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Prescription Pattern of Antidiabetic Drugs among Type 2 Diabetes Patients of Sir Ganga Ram Hospital, Lahore.

Byline: Zahra Ali, Sardar Fakhar Imam, Muhammad Adnan, Iffat Shabbir and Tayyaba Rahat

Introduction

Diabetes mellitus (DM) is an endocrine disorder associated with abnormal carbohydrate, protein and lipid metabolisim1,2. It is a major cause of morbidity and mortality in developed and developing countries3. There is an estimate of 250 million cases of DM worldwide4 and its occurrence is on increase, especially in developing countries. In Pakistan, its reported prevalence is 10%, and nearly 10% population has impaired glucose tolerance5,6,7. This is a chronic disease and can lead to devastating complications if not properly managed8. The American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD), emphasize on need of progressive and early addition of glucose lowering strategies2. Various guidelines are available that recommend for different classes of drugs to treat diabetes9. Drug utilization studies are powerful exploratory tools to ascertain the role of drugs in society10.

The study of prescribing pattern is a component of medical audit that does monitoring and evaluation of the prescribing practice of the prescribers as well as recommends necessary modifications to achieve rational and cost-effective medical care. In the setting, no similar study has been carried out to establish the prescription pattern of antidiabetic drugs among type 2 diabetics. The study was designed to observe the current status of anti-diabetic drugs prescription pattern.

Patients, Methods and Results

The case series prospective study was carried out at Diabetes Clinic of Sir Ganga Ram Hospital, Lahore. Two hundred known type 2 diabetics, age more than 18 years, of both genders, using anti-diabetic drugs at least for last one month were included in the study. Study duration was three months (Jan-Mar 2014). An interview was conducted to collect demographic and clinical information of the patients. The demographic details included age, gender, socio-economic status and education. Clinical and biochemical data included random plasma glucose level, duration of diabetes, family history of diabetes, co-morbidities and antidiabetic drugs prescribed. Data analysis was performed by using Statistical Package for Social Sciences (SPSS) version 21. Categorical variables were presented as number (percentage) and numerical variables in mean (standard deviation).

Mean age of the patients and male-to-female ratio was 539 years and 1:2, respectively. Mean for plasma glucose level was 24493 mg/dl. Patients who reported family history of diabetes were 127(63.5%). Mean duration of diabetes was 7.25.7 years. Patients using insulin had mean duration of diabetes 9.35.7 years; and on two drugs combination had 7.65.7 years.

Socioeconomic status showed that majority of patients 163(81.5%) were from poor class and 37(18.5%) from middle class. None of them was from upper class. There was no significant difference (p greater than 0.05) present between poor and middle class regarding prescribed medicines or type of treatment.

It was observed that only 78% patients were attending the diabetes clinic regularly, while 22% patients were visiting healthcare facility occasionally; and were not taking antidiabetic drugs regularly. History of hypertension (HTN) was reported by 76.5% patients; ischemic heart disease (IHD) 21.5% patients; lipid abnormalities 19.0% patients; diabetic nephropathy (DN) 8.5% patients; and diabetic retinopathy (DR) 8.0%. No significant difference (p greater than 0.05) was present between the comorbidity (HTN, dyslipidemia, DN and DR) and antidiabetic drug prescription. Patients who had history of IHD (53.5%) were on Insulin; contrary to this 22.2% patients without IHD were also on Insulin. Therefore significant association was found between IHD and Insulin prescription (p 0.002).

The frequency for users of mono antidiabetic drug was 130 (65%) patients; and for combination antidiabetic drug was 70 (35%) patients. Metformin was the leading drug which was prescribed in total of 109 (54.5%) patients; as monotherapy to 47 (23.5%) patients; and as combination therapy to 47 (23%) patients. Insulin prescription to 39 (19.5%) patients was second highest as monodrug; followed by Sulphonylurea to 34 (17.0%) patients. However, as combination, Sulphonylurea prescription was greater than Insulin. Combination of metformin and sulphonylurea as two drugs was more prescribed to 37 (18.5%) patients than as fixed dose to 11 (5.5%) patients. Combination of metformin and insulin was prescribed to 10 (5.0%) patients.

