Rational Use of Drugs in Acute Pharyngitis

 

Dr. Dhananjay Sangale¹, Dr. Rahul A. Jadhav², Dr Bhaupatil D. Darade², Mrs. Anjali N. Sanap²

¹Assistant Professor, University Department of Interpathy Research and Technology (UDIRT),

Maharashtra University of Health Sciences (MUHS), Nashik, Maharashtra, India.

²Scholars –Master of Science in Pharmaceutical Medicine, UDIRT, MUHS, Nashik, Maharashtra, India.

*Corresponding Author E-mail: rahul20.jadhav@gmail.com

 

Background: Rational use of drugs is well recognized as an important part of health policy. The studies which had done to document drug use patterns indicates that overprescribing, multidrug prescribing, misuse of drugs, use of unnecessary expensive drugs and overuse of antibiotics and injections are most common problems of irrational use drugs by prescriber as well as consumers. Acute pharyngitis is second most common and self limiting minor upper respiratory tract infections (URTI) in India and worldwide so everyone is worried about it and hence many drugs are still over prescribed especially antibiotics. So it is important to promote appropriate use of drugs in health care system is must and needed in achieving quality of health and medical care for patients and community. Therefore present study was done to analyze the appropriate and Rational Use of Drugs (RUD) in Acute Pharyngitis(AP).

Objective: The goal was to study and evaluate the prescription patterns with respect to rationality of drugs used in the patients clinically diagnosed for acute pharyngitis.

Method: This was an observational, cross sectional study carried out in civil hospital and Private ENT hospital at Nashik. Total 178 prescriptions of patients clinically diagnosed as acute pharyngitis and written by qualified physician were collected and assessed for RUD as per WHO’s standard guidelines.

Results: We studied 178 prescriptions of acute pharyngitis between age group 18-60 years. Total 47 different drugs from different categories were used out of which 80.85% were right for treating pharyngitis. From prescription it had been noticed that only 66.85% prescriptions were correct and respective to indication. Right dose of used drugs was mentioned in 40.44% prescriptions where as duration of therapy is right in about 71.35% prescriptions. Around 60% drugs are prescribed from essential medicine list. It had been come to our knowledge that in 26.40% prescription act of commission is followed and in 18.53% act of omission is followed. There was not a single prescription in which banned drug formulation was used for treating clinically diagnosed acute pharyngitis.

Conclusion: Prescription patterns of AP are most irrational with respect to right indication and right dosage schedule than duration of therapy. Inappropriate dose and indication may lead to different ADRs and may increase the cost of treatment.

 

 

INTRODUCTION:

Acute pharyngitis is defined as an infection of the pharynx and/or tonsils. It is a very common pathology among children and adolescents. Although viruses cause most acute pharyngitis episodes, group A Streptococcus (GABHS) causes 37% of cases of acute pharyngitis in children older than 5 years (1). Acute pharyngitis is second most common upper respiratory tract infections in India and worldwide. It has a prevalence of approximately 30% in pediatric pharyngitis but only 5% to 15% in adult pharyngitis in non-epidemic conditions (2-9).

 

Acute pharyngitis is one of the most common chief complaints of adults treated in an outpatient setting. It accounts for 1% to 2% of all visits to outpatient departments, physician offices and emergency departments (10). Although it’s differential diagnosis is large and includes many other causes that are important to recognize the vast majority of immunocompetent adults presenting with acute infectious pharyngitis. Other bacterial causes of pharyngitis are Group C Streptococcus (5% of total cases), C. pneumoniae (1%), M. pneumoniae (1%) and anaerobic species (1%). Between viruses Rhinovirus, Coronavirus and Adenovirus account for the 30% of the total cases, Epstein Barr virus for 1%, Influenza and Parainfluenza virus for about 4% and acute HIV infection (11).  In the vast majority of cases, acute pharyngitis in an otherwise healthy adult is self-limited and rarely produces significant  sequelae (12).

