Practice Of Analgesia Research Articles

P.2.f.030 - Side effects breaking the blind does not explain the antidepressant effects of the selective serotonin reuptake inhibitors

Since pain and post-operative nausea and vomiting (PONV) are the main reasons for failed discharge after day-case surgery, assessing pain and PONV is important. The aim was to describe the perioperative pain and PONV management within selected day-case surgical procedures in France.The OPERA trial was carried out on given days between December 2013 and December 2014. Each participating centre was required to fill out 3 separate questionnaires aiming at describing (1) protocols about pain and PONV, (2) patients’ characteristics and procedures, (3) analgesic and PONV practice patterns for selected procedures.Over the two days of investigation in each of the 221 randomly selected healthcare institutions, 7382 patients were included, of whom 2144 patients above 12 years underwent one of 10 selected procedures. Among responding institutions, 40% [33;47] had a dedicated pain management written protocol. Combination of tramadol and paracetamol was the most commonly prescribed (78% [71;83] of centres). Oral morphine was prescribed in 59/199 (30% [23; 37]) centres, for home treatment in 25/59 (42% [30; 56]) centres. However, there was no standardised take-home analgesic and PONV strategies for selected surgical procedures at risk of moderate to severe pain. PONV management guidance after discharge was included in only 12 % of centres.This survey demonstrates that practice patterns for pain treatment and PONV prophylaxis after ambulatory surgery vary among French centres and are not always in line with national guidelines. Strategies to improve practices and make them more homogeneous are necessary.

Survey of Sedation and Analgesia Practice Among Canadian Pediatric Critical Care Physicians.

Despite the fact that almost all critically ill children experience some degree of pain or anxiety, there is a lack of high-quality evidence to inform preferred approaches to sedation, analgesia, and comfort measures in this environment. We conducted this survey to better understand current comfort and sedation practices among Canadian pediatric intensivists. The survey was conducted after a literature review and initial focus groups. The survey was then pretested and validated. The final survey was distributed by email to 134 intensivists from 17 PICUs across Canada using the Research Electronic Data Capture system. The response rate was 73% (98/134). The most commonly used sedation scores are Face, Legs, Activity, Cry, and Consolability (42%) and COMFORT (41%). Withdrawal scores are commonly used (65%). In contrast, delirium scores are used by only 16% of the respondents. Only 36% of respondents have routinely used sedation protocols. The majority (66%) do not use noise reduction methods, whereas only 23% of respondents have a protocol to promote day/night cycles. Comfort measures including music, swaddling, soother, television, and sucrose solutions are frequently used. The drugs most commonly used to provide analgesia are morphine and acetaminophen. Midazolam and chloral hydrate were the most frequent sedatives. Our survey demonstrates great variation in practice in the management of pain and anxiety in Canadian PICUs. Standardized strategies for sedation, delirium and withdrawal, and sleep promotion are lacking. There is a need for research in this field and the development of evidence-based, pediatric sedation and analgesia guidelines.

Topical NSAIDs significantly reduces pain in adults with acute musculoskeletal injuries.

Commentary on: Derry S, Moore RA, Gaskell H, et al. Topical NSAIDs for acute musculoskeletal pain in adults. Cochrane Database Syst Rev 2015;(6):CD007402. Use of topical non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief is widely controversial in analgesic practice.1 For the topical NSAIDs to have an effect on acute pain, the formulation has to penetrate the skin. The expected advantages of this type of administration are both potential minimisation of systemic side effects and increase of local effect. However, there is still debate on these potential advantages as there is continuous lack of significant positive results.2–4 A Cochrane review update was recently carried out to assess the effect of topical NSAIDs used for acute musculoskeletal pain in adults.5 This review aimed to strengthen conclusions on the efficacy and safety of topically applied NSAIDs in acute musculoskeletal pain in adults, adding recently published studies to the previous search. The review included only double-blinded …

Pain management framework in the emergency department: patterns in 40 emergency departments worldwide.

Many studies illustrate variation in pain management protocols in emergency medicine. This study examines analgesia frameworks in emergency departments (EDs) in multiple countries, compares them with the recent literature, and illuminates the variability in protocols and treatment. A survey was conducted assessing the pain management framework and practices in a convenience sample of 40 hospitals distributed over 22 countries. Most EDs (80%) indicated that pain intensity was routinely documented, most commonly (42.5%) using a verbal numerical 0-10 scale. Most (57.5%) reported specific protocols for specific conditions, with 56.5% reporting that these protocols were mandatory. Structured training was reported by 27.5% of responders. All (100%) reported analgesia administration in the trauma room. Oral paracetamol (67.5%) and intravenous morphine (92.5%) were the most commonly used analgesics. The variability in the pain management framework is high among EDs worldwide, highlighting the need for more international uniformity in analgesia practices in the ED.

