Purpose: Due to a wide variation of diseases reported and drugs utilized in different regions, It became necessary to assess the pattern of diseases commonly reported and drugs utilized prior to and after visiting the University of Benin Teaching Hospital, Benin City, Edo State, Nigeria. Materials and Methods: Patients who reported with various diseases at the first point of visit were randomly selected after obtaining ethical consent from the health institution. Results: Out of 4253 patients who were assessed, the male to female ratio was 0.92:1. The age range was 56 ± 26.02 [mean ± standard deviation (SD)] years. The diseases reported were classified; the most common was trauma (open wounds: 62.69%) followed by infection (malaria: 62.51%), gastrointestinal disease (upset stomach: 65.06%), respiratory disease (cough: 69.79%), cardiovascular disease (hypertension: 68.51%), central nervous system disease (headache: 63.97%), endocrine disease (diabetes: 81.66%), musculoskeletal disorder (pain: 91.40%), and dermal disease (rash: 63.15%). The commonly utilized classes of drugs prior/post visits were analgesics (acetaminophen 44.87%/diclofenac 24.24%), antiallergic (chlorpheniramine 1.01%/loratadine 0.16%), anti-infective (ampicillin-cloxacilline 12.16%/ciprofloxacine 18.75%), antidiarrhea (oral rehydration salt 0.6%/zinc sulfate 0.25%), antifungal (clotrimazole 1.42%/fluconazole 3.12%), antihypertensive (Moduretic 10.02%/amlodipine 7.02%) antimalarial (artemether-lumefantrine 24.42%/artemether-lumefantrine 41.51%), antiulcer (mist magnesium trisilicate 1.08%/omeprazole 2.40%), anxiolytic (diazepam 0.42%/bromazepam 0.55%), and minerals/vitamins (ascorbic acid 4.00%/ferrous sulfate 1.48%). There was a significant difference in the pattern of disease among the ages (P < 0.05) but the difference was insignificant between the sexes (P > 0.05). Conclusion: Essential drugs were being prescribed and utilized prior to and after hospital visits. It is therefore, recommended that an enhanced adequate stocking and prescribing be encouraged in accordance with the reported diseases. Keywords: Disease, drugs, Essential Drug List (EDL), pharmacoepidemiology
Pharmacoepidemiology is the study of the use of drugs in a large number of people.[1] It is a growing discipline that applies epidemiological techniques to study drugs used in a large population. Just as the term implies, pharmacoepidemiology combines clinical pharmacology with epidemiology. Pharmacology is the study of the effects of medications on humans;[2] it pertains to using pharmacokinetic and pharmacodynamic parameters of patients to predict the effect of drugs.[1] Epidemiology, on the other hand, is the study of the factors that determine the occurrence and distribution of diseases in a population.[2] In its broad concept, it encompasses drug utilization studies, and identification and quantification of adverse drug reactions (ADRs);[3] its aim is to improve the quality and use of medicines. Drug utilization studies are known to involve the marketing, distribution, prescription, and use of drugs in a society with special emphasis on the medical, social, and economic consequences.[4] Recently, drug utilization studies have widened the arena to newer applications of drugs, individual differences in drug responses, patient counseling, pharmacoeconomic aspects, and social aspects of drug use and misuse. Correlation between clinical trials and clinical practice, formulation of better therapeutic guidelines, new drug discoveries, and pharmacovigilance are also embedded in drug utilization studies.[5] In our environment, many individuals are exposed to different drugs irrespective of the diseases. It is essential that the pattern of disease resolution be monitored in order to appreciate the full effect of the drugs, whether in the form of therapeutic resolution or adverse effects. Following the wide variation in the pattern of diseases reported globally,[6],[7],[8] there is a need to evaluate the pattern of diseases reported and the drugs utilized prior to and after visiting the University of Benin Teaching Hospital, Benin City, Edo State, Nigeria.
