Abstract
Rational use of steroids is essential in the long term for improving patient safety. Systemic steroids are important in clinical treatment, but if they are misused, they might have negative effects. This study assessed systemic steroid use and its determinants at Debre Berhan University Hakim Gizawu Teaching Hospital (DBUHGTH), Ethiopia. A cross-sectional study was conducted among 210 admitted patients at the Medical ward of DBUHGTH. A simple random sampling method was used to recruit study participants. The data was collected from patient medical records and patient interviews using a structured data abstraction and patient interview format. Binary logistic regression was employed to identify the potential predictors of systemic steroid use. Finally, the results were interpreted and presented by tables, charts, and graphs. Most study participants were 142 (67.62%) male. The mean age of the participants was 44.94 (SD, 19.2) years. Prednisolone was mostly utilized drug 130 (42.07%), followed by hydrocortisone 81 (26.21%), beclomethasone 58 (18.77%), and dexamethasone 40 (12.94%). Respiratory disorders 112 (53.34%), meningitis 25 (11.91%), and rheumatoid arthritis 19 (9.05%) were the top three disease conditions in which steroids were used with the highest frequency. Most systemic steroids were administered orally, 130 (42.07%). Short-acting (hydrocortisone, beclomethasone) 139 (44.98%) were mostly used, followed by intermediate-acting steroids (prednisolone) 130 (42.07%). Study participants in the 18–40 age range were approximately 2.5 times more likely than those in the 65 + age group to be using systemic steroids (AOR = 2.5, 95% CI 2.86–6.07). Prednisolone was mostly utilized, followed by hydrocortisone, beclometasone, and dexamethasone drugs in the medical ward of DBUHGTH.
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Introduction
Steroid hormones like, natural hormones, exhibit glucocorticoid (GCS) and mineralocorticoid properties1. Prednisone, methylprednisolone, hydrocortisone, dexamethasone, and other systemic glucocorticoids involve intracellular glucocorticoid receptors in the cytoplasm to mimic the physiological effects of naturally occurring glucocorticoids2.
Steroids emerged as one of the most commonly utilized and successful treatments for different inflammatory and autoimmune conditions during the 1950s3. The steroids are utilized for hormone replacement in cases of adrenal insufficiency at natural levels and also at levels exceeding normal physiology for treating a range of skin, eye, joint, lung, blood, and digestive system disorders4. Systemic steroids are utilized in the respiratory system to manage acute flare-ups of Chronic Obstructive Pulmonary Disease (COPD) and severe, uncontrolled asthma. They are also employed in the treatment of inflammatory parenchymal lung conditions like hypersensitivity pneumonitis and immune-mediated vasculitis5.
Even while systemic glucocorticoids are effective, using them improperly can have negative effects6 including Cushing’s syndrome, osteoporosis, hypertension, adrenal insufficiency, and gastrointestinal bleeding, which could put the patient’s life in harm and escalate the cost of healthcare7. Glucocorticoids have a major impact on metabolism, changing the way that fat, bone, and protein are metabolized as well as increasing gluconeogenesis. Steroid use also increases the risk of developing new infections, hyperglycemia, and critical illness myopathy in critically sick individuals8,9,10,11. There has been an increasing concern regarding the safety of corticosteroids, as a large number of patients are prescribed these drugs for long-term prophylactic treatment12.
Based on a survey conducted by the World Health Organization (WHO), GCS in particular is responsible for wrongly prescribing, administering, or selling 50% of all drugs13,14. When steroids are used insufficiently, the effects are sub-therapeutic; however, when steroids are overdosed without proper dosage calculation, distinct side effects occur15. The illness and how it progresses, the problems brought on by inadequate care, and the effects of drug use and misuse should all be taken into account by patients16.
In India, a survey revealed that 88.4% of patients were using glucocorticoids inappropriately, which included receiving inaccurate diagnoses and using them for incorrect indications17. In 27 primary care institutions in China, a study found that 63.5% of inappropriate prescriptions were attributed to steroids7. In India, a study found that prednisolone 70 (95.9%) was the most frequently prescribed oral steroid, followed by methylprednisolone 3 (4.1%). As for injectable steroids, dexamethasone was the most commonly prescribed at 42 (95.4%), followed by betamethasone injection at 2 (4.5%)18. In addition, the study done in Minilik II Hospital, Addis Ababa, Ethiopia, reported that the most frequently prescribed drug was prednisolone (42.4%)19.
Assessment of systemic steroid usage was done at DBUHGTH in this study. The aim of the study was to assess systemic steroids use and its determinants at DBUHGTH.
Methods and materials
Study area, design, and period
We used an institutional-based cross-sectional study design. It was done in DBUHGTH at Debre Berhan town. Debre Berhan is a city in central Ethiopia located in the North Shewa Zone of Amhara Regional State, which is located 130 km away from Addis Ababa. The data collection period was from April 4, 2024, to May 30, 2024.
