"The Injection Paradigm": non-steroidal anti-inflammatory drug utilization in real-world clinical practice

Introduction . Although clinical guidelines consistently prioritize oral non-steroidal anti-inflammatory drugs (NSAIDs), the actual pattern of administration routes in Russian inpatient practice remains insufficiently quantified; formulary concentration indices and expenditure decomposition have rarely been applied in domestic drug utilization research. Objective . To characterize, using aggregated real-world data, the structure and dynamics of NSAID consumption in a multidisciplinary healthcare facility over 2022–2025, assessing route asymmetry, formulary concentration, and structural shift in the pharmacoeconomic profile of ATC group M01A. Working hypothesis: NSAID utilization in a multidisciplinary hospital is characterized by a persistent predominance of parenteral formulations, inconsistent with the step-down principle, and by high and increasing formulary concentration. Materials and methods . A retrospective drug utilization study was conducted over four calendar years without intervention in clinical practice. Forty-five nomenclature lines (selected stepwise from 3,645 lines of inventory turnover records) were aggregated into eight systemic NSAID INNs: diclofenac, ibuprofen, ketoprofen, ketorolac, lornoxicam, meloxicam, nimesulide, and etoricoxib. WHO ATC/DDD methodology (DDD per 100 bed-days), ABC, VEN, and XYZ analysis, the Herfind- ahl-Hirschman Index (HHI), CR3, Laspeyres-Paasche expenditure decomposition, and scenario analysis across a PDD range of 30–90 mg/day for estimated Days of Therapy (DOT) were used. The primary outcome was the share of parenteral DDDs in annual consumption; secondary outcomes were DDD/100 bed-days, HHI, CR3, the ABC/VEN/XYZ profile, and expenditure decomposition. Data were aggregated; no individual clinical parameters were collected. Results . Total NSAID expenditure in 2022–2025 was RUB 2 860 727. Consumption intensity remained stable at 42.1– 45.9 DDD/100 bed-days (mean 43.7). Parenteral DDDs accounted for 99.49–99.96 %, oral DDDs for 0.04–0.51 %. Ketorolac accounted for 68.0 % of expenditure (RUB 1,945,645) and 76.9–93.7 % of annual DDD; by 2025, a single INN covered 90 % of consumption (DU90 %). HHI increased from 0.437 to 0.655 against a high-concentration threshold of 0.25; CR3 rose from 92.3 % to 98.0 %. Budget growth over 2022–2025 (+RUB 34,543) was driven solely by the structural effect (+RUB 364,521), with negative volume (-RUB 173,568) and price (-RUB 156,410) effects. Meloxicam procurement ceased after 2022; the share of COX-2-preferential and selective NSAIDs fell to 0 % by 2025. Conclusions . The working hypothesis was confirmed: the facility demonstrated a stable ultra-parenteral NSAID utilization pattern inconsistent with step-down therapy and progressive mono-formulary concentration on ketorolac. To reduce risks and improve pharmacotherapy rationality, the formulary should be expanded with oral formulations, a local step-down analgesia protocol should be introduced, a reserve COX-2-selective/preferential NSAID should be restored for high gastrointestinal-risk patients, and HHI and CR3 should be incorporated into internal pharmacotherapy audit. The proposed audit thresholds (oral DDD share ≥0.2; HHI >0.5) are operational benchmarks rather than validated standards.