The study was conducted in the University of Benin Teaching Hospital, Benin City located in the South South region of Nigeria. The center is a tertiary health institution that receives patients with medical challenges. The first unit where these patients report is the General Practice Clinic (GPC) and the Accident and Emergency Centre (A and E). At these centers, the patients are attended to or referred to specialist consultants for further management. Ethical approval was sought and obtained from the University of Benin City Teaching Hospital, Benin City, Edo State, Nigeria. Patients were selected randomly and their data were entered into a structured data form consisting of their demographics, diseases, drugs utilized within 1 week prior to hospital visit, and drugs prescribed after the hospital visit. Other information assessed consisted of whether the prescribed drugs were in the Essential Drug List (EDL) of the World Health Organization, Federal Ministry of Health, Nigeria, and the University of Benin City Teaching Hospital. The commonly reported diseases were classified as they affected the different systems of the body and the drugs were grouped according to their therapeutic indications. Data that did not contain disease and drug were excluded. The World Health Organization drug use indicators [9] was applied in summarizing the data. Data analysis All the data were entered into Microsoft Excel, Statistical Package for the Social Sciences (SPSS) version 11.0 (SPSS, Inc. Chicago, IL, USA). Where necessary, they were computed as mean ± standard deviation (SD). The data were assessed using Student’s t-test and analysis of variance. P values less than 0.05 were regarded as significant.
Out of the 4,253 patients who were assessed, the male to female ratio was 0.92:1. The age range was 56 ± 26.02 (mean ± SD) years. The diseases reported were classified; the most common was trauma (open wounds: 62.69%) followed by infection (malaria: 62.51%), gastrointestinal disease (upset stomach: 65.06%), respiratory disease (cough: 69.79%), cardiovascular disease (hypertension: 63.97%), central nervous system disease (headache: 63.97%), endocrine disease (diabetes: 81.66%), musculoskeletal disorder (pain: 91.40%), and dermal disease (rash: 63.15%). The commonly utilized classes of drugs prior/post visits were analgesics (acetaminophen 44.87%/diclofenac 24.24%), antiallergic (chlorpheniramine 1.01%/loratadine 0.16%), anti-infectives (ampicillin-cloxacilline 12.16%/ciprofloxacine 18.75%), antidiarrhea (oral rehydration salt 0.6%/zinc sulfate 0.25%), antifungal (clotrimazole 1.42%/fluconazole 3.12%), antihypertensive (Moduretic 10.02%/amlodipine 7.02%) antimalarial (artemether-lumefantrine 24.42%/artemether-lumefantrine 41.51%), antiulcer (mist magnesium trisilicate 1.08%/omeprazole 2.40%), anxiolytic (diazepam 0.42%/bromazepam 0.55%), and minerals/vitamins (ascorbic acid 4.00%/ferrous sulfate 1.48%). There was a significant difference in the pattern of disease among the ages (P< 0.05) but the difference was insignificant between the sexes (P > 0.05). A higher proportion of patients above 60 years presented with cardiovascular diseases.
The study showed a wide pattern of disease and drug utilization among individuals irrespective of their sex and age. This was similar to earlier studies in different health facilities in Nigeria.[10],[11],[12],[13],[14],[15] All the results were observed to have varied widely in frequency. Trauma being the most frequently reported as observed in other related studies at the center [16],[17] could be attributed to the center for the collection of data. A high proportion of patients seek medical/surgical attention at the first time of visit before they are referred to specialist unit for further management. This prevalent trauma cases as in [Table 1] and [Table 2] may have necessitated the use of diclofenac as a potent anti-inflammatory drug. This incidence of trauma was found to be higher among males because they were commonly involved in the use of motorcycles and bikes for commercial purposes. This unskilled job and other social activities such as partying and sports might have contributed to their exposure as noted with gunshot injuries and road traffic accidents.[18],[19] Meanwhile, the higher prevalence has been proposed globally;[19],[20] therefore, preventive measures should be adopted to reduce this burden.