Treatment of Acute Renal Colic in US and French EDs: Simulated Cases and Real Cases in Acute Pain Management

ObjectivesTo assess the prescribing patterns in acute renal colic in emergency departments in US and France, by comparing physicians' intended prescription practices with actual prescription data in a sample of emergency practitioners. MethodsPharmaco-epidemiological international study in two phases. First, we surveyed emergency physicians in US and France as to what analgesics they would use for simulated cases of renal colic. We then conducted a retrospective review of actual cases of emergency department patients with pain scores ≥6/10 with acute renal colic during a period of 6 months before the survey. We compared nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids used for pain treatment in the two groups, and the differences between the two countries. ResultsOne hundred six prescribers and 100 patients were included in the study. Comparison between simulated and real cases showed that NSAIDs and opioids were less frequently prescribed in real life (78% vs 99% and 51% vs 100% respectively). Morphine was the most prescribed opioid (96% of simulated cases and 34% of real ones). Acetaminophen use was increased in real life cases (58% vs 0%). Concerning the differences between countries, US physicians are more likely to administer morphine (64% vs 38%) and French physicians NSAIDs (88% vs 68%). The NSAIDs used are ketorolac in the United States (94% of simulated cases vs 64%) and ketoprofen in France (94% and 88% respectively). DiscussionWe showed clear differences between intended and real analgesic prescription practices for patients suffering from renal colic. Some differences exist for pain perceptions and treatments between US and France.

Making of a Successful Early Mobilization Program for a Medical Intensive Care Unit.

To provide a guideline for intensive care unit (ICU) early mobilization program development and implementation and to describe the patient characteristics and endpoints for those who participated in our hospital's early mobilization program. An ICU early mobilization program was developed with five guiding principles: analgesia/sedation optimization, sedation minimization, protocol of progressive mobility, physical therapy and occupational therapy recruitment, and nursing education. This program began in April 2014, and the initial 32 patients who ambulated while receiving mechanical ventilation were retrospectively assessed and their characteristics described. After program implementation, more than 50 mechanically ventilated patients ambulated in the first year following early mobilization initiation. Patients with an FiO2 as high as 1.0 and on nonconventional modes of mechanical ventilation successfully ambulated without adverse events. The mean ambulation distance was 102 ± 152 f. and usually required three ICU staff members with 5 to 10 minutes of preparation before ambulation. After implementation, a retrospective analysis revealed a decrease in the average length of ICU stay, from 4.8 to 4.1 days. Addressing analgesia and sedation practices, along with instituting a progressive mobility protocol and recruiting physical and occupational therapy, may serve as a guide to the creation of a successful early mobilization program. This study provides additional supportive evidence that early mobilization in the ICU is safe and effective.

Prevalence and Predictors of Prehospital Pain Assessment and Analgesic Use in Military Trauma Patients, 2010–2013

Introduction: Pain is the most common symptom in patients presenting for prehospital (PH) care. Research in civilian emergency medical systems has shown wide variability in PH pain assessment and analgesic practices, yet a minimal amount is known about pain assessment and analgesic intervention practices in the military, particularly when PH care is delivered in a combat zone. Objective: To describe prehospital (PH) pain care practices for U.S. military personnel injured in Iraq and Afghanistan 2010–2013 and explore potential relationships to explain variation. Methods: An exploratory retrospective, cross-sectional study of Department of Defense Trauma Registry data from 2010 to 2013 was performed. Demographic, clinical, or health system variables for associations with three outcomes: 1) pain assessment documentation; 2) pain severity (0–10 scale); and 3) analgesic administration (yes/no). Including only variables with significant associations, backward stepwise regression was used to develop explanatory models for each outcome. Results: Patient records (n = 3,317) were evaluated for documentation of PH pain assessment and analgesic administration. The prevalence of PH pain score documentation was 37.8% (n = 1,253). Overall, the proportion of records with PH pain scores increased over time: 19.8% (2010), 35.1% (2011), 58.2% (2012), and 62.2% (2013). Severity of pain scores ranged 0–10; mean = 5.5 (SD = 3.1); median = 6 (IQR = 3–8). Analgesics were reported for 50.8% (n = 1,684), of whom 38.3% had a pain severity score documented. The pain assessment documentation model included any documented vital signs, injury year, and mechanism of injury and explained 19.3% of the variance in documentation. The pain severity model included vital signs and injury severity score (ISS) and explained 5.0% of the variance in severity. The analgesic model included any vital signs, pain severity, trauma type, mechanism of injury, ISS, and year. Conclusions: Pain assessment and treatment documentation improved each year, but remain suboptimal. Available data yielded poor prediction of the outcomes of interest, emphasizing the importance of individual assessment. Analgesic effectiveness could not be evaluated.

