DISCUSSION The present study was conducted to evaluate the prescribing pattern of analgesics among orthopaedic inpatients in a tertiary care hospital using WHO core prescribing indicators, analgesic-specific prescribing parameters, and pain severity assessment using the Numerical Rating Scale (NRS). Out of 100 patients evaluated, it was identified that majority of the study population belonged to the age group of 70 years and above, with 21 patients in the age group out of 100 , followed by patients aged 40-49 years forming 20% of the study population, 19% of the population consists of patients of the age group 60-69 years, 15% of the population consists of patients from age group 30-39 years, 13% of the population consists of age group of 50-59 years, the least relevant age groups were 20-29 years with 10%, 18-20 years with 2% of the study population, similar to study conducted by Shrikant and Razvi (2020), Bhavana Chandran and Vikram Shetty (2020) and Rohini Gupta et al. (2018), the majority of study population were above the age of 50 years. The predominance of elderly patients shows the increased prevalence of fractures, osteoarthritis, degenerative joint disease results in persistent pain and functional impairment, thereby increasing the need for analgesic therapy. Increased musculoskeletal disorders with advancing age have also been highlighted by the WHO musculoskeletal conditions report. Comparably, Mekonnen et al. (2021), also highlighted that advanced age is major determinant in inappropriate prescribing. It was also analysed that the majority of study population, 71 were female (71%), and 29 were male (29%), which is similar to a study conducted by Shrikant and Razvi (2020) and Rohini Gupta et al. (2018). The observed female predominance in this study highlights the increased vulnerability of females to post-menopausal bone loss and degenerative musculoskeletal disorders such as osteoarthritis. The diagnosis-wise distribution showed that Traumatic Fracture were the most common presenting condition, observed in 69 patients (69%), followed by soft tissue/ligament/tendon injuries (10%), spinal disorders (9%), arthritic disorders (7%), other conditions (3%), and post-traumatic orthopaedic conditions (2%), which is similar to findings of Abhilash et al.(2018) and Khanikar et al.(2024). Acute trauma and bone fractures represent the predominant reason for hospitalization in orthopaedic inpatient settings, requiring active pharmacological pain relief and surgical or conservative management. From the total of 100 patients, it was observed that, 78% of patients had no comorbid conditions, while 9% presented with one comorbidity, 7% with two comordities, 4% with three comorbidities, and 2% with four comordbities, which is similar to findings reported in a study conducted by Dwipen Khanikar et al. (2024) and Bhavana Chandran K et al. (2020). Although the majority of patients did not have co-existing systemic diseases, the presence of comordbities like hypertension and diabetes in patients necessitates careful consideration when prescribing NSAID’s to prevent renal, cardiovascular, or gastrointestinal complications. Out of 100 patients, 84(84.0%) had no prior medication history, whereas 16(16.0%) had a documented medication history, which is similar to study conducted by Anitha Nandagopal et al. (2019), a relatively low proportion of patients with pre-existing therapy reduces the likelihood of drug duplication or interaction with newly initiated analgesics on admission. A total of 407 drugs belonging to the commonly prescribed therapeutic classes were analysed. Analgesics were the most frequently prescribed class, accounting for 113 (27.76%) prescriptions, followed by antiulcer/gastroprotective agents 87 (21.37%) prescriptions, miscellaneous drugs with 60 (14.74%) prescriptions, antibiotics with 52 (12.78%) prescriptions, enzyme preparations with 29 (7.12%) prescriptions, vitamin preparations with 22 (5.40%) prescriptions, antihypertensives with 16 (3.93%) prescriptions, antidiabetic with 13(3.19%) prescriptions and calcium supplements with 12 (2.94%) prescriptions. Antispasmodics were the least frequently prescribed drug class, consisting of 3(0.73%) prescriptions. The predominance of analgesics reflects pain relief as the primary therapeutic goal in orthopaedic management, while antiulcer agents were co-prescribed to prevent NSAID-induced mucosal damage and antibiotics were used for prophylaxis and infection control. As similar study conducted by Dwijen Kumar Choudhury et