PRESCRIPTION PATTERNS OF ANTIHYPERTENSIVE DRUGS AND ADHERENCE TO JNC VII GUIDELINES IN A TERTIARY CARE HOSPITAL IN NORTH INDIA

SOOD M¹*, BAJAJ J.K², SINGH S.J.³, JERATH P.^4
1Department of Pharmacology, Punjab Institute of Medical Sciences
²Department of Pharmacology, Punjab Institute of Medical Sciences
³Medical Officer, PCMS, Civil Hospital, Jalandhar, Punjab
⁴Consultant Pathologist, Jerath Path Labs, Jalandhar, Punjab
* Corresponding Author : msood11@gmail.com

Received : -     Accepted : -     Published : 29-02-2012
Volume : 3     Issue : 2       Pages : 118 - 120
Int J Med Clin Res 3.2 (2012):118-120
DOI : http://dx.doi.org/10.9735/0976-5530.3.2.118-120

Conflict of Interest : None declared

Introduction Hypertension is a chronic illness associated with high morbidity & mortality. A large number of antihypertensive drugs alone or in various combinations are available and physicians need to choose the most appropriate drug for a particular patient. The standard treatment guidelines and drug utilization studies at regular intervals help physicians to prescribe drugs rationally. The present study was conducted to analyze the prescription patterns of antihypertensive drugs and adherence to JNC VII guidelines in a North Indian tertiary care hospital. Methods Drug utilization data of 500 hypertensive patients, attending medicine Out Patient Department of Punjab Institute of Medical Sciences Hospital from October 2010 to March 2011 was collected from 24 hour hospital pharmacy. Following groups of anti hypertensive drugs were analyzed; Angiotensin converting enzyme inhibitors (ACE inhibitors), Angiotensin Receptor Blockers (ARBs), Beta Blockers, Calcium Channel Blockers (CCBs), Diuretics, Alpha Adrenergic Blockers and Central Sympatholytics. Patients suffering from essential hypertension with or without other co-morbid conditions were included in the study. Frequency and proportion of prescribing different groups of anti hypertensive drugs as monotherapy or combination therapy and prescription of fixed drug combinations (FDCs) was analyzed. Results The most frequently prescribed antihypertensive drugs were diuretics followed by ARBs, Beta Blockers, CCB’s and ACE inhibitors. 42.6% received monotherapy and 57.4% received combination therapy. 41.6% patients received fixed drug combinations. The prescription pattern was found to be in accordance with JNC VII guidelines.

Antihypertensives, drug utilization, ACE inhibitors, ARBs, Diuretics, JNC VII

Hypertension is a public health problem causing 4.5% of global disease burden. Prevalence is estimated to increase further from 26.4% in 2000 to 29.2% in 2025 worldwide [1] . Raised blood pressure is an important risk factor for cardiovascular disease [2] . Hypertension related deaths constitute 1/3rd of global mortality cases [3] Sufficient scientific evidence exists to suggest that such adverse outcomes can be prevented by lowering blood pressure effectively [4,5] . Therefore, once hypertension is diagnosed, starting rational antihypertensive therapy on long term basis along with regular follow up is immensely important.
A wide range of antihypertensive drugs belonging to different pharmacological classes are available such as Angiotensin Converting Enzyme inhibitors, Beta Blockers, Angiotensin Receptor Blockers, Calcium Channel Blockers, Diuretics, Alpha adrenergic blockers and central sympatholytics. Choice of drugs for a particular patient changes at short intervals because of factors like efficacy, side effects, cost and development of newer drugs [6] . Recommendations of various expert groups regarding choice of drugs are available as treatment guidelines to reduce practice variability, cost and improve rational pharmacotherapy. Implementation of these guidelines has been shown to be effective in raising quality of antihypertensive therapy [7] .
The 7th report of Joint National Committee on prevention, detection, evaluation & treatment of high blood pressure (JNC VII) recommends the use of thiazide type diuretics alone or in combination with drugs from other classes in uncomplicated essential hypertension. Presence of certain high risk conditions is indication for initiating therapy with other drug classes like ACE inhibitors, ARBs, Beta blockers or CCBs. For BP > 20/10 mm of Hg above goal BP, combination of two agents is recommended with one of them usually being a thiazide diuretic [8] .
In such a scenario it is necessary to survey prescription patterns as a component of medical audit for monitoring, evaluation & necessary modifications in prescribing practices to achieve rational and cost effective medical care [9] . Keeping all these facts in mind, the present study was designed to analyze the prescribing patterns of anti hypertensive drugs & adherence to JNC VII guidelines in 500 hypertensive patients in a tertiary care hospital in North India.

The study was approved by institutional ethics committee. Drug utilization data was collected from the 24 hour hospital pharmacy of Punjab Institute of Medical Sciences, Jalandhar for a period of 6 months from October 2010 to March 2011. Prescriptions of hypertensive patients with diabetes mellitus and bronchial asthma as co morbidities were also included. Age and sex of patients was recorded. Mean age along with SE was calculated. Z test was used to calculate the P value of age difference between two sexes. Depending on age patients were divided into 3 groups (< 40 years of age, 40 - 60 years & > 60 years of age). Antihypertensive drugs were divided into following 7 categories: ACE inhibitors, ARB’s, Beta blockers, CCB’s, Diuretics, Alpha adrenergic blockers and Central sympatholytics. Fixed drug combinations were counted separately. The components of FDCs were counted in their respective groups as well. Adherence to JNC VII guidelines was studied by assuming that drugs recommended as first line should be the most frequently prescribed ones with highest utilization.

As shown in [Table-1] , 210 patients (42%) were males & 290 (58%) were females indicating 16% higher prevalence of hypertension in female population. Mean age of male patients was 57.04 ± 0.94 years and female patients were 52.71 ± 0.81 years. The age difference between two gender groups (p≤ 0.1) was statistically not significant.
Most of male hypertensive patients (43.3%) were in the age group of > 60 years & most of female patients (56.9%) were in the age group of 40 to 60 years indicating an earlier onset of hypertension in female population in our study group [Table-2] .
15.8% of patients had diabetes mellitus & 3.8% had bronchial asthma as coexistent conditions [Table-3] . The most frequently prescribed antihypertensive drug group was Angiotensin receptor blockers in diabetics (56.25%) as well as asthmatics (68.42%). None of the asthmatic hypertensive patient received beta blockers. Alpha adrenergic blockers & central sympatholytics were also not prescribed to any of the diabetic or asthmatic patient with hypertension [Table-4] [Table-5] shows that diuretics was the most commonly prescribed group of antihypertensive drugs in 53.4% patients, followed by angiotensin receptor blockers in 42.6%, beta blockers in 38.6% & calcium channel blockers in 26.4% patients. Out of diuretics, thiazides group was the most commonly used [Table-6] again shows diuretics to be the most commonly prescribed group of drugs in all the three age groups viz < 40 years, 40 - 60 years & > 60 years. 42.6% patients received monotherapy and rest 57.4% combination therapy. 37% of total patients received two drugs, 17.2% three drugs & 3.2% received four or more drugs [Table-7] .
(Monotherapy Vs Combination Therapy)
FDCs are quite frequently used in treatment of hypertension. 41.6% of all prescriptions had FDCs [Table-8] .

Hypertension is a worldwide problem. Its prevalence depends upon several ethnic, genetic, environmental & psychosocial factors. In India prevalence of hypertension (B.P. ≥ 140/90 mm of Hg) is reported to be 25-30% in urban & 10-15% in rural adults and it further increases with age. In elderly Indian population, a prevalence rate of 51.8% is reported [10] . Our study group also showed higher prevalence of hypertension in elderly patients (> 40 years). However, most females showed an earlier onset of hypertension than males. Main aim of antihypertensive therapy is to prevent hypertension related morbidity, mortality and complications. As antihypertensive prescription is required lifelong, therefore the side effects, quality of life and cost of drugs are also important aspects. Keeping all such factors in mind various prescribing guidelines have been formulated.
Guidelines given by Joint National Committee on prevalence, detection, evaluation and treatment of high blood pressure VIIth report suggest that treatment of choice for early stage, uncomplicated, essential hypertension should be thiazide diuretics. Presence of high risk conditions and blood pressure greater than 20/10 mm of Hg above normal is indication for starting therapy with drugs from other classes like ACE inhibitors, ARB's, beta blockers or calcium channel blockers alone or in combination with thiazides. Adherence to treatment guidelines can be monitored by several methods. Drug utilization studies are one such important method. Our data shows that JNC VII guidelines have been followed in totality in this study group. Thiazides are prescribed most frequently alone or in combination with other drugs. ARB's are the most frequently prescribed group in hypertensive diabetics and asthmatics as angiotensin antagonism is reported to decrease the onset & progress of microvascular complications of hypertension and diabetes mellitus [11] . More than half (57.4%) of patients in this study group received two or more antihypertensive drugs. FDCs have also been quite frequently used (41.6%). This may be an attempt to improve patient compliance and reduce treatment costs. Such trend of multiple drug therapy in hypertension has also been reported in some other studies in India [6,10] .
Main limitation of drug utilization studies is the lack of detailed patient records for justifying the prescribed drugs based on grade of hypertension, presence of complications and previous drug therapy.

Angiotensin converting enzyme inhibitors: ACE inhibitors
Angiotensin Receptor Blockers: ARBs
Calcium Channel Blockers: CCBs
Fixed Dose Combinations: FDCs
Blood Pressure: BP

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	Table 1- Demographic Profile of Patients
	Table 2- Age Group Distribution of Patients
	Table 3- Comorbidities Of The Patients
	Table 4- Treatment Of Hypertension In Diabetics and Asthmatics
	Table 5- Frequency Of Administration Of Individual Drugs
	Table 6- Antihypertensives Prescribed In Different Age Groups
	Table 7- Number of Drugs Prescribed
	Table 8- Frequency of Prescribing FDC’s