DRUG USE EVALUATION OF ANTIHYPERTENSIVE DRUGS IN THE TERTIARY CARE HOSPITAL

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1 Page6558 Indo American Journal of Pharmaceutical Research, 2016 ISSN NO: DRUG USE EVALUATION OF ANTIHYPERTENSIVE DRUGS IN THE TERTIARY CARE HOSPITAL Kamal Pandey, Prithvi Bikram Thakur, K. RamKumar, Dr. Praveen Kumar, Dr. B.A Vishwanath Aditya Bangalore Institute for Pharmacy Education and Research. ARTICLE INFO Article history Received 01/09/2016 Available online 30/09/2016 Keywords Drug Utilization, Co-Morbidities, Antihypertensive, JNC VIII, DI. Corresponding author Kamal Pandey 5 TH year Pharm D student, Aditya Bangalore Institute for Pharmacy Education and Research Kamalpandey2048@gmail.com ABSTRACT AIM: To assess the Drug use evaluation of antihypertensive drugs in Tertiary Care Hospital. MATERIALS AND METHODS: Drug use utilization data of 200 Patients, attending inpatient department of Aster CMI Hospital for 6 month was collected from Patients Case Notes and prescriptions. This study is retrospective study. The data were analyzed to find out the demographic characteristics of the patient, number of drugs prescribed per patients, drugs which are commonly prescribed, mono therapy, combination therapy (two drug therapy, three drug therapies), route of drug administration, adherence with JNC VIII, drug treatment based on stages of hypertension, co-morbidities of patients. Patients suffering from hypertension with or without co-morbid conditions were included in the study. RESULTS: During the 6 months period of study 200 prescriptions for Hypertension were analyzed. Among 200 prescriptions most of the patients were Male (57%) while 43% were female and major age group having HTN was found to be years (32%). Regarding co-morbidity 33.5% patients had HTN with DM. The study revealed that most of the patients were on combination of antihypertensive drugs (59%) while 41% patients received monotherapy. Mostly prescribed route of administration was oral route (96%). Among 200 prescription 24% prescriptions had drug interactions. Among 200 prescriptions 75% of prescriptions were found to be adhered with JNC VIII guidelines. CONCLUSION: 25% deviation from JNC VIII guidelines and 24% prescription had drug interaction was observed in the treatment with respect to selection of antihypertensive drugs. Please cite this article in press as Kamal Pandey et al. Drug Use Evaluation of Antihypertensive Drugs in the Tertiary Care Hospital. Indo American Journal of Pharmaceutical Research.2016:6(09). Copy right 2016 This is an Open Access article distributed under the terms of the Indo American journal of Pharmaceutical Research, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 Page6559 INTRODUCTION Drug utilization study is an ongoing authorized process that evaluates prescribing pattern and recommends necessary modification to accomplish rational drug use and a process done to analyze prescribed drugs to patients, taking into account patient safety, clinical evidence, cost effectiveness and treatment efficacy and other factors 1. Hypertension is defined as persistently elevated blood pressure in the arteries. Normal adult blood pressure is defined as a blood pressure of 120 mmhg called as systolic blood pressure occurred when the heart contracts and a blood pressure of 80 mm Hg called as diastolic blood pressure occurred when the heart relaxes. When systolic blood pressure is equal to or above 140 mm Hg and/or a diastolic blood pressure equal to or above 90 mm Hg the blood pressure is considered to be raised or high 2. The prevalence of hypertension is found to increase with age. In US, the overall prevalence of hypertension is 28.7%, where prevalence above 65 years is found to have 65.4%.According to WHO health statistics 2012, In India the prevalence of hypertension was 22.6% in women and 23.1% in men which was measured equal to or above 25 years age 8. In India Prevalence of HTN is reported to contrast from 4 to 15% in urban and 2-8% in rural population. It is approximate that the global prevalence of HTN would increase from 26.4% in 2000 to 29.2% in Blood pressure classification 4. STAGE Systolic BP, in mmhg Diastolic BP, in mmhg Normal <120 mmhg < 80 mm Hg Prehypertension ( ) mm Hg mm Hg Stage 1 hypertension ( ) mm Hg mm Hg Stage 2 hypertension >160 mm Hg >100 mm Hg Hypertension is one of the leading causative factors to many other diseases including heart failure, stroke, myocardial Infarction (MI), kidney failure and retinopathy, a leading reason of death also 5. The organs mainly involved include the blood vessels present in the eyes, heart, and brain, kidney with its resulting complications including heart attacks, Nephropathy, metabolic syndrome and cerebrovascular accident 6. Diuretics, Beta blockers, Calcium channel blockers (CCBs), angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARBs) are the choice of drugs available for hypertension management along with other drug which include aldosterone antagonists, alpha-blockers, and direct renin inhibitors 7. JNC VII recommends lifestyle modifications for the initiation of Hypertension treatment, once lifestyle modification does not control blood pressure, thiazide diuretics should be used as initial therapy for most patients, which can be used alone or in combination with other antihypertensive drug classes (i.e., angiotensin- converting enzyme inhibitors [ACEIs] or angiotensin II receptor antagonists [ARBs], beta-adrenergic blockers [BBs], or calcium channel blockers [CCBs]) or Diuretics 8. Most patients require two or more drugs to achieve BP goal during treatment of hypertension 9. In recent JNC VIII guidelines, diuretics is not consider as the first choice of drug for treatment of hypertension rather considers 4 classes of medications as first line therapy which include calcium channel blockers (CCBs), ACE inhibitors, thiazide-type diuretics, and ARBs. Combinations of ACE inhibitors, ARBs, thiazide-type diuretics and CCBs or any alternate drug is preferred if single drug therapy is ineffective 10. According to JNC VIII guidelines, second line treatment of Htn include beta-blockers, aldosterone antagonists, alpha-blockers, and direct renin inhibitors. Beta-blockers used for Htn treatment include atenolol, bisoprolol, metoprolol tartrate, metoprolol succinate extended release, carvedilol, labetalol. Alpha blocker includes prazocin, terazocin. According to the JnC-8 guidelines, beta-blockers should be initiated if first-line therapy is not effective in lowering blood pressure and use only when a patient has a compelling indication (recent stroke or heart attack) 11. JNC VIII GUIDELINES (2014 Hypertension Guideline) 12. Guidelines Population Goal BP, mmhg Initial drugs treatment Option JNCVIII:2014 Hypertension Guideline General 60 y General <60 y <150/90 mmhg <140/90 mmhg Nonblack: CCB, ACEI, ARB,thiazide-type Diuretic. Black: CCB or thiazide-type diuretic. Diabetes <140/90 mmhg CKD <140/90 mmhg ACEI or ARB METHOD AND MATERIALS Duration of study The study was conducted for a period of 6months. Site of the study The study was conducted at tertiary care hospital. It is 300-bedded tertiary hospital having different specialities like medicine, surgery, orthopedics, paediatrics, obstetrics and gynaecology. Study design A hospital based retrospective study.

