Comment on: Improving quality in IBD - evaluation of corticosteroid excess prescription trends and its predictive role in disease-related outcomes: when its rational use is a target.

Background Asthma is a chronic airway disorder causing recurrent wheezing, breathlessness, chest tightness, and cough, often requiring long-term pharmacotherapy. Antiasthmatic agents such as bronchodilators, corticosteroids, leukotriene receptor antagonists, and biologics are prescribed alone or in combination based on disease severity. While rational prescribing ensures better control, inappropriate patterns may lead to poor outcomes and higher healthcare burden. Despite their effectiveness, antiasthmatic drugs can cause adverse drug reactions (ADRs) ranging from mild effects like tremors and oral thrush to severe complications including cardiovascular events and corticosteroid toxicity. Monitoring ADRs and their severity is vital for patient safety and adherence. Drug utilization studies, when combined with pharmacovigilance provide insights into prescription trends, rationality, and ADR severity, thereby supporting safer therapeutic decisions. The present study evaluates prescribing patterns of antiasthmatic agents and assesses the severity of associated ADRs to promote rational drug use and improved patient care. Aim To evaluate the prescribing patterns of antiasthmatic agents and assess the severity of adverse drug reactions (ADRs) associated with their use. Objectives To evaluate the prescribing patterns of antiasthmatic agents in asthma management. To assess and categorize the severity of adverse drug reactions (ADRs) associated with antiasthmatic therapy. Material and Methods 150 patients were enrolled for evaluating adverse effects with antiasthmatic drugs. All patients were followed up by medical history, history of drugs, and any severity of ADR. The study was assessing the distribution, prescribing pattern the management of ADRs. Also, the study determined the severity of ADRs with antiasthmatic agents in pulmonary medicine departments in tertiary care teaching hospitals. Results and observations In 150 patients (mean age 47.6 years), β2-agonists were most prescribed (44.6%), followed by methylxanthines (20.6%), corticosteroids (18%), and anticholinergics (9.3%). ADRs were most frequent with β2-agonists, including tremors (27.2%), sleepiness (36.3%), and headache (36.3%). Corticosteroids caused mouth ulcers (14.2%), epigastric pain, vomiting, and acne (21.4% each). Anticholinergics produced dry mouth (25%) and constipation (75%), while methylxanthines were associated with insomnia (33.3%), headache (66.6%), and nausea (22.2%). Conclusion The study highlights that β2-agonists were the most frequently prescribed antiasthmatic agents and also accounted for the majority of adverse drug reactions, followed by methylxanthines, corticosteroids, and anticholinergics. While most ADRs were mild to moderate in nature, their occurrence emphasizes the need for careful monitoring and rational prescribing. Regular assessment of prescription patterns and ADR severity can improve patient safety, optimize therapeutic outcomes, and promote rational use of antiasthmatic drugs in clinical practice.

Improving quality in IBD - Evaluation of corticosteroid excess prescription trends and its predictive role in disease-related outcomes.

Background Corticosteroids (CS) are effective in induction of remission in inflammatory bowel disease (IBD), but should be used sparingly, given their unfavourable safety profile. In fact, CS excess has been incorporated in quality of care standards in IBD, highlighting the importance of auditing CS use. A CS sparing strategy is frequently recommended due to risk of side effects, but its consequences in IBD outcomes have been less studied. Our primary aim was to evaluate current CS use and excess in IBD patients, and compare them with a historic cohort. Our secondary aims were to identify predictors of CS excess prescription and compare prognostic outcomes (surgery, hospitalisation, new CS cycle, structural damage and a composite outcome) at 12 months between three prescription groups (no CS use, CS use with no excess, and CS excess). Methods Adult outpatients with IBD were included from one trimester in 2014 and one in 2023. CS prescription trends were compared between groups. The latter group was then used to identify predictors of excess CS prescription and to compare outcomes between prescription groups. Results A total of 1131 outpatients with IBD were included, 374 in 2014 and 757 in 2023. CS use was significantly lower in 2023, compared to 2014 (6.4% vs 20.6%, p<0.001), as was CS excess (12.0% vs 2.2%, p<0.001). C reactive protein (CRP) (OR = 1.055, IC 95% 1.024-1.087, p<0.001) and number of previous biologics (OR = 1.703, IC 95% 1.054-2.753, p=0.030) were independent predictors of CS excess prescription. The rates of hospitalisation, new CS cycle and composite outcome were significantly different between the 3 prescription groups (p<0.001). In multivariable Cox regression, CS excess prescription was an independent predictor of hospitalisation, new CS cycle and the composite outcome. CRP and clinical activity were also independent predictors of the latter outcomes. Conclusion CS prescription rate has significantly decreased, possibly due to different monitoring and treatment strategies. CS excess was associated with negative outcomes, namely hospitalisation and new CS cycles. Improving quality of care in IBD should target measures to avoid excess CS prescription.

