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

Implementing Single-Pill Combination Therapy for Hypertension: A Scoping Review of Key Health System Requirements in 30 Low- and Middle-Income Countries

Objective

The World Health Organization (WHO) included single-pill combination (SPC) antihypertensive medications on their 2019 essential medicines list (EML) to encourage uptake and improved hypertension control. We documented key national-level facilitators (SPCs on national EMLs, recommendation for SPCs in national hypertension guidelines and availability of SPCs on the market) supporting uptake of SPCs in the 30 most populous low- and middle-income countries (LMICs).

Methods

A hierarchical information gathering strategy was used including literature and web searches, the use of organisational databases and personal communications with colleagues to obtain information on (1) whether SPC antihypertensives are on national EMLs, (2) whether SPC antihypertensives are recommended in national hypertension guidelines and (3) whether SPCs are available on the market.

Results

Eleven of 30 LMICs had all facilitators in place being Egypt, Kenya, Nigeria, Sudan, China, the Philippines, Thailand, Iran, Argentina, Colombia and Mexico. Twenty-six countries had national hypertension guidelines (or similar) in place with SPCs being recommended in 18 of these. Apart from Afghanistan, SPCs were available on the market in all countries. The facilitator least present was the inclusion of SPC antihypertensives on national EMLs at 12 of 29 (Turkey does not have an EML).

Conclusion

This study demonstrated that many LMICs have made significant progress in their uptake of SPC antihypertensives and several had included SPCs on their EMLs and guidelines prior to their inclusion on the WHO EML. Despite this progress, the uptake of SPC antihypertensives in LMICs could be improved including through their further inclusion on EMLs.

Clinicians' prescribing pattern, rate of patients' medication adherence and its determinants among adult hypertensive patients at Jimma University Medical Center: Prospective cohort study

BACKGROUND

Many studies conducted in the past focused on patients' sociodemographic factors and medical profiles to identify the determinants of suboptimal blood pressure control. However, prescribing patterns and clinicians' adherence to guidelines are also important factors affecting the rate of blood pressure control. Therefore, this study aimed to determine clinicians' prescribing patterns, patients' medication adherence, and its determinants among hypertensive patients at Jimma University Medical Center.

METHODS

A general prospective cohort study was conducted among hypertensive patients who had regular follow-up at Jimma university ambulatory cardiac clinic from March 20, 2018, to June 20, 2018. Patients' specific data was collected with a face-to-face interview and from their medical charts. Clinicians' related data were collected through a self-administered questionnaire. Data were analyzed using SPSS version 21.0. Bivariate and multivariable logistic regression analyses were done to identify key independent variables influencing patients' adherence. P-Values of less than 0.05 were considered statically significant.

RESULTS

From the total of 416 patients, 237(57.0%) of them were males with a mean age of 56.50 ± 11.96 years. Angiotensin-converting enzyme inhibitors were the most frequently prescribed class of antihypertensives, accounting for 261(63.7%) prescriptions. Combination therapy was used by the majority of patients, with 275 (66.1%) patients receiving two or more antihypertensive drugs. Patients' medication adherence was 46.6%, while clinicians' guideline adherence was 44.2%. Patients with merchant occupation (P = 0.020), physical inactivity (P = 0.033), and diabetes mellitus co-morbidity (P = 0.008) were significantly associated with a higher rate of medication non-adherence.

CONCLUSION

The rate of medication adherence was poor among hypertensive patients. Physicians were not-adherent to standard treatment guideline. The most commonly prescribed class of drugs were angiotensin-converting enzyme inhibitors. Effective education should be given to patients to improve medication adherence. Prescribers should be trained on treatment guidelines regularly to keep them up-to-date with current trends of hypertension treatment and for better treatment outcomes.

SPECIFICS OF ANTIHYPERTENSION THERAPY IN HYPERTENSIVES OF VARIOUS CARDIOVASCULAR RISK (BY THE REGISTRY OF CHRONIC NON-COMMUNICABLE DISEASES IN TYUMENSKAYA OBLAST)

Aim. To assess the specifics of antihypertension therapy (AHT) in hypertensives of various cardiovascular risk, in the registry of chronic non-communicable diseases in Tyumenskaya oblast.

Material and methods. A random sample studied, of 1704 patients with hypertension, inhabitants of Tyumenskaya oblast (region), ascribed to dispensary follow-up. Mean age 62±7,5 y.o. Of those 31,5% (n=537) males. The prevalence and efficacy of AHT assessed according to cardiovascular risk level. The significance was evaluated with the criteria χ2.

