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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 17  |  Issue : 2  |  Page : 81-85

The pattern of antihypertensive medication use among elderly patients in a tertiary care teaching hospital in South India


Department of Pharmacology, Dhanalakshmi Srinivasan Medical College and Hospital, Siruvachur, Perambalur, Tamil Nadu, India

Date of Web Publication9-Sep-2014

Correspondence Address:
Sandeep Kumar Gupta
Assistant Professor, Department of Pharmacology, Dhanalakshmi Srinivasan Medical College and Hospital, Siruvachur, Perambalur 621 212, Tamil Nadu
India
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DOI: 10.4103/1119-0388.140418

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  Abstract 

Background: The blood pressure (BP) control rates in elderly patients remain low and hypertension in them is a management dilemma to the treating physician. Objective: The primary objective of this study was to characterize the prescribing pattern of antihypertensive agents among elderly patients in a tertiary care teaching hospital. Materials and Methods: This study was part of a larger cross-sectional retrospective study to assess the pattern of prescribing for inpatient hypertensive cases in the Inpatient Department of General Medicine at Dhanalakshmi Srinivasan Medical College and Hospital (DSMCH), Perambalur (Tamil Nadu). The data were collected for a period of 10 months. Only elderly patients who are 65 and above and those who were suffering from essential hypertension and had been prescribed at least one antihypertensive drug with or without other co-morbid conditions were included. Results: Among 106 patients studied, approximately 51% and 49% were on monotherapy and combination therapy, respectively. The antihypertensive drugs were prescribed alone or in combination in the following order: Calcium channel blockers (CCBs), diuretic, beta blockers (BBs), ACE inhibitors (ACEIs), and angiotensin receptor blockers (ARBs). The commonest monotherapy agents prescribed were CCBs (29.2%), followed by diuretic (11.3%), ACEI (4.7%), BB (4.7%), and ARBs (0.9%). The most prevalent two-drug therapy was with a CCB and diuretic (19.8%), followed by a CCB and BB (7.5%), CCB and ACEI (1.9%), ACEI and diuretic (2.8%), CCB and ARB (1.9%), BB and diuretic (1.9%), BB and ACEI (0.9%), and BB and ARB (0.9%). The commonest three-drug therapy was with a CCB, BB, and diuretic (2.8%). Other three-drug therapies were an ACEI + CCB + BB (0.9%), an ARB + diuretic + CCB (0.9%), a BB + CCB + ARB (0.9%), a BB + ACEI + diuretic (0.9%), a BB + ARB + diuretic (0.9%), and a CCB + diuretic + ACEI (0.9%). The commonest four-drug therapy was with a CCB, BB, ARB, and diuretic (1.9%) followed by a CCB + BB + ACEI + diuretic (0.9%). Conclusion: The most commonly prescribed antihypertensive drug was CCBs followed by diuretics, BBs, ACEIs, and ARBs. Overall, there was less utilization of diuretics and ACEIs or ARBs.

Keywords: Blood pressure, elderly, hypertension, JNC-7, prescribing pattern


How to cite this article:
Gupta SK, Nayak RP. The pattern of antihypertensive medication use among elderly patients in a tertiary care teaching hospital in South India. Trop J Med Res 2014;17:81-5

How to cite this URL:
Gupta SK, Nayak RP. The pattern of antihypertensive medication use among elderly patients in a tertiary care teaching hospital in South India. Trop J Med Res [serial online] 2014 [cited 2019 Jan 18];17:81-5. Available from: http://www.tjmrjournal.org/text.asp?2014/17/2/81/140418


  Introduction Top


Hypertension is a significant risk element for cardiovascular morbidity and mortality, especially in elderly people. [1] Thus, it is not shocking that as per the Framingham Heart Study the lifetime risk of developing hypertension among 55- and 65-year-old persons is >90%. [2],[3] Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC-7) states that hypertension develops in a majority of people after the age of 65. [4] Therefore, desired hypertension control is vital in the care of elderly patients in order to decrease cardiovascular morbidity and mortality. [1]

Numerous studies have shown that treating hypertension decreases the chance of stroke and other serious cardiovascular events and most of the elderly patients benefit from proper antihypertensive therapy. [5] Regardless of that, blood pressure (BP) control rates in elderly patients remain low and the quality of care provided to elderly hypertensive patients is essentially disappointing. [1],[6] The management of hypertension in elderly individuals requires deliberation of not only modified drug metabolism but also unique physiological factors, such as postural hypotension, a decrease in cardiac output, plasma volume, renal function, and sometimes altered mental status. [7],[8] Furthermore, most elderly hypertensive patients have multiple co-morbidities, which hugely affect the management of their hypertension. They are also more prone than younger patients to have resistant hypertension and may require multiple drugs for management of their BP. [9] Hence, the primary objective of this study was to characterize the prescribing pattern of antihypertensive agents among elderly patients in the tertiary care teaching hospital in order to get an insight into patterns of care for elderly inpatients with hypertension.