Among sulphonylurea, Glimepiride was more prescribed (23.5%), than Glibenclamide (17.5%) and Gliclazide (4%). Among Glitazone, commonly prescribed drug was Pioglitazone (4.5%) followed by Roziglitazone (0.5%). As two drugs combination, Metformin plus Sulphonylurea was most frequently prescribed combination followed by Metformin plus Insulin. DPP-4 inhibitors were prescribed neither as monodrug nor as combination to any diabetic in the setting (Table).

Table: Prescription pattern of antidiabetic drugs among type 2 diabetes patients.

###Groups (n=200)###Drugs###n (%)

Mono Therapy (n=130)###Metformin###47(23.5)

###Insulin###39(19.5)

###Sulphonylurea###34(17)

###Thiazolidinedione/Glitazones###10(5)

###DPP-4 Inhibitors/Gliptins###0

Combination Therapy (n=70)

Fixed Dose (n=14)

###Metformin + Sulphonylurea###11(5.5)

###Metformin + Glitazone###3(1.5)

###Metformin + Dpp4 inhibitor###0

Two Drugs (n=56)###Metformin and Sulphonylurea###37(18.5)

###Metformin and Insulin###11(5.5)

###Sulphonylurea and Insulin###8(4)

Comments

Metformin was the most prescribed anti diabetic drug to 109(54.5%) patients. The reason might be that it is the drug of choice for most type 2 diabetics because it does not promote weight gain and has beneficial effects on several cardiovascular risk factors6. This fact complies with its endorsement as the preferred anti diabetic agent by Canadian Diabetes Association, International Diabetes Federation, National Institute of Health and Clinical Excellence7,11,12. Results by Sudha et al reported that 50.4% patients received metformin in combination or as monodrug13 also validate the observation of this study.

Mean age of the patients was 539years, which is similar to the age of type 2 diabetics reported by different studies14,15. Gender female (68.5%) was larger in number than male; similar finding was reported from UAE study16, In contrast, some studies indicated male predominance in their reports13,17. Mean duration of diabetes observed 7.25.7 years was comparable to Indian cohort study, where it was 8.39.4 years18. History of self reported comorbidity revealed that frequency of hypertension (76.5%) was higher than other observed comorbidity. Same observation regarding comorbidity has been reported in diabetics by various studies18-20.

Monodrug therapy (65%) was preferred than two drugs therapy (35%) in the present study. Similar results were found in another study where 59% patients were on monotherapy and 41% were on combination therapy21. Metformin was prescribed to 23.5% as monotherapy which is comparable to the of findings Dhanaraj et al who also reported metformin prescription as monotherapy to 23.0% patients22. Another study from Pakistan reported that Metformin (32%) was the commonly prescribed antidiabetic drug23. In contrast, few studies demonstrated that sulphonylurea was the commonly prescribed antidiabetic drug41, followed by combination of sulphonylurea and metformin, and metformin alone24-27. Glimepiride was the most widely used Sulphonylurea22 as concluded in this study. Combination of metformin and sulphonylurea was prescribed to 24% patients; followed by combination of metformin and pioglitazone to 1.5% patients. These prescribed combinations were also reported by other studies13,19,24.

DPP-4 inhibitors were not prescribed to any diabetic patient. The reasons could be that it is expensive medicine and majority of studied patients (81.5%) were poor. On the other hand metformin is cost effective drug and safer in terms of hypoglycemia. This could be the reason for its preferred use for type 2 diabetics in a public sector hospital.

Oral antidiabetic drugs, metformin and sulphonylurea, were frequently used medicines both mono as well as in combination therapy. However its two drugs combination was more commonly prescribed than as fixed dose.

A limitation of the study was small sample size which restricts the generalization of the findings. The study could be extended over the private hospitals for comparison with the findings of public sector hospital.

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Publication:Pakistan Journal of Medical Research
Article Type:Report
Date:Sep 30, 2015
Words:2112
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