Patterns Of Antihypertensive Use Research Articles

Trends in antihypertensive drug utilization in British Columbia, 2004-2019: a descriptive study.

Clinical guidelines for hypertension were updated with lower blood pressure targets following new studies in 2015; the real-world impact of these changes on antihypertensive drug use is unknown. We aimed to describe trends in antihypertensive drug utilization from 2004 to 2019 in British Columbia. We conducted a longitudinal study to describe the annual prevalence and incidence rate of use of 5 antihypertensive drug classes (thiazides, angiotensin-converting enzyme [ACE] inhibitors, angiotensin II receptor blockers [ARBs], calcium channel blockers and β-blockers) among BC residents aged 30-75 years. We also conducted a cohort study to compare the risk of discontinuation and switch or add-on therapy between incident users of the above drug classes. We used linkable administrative health databases from BC. We performed a Fine-Gray competing risk analysis to estimate subhazard ratios. Among BC residents aged 30-75 years (population: 2 376 282 [2004] to 3 014 273 [2019]), the incidence rate of antihypertensive drug use decreased from 23.7 per 1000 person-years in 2004 to 18.3 per 1000 person-years in 2014, and subsequently increased to 22.6 per 1000 person-years in 2019. The incidence rate of thiazide use decreased from 8.9 per 1000 person-years in 2004 to 3.2 per 1000 person-years in 2019, and incidence rates for the other drug classes increased. Incident users receiving thiazide monotherapy had an increased risk of discontinuing any antihypertensive treatment compared with ACE inhibitor monotherapy (subhazard ratio 0.96, 95% confidence interval [CI] 0.95-0.97), ARB monotherapy (subhazard ratio 0.84, 95% CI 0.81-0.87) and thiazide combination with ACE inhibitor or ARB (subhazard ratio 0.86, 95% CI 0.84-0.88), and had the highest risk of switching or adding on. First-line use of thiazides continued to decrease despite a marked increase in incident antihypertensive therapy following updated guidelines; incident users receiving ARB monotherapy were least likely to discontinue, and incident users receiving thiazide monotherapy were more likely to switch or add on than users of other initial monotherapy or combination. Further research is needed on the factors influencing treatment decisions to understand the differences in trends and patterns of antihypertensive drug use.

Appraising the compliance to Joint National Committee-8 Guidelines for antihypertensives in a teaching hospital by drug utilization evaluation method and impact of patient counselling

Abstract Objectives To evaluate the prescribing pattern of antihypertensive drugs and its compliance to the recommendations of Joint National Committee 8 (JNC 8) guidelines and assess the impact of pharmacist led patient counselling on hypertension management. Methods A prospective study was carried out for a period of one year (September 2020–October 2021) among 150 hypertensive patients of various departments in a tertiary care hospital, Kerala, India. All the cases were prospectively analysed to study the pattern of antihypertensive use and patients were counselled with a patient information leaflet. Key findings Out of 150 patients, 53% were women and 47% were men. Majority of patients were aged 60 years and above (66.0%). Diabetes mellitus (26%) was the most common co-morbidity associated with hypertension. About half of the patients had received dual therapy (49%) followed by monotherapy (31.3%), triple therapy (18%) and quadruple therapy (2%). Calcium channel blockers (59.8%) were the most frequently prescribed drug class followed by angiotensin II receptor blockers (30.5%) either alone or in combination for effective control of blood pressure. Cilnidipine (8.7%) was the most commonly used antihypertensive drug followed by telmisartan (8%). It was observed that 80% of prescriptions were adherent to JNC 8 hypertension treatment recommendations. There was a significant difference (P < 0.001) in the knowledge-awareness scores before (18%) and after (52%) patient counselling. Conclusion The study represents the utilisation pattern of antihypertensive drugs. The adherence of antihypertensive medication use to JNC 8 guidelines was high level at the study site but needs to improve further. The study concludes that pharmacist-led counselling plays a vital role in improving patients’ knowledge and awareness towards hypertension management.

Effect of patient and treatment factors on persistence with antihypertensive treatment: A population-based study.