al. (2016). Among the 135 analgesics were prescribed to the 100 patients included in the study. Among these, NSAID’s were the most commonly prescribed analgesic class, accounting for 82 (60.74%) prescriptions, followed by non-opioid analgesics with 29 (21.48%) prescriptions, Opioid analgesics with 17(12.59%) prescriptions, and Adjuvant Analgesics with 7(5.1%) prescriptions. NSAIDs remain the first-line preference in orthopaedic practice due to their dual analgesics and anti-inflammatory properties. As similar study conducted by Dr. Semira et al. (2025) and Sunaina Khajuria et al. (2023), confirming NSAIDs as the most widely prescribed class of analgesics in orthopaedic wards. At the individual drug level, Diclofenac was the most frequently prescribed analgesic, consisting for 64 (47.4%) of 135 prescriptions, followed by Paracetamol (21.48%, n=29), Aceclofenac (12.5%, n=17), and Tramadol (12.59%, n=17), Gabapentin (2.96%, n=4), Nortriptyline (2.23%, n=3), and Etoricoxib (0.74%, n=1). The predominance of Diclofenac in orthopaedic inpatient wards is well established in Indian clinical settings, as similar to the study conducted by Pooja Agrawal et al. (2016), Choudhury and Bezbaruah (2016), and Chandrakantha et al. (2019). A total of 113 analgesic prescriptions were analysed according to the frequency of administration. The majority of analgesics were prescribed twice daily (BD), forming 92 (81.4%) prescriptions, followed by SOS (as needed) with 13(11.5.%) prescriptions, once daily (OD) with 6(5.3%) prescriptions, and three times daily (TID) with 2 (1.76%) prescriptions. BD was the most commonly prescribed dosing frequency for analgesics among the study population. As similar study conducted by R. Asha Latha et al. (2018). Twice-daily dosing corresponds with biological half-life of analgesics (like Diclofenac and Aceclofenac) which maintains consistent pain relief and optimizes patient adherence. A total of 113 analgesics were analysed according to the route of administration (ROA). The majority of analgesics were administered through the intravenous (IV) route, accounting for 78(69.0%) prescriptions, whereas the oral route was used for 35 (30.97%) prescriptions. The IV route was the preferred mode of analgesic administration in orthopaedic patients, likely reflecting the need for rapid and effective pain management during the acute phase of hospitalization. As similar study conducted by Chandrakantha T et al. (2019). Among the 100 patients included in the study, Severe pain (NRS score 7-10) was the most common level of pain, reported in 50 (50.0%) patients, followed by Moderate pain (NRS score 4-6) in 40 (40.0%) patients, and Mild pain (NRS score 1-3) in 10 (10.0%) patients. The majority of orthopaedic patients presented with moderate to severe pain, highlighting the need for appropriate and effective analgesic management. As similar study conducted by Saraswathi K et al. (2021). A total of 135 analgesics were prescribed across different pain severity categories. NSAIDs were the most commonly prescribed analgesic class in all pain severity groups (7 prescription in patients with mild pain, 36 in moderate pain, and 38 in severe pain). Opioids were prescribed predominantly in severe pain (13 prescriptions), followed by moderate pain (4 prescriptions), while non-opioid analgesics were more frequently used in mild (8) and moderate (13) pain. The association between pain severity and analgesic class was evaluated using the Chi-square test (χ² = 18.336, df= 9, p= 0.0315), which was statistically significant. As similar study conducted by Hsu JR et al. (2019). A total of 113 analgesics were analysed according to the route of administration and pain severity. Among patients with mild pain, the oral route was most commonly used (8 prescriptions), while 2 prescriptions were administered through the injectable route, whereas in moderate pain (26 injectable vs 14 oral) and severe pain (43 injectable vs 7 oral), the injectable route was predominantly used. The association between pain severity and route of administration was evaluated using the Chi-square test (χ²= 23.714, df=3, p < 0.001), which was statistically significant. As similar study conducted by Amit Kumar Ambasta et al. (2021). A total of 113 analgesic prescriptions were analysed according to frequency of administration and pain severity. Twice-daily (BD) dosing was the most commonly prescribed regimen across all pain severity categories (7 in mild, 37 in moderate pain, and 48 in severe pain). Once-daily (OD) dosing was prescribed