DRUG UTILIZATION EVALUATION OF BRONCHIAL ASTHMA IN TERTIARY CARE HOSPITAL

Transcription

1 WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES Michael et al. SJIF Impact Factor Volume 5, Issue 2, Research Article ISSN DRUG UTILIZATION EVALUATION OF BRONCHIAL ASTHMA IN TERTIARY CARE HOSPITAL Babitha Michael *, Nithina James, Sreena S., Koneru Sindhuja, Basavaraj K. Nanjwade The Oxford College of Pharmacy, Hongasandra, Bengaluru , Karnataka, India and The Oxford Medical College, Hospital and Research Centre, Attibele, Bengaluru , Karnataka, India. Article Received on 07 Nov 2015, Revised on 27 Dec 2015, Accepted on 16 Jan 2016 *Correspondence for Author Babitha Michael The Oxford College of Pharmacy, Hongasandra, Bengaluru , Karnataka, India and The Oxford Medical College, Hospital and Research Centre, Attibele, Bengaluru , Karnataka, India. ABSTRACT Asthma was seen as one of the leading cause of morbidity and mortality in rural areas. Even though the DUE studies for asthma in pediatrics are common in South India, studies in adults are sparse. To study the drug utilization evaluation, assess the drug interaction and adverse drug effects in adult asthmatic patients in tertiary care hospital. Data of all the asthmatic patients admitted in the General Medical Ward between the periods of September 2014 to February 2015 were collected. Only the adult patients (>18 years) without any comorbidities were eligible for the study. During the study period 153 patients were enrolled. The mean age of the study population was found to be ± years. The gender ratio in our study showed a male preponderance at 2.55:1. Males were more prone to asthma as compared to females and the maximum prevalence of asthma was in the age group of 41-60years. All the patients received multiple drug therapy at an average of drugs per prescription. Methyl xanthines were the most commonly prescribed group of antiastmatics (86.27%). Contradicting to the popular belief, our study showed that oral dosage form (55.80%) were preferred over inhalation (27.76%) and parenteral (16.43%) route % of the asthma patients who were received drug therapy developed ADRs. Out of all the ADRs observed, tremor occurred mostly. Equal numbers of major and moderate drug interactions were found by analysing the prescription. Multiple drug therapy is preferred over other therapies for better management of asthma and Methyl xanthine was the most commonly prescribed class of drug. Tremor was the Vol 5, Issue 2,

2 commonest ADR observed. Equal numbers of major and moderate drug interactions were also found by analysing the prescription. KEYWORDS: Bronchial Asthma, Drug utilization review, Anti asthmatic drugs. INTRODUCTION Drug Utilization Reviews (DUR), also referred to as Drug Utilization Evaluations (DUE) or Medication Utilization Evaluations (MUE) and is defined as an ongoing, systematic process designed to maintain the appropriate and effective use of medications. [1] The designed study involves a comprehensive review of patient s prescription and medication data before, during and after medication dispensing in order to assure appropriate therapeutic decision making and positive patient outcomes. [2] Classification of DUE s 1. Prospective is evaluation of a patient's therapy before medication is dispensed. 2. Concurrent is ongoing monitoring of drug therapy during the course of treatment. 3. Retrospective is review of therapy after the patient has received the essential drugs. [3] Globally asthma disease is one the most common chronic disease and currently affects approximately 300 million people in the world. It is a chronic inflammatory disorder of the lung airways characterized and determined by increased responsiveness of tracheobronchial tree to a multiplication of stimuli. [4] Asthma disease characteristic symptoms are wheezing, dyspnea and coughing which may variable, both spontaneously and with therapy. The prevalence of asthma has risen in affluent countries over the 30 years but now appears to have stabilized, with approximately 10-20% of adults and 15% of children affected by the serious asthma disease. [5] The aim and goal of asthma disease treatment is to achieve and maintain clinical control. Clinical studies data were shown that asthma can be effectively prevented and controlled by intervening to suppress inflammation and also reverse the inflammation as well as treating and controlling the bronchoconstriction and related symptoms. Medications are available to treat asthma can be classified as controllers and relievers. Controllers are taken medications daily on a long-term basis to keep asthma disease under clinical control chiefly through their anti-inflammatory effects. It includes inhaled and systemic glucocorticoids, leukotriene receptor antagonists and long-acting inhaled β2- Vol 5, Issue 2,

