Drug Utilization Pattern and Co-morbidtities Among ... - IOMC

Review of Global Medicine and
Healthcare Research
Volume 2 Number 2 (2011)
Publisher: DRUNPP
Managed by: IOMC Group
ISSN: 1986-5872
Website: www.iomcworld.com/rgmhr/

REVIEW OF GLOBAL MEDICINE AND HEALTHCARE RESEARCH (RGMHR)
ISSN: 1986-5872
Drug Utilization Pattern and Co-morbidtities Among
Hypertensive Patients in Sub-Urban Hospital, Malaysia
Baig MR 1 , Shih Yuit W 1 , Ramani M 1 , Chia Jin P 1 , Asma M 2 , Tahir MK 3 *
1 Department of Pharmacy, Asian Institute of Medical Sciences, 08100, Bedong, Kedah Darul
Aman, Malaysia
2 Chief Pharmacist, Hospital Sultan Abdul Halim, Sungai Petani Malaysia
3
College of Clinical Pharmacy, King Faisal University, Alahsah, Kingdom Of Saudi Arabia
* Corresponding author; Email: tahir.pks@gmail.com
ABSTRACT
Background: To reach an optimum blood pressure level among hypertensive patients,
combinations of two or more antihypertensive drug classes may be needed.
Objective: This study aimed to describe the drug utilisation pattern of anti-hypertensive
agents in sub-urban government hospital, Hospital Sultan Abdul Halim, Sungai Petani,
Malaysia.
Methodology: A cross-sectional retrospective evaluation of prescription was done from 30
March 2009 to 19 June 2009. Data analysis was conducted using Statistical Package for
Social Sciences (SPSS) software version 13.0. The chi-square test was used to determine the
differences between proportions. Odd rations were calculated to identify the groups at higher
risk of co-morbidities.
Results: A total of 500 hypertensive patient’s prescriptions were screened for the study, in
which 288 (57.6%) were males and 212 (42.4%) were females. The most common comorbidity
found in these hypertensive patients were cardiac disease (39.8%), followed by
diabetes mellitus (38%) with nephropathy. The male patients were with high risk of comorbidities.
Polytherapy was found to be the most preferred prescribing pattern, 318 (63.6%)
patients were given polytherapy, while 182 (36.4%) patients were given monotherapy. Beta
blocker (BB), 242 times (48.4%) is the highest prescribed drug class followed by angiotensinconverting
enzyme inhibitors (ACEI), 235 times (47.0%); calcium channel blockers (CCB),
218 times (43.6 %); diuretics, 146 times (29.2%); and the least prescribed drug is alpha
blockers, 15 times (0.03%). An increase of 42.3% was found in antihypertensive drug
consumption in hospital from 2001 to 2009.
Conclusion: The study shows Polytherapy is the most preferred prescribing pattern for
treating hypertension in Hospital Sultan Abdul Halim when compared to the use of a single
type of antihypertensive drug, monotherapy. The use of beta blockers and short-acting
preparations were commonly used both as monotherapy and combination treatment. Overall
therapy was not found complaint with the Malaysian guidelines for the management of
hypertension.
Keywords: Drug utilisation, Anti-hypertensive agents, Diabetes mellitus, Beta blocker,
Angiotensin-converting enzyme inhibitors, Malaysian guidelines
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REVIEW OF GLOBAL MEDICINE AND HEALTHCARE RESEARCH (RGMHR)
ISSN: 1986-5872
Introduction
Among the developed nations like U.S there are more than 70 million adults with confirm
diagnosis of hypertension [1] which latter put an addition burden due to serious adverse
cardiovascular and cerebrovascular events, including myocardial infarction (MI), angina
pectoris, stroke, and renal disease [2]. These risks can be avoided by the proper management
of hypertension. Commonly used anti-hypertensive agents are thiazide-type diuretics such as
hydrochlorothiazide (HCTZ), angiotensin-receptor blockers (ARBs), angiotensin-converting
enzyme (ACE)–inhibitors, and calcium-channel blockers. 3 Mono therapy is more affective at
initial stages however, in most of the case a combination therapy is recommended to control
hypertension [2, 3]. It is seen that in developed countries, only 27% of hypertensive on
treatment had adequate blood pressure control i.e below 140/90 mmHg [4]. The scenario is
worse in developing countries [5]. In Malaysia a review from the Information and
Documentation System Unit of the Ministry of Health of Malaysia showed that cardiovascular
disease had been the principal cause of death in government hospitals over the years,
accounting for 23% to 26% of deaths from 1994 to 2001. Cardiovascular disease is the major
cause of hospital admissions and death in government hospitals in Malaysia. The National
Health and Morbidity survey showed 61% of Malaysians had co-morbidity along with
hypertension. The prevalence of hypertension in Malaysians aged 30 years and above was
42.6% in 2006 [6]. The choice of anti hypertensive drug class patients is influenced by, many
factors like the presence of multiple co-morbid conditions and the possibility or risk of drugdrug
interactions. To reach an optimum blood pressure level in these patients, combinations
of two or more antihypertensive drug classes may be needed. This study aimed to describe the
pattern of use in a sub-urban government hospital, its compliance with guidelines, and its
economic impact.
