DRUG PRESCRIBING DRUG PRESCRIBING PATTERN IN PATTERN IN OBSTETRICSOBSTETRICS

A CASE STUDY OF UNIVERSITY OF A CASE STUDY OF UNIVERSITY OF BENIN TEACHING HOSPITAL (UBTH), BENIN TEACHING HOSPITAL (UBTH),

NIGERIANIGERIA

BY BY DR TAIWO FILUSI, DR PATRICK ERAH AND DR TAIWO FILUSI, DR PATRICK ERAH AND

DR ADEDAPO ANDEDR ADEDAPO ANDE

AUTHORSAUTHORS

DR TAIWO EMMANUEL FILUSI; B.PHARM, PHARM D

PHARMACIST COUNCIL OF NIGERIA, LAGOS

DR PATRICK ERAH; B.PHARM, M PHARM, PHD

DEPT OF CLINCAL PHARMACY AND PHARMACY PRACTICE, UNIVERSITY OF BENIN, NIGERIA

DR ADEDAPO ANDE; BSc, MB:ChB, FWACS, FICS,MPH

CONSULTANT OBSTETRICIAN AND GYNAECOLOGIST UBTH, NIGERIA

DEFINITIONSDEFINITIONS

• ObstetricsObstetrics- The science that deals with - The science that deals with management of pregnancy from management of pregnancy from prenatal, parturition, to pueperal stages.prenatal, parturition, to pueperal stages.

• PrenatalPrenatal- Between the last menstrual - Between the last menstrual period and delivery (usually 40 weeks)period and delivery (usually 40 weeks)

• ParturitionParturition- Labour or act of delivery- Labour or act of delivery• PueperiumPueperium- The period immediately - The period immediately

following delivery till involution. (usually following delivery till involution. (usually 6-8 weeks)6-8 weeks)

The Thalidomide TragedyThe Thalidomide Tragedy• Thalidomide – A wonder drug that Thalidomide – A wonder drug that

turned to a wasteful dragonturned to a wasteful dragon

………………………………

Summary of Other Sordid Summary of Other Sordid talestales

• Margaret from USA took Isotretinoin Margaret from USA took Isotretinoin (Acutane) for 6 weeks for treatment of (Acutane) for 6 weeks for treatment of acne but had a premature deliver at 34 acne but had a premature deliver at 34 weeks of a baby with water in brain and weeks of a baby with water in brain and heart deformitiesheart deformities

• Deborah in the UK was given Ritodrine Deborah in the UK was given Ritodrine (Yutopar) to inhibit premature labour. (Yutopar) to inhibit premature labour. She died as a result of adverse drug She died as a result of adverse drug reactions due to an error in mixing the reactions due to an error in mixing the drug with saline solution instead of drug with saline solution instead of dextrose solution.dextrose solution.

REMEMBERREMEMBER

• Drugs can have harmful effects at anytime Drugs can have harmful effects at anytime during pregnancyduring pregnancy

• 11stst trimester- drugs cause congenital trimester- drugs cause congenital malformations (teratogenesis)malformations (teratogenesis)

• 22nd &nd & third trimesters- growth and third trimesters- growth and functional development and fetal tissues functional development and fetal tissues are affectedare affected

• Before term/Labour –Labour Before term/Labour –Labour complications and effect on the neonate.complications and effect on the neonate.

• However, irrational fear of using drugs However, irrational fear of using drugs during pregnancy can also result in harmduring pregnancy can also result in harm

RULES FOR PRESCRIBING RULES FOR PRESCRIBING IN PREGNANCYIN PREGNANCY

......................

