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PRESCRIPTION PATTERN OF ANTI –HYPERTENSIVE DRUGS AMONG
HYPERTENSIVE PATIENTS AT DISTRICT HOSPITAL
K. DEEPAK MAHARSHI1*, T. VANI1, M. NAVANEETHA1, G. JYOTHI1, SHANTVEER HALCHER2, GURURAJ V WADAGERI3
1 Pharm. D. (Doctor of Pharmacy), RGUHS, Bangalore, Karnataka, India.2 Department of Pharmacy Practice, RMES’s college of Pharmacy, Gulbarga, Karnataka, India.3 Department of Pharmaceutics, RMES’s college of Pharmacy, Gulbarga, Karnataka, India.*Corresponding author
Email id: [email protected]
ARTICLE TYPE: Research Article
ABSTRACT:
BACKGROUND: To conduct a prospective observational study on prescribing pattern of anti-hypertensive drug in the department of GENERAL MEDICINE in Government District hospital, Gulbarga. In this study it was aimed to evaluate the current practice of anti-hypertensive drug by comparing with JNC-8 guidelines in population. OBJECTIVES: The objective of our study is to determine the prescription pattern of antihypertensive drugs and adherence to JNC8 guidelines and to find out the most prescribed anti-hypertensive drugs. Methods: A Prospective Observational Study of 06 months was conducted. Undertaken 174 patients data collection form of all the patients of inpatient department of age 18 ? years of hypertensive with or without co-morbidities. Result: The results of this analysis suggests that out of the total 174 hypertensive patients included in the study, 92 patients were males while 82 patients were females, indicating the higher prevalence of hypertension in male population than in female population, that is 10% higher prevalence in males than in females. Out of the total study subjects, 169 hypertensive patients were found to have other co morbid conditions. Considering out of the total 174 patients, majority of the patients received monotherapy (129) while remaining patients receiving the Combinational therapy are 45. However in the case of overall utilization pattern of antihypertensive agents, CCBs are the most frequently prescribed class of drugs, followed by ARBs , BBs and finally ACEIs .

KEYWORDS: ACEI, ARB, BB, CCB, DM, HTN.

INTRODUCTION:
Hypertension is the major health problem and the expenses of its treatment are high. In the united states, approximately 50 million people have been diagnosed with hypertension, and half of them are treated with anti-hypertensive medication. In the early 1980’s calcium antagonist and angiotensin converting enzyme inhibitors gained ground as the first line anti-hypertensive drugs. 1
Antihypertensive pharmacotherapy effectively reduces hypertension-related morbidity and mortality. Appropriate pharmacotherapy for uncomplicated hypertension assumes paramount importance to public health because _70% of US hypertensive adults lack co-morbidities that compel the use of certain antihypertensive drug. 2
Most patients with hypertension require two or more antihypertensive medications. Thiazide diuretics, ?-blockers, angiotensin converting enzyme inhibitors (ACEIs), angiotensin receptor blockers and calcium channel blockers have all been shown to reduce complications of hypertension and may be used for initial drug therapy. In 2002, a clinical trial comparing different classes of antihypertensive medications for initial therapy found that chlorthalidone, a thiazide diuretic, was as effective as other agents in reducing coronary heart disease, death and non fatal myocardial infarction. The drug was superior to amlodipine in preventing heart failure and to lisinopril in preventing stroke. Selection of antihypertensive agents should therefore be based primarily on the comparative ability to prevent these complications. 3
More than 50% of treated hypertensive patients have a blood pressure level greater than 140/90 mm Hg (uncontrolled hypertension). Several factors including, among others, poor adherence to therapeutic regimen, ignorance, and poverty have been adduced for the high prevalence of uncontrolled hypertension. Recent reports have however focused on the role of health care provider to poor adherence to antihypertensive drugs. Consequently, compliance with standard guidelines aiding physicians in effective prescription of antihypertensive drugs have been emphasized. This study is aimed at determining the physician’s prescription pattern of antihypertensive medications in a tertiary health institution in north western Nigeria. Physician’s compliance with the existing guidelines is described. 4
The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) is the largest randomized trial ever conducted to compare antihypertensive medications. Sponsored by the US National, Heart, Lung, and Blood Institute in conjunction with the US Department of Veteran’s Affairs, ALLHAT was designed to compare the efficacy of 4 types of antihypertensive medications – chlorthalidone (a thiazide-type diuretic), amlodipine (a calcium channel blocker CCB), lisinopril (an angiontensin-converting enzyme ACE inhibitor) and doxazosin (an ?-adrenergic blocker) – for reduction of risk of coronary heart disease (CHD) or other cardiovascular events .5
The seventh report of the joint national committee on the detection evaluation and treatment of high blood pressure (JNC 7) is the most prominent evidence based clinical guideline for the management of the hypertension. 6
JNC 8 Guidelines 7:
Hypertension is one of the most important preventable contributors to disease and death in the United States, leading to myocardial infarction, stroke, and renal failure when it is not detected early and treated appropriately. The Eighth Joint National Committee (JNC 8) recently released evidence-based recommendations on treatment thresholds, goals, and medications in the management of hypertension in adults. In the general population of adults 60 years and older, pharmacologic treatment should be initiated when the systolic pressure is 150 mm Hg or higher, or when the diastolic pressure is 90 mm Hg or higher. Patients should be treated to a target systolic pressure of less than 150 mm Hg and a target diastolic pressure of less than 90 mm Hg. Treatment does not need to be adjusted if it results in a systolic pressure lower than 140 mm Hg, as long as it is not associated with adverse effects on health or quality of life.In the general population younger than 60 years, pharmacologic treatment should be initiated when the systolic pressure is 140 mm Hg or higher, or when the diastolic pressure is 90 mm Hg or higher. The target systolic pressure in this population is less than 140 mm Hg, and the target diastolic pressure is less than 90 mm Hg.