3 agonists in combination with orally inhaled glucocorticoids, sustained-release theophylline, cromones, anti-ige and Other systemic steroid-sparing therapies. Inhaled glucocorticoids are the most effective controller medications are currently available. Relievers are used medications on an as-needed basis that act quickly to reverse bronchoconstriction and relieve its symptoms. It include rapid-acting inhaled β2-agonists, inhaled anticholinergics, short-acting theophylline and short-acting oral β2-agonists. Thus these medications were control and relieve asthma disease can be used for prophylaxis and treatment of acute asthma episodes. [6] Present study is conducted to evaluate the drug pattern used in Bronchial Asthma and their rationality. MATERIALS AND METHOD Study site: The Oxford Medical College Hospital and Research Centre, Attibele, Bangalore Study design: This was Prospective observational study. Duration of study: Study was conducted for a period of 6 months. Study population included all the patients who are admitted during the period of 2014 to Study criteria Inclusion criteria Adult asthmatic patients (above 18 years) admitted in the General Medical Ward during the study period. Exclusion criteria Out patients. Pediatrics. Sample size: Total of 153 patients, diagnosed with asthma. Sources of Data Collection All the necessary and relevant data were obtained from the medical records of patients which mainly included admission sheets, patient history notes, patient treatment charts, laboratory data reports, progress sheets, nurses, records, prescriptions, doctors, orders. Materials used 1. Standard Case Record Form (CRF) (Annexure I) To collect the necessary data from the patient medical records, a suitable CRF was designed. The CRF basically contains demographics-age, gender, occupation, personal history, medical and medication history, etiological factors, vital signs, duration & severity of disease, diagnosis, drug treatment chart, identification of adverse drug reactions and drug interactions. Vol 5, Issue 2,

4 2. Informed Consent Form (Annexure II) Consent from the patient was taken by signing the Informed Consent Form during the data collection required for the study. 3. Adverse drug reaction (ADR) reporting form (Annexure III) The standard ADR reporting form was obtained from the department. The form comprised of patient demography, drug(s) prescribed, date of commencement and date of stopping therapy, date of onset of ADR s. 4. Naranjo s causality assessment scale (Annexure IV) Naranjo s causality assessment scale is used to categorize the adverse drug reactions into Definite, Probable, Possible and Unlikely. Operation Modality a. Identification of patient Asthma cases from General Medical Ward of The Oxford Medical College Hospital and Research Centre. b. Collection of data The medical records of Asthma patients who are admitted in the hospital during the period of collected from the General Medical Ward. Demographical details like name, age, sex, occupation and history like medical, medication, family and social were recorded. Along with that other details like duration of disease, severity of disease, allergic status, treatment pattern, cost, identification of ADR of drugs and drug interactions were recorded in a predesigned CRF. The data gathered were analyzed for different parameters statistically. c. Interpretation of Data c. 1. Demography Age The mean age and standard deviation of the study population was calculated. Gender wise distribution of study population All the cases were categorized based on gender and the percentage of each was presented. Along with it male to female ratio was determined. Vol 5, Issue 2,

5 Occupational history, Economic status, family history, Social habits of study population Patient s family history, social habits such as alcoholism, cigarette smoking and tobacco usage were recorded and their percentages were calculated. The patients were categorized into four grades (group) I, II, III and IV according to their occupation to determine the economic status. People who are government employees, doctors, engineers and teachers were included in Grade-I, while clerical staff, driver, security, peon, cook, carpenter in Grade-II and gardeners, sweeper, painter, textile worker and others were included in Grade- III. Grade IV include patients who are not working. The required data were collected and the percentage was calculated. c. 2. Precipitating Factor Patient s allergies towards dust, pollen, food etc. and any preinfections such as bronchitis, LRTI, hay fever, pneumonia, pharyngitis, eczema were recorded and percentage were calculated. c. 3. Symptoms of asthma Clinical signs and symptoms at the time of admission were noted in the predesigned CRF. The frequency and percentage of every sign and symptoms were calculated. c. 4. Duration of asthma The mean duration of disease in days of the study population was calculated. c. 5. Severity of asthma The Global Initiative of Asthma (GINA) subdivided asthma by severity based on level of symptoms, airflow limitations and lung function variability into four categories: Mild intermittent, Mild persistent, Moderate persistent and Severe persistent and in this study their percentage were calculated. c. 6. Diagnosing Pattern According to which technique (PFT, Chest X-ray) the patient was diagnosed were recorded and percentage were calculated. c. 7. Treatment pattern Treatment was given to the patient according their symptoms of disease were recorded. From the prescriptions we collected information such as drugs prescribed, dose, frequency, route of administration and cost for each drug were recorded. From this the most commonly used Vol 5, Issue 2,

