Antidiabetic prescribing patterns, quality, and economic influence in resource-limited settings: evidence from a Pakistani tertiary care hospital using WHO/INRUD indicators

Pakistan currently has the highest prevalence of diabetes globally, making rational prescribing of antidiabetic medications essential for safe, effective, and affordable care. Similar challenges are faced across low- and middle-income countries (LMICs), where resource constraints, limited access to essential medicines, and substandard prescribing practices exacerbate the diabetes burden. This study aimed to assess the prescribing patterns, prescription quality using WHO/International Network for Rational Use of Drugs (INRUD) indicators, potential drug-drug interactions (pDDIs), and estimated drug costs. A cross-sectional study was conducted in the outpatient department of a large tertiary care hospital in Abbottabad, Pakistan. Four hundred and sixty-seven patient prescriptions were collected through consecutive sampling. Prescriptions were comprehensively analyzed for prescribing patterns, WHO/INRUD core indicators, and pDDIs using online drug interaction checkers. The estimated prescription cost and cost by therapeutic category were calculated to assess the approximate economic burden of antidiabetic treatment. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were calculated for key study variables. The most frequently prescribed antidiabetic drug was Sitagliptin/Metformin combination (n = 266). The study revealed concerning prescribing practices: excessive polypharmacy (average 3.16 drugs per prescription; 23.77% with ≥ 5 drugs), poor generic prescribing (2.58%), and suboptimal compliance with the National Essential Medicines List (NEML, 59.52%). The mean prescription cost was PKR 3,404.7 ± 2,316.9 (≈ USD 12.6), with the highest estimated costs observed for insulins, followed by combination oral anti-diabetics. Gaps in medical history recording (19.1%) and route of administration (19.5%) were found in prescription documentation. Findings highlighted significant deviations from rational prescribing standards and a considerable economic burden, primarily from non-NEML medications. These results mirror challenges seen across LMICs, where gaps in rational medicine use, essential medicines policy, and affordability persist. Targeted interventions such as prescriber training for cost-conscious prescription, formulary policy alignment, standardized documentation systems, and pDDI monitoring are essential to optimize diabetes care quality, safety, and affordability in resource-limited settings.