only in patients with moderate (3) and severe (3) pain, while three-times-daily (TID) dosing was infrequently prescribed, with 1 prescription each in moderate and severe pain. The association between pain severity and frequency of analgesic administration was evaluated using the Chi-square test (χ² = 6.585, df = 9, p = 0.6802), which was statistically not significant. As similar study conducted by R, Asha Latha et al. (2018). A total of 100 patients were analysed according to therapy type and pain severity. Overall, 72(72.0%) patients received monotherapy and 28(28.0%) received combination therapy. Monotherapy predominated in moderate pain (25 patients) and severe pain (43 patients), whereas combination therapy was higher in mild pain (6 patients). The association between pain severity and therapy type was evaluated using the Chi-square test (χ² = 11.111, df = 3, p = 0.0111), which was statistically significant. As similar study conducted by Dwijen Kumar Choudhury et al. (2016). Among the 72 patients who received monotherapy, Diclofenac was the most commonly prescribed analgesic, accounting for 58 (80.5%) patients. This was followed by Tramadol, prescribed to 11 (15.2%) patients, while Paracetamol was the least frequently prescribed monotherapy analgesic, used in 3 (4.1%) patients. These findings indicate that Diclofenac was the preferred analgesic for monotherapy in the management of pain among orthopaedic patients included in the study. A s similar study conducted by Bhavana Chandran K et al. (2020). Among the 28 patients who received combination analgesic therapy, Aceclofenac + Paracetamol was the most frequently prescribed combination, accounting for 17 (60.7%) patients, followed by Diclofenac + Paracetamol in 6 (21.4%) patients, followed by Tramadol + Paracetamol, prescribed to 3 (10.7%) patients and Diclofenac + Tramadol, prescribed to 2 (7.14%) patients. Aceclofenac + Paracetamol was the preferred combination analgesic therapy for pain management among orthopaedic patients in the study. As similar to study conducted by Bhavana Chandran K et al. (2020). WHO core prescribing indicators consist of five indicators, which are: Average number of drugs per encounter, Percentage of drugs prescribed by generic name, Percentage of encounters with an antibiotic, Percentage of encounters with an injection, and Percentage of drugs prescribed from the Essential drug list/formulary. From the first indicator, the average number of drugs per encounter, the obtained value for our current study is 4.05 drugs per encounter, whereas the WHO reference value is 1.6-1.8; the obtained value for our study is far higher than the optimal range. Comparably but lower values were reported by Choudhury and Bezbaruah (2016) (mean=1.46), Pooja Agrawal and Vijender Kumar Agrawal (2016) (mean=1.48) and Prakruti P. Patel et al. (2023) (mean=1.50), our mean is more comparable to the higher values found by Dwipen Khanikar et al. (2024) (mean = 4.84) and Abdul Hamid Kakar et al. (2021) (mean=5.10). The second indicator is the Percentage of drugs prescribed by generic name. Our study obtained the value of 9.8% for this parameter, whereas the WH0-recommended reference value is 100%, which indicates very poor adherence to generic prescribing in the clinical settings. Abhilash S et al. (2018) (value=9.8%) and Dwipen Khanikar et al. (2024) (value=48%) similarly noted under prescribing of drugs by generic name. Our results contrast with the findings of P. R. R. Vaishnavi, Nitin Gaikwad et al. (2017) where the percentage of drugs prescribed by generic name is 91.15% and Dwijen Kumar Choudhury et al (2016) (value=57.19). The third indicator is the Percentage of antibiotics prescribed per encounter; in our study, the findings for this indicator were 52%. The WHO reference range is 20-26.8% which indicates our findings exceed the WHO reference range. Similarly high rates were reported by Abdul Hamid Kakar et al. (2021) with 19.27%, and Anitha Nandagopal et al. (2019). These results indicate that overuse of antibiotics is a persistent problem across countries, and this overprescription leads to antimicrobial resistance. The fourth indicator is the Percentage of injections per encounter. Our study has obtained a value of 84.0% for this indicator, whereas the WHO reference value is 13.4-24.1%, which again shows poor adherence to the WHO core indicators, as our study value far exceeds the reference value. give conclusion of the study keeping result same data same keep

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