Prescription Analysis of Antiepileptic Drugs in a Tertiary Care Hospital

 

T. Tamilselvan2*,  Arokia Rani C.1, Ashna Raj1, Leena Priya M.1, Nissy Varghese1,

Sojan P. Paul2

1Pharm.D Interns, Department of Pharmacy Practice, Swamy Vivekanandha College of Pharmacy, Elayampalayam - 637205,

2Department of Pharmacy Practice, Swamy Vivekanandha College of Pharmacy, Elayampalayam - 637205,

*Corresponding Author E-mail: tamilrx@gmail.com

 

ABSTRACT

The objective of the study was to analyze the prescription pattern and drug related problems of antiepileptic drugs. The prospective descriptive study was carried out for a period of 6 months in a tertiary care hospital. The prescriptions were analyzed to identify the polypharmacy, adverse drug reactions and medication error. The patients were included in the study was with all type of epilepsy of both male and female patients with any age group of in and out patients. The identified medication error was categorized with the help of NCC MERP category. Causality assessment of adverse reaction was performed by the Naranjo algorithm. Analyzed the obtained prescription and identified the Polypharmacy in geriatric patients. Total 50 patients with 406 drugs, of these 6 Polypharmacy (12%), 7 medication error (16%) and 6 serious ADR were identified. The current study observed that the prescription contains drug-related problems were assessed to a greater extent and are comparable with the existing literature. Continued relationship with clinical pharmacist should be encouraged for better treatment option thereby improving the patient's quality of life effectively.

 

KEYWORDS: Prescription, Epilepsy, Polypharmacy, Medication Error, Adverse Drug Reaction.

 

 


INTRODUCTION:

Epilepsy is a chronic seizure disorder or a group of disorders characterized by recurrent seizures associated with the disturbance of consciousness and characteristic body movement as a result of an uncontrolled discharge of neurons suddenly for a short period. According to World Health Organization, “Epilepsy is a chronic non communicable disorder of the brain that affects people of all ages”.1,2 Approximately, 50 million people in the total world population are having epilepsy, and focused that there are 55, 00,000 persons are from India, (i.e.) one-eighth of the total epilepsy patient in the world.3

 

Prescription analysis and review of medication records help in identifying the drug-related problems depending on patient-related factors or drug-drug interaction between different prescribed drugs. Among elderly patients, Polypharmacy is fetching a major common problem and it is projected to be the 5th major cause of death.

 

Medication errors occurred during medication delivery process, the error may include prescribing, transcribing, dispensing, and administration medication errors.4 ADR to antiepileptic drugs is a major clinical problem in treating both pediatric and adult patient. Positive or negative cognitive and behavioral effects are common in both old and new generation AEDs.5

 

METHODOLOGY:

This prospective descriptive study was conducted in a Neurology and General medicine department of more than 300 bedded multispecialty tertiary care hospital. The study was approved by the Institutional Ethics Committee of Vivekanandha Medical Care Hospital. The study was carried out for the period of 6 months. About 50 epileptic patients were included in this study after getting patient’s consent. Patients were screened according to inclusion and exclusion criteria.

 

All type of epilepsy patients were included in the study.The identified medication error was categorized with the help of NCC MERP category. Causality assessment of adverse reaction was performed by the NARANJO algorithm. Analyzed data was represented in the percentage.

 

RESULTS:

Demographics:

The study included 50 epileptic patients from both inpatient and outpatient of neurology and general medicine department. In the study population male and female was 56% (28) and 44 % (22) accordingly.

 

Among overall age distribution in 50 patients, most of the patients were in the early adulthood (28%) followed by children (20%), adulthood (16%), late adulthood (14%), young old (10%), adolescents (6%), old (2%), neonates (2%) and infants (2%). The mean age of the study population was 33.42 ± 23.478 (Range from 1 to 75). (Table-1)

 

Table 1: Age Wise Distribution (n=50)

Age

No of Patient

Percentage

Neonates (under 28 days)

1

2%

Infants (1 -12 months)

1

2%

Children (1-12 yrs)

10

20%

Adolescents (13 – 18 yrs)

3

6%

Early adulthood (19-35 yrs)

14

28%

Adulthood (36 – 50 yrs)

8

16%

Late adulthood (51 – 65 yrs)

7

14%

Young old (66 – 74 yrs)

5

10%

Old (75 – 85 yrs)

1

2%

 

Types of Seizures Occurred:

The physician of the hospital had performed a thorough clinical investigation and diagnosed the patient and such diagnosis was reported as types of seizures. The result shows that patient with generalized tonic-clonic seizures (32%) were majorly diagnosed at the study site followed by Complex partial seizure (20%), and simple partial seizure (14%). (Table-2)


 

Table 2: Types of Seizures Occurred (n=50)

TYPES OF SEIZURES

NO OF PRESCRIPTION

PERCENTAGE

Generalized tonic-clonic seizures

16

32%

Complex partial seizures

10

20%

Simple partial seizures

7

14%

Febrile seizures

4

8%

Partial seizures with secondary generalized seizures

4

8%

Break through seizures

4

8%

Post-traumatic seizures

3

6%

Atonic seizures

1

2%

Absence seizures

1

2%

 


Prescription Analysis:

The study populations were treated with the different class of antiepileptic drugs. The most commonly prescribed drugs were Levetiracetam (46%) and Clobazam (28%). (Table-3)

Table 3: Classification of Prescribed Anti-Epileptic Drugs (n=50)

DRUG NAME

NO: OF PATIENTS

PERCENTAGE

Phenytoin

9

18%

Fosphenytoin

6

12%

Sodium valproate

5

10%

Valproic acid

2

4%

Divalproex sodium

2

4%

Levetiracetam

23

46%

Gabapentin

2

4%

Lacosamide

1

2%

Phenobarbitone sodium

2

4%

Clobazam

14

28%

Clonazepam

2

4%

Topiramate

1

2%

Carbamazepine

3

6%

Acetazolamide

1

2%

Drug Related Problems:

In the study population, percentage of drug related problems which include polypharmacy (12%), medication error (14%), and adverse drug reaction (12%).