AIM & OBJECTIVE:
To determine the prescribing pattern of anti- hypertensive drugs in the department of general medicine & to find out the most prescribed anti-hypertensive drugs.

METHODOLOGY:
A prospective observational study involving 174 patients carried out at Department of GENERAL MEDICINE, Gulbarga dist hospital, for the period of 6 Months (October 2016 to March 2017) Patients The data is collected from all the patients of either sex with primary and secondary hypertension in medicine inpatient department and who are willing to participate in the study, & not from the Patient below the age of 18 years, pregnant women and patients who are not willing to participate in the study. Patient data relevant to the study will be obtained from Case-sheets, medication chart & laboratory reports.

RESULT:
DEMOGRAPHIC PROFILE OF PATIENTS: Table 1
In our study Involving 174 patients in total, 92 patients are male and 82 patients are female (Table 1)
SL.NO GENDER NUMBER
1 Males 92
2 Females 82

FIG NO 1: DEMOGRAPHIC PROFILE OF PATIENTS
AGE IN YEARS COLLECTED : TABLE NO .2
SL.NO AGE IN YEARS NO.OF PATIENTS
1 40-50 YEARS 13
2 50-60 YEARS 65
3 60-70 YEARS 70
4 70-80 YEARS 21
5 80-90 YEARS 05

FIG NO 2: AGE IN YEARS COLLECTED
SOCIAL HISTORY FACTOR IN MALES:TABLE NO.3
SL.NO NO OF PATIENTS SMOKER ALCOHOLIC SMOKER
&
ALCOHOLIC NON SMOKER
& ALCOHOLIC
1 92 11 09 53 19

FIG NO 3: SOCIAL HISTORY IN MALES
MONOTHERAPY USED IN HYPERTENSIVE PATIENTS: TABLE NO.4
SL.NO DRUGS PRESCRIBED NO OF PATIENTS
1 AMLODIPNE 81
2 ATENOLOL 11
3 TELMISARTAN 17
4 RAMIPRIL 11
5 LOSARTAN 03
6 NICRADIPINE 01
7 ENALAPRIL 01
8 NEFIDIPINE 04

FIG NO 4: MONOTHERAPY USED IN HYPERTENSIVE PATIENTS
COMBINATIONAL THERAPY USED IN HYPERTENSIVE PATIETS: TABLE NO:5SL.NO DRUGS PRESCRIBED NO OF PATIENTS
1 NEFIDEPIN+AMLODIPINE 06
2 AMLODIPINE+TELMISARTAN 14
3 AMLODIPINE+ATENOLOL 10
4 AMLODIPINE+NITROGLYCERINE 05
5 AMLODIPINE+RAMIPRIL 01
6 AMLODIPINE+LOSARTAN 01
7 ATENOLOL+NITROGLYCERINE 01
8 LOSARTAN+TELMISARTAN 01
9 TELMISARTAN+NITROGLYCERINE 01

FIG.NO 5: COMBINATIONAL THERAPY USED IN HYPERTENSIVE PATIENTS
COMBINATIONAL THERAPY PRESCRIBED FOR HYPERTENSIVE PATIENTS: TABLE NO.6
SLNO DRUGS PRESCRIBED NO OF PATIENTS
10 AMLODIPINE+ATENOLOL+TELMISARTAN+
NITROGLYCERINE 01
11 LOSRATAN+AMLODIPINE+NITROGLYCERIN 01
12 TELMA+NITROGLYCERIN+AMLODIPINE 01
13 NITROGLYCERINE+ NEFIDEPIN+AMLODIPINE 01

