Preference Trends for Antispasmodics Among Indian Healthcare Professionals: Results of a Cross Sectional Survey
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Original Article Preference trends for antispasmodics among Indian healthcare professionals: Results of a cross sectional survey Gabhane M1, Braganza L2 Abstract Objective: Understanding antispasmodics usage pattern among Indian healthcare practitioners (HCPs). Material and methods: HCPs were interviewed in person to understand preference of antispasmodics. The preference of formulation in acute/chronic pain, perceptions about attributes of antispasmodics, medicine recall and indications of different antispasmodics were noted. Results: Acute spasmodic pain is more common than chronic pain (61% vs 39% pediatrics; 58% vs 42% other special- ties). In mild acute spasmodic pain tablet is used by 58% and in severe acute spasmodic pain injection is preferred by 55% HCPs. In mild and moderate chronic spasmodic pain, almost half of HCPs use tablet. Injection is used by 53% of HCPs for severe acute / chronic spasmodic pain. Injection is preferred for better efficacy by 67% HCPs. 80% health- care practitioners use injection for quick onset of action. Tablets provide prolonged relief and are easy to administer according to 46% and 58% HCPs respectively. Camylofin plus paracetamol was the most common antispasmodic preparation recalled (91% HCPs). Conclusion: Spasmodic pain is common clinical condition. Antispasmodic injection is used in severe condition and quick onset of action while oral formulations are preferred for prolonged relief. Camylofin plus paracetamol is recalled by about nine out of ten HCPs. Key words: Antispasmodic, Healthcare Practitioners, Survey. 1 Medical Advisor, Medical Dept., Abbott; 2 Chief Manager, Medical Dept., Abbott. 32 The Indian Practitioner q Vol.68 No.5. May 2015 Original Article Introduction Pediatrician Consulting pasmodic conditions such as abdominal cramp and Physicians abdominal pain are often encountered in routine 20.47% clinical practice because of its common occurrence 34.50% S 34.50% and numerous etiologies affecting up to 30% adults in Gastro- western countries.1 The colic pain could be because of enterologist the spasm or obstruction of intestinal, biliary or uter- 2 ine smooth muscles. The clinical presentation of spasm 39.18% could be acute, subacute or chronic in nature. Untreated spasmodic pain is associated with patient discomfort and may result in complications, if untreated. Antispasmodic agents are commonly used in clinical practice for treat- General Practitioner ing various spasmodic conditions including abdominal Fig 1: Distribution of survey participants cramping pain3, renal colic4, acute abdominal spasm, spasm of biliary system or genito-urinary tract.5 In fe- ranking of preference on the scale of 1-3 (1-most pre- males, dysmenorrhea is another indication where anti- ferred; 3-less preferred) according to preference and indi- spasmodic analgesic agents are used for providing pain cations of different antispasmodic preparations and their relief.6 An analgesic antispasmodic can provide signifi- formulations (tablets, drops, injections and syrup) were cant pain relief to patients with spasmodic conditions.7 noted as reported by the HCPs. The severity of condition was graded into three categories: mild-no impairment of Different types of formulations of antispasmodic routine activities; moderate-slight impairment of activi- agents are available in Indian pharmaceutical market in- ties; severe-profound impairment of activities. cluding oral formulations and injection. However, there are no formal guidelines on the criteria for selecting anti- Results spasmodic agents for different spasmodic conditions seen A total of 171 HCPs were interviewed in this survey. during clinical practice. In the absence of clear guidelines, The distribution of HCPs is shown in figure 1. the choice of antispasmodic differs from physician to Pain, fever, cough and cold and acidity are the most physician. The preference pattern of antispasmodics and common ailments treated by HCPs. Pain is most com- attributes for selecting one agent over the other in spas- mon indication seen by all HCPs (100% HCPs). Similarly, modic conditions are largely unknown in India. patients with spasmodic pain are also encountered by all specialties surveyed. The HCPs reported that acute Objective spasmodic pain is more common type of presentation The objective of survey was to understand preference compared to chronic pain (61% vs 39% pediatrics; 58% vs of different antispasmodic formulations among Indian 42% other specialties). Oral formulations are the mostly healthcare practitioners (HCPs). recommended for mild to moderate cases of acute and Material and methods chronic pain while injections are mostly recommended In this cross sectional