– If possible, review patients and counsel If possible, review patients and counsel them before planning a pregnancythem before planning a pregnancy

– Question the real need for any drug in Question the real need for any drug in pregnancy giving due consideration to pregnancy giving due consideration to alternative methods of treatmentalternative methods of treatment

– Review all drug regimens carefully to Review all drug regimens carefully to minimize risksminimize risks

– Use medicines that have been widely Use medicines that have been widely employed in pregnancy for years in employed in pregnancy for years in preference to the latest drugspreference to the latest drugs

CONDITIONS WHEN CONDITIONS WHEN DRUGS MIGHT BE USED DRUGS MIGHT BE USED

IN PREGNANCYIN PREGNANCY………………– Infertility, when drugs may be used to stimulate Infertility, when drugs may be used to stimulate

ovulationovulation– Acute conditions that arise during pregnancy (pain, Acute conditions that arise during pregnancy (pain,

fever, infections, coughs and colds) or chronic fever, infections, coughs and colds) or chronic conditions unrelated to pregnancy (Asthma, Epilepsy, conditions unrelated to pregnancy (Asthma, Epilepsy, Diabetics).Diabetics).

– Conditions commonly related to pregnancy (morning Conditions commonly related to pregnancy (morning sickness, hypertension, anaemia)sickness, hypertension, anaemia)

– Complications of pregnancy and labour (threatened Complications of pregnancy and labour (threatened abortion, premature labour, toxaemia, pain in abortion, premature labour, toxaemia, pain in childbirth. childbirth.

TERATOGENIC DRUGSTERATOGENIC DRUGSFew essential drugs conclusively proven Few essential drugs conclusively proven to be teratogenic in human include:to be teratogenic in human include:– Alkylating agents, e.g Cyclophosphamide, Alkylating agents, e.g Cyclophosphamide,

Chlormethidine,Chlormethidine,– Antimetabolite agents e.g. Cytarabine, Antimetabolite agents e.g. Cytarabine,

Fluorouracil, Mercaptopurine, Methotrexate Fluorouracil, Mercaptopurine, Methotrexate etc.etc.

– CarbamazepineCarbamazepine– Common anticoagulants e.g WarfarinCommon anticoagulants e.g Warfarin– LithiumLithium– PenicillaminePenicillamine– PhenytoinPhenytoin– Valproic acidValproic acid

SAFETY OF ANTIBIOTICS SAFETY OF ANTIBIOTICS DURING PREGNANCYDURING PREGNANCY

• All drugs, including antibiotics All drugs, including antibiotics should be avoided during should be avoided during pregnancy, however when pregnancy, however when necessary, the following necessary, the following guideline can be usedguideline can be used

SAFETY OF SAFETY OF ANTIBIOTICS DURING ANTIBIOTICS DURING

PREGNANCYPREGNANCYAntibiotiAntibioticc

Trimester Trimester in which in which antibiotic is antibiotic is considered considered safesafe

CommentsComments

PenicillinPenicillinss

AllAll Studies of combination with Studies of combination with clavulanic have not clavulanic have not demonstrated toxic effectsdemonstrated toxic effects

QuinolonQuinoloneses

NoneNone Diseases of the joints have Diseases of the joints have been noted when used in been noted when used in immature animals, nalidxic immature animals, nalidxic acid has been used safely in acid has been used safely in second and third trimesters second and third trimesters but should be discontinued but should be discontinued at labourat labour

SAFETY OF ANTIBIOTICS SAFETY OF ANTIBIOTICS DURING PREGNANCY CONTDDURING PREGNANCY CONTD

SulphonamiSulphonamidesdes

SecondSecond Possible antifolate Possible antifolate effects in first effects in first trimester, risk of brain trimester, risk of brain damage caused by bile damage caused by bile pigment(bilirubin) in pigment(bilirubin) in third trimester.third trimester.

TetracyclineTetracycline NoneNone Material risk of liver, Material risk of liver, pancreas, or kidney pancreas, or kidney diseases; fetal risk of diseases; fetal risk of teeth discoloration, teeth discoloration, abnormal development abnormal development of of bone tissues and of of bone tissues and retarded bone growthretarded bone growth

TrimethopriTrimethoprimm

First & First & thirdthird

Folate antagonismFolate antagonism

WHO Core Prescribing WHO Core Prescribing IndicatorsIndicators

The WHO Core indicators provide an The WHO Core indicators provide an objective evaluation of drug use situation in a objective evaluation of drug use situation in a country, region or individual health facility. country, region or individual health facility. They include:-They include:-

• Average no of drugs per encounterAverage no of drugs per encounter• % of drugs prescribed by generic name% of drugs prescribed by generic name• % of encounters with an antibiotic prescribed% of encounters with an antibiotic prescribed• % of encounter with an injection prescribed% of encounter with an injection prescribed• % of drugs prescribed from the essential % of drugs prescribed from the essential

drug list or formulary.drug list or formulary.

