الفهرس 
PharmacoepidemiologyOnly 14 pages are availabe for public view
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Abstract
Rational use of medicine can be defined as ”patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and their community”. Irrational use is the use of medicines in a way that is not compliant with rational use as defined above. Worldwide, more than 50% of all medicines are prescribed, dispensed, or sold inappropriately, while 50% of patients fail to take them correctly.
Pain represents a major clinical, social and economic problem, with prevalence ranging from 8% to more than 60%, depending on the patient population. Studies have shown that one of the most common reasons for using analgesics is relieving or treating pain and their symptoms and it has been reported that non-prescribed and improper use of analgesics has reached worrisome levels. Analgesics are classified into opioids and non opioids. The opioid analgesics are principally used for the relief of severe pain or chronic malignant pain, and may produce dependence. The non-opioids analgesics are used for mild to moderate pain, for fever and they all except paracetamol have anti-inflammatory effects.
NSAIDs have a generally low risk of adverse effects when used appropriately by healthy adults for occasional symptom relief. However, the irrational use of these medications may lead to adverse events, including the following: gastrointestinal effects as dyspepsia, nausea, vomiting and sometimes gastric bleeding and ulceration, adverse renal effects which may lead to analgesic nephropathy (AN) on chronic use, cardiovascular effects especially with COX-2 inhibitors and hepatic injury.
NSAIDs should be used with precaution for patients with peptic ulcer disease and GI bleeding disorders, impaired renal function, hepatic impairment and history of hypersensitivity reactions. NSAIDs can significantly interact with other medications as anti-coagulant, ACE- inhibitors and diuretics.
The study was conducted: to assess the magnitude and determine the pattern of analgesics utilization among adults in Alexandria, to identify the factors associated with frequent analgesics use and misuse and to investigate adults’ knowledge concerning analgesics use.
The study was conducted using a cross-sectional approach. It included 607 adults attending 30 private pharmacies in the 8 districts of Alexandria, whose ages were above 18 years old, excluding those using opioids and those receiving non opioids for prophylaxis. Pharmacies were randomly selected and were proportionately allocated according to the number of pharmacies in the eight selected districts. The sample was calculated using EPI INFO 7.1.1.14, 2013. Based on an expected frequency of 20% adults suffering from pain, a design effect of 2, the required sample at 95% confidence level was 510 adults.
Data collection was done using a pre-designed interview questionnaire with adults. The collected data included: socio-demographic characteristics, medical history, life style factors, analgesics used (number of analgesics taken, type, doses and frequency, source of consultation, purpose of use and adverse effects). Also data about the knowledge of studied adults were collected concerning: adverse effects, interactions as well as precautions of analgesics use.
The study revealed the following main results:
The age of the studied adults ranged between 18 and 86 years with a mean age of 36.3±12.9 years. About one third (33.8%) of the studied adults were aged 25 to less than 35 years of age. Those aged from 35 to less than 45 years constituted 21.7%. The percentage of females was slightly higher than that of males (51.4% and 48.6% respectively). Forty two and half percent of the studied adults were university graduates. Those with lower education (secondary, preparatory and primary) constituted approximately half of the sample (48.6%). Illiterates were 7.9%. Non-professionals constituted 36.4% and professionals were 30.8%. Housewives, students, retired interviewees and those who were without a job constituted 19.9%, 8.1% and 4.8% respectively. About two thirds of studied adults were married. Nearly one third of them (31.5%) were single and 3.3% were divorced or widowed. The majority of interviewed adults were from urban areas (83.9%) and 16.1% were from rural areas. About 24.1% of the studied adults were smokers. More than that two thirds (64.7%) of the studied adults had moderate physical activity. Those with high and low physical activity were 18.8% and 16.5% respectively. About 33.9% of adults had normal weight, 33.3% were overweight and 32.8% were obese.
There was a statistically significant association between age, gender and analgesics use. No significant association was found between analgesics intake and occupation or marital status or place of residence. Also no significant association was found between analgesics use and smoking or physical activity or obesity.
