Original Article PRESCRIPTION PATTERN OF ANTI HYPERTENSIVE DRUGS IN SHRI SATHYA SAI MEDICAL COLLEGE & RESEARCH INSTITUTE Annamalai Maduram 1, Harikrishna 2 INTRODUCTION High blood pressure, termed "hypertension," is a condition that afflicts almost 1 billion people worldwide and is a leading cause of morbidity and mortality. Therefore, this disease is sometimes called the "silent killer." This disease is usually asymptomatic until the damaging effects of hypertension (such as stroke, myocardial infarction, renal dysfunction, visual problems, etc.) are observed. Hypertension is a major risk factor for coronary artery disease, myocardial infarction ("heart attacks") and stroke.1from the estimated prevalence of hypertension would increase from 26.4% in 2 to 29.2% in 225.2 Drug prescription pattern studies which evaluate and analyze the drug therapy in hypertension and hypertension associated with DM is very essential from time to time to observe the prescribing attitude of physicians with the aim of rational use of drugs based on the WHO guidelines. Hypertension (HTN) is one of the major chronic diseases resulting in high morbidity and mortality in the world population. Prevalence of HTN in India is reported to vary from 4-15% in urban and 2-8% in rural population. Socioeconomic, behavioral, stressful lifestyle and nutritional issues of the people led to enormous increase of cardiovascular diseases. HTN and Diabetes Mellitus (DM) frequently coexist which increases with age. HTN is about twice as common in patients with DM as in those without (8%).3 REVIEW OF LITERATURE Hypertensive is defined as an abnormal elevation in diastolic pressure and/or systolic pressure; mean arterial pressure is also elevated in hypertension, but it is not usually measured in people. In past years, the diastolic value was emphasized in assessing hypertension. However, elevations in systolic pressure ("systolic hypertension") are also associated with increased incidence of coronary and cerebrovascular disease (e.g., stroke). Therefore, we now recognize that both systolic and diastolic pressure values are important to note. According to the latest U.S. national guidelines (JNC 7 Report)), the following represents different stages of hypertension: Classification Systolic (mmhg) Diastolic(mmHg) Normal <12 <8 Prehypertension 12-139 8-89 Stage 1 14-159 9-99 Stage 2 >16 > Patients with primary hypertension are generally treated with drugs that 1) reduce blood volume (which reduces central venous pressure and cardiac output), 2) reduce systemic vascular resistance, or 3) reduce cardiac output by depressing heart rate and stroke volume. Many antihypertensive drugs have their primary action on systemic vascular resistance. Some of these drugs produce vasodilation by interfering with sympathetic adrenergic vascular tone (sympatholytics) or by blocking the formation of angiotensin II or its vascular receptors. Other drugs are direct arterial dilators, and some are mixed arterial and venous dilators. Although less commonly used because of a high incidence of side effects, there are drugs that act on regions in the brain that control sympathetic autonomic outflow. By reducing sympathetic efferent activity, centrally acting drugs decrease arterial pressure by decreasing systemic vascular resistance and cardiac output. Some antihypertensive drugs, most notably betablockers, depress heart rate and contractility (this 68
Annamalai Maduram et al; Prescription Pattern of Anti www.ijbms.com decreases stroke volume) by blocking the influence of sympathetic nerves on the heart. Calcium-channel blockers, especially those that are more cardioselective, also reduce cardiac output by decreasing heart rate and contractility. Some calcium-channel blockers (most notably the dihydropyridines) are more selective for the systemic vasculature and therefore reduce 1 systemic vascular resistance. The Classes of drugs used in the treatment of 1 hypertension are listed below. Diuretics like Thiazide diuretics, loop diuretics, potassium-sparing diuretics Vasodilators like (alpha-blockers), Angiotensin converting enzyme inhibitors (ACE inhibitors),angiotensin receptor blockers (ARBs), calcium-channel blockers, Direct acting arterial dilators, ganglionic blockers, nitro dilators, Potassiumchannel openers, Reni inhibitors. Cardioinhibitory drugs like Beta-blockers, Calciumchannel blockers centrally acting sympatholytics. Summary of antihypertensive drug treatment. 