to study drug prescribing pattern, cost and clinical

www.wjpps.com Vol 8, Issue 12, 2019.

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Joshi et al. World Journal of Pharmacy and Pharmaceutical Sciences

TO STUDY DRUG PRESCRIBING PATTERN, COST AND CLINICAL

BENEFITS IN MYOCARDIAL INFARCTION PATIENTS IN

TERTIARY CARE HOSPITAL – A PROSPECTIVE OBSERVATIONAL

STUDY

Dr. Anil Joshi*, Priyanka Singh1, Poorva Kanade

1, Nisharg Patel

1 and Dr. Sadhana

Shahi2

*Associate Professor, Department of Medicine, Government Medical College and Hospital,

Aurangabad, Maharashtra, India.

1Pharm D Students, Government College of Pharmacy, Aurangabad, Maharashtra, India.

2Associate Professor, Government College of Pharmacy, Aurangabad, Maharashtra, India.

ABSTRACT

Objective: To study drug prescribing pattern, cost and clinical benefits

in Myocardial Infarction patients in tertiary care hospital- A

Prospective Observational Study. Method: 262 samples were included

in the study, detailed history was taken and noted in the designed

proforma. Drugs prescribed and cost of therapy was analyzed. On

follow-up, patients were enquired for clinical benefits, improvement or

deterioration in clinical conditions. Result: Out of 262 patients

maximum were males 182 (69.47%). Prevalence of Myocardial

Infarction was found to be higher among age group 51-60 years

(32.82%) while least number of patients were observed in age group of

below 20 years and above 80 years. Categories of drugs for

management of Myocardial Infarction were Antihyperlipidemic 252

(96.18%), 249 (95.04%) Antiplatelet, 176 (67.18%) Antihypertensives, 139 (53.05%)

Thrombolytics, 128 (48.85%) Antianginal, 122 (46.56%) Anticoagulant, respectively. Certain

untoward reactions revealed the frequency of headache, muscle weakness, and syncope. The

occurrence of haematemesis and haematuria was less. The study revealed the minimum and

maximum cost per day hospitalization borne by the patient was from Rs.0 to Rs. 35.83.

Average cost for the management of MI is Rs. 24.45 per day excluding the cost of

Anticoagulant and Thrombolytic drugs which was borne by Government hospital.

WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES

SJIF Impact Factor 7.632

Volume 8, Issue 12, 715-729 Research Article ISSN 2278 – 4357

Article Received on

26 Sept. 2019,

Revised on 16 Oct. 2019,

Accepted on 06 Nov. 2019,

DOI: 10.20959/wjpps201912-14700

*Corresponding Author

Dr. Anil Joshi

Associate Professor,

Department of Medicine,

Government Medical

College and Hospital,

Aurangabad, Maharashtra,

India.


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Conclusion: The prevalence of MI is more in males as compared to females. The cost of

medicines purchased by patients varied from Rs. 0 to Rs. 35 with an average cost of Rs. 24

because all other cost were borne by Government hospital.

KEYWORDS: Myocardial Infarction, Prescribing Pattern, Clinical benefits.

INTRODUCTION

Myocardial infarction (MI) is a major cause of mortality and morbidity worldwide. The term

MI reflects death of cardiac myocytes caused by ischemia, as a result of perfusion imbalance

between supply and demand. The most obvious classical clinical symptoms include various

combination of chest, upper extremity, jaw or epigastric discomfort on exertion or at rest. The

discomfort associated with acute myocardial infarction (AMI) usually lasts at least 20

minutes. Often the discomfort is diffuse, not localized, not positional, not affected by the

movement of the region, and it may be accompanied by dyspnea, diaphoresis, nausea or

syncope.[1]

Cardiovascular diseases are the major cause of morbidity and mortality in India. As per WHO

reports an estimated 17.7 million people died from cardiovascular diseases in 2015.[2]

With

such high prevalence and rapid growth in incidence rate of MI, it’s a need of the hour to

adopt certain strategies for better management of the disease.

