Evaluation of NSAID Prescription Patterns in a Tertiary Care Teaching Hospital using WHO Prescribing Indicators

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) are among the most widely prescribed medications worldwide for the management of pain, inflammation, and fever.¹ Over the past two decades, NSAIDs have become first-line agents for the management of acute and chronic pain.² Globally, approximately 8-11% of the general population receives at least one NSAID prescription annually, with  higher utilization  among women and increasing use with advancing age.³

NSAIDs are broadly classified into non-selective cyclooxygenase (COX) inhibitors, preferential COX-2 inhibitors and selective COX-2 inhibitors, each differing in their pharmacological profile and adverse effect spectrum.

NSAIDs make up one of the largest groups of pharmaceutical agents used worldwide. In the past, NSAIDs were used by 20% or more of the population. NSAIDs are also one of the most common causes of adverse drug reactions reported to drug regulatory agencies as well as in many clinical and epidemiological studies.⁴

The most commonly used NSAIDs are diclofenac and ibuprofen, which account for almost 40% of global NSAID sales, excluding OTC use. Ibuprofen and naproxen are the most commonly prescribed NSAIDs in the USA, while diclofenac prescription is more common in the UK, and the regional variation may not just relate to drug properties but may also include which NSAID was first to market in a particular region.⁵

According to the World Health Organisation (WHO), rational use of medicines is defined as “patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period, and at the lowest cost to them and their community”.⁶ More than 50% of medicine expenditure is estimated to be wasted because of irrational prescribing, dispensing and medicine use; also, concurrent use of multiple medications by a patient results in drug-induced disease, such as adverse drug reactions (ADR), which is reported to be as high as 28%.⁷ Illiteracy, limited financial resources and lack of awareness among patients make the rational use of medicines even more important in developing countries like India.⁸

To promote rational prescribing and evaluate medicine use in healthcare settings, the World Health Organization (WHO) developed a set of core prescribing indicators.⁹ The WHO has developed various indicators to evaluate the condition of the services offered to the population concerning medication, among which the core prescribing indicators are aimed at measuring the degree of polypharmacy, tendency to prescribe drugs by generic name, overall level of use of antibiotics and injections, and the degree to which drugs are prescribed from the essential drug list.¹⁰ Drug usage pattern is an essential indicator of careful selection of a drug in accordance with the therapeutic diagnosis, and drug utilisation research aids in surveying and understanding the diverse processes involved in healthcare.¹¹

The WHO core prescribing indicators used for NSAID utilization consist of ten indicators that assess rational prescribing practices.

1. Average number of drugs per prescription/encounter
2. Average number of NSAIDs per encounter
3. Percentage of encounters with NSAIDs prescribed
4. Percentage of encounters with an injection of NSAIDs prescribed
5. Percentage of encounters with non-selective NSAIDs prescribed
6. Percentage of encounters with COX-2 selective NSAIDs prescribed
7. Percentage of NSAIDs prescribed by generic names
8. Percentage of encounters with NSAIDs prescribed from National List of Essential Medicine
9. Percentage of encounters with fixed dose combinations (FDCs) of NSAIDs prescribed
10. Percentage  of encounters in which gastroprotective agents were co-prescribed with NSAIDs.¹²

Despite several published studies on NSAID prescribing patterns, periodic evaluation using WHO Core Prescribing Indicators remains essential to monitor prescribing practices and promote rational drug use in individual healthcare institutions.

Therefore the present study was undertaken to evaluate the prescribing patterns of NSAIDs among inpatients admitted to the Orthopaedics, Obstetrics and Gynaecology and General Medicine departments of a tertiary care teaching hospital using the WHO Core Prescribing Indicators.

MATERIALS AND METHODS

Study Site:

The study was conducted in the inpatient departments of Chigateri Government Hospital, a tertiary care teaching hospital, Davangere, Karnataka, India.

Study Design:

Prospective observational study.

Study Period:

The study was conducted over a period of six months

Sample Size:

A total of 203 eligible inpatients admitted to the Departments of Orthopaedics, Obstetrics and Gynaecology, and General Medicine were included in this study.

Study Criteria:

The study was carried out by considering the following inclusion and exclusion criteria.

Inclusion Criteria:

Patients aged 18 years or older.

Patients who are prescribed at least one NSAID.

Patients of either gender.

Exclusion Criteria:

Patient having incomplete or insufficient clinical data.