Malaria, which was the second most common disease reported, is health-challenging in the environment. New therapies have been fully adopted.[21] The patterns of prescription and utilization seem similar.[22] It is hoped that the same tolerabilities [23] will be maintained in a large populace. It is interesting to note that some of these individuals adopted home therapies as noted previously.[24] Withdrawal from the use of chloroquine may have been due to the prevalence of chloroquine-induced pruritus.[25] Although few patients were observed to have used chloroquine in this study, it may have been due to multiple indication.[26] The low incidence of malaria compared to trauma could have been due to the reduction of the burden globally.[27] Most cases assumed to be malaria may be mis-interpreted among the patients that took antimalarials prior to hospital visit. Individuals may have yielded to buying drugs themselves without consulting adequate health personnel; this could account for the observed hospital admissions in developing countries.[28],[29] The cost of running culture and sensitivity tests is always a burden for some of them. For this reason, many of them may have been reclassified as infectious disease after definitive diagnosis rather than malaria. This may have accounted for the low percentage of other infections at the time of first visit. Respiratory diseases such as bronchial asthma seemed rare; this may have been due to tolerance in the face of contact with immunogenic factors such as allergens. These allergens may be present and individuals may be exposed and reexposed by virtue of their daily activities, thereby leading to the development of immunogenic tolerance. This aspect calls for exploratory research to see the differences in regions among individuals who were previously exposed and first-time encounters. The same phenomenon can be attributed to oncological disorders although very few cases of antineoplastics were prescribed. Other respiratory infections such as tuberculosis reduced greatly due to the awareness in preventive techniques and the provision of free essential antitubercular drugs. The few patients who reported may have done so due to comorbid conditions such as human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS). The institution has adopted Bacillus Calmette–Guérin vaccine over the years, thus contributing to the reduction in spread. Many individuals that are given birth to in the hospital are compelled to have the routine immunization immediately after birth. Hypertension was observed to be of higher proportion among females with cardiovascular diseases; there seemed to be an increased prevalence from 40 years onward but a higher proportion among individuals above 60 sixty years. This has been fully attributed to their lifestyle, especially among the middle age group.[30],[31],[32],[33] Medications such as amiloride-hydrochlorothiazide or amlodipine were noted to be routinely used prior to and after hospital visitation, respectively. It a common practice that when patients fall short of their medication during chronic therapies,[12] they purchase them from registered pharmacy outlets. This is because the regular use of their medication makes them remember the medicines easily. The use of lipid lowering drugs and antidiabetic agents, though of a lower percentage, may be associated with comorbid reports. It is interesting to note that the authors have advised to keep the number of drugs in a prescription as low as possible to minimize adverse effects, potential drug–drug interactions, and to reduce the cost of treatment.[34] Contrary to this cardiovascular report, males have been found to report more in medical emergencies than females, and hypertension was also more common among them.[35] This difference can be attributed to geographic/ethnic variation. Reports also have it that the disease patterns and mortality rates from cerebrovascular accidents, cardiovascular diseases, diabetes, and renal diseases are on the increase in Africa.[36] This may be due to the increased desire for refined food. Drugs prescribed in brands have a higher risk of duplication; hence, the generic names can eliminate the duplication of drug products and decrease the cost for patients.[37] Multiple indications of the antimicrobial due comorbidity of microbial infection with other systemic diseases were observed in the prescriptions. This may not be due to the severity of infection but may be associated with cost. However, in anticipation of drug failures, antimicrobials may have been used irrationally. All these may have influenced the use of a high proportion of antimicrobials prior to reporting at the hospital. The authorities have stated that inappropriate use of antibiotics can potentially lead to antimicrobial resistance and increase the necessity to use more expensive antibiotics to treat life-threatening infections.[12],[38],[39],[40] However, drug utilization studies have widened the arena to newer application of drugs, individual differences to drug response, patient counseling, pharmacoeconomic aspects, social aspects of drug use and misuse, and correlation among clinical practice, formulation of better therapeutic guidelines, discovery of new indications, new drug discovery, and pharmacovigilance.[5] This study is in line with pharmacoepidemiology that quantifies drug use pattern and adverse drug effects.