The present study is an attempt to analyze the prescribing pattern of drugs used for the

treatment of myocardial infarction in order to ensure appropriate drug use to reduce the

morbidity and mortality of the disease and also reduce the economic burden of the patient.

The finding of the study are expected to provide relevant and useful feedback to physicians.

Prescription pattern explains the extent and profile of drug use, trends, quality of drugs, and

the National guidelines like guidelines of American Heart Association. There is an increasing

importance of prescription pattern monitoring studies (PPMS) because of a boost in

marketing of new drugs, variation in pattern of prescribing and consumption of drugs,

growing concern about drug interactions, cost of drugs.[3]

Prescribing pattern studies deduce

to monitor, evaluate and insinuate modifications in the practitioner’s prescription habits, so as

to make patient care rational and cost effective.[4]

The cost effective treatment may be possible through doctors prescribing the drugs in

consultation with the pharmacist in the hospital; since the pharmacist is acquainted with


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drugs, its brand and generic. The present study is envisaged to assess the drug prescribing

pattern, cost and clinical benefits in myocardial infarction patients.

MATERIALS AND METHODS

Study Site: The study was conducted at Government Medical College and Hospital,

Aurangabad, a tertiary care center during the period of October 2018 to March 2019.

Study Design: Prospective observational study.

STUDY POPULATION

Study Population: Patients admitted in ICCU and medicine ward, Department of Medicine,

Government Medical College and Hospital, Aurangabad.

Inclusion Criteria: All male and female myocardial infarction patients admitted in coronary

care unit and medicine ward; given consent for the study.

Exclusion Criteria: Patients not given consent. During follow-up the information was

inadequate (i.e. death).

Sample Size: 262.

Study Procedure: The patients were screened for inclusion and exclusion criteria and

thereafter enrolled for the study. All the enrolled patients were uniquely identified by

Inpatient number, patient’s name, age, gender, contact details and clinical details were

recorded at the time of enrollment.

Baseline Screening Process and Recording: Patient’s case file were observed as a baseline

screening process and data was filled in data entry proforma. The format for proforma

included details such age, gender, complains on admission, past medical history, addiction

habits, drugs prescribed, dose, frequency and route of drug administration, untoward

reactions etc.

Detail Procedure of Study: The study was executed after getting clearance from the

Institutional Ethics Committee of Govt. Medical College and Hospital, Aurangabad (No :

Pharma/IEC-GMCA/401/2018, Dated :16/10/2018). The study procedure was explained to

the patients diagnosed with myocardial infarction and patients giving consent were included

for the study. Detailed history and clinical examination details were recorded with the


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assistance of medicine resident on duty. Drugs prescribed, untoward reactions and the cost of

therapy was analyzed. On follow-up the patients were enquired for clinical benefits,

improvement or deterioration in clinical condition(s) under the guidance of medicine resident.

Clinical benefits were assessed with the help of MIDAS 35 SCALE and untoward reactions

were noted down.

Follow-up Schedule: The patients enrolled for the study were followed-up for a period of 30

days.

OBSERVATION AND RESULTS

Age Wise Distribution

Chart 1: Age Wise Distribution.

The highest incidence of MI was observed in the age group 51-60 years and least in the age

groups 21-30 years and 81-90 years, respectively.

Gender Wise Distribution

Fig. 2: Gender Wise Distribution.


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The observation revealed that males were more (69.47%) as compared to females (30.53%).

Distribution According to Complaints on Admission

Fig. 3: Complaints on Admission.

The study revealed that chest pain (98.85%) and sweating (66.41%) were the most common

complaints of admitted patient.

Risk Factors

Fig. 4: Risk Factors.

In this study, it was found that smoking was the leading risk factor (21.37%) and alcohol

being the least (8.4%). The probability of risk factors in smokers, tobacco chewers and

alcoholics were found to be significant (p-value ≤ 0.05).


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Categories of Drugs Prescribed

Fig. 5: Categories of Drugs Prescribed.