To analyze patterns of antihypertensive drug use among new users in a Southern European population, and identify patient- and treatment-related factors that influence persistence. This is a retrospective observational study of new antihypertensive drug users aged ≥40 years in Aragón, Spain. Information on antihypertensive drugs (2014-2016) prescribed and dispensed at pharmacies via the public health system were collected from a regional electronic population-based pharmacy database. Persistence was assessed using the gap method. Kaplan-Meier and Cox regression analyses were conducted to analyze patterns of use and factors that influence persistence. The 25,582 new antihypertensive drug users in Aragón during the study period were prescribed antihypertensive drugs in monotherapy (73.3%), fixed combination (13.9%), free combination (9.1%), or other (3.7%). One in five received antihypertensive drugs within 15 days of the prescription date, but not after. During the first year of follow-up, 38.6% of the study population remained persistent. The likelihood of treatment discontinuation was higher for participants who were male, aged ≥80 years, and received an antihypertensive drug in monotherapy compared with fixed combination. Overall persistence with antihypertensive therapy was poor, and was influenced by the sex, age and type of therapy. Fixed combinations appear to be a good choice for initial therapy, especially in patients with a higher risk of discontinuation. Nonetheless, adverse drug effects and the patient's preferences and clinical profile should be taken into account.

Gender Differences in Prescribing Antihypertensive Drugs in a Public Hospital in Alkharj

Introduction: Hypertension is considered one of the most significant risk factors for mortality and morbidity worldwide. There are major clinical implications for gender-specific pharmacokinetics and pharmacodynamics. It is important to know the potential gender differences in hypertension treatment and to know the prescribing trends in male and female hypertensive patients in order to optimize the treatment of hypertension.
 Aim: This is a retrospective study that aims to describe the difference in prescribing antihypertensive drugs between male and female patients.
 Methodology: This is a retrospective study that includes the revision of patient electronic records of outpatients with hypertension in 2018 in Alkharj.
 Results: The total number of prescribed antihypertensive drugs was 1838 drugs. The calcium channel blocker was the most commonly prescribed antihypertensive class (27.86%). The study showed that there are different patterns of antihypertensive drug use among hypertensive men and women and showed that female patients are more frequently treated with diuretics and less frequently with angiotensin-converting enzyme inhibitors and angiotensin receptors blockers than male patients.
 Conclusion: Stratified guidelines and policies based on gender will be appropriate if more studies show a difference in the efficacy and safety of antihypertensive drugs between male and female patients. It is important to conduct more studies about these differences.

Antihypertensive use for stroke in United States emergency departments.

ObjectiveTimely emergency department (ED) control of hypertension in the acute phase of stroke is associated with improved outcomes. It is unclear how emergency physicians use antihypertensive medications to treat severe hypertension associated with stroke. We sought to determine national patterns of antihypertensive use associated with ED visits for stroke in the United States.MethodsWe analyzed data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2008–2017. We included ED visits associated with ischemic stroke (ICD9 433–434, ICD10 I630–I639) or hemorrhagic stroke (ICD9 430–432, ICD10 I600–I629). We estimated the number and proportions of stroke ED visits with triage blood pressure meeting treatment thresholds (triage systolic blood pressure [SBP] ≥180 mm Hg). We identified the frequency of antihypertensive use, as well as the most commonly used agents.ResultsBetween 2008–2017, of a total 135,012,819 ED visits, 619,791 were associated with stroke (78.3% ischemic strokes and 21.7% hemorrhage strokes). Of all stroke visits, 21.8% received antihypertensive medications. Of the identified visits, 9.0% (95% confidence interval [CI] = 6.0%, 13.1%) ischemic stroke visits and 58.2% (95% CI = 49.0%, 66.9%) hemorrhagic stroke visits met criteria for BP reduction. A total of 47.6% (95% CI = 29.1%, 66.7%) of eligible ischemic stroke visits and 41.5% (95% CI = 30.5%, 53.3%) of eligible hemorrhagic strokes visits received antihypertensives. The most common agents used in ischemic stroke were beta‐blockers, calcium‐channel blockers, and ACE inhibitors. The most common agents used in hemorrhagic stroke included calcium‐channel blockers, beta‐blockers, and vasodilators.ConclusionIn this national sample, less than half of strokes presenting to the ED with hypertension received antihypertensive therapy.