6 drugs and their preferred route of administration and the method of therapy (mono or combination therapy) were found out. c. 8. Adverse drug reactions Drugs and its adverse drug reactions were recorded. The frequency and the percentage were calculated. c. 9. Drug interactions Most commonly occurring drug interactions with in the prescription were found out and recorded. c. 10. Statistical analysis of data Data Analysis was performed using Descriptive statistics. RESULTS A total of 153 patients admitted in The Oxford Medical College Hospital and Research Centre for the management of bronchial asthma during the period of September 2014 to February 2015 were enrolled in the study based on study criteria. Patient distribution based on Age and Gender The prescription data of 153 asthma patients were analysed in the current study, out of which 110 were of males (71.89%) and 43 of females (28.10%). The mean age of all patients was found to be ± years being ± and ± years in male and female respectively. The male to female ratio was found to be 2.55 from the study (Table 1). Table 1: Tabular representation of Age and Gender. Gender No of patients, N (%) Mean age ± SD (Years) Total ±13.92 Male Female 110(71.89) 43(28.10) 52.52± ±15.27 Patient distribution based on Age Group Asthma patients were divided into 3 groups. Majority of the asthma patients were likely to fall in the age group of years was 89 (58.16%) (Figure 1). Vol 5, Issue 2,

7 Figure 1: Graphical representation of Age Group wise distribution. Patient distribution based on Economic status As per analysis, out of 153 patients most of them were in Grade III 86(56.20%) followed by Grade II 39(25.49%), Grade I 14(9.15%) and Grade IV 14(9.15%) (Figure 2). Figure 2: Graphical representation of Economic status. Patient distribution based on Socio Family history We divided total 153 patients into 3 different categories. 39 without any habits, 52 had mixed habits of tobacco, smoking and alcoholism and 62 with any one of these habits as shown in the (Figure 3). Vol 5, Issue 2,

8 Figure 3: Graphical representation of Social history. Patient distribution based on precipitating factor We categorized total number of patients into 3 based on precipitating factor. It was found that 74(48.36%) patients were allergic, 49(32.02%) were idiopathic and 30(19.60%) were infective (Figure 4). Figure 4: Graphical representation of Precipitating Factors. Patient distribution based on Asthma symptoms Among the symptoms of bronchial asthma, shortness of breath (SOB) was found to be highest 118(78.6%) followed by wheezing 102(68%), cough with sputum 84(56%), chest tightness 68(45%), dry cough 34(22.6%) and headache 26(17.3%) (Figure 5). Figure 5: Graphical representation of Asthma symptoms. Vol 5, Issue 2,

9 Patient distribution based on Duration of disease Out of 153 patients in our study, the average duration of asthma was found to be 1.21 years, in males and females it was 1.09 and 1.50 years respectively. Patient distribution based on Severity grading In our study the majority of population had mild intermittent asthma 87(56.86%) and severe persistent asthma accounts for very few number of patients 9(5.88%) (Figure 6). Figure 6: Graphical representation of Severity grading of asthma. Patient distribution based on diagnosing pattern Our study population was diagnosed with asthma by physical examination and laboratory techniques like Pulmonary Function Test (PFT), Chest X-ray etc. All the patients had undergone physical examination for the signs and symptoms of asthma. Out of 153 patients, 101(66.01%) were diagnosed with both PFT and Chest X-ray and 52(33.98%) were diagnosed with only PFT. Patient distribution based on Drug therapy regimen Out of 153 patients, majority of them 64(41.83%) received multiple drug therapy (>4 drugs) followed by 4 drugs 53(34.64%), 3 drug 28(18.30%) and 2 drug 8(5.22%) (Figure 7). Figure 7: Graphical representation of Drug therapy regimen. Vol 5, Issue 2,