Background: The World Health Organization (WHO) aims to promote strategies that ensure efficacy, safety, suitability, and cost-effectiveness of medicine prescription. Health systems should design effective mechanisms to monitor prescription and rational use of medicines at all healthcare settings. This study aimed to determine and analyze prescription patterns of general practitioners and specialists in Kerman/Iran from 2005 to 2015.Methods: This is an explanatory mixed method study. Data were gathered during two phases. At the first phase, prescriptions issued by physicians during 2005-2015 were reviewed to extract information required to develop eight main prescription indicators. In the second phase, the indicators trends were presented to experts participating in expert panel to have their opinions and analyses on the data obtained in the first phase. Experts were selected based on their experience and expertise in medicine and/or health policy and/or experience in implementation of polices to promote rational use of medicines. Some experts attending the panel were a sample of physicians whose prescriptions were included in the first phase.Results: Findings revealed that two indicators of the average price of prescriptions and the maximum number of medicines in each prescription had an increasing trend over the study period. Reasons including unprecedented devaluation of the Iranian Rial and willingness of young physicians to prescribe more medications were proposed as the primary contributors to the observed increasing trends. However, other indicators including types of prescribed medicines, average number of medicines per prescription, the percentage of prescriptions with more than four medications, a percentage of encounters with a corticosteroid prescribed, a percentage of encounters with an antibiotic prescribed, and a percentage of encounters with an injection prescribed decreased in the study period. Reasons of controlling initiatives adopted by the Ministry of Health, the higher responsibility of physicians, adoption of continued medical education (CME) programs, and improved knowledge of pharmacists, physicians, and patients about irrational use of medicines were proposed by participants as the main reasons for the decreasing trend.Conclusion: Findings indicated that prescription indicators were better in Kerman than those of country average over the study period based on comparing the results of this study and others in Iran. However, they were non-desirable when compared to the international average. The number of factors contributes to the irrational use of medicines, including lack of knowledge among healthcare providers and patients, patients’ misunderstanding about the efficacy of some particular medicines, the high cost of drug development and manufacturing, and unavailability of effective medicines.

Objective:This study examined the effects of a national policy advocating rational drug use (RDU), namely, the ‘RDU Service Plan’, starting in fiscal year 2017 and implemented by the Thai Ministry of Public Health (MOPH), on trends in antibiotic prescribing rates for outpatients. The policy was implemented subsequent to a voluntary campaign involving 136 hospitals, namely, the ‘RDU Hospital Project’, which was implemented during fiscal years 2014-2016.Methods:Hospital-level antibiotic prescribing rates in fiscal years 2014-2019 for respiratory infections, acute diarrhea, and fresh wounds were aggregated for two hospital groups using equally weighted averages: early adopters of RDU activities through the RDU Hospital Project and late adopters under the RDU Service Plan. Pre-/post-policy annual changes in the prescribing levels and trends were compared between the two groups using an interrupted time-series analysis.Results:In fiscal years 2014-2016, decreases in antibiotic prescribing rates for respiratory infections and acute diarrhea in both groups reflected a trend that existed before the RDU Service Plan was implemented. The immediate effect of the RDU Service Plan policy occurred in fiscal year 2017, when the prescribing level among the late adopters dropped abruptly for all three conditions with a greater magnitude than in the decrease among the early adopters, despite nonsignificant differences. The medium-term effect of the RDU Service Plan was identified through a further decreasing trend during fiscal years 2017-2019 for all conditions in both groups, except for acute diarrhea among the early adopters.Conclusions:The national policy on rational drug use effectively reduced antibiotic prescribing for common but questionable outpatient conditions.