 

Clinical manifestations of acute pharyngitis include sore throat and fever with sudden onset, red pharynx, enlarged tonsils covered with a yellow, blood-tinged exudate. There may be petechiae on the soft palate and posterior pharynx. The anterior cervical nodes are enlarged and swollen. Headache and gastrointestinal symptoms (vomiting and abdominal pain) are frequently seen (13). Antibiotics are prescribed to a substantial majority (approximately 75%) of adult patients with acute pharyngitis (14).  Physicians may consider prescribing antibiotics for streptococcal pharyngitis to prevent rheumatic fever, prevent acute glomerulonephritis, prevent suppurative complications, decrease contagion, and relieve symptoms (12). Because of its common incidence everyone is worried about this self limiting minor URTI and hence many drugs are still over prescribed especially antibiotics. (15) When any patient experiences acute pharyngitis his /her main concern is to obtain alleviation for their symptoms and so they are willing to get strong medicine for early relief. This unnecessary prescribing of antibiotics for acute pharyngitis adds the burden of antibiotics consumed in the community which is a driver of antimicrobial resistance.

 

This unnecessary prescribing of antibiotics for acute pharyngitis adds the burden of antibiotics consumed in the community which is a driver of antimicrobial resistance (16). Antibiotics prescribing for upper respiratory tract infection are related to defensive attitude of family physicians. (17) Hence it is necessary to assess rational use of medicine in acute pharyngitis. Several studies have shown however, that patient’s expectations are often not made explicit during office visits. (18) And correlate poorly with physician’s perceptions of these expectations (19).

 

So it is important to promote appropriate use of drugs in health care system and needed in achieving quality of health and medical care for patients and community. Rational drug use is one of the well recognized as an important part of health policy. The term rational drug use is in this overview limited to the medical therapeutic view accepted at the WHO conference of 1985 in Nairobi: rational use of drugs requires that patients receive medications appropriate to their clinical needs, in doses that meet their own requirements, for an adequate period of time, and at the lowest cost to them and their community (20).

 

Promotion of an appropriate rational use of drug is based on Rule of right i.e. right drug given to right patient, in right dosage at the right cost. It should also fulfill SANE criteria which mean S-safety, A-affordability, N-need, E-efficacy of drug should always be considered first before prescribing it to the patient (20). Rational use of drug research increases our understanding of how drugs are being used in number of patients within the selected time period. On the basis of epidemiological data of a disease we can estimate to what extent the drugs are properly used, over used or under used. Rational use of drug (RUD) in any disease will gives us clue on improving the proper information about use of drugs, its indications, contraindications and appropriate dosages to assure a safer use so that we can avoid ADRs. (21)

 

Many studies have been done to document drug use patterns, and indicate that overprescribing, multi-drug prescribing, misuse of drugs, use of unnecessary expensive drugs and overuse of antibiotics and injections are the most common problems of irrational drug use by prescribers as well as consumers. Improving drug use would have important financial and public health benefits. Many efforts have been undertaken to improve drug use, but few evaluations have been done in this field. Therefore present study is planned to analyze the an appropriate and Rational Use of Drugs in Acute Pharyngitis based on rule of right i.e. right drug given to right patient, in right dosage at the right cost. The goal of this paper is to examine the available treatment of acute pharyngitis in adult patients which were clinically diagnosed by physicians.

 

METHODOLOGY:

The study was conducted in compliance with the protocol, ICH GCP guidelines, ICMR, Schedule ‘Y’ and Indian Regulatory requirements. This was an observational, cross sectional study carried out in civil hospital and Private ENT hospital at Nashik city of Maharashtra state. While collecting prescription patients were screened for selection criteria. Those were willing to give signed, dated, written, informed consent; above the age of eighteen years and clinically diagnosed as acute pharyngitis were chosen for study after providing them with patient information sheet. Prescription written by qualified physician and post graduate students for clinically diagnosed acute pharyngitis were collected and assessed for RUD as per WHO’s standard guidelines for assessment of rational use of drugs. This was four week study and during this total 178 prescriptions of patients clinically diagnosed as acute pharyngitis and written by qualified physician were collected and assessed for Rational Use of Drugs as per WHO’s standard guidelines. The data was collected in case record form and analysis done by descriptive statistics.