Population
Source population
All admitted adult medical patients at the medical ward of DBUHGTH were the source population.
Study population
All admitted patients at the medical ward of DBUHGTH on systemic steroid drugs.
Eligibility criteria
Inclusion criteria
Patients who were greater than 18 years admitted to the medical ward at DBUHGTH and had systemic steroidal drugs listed in their medical records were included.
Exclusion criteria
Patients who had incomplete medical records were not included.
Sample size determination
The sample size was calculated by using the single population proportion formula20 by considering a 50% proportion of systemic steroidal utilization pattern, 95% confidence level, and 5% marginal error. For population < 10,000, we use the finite population correction formula; finally, a total of 210 study participants were included in the current study.
Sampling procedure
The study participants were selected using a simple random sampling method using a lottery method.
Data collection procedure
The author-designed checklist was used for collecting the data. The patient’s medical records were reviewed to gather data on the use of systemic steroidal drugs. Two intern pharmacists were involved in the data collection. The data collection was conducted between April 4, 2024, to May 30, 2024.
Study variables
Dependent variable
Systemic steroid use pattern.
Independent variables
Socio-demographic features: age, sex, marital status, and residence.
Indication, type of drug dose, and route of administration.
Operational definition
Systemic steroid: Any steroidal medication that is administered systemically and enters the bloodstream, exerting systemic effects throughout the body.
Adverse drug reaction: After taking medication, an individual may experience an adverse response.
Utilization pattern: Frequency, dosage, duration, indications, and specific drugs used in the treatment of patients.
Data quality assurance
To ensure the data quality, on each day of the data collection, the data was checked for completion, accuracy, and clarity. Again, the principal investigator checked the data for missing values during data entry.
Data processing and analysis
We utilized SPSS version 25 statistical software to input and analyze the data. To identify potential predictors of systemic steroid use patterns; binary logistic regression was utilized. The data was organized and summarized using frequencies and percentages. The results were then presented using tables, graphs, and charts.
Ethical issues
Ethical clearance for the study was obtained from the Debre Berhan University Institutional Review Board (IRB), and the ethical clearance was written on 02/04/2024. Informed consent was obtained from all study participants. An official letter of cooperation was written from the Debre Berhan University Department of Pharmacy to DBUHGTH. To ensure confidentiality, the names and other identifiers of the participants were not registered. All procedures were followed in compliance with applicable rules and regulations.
Results
Socio-demographic characteristics
Of 210 study participants, 142 (67.62%) were male. The average age of the research subjects was 44.94 (SD, 19.2) years. Among the participants, 131 (62.38%) lived in urban areas. Approximately two-thirds of the participants were married. Furthermore, 112 (53.33%) of the study participants are between the ages of 18 and 40 years (Table 1).
Systemic steroid use
The most commonly used medication was prednisolone, which was used 130 times (42.07%). Other commonly used drugs were hydrocortisone, which was used 81 times (26.21%), beclomethasone, which was used 58 times (18.77%), and dexamethasone, which was used 40 times (12.94%) (Fig. 1).
Indication of systemic steroid
Steroids were administered most frequently for respiratory diseases 112 (53.34%), meningitis 25 (11.91%), and rheumatoid arthritis 19 (9.05%). Conversely, the lowest frequency of steroids was seen in the treatment of vitiligo, lupus pneumonitis, and acute tonsillitis.
Administration route
Figure 2 illustrates that most systemic steroids (130, 42.07%) were administered orally while a smaller quantity (58, 18.77%) were administered by inhaling.
A common class of steroidal drugs
Short-acting (hydrocortisone, beclomethasone) 139 (44.98%) were mostly used, followed by intermediate-acting steroids (prednisolone) 130 (42.07%), and long-acting steroids (dexamethasone) 40 (12.94%).
Chronic illnesses
Nearly half 103 (49.04%) of the participants have chronic illnesses. There were 111 chronic cases; the most predominant was asthma 69 (62.16%) and the least was hypertension 10 (9.01%).
Contributing factors for systemic steroid use
In the binary logistic regression analysis, the study participants’ age classification was significantly associated with systemic steroid use. Study participants in the 18–40 age range were approximately 2.5 times more likely than those in the 65+ age group to be using systemic steroids (AOR = 2.5, 95% CI 2.86–6.07). The marital status, sex, and residence didn’t have an association with systemic steroid use (Table 2).
Discussion
Prednisone, prednisolone, methylprednisolone, and dexamethasone are steroids that have strong anti-inflammatory, immunomodulatory, and antineoplastic qualities. These steroids are essential in the treatment of a variety of illnesses, such as autoimmune diseases, allergic reactions, exacerbations of asthma, and chronic obstructive pulmonary disease21,22. Among the patients treated with systemic steroids, 142 (67.62%) were identified as male. The age distribution is consistent with a study conducted at the District General Hospital in the Amravati region of India, which reported that 94 (53%) of the participants were male9. Yet, it differs from a study done in Menelik II Referral Hospital, Ethiopia, where 235 patients (61.2%) were female19.
