Rathnakar U.P. Kasturba Medical College, Mangalore. M.S.Kotian, Kasturba Medical College, Mangalore

K.Mukund. Mangalore Heart Scan Foundation. Mangalore

Manipal University

Increasing incidence of diseasewith age

Multiple diseases in elderly Nutritional problems Expense of drugs

[Entirely dependent on children] No health insurance Polypharmacy and drug interactions Compliance

Important

in

elderly

Auditing prescriptions →Drug utilization studies

Monitors, evaluates and if necessary, suggests modifications in prescribing practices

Provides feedbacks to prescribers and creates an awareness about the irrational use of drugs.

70,000 formulations available in India

WHO lists only about 350 preparations in essential drug list

This study was undertaken to Determine the utilization of

drugs in elderly patients For Cardiovascular diseases And important co-morbid

condition - Diabetes mellitus (DM)

Also to estimate the cost of medications in these patients.

Study design  A longitudinal Retrospective design was

employed To analyze the prescriptions

of all the geriatric patients Attending an exclusive

cardiac clinic in Mangalore, during 2007

Computerized demographic and clinical data were accessed

All the prescriptions for the year 2007 stored in the computer were analyzed.

Aged 65 years or more - considered as belonging to geriatric age group.

Number of drugs prescribed in every prescription was considered to calculate the incidence of polypharmacy.

Cost calculated using ‘Drug today ready reckoner of current medical formulations’ and the website www.mims.com.

Age in Years

No. of Pts

5263

99

34

27

135

Age And Sex Profile[n=212]

HTN[55.2%]

MI/Angina[63.2%]

DM[26.41%]

COPD

Others

No. Of Drugs per Prescripti

on

AgeTotal

n=212(%)65-69

n=86(%)70-74

n=90(%)75-79

n=22(%)>80

n=14(%)

1 4(4.6) 4(4.4) 0(0) 0(-) 8(3.7)2 9(10.4) 10(11.1) 1(4.5) 1(7.1) 21(9.9)3 14(16.3) 13(14.4) 2(9.0) 2(14.2) 31(14.6)4 20(23.2) 19(22.1) 3(13.5) 4(28.4) 46(21.6)5 21(24.4) 20(22.2) 7(31.5) 4(28.4) 52(24.5)6 8(8.3) 11(12.2) 4(18) 1(7.1) 24(11.32)7 6(6.9) 7(7.7) 2(9) 1(7.1) 16(7.4)8 2(2.3) 5(5.5) 1(4.5) 0(-) 8(3.7)9 1(1.1) 1(1.1) 2(9) 1(7.1) 5(2.3)

10 1(1.1) 0(-) 0(-) 0(-) 1(6.4)

Incidence of Polypharmacy

Χ62 = 4.69, p=0.584

Drugs No.of prescriptionsn=212

Percentage

Antiplatelets* 155 73.1Beta blockers 117 55.1Nitrates 115 55.24Statins* 87 41.03Diuretics 73 3.43Ca++ channel blocker 65 36.66ARB 44 20.75ACE-I 34 16.03

Drugs prescribed for diseases of CVS

* Accounted for 25% 0f the cost

[0.49] [0.40]

[0.14]

Details of prescription NumbersNumber of prescriptions 212Total number of drugs prescribed 962No. of drugs from essential drug list (WHO or India) 436

Average no. of drugs per prescription 4.5Number of fixed dose combinations 128Fixed dose combinations in the WHO approved list 0

INR21.64 INR

17.53 INR6.03

PRESCRIPTION ANALYSIS

Combinations No.Of Prescriptions

Percentage(n=212)

Atenolol+Hydrochlorthiazide 1 0.47Atenolol+Nefedipine 1 0.47Atenolol+Amlodipine 16 7.52Enalapril+Hydrochlorothiazide 8 3.77Losartan+Hydrochlorothiazide 21 9.90Telmisartan+Hydrochlorothiazide 2 0.94Clonidine+Hydrochlorothiazide 3 1.41Amiloride+Hdrochlorothiazide 7 3.30Amiloride+Furosamide 2 0.94Clopidogrel+Aspirin 50 23.58Isosorbide-5-Mononitrate+Aspirin 1 0.47Atorvastatin+Niacin 1 0.47Atorvastatin+Ezetimibe 3 1.41Glibenclamide+Metformin 6 2.83Glipizide+Metformin 6 2.83

Fixed dose combinations

Polypharmacy of more than 1 drug was seen in 96% of the prescriptions where as 142 (67%) prescriptions had 4 drugs or more

Among 962 drugs prescribed nearly half (436) were not from the WHO approved essential drug list

Antiplatelets (155) were the most often prescribed drug

Antiplatelets were prescribed for 155 (73%) patients, more than the prevalence of cases of IHDs (134) [Primary prevention]

For cardiovascular diseases money spent/ prescription /day was INR 17.53 (0.40 USD)

For DM ,INR 6.03 (0.14 USD) Clopidogrel- Aspirin combination

and Atorvastatin accounted for more than 25% of the cost of medications in prescriptions for diseases of CVS.