survey, the HCPs were inter- used for severe cases of acute and chronic pain. Drops viewed in person to understand the preference of different antispasmodics available in Indian pharmaceutical mar- ket. The interviewed HCPs included Graduates/general practitioners (MBBS), Postgraduates (MD) and Super specialist (DM/MD, DNB). The postgraduates were either physician or pediatrician while the super specialists were gastroenterolo- gists. The preference of usage of tablet or injection in acute/chronic spasmodic pain according it severity of condition, percep- tions about attributes (efficacy, quick onset of action, prolonged relief, ease of admin- istration) of different antispasmodic for- mulations, medicine recall (spontaneous Fig 2: Use of oral formulation (n=157) or injection (n=152) in acute or aided) of antispasmodic preparations, spasmodic pain The Indian Practitioner q Vol.68 No.5. May 2015 33 Original Article called by more than 70% HCPs included dicyclo- mine plus paracetamol, camylofin plus diclof- enac, mefenamic acid plus dicyclomine and drotaverine. Camylofin plus paracetamol fol- lowed by dicyclomine plus paracetamol and drotaverine were ranked as number one by 24%, 17% and 14% HCPs respectively. Overall camylofin plus paracetamol tablet is the most commonly used preparation for Fig 3: Use of oral formulation (n=157) or injection (n=152) in chronic spasmodic pain spasmodic conditions. The most common in- are mostly recommended for mild acute and chronic pain dication for the use of camylofin plus paracetamol is ab- with higher recommendation by pediatricians in chronic dominal spasmodic pain. For dysmenorrhea, mefenamic cases of spasmodic pain. The preference of oral therapy acid plus dicyclomine and camylofin plus paracetamol versus injection based on the severity of spasmodic pain each are used by 35% of HCPs. The indications for oral is shown in figure 2 and figure 3. In mild acute spasmodic antispasmodic formulation are shown in table 1. pain oral formulation is used by 58% of HCPs while injec- Spasmodic condition (abdominal/stomach pain) and tion is not used in mild pain. On the contrary, in severe dysmenorrhoea are the most preferred aliments for ca- acute spasmodic pain, injection is preferred by 55% HCPs mylofin plus paracetamol while for camylofin plus diclof- versus 26% practitioners who prefer to use oral medica- enac the top two indications are abdominal pain and gall tion (figure 2). bladder problem. In mild and moderate chronic spasmodic pain, almost Dicylcomine plus paracetamol combination is com- half of the HCPs use oral formulation of antispasmodic monly used for abdominal pain, intestinal colic, abdomi- medication for the management of pain. Injection of anti- nal colic, gastric pain and duodenal ulcer. Dysmenorrhoea spasmodic medicine is used by 53% of HCPs to manage severe chronic spasmodic pain (figure 90% 3). 80% 80% Injection (67%) is most com- 67% monly preferred for better effi- 70% cacy followed by tablet (37%), 60% 58% syrup (15%) and drops (11%). A total of 80% HCPs use injec- 50% 46% Tablet/Capsule tions for quick onset of action. 40% 37% 38% Injection Tablets provide prolonged re- lief and are easy to adminis- 30% 27% 28% Drops 25% 28% ter according to 46% and 58% % of HCPs 20% Syrup HCPs respectively (figure 4). 15% 16% 11% 11% 13% Camylofin plus paracetamol 10% 9% was the most common anti- 0% spasmodic preparation re- Efficacy Quick onset Prolonged Easy to called (91% HCPs). The other of action relief administer antispasmodic preparations re- Fig 4: Perception about attributes of different antispasmodic formulations (n=171) 34 The Indian Practitioner q Vol.68 No.5. May 2015 Original Article % of HCPs Camylofin+ Dicyclomine+ Mefenamic Drotavarine Camylofin+ Drotavarine+ Dicyclomine Hyosine Dicyclomine+ Camylofin paracetamol paracetamol acid+ diclofenac mefenamic simethicone dicyclomine acid Fig 5: Medicine recall among HCPs (n=171) is the most common indication for mefenamic acid plus dysmenorrhea and abdominal spasm 7% HCPs use ca- dicylomine. Gallbladder problem and gastritis are the top mylofin injection while dicyclomine injection is used by two indications for preference of drotaverine. 11% HCPs for intestinal colic and 7% HCPs for gall blad- Overall prescriptions for drotaverine plus paracetamol, der problem. drotaverine plus mefenamic acid, dicylomine plus diclof- Discussion enac and hyosine are less. Duodenal ulcer and gallblad- Antispasmodics also known as spasmolytics agent der problem are the two top most aliments for use of relieve spasmodic pain by different mechanisms. Some drotaverine plus paracetamol. Intestinal colic, abdominal agents are direct smooth muscle relaxants while some act colic, duodenal ulcer and bowel irregularity are the most by blocking cholinergic action or calcium channels.8 common ailments for use of drotavarine