The study revealed that Antihyperlipidemic (Atorvastatin) was prescribed to maximum

patients (96.18%) and the least prescribed was Anticoagulant (46.56%).

Anti-platelet Drugs Prescribed

Fig. 6: Anti-platelet Drugs Prescribed.

The study showed that maximum number (94.65%) of patients received both Aspirin and

Clopidogrel simultaneously.


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Anticoagulant Drugs Prescribed

Fig. 7: Anticoagulants Drugs Prescribed.

The study showed that Dalteparin was the maximum prescribed Anticoagulant (46.56%).

Antihypertensive Drugs Prescribed

Fig. 8: Antihypertensive Drugs Prescribed.

The study revealed that Beta Blockers were administered to maximum patients (67.17%) and

the least administered was (CCB) calcium channel blocker (2.29%).


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Drugs Prescribing Pattern

Fig. 9: Drugs Prescribing Pattern.

In the present study, Atorvastatin (96.18%), Aspirin (95.04%) and Clopidogrel (94.66%)

were prescribed to more number of the patients.

Patients Clinically Benefited

Fig. 10: Patients Clinically Benefited.

The study revealed that more number of females benefited (82.5%) as compared to males.

The probability observed is insignificant (p value ≥0.05).


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Untoward Reactions

Fig. 11: Distribution of Untoward Reactions.

The study revealed untoward reactions in 70 patients of which headache was prominent

(12.21%).

Prescription Cost of MI Patients

Table 1: Prescription Cost of MI Patients.


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The actual cost of medication for patient per day was Rs. 1895.43. The treatment was taken

in Government Hospital and the cost of Anticoagulant and Thrombolytic drugs were borne by

the Hospital. Thus, the maximum cost borne by patients was Rs. 49.63 per day.

DISCUSSION

Of the enrolled patients in the present study, the age group ranged from 28 to 83 yrs of which

only 2 were in the age group 21-30 yrs and 1 in the age group above 80 yrs. Maximum

patients were in the age group of 51-60 yrs (32.82%) followed by age group 41-50 yrs

(22.14%). Previous studies by Riffat Iqbal et al 2015, Patel Ramesh et al 2015, K.L.K. Sneha

et al 2017 and Dr. Lithin Joseph et al 2018 concluded that the highest incidence of MI was in

the age group of 41-60 yrs, 61-70 yrs, 51-75 yrs and 61-70 yrs respectively.[9,10,13,6]

Among 262 patients, 182 (69.47%) were male and 80 (30.53%) female. The higher rate of MI

in males may be accounted to addiction habits while in females it’s the protection by the

hormone estrogen which is vasodilatory before menopause. The result of the present study

were consistent with previous studies. Patel Ramesh et al 2015, reported that among 45

patients 30 (66.66%) were males and 15 (33.34%) were females indicating that the incidence

of myocardial infarction is more prevalent in males.[10]

Study by K.L.K. Sneha et al 2017

concluded that males were more prone to myocardial infarction than females.[13]

Study by Dr.

Lithin Joseph et al 2018 concluded that out of 45.45% of known case of myocardial

infarction 61.81% were males and 38.18% were females.[6]

The maximum number of patients complained of chest pain 259 (98.85%) followed by

sweating 174 (66.41%). Other symptoms were breathlessness 144 (54.96%), vomiting 55

(20.99%), giddiness 45 (17.18%) and nausea 13 (4.96%), respectively. Many of them had

two or more symptoms. A study by Mehmet Kayhan et al 2017 performed in Eskişehir

Osmangazi University, Turkey found chest pain (58.90%) was commonest complaint on

admission in acute myocardial infarction.[8]

Among 262 MI patients, 56 (21.37%) patients were smokers, 51 (19.47%) hypertension, 48

(18.32%) diabetes mellitus, 36 (13.74%) tobacco chewers and 22 (8.4%) alcoholic,

respectively. Similarly, Shruthi Dawalji et al 2014 concluded that the most common co-

morbid conditions were hypertension in 110 (64.71%) and diabetes in 66 (38.88%).[11]

