Antihypertensive Prescription Patterns Research Articles

Profile of antihypertensive prescription in a developing country

Data from pharmocoepidemiologic studies examining the patterns of antihypertensives prescription within a population are important for identifying any discordance between published recommendations and clinical practice. The aims of this article are to investigate the antihypertensive drug prescription pattern and utilization in the management of systemic hypertension among Nigerians, and to relate these to established guidelines. Within the population, the prescription pattern of antihypertensive drugs is still at variance with established guidelines.

Pharmacoepidemiology of antihypertensive drugs in primary care setting of Bahrain between 1998 and 2000

To compare pattern of antihypertensive drug utilization in 1998 with 2000 following the: (a) publication of 1999 World Health Organization/International Society of Hypertension (WHO/ISH) guidelines for drug management of hypertension; and (b) introducing new antihypertensives to the essential drug list, in primary care, Bahrain. Retrospective prescription-based survey carried out in seven out of 20 primary care health centers in Bahrain. A total of 9272 patients comprising 6543 with uncomplicated hypertension and 2729 with diabetic hypertension were studied. Between 1998 and 2000, the prescription rate of beta-blockers and methyldopa significantly declined (p < 0.0001) while the rate of angiotensin converting enzyme (ACE) inhibitors and calcium channel blockers (CCBs) increased (p < 0.0001) in uncomplicated hypertension. However, in diabetic hypertension there was a non-significant decline in utilization of beta-blockers, CCBs, methyldopa, and diuretics whereas a significant increase in prescribing of ACE inhibitors (p < 0.0001). Inclusion of Perindopril into the essential drug list resulted in an overall increase in utilization of ACE inhibitors: use of captopril and enalapril declined while lisinopril and perindopril increased. Substitution of immediate-release (IR) indapamide by sustained-release (SR) formulation did not change the overall utilization of diuretics; however, intra-class changes were evident with a significant decline in use of thiazide diuretics and concomitant increase in use of SR indapamide by 2000. The antihypertensive prescribing pattern is influenced by WHO/ISH guidelines as well as by introduction of new antihypertensives to primary care essential drug list in primary care. The choice of a drug is also influenced by presence of co-morbidity with diabetes mellitus.

Antihypertensive Medications Prescribed at Discharge After an Acute Ischemic Cerebrovascular Event

Hypertension is poorly controlled in stroke survivors, thereby placing them at increased risk for recurrent events. Clinical trial evidence suggests that antihypertensive treatment may be beneficial for stroke prevention in hypertensive and normotensive stroke patients. We aimed to evaluate the discharge antihypertensive prescription patterns in patients hospitalized for an ischemic cerebrovascular event and to determine factors associated with treatment utilization. We analyzed patients diagnosed with ischemic stroke or transient ischemic attack (TIA) in the California Acute Stroke Prototype Registry (CASPR). We used generalized estimating equations to identify factors independently associated with receiving antihypertensives at the time of hospital discharge. Data were collected on 764 consecutive patients with ischemic stroke or TIA encountered at 11 hospitals representative of facilities in the state of California. Overall, the rate of discharge with a prescription for any antihypertensive in the CASPR cohort was 69.4%. Hospital-specific rates were heterogeneous (P=0.04), varying from 55% to 100%. In multivariate analysis, independent predictors of prescription for antihypertensive medication at discharge were a history of hypertension (P<0.0001), diabetes (P=0.0009), and older age. About two-thirds of patients hospitalized with acute ischemic cerebrovascular events are discharged from the hospital on > or =1 antihypertensive medication. However, there is great variability in prescription rates between hospitals and considerable room for improvement.