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REVIEW OF GLOBAL MEDICINE AND HEALTHCARE RESEARCH (RGMHR)
ISSN: 1986-5872
Methodology
A cross-sectional retrospective evaluation of prescription was done for the patients attended
Hospital Sultan Abdul Halim, Sungai Petani.
- Study Duration: The study was conducted from 30 March 2009 to 19 June 2009.
- Study Design: A retrospective study was conducted based on the availability of the
prescription forms of the patients with diagnosis of hypertension. A standard data
collection form was developed and validated by a group of a Pharmacist; Medical
Doctor and a Professor. The data form was designed in such a way that it collects the
information about the patient’s demographic characteristics and drug utilization
pattern, which includes age, gender, race, indication, dosage of commonly prescribed
antihypertensive drugs in the Hospital.
Sampling Method: All the information was collected with the permission of the director and
the ethical committee of the state with the supervision of the concern Pharmacist. This
research is registered in Clinical Research Centre (CRC) with a government approval.
Sample sizes of 500 prescription forms of patients with hypertension were selected.
Convenience sampling technique was employed for the selection of patients. Information was
analyses based on data regarding race, age, gender, indications and trends in the prescribing of
antihypertensive medications at Hospital Sultan Abdul Halim, Sungai Petani. Data analysis
was conducted using Statistical Package for Social Sciences (SPSS) software version 13.0.
The chi-square test was used to determine the differences between proportions. Odd rations
were calculated to identify the groups at higher risk of co-morbidities.
Results
A total of 500 patients’ prescription was collected. The patients receiving medications for
antihypertensive agent were 288 (57.6%) males and 212 (42.4%) females. The age
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REVIEW OF GLOBAL MEDICINE AND HEALTHCARE RESEARCH (RGMHR)
ISSN: 1986-5872
distribution of 500 patients studied shows that the highest number of patients receiving
medication of antihypertensive agent was within the age range of 51-60 years having 166
(33.2%). In terms of race majority of the patients were Malay 298 (59.6%) followed by
Chinese 113 (22.6%) and 89 (17.8%) of Indian (Table 1). In most of the case the patients
have other medical complications in addition to hypertension. Majority, 199 (39.8%) were
with cardiac disease like; angina, Myocardial infraction and ischemic heart diseases followed
by Diabetes Mellitus patients and renal failure. Details are described in Table 1. However, the
prevalence of comorbid diabetes mellitus was significantly higher among Malays than
Chinese and Indians (Table 2). In terms of gender, men were more like to be at the risk of
cardiac complications (OR 1.335 [CI 1.153-1.545]) and renal failure (OR 1.128 [CI 0.788-
1.616]). While female were found at higher risk of diabetes mellitus (OR 1.114[CI 0.906-
1.369]). About 318(63.6%) patients were on treatment with poly-therapy for hypertension
while rest were treated with mono-therapy. Beta blockers (BB) were the most frequently
prescribed drugs for antihypertensive treatment. Those receiving antihypertensive therapy, the
most frequently prescribed drug types were, metoprolol 161(32.2%); perindopril 154(30.8%);
amlodipine 98(19.6%); atenolol 67(13.4%); frusemide 66(13.2%); captopril 59(11.8%);
vastarel 58(11.6%); felodipine 57(11.4%); chlorthiazide 42(8.4%); nifedipine 40(8.0%); and
the least are carvedilol, losartan, ramipril, terazosin 2(0.4% each); and doxasin 1(0.2%).
Details about the various anti-hypertensive agents used are shown in Table 3.
Discussion
Findings of the current study demonstrate that the most frequently prescribed antihypertensive
drug class were Beta-Blockers (48.4%). In about n=37 cases it is used as a
single therapy however, in n=205 it is used in combination with other antihypertensive drugs.
Unlike the finding of [1] the use of ACEI, CCBs, Diuretics or ARBs was found least in our
study. BB was observed to be most commonly prescribed regimens. These finding are not in
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REVIEW OF GLOBAL MEDICINE AND HEALTHCARE RESEARCH (RGMHR)
ISSN: 1986-5872
compliance with the findings of [1]. Moreover, the compliance level to the Malaysian clinical
practice guidelines for the treatment of hypertension was also low, which prefer the use of
ACEI, CCBs, Diuretics or ARBs as first line of therapy. β-blockers are no longer preferred as
compelling evidence showed that they were associated with 16% increase in the risk of stroke
when compared to other agents [6] and an excess cardiovascular event risk of 18% in older
patients (>60years) [7] It has also been shown to increase the incidence of new-onset diabetes
compared to other drugs, especially in those with high metabolic risk [8]. They were the least
effective agents in terms of LVH regression [9] and reduced central aortic pressure less
effectively [10] than newer antihypertensive agents. β-blockers should only be prescribed
when compelling indications such as heart failure or ischaemic heart disease co exist [11]. In
addition its is also seen that in about 76 (%) diabetic patients, BB were used in combination or
as a single line of therapy. Evidence are there that discourage the use of BB among diabetic
patients which make it difficult to predict signs and symptoms of hypoglycemia such as
tremors and tachycardia may be absent, making it more difficult for patients to recognize an
oncoming episode. In addition, multiple effects on glucose metabolism have been reported,
usually with the noncardioselective beta-blockers (e.g., propranolol, pindolol, timolol) but
occasionally also with relatively beta-1 selective agents (e.g., metoprolol).