MP011: Using GRADE-based recommendations for analgesia and antiemetics in electronic order sets to influence physician behaviour towards best practice and cost-savings

Introduction: The addition of computerized physician order entry (CPOE) to Emergency Departments in recent years has led to speculation over potential benefits and pitfalls. Recent studies have shown benefits to CPOE, though there lacks sufficient evidence on how it could change physician behaviour. Physician practices are known to be difficult to change, with getting evidence into daily practice being the main challenge of knowledge translation. Our study aims were to determine if well-designed electronic order sets for CPOE improved MD practices. Methods: The Calgary Zone Pain Management in the Emergency Department Working Group relied on a GRADE-based literature review for identifying best practices for analgesia and antiemetics, resulting in soft changes to the dedicated analgesia and antiemetic electronic order set noting working group preference, and emphasizing hydromorphone over morphine, as well as 4 mg ondansetron over 8 mg. The new electronic order set was started in the only Calgary Region order entry system on December 11th, 2014. Data was collected from July 2014 - May 2015. A Yates chi-squared analysis was completed on all orders in a category, as well as the subgroups of ED staff and residents, and orders placed using the new order set. Results: A total of 100460 orders were analyzed. The use of hydromorphone increased significantly across all 4 EDs. IV hydromorphone use increased (5.82% of all opioid orders up to 26.93%, P<0.0001) with a reciprocal decline in IV morphine (67.81% of all opioid orders down to 46.56%, P<0.0001). Similar effects were observed with ondansetron 4 mg IV orders increasing (1.37% of all ondansetron orders to 18.64%, P<0.0001) with a decrease in 8 mg dosing (15.75% of all ondansetron orders to 7.23%, P<0.0001). These results were replicated to a lesser degree in the non-ED staff and non-order set subgroups. Implementation of the new order set resulted in an increase of its use (37.64% of all opioid orders up to 49.29%, P<0.0001). Finally, a cost-savings analysis was completed showing a projected annual savings of $185,676.52 on medications alone. Conclusion: This data supports the manipulation of electronic order sets to help shape physician behaviour towards best practices. This provides another strong argument towards the benefits of CPOE, and can help maintain best practices in Emergency Medicine.

36th International Symposium on Intensive Care and Emergency Medicine : Brussels, Belgium. 15-18 March 2016.

36th International Symposium on Intensive Care and Emergency Medicine : Brussels, Belgium. 15-18 March 2016.

Sedation for Gastrointestinal Endoscopy: Practical Issues in Patient Safety and Quality Management

Sedation for Gastrointestinal Endoscopy: Practical Issues in Patient Safety and Quality Management

Considerable Variability of Procedural Sedation and Analgesia Practices for Gastrointestinal Endoscopic Procedures in Europe.

Background/Aims:The use of moderate to deep sedation for gastrointestinal endoscopic procedures has increased in Europe considerably. Because this level of sedation is a risky medical procedure, a number of international guidelines have been developed. This survey aims to review if, and if so which, quality aspects have been included in new sedation practices when compared to traditional uncontrolled sedation practices. Methods:A questionnaire was sent to the National Associations of Nurse Anesthetists in Europe and the National Delegates of the European Section and Board of Anaesthesiology from January 2012 to August 2012. Results:Huge variation in practices for moderate to deep sedation were identified between and within European countries in terms of safety, type of practitioners, responsibilities, monitoring, informed consent, patient satisfaction, complication registration, and training requirements. Seventy-five percent of respondents were not familiar with international sedation guidelines. Safe sedation practices (mainly propofol-based moderate to deep sedation) are rapidly gaining popularity. Conclusions:The risky medical procedure of moderate to deep sedation has become common practice for gastrointestinal endoscopy. Safe sedation practices requiring adequate selection of patients, adequate monitoring, training of sedation practitioners, and adequate after-care, are gaining attention in a field that is in transition from uncontrolled sedation care to controlled sedation care.

