STEROID

Abstract

Background: Because systemic corticosteroids are associated with severe adverse effects, a study on the prescribing pattern for rationalizing drug therapy is needed. Objective: The purpose of this study was to assess the prescription pattern of systemic steroidal drugs at the outpatient department of Menelik II Referral Hospital, Addis Ababa, Ethiopia, 2019. Methods: A cross-sectional study design was used to assess the prescription pattern of systemic steroidal drugs in the outpatient department of Menelik II Referral Hospital. A total of 384 patient charts were included in the study. The sample was selected by using a non-probability quota sampling method. The data was collected from patient charts by using a checklist and analyzed by using SPSS version 20 computer software package. Finally, the data was presented with tables, graphs and charts. Results: A total of 384 patient medical charts were reviewed during the study period. From which, 61.2% were females and 22.4% were in the age group of 31-40 years. The majority, 63.5%, of systemic corticosteroid use was indicated for respiratory disorders and the most frequently prescribed drug was prednisolone (42.4%). It was also found that intermediate acting corticosteroids (prednisolone and methyl prednisolone) were mostly prescribed during the study period. Conclusion: In this study, most steroids were indicated for respiratory disorders and prednisolone was found to be the most widely prescribed medication among systemic steroids.

Full text

ORIGINAL RESEARCH
Assessment of Prescription Pattern of Systemic
Steroidal Drugs in the Outpatient Department of
Menelik II Referral Hospital, Addis Ababa,
Ethiopia, 2019
This article was published in the following Dove Press journal:
Patient Preference and Adherence
Yohannes Tsegyie Wondmkun
Akeberegn Gorems Ayele
Department of Pharmacology and
Clinical Pharmacy, School of Pharmacy,
College of Health Sciences, Addis Ababa
University, Addis Ababa, Ethiopia
Background: Because systemic corticosteroids are associated with severe adverse effects,
a study on the prescribing pattern for rationalizing drug therapy is needed.
Objective: The purpose of this study was to assess the prescription pattern of systemic
steroidal drugs at the outpatient department of Menelik II Referral Hospital, Addis Ababa,
Ethiopia, 2019.
Methods: A cross-sectional study design was used to assess the prescription pattern of
systemic steroidal drugs in the outpatient department of Menelik II Referral Hospital. A total
of 384 patient charts were included in the study. The sample was selected by using a non-
probability quota sampling method. The data was collected from patient charts by using
a checklist and analyzed by using SPSS version 20 computer software package. Finally, the
data was presented with tables, graphs and charts.
Results: A total of 384 patient medical charts were reviewed during the study period. From
which, 61.2% were females and 22.4% were in the age group of 31–40 years. The majority,
63.5%, of systemic corticosteroid use was indicated for respiratory disorders and the most
frequently prescribed drug was prednisolone (42.4%). It was also found that intermediate
acting corticosteroids (prednisolone and methyl prednisolone) were mostly prescribed during
the study period.
Conclusion: In this study, most steroids were indicated for respiratory disorders and
prednisolone was found to be the most widely prescribed medication among systemic
steroids.
Keywords: prescribing pattern, systemic steroid, corticosteroid, prednisolone
Introduction
Steroids are among the most frequently prescribed drugs in the world because they are
extremely effective for the relief of symptoms of many inammatory and immune
disorders and other conditions.
1
Systemic steroids are synthetic forms of natural
steroids, cortisol, developed by adrenal glands, which have powerful anti-
inammatory effects. Oral or parenteral systemic corticosteroids (e.g. dexamethasone,
prednisolone, and methyl prednisolone) exhibit strong immunomodulatory, anti-
inammatory, and anticancer properties and are essential to the treatment of various
disorders, including autoimmune disorder, allergic reactions, chronic obstructive
pulmonary disease, asthma exacerbations, and in some selected malignancies
2,3.
Correspondence: Yohannes Tsegyie
Wondmkun
Department of Pharmacology and Clinical
Pharmacy, School of Pharmacy, College of
Health Sciences, Addis Ababa University,
P.O. Box 1176, Addis Ababa, Ethiopia
Email yonitse2015@gmail.com
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http://doi.org/10.2147/PPA.S285064
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accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly
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2021:15

Glucocorticoids (GCs) provide rapid relief within hours of
treatment. Systemic treatment is started with large doses that
are then tapered quickly and tapering is frequently part of
treatment protocols to decrease the risk of relapse.