Patel

Ramesh et al in 2015 found higher number of alcoholism 28 (62.22%) in myocardial

infarction.[10]

In a prospective study by Dr. S. P. Narwane et al in 2017 found risk factors like


725


hypertension 235 (39.1%), tobacco 129 (21.5%), diabetes mellitus 41 (6.8%), alcohol

consumption 20 (3.3%), respectively.[7]

The category of drugs prescribed to 262 MI patients were found to be Antihyperlipidemic

252 (96.18%), antiplatelet 249 (95.04%), antihypertensives 176 (67.18%), Thrombolytic drug

streptokinase 139 (53.05%), antianginal 128 (48.85%) and anticoagulant 122 (46.56%),

respectively. Similarly, Manohar Revankar et al 2018 concluded that the prescription pattern

was Antiplatelet Agents (91.7%), Antianginal drugs (66.7%), Hypolipidaemics (63.9%), Beta

receptor blockers (35.2%), Angiotensin Converting Enzyme Inhibitors (ACEI) (31.5%),

Diuretics (25%), Anticoagulants (15.7%), Calcium Channel Blockers (CCBs) (13.9%) and

Angiotensin Receptor Blockers (ARBs) (12.9%), respectively.[5]

Streptokinase was prescribed in 139 (53.05%) out of 262 patients in the dose of 15 L IU over

the period of 1 hour from Government supply of Maharashtra and nobody received any other

thrombolytic agent. Dr. Lithin Joseph et al in 2018 found that streptokinase was given in 12

(13.95%) patients.[6]

Of 262 patients, 252 (96.18%) patients were prescribed Atorvastatin, 249 (95.04%) Aspirin,

248 (94.66%) Clopidogrel, 176 (67.18%) Metoprolol, 139 (53.05%) Streptokinase, 128

(48.85%) Sorbitrate, 126 (48.09%) Ramipril, 122 (46.56%) Dalteparin, 88 (33.59%)

Enoxaparin, 62 (23.66%) Furosemide, 11 (4.20%) Heparin, 7 (2.67%) Telmisartan and 6

(2.29%) Amlodipine, respectively. Similarly, Manohar Ganapathi Revankar et al 2018

concluded that the prescription pattern of various classes of drugs was Antiplatelet Agents

(91%), Antianginal drugs (66.7%), Hypolipidemics (63.9%), Beta receptor antagoist (35.2%),

Angiotensin Converting Enzyme Inhibitors (ACEI) (31.5%), Diuretics (25%), Anticoagulants

(15.7%), Calcium Channel Blockers (CCBs) (13.9%), Angiotensin Receptor Blockers

(ARBs) (12.9%) and Fibrinolytics (9.3%), respectively.[5]

Among 262 patients, 252 (96.18%) received Atorvastatin in the dose of 20 mg per day. A

prospective study by Dr. S. P. Narwane et al in 2017, Manohar Revankar et al 2018

concluded that antihyperlipidemics were given to (91.16%) and (63.9%) patients,

respectively.[7,5]

The antiplatelet drugs Aspirin and Clopidogrel were prescribed in 248 out of 262 (94.65%)

patients. The 262 prescriptions analyzed revealed that 249 (95.03%) patients were prescribed


726


Aspirin. Study by K. Jyothi et al 2011-2013 at Kadappa found that aspirin and Clopidogrel

were prescribed in 96.1% of IHD without co-morbidities and in 93.2% of IHD with co-

morbidities.[12]

Manohar Ganapathi Revankar et al 2018 found (91.7%) were prescribed the

combination of Aspirin and Clopidogrel.[5]

The study revealed that the drug Dalteparin was prescribed to maximum patients 46.56%

followed by Enoxaparin 88 (33.58%) and Heparin 11 (4.97%), respectively. Similarly,