 

Assessment of Rational use of drugs done under following headings

§  Right drug

§  Right indication

§  Right Dosage

§  Right duration of therapy

§  Percentage of banned drug formulations used.

§  Percentage of medicines prescribed from essential medicine list.

§  Act of commission

§  Act of omission

 

RESULTS:

We studied 178 prescriptions of acute pharyngitis between age group 18-60 years. Total 47 different drugs from different categories were used out of which 80.85% were right for treating pharyngitis.

 

 

From prescription it had been noticed that only 66.85% prescriptions were correct and respective to indication. Right dose of used drugs was mentioned in 40.44% prescriptions where as duration of therapy is right in about 71.35% prescriptions. Around 60% drugs are prescribed from essential medicine list. It had been come to our knowledge that in 26.40% prescription act of commission is followed and in 18.53% act of omission is followed. There was not a single prescription in which banned drug formulation was used for treating clinically diagnosed acute pharyngitis. (fig 1)

 

DISCUSSION:

While studying rational use of drugs for acute pharyngitis we found that various drugs from different categories were used to treat AP. Total 47 various types drugs used in our study which includes antibiotics, antacids, analgesics(NSAIDs), antiallergic, antitussives and multivitamins. In most cases antibiotics are commonly used almost 91.02% prescriptions where antibiotics prescribed.  Evidence based guidelines on the management of pharyngitis in primary care point to self-limiting nature of condition and recommend restricted use of antibiotics. (22) Antibiotics prescribing for upper respiratory tract infection are related to defensive attitude of family physicians (17). Recent management guidelines of Patients with acute GAS pharyngitis stated that patient should be treated with an appropriate antibiotic at an appropriate dose for duration likely to eradicate the organism from the pharynx (usually 10 days). Based on their narrow spectrum of activity, infrequency of adverse reactions, and modest cost, penicillin or amoxicillin is the recommended drug of choice for those non-allergic to these agents (strong, high). Treatment of GAS pharyngitis in penicillin-allergic individuals should include a first generation cephalosporin (for those not anaphylactically sensitive) for 10 days, clindamycin or clarithromycin for 10 days, or azithromycin for 5 days (strong, moderate).(23)

 

Another thing we observed is that among these 47 drugs almost 80.85% (38 out of 47) are right indicated drugs for acute pharyngitis and only 66.85% prescriptions (119 out of 178) which are written respective to indication and right. Drugs which are irrespective to indication include vitamins, calcium, antibiotics like ciprofloxacin. As we explained before, antibiotic treatment is not routinely recommended, due to the prevalent viral etiology of pharyngitis. However, when antimicrobial treatment is indicated, it is important to choose a good therapeutic option.

 

All the authors and national guidelines agree in suggesting penicillin as first choice treatment, since GABHS remains universally susceptible to penicillin (24). Although penicillin V is the drug of choice, ampicillin or amoxicillin equally are effective and, due to the good taste, represent a suitable option in children (25).  We also found that only adjunctive therapy (no antibiotics) used in 9% prescriptions which may be useful in the management of GAS pharyngitis. If warranted, use of an analgesic/antipyretic agent such as acetaminophen or an NSAID for treatment of moderate to severe symptoms or control of high fever associated with GAS pharyngitis should be considered as an adjunct to an appropriate antibiotic (strong, high). Adjunctive therapy with a corticosteroid is not recommended (23)

 

Korb K et. al of view that steroids were effective for pain reduction in adult and pediatric patients in acute pharyngitis. Although the authors' conclusion appeared to reflect the evidence presented, the few methodological and reporting concerns (particularly the absence of results for some outcomes) indicate that it should be interpreted with a degree of caution.  The authors stated a need for further studies to establish the safety of steroids without antibiotic coverage and the added benefits of steroids when used with regular administration of over-the-counter analgesic medications (26).

