PRESCRIBING PATTERN OF DRUGS IN THE TREATMENT OF HYPERTENSION IN A TERTIARY CARE TEACHING HOSPITAL: A PROSPECTIVE OBSERVATIONAL STUDY

www.wjpr.net Vol 8, Issue 12, 2019. 1072

PRESCRIBING PATTERN OF DRUGS IN THE TREATMENT OF

HYPERTENSION IN A TERTIARY CARE TEACHING HOSPITAL: A

PROSPECTIVE OBSERVATIONAL STUDY

Dr. Nazish Fathima*, Haran Prasad H. J., Hephzibha S. Mathew, Jasmin Seira Jose and

Jemimah V. Cherian

Department of Pharmacy Practice, Bapuji Pharmacy College Davangere, Karnataka.

ABSTRACT

Background: Hypertension is a common chronic medical condition

which is identified as the 3rd leading risk factor for global burden of

diseases. According to Joint National Committee guidelines,

hypertension is defined as elevated systolic blood pressure of

≥140mmHg or diastolic blood pressure of ≥ 90mmHg. Objective: The

objective of this study is to analyse the prescribing pattern associated

with antihypertensives. Materials and Methods: A Prospective

Observational study was carried out for a period of 6 months in an

inpatient department in Shamanur Shivashankarappa Institute of

Medical Science and Research Centre, a tertiary care teaching hospital,

Davangere. The data was collected from case sheets of all inpatients taking at least one

antihypertensive. Results: A total of 150 prescriptions were analysed, out of which,

88(58.66%) were males and 62(41.33%) were females. The mean age group of study

population was found to be 60-80 years (52%). The most commonly reported co- morbidity

along with hypertension was Diabetes mellitus 80 (53.33%). Monotherapy was most

preferred therapy which was given in almost 76 (50.66%) followed by combination therapy.

In monotherapy Calcium channel blockers 35(46.04%) was most commonly prescribed.

Conclusions: The present study confirms that the Prescribing patterns of antihypertensive

drugs were in concordance with joint national committee 8 guidelines for patients with

different compelling indications. The most frequently prescribed class of drug as

monotherapy was Calcium Channel Blockers, followed by diuretics, which was also the most

commonly used class of drugs in combination therapy.

KEYWORDS: Hypertension, Prescribing pattern, Anti-hypertensives, JNC-8.

Volume 8, Issue 12, 1072-1089. Research Article ISSN 2277– 7105

Article Received on 30 August 2019,

Revised on 19 Sept. 2019, Accepted on 09 Oct. 2019,

DOI: 10.20959/wjpr201912-16064

*Corresponding Author

Dr. Nazish Fathima

INTRODUCTION

Hypertension (HTN) also known as high blood pressure (BP) is a common chronic medical

condition.[1] According to Joint National Committee (JNC 8) guidelines, HTN is defined as elevated systolic BP of ≥140mmHg or diastolic BP of ≥90mmHg.[3]

According to JNC 8, BP in adults is classified into[7]

Categories of HTN Systolic BP (mmHg) Diastolic BP (mmHg)

Normal Pre HTN Stage I HTN Stage II HTN

<120 120-139 140-159 >160 <80 80-89 90-99 >100

The GBD Study found HTN as the third most preventable cause of death worldwide and the

second most common condition in Western countries.[8] For rational planning of health

services accurate estimates of the worldwide prevalence of this condition are essential as a

source of primary information.[2] Worldwide prevalence for HTN is estimated to be in 1

billion individuals, in which approximately 7.1 million deaths per year may be attributable to

HTN and its complications.[9] Approximately 40% of adults aged 25 and above had been

diagnosedwith HTN; the number of people with the condition increased from 600 million in

1980 to1 billion in 2008.[4] The prevalence of HTN is highest in the African Region in 46%

of adults aged 25 and above, while the lowest prevalence is in America in 35% of adults.

Overall, high-income countries have a lower prevalence of HTN 35% than other groups at

40%.[4] The prevalence of compelling indication was high among stage II HTN patients

(59.45%).[10]

According to WHO health statistics 2012, the prevalence of HTN in adults ≥25 years of age

was 23.1% in men and 22.6% in women.[11] Overall in 2000, 26·4% of the world’s adult

population had HTN- 26·6% in men and 26·1% in women, and 29·2% were predicted to have

HTN by 2025- 29·0% in men and 29·5% in women.[2] According to the data published in

United States, the prevalence of HTN is 28.7%, but the same rises to 65.4% in those above 65

years of age.[12] The estimated total number of adults with HTN in 2000 was 972 million; 333

million in economically developed countries and 639 million in economically developing

countries.[7] In India, the overall prevalence for HTN was estimated to be 29.8%.[11] The

overall occurrence of HTN is similar between both men and women but it differs with age.