10 Commonly prescribed Anti-Asthmatics It has been seen that all the patients received therapy at an average of drugs per prescription. Methyl Xanthines were the most frequently prescribed group of anti-asthmatic drugs (132 patients) followed by corticosteroids (58 patients), antihistamines (49 patients), short acting β 2 agonist (10 patients), leukotriene receptor antagonist (6 patients) and anticholinergics (4 patients) (Figure 8). Figure 8: Graphical representation of commonly prescribed anti-asthmatic drugs. Patient distribution based on fixed dose combinations Majority of the patients were prescribed with Salbutamol+Ipratropium bromide (55.49%), followed by Salbutamol+Beclomethasone (16.33%), Budesonide+Formetrol (9.80%) and Salmetrol+Fluticasone (7.18%) (Figure 9). Figure 9: Graphical representation of fixed drug combinations. Patient distribution based on Adjuvant therapy Our study also showed that antibiotics (35.29%), antacids (33.33%), multi-vitamins (24.83%) and NSAIDs (17.64%) were prescribed as adjuvant therapy. Among the antibiotics, Vol 5, Issue 2,

11 levofloxacin (50%) were prescribed mostly followed by, ofloxacin (29.62%), amoxicillin (14.81%) and azithromycin (5.55%) which are highly effective against respiratory infections. Among antacids, pantoprazole (43.13%), omeprazole (37.25%) and ranitidine (19.60%) were prescribed. Paracetamol (74.04%) ibuprofen (14.81%) and diclofenac (11.11%) were given for pain management % of patients were prescribed with multi-vitamins. Patient distribution based on route of administration Our study also revealed that oral route (55.80%) was the most preferred one over inhalation (27.76%) and parenteral route (16.43%) (Figure 10). Figure 10: Graphical representation of Route of Administration. Drug regimen based on duration of disease From the study it was evident that, patients with longer duration of disease were prescribed with more number of drugs for the management (Table 2). Table 2: Tabular representation based on average duration of disease and drug regimen prescribed. Average duration of disease (in years) Adverse Drug Reaction (ADR) profile Drug regimen prescribed Drug Drug Drug 3.98 >4 Drug In our study, out of 153 patients, Adverse Drug Reaction (ADR) was observed in 34(22.22%) patients. Most common age group developed ADR was found to be 61-80(52.94%) followed by 41-60(29.41%) and 20-40(17.64%). Among 34 patients 28 were males and 6 were females experienced the ADR. Out of all the ADRs observed, tremor was the mostly occurred one. Vol 5, Issue 2,

12 Causality assessment was done for each adverse drug reactions by Naranjo s Causality Assessment Scale. It was found that 4(66.66%) of the adverse drug reactions fell into Probable category and 2(33.33%) adverse drug reactions were in Possible category. Drug Interactions From the prescription analysis, equal number of major and moderate drug interactions was found which are given in the Table-3. Table 3: Tabular representation of Drug Interactions. Drugs interacted Severity Effects Levofloxacin+Theophylline Major Aminophylline+Levofloxacin Major Azithromycin+Levofloxacin Budesonide+Levofloxacin Azithromycin+Theophylline Budesonide+ Ofloxacin Major Moderate Moderate Moderate Results in theophylline toxicity(nausea, vomiting, palpitation, tremor) Results in theophylline toxicity(nausea, vomiting, palpitation, tremor) Results in increased risk of QT interval prolongation Results in increased risk of tendon rupture Results in increased serum theophylline concentrations Results in increased risk of tendon rupture No of patients (%) 22(14.66%) 4(2.66%) 2(1.33%) 9(6%) 4(2.66%) 2(1.33%) DISCUSSION Bronchial asthma was seen as one of the leading cause of morbidity and mortality in rural India. [7] We carried out a prospective observational study to assess the drug utilization in asthma patients in tertiary care hospital. By analysis 153 asthmatic cases, our study revealed that asthma was more prevalent in males (71.89%) than in females (28.10%). [8] This is synonymous with the study conducted in Andhra Pradesh by Languluri Reddenna et al. As per the socio economic status most of the patients in our study were from Grade III (56.20%). A study conducted by R.D Shimpi et al showed similar results. [9] Among all the patients involved in the study 50% were smokers 35.48% were tobacco chewers and 14.51% were alcoholic. This concludes that higher prevalence of asthma was Vol 5, Issue 2,

