G.B. SIMPSON, D. GOVINDA DAS

Access to standardised and validated information on drug use is essential to verify patterns of drug utilization, identify problems and monitor the outcome of educational or other interventions. Very few studies of in-patient drug use have been reported from developing countries, but in April 2000 Osmania General Hospital in Hyderabad, India, began a four-year study to analyse drug utilization trends among its in-patients. Osmania is a tertiary level government teaching hospital with 39 wards, 21 departments and 1168 beds, with patients coming from throughout Andhra Pradesh State. The research uses WHO drug indicators, with the data collected becoming the basis for the design and evaluation of interventions. In line with WHO recommendations for such studies, researchers are using the Anatomical Therapeutic Chemical (ATC) classification system and the measuring unit is the number of defined daily doses per thousand patient days (DDD/1000PD Defined Daily Dose). A DDD is the typical dose of a drug, used to treat the most common medical problem for which the drug is prescribed. Its use facilitates comparison and discussion of differences in drug use in internationally accepted units.^{1 5}

Retrospective data from 1-4-2000 to 31-3-2002 were collected and analysed for the use of drugs and a two-year prospective study is underway for the period 1-4-2002 to 31-3-2004. The retrospective data were used to design interventions to change prescribing behaviour, and evaluate the outcome of interventions.

The statistical analysis consisted of the names and quantities of drugs used for a year, as well as the annual number of patient days (the sum of all days which all patients spent in a hospital for a year).

The total quantity of a drug used is divided by the DDD for that drug and the number of DDDs used for a year is calculated. This number is further divided by the number of thousands of days that all patients have spent in Osmania General Hospital for that year. Finally the drug utilization is expressed in number of DDD used per 1000 patient days.

The 20 most used drugs are shown in Table 1. Overall drug utilization in Osmania General Hospital was 4426.66 DDD/1000PD during 2000-2001 and 4484.35 DDD/1000PD during 2001-2002. On average each patient received 4-5 drugs daily. In comparison in a Serbian study the drug utilization was 7133.87 DDD/1000PD during 1997 and 8597.03 DDD/1000PD during 1998.⁶ At Osmania Hospital two major prescribing irrationalities were observed after an analysis of use of individual drugs and drug groups.

Table 1
Top 20 drugs used in Osmania General Hospital (Drug use is expressed as number of DDDs/1000 PD)

Corticosteroids

The use of corticosteroids during 2000-2001 was 508.42 DDD/1000PD and during 2001-2002 was 536.81 DDD/1000PD. In Serbia during 1997 the rates were 325.00 DDD/1000PD and in 1998, 320.70 DDD/PD.⁶ In Osmania Hospital there is widespread use of corticosteroids, which may lead to many toxic effects. Two categories of toxic effects result from the therapeutic use of corticosteroids, those resulting from withdrawal of steroid therapy and those resulting from continued use of supraphysiological doses. The side-effects from both of these categories are potentially life threatening and a careful assessment of the risks and benefits in each patient is essential.⁷

Ranitidine

Ranitidine use was 380.42 DDD/1000PD during 2000-2001 increasing to 488.92 DDD/1000PD during 2001-2002. At Osmania, ranitidine is prescribed as prophylaxis against Non Steroidal AntiInflammatory Drugs (NSAIDs) induced ulcers, and treatment of peptic ulcer, gastroesophageal reflux disease, and non-ulcer dyspepsia. Prophylactic use of ranitidine is not needed with short-term NSAIDs therapy in patients without any history of ulcer disease.

Taking action

An intervention programme to change doctors’ prescribing behaviour is underway at Osmania General Hospital, through educational activities such as lectures, seminars, group teaching and distribution of printed material to reduce the use of corticosteroids and ranitidine. Already another Indian study has shown the benefits of such educational interventions to improve prescribing. In a drug utilization study done in Government Headquarters Hospital, Ooty, 46% of patients admitted were prescribed ranitidine. After an educational programme a 30% decrease in ranitidine use was noticed after one year.⁸

Dr G.B.Simpson and Dr D.Govinda Das, Department of Clinical Pharmacology and Therapeutics, Osmania Medical College/Osmania General Hospital, Hyderabad-500012, India. E-mail: dicindia@yahoo.co.in

References

1. WHO. The use of essential drugs. Technical Report Series No.895. Geneva: World Health Organization; 2000, 1-8.

2. WHO. How to investigate drug use in health facilities, Geneva: World Health Organization; 1993. EDM Research Series No.7, 3-27.

3. WHO. How to develop and implement a national drug policy, 2^nd ed. Geneva: World Health Organization; 2001, 59-68.

4. Quick JD, Rankin JR, Laing RO, O Connor RW, Hogerzeil HV, Dukes MN, Garnett A, eds. Managing drug supply, 2^nd ed. West Hartford, CT: Kumarian Press; 1997, 430-449.

5. WHO. ATC index with DDDs. Olso: WHO Collaborating Centre for Drug Statistics Methodology; 2002. Web site: http://www.whocc.no/atcddd/

6. Jankovic SM. Drug utilization trends in Kragujevac clinical hospital centre from 1997 to 1999. Indian Journal of Pharmacology 2001; 33; 29-36.

7. A.Gilman, J.Hardman and L.Limbird, eds. Goodman & Gilman’s the pharmacological basis of therapeutics. 10^th ed. New York: McGraw-Hill Press; 2001, 1666-1668.

8. Johnson G. Impact of drug utilization programme on ranitidine in a South Indian Hospital. Indian Journal of Pharmacology 2001;33:43.