OPD patients

Pediatric patients

Study Procedure

Data were collected prospectively from the case records of eligible inpatients admitted to the Departments of Orthopaedics, Obstetrics and Gynaecology, and General Medicine. The collected data included patient demographics (age and gender), department of admission, prescribed NSAIDs, route of administration, type of NSAID therapy, generic or brand-name prescribing, fixed-dose combinations, co-prescription of gastroprotective agents, and WHO core prescribing indicators. The collected data were then evaluated using the WHO Core Prescribing Indicators.

Statistical Analysis

The collected data were entered inti Microsoft Excel and analyzed using descriptive statistics. Categorical variables were expressed as frequencies and percentages, while continuous variables were presented as means. The WHO Core Prescribing Indicators were calculated according to the World Health Organization guidelines.

RESULTS

A total of 203 patients were enrolled in this study in accordance with the inclusion criteria from the General Medicine, Obstetrics and Gynaecology, and Orthopaedics departments of the Chigateri Government Hospital, Davangere.

1. 1. Gender Distribution:

Among the total number of patients (203) surveyed for this study. Male patients were found to be 74 (36.46%) in number, and female patients were 129 in number (63.54%).

Table 3.1 Gender distribution in the study population

1. 2. Age Distribution:

The majority of patients belonged to 18-29 year age group, while the smallest proportion was observed among patientrs aged 70 years and above.

Table 3.2 Age wise distribution in the study population

3.3 Department-wise distribution of prescriptions

Considering all the inclusion and exclusion criteria, the majority of the patients were from Orthopaedics 85(41.87%), followed by Obstetrics and Gynaecology 51(33%) and then General Medicine 51(25.12%), making Orthopaedics a key contributor to the overall analysis. (Table no 5.3)

Table 3.3 Department-wise Distribution of Prescriptions

Figure 3.1: Department-wise Distribution of Prescriptions

Figure 3.2: Individual NSAIDs prescribed

Figure 3.3 NSAIDs Therapy Route Comparison

Figure 3.4 Types of NSAID Therapies Prescribed

Figure 3.5 Comparison of Generic name vs Brand name of NSAIDs prescribed

3.10 WHO Core Prescribing Indicators

The average number of NSAIDs per encounter was 1.7, while the average number of drugs per encounter was 8.12. NSAIDs were prescribed in 100% of encounters. The proportion of encounters in which an NSAID injection was prescribed was 79.80%. Non-Selective NSAIDs were prescribed in 73.89% of encounters, while no prescriptions for COX-2 Selective NSAIDs were observed. Only 49.27% of NSAIDs were prescribed by their generic name. A majority (95.07%) of NSAID prescriptions were from the National List of Essential Medicines (NLEM). Fixed-dose combinations of NSAIDs accounted for 6.9% of prescriptions, while gastroprotective agents were co-prescribed with NSAIDs in 99.51% of encounters.

Table 5.10 WHO core prescribing indicators

DISCUSSION

NSAIDs are widely prescribed for the management of pain, inflammation and fever. However their use requires careful consideration because inappropriate prescribing may contribute to polypharmacy and unnecessary exposure to injectable formulations. In the present study, NSAID prescribing patterns were evaluated using the WHO Core Prescribing Indicators to identify areas requiring improvement in rational prescribing practices.

A total of 203 patient encounters were analyzed. Females (63.54%) accounted for a higher proportion of encounters than males (36.45%), which is consistent with findings from Jayakumari et al..⁴ The 18-29 year age group represented the large proportion of the study population, consistent with the findings of Carina Monteiro et al.¹³ Department-wise, Orthopaedics accounted for the highest NSAID-containing encounters (41.87%), followed by Obstetrics and Gynaecology (33%) and General Medicine (25.12%). The predominance in Orthopaedics may be attributable to the frequent use of NSAIDs for musculoskeletal pain, trauma, and postoperative conditions, with the observations of Anandhan et al.¹²

In our study, diclofenac was the most frequently prescribed NSAID (40.58%), followed by paracetamol (31.30%). A similar prescribing pattern was reported by Byndoor et al.,¹⁴ in which diclofenac accounted for more than one-third of the total NSAID prescriptions.

The parenteral route accounted for 62.32% of all NSAID prescriptions, compared with 37.68% administered orally. The finding was consistent with the observations of Inamdar et al.,² and may reflect the acute and inpatient nature of the study population, where parenteral therapy may be preferred when rapid analgesic effect is required or oral administration is not feasible. Injectable NSAIDs were prescribed in 79.80% of encounters, which was higher than the WHO’s reference range of 13–24%. This relatively high use may be partly attributable to the substantial proportion of post-operative and orthopaedic patients in the study population.

The majority of prescriptions contained a single NSAID (106;52.22%), which was similar to the findings reported by Farheen H et al.¹⁵

 A slight predominance of brand-name prescribing was observed, with 175(50.72%) of NSAID prescriptions written by brand name, compared with 170(49.27%) prescribed by generic name. This finding was comparable to that reported  by Khoshroz Samad et al.,¹⁶

In the present study, fixed-dose combinations (FDCs) of NSAIDs accounted for 14(4.06%) of total NSAID prescriptions, which was lower than the proportions reported in several other studies. The most frequently prescribed FDC was tranexamic acid + mefenamic acid (2.9%), followed by diclofenac + serratiopeptidase (0.58%), mefenamic acid + dicyclomine hydrochloride (0.29%), and aceclofenac + serratiopeptidase + paracetamol (0.29%), while Kandasamy et al.,⁹ reported aceclofenac + paracetamol to be more prevalent. In summary, while the overall proportion of NSAID FDC prescriptions in this study is much lower than in other published reports, the specific combinations used reflect speciality-driven needs, local availability, and prescriber preferences.

Gastroprotective agents were co-prescribed with nearly all encounters (100%), with proton pump inhibitors (69.95%) and H₂ receptor blockers (30.05%). This finding was similar to that reported by S. Kumar et al.¹⁷ This high rate of gastroprotective co-prescription may reflect the routine use of gastroprotection alongside NSAID therapy in the study setting, particularly given the potential for NSAID-associated gastrointestinal adverse effects.

The average number of drugs per encounter was 8.12, which was higher than the WHO standard (1.6–1.8) and also greater than 4.6 reported by Inamdar et al.,² (2022), indicating substantial polypharmacy among the study population. The average number of NSAIDs per encounter was 1.7, compared with 1.36 reported by Inamdar et al.,² indicating a higher average number of NSAIDs prescribed per encounter in the present study. The percentage of encounters with NSAIDs was 100% in both studies, confirming widespread use of this class. Injectable NSAIDs were prescribed more frequently in our study (79.8%) compared to 70% in Inamdar et al.,² suggesting stronger reliance on parenteral therapy.

In terms of choice of NSAIDs, our study showed diclofenac (40.58%) as the most common drug, followed by acetaminophen (31.3%) and aceclofenac (24.6%). In contrast, Inamdar et al.² reported paracetamol (95%) as the dominant drug. Non-selective NSAIDs were predominant in our prescriptions (73.89%), while selective COX-2 use was absent, compared to 2% in their study.

Generic prescribing was better in our study (49.27%) than in theirs (9%), though still below the WHO recommendation of 100%. Adherence to the National List of Essential Medicines was also stronger in our hospital (95.07% vs. 85.7%). Fixed-dose combinations were used sparingly in our study (4.06%), whereas Inamdar et al.,² observed 19%. Co-prescription of gastroprotective agents was nearly universal in both studies (100% vs. 97%).

Overall, compared with the findings of Inamdar et al.,² the present study demonstrated a higher average number of drugs and NSAIDs per encounter and greater use of injectable NSAIDs, while generic prescribing and adherence to the NLEM were comparatively higher.

CONCLUSION

This study identified important patterns and areas for improvement in NSAID prescribing in a tertiary care teaching hospital using WHO Core Prescribing Indicators.

High adherence to the National List of Essential Medicines (95.07%) and frequent co-prescription of gastroprotective agents were notable findings. However, substantial polypharmacy, high use of injectable NSAIDs and prescribing by generic name in only 49.27% of NSAID prescriptions indicate opportunities to strengthen rational prescribing practices.

Fixed-dose combinations accounted for 4.06% of NSAID prescriptions, while no selective COX-2 inhibitors were prescribed during the study period. Continuous prescription auditing, clinical education, and adherence to evidence-based prescribing guidelines may help improve NSAID prescribing practices. Further multicentre studies including outpatient populations and clinical outcomes are warranted to provide a broader assessment of NSAID utilization.

ACKNOWLEDGEMENT

The authors express their gratitude to Dr. Nagendra Rao, the principal of SCS College of Pharmacy in Harapanahalli, for the encouragement and significant support received throughout the research.

AUTHOR’S CONTRIBUTION

All the authors have contributed equally in this research.

CONFLICT OF INTEREST

All authors declare that there are no conflicts of interest.

ETHICS DECLARATION

The Institutional Ethics Committee at SCS College of Pharmacy approved the protocol. All residents in the hospital provided with informed consent.

CONSENT FOR PUBLICATION

All authors have provided consent for publication of their work.

COMPETING INTEREST

The authors have confirmed that they have no competing interest.

AUTHOR’S FUNDING

The authors hereby declare that they did not obtain any financial support from any source for the writing, or publication of this article.

REFERENCES

1. Jeeja Mathummal Cherumanalil, Jayakrishnan Thayyil, Madeehs Habeebulla. Prescription pattern of Non-Steroidal Anti-Inflammatory drugs among patients admitted with fever in a tertiary hospital. International Journal of Basic and Clinical Pharmacology. 2023 March;12(2):167-172.
2. Zeba Inamdar, Sarwamangala SN, Padmavati V. Prescription pattern analysis of Non-Steroidal Anti-Inflammatory drugs in tertiary care hospital. Asian Journal of Pharmaceutical and Clinical research. Vol 15, Issue 7, 2022, 177-180.
3. Leufkens HG, Ameling CB, Hekster YA, Bakker A. Utilisation patterns of Non-Steroidal Anti-Inflammatory drugs in an open Dutch population. Pharm Weekbl [Sci]. 1990;12(3):97-103.
4. S.Jayakumari, A.Gokul Krishna. Prescription pattern analysis of Anti-Inflammatory drugs in general medicine and surgery department of a tertiary care hospital. Int J Pharm Sci. Vol 8, Issue 7, 114-118.
5. Philip G Conaghan. A turbulent decade for NSAIDs update on current concepts of classification, epidemiology, comparative efficacy and toxicity. Rhetumatol Int. ( 2012);32:1491-1502.
6. P.R.R.Vaishnavi, Nitin Gaikwad. Assessment of non-steroidal anti-inflammatory drug use pattern using World Health Organization Indicators: A cross sectional study in a tertiary care teaching hospital of Chhattisgarh. Indian J Pharmacol. 2017;49:445-450.
7. Berha AB, Seyoum N. Evaluation of drug prescription pattern using WHO prescribing indicators in Tikur Anbessa specialized hospital: a cross-sectional study. Journal of Drug delivery and Therapeutics. 2018; 8(1):74-80.
8. Khajuria S, Bhat NK, Kumar R. Prescribing pattern of Analgesics in Indoor patients of Orthopedic department in a tertiary care teaching hospital in North India. JK Science. 2023;25(1):39-42.
9. Geetha Kandasamy, Dalia Almaghaslah. A study of prescribing patterns of Non-Steroidal Anti-Inflammatory drugs in a Tertiary Care Teaching Hospital. Indian Journal of Pharmaceutical Sciences. 2021;83(2):278-283.
10. Akshitha S Ragam, Swathi Acharya. Assessment of drug use pattern using World Health Organization prescribing indicators in a tertiary care hospital in Mangalore: A cross-sectional study. National journal of Physiology, Pharmacy and Pharmacology. 2017;Vol 7, Issue 10:1026-1030.
11. Meenakshi R, Selvaraj N, Anandabaskar N, Dhamodharan A, Badrinath AK. Prescription audit of a teaching hospital in South India using WHO core prescribing indicators - a cross sectional study. Perspect Clin Res. 2022;13:132-136.
12. Anandan I, Selvaraj N, Meenakshi R. Assessment of drug use pattern of nonsteroidal anti-inflammatory drugs using the WHO core indicators in a tertiary care teaching hospital – A cross sectional study. Natl J Physiol Pharm Pharmacol. 2019;9(10):1021-1026.
13. Monteiro, C., Miranda. Consumption patterns of NSAIDs in central Portugal and the role of pharmacy professionals in promoting their rational use. Drugs and therapy prespectives. 32(10),419-425.
14. Byndoor Y, Sagar TV, Palla J. Prescription pattern of non-steroidal anti-inflammatory drugs and their effects on symptoms and disease progression in patients with osteoarthritis in tertiary care centre. Panacea J Med Sci. 2024;14(2):332-336.
15. Farheen H, Subhani G. Prescripation Pattern of non-steroidal Anti-inflammatory Drugs in Patient with Acute Musculoskeletal pain. Int Basic Clin Pharmacol. 2016;5:2504-9.
16. Khoshroz Samad, Muhammed Abdul Gani. Prescribing Patterns of non-steroidal anti-inflammatory drugs in Dhaka City. The Insight. 2021;4(2):55-63.
17. S Kumar, PK Thakur. Evaluation of prescribing pattern of NSAIDs in South Indian Teaching Hospital. Journal of Chitwan Medical College. 2016;6(18):54-58.