13 associated with active smoking and tobacco chewing. Studies done by PR Gupta and DK Mangal also conclude the same. [10] Our study showed that the major precipitating factors for asthma were allergies (48.36%), followed by infections (19.60%) and unknown causes (32.02%). Similar results were also given by the studies of T. Rajathilagam et al. In our study, among the symptoms of bronchial asthma, shortness of breath (78.6%) was found to be highest than other symptoms. Our study is similar to the study done by Languluri Reddenna et al. Study carring of 153 patients the average duration of asthma was found to be 1.21years, in males and females it was 1.09, 1.50 years respectively. Study of T. Rajathilagam et al. showed that average duration of bronchial asthma in all patients was 5.4 years, being 5.4 and 5.3 years in men and women respectively. This made us to conclude that there is significant reduction in the average duration of asthma in India during this period. In our study majority of patient suffered from mild intermittent asthma (56.86%) and very few with severe persistent asthma (5.88%). These results were contrast to study conducted by Languluri Reddenna et al showed higher number in severe persistent asthma. The diagnosis of asthma is usually done by physical examination, spirometry, airway responsiveness, imaging, hematologic test, skin test, exhaled NO test etc. Drummond et al suggested that improving access to spirometry in primary care may improve diagnosis and compliance with asthma guidelines. [11] In our study all the patients had undergone physical examination for the signs and symptoms of asthma. Out of 153 patients, 66.01% were diagnosed with both spirometry and Chest X-ray and 33.98% were diagnosed only with spirometry. Since asthma patients often require more than one drug for control of asthma symptoms hence combination are required to treat asthma. In this study majority of them (41.83%) received multiple drug therapy (>4 drugs) followed by 4 drugs (34.64%), 3 drug (18.30%) and 2 drug (5.22%). This is analogous with the study done by Patel Pinal D et al. This prescribing trend may be attributed to the goals of asthma therapy to minimize chronic symptoms of asthma, to prevent recurrent exacerbations, to reduce the need for hospitalization and also maintain near normal pulmonary function. Overall drug utilization Vol 5, Issue 2,

14 pattern showed Methyl xanthine (86.27%) was to be among maximum used category probably due to their lower cost. Studies of Arumugam et al and Kumar et al also showed similar trends. [12,13] The study analysis suggests that symptomatic relief agents were more prescribed than asthma controlling agents. In our study some patients were also prescribed with fixed dose combinations. Among them Salbutamol with ipratropium bromide was the most frequently prescribed combination (52.49%). These were contrast to the results of Adil Hameed et al in which Salbutamol with Beclamethasone (90%) was the most frequently prescribed one. [14] Our study also showed that antibiotics, multivitamins, antacids and NSAID s were prescribed as adjuvant therapy. Among the antibiotics, Levofloxacin (50%) were prescribed mostly followed by, Ofloxacin (29.62%), Amoxicillin (14.81%) and Azithromycin (5.55%) which are highly effective against respiratory infections. It was contrast to the studies of T Rajathilagam et al in which amoxicillin was the more prescribed antibiotic. The route of administration of anti-asthmatics is concerned it was observed that in our study that oral route was the mostly preferred route (55.80%) followed by inhalation (27.76%) and parenteral route (16.43%). These results were in par with the studies conducted by R.D Shimpi et al. The inhalation route to lungs causes a high local concentration in the lungs with a low systemic delivery, significantly improves the therapeutic effectiveness and minimizes the systemic side effect. [15,16] According to the standard treatment guidelines of asthma, inhalation therapy should be the first choice, but only 27.76% patients at the time of study used inhalers this could be because of prescribers do not believe in prescribing it or on the patient s side, the level of acceptance is low apart from patients non-compliance and coordination associated with use of inhaler. However this will require more of patient s education and knowledge convincing by the treating physician or by the clinical pharmacist for inhalation therapy. Our study also identified certain Adverse Drug Reactions (ADRs) caused by anti-asthmatic agents. Patients in the age group of (52.94%) encountered majority of the Adverse Drug Reactions (ADRs). In general the incidence of Adverse Drug Reactions (ADRs) is Vol 5, Issue 2,

