A STUDY ON PRESCRIBING PATTERN OF ANTIHYPERTENSIVES AT A TERTIARY CARE HOSPITALHTML Full Text
A STUDY ON PRESCRIBING PATTERN OF ANTIHYPERTENSIVES AT A TERTIARY CARE HOSPITAL
S Palanisamy *, R Tharabai 2 and A Sumathy
Department of Pharmacy Practice, KMCH College of Pharmacy 1, Coimbatore, Tamil Nadu, India Department of Pharmaceutical Chemistry, Madurai Medical College 2, Madurai, Tamil Nadu, India
The retrospective study on prescribing patterns of antihypertensives showed that the prevalence of hypertension was predominantly more with male patients than in female patients. It was also found that the average age of the overall study population was 56 years. The average age of the population clearly indicates the elderly patients were affected more. The results indicates that around 57.6% of the patients were brought to normal or prehypertension after the successful treatment with antihypertensive agents. The remaining 42.4% were brought to high normal after the treatment. The study revealed that the physician were treated 44.73% of the patients population with Ramipril alone as mono therapy, 21.05% were treated with Atenolol, 10.52 % were treated with Amlodipine, and other patients are treated with Amiodarone, Prazonin HCL, and Telmisarten etc. The most commonly prescribed combination was found to be Ramipril with Atenolol and it is followed by Ramipril with Amlodipine. The overall percentages of these combinations were found to be 37.25 % and 25.0% respectively.
Prescribing Pattern, Hypertension, Antihypertensives, Blood Pressure
INTRODUCTION: Hypertension is defined as a systolic blood pressure (SBP) higher than 140 mmHg or a diastolic blood pressure (DBP) higher than 90 mmHg; the diagnosis is based on the average of 2 or more readings taken at each of 2 or more visits after an initial screening 1, 2. When determined by these criteria, hypertension affects 20% to 30% of the adult population in most developed countries, and its prevalence appears to increase with the age of the patient.3-5 Recent publications have shown that the lifetime risk of hypertension for patients who are normotensive at age 55 is 90% 1.
African Americans are affected by hypertension nearly twice as often as whites and seem to be more vulnerable to its complications 5, 6. Hypertension is an important risk factor for cardiovascular accidents, coronary heart disease, cardiac hypertrophy with heart failure (hypertensive heart disease), aortic dissection, and renal failure. Hypertension can also accelerate atherogenesis and can induce changes favourable for aortic dissection and cerebrovascular haemorrhage 7. Despite the prevalence of hypertension and its associated complications, only 29% of patients with hypertension are treated, and only 45% of those treated with antihypertensive medications have controlled disease
GOAL OF THE TREATMENT FOR HYPERTENSION (JNC 9, ESH 10, WHO-ISH 11, BSH 12): The ultimate goal of public health in antihypertensive therapy is to minimize the cardiovascular and renal morbidity and mortality. Those with age more than 50 years, hypertension will reach the diastolic blood pressure goal once the systolic blood pressure goal is achieved, the primary focus should be on attaining the systolic blood pressure goal. Decrease in cardiovascular disease rate can be obtained when blood pressure less than 140/90 mmHg. In patients with hypertension and diabetes or renal disease, the blood pressure goal is less than 130/80 mmHg.