3 Page6560 Size of study Study was conducted in 200 patients. Sources of data and materials Patient case sheet STUDY CRITERIA INCLUSION CRITERIA All the inpatient and outpatient in hospital who are treated for hypertension in Tertiary care hospital. EXCLUSION CRITERIA Psychiatric patient Children Pregnancy STUDY PROCEDURE: Eligible patients were enrolled based on inclusion and exclusion criteria. Structured data collection was used for collecting the details. This form mainly contains demographic details, social habits, current medication, past medical and medication history, laboratory investigations, and other relevant data needed for present study were collected from patient s progress records, treatment chart, and laboratory reports. The data collected are subjected for various drug-drug interaction and ADR by using, primary (Micromedex), secondary and tertiary resources which are available in clinical pharmacy department. The collected information was documented and subjected for assessment using suitable statistical method. Statistical Methods: Descriptive statistical analysis has been carried out in the present study. Simple percentage calculations were used and expressed using charts and graphs. RESULT AND DISCUSSION TABLE 1: MALE AND FEMALE PATIENTS. MALE 114 FEMALE 86 TABLE 2: NUMBER OF PATIENTS ADMITTED TO HOSPITAL. AGE MALE PATIENT FEMALE PATIENT > TABLE 3: ALCHOLIC AND SMOKER PATIENTS. NATURE OF PATIENTS NUMBER OF PATIENT PERCENTAGE (%) ALCHOLIC 45 20% SMOKER 65 30% NON ALCHOLIC AND NON SMOKER % TABLE 4:CO-MORBIDITY. S.NO COMORBIDITY NO.OF PATIENTS PERCENTAGE (%) 1 HTN+DM+OTHERS % 2 HTN+CAD % 3 HTN+OTHER 28 14% 4 HTN+CKD 36 18% 5 HTN+STROKE 18 9% 6 HTN+ HEART FAILURE 8 4%