Awareness, Treatment, and Control Rates of Hypertension in Adults Aged 35–75 Years in Three Provinces of Central China

Abstract Background To describe the status of hypertension awareness, treatment, and control rates and their relationships with individual characteristics in Henan, Hubei, and Hunan provinces in central China, and to describe the patterns of antihypertensive drug use in this region. Methods The awareness, treatment, and control rates of hypertension in this area were identified through analysis of the data from China Patient-Centered Evaluative Assessment of Cardiac Events (PEACE) Million Persons Project in three provinces (Henan, Hubei, and Hunan) of central China. The patterns of antihypertensive drug use were also examined. The mixed model was used to analyze the relationship between the awareness, treatment, and control rates and individual characteristics at the patient level. Results A total of 268,461 subjects were enrolled with 37.9% male and an average age of (56.3 ± 9.7) years. Among them, 129,099 (48.1%) had hypertension, of which 49.5% were aware of hypertension, 42.9% received antihypertensive drugs, and 11.5% had blood pressure under control. Calcium channel antagonists (54.6%) were the most widely used among all antihypertensive drugs. Of the patients whose blood pressure were not controlled, 25,482 patients (86.4%) took only one antihypertensive drug. In addition, the rate of awareness, treatment, and control of hypertension varied significantly among different populations: the rates were higher among the older, as well as among subjects with higher annual family income, higher educational status, and history of myocardial infarction, stroke, and diabetes (all P < 0.05). Conclusions The awareness, treatment, and control rates of hypertension in adult patients of central China require further improvement. Meanwhile the proportion of combination drug therapy is low.

Antihypertensive drugs use over a 5-year period among children and adolescents in Beijing, China: An observational study.

Evidence on the prescription patterns of antihypertensive drug use in children and adolescents in China is scarce. A descriptive analysis of the Beijing Medical Claim Data, which covered over 95% of the urban residents, was conducted to investigate antihypertensive prescribing patterns and trends in children and adolescents aged under 18 from 2009 to 2014 in Beijing, China. An additional meta-analysis of trends in hypertension prevalence was conducted to compare trends with antihypertensive medications.A total of 11,882 patients received at least 1 prescription for antihypertensive drugs from 2009 to 2014. The number of annual antihypertensive users increased from 2009 to 2012, then declined steadily until 2014, which was consistent with the trend of the hypertension prevalence estimated from the meta-analysis. β-receptor blockers, thiazide diuretics, and angiotensin-converting enzyme inhibitors were the 3 most commonly prescribed antihypertensive drugs. More boys took the antihypertensive drugs than girls. For users aged under 3 years, thiazide diuretics, α-receptor blockers, and angiotensin-converting enzyme inhibitors were the most prescribed drugs, while β-receptor blockers, thiazide diuretics were the most used drugs for users above 3 years.In conclusion, antihypertensive drug prescribing for children and adolescents increased from 2009 to 2014, with different characteristics in different subgroups.

Sex differences in antihypertensive drug use and blood pressure control

BackgroundHypertension is the most important modifiable cardiovascular risk factor. Epidemiological studies have shown the benefits of lowering blood pressure (BP), but BP control is a major challenge. Furthermore, there are...

Antihypertensive drug use and blood pressure control among stroke survivors in the United States: NHANES 2003-2014.

Understanding the patterns of antihypertensive drug use and blood pressure (BP) control among stroke survivors in the "real-world" setting is important to identify gaps in treatment and control, if any. The objective of our study was to assess trends and patterns in antihypertensive drug use and BP control among stroke survivors in the United States. We performed a retrospective cross-sectional analysis of the 2003-2014 National Health and Nutrition Examination Survey (NHANES). Stroke and hypertension diagnoses were self-reported. Information regarding the use of antihypertensive drugs was collected during an in-person interview. Measurement of BP was performed by trained medical professionals in mobile examination centers. A total 1244 adult stroke survivors (equating to 6232215 stroke survivors nationwide) were identified, of which 956 had hypertension. Antihypertensive drug use increased from 2003 (79.5%) to 2014 (92.2%; P for trend<0.001). The prevalence of drug use was lower (52%) among survivors aged 20-39years compared with older age groups. Use of ≥2 antihypertensive drugs was prevalent (63.8%), but diuretics alone or in combination with angiotensin-converting enzyme inhibitors were underutilized (22.4%). More than one-third of the survivors were not at BP goal (ie, BP<140/90mmHg). Males were more likely to attain BP goal than female stroke survivors (odds ratio [OR]=2.02; 95% CI: 1.34-3.05). Our findings suggest that despite improvements in antihypertensive drug use in the recent years, BP is not adequately controlled in a significant proportion of stroke survivors. Further research focusing on understanding the reasons for unmet BP goal in stroke survivors is needed.