Consistent with previous research, the current study found that respiratory illnesses accounted for the majority of systemic steroids used, 112 (53.34%)23,24,25,26. Additionally, this finding is in line with the study conducted in China indicated diseases of the respiratory system (60.8%)7 were the most common indications for steroids. However, the studies done in the United States and South Korea reported that 11.8%27 and 6.8%28 systemic steroids were applied, correspondingly, to treat acute upper respiratory tract infections. The discrepancies may be due to variations in the clinical features of the research participants.
In the current study, systemic steroids were used for meningitis 25 (11.91%) and rheumatoid arthritis 19 (9.05%) disease. Comparable results were found in a Chinese study that indicated systemic steroids are used to treat arthritic disorders and other joint problems that are not otherwise characterized (730, 1.2%), arthrosis (487, 0.8%), asthma (444, 0.7%), and COPD (204, 0.3%)28.
Among the specific drugs within the systemic steroids class, prednisolone was the most utilized steroids accounting for 130 (42.07%), while dexamethasone was the least utilized drug 40 (12.94%) in this study. This finding is comparable with a study done in Denmark where prednisolone was the most commonly prescribed drug29. The Indian study reported that prednisolone (70 (95.9%)) was most commonly prescribed followed by methylprednisolone in 3 (4.1%) patients18. However, the study was done in China (86.5%)7 and India (58.3%)17 reported that dexamethasone was the most prescribed steroid, respectively. The variations could be differences in the study setting and level of health institutions.
In this study, of all the routes of administration, the oral route received 130 (42.07%) of systemic steroids, while the inhalation route received 58 (18.77%) of them. This finding is in contrast to a study conducted in India, where systemic steroids delivered via inhalation have a higher frequency (44.5%) compared to the intravenous route (24%)11 and (89.8%) systemic steroids were administered by the parenteral route7. An investigation carried out at Menelik II Referral Hospital, Ethiopia, revealed that the intramuscular method accounted for the least amount of systemic steroids provided, with 5 (1.3%), whereas 197 (51.3%) were given by IV12. Generally, when a patient experiences an exacerbation or an emergency, systemic steroids are utilized30. The possible justification may be differences in study participants’ clinical condition and the presence or absence of co-morbidities.
In our study, systemic steroid use was associated with the study participants’ age. Study participants in the 18–40 age range were approximately 2.5 times more likely to use systemic steroids than those in the 65+ age group. However, the study conducted in China found patients 65 years of age and older had a higher likelihood of using steroids wrongly7.
The above findings are used to create awareness amongst the scientific community and the health care system regarding systemic steroid usage and to show the risks and benefits of their use and overuse.
Limitations of the study
A causal relationship cannot be established in this cross-sectional analysis due to the absence of a temporal association. There are also incomplete medical records. Since this study was limited to one Ethiopian healthcare setting, its conclusions might not apply to other Ethiopian healthcare settings.
Conclusion
Prednisolone was mostly utilized, followed by hydrocortisone, beclometasone, and dexamethasone drugs in the medical ward of DBUHGTH. The majority of steroids were prescribed for the treatment of respiratory diseases. The majority of systemic steroids were taken orally. The study participants’ age was the only predictor variable associated with systemic steroid use.
Recommendations
✔ Implementing regular monitoring and audit systems for systemic steroid use is essential to evaluate steroid use and identify areas for improvement.
Conducting longitudinal studies to assess the long-term outcomes and safety profile of systemic steroid use among admitted patients is recommended.
Data availability
The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.
Abbreviations
- COPD:
-
Chronic Obstructive Pulmonary Disease
- DBUHGTH:
-
Debre Berhan University Hakim Gizawu Teaching Hospital
- DUR:
-
Drug Utilization Research
- GI:
-
Gastrointestinal
- NGO:
-
Non-Governmental Organization
- WHO:
-
World Health Organization
- GCSs:
-
Glucorticosteroids
- SCs:
-
Systemic corticosteroids
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Acknowledgements
We truly thank all the study participants who volunteered for the current study.
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AWT, KS, DAB, KDA, YTW, BLE, ASA, SBD, and SGA contributed to the conception, design, interpretation, and write-up of the manuscript; KS contributed to data collection and analysis. AWT oversees the data collection processes. All authors read and approved the manuscript.
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Tsige, A.W., Simegn, K., Beyene, D.A. et al. Assessment of systemic steroid use and its determinants among admitted patients at Debre Berhan University Hakim Gizawu Teaching Hospital. Sci Rep 14, 30804 (2024). https://doi.org/10.1038/s41598-024-81425-8
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DOI: https://doi.org/10.1038/s41598-024-81425-8