Print ISSN: 2319-2003 | Online ISSN: 2279-0780

IJBCP International Journal of Basic & Clinical Pharmacology

DOI: http://dx.doi.org/10.18203/2319-2003.ijbcp20162893
Research Article

Drug utilization 90%: an innovative method in assessing quality of drug

prescription with specific reference to non-steroidal
anti-inflammatory drugs prescription
Dhananjay Kulkarni1*, Kokila B. N.2, Santosh Kumar Sahu3, Ravindra Kumar G.1

1
Department of Pharmacology,
Konaseema Institute of Medical
Sciences and Research
Foundation (KIMS & RF),
Amalapuram, Andhra Pradesh, ABSTRACT
India,
2 Background: DU90% is useful tool for assessing drug prescribing pattern. In
Department of Pharmacology,
KVG Medical College, Sullia this, drugs constituting 90% of the prescription volume are identified. Size of
(DK), Karnataka, India, the DU90% segment helps us to assess rational prescribing. Large number of
3 drugs in the DU90% segment indicates less rational prescribing, whereas small
Department of Orthopaedics
Konaseema Institute of Medical number suggests more rational prescribing.
Sciences and Research Methods: Study was carried out in orthopaedic out-patient department (OPD)
Foundation (KIMS and RF), for a period of three months. Only OPD based NSAID containing prescriptions
Amalapuram, Andhra Pradesh, were included. Data was analyzed based on demographic parameters,
India prescription indices, fixed dose combinations (FDC) and co-prescription of
gastro-protective agents (GPA). DU90% was calculated based on defined daily
Received: 12 August 2016 dose (DDD) with their respective value in Anatomical Therapeutic Chemical
Accepted: 16 August 2016 (ATC) classification code. Defined daily dose is calculated as DDD/1000/day.
Results: Diclofenac (38%) was the commonest NSAID prescribed. Diclofenac
*Correspondence to: +chymotrypsin (25%) was the commonest FDC prescribed. Piroxicam (19%)
Dr. Kulkarni Dhananjay, was the commonest NSAID prescribed in monotherapy form. Co-prescription
Email: [email protected] of GPA was high (96%). 5 of the 7 prescribed NSAIDs constitute to DU90%
segment.
Copyright: © the author(s), Conclusions: Preferential cyclooxygenase-2 (COX-2) inhibitor NSAIDs were
publisher and licensee Medip more preferred. Number of prescribed NSAIDs constituting to DU90% is more,
Academy. This is an open- thus prescription pattern needs further rationalization. Further large scale study
access article distributed under is required to bring out more details about NSAID prescription pattern and its
the terms of the Creative rational use.
Commons Attribution Non-
Commercial License, which Keywords: DU90%, FDC, DDD, NSAID, Prescription pattern, GPA
permits unrestricted non-
commercial use, distribution,
and reproduction in any
medium, provided the original
work is properly cited.

INTRODUCTION an assumption that a low number of products prescribed

is associated with more rational prescribing practices.
DU90% is an innovative approach to assess drug Furthermore, the approach can be used to assess what
prescribing. Using this approach, the drugs that represent proportion of the drugs that represent 90% of the volume
90% of the drug prescription/sales volume are identified.1 is made up by drugs listed in essential drug list.2
The rationale behind the development of DU90% rests on

www.ijbcp.com International Journal of Basic & Clinical Pharmacology | September-October 2016 | Vol 5 | Issue 5 Page 1746
 Kulkarni D et al. Int J Basic Clin Pharmacol. 2016 Oct;5(5):1746-1751

