& reabilative services using criteria of risk-benefitratio, cos-effectiveness, quality, practicaladministrationas well Iraqi J Pharm Sci, Vol.21(1) 2012 Prescribing pattern in maysan 112 Prescribing Pattern and Rational use of Drugs in Maysan Governorate, Iraq. Haydar F. Al-Tukmagi *,1 and Abdul Rasool M.Wayyes ** *Department of Clinical Pharmacy, College of Pharmacy, University of Baghdad, Baghdad, Iraq. **Department of Pharmacology and Toxicology,College of Pharmacy,University of Baghdad, Baghdad, Iraq. Abstract This study was designed to investing the drug prescribing pattern which is the important point in the rational or irrational use of drugs among patients dispensing their prescriptions from the private pharmacies in Maysan governorate, Iraq for a period of 1 month. The data collected from prescriptions were calculated and analyzed according to the WHO prescribing guidelines. The data showed that the mean of drugs included in single prescription was 3.4, and 12% of prescribed drugs were written as generic names; moreover, the percentage of antibiotics, corticosteroids and anxiolytics were 33.3%, 11.4% and 23.8% respectively. Those results indicate the irrational use of drugs when compared with the world health organization standard values of prescribing indicators, in addition to the bad prescribing pattern regardless of the degree of specialization of the physician, where 52% of those prescriptions (analyzed in the present study) written by specialized physicians. In conclusion, actual intervention and follow up, training on rational use of drugs and intervention strategies for prescribers is required to improve the rational use of drugs. Key words: prescription pattern, polypharmacy, rational drug use نمورج انوصف واالستعمال األمثم نهذواء في محافظت ميسان / انعراق حيذر فخري انتكمجي * ،1 ويس** محمود انرسول بذع و *فزع انصيذنخ انسزيزيخ، كهيخ انصيذنخ ، خبيؼخ ثغذاد،ثغذاد ، انؼزاق خبيؼخ ثغذاد،ثغذاد ، انؼزاقوانسًىو ، كهيخ انصيذنخ ، األدويخ** فزع الخالصة نهذواء ثيٍ األيثمغيز أو األيثمصًًذ هذِ انذراسخ نزحذيذ طزيقخ وصف انؼالج وهى ػُصز يهى في رحذيذ االسزخذاو في يحبفظخ ييسبٌ/انؼزاق ونًذح شهز واحذ. خًؼذ انجيبَبد وحههذ اػزًبداً ػهى يقبييس األههيخانًزضى انًزاخؼيٍ نهصيذنيبد انًىصىفخ األدويخفي كم وصفخ، انُسجخ انًئىيخ نؼذد ُظًخ انصحخ انؼبنًيخ وقذ اظهزد هذِ انجيبَبد ثبٌ يؼذل االدويخ انًىصىفخ ي وأخيزاثبسزخذاو االسى انؼهًي، انُسجخ انًئىيخ نؼذد انًضبداد انحيىيخ انًىصىفخ، انُسجخ انًئىيخ نكًيخ انكىريزكىسيززويخ انًىصىفخ، %. رذل هذِ انُزبئح وثبنًقبرَخ 14.2% و 22.3%، 44.4%، 21، 4.3: كبألرييخ نهًهذئبد انًىصىفخ وكبَذ ثبنزسهسم انُسجخ انًئى % 21يبيقبرة انـ إٌطزيقخ انىصف انسيء نهىاصفيٍ ثبنزغى يٍ إنى ثبإلضبفخنهذواء األيثميغ يقبييسهب انؼبنًيخ ػهى االسزخذاو غيز هيٍ ػهى درخخ ػبنيخ يٍ انزخصص. هذا يذػى وثصىرح يهحخ انى اَقالة حقيقي ويزبثؼخ خذيخ انحبص األطجبءيٍ انىاصفيٍ هى يٍ انىصف انديذ نهذواء. إنىنهذواء وانزذريت انًسزًز نهىاصفيٍ يٍ اخم انىصىل األيثماالسزخذاو إنىنغزض انىصىل نهذواء .انكهماث انمفتاحيت : نمورج انوصف ، كثرة وصف األدويت ، االستخذاو األمثم Introduction According to the World Bank (1) , governments in developing countries expend between 20% and 50% of their national health budgets on drugs and medical sundries. Unfortunately, the World Health Organization (WHO) believes that much of such expenditure is misapplied, as irrational use of drugs is prevalent especially in developing countries (2) . Hence, governments, health workers and the community are concerned with the availability, handling, effectiveness and safe use of drugs. The prescribing of drugs is an important issue for the individual patient, since risks and benefits of the treatment directly affect the patient. Prescribed drugs are reimbursed by the society. Hence, prescribing of drugs is also a key question from a public expense perspective. Financing of drugs is a vast problem, since costs for drugs are increasing and resources are limited (3) . Evaluation of costs and benefits for alternative treatment strategies is essential and rational drug use implies physicians’ prescribing of drugs with favorable cost-benefit balances. Guidelines for recommended drugs are important for rational drug use. However, prescribing and adherence to prescribing guidelines vary between health care units (4) , for example according to patient characteristics (5-7) , physician characteristics (6) , practice settings (6) , budgetary policies (8) and country of residence (9) . 