Conclusion
Polytherapy is the most preferred prescribing pattern for treating hypertension in Hospital
Sultan Abdul Halim when compared to the use of a single type of antihypertensive drug,
monotherapy. The use of beta blockers and short-acting preparations were commonly used
both as monotherapy and combination treatment. Overall therapy was not found complaint
with the Malaysian guidelines for the management of hypertension.
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REVIEW OF GLOBAL MEDICINE AND HEALTHCARE RESEARCH (RGMHR)
References
ISSN: 1986-5872
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Subcommittee. Circulation. 2007;115(5):e69–e6171.
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Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure:
The JNC 7 Report. JAMA. 2003;289(19):2560–2572.
3. Law MR, Wald NJ, Morris JK, Jordan RE. Value of low dose combination treatment with
blood pressure lowering drugs: Analysis of 354 randomised trials. BMJ.
2003;326(7404):1427.
4. Colhoun HM, DongW, Poulter NR. Blood pressure screening, management and control
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5. Murray CJL, Lopez AD (eds). The Global Burden of Diseases, Comprehensive
Assessment of Mortality and Disability From Diseases, Injuries and Risk Factors in 1990
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6. Lindholm LH, Carlberg B, Samuelsson O. Should beta-blockers remain first choice in the
treatment of primary hypertension? A meta-analysis. Lancet. 2005;366(9496):1545-53.
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7. Khan N, McAlister FA. Re-examining the efficacy of beta-blockers for the treatment of
hypertension: a meta-analysis. CMAJ. 2006;174(12):1737-42.
8. Elliot WJ, Meyer PM. Incident diabetes in clinical trials of antihypertensive drugs: a
network meta-analysis. Lancet. 2007;369(9557):201-7.
9. Schmieder RE, Martus P, Klinbeil A. Reversal of left ventricular hypertrophy in essential
hypertension. A meta-analysis of randomized double-blind studies. JAMA.
1996;275(19):1507-13.
10. Williams B, Lacy PS, Thom SM, et al. Differential impact of blood pressure-lowering
drugs on central aortic pressure and clinical outcomes: principal results of the Conduit
Artery Function Evaluation (CAFÉ) study. Circulation. 2006; 113(9):1213-25.
11. Malaysian Hypertension Guideline Working Group. Clinical Practice Guidelines on
Management of Hypertension. 3rd ed. 2008. MOH/P/PAK/156.08 (GU).
Vol. 2 No 2 (2011) Page | 144

REVIEW OF GLOBAL MEDICINE AND HEALTHCARE RESEARCH (RGMHR)
Table 1: Demographic and Medical information of patients
Demographics N= 500 %
Gender
Male
Female
288
212
ISSN: 1986-5872
57.6
42.4
Age of Patients Range 12-98 Year
Mean age= 57±12.94
Race
11-20
21-30
31-40
41-50
51-60
61-70
71-80
81-90
>90
Malay
Chinese
Indian
2
9
34
90
166
104
80
13
2
298
113
89
0.4
1.8
6.8
18.0
33.2
20.8
16.0
2.6
0.4
59.6
22.6
17.8
Co-morbidities
Heart Disease
Diabetes Mellitus
Renal Failure
199
190
17
39.8
38.0
3.4
Number of Patient with one of Multiple Medical
complication
HPT+DM+CD+RD
HPT+DM+CD
HPT+DM+RD
HPT+CD+RD
HPT+DM
HPT+CD
HPT+RD
HPT alone
1
74
5
2
110
122
9
177
0.2
14.8
1
0.4
22
24.4
1.8
35.4
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REVIEW OF GLOBAL MEDICINE AND HEALTHCARE RESEARCH (RGMHR)
Table 2: Prevalence of co-morbidities as per Age and Race of the Patient
ISSN: 1986-5872
Demographics
Age
Race
11-20
21-30
31-40
41-50
51-60
61-70
71-80
81-90
>90
Malay
Chinese
Indian
Diabetes Mellitus
N(190)
0
2(1.1%)
6(3.2%)
34(17.9%)
75 (39.5%)
38 (20.0%)
29 (15.3%)
6(3.2%)
0
X 2 13.581, df=8, p=