older people they were higher in women than in men.[5] The lowest estimated prevalence of HTN for both men and women was in the region “other Asia and islands”.[2]

Uncontrolled HTN leads to severe long term complications such as stroke, heart failure,

congestive heart disease and end-stage renal disease.[6] Generally, HTN is commonly

associated with diabetes and chronic renal failure.[13] The higher prevalence of HTN is the

major cause for more than half of the cardiovascular diseases (CVD) and is a leading risk

factor for foetal and maternal deaths in pregnancy, dementia.[14] HTN attributes to 29% of

Stroke, 24% of Acute MI, 21% of peripheral vascular disease and 10% of ischemic heart

disease.[15] Worldwide, complications of HTN accounts for 9.4 million deaths every year.

HTN is responsible for 51% of deaths due to stroke (total stroke mortality) and 45% of deaths

due to heart disease (total ischemic heart disease mortality).[4] If HTN left untreated about

50% of the patients will die of coronary artery disease, 33% of cerebrovascular stroke, 20%

of diabetes and 10-15% chronic renal failure.[16] Hence, lifelong management and lifestyle

modification, and pharmacotherapy are needed for its treatment and management. The main

goal is to reduce morbidity and mortality through a reduction in hypertensive associated

complications.[17]

Rational use of drug is important for the wellbeing of the patient.[20] Prescribing pattern is a

component of medical review, which seeks monitoring, evaluation and necessary

modification in prescribing practices of prescribers to achieve rational and effective medical

care.[21] Prescribing pattern in HTN is complex and many factors make this group a high risk

such as polypharmacy, comorbid conditions, pharmacokinetic and pharmacodynamics

variability, and noncompliance.[4] The choice of drugs for a particular patient changes at short

intervals because of factors like efficacy, side effects, cost and development of newer

drugs.[22] Medication quality and patient safety requires a rational prescription of medication

and avoidance of inappropriate prescribing patterns.[18] In medicine practice, there is growing

concern regarding the irrational prescription pattern and use of antihypertensive drugs.[8]

Irrational prescribing of drugs is of common occurrence in the clinical practice, important

reasons being lack of knowledge about drugs, unethical drug promotions and irrational

prescribing habits of clinicians.[23] Inappropriate prescribing habits lead to ineffective and

unsafe treatment, prolongation of illness, distress and unnecessary economic burden to the

patient.[19] Prescribing pattern helps to assess whether the current usage is rational or in

use of least number of drugs to obtain the best possible effect in shortest period.[25] A

prescription-based survey is considered to assess and evaluate the prescribing attitude of

physicians and dispensing practice of pharmacists.[8] The prescribing pattern of

antihypertensive with or without co-morbidities is assessed based on drug class, dosage,

frequency, route, generic, duration and severity of HTN. A large number of antihypertensive

drugs are available, either as alone or in various combinations with other drugs. Monitoring

of prescription components helps identifying the problems while prescribing and provide

feedback to the prescribers.[22] Recommendations regarding the choice of drugs are available

as treatment guidelines to reduce practice variability, cost and improve rational

pharmacotherapy. Implementation of these guidelines is effective in raising the quality of

antihypertensive therapy.[9]

According to the updated 2014 JNC-8 guidelines on HTN, evidence from clinical trials

indicate that antihypertensive medications (BP medication) should be initiated in patients less

than 60 years old if the systolic BP is persistently >140 mmHg and the diastolic BP is

persistently >90 mmHg despite non pharmacologic therapy. If a patient is 60 years or older,

antihypertensive therapy should be initiated if the systolic BP is >150mmHg and the diastolic

BP is >90 mmHg.[5]

With the increasing prevalence of HTN, there is an increase in the use of antihypertensive

drugs, which to a far extent can improve the quality of life and decrease the attributed

morbidity and mortality.[15] The JNC-8 is considered the “gold standard” consensus

guidelines for the management of HTN. A 2014 JNC8 report suggests that in patients aged

≥60 years, BP should be targeted to <150/90 mm Hg.[4]

The updated JNC8 guidelines

treatment is addressed separately based on ethnicity and it also consider first –line and

later-line treatments to be limited to 4 classes of medications: Thiazide type diuretics, CCB, ACE

inhibitors, and ARBs followed by second- and third- line alternatives included higher doses

or combinations of ACE inhibitors, ARBs, Thiazide – type diuretics and CCBs.[13]

MATERIALS AND METHODS

A prospective observational study was conducted in SSIMS&RC, a tertiary care teaching

hospital, Davangere, for a period of 6 months. Before commencement of the study, ethical

clearance was obtained from Institutional Ethical Committee. A total of 150 patients were

included in the study. All patients admitted above 18 years of age who are diagnosed with

Patients who are not willing to participate in the study, pregnant and lactating women with

hypertension were excluded from the study. A suitably relevant patient data collection form

was developed containing patient demographics, co-morbidities, past and present medication,

HTN complication, BP and other monitoring parameters. Collected data was then analysed.

