Use of antihypertensive drugs in the Italian hospitals. GIFA group. Gruppo Italiano di Farmacoepidemiologia nell'Anziano

Potentially inappropriate medication in elderly hospitalized patients

Balanced and safe prescribing is difficult to achieve in frail older adults with multiple comorbid diseases. This issue is of particular concern, especially in elderly hospitalized patients because hospitalization exposes such individuals to an increased risk of adverse drug reactions (ADRs). The avoidance of medications that are considered to be inappropriate is among the interventions for treatment options in elderly patients. A potentially inappropriate medication (PIM) is a drug in which the risk of an adverse event outweighs its clinical benefit, particularly when there is a safer or more effective alternative therapy for the same condition. Explicit criteria have been developed to identify PIMs and among these, Beers' criteria are the most frequently applied in the literature. However, evidence suggests that such criteria cannot easily be applied to elderly hospitalized people in European countries; approximately 20% of drugs listed in Beers' criteria are rarely prescribed or are not available in Europe, and Beers' listed PIMs are not associated with inhospital mortality, length of hospital stay and/or ADRs in Italian studies. On the contrary, ADRs can contribute to accelerated functional decline in elderly hospitalized patients independently of the use of Beers' listed PIMs. Therefore, we will review the evidence pertaining to the application of Beers' criteria in elderly hospitalized patients, while focusing on Italian studies that have investigated the role of PIMs as potential predictors of negative hospital outcomes. In addition, we will also review the available evidence regarding new European criteria on identifying PIMs, because clinical application in elderly hospitalized Europeans is still under investigation.

Prescribing pattern of antihypertensive drugs in primary care units in Turkey: results from the TURKSAHA study

OBJECTIVES

The prescribing pattern of drugs used for treating hypertension changes over time in response to changes in recommended guidelines and innovations in drug formulations, among others. In addition, the classes of antihypertensive drugs used vary among the countries. The aim of this study was to investigate the practice of antihypertensive medications in primary care units in Turkey.

METHOD

TURKSAHA is a cross-sectional screening study conducted in 1000 primary care units considered to be representative of primary care in Turkey, with the purpose of defining the demographic characteristics, clinical features, rate of blood pressure control achieved and the antihypertensive drugs prescribed for the hypertensive patients treated in these centers. In this analysis, we investigated the agents used in the treatment regimen.

RESULTS

Of the 16,270 patients considered to be eligible for inclusion in the study, 15,187 (93.3%) were on an antihypertensive treatment, and 1083 (6.7%) were receiving no treatment. Patients who received treatment but whose antihypertensive medication was not specified (2290 patients) were subsequently excluded, and the trial was carried out with the remaining 12,897 patients. The mean age of the patients was 60 +/- 11 years (60.2% female). Of the 12,897 patients, 75.7% were receiving monotherapy, 19.7% two drugs, 4.1% three drugs and 0.5% four or more drugs. The rate of successful blood pressure control (<140/90 mmHg; for diabetics <130/80 mm Hg) in relation to the number of drugs received was 26.3, 25.9, 24.5 and 26.2%, respectively. Among the patients receiving monotherapy, the most frequently used antihypertensive drug class was angiotensin-converting enzyme inhibitors (30.1%), followed by beta-blockers (20.6%), calcium-channel blockers (17.9%), diuretics (15.4%) and angiotensin-receptor blockers (14%).

CONCLUSION

As in other European countries, the rate of successful blood pressure control was low among hypertensive patients receiving treatment, and despite the inadequacy of monotherapy to control blood pressure, many of the patients continued this treatment regimen. Consistent with the global trend, the most frequently prescribed anti-hypertensives were angiotensin blockers.

The INSIGHT and NORDIL trials: Are calcium antagonists equivalent to established drug therapies for cardiovascular protection?

Calcium channel blockers have come into worldwide use for treating hypertension and other circulatory disorders. In recent years, results of several observational studies have suggested that these drugs may not be as safe or effective as other available therapies, such as diuretics and beta-blockers, in the prevention of cardiovascular events. The Nordic Diltiazem (NORDIL) and the International Nifedipine GITS Study: Intervention as a Goal in Hypertension Treatment (INSIGHT) studies were the first two randomized interventional trials in hypertensive patients that directly compared the effects of therapy based on calcium antagonists with those of diuretic and beta-blocker-based treatment on major cardiovascular endpoints. Both studies found that the effectiveness of calcium antagonist therapy was similar to that of diuretic and beta-blocker therapy for preventing the composite primary endpoint of fatal and nonfatal stroke, myocardial infarction, and other cardiovascular death. The two studies shared several nonsignificant trends for cause-specific events, including greater stroke prevention and lesser coronary event prevention in the calcium antagonist groups compared with the diuretic and beta-blocker groups. There is not yet sufficient evidence to prove whether cause-specific differences exist. Results of the NORDIL and INSIGHT studies support incorporating calcium antagonist-based therapy as an additional safe and effective approach for preventing blood pressure-related illness and death.

Management of hypertension by general practitioners: an Italian observational study

Data on patients receiving antihypertensive therapy were collected from 20 general practitioners (GPs) in Campania, Italy, to determine the prescription of different antihypertensive classes and their use with other drugs for concomitant diseases, to investigate the main factors influencing antihypertensive choice, to document treatment outcome, and to assess adverse drug reactions (ADRs). Each GP completed a data card for each consultation that produced an antihypertensive prescription; 1900 cards were collected. The most frequently used antihypertensives were angiotensin-converting enzyme inhibitors (49.6%), calcium antagonists (24.8%), beta blockers (11.7%), angiotensin II-receptor blockers (5.5%), and alpha blockers (0.9%). In 82% of patients, blood pressure was reduced but did not reach normotensive levels. The choice of antihypertensive treatment was influenced by international guidelines (56%), clinical diagnosis (25%), concomitant diseases (8%), cost (4%), compliance (3%), and other factors (5%). ADRs--most often cough (35.7%), edema (22.7%), headache (13.3%), and tachycardia (7.8%)--occurred in 11.8% of patients.