Objective: This study examined the effects of a national policy advocating rational drug use (RDU), namely, the ‘RDU Service Plan’, starting in fiscal year 2017 and implemented by the Thai Ministry of Public Health (MOPH), on trends in antibiotic prescribing rates for outpatients. The policy was implemented subsequent to a voluntary campaign involving 136 hospitals, namely, the ‘RDU Hospital Project’, which was implemented during fiscal years 2014-2016. Methods: Hospital-level antibiotic prescribing rates in fiscal years 2014-2019 for respiratory infections, acute diarrhea, and fresh wounds were aggregated for two hospital groups using equally weighted averages: early adopters of RDU activities through the RDU Hospital Project and late adopters under the RDU Service Plan. Pre-/post-policy annual changes in the prescribing levels and trends were compared between the two groups using an interrupted time-series analysis. Results: In fiscal years 2014-2016, decreases in antibiotic prescribing rates for respiratory infections and acute diarrhea in both groups reflected a trend that existed before the RDU Service Plan was implemented. The immediate effect of the RDU Service Plan policy occurred in fiscal year 2017, when the prescribing level among the late adopters dropped abruptly for all three conditions with a greater magnitude than in the decrease among the early adopters, despite nonsignificant differences. The medium-term effect of the RDU Service Plan was identified through a further decreasing trend during fiscal years 2017-2019 for all conditions in both groups, except for acute diarrhea among the early adopters. Conclusions: The national policy on rational drug use effectively reduced antibiotic prescribing for common but questionable outpatient conditions.

Background Antibiotics misuse is a global problem. To study the knowledge and practice regarding antibiotic use in care-givers of children and antibiotic prescription pattern in paediatrics out-patient department of a secondary care hospital at Gurgaon, Haryana, India. Methods The present study was undertaken to screen rational use of antibiotics among paediatric outpatient population in Gurgaon. As per WHO guidelines, 100 prescriptions were collected from paediatrics out-patient department and prescriptions containing antibiotics were analysed. One hundred caregivers were interviewed using a structured questionnaire to determine the knowledge of antibiotics. Results 45% of patients were prescribed antibiotics and out of the total antibiotics prescribed, 87% were generic drugs, 93% were from the WHO Essential Drugs List and 71% were as per National Formulary of India guidelines. 36% caregivers had knowledge of antibiotics and 14% knew that antibiotics are used for bacterial infections. Very few of the caregivers believed that antibiotics have side-effects (33%), 8% were aware of antibiotic resistance. Knowledge of antibiotics was significantly associated with high education and socioeconomic status ( p Conclusions Though the prescription of generic drugs and drugs from WHO Essential Drugs List is satisfactory, the low rate of rational prescriptions and poor knowledge of antibiotics among the caregivers and poor compliance to the given course of treatment is a matter of concern. Copyright © 2014, Indian Journal of Medical Specialities. Published by Reed Elsevier India Pvt. Ltd. All rights reserved.