Prescribing patterns for antihypertensive drugs after the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial: Report of experience in a health maintenance organization

The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) reported that primary cardiovascular outcomes were the same in hypertensive patients treated with thiazide-type diuretics as in those treated with calcium channel blockers or angiotensin-converting enzyme inhibitors. The aim of this study was to assess prescribing patterns of antihypertensive agents in a health maintenance organization (HMO) before and after the publications of ALLHAT results. Our analysis used computer-stored information from the pharmacy system of the HMO for the period between January 1, 1996, and December 31, 2003. The study assessed prescribing patterns for antihypertensive drugs in six classes: thiazide-type diuretics, other-type antihypertensive diuretics, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, calcium channel blockers, beta-blockers, and alpha-blockers. The monthly total number and relative percentage of dispensed prescriptions for each class of antihypertensive agent, including new prescriptions and refills, were calculated. The use of alpha-blockers for all prescriptions began to decrease after the closure of the alpha-blocker (doxazosin) arm of ALLHAT in January 2000. Prescriptions for the thiazide-type diuretics immediately increased after the ALLHAT publication in December 2002. During the first 6 months of 2003, the percentages of thiazide-type diuretics were statistically significantly higher compared with the predicted values. This pattern held for all as well as for new antihypertensive prescriptions. The ALLHAT publications had large effects on the antihypertensive prescribing patterns in our population. Prescription of thiazide-type diuretics significantly increased after the ALLHAT publication. Our findings establish that the response of physicians to new clinical evidence can be very rapid.

Characteristics of treated hypertension in incident hemodialysis and peritoneal dialysis patients

Background: The treatment of hypertension in dialysis patients is prevalent and poorly characterized. β-Blockers and calcium channel blockers (CCBs) have been associated with reduced all-cause and cardiovascular mortality. This study describes the treatment of hypertension and assesses the association between mortality and class of antihypertensive medication among a cohort of dialysis patients. Methods: The US Renal Data System (USRDS) Dialysis Morbidity and Mortality Study Wave II cohort was analyzed. A total of 2,877 patients initiating hemodialysis or peritoneal dialysis in 1996 or 1997 and treated with antihypertensives were included in this analysis. Vital status was followed until November 2000. Results: Calcium channel blockers were prescribed to 70.3% of patients. Only 31.5% and 27.0% of patients with cardiovascular disease were prescribed angiotensin-converting enzyme inhibitors and β-blockers, respectively. Mono-, double-, triple-, and more than triple-therapy were reported in 48.0%, 36.1%, 13.2%, and 2.7% of the cohort, respectively. In multivariable, fully adjusted models, no individual class of antihypertensives was associated with changes in all-cause mortality. In all patients, nondihydropyridine CCBs (non-DHP CCBs) were associated with a reduced risk of cardiovascular death (hazard ratio, 0.78; 95% confidence interval, 0.62 to 0.97) and among end-stage renal disease patients with preexisting cardiovascular disease, dihydropyridine CCBs (DHP CCBs) and non-DHP CCBs were associated with reduced risk of all-cause and cardiovascular mortality. Conclusion: Calcium channel blocker use is widespread among hypertensive dialysis patients. Antihypertensive prescription patterns suggest a lack of consensus regarding treatment of hypertension. Multivariable analysis of associations between antihypertensive class and mortality reveals results of uncertain clinical significance. Hypertension treatment trials in dialysis patients should be performed to appropriately inform treatment decisions.

Academic detailing to improve antihypertensive prescribing patterns

Several studies indicate that treatment of hypertension in the United States does not follow recommendations from expert bodies. We thus implemented a program using academic detailers to increase practitioner compliance with antihypertensive treatment guidelines. Five Veterans Affairs medical facilities including academic medical centers and community based outpatient clinics were chosen for the intervention. Pharmacists were trained as academic detailers, and the intervention included lectures, educational materials, provider profiling, and meetings with 25 to 50 providers each. After intervention, the proportion of hypertensives receiving calcium antagonists decreased from 43% to 38% ( P < .001), whereas the proportion receiving a β blocker or thiazide diuretic increased from 58% to 64% ( P < .001). For hypertensive subjects with diabetes mellitus or congestive heart failure, the proportion receiving an angiotensin converting enzyme inhibitor or angiotensin receptor blocker increased from 72% to 76% for the former and from 74% to 78% for the latter ( P < .001 for both). Among hypertensive subjects with coronary artery disease an increase in β blocker use was noted after intervention ( P < .001 for change from baseline). Prescribing patterns after academic detailing more closely followed national recommendations.

