DRUG UTILIZATION STUDY OF ANTIHYPERTENSIVE MEDICATIONS IN A TERTIARY CARE TEACHING HOSPITAL IN TAMILNADU

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1 WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES Behanan et al. SJIF Impact Factor Volume 5, Issue 10, Research Article ISSN DRUG UTILIZATION STUDY OF ANTIHYPERTENSIVE MEDICATIONS IN A TERTIARY CARE TEACHING HOSPITAL IN TAMILNADU Ahana Behanan* 1, Ammu A. 1, A. Supriya 1, Aneena Devassy K. 1, Alka S. Kumar 1, T. Sivakumar 2 1 Pharm-D interns, Nandha College of Pharmacy, Perundurai, Erode, Tamilnadu. 2 Department of Pharmacy Practice, Nandha College of Pharmacy, Perundurai, Erode, Tamilnadu. Article Received on 19 August 2016, Revised on 09 Sept. 2016, Accepted on 29 Sept DOI: /wjpps *Corresponding Author Ahana Behanan Pharm-D interns, Nandha College of Pharmacy, Perundurai, Erode, Tamilnadu. ABSTRACT Hypertension is a het2389erogenous medical condition considered as a major public health issue. The aim of our study is to analyze the drug utilization of antihypertensive agents in a tertiary care teaching hospital. About 178 patients were enrolled in the study in a period of three months. The data were collected using well designed data collection form which includes patient demographic details, duration of hypertension, social history, blood pressure charting, drug name, dose and duration of therapy. Out of 178 patients 91 (51%) males and 88 (49%) females were included. From the study it was reported that most of patients were prescribed with monotherapy regimen, followed by two drug combinations and three drug combinations. Calcium channel blockers were commonly prescribed drug. KEYWORDS: Drug utilization, antihypertensives, calcium channel blockers. INTRODUCTION According to WHO hypertension is the third leading cause of death in the World. 9.4 million Deaths accounts for hypertension globally. In India hypertension among elderly were 65%. [1] The excess intake of sodium, sedentary life style, stress, endocrine disorders, diabetes mellitus, drugs, kidney diseases is the factors that cause hypertension. It is mainly responsible for heart disease and stroke. It also causes target organ damage, left ventricular hypertrophy, Vol 5, Issue 10,

2 angina pectoris, myocardial infarction, congestive heart failure, peripheral arterial disease, nephropathy, retinopathy etc. The conditions like dissecting aortic aneurysm, atrial fibrillation, diabetes mellitus, angina pectoris, chronic kidney disease, sudden cardiac death and ophthalmologic disorders are risk factors of hypertension. According to NICE guidelines Angiotensin converting enzyme inhibitor and angiotensin receptor blocker are the first line medication for hypertension under 55 years old patients and for the patients above 55 years calcium channel blockers are recommended. [2] The combination of drugs is effective in the long term treatment of hypertension. The modification of guidelines and the development of new drugs, results changes in prescription pattern. The patients having stage I and stage II hypertension needs pharmacological treatment and pre hypertensive patients mainly requires non pharmacological treatment like diet control and exercise. Older patients are more prone to these diseases and lowest rate of blood pressure control. [3] The reason for lowest blood pressure rates in older patients were polypharmacy, side effects, high cost of medication. [4] Drug utilization studies are vital part of epidemiological researches and it describes drug exposure to the patients. These studies are used as a tool to learn the role of drugs in society. It helps in decision making. The regular evaluation of drugs prescribing are necessary due to the higher incidence rate of hypertension, increased number of newer and combination of drugs in the market. This study is to understand drug utilization pattern of antihypertensive agents in various patients. MATERIALS AND METHODS This is a prospective observational study conducted in a tertiary care teaching hospital. The study was conducted from May 2016-july 2016 for 3 months with a sample size of 178. For the purpose of the study, a suitable data collection form was designed. The patient s medication charts with anti-hypertensive drugs were reviewed and the patients were interviewed in the general medicine department. The age, sex, social habits, anti hypertensive drugs and stages of hypertension were noted. We included all the patients above 20 years who had hypertension. The patients below the age of 20 and with co morbidities such as coronary artery disease, myocardial infarction and diabetes mellitus were excluded. Vol 5, Issue 10,

