancy details, diagnosis, prescribed drugs, etc through a data entry form.

Step 3: Assessment of Prescription pattern of Nonsteroidal Anti-Inflammatory Drugs (NSAIDS) in Osteoarthritis patients using WHO prescribing indicators which include,

• Average number of drugs per prescription.

• Percentage of prescription with an NSAID prescribed.

• Percentage of Nonsteroidal Anti-Inflammatory Drugs (NSAIDS) prescribed by Generic name.

• Percentage of Nonsteroidal Anti-Inflammatory Drugs (NSAIDS) prescribed from National 5) List of Essential Medicine (NLEM).

Step 4: To provide the feedback results to clinicians and other relevant groups.

Results

A total of 100 patients were enrolled in this study in accordance to the inclusion criteria from the Orthopedics department of the Oxford Medical College Hospital and Research Centre, Bengaluru.

DEMOGRAPHIC DETAILS OF STUDY POPULATION

Distribution of patients based on their Gender

100 patients diagnosed with osteoarthritis were included in the study. Treatment charts of all the patients were analyzed, out of which n=61 (61%) were females, and n=39 (39%) were males. Table 1 displays the gender distribution of the patients. Figure 1

Distribution of the patients based on their age

The present study results revealed that OA was more prevalent in the age group of 46-60 years, n=37 (37%) and followed by 31-45 years where n =29. The specifics are displayed in Table 2, Figure 2.

Distributions of patients based on occupational status

Out of the total subjects, 34% are House Wife and the occupations of the remaining subjects are Agriculture (26%), Labour (16), Tailor (13%), Driver (11%) etc., respectively. The specifics are displayed in Table 3, Figure 3.

Distribution of the patients based on their Past Histories

This study reveals that the past histories of the subjects are more with hypertension compared to the other past histories like DM, menopause, CKD, Asthma. The specifics are displayed in Table 4, Figure 4.

Analysis of WHO core Prescribing Indicators

A total of 392 drug products were prescribed.

1. Average number of drugs per encounter (C): First total number of prescriptions collected were taken (A=100). Then a total number of drugs prescribed were added during these encounters (B=392). The result was expressed by dividing the total number of drugs by the number of encounters.

Formula: Average number of drugs prescribed: [C = B/A] = 392/100 = 3.92.

2. Percentage of drugs prescribed by generic name (E): The result was calculated by dividing the total number of generic drugs prescribed (D=15) by the total number of drugs prescribed (B=392), and multiplied by 100 to make a percentage (E).

Formula: % of drugs prescribed as generic: [E = (D/B) × 100%] = 15/392×100= 3.83 %.

3. Percentage of encounters with NSAIDs prescribed (G): It was calculated by dividing the total number of patients who received one or more NSAIDs (F=143) by the total number of encounters (A=100) and multiplying by 100 to make a percentage.

Formula: % of NSAIDs prescribed: [G = (F/A) × 100%] = 143/100 ×100 = 143%.

4. Percentage of drugs prescribed from National List of Essential Medicines or formulary (I): The result was calculated by dividing the total number of National List of Essential Medicines prescribed (H=81) by the total number of drugs prescribed (B=392) and multiplied by 100 to make a percentage (I).

Formula: % of drugs prescribed from National List of Essential Medicines: [I = (H/B) × 100%] = 81/392×100 = 20.66%.

Distribution of NSAID

Table 7 and Figure 5 depicts that 45 (31.5%) patient was on NSAIDs with combinations and 98 (68.5%) patient was on NSAIDs without combination. Table 5, Table 6

NSAIDS Prescribed

Table 8 and Figure 6 depicts that 22 (15.4%) Patients were prescribed Paracetamol, 48 (33.6%) were on Diclofenac, 46 (32.2%) were on Aceclofenac, 7 (4.9%) were on Ibuprofen, 6 (4.2%) were on Piroxicam, 10 (6.9 %) were on Etodolac, 4 (2.8%) were on Nefopam.

