Original Article Pattern of Use of Anti-Hypertensive Drugs In a North Indian Tertiary Care Hospital 1 1 2 3 Renu, Hema Chhabra, Anita Gupta, Neetu Sharma 1 2 3 Junior Resident, Professor and Head, Assistant ProfessorDepartment of Pharmacology, Government Medical College & Rajindra Hospital, Patiala, Punjab. ABSTRACT Background: Hypertension is a worldwide medical concern whose proper management forms the core of its control and prevention of its complications. Aims and objectives: To evaluate the prescribing patterns of anti-hypertensive drugs in the Cardiology department, Government medical college and Rajindra hospital, Patiala. Material and methods: It was a cross-sectional and observational study conducted over a period of 6 months. Results: During the study period, 192 prescriptions of hypertensive patients were analyzed. Among the anti-hypertensive drugs, 6 major classes were observed to be prescribed: Angiotensin receptor blockers (ARBs), beta blockers (BBs), calcium channel blockers (CCBs), diuretics (DUs), angiotensin converting enzyme inhibitors (ACEIs) and alpha blockers (ABs). Out of total 192 cases, 45 (23.4 %) received monotherapy, while 147 (76.6 %) received multi-drug therapy of antihypertensive agents. Angiotensin receptor blockers (ARBs) were the most commonly prescribed category both as monotherapy as well as in combination therapy. Two-drug combination was the most prevalent. Among two-drug therapy, ARBs + CCBs was the most commonly prescribed combination. Conclusion: ARBs were the most frequently prescribed anti-hypertensive category. Dual therapy was a part of majority of prescriptions ; ARBs + CCBs being the commonest combination. Keywords: Anti-hypertensive drugs, Hypertension, Prescription pattern, drug utilisation INTRODUCTION: ypertension is one of the major and i n d e p e n d e n t r i s k f a c t o r s f o r Hcardiovascular and cerebrovascular 1 events. According to the World Health Organization (WHO) global health observatory data 2016, it accounts for 12.8 % of the total deaths worldwide which is roughly 7.5 million people 2 across the globe. 3 blood pressure (DBP) 90 mmhg. The seventh report of the joint national committee (JNC 7) on prevention, detection, evaluation and treatment of high blood pressure (B.P.) classified hypertension 4 as follows: JNC 7 classification of hypertension[4] WHO defines hypertension as systolic blood pressure (SBP) 140 mmhg and/or diastolic Address for correspondence: Dr. Hema Chhabra, Junior Resident, Department of Pharmacology, Government Medical College, Patiala, Punjab, India. Email id: hemachhabra@rediffmail.com Ph. No.: +91-94170-25189 182
Dr. Hema Chhabra, et.al : Pattern of use of anti-hypertensive drugs Rational use of various anti-hypertensive drugs alone or in combination is the crux for proper health care management and improved quality of life of hypertensive patients. Purpose of the present study was to evaluate the drug utilization pattern of various anti-hypertensive agents in a routine clinical setting. MATERIAL AND METHODS: The present study was conducted over a period of six months (February 2016 - July 2016) at Cardiology Out Patient Department (OPD), Government medical college and Rajindra hospital, Patiala. It was a cross-sectional and observational study. Patients with hypertension in stage I/stage II, newly diagnosed and old patients of hypertension and hypertensive patients with or without comorbidities were included in the study and pregnant patients with hypertension and patients with systolic BP > 210 and/or diastolic BP > 120 mm Hg, requiring emergency care were excluded. Their demographic and personal data: age, sex, diagnosis (stage of hypertension), h/o smoking and alcohol consumption were also collected. The prescriptions were evaluated. The study was approved by the Institutional Ethics Committee and written informed consent was taken from all the patients. Statistical analysis: The results of observations of individual patients were pooled and analyzed. The results were expressed as mean ± standard deviation and percentage as per applicability. Statistical analysis was performed using Statistical Program for Social Sciences (SPSS) software version 20.0 Chicago, Illinois, USA. RESULTS: In the present study, 192 prescriptions of hypertensive patients were evaluated over a period of six months. The mean age of presentation was found to be 55.17 ± 10.96 years. History of smoking was positive in 10 (8.7 %) patients and of alcohol in 4 (3.4 %) patients. Out of 192 cases, 100 (52 %) were males and 92 (48 %) were females. Majority of male patients were in the age range of 56-65 years (33 %), while female preponderance was seen in the age range of 46-55 years (35.87 %) (table 1). The mean systolic blood pressure (SBP) was 148.52 ± 11.75 mm Hg and mean diastolic blood pressure (DBP) was 92.35 ± 7.78 mm Hg. The average number of drugs per prescription was 2.3 ± 0.86. About 106 (55 %) patients were diagnosed with stage 1 and 86 (45 %) patients were diagnosed with stage 2 hypertension. Out of total 192 cases, 45 (23.4 %) received monotherapy, while 147 (76.6 %) received multidrug therapy of anti-hypertensive agents (table 2). Among monotherapy, the decreasing order of prescribing was as follows: Angiotensin receptor blockers (ARBs) 27 (60 %), calcium channel blockers (CCBs) 11 (24.4 %), diuretics (DUs) 4 (8.9 %) and angiotensin converting enzyme inhibitors (ACEIs) 3 (6.7 %) (figure 1). Beta blockers (BBs) and alpha blockers (ABs) were a part of combination therapy only. Two-drug combination was the most prevalent (table 2). Among two-drug therapy, ARBs + CCBs was the most commonly prescribed 21 (14.28 %) combination. Among three-drug therapy, ARBs + 183
Dr. Hema Chhabra, et.al : Pattern of use of anti-hypertensive drugs BBs + DUs was the most frequently prescribed 13 (8.84 %), while there was only one four-drug Table-2 : Monotherapy versus multi-drug therapy of anti-hypertensive drugs combination ARBs + BBs + CCBs + DUs in 7 (4.76 %) prescriptions (table 3).The most common combination prescribed in stage 1 hypertension was ARBs + BBs, while in stage 2 hypertension, it was ARBs + CCBs. The most frequently prescribed anti-hypertensive group either as monotherapy or in combination therapy was that of ARBs129(67.17 %) followed by BBs 99 (51.55%), CCBs 58 (30.2%), DUs 57 (29.65%), ACEIs 39 (20.3%) and ABs 1 (0.52 %) Figure-1 : Frequency of prescribing of antihypertensive category among monotherapy (figure 2). Analysis of frequency of prescribing pattern of individual anti-hypertensive drugs was also done. It was found that telmisartan was the most commonly prescribed 68 (35.41 %) and prazosin and cilnidipine were the least frequently prescribed anti-hypertensive agents 1 (0.52 %) (table 4). Around 62 (32.29 %) were on anti-platelet agents, 56 (29.16 %) were on anti-diabetics and 53 (27.60 %) were on hypolipidemics. Table 3. Frequency of prescribing of various combinations of anti-hypertensive drugs Table-1 : Distribution of males and females with respect to age ARBs: Angiotensin receptor blockers, CCBs: Calcium channel blockers, BBs: Beta blockers, DUs: Diuretics, ACEIs: Angiotensinconverting enzyme inhibitors, ABs: Alpha blockers 184
Dr. Hema Chhabra, et.al : Pattern of use of anti-hypertensive drugs Figure-2 : Overall frequency of prescribing according to category of anti-hypertensive drug Table-4 : Frequency of prescribing of individual anti-hypertensive drug 192 prescriptions of hypertensive patients were analyzed over a period of six months. Out of total 192 cases, 45 (23.4 %) received monotherapy, while 147 (76.6 %) received multidrug therapy of anti-hypertensive agents. Amruth et al showed comparable results where monotherapy was prescribed in 39.24 % and multidrug therapy in 60.76 % cases. 5 Among monotherapy, the decreasing order of prescribing was as follows: ARBs 27 (60 %), CCBs 11 (24.4 %), DUs 4 (8.9 %) and ACEIs 3 (6.7 %). Studies conducted by Tandon et al and Sikidar et al also reported ARBs to be the most commonly employed 6,7 anti-hypertensive agent as monotherapy. This is in contrast to studies by Arief M and Mishra et al where ACEIs and CCBs were the most prevalent 8,9 drugs among monotherapy respectively. Two-drug combination was the most prevalent. Similar results were obtained in the study by Agarwal et al where dual therapy was a part of 67.84 % prescriptions.10 Among two-drug therapy, ARBs + CCBs was the most commonly prescribed combination 21 (14.28 %). Similar results were obtained by Eslampanah Z et al and Hasan et al.11,12 In contrast, studies done by Pavani et al and Sindhu et al reported ARBs + BBs and ARBs + DUs as the commonest dual therapies.13,14 Among three-drug therapy, ARBs + BBs + DUs was the most frequently prescribed 13 (8.84 %), while there was only one four-drug combination ARBs + BBs + CCBs + DUs in 7 (4.76 %) prescriptions. DISCUSSION: Drug utilization studies are a parameter to assess rationality/irrationality in drug usage. Evaluation of prescribing trends over time helps in improvement of appropriateness and quality of drug usage in clinical scenario. In the present study, In the present study, the most commonly prescribed anti-hypertensive group either as monotherapy or in combination therapy was that of ARBs129 (67.17 %) followed by BBs 99 (51.55 %), CCBs 58 (30.2 %), DUs 57 (29.65 %) ACEIs 39 (20.3 %) and ABs 1 (0.52 %). These results are comparable to the study done by Hussain et al, while Shukrala et al revealed that the overall prescribing frequency 185
Dr. Hema Chhabra, et.al : Pattern of use of anti-hypertensive drugs 15,16 was maximum for diuretics and ACEIs. However, telmisartan was the most commonly prescribed 68 (35.41 %) and prazosin and cilnidipine were the least frequently prescribed anti-hypertensive agents 1 (0.52 %) among individual anti-hypertensive agent prescribing analysis.pawah et al observed telmisartan to be the most frequently prescribed drug, while Agarwal et al found losartan as the most preferred drug by the 17,10 prescribing physicians. Time trends in prescription of anti-hypertensive agents have shown diverse changes over the last decade. ARBs have superseded other antihypertensive categories in the present scenario. Prescribing of ACEIs has also increased over the years. Beta blockers have taken a back seat as an anti-hypertensive monotherapy agent and are restricted to combination therapy only. Calcium channel blockers are preferred in the elderly population and in isolated systolic hypertension. Alpha blockers have role in severe hypertension and benign prostatic hyperplasia in elderly males. CONCLUSION: Prescription pattern studies are an important part of rational medical care. They provide a means to judge the current status of drug use in medical set ups and to evaluate whether they are in accordance with the standard updated recommendations and guidelines or not. In this study, ARBs were the most frequently prescribed anti-hypertensive category. Dual therapy was a part of majority of prescriptions ; ARBs + CCBs being the commonest combination. Combination therapy was thus the trend in the present study. However, still a lot of loopholes exist in the adequate management of hypertension. Goal of treatment must be focused on effective blood pressure control and prevention of cardiovascular and cerebrovascular events. REFERENCES: 1. Artham SM, Lavie CJ, Milani RV, Ventura HO. Cbesity and Hypertension, Heart Failure, and Coronary Heart Disease Risk Factor, Paradox, and Recommendations for Weight Loss. The Ochsner Journal 2009;9:124-32. 2. Raised blood pressure. Global Health Observatory (GHO) data. World Health O r g a n i z a t i o n [ L a s t a c c e s s e d o n : 2 4 t h F e b 2 0 1 7 ] A v a i l a b l e a t : www.who.int/gho/ncd/risk_factors/blood_p ressure_prevalence_text/en/ 3. A global brief on Hypertension. Silent Killer, global public health crisis. World Health Day 2013.Geneva, Switzerland. [ L a s t a c c e s s e d o n ; 2 4 t h F e b 2017].Available at: http://ishworld.com/downloads/pdf/global brief hypertension.pdf 4. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL et al. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood P r e s s u r e ; t h e J N C report.jama.2003;289(19):2560-72. 5. Amruth RV, Gautam A, Ghimire S, Shashidhar G, Mahesh NM, Gyawali S. Prescribing pattern of antihypertensive drugs and cost analysis in a tertiary care teaching hospital. World Journal of Pharmacy and Pharmaceutical Sciences2015;4(5):958-76. 6. Tandon VR, Sharma S, Mahajan S, Mahajan A, Khajuria V, Mahajan V et al. Antihypertensive drug prescription patterns, rationality, and adherence to Joint National 186
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