Deprescription: a global need to rationalize drug prescribing

Appropriate prescribing and deprescription of unwanted medicines are a global concern. Polypharmacy is common in old age due to multiple comorbidities. This poses many risks that can be prevented by deprescription as a measure of planned reduction in number of medicines no longer needed. For articles to be included in this narrative review, a non-systematic search of deprescription and related term was conducted at PubMed and Google Scholar database. Articles detailing deprescription in general were included whereas those about deprescription in a particular disease or of particular drug groups were excluded. The review discusses about related terms, process of deprescription, when it is to be planned, which patients need deprescription, tools available for appropriate prescription, importance of patient oriented deprescription, actual steps involved in deprescription, present scenario, future scope of trials and formulation of guidelines for deprescription, and finally current state of deprescription in India and actions needed.

Acute hepatic failure due to dengue: A case report

Dengue is an arboviral disease endemic in many parts of the world. Although it is known to cause hepatic involvement commonly, it only occasionally results in acute hepatic failure. We present the case of a young male who developed acute hepatic failure due to dengue. The differentials and the management is discussed

Concurrent reactive arthritis and myelitis – a case report

Reactive arthritis is a post infectious multisystem illness which usually occurs after episodes of diarrhoea or urinary tract infections. It can cause many manifestations other than the musculoskeletal system including skin, urogenital system and eyes. However the central nervous system is only occasionally involved. We discuss the case of a 32 year old male who presented with myelitis in association with reactive arthritis

Study of antimicrobial prescribing pattern in a tertiary care teaching hospital at Dehradun, Uttarakhand, India - A tool to teach clinical pharmacology to MBBS students

Background: Due to increasing resistance to a majority of antimicrobials, it becomes very necessary to teach undergraduate students, the future prescribers, about the judicious and rational use of antimicrobial drugs. The objective of this study was to impart the basic clinical skills to undergraduate MBBS students which will form an integral component of practising rational therapeutics.Methods: A total no of 737 cases were followed up by the 5th semester 2nd Professional MBBS students in the Department of Pharmacology at Shri Guru Ram Rai Institute of Medical and Health Sciences (SGRRIM and HS), Dehradun from June 2013 to July 2015. Patients were analysed on various WHO drug use indicators like drug formulations, drugs prescribed per prescription, Fixed dose Combinations (FDCs), drugs prescribed from National List of Essential Medicines (NLEM) and drugs prescribed by generic names.Results: A total of 737 prescriptions were analysed. Male: Female ratio was 1.74:1 (63.50%:36.50%). Majority of the patients 218 (29.58%) were in 16-30 years age group. A total of 1205 antimicrobials were prescribed. 304 (25.23%) cephalosporins were most frequent followed by 184(15.27%) penicillins, 176(14.61%) antitubercular drugs, 163(13.53%) nitroimidazoles, 143 (11.87%) fluoroquinolones, 102 (8.46%) aminoglycosides, 29 (2.41%) macrolides, 19 (1.58%) tetracyclines, 12 (1%) carbapenems, 11 (0.91%) antimalarials, 11 (0.91%) antihelminthics, 6 (0.50%) glycopeptides, 4 (0.33%) lincosamides and 41 (3.41%) miscellaneous antimicrobials. Most frequently prescribed antimicrobial was Ceftriaxone which was given in 97 (8.05 %) patients. A total of 424 (35.19%) oral antimicrobials, 777 (64.48%) injectable antimicrobials and 04 (0.33%) local/topical antimicrobial drugs were prescribed. 5.13 drugs per prescription and 1.64 antimicrobials per prescription were prescribed. 2100 (55.56%) drugs were prescribed from National List of Essential Medicine 2015 (NLEM 2015). 1177 (97.68%) antimicrobials were prescribed from NLEM. 1110 (92.12%) antimicrobials were prescribed by brand names. A total of 342 (28.38%); fixed dose combinations of antimicrobials were prescribed.Conclusions: Majority of the prescriptions revealed poly-pharmacy and a very high percentage of drugs were prescribed by their respective brand names. It is only by observing drug utilization patterns, current trends and common errors in prescriptions can be highlighted and rational prescription of antimicrobials can be taught to MBBS students

Prospective study comparing the safety and efficacy of totally tubeless percutaneous nephrolithotomy vs standard percutaneous nephrolithotomy

Background: To evaluate the feasibility and safety of totally tubeless percutaneous nephrolithotomy (PCNL) Vs standard PCNL.Methods: From August 2014 to January 2016, 66 patients underwent PCNL in our institute. Of this group, 35 patients underwent traditional nephrostomy drainage following PCNL. A tubeless procedure was performed in the remaining 31 patients. These  groups were compared with respect to age, stone burden, intraoperative events, postoperative pain, analgesic requirements, soakage, postoperative change in hemoglobin, hospitalization time and complication rates.Results: Two groups were comparable with respect to age, stone burden (2.03 cm Vs. 2.12 cm) and intraoperative events. The mean pain score (day2 - 4.95 vs. 2.95) (day3 - 4.33 vs. 1.44) and analgesic requirement (mg diclofenac) (day2 - 140.22 vs. 65.31) (day3 - 124.44 vs. 43.89) was significantly less for group 2 on day 2 and 3. There was significant problem of soakage from nephrostomy tract in group 1. Patients in group 2 returned faster to normal activities but there was no difference found in drop in hemoglobin, complication rates even in subset of patients with large stone burden. No patient required readmission in the follow-up for pain, obstruction or infection in group 2. One patient developed urinoma which resolved conservativelyConclusions: In selected cases totally tubeless PCNL is feasible and safe