4 Page6561 Table 5: DRUG THERAPY. S.NO THERAPY NUMBER OF THERAPY PERCENTAGE ( % ) 1 MONOTHERAPY 82 41% 2 TWO DRUG THERAPY 96 48% 3 THREE DRUG THERAPY 22 11% TABLE 6: USE OF DRUGS. TYPE OF DRUG NO: OF PATIENTS PERCENTAGE ( %) ENALAPRIL 5 2.5% RAMIPRIL 3 1.5% AMLODIPINE % ATENOLOL 12 6% METOPROLOL 7 3.5% CARBIDOLOL 3 1.5% NEVIBOLOL 4 2% LOSARTAN 4 2% TELMISARTAN 10 5% OLMESARTAN 5 2.5% FURESOMIDE 4 2% COMBINATION OF ALL % TABLE 7: CLASSIFICATION OF MONOTHERAPY DRUG. CLASS NO.OF PATIENTS PERCENTAGE (%) MONOTHERAPY ACE inhibitors 8 4% B Blocker 26 13% Calcium channel blocker % Diuretic 4 2% ARB inhibitor % TABLE 8: COMBINATION THERAPY. Combination of drugs NO. OF PATIENTS Percentage (%) Diuretic +CCB % Diuretic + ACE inhibitor 9 4.5% Diuretic + Beta-Blocker 8 4% Diuretic +ARB inhibitor % CCB +Beta-Blocker % CCB+ ARB inhibitors 8 4% CCB +ACE Inhibitors 6 3% ARB inhibitors +beta blocker 8 4% ACE inhibitors+ Beta blockers 10 5% CCB +Diuretic+ beta Blocker 9 4.5% ACE Inhibitors+ Diuretic + Beta blocker 6 3.5% ARB +Diuretic +Beta blocker 7 3.5% TABLE 9: ROUTE OF ADMINISTRATION. ROUTE OF ADMINISTRATION NO.OF PATIENTS PERCENTAGE (%) ORAL % INTRAVENOUS 8 4%

5 Page6562 TABLE 10: DRUG INTERACTION. DRUGS INTERACTING DRUGS EFFECT NO. OF PATIENTS Ramipril Aspirin Aspirin decreases effect of Ramipril 5 Atenolol Amiodarone Pharmacodynamic synergism 1 Metoprolol Aspirin Both increases serum potassium level 8 Spironolactone Potassium chloride Both increases serum potassium level 3 Spironolactone Atorvastatin Spironolactone increases level or effect of Atorvastatin 4 Amlodipine Carbidopa Pharmacodynamic synergism 11 Amlodipine Levodopa Pharmacodynamic synergism 11 Telmisartan Mefenamic acid Both increases serum potassium 5 PRESCRIPTION PRESCRIPTION WITH DRUG INTERACTION PRESCRIPTION WITHOUT DRUG INTERACTION PRESCRIPTION COMPARISION WITH JNC VIII. S.NO COMORBIDITY DRUGS ACCORDING TO JNC VIII 1 HTN +DM ACEI or ARB + CCB +OTHER or THIAZIDE 2 HTN+CKD ACEI or ARB + CCB or THIAZIDE 3 HTN+CAD BB + ACEI or ARB + CCB 4 HTN + HEART ACEI or ARB + BB + FAILURE DIURETIC 5 HTN+STROKE ACEI or ARB + CCB or THIAZIDE 6 HTN +OTHER CCB or ACEI or ARB or DIURETIC TOTAL PRESCRIPTION PRESCRIPTION ADHERENCE TO JNC VIII PRESCRIPTION NONADHERENCE TO JNC VIII TABLE 11: DRUG COMPARISION WITH JNC VII. PRESCRIPTION STATUS NO OF PRESCRIPTION PRESCRIPTION ADHERENCE TO JNC VIII 150 PRESCRIPTION NONADHERENCE TO JNC VIII 50 TABLE 12: DRUG TREATMENT BASED ON STAGE OF HTN. NORMAL PRE-HTN STAGE I STAGE II 120/80 mmhg >160 >90 ADHERANCE NON-ADHERANCE PRESCRIPTION STATUS NO. OF PRESCRIPTION PRESCRIPTION ADHERANCE 140 PRESCRIPTION NON-ADHERANCE 60

6 Page6563 FIGURE 1: MALE AND FEMALE PATIENTS. 200 cases were examined in tertiary care hospital among that 57 % male and 43% female (Figure 1) FIGURE 2: NO OF PATIENTS ADMITED TO HOSPITAL. Accompanying major age group having hypertension is years i.e. 32 % and yrs. i.e. 25.5% (figure 2). FIGURE 3: ALCHOLIC AND SMOKER PATIENTS. In 200 patients 30% of patient was found to be smoker, 20% alcoholic. (Figure 3).

7 Page6564 FIGURE 4: CO-MORBIDITY OF HYPERTENSION. Regarding co-morbidity, 33.5% of patient had HTN and DM, 23.5% patients had HTN with CAD. FIGURE 5: DRUG THERAPY USED IN TREATMENT. In the management of HTN, combination therapy was preferred and having 59% of management rate with combination therapy which includes 48% two drug therapy and 11% three drug therapy and 41% with monotherapy. FIGURE 6: USE OF DRUGS.