Shruthi Dawalji et al 2014 at St. Peter’s Institute of Pharmaceutical Sciences, Warangal

studied 110 patients and found the prescription rate of unfractionated heparin 40% (44/110)

and low molecular weight heparin 60% (66/110).[11]

Manohar Revankar et al 2018 concluded

that prescription rate of Antianginal drugs was 66.7%.[5]

Of 262 MI patients, 176 (67.17%) patients were prescribed Beta blockers, 126 (48.09%) ACE

inhibitors, Diuretics 62 (23.66%), ARB 7 (2.67) and Calcium Channel Blocker 6 (2.29%),

respectively. Similarly, Manohar Ganapathi Revankar et al 2018 reported the use of

Antihypertensives as Beta blockers (35.2%), ACEIs (31.5%), Diuretics (25%), Calcium

Channel Blockers (13.9%), respectively. Slight variation was observed between the two

studies.[5]

Of 262 patients, 206 patients were benefited clinically as per MIDAS-35 scale. 82.5%

females (66/80) were benefited compared to 76.92% males (140/182). The responses in 56

patients were not significant.

Of 262 patients, 32 (12.21%) patients developed headache, 17 (6.49%) feeling of weakness,

15 (5.73%) syncope, 3 (1.15%) haemoptysis, 2 (0.76%) haematuria and 1 (0.38%)

haematemsis, respectively. Study by Naser Aslanabadi et al 2018 reported that streptokinase

induced adverse drug reaction found were headache 13 (6%), hematuria 7 (3.3%), hemoptysis

7 (3.3%) and pain in the extremities 22 (10.2%), respectively.[14]

Average cost for drugs purchased by patient is Rs.24.45 per day excluding the cost of

Anticoagulants, Thrombolytics and drugs which were used from Government supply. For the

treatment of MI, the drug categories included are Antiplatelet, Antihyperlipidemic and

Antihypertensive with an average cost per day being Rs.5.14, Rs.12.5 and Rs.6.22

respectively, which was borne by the patient. The study revealed the minimum and maximum

cost of drugs purchased by patient per day by the patient varied from Rs.0 to Rs.35.83. The


727


amount of Rs.0 for 3 patients, since the patients were not prescribed any drug that needs to be

purchased from outside and were given thrombolytic which were provided by Government

Medical College and Hospital, Aurangabad. Riffat Iqbal et al 2015 concluded that the mean

monthly cost of medicines and physicians’ fees per patient was found to be 2381.132

Pakistani rupees (24.24 USD).[13]

CONCLUSION

The prevalence of MI is more in males as compared to females. The major risk factors for MI

were found to be smoking and tobacco chewing (higher in males), hypertension and diabetes

mellitus were high among the patients. However, the use of drugs among various groups was

almost same during hospitalization. The drugs prescribed were Antihyperlipidemic 252

(96.18%), 249 (95.04%) Antiplatelet, 176 (67.18%) Antihypertensives, 139 (53.05%)

Thrombolytics, 128 (48.85%) Antianginal, 122 (46.56%) Anticoagulant, respectively.

Combination of drugs were prescribed to the patients for effective therapy and majority of

patients were clinically benefited (78.62%) by the treatment received. The incidence of

untoward reaction was minimal (headache 12.21% and serious bleeding 2.29%). The cost of

medicines purchased by patients varied from Rs. 0 to Rs.35 with an average cost of Rs. 24

because all other cost were borne by the Government hospital. The cost effectiveness with

maximum benefit is the need of hour and the well-being of the society at large.

ACKNOWLEDGEMENTS

We owe our deepest gratitude to Department of Medicine, Government Medical College and

Hospital, Aurangabad and the Government College of Pharmacy, Aurangabad for providing

us resources required for this study. We are thankful to Dr. Anil Joshi and Dr. Sadhana Shahi

for their valuable guidance and support.

Funding: No.

Conflict of interest: None.

Ethical approval: The study was approved by Institutional Ethics Committee.

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to study drug prescribing pattern, cost and clinical

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