 Most of the geriatric patients were prescribed more than 2 drugs -as nearly 70% of the patients were suffering from 2 or more diseases.

Increasing age was not related to increase in the number of drugs per prescription

Higher prevalence of use of clopidogrel –aspirin combinations (23.60%) and statins (41.03%) added substantially to the cost of medications (18.73%).

Most important aspect of polypharmacy-drug interactions-could not be studied because of the retrospective nature of study design.

Defined daily dose (DDD) if calculated allows drug utilization data to be compared more realistically

Detailed interview of the treating physician on the day prescription is issued, may provide reasons for the use of drugs not found in the essential drug list

True financial burden of drug costs can be evaluated from the patient’s perspective only when the economic status of the patient is known

1. Bertram G.Katzung. Basic and clinical pharmacology. 9th ed. McGraw-Hill; 2004. p. 1007-1010.

2. Studies in drug utilization. European series No.8. Copenhagen, WHO regional publications, 1979 

3. Shrishyla MV, Mahesh Krishnamurthy, Naga Rani MA, Sr.Mary Clare, Andrade C, Venkataraman BV. Prescription audit in an Indian hospital setting using the DDD (Defined daily dose) concept. Indian J Pharmacol. 1994 Jan 26:23-28.

4. Pradhan SC, Shewade DG, Shashindran CH, Bapna JS. Drug utilization studies. National Med J lndia 1988; 1 :185-9.

5. Mashford ML. Update -Victorian Medical Postgraduate Foundation Group. Aust J Hosp Pharm 1988(Supple)18:17-8.

6. Ramsay LE. Bridging the gap between clinical pharmacology and rational drug prescribing. Br J Clin Pharmac. 1993;35:575-6.

7. Patel Vikram, Vaidya R, Naik D, Borker P. Irrational drug use in India:A prescription survey from Goa. J Postgrad Med. 2005; 51:9-12

8. Hardeep Singh, Michael L. Johnson. Prescribing patterns of diuretics in Multi-drug antihypertensive regimens. J Clin Hypertens. 2005; 7(2):81-87

9.  Drug today ready reckoner of current medical formulations. Mishra L. Editor. Lorina publications(India) Inc. New Delhi: 2006

10.  Data base of drugs manufactured in India. Available at http://www.mims.com/index.aspx 

11. Hede SS, Dinz RS, Agshikar NV, Dhume VG, Pattern of prescribed and OTC drugs in North Goa. Indian J Clin Pharmacol. 1987: 19:145-148 

12. Kapoor B, Raina RK, Kapoor S. Drug prescribing pattern in a teaching hospital. Indian J Pharmacol 1985; 17 Suppl 1:168 

13. Kumar H, Guptha U, Garg KC, Agarwal KK. A study of trend of drug usage in a hospital unit. Indian J Pharmacol 1986; 18-50 

14. Sood B, Verma RK, Gulati PV. Diagnosis and treatment in a general hospital. The Clinician; 1984;48:263-270. 

15. Nies SA, Principles of therapeutics, In: Gilaman GA, Rail WT, Nies SA, Taylor P, editors. The pharmacological basis of therapeutics. New York:Penguin press, 1990:41:346-349 

16. Laurence DR, Bennet PN, editors. Clinical pharmacology. Edinburgh:Livingstone, 1992. 

17. Denis Xavier, Noby Mathew, Johnson Pradeep, Prem Pais. Pattern of drug use in hypertension in a tertiary hospital. Indian J Pharmacol.2001; 33:256-457. 

18. Tripathi KD. Essentials of medical pharmacology. 6th edition, New Delhi: Jaypee brothers medical publishers (P) limited; 2008:608-611. 

19. Marieke D, Schoen, Pharm.D, Robert J, DiDomenico, Pharm.D, Sharo E, Connor, Pharm.D, Jill E, Dischler, Pharm.D, and Jerry L, Bauman, Pharm.D. Impact of the cost of prescription drugs on clinical outcomes in patients with heart disease. Pharmacotherapy, 2001:21(12):1455-1463.

Dr.U.P.Rathnakar. MD.DIH.PGDHM Asst.Prof.Department of Pharmacology, Kasturba Medical College. Manipal University.

INDIA Mr. M.S.Kotian, Asst.Prof.Dept.Of Community

Medicine, Kasturba Medical College, Manipal university.

INDIA Dr.K.Mukund.MD.DM.Interventional

cardiologist. Mangalore Heart Foundation. Mangalore.

INDIA CONTACT:rathnakar26@yahoo.com