1 Corresponding author E- mail : h.tukmagi@hotmail.com Received : 27/2/2012 Accepted : 24/4/2012 Iraqi J Pharm Sci, Vol.21(1) 2012 Prescribing pattern in maysan 113 RxsofnoTotal DrugsofnoTotal . . Sources of drug information used by the physicians may be of additional significance (10) .There are a limited number of objective measures or indicators that can describe the drug use situation in a country, region or individual health facility (11) . Those indicators include prescribing pattern, patient care and the facility indicators; the most reliable type is the prescribing indicators that measure the performance of health care providers in several key dimensions related to the appropriate use of drugs (12) . This project was designed to evaluate prescribing pattern and rational drug use in Maysan governorate, Iraq. Materials and Methods This study was based on a surveillance conducted in private pharmacies in Maysan governorate during June to July 2005. The pharmacies were chosen randomly depending on systematic random sampling method (13) . To calculate sampling interval, we divide the size of the list (no. of pharmacies in the governorate) by desired sample size (10 pharmacies), then choosing random number between 0 and 1 from the table of random numbers and multiplying it by sampling interval; this result must be rounded upward to get the number of the 1 st pharmacy. A total of 585 prescriptions were selected randomly from the 10 pharmacies and the data obtained from each prescription were introduced in the prescribing indicator from (Table 1). In addition to those prescribing indicators, the degree of specialization of the physicians was taken into account to check whether it affects the prescribing pattern or not. Calculations were done using the following equations: Average No. of drugs per each Rx = % of Drugs prescribed in Generic name = 100 . . x prescribedDrugsofnoTotal namesgenericinDrugsofnoTotal % of Rxs containing antibiotics (AB) = 100 . . x RxsofnoTotal ABcontainingRxsofNo % of Rxs containing corticosteroids (CS.) = 100 . . x RxsofnoTotal CScontainingRxsofNo % of Rxs containing anxiolytics = 100 . . x RxsofnoTotal sAnxiolyticcontainingRxsofNo The ten pharmacies were coded as (A, B, C, D, E, F, G, H, I & J). Table 1: Prescribing indicators form Sequence No. of drugs/Rx Drugs in Generic name Antibiotics Corticosteroids Axiolytics 1. 2. 3. 4. 5. 6. 7. 8. Total Average Percentage %of total Drugs %of AB in Rxs % of CS in Rxs % of anxiolytics in Rxs Results The prescribing indicators were calculated from each pharmacy and summarized in the table 2 in addition to the WHO standard value for each indicator (14) . From table 2, we can find that the average number of drugs in prescription is 3.4, the percentage of drugs prescribed in generic name is 12% which mean that the prescriber used the trade name in about 88% of the prescriptions. The percentage of AB prescription is 33.3% and the predominant type is cephalosporin derivatives ( especially cephotaxim) which is Iraqi J Pharm Sci, Vol.21(1) 2012 Prescribing pattern in maysan 114 22% and then penicillin derivatives (especially amoxicillin) which is (17%), while the other types of AB represent the remaining percent. The percentage of the prescribed CS is 11.4% and the Anxiolytics percentage was 23.8%. The comparisons between each prescribing indicators value with its counterpart WHO value were shown in figures 1-4. Table 2:The values of each prescribing indicator for 10 pharmacies with the mean & the WHO standard value. Indicator P/A P/B P/C P/D P/E P/F P/G P/H P/I P/J Mean WHO value % Average no. of D/Rx 3.8 2.8 3.4 3.6 4.0 3.0 3.5 2.8 3.7 3.4 3.4 1.6-1.8 % of Drug in generic name 10 14 14 18 12 9 11 12 10 11 12% 100% % of AB/Rx 30 30 34 35 38 40 28 26 39 32 33.3% 20-26.8% % of CS./Rx 9 10.5 12 15.5 20 7 8 10.5 10.3 11.5 11.4% 1.6% % of Anxiolytics/Rx 22 30 27 22 19 28 20 19 26 25 23.8 - P: Pharmacy; D: Drug; Rx: Preemption; AB: Antiobiotic; CS: Corticosteroid Figure 1: Comparison of the mean of average number of D/Rx in 10 pharmacies with WHO standard value. Figure 2: Comparison of the mean of Drugs in Generic name of 10 pharmacies with WHO standard value. Figure 3: Comparison of the mean of percent AB/Rx of 10 pharmacies with WHO standard value. Figure 4: Comparison of the mean of percent CS/Rx of 10 pharmacies with WHO standard value. 