TABLE 1: STANDARD TREATMENT GUIDELINES FOR TREATMENT OF HYPERTENSION BY JNC79, WHO- ISH11, BSH12, ESH10
|COMPELLING INDICATIONS||JNC7 GUIDELINES||WHO-ISH GUIDELINES||BSH GUIDELINES||ESH GUIDELINES|
a. Heart Failure/CHF
Diuretics/BBs/ ACEIs/Aldosterone antagonists
|b. Left Ventricular dysfunction||BBs/ ACEIs||ACEIs||ACEIs|
|c. Left Ventricular hypertrophy||ARBs||ARBs||ARBs|
|d. Heart failure in ACE intolerance patients after MI||ARBs|
|e. Post MI||BBs/ ACEIs/ Aldosterone antagonists||ACEIs||CAEIs||Diuretics/BBs/ ACEIs/Aldosterone antagonists|
|f. Angina||BBs/CCBs||BBs/CCBs (DHCCBs/ verapamil/ diltiazem )|
|g. Recurrent stroke prevention/Cerebrovascular disease||Diuretics/ ACEIs||Diuretics/ ACEIs||Diuretics (Thiazides)/ ACEIs|
|h. High coronary disease risk||Diuretics/BBs/ ACEIs/CCBs|
|i. Supra ventricular tachycardia||CCBs (verapamil/ diltiazem)|
|j. Carotid atherosclerosis||CCBs (DHCCBs/ verapamil/ diltiazem )|
Diuretics /BBs/ACEIs/ ARBs/CCBs
|b. Type I Diabetic Nephropathy||ACEIs||ACEIs||ACEIs|
|c. Type II Diabetic Nephropathy||ARBs||ARBs||ARBs|
|d. Proteinuria / Diabetic micro albuminuria||ACEIs/ ARBs|
|e. Non Diabetic Nephropathy||ACEIs||ACEIs|
Elderly hypertensive/ Isolated Systolic Hypertension
Diuretics (Thiazides/ Thiazides like) /CCBs
|Diuretics (Thiazides) / CCBs(DHCCBs)|
a. Chronic Kidney Disease
b. Renal insufficiency
a. Benign Prostate Hypertrophy, Hyperlipidemia
|b. Peripheral Vascular Disease||CCBs (DHCCBs)|
|c. ACEI intolerance||ARBs||ARBs|
|d. Hypertension with pregnancy||BBs / CCBs (DHCCBs)|
BBs-Beta Blockers, ACEIs-Angiotensin Converting Enzyme Inhibitors, ARBs-Angiotensin Receptor Blockers, CCBs-Calcium Chanel Blockers, DHCCBs- Dihydropyridine Calcium Channel Blockers
TABLE 2: PHARMACOLOGICAL TREATMENT
|SITE OF ACTION||DRUG||DOSAGE||CONTRAINDICATION||SIDE EFFECTS|
|RENAL TUBULE||Thiazides e.g.: Hydrochlorothiazide||Oral:-12.5-25 mg daily||Diabetes Mellitus, Hyperuricemia, Primary Aldosteronism||Potassium Depletion, Hyperglycemia, Hyperkalemia, Dermatitis|
|Loop acting||Oral:- 20-80 mg 2 or 3 times daily||Hyperuricemia, Primary aldosteronism||Potassium depletion, Hyperglycemia, Nausea, Vomiting, Diarrhoea|
|Potassium sparing e.g.: Spironolactone||Oral:- 25 mg 2 to 4 times daily||Renal failure||Hyperkalemia, Diarrhea, Gynaecomastia, Menstrual irregularities|
|Amiloride||Oral:- 5-10 mg daily||Hyperkalemia, Nausea, Vomiting, Leg cramps, GI disturbances|
|Clonidine||Oral:- 0.05-0.6 mg twice daily||Postural Hypotension, Drowsiness, Dry mouth, Insomnia|
Oral:- 250-1000 mg twice daily
Pheochromocytoma, Active hepatic disease
|Postural Hypotension, Sedation, Fever, Gynaecomastia, Diarrhea,|
|Oral:- 0.05-0.25 mg daily||Pheochromocytoma, Peptic ulcer, Depression, Severe coronary artery disease||Depression, Night mares, Nasal congestion, Dyspepsia, Impotence|
|Oral:- 10-150 mg daily||Pheochromocytoma, Peptic ulcer, Depression, Severe coronary artery disease||Bradycardia, Dry mouth, Diarrhea, Fluid Retention, Asthma|
|ALPHA RECEPTOR BLOCKER
|Prazosin||Oral:- 1-10 mg twice daily||Use with caution in the elderly||Fluid retention, head ache, sedation, dizziness, tachycardia|
|Terazosin||Oral:- 1-20 mg daily||Use with caution in the elderly||Fluid Retention, Head Ache, Sedation, Dizziness, Tachycardia|
|Doxazosin||Oral:- 1-8 mg daily||Use with caution in the elderly||Fluid retention, Head Ache, Sedation, Dizziness, Tachycardia|
|BETA RECEPTOR BLOCKER||
|Oral: 10-120 mg 2 to 4 times daily||CHF, Asthma, Diabetes, COPD, Heart block||Dizziness, Depression, Bronchospasm, Nausea, Vomiting|
|Oral: 25-150 mg twice daily||CHF, Asthma, Diabetes, COPD, Heart block||Dizziness, Depression, Bronchospasm, Nausea, Vomiting|
|Oral: 25-100 mg daily||CHF, Asthma, Diabetes, COPD, Heart block||Dizziness, Depression, Bronchospasm, Nausea, Vomiting|
|ALPHA/ BETA RECEPTOR BLOCKER||
|Oral:25-100mg daily, IV: 2mg/min|
VASCULAR SMOOTH MUSCLE
|Hydralazine||Oral: 10-75mg 4 times daily, IV or IM: 50mg every 6 hours||Lupus Erythematous, Severe coronary artery disease||Head ache, Tachycardia, Angina Pectoris, Anorexia, Nausea, Vomiting, Rash, Diarrhea, Fluid retention|
|Minoxidil||Oral: 25-100mg daily, IV: 2mg/min||Severe coronary artery disease||Tachycardia, Fluid Retention|
|Nitroprusside||IV: 0.5-8 (µg/kg)/min||Nausea, Vomiting, Weakness|