A Prospective Drug Utilization Study in Geriatric Hypertensive Patients in a Tertiary Care Hospital, Mumbai

Introduction: The geriatric population assumes great significance in terms of both preventive and curative health care services utilized. The patho-physio-psychological changes associated with ageing make their problems unique. In the geriatric population, hypertension accounts for a huge proportion of cardiovascular and all cause mortality and morbidity. We conducted a study to describe the patterns of antihypertensive drug use in the geriatric population, compare it to the current recommendations and conduct an analysis using the WHO-INRUD drug use indicators. Methods: A prospective cross sectional drug utilization study of 100 prescriptions of hypertensive patients (as per JNC 7) of either sex and ≥60 years was undertaken as per the WHO – DUS and the STROBE guidelines. Results: Statistically significant relation was found between BP control, and addictions and CIRSG score. The 100 prescriptions contained 344 drugs, out of which, 171 were antihypertensive drugs. Three percent of antihypertensive drugs were prescribed by generic names. Seventy nine

Claims analysis of hypertension occurrence, severity changes and patterns of antihypertensive use in cancer patients receiving vascular endothelial growth factor inhibitors.

Vascular endothelial growth factor inhibitors such as bevacizumab, sorafenib, and sunitinib are utilized in the treatment of multiple cancers. Although these agents are associated with hypertension, there is a lack of evidence describing patterns of antihypertensive use in patients with vascular endothelial growth factor inhibitor-associated hypertension in a non-trial, "real-world" setting. To describe the occurrence and severity of vascular endothelial growth factor inhibitor-associated hypertension, patterns of antihypertensive use and occurrence of cardiovascular complications in a non-trial population, and to describe patterns of initial antihypertensive therapy in patients developing hypertension during treatment with a vascular endothelial growth factor inhibitor. This retrospective cohort study utilized claims data from the Medstat MarketScan Commercial Claims and Encounter database to identify patients with claims for a vascular endothelial growth factor inhibitor and a diagnosis of cancer using International Classification of Diseases, 9th Revision, Clinical Modification codes, Healthcare Common Procedure Coding System J-codes and National Drug Codes. The study period encompassed claims from one year before the patient's first claim for a vascular endothelial growth factor inhibitor, and continued through one year after the initial vascular endothelial growth factor inhibitor claim. Patients meeting study criteria were classified into cohorts A1, patients with no hypertension throughout the study period; A2, patients without hypertension at baseline who developed hypertension after starting a vascular endothelial growth factor inhibitor; and cohort B, patients with hypertension prior to receiving a vascular endothelial growth factor inhibitor. We utilized medical and pharmacy claims data to describe the presence of hypertension, its severity, and the occurrence of cardiovascular complications throughout the study period. Initial antihypertensive use in cohort A2 was described. In all, 2177 patients met study criteria and were categorized into cohorts A1 (n = 708), A2 (n = 333) and B (n = 1136). Approximately 32% of patients without hypertension at baseline had claims suggestive for hypertension during the study period. Life-threatening (Grade 4) hypertension increased throughout the study period for cohorts A1, A2, and B, to 3.4%, 10.2%, and 16.4%, respectively (p < 0.001 for all). Claims suggestive of Grade 3 hypertension occurred in more patients in cohort B (45.8%) than in cohort A2 (32.7%, p < 0.001). Cardiovascular complications occurred in 4.7%, 15.6%, and 22.7% of patients in cohorts A1, A2, and B, respectively. Initial antihypertensive agent selection did not impact the occurrence of cardiovascular complications in cohort A2. Our study provides valuable insight into non-trial patterns of vascular endothelial growth factor inhibitor-associated hypertension occurrence and severity, and is consistent with prior claims analysis. Identification of optimal strategies to manage vascular endothelial growth factor inhibitor-associated hypertension remain to be clarified with the advent of more comprehensive data sets.