4 Aged under 65 Alpha-adrenoceptor antagonists Aged over 65 Year or *2. CCB is preferred but consider a thiazide-like diuretic if a CCB is not tolerated or the person has oedema, evidence of heart failure or a high risk of heart failure. *3 Consider a low dose of spironolactone15 or higher doses of a thiazide-like diuretic. *4 At the time of publication (August 211), spironolactone did not have a UK marketing authorization for this indication. Informed consent should be obtained and documented. *5 Consider an alpha- or beta-blocker if further diuretic therapy is not tolerated, or is contraindicated or ineffective. AIM & OBJECTIVE: To evaluate drug utilization in hypertensive s and gain knowledge of existing prescription patterns in the treatment of diagnosed hypertension can provide useful information for improving clinical practice in this field. The aims of this study are to describe current treatment practices and to summarize different treatment practices of Shri Sathya Sai Medical College and Research Institute, medical outpatient department patterns and time trends for antihypertensive medication USE OF SELECTION INDICATORS To know the percent of male and female patient number and percent of various groups of drugs. Step 1 A C Percentage of utilization of different categories antihypertensive drugs. Percentage of antihypertensive drugs in combination with other category drugs. Percentage of combination of antihypertensive Step 2 A+ C Key A- drugs Percentage of co added drugs Step 3 A + C + D receptor *1 C Calcium To describe the current treatment practice in Shri Sathya Sai Medical College and Research Step 4 A + C + D * 3, 4 or alph * 5 *2 D- Institute. Drug selection indicators selected for present study includes 5 Ratio of male and female patients, *1. Choose a low-cost ARB 69
www.ijbms.com Annamalai Maduram et al; Prescription Pattern of Anti The prevalence of age group OBSERVATIONS & RESULTS Percentage of one/two drug combination, Types of dosage forms, The total % of utilization of different categories of antihypertensive drugs The % of antihypertensive drugs in combination with other category drugs. MATERIAL AND METHODS This was a cross-sectional observational study done in the outpatient department of Shri Sathya Sai Medical College and Research Institute, from March to April 212 for duration of two months a total of 466 prescriptions were collected from outpatient medicine department according the Performa given by WHO based prescription Audit format. From which the A total of 466 prescriptions for essential hypertension were studied. The major findings of our studies are discussed below. Age group of 61-7 (125). Less number of patients with age group of 81 9 years 6 patients Demographic profile of the study population was found to be the age group from 19-9 years. The distribution of age as given in the graph below (Fig 1) higher number of patients under the 61-7 age groups 71-8 age 61-7 age Form no. : PRESCRIPTION AUDIT PERFORMA Patient name.... Age... Sex Address 51-6 age 41-5 age 31-4 age 2-3 age 2 4 6 8 12 14... Department: medicine IPD / OPD No Diagnosis / Provisional Diagnosis / Symptoms: Sr. No. Drug Name Dose Duration Gender Sex had been relevant factor in the clinical representation of hypertension out of 466 patients 284 were s and 182were s. 3 25 2 Signature of Data Collector 15 data s such as age, sex, address diagnosis and prescribed drug route of drug administration, dose, duration, single drug, combination of drug used were collected from the prescription and written in the 5 Performa form attached above. 7
Annamalai Maduram et al; Prescription Pattern of Anti www.ijbms.com Co- morbidities: A Total of 236 patients had one or more concurrent diseases including Diabetes Millets (114), Asthma (11) and CHF (2) and Hypothyroid (6).Statins and Aspirin were also used for the treatment of hypertension (2%). Drug treatment The patients with asthma and diabetes millets were commonly prescribed either Enalapril or Amlodipine. Only two patients on Beta blocker (Atenolol) Whereas 9 patients were on Atenolol and Amlodipine therapy. the number of patients receiving single drug were 314(67%) among which were 173(55%) and were 14 (45%). The highly prescribed single drug was Amlodipine 42% followed by Enalapril of 16%, Atenolol of 8% with 1% of each verapamil, Propranolol and Metoprolol. In the Medicine department the maximum no patient used Amlodipine