Evaluation of prescribing rationality for rheumatoid arthritis patients at a regional hospital in Indonesia

Alya Fauziah Zahra; Umi Yuniarni; Bambang Tri Laksono

doi:10.51511/pr.109

Alya Fauziah Zahra Department of Pharmacy, Faculty of Mathematics and Natural Science, Universitas Islam Bandung
Umi Yuniarni Department of Pharmacy, Faculty of Mathematics and Natural Science, Universitas Islam Bandung
Bambang Tri Laksono Department of Pharmacy, Faculty of Mathematics and Natural Science, Universitas Islam Bandung

Keywords: drug utilization evaluation, medication safety, prescribing appropriateness, rational pharmacotherapy, rheumatoid arthritis

Abstract

Rheumatoid arthritis requires long-term pharmacotherapy with disease-modifying antirheumatic drugs, corticosteroids, and non-steroidal anti-inflammatory drugs. Irrational prescribing can lead to treatment failure, adverse effects, and increased healthcare costs. This study evaluated prescribing rationality for rheumatoid arthritis patients at RSUD Al Ihsan, Bandung, Indonesia, during 2023. A retrospective cross-sectional design was employed, analyzing medical records of 81 outpatients using five rationality criteria: appropriate indication, appropriate drug, appropriate dose, appropriate patient, and appropriate dosing interval. Results showed complete compliance for appropriate indication (100%) and appropriate drug selection (100%). However, deficiencies were identified in dose appropriateness (81.82%), patient appropriateness (97%), and dosing interval appropriateness (81.82%). Dose-related errors involved diclofenac sodium prescribed below therapeutic range and etoricoxib exceeding recommended doses. Patient-related inappropriateness included diclofenac sodium use in four elderly patients over 65 years without documented gastroprotection. Interval-related errors involved etoricoxib and meloxicam prescribed more frequently than recommended. Overall prescribing rationality was 92.1%, indicating generally appropriate practices with specific areas requiring improvement through clinical decision support systems, prescriber education, and regular prescribing audits.

References

Guo Q, Wang Y, Xu D, Nossent J, Pavlos NJ, Xu J. Rheumatoid arthritis: pathological mechanisms and modern pharmacologic therapies. Bone Res. 2018;6:15. https://doi.org/10.1038/s41413-018-0016-9

GBD 2021 Rheumatoid Arthritis Collaborators. Global, regional, and national burden of rheumatoid arthritis, 1990-2020, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. Lancet Rheumatol. 2023;5(10):e594-e610. https://doi.org/10.1016/S2665-9913(23)00211-4

Kementerian Kesehatan Republik Indonesia. Laporan Nasional Riset Kesehatan Dasar (Riskesdas) 2018. Jakarta: Badan Penelitian dan Pengembangan Kesehatan, Kemenkes RI; 2018.

Fraenkel L, Bathon JM, England BR, St.Clair EW, Arayssi T, Carandang K, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken). 2021;73(7):924-939. https://doi.org/10.1002/acr.24596

Smolen JS, Landewé RBM, Bergstra SA, Kerschbaumer A, Sepriano A, Aletaha D, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3-18. https://doi.org/10.1136/ard-2022-223356

World Health Organization. Promoting rational use of medicines: core components. WHO Policy Perspectives on Medicines No. 5. Geneva: WHO; 2002. Document WHO/EDM/2002.3.

Del Grossi Moura M, Lopes LC, Silva MT, Barberato-Filho S, Motta RHL, Bergamaschi CC. Use of steroid and nonsteroidal anti-inflammatories in the treatment of rheumatoid arthritis: systematic review protocol. Medicine (Baltimore). 2018;97(22):e10870. https://doi.org/10.1097/MD.0000000000010870

Kementerian Kesehatan Republik Indonesia. Modul Penggunaan Obat Rasional. Jakarta: Kementerian Kesehatan RI; 2011.

Wang X, Cheng Z. Cross-sectional studies: strengths, weaknesses, and recommendations. Chest. 2020;158(1S):S65-S71. https://doi.org/10.1016/j.chest.2020.03.012

Perhimpunan Reumatologi Indonesia (IRA). Diagnosis dan Pengelolaan Artritis Reumatoid. Jakarta: Perhimpunan Reumatologi Indonesia; 2021.

Schwinghammer TL, DiPiro JT, Ellingrod V, DiPiro CV. DiPiro's Pharmacotherapy Handbook. 12th ed. New York: McGraw-Hill Education; 2023.

Lexicomp Online. Drug Information Handbook. Hudson, OH: Wolters Kluwer; 2023 [cited 2024 Jan]. Available from: https://online.lexi.com

Hazra A. Using the confidence interval confidently. J Thorac Dis. 2017;9(10):4125-4130. https://doi.org/10.21037/jtd.2017.09.14

Sostres C, Gargallo CJ, Lanas A. Nonsteroidal anti-inflammatory drugs and upper and lower gastrointestinal mucosal damage. Arthritis Res Ther. 2013;15(Suppl 3):S3. https://doi.org/10.1186/ar4175

Ma SN, Huri HZ, Yahya F. Drug-related problems in patients with rheumatoid arthritis. Ther Clin Risk Manag. 2019;15:505-524. https://doi.org/10.2147/TCRM.S194921

Mittal G, Bisht M, Pai VS, Handu SS. Evaluation of prescription practices in rheumatoid arthritis at the rheumatology clinic in a tertiary care teaching hospital in Uttarakhand: A cross-sectional study. J Family Med Prim Care. 2021;10(2):745-751. https://doi.org/10.4103/jfmpc.jfmpc_1366_20

Rutherford AI, Subesinghe S, Bharucha T, Ibrahim F, Nikiphorou E, Galloway JB. Changes in the pharmacological management of rheumatoid arthritis over two decades. Rheumatology (Oxford). 2021;60(9):4346-4354. https://doi.org/10.1093/rheumatology/keab040

Bogale Z, Feleke Y. Prevalence, clinical manifestations, and treatment pattern of patients with rheumatoid arthritis attending the rheumatology clinic at Tikur Anbessa Specialized Hospital, Ethiopia. Open Access Rheumatol. 2022;14:221-229. https://doi.org/10.2147/OARRR.S383778

Rongen GA, Marquet P, Van Gerven JMA. The scientific basis of rational prescribing: a guide to precision clinical pharmacology based on the WHO 6-step method. Eur J Clin Pharmacol. 2021;77:677-683. https://doi.org/10.1007/s00228-020-03044-2