Usage Pattern of Fixed-dose Combinations at ICMR Network of Rational Use of Medicine Centres across India: Recommendations for Policymakers and Prescribers

AIM

Irrational use of medicines is a global problem. In India, one contributing factor is the availability of a large number of fixed-dose combinations (FDCs). To improve rational use and to strengthen policies, it is important to assess the usage patterns and rationality of FDCs.

METHODS

This study was conducted as part of a 1-year prospective cross-sectional analysis of prescriptions in the outpatient clinics of broad specialities from 13 tertiary care hospitals across India. Five most commonly prescribed FDCs in each center were analyzed. In addition, all the prescribed FDCs were classified as per the Kokate Committee classification and it was noted whether any of the FDCs were irrational or banned as per the reference lists released by regulatory authorities.

RESULTS

A total of 4,838 prescriptions were analyzed. Of these, 2,093 (43.3%) prescriptions had at least one FDC. These 2,093 prescriptions had 366 different FDCs. Of the 366 FDCs, 241 were rational; 10 were irrational; 14 required further data generation; and the remaining 96 FDCs could not be categorized into any of the above. Vitamins and minerals/supplements, antibacterial for systemic use, and drugs for gastroesophageal reflux disease (GERD) and peptic ulcer were the most used FDCs.

CONCLUSION

Based on the finding that some prescriptions contained irrational FDCs, it is recommended that a rigorous, regular, and uniform method of evaluation be implemented to approve/ban FDCs and that prescribers be periodically notified about the status of the bans.

Assessment of prescribing pattern of drugs and completeness of prescriptions as per the World Health Organization prescribing indicators in various Indian tertiary care centers: A multicentric study by Rational Use of Medicines Centers-Indian Council of Medical Research network under National Virtual Centre Clinical Pharmacology activity

OBJECTIVE

The rational use of medicines as per the World Health Organization (WHO) should be practiced globally. However, data regarding the completeness of the prescriptions and their rational use is lacking from developing countries like India. Thus, the aim of this study was to assess the prescribing patterns of drugs and completeness of prescriptions as per WHO core drug use and complementary indicators to provide real-life examples for the Indian Council of Medical Research (ICMR) online prescribing skill course for medical graduates.

METHODS

Prescriptions of the patients, fulfilling inclusion criteria, attending Outpatient Departments of various specialties of tertiary care hospitals, were collected by thirteen ICMR Rational use of medicines centers located in tertiary care hospitals, throughout India. Prescriptions were evaluated for rational use of medicines according to the WHO guidelines and for appropriateness as per standard treatment guidelines using a common protocol approved by local Ethics committees.

RESULTS

Among 4838 prescriptions, an average of about three drugs (3.34) was prescribed to the patients per prescription. Polypharmacy was noted in 83.05% of prescriptions. Generic drugs were prescribed in 47.58% of the prescriptions. Further, antimicrobials were prescribed in 17.63% of the prescriptions and only 4.98% of prescriptions were with injectables. During the prescription evaluation, 38.65% of the prescriptions were incomplete due to multiple omissions such as dose, duration, and formulation.

CONCLUSION

Most of the parameters in the present study were out of the range of WHO-recommended prescribing indicators. Therefore, effective intervention program, like training, for the promotion of rational drug use practice was recommended to improve the prescribing pattern of drugs and the quality of prescriptions all over the country.

Price Dispersion of Vitamin D Supplements Over Time: An Initiative for Prescriber Education

OBJECTIVES

High prevalence of vitamin D deficiency mandates prescribing an appropriate form of vitamin D that allows attainment of sufficiency in a cost-effective manner. We aimed to compare vitamin D products in Indian market in terms of composition and cost in 2020 with 2013 to understand price dispersion over 7 years.

METHODS

Constituents, formulations, and prices of 'branded' and generic vitamin D products were sourced from various drug information compendia and online sources. Price per defined daily dose (DDD), percentage cost variation, and change in prices over 7 years (2020 vs. 2013) was determined.