3.4 1.8 0 0.5 1 1.5 2 2.5 3 3.5 A v . n o . o f D /R x mean of 10 pharmacies W HO value 12 100 0 20 40 60 80 100 % o f D ru g i n G e n e ri c n a m e mean of % Drug in Generic nam of 10 pharmacies W HO value 33.3 26.8 0 5 10 15 20 25 30 35 % o f A B R x mean of % of AB/Rx of 10 pharmacies W HO value 11.4 1.6 0 2 4 6 8 10 12 % o f C S / R x o f 1 0 p h a rm a c ie s mean of % of CS/Rx of 10 pharmacies W HO value Iraqi J Pharm Sci, Vol.21(1) 2012 Prescribing pattern in maysan 115 Discussion The core drug use indicators evaluate prescribers, patient care and the facility. Among the uses of these indicators are to describe current treatment practices, compare health facilities and prescribers and allow for identification of potential drug use problems that may affect patient care (15,16) . The present study represent an insight on the prescribing pattern in private sector health facilities, because this sector is continuously growing and share important part in health providing services in Iraq; however, many serious problems and challenges emerged in this issue, including minimal, professional categorization with regard to drug prescribing, inefficient patient counseling, and finally high percentage of prescriptions are misused. The study showed that the average number of drugs in prescription that represent a polypharmacy approach (more then one drug in single prescription) was greater than that mentioned by WHO list; this will definitely lead to high consumption of drugs, loss of resources, increasing side effects due to drug interactions and misuse of drugs. Though no universal or even national standards exist for what the number of drugs in each prescription should be, the disparity between developing countries is worrisome and the number is quite high. Our findings are higher than those from Sudan 1.4 and Zimbabwe 1.3 (16) . The prescription of several drugs per prescription (polypharmacy) is a serious problem; it has been attributed to patients' demand (17) ; desire to treat several ailments at the same time and inadequate diagnostic facilities to determine definitive cause of ill health (18) . There is a need for education of patients and prescribers on the hazards of poly pharmacy. Also, managerial interventions to improve training of prescribers to ensure accurate diagnosis and provision of diagnostic facilities at the primary care level in Iraqi health facilities would alleviate such tendency. In the present study, the percentage of drugs prescribed in generic names is 12% only, which is very low percentage compared with the WHO standard value that may reach 100%; this could be due to low training prescribers, no health education about the importance of restriction in drug use. Moreover, many prescribers believe that the patient satisfy by receiving more than one or two drugs and finally lack of education facilities like leaflets or posters accessible by the prescribers (19) . The percentage of AB prescribed in each prescription is 33.3%; this value is higher than WHO standard value (26.8%) which indicates the well known problem of misuse of AB with disputable problems like hypersensitivity, higher cost, resistance and drug interaction. However, another study in Iraq reported more serious data in this respect that reflect antibiotics misuse in governmental institutions (20) . This could be due to the same reasons that Reez et al. (21) mentioned in his study, where physicians prescribe AB for any reason, just because they believe that the illness was attributed to bacterial infection. When comparing the percentage of the prescribed corticosteroids in our study (11.4) with the WHO value (1.6), the data revealed a real dangerous problem related to misuse of such agents with high and severe side effects. Choosing the anxiolytics as prescribing indicators in our study is due to the increase in consumption of such compounds in the community, especially during the period of unstable situation of the country and the well known consequences of war and its disasters. So, in spite of lack of the WHO value of prescribed anxiolytics, we reported a high percentage (23.8%); this is also a frightening percentage due to the wide range of side effects associated with these compounds. The last indicator considered in the present study is the level of