JK-Practitioner volume 17 No.

4 October- December 2012

clinical pharmacy

Prescribing pattern of antihypertensive drugs in a tertiary care hospital in

Jammu- A Descriptive study.

Sharminder Kaur , Dr Seema Gupta , Dinesh Kumar , Mohan Lal , Zahid Gilani .

Sharminder Kaur Demonstrator , Seema Gupta Assistant Professor,Zahid Gilani Associate

Professor:Department of Pharmacology and Therapeutics:Dinesh Kumar ,Assistant Professor:
Department of Community Medicine:Mohan lal ,Professor Department of Cardiology:
Government medical College Jammu (India)-180001

Correspondence:
Dinesh Kumar, Department of Community Medicine,GMC,Jammu 180001

Abstract
A descriptive drug utilization study was conducted on randomly selected 297
prescriptions of hypertensive patients attending the medical OPD at tertiary
care hospital, Govt. Medical College Jammu for a period of 6 months to find out
the prescribing pattern of usage of antihypertensive drugs. Prescriptions of
hypertensive patients already on antihypertensive drugs were included in the
study for analysis. Data was collected regarding the selected socio-
demographic characteristics of these patients and the prescribing pattern of
antihypertensive drugs was studied. The study revealed that Angiotensin
Converting Enzyme inhibitors (ACE Inhibitors) and Calcium Channel Blockers
were the most commonly prescribed antihypertensive drugs(33.8% and 30.7%
respectively) followed by beta blockers (13.8%), Angiotension Receptor
Blockers (10.7%) and diuretics (9.23%) as monotherapy among the first line drugs.
The combination therapy was prescribed to 55.29% of patients and the most
frequent two drug combination prescribed consisted of CCBs and ACE
inhibitors.
JK-Practitioner 2012;17(4):38-41

Key Words: Hypertension, Antihypertensive drugs, prescribing pattern.