Trends in using beta-blockers and methyldopa for hypertensive disorders during pregnancy in a Canadian population

ObjectiveTo describe trends in and patterns of antihypertensive drug use in a general obstetric population. Study designHistorical cohort study. A total of 18,117 women who gave birth in a Saskatchewan hospital between January 1, 1980 and December 31, 2005 with a diagnosis of hypertensive disorders in pregnancy were identified and included in the analysis. ResultsThe rate of treatment with antihypertensive drugs for pregnant women with chronic hypertension rose from 19.94% in 1980–1984 to 37.63% in 2000–2005. There were similar increases in antihypertensive drug use from 1.51% to 14.47% for gestational hypertension/non-severe preeclampsia, and from 1.56% to 20.86% for severe preeclampsia/eclampsia. Methyldopa was the most frequently used drug, followed by beta-blockers, with other antihypertensive drugs accounting for about 18.43% of total uses. The use of both methyldopa and labetalol has increased in recent years while the use of other antihypertensive drugs has decreased. Other antihypertensive drugs were more commonly prescribed in earlier gestation, while methyldopa and labetalol were generally prescribed in later gestation. ConclusionThe use of antihypertensive drugs in pregnancy is relatively common and is increasing, with the liberal use of methyldopa and (especially) labetalol contributing appreciably to this increase.

Factors Affecting Blood Pressure Control in Hemodialysis

Background: Hypertension is poorly controlled in hemodialysis (HD). Extracellular fluid volume control, restriction of salt intake and antihypertensive therapy are needed to control blood pressure (BP) control in this population. Research on patterns of antihypertensive use on BP has not been extensively studied in the chronic HD population. Methods: A descriptive secondary correlational analysis of n = 118 chronic HD patients was conducted to determine the patterns of antihypertensive medication use and their relationship to BP. Results: Participants were taking an average of three antihypertensive medications. Total number of antihypertensive medications was not correlated with BP. There were no differences in BPs in patients who took or did not take a specific antihypertensive drug class except for ace-inhibitors. Those participants who did take ace-inhibitors had significantly higher BPs. Conclusions: Future studies examining antihypertensive class, optimal dosing and time of administration need to be conducted to determine the best hypertensive management intervention for chronic HD patients.

Antihypertensive Therapy in African Americans: Findings From an Inner‐City Ambulatory Clinic

African Americans bear a greater burden of hypertension. Understanding prevailing epidemiologic patterns can facilitate the implementation and successful outcome of community programs. The authors assessed practice patterns of antihypertensive drug utilization and blood pressure (BP) control in a predominantly African American population in Brooklyn, NY, from January 1 to January 31, 2008. A total of 416 (53.1%) had hypertension, with a mean age of 61 years, and 267 (64%) were women. In general, 212 (50.9%) were at goal BP and 59.9% of those at goal were taking at least 2 drugs. Patient age correlated with the number of drugs used (r=0.14; P=.004). Patients taking beta-blockers and calcium channel blockers were older: 63.6 vs 60.1 years (P=.01) and 62.7 vs 60.3 years (P=.07), respectively. The pattern of antihypertensive use was as follows: angiotensin-converting enzyme inhibitors, 194 (46.6%); calcium channel blockers, 162 (38.9%); diuretics, 162 (38.9%); beta-blockers, 133(32%); and angiotensin receptor blockers, 93 (22.4%). The findings of age associated with the class of medications used and a predominance of angiotensin-converting enzyme inhibitors usage highlight possible gaps in appropriateness of antihypertensive therapy. The application of age-appropriate race-based antihypertensive therapy might improve BP control rates. These results strengthen arguments for investing in community-based programs to overcome possible provider-related and local health system barriers to achieving BP control goals.

Stroke prevention in patients with atrial fibrillation: The diagnosis and management of hypertension by specialists