4
Since
GCs potently inhibit inammation and are used in a number
of inammatory and autoimmune diseases, they are one of
the most commonly prescribed drug categories. Because
GCs affect almost every organ system, the therapeutic use
and removal of corticosteroids is affected by a variety of
severe adverse effects, some of which are life-threatening.
Therefore, the decision to apply systemic corticosteroid
therapy also requires careful consideration of relative risks
and benets for each patient, intra-articular GCs are useful if
only a few joints are involved and septic arthritis is
removed.
5
The under-use of steroids results in a sub-therapeutic
effect, while overdose of steroids, not considering the
exact amount of steroids, results in different adverse effects.
The pharmacists should also share responsibility for educat-
ing patients on the proper administration of systemic corti-
costeroids, the pace of administration, and so on. Patients
should also consider the disease and its progression, the
complications caused by insufcient treatment, and the use
and abuse of drugs and their consequences.
6
Drug use or drug use measurement trials are legitimate
and structured quality assurance systems. These studies
are designed to review medication usage and suggest
medication trends with existing recommendations or
guidelines for the treatment of a particular disease. Drug
use is measured at the community level by age, sex, and
social status. Daily audits of medications are required to
improve clinical efcacy, minimize adverse effects, ques-
tion prescribers and assess the application of medical care
requirements. Inappropriate prescriptions are known
worldwide as a main healthcare concern, particularly in
developing countries.
7,8
Since corticosteroids play
a crucial role in the treatment of many diseases, including
the skin, they are commonly prescribed by clinicians.
According to World Health Organization gures, 50% of
all drugs are wrongly prescribed, administered or sold, in
particular, by GCS. These drugs are extensively adminis-
tered due to their strong immunosuppressive and anti-
inammatory action. This activity has also contributed to
over-prescription of these medications and, as a result,
increased adverse drug reactions. Corticosteroids were
developed in the early 1950s; since then, these drugs
have been commonly used for different clinical condi-
tions, requiring important caution in the selection of
corticosteroid medications for use and their dosing
schedule.
9,10
Although drug prescription patterns are
widely studied in Ethiopia,
11,12
specic information is
lacking for GCs in this regard. It is therefore essential to
research the medication prescription pattern of systemic
corticosteroids. Therefore, this study was aimed to assess
prescription pattern of systemic steroid drugs at the out-
patient department of Menelik II Referral Hospital, Addis
Ababa, Ethiopia.
Methods
Study Area and Period
This study was conducted in Menelik II Referral Hospital,
Addis Ababa, the capital city of Ethiopia and the head-
quarter of the African Union. Addis Ababa has 13 public
hospitals, 32 private hospitals and 93 health centers. The
study was conducted from April to June 2019 GC.
Study Design and Population
A cross-sectional study design was used to assess prescrip-
tion patterns of systemic steroidal drugs at the outpatient
department of Menelik II Referral Hospital. All patient
medical charts with systemic steroidal drugs at the out-
patient department of Menelik II Referral Hospital were
included in the study.
Sample Size Determination and Sampling
Techniques
The sample size for the study was determined using single
population proportion formula by assuming 95% con-
dence level, 5% marginal error, and 50% proportion of
appropriate systemic steroidal prescription pattern.
zα=2
 �2P�1pð Þ
d2¼1:96ð Þ2�0:5� ð10:5Þ
0:05ð Þ2¼384
Therefore, the sample size for the study was 384 patient
medical charts with systemic steroidal prescriptions. Non-
probability quota sampling method was used to select
patient medical charts. Patient medical charts with sys-
temic steroidal prescription were included in the study
until the required sample size is reached (384 patient
medical charts with systemic steroidal prescriptions).
Inclusion and Exclusion Criteria
Medical charts which contain systemic steroidal drugs
were included in the study whereas, incomplete patient
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medical charts and those contain non-systemic steroidal
drugs were excluded from the study.
Study Variables
The dependent variable was systemic steroidal prescription
pattern while the independent variables were socio demo-
graphic characteristics (sex and age), indication, type of
drug dose, route of administration, frequency and duration.
Data Collection Procedure
Data was collected by using a data abstraction checklist
developed by the investigators. The data were collected by
reviewing patient medical charts that contain systemic
steroidal prescriptions.
Data Quality Management
To maintain the quality of the data only complete medical
charts were included in the study. The collected data were
checked for completeness and accuracy. After data entry,
data cleaning was performed.