3 RESULTS AND DISCUSSION We enrolled 178 patients, among them 90 (51%) patients were males and 88(49%) patients were females. WHO STEPs survey conducted in a rural community of Vietnam demonstrates that men were more hypertensive than women. [5] Pai et al in a study reported that about 50.5% males and 40.5% of females were found to be hypertensive. [6] In a study conducted by Tiwari et al report that most of patients range in the age (33.3%) followed by years and years. [7] Similarly another study result shows that for every age- race group up to 59 years of age men had a higher age specific rate of hypertension than women. [8] In the present study majority of patients were under the age group of years (37%) and above 60 years (38%). Table 1: Demographic details of Patients Variables n=178(%) Gender Male Female Age Above 60 Duration 0-1 years 2-5 years 6-10 years years Social Habits Smoking Alcohol Smoking & alcohol Tobacco No social habits Stages of hypertension Pre-hypertension Stage I Stage II 90 (51) 88 (49) 2 (1) 6 (3) 36 (21) 66 (37) 68 (38) 8 (4) 112 (70) 48 (30) 10 (6) 16 (9) 18 (10) 20 (11) 8 (4) 116 (66) 66 (37) 76 (43) 36 (20) Vol 5, Issue 10,

4 Most of the patients had a history of hypertension for 2-5 years (70%) and 30% of patients had a history of 6-10 years and 6% of patients had years followed by 4% of patients with 0-1 year history. Social habits such as smoking and alcohol were found to be an important contributing factor for the hypertension. On account of social habits, 9% of patients were smokers and 10% were alcoholics while 11% of patients were both smokers and alcoholics, 4% of patients were tobacco chewers and 66% were not addicted to any of these habits. According to JNC 7 hypertension were classified into four stages as:- a) Normal-systolic <120mmHg and diastolic <80mmHg b) Prehypertension-systolic mmHg and diastolic 80-89mmHg c) Stage I hypertension- systolic mmHg and diastolic 90-99mmHg d) Stage 2 hypertension- systolic 160mmHg and diastolic 100mmHg. On the basis of stages of hypertension, 37% of patients had prehypertension followed by 43% of stage I and 20% of stage II. n assessment of the prescription pattern of drug therapy it was found that mostly mono therapy (72%) was used followed by dual (22%) and triple therapy (6%). A pilot study conducted in a private clinic in Kuala Lumpur shows that monotherapy was more frequently used than combination therapy. [9] Another study reports a similar result which illustrates that out of 400 patients 260 (65.5%) were on monotherapy and 140 (34.5%) were on combinationtherapy. [10] A prospective study conducted in a multi-specialty hospital in South India points out that higher patient population was prescribed with calcium channel blockers (48.7%) followed by ARB and ACEIs. [11] In our study, calcium channel blockers were used 33% and Angiotensin converting enzyme inhibitors were used 22% as monotherapy. The other drugs used in mono therapy were, angiotensin receptor blockers (9%), diuretics (8%) and β blockers (1%). Table 2:Pattern of Drug Therapy Drug Therapy n (%) Mono Therapy 128 (72) Dual Therapy 40 (22) Triple Therapy 10 (6) More recent studies suggest that the treatment of hypertension using monotherapy is not likely to be successful in most patients and the achievement of blood pressure control usually require 2 0r more medications. More than 70% of hypertensive patients achieve BP goals on Vol 5, Issue 10,

