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Deviant prescriptions contribute to AMR
This article is authored by Abantika Ghosh, journalist and public policy professional.
That urinary tract infections (UTIs) are getting difficult to treat, particularly in the elderly is a common refrain among doctors across hospitals, and across cities. More and more patients within and outside hospitals are being asked to do culture tests based on their initial response (or lack of it) to first line antibiotics. Cultures try to grow and identify a pathogen in laboratory conditions.
These are why the findings of the eighth report of the AMR Surveillance Network brought out by Indian Council for Medical Research (ICMR) - which has flagged increasing difficulty in treating UTIs, diarrhoea and respiratory infections--while extremely significant from a public health perspective and in setting the guidance for treatment of these ailments going forward, does not necessarily come with new revelations. That many of these are health care associated infections and ICUs are the “hotbeds” for contracting those, is also a reiteration of a known fact. The findings are literally being lived every day by India’s patients and medical fraternity.
Lax regulations, easy availability of prescription medicines over the counter, our penchant for self-medication and reluctance to finish an antibiotic course especially when it is long (such as in the case of tuberculosis) are all frequently talked about reasons for AMR. There is also some blame that falls at the doctor's doorstep as one of the other common contributors to the problem is over-prescription or prescriptions that deviate from norms.
But here’s the catch - antibiotics are just one among a very diverse range of overprescribed or wrongly prescribed medicines. ICMR had some time back taken upon itself to study prescription practices in the outpatient departments of several hospitals. In that study which was published last year in the Indian Journal of Medical Research, it was found that the top consequence of what the researchers called “unacceptable” deviations in prescription norms was increased cost which happened in 63% of the analysed prescriptions. The survey looked only at OPD prescriptions but in a hospital setting the cost implications may be far more significant as private hospitals usually charge MRP for drugs that are available for a discount at chemist shops outside the premises. This is one of the many ways that hospital bills have skyrocketed in recent years.
The ICMR study also found some patterns of over-prescription. The list of wrongly prescribed medicines included antibiotics such as azithromycin and amoxicillin but there were other medicines such as proton pump inhibitors (used for acid reflux complaints) and anti-vomiting medicines; some of the drugs were being prescribed not to treat symptoms but to treat side-effects of the primary drug.
For reasons that are extremely valid, AMR has been the vanguard of the overmedication conversation but the consequences of irrational drug use can go far beyond the lack of sensitivity of common pathogens to first- and second-line drugs. There are a host of other medicines that are routinely overused, triggering unintended consequences.
For example, proton pump inhibitors are often prescribed alongside pain killers to ensure that the heightened production of gastric juices that is triggered by some painkillers, does not damage the stomach lining. So, it is a common medicine that arthritic or osteoporotic patients have, sometimes on a daily basis because of their need for painkillers. But, there is a snag. Proton pump inhibitors (PPI) are also known to increase the risk of fractures when used over the long term as they impede the absorption of calcium in the body and over time reduce bone density. This could significantly heighten the risks for a person whose bone health is already compromised. The patient in effect is caught in a vicious circle where the drug they are taking to nullify the side-effects of their daily dose of painkillers, is essentially triggering changes in the body that can aggravate the condition that is causing the pain in the first place - osteoporosis. The painkiller-PPI combo was mentioned in the ICMR prescription analysis too.
Supplements are another category of irrationally prescribed drugs that can jack up health expenditure. In 2022 in another article in IJMR researchers pointed out the need for reassessment of the tendency to prescribe B complex supplements in order to keep out of pocket expenditure under check. Vitamins, the study said constitute almost a quarter of all prescribed drugs in the country. “In countries like India where 70% of health care expenses are met by out-of-pocket expenditure by patient and medicines account for over half of this expenditure, it is important to reduce indiscriminate use of multivitamin preparations, and the savings could be better spent elsewhere,” the researchers wrote. The industry too has been quick to spot this trend and get onto the bandwagon. The rise in irrational use of Vitamin D supplements has happened concomitant with a spurt in the diversity of brands and their prices.
India’s commitment to accessible, affordable health care has largely attempted to tackle the drug pricing questions through promotion of generic options. But health care inflation needs a systemic approach. Prescription audits can be a good starting point for the conversation on out of pocket expenditure on medicines. The findings can also inform policy level interventions on AMR.
This article is authored by Abantika Ghosh, journalist and public policy professional.