Background:The inappropriate use of pharmacological treatments for insomnia may increase patients' risk of serious adverse events. However, few epidemiological studies on the use of medications for insomnia in China have been conducted to date.ObjectiveWe aimed to investigate the current pharmacological treatments for insomnia and guide the rational use of drugs.MethodsThe prescription data of outpatients with insomnia between 2015 and 2019 in Zhejiang province were extracted from the Hospital Prescription Analysis Cooperative Project of China and evaluated. The demographic characteristics of insomnia and the proportion and prescription trends of different drugs were analyzed along with multidrug combinations for insomnia.ResultsThe number of patients with insomnia who were prescribed medications for insomnia increased from 2,385 in 2015 to 3,919 in 2019, with an increase of 64.32%, whereas the mean age of these patients decreased from 64.07 years to 60.94 years. There were nearly 1.42 times as many female patients prescribed medications for insomnia as male patients, and female patients tended to be younger than male patients. Benzodiazepines (53.99%) were the most common type of medicine for insomnia. The incidence of benzodiazepine usage decreased significantly yearly (P < 0.01), whereas the incidences of non-benzodiazepine receptor agonist (nBZRA) and antidepressant usage increased (P < 0.05). The most common benzodiazepine, nBZRA, antidepressant, and antipsychotic were estazolam, zolpidem, trazodone, and olanzapine, respectively. A total of 13.97% of outpatients with insomnia were prescribed multiple drugs for insomnia, even though nearly half of the drug combinations had similar pharmacological mechanisms.ConclusionsBenzodiazepines remained the most common medication for insomnia, but the prescription rates of nBZRAs and antidepressants increased. Attention should be paid to multidrug combinations for insomnia, which may lead to an increased risk of serious adverse effects.

Rational use of medicines (RUM) is highly desired worldwide yet many shortcomings are found. This study aims to evaluate prescription pattern and RUM using World Health Organisation (WHO) prescribing indicators. The impact of audit and feedback has also been studied, along with comparison with published data. A cross-sectional observational study was conducted in the outpatient department setting of a tertiary care centre in central India. Data were collected from 2719 prescriptions across different departments from hospital pharmacies from 2016 to 2018 at different time periods. The data was analysed using WHO core prescribing indicators. Average number of drugs per prescription was found to be 2.53±1.23 (WHO optimal value≤2). The mean values of prescribing indicators for antibiotics (19.82% vs.≤30%) and injection prescribing (1.98% vs. ≤10%) were within optimal values. Generic prescribing (15.96% vs. 100%) and prescribing from National List of Essential Medicines (NLEM; 37.37% vs. 100%) were found to be significantly lesser. Annual audit and feedback showed improvement in generic prescribing and prescribing from NLEM, but the other trends continued to be similar. While use of antibiotics and injections among outpatients was found to be rational, there is scope of improvement in most domains that can be addressed with appropriate interventions.

Introduction Oral antibacterial prescribing is a key contributor to antimicrobial resistance.[1] Understanding prescribing patterns and impact of antimicrobial stewardship (AMS) interventions is essential to promote rational use. This is particularly important in primary care out-of-hours (OOH) services (weekdays 18:30–08:00, weekends, and holidays), where antibacterial prescribing is common and evidence lacking.[2] While previously collected quantitative data from Wales showed declining prescribing trends, deeper exploration can reveal broader context, underlying drivers, and opportunities to strengthen AMS. Aim To explore lead antimicrobial pharmacists’ perspectives on oral antibacterial prescribing in Wales primary care overall, focusing on OOH services. Methods A qualitative methodology was employed. Online semi-structured interviews were conducted with lead and/or primary care antimicrobial pharmacists, or equivalent professionals when suitable, from each Health Board (HB) in Wales (n = 7). Purposive sampling ensured inclusion of participants with relevant national and HB knowledge and expertise in antimicrobial prescribing and stewardship who could contextualise the quantitative prescribing trends shared with them. The interview schedule explored perspectives on prescribing patterns, influencing factors, available AMS interventions, and barriers and facilitators within OOH services. Participants were identified and contacted by a gatekeeper, and those who consented were interviewed. Interviews were audio- and video-recorded, transcribed verbatim, and analysed thematically. Results Seven interviews were conducted. Participants attributed declining prescribing to collective efforts toward national targets rather than specific interventions. They highlighted limitations in the presented data, noting factors to consider when comparing HBs (e.g. demographics, socioeconomic conditions), restricting their ability to elaborate on these trends. Five themes and fourteen subthemes were constructed (Table 1). Conclusion This study identifies multiple influences on oral antibacterial prescribing in primary care, including OOH services, highlighting challenges, opportunities for improvement, and limitations of OOH data. Although the sample was small, information power was considered adequate with one representative from each HB included as intended given participants’ oversight role. As shared data spanned several years, some participants lacked direct experience of earlier prescribing, which may have limited awareness of past influences. Nonetheless, the insights gained may help stakeholders enhance current systems, refine interventions, or develop strategies to support prescribers across healthcare settings.