 

While studying rational use of drugs in acute pharyngitis we found that rationality with respect to using right dosage is very poor. Only in 40.44% prescriptions drugs are used in right dosage. In remaining prescriptions dose is not mentioned, there is no correct information about repetition of dose schedule. This irrationality of dosage is seen in all types of drug used. For standard dosage schedule we took a reference of package insert and dosing schedule listed by WHO and Infectious diseases society of America for treatment of acute pharyngitis in adults.

 

When we assessed our next indicator of RUD in acute pharyngitis it is come to our knowledge that in 71.35% prescription duration of therapy for AP is right. Here we had been proposed to shorter duration of therapy i.e. 3-6 days so to improve the compliance (26). The standard duration of antibiotic therapy is 10 days. The authors compared short duration therapy (three to six days) of oral antibiotics (all types included) to standard duration treatment. They found that short duration treatment presented lower risk of early clinical treatment failure and no significant difference in early bacteriological treatment failure, or late clinical recurrence. Authors conclude that a short course (2 to 6 day) of oral antibiotics has an efficacy comparable to the standard duration therapy in treating children with acute GABHS pharyngitis (26).

 

In RUD study most commonly used intervention is an essential drug list and standard treatment guidelines. Shortages of essential drugs often occur due to inadequate selection of drugs, improper storage, irrational prescribing and non-adherence by patients. Hence we also assessed prescription for medicines prescribed from essential medicine list. And we observed that 59.57% of drugs are from essential medicine list 2011.All antibiotics are from EML 2011 but commonly prescribed antacid i.e. ranitidine in tablet form is not recommended by EML. Irrational drug use is a major public health problem worldwide with far reaching economic consequences.

 

Our result about act of commission and act of omission with respect to RUD is 26.40% and 18.53% respectively. In act of commission we observed about 47 prescriptions in which unnecessary medicines like multivitamins, herbal products like Liv 52 as an appetizer were prescribed. Where as in act of omission we consider only those prescriptions in which antacids not prescribed to relive adverse effect of antibiotics like amoxicillin.

 

Limitations of our study are that due to lack of time period we select less number of prescriptions as this is our academic project. Another limitation of this paper is that we collect prescriptions of clinically diagnosed patients which may be viral or bacterial and there is no any specific guidelines given to physician for diagnosis of AP. Therefore, improper documentation in patient records may have resulted in a misclassification bias. Patients in this study were predominantly above 18 years old which may limit the generalizability of the results to other populations.

 

CONCLUSION:

Prescription patterns of acute pharyngitis are most irrational with respect to right duration and right dosage than right indication. Inappropriate dose and indication may lead to different ADRs and may increase the cost of treatment.

 

REFERENCES:

1)       Shaikh N, Leonard E, Martin JM. Prevalence of Streptococcal Pharyngitis and Streptococcal Carriage in children: a meta-analysis. Pediatrics. 2010;126:e557–64.

2)       Gwaltney JM, Bisno AL., Mandell GL, Bennett JE, Dolin R Mandell, Douglas and Bennett's Principles and Practice of Infectious Diseases. 5th ed. Philadelphia Churchill Livingstone2000;656-61

3)       Huovinen P, Lahtonen R, Ziegler T, Meurman O, Hakkarainen K, Miettinen A, et al.. Pharyngitis in adults: the presence and coexistence of viruses and bacterial organisms. Ann Intern Med. 1989;110612-6

4)       Komaroff AL, Pass TM, Aronson MD, Ervin CT, Cretin S, Winickoff RN, et al.. The prediction of streptococcal pharyngitis in adults. J Gen Intern Med. 1986;11-7.

5)       Poses RM, Cebul RD, Collins M, Fager SS. The accuracy of experienced physicians' probability estimates for patients with sore throats. Implications for decision making. JAMA. 1985; 254925-9.