Data Analysis and Procedures
Data were entered and analyzed using SPSS version 20
statistical software. Frequencies and percentages were
done to organize and summarize the data. Finally, the
result was presented with tables, graphs and charts.
Ethical Consideration
Ethical clearance was obtained from Addis Ababa
University, College of Health Sciences, School of
Pharmacy institutional review board with a reference num-
ber of ERB/SOP/251/02/2019 and an ofcial letter was
written to Menelik II Referral Hospital to secure permis-
sion. Condentiality and privacy of the data was ensured
during the collection period. The patient’s name and
address were not recorded on the data abstraction checklist
and the collected information was used for research only.
Moreover, the study was carried out in accordance with
World Medical Association Declaration of Helsinki.
13
Operational Denition
Adverse Drug Reaction
Unwanted or harmful reaction following administration of
drugs.
Prescription Pattern
Are prescribing, dispensing and distribution of medicine.
Systemic Steroid
Is one of a group of chemical substances found in our
body and made articially and used for the treatment of
various disease ailments.
Outpatient
A patient who is not hospitalized, but instead comes to
a physician ofce, clinic, for treatment.
Results
Socio-Demographic Characteristics
In this study, from 384 assessed patient medical charts with
steroids, the majority of them, 235 (61.2%), were female. The
age group of 31–40 and <20 years accounted for the highest
and the lowest number of patients respectively (Table 1).
Common Indication of Systemic
Corticosteroids
A total of 384 patient medical charts were analyzed in
Menelik II Referral Hospital in the outpatient department.
Out of this, respiratory disorders 244 (63.5%), meningitis 39
(10.2%) and rheumatoid arthritis 29 (7.6%) are the top three
disease conditions in which corticosteroids are prescribed
with the highest frequency (Table 2). On the other hand,
stroke, deep vein thrombosis, lung and esophageal cancer
represent conditions where corticosteroids are prescribed
with the lowest frequency 1 (0.26%) (not shown on the table).
Patterns of Systemic Corticosteroid Use
From the total of 384 patient medical charts analyzed,
prednisolone was the most frequently prescribed drug 163
(42.4%), followed by hydrocortisone 117 (30.5%),
Table 1 Socio-Demographic Characteristics of Patients
Receiving Systemic Corticosteroids, Menelik II Referral
Hospital, Addis Ababa, Ethiopia, 2019
Variable Frequency Percent
Sex Male 149 38.8
Female 235 61.2
Age <20 yrs 47 12.2
21–30 yrs 54 14.1
31–40 yrs 86 22.4
41–50 yrs 77 20.1
51–60 yrs 58 15.1
>60 yrs 62 16.1
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dexamethasone 92 (24.0%), beclometasone puff 10 (2.6%),
and methyl prednisolone 2 (5%) (Figure 1).
Route of Administration of Systemic
Steroidal Drugs
Most systemic GCs were administered intravenously (IV)
(51.3%) out of the total of 384 examined patient medical
charts at Menelik II Referral Hospital, while the least
number of GCs were given through intramuscular (IM)
route 5 (1.3%) (Figure 2).
Polypharmacy
The number of drugs per prescription varied from one
to three and greater than three. The majority of the
prescriptions contained two drugs per prescription
163 (42.4%), followed by >three drugs per prescription
94 (24.5%), three drugs per prescription 75 (19.5%), and
one drug per prescription 52 (13.5%) (Table 3).
Common Class of Steroid Use Based on
the Duration
Intermediate-acting corticosteroids (prednisolone, methyl
prednisolone) were mostly prescribed 165 (43.0%) fol-
lowed by short-acting (hydrocortisone, beclomethasone)
127 (33.1%) and long-acting corticosteroids (dexametha-
sone) 92 (24%) (Table 4).
Discussion
In the present study, patients treated with corticosteroids
were mostly between 31–40 years of age (22.4%), and
most of them were female (61.2%). As per the demo-
graphic data collected, this result was in line with the
study conducted in India in which out of the total, 58.3%
were female patients.
14
This data showed that mid-aged
group in both populations are almost equally prone to
diseases for which steroids are used. But it is inconsistent
with the study done at the District General Hospital in
Amravati region, India which showed that 94 (53%) indi-
viduals were male patients.