 

Assessment of ADRs According to Naranjo Adverse Drug Reaction Probability Scale:

According to Naranjo ADR probability scale, identified ADR was assessed and their causality level with the score was tabulated. (Table-4)

 

Medication Error:

The Medication error was checked according to NCC MERP category. From that, 8% of prescription error, 4% of dispensing error and 2% of administration error were found and categorized. (Table-5)

 

 


Table 4: ADR of Prescribed Drugs (n=50)

Drug Name

ADR

Causality Score

Causality term

No. of Patients

Percentage

Carbamazepine

Induce hyponatraemia

6

Probable

1

20%

Lorazepam

Induce Respiratory depression

7

Probable

1

20%

 

Table 5: Medication Error (n=50)

Types of error (%)

Prescribed drug with dose

Inference

Ncc merp category

Prescribing error (8%)

T. Alprazolam  5mg PO HS

T. Alprazolam  Available dose: 0.5mg PO HS

B

T. Tolvaptan  150 mg PO OD

T. Tolvaptan Available dose 15,30mg

B

Inj. Phenytoin 40 mg IV Stat

Neonates dose: 20mg/kg as loading dose, then 2.5-5mg/kg BD

C

T. Clopidogrel 750mg PO Stat

T. Clopidogrel Available dose:75mg PO Stat

B

Dispensing error (4%)

T. Neurobion forte

T. Neurobion plus was dispensed

B

T. Clonazepam  0.5mg PO

T. Clobazam5mg PO

B

Administrating error (2%)

Inj. Ceftriaxone. 2g IV BD

Inj. Ceftriaxone 1g IV BD

D

 

 


DISCUSSION:

In the present study, epilepsy was significantly higher in males6, 7 with 56%. Based on age wise distribution, most commonly occurred age group in this study was early adulthood with 28% and followed children with 20%.3

 

According to the types of seizure, Generalized Tonic-Clonic Seizure (GTCS) has the most occurrences8 in the study population (32%), Complex partial seizure (20%), Simple partial seizure (14%), Febrile seizures (8%), Partial seizures with secondary generalized seizures (8%), Breakthrough seizures (8%), Post-traumatic seizure (6%), Atonic and absence seizure (2%).

 

Levetiracetam, a most commonly prescribed drug (46%) for epilepsy and followed by Clobazam (28%).The present study shows Lacosamide, Topiramate and Acetazolamide are least commonly prescribed with 2%. Generally, serious neurological disorder is difficult to treat rationally; sometimes the prescribed drugs may develop several problems in the patients. Medication error and adverse reaction are considered as drug-related problems.

 

Carbamazepine induced hyponatremia was having the causality score of 6 and it was assessed as probable ADR.10,11,17 Lorazepam induced respiratory depression was predicted as probable ADR (Causality Score-7). The previous study reported that a seizure themselves leads to respiratory depression. However, that the use of multiple small doses of Lorazepam increases the risk of respiratory depression in the management of prolonged seizures.12-14 In this study, identified medication error was categorized in terms of harm to the patient by using NCC MERP

 

CATEGORY:

Phenytoin is the drug having the narrow therapeutic index which was prescribed in excess dose in neonates. It may produce the life-threatening complication. Prescribed over dose in a neonate was 40mg/kg IV Stat, but the actual dose is 20mg/kg as the loading dose. Other prescribing errors made by the physician are unavailable dose i.e. errors in the decimal point, the addition of zeros.15 Apart from the prescribing error, the dispensing error occurred in the pharmacist's hand. In this study instead of Neurobion forte, Neurobionplus was dispensed. Most commonly occurred error but may produce severe harm is dispensing the wrong dose. Here, Clobazam 5 mg was dispensed instead of 0.5 mg.16 Administrating errors mainly happens in nursing care, Ceftriaxone 2g was prescribed but administered Ceftriaxone 1g. These types of interactions may produce life-threatening effects in patients.18

 

CONCLUSION:

The current study observed that the prescription contains drug-related problems were assessed to a greater extent and are comparable with the existing literature. We may reduce the incidence of polypharmacy by avoiding the medication used for minor problems or use lifestyle measures whenever possible. Prescription, transcribing and interpretation errors can be reduced by using computerized physician order. Education of nursing staff involved in the process of drug distribution is another important measure for preventing medication errors. Understanding and applying good clinical practice reduces the potential problems, avoidance of drug toxicities and improvements in treatment efficacy. Continued relationship with clinical pharmacist should be encouraged for better treatment option thereby can improve the patient's quality of life effectively.

 

ACKNOWLEDGEMENT:

We would like to acknowledge Dr. S. Arthanareeswaran, Executive Director, Vivekanandha Medical Care Hospital, Tiruchengode, Tamilnadu, India for giving us an opportunity to conduct the study and guiding our research work.

 

DECLARATION OF INTEREST:

The author has declared no conflict of interest.

 

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Received on 18.11.2017          Accepted on 10.02.2018         

© Asian Pharma Press All Right Reserved

Asian J. Pharm. Tech.  2018; 8 (1):43-46 .

DOI: 10.5958/2231-5713.2018.00007.7