Aims and objectivesAims and objectives

Main Objective:-Main Objective:-To investigate drug prescribing pattern by To investigate drug prescribing pattern by

obstetricians in UBTHobstetricians in UBTHSpecific ObjectivesSpecific Objectives1.1. To assess rational prescribing by obstetricians To assess rational prescribing by obstetricians

in UBTH using WHO core prescribing indicatorsin UBTH using WHO core prescribing indicators2.2. To determine the most frequently prescribed To determine the most frequently prescribed

drugs in prenatal, parturition, and puerperiumdrugs in prenatal, parturition, and puerperium3.3. To determine the most commonly prescribed To determine the most commonly prescribed

classes of drugs in prenatal, perinatal, and classes of drugs in prenatal, perinatal, and puerperiumpuerperium

Aims and objectives……Aims and objectives……

4. To determine the most commonly 4. To determine the most commonly prescribed antibioticsprescribed antibiotics

5. To determine the most frequently 5. To determine the most frequently diagnosed illness.diagnosed illness.

6. To determine the most commonly 6. To determine the most commonly prescribed drug for the most prescribed drug for the most frequently diagnosed illnessfrequently diagnosed illness

MethodologyMethodologyStudy LocationStudy LocationObstetrics and gynaecology department, Obstetrics and gynaecology department,

UBTH.UBTH.UBTH is 550 bed, tertiary health care facility, UBTH is 550 bed, tertiary health care facility,

having all the basic areas of medical having all the basic areas of medical specialty. It also serves as a teaching specialty. It also serves as a teaching hospital for medicine, pharmacy, nursing, hospital for medicine, pharmacy, nursing, and medical laboratory students.and medical laboratory students.

• Sample Selection: Case notes of patients from each of the ten consulting units in Jan.–Dec. 2003 were randomly selected and reviewed retrospectively for drug use from antenatal booking through labour and delivery to six weeks post partum.

• Sample Size: 473 encounters and 839 prescriptions

ProcedureProcedure

1.1. Consent to undertake the study was obtainedConsent to undertake the study was obtained

2.2. Familiarization with the department, operations Familiarization with the department, operations and staffand staff

3.3. Discussion and consultation with relevant staffDiscussion and consultation with relevant staff

4.4. Casenotes retrospectively reviewed through Casenotes retrospectively reviewed through prenatal, perinatal and postnatal careprenatal, perinatal and postnatal care

5.5. Data recorded in a customised data sheetData recorded in a customised data sheet

6.6. Consultants were asked questions arising from Consultants were asked questions arising from case-note reviewcase-note review

Data management and Data management and analysis analysis

Evaluation was done using:Evaluation was done using:

1.WHO core prescribing indicators1.WHO core prescribing indicators

2. Other parameters2. Other parameters

3.Microsoft excel3.Microsoft excel

4. Manual calculations4. Manual calculations

S/N Unit No. of Consultant

1 Fertility regulation (family planning)

3

2 Infertility, human reproduction and

Endocrinology

1

3 Faeto-maternal unit 3

4 Urogynaecology 3

Results.. Subspecialty Results.. Subspecialty division and consultant division and consultant

distributiondistribution

Results... Results... Prescribers Distribution in the ten

consulting unitsConsulting unit

1 2 3 4 5 6 7 8 9 10

Doctor’s Cadre

Consultant 1 1 1 1 1 1 1 1 1 1

Senior Registrar

11 11 11 00 11 11 11 00 11 11

Registrar 11 22 11 11 11 22 11 11 11 11

Senior House Officer(medical officer)

11 11 11 11 11 11 11 11 11 11

House Officer

22 22 22 22 22 22 22 22 22 22

Results…..Pharmacists Results…..Pharmacists staffing and cadre at O &G staffing and cadre at O &G