5 combination therapy. [12] Studies shows that combination therapy improves the blood pressure rate in less time with equivalent or better tolerability than higher dose of monotherapy. [13] Sood et al. demonstrates that out of 185 prescription on combination therapy 97 prescriptions were reported with a combination of diuretics with angiotensin converting enzyme inhibitors/angiotensin receptor blocker, β blockers or calcium channel blockers. [14] The present study report dual therapy with calcium channel blockers + diuretics and Angiotensin converting enzyme inhibitors + diuretics were prescribed more (6%). The other dual therapies prescribed CCB +β blockers (2%), CCB + ARB (3%), CCB + CCB (1%), CCB + ACE (2%), ACE +β blockers (2%). In triple therapy Diuretics + Diuretics +ACE (2%) were given more. Diuretics +ACE+β blockers, CCB+ACE + β blockers, β blockers+β blockers+ ACE were the other triple based regimens. Table 3: Classes of antihypertensive drugs Classes of Therapy n (%) Mono Therapy CCBs 58 (33) β blockers 2 (1) ACEI 38 (22) ARB 16 (9) Diuretics 14 (8) Dual Therapy CCB + Diuretics 10 (6) CCB+ β blockers 4 (2) CCB + ARB 6 (3) CCB + CCB 2 (1) CCB+ACEI 4 (2) ACEI + Diuretics 10 (6) ACEI + β blockers 4 (2) Triple Therapy Diuretics + Diuretics +ACE 4 (2) Diuretics + ACEI +β blockers 2 (1) CCB + ACEI + Diuretics 2 (1) β blockers + β blockers + ACE 2 (1) CCB: Calcium channel blocker, βblockers: Beta Blockers, ACEI: Angiotensin Converting Enzyme Inhibitors, ARB: Angiotensin Receptor Blocker. CONCLUSION Hypertension is a lifelong chronic disorder in which the prescription pattern differs according to various factors such as age, gender, comorbidities and other complications of disease. Calcium channel blockers were frequently prescribed as monotherapy regimen in most of the Vol 5, Issue 10,

6 hypertensive patients. In combination therapy, diuretics with angiotensin converting enzyme/ calcium channel blockers were widely used. The present study shows that the prescription pattern of antihypertensive drugs where in standard line with JNC8. REFERENCE 1. Hypertension Study. Bull World Health Organ. 2001; 79: Hypertension: Clinical management of primary hypertension in adults- NICE guideline: Aug [Internet] [cited 2012 Sep 20]. Available from: 3. Hyman DJ, Pavlik VN. Characteristics of patients with uncontrolled hypertension in the United States. New England Journal of Medicine, 2001; 345: Gandelman G, Aronow WS, Varma R. Prevalence of adequate blood pressure control in self-pay or Medicare patients versus Medicaid or private insurance patients with systemic hypertension followed in a university cardiology or general medicine clinic. American Journal of Cardiology, 2004; 94: Minh H V, P Bypass, N T Chuc, S Wall. Gender differences in prevalence and socioeconomic determinants of hypertension: findings from the WHO STEPs survey in the rural community of Vietnam. Journal of Human Hypertension. 2006; 20: Pai PG, Shenoy J, Sanji N. Prescribing patterns of antihypertensive drugs in a South Indian tertiary care hospital. Drug Invention Today, 2011; 3: Tiwari H, Kumar A, Kulkarni S K. Prescription monitoring of antihypertensive drug utilization at the Punjab University health center in India. Singapore Medical Journal, 2004; 45: Burt V L, Whelton P, Roccella E J, Brown C, Cutler J A, Higgins M et al. Prevalence of hypertension in the US adult population: Results from the third National health and nutrition examination survey, Hypertension. 1995; 25(3): Heethal Jaiprakash, Vinotini K, Vindiya, Vsalni, Vikneshwara, Vigneshwaran et al. Drug utilization study of anti hypertensive drugs in a clinic in Malaysia. Int Journal of Basic Clinical Pharmacology. 2013; 2(4): Shukrala F, Gabriel T. Assessment of prescribing, dispensing and patient use pattern of antihypertensive drugs for patients attending outpatient department of Hiwot Fana Specialised University Hospital, Harar, Eastern Ethiopia. Drug Design & Development Therapy. 2015; 9: Vol 5, Issue 10,

7 11. Sindhu P R, Reddy M S. Study of prescriptive patterns of antihypertensive drugs in South India. International Journal of Advancements in Research & Technology. 2013; 2: Sanjay Kalra, Bharti Kalra, Navneet Agrawal. Combination therapy in hypertension: An update. Diabetology and Metabolic Syndrome. 2010; 2: Frank J. Managing hypertension using combination therapy. American Family Physician. 2008; 77: Bajaj J K, Sood M, Singh S J, Jerath P. Prescription patterns of antihypertensive drugs and adherence to JNC VII guidelines in a tertiary care hospital in North India. International Journal of Medical and Clinical Research. 2012; 3: Vol 5, Issue 10,