The summarized findings were rearranged and tabulated in a graphical and table form.

RESULTS

Gender distribution

Among 150 individuals 58.67% (88) of males and 41.34% (62) females received anti-HTN

drugs. Table 1 shows the gender distribution in the study population.

Table 1: Gender distribution, n=150.

GENDER NUMBER OF

PATIENTS(n)

PERCENTAGE (%)

MALE 88 58.67

FEMALE 62 41.33

Figure 1.1: Gender Distribution.

Age distribution

Out of 150 patients enrolled, majority of subjects fall under the age group of 60-80 years 52%

(78) followed by 39-59 years 40.66% (61). The mean age group of the study population was

found to be 58.97±12.42 years. The table 2 shows the age distribution in the study

Table 2: Age Distribution. n=150.

AGE(YEARS) NUMBER OF PATIENTS(n) PERCENTAGE (%)

18-38 9 6

39-59 61 40.66

60-80 78 52

>80 2 1.34

Figure 2.1: Age Distribution.

Distribution of co morbidities in study population

Among 150 patients, the most commonly occurred co morbid condition was found to be

Diabetes mellitus followed by cardiovascular diseases. Table 3 shows the distribution of co-

morbidities in the study population.

Table 3: Distribution of Comorbidities in Study Population. n=150.

SL NO CO MORBID

CONDITION FREQUENCY(n)

PERCENTAGE (%)

1 Diabetes mellitus 80 53.33

2 Cardiovascular diseases 53 35.33

3 Respiratory disorder 41 27.33

4 Cerebrovascular attack 33 22

5 Chronic kidney disease 25 16.66

Figure 3.1: Distribution of Comorbidities in Study Population.

Stages of hypertension in the study population

Among the 150 patients, 33.33% (50) were suffering with stage 2 hypertension followed by

31.33% (47) stage 1 hypertension and 19.33% (29) pre-hypertension. The details of stages of

HTN in the study population is shown in table 4.

Table 4: Stages of Hypertension in Study Population, n=150.

CLASSIFICATION NUMBER OF PATIENTS(n) PERCENTAGE (%)

Normal 24 16.01

Pre-hypertension 29 19.33

Stage 1 HTN 47 31.33

Stage 2 HTN 50 33.33

PRESCRIBING PATTERN

Prescribing Pattern of Antihypertensives

Among 150 patients, monotherapy was given in almost 50.66% (76) patients, dual therapy

was indicated in 38.66% (58) patients, and triple therapy was used only in 8% (12) patients.

Quadruple therapy is the least preferred combination therapy which accounts only in 2.66%

(4) patients.

Table 5: Prescribing Pattern of Antihypertensives. n=150.

TREATMENT NO. OF PATIENTS(n) PERCENTAGE (%)

Monotherapy 76 50.66

Dual Therapy 58 38.66

Triple Therapy 12 8

Quadruple Therapy 4 2.68

Figure 5.1: Prescribing Pattern of Antihypertensives.

Prescribing Pattern of Antihypertensives as Monotherapy

In monotherapy Calcium channel blockers 46.04% (35) were most commonly prescribed

anti- hypertensive followed Diuretics 22.33% (17) and ARB’s 18.64% (14).

Table 6: Prescribing Pattern of Antihypertensives as Monotherapy. n=76.

CLASS NUMBER OF PATIENTS(n) PERCENTAGE (%)

CCB 35 46.04

Diuretics 17 22.33

ARB 14 18.64

ACE 7 9.32

ᵦ blocker 2 2.33

Figure 6.1: Prescribing Pattern of Antihypertensives As monotherapy.

Commonly Prescribed Antihyperytensives as Monotherapy

Among the Calcium channel blockers, amlodipine (46), among Diuretics, Furosemide (28)

and among ARB, Telmisartan (23) were most commonly prescribed.

Table 7: Commonly Prescribed Antihypertensive as Monotherapy.