at dose of 5mg for seven day and advised to come after seven day for a follow up. The next higher no of patient used enalapril of 2.5mg dose for seven day. Commonly the drugs were given once a day. single Drug 173 18 16 141 14 115 12 81 8 6 48 4 26 27 2 9 Amylodipin Enalapril single drug the number of patients receiving Two drugs combinations were 139(3%) among which were 95(68%) and were 44 (32%). The highly prescribed combinations of drug were Amlodipine and Enalapril of 74% of which female were 68(66%) male were 35(34%) followed by the drug combination of Amlodipine and Atenolol of 16 (12%)with 14 female and 2 males with the other combination of just 1% of each combination as follows Amlodipine and Lasix, Enalapril and Lasix Enalapril and Atenolol, Enalapril and verapamil, Amlodipine and Propranolol and Amlodipine and Metoprolol. Fig: 12 35 8 6 4 68 44 95 2 2 14 41 14 Triple drugs combination: the number of patients receiving three drugs combinations were 6(1%) among which were 1 and were 5. The drugs prescribed in combinations were Amlodipine, Enalapril and Atenolol or Nifedipine or Lasix or Metoprolol and the other combination of Atenolol and Lasix, Enalapril or Metoprolol. DISCUSSION The present study reveal that higher numbers of patient belongs to the age group of (61-7years) the drug used in this age are appropriate to the guidelines. The study finding clearly indicate that hypertension was higher in female(61%)than male(39%).from this study we found that out of 466 patients. 236 patients has one or more concurrent diseases like Diabetes Milletswere14%, Asthma 2 %, CHF. 4% and Hypothyroid 1%. The presence of concurrent diseases could influence the choice of antihypertensive drugs. The patients with Asthma 71
www.ijbms.com Annamalai Maduram et al; Prescription Pattern of Anti and Diabetes Millets commonly received either Enalapril or Amlodipine. Sixty seven percent of total hypertensive patients received single drugs like Amlodipine (42%), Enalapril (16%), Atenolol (8%) and 1% of patients received Verapamil or Propranolol and Metoprolol. Thirty percent of patients on two drugs treatment the drugs are Amlodipine and Enalapril (24%) followed by Amlodipine and Atenolol (12%).One percent of patients on treatment with any one of the combinations, Amlodipine + Lasix, Enalapril + Verapamil, Amlodipine + Propranolol and Amlodipine + Metoprolol. From this study we found that calcium channel blocker commonly followed ACE inhibition. One percent of patients on 3 drugs treatments. The combinations were used are Amlodipine+ Enalapril +Atenolol or Nifedipine. CONCLUSION This study showed that most of outpatients with hypertension in Shri Sathya Sai Medical College and Research Institute, medical outpatient department received monotherapy we also found that the most frequently used class of antihypertensive drugs were the calcium channel blocker and angiotensin converting enzyme inhibitors. This was in accordance of WHO guidance. ACKNOWLEDGEMENT I would like to thank the HOD and staff of Department of medicine Shri Sathya Sai Medical College and Research Institute, for providing us the valuable data for this study. My sincere thanks to my guide for guiding me to do this study. I also would like thank the Hospital staff, the technical support given by the technician of department of pharmacology and patients for the kind cooperation during this study. The lost but not the least I would like to thank the ICMR for giving me an opportunity to this study. REFERENCE 1. Richard E. Klabunde PhD, Text book of Cardiovascular Physiology Concepts, 2nd edition, Published by Lippincott Williams & Wilkins, 211. 2. Kearney PM; Whelton M; Reynolds K;Munter P;Whelton PK; He J.Global burden hypertension: analysis of worldwide data.lancet.,25,217-223. 3. McInnis NH, Fodor G, Lum-Kwong MM, Leenen FH. Antihypertensive medication use and blood pressure control: a community-based crosssectional survey (ON-BP). University of Ottawa Heart Institute, Ottawa, Ontario, Canada. Am J Hypertens. 28 Nov; 21(11):121-5. Epub 28 Sep 4. 4. www.nice.org.uk/guidance/cg127 cited on 1/8/212. 5. Ansari K.U, Singh.S, Pandey R.C. Evaluation of prescribing patterns of doctors for rational Drug therapy, IndianJ.Pharmacol 1998:3:43-46. 1. Annamalai Maduram 2. Harikrishna Professor, Shri Sathya Sai Medical College and Research Institute, Chennai. Asst. Professor, Shri Sathya Sai Medical College and Research Institute, Chennai. 72