  Materials and Methods Top


This study was part of a larger cross-sectional retrospective study to assess the pattern of prescribing for inpatients with hypertension in the Inpatient Department of General Medicine at Dhanalakshmi Srinivasan Medical College and Hospital (DSMCH), Perambalur (Tamil Nadu). Data were collected for a period of 10 months (May 2012 - March 2013). The study was approved by institutional ethics committee of DSMCH, Perambalur. Permission was also obtained from the Head of the Institute to access case records. Initially the case records of patients ≥65 years of age from the Medical Records Unit of the hospital were retrieved. All the outpatient cases were excluded and only in-patient cases of Department of General Medicine regardless of the span of hospitalization were included in the study. Then the relevant information from the case record was entered in the preformed proforma. In this study, only elderly patients who are of age 65 and above and those who were suffering from essential hypertension and had been prescribed at least one antihypertensive drug with or without other co-morbid conditions were included. The data were collected in the structured proforma. The requisite patient information included: Registration number, age, gender, systolic and diastolic BP readings (at the time of admission), the antihypertensive medications prescribed and co-morbid conditions. The name of the patient was not included in the recording format to maintain the confidentiality. The hypertension was classified in the study based on JNC-7 guidelines. It should be noted that the JNC-7 guideline for management of high BP is based on the staging of hypertension; different stages of hypertension are categorized as follows: Pre-hypertension (systolic BP 120-139 or diastolic BP 80-89 mmHg), Stage 1 hypertension (systolic BP 140-159 or diastolic BP 90-99 mmHg) and Stage 2 hypertension (systolic BP ≥160 or diastolic BP ≥100 mmHg). The prescribing pattern of antihypertensive drugs in the studied population was noted and whether patients were on monotherapy or poly therapy was also observed. The Statistical Program for the Social Sciences (SPSS) software, version 16 was used for data analysis. The collected data were coded as per variables and entered in the SPSS data sheet. Descriptive statistical analysis was done.


  Results Top


In this study, 106 hypertensive patients on treatment were included; of these 62.3% were female and 37.7% male [Figure 1]. Mean age was found to be 69.9 ± 5.8 years. Most of the patients in this study were classified as Stage 2 hypertension in line with the JNC-7 classification criteria. Others were classified as Stage 1 and minimum number of patients in pre-hypertensive category of JNC-7 [Table 1]. Hypertension solely was present in 22.6% of the patients, whereas diabetes mellitus was the most common co-morbid condition in 18.9% of the cases. Other co-morbid conditions were nephropathy (12.3%), ischemic heart disease (10.4%), and cerebrovascular disease (8.5%). Several patients were additionally affected by more than one co-morbid condition concurrently.
Table 1: Hypertension classification as per the JNC-7 criteria

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Figure 1: Sex of the patients in the study

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Among 106 patients studied, approximately 51% and 49% were on monotherapy and combination therapy, respectively. Of the patients on combination therapy, 37.7%, 8.5%, and 2.8% were on two, three, and four drugs, respectively [Figure 2]. The commonest monotherapy agents prescribed were calcium channel blockers (CCBs) (29.2%) followed by diuretics (11.3%), ACE inhibitors (ACEIs; 4.7%), beta blockers (BBs; 4.7%) and angiotensin receptor blockers (ARBs; 0.9%). The commonest two-drug therapy was with a CCB and diuretic (19.8%), followed by a CCB and BB (7.5%), CCB and ACEI (1.9%), ACEI and a diuretic (2.8%), CCB and ARB (1.9%), BB and diuretic (1.9%), BB and ACEI (0.9%) and BB and ARB (0.9%). The commonest three-drug therapy was with a CCB, BB, and a diuretic (2.8%). Other three-drug therapies were ACEI + CCB + BB (0.9%), ARB + diuretic + CCB (0.9%), BB + CCB + ARB (0.9%), BB + ACEI + diuretic (0.9%), BB + ARB + diuretic (0.9%), and CCB + diuretic + ACEI (0.9%). The commonest four-drug therapy was with a CCB, BB, ARB, and diuretic (1.9%) followed by a CCB + BB + ACEI + diuretic (0.9%) [Table 2].
Table 2: Frequency (%) of prescription of one, two, three and four antihypertensive drug

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Figure 2: Patients on monotherapy and combination therapy in the study

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The commonest monotherapy agents prescribed in hypertensive patients with diabetes mellitus were CCB (5.66%), diuretic (3.77%), ACEI, BB and ARB (0.94% each). The only monotherapy agents prescribed in hypertensive patients with nephropathy were CCB (4.71%). The different monotherapy agents prescribed in hypertensive patients with ischemic heart disease were a CCB (2.83%), BB (1.88%) and diuretic (0.94%). The different monotherapy agents prescribed in hypertensive cases with cerebrovascular disease were CCB (1.88%), diuretic (1.88%), and ACEI (0.94%).