Hypertension is common in patients with atrial fibrillation (AF) and is an important cause of stroke. To determine how effectively hypertension is managed among specialist-treated outpatients with AF. Investigators reviewed the charts of patients with a diagnosis of AF cared for by medical specialists to determine the change in blood pressure, patterns of antihypertensive drug use and the role of the specialist in the management of hypertension. Of 209 patients with AF, 118 had a history of hypertension or an office blood pressure greater than 140/90 mmHg. Blood pressure was measured at 73% of all visits. Hypertension was identified as an important problem in 57% of patients and antihypertensive therapy was either initiated or suggested in 77%. One year after the initial specialist visit, systolic blood pressure was significantly lower (140+/-20 mmHg at one year versus 148+/-23 mmHg initially; P=0.015); however, there was no change in diastolic blood pressure (80+/-12 mmHg at one year versus 81+/-16 mmHg initially; P=0.602) and only 50% of patients had a blood pressure less than 140/90 mmHg. In contrast, the percentage of patients receiving warfarin increased from 46% to 78% (P=0.0001). In patients treated by specialists for AF, systolic blood pressure is significantly reduced during follow-up; however, 50% of patients continue to have suboptimal blood pressure control. In many patients, hypertension is not identified as an important comorbid illness and antihypertensive therapy is neither recommended nor initiated by the specialist. Greater specialist involvement in the identification and treatment of hypertension in patients with AF could lead to an important, additional reduction in stroke.

Patterns of antihypertensive therapy among patients with diabetes

Hypertension is extremely prevalent in patients with diabetes. Limited data exist on whether patterns of antihypertensive use in this population are consistent with evidence-based practice guidelines. To evaluate utilization patterns of antihypertensive agents and blood pressure (BP) control among diabetic patients with hypertension. Retrospective cohort study. In all, 9,975 patients with diabetes and hypertension as of March 2001 from an outpatient medical center of the Department of Veterans Affairs. Proportions of use of 6 different antihypertensive drug classes were compared for all patients receiving 1, 2, 3, or 4 or more drugs, and separately among patients with and without coronary artery disease (CAD). Blood pressure control (<130/85 mmHg) was compared for untreated patients, those on monotherapy, and patients on multi-drug regimens. Over 60% of patients were receiving angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blocker (ARB), followed by diuretics (38.1%), calcium channel blockers (35.3%) and beta-blockers (28.5%) with 19.1% of patients untreated. Patients on monotherapy were mostly receiving ACEI/ARB (59.5%). The majority (70.7%) of treated patients were on multidrug regimens. In patients with CAD, beta-blocker and ACEI/ARB use was higher, and 70.5% of patients on single-drug regimens received either ACEI/ARB or beta-blockers. The proportions of patients not on medications, on monotherapy, or multidrug regimens achieving BP control were 23.4%, 27.4%, and 24.9%, respectively. Patterns of anti-hypertensive therapy were generally consistent with evidence-based practice guidelines. Areas of improvement include increasing ACEI/ARB and diuretic use, decreasing the number of untreated patients, and increasing the proportion of patients with controlled BP in this population.

Patterns of antihypertensive medication use in hemodialysis patients

Patterns of antihypertensive drug use in patients undergoing long-term hemodialysis therapy were studied. Patients attending seven outpatient hemodialysis units in Ohio were eligible for the study if they had been receiving the treatment for at least three months. Demographic and clinical data were obtained from patient interviews and computerized databases, and blood pressure (BP) measurements were obtained before dialysis. Labeled names and dosages of antihypertensive drugs were recorded from containers the patients brought with them. Patients were asked to describe their adherence to the medications, their ability to afford the drugs, and their knowledge and beliefs about hypertension. Physical impairments in taking medication were also evaluated. The frequency of hypertension was 89% in the 270 participants. Antihypertensive drugs were prescribed for 76% of the patients; 25% required three or more drugs. Hypertensive patients who were not receiving antihypertensive drugs (14%) had significantly higher BP than patients who were. Calcium-channel blockers were prescribed for 60% of patients, angiotensin-converting-enzyme inhibitors for 33%, and beta-blockers for 34%. Eighty-three percent said the cost of drugs was never a problem, and 23% said they sometimes forgot to take their medication. Almost all patients said they would not stop taking antihypertensive drugs if they were feeling better and agreed that monitoring BP was important. Twenty-two percent could not read the warning on a standard tablet container, and 12% could not remove one tablet from the container. Multidrug antihypertensive therapy was common among hemodialysis patients and was associated with significantly lower BP; calcium-channel blockers were the most frequently prescribed agents. Most patients said they could afford drugs and reported good adherence to antihypertensive drug therapy.

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.