Regarding the medical history, about 42% of the sample suffered from chronic diseases. The most common diseases were chronic sinusitis (24.2%), hyperacidity (22.3%) and hypertension (18.8%). Nearly three quarters (73.8%) of those with chronic diseases didn’t use any of the selected medications (anti-hypertensives, anti-diabetics, anti-coagulants and low dose aspirin), while about 42.2% were taking anti-hypertensives, 27.8% were taking anti-diabetics, 22.6% were taking low dose aspirin. No significant association was found between chronic diseases and analgesics use except for hyperacidity. Also, no significant interaction was found between analgesics use and current intake of any of the selected medications.
More than three quarters of adults (82%) reported taking one or more analgesics. Nearly two-thirds (64.1%) used to take only one analgesic, 29.9% used to take two analgesics and 6% used to take three or more analgesics.
Paracetamol was used by 27.5% of analgesic users. The majority of them (41.6%) took it for self-medication and it was prescribed in less than one quarter (23.4%). Regarding the frequency of use, it was less than once monthly in 31.4%, twice weekly and once to twice monthly in 16.8% each. Those who used to take paracetamol once per week and everyday were 15% and 13.9% respectively. The most common reason for taking paracetamol was headache 89.1%. The oral route was the only used route. The commonly used dose was 500 mg/day (65.7%). Only 2.2% of studied adults mentioned suffering from GIT side effects, but all of them mentioned continuing taking paracetamol .
About 86.6% of analgesic users took NSAIDs. NSAIDs were taken for self-medication by 39.9% of adults. About one quarter (25.9%) took NSAIDs after consultation of a pharmacist and 22.8% had a prescription. NSAIDs were used for headache by 77%.The route of administration was mainly the oral route (97.4%). Less than one sixth (15.7%) reported GIT side effects, where 31.1% of those who reported suffering from adverse effects stopped taking NSAIDs.
The most commonly used NSAID was ketoprofen (52.8%), followed by diclofenac (35.7%), ibuprofen (9.6%), aspirin (6.2%), keterolac (2.8%), metamizole (2.4%) and piroxicam (0.6%). The most frequent doses taken by ketoprofen users were 150 mg/day and 50 to 100 mg /day and they amounted to 47.5% and 45.2% respectively. Nearly two thirds (68.5%) of diclofenac users took 50 mg/day and about one quarter (25.8%) took 100 mg/day. Approximately 90% of ibuprofen users took from 200 to 400 mg per day.
More than one third (37.3%) of studied adults were considered as frequent analgesic users, while about 16.5% were misusers. Smoking in males was a common factor significantly associated with both frequent analgesics use and misuse. Education through primary schools was significantly interacting with frequent analgesics use.
Regarding the knowledge of adults about side effects of analgesics, more than half of the studied adults (57.5%) mentioned that analgesics may cause side effects and 26% did not know whether analgesics may cause side effects or not. More than half of the respondents (60.5%) didn’t know whether analgesics can interact with other medications or not. Among those adults who believed that analgesics can interact with other medications, 84.8% did not know what these medications were. Almost half of the respondents (49.8%) knew that analgesics should be used with precautions in certain diseases, while less than the half (44.2%) of them responded that analgesics can be used safely for any disease and without precautions.
Regarding the source of information on analgesic use, 37.7% of the studied adults read the pamphlet, and 35.7% consulted their pharmacist, and 29.8% consulted their physicians. Only 3.3% were dependent on their own experience and 3.1% asked a family member and/or friend or used the internet. The most important sections of the pamphlet for studied adults were indications (41.4%), side effects (39.9%). Precautions and entire pamphlet were read by 37.7% of studied adults. The reasons for not reading the pamphlet were: being not important (57%), not understanding the pamphlet (15.6%), and being illiterate (18.3%), being mainly scientific information (7%).
It was concluded from the present study that the utilization of analgesics was widely prevalent among adults in Alexandria. NSAIDs were the most commonly used analgesics. About one-third of analgesic users were frequent analgesic users and 16.5% used analgesics irrationally.
The most important recommendations of the study were:
• Banning self-medication with NSAIDs at doses higher than the recommended OTC daily dose.
• Education of medical students, prescribers and practicing pharmacists about the rational use of analgesics.
• A warning label should be displayed to all prescription-strength NSAIDs for informing consumers that this analgesic shouldn’t be used without a prescription.