Results. AHT was characterized by the growth of the frequency of treatment approaches with cardiovascular risk consideration. Regular treatment took 33,9% patients of low and moderate risk vs 41,3% of high and very high (p<0,01). In the male group such tendency also took place. Gender specifics of AHT was characterized by that in the groups of high and very high risk females took medications significantly more commonly than males — 46,6% vs 29,1% in high risk group (p<0,01) and 47,5% vs 30% in very high risk group (p<0,01). With the increase of the risk level, there was decline of treatment efficacy — from 95% in low risk group to 32,5% in very high risk group; 53,1% of the participants were taking monotherapy, 32,9% — two drugs, 14,0% — ≥3 drugs. With the increase of risk grade there is tendency to increase of combinational AHT, however with no significant increase of efficacy. Treatment efficacy in high and very high risk patients comparing to patients with low and moderate risk was significantly lower — 33,1% vs 69,7% (p<0,01), respectively. Statins intake among the high and very high risk patients was 10,6-11,0% males and 7,8% females (p<0,05).

Conclusion. AHT in hypertensives in Tymenskaya oblast, under dispensary follow-up, is characterized by insufficient usage of combinational drugs. With the raise of cardiovascular risk there is tendency to higher rate of combinational AHT. However there is no significant increase in efficacy of treatment with the increase of medications number. A very low rate of statins intake is noted. The obtained specifics witness for the necessity to optimize AHT among the high and very high risk patients — inhabitants of Tyumenskya oblast.

Antihypertensive drug prescription patterns and their impact on outcome of blood pressure in Ethiopia: a hospital-based cross-sectional study

Background

Irrational prescription is strongly associated with poor control of hypertension. The present study aimed to evaluate antihypertensive drug prescription trends and to measure their impact on the level of blood pressure (BP) control in Gondar University Hospital, Gondar, Ethiopia.

Methods

A hospital-based retrospective cross-sectional study was conducted from May 30 to June 30, 2016. All hypertensive patients on medication were included. A structured data abstraction form was prepared to gather the necessary information. The prescription patterns and BP level were measured retrospectively. A binary logistic regression was computed to determine the effect of different prescription patterns on BP control.

Results

A total of 596 hypertension patients were recruited for the study; of them, 561(94%) met the study criteria. The mean age of the respondents was 55.96±14.6 years. Females constituted 58.2% of the study population. Approximately fifty percent of the prescriptions were monotherapies. Twice-daily dosing was associated with lower risk of uncontrolled hypertension (crude odds ratio [COR] =0.51[0.15–0.73], adjusted odds ratio [AOR] =0.69[0.163–0.91]). Monthly appointment was linked with a nearly 90% reduced incidence of uncontrolled BP (COR =0.15[0.04–0.73], AOR =0.093[0.024–0.359]).

Conclusion

Monotherapies were the most frequently prescribed regimens. Twice-daily dosing and monthly appointments were associated with low incidence of uncontrolled BP. Clinicians should be vigilant in adjusting the frequency of dosing and should fix appointment date in consultation with their patients.

Prescription patterns of antihypertensives in a community health centre in Mexico City: a drug utilization study

Hypertension is highly prevalent; in Mexico, the 2012 National Health and Nutrition Survey reported a prevalence of hypertension of 31.5% in the adult population. Pharmacological treatment is the commonest intervention and has been shown to reduce cardiovascular mortality and morbidity, and total mortality. Accordingly, the type and number of antihypertensives used and the outcome - in terms of blood pressure (BP) control - are important. Therefore, our purpose is to learn the pattern of antihypertensive drug prescription and explore the determinants of BP control in an urban population in Mexico. A retrospective cross-sectional drug utilization study was conducted. Medical records from a community health centre were searched to identify those corresponding to patients diagnosed with hypertension; information upon antihypertensives used and control of the disease was carefully retrieved. A logistic regression model was built to know the main determinants of BP control. A sample of 345 clinical records of interest was identified. Most patients received antihypertensives (86.4%); the leading medications used were angiotensin-converting enzyme inhibitors, 63.8%; beta-blockers (26.5%), diuretics (19.8%), angiotensin-receptor blockers (15.8%) and calcium-channel blockers (6.4%). Only the age (≥55 years) and BMI (>30) of the patients, and the age of the doctors (≥55 years), had an important influence on BP control. Obesity is a particular and important determinant of uncontrolled hypertension; it is worth to act on body weight, on an individual basis. As lack of control has been also tied to elderly doctors, an education programme could be envisaged.