PharmacyPharmacy

Cadre No

Senior Pharmacist 1

Intern Pharmacist 1

Others Nil

Results…Age distribution of Results…Age distribution of booking (Prenatal) patients booking (Prenatal) patients

Mean Std. Deviation

28.5 2.12

Age range No %

<16 0 0

16-20 5 2.9

21-25 42 24.7

26-30 56 32.9

31-35 48 28.2

36-40 15 8.8

41-45 3 1.8

46 1 0.6

Results…Conformity of Results…Conformity of prescribers to WHO prescribers to WHO

prescribing indicatorsprescribing indicatorsPrescribing

indicatorsPrenatal Perinat

alPuerperi

umStandar

d

1 Average number of drugs per encounter

2.5 1.6 2.6 1.6 – 1.8

2 Percentage drugs prescribed by generic name

30.8% 37.1% 49.6% 100%

3 Percentage encounters with an antibiotic prescribed

5.9% 11.5% 32% 20.0 - 26.8%

4 Percentage encounters with an injection prescribed

5.2% 90.4% 14.4% 13.4 – 24.1%

5 Percentage of drugs prescribed from essential drug list

99.7% 97.6% 99.6% 100%

Summary of most frequently Summary of most frequently prescribed drugs and diagnosed prescribed drugs and diagnosed

illnessillnessCriteriuCriteriumm

PrenataPrenatall

PerinatalPerinatal PuerperiuPuerperiumm

Most Most frequentlfrequently y prescribeprescribed drugsd drugs

Routine Routine HaematiniHaematinics(Ferrous cs(Ferrous sulphate,Fsulphate,Folicacid,Pyolicacid,Pyrime-rime-thamine) thamine) (58% )(58% )

Oxytocin inj. Oxytocin inj. (15%)(15%)

Pentacozin Pentacozin (Sosegon) inj.(Sosegon) inj.(9% )(9% )

Paracetamol Paracetamol (14% )(14% )

Metronidazole Metronidazole (13% )(13% )

Classes Classes of most of most frequentlfrequently y prescribeprescribed drugsd drugs

HaematiniHaematinics( 66% )cs( 66% )

AntimalariAntimalarials(13%)als(13%)

Oxytocics (35% Oxytocics (35% ) )

Analgesics Analgesics (32% )(32% )

Haematincs Haematincs

(31% )(31% )

Antibiotics Antibiotics

(46% )(46% )

Summary of most frequently Summary of most frequently prescribed drugs and diagnosed prescribed drugs and diagnosed

illnessillnessMost frequently Most frequently prescribed prescribed antibioticsantibiotics

Metronidazole(37% )Metronidazole(37% )

Augmentin(33% )Augmentin(33% )

Most frequently Most frequently diagnosed illnessdiagnosed illness

Malaria (45% )Malaria (45% )

Anaemia (40% )Anaemia (40% )

Most frequently Most frequently prescribed drugs prescribed drugs for most for most frequently frequently diagnosed illnessdiagnosed illness

Chloroquine(58% )Chloroquine(58% )

Quinine (26% )Quinine (26% )

127

25 2417

0

20

40

60

80

100

120

140

RoutineHaematinics

(RH)

Vitamin C Paracetamol Chloroquine

(Tablets)

Nu

mb

er o

f tim

e P

rscr

ibed

Four Most Frequently Four Most Frequently Prescribed drugs in Prescribed drugs in

Prenatal carePrenatal care

Routine Haematinics includes Ferrous Sulphate tablets, folic acid tablets and pyremethamine (Daraprim) tablets.Total number of prescriptions - 218

Results…. Five most Results…. Five most frequently prescribed drugs frequently prescribed drugs

in perinatalin perinatal

Total number of prescriptions - 218Total number of prescriptions - 218Total number of prescriptions - 218Total number of prescriptions - 218Total number of prescriptions - 218Total number of prescriptions - 218Total number of prescriptions - 218Total number of prescriptions - 218Total number of prescriptions - 218