DU90% does not directly reflect the quality of serious life threatening injury patients or patients who
prescribing but it seems to be a useful tool in the quality refuse to give consent for the screening of their
assessment process through indicating areas that need to prescriptions were not included.
be analysed in more depth. The approach can be used for
exploring drug prescribing data in a rapid, effective and Since it was a non-invasive and descriptive study,
inexpensive way.3 DU90% identifies the number of drugs patient’s willingness to screen their prescription will be
making up to 90% of the total volume, measured in considered as their consent. Due co-operation from the
Defined Daily Dose (DDD) or number of prescriptions staff of orthopaedic department was sought. Personal
(NP), during a certain period of time. According to details of the patients were kept confidential. All the
DU90% concept a physician using few, well known and relevant prescription data was noted down in a
proved drug alternatives in the daily practice, would specialized proforma for Microsoft excel entry.
provide a more rational prescribing and hence a higher
quality of care. It is a purely descriptive prescription Descriptive statistical analysis of the data using tabular
indicator.4 Size of the DU90% segment helps us to assess forms, percentage and bar diagrams was done. Data on
rational prescribing. A very large number of drugs in the demographic parameters, prescription indices, fixed dose
DU90% segment indicate less rational prescribing. On combinations and gastro-protective drugs was high
the other hand, a small number of drugs in DU90% could lightened. DU90% was calculated based on number of
suggest a more rational prescribing. The assumption that prescriptions as well as by defined daily dose (DDD)
less is better is used as prescribing indicator in DU90%.2 with their respective value in anatomical therapeutic
chemical (ATC) classification code. Here Defined daily
The defined daily dose (DDD) is the assumed average dose is calculated as DDD/1000/day and the formula used
maintenance dose per day for a drug used for its main was:
indication in adults. It will only be assigned for drugs that
already have an anatomical therapeutic chemical (ATC)
classification code. DDD is a unit of measurement and
does not necessarily reflect the recommended or
prescribed daily dose.5 Drug consumption data presented RESULTS
in DDDs only give a rough estimate of consumption and
not exact picture of actual use. DDDs are not established Overall 200 NSAIDs containing prescriptions were
for topical preparations, sera, vaccines, anti-neoplastic included in this study. Female cases (56%) were more
agents, allergen extracts, general and local anaesthetics than male counterparts. Maximum cases (48%) belong to
and contrast media.4 DDD is most commonly calculated 26 years to 59 years of age group. Table 1 highlights
as DDD/1000/day. demographic profile and prescription indices of the
present study. Number of NSAIDs prescribed in 200
The treatment of pain and inflammation is an important prescriptions was 248; hence average NSAID prescribed
area of therapeutics. Over the past two decades, non- per prescription was 1.24. Antibiotics were prescribed in
steroidal anti-inflammatory drugs (NSAIDs) have played 40 prescriptions. Calcium supplementations were
a central role in these indications. NSAIDs constitute the prescribed to 120 cases; mainly to above 40 year female
largest single group of drugs used worldwide, patients.
constituting more than 20% of all drug prescriptions. 6 In
India over 400 formulations of NSAIDs are marketed, In this study NSAIDs were prescribed both as
resulting in wide spread exposure of patients to this class monotherapy and as FDCs. Monotherapy was prescribed
of drugs and its adverse effects.7 Hence studies that in 88 cases and FDCs to 160 cases. Table 2A shows
evaluate the pattern, extent and frequency of NSAID details of NSAID containing FDCs.
prescriptions are valuable, thus in this regard this present Diclofenac+chymotrypsin (25%) was the commonest
study attempts to assess NSAID prescription pattern FDC prescribed, followed by etodolac+paracetamol
using DU90% methodology. (20%) combination. Thiocolchicoside was the commonest
non-NSAID component found in FDC. Paracetamol was
METHODS only prescribed (72) in FDC form, either with other
NSAIDs (48) or with tramadol (24). In this study co-
A prospective, non-interventional, cross sectional prescription of Gastro-protective agents (GPA) was high.
(observational) study was carried out in the out-patient Table 2B shows details of GPA co-prescription. Almost
department of orthopaedics, Konaseema Institute of all NSAID prescriptions (96%) were associated with GPA
Medical Sciences (KIMS), Amalapuram, Andhra co-prescription. Ranitidine was the commonest GPA
Pradesh. Necessary Institutional ethics committee (83.33%) prescribed.
clearance for the conduct of the study was taken. The
study was conducted over a period of three months Figure 1 shows details of NSAIDs prescribed in
(March to May 2016). During the study period NSAIDs monotherapy and in FDC form. Piroxicam, indomethacin
containing prescriptions were included in the study. and lornoxicam were only prescribed in monotherapy
Prescriptions of in-patients, surgical intervention patients,