BackgroundProton pump inhibitors (PPIs) remain one of the world’s most frequently prescribed medications and there is a growing number of publications on correct versus incorrect use of PPIs worldwide. The objective of this observational retrospective study was to assess changes in PPI prescribing trends over the past decade and pharmacists’ effect on optimizing PPI prescribing practice at a tertiary hospital in China.MethodsWe collected the prescriptions of PPIs in our hospital from January 2007 to December 2016. Then the rate of PPI prescribing, the defined daily doses (DDDs) and expenditures were calculated and plotted to show the change in utilization of and expenditure on PPIs. Reasons behind this change and effect of pharmacists’ intervention were evaluated by investigating the rationality of PPI use through sample surveys of patients of pre-intervention (Jul.-Dec. 2015) and post-intervention (Jul.-Dec. 2016).ResultsIn outpatient settings, the rate of PPI prescribing remained almost constant, utilization (from 135,808 DDDs to 722,943 DDDs) and expenditure (from 1.85 million CNY to 7.96 million CNY) increased for the past ten years, dominated by oral formulations and rabeprazole. In contrast, in inpatient settings, the rate of PPI prescribing (from 20.41 to 37.21%), utilization (from 132,329 DDDs to 827,747 DDDs) and expenditure (from 3.15 million CNY to 25.29 million CNY) increased from 2007 to 2015 and then decreased, dominated by injection formulations and omeprazole. Pharmacist interventions could significantly promote the rational use of PPIs (44.00% versus 26.67%), decrease PPI use and reduce patients’ charges (P < 0.05).ConclusionsThe utilization of and expenditure on PPIs grew due to the increase of patients and irrational use of PPI. Pharmacist interventions help to reduce PPI utilization and expenditure and enhance rationality for inpatients, but much work should be done to regulate injection and originator formulas, and improve the rationality in the future.

Objetivo: Identificar tendências na prescrição de antimicrobianos em idosos hospitalizados em um hospital universitário no estado do Pará. Método: Estudo observacional e transversal que avaliou e analisou prontuários em relação a características do paciente, diagnóstico e tratamento. Sendo tendências de prescrição identificadas por análise de frequência. Resultados: Foram avaliados 299 prontuários, sendo observado uma predominância de idosos jovens (80%) do sexo feminino (56,5%) que tiveram como principal causa de internação infecções do trato respiratório. O tratamento foi predominantemente empírico, predominando a utilização de cefalosporinas de 3º geração, macrolídeos e quinolonas. Quando relacionado a patologia ao medicamento predominou a utilização de cefalosporinas para o tratamento de infecções do trato respiratório e complicações da diabetes mellitus tipo II. Conclusão: Identificou-se a necessidade de desenvolvimento de protocolos clínicos na instituição para padronização do tratamento e estímulo ao uso racional de antimicrobianos com o objetivo de garantir a segurança do paciente.