Study of prevalence and prescribing trends in infectious diseases: as a teaching tool for MBBS 2nd professional students

Background: Irrational prescription of drugs is a common occurrence in clinical practice. Introduction of clinical pharmacology at the undergraduate level as an integral part of rational therapeutics is the need of hour. The present drug utilization study, prevalence and prescribing pattern in infectious diseases in a tertiary care teaching hospital was carried out to teach clinical pharmacology to 2nd professional MBBS students, to sensitize and promote rational prescribing.Methods: A total of 621 prescriptions were collected by 2nd professional MBBS students at Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun. Prescriptions were analyzed on various parameters, using WHO drug use indicators.Results: A total of 621 prescriptions were analyzed. 477 (76.81%) were males and 144 (23.19%) were females. Majority of patients 357 (57.49%) were 16-60 years’ age group. The infectious diseases prevalence was 153 (24.63%) enteric fever, 132 (21.26%) hepatitis, 111 (17.87%) pyrexia of unknown origin, 90 (14.49%) cellulitis, 135 (21.74%) belongs to miscellaneous category respectively. A total of 4446 drugs were prescribed, which includes antibiotics 2025 (45.55%), multivitamins 969 (21.79%), antacids 699 (15.72%), analgesics 408 (9.18%), antiemetic 273 (6.14%) and antiepileptic 72 (1.62%) respectively. 3096 (69.64%) oral, 1350 (30.36%) injectable and 786 (17.68%) fixed dose combinations (FDCs) were prescribed. 3.26 antibiotics and 7.15 drugs per prescription were prescribed. 2622 (58.97%) drugs were prescribed from national essential medicine list 2015. 100% drugs were prescribed by brand names.Conclusions: The prescriptions revealed polypharmacy. This study can help to provide feedback to the prescribers, thereby increase in awareness and improve patient care by rational utilization of drugs

Prescribing pattern in Rheumatoid Arthritis patients in a tertiary care teaching hospital

Background: Rheumatoid arthritis (RA) is associated with joint deformity and significant health care related expenses. This disease affects approximately 1% of the adult population, the prevalence of RA in India is approximately 0.75% and increasing trend has been observed. Irrational prescribing is a common phenomenon around the globe. The drug utilization studies form an important tool for the assessment of rational or irrational prescribing and WHO drug use indicators. Thus keeping this in view the prescribing pattern analysis in RA patients was done.Methods: This prospective study was carried out by the department of pharmacology in medicine OPD of SGRRIM and HS, Dehradun for one year. A total of 450 RA diagnosed patients were included in the study. The diagnosis was made on the basis of clinical assessment and lab parameters as rheumatoid factor and anti-ccp. The collected prescriptions were analyzed by using WHO drug use indicators.Results: Total of 450 prescriptions was analyzed. 378 (84%) were females and 72 (16%) were males. Most commonly presenting age group was 31-60 years 276 (61.33%). Family history and RA factor was positive in 168 (37.33%) and 318 (70.67%) patients respectively. Anti-ccp was raised in 408 (90.67%) patients. The comorbid conditions were type-2 diabetes mellitus 72 (16%), hypertension 48 (10.67%), hypothyroidism 36 (8%) and other associated illness 54 (12%). Total of 1655 drugs were prescribed during the study period. The prescribed drugs were disease modifying anti-rheumatic drugs (DMARDs) 582 (35.18%), vitamin-D3 and calcium supplements 320 (19.34%), analgesics 311 (18.80%), antacids 204 (12.33%), others 238(14.38%). 437 (26.40%) fixed dose combinations (FDCs), 3.67 drugs per prescription, 1145 (69.18%) drugs by brand names and 1161 (70.15%) drugs from the National List of Essential Medicine (NLEM) 2015 were prescribed.Conclusions: Drug prescribing pattern depicts that most commonly prescribed were DMARDs, vitamin-D3 and calcium supplements and analgesics. Most of the drugs were prescribed from NLEM 2015

Prescribing trends in respiratory tract infections in a tertiary care teaching hospital

Background: Respiratory tract infections are a major cause of morbidity and mortality in developing countries. Polypharmacy and irrational prescribing in respiratory diseases are common practice worldwide. Keeping in consideration this scenario, present study was undertaken to analyze the drug utilization pattern of respiratory tract infections.Methods: This drug utilization study was conducted by Pharmacology department at SGRRIM & HS to analyze drug utilization pattern of respiratory infections. A total of 585 prescriptions were collected from hospital and randomly evaluated for prescribing pattern using WHO drug indicators.Results: A total of 585 prescriptions were analyzed. Male:Female ratio was 1:0.77. Age wise distribution was done; 81(13.84%) 0-15 years, 54(9.23%) 16-30 years, 198(33.84%) 31-45 years, 75(12.82%) 46-60 years and 177(30.25%) patients belongs to >60 years of age group respectively. A total of 4869 drugs were prescribed, 2754(56.56%) antibiotics, 675(13.8%) bronchodilators, 630(12.93%) corticosteroids, 303(6.22%) antacids, 507(10.41%) in miscellaneous category respectively. 2562(52.61%) oral, 1491(30.62%) injectable and 816(16.75%) inhalational drugs were prescribed. Numbers of Fixed dose combinations were 645(13.24%). 8.32 drugs were prescribed per prescription. 2409(49.47%) drugs were prescribed from national essential medicine list 2015. 4320(88.72%) drugs were prescribed by their brand names.Conclusions: Irrational prescribing and polypharmacy was observed. The drug utilization studies are important tool to sensitize and increases awareness among physicians, which ultimately improves rational prescribing and patient care