WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES Sarumathy S et al. Volume 2, Issue 6, 5913-5919. Research Article ISSN 2278 4357 A STUDY ON DRUG USE PATTERN AND COST IMPACT OF ANTIDIABETIC DRUGS IN TYPE 2 DIABETIC PATIENTS IN A SECONDARY CARE HOSPITAL Sarumathy S* 1, Ravichandiran V 1, Mohammed Sulaiman Sait J 1, Manjula Devi K 2 1 Department of Pharmacy Practice, School of Pharmaceutical Sciences, Vels University, Pallavaram, Chennai-600117, India. 2 Department of Pharmacology, Swamy Vivekanandha College of Pharmacy, Tiruchengode, Namakkal-637205, India. Article Received on 18 September 2013, Revised on 21 October 2013, Accepted on 29 November 2013 *Correspondence for Author: * Sarumathy S. Assistant Professor, Department of Pharmacy Practice, School of Pharmaceutical Sciences, Vels University, Pallavaram, Chennai-600117, India. saruprabakar@gmail.com ABSTRACT In this prospective observational study, a total number of 77 diabetes inpatients were selected in a secondary care hospital. The demographic details, disease and treatment data from the patient case sheets were collected in a separate proforma, updated timely and analyzed. The prescribing pattern of antidiabetic drugs and the mean prescription cost were determined. Higher percentage of male patients was affected with diabetes when compared to the female patients. Age group of 50-59 years had a higher prevalence of type 2 diabetes. Hypertension with diabetes was the predominating co morbidity condition. By analyzing the prescriptions 64.65% of drugs were prescribed in generic. 46% of the drugs were prescribed from WHO essential drug list. Premixed insulin mixtures were the highest prescribed medication. Polypharmacy was seen in more number of prescriptions. The average prescription cost was found to be lesser for treating diabetes (hypoglycemic) alone compared to diabetes associated complaints. KEYWORDS: Diabetes, Polypharmacy, Hypertension, Mean Prescription Cost. www.wjpps.com 5913
INTRODUCTION Diabetes is a chronic metabolic disease associated with significant morbidity and mortality [1]. According to the International Diabetes Federation, 61.3 million people in India had diabetes in 2011. That figure is projected to rise to 101.2 million by 2030 [2]. Data regarding drug use pattern in diabetes is lacking in South Asian countries. Diabetic patients are at a higher risk of polypharmacy and more vulnerable to irrational prescription [3]. Several antidiabetic drug utilization reviews have been published from across the world. Drug utilization review (DUR) of antidiabetic medicines in the healthcare setting can facilitate rational drug use in patients with diabetes [3-8]. They provide useful insights into the current prescribing practices and also identify irrational prescribing [9]. Hence we aimed to study the drug use pattern of antidiabetic drugs in a secondary care hospital. The objectives of this study included the collection of demographic details of the diabetic patients, study of the pattern of drug use among the diabetic patients and calculation of mean prescription cost for the diabetic patients. MATERIALS AND METHODS Study design This prospective observational study was carried out at inpatient department of a secondary care hospital at Salem from October 2010 to April 2011. A total number of 77 diabetes patients, who were joined as in-patient in general medicine ward of a secondary care hospital were selected according to the patient selection criteria. The demographic details, disease and treatment data of patients with diabetes mellitus from the case records were collected in specially designed proformas. The datas were updated timely and were analyzed by using graph pad software. The prescription pattern of antidiabetic drugs according to WHO essential drug list [10] and the mean prescription cost was determined. For the feasibility of analysis, the mean prescription cost was calculated for about 5 days out of each case, irrespective of the total number of days they stayed as in-patients in the ward. Patient Selection Diabetic patients older than 18 years of age of both genders were selected. Exclusion criteria included outpatients and inpatients with type 1 diabetes. RESULTS The study comprised of 77 diabetic patients of which 66% were male and 34% were female patients. The demographic details such as age, gender, social habits and family history of www.wjpps.com 5914