specialization of the physician; the result showed a disappointed point, where 52% of the prescriptions categorized as bad prescribing pattern in this study, were ordered by highly specialized physicians; such finding reveal no relation between the highly specialization level and the prescribing pattern as one may expect. In conclusion, the rational use and prescription practice of drugs in Maysan/Iraq has many problems associated with misuse of drugs and the prevalent problems among physicians working in the private clinics; this require urgent intervention and follow up to promote the rational use of drug in this city. References 1. WHO. Report of the conference of experts. The rational use of drugs, 25-29 November 1985, World Health Organization, Geneva 1987. 2. Quick JD, Rankin J, Laing RO, O′Connor R, Hogerzeil HV, (editors). Management Sciences for Health/WHO/DAP. Managing drug supply, (2 nd ed.), Kumarian Press, Hartford, CT; 1997. 3. Hoffman JM, Shah ND, Vermeulen LC, Doloresco F, et al. Projecting future drug expenditures–2008. Am J Health Syst Pharm 2008; 65(3):234-253. 4. Ohlsson H, Lindblad U, Lithman T, Ericsson B, et al. Understanding adherence to official guidelines on statin Iraqi J Pharm Sci, Vol.21(1) 2012 Prescribing pattern in maysan 116 prescribing in primary health care–a multi-level methodological approach. Eur J Clin Pharmacol 2005; 61(9):657-665. 5. Kasje WN, Denig P, Stewart RE, de Graeff PA, Haaijer-Ruskamp FM. Physician, organizational and patient characteristics explaining the use of angiotensin converting enzyme inhibitors in heart failure treatment: a multilevel study. Eur J Clin Pharmacol 2005; 61(2):145-151. 6. Tamblyn R, McLeod P, Hanley JA, Girard N, Hurley J. Physician and practice characteristics associated with the early utilization of new prescription drugs. Med Care 2003; 41(8):895-908. 7. Kozyrskyj A, Raymond C, Racher A. Characterizing early prescribers of newly marketed drugs in Canada: a population- based study. Eur J Clin Pharmacol 2007; 63(6):597-604. 8. Ohlsson H, Merlo J. Understanding the effects of a decentralized budget on physicians’ compliance with guidelines for statin prescription–a multilevel methodological approach. BMC Health Serv Res 2007; 7:68. 9. Sturm HB, van Gilst WH, Veeger N, Haaijer-Ruskamp FM. Prescribing for chronic heart failure in Europe: does the country make the difference? A European survey. Pharmacoepidemiol Drug Safety 2007; 16(1):96-103. 10. Edward C, Himmelmann A, Wallerstedt SM. Influence of an e-mail with a drug information attachment on sales of prescribed drugs: a randomized controlled study. BMC Clin Pharmacol 2007; 7:12. 11. de Bakker DH, Coffie DS, Heerdink ER, van Dijk L, Groenewegen PP. Determinants of the range of drugs prescribed in general practice: a cross- sectional analysis. BMC Health Serv Res 2007; 7:132. 12. Carlzon D, Gustafsson L, Eriksson AL, Rigner K, et al. Characteristics of primary health care units with focus on drug information from the pharmaceutical industry and adherence to prescribing objectives: a cross-sectional study. BMC Clinical Pharmacology 2010; 10:4-8. 13. World Health Organization. WHO policy perspectives on medicines, promoting rational use of medicines: Core component, September 2002. 14. Hogerzeil HV. Promoting rational prescribing: An international perspective. Br J Clin Pharmacol 1995; 39:1-6. 15. WHO. Action Program on Essential Drugs. How to investigate drug use in health facilities. World Health Organization, Geneva: 1993; p. 187. 16. Hogerzeil HV, Ross-Degnan D, Laing RO, Ofori-Adjei D, Santoso B, et al. Field tests for rational drug use in twelve developing countries. Lancet 1993; 4:1408-1410. 17. Erah PO, Olumide GO, Okhamafe AO. Prescribing practices in two health care facilities in Warri, Southern Nigeria: a comparative study. Trop J Pharm Res 2003; 2:175-182. 18. Odusanya OO. Drug use indicators at a secondary health care facility in Lagos, Nigeria. Nig J Comm Med Pri Health Care 2004; 16:2I-24. 19. Laing RO. Promoting Rational Drug Use. Contact 1994; 5:1-6. 20. Juma'a KM, Hussain SA, et al. Antibiotic prescription pattern in surgery department, Baquba Teaching Hospital. New Iraqi J Med 2010; 1:15-20. 21. Reeze RE, et al. part A: principles of AB use. In: Hand Book of Antibioties, (3 rd ed.), Lippincott Williams and Wilkins, Philadelphia USA, 2000.