[41] This study will also spur further studies in pharmacogenetic variation during drug utilization, which will help in understanding the pattern of drug prescribing, appropriateness of use, medication adherence and persistence pattern, and the identification of predictors for medication use. Pharmacoepidemiologists can also conduct safety studies of drug uses in large populations in countries with well-established health care systems. These studies were conducted at various levels depending on the purpose of the study and the information available.[42] Prescriptions of drugs to individual patients varied, which might have been due to differences in the experiences of clinicians. Some clinicians tend to not adhere to the EDL due to unreliable pharmacokinetic and pharmacodynamic profiles of some drugs. However, a prescription provides an insight into the prescriber’s attitude to the disease being treated and the nature of health care delivery system in the community.[12] This study has provided a better understanding of the prescribing practices in the health care facility studied and strategies for intervention. The multiple drug prescription observed could be appropriate for persons having multiple diseases but the challenges of compliance and ADRs are prominent in practice. There could have been a wide variation among prescribers in the choice of medication from the EDL. This study had a high rate of prescribed drugs in the EDL as reported before.[43] Generic prescription is a core principle in the EDL; it enhances the accessibility of drugs rather than insisting on a particular brand that the patient may not be able to find. Patients continuing on substitutes may be at risk if they do not consult their doctor routinely. This can make worsen the disease, bearing in mind the pharmacokinetic and pharmacodynamic adverse effects on chronic use. The routine utilization prior to hospital visit could be attributed to continuing previous medication, emergence of a new disease, ADR, self-medication, and resolution of previous/intensified ailment prior to hospital. The generic prescription pattern observed may also be associated with the nonavailability of special brands. It is noted that generic substitution can be of help to patients in terms of getting the drugs on time. The common risk associated with it is that there may be unpredictable pharmacokinetic and pharmacodynamic profiles compared to branded formulations. The principle guiding the prescription of drugs in the EDL encourages generic substitution. This study will be useful for the therapeutic committee, patient safety committee, and other groups where decisions are taken that ultimately affect the health care plan in other to answer drug/disease related questions. Also, this study will be of relevance in disseminating new findings to other centers and improving the quality and use of medicines, designing interventions to improve prescribing and the conduct and evaluation of pharmacoeconomic studies as observed.[1] Inappropriate use of antibiotics can lead to antimicrobial resistance and increase the necessity to use more expensive antibiotics to treat life-threatening infections. In Nigeria, irregular use of antibiotics is at present being controlled through wide publicity on the consequences of irregular use. Hence, the widespread of resistance has reduced. These anomalies are usually incorrect or suboptimal.[44],[45],[46],[47] The use of antibiotics in place of oral rehydration salt has raised questions as to whether the approach is appropriate. This area requires more studies because the use of antibiotics in place of oral rehydration salt is a common malpractice among patients prior to hospital visit. The use of antibiotics may be inappropriate prior to hospital report and malaria which was the second most commonly reported disease is a challenging health issue in the environment. In this study, zinc sulfate tablet was commonly prescribed for children for the resolution of diarrhea as observed previously.[48] The result showed a higher percentage of female patients reporting to the health facility compared to males; the reason for this was that there was a higher population of females suffering from the disease. This denotes that females easily fall ill compared to males. However, females are burdened with child-caring and domestic work in addition to their official work in public or private organizations. The extra work can cause extra stress in them, thus necessitating their seeking medical attention more frequently. A significantly high rate of the use analgesic could be ascribed to encounters of pain irrespective of the ailment. These analgesic agents have been found useful in pain emanating from infection. There could be multiple presentations of symptoms such as pain, headache that may be associated with malaria, hypertension, and traumatic diabetes that may also have existed as a comorbid condition with other cardiovascular illnesses, thus requiring the use of paracetamol and diclofenac. The study showed a high prevalence in the use of antibiotics, especially prior to and after hospital visitation. Ampicillin-cloxacillin and ciprofloxacin were found to be common prior to and after hospital visitation, respectively. The use of ampicillin-cloxacillin could be associated with the cost and availability. The use of ciprofloxacin was similar to earlier reports.