HYT-hypertension in Turkey: a cross-sectional survey on blood pressure control with calcium channel blockers alone or combined with other antihypertensive drugs

INTRODUCTION

Although improved during the past few years, high blood pressure control still remains an unmet goal of antihypertensive drug treatment. Among different antihypertensive agents, calcium channel blockers (CCBs), either as monotherapy or in combination with other drugs are recommended by several guidelines for initiation and maintenance of antihypertensive treatment.

AIM

The HYT-HYperTension survey, carried out in Turkey was aimed to assess (a) blood pressure control in hypertensive patients under treatment with dihydropyridine CCBs, either as monotherapy or in combination with other drugs and (b) the prevalence of blood pressure control in subgroups of patients with cardiovascular risk factors (previous cardiovascular disease, diabetes, renal disease, isolated systolic hypertension, visceral obesity, overweight, current smoking habit).

METHODS

More than 7000 hypertensive patients (60.0 % men, mean age 61.2 ± 11.5 years), routinely visited by either a specialist or a non-specialist physician in the Primary Care Units of 26 cities across Turkey, were enrolled in the survey. Only patients treated with dihydropyridine-type CCBs, as mono- or combination therapy were included in the study, whereas individuals treated with non-dihydropyridine-type CCBs or with other drug classes (as monotherapy or combination therapy), were excluded. Demographic data (age, gender, height, weight, waist circumference, current smoker habit), clinical data and drug treatments were collected at each visit. Blood pressure was measured with a semiautomatic device (Omron-M6) with the patient in sitting position and after at least 5 min of rest. Measurements were repeated three times, at intervals of 5 min each other.

RESULTS

In the overall survey population blood pressure control (blood pressure <140/90 mmHg) was achieved in 31.7 % of patients and the average systolic and diastolic blood pressure was 145.3/88.2 mmHg. Prevalence of patients treated with dihydropyridine-type CCBs, either as monotherapy or combined with other drugs, was superimposable (51.6 vs 48.4 %, P = NS). Dihydropyridine-type CCBs were more frequently combined with drugs acting on the renin-angiotensin-aldosterone system (86.4 %), particularly with ACE-inhibitors (34.1 %) and angiotensin II receptor antagonists (52.3 %), while in 13.6 % of patients CCBs were combined with diuretics and/or beta-blockers. Diabetes mellitus was detected in 22.7 % of patients, obesity in 41.5 % and history of cardiovascular disease in 23.0 % (coronary artery disease in 19.2 % and stroke in 3.8 %). Blood pressure control was more difficult to be achieved in complicated hypertension, particularly when cigarette smoking, obesity, overweight, visceral obesity and renal disease were associated with hypertension.

CONCLUSIONS

Taken together these findings provide evidence that dihydropyridine-type CCBs, particularly when combined with ACE-inhibitors or angiotensin II receptors blockers, allow to achieve a blood pressure control better than the one reported in the same geographic area by other treatment strategies based on different combinations of diuretics, beta-blockers, ACE-inhibitors, angiotensin II receptors blockers and calcium channel blockers.

Diuretics for hypertension-reasons for a contradiction in primary care prescribing behavior: a qualitative study

There has been a long international discussion on diuretics as first-line therapy for hypertension. In Germany, thiazide diuretics are very rarely prescribed in monotherapy and concurrently highly prescribed in fixed-combinations. The aim of this study was to approach the reasons for this inconsistency in primary care prescribing behavior. A qualitative study design consisting of single interviews with general practitioners (GPs) was chosen. Most GPs perceived diuretics as too weak to treat arterial hypertension effectively in monotherapy. In combination therapy, GPs expected to spare the dose and to offset certain side effects of other drugs. The convenient availability of diuretics in most fixed-dose combinations on the German drug market was seen as an important reason for their frequent prescription in combination therapy. Thus, the reasons given by the GPs differed from the main arguments of the academic debate. Dissemination strategies for guidelines should take the perceptions and opinions of practicing GPs into account.

Spectrum of antihypertensive therapy in South Asians at a tertiary care hospital in Pakistan

Background

Despite available guidelines on hypertension (HTN), use of antihypertensives is variable. This study was designed to ascertain frequency of patients on monotherapy and > 1 antihypertensive therapy and also to ascertain proportion of patients on diuretic therapy.

Methods

It was a crossectional study conducted on 1191 adults(age > 18 yrs)hypertensive patients selected by computerized International Classification of Diseases -9-coordination and maintenance (ICD-9-CM) presenting to a tertiary care hospital in Pakistan. Data on demographics, comorbids, type of antihypertensive drug, number of antihypertensive drug and mean duration of antihypertensive drug was recorded over 1.5 year period (2008-09). Blood pressure was recorded on admission. Primary outcome was use of combination therapy and secondary outcome was use of diuretic therapy.