15 higher in elderly patients, the reason could be that metabolizing capacity and the excretory functions are generally diminished and leading to accumulation of drugs in the body. In the present study males were found to have more number of Adverse Drug Reactions (ADRs) when compared to females as our study population includes majority of the male patients. From the present study analysing the prescription equal numbers of major and moderate drug interactions were found. It was contrast to the studies of R. D. Shimpi et al who did not found any of the drug interactions. Major interactions were seen with Levofloxacin+Theophylline, Aminophylline+Levofloxacin, Azithromycin+Levofloxacin and moderate once with Budesonide+Levofloxacin, Azithromycin+Theophylline, Budesonide+Ofloxacin. Either prescribing an alternative drug or adjusting the dose of prescribed medicine can resolve the effects of drug interactions. CONCLUSION Prospective observational studies were conducted to evaluate the drug utilization, assess the drug interaction and adverse drug effects in asthmatic patients in tertiary care hospital, Bangalore. In our study, we observed that the incidence of asthma was more common in males when compared to females. Majority of the patients were from the age group of years. Most of the patients were prescribed with multiple drug therapy out of which oral route was the most preferred one. Even though Methyl xanthine was the most commonly prescribed class of drug, they could have been avoided due to their adverse effects and instead could have used other safe antiastmatics which are available. Adverse drug reactions were found in 22.22% of asthma patients who received drug therapy. The age group of (52.94%) had a higher incidence of ADRs. Tremor is the commonest ADRs reported. According to the Naranjo s scale the majority of ADRs (66.66%) were found to be probable. Equal numbers of major and moderate drug interactions were also found in our study by analysing the prescription. ACKNOWLEDGEMENTS Authors would like to express sincere gratitude and respectful thanks to Prof. Dr. Padmaa M. Paarakh, Principal, The Oxford College of Pharmacy, Bengaluru for providing necessary facilities to carry out research. Also would like to thanks to faculty members of Department Vol 5, Issue 2,

16 of Pharmacy Practice, The Oxford College of Pharmacy, Bengaluru for their constant support and help. REFERENCES 1. Joint Commission on the Accreditation of Healthcare Organizations comprehensive accreditation manual for hospitals. Oakbrook Terrace (IL): Joint Commission on the Accreditation of Healthcare Organizations, Kubacka RT. A primer on drug utilization review. J Am Pharm Assoc, 1996; NS (4): Sachdeva PD, Patel BG. Drug Utilization Studies-Scope and Future Prespectives. International Journal on Pharmaceutical and Biological Research, 2010; 1(1): McFadden ER. Disease Of The Respiratory System', in Braunwald, Eugene., et al (ed.) Harrison's Principles Of Internal Medicine. USA: McGraw-Hill Companies, Inc., 2001; Longo LD, Kasper LD, Jameson LJ, Fauci SA, Hauser LS, Loscalzo Joseph. Harrison's Principles of Internal Medicine, 18 th ed. United States of America: McGraw-Hill companies, 2012; Rajathilagam T., Sandozi Tasneem, Nageswari AD., Paramesh P., Rani Jamuna R. Drug Utilization Study in Bronchial Asthma in a Tertiary Care Hospital International Journal of Pharmaceutical Applications, 2012; 3(ISSN ): Patel PD, Patel RK, Patel NJ. Analysis of Prescription Pattern and Drug Utilization in Asthma Therapy. International Research Journal of Pharmacy, 2012; 3(7): Reddenna Languluri, Krishna Rama Tedlla, Basha Ayub Shaik, Venugopal Donthu. Assessment of Prevalence, Risk factors, Treatment in Asthmatic patients in a South Indian hospital. American Journal of Pharmacy and Health Research, 2013; 1(8): Shimpi RD, Salunkhe PS, Bavaskar SR, Laddha GP, Kalam, A. (2012) Drug utilization evaluation and prescription monitoring in asthmatic patients, International Journal of Pharmacy and Biological Sciences, 2012; 2(eISSN: ): Gupta PR, Mangal DK. Prevalence and risk factors of bronchial asthma in adults in Jaipur District of Rajasthan (India). Lung India, 2006; (23): (accessed 09 March 2015): Vol 5, Issue 2,

17 11. Drummond N, Abdalla M, Bcukingham JK, Osman LM. Effectiveness of routine selfmonitoring of peak flow in patients with asthma. BMJ, 1994; 308: Carruthers AA. Thrombolytics-drug utilization review in a district general hospital, J Clin Pharm Ther, 1997; 22: Anil K, Tiwari HK, Kulkarni SK. Drug utilization assessment in Asthma Therapy through prescription monitoring. Indian Journal of Hospital Pharmacy, 2004; 2: Hameed Adil, Bukhsh Allah, Raza Sohaib, Asif Muhammad, Ali Asad, Ahmed Rohan, et al. Prescribing trends in Asthmatic patients in Lahore. British Biomedical Bulletin, 2014; 2(2): Johnson CE. Aerosol corticosteroid for the treatment of asthma. Drug Intell Clin Pharm., 1987; 21: Taburet AM Schmit B. Pharmacokinetic optimization of asthma treatment. Clin Pharmacokinet, 1994; 26: Vol 5, Issue 2,