Original article: A Study of prescription pattern of antihypertensive drugs in a tertiary Care teaching hospital Pyarelal Associate Professor, Department of Pharmacology, Mediciti Institute of Medical Sciences, Ghanpur, Telangana, India. Corresponding author : Pyarelal Abstract: Introduction: Hypertension is among the most common chronic medical conditions and leading contributor to the global burden of diseases.drug utilization studies are done to analyze prescribed drugs to patients, taking into account patient safety, clinical evidence, cost effectiveness and treatment efficacy.present study was conducted to find out current trend of drug prescribing of anti-hypertensive drugs prescribed either as monotherapy or in combinations with others. As well as variations were seen in prescribing drugs with regards to the age and comorbidities. Materials and methods: An observational, prospective, cross-sectional study involving 150 prescriptions for hypertensive patients was conducted.hypertensive patients of 20 years and above of both sexes with or without other physical illnesses were included while subjects with pregnancy and lactation were excluded. Results: Most of patients were in the age group of 40-60 years and above, constituting 96.7 % of total patients. Comorbidities were found in 90 subjects, the most common one being Diabetes mellitus. Angiotensin receptor blockers were the most commonly prescribed drug group, the next in the order was calcium channel blockers. Conclusion: Angiotensin receptor blockers and calcium channel blockers were the most common single drugs used for most of the uncomplicated essential hypertension followed by angiotensin-converting enzyme inhibitors. Therapeutic regime depends on age, young hypertensive patients (20 40 years) compared with the older age groups were substantially less aggressively treated mostly with monotherapy. Treatment intensity increased when concomitant comorbid diseases were present. Key words: Antihypertensive, Drug utilization, Hypertension, Prescription Introduction angiotensin-convertingenzyme (ACE) inhibitors, and Hypertension is among the mostcommon chronic angiotensin receptor blockers(arbs), are available medical conditions and leading contributor to the for hypertension management. 5 global burden of diseases. 1 as well as its incidence is Greater than 50% of treated patients of hypertension increasing continuously worldwide. 2,3 According to have a blood pressure level more than 140/90 mm Hg the joint National committee (JNC VII) report, (uncontrolled hypertension). Several factors can be hypertension is a major risk factor for stroke, heart implicated for the high prevalence of uncontrolled failure, coronary heart disease, and end-stage renal hypertension like poor adherence to treatment disease. Hypertension is also commonly associated regimen, ignorance and poverty. 6,7 New joint national with diabetes and chronic renal failure generally. 4 A committee (JNC VII) guidelines proposes even lower large number of drugs, including diuretics, Beta BP targets and states patients of BP values of 120 blockers,calcium channel blockers (CCBs), 584
139/80 89 mmhg as pre-hypertensiverequiring lifestyle modification. 4 Drug utilization studies are done to analyze prescribed drugs to patients, taking into account patient safety, clinical evidence, cost effectiveness and treatment efficacy and other factors. As well as hypertensive treatment is life long treatment, the prescription needs special emphasis of consideration of these factors.according to new joint national committee (JNC VII) guidelines, diuretics should be the drugs of first choice for uncomplicated hypertension. 4 However, a plethora of new drugs like Beta blockers, calcium channel blockers (CCBs), angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARBs) are now available. To our knowledge, there are no major drug utilization studies conducted that directly link the patient s diagnoses to actual treatment patterns in Indian population.therefore present study was conducted to find out current trend of drug prescribing of antihypertensive drugsprescribed either as monotherapy or in combinations with others. As well as variations were seen in prescribing drugs with regards tothe age and comorbidities. Materials and methods An observational, prospective, cross-sectional studyinvolving 150 prescriptions for hypertensive patients was conducted in the outpatient department of Mediciti Institute of Medical Sciences, Ghanpur, Telangana. Hypertensive patients of20 years and above of both sexes with or without other physical illnesses were included while subjects with pregnancy and lactation were excluded.all hypertensive patients visiting the medicine outpatient department were reviewed daily and subjects were selected according to inclusion criteria. The blood pressure (BP) measurement was done at the time of enrolment and other patient information like demographics and the drug details were recorded in proforma sheet. Further, comorbidities were identified and recorded. Data obtained were analyzed and expressed in percentage. Results 90 males and 60 female hypertensive patients were included in study.most of patients were in the age group of 40-60 years and above, constituting 96.7 % of total 150 patients. (Table1) Comorbidities were found in 90 subjects, the most common one being Diabetes mellitus (57.7%), followed by Anemia, COPD and others. (Table 2) ARBs were the most commonly prescribed drug group (34%), the next in the order was CCBs (23.1%) and ACE inhibitors (21.7%). However beta blockers and Diuretics too were prescribed, but less commonly. (Table 4) Table 1: Age Group Distribution of Patients <40 years 40-60 years >60 years Category Number Percentage Number Percentage Number Percentage Male 3 43 44 Female 2 32 26 585