SL NO DRUGS NO.OF PATIENTS(n)

1 Amlodipine 47

2 Furosemide 28

3 Telmisartan 23

4 Spironolactone 10

5 Torsemide 9

6 Ramipril 7

7 Carvedilol 7

8 Metoprolol 6

9 Atenolol 2

10 Hydrochlorothiazide 2

11 Losartan 2

12 Cilnidipine 2

13 Propranolol 1

14 Labetalol 1

15 Enalapril 1

16 Felodipine 1

Figure 7.1: Commonly prescribed antihypertensive as monotherapy.

Prescribing Pattern of Antihypertensives as Dual Therapy

In dual therapy calcium channel blockers + diuretics 24.13% (14) were mostly prescribed

followed by ARB + diuretics 20.68% (12) and CCB+ ᵦ blocker 18.96% (11).

Table 8: Prescribing Pattern of Antihypertensives as Dual Therapy. n=58

CATEGORY NUMBER OF PATIENTS(n) PERCENTAGE (%)

CCB+ Diuretics 14 24.13

ARB+ Diuretics 12 20.68

CCB + ᵦ blocker 11 18.96

ARB +CCB 6 10.35

ᵦ Blocker+ ARB 3 5.17

Diuretic +αᵦ blocker 3 5.17

ᵦ Blocker + diuretics 3 5.17

ᵦ Blocker + ACE 2 3.45

Diuretics + ACE 1 1.73

ACE + αᵦ blocker 1 1.73

ARB +αᵦ blocker 1 1.73

Figure 8.1: Prescribing Pattern of Antihypertensives as Dual Therapy.

Prescribing Pattern of Antihypertensives as Triple Therapy

In triple therapy, diuretics + CCB+ ARB 4(33.36%) was most commonly prescribed followed

by CCB+ ARB+ ᵦ blocker 25% (3).

Table 9: Prescribing Pattern of Antihypertensives as Triple Therapy. n=12.

CATEGORY NUMBER OF PATIENTS(n) PERCENTAGE (%)

Diuretic+ CCB+ ARB 4 33.36

CCB +ARB+ᵦ blocker 3 25.00

Diuretics+ ARB+αᵦ blocker 2 16.66

Diuretics+ CCB +ᵦ blocker 1 8.33

ARB +Diuretic +α2 agonist 1 8.33

αᵦ blocker + diuretic + ACE 1 8.33

Prescribing Pattern of Antihypertensives as Quadruple Therapy

In quadruple therapy, ARB+ CCB+ Diuretics+ ᵦ blocker 75% (3) was commonly prescribed

followed by ARB+ ACE+ Diuretics+ ᵦ blocker 25% (1).

Table 10: Prescribing Pattern of Antihypertensives as Quadruple Therapy.

CATEGORY NO OF PATIENTS(n) PERCENTAGE (%)

ARB+ CCB+ Diuretics+ ᵦ Blocker 3 75

Diuretic + ᵦ Blocker+ ARB+ ACE 1 25

Figure 10.1: Prescribing Pattern of Antihypertensives as Quadruple Therapy.

DISCUSSION

Increased life expectancy and high global prevalence of HTN and its complication render

treatment of this condition a lifelong personnel and social burden. The increasing prevalence

of HTN along with world’s ageing population places an increasing burden on health care

system. Antihypertensives plays an important role in improving, preserving and restoring

health. Prescribing pattern helps to assess whether the current usage is rational or in

concordance with current treatment guidelines for HTN.

This study was carried out in a tertiary care hospital for a period of 6 months. During the

study period, general prescribing pattern of antihypertensives, prescribing pattern of

antihypertensives as monotherapy, dual therapy, triple therapy and quadruple therapy were

done. A total of 150 cases of patients who were receiving antihypertensives were

prospectively monitored during the study of which 88 (58.67%) were males and 62 (41.33%)

were females which is in concordance with the study carried out by Yadav et.al where a male

patients in the age group 60-80 years have more incidence of HTN followed by 39-49 years,

and this incidence is less observed in other study.[4]

Altogether 143 (95.33%) patients in our study were found to have concomitant comorbidities

and Diabetes Mellitus (27.02%) was highly prevalent comorbidity followed by

cardiovascular disease (17.90%), respiratory disorders (13.86%), Cerebrovascular

accidents(11.15%), CKD (8.44%). Other comorbidities found were metabolic

encephalopathy, anemia, hypothyroidism, deep vein thrombosis, Urinary tract infection etc.

majority of the patients were comorbid with Diabetes Mellitus which was in accordance with

study conducted by Abegaz et al.[26]

About 50 (33.33%) patients had stage II HTN followed by 47 (31.33%) patients had stage I

HTN and 29 (19.33%) patients had pre-HTN respectively, as per JNC 8 classification, was

found to be similar to the study conducted by Nwaka et al where 115 (56.9%) patients had

stage II HTN, 75 (37.1%) patients had stage I HTN and 12 (5.9%) patients had pre HTN.[17]

In the present study monotherapy was given in almost 76 (50.66%) patients prescribed with

CCB (46.04%) followed by diuretics (22.33%), ARB (18.64 %), ACE inhibitors (9.32%).