Pharmacotherapeutic Analysis and Prescription Pattern of Antihypertensive Drugs Dispensed at Community Pharmacies in Palestine

The objective of this study is to explore the influence of current therapeutic recommendations on the prescribing trends of anti-hypertensive drugs in general medical practice in Palestine. Five hundred and seventy four anti-hypertensive prescriptions were analyzed. The percentage of mono-therapy prescriptions was 48.25% and that for combinational therapy prescriptions was 51.75%. Among the mono-therapy prescriptions, b- blockers were the most commonly prescribed, while diuretics were under-utilized. Inappropriate dose strength of atenolol was seen in mono-therapy prescriptions. Expensive and newer angiotensin converting enzyme inhibitor drugs (ACE-I) and calcium channel blocking drugs (CCB) were frequently seen in mono therapy prescriptions. Among the combinational therapy, the b-blockers / diuretics was most common. Irrational combinational therapy of b-blockers / ACE-I was noticed. Use of modern and new CCB, ACE-I and angiotensin II type 1 receptor antagonists (AT1-RA) was seen in both mono therapy and combinational therapy. The overuse of nonprefered drugs and the under-use of prefered medications is indicative that education of JNC VI guidelines for physicians and health professionals in Palestine is needed.

Blood pressure and angiotensin converting enzyme inhibitor use in hypertensive patients with chronic renal insufficiency

Background Hypertension treatment is important in managing chronic renal insufficiency (CRI). Little is known, however, about the blood pressure (BP) control achieved or the pattern of antihypertensive drug prescription among CRI patients. Methods Using computerized medical records, we studied 3089 adult hypertensive subjects treated at Brigham and Women’s Hospital (Boston, MA) from 1990 through 1998. All subjects had at least two serum creatinine measurements ≥2 years apart, at least two BP readings, and online weight (to estimate Cockcroft-Gault creatinine clearance [CrCl]). Results The average mean arterial pressure over time (mean MAP) was 103 ± 9 mm Hg among those with CrCl >60 mL/min, 102 ± 9 mm Hg among those with CrCl 41 to 60 mL/min, and 101 ± 9 mm Hg among those with CrCl 21 to 40 mL/min. There were no significant differences in mean MAP among the different categories of renal function in the multivariate analysis ( P = .26 for trend). The proportion of patients with final systolic BP <160 mm Hg and diastolic BP <90 mm Hg was 68% and did not vary with renal function ( P = .68 for trend). The proportion of subjects who were prescribed ACE inhibitors was 38% among those with CrCl >60 mL/min, 36% among those with CrCl 41 to 60 mL/min, and only 27% among those with CrCl 21 to 40 mL/min ( P = .003 for trend). Conclusions The BP control achieved among hypertensive CRI subjects, although no worse than that among those without CRI, was found to be suboptimal. Patients with CrCl 21 to 40 mL/min were less likely to be prescribed ACE inhibitors than were those with CrCl >60 mL/min. Improvement is needed in the clinical management of these factors that can influence the progression of CRI.

Antihypertensive drug prescription trends at the primary health care centres in Bahrain.