RESULTS

There has been a disproportionate increase in the number of brands and cost variation of cholecalciferol and calcitriol in the last 7 years. The percentage cost variation increased almost 10 times for calcitriol and 4.4 times for alfacalcidiol tablets and cholecalciferol granules. An analysis of >1,100 products in 2020 showed that the predominant form was calcitriol which was combined with calcium in >90% of the products with huge cost variation (>3000%). Ergocalciferol and cholecalciferol were available in 22 and 15 different strengths respectively. Median price/unit of cholecalciferol (60,000IU) was lower for tablets/capsules compared to other formulations; but with >1000% cost variation.

CONCLUSION

A wide cost variation exists with the use of different vitamin D brands and preparations with conventional cholecalciferol tablets and capsules being a low-priced alternative. Quality control measures and strict enforcements of existing regulations are essential to ensure that competitive prices of branded generics are translated into availability and affordability for the population.

Spaced education and student learning: Results from a medical school

BACKGROUND

It is critical for medical students to retain and apply their knowledge of basic sciences to become competent prescribing physicians. Poor long-term retention is a pervasive concern. We investigated the impact of 'spaced education' teaching modules to improve knowledge retention in medical students on a topic of public health: vitamin D and its role in health and disease. It is critical for medical students to retain and apply their knowledge of basic sciences to become competent prescribing physicians METHODS: In a self-matched design, 148 medical students were randomised and evaluated on vitamin D-related topics to assess reinforced and non-reinforced knowledge in a multiple-choice question format. Initial learning and long-term retention were assessed with an estimation of Cohen's effect size at 24 and 72 weeks, respectively.

RESULTS

The administration of spaced educational material significantly improved composite formative test scores at 24 weeks (p < 0.001, effect size = 1.33). Although the scores dipped, there was a retention of knowledge at 72 weeks (effect size = 0.48).

DISCUSSION

Spaced reinforcement and testing statistically improved knowledge retention among our medical students. Gaps in the present teaching could be bridged by motivating the students to extend their learning time by appropriate spacing intervals and to understand the relevance of course content in different scenarios as a physician. Further research could be instrumental in optimising interventions to enhance learning opportunities for medical students.

An assessment of vitamin supplements in the Indian market

We aimed to study the composition and availability of various vitamin preparations in the Indian market, data about which was collected from an annual Drug Compendium. The preparations were assessed for total number, different formulations, constituents and amount of each constituent present in the formulation. A large number of vitamin supplements are available in the Indian market. It includes single-ingredient products and various combinations of vitamins, minerals, and other constituents. Among single products, the maximum number was that of vitamin D3 (n=150). Most of the supplements are available as combinations (76.49%), with vitamin-minerals combinations constituting the maximum number. In a large number of products, amount of the vitamins was not specified. The most common formulation for oral administration was capsules (34.1%). In our research, majority of the supplements contained nutrient amounts higher than the recommended intakes recommended dietary allowance. Unsupervised intake of vitamins can pose a serious health risk in the susceptible population. The composition and amount of each constituent in the dietary supplement should be detailed and properly labelled for each preparation. Availability of a large number of preparations with unknown composition as ‘over the counter’ agents requires a serious review of the legal provisions in India for drug manufacturing and marketing. There is a need for proper guidelines and regulations for the manufacturing, labelling and marketing of dietary supplements in India. Strict enforcement of such provisions is essential to safeguard the health of the population at large.

Belimumab: targeted therapy for lupus

Systemic lupus erythematosus (SLE), a complex autoimmune disease with multisystem involvement, is characterised by recurring flares and remissions throughout the course of illness. The agents currently being used for management include corticosteroids, antimalarials and various immunosuppressants. Belimumab, a B lymphocyte stimulator (BLyS) inhibitor has been recently approved for the treatment of SLE. This review aims to discuss the role of belimumab in the treatment of SLE and the trials leading to its FDA approval. Belimumab demonstrated high degree of activity in patients with autoantibody-positive active SLE disease on a stable treatment regimen. There was a significantly greater response compared to placebo as assessed with the SLE Responder Index (SRI) in two randomized, double-blind, phase III trials (BLISS-52 and BLISS-76). The treatment was well tolerated. Additional studies are required to evaluate belimumab in special populations and assess its long-term safety. This therapy could change the focus of management from symptomatic treatment to targeting an important step in the disease pathogenesis. It could enable development of treatment which could halt long-term progression, minimize target organ damage and thus provide a better quality of life for these patients.