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A study on pattern of adverse drug reaction in an adverse drug reaction monitoring centre of a tertiary care hospital in South Kerala, India

Adverse drug reactions (ADR) are rated as fifth leading cause of death and accounts for approximately 5% of all hospital admissions. As per WHO, Adverse drug reaction is ‘any noxious change which is suspected to be due to a drug, occurs at doses normally used in man, requires treatment or decrease in dose or indicates caution in the future use of the same drug’. Pharmacovigilance is defined by World Health Organization as “the science and activities relating to the detection, assessment, understanding and prevention of adverse effects or any other possible drug-related problems”. ABSTRACT


INTRODUCTION
Adverse drug reactions (ADR) are rated as fifth leading cause of death and accounts for approximately 5% of all hospital admissions. 1 As per WHO, Adverse drug reaction is 'any noxious change which is suspected to be due to a drug, occurs at doses normally used in man, requires treatment or decrease in dose or indicates caution in the future use of the same drug'. 2 Pharmacovigilance is defined by World Health Organization as "the science and activities relating to the detection, assessment, understanding and prevention of adverse effects or any other possible drug-related problems" 2 .
It is one of the indispensable steps taken by Ministry of Health and Family Welfare, Government of India for ensuring rational and safe use of medicine. This program was launched nation-wide in July 2010. The mission of pharmacovigilance program of India (PvPI) is to safeguard the health of Indian population by ensuring that the benefit of use of medicine outweighs its risk. Since there is a considerable social and economic impact due to adverse drug reactions there is a need to engage each and every healthcare professionals and the public in this country for close monitoring of adverse drug reaction. 3 Pharmacovigilance centres have been set up in most countries. The Uppsala Monitoring Centre (Sweden) is the international collaborating centre. Indian Pharmacopoeia Commission (IPC) at Ghaziabad functions as National Coordinating Centre (NCC) for PvPI. Main responsibility of NCC is to monitor all ADRs of medicine being used in Indian population and to develop and maintain its own pharmacovigilance database for patient safety, so that regulatory intervention can be done. 3 There are four regional centres under PvPI, and they are expected to give training and technical supports to the newly enrolled AMCs and all other stakeholders under PvPI. 3 ADR monitoring centres (AMCs) are the corner stone of PvPI. 3 They are located in medical colleges and other institutes including peripheral hospitals.
They are expected to collect individual case safety reports and to provide expertise for assessing causality and severity of ADRs by using standard algorithms and rating scales. 2 In Kerala there are 9 AMCs. 4 Department of pharmacology government medical college Trivandrum has been recognized as adverse reaction monitoring centre since 2014 under PvPI. We are coordinating the pharmacovigilance activities in the state. The suspected ADRs were diagnosed by the treating physician of various clinical departments. Authors are receiving details of ADR in spontaneous ADR reporting form from various clinical departments of our institute and other hospitals. We first verify the report, and send through 'vigiflow' software to NCC, IPC Ghaziabad. Simultaneously we enter ADR data in the Microsoft excel sheet. In addition to this we are conducting awareness programs on pharmacovigilance activities for doctors and health professionals of various clinical specialities.
Despite the progress that has been made in pharmacovigilance, the burden on public health of adverse reactions to medicines (traditionally referred to as ADRs) remains significant. Pharmacoeconomic studies on the costs of ADRs suggest that governments pay considerable amounts from their health budgets towards covering the costs associated with them. 5 Under reporting of ADR from health professionals is another big problem. Through this study authors attempt to produce a detailed analysis of various patterns of ADRs using available data in this AMC. Also, in the study an attempt is made to assess causality and severity of ADR reported. This consolidated data can be used to educate health care professionals regarding various aspects of recently reported ADRs and presented to the policy makers to produce required regulatory steps. We hope this study will definitely give more insight in to various issues related to ADRs and thus helpful in strengthening the pharmacovigilance program in the country. And we hope this study will have the advantages in the following perspectives, • In Physician perspective, they will be more updated on ADRs, which will help them in safe and judicious use of drugs for better care of their patients. • In patient perspective, drug compliance will be improved due to less ADR, and hence overall cost of treatment can be reduced and hence better quality of life can be ensured.

Exclusion Criteria
• Cases which occurred outside Government Medical College, Trivandrum.
The details of the various adverse drug reactions were identified and analysed to find the pattern of adverse drug reactions including distribution of age, gender, causal drug group, system organ class. Also, an attempt is made to do causality assessment using WHO UMC scale and severity by using Heart wig Seigel Scale.

Statistical analysis
Data entered in Microsoft excel software and proportions were calculated.