Effect of Karamardādi Yoga versus diclofenac sodium in post-operative pain management: A randomized comparative clinical trial.

Introduction:Post-operative pain is Nociceptive i.e., anticipated unavoidable physiological pain which is caused due to tissue trauma. Drugs such as NSAIDs (Non Steroidal Anti Inflammatory Drugs) and Opioids are used for post-operative pain management but are associated with their own drawbacks. Karamardādi Yoga has been in use in Ayurvedic practice for analgesia. It is known to relieve pain and can be used to supplement anaesthesia and also get rid of adverse effect of modern analgesic drugs.Aims and Objective:To study the comparative effect of Karamardādi Yoga and Diclofenac sodium in post-operative pain management.Materials and Methods:Randomized clinical trial with Group A (Control Group: Tab Diclofenac sodium 50 mg as a single dose) and Group B (Trial Group: Cap Karamardādi Yoga 500 mg as a single dose). Those who had undergone haemorrhoidectomy operation under local anaesthesia were selected as per inclusion criteria. Vitals, desirable effect and undesirable effect, total surgical time, requirement of 1st dose of analgesic, requirement of rescue analgesic and pain determined by VAS (Visual Analog Scale) were the assessment criteria and were observed and recorded.Results:Karamardādi Yoga does not show any undesirable or serious ill effects and altered values of vitals as per statistical analysis. As per VAS scale, pain felt by Trial group was earlier than control group.Conclusions:Karamardādi Yoga has analgesic property but its analgesic property and pain threshold capacity is lesser than those of Diclofenac sodium.

Pediatric Adenotonsillectomy in a Low Resource Setting: Lessons and Implications.

Objectives:To examine the practices related paediatric adenotonsillectomy in our setting especially in relation to blood request and transfusion, routine investigations, post-operative analgesic practice and complications.Methods:We reviewed the record of paediatric patients who had adenotonsillectomy in our facility over a 5-year period to obtain relevant information to our study.Results:There were 33 males and 19 females with mean age of 3.27 ± 2.76 years. Sinus tachycardia was found in 11(21.2 %) of the subjects and T wave anomaly in 1(1.9%) of the subject. Thirty-five (67.3%) patient had adenotonsillectomy, 13(25.0 %) adenoidectomy only and 4(7.7%) tonsillectomy only. Majority of the patients (24, 46.2%) were classified as ASA physical status I. Pre-operative blood request rate was high (49, 94.3%) though the transfusion rate was 1.9 % (1 patient). Acetaminophen combined with other analgesics was used for post-operative analgesia for most of the patients. There was significant weight gain post-operatively among patientConclusions:Cold steel adenotonsillectomy is safe and effective in our environment. We believe that there is no justification for routine pre-operative blood request as a preconditions for surgery. We also like to suggest that post-operative pain management be streamlined taking into consideration the available analgesics in our setting.

Time to analgesia and pain score documentation best practice standards for the Emergency Department - A literature review.

Emergency Department pain management is an often overlooked aspect of acute care and is of paramount importance. Patients are often forced to wait extended periods of time without pain assessment or being offered analgesia for their painful condition. This has been associated with poor psychological and physiological consequences both for the health system and the patient. This is suggestive of a lack of clarity around best practice standards for time to analgesia and pain score documentation in the ED. A literature review was undertaken to investigate best practice in relation to acute pain management. Key outcomes were pain score documentation and time to analgesia. After a search of the electronic databases, a total of 992 abstracts were screened and 38 potentially relevant full articles were reviewed. There were 23 articles excluded for a variety of reasons including poor methodology, indirect specialty and inappropriate focus or age of study. A total of 15 studies were appropriate for inclusion in the review. Of the 15 studies, only eight included pain score as an outcome and 13 used time to analgesia as a measure. Four studies specifically investigated nurse initiated analgesia programs in relation to improving acute pain management. A higher incidence of pain assessment, reassessment and pain score documentation was generally correlated with decreased time to analgesia. Whilst there is an abundance of evidence available on the current practice and challenges of quality acute pain management in the ED, there is a lack of well-controlled studies on best practice standards for health care services to benchmark their practice and improve. Mandating pain score reporting, pain assessment and reassessment within specific timeframes and analgesia administration within 30 min of arrival is highly recommended. The implementation of nurse led analgesia protocols should be encouraged to increase incidence of documented pain assessment and reduce time to analgesia.