FIG NO:6 COMBINATIONAL THERAPY USED IN HYPERTENSIVE PATIENTS
HYPERTENSION WITH OTHER COMORBID DISEASES TABLE NO:7SL.NO HTN WITH OTHER COMORBID DISEASES NO OF PATIENTS
1 DM ,HTN & CVA 02
2 CVA , HTN 10
3 HTN ,DM & LVF 03
4 AGN ,ASTHMA ,HTN 01
5 BRONCHIAL ASTHMA , HTN 12
6 CVA &ASPIRATION PNEUMONIA & HTN 01
7 ACCELERATED HTN 11
8 HTN WITH ACUTE GE 01
9 ACCELERATED HTN & CCF 02
10 HTN WITH ANEMIA 07
11 DM WITH HTN 20
12 ACUTE GE & HTN & DM & MILD DEHYDRATION 01
13 COPD WITH HTN 06
14 ACUTE BRONCHITIS, HYPOTHYROIDISM&HTN 02

FIG NO :7 HTN WITH OTHER COMORBID DISEASES
HTN WITH OTHER COMORBID DISEASES TABLE NO:815 HTN,LRTI 02
16 HTN,CKD,ANEMIA 03
17 HTN,DM,CKD 01
18 HTN,COPD,CORPULMONALE 04
19 HTN,COPD,CORPULMONALE ,PTB 03
20 HTN,COPD, HEMOPTYSIS 04
21 ACCELERATED HTN,ANEMIA 02
22 HTN,ANEMIA,PNEUMONIA 02
23 HTN,CVA,DM,ANGINA 03
24 HTN,CVA,HEMIPARESIS,LRTI 01
25 HTN,CVA,ASTMA 01
26 HTN,CVA,SEIZURE DISORDER 03
27 HTN,SEIZURE DISORDER 01

FIG NO: 8 HTN WITH OTHER COMORBID DISEASES
DISCUSSION:
The results of this analysis suggests that out of the total 174 hypertensive patients included in the study, 92 patients were males while 82 patients were females, indicating the higher prevalence of hypertension in male population than in female population, that is 10% higher prevalence in males than in females.The highest number of hypertensive patients 70 belonged to the age group of 60-70 years and then belonged to the age group of 50-60 years 65 patients , 70-80 age group 21 patients then 13 patients were belonging to the age group of 40-50 years, then 5 members were belonging to the age group of 80-90 years. Out of the total study subjects174, 11 hypertensive patients were not found to have other co morbid conditions, Remaining 163 Patients were found to be comorbid like DM (20), Bronchial asthma(12), CVA(10) , Anemia (7), COPD (6), corpulmonale (4) etc. Considering out of the total 174 patients, majority of patients received monotherapy (129) while combinational therapy were received by the patients( 45) . Among the monotherapy category the various hypertensive classes prescribed were ranked as follows CCB’s (81) followed by ARB’s like telmisartan (17) and ACE inhibitors like Ramipril (11) etc. As a monotherapy Amlodipine (15%) was the most frequently prescribed drug as monotherapy along with telmisartan and losartan and ramipril . In the overall utilization pattern of antihypertensive agents, CCB’s and Diuretics ARBS were the most frequently prescribed class of drugs, followed by ACEI’s , and finally BB blockers.
CONCLUSION:
Hypertension is more seen in male patients compared to female patients. Most of the patients were in the age group of 60-70 years and above constituting 96.7% of total patients. Prescription Pattern Varies with age, gender and other complications associated with hypertension. Physician need to maintain a vital therapy for the successful treatment of hypertensive patients. A Pharmacist job is to monitor all the interventions like physician analysis, Drug intercations etc. Prescription pattern of the present study concluded amlodipine was the most commonly prescribed anti – hypertensive drug in the monotherapy followed by Telmisartan. Most of the combinational therapy prescribed in hypertensive patients were amlopdipine + telmisartan. Anti-Anginal drug like Nitroglycerine are also used for complicated hypertension. Drug used in hypertensive patients such as CCBs like amlodopine, Nefidipine, Nicardipine & ARBs like Telmisartan. Losartan & ? Adreneric blockers like Atenolol & ACE inhibitors like Ramipril were the most commom drugs used for uncomplicated patients. Therapeutic Regimen depends on age, young hypertensive were compared with older age groups were substantially were less aggressively treated mostly with monotherapy. Treatment was increased when concomitant comorbid disease were present.

Finally the overall findings of the study show that there is a further improvement in the prescription pattern of anti-hypertensives.

CONFLICTS OF INTEREST:
None
ACKNOWLEDGMENT:
Authors thank Dr. IJAZ AHMED KHAN for helping us in editing.

REFERENCES:
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