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 Kulkarni D et al. Int J Basic Clin Pharmacol. 2016 Oct;5(5):1746-1751

form, whereas etodolac, paracetamol and aceclofenac the commonest NSAID prescribed followed by etodolac
were only prescribed in FDC form. (56), aceclofenac (40), piroxicam (38), paracetamol (24),
Indomethacin (8) and lornoxicam (6) respectively.
Table 1: Demographic profile and prescription Number of paracetamol FDCs prescribed were 72, of
indices. these 24 was with tramadol combination. Only these 24
FDCs were shown in Figure 1, as the rest 48 FDCs were
Demographic profile with other NSAIDs like etodolac and aceclofenac and are
Total sample size 200(n) already included in their respective sections.
 Male 88
 Female 112 60
Monotherapy
Age
 25 years and below 56 50
56 FDC
 26-59 years 96 40
 60years and above 48 40 38 40
Prescription indices 30
36 24 # (72)
Total number of drugs prescribed 728
20
Average Number of drugs per prescription 3.64
Number of prescription containing calcium 120 10
supplementation. 0 0 0 0 6 0 8 0
Average number of NSAIDs per 1.24 0
prescription
Number of FDCs containing NSAIDs 160
prescribed
Number of NSAIDs prescribed in 88
monotherapy form #Overall paracetamol FDCs were 72, of this 24 is with tramadol
and is shown in figure, rest 48 is with other NSAIDs like
Number of analgesic gel prescribed 08 etodolac and aceclofenac and thus already included in their
Number of antibiotics prescribed 40 respective sections.

Table 2: Details of NSAID containing FDCs and co- Figure 1: Details of NSAIDs prescribed in FDC and in
prescription of GPA. monotherapy form.

A. Fixed Dose combinations of NSAIDs Table 3 shows various indications for NSAID prescription
FDC of NSAIDs Number of Percentage in this study. Low backache (28%) was the commonest
prescriptions (n = 160) indication, followed by joint sprain (21.5%), trauma
Diclofenac + 40 25 (18%) and others (32.5%) respectively.
chymotrypsin
Etodolac + 32 20 Table 3: Indications for NSAID prescription.
Paracetamol
Etodolac + 24 15 Clinical No. of Percentage
Thiocolchicoside conditions prescriptions (n=200)
Tramadol + 24 15 Low backache 56 28
Paracetamol Joint sprains 43 21.5
Aceclofenac + 24 15 Trauma 36 18
thiocolchicoside Tendinits and
30 15
Aceclofenac + 16 10 bursitis
Paracetamol Arthritides 29 14.5
B. Co-prescription of gastro-protective agents Others 06 03
(GPA)
GPA drug Number of Percentage Table 4 shows details of drug constituting DU90% (based
Prescriptions (n = 192) on number of prescription and DDD). For each drug
Ranitidine 160 83.33 defined daily dose (DDD) and ATC code was provided.
Pantoprazole 32 16.67 DDD/1000/days was calculated as per its formula for each
drug. Out of seven different NSAID prescribed, five of
Diclofenac was the only NSAID which was prescribed in them constitute to DU90% and these are diclofenac,
both forms. Piroxicam was the commonest NSAID etodolac, aceclofenac, paracetamol and piroxicam
prescribed in monotherapy form. Etodolac was the respectively. Only indomethacin and lornoxicam were out
commonest NSAID prescribed in FDC form. With the of purview of DU90%.
combination of both forms, overall Diclofenac (76) was

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 Kulkarni D et al. Int J Basic Clin Pharmacol. 2016 Oct;5(5):1746-1751

Table 4: Details of NSAIDs constituting to DU90%.