|ANGIOTENSIN CONVERTING ENZYME INHIBITORS|
|CONVERTING ENZYME||Captopril||Oral: 12.5-75 mg twice daily||Renal failure||Leucopenia, Pancytopenia, Cough, Angioedema Fever, Hyperkalemia,|
|Enalapril||Oral: 2.5-40 mg daily||Leucopenia, Cough, Angioedema|
|Lisinopril||Oral: 5-40 mg daily|
|Ramipril||Oral: 2.5-20 mg daily|
|ANGIOTENSIN RECEPTOR ANTAGONISTS|
|ANGIOTENSIN RECEPTOR BLOCKER||Losartan||Oral:2.5-50 mg once or twice daily||Pregnancy, Bilateral Renal Artery Stenosis||Hypotension, Acute Renal Failure in Bilateral Renal Artery Stenosis|
|CALCIUM CHANNEL ANTAGONISTS|
|VASCULAR SMOOTH MUSCLE||Nifedipine||Oral:10-30 mg 4 times daily||Heart failure||
Tachycardia, Flushing, Gastro Intestinal Disturbances, Hyperkalemia
|Amlodipine||Oral: 2.5-10 mg daily|
|Felodipine||Oral: 5-10 mg daily|
Non-Pharmacological Treatments 10: Broadly non-pharmacological treatment can be divided into 2 categories. They are dietary interventions and behavioral interventions.
Dietary Interventions: Weight reduction, Reduction of alcohol intake, Reduction of salt intake, Potassium supplement, Calcium supplement, Magnesium supplement, Dietary fats, Dietary fiber, Fish oil, Caffeine and Vit. C.
Behavioral Interventions: Smoking cessation, Physical exercise, Relaxation. The primary objectives of the retrospective study were To analyze the patient history to identity the risk factors involved in the hypertension, To identify the co-morbidities, past and present illness, To monitor the prescription and trends in the treatment of hypertension.
METHODOLOGY: The retrospective study was carried out for a period of 4 months at a tertiary care teaching hospital. General Medicine and Cardiology department cases from the Medical Record Department were selected for the study, as there were many cases of hypertensive being admitted for the treatment of hypertension with various co-morbid conditions. Inpatients having Hypertension, Cardiac disorders, renal failure, diabetes mellitus and any co- morbid conditions were included in the study. Children’s below 12 years, ICU patients, terminally ill patients were excluded from the study. Data were collected from patient’s case sheet and transferred to data entry format for evaluation. The collected data were analyzed for its appropriateness and suitability. The interpretation was made for the collected data. From the data analysis, results were obtained and presented.
RESULTS AND DISCUSSION: The total number of patients included in the study was 86. Around 70.9 % (n=61) of the patients was found to be male and 29 % (n=25) was found to be female. The prevalence of hypertension was predominantly more with male patients than in female patients. The patients in this study population show a wide distribution among the age. A maximum of 76.7% (n=66) of population lies with the age between 40 and 70. A minimum of 9.3% of population lies with the age between 20 and 30. It was also found that the average age of the overall study population was 56 years. The average age of the population clearly indicates the elderly patients were affected more.
Hypertensive Status: In this study, we categorized the patient’s population as previously hypertensive and hypertension for first time. It was alarming that 30 % of the total study population was identified as the first time hypertensive in the overall population.
Classification of Patients: We categorize the patients based on their systolic and diastolic blood pressure which was given in various guidelines. The result indicates that around 57.6% of the patients were brought to normal or prehypertension after the successful treatment with antihypertensive agents. The remaining 42.4% were brought to high normal after the treatment. 26.7% of the study population was found to be grade 1 (mild) hypertensives as per ESH, BHS, WHO-ISH, and JNC guidelines. Around 23.3% of the study population was found to have isolated systolic hypertension and rest of the population were moderate and severe hypertension.
Common Symptoms: The common symptoms of the study population were found to be 26% of the patients, had giddiness, 50% had vomiting, 24% had breathing difficulty, and 11% had sweating and cough. A variety of symptoms were found like nausea, general tiredness, loss of consciousness, headache etc.