8 Page6565 In tertiary care hospital: Amlodipine, Atenolol, Telmisartan are the major drug used to treat hypertension having 12.5%, 6%, 5% respectively (figure 6). FIGURE 7: MONO-THERAPY DRUG. In management of HTN with mono-therapy drug beta blocker (32%), calcium channel blocker (30%), ARB s inhibitor (23%), ACE inhibitors (10%), Diuretic(5%) was prescribed. FIGURE 8: COMBINATION THERAPY. 59% cases treated with combination therapy includes: Diuretic + ACE inhibitors/ Calcium channel blocker/ B-blocker/ARB s inhibitors.

9 Page6566 FIGURE 9: ROUTE OF ADMINISTRATION. In 200 patients 96% was prescribed oral route and 4% was prescribed with intravenous route. FIG 10: DRUG INTERACTION. In 200 prescription 24% of prescription have interaction among prescribed drugs while 76% prescription were without drug interaction. FIG 11: DRUG COMPARISION WITH JNC VIII.

10 Page6567 In 200 prescription 75% of prescriptions was found to be adherence with JNC VIII guidelines while 25% was non-adherence to JNC VIII guidelines. PRESCRIPTIONS ADHERANCE PRESCRIPTIONS NON-ADHERANCE 30% 70% FIG 12: DRUG TREATMENT BASED ON STAGE OF HTN. IN 200 prescriptions 70% of prescriptions were adhered with drug treatment based on stage of HTN while 30% were deviated. CONCLUSION A 25% deviation from guidelines was observed in the treatment was observed with respect to Selection of antihypertensive drugs in various clinical conditions and Concomitant drugs used and reported to the study department and suggestions were given. No errors were observed with respect to route of administration. Around 24% prescription had Drug interaction (DI) and reported to the study department. ACKNOWLEDGEMENT As he is the first and the last, we thankfully bow with reverence before the almighty who is the source of all wisdom and knowledge, the creator who by his wishes and blesses made us to attain successful completion of this dissertation. We extend our special thanks to Aditya Bangalore Institute for Pharmacy Education and Research Aster CMI hospital for providing us opportunity to conduct this study. Our sincere thanks also goes to our parents, guide, teaching staff, and friends. Last but not the least, we extend our thanks to all those who have been directly or indirectly associated with our study REFERENCE 1. Elahe Elhami. Drug utilization evaluation of antihypertensive drugs in patients with renal failure. World journal of pharmacy and pharmaceutical sciences. Volume 5, Issue 1, Davangere Londhe SP, Silvy S, Sridevi SS, Cherian TS, Baishnab S.Evaluation of Cost and Different Treatment Alternatives for Hypertensive Patients in a Tertiary Care Teaching Hospital. International journal for pharmaceutical research scholars (IJPRS). V- 4, I-1, Bipin B Panda, Manas R Pati, Pratap K Sahu. Survey of Prescription Pattern of Antihypertensive Drugs In Hypertensive And Diabetic Hypertensive Patients. Asian J Pharm Clin Res, Vol 8, Issue 1, 2015, Chandarana Anish. Hypertension Guidelines. Gujarat Medical Journal. July Vol.65 No.2 5. Krishna Murti, M. Arif Khan,Akalanka Dey, Manoj Kumar Sethi, Pradeep Das and Krishna Pandey. Prescription Pattern of Anti- Hypertensive Drugs in Adherence to JNC- 7 Guidelines American Journal of Pharmacology and Toxicology 2015, 10 (1): J.M. Okonta, S.O. Nduka, V. E. Idodo. Prescribing Pattern of Antihypertensive and Antidiabetic Agents in a Secondary Healthcare Institution in Nigeria. J. Pharm. Sci. & Res. Vol.5(1), 2013, Pyarelal.A Study of prescription pattern of antihypertensive drugs in a tertiary Care teaching hospital. Indian Journal of Basic and Applied Medical Research; June 2015: Vol.-4, Issue- 3, P Mahanjit Konwar, Pranab Kumar Paul, Swarnamoni Das. Prescribing Pattern of Antihypertensive Drugs In Essential Hypertension In Medicine Out Patients Department In a Tertiary Care Hospital. Asian J Pharm Clin Res, Vol 7, Suppl 2, 2014, Dr. Amruth Raj V, Ashesh Gautam, Sumit Ghimire1, Dr.Shashidhar G, Dr.Mahesh N M1 and Sunil Gyawali. Prescribing Pattern Of Atihypertensive Drugs And Cost Analysis In a Tertiary Care Teaching Hospital. World Journal of Pharmacy and Pharmaceutical Sciences. Vol 4, Issue 05, Fowad Khurshid, Mohammed Aqil, Mohammad Shamshir Alam, Prem Kapur and Krishna K Pillai. Antihypertensive Medication Prescribing Patterns in a University Teaching Hospital in South Delhi. IJPSR, 2012; Vol. 3(7):

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