Results

A total of 1191 participants were included. Mean age(SD) was 62.55(12.47) years, 45.3%(540) were males. Diabetes was the most common comorbid; 46.3%(551). Approximately 85% of patients had controlled hypertension. On categorization of anti hypertensive use into 3 categories;41.2%(491) were on monotherapy,32.2%(384) were on 2 drug therapy,26.5%(316) were on ≥3 drug therapy. Among those who were on monotherapy for HTN;34%(167) were on calcium channel blockers,30.10%(148) were on beta blockers, 22.80%(112) were on Angiotensin converting enzyme (ACE) inhibitors,12%(59) were on diuretics and 2.20%(11) were on Angiotensin receptor blockers(ARB). Use of combination antihypertensive therapy was significantly high in patients with ischemic heart disease(IHD)(p < 0.001). Use of diuretics was in 31% (369) patients. Use of diuretics was significantly less in patients with comorbids of diabetes (p 0.02), Chronic kidney disease(CKD)(p 0.003), IHD (p 0.001) respectively

Conclusion

Most patients presenting to our tertiary care center were on combination therapy. Calcium channel blocker is the most common anti hypertensive drug used as monotherapy and betablockers are used as the most common antihypertensive in combination. Only a third of patients were on diuretic as an antihypertensive therapy.

Cardiovascular medication exposures and poisonings in Izmir, Turkey: A 14-year experience

Cardiovascular medications (CVMs) are frequently prescribed for cardiovascular diseases. The unconscious use of cardiovascular drugs may lead to severe clinical manifestations, even to death, especially when in overdose. The objective of this study is to clarify the profile of CVM exposures admitted to Department of Emergency Medicine in Dokuz Eylul University Hospital (EMDEU) between 1993 and 2006. Case demographics, type of the medication, route and reason for exposure, clinical effects and outcome were recorded. Related to the CVM exposures, 105 poisoning cases were admitted. Mean age of children and adults were 12.8 ± 1.0 and 30.1 ± 1.8, respectively. Females were dominating (77.1%). Poisoning by accident occurred mainly among children in the 0—6 age group (64.3%) and suicide attempt was predominant in the 19—29 age group (47.8%). The most common ingested CVMs admitted to EMDEU were calcium channel blockers (19.7%), beta-blockers (17.3%), angiotensin converting enzyme inhibitors and diuretics (11.8%). Most of the patients were asymptomatic (59.1%). Frequently observed symptom was altered consciousness (18.6%). Antihypertensive drugs are responsible for the most of the CVM exposures. Prospectively designed multi-centered studies are needed to reflect the epidemiological properties of cardiovascular drug exposures throughout our country and would be very valuable for the determination of preventive measures.

The effect of selected patient's characteristics on the choice of antihypertensive medication in the elderly in Slovakia

PURPOSE

The aim of the present study was to determine which patient-related characteristics influence the selection of the antihypertensive drug class in elderly patients in Slovakia.

METHODS

The sample for our study (n = 401) was selected from 1045 patients admitted to the Department of Internal Medicine of a general hospital during the period of 1 December 2003-31 March 2005. Patients aged 65 or more with documented arterial hypertension and treated with at least one antihypertensive drug were enrolled in our retrospective study. Specific socio-demographic and clinical characteristics as well as cardiovascular comorbid conditions were evaluated as potential factors that could have influenced the choice of antihypertensive drug class.

RESULTS

The most frequently prescribed antihypertensive drugs were angiotensin-converting enzyme (ACE) inhibitors and diuretics (61.8% and 60.1% of patients, respectively). Patients aged >/= 85 years had lower probability of ACE inhibitors prescription (OR = 0.49). Females had higher chance of calcium channel blockers use (OR = 3.84) and lower odds of diuretics administration (OR = 0.50). In patients living alone, ACE inhibitors were preferred (OR = 2.16). The use of diuretics was more frequent in polymorbid patients (OR = 1.95). Immobile patients had lower chance of being prescribed beta-blockers and calcium channel blockers (OR = 0.25 and OR = 0.39, respectively).

CONCLUSION

The present study revealed that the selection of the antihypertensive drug class in elderly patients is influenced not only by comorbid conditions present but also by socio-demographic and clinical characteristics, such as age, sex, living alone, polymorbidity and immobilization. These characteristics reflect the doctor's perception of risk from pharmacotherapy of hypertension in elderly patients.