This was in concordance with the study conducted by Prasanna et al where monotherapy was

given in 200 patients followed by dual therapy 166 (42.13%) patients, triple therapy in 24

(6.09%) patients, quadruple therapy in 4 (1.01%) patients.[9] According to JNC 8 on

detection, evaluation, prevention and treatment recommends the use of ACE inhibitors,

ARBs, thiazides, diuretics and CCBs alone or in combination for the management of early

stages of HTN. Thus suggesting that the above trend is in conformity to the recommendation

of JNC8 guidelines. In our study CCB (46.04%) constitutes the most frequently prescribed

antihypertensive drug class followed by diuretics (22.33%), ARB (18.63%), and ACE

Inhibitors (9.32%) which were comparable with the study carried out by Bhandari et al where

CCB (87.34%) were most commonly prescribed followed by diuretics (3.80%), ACE

inhibitors (3.80%), ARBs (2.53%) and beta blocker (1.26%). But in our study the third

commonly prescribed antihypertensive category was diuretics, ACE and beta blocker. In our

study among CCBs amlodipine was most commonly prescribed drug as monotherapy and

among diuretics furosemide was most commonly prescribed. This finding is supported by the

CCB +diuretics combination (24.13%) was mostly used in 2 drug combination therapy

followed by ARB + diuretics (20.68%) and CCB+ beta blocker (18.96%) combination. 3

drug combination as an antihypertensive mainly Diuretics +CCB+ ARB (33.36%) followed

by CCB+ ARB+ beta blocker (25%) and diuretics +ARB + alpha beta blocker (16.66%). In 4

drug combinations, ARB+CCB+ Diuretic+ beta blocker (75%) followed by diuretic+

betablocker + ARB+ACE (25%). In combination therapy CCB+ Diuretics were most

commonly used in our study in accordance with Sharma et al.[3] But the other combinations in

our study is not in compliance with the study done by Sharma et al.[3] In the present study

most of the 3 drug combinations consists of diuretics where the leading drug combinations to

be the most commonly prescribed indicating that diuretics were used more common as

component of multi drug therapy, the use of diuretic in multi drug regimen is recognized as

essential for reduction of blood volume, vascular resistance and hence efficiency of the

combined regimen. This is consistent with the study done by Gupta et al.[27]

CONCLUSION

The present study confirms that the Prescribing patterns of antihypertensive drugs were in

concordance with joint national committee (JNC) 8 guidelines for patients with different

compelling indications. The study also provides the baseline data for similar studies in future,

as the pattern in prescribing antihypertensive drugs keep changing.

In the present study male predominance could be seen. Most of patients were in the age group

of 60-80 years, constituting 52% of total patients. It was also observed that the physicians had

preferred monotherapy more often than the combination therapy. The most frequently

prescribed class of drug as monotherapy was CCBs, on account of its fewer side effects,

followed by diuretics, which was also the most commonly used class of drugs in combination

therapy. In CCBs, most commonly prescribed was amlodipine and Furosemide was most

commonly prescribed in diuretics. Approximately 95.3% of the sample patients had

co-morbidities, in which Diabetes mellitus was the commonly identified co morbid condition.

CCBs were the most commonly prescribed class of drug alone or as part of combination

therapy.

However, further studies are necessary to set up a rationale or pattern for the choice of

medication; taking into consideration the demographic factors involved in the prevalence of

hypertension. Furthermore, physicians should be sensitized to adhere to the standard

health outcome and improvement in quality of life of patients suffering from hypertension

with co-morbidities. Physician should use standard guidelines to treat hypertensive patients

for the effective management of hypertension. The evaluation pattern, patient adherence to

the treatment, physician adherence to hypertension management guidelines, and other data

concerning co morbid conditions have been explored in many clinical studies. In spite of

these data and published guidelines, inconsistencies exist towards treatment approach,

because of which physicians sometime shave to individualize the therapy, based on specific

patient characteristics and response to treatment. In developing countries like India, more

systematic studies are required on the evaluation of prescribing patterns and guideline based

antihypertensive medications’ use, which can be tailored to suit the patients' requirements.

ACKNOWLEDEMENT

We are grateful to our Principal, HOD and Faculties of Pharmacy Practice Department,

Bapuji Pharmacy College for their continuous support and encouragement.

CONFLICT OF INTEREST

There was no conflict of interest between the authors.

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