To determine the antihypertensive drug prescribing pattern by primary care physicians in patients with uncomplicated essential hypertension; to identify whether such pattern of prescription is appropriate and in accordance with international guidelines for pharmacotherapy of hypertension; and to estimate the impact of such prescriptions on cost of treatment. A prescription-based survey among patients with uncomplicated essential hypertension was conducted in seven out of a total of 18 health centres in Bahrain. The relevant data for our study was collected using cards, designed for chronically-ill patients. A total of 1019 male and 1395 female (62.9%) out of 3838 of the study population were on monotherapy, whereas 596 male and 828 female (37.1%) were on antihypertensive combination therapy. Among the monotherapy category, the various antihypertensive drugs used were as follows: beta-blockers (58.8%), angiotensin converting enzyme (ACE) inhibitors (14.2%), calcium channel blockers (11.1%), diuretics (8.1%) and alpha-methyldopa (7.0%). With respect to overall utilization pattern, beta-blockers were the most frequently prescribed (65.5%), diuretics ranked second (27.4%), followed by ACE inhibitors (20.6%), calcium channel blockers (19.9%) and alpha-methyldopa (8.5%). Within each class of antihypertensives used, the most frequently used individual agents were as follows: (a) among beta-blockers 97.7% used atenolol; (b) among the diuretics, indapamide (35.4%), hydrochlorothiazide (HCTZ) (32.7%), HCTZ in combination with triamterene (25.7%), and chlorthalidone (4.6%); (c) among the ACE inhibitors, captopril (44.9%), enalapril (29.7%), and lisinopril (19.0%); (d) among the calcium channel blockers, nifedipine (98.2%). Significant age- and gender-related differences in prescribing patterns were seen. Short-acting nifedipine monotherapy was inappropriately prescribed in a significant number of patients above the age of 50 years. ACE inhibitors accounted for approximately two-thirds of the total antihypertensive drug expenditure, although these drugs represent only one-fifth of overall antihypertensives used. There is a trend towards excessive use of expensive thiazide-like diuretics such as indapamide which seems to be unjustifiable practice, particularly in a study population free from diabetic hypertensive patients. The general pattern of antihypertensive utilization appears to be in accordance with the guidelines of WHO and the Joint National Committee issued in the 1990s. The trends of prescribing of antihypertensives were in favour of conventional ones such as the beta blockers and diuretics, and the introduction of newer classes of antihypertensives had a generally minimal impact on the prescribing profile. Almost two-thirds of the patients were treated with monotherapy. A disproportionately large percentage of antihypertensive drug cost was due to overt use of ACE inhibitors, and indapamide, instead of thiazide diuretics. The use of short-acting calcium channel blockers especially in the elderly is unjustifiable.

The influence of national guidelines on antihypertensive prescribing patterns.

Efforts to influence medical practice include the formation of expert medical panels who make recommendations for the evaluation and treatment of clinical problems. Despite the considerable expense and effort that go into these activities, it is unclear whether they are successful. Recent studies have evaluated whether recommendations from the Fifth Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure (JNC V) published in 1993 influenced antihypertensive prescribing patterns. These included a national study of medications dispensed by retail pharmacies and an evaluation of antihypertensive prescribing patterns in US Veterans Affairs (VA) medical facilities. Despite recommendations from JNC V that hydrochlorothiazide and beta-blockers be used as first choice for most hypertensive patients, calcium antagonists and angiotensin converting enzyme (ACE) inhibitors were the most common drugs prescribed for hypertension in both 1992 (before JNC V) and 1995 (after JNC V). In retail pharmacies, changes in antihypertensive drug dispensing patterns from 1992 to 1995 reflected increased use of calcium antagonists and ACE inhibitors and decreased use of diuretics and beta-blockers, suggesting that JNC V recommendations had little effect on prescribing patterns. Similar patterns of antihypertensive drug use were found in VA facilities. The reasons for the lack of influence of JNC V recommendations on antihypertensive prescribing patterns must be explored and alternative ways of educating health care providers implemented.