0

5

10

15

20

25

30

Oxytocin inj Sosegon inj Vitamin K inj Paracetamoltablets

Ergotamineinj

No

. o

f ti

me

pre

scri

bed

Series1

Results…. Six most Results…. Six most frequently prescribed drugs frequently prescribed drugs

in puerperiumin puerperium

0

5

10

15

20

25

30

35

40

Parac

etam

ol Tab

s

Met

ronid

azole

Tab

s

Vitam

in C T

abs

Augm

entin

Tab

s

Folic A

cid T

abs

Ferso

late

Tabs

No

. o

f ti

me

pre

sc

rib

ed

Results…… Five most Results…… Five most frequently prescribed frequently prescribed

classes of drugs in prenatalclasses of drugs in prenatal

13%

66%

8%

10%

3%

Haematinics

Analgesics

Antibiotics

Antimalarial

Antihistamine

Results… Four most frequently Results… Four most frequently prescribed classes of drugs in prescribed classes of drugs in

parturitionparturition

35%

32%

15%

18%

Oxytocics

Analgesics

Antibiotics

Haemetinics

Results... Five most commonly Results... Five most commonly prescribed classes of Drugs in prescribed classes of Drugs in

Puerperium Puerperium

46%

31%

16%4% 3%

Haemetinics

Antibiotics

Analgesics

Antimalarial

Chymotrypsin

Results… Three most Results… Three most commonly prescribed classes commonly prescribed classes

of drugs in prenatal, of drugs in prenatal, Parturition, PuerperiumParturition, Puerperium

60%19%

21%

Haematinics

Analgesics

Antibiotics

Results…Seven most Results…Seven most commonly prescribed commonly prescribed

antibiotics in Prenatal, antibiotics in Prenatal, Parturition and PuerperiumParturition and Puerperium

38

43

13

6 5 5 5

0

5

10

15

20

25

30

35

40

45

50

No

. o

f T

ime

Pre

sc

rib

ed

Results…Three most Results…Three most frequently diagnosed illness frequently diagnosed illness

(in Prenatal)(in Prenatal)

2623

9

0

5

10

15

20

25

30

No. of diagnosis

Malaria Anaemia UTI

Results…Frequency of Results…Frequency of Antimalarial Prescription Antimalarial Prescription

Frequency of Antimalarial Prescription

29

13

13

4

0

5

10

15

20

25

30

35

Chloroquine Quinine Paluther Daraprim Fansidar

29

13

1

34

0

5

10

15

20

25

30

35

Chloroquine Quinine Paluther Daraprim Fansidar

RECOMMENDATIONSRECOMMENDATIONS• Pharmacists like Medical Doctors, need

more concentration or specialization in basic clinical areas to enhance their professional relevance in medical practice.

• WHO should conduct studies in Obstetrics to establish standard core prescribing indicators, because the currently available standard are not applicable to Obstetrics

• Use of Daraprim (Pyrimethamine) as routine drug in first trimester should be reconsidered since Pyrimethamine (Daraprim) is a folate antagonist and in fact theoretically teratogenic.

RECOMMENDATIONS …..RECOMMENDATIONS …..

• The obstetricians need more awareness on the necessity of prescribing in generics as advocated by WHO.

• There is need to repeat this study using another facility to compare and contrast the results.

• It is pertinent to note that ACT use is now incorporated in the Malaria Treatment Policy for management of malaria in pregnant women in Nigeria. There is need for caution in order to avoid another “Thalidomide tragedy”.

CONCLUSIONCONCLUSION

• The WHO prescribing indicators are useful partly but not absolutely in analyzing rational prescribing in obstetrics.

• UBTH Obstetricians conform to applicable indicators except prescription in generics which fell below standard.

• Malaria and Anaemia were the most commonly diagnosed illness in pregnancy.

• Overall, prescriptions compare favourably with documented standard and drugs that commonly pose risk to faeto-maternal well being are not used in UBTH.

REFERENCES

• Chetley A., problem drugs, ‘Drugs in Pregnancy’ Amsterdam health action International, 1992, p. 125 – 135.

• How to investigate drug use in health facilities – selected drug use indicators, WHO, Geneva, 1993, (WHO/DAP/93.1).

• WHO, Geneva, 1993, (WHO/DAP/93.1).• WHO Model Formulary, WHO, U.K,

2002. P. 477.478.

Thank you for your Thank you for your attentionattention