Drugs ATC CODE DDD No. of prescription (n=248*) DDD/1000/days

Diclofenac M01AB05 100 mg 76 29.56
Etodolac M01AB08 400 mg 56 43.55
Aceclofenac M01AB16 200 mg 40 15.56
Paracetamol FDC
With other NSAIDs(48**) N02BE71
325 mg 24 18.67
and
With Tramadol (24) N02AJ13
Piroxicam M01AC01 20 mg 38 14.77
Indomethacin M0IAB01 100 mg 08 3.11
Lornoxicam M01AC05 12 mg 06 3.11
*Here n is 248 as some prescriptions has more than one NSAID, although total number of prescriptions for the study were 200. Hence
average NSAIDs prescribed per prescription was 1.24.
**48 is not part of the calculation, as NSAID in these FDCs of paracetamol is taken as principal component and is already included in
their respective column.

DISCUSSION are more prone to cause gastritis and peptic ulceration.

Similar high trend was also observed in two different
The study was conducted in out-patient orthopaedic Spanish studies where frequency of GPAs co-prescription
department for a period of three months. Overall 200 was 64% and 85% respectively.14,15 This high co-
NSAID containing prescriptions were included and prescription of GPA can also be attributed to defensive
analyzed in this study. Overall diclofenac was the trend observed by prescribers in order to decrease NSAID
commonest NSAID prescribed in this study, same trend induced complication, especially after the withdrawal of
was observed in Dhaka prescription study.8 Similarly rofecoxib.16 In our study ranitidine was the commonest
diclofenac was also the commonest NSAID prescribed in GPA prescribed and was more preferred than
a study conducted by VS Manohar et al.9 In this present pantoprazole, unlike the study done by VS Manohar et al
study none of the selective cyclooxygenase-2 (COX-2) where proton pump inhibitors were more preferred.9
inhibitors were prescribed, instead preferential COX-2
inhibitors (diclofenac, etodolac and aceclofenac) and In this study NSAID containing FDCs are prescribed in
traditional NSAIDs (like piroxicam) were more large numbers (n=160). Diclofenac+Chymotrypsin
preferred.10 combination is the commonest FDC prescribed followed
by Etodolac+Paracetamol, aceclofenac+paracetamol,
High frequency of preferential COX-2 inhibitor and non- tramadol + paracetamol and others. This high prevalence
selective NSAID prescription points towards the changing of FDC prescription is similar to a study conducted in
trends observed in the prescriber‘s preference for NSAID Uttaranchal, where FDC prescription frequency was more
prescription after the withdrawal of rofecoxib. 11 This than 49%.17 A similar combination of NSAID FDCs were
changing trend might be due to increased awareness and also prescribed in Ahmedabad study.18 However many
recent reports of cardiovascular (CVS) complications combination of NSAID as FDCs is not recommended as
associated with various selective COX-2 inhibitors.9 these combinations have no drug synergism and moreover
Similarly a study conducted in New York, shows that the combination can increase the chances of adverse
COX-2 inhibitors constituted 37% of NSAID prescription events and overall cost of prescribing.19 Nevertheless
before the withdrawal of rofecoxib. After withdrawal, some useful analgesic combinations do exist, such as
their frequency decreased to 16% within one year and combination of tramadol with paracetamol. They
progressively decreased further in follow up studies. 12 synergise with each other as site of actions are different
for both the drugs.20
Low backache was the commonest indication for NSAID
prescription. Similar indication is seen in other studies, The anatomical therapeutic chemical (ATC) classification
like in Dhaka study, where low backache and trauma were divides drugs into different groups according to the organ
the commonest indications for NSAIDs; another study in or system on which they act and their chemical,
Dhaka also shows similar findings.8,13 Present study pharmacological and therapeutic properties.21 The DDD is
shows high prevalence of co-prescription of GPAs (96%). the assumed average maintenance dose for a drug used for
High frequency of GPA prescription can be attributed to its main indication in adults. The DDD provides a fixed
prescriber‘s preference for non-selective NSAIDs, which unit of measurement that is independent of price and
formulation, and makes it easier to compare drug