PCV9 Study of Hypertensive Prescribing Practices

Fifty million people in the US have hypertension. The JNC-V guidelines provide treatment recommendations for hypertension. These guidelines promote initiating therapy with diuretics and beta blockers since these agents have been shown to reduce hypertension-related morbidity and mortality. OBJECTIVES: To survey primary care physicians' antihypertensive prescribing practies, their perceptions about antihypertensive medication cost and safety and the perceived impact of managed care. METHODS: A direct mail survey was sent to a national random sample of 500 office-based, primary care internists, family practitioners, and general practitioners. RESULTS: Seventy-two percent of physicians reported being aware of the JNC-V guidelines. Younger physicians claimed to be more aware of and more likely to follow JNC-V guidelines than older physicians. Only 25% of physicians reported initiating treatment at systolic blood pressures greater than 140 mm Hg as recommended by the JNC-V guidelines. Diuretics were selected by 36% of physicians, angiotensin-converting enzyme (ACE) inhibitors by 35%, beta blockers by 16%, and calcium channel blockers (CCBs) by 7% for initial antihypertensive treatment. Up to 27% of physicians admitted not knowing the cost of specific medications. Approximately half of physicians reported that they and their patients were more concerned about medication cost and safety today than 18 months ago. A greater number of younger physicians than older physicians reported that managed care formularies infringed upon their prescribing practices. CONCLUSIONS: Antihypertensive prescribing patterns are inconsistent with JNC-V guidelines. Actual practice may deviate even more from these guidelines than reported in this survey. Also, primary care physicians perceive that managed care is increasingly affecting their prescribing practices.

Trends in antihypertensive drug use in the United States: do the JNC V recommendations affect prescribing? Fifth Joint National Commission on the Detection, Evaluation, and Treatment of High Blood Pressure.

The choice of pharmacological treatment for the approximately 50 million people in the United States with hypertension has important therapeutic and financial implications. To describe national antihypertensive medication prescribing patterns for 1992 and 1995; to explore the influence of the Fifth Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure (JNC V), published in 1993, which recommended diuretics and beta-blockers as first-line antihypertensive therapy unless contraindicated; and to estimate the impact of these prescribing patterns on the cost of antihypertensive treatment. All prescriptions for drugs approved for the treatment of hypertension dispensed by 35000 retail pharmacies were tabulated for 1992 and 1995 (62% of all US retail pharmacies were surveyed). Number of prescriptions for each dosage form of medication and national cost estimates based on wholesale costs of medications dispensed. In 1992, of the 10 most frequently prescribed antihypertensive drugs, 3 were calcium antagonists, 3 were angiotensin-converting enzyme (ACE) inhibitors, 3 were beta-blockers, and 1 was the combination of triamterene and hydrochlorothiazide. In 1995, 4 were calcium antagonists, 3 were ACE inhibitors, 1 was a beta-blocker, 1 was the combination of triamterene and hydrochlorothiazide, and 1 an alpha-blocker. In 1992, calcium antagonists accounted for 33% of antihypertensive prescriptions compared with 38% in 1995, ACE inhibitor use went from 25% to 33%, beta-blocker use from 18% to 11%, and diuretic use from 16% to 8%. The estimated wholesale costs for calcium antagonists in 1995 dollars increased from $2.67 billion in 1992 to $2.86 billion in 1995; ACE inhibitor costs increased from $1.37 billion to $1.67 billion; costs for diuretics declined from $353 million to $168 million; and costs for beta-blockers declined from $763 million to $433 million. From 1992 to 1995 use of calcium antagonists and ACE inhibitors for treatment of hypertension increased and diuretics and beta-blockers declined, suggesting that the recommendations from JNC V had little effect on prescribing patterns. The cost implications of these practice patterns are enormous.