Table 2: Comorbidities present in hypertensive Patients Comorbid Conditions No. of Patients (150) % Diabetes mellitus 52 57.7 COPD 12 13.3 Anemia 14 15.6 CHD 8 8.8 Heart disease other than CHD 11 12.2 Cerebral Infarction 4 4.4 Pulmonary TB 01 1.1 Osteoarthritis 5 5.6 Bronchial asthma 4 4.4 Table 3: Drugs Prescribed Number of Total Number of antihypertensives prescriptions (150) Percentage 1 drug 99 66 2 drug 42 28 3 drug 7 4.7 4 drug 2 1.3 Table 4: Individual Anti-Hypertensives Drugs Prescribed Antihypertensive group No. of Percentage Prescriptions Angiotensin Receptor Blockers 72 34 Calcium Channel Blockers 49 23.1 angiotensin-converting enzyme (ACE) inhibitors 46 21.7 Diuretics 24 11.3 Beta Blockers 21 9.9 Discussion The results of our study suggest that hypertension is more prevalent in male patients(60%) than female patients (40%). This finding was in conformity with some of the previous studies. 8,9 while some studies gives conflicting results and stated incidence of 61% in females as against 39% in males. 10 Most of patients were in the age group of 40-60 years and above, constituting 96.7 % of total 150 patients. Blood pressure greater than 20/10 mm of Hg above normal as well as presence of other high risk conditions is indication for therapy with drugs from 586 585
classes like ACE inhibitors, ARB's, beta blockers or calcium channel blockers alone or in combination with diuretics. Drug utilization studies are conducted to monitor adherence to treatment guidelines. Our data shows ARBs (34%) and CCBs (23.1%) were the most common single drugs used for most of the uncomplicated essential hypertension followed by ACE inhibitors (21.7%).The patients with comorbid conditions were prescribedone or two antihypertensive drugs along with other drugs to treat their associated diseases such as diabetes mellitus, COPD, Anemia, Bronchial asthma, osteoarthritis and others.in present study, it was found that therapeutic regime depends on age, young hypertensive patients (20 40 years) compared with the older age groups were substantially less aggressively treated mostly with monotherapy. Treatment intensity increased when concomitant comorbid diseases were present. Increased cardiovasculardisease risk among older men may have contributed to the Increased prescribing of antihypertensive drugs to those aged 60 years. 11 Recently, several large clinical trials demonstrated thatin most patients lowering BP levels can be achieved and sustained bythe use of multipleantihypertensive drugs. 12,13 Initiating drug therapy with adiuretic, either alone or in combination with an agent fromanother drug class, apparently provides the best outcomes for BP control, and these guidelines have beenincorporated into the current JNC VII report. 4 While in present study it was found thatarbs (34%) and CCBs (23.1%) were the most common drugs used for initiating therapy.for management of hypertensivewith comorbidities, JNC VIIguidelines recommend ACE inhibitors as the preferred drugfor hypertension in the setting of diabetes, orcongestiveheart failure; ACE inhibitors or diuretics for recurrentstroke prevention; and Beta blockers for those with prior myocardialinfarction. 4 Certainlimitations have to be taken into account during present study like becauseof the cross-sectional design of study, there was no assessmentwhether the present therapy was the initial one or whether it switch or add-on to the original one. Therefore, no information about thetreatment strategies over time can be provided. As well as study population was single centered. Conclusion Hypertension is more prevalent in male patientsthan female patients. Most of patients were in the age group of 40-60 years and above, constituting 96.7 % of total patients. ARBs and CCBs were the most common single drugs used for most of the uncomplicated essential hypertension followed by ACE inhibitors. Therapeutic regime depends on age, young hypertensive patients (20 40 years) compared with the older age groups were substantially less aggressively treated mostly with monotherapy. Treatment intensity increased when concomitant comorbid diseases were present. References 1. Lawes C.M., Vander Hoorn S., Law M.R., Elliott P., Mac Mahon S. and Rodgers A. Blood pressure and the global burden of disease 2000. Part II: estimates of attributable burden. J Hypertens 2006; 24(3):423-30. 2. Wolf maier K. Cooper RS, Kramer H, Banegas JR, Giampaoli S, JoffresMR et al. Hypertension treatment and control in five European countries, Canada, and the united states. Hypertension2004; 13:10-17. 587 585
3. Sharma AM, Wittchen HU, Kirch W. Pittrow D, Ritz E, Goke B et al. High prevalence and poor control of hypertension in primary care: cross sectional study. J Hypertension. 2004; 22:479-86. 4. Chobanian AV, BakrisGL, Black HR et al (2003) The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 289:2560 2572 5. Psaty BM, Smith NL, Siscovick DS, Koepsell TD, Weiss NS, Heckbert SR, Lemaitre RN, Wagner EH, Furberg CD. Health outcomes associated with antihypertensive therapies used as first-line agents: a systematic review and meta-analysis. JAMA. 1997;277:739 745. 6. Isezuo AS, Njoku CH. Blood pressure control among hypertensives managed in a specialized health care setting in Nigeria. Afr J Med Med Sci. 2003; 32:65-70. 7. Isezuo SA, Opara TC. Hypertension awareness among Nigerian hypertensives in a Nigerian tertiary health institution. Sahel Medical Journal. 2000; 3:93-97. 8. Jhaj R, Goel NK, Gautam CS, Hota D, Sangeeta B, Sood A, et al.prescribing patterns and cost of antihypertensive drugs in aninternal medicine clinic. Indian Heart J. 2001; 53:323-7. 9. Anand RK, Bhandare B, Hemamalini MB, Krishna MV. A Prospective Study of Prescribing Pattern of Antihypertensive Drugs in Tertiary Care Hospital, Bangalore. Journal of Evolution of Medical and Dental Sciences 2014; 2 (52); pp:10339-10344. 10. Tiwari H, Kumar A, Kulkarni SK. Prescription monitoring of anti- hypertensive drug utilisation at the Punjab University HealthCentre in India. Singapore Med J. 2004; 45:117-20. 11. Kannel WB. The Framingham Study: historical insight on the impact of cardiovascular risk factors in men versus women. J GendSpecif Med. 2002;5:27 37. 12. Law MR, Wald NJ, Morris JK, Jordan RE. Value of low dose combination treatment with blood pressure lowering drugs: analysis of 354 randomised trials. BMJ. 2003;326:1427. 13. Moser M. Rationale for combination therapy in the management of hypertension. J ClinHypertens (Greenwich). 2003;5:17 25. 588 585