Background: Gastroesophageal reflux disease (GERD) is one of the most common diseases seen in many countries for which majority of the population prefer proton pump inhibitors (PPI) and histamine-2 (H2) blockers along with medications like non-steroidal anti-inflammatory drugs (NSAIDs) and other drugs. Concerns have been raised about the prescription of these drugs as they are often prescribed without clear indications. Prescribing pattern should be evaluated periodically to promote rational use of medicine. Moreover, an understanding of the appropriate treatment plan for GERD based on the patient’s condition is essential for practitioners across medical specialties. Methodology: A cross-sectional questionnaire-based survey conducted among 249 clinicians focusing on the prevalence, symptoms, causes, clinical characteristics, management of GERD and the usage of its medications in clinical practice was conducted. Results: Obesity (39%) is the most common risk factor for GERD. About 42% respondents said the most commonly age group diagnosed with GERD was 40-55 years. Heart burn (56%) is the most common symptoms present in patients with GERD. Obesity (43%), diabetes mellitus (27%), dyslipidemia (11%), hypertension (16%) and asthma (3%) are the most common co-morbid conditions observed with GERD. Only 39% respondents said their patients complained of reflux symptoms being at both day and night, 29% said night time, 9% said both the above options and 3% said daytime. 41% respondents suggested PPI+ pro-kinetic agents as preferred therapy for GERD treatment. Pantoprazole (79%) is the most preferred PPIs in practice for GERD treatment. About 31% of respondents said that pantoprazole and domperidone cure rate for treatment of GERD is 70-80%. Pantoprazole 40mg twice daily (41%) is chosen by respondents as most effective therapy for refractory GERD when high dose of pantoprazole is required. PPI low dose (63%) is the most preferred therapy by respondents in GERD cases. Conclusion: Despite the challenges in managing GERD, clinicians generally felt confident in their ability to address this condition effectively. This survey highlights the importance of tailored management and the significance of evidence-based approaches to reduce GERD complications.

Background:Usually, surgical management cannot be completed without the use of antimicrobial and analgesic drugs. Irrational prescription may lead to severe postoperative complications.Aim:The objective of this study was to evaluate the prescription trend in the surgery department of a tribal district hospital so as to determine the extent of rational use of medicines.Materials and Methods:It was a retrospective study in which 50 cases were selected randomly. Case records were analyzed for prescription trend. Data was analyzed using Microsoft Office Excel 2007 and values were presented descriptively.Results:Most of the cases were between the age group of 21 and 40 years, 18 cases (36%). Commonest cause of hospitalization was renal calculi (10 (20%)) followed by acute abdomen and abscess (6, (12%)). Total of 255 numbers of drugs were used with an average of 5.1 drugs per patient. Most preferred route was intravenous route (174 drugs, 68.2%). Antimicrobial was the most common (97 (38.0%)) group of drugs followed by analgesic/antipyretics (50 (19.6%)). Among antimicrobials, ciprofloxacin (22 (22.7%)) was the most common drug followed by metronidazole (21 (18.5%)). All the cases were managed by empirical treatment. Two different antimicrobials were prescribed to 20 (40%) of cases. Dosage of 83 (32.6%) drugs was inappropriate while frequency was inappropriate in 26 (10.2%) cases.Conclusion:Urgent steps like specific guidelines, training, and monitoring of drugs use are needed to correct some irrational approaches.

Pregabalin and gabapentin are increasingly used for pain and other conditions. Concerns exist about overuse as well as potential misuse and abuse. To guide rational prescribing practices, we provide detailed nationwide data on the use of gabapentinoids in Denmark. We conducted a nationwide descriptive drug utilization study using the Danish healthcare registries to describe the use of gabapentinoids among Danish adults 2010-2023. We described overall use patterns, temporal trends, user characteristics, skewness of use, treatment duration and concomitant medication use. The prevalence of gabapentinoid use increased almost four-fold from 11 per 1000 adults in 2010 to 41 in 2023 with the highest use among individuals aged 80+ years (96 per 1000 in 2023). Gabapentin and pregabalin were used equally. The median age of users increased from 58 years in 2010 to 63 years in 2023, while a decline was observed in the proportion with concomitant use of other drug classes, including benzodiazepines or opioids. Only 7% of patients were continuously treated for 3 years following initiation, while 22% were currently treated after 3 years (allowing treatment breaks). The use of gabapentinoids were somewhat skewed with 1% of users accounting for 7.3% of use in 2023. The use of gabapentinoids has increased dramatically in recent years, in particular, among the elderly, and adherence was low. Increased attention to the increasing use of gabapentinoids is warranted to ensure rational use of this drug class.