The commonest two-drug therapy in hypertensive patients with diabetes mellitus was with a CCB and BB (2.83%), CCB and diuretic (0.94%), and CCB and ACEI (0.94%). The commonest two drug therapy in hypertensive with nephropathy was with a CCB and diuretic (4.71%). The commonest two-drug therapy in hypertensive patients with ischemic heart disease was CCB and diuretic (2.83%) and CCB and ACEI (0.94%). The commonest two-drug therapy in hypertensive with cerebrovascular disease was a CCB and diuretic (1.88%) followed by a CCB and BB (0.94%) The commonest three-drug therapy in hypertensive patients with ischemic heart disease was a BB + CCB + diuretic (0.94%).


  Discussion Top


In this study, hypertension was found to be more prevalent in women. In fact it is a well-documented fact that the incidence of hypertension is much greater in women over 65 years of age. Pathological state of the endothelium, exaggerated blood vessel stiffness, overweight, genetic factors, high total cholesterol, and low high-density lipoprotein cholesterol levels are involved in menopause-related BP elevation. [3],[10]

In this study the antihypertensive drugs were prescribed alone or in combination in the following order: CCB, diuretic, BB, ACE inhibitor, and ARB [Table 3]. It was noted that though the use of diuretics was present it was in less proportions. The ACCF/AHA 2011 guidelines emphasize that if possible primary treatment should be with a diuretic and if another class was prescribed as first-line, the second drug should always be a diuretic. [6],[11]

Amlodipine was the most commonly prescribed individual drug [Table 4]. Similarly, amlodipine was the most commonly used antihypertensive monotherapy in a prospective observational study conducted among elderly patients (>65 years) in a super specialty hospital by Mohd et al. [12] It has been recommended that alternatively the first-line treatment in the elderly can be with a CCB or an ACE inhibitor or angiotensin II receptor blocker. [1],[11]
Table 3: Frequency of antihypertensive drugs prescribed as monotherapy and in overall utilization

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Table 4: Individual antihypertensive drugs prescribed in overall prescriptions

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Beta blockers were ranked third in overall utilization among elderly patients with hypertension in our study ahead of ACEI or angiotensin II receptor blocker [Table 3]. The advantages of BB therapy for elderly patients with hypertension have been challenged recently. [4],[13],[14] In fact the data suggest that BBs should not be used as primary therapy for hypertension in the elderly. They do not seem to be superior to other groups in primary prevention of myocardial infarction in this population. They may be less effective in stroke prevention than other agents. [13],[15] Unless indicated otherwise (post myocardial infarction or coronary heart failure), BBs should not be prescribed in very elderly patients. [13]

Relative underutilization of ACEI or angiotensin II receptor blocker was reported in this study and this group of drug was ranked last in overall utilization among elderly hypertensive patients [Table 3]. ACEIs decrease the risk of major vascular events in elderly hypertensive patients. Other than BP control, the renin-angiotensin system blockade may play an unequivocal role in reducing the possibility of Alzheimer's dementia and cognitive deterioration in elderly patients. There is proof of positive alliance between use of ACEIs and many functionally helpful consequences on muscle function and exercise capability. ARBs and ACEIs are identically significant in the therapy of hypertension. However, the employment of ARBs does not have any effect on muscle function in this patient group. [1]

In this study, approximately 49% patients were on combination therapy and diuretic was part of most of the combination regimen in this study. Severe, monotherapy-resistant hypertension is prevalent in the elderly and in most situations this requires combination therapy. Various reports have proved that the efficacy of antihypertensive therapy can be augmented by using combinations of agents from different classes. The rationale for this therapeutic approach is strengthened by the fact that end-organ damage or co-morbidities are widespread in elderly population. [6],[16],[17]


  Conclusion Top


In this study the most commonly prescribed antihypertensive drug was CCBs followed by diuretics, BBs, ACEIs, and ARBs. Overall, there was less utilization of diuretics and ACEIs or ARBs and they should be prescribed more frequently in elderly hypertensive patients. Because a diuretic is a recommended initial therapy of hypertension in the elderly, and a thiazide or thiazide-like diuretic is the most appropriate to use. But for elderly patients one has to be extra cautious due to their sensitiveness to diuretics. Inappropriate doses could precipitate hypotension, electrolyte imbalances, or uremia. There is less chance of hypokalemia if a diuretic is combined with either a potassium sