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Analgesic prescribing trends in musculoskeletal disorders

Inflammatory disorders, both arthritic and non arthritic, are the most commonly encountered in orthopedic practice, and are generally treated with various non steroidal anti-inflammatory drugs (NSAIDs) with or without additional or specific therapies like steroids, immunomodulators or disease modifying agents. The use of NSAIDs in inflammatory conditions is mainly empirical, as they provide only symptomatic relief without addressing the underlying disease process. NSAIDs also happen to be the most widely prescribed and often misused by self-medication, even for trivial complaints.


INTRODUCTION
Inflammatory disorders, both arthritic and non arthritic, are the most commonly encountered in orthopedic practice, and are generally treated with various non steroidal anti-inflammatory drugs (NSAIDs) with or without additional or specific therapies like steroids, immunomodulators or disease modifying agents. The use of NSAIDs in inflammatory conditions is mainly empirical, as they provide only symptomatic relief without addressing the underlying disease process. NSAIDs also happen to be the most widely prescribed and often misused by self-medication, even for trivial complaints. 1 Additionally, NSAIDs account for more than 60% of overthe-counter (OTC) analgesic market. The British National Formulary (BNF) lists more than 20 NSAIDs that are available in at least 40 different formulations. Patients' response to NSAIDs is highly variable. There are several factors that contribute to patients' preference for one drug over another such as treatment efficacy, time and chance to benefit, potential side effects, ease of administration, cost, physician and patient beliefs, drug interaction, severity of disease, and health status. 2 Despite wide clinical use of classical NSAIDs as analgesics, antipyretics, and anti-inflammatory agents their gastrointestinal toxicity (dyspepsia, peptic ulcers and gastrointestinal bleeds) is a major clinical limitation. 3 There are a variety of NSAIDs available for prescription: traditional non selective (NSAIDs), and the more selective COX-2 inhibitors (Coxibs). The analgesic effects of the different NSAIDs are more or less identical; however, the Coxibs are associated with a lower risk for upper gastrointestinal side effects. 4 Tramadol is an opioid analgesic that is frequently prescribed in orthopedics outpatient department (OPD). Tramadol is a synthetic codeine analog, which is a weak μ opioid receptor agonist. Part of its analgesic effect is produced by inhibition of uptake of norepinephrine and serotonin. In the treatment of mild to moderate pain, tramadol is as effective as morphine or meperidine. Management of pain is important in the majority of the orthopedic conditions like rheumatoid arthritis (RA), osteoarthritis (OA), chronic low back pain (LBP), musculoskeletal pain, etc. Both narcotic and non narcotic analgesics analgesics can be chosen to manage pain. 5 Periodic Evaluations of drug utilization pattern enable suitable modifications in NSAID prescribing to increase the therapeutic benefit and to minimize the adverse effects. Such studies monitor, evaluate and if necessary, suggest modifications in prescribing behaviours of medical practitioners to make the medical care rational and cost effective. 6 In developing countries like India, where the financial resources are scarce and affordability of the patients is less, implementation of rational use of medicine (RUM) becomes more important and therefore, the assessment of drug utilization is vital for clinical, economic, and educational purpose. 7 Studies on the utilization of analgesic drugs in the orthopaedics outpatient department (OPD) are few and therefore this study is undertaken to determine the current prescribing trends in musculoskeletal disorders.

METHODS
It is unicentric, observational study that was carried out at NKP salve institute of medical sciences and research centre, Nagpur (Maharashtra).
It was conducted in the Orthopaedics OPD of a tertiary care, teaching hospital from October 2017 to March 2018. Ethical committee permission was obtained prior to the study. A total of 200 prescriptions were collected. Prescriptions of patients reported to orthopedic outpatient department, with presenting complaints of musculoskeletal disorder and rheumatological conditions like osteoarthritis, rheumatoid arthritis, bursitis, backache, tendinitis, cervical spondylitis etc. were noted for the various analgesic drugs prescribed for these disorders.

Statistical analysis
Data store, data compilation and statistical analysis were performed in Department of Pharmacology, NKPSIMS, Nagpur. Data was analysed for proportion and the results were described in the form of tables and percentages.
Fixed dose combination (FDC) of NSAIDS with other NSAIDS or opoid anlgesic or muscle relaxant were prescribed in 107 (53.3%) patients. Diclofenac + Paracetamol and Tramadol + Paracetamol were most commonly prescribed in 30 (15%) and 19 (9.5%) patients followed by others as shown in Table 4.

DISCUSSION
This is a record based observational study. In the present study out of 200 patients attending the outpatient department of orthopaedics who have received analgesics for various complaints of musculoskeletal and rheumatological conditions, the two most common age group of patients were between 41-50 years (14.5%) and 31-40 years (20%) of age range followed by other age groups. In a study of analgesic use at a south Delhi hospital in 300 subjects it was observed that maximum number of patients 83 (27.6%) were in the age range of 31-40 years followed by 68 (22.6%) patients in the range of 41-50 years.8 Also in a study at west Bengal out of 200 new patients who attended orthopaedic OPD, patients between 18-30 years (28%) and 31-40 years (26.5%) attended OPD more frequently than other age groups. 9 These findings are in accordance with present study.
In an observational study in the year 2013 in 200 orthopaedic OPD patients it was found that low back pain 87 (43.5%), various arthritis and osteoporosis 18 (9%) and cervical spondylosis in 18 (9%) were the common causes to visit orthopaedic OPD.10 In a cross sectional, utnicentric study conducted in the orthopaedics OPD of an urban, tertiary care, teaching hospital showed low back pain 32%, cervical spondylosis 14%, and osteoarthritis involving different joints 14.5% were the common conditions for OPD visit. 9 In present study also, the common conditions for which patient attended orthopaedic OPD were low backpain 42 (21%) and osteoarthritis in 41 (20.5%) patients.
In a drug utilization of NSAIDs in selected areas of south Delhi region during the six months study period which included 300 patients in OPD and IPD using NSAIDs, it was observed that aryl acetic acid derivatives (aceclofenac, diclofenac) were the most frequently prescribed drugs category (52.5%) followed by paracetamol (26.6%), ibuprofen (10.5%), nimesulide (6.26%) and lornoxicam (4%). 8 Also, in a retrospective study of eight months to assess the prescribing pattern of NSAIDs utilized in outpatient department of an orthopedic specialty hospital found that osteoarthritis (40%) was the most predominant presenting complaint and analgesics like aceclofenac (24.73%) and diclofenac (21.20%) were most commonly prescribed. 3 Also in a study to determine the pattern of NSAIDs prescribing for arthritic and non-arthritic conditions in orthopedic OPD found that NSAIDs commonly prescribed were aceclofenac 45%, etodolac 20% and diclofenac 24%. 6 These findings shows that aceclofenac is the most commonly use NSAID followed by diclofenac which is in accordance with our study in which aceclofenac is prescribed to 25(26.8%) and diclofenac to 18(19.3%) patients. Aceclofenac is a chemical congener of diclofenac with a better gastric tolerability with longer duration of action. 1 In present study another commonly prescribed NSAID was etodolac in 18.2% of patients. It is a moderately selective COX-2 inhibitor with properties similar to diclofenac and at lower doses gastric tolerability is better than older NSAIDS. 11 Etoricoxib was used in 13.9% of patients. Selective COX-2 inhibitors continue to be used, but their use has declined probably due to the increased risk of heart attack and stroke associated with etoricoxib and other coxibs. 12 In present study FDCs were prescribed in 53.5% of patients and combination of diclofenac with paracetamol and tramadol with paracetamol were most commonly prescribed. In a prospective cross-sectional study which evaluated 324 orthopaedic OPD prescriptions, 33.6% received combination of analgesics and diclofenac+paracetamol (37.6%) followed by tramadol+paracetamol (22.9%) were the most commonly prescribed combinations. In a study of prescriptions from the OPD of Orthopedics at Dr. B. R. Ambedkar Medical College of the 300 patients, 227 (75.66%) received FDCs and combination of diclofenac with paracetamol (27.31%) was the most commonly prescribed. 5 These findings are in accordance with our study. In an observational prospective study of prescription patterns of 200 patients for six months duration in 2013 in orthopaedic OPD found that tramadol plus paracetamol fixed drug combinations was more commonly prescribed as compared to other FDCs, which is not in alignment with our study. 10 Combining two NSAIDs is irrational as the two drugs act on the same pathway and irrational FDCs increase chances of adverse drug effects and drug interactions.

CONCLUSION
Low backpain and osteoarthritis are the common musculoskeletal disorders for which patient attend orthopaedic OPD. As monotherapy aceclofenac and diclofenac were the most commonly prescribed NSAIDS for these disorders. Fixed dose combinations of NSAIDS with other NSAIDS or opoid anlgesic were also prescribed to many patients. Diclofenac plus paracetamol and tramadol plus paracetamol were the most commonly prescribed combinations in our study.