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 Kulkarni D et al. Int J Basic Clin Pharmacol. 2016 Oct;5(5):1746-1751

utilisation across studies. The major benefit of studying 2. Bergman U, Popa C, Tomson Y, Wettermark B,
drug utilization using DDD is that the dosage and the Einarson TR, Aberg H, Sjoqvist F. Drug utilization
duration of use are both factored in to the calculation. The 90%-a simple method for assessing the quality of
dosage, frequency and duration of use are variable in drug prescribing. Eur J Clin Pharmacol.
different patients, and these differences can be overcome 1998;54(2):113-8.
by using the DDD as a measure of drug consumption. 22 3. Bergman ULF. Pharmacoepidemiology-from
DU90% which can also be expressed in terms of DDD, description to quality assessment: A Swedish
basically assess what number of drugs constitutes to 90% perspective. Norwegian J Epidemiol. 2001;11(1):31-
of prescription, less the number of drugs constituting 6.
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Five of the seven NSAIDs prescribed in this study (MPH). 2005;18:17-8.
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DU90%; prescription pattern needs further rationalization. between prescribed and defined daily doses: a matter
In this study only preferential COX-2 inhibitors and of patients or drug classes? Eur J Clin Pharmacol.
traditional NSAIDs are part of DU90%. This finding is 2011;11:1014-7.
similar to study done by J Ćalasan et al where only 6. Pincus T, Swearingen C, Cunmine P, Callahaw LP.
preferential COX-2 inhibitors were part of DU90%.23 Preference for non-steroidal anti-inflammatory drugs
Contrary to our result COX-2 inhibitors were the major versus acetaminophen and concomitant use of both
constituents of DU90% in Korean study.24 Similarly in types of drugs in patients with osteoarthritis. J
PGI Chandigarh, before the withdrawal of rofecoxib, Rheumatol. 2000;27:1020-7.
COX-2 inhibitors were the major component of 7. Paul AD, Chauhan CK. Study of usage pattern of
DU90%.25 nonsteroidal anti-inflammatory drugs (NSAIDs)
among different practice categories in Indian clinical
After the withdrawal of rofecoxib (2004) and subsequent setting. Eur J Clin Pharmacol. 2005;60:889-92.
news of increased CVS adverse effect seen with selective 8. Rahman MS, Begum ZA, Samad MK. Prescribing
COX-2 inhibitors, prescribers increasingly replaced COX- pattern of non-steroidal anti-inflammatory drugs at
2 inhibitors with non-selective NSAIDs and preferential outpatient departments of teaching hospitals.
COX2 inhibitors, considering it as a class effect and not Bangladesh J Pharmacol. 2007;2:1-6.
as individual drug effect.26 This observation can very well 9. Manohar VS, Vinay M, Jayasree T, Kishan PV,
be noted in our study as DU90% segment is mainly Ubedulla S, Dixit R. Prescribing pattern of
constituted by preferential COX-2 inhibitors and non- gastroprotective agents with non-steroidal anti-
selective NSAIDs. inflammatory drugs. J Pharmacol Pharmacother.
2013;4:59-60.
CONCLUSION 10. Nonsteroidal Antiinflammatory Drugs and
Antipyretic-Analgesics. In: KD Tripathi; Essentials
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seven NSAIDs, five were part of DU90%. As more drug Characterizing new users of NSAIDs before and
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13. Samad MK. Consumption patterns of non-steroidal
Funding: No funding sources anti-inflammatory drugs by the community without
Conflict of interest: None declared prescription in Dhaka city. Bangladesh J Pharmacol.
Ethical approval: The study was approved by the 2009;4:43-5.
Institutional Ethics Committee 14. Lanas A, Garci-Tell G, Armada B, Oteo-Alvaro.
Prescription patterns and appropriateness of NSAID
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