6)       McIsaac WJ, White D, Tannenbaum D, Low DE. A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CMAJ. 1998; 15875-83.

7)       McIsaac WJ, Goel V, To T, Low DE. The validity of a sore throat score in family practice. CMAJ. 2000; 163811-5.

8)       Putto A. Febrile exudative tonsillitis: viral or streptococcal? Pediatrics. 1987; 806-12.

9)       Group A streptococcal infections. American Academy of Pediatrics. In: Pickering LK, ed. 2000 Red Book: Report of the Committee on Infectious Diseases. 25th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2000:553.

10)    Schappert SM. Ambulatory care visits to physician's offices, hospital outpatient departments, and emergency departments: United States, 1996. Hyattsville, MD National Center for Health Statistics1998

11)    Bisno AL. Acute pharyngitis. N Engl J Med. 2001;344:205–11.

12)    Richelle JC, Jerome RH, John GB, Richard EB, Ralph G, John MH, et al Principles of Appropriate Antibiotic Use for Acute Pharyngitis in Adults: Background Ann Intern Med. 20 March 2001;134(6):509-51-

13)    Choby BA. Diagnosis and treatment of streptococcal pharyngitis. Am Fam Physician. 2009; 79:383–90.

14)    Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians. JAMA. 1997;278901-4 PubMed

15)    Micke L, van Driel, An de Sutter, Myrian D, Wim Peersman, Chritopher C, Butter, Max DM et al., Annals of Family Medicine .Vol.-4,No.6 Nov/Dec 2006:494-498.

16)    Gossens H, French M, Elseviers M. Outpatient antibiotic use in Europe and association with resistance a cross national database Study. Lancet. 2005, 365,579,587.

17)    De sutter Al, De Maeseneer J M. Antibiotic prescribing in acute infection of the nose or sinuses: a matter of personal habit? Fam Pract.2001:18, 209-213

18)    Rollnick S, Seale C, Rees M, et al. Inside the routine general practice consultation: an observational study of consultations for sore throats. Am Pract.2001; 18:506-510.

19)    Himmel W, Lippert-Urbanke E, Kochen MM. Are patients more satisfied when they receive a prescription? The effect of patient expectations in general practice. Scand J Prim Health Care. 1997; 15:118-122.

20)    Sharma HL, Sharma KK. Concept of essential medicine and rational use of drugs in Principle of Pharmacology, Pras publication 2001:9, 106-107.

21)    WHO booklet “Assessing the problems of irrational use of drugs” 2003, ISBN 92 4 156234X

22)    Snow V, Cooper RJ. Principles of appropriate antibiotics used for acute pharyngitis in adults. Ann Intern Med. 2001; 134:506-508.

23)    Stanford TS, Alan LB, Herbert WC, Michael AG, Edward LK, Grace L et al Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America Clin  Infect  Dis 2012 Nov 15; 55:1279.

24)    Gerber MA. Nelson, Group A Streptococcus in Textbook of pediatrics, International editions. 18. Vol. 182. 2007; pp. 1135–39.

25)    American Academy of Pediatrics, Committee on Infectious Diseases. Red Book: Report of the Committee on Infectious Diseases. 27. Elk. Grove Village; 2006.  

26)     Korb K, Scherer M, Chenot JF. Steroids as adjuvant therapy for acute pharyngitis in ambulatory patients: a systematic review. Annals of Family Medicine 2010; 8(1): 58-63

27)    Altamimi Saleh, Khalil Adli, Khalaiwi Khalid A, Milner Ruth, Pusic Martin V, Al Othman Mohammed A. Short versus standard duration antibiotic treatment for acute streptococcal pharyngitis in children. Cochrane Database Syst Rev. 2009; 21:CD004872.

 

 

 

Received on 19.02.2013       Modified on 02.03.2013

Accepted on 10.03.2013      © RJPT All right reserved