Evaluation of rational nonsteroidal anti-inflammatory drugs and gastro-protective agents use; association rule data mining using outpatient prescription patterns

Oraluck Pattanaprateep,Mark Mcevoy,Ammarin Thakkinstian,John Attia

doi:10.1186/s12911-017-0496-3

Abstract

BackgroundNonsteroidal anti-inflammatory drugs (NSAIDs) and gastro-protective agents should be co-prescribed following a standard clinical practice guideline; however, adherence to this guideline in routine practice is unknown. This study applied an association rule model (ARM) to estimate rational NSAIDs and gastro-protective agents use in an outpatient prescriptions dataset.MethodsA database of hospital outpatients from October 1st, 2013 to September 30th, 2015 was searched for any of following drugs: oral antacids (A02A), peptic ulcer and gastro-oesophageal reflux disease drugs (GORD, A02B), and anti-inflammatory and anti-rheumatic products, non-steroids or NSAIDs (M01A). Data including patient demographics, diagnoses, and drug utilization were also retrieved. An association rule model was used to analyze co-prescription of the same drug class (i.e., prescriptions within A02A-A02B, M01A) and between drug classes (A02A-A02B & M01A) using the Apriori algorithm in R. The lift value, was calculated by a ratio of confidence to expected confidence, which gave information about the association between drugs in the prescription.ResultsWe identified a total of 404,273 patients with 2,575,331 outpatient visits in 2 fiscal years. Mean age was 48 years and 34% were male. Among A02A, A02B and M01A drug classes, 12 rules of associations were discovered with support and confidence thresholds of 1% and 50%. The highest lift was between Omeprazole and Ranitidine (340 visits); about one-third of these visits (118) were prescriptions to non-GORD patients, contrary to guidelines. Another finding was the concomitant use of COX-2 inhibitors (Etoricoxib or Celecoxib) and PPIs. 35.6% of these were for patients aged less than 60 years with no GI complication and no Aspirin, inconsistent with guidelines.ConclusionsAround one-third of occasions where these medications were co-prescribed were inconsistent with guidelines. With the rapid growth of health datasets, data mining methods may help assess quality of care and concordance with guidelines and best evidence.

Highlights

Nonsteroidal anti-inflammatory drugs (NSAIDs) and gastro-protective agents should be co-prescribed following a standard clinical practice guideline; adherence to this guideline in routine practice is unknown
Gastro-protective agents are commonly co-prescribed with NSAIDs; alternatively, cyclooxygenase (COX)-2 inhibitors (e.g., Etoricoxib, Celecoxib) are used, a new generation of NSAIDs claimed to cause fewer gastrointestinal adverse events [2,3,4]
An electronic database of outpatients records at Ramathibodi Hospital between October 1st, 2013 and September 30th, 2015 was extracted from the hospital data warehouse focusing on H2RAs and PPIs (A02A and A02B codes), and NSAIDs and COX-2 inhibitors (M01A)

Summary

Introduction

Nonsteroidal anti-inflammatory drugs (NSAIDs) and gastro-protective agents should be co-prescribed following a standard clinical practice guideline; adherence to this guideline in routine practice is unknown. Conventional NSAIDs (e.g., Diclofenac, Meloxicam, Ibuprofen) can induce gastrointestinal (GI) upset and adverse events, especially peptic ulceration [1]. To reduce this risk, gastro-protective agents are commonly co-prescribed with NSAIDs; alternatively, cyclooxygenase (COX)-2 inhibitors (e.g., Etoricoxib, Celecoxib) are used, a new generation of NSAIDs claimed to cause fewer gastrointestinal adverse events [2,3,4]. Used gastro-protective agents are histamine H2-receptor antagonists (H2RAs, e.g., Ranitidine) and proton pump inhibitors (PPIs, e.g., Omeprazole, Pantoprazole, Esomeprazole, Lansoprazole). Concomitant use of H2RAs and PPIs are recommended only in the treatment of gastro-oesophageal reflux disease (GORD) [10, 11]

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Discussion

Conclusion