Treatment: The study revealed that the physician were treated 44.73% of the patients population with Ramipril alone as mono therapy, 21.05% were treated with Atenolol, 10.52% were treated with Amlodipine, and other patients are treated with Amiodarone, Prazosin HCL, Telmisarten, Nifedepine, Furosemide, Losartan potassium, Spironolactone, Captopril, Enalapril and Clonidine as mono therapy (Table 3).
TABLE 3: ANTIHYPERTENSIVE PRESCRIBED AS MONO THERAPY (N=54) (62.8%)
|NAME OF THE DRUG||NUMBER OF PATIENTS||PERCENTAGE OF PATIENTS|
The most commonly prescribed combination was found to be Ramipril with Atenolol and it is followed by Ramipril with Amlodipine. The overall percentages of these combinations were found to be 37.25 % and 25.0% respectively (Table 4).
TABLE 4: ANTIHYPERTENSIVES PRESCRIBED AS COMBINATION THERAPY (N=32) (37.2%)
|NAME OF THE DRUG||NUMBER OF PATIENTS||PERCENTAGE OF PATIENTS|
|Ramipril + Atenolol||10||31.25|
|Ramipril + Amlodipine||8||25.0|
|Amlodipine + Atenolol||6||18.75|
|Amlodipine + Spironolactone||3||9.4|
|Spironolactone + Furosemide||3||9.4|
|Ramipril + Metaprolol||1||3.1|
|Prazosin HCL + Nifedepine||1||3.1|
CONCLUSION: The study revealed that the prevalence of hypertension was predominantly more in male patients than in female patients. The average age of the population clearly indicates that elderly patients were affected more than other age group patients. About 30 % of the overall study population was identified as the first time hypertensive. The result also indicated that around 57.6% of the patients were brought to normal or prehypertension after the successful treatment with antihypertensive agents. This indicates that drugs were selected based upon the patient clinical conditions. A variety of common symptoms were found in the study population such as giddiness, vomiting, breathing difficulty, sweating, cough, nausea, general tiredness, loss of consciousness and headache. The study revealed that the physician were treated the patients population with Ramipril, Atenolol, Amlodipine, Furosemide, and Losartan potassium as mono therapy. The most commonly prescribed combination was found to be Ramipril with Atenolol and it is followed by Ramipril with Amlodipine.
- Bethesda. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute, National High Blood Pressure Education Program, May 2003. Accessed at; www.nhlbi.nih.gov/guidelines/hypertension/
- Carter BL. Highlights of the sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Am J Health Syst Pharm. 55; 382: 1998.
- Brown MJ, Haydock S. Pathoaetiology, epidemiology and diagnosis of hypertension. Drugs. 59; 1: 2000 (2).
- Pardell H, Tresserras R, Armario P, et al. Pharmacoeconomic considerations in management of hypertension. Drugs. 59; 13: 2000 (2).
- Schoen FJ, Kumar V, Abbas AK, Fausto N, Robbins, Cotran. Pathologic Basis of Disease (7). Philadelphia, PA, Saunders. 2004: pp 511–529
- Ashaye MO and Giles WH. Hypertension in blacks: A literature review. Ethn Dis. 13; 456: 2003.
- Burt VL, Cutler JA, Higgins M, et al. Trends in the prevalence, awareness, treatment, and control of hypertension in the adult US population: data from the Health Examination Surveys, 1960 to 1991. Hypertension. 26; 60: 1995.
- Pickering TG. Optimal blood pressure levels. Am J Hypertens. 11; 877: 1998.
- Joint National Committee. Seventh report of the Joint National Committee on detection, evaluation and treatment of high blood pressure. Available from URL: http://www.nhlbi.nih.gov/guidelines/hypertension/jnc 7fullpdf.
- Guidelines committee. 2003 European society of hypertension-European society of cardiology guidelines fro the management of arterial hypertension. Journal of hypertension. 2003; 21: 10011-53
- WHO Cindi working group. Pharmacy –based hypertension management model: protocol and guidelines. Available from: http://www.euro.who.int/documents/E85730pdf.Accessed April 01, 2005
- William B, Poulter NR, Brown MJ, Davis M, Mclnes GT, Potter JF, et al. Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society. J Hum Hyp. 200; 18: 139-85. Available from: http://www.hyp.ac.uk/bhs/pdf)BHS-IV_guidelines.pdf
S Palanisamy *, R Tharabai and A Sumathy
Department of Pharmacy Practice, KMCH College of Pharmacy, Coimbatore, Tamil Nadu, India
15 March, 2010
14 June, 2010
09 July, 2010
01 August, 2010