Dissertation Title: Drug Prescribing Pattern among General Medicine

Outpatients in Government Hospital of Province 1, Nepal

Author: Mr. Shambhu Shah

Major Program: Master in Clinical Pharmacy
Year: August 2019
Examining Committee
Chairperson
…………………………………….
(Dr.KajiramAdhikari, M Pharm, PhD)

……………………………………..
(Dr.Anil Kumar Sah, M.Pharm, Ph.D)

……………………………………
(Dr.Prasanna Dahal, B.PharmSC, PharmD)

……………………………………..
(Dr. Kadir Alam, M.Pharm,Ph.D)
External Examiner

……………………………………..
(Ms. Kabita Adhikari)
Campus Chief
Faculty of Health Sciences, Purbanchal University, has approved this dissertation as the
fulfilment of the requirements for the Degree of Master of Pharmacy (M Pharm in Clinical
Pharmacy).
……………………………………………
(Dr. Shailesh Mani Pokharel)
Dean
Faculty of Medical and Allied Sciences
Purbanchal University

i
 CERTIFICATE

This is to certify that the Dissertation entitled “Drug Prescribing Pattern among General
Medicine Outpatients in Government Hospital of Province 1, Nepal” submitted by Mr.
Shambhu Shah in the partial fulfillment for the Master of Pharmacy in Clinical Pharmacy
was carried out under our guidance and supervision during all stages of planning, execution
and analysis. The results of this work have not been previously submitted to any institution
to acquire any other academic degree or diploma.

………………………….. ……………………………

Dr. Anil Sah, (M.Pharm, PhD) Dr. Prasanna Dahal, (BPharmSc, PharmD)
Supervisor Co-Supervisor
Assistant Professor, Assistant professor
Purbanchal University College of Purbanchal University College of
Medical and Allied Sciences Medical and Allied Sciences
(PUCMAS) (PUCMAS)
Purbanchal University Purbanchal University
Gothgaon, Morang, Gothgaon, Morang,
Nepal Nepal

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 DECLARATION

The results presented in the Dissertation entitled “Drug Prescribing Pattern among General
Medicine Outpatients in Government Hospital of Province 1, Nepal” has been entirely
carried out under the guidance and supervision of Dr. Anil Kumar Sah and Dr. Prasanna Dahal. I
hereby declare that this work is original and has not been submitted in part or full to any other
institutions for the award of any other degree or diploma.

…………………………………

Shambhu Shah
PUCMAS, Purbanchal University
Gothgaon
Reg. Number: 152-6-3-07648-2017

College of Medical and Allied Sciences, Purbanchal University, has approved this dissertation as
fulfillment of the requirements for the Degree of Master of Pharmacy (M Pharm. in Clinical
Pharmacy).

……………………… ……………………………..

(Head of the Program) (Campus Chief)

Dr. Kajiram Adhikari, PhD Mrs. Kabita Adhikari
PUCMAS, PU PUCMAS, PU

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 ACKNOWLEDGEMENT

I would like to express my very great appreciation to all those who have generously contributed
to the completion of this dissertation with their help, knowledge, expertise and time.

I would like to express my very great appreciation to my research supervisors Dr. Anil Kumar
Sah and Dr. Prasanna Dahal, for their guidance, enthusiastic encouragement and useful critiques
of this research work.

I would like to express my deep gratitude to Dr. Prasanna Dahal for his valuable and constructive
guidance in planning and designing of this research work as well as reviewing and editing for
intellectual content. His willingness to give his time so generously has been very much
appreciated and will be an great inspiration. My grateful thanks are also extended to Dr. Kajiram
Adhikari, Head of Program Pharmacy Department, Mrs. Kabita Adhikari, Campus chief, Dr
Shyam Kumar Mallik Purbanchal University College of Medical and Allied Sciences
(PUCMAS), for their encouragement for the completion of my dissertation work.