Class of NSAIDs

Of 143 NSAIDs prescribed, 13 (9.1%) were Non-Selective COX Inhibitors, 2 (1.4%) were Selective COX-2 inhibitors, 102 (71.3%) were Preferential COX-2 Inhibitors, 26(18.9%) were Analgesics-Antipyretic with low Anti-inflammatory Action (Table 9; Figure 7)

Drugs from NLEM

Table 10 and Figure 8 depicts the list of drugs from NLEM, among which 48 (33.6%) were Diclofenac, 7 (4.9%) were Ibuprofen, 4 (2.8%) were Fentanyl and 22 (15.3%) were Paracetamol.

Discussion

The study was conducted to analyze the Prescription Pattern of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) in osteoarthritis patients. Total of 100 patients were enrolled in this study. 1, 2, 3

Considering the gender-wise distribution female predominance was found, 4 Females 61% were mostly affected compared to the Males 39% which is similar to the study conducted by Poornima B et al. 5 which shows more Females were affected than Males. The maximum number of patients enrolled both male and female belongs to the age group of 46-60 years 37(37%) and 31-45 years 29 (27.69%) respectively, which is similar to the study conducted by Lokesh V et al. 6 that showed the majority number of patients was in 46-60 years 37(37%) patients followed by 31-45 years group patients. The mean age of the study participants in this study was found to be 52.45 years. The past history of the subjects was analyzed and it showed that more patients with OA are affected with hypertension (42%) and 25% were affected with DM compared to the other past histories like menopause (15%) & CKD (8%). And 5% of patients had no other past histories other than OA. This was similar to the study reports of Chintala Srilekha et al.7 which shows that OA patients was affected more by HTN & DM. In this study, we found that the date of prescription and patient's details name, age, sex, and address were complete in all the prescriptions. In this study total number of drugs from 100 prescriptions was 392 and average number of prescribed drugs was 3.92 and the average number of NSAIDs prescribed per prescription was found to be 1.43 which is similar to the study done by Ingle et al.8 which shows 3.5 as average number of drugs per prescription. This study shows the percentage of drugs prescribed by generic names is 3.83%. A study conducted by Mohammed A Alshakka et al.9 shows 18.5% of drugs were prescribed by generic name. Another study conducted by Chinju Anil et al.10 showed 21.0% of drugs were prescribed in generic name indicating that our study has a lesser number of generic drugs. The percentage of drugs prescribed from the essential drugs list or formulary from the WHO organization model list of essential medicines was 20.66%, whereas in Chennai, conducted by Ingle et al.8 shows 51.05% and a study conducted by Chinju Anil et al.10 and Mohammed A Alshakka et al.9 shows 59.94% and 73.3% of drugs were prescribed from EDL respectively. Out of 100 prescriptions in the orthopedic department, 98 (68.5%) were NSAIDs without combination and 45 (31.5%) were NSAIDs with combinations. Among the use NSAIDs as monotherapy 48 (33.6%) was Diclofenac and 46 (32.2%) was Aceclofenac, 22 (15.4%) was Paracetamol, 7 (4.9%) was Ibuprofen, 6 (4.2%) was Piroxicam, 10 (6.9 %) was Etodolac, 4 (2.8%) was Nefopam. The study conducted by Haseeb Mohammed AR et al.11 shows a report with the present result that Diclofenac was the most commonly prescribed NSAIDs followed by Aceclofenac. In this study, it is evident that the most preferred class of NSAIDS was Preferential COX-2 Inhibitors 102 (71.3%) followed by Analgesics-Antipyretic with low Anti-inflammatory Action 26(18.9%), Non-Selective COX Inhibitors 13 (9.1%) and Selective COX-2 inhibitors 2 (1.4%).

Conclusion

In this study total number of drugs from 100 prescriptions was 392. Percentage of encounters with NSAIDs is found to be 143 %. Percentage of drugs prescribed by Generic name is 3.83 % and the Percentage of drugs from the National list of Essential medicine is found to be 20.66 %. Among the NSAIDS Diclofenac and Aceclofenac was most commonly prescribed. NSAID Monotherapy is more prescribed over NSAIDS with combinations. Preferential COX-2 Inhibitors were more preferred Nonselective COX. Diclofenac is more prescribed from NLEM and our study highlighted the need to maximize the prescribing patterns according to NLEM and to accelerate prescribing patterns by means of generic use where clinical pharmacists could play important role in the selection of drugs and to do an educational intervention on the promotion of rational prescribing drugs like NSAIDS.