JK- Practitioner Vol.17, No. 4 October-December 2012 38


Introduction:
Hypertension is one of the strongest modifiable risk
factors for cardiovascular and kidney disease and has
been identified to contribute significantly to
cardiovascular mortality1. In 2000 hypertension was
estimated to affect almost one billion patients
worldwide prevalence is predicated to increase by
approximately 60% by 20252 . Prospective studies
collaboration has reported that reducing BP can
substantially decrease cardiovascular risk and all- cause
mortality .Treatment of hypertension is constantly
evolving in response to new evidence published every
now and then and a plethora of new drugs are being
added at a rapid pace3. The resultant changes in drug use
in time and place may have medical, social and
economic implications both for the individual patient
and for populations. These differences need to be
identified, explained and corrected if need be. Drug
utilization studies are necessary to this effect with a
particular focus on socio- demographic characteristics,
co-morbid conditions and pattern of anti- hypertensive
drugs usage. The twin issues of rationality and
effectiveness also needs careful consideration.
Therefore, the present study was conducted to analyse
the prescribing patterns of anti- hypertensive agents in
view of reported disparity between the recommended
and actual practices for pharmacological management
of hypertension.
Material and methods
The present study is a descriptive drug utilization study
conducted in the out patient department of internal
medicine, Govt. Medical College, Jammu for a period of
6 months after getting approval from the Institutional
Ethics Committee. A total of 297 prescriptions of out
patients with Essential hypertension above 18 yrs of age
were randomly selected employing systematic
sampling. Patients attending the OPD for the first time
were excluded. Hypertension was defined and staged
into three stages i.e., pre hypertension, stage -1 and stage
2 according to guidelines of 7th report of the Joint
National Committee on prevention, detection,
evaluation and treatment of high blood pressure4. Data
was collected regarding socio- demographic
characteristics (age, sex, residence), co-morbid
conditions and current antihypertensive drugs
prescribed. Blood pressure measurements were made in
accordance to the methods described in JNC 7. Anti
hypertensive drugs were classified into six major
groups-diuretics, beta-blockers, calcium channel
blockers, ace-inhibitors, angiotensin receptor blockers
a n d a l p h a b l o c k e r s . D i ff e r e n t c l a s s e s o f
antihypertensive drugs prescribed were also analysed in
accordance with WHO essential drug list (2005)5.
Analysis
Percentages were calculated and results presented as
tables and diagram as deemed appropriate for the
qualitative nature of the variable.
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clinical pharmacy
Results
A total of 297 prescriptions were studied. 293
prescriptions of them were finally taken up for analysis
as four prescriptions were excluded as these were not in
accordance with the inclusion criteria. The patients
studied were in the age group of 20 to 90 years with
mean age being 56.21?.20 years. The sample had slight
male predominance (Male/Female ratio as 1:.85 .Nearly
one third of patients were in 5th to 6th decade of their lives
with slightly higher proportion of males as compared to
females (38.7% males and 31.88% females
respectively). Approximately 2/3rd patients in the
sample were residing in urban areas at the time of
interview .
Majority of patients studied had stage 1 hypertension
(37.2%). Type 2 diabetes mellitus was the most common
co morbidity observed in the patients (40%).
Commonly prescribed anti hypertensive group of drugs
in decreasing order of frequency were; ACE inhibitors
and CCBs followed by beta-blockers, ARBs and
diuretics. Ramipril, Amlodipine, Atenolol, Losartan and
Hydrochlorthiazide were the leading drugs in the
respective groups. A slightly more than half of patients
studied (55.6%) were prescribed combination therapy.
CCBs, diuretics and ACE inhibitors were most
commonly prescribed as single agents whereas most
commonly prescribed combination comprised of CCB
and ACE inhibitors. Most of the drugs were in
accordance with WHO essential drug list with the
exception of ACE inhibitors where ramipril was more
frequently prescribed as against enalapril.
DISCUSSION
One-quarter of the world's adult population has
hypertension, and this is likely to increase further by
2025. Modelled projections indicate an increase to 1.15
billion hypertensive patients by 2025 in developing
countries including India. The variability in the global
prevalence of hypertension is attributed to demographic
and epidemiological transition, urbanization with
resultant changes in lifestyle, ethnic differences,
nutritional status, and birth weight to name a few6. Age
probably represents an accumulation of environment
influences and the effect of genetically programmed
senescence in body systems . The prevalence of
hypertension in India is highest in age group of 50-59
years in males and 60-64 in females in urban areas
whereas in rural areas an age related increase is seen in
both sexes in the age group 60-647. This is in
concurrence with our study where maximum number of
patients was found in the age group of 51-60 years and
approximately two third patients studied belonged to
urban areas. Sex wise differences are known to present
in various countries ranging from 4% in USA to 11% in
Western Europe8. We observed a difference of 6.9% in
our study which is fairly consistent with the reported
literature and perhaps points to joint effects of
environment and genetic interplay.
Over the last couple of decades, there has been an
JK- Practitioner Vol.17, No. 4 October-December 2012
 clinical pharmacy
exponential increase in the use of new anti-
hypertensives like ACE inhibitors, ARBs and CCBs
despite many robustly conducted clinical trials showing
no consistent differences in anti hypertensive efficacy,
side effects and quality of life within the major classes of
drugs9. Diuretic and beta blockers were the most
commonly prescribed drugs for the treatment of
hypertension during 1980-90. However, the
prescription for CCBs & ACE inhibitors increased
sharply after 1990s 10 . The present study also
documented a similar shift in the choice of drugs for
hypertension from beta blockers and diuretics to ACE
inhibitors, ARBs and CCBs with 33.8% prescriptions
analysed showing ACE inhibitors as most frequently
prescribed drug as monotherapy followed by CCBs
(30.7%), beta-blockers (13.8%) and diuretics(6.9%).
The effectiveness and tolerability of ACE inhibitors
such as enalapril, lisinopril, ramipril and perindopril is
not disputed in the light of overwhelming evidence in
their favour. In individuals with diabetes, these agents
retard the onset and progression of renal disease7, 11. In
adults, the prevalence of diabetes, hypertension and
coronary artery disease is two- to threefold greater in the
urban population than in rural populations6. Coexistence
of hypertension and diabetes mellitus is being
increasingly recognised with approximately one in three
patients having both the conditions. Studies like
UKPDS and HOT have stressed the importance of
effective BP control irrespective of the antihypertensive
agent in such patients in order to significantly reduce the
risk of cardiovascular disease12, 13, 14. The study also
pointed out that that polypharmacy is required for
optimal control. It is also mentioned that ACE inhibitors
have an edge over the other drugs in view of its
favourable effect on the accompanying co- morbid
conditions15. Since DM and IHD were the two most
commonly encountered co-morbid conditions
associated with hypertension in our setting as well,
approximately one third of patients being prescribed
ACE inhibitors seems justified.
JNC-VII guidelines stipulate that thiazide diuretics
should be used as initial therapy for most patients with
uncomplicated hypertension either alone or in
combination with drugs from other classes. As diuretics
are known to enhance the anti- hypertensive efficacy of
multidrug regimen, they can be useful in achieving BP
control and are most cost effective than other anti-
hypertensive agents16. Despite these recommendations,
diuretics were found to be prescribed less often to
patients as single drug treatment in our study; however,
as combination therapy, it was second only to CCBs
(42.3%).
Similarly prescription of beta blockers in our study was
also not found to be consistent with recommendations of
JNC VII. Contrary evidence emerged out of major
studies like ASCOT-BPLA and NICE which suggested
that beta blockers are less effective than ACE inhibitors
or CCBs in reducing the risk of DM and stroke16.The
most likely explanation of under prescription of beta
JK- Practitioner Vol.17, No. 4 October-December 2012
blockers in our study might be due to the fact that 40% of
our patients were concurrently suffering from DM
and/or stroke and these drugs are relatively
contraindicated in diabetes.
Studies have shown that good BP control below
(140/90) is achieved only in minority of patients on
antihypertensive mono therapy. Majority of patients
will require a combination of two or more drugs for
sustained and effective control of blood pressure4,9.
Drug prescription pattern in our study showed that
combination therapy was more frequently prescribed as
compared to monotherapy. Use of more drugs and for a
longer period of time has its own limitations and
challenges. The adverse effects are rightly regarded as a
significant obstacle to the successful treatment of
hypertension and as most of these are dose related; the
problem could be minimized by the use of low-dose
combinations17. .Low dose combinations can doubly
benefit the patients by being more efficacious and more
safe thereby has the potential to improve the quality of
life of the patient . Further, several studies have
documented the long term benefits of use of anti
hypertensive combinations in high risk population such
as black hypertensives who have higher incidence of
concurrent diseases such as heart failure ,diabetes and
chronic renal failure (18).
CONCLUSION
Analysis of 293 prescriptions revealed that combination
therapy was prescribed more frequently than
monotherapy. Approximately 60% of the sample
patients were suffering from co-morbid conditions.
Diuretics were less often prescribed. However, since
this study is mainly limited to pattern of drug usage in
hypertensive population in a tertiary care hospital, care
must be exercised in generalizing the study results to
prescribing pattern of the whole region.
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JK- Practitioner Vol.17, No. 4 October-December 2012