diabetes and duration of existence of diabetes were shown in Table 1. Table 1. Demographic details of the diabetic population S.No. Baseline Parameters Number of patients (n=77) Percentage (%) 1. Gender 51( males) 26 (females) 2. Mean Age in Years 56.70 ± 15.08 years 3. Age 50-59 yrs (27) 70-79 yrs (15) 60-69 yrs (11) 40-49 yrs (9) 30-39 yrs (9) 20-29 yrs (3) 80-89 yrs (3) 4. Social Habits Smoker (14) Alcoholic (8) Smoker and alcoholic (12) Tobacco use (4) None (39) 5. Family history of diabetes Present (17) 6. Duration of existence of diabetes Absent (60) 1-6 months (9) 7-12 months (6) 13-18 months (2) 19-23 months (11) 2-3 yrs (6) > 3 yrs (20) None (23) 66% 34% 35% 19% 14% 12% 12% 04% 04% 18 % 10% 16 % 05 % 51 % 22% 78% 12% 08% 02% 14% 08% 26% 30% Table 2. Distribution based on co morbid illness Co-morbid Conditions No. of diabetic Percentage (%) patients (n = 39) Hypertension 20 51% Renal disorders 8 21% Cardiac disorders 6 15% Foot ulcer 3 8% Neurological disorders 2 5% In this study, 39 (51%) diabetic patients were affected with co morbid disease complications, of which 31 (40%) had diabetes alone and 7 (9%) had diabetes with other complications. Hypertension was the highest associated co morbid disease condition (Table 2). www.wjpps.com 5915
Table 3. Prescription details of the Diabetic patients Details of Prescription Number (%) Total number of drugs prescribed 546 The number of analyzed prescription were 77 Average number of drugs per prescription was found to be 7.09 ± 3.48 Number of drugs prescribed from the WHO List 254 (46.52) Number of drugs prescribed by generic name 353 (64.65) Number of injections prescribed 174 (31.87) Total number of times the antidiabetics prescribed 131 (23.99) The prescription details of the type 2 diabetic patients were shown in Table 3. On analyzing the data, prescriptions containing oral hypoglycaemics + insulin (36%) were found to be higher followed by prescriptions containing oral hypoglycaemic agents + antihypertensive drugs (27%), prescriptions containing oral hypoglycaemics alone (20%) and prescriptions containing insulin alone (17%). The average number of drugs per prescription was found to be 7.09±3.48. Table 4 depicts the distribution based on generic and brand drug usage in the analyzed prescription. Table 4. Distribution Based on Generic and Brand usage Prescription item (n=546) No. of Drugs (%) Generic alone (353) 64.65% Brand alone (193) 35.35% Table 5. Drug Use Pattern Of Anti Diabetic Drugs Drug Number of times prescribed (%) Biguanides Metformin 15 (11.5) Sulphonyl ureas Glimepride Glipizide Glibenclamide 2 (1.5) 4 (3) 4 (3) Thiazolidinediones Pioglitazone 11 (8.4) Alpha-glucosidase inhibitors Voglibose Acarbose Combination 7 (5.3) 1 (0.76) www.wjpps.com 5916
Metformin + Glibenclamide 27 (20.6) Insulin Human insulin (short acting) Human insulin (long acting) 20 (15.26) 02 (1.5) Pre-mixed insulin (Human 38 (29) Mixtard) From the drug use pattern of antidiabetic drugs it was found that human mixtard was the highest prescribed drug compared to that of short acting and long acting insulin. In oral hypoglycaemic category, metformin along with glibenclamide combination was the highest prescribed drug followed by metformin alone and pioglitazone (Table 5). Table 6. Calculation of average prescription cost Therapy type Mean Prescription Cost Antidiabetic drugs 65.26 Others Drugs 389.77 The average prescription cost was found to be 65.26 for treating diabetes alone with hypoglycaemics and 389.77 in order to treat diabetic associated complaints (Table 6). DISCUSSION The present study assessed the drug use pattern of antidiabetic drugs in a secondary care hospital. In our study we found that the mean age was 56.70 ±15.08 years in contrast with the other studies [11, 12]. The average number of drugs prescribed was 7. By analyzing the prescriptions it was found that the prescriptions with generic use (64.65%) were found to be more than those in which brand alone