Trends in Antihypertensive Drug Use in the United States

<h3>Context.</h3> —The choice of pharmacological treatment for the approximately 50 million people in the United States with hypertension has important therapeutic and financial implications. <h3>Objectives.</h3> —To describe national antihypertensive medication prescribing patterns for 1992 and 1995; to explore the influence of the Fifth Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure (JNC V), published in 1993, which recommended diuretics and β-blockers as firstline antihypertensive therapy unless contraindicated; and to estimate the impact of these prescribing patterns on the cost of antihypertensive treatment. <h3>Design.</h3> —All prescriptions for drugs approved for the treatment of hypertension dispensed by 35000 retail pharmacies were tabulated for 1992 and 1995 (62% of all US retail pharmacies were surveyed). <h3>Main Outcome Measures.</h3> —Number of prescriptions for each dosage form of medication and national cost estimates based on wholesale costs of medications dispensed. <h3>Results.</h3> —In 1992, of the 10 most frequently prescribed antihypertensive drugs, 3 were calcium antagonists, 3 were angiotensin-converting enzyme (ACE) inhibitors, 3 were β-blockers, and 1 was the combination of triamterene and hydrochlorothiazide. In 1995,4 were calcium antagonists, 3 were ACE inhibitors, 1 was a β-blocker, 1 was the combination of triamterene and hydrochlorothiazide, and 1 an a-blocker. In 1992, calcium antagonists accounted for 33% of antihypertensive prescriptions compared with 38% in 1995, ACE inhibitor use went from 25% to 33%, β-blocker use from 18% to 11% and diuretic use from 16% to 8%. The estimated wholesale costs for calcium antagonists in 1995 dollars increased from $2.67 billion in 1992 to $2.86 billion in 1995; ACE inhibitor costs increased from $1.37 billion to $1.67 billion; costs for diuretics declined from $353 million to $168 million; and costs for β-blockers declined from $763 million to $433 million. <h3>Conclusions.</h3> —From 1992 to 1995 use of calcium antagonists and ACE inhibitors for treatment of hypertension increased and diuretics and β-blockers declined, suggesting that the recommendations from JNC V had little effect on prescribing patterns. The cost implications of these practice patterns are enormous.

Importance of Product Attributes in Antihypertensive Product Selection by Physicians

ABSTRACTIn treating hypertension, physicians are often faced with the difficult task of prescribing drugs that provide the greatest benefit with the lowest risks. Physicians treat patients on an individualized. case-by-case basis; however, it is likely that physicians maintain an established procedure for treating their hypertensive patients within the constraints of select patient characteristics and product attributes. The purpose of this study was to supplement understanding of antihypertensive drug prescribing patterns and, using conjoint analysis and direct question ratings, to determine the relative importance of product attributes in physicians' evaluation of a new antihypertensive that is similar to presently marketed products. A 5-page questionnaire was mailed in March 1991 to a national sample of 2.505 physicians that included 835 cardiologists (CARDs). 835 internists (IMs), and 835 family practitioners (FPs). From a total of 630 responses, 562 responses were usable for data analysis. This study...

Marked changes occur in antihypertensive prescription patterns in 2 European centres over a 10-year period

Marked changes occur in antihypertensive prescription patterns in 2 European centres over a 10-year period

Antihypertensive Prescription Pattern and Associated Medication Costs: A Retrospective Review of Prescriptions in A Tertiary Hospital

Background: Hypertension is the leading cardiovascular disease most associated with high risk of morbidity and mortality. Recent evidence indicate that in low and medium income countries hypertension is a growing healthcare challenge compounding already existing high burden of infectious diseases. The overall goal of treatment is to reduce the risk of associated secondary complications which increases the risk of mortality. The choice of antihypertensive medications vary widely between and within health facilities, however concerns remain whether prescribed drugs affordable as well as optimize treatment outcomes.&#x0D; Aim: The aim of this study is to determine antihypertensive prescription pattern and its impact on affordability of drug treatment&#x0D; Results/Discussions: The results showed that monotherapy with CCBs were the most prescribed drugs accounting for over half of all antihypertensive prescriptions. In addition CCB based combination therapies were found in more than three quarters of all prescriptions. The cost of one month supply of innovator brands was significantly higher than generic versions, which made them far less affordable to majority of patients. The prescription pattern did not significantly adhere to current treatment guidelines for the management of hypertension. This makes the case for improvement in prescription practices that emphasize rational drug therapy that take into cognizance costs, particularly among the poor.&#x0D; Conclusion: Antihypertensive prescription pattern did not largely comply with guidelines and the widespread prescription of innovator drug brands makes medicines largely unaffordable to majority of patients. It is imperative that drug treatment of high blood pressure allow patients to benefit from reduced cost of low priced generic drugs.