Pharmacologic treatment of hypertension in the Department of Veterans Affairs during 1995 and 1996

Patterns of antihypertensive drug use, the cost of this care and potential savings with changes of treatment patterns, were studied for all hypertensives treated at US Veterans Affairs (VA) medical facilities for fiscal years 1995 and 1996. Data was aggregated by individual medication as well as by antihypertensive drug class. Cost estimates were based on median cost and number of units for each dosage form of each medication dispensed at all facilities. Potential savings were estimated by substituting β-blockers or diuretics for calcium antagonists. In a subset of patients the prevalence of hypertension, and among hypertensives the prevalence of coronary artery disease, congestive heart failure, and diabetes mellitus, was determined. For these patients, patterns of treatment by antihypertensive drug class was examined. For all VA facilities, of the 10 most frequently prescribed antihypertensives in 1995, four were calcium antagonists, two angiotensin converting enzyme (ACE) inhibitors, two β-blockers, and two diuretics. In 1996, this was changed by the addition of an ACE inhibitor and the subtraction of a diuretic combination. Calcium antagonists accounted for 37% of treatment days in 1995 and 35% in 1996, ACE inhibitor use went from 34% to 36%, β-blockers from 17% to 18%, and diuretic use remained at 12%. In 1996, approximately 86.6 million dollars were spent on calcium antagonists, 51.8 million on ACE inhibitors, 7.9 million on β-blockers, and 3.6 million on diuretics. The estimated annual cost savings for each 1% conversion of calcium antagonists to β-blockers would be $713,000 and to diuretics $758,000. In a subset of 7526 hypertensive patients with known comorbid conditions, calcium antagonists and ACE inhibitors were also the most commonly used drug classes for all categories of patients, including those without coronary artery disease, congestive heart failure, and diabetes mellitus. Calcium antagonists and ACE inhibitors were the most commonly dispensed antihypertensives at VA facilities for both 1995 and 1996, with a small decrease in calcium antagonist use from 1995 to 1996. The cost implications of these practice patterns as compared with the primary use of diuretics and β-blockers are enormous.

Patterns of antihypertensive use among patients in the US Department of Defense database initially prescribed an angiotensin-converting enzyme inhibitor or calcium channel blocker

The US Department of Defense recently assembled electronic records of outpatient prescriptions dispensed through the Uniformed Services Prescription Database Project (USPDP) going back to 1990. The objectives of this portion of a larger study were: (1) to examine longitudinally the patterns of antihypertensive drug use during the first year of therapy in patients whose initial therapy was with an angiotensin-converting enzyme (ACE) inhibitor or a calcium channel blocker (CCB); (2) to determine continuous and noncontinuous users of antihypertensive drugs; and (3) to estimate the direct medication costs for each pattern of medication use. Filtering criteria for patient and prescription identification were developed, because the USPDP contains no records of confirmatory diagnoses of hypertension. Once data filters were implemented, information for 771 patients was analyzed. An ACE inhibitor was the initial therapy for 328 patients, accounting for 1935 antihypertensive medication prescription fills, and a CCB was the initial therapy for 443 patients, accounting for 2459 fills (including refills). Slightly more than half of the patients (n = 401, 52.0%) were classified as continuous users (≥80% medication-possession ratio [supply of medication in days divided by the number of days in the 12-month study period]). In the first year, 177 of these continuous users (44.1%) had no change in therapy in the first year, 49 (12.2%) had an increase in dose, 8 (2.0%) had a decrease in dose, 15 (3.7%) had a change to a different therapeutic class of antihypertensive medication, 14 (3.5%) were changed to a different medication in the same therapeutic class, 20 (5.0%) had a new medication added to the regimen, and 118 (29.4%) had complex regimens involving more than one change. For continuous users, the mean medication supply in days was 354.6, and the average time before a medication change was 152.1 days for those continuous users who had one change in therapy. The overall average wholesale price (AWP) and average manufacturer price (AMP) for continuous users during 1 year of therapy were $471.31 and $378.51, respectively. For those patients whose therapy was changed to an ACE inhibitor/CCB combination and who were continuous users, the average AWP was $598.47 per year ($492.05 AMP). Once the change from monotherapy to an ACE inhibitor/CCB combination occurred in continuous users, AWP costs per member per month increased by approximately $22.00 ($18.00 AMP). Over half of the patients whose initial therapy was an ACE inhibitor or CCB had at least one change in their first year of therapy. Research into the reasons for these changes and their outcomes is needed.