[49] These agents may have been used irrationally prior to their visitation to the hospital despite being prescription-only medicines (POMs). It is important to mention that when infections are reported, ampicillin or ampicillin-cloxacillin is prescribed as a first-line drug while culture and sensitivity results are awaited. Reserved cephalosporine or fluoroquinolones are prescribed in the latter stage. Metronidazole was used where necessary in suspected cases of anaerobic infections. The increase in the use of antibiotics accounts for systemic diseases such as gastrointestinal, respiratory, and reproductive diseases where microbial organisms are causative tools. There were a higher number of female patients compared to males showing a high prevalence of urinary tract infection (UTI) caused by bacteria and fungi due to increased susceptibility of the female urinary tract to fungal infection. This necessitated the appropriate use of antibiotic and antifungal therapies. Ampicillin-cloxacillin and fluconazole were the most utilized for the treatment of UTIs. Other antifungals in the form of form of creams, pessaries, tablets, and capsules were also widely utilized. On a general note, appropriate use of antibiotics has been documented as necessary approach in the prevention of microbial resistance.[50] A high percentage of geriatric patients reported with some central nervous diseases such as insomnia and depression, which necessitated the use of anxiolytics and antidepressants. Meanwhile, newer anxiolytics and antidepressants were observed to be absent in the EDL. These newer agents were not sufficiently available at the time of the last review of the EDL of the institution. It is essential that the pattern of disease resolution be monitored in order to appreciate the full effect of the drugs, whether in form of therapeutic resolution or adverse effects. The pattern of disease resolution may be difficult to measure in epidemiological studies, bearing in mind the cost and patient compliance. Gastrointestinal ailments also accounted for the utilization of the most common antispasmodic, hyoscine-N-methyl bromide. The other medications utilized were oral rehydration solution (ORS) that was necessary for replacing the loss of electrolyte. Allergies such as catarrh and some other dermatological presentations were also reported and required the use of specific antiallergies for the management; these antiallergies also found use as an adjunct therapy in the management of symptoms of respiration infection, which present as rhinitis. Chlorpheniramine may have been used in other indications where pruritus was observed as reported in [Table 3].
Minerals and vitamins were also found to be widespread in use. Zinc was found to be mostly in use as a support in managing diarrhea as one of the gastrointestinal disorders. This supported previous studies.[48] The prescription seemed to be more common for pediatric patients who presented with diarrhea-related illnesses. Vitamins and supplements are important for the healing process when patients appear undernourished or when dietary patterns are inadequate, especially in the elderly. These have been fully recommended in developing countries.[14] Antivirals were rarely prescribed. The only antiviral prescribed was ribavirin, which is a reflection of the suspected cases of Lassa fever. Meanwhile, this agent was observed to be absent in the EDL. Since cases has been reported in some nearby tertiary institution,[33] It is however, important to stock the drug for use when the need arises. Patients who may have reported for the first time to the clinic might were evaluated by the attending physician and were further referred to the specialist consultant team for further management. Antiseptic use prior to and after hospital visitation were rare; this might have been due to the routine formulation and dispensing at the quality control unit of the hospital. These antiseptics are always made available at the nurses’ bay at the individual wards. They are hardly prescribed except in cases of wound dressing. Antiemetics were rarely prescribed, a few prescriptions of metochlorpramide and promethazine may have been due to emesis resulting from malarial. Drugs prescribed such as celecoxib, loratadine, cefixime, zinc sulfate, dihydroartemisinin-piperaquine, selenium, simvastatin, fluticasone, ribavirin, and rabeprazole were observed to be absent in the EDL. They were not frequently prescribed. The reason may have been due to other alternatives that may be safer and more effective during routine use. Although some of these agents are in the EDL, care is taken for the drug to be strictly monitored. That is why most of these drugs are left to be monitored by the consulting physicians. From the foregoing, it has been observed that the study supports drug prescription that is believed to depend on the local morbidity pattern, which influences the number of medications prescribed.[15] The observed increase in the use of analgesics, antibiotics, and hematinics also reflects the common trend in many other health care facilities in Nigeria.[51] This research is therefore, recommended for medical, pharmaceutical, administrative, and commercial activities, which will aid in drug selection, procurement, and prescription.
Due to the findings in this study in terms of the diseases reported and drugs utilized, it is essential that effective workflow such as diagnoses, generation of prescription, procurement and dispensing pattern of drugs be adequately put in place to improve the services rendered to patients. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3] |
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