RESULTS
In this study period our AMC have received 320 ADR cases from various specialities of our hospital, majority of reports were due to cutaneous manifestations. All cases were analysed for system organ class, various classes of drugs, causality, severity, outcome and seriousness. A high occurrence of ADR was seen in females (56%) compared to males (44%) and male: female ratio according to ADR occurrence was 0.78 ( Figure 1). Majority cases (62.2%) were of adult age group (between 18 and 60 years). 57(17.8%) paediatric patients i.e. 18 years and below experienced ADRs and 64(20%) geriatric patients i.e. 60 years and above experienced ADRs (Table 1).  The causality (Figure 2) was assessed for all 320 cases using WHO-UMC scale. Most of the ADR reported during study period were probably related (91.88%), possibly related were 7.8% and certainly related were 0.31%. Regarding the severity (Figure 3) of ADR, 75.6% were mild, 22.5% were moderate and 1.9% were severe. 80(25%) out of 320 cases were considered serious ( Figure 4) as they required hospitalisation, or it was a life-threatening event. The remaining 240 (75%) were non-serious and treated on outpatient basis. There was no death due to ADR during this study period. Analysis of frequency of ADR reported during study period based on various outcome ( Figure 5) categories shows that most of the reactions came under recovered category (77.5%), and not recovered were only 3.12% (Table 2).   If we exclude mild reaction (erythema and induration) caused by immunoglobulin and vaccines on giving test dose, major class of drugs that caused ADR was antibacterial (25, 7.8%) followed by anti-epileptics (24, 7.5%). In the antibacterial anti TB drugs (20%) and in antiepileptics' phenytoin (75%) produced highest number of reactions. In the organ system class affected, skin and subcutaneous system including administration site reaction (88.12%) were most common followed by gastrointestinal system including hepatobiliary, and next affected was nervous system.   Adverse drug reactions of some of the commonly seen drugs were given in the appendix 1. Most common ADRs were erythema, induration, and rash, itching (Table 3, 4, Appendix 1).

DISCUSSION
Adverse drug reaction (ADR) can cause considerable amount of morbidity and mortality with an increase in the medical expenses. 6 ADR can be considered as a differential diagnosis of variety of conditions, as it is difficult to diagnose. 7 In General Practice consultations around 3% and in unscheduled hospital inpatients around 6% were found to be due to ADRs. 7 In the present study we evaluate the pattern of the ADRs and tried to assess causality, severity, seriousness and outcome.
As per a recent study done in a private hospital in South India, ADR incidence was found to be 1.8%, which means around 2 cases per 100 patients. 8 In this study a total of 320 ADR cases were reported to our AMC in 6 months.
In this study 56% of cases reported were females and 44% were male with, male-Female ratio of 0.78. In a study done in a teaching hospital in India shows similar result, out of the total cases reported females were more compared to males. 6 In this study mean age of patients reported with ADRs was 40.41±1.14 years (mean±standard error of mean) (95% confidence interval, 38.18-42.64 years). And regarding the age distribution Out of 320 cases reported, majority belongs to the age group 18-60 (62.2%), paediatric and elderly cases were less. In a similar study. 6 done in teaching hospital of south India, most common age group of ADR cases were between 18 and 59 years (73.33%). Analysis of frequency of distribution of ADR reported during study period based on various causality categories ( Figure 2) shows that most of the reactions came under "probable" category 91.88%, and "certain" category was 0.31%.
Regarding the severity of ADR (Figure 3) Table 2 and Figure 4 shows that out of 320 cases of ADR reported during the study period 80 were serious with an occurrence rate of 25% in which threatening cases reported were 6(1.9%). A recent study also showed a low number in the serious category, i.e. only 7 (9.33%) out of 75 reactions were considered serious in that study. 9 In this study recovering and recovered together comes around 96.25% ( Figure 5). A recent study done in south India also showed similar result, in that study, most patients (72.6%) were recovered from the incidence. 10 Analysis of frequency of ADR reported during study period based on various system organ classes (Table 3) shows that most of the reactions came under skin and subcutaneous disorder including administration site reaction (88.12%), followed by hepatobiliary system (4.38%) and nervous system (3.44%). Skin and subcutaneous ADRs findings were comparable with an international study. 11 Regarding the distribution of different classes of drugs (Table 4) causing ADR, immunoglobulin was the most common class of drugs (55.3%) followed by vaccines (16.9%). Other common class of drugs reported were due to antibacterial (25,7.8%), and antiepileptic (24,7.5%). In one previous study antibacterial, and antiepileptic were shown as most implicated drug classes. 11

CONCLUSION
The pattern of adverse drug reactions reported to this ADR Monitoring Centre is comparable to the studies done in other parts of country. It gives a database of commonest drugs prescribed in this hospital, and this will help the clinicians for the optimum and safe use of commonest drugs used in this hospital. In this study adverse drug reactions reported were commonly due to antimicrobials and antiepileptic, if we exclude mild administration site reaction due to immunoglobulin and vaccines. And the most of the suspect ADR reported in the causality category of probable or possible. The commonest organ system affected was skin and cutaneous system. A strong need for streamlining of ADR monitoring system and reporting reemphasized by this study, which will promote the ADR reporting in the healthcare professionals.