I would also like to express my sincere gratitude to Dr. Surya B. Parajuli, Prof. Naveen Shrestha
for support in data analysis, reviewing, editing, this work for intellectual content. I would also
like to extend my thanks to Dr. Deepak Sigdel, Dr. Laxmi Narayan Yadav, Dr. Pitambar Thakur,
Mr. Durgaraj Bhandari (Pharmacy Officer) Mr.Anand Sarda, Mr. Saroj Thakur, Mr. Rajendra
Paudel and Mr. Sashim Pokhrel and all staffs from Koshi and Mechi Zonal Hospital for their
assistance with the collection of my data.
Finally, I wish to thank my parents and family and my colleagues for their support and
encouragement throughout my study.
Lastly I would prefer to pay homage by dedicating my thesis to my late father for their great role
and their numerous sacrifices for me.

With warm regards

Shambhu Shah
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Table of Content Page no

Certificate ii

Declaration iii

Acknowledgement iv

Table of Contents v

List of Tables viii

List of Figures viii

List of Abbreviations ix

Abstract x

Table of Contents

CHAPTER I 1

1. Introduction 1
1.1 Background 1
1.2 Problem Statement 2
1.3 Rationale of study 3
1.4 Objectives 4
1.4.1 General Objective 4
1.4.2 Secondary Objectives 4

CHAPTER II 5

2. Literature review 5

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 2.1 Drug Utilization Study 5
2.2 Scope of Drug Utilization Study 5
2.3 Types of Drug Utilization Study 6
2.4 Review of methods used in drug utilization studies 7
2.5 Drug Classification system 8-9
2.6 Steps involved in drug utilization study 10
2.7 Drug use situation in Nepal 11
2.8 Health care structure in Nepal 12
2.9 Common morbidity in Nepal 13-14
2.10 Studies on Prescribing pattern in abroad 15-18
2.11 Studies on Prescribing pattern in Nepal 19
2.12 WHO drug use indicator 20
2.13 Definition and Key Concepts 22-23

CHAPTER III 24

3. Research methodology 24
3.1 Study design and 24
3.2 Study period 24
3.3 Study population, 24
3.3.1 Inclusion criteria 24
3.3.2 Exclusion criteria 24
3.4 sample size and sampling procedure 24
3.5 Data collection tool and method of data collection 25
3.6 Ethical approval and consent of participants 25
3.7 Statistical analysis 26

CHAPTER IV 27

4. Result and Discussion 27

4.1 Result 27
4.1.1 Demography details 27
4.1.2 Morbidity Classification 27

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 4.1.3 Drug Prescribed on the basis of ATC classification 29
4.1.4 Commonly prescribed drug in single drug 31
4.1.5 Commonly prescribed drug in fixed dose combination 33
4.1.6 WHO prescribing indicators summary of hospital 34
4.1.7 Comparison of prescribing indicator of Two Zonal Hospitals 34

4.2 Discussion
4.2.1 Morbidity profile 36
4.2.2 Drug prescribing pattern 37
4.2.3 Level of Polypharmacy 37
4.2.4 Prescription encounter with antibiotics 38
4.2.5 Prescription encounter with injectable 38
4.2.6 Generic prescribing 39
4.2.7 Prescribing from EDL 39

CHAPTER V 40

5. Conclusion and Recommendation 40

5.1 Conclusion 40
5.2 Limitation 40
5.3 Recommendation 40-41
6. References 42-49
7. Appendices 50
Annex 1- Data Collection Tool 50-51
Annex 2- Informed Consent Form 52
Annex 3- Ethical Approval letter from NHRC 53
Annex 4- Recommendation letter from University 54-56
Annex 5- Work plan and schedule 57

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LIST OF TABLES

2.9.1 Communicable and non-communicable disease among outpatients by province 14

2.9.2 Communicable and non-communicable disease cases and deaths FY 2075/76 14
2.10.1 Prescribing pattern studies in abroad 16
2.11.1 Prescribing pattern studies in Nepal 20
4.1.1 Demography Details 27
4.1.2 Morbidity profile of patients as per ICD-10 28
4.1.2 Ten most prevalent diseases among general outpatients 29