15
Respiratory diseases 244 (63.5%) were the major and
cancer 4 (1.0%) was the least disorder for systemic corti-
costeroids to be indicated. This result is comparable with
Table 2 Common Indications of Systemic Corticosteroids at
Menelik II Referral Hospital in Outpatient Department, Addis
Ababa, Ethiopia, 2019
Indications Frequency Percent
Respiratory disorders 244 63.5
Extrapulmonary tuberculosis 19 4.9
Meningitis 39 10.2
Cancer 4 1.1
Kidney disorders 7 1.8
Pneumocystis pneumonia 14 3.6
Allergic dermatitis 5 1.3
Rheumatoid arthritis 29 7.6
Others 23 6.0
Total 384 100
Figure 1 Patterns of systemic corticosteroid use at the OPD of Menelik II Referral Hospital, Addis Ababa, Ethiopia, 2019.
Figure 2 Route of administration of systemic steroidal drugs outpatient depart-
ment at Menelik II Referral Hospital, Addis Ababa, Ethiopia, 2019.
Abbreviations: IM, intramuscular; IV, intravenous; PO, per oral route.
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a study done in India, where 61.82% of indications were
for respiratory tract disorders.
16
The nding of this study
also showed that prednisolone was the most commonly
prescribed corticosteroid 163 (42.4%) while beclometha-
sone was the least prescribed drug 10 (2.6%). This nding
is comparable with a study done in Denmark where pre-
dnisolone was the most frequently prescribed GC,
accounting for 50% of all prescriptions assessed in the
period.
17
Out of the 384 patient medical charts analyzed,
the highest number of systemic corticosteroids were admi-
nistered through the intravenous (IV) route, accounting for
197 (51.3%), and the least was intramuscular, 5 (1.3%).
This result is contrary to a study done in India where
systemic corticoids administered through inhalation
(44.5%) is higher than the IV route (24%).
18
The majority
of the prescriptions in this study contained two drugs per
prescription 163 (42.4%). But, in another study done in
India, the most common number of drugs per prescription
was three (42.2%).
19
This difference might be due to the
degree of disease progression which requires more drugs
in the latter study. Intermediate-acting corticosteroids (pre-
dnisolone, methyl prednisolone) were prescribed in most
of the cases 165 (43.0%). This nding was in line with
a study done in India, in which out of 119 GCs prescribed,
intermediate acting corticosteroids that comprised of pre-
dnisolone and methyl prednisolone were most commonly
prescribed (38.66%).
18
Limitation of the Study
This was a cross-section study and the cause and effect
were evaluated simultaneously. Therefore, the causal link
could not be established due to the lack of a temporal link.
As the sample size for this analysis was taken from one
hospital using a quota sampling procedure, the ndings
presented here should be interpreted with caution and
cannot be generalized to the entire population. The present
study was also focused on the examination of the records;
therefore, there were no inherent design limitations such as
incompleteness of the data.
Conclusion
From this study, it can be concluded that among sys-
temic steroids prednisolone was found to be the most
frequently prescribed drug followed by hydrocortisone.
Most of these corticosteroids were prescribed for
respiratory disorders.
Abbreviations
GC, glucocorticoids; IV, intravenous; IM, intramuscular;
PO, per oral; WHO, World Health Organization.
Data Sharing Statement
The datasets used during the current study are available
from the corresponding author on reasonable request.
Acknowledgments
The authors sincerely thank Addis Ababa University,
College of Health Sciences, School of Pharmacy,
Department of Pharmacology and Clinical Pharmacy for
approving this study. We also thank the staff of Menelik II
Referral Hospital for their cooperation and allowing us to
conduct this study.
Author Contributions
All authors contributed to data analysis, drafting or revis-
ing the article, have agreed on the journal to which the
article will be submitted, gave nal approval of the version
to be published, and agree to be accountable for all aspects
of the work.
Funding
This study was done with no nancial support for any of
the partial or complete work.
Table 3 Number of Drugs per Prescription at Menelik II Referral
Hospital in Outpatient Department, Addis Ababa, Ethiopia, 2019
Number per Prescription Frequency Percentage
1 drug 52 13.5
2 drugs 163 42.4
3 drugs 75 19.5
>3 drugs 94 24.5
Total 384 100
Table 4 Common Class of Corticosteroid Use Based on
Duration at OPD of Menelik II Referral Hospital, Addis Ababa,
Ethiopia, 2019
Common Class of Steroid Frequency Percent
Short-acting 127 33
Intermediate-acting 165 43
Long-acting 92 92
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Disclosure
The authors declare that they have no nancial and/or non-
nancial competing interests.
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