preparations (35.35%). The most associated co morbidity along with diabetes was found to be hypertension [13]. Prescriptions containing combination of oral hypoglycaemics and insulin (36%) were higher followed by oral hypoglycaemic agents with antihypertensive drugs (27%). While considering the drug use, it was found that the most prescribed drug in oral hypoglycaemic was metformin followed by pioglitazone and sulphonyl ureas. In combination category, metformin + glibenclamide combination was the highest prescribed combination. In the insulin category it was found that human mixtard was used more frequently when compared to other type of insulin. While considering the cost of the therapy, it was found that cost for treating diabetic associated complications was higher than diabetes alone. Thus metformin alone and metformin www.wjpps.com 5917
combination was the commonly prescribed antidiabetic drug observed in the present study, in line with findings of other studies [3-5]. CONCLUSION From the above studies it may be concluded that the mostly occurring co morbidity with diabetes is hypertension and most frequently used oral hypoglycaemic agent included metformin. Polypharmacy stands as a hazard in diabetic patients. Patient counseling should be mandatory to the diabetic patients in order to screen out the diabetic risk and taking steps to avoid the diabetic complications becoming worse. Further studies with more patient population and longer period were needed to confirm the study results and also to check the influence of patient counseling in improving the quality of life of the diabetic patients. REFERENCES 1. Mayor S, Diabetes affecting nearly 250 million adults in the world. Br Med J, 2006; 333:1191. 2. IDF diabetes atlas, available at http://www.diabetesatlas.org/content/sea-data/. 3. Upadhyay DK, Palaian S, Ravi Shankar P, Mishra P, and Shah AK, Prescribing pattern in diabetic outpatients in a tertiary care teaching hospital in Nepal. Journal of Clinical and Diagnostic Research, 2007; 1(4): 248 255. 4. Sultana G, Kapur P, Aqil M, Alam MS, and Pillai KK, Drug utilization of oral hypoglycemic agents in a university teaching hospital in India. Journal of Clinical Pharmacology and Therapeutics, 2010; 35: 267 277. 5. Yurgin N, Secnik K, and Lage MJ, Antidiabetic prescriptions and glycemic control in German patients with type 2 diabetes mellitus: a retrospective database study. Clinical Therapeutics, 2007; 29: 316 325. 6. Chiang CW, Chiu HF, Chen CY, Wu HL, and Yang CY, Trends in the use of oral antidiabetic drugs by outpatients in Taiwan: 1997 2003. Journal of Clinical Pharmacy and Therapeutics, 2006; 31: 73 82. 7. Johnson JA, Pohar SL, and Secnik K, Utilization of diabetes medication and cost of testing supplies in Saskatchewan, 2001. BMC Health Services Research, 2006; 6: 159. 8. Boccuzzi JS, Wogen J, Fox J, Sung CY, Shah BA, and Kim J, Utilization of oral hypoglycemic agents in a drug-insured US population. Diabetes Care, 2004; 24(8): 1411 1415. www.wjpps.com 5918
9. John LJ, Arifulla M, Sreedharan J, Muttappallymyalil J, Das R, John J, and Basha A, Age and gender-based utilization pattern of antidiabetic drugs in Ajman, United Arab Emirates. Malaysian Journal of Pharmaceutical Sciences, 2012; 10(1): 79 85. 10. WHO Model List of Essential Medicines. 16th ed., March 2010, Available at http://www.who.int/medicines/publications/essentialmedicines/en/index.html/. 11. De Pablos-Velasco PL, Martinez-Martin FJ, Molero R, Fodríguez-Perez F, Garcia Puente I, and Caballero A, Pattern of prescription of hypoglycemic drugs in Gran Canaria (Canary Islands, Spain) and estimation of the prevalence of diabetes mellitus. Diabetes & Metabolism, 2005; 31(5): 457-462. 12. Van den Brink G, Schwartzenberg RR, Hoeve LJ, Porsius AJ, and Hoeve LL, The use of hypoglycemic and cardiovascular drugs in 582 patients with diabetes mellitus. Description and quality assessment. Pharmacy World & Science, 1993; 15(3):128-131. 13. Sandozi T and Emani VK, Survey of prescription pattern of anti-hypertensive drugs in hypertensives & hypertension associated diabetics. International Journal of Pharma and Bio Sciences, Oct- Dec 2010; 1(4):23-26. www.wjpps.com 5919