4.1.3 Frequency of drug prescribed on the basis of Anatomical Therapeutic Classification (ATC)
classification 30

4.1.4 Most commonly prescribed drug in single drug 31-32

4.1.5 Ten most commonly prescribed drug in fixed dose combination form 33
4.1.6 WHO prescribing indicator summary of hospitals 34
4.1.7 Comparison of WHO prescribing indicator of two zonal hospitals. 35

LIST OF FIGURES

2.8.1 Health care structure in Nepal 12

2.9.1 Top ten outpatients morbidities in FY 2075/76 13
2.9.2 Top ten inpatient morbidities in FY 2075/76 13
2.9.3 Top ten causes of death among inpatients, FY 2075/76 14
4.1. 2 Ten most prevalent diseases among general outpatients 29
4.1.3 Frequency of drug prescribed on the basis of ATC classification 30
4.1.4 Most commonly prescribed drugs in single drug 32
4.1.5 Ten most commonly prescribed drugs in fixed dose combination form 33

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List of abbreviation

ADE Adverse Drug Events

BEP Benign Enlargement of Prostate

COPD Chronic Obstructive Pulmonary Disease

DDA Department of Drug Administration

DOTS Directly Observed Treatment Short course

DM Diabetes Mellitus

DTC Drug Therapeutic Committee

EDL Essential Drug List

FDCs- Fixed Dose Combinations

FDA Food and Drug Administration

GERD Gastro Esophageal Reflux Disease

HTN Hypertension

INRUD International Network for Rational Use of Drugs

IHD Ischemic Heart Disease

NLEM National List of Essential Medicines

NSAIDS Non-steroidalAnt-inflammatory Drugs

PPI Proton Pump Inhibitors

PID Pelvic Inflammatory Disease

PUD Peptic Ulcer Disease

SD Standard Deviation

STGs Standard Treatment Guidelines

WHO World Health Organization

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Abstract

Background: Periodic assessment of morbidity and drug use at various levels of health care
delivery system is important to recognize common prevalent morbidities and rationalize the use of
medicines. The study was conducted to determine the morbidity and prescribing pattern among
general medicine outpatients in government operated tertiary hospitals of Nepal.

Methods: A cross-sectional study was carried out in two tertiary hospitals of Province 1, Nepal,
from March 2019 to August 2019. Prescribing characteristics were evaluated using guidelines of
World Health Organization (WHO) prescribing indicators. For analysis, descriptive statistics were
used.

Results: Six hundred prescriptions (300 from each hospital) were analyzed. The most common
morbidities were non-communicable type of diseases like hypertension (18.7%), diabetes (15.5%)
and acid peptic disorders (14%). A total of 2072 drugs were prescribed, of which 1634 (78.9%) of
medicines were prescribed as single drugs and 438 (21.1%) of medicines were prescribed in fixed-
dose combination. Proton pump inhibitors (17.4%) followed by antihistamines (8.3%) and NSAIDS
(7.3%) were the most common prescription drugs as single medication while cough syrup
preparations (15.3%) and multivitamins preparations (12.8%) were mostly prescribed among fixed
dose combination. Patients were prescribed an average of 3.45 (± 1.39) drugs per consultation. About
30.2% of encounters were prescribed with one or more antibiotics, whereas injectable was prescribed
in 1.8% of all consultations. Only 3.9% out of total drugs were prescribed in generic and 31.7% of
drugs prescribed were from essential medicine list.

Conclusion: Among the prescriptions evaluated, disease of endocrine, respiratory, cardiovascular,

and gastrointestinal system were the most common morbidity conditions of patients. Evaluation of
prescription indicates that polypharmacy was prevalent to some extent whereas prescribing in generic
and essential medicine list was poor relative to WHO recommended standard. However, overall
prescribing of antibiotics and injection were found to be satisfactory.

Keywords: Polypharmacy, Rational Use of Drugs, Essential medicine List (EML), Generic
Name, WHO/ INRUD drug use indicators,