PRESCRIPTION PATTERN OF DIURETICS IN A TERTIARY CARE HOSPITAL

Diuretics are drugs that increase the rate of urine flow; clinically useful diuretics also increase the rate of excretion of Na+ (natriuresis) and an accompanying anion, usually Cl. Diuretics are a mainstay of therapy for a wide variety of diseases ranging from hypertension to the nephrotic syndrome. Objective: To study the prescribing patterns of diuretics in General Medicine and ICU. To assess the drugdrug interaction of diuretics. To study the route of administration of diuretics. Materials and methods: A prospective observational study was conducted over a period of six months at general medicine and ICU department of Basaveshwara Medical College and Hospital and Research Centre, Chitradurga.a otal of 100 in-patients are included as study subject. Results: Mostly prescribed diuretic in this study were furosemide (52.9%), followed by mannitol (28.1%), spironolactone (11.57%), torsemide (5.79%), amiloride (0.82%) and hydrochlorothiazide (0.82%). Out of 100 prescriptions 84.4% of diuretics prescribed in intravenous route, 15.6% of diuretics prescribed in oral route. Out of 100 prescriptions total 89 drug interactions with diuretics are found. In that 2.3% major interactions and 67.4% moderate interactions and 30.3% minor interactions are found. Conclusion: Prescription monitoring helped to reduce the diuretic usage errors with respect to dose and drug-drug interaction with other prescribed drugs to provide better patient care.


INTRODUCTION
Diuretics are drugs that increase the rate of urine flow; clinically useful diuretics also increase the rate of excretion of Na + (natriuresis) and an accompanying anion, usually Cl -. Most clinical applications of diuretics aim to reduce extracellular fluid volume by decreasing total-body NaCl content. Although continued administration of a diuretic causes a sustained net deficit in total-body Na + , the time course of natriuresis is finite because renal compensatory mechanisms bring Na + excretion in line with Na + intake, a phenomenon known as diuretic braking. 1 Diuretics are a mainstay of therapy for a wide variety of diseases ranging from hypertension to the nephrotic syndrome. 2 Diuretics are the drugs of choice for congestive heart failure, preferably combined with an ACEI .For patients with resistance to oral furosemide, bumetanide is an alternative loop-diuretic due to its better bioavailability. The indications for daily diuretic use may be inappropriate, e.g. Postural oedema, Climacteric complaints, Mastalgia, and the Premenstrual syndrome. 3 Loop diuretics inhibit the Na/2Cl -/K co-transporter in the thick ascending loop of Henle, resulting in decreased urine sodium and chloride reabsorption with natriuresis and diuresis. 4 . Generalized edema can develop in nephrotic syndrome, chronic kidney disease, heart failure, and liver cirrhosis. Usually patients with edema respond to dietary sodium restriction in combination with a loop diuretic. However, some patients become resistant to diuretics. Diuretic resistance is defined as failure to achieve the therapeutically desired reduction in edema even when a maximal dose of diuretic is employed. 5 Guidelines for the treatment of hypertension recommend that thiazide diuretics should be the preferred drugs in most hypertensive patients, including in diabetics, either alone or combined with drugs from other classes. 6 Diuretic drugs are prescribed for ankle oedema. Ankle oedema is a misleading sign only occasionally being associated with heart failure hence withdrawal of diuretics has been suggested for elderly patients with ankle oedema provided that the oedema is not caused by cardiac, renal, or hepatic insufficiency . 7 Acute decompensated heart failure (ADHF) is predominantly a disease of fluid overload and the primary therapeutic objective of most ADHF hospitalizations is fluid removal, with intravenous loop diuretics. 8 Of all drugs for HF treatment, diuretics are therapeutically superior in their efficacy in relieving clinical symptoms and signs. They are recommended in the presence of congestion until achievement of a euvolemic state and subsequently to prevent the recurrence of fluid retention. 9

Distribution of patients according to gender
Out of 100 patients 63 patients are male and 37 patients are female.

Distribution of patient based on number of diuretics per prescription
Among 100 patients, 81 patients were prescribed with single diuretic, 17 with two diuretics and 2 with three diuretics. The details are given in table 4 and graphically represented in fig 4.

Distribution according to route of administration.
Out of 100 prescriptions 84.4% of diuretics prescribed in intravenous route, 15.6% of diuretics prescribed in oral route. The details are shown in table 6 and graphically represented in fig 5.

DISCUSSION
In this study out of 100 prescriptions total 89 drug interactions with diuretics are found.

CONCLUSION
With the result obtained the following conclusions are made; • Mostly prescribed diuretic in present study was furosemide, and least prescribed was amiloride and hydrochlorothiazide.
• Age group of 71-80 found more in the study. Male patient were more when compared to female.
• Intravenous administration is most preferable route.
• Mostly found drug -drug interaction is moderate type.
• Prescription monitoring can reduce the diuretic usage errors with respect to dose and drug-drug interaction with other prescribed drugs to provide better patient care. Present study provides an idea for conducting Pattern of prescription on diuretic drugs at BMCH&RC and future studies are needed for the improvement in more diuretic drug use.

ACKNOWLEDGEMENT:
It is a pleasure and privilege to express my deep sense of thanks and indebtedness to the management of SJM College of Pharmacy Karnataka, dr. Yogananda r, professor and hod ,dept of pharmacy practice and Dr Bharathi DR , Principal of SJM College of Pharmacy for giving the consent and facilities to carry out this work