Efficacy of Current Practices for Pain Assessment in Premature Ventilated Infants in the NICU Exposed to a High Number of Pain-Associated Procedures.

To study infant factors, characteristics of pain scores, and analgesic practices associated with patient-days in the NICU with a high frequency of pain-associated procedures (defined as >10 pain-associated procedures in the day). This is a secondary analysis of data from a cross-sectional study that used medical record audits of premature, ventilated infants. The primary two-institution study yielded data for 196 patient-days. Data included 804 pain scores and 836 pain-associated procedures. A high frequency of pain-associated procedures occurred in 8% of days at Site A and in 25% of days at Site B. Prevalence of days with high frequency of pain-associated procedures differed by institution, and was higher at the institution where infants were more mature at birth and had fewer surgical procedures. High frequency of pain-associated procedures was related to endotracheal intubation at both institutions. There were no elevated pain scores and no documented analgesic administrations on days with over 20 pain-associated procedures. High exposure to pain-associated procedures during a 24-hour period for a premature, ventilated infant is rarely associated with elevated pain scores or analgesic administration. Prevalence of days with high-procedural exposure at an institution appears to be closely related to use of invasive ventilation and to individual institutional practices. Examination and discussion of the daily frequency of pain-associated procedures for premature, ventilated infants (especially for those receiving invasive ventilation) may be helpful in developing approaches for attenuating the cumulative pain experience for these babies. Resources that are expended on regular pain reassessment documentation processes in the NICU may need to be reconsidered in light of the very low yield for clinical alterations in care in this setting.

Dental presentations to an emergency department in a regional centre: prescribing practices for analgesia

Dental presentations to an emergency department in a regional centre: prescribing practices for analgesia

Sedation and analgesia practices in neonatal intensive care units (EUROPAIN): results from a prospective cohort study

Neonates who are in pain or are stressed during care in the intensive care unit (ICU) are often given sedation or analgesia. We investigated the current use of sedation or analgesia in neonatal ICUs (NICUs) in European countries. EUROPAIN (EUROpean Pain Audit In Neonates) was a prospective cohort study of the management of sedation and analgesia in patients in NICUs. All neonates admitted to NICUs during 1 month were included in this study. Data on demographics, methods of respiration, use of continuous or intermittent sedation, analgesia, or neuromuscular blockers, pain assessments, and drug withdrawal syndromes were gathered during the first 28 days of admission to NICUs. Multivariable linear regression models and propensity scores were used to assess the association between duration of tracheal ventilation (TV) and exposure to opioids, sedatives-hypnotics, or general anaesthetics in neonates (O-SH-GA). This study is registered with ClinicalTrials.gov, number NCT01694745. From Oct 1, 2012, to June 30, 2013, 6680 neonates were enrolled in 243 NICUs in 18 European countries. Mean gestational age of these neonates was 35.0 weeks (SD 4.6) and birthweight was 2384 g (1007). 2142 (32%) neonates were given TV, 1496 (22%) non-invasive ventilation (NIV), and 3042 (46%) were kept on spontaneous ventilation (SV). 1746 (82%), 266 (18%), and 282 (9%) neonates in the TV, NIV, and SV groups, respectively, were given sedation or analgesia as a continuous infusion, intermittent doses, or both (p<0.0001). In the participating NICUs, the median use of sedation or analgesia was 89.3% (70.0-100) for neonates in the TV group. Opioids were given to 1764 (26%) of 6680 neonates and to 1589 (74%) of 2142 neonates in the TV group. Midazolam was given to 576 (9%) of 6680 neonates and 536 (25%) neonates of 2142 neonates in the TV group. 542 (25%) neonates in the TV group were given neuromuscular blockers, which were administered as continuous infusions to 146 (7%) of these neonates. Pain assessments were recorded in 1250 (58%) of 2138, 672 (45%) of 1493, and 916 (30%) of 3017 neonates in the TV, NIV, and SV groups, respectively (p<0.0001). In the univariate analysis, neonates given O-SH-GA in the TV group needed a longer duration of TV than did those who were not given O-SH-GA (mean 136.2 h [SD 173.1] vs 39.8 h [94.7] h; p<0.0001). Multivariable and propensity score analyses confirmed this association (p<0.0001). Wide variations in sedation and analgesia practices occur between NICUs and countries. Widespread use of O-SH-GA in intubated neonates might prolong their need for mechanical ventilation, but further research is needed to investigate the therapeutic and adverse effects of O-SH-GA in neonates, and to develop new and safe approaches for sedation and analgesia. European Community's Seventh Framework Programme.

Sedation and analgesia practices among Spanish neonatal intensive care units

Introduction: Pain management and sedation is a priority in neonatal intensive care units. A study was designed with the aim of determining current clinical practice as regards sedation and analgesia in neonatal intensive care units in Spain, as well as to identify factors associated with the use of sedative and analgesic drugs. Method: A multicenter, observational, longitudinal and prospective study. Results: Thirty neonatal units participated and included 468 neonates. Of these, 198 (42.3%) received sedatives or analgesics. A total of 19 different drugs were used during the study period, and the most used was fentanyl. Only fentanyl, midazolam, morphine and paracetamol were used in at least 20% of the neonates who received sedatives and/or analgesics. In infusions, 14 different drug prescriptions were used, with the most frequent being fentanyl and the combination of fentanyl and midazolam.

Prescription pattern of analgesics in orthopedics outpatient department at a tertiary care hospital

Background: Analgesics are the most common class of drugs prescribed for various conditions in the orthopedics outpatient department (OPD). This study is performed for a better understanding of analgesics prescribing pattern in orthopedics and to correlate the use of selective cyclooxygenase-2 (COX-2) inhibitors, conventional non-steroidal anti-infl ammatory drugs (NSAIDs), and opioid analgesics in practice in the present scenario. Methods: The prescriptions from the OPD of Orthopedics at Dr. B. R. Ambedkar Medical College was reviewed between June 2013 and November 2013, entered in a pre-designed proforma. Pain was quantifi ed using numeric rating scale. The type of analgesics administered, whether monotherapy or combined therapy and the duration of therapy, was analyzed to obtain an overview of the current prescribing pattern. Results: A total of 300 prescriptions were analyzed. 800 drugs were prescribed with an average of 2.6 drugs per prescription. Of these, 62.3% were NSAIDs, 15.4% were opioid analgesics and 22.3% were gastroprotective agents. 61% of the NSAIDs were prescribed as monotherapy and 39% were prescribed as fi xed drug combination (FDC). The ratio of selective to non-selective NSAIDs is 1.3:1. Conclusions: The results of the present study show frequent use of selective COX-2 inhibitors, although non-selective NSAIDs topped the list of various selective NSAIDs, non-selective NSAIDs, and opioid analgesics. This suggests that gastrointestinal safety was an important concern while prescribing these drugs. Many FDCs were found to be irrational.

Prescription pattern of analgesics in orthopaedics OPD at a tertiary care hospital

Background: Analgesics are the most common class of drugs prescribed for various conditions in the orthopedics outpatient department (OPD). This study is performed for a better understanding of analgesics prescribing pattern in orthopedics and to correlate the use of selective cyclooxygenase-2 (COX-2) inhibitors, conventional non-steroidal anti-inflammatory drugs (NSAIDs), and opioid analgesics in practice in the present scenario. Methods: The prescriptions from the OPD of Orthopedics at Dr. B. R. Ambedkar Medical College was reviewed between June 2013 and November 2013, entered in a pre-designed proforma. Pain was quantified using numeric rating scale. The type of analgesics administered, whether monotherapy or combined therapy and the duration of therapy, was analyzed to obtain an overview of the current prescribing pattern. Results: A total of 300 prescriptions were analyzed. 800 drugs were prescribed with an average of 2.6 drugs per prescription. Of these, 62.3% were NSAIDs, 15.4% were opioid analgesics and 22.3% were gastroprotective agents. 61% of the NSAIDs were prescribed as monotherapy and 39% were prescribed as fixed drug combination (FDC). The ratio of selective to non-selective NSAIDs is 1.3:1. Conclusions: The results of the present study show frequent use of selective COX-2 inhibitors, although non-selective NSAIDs topped the list of various selective NSAIDs, non-selective NSAIDs, and opioid analgesics. This suggests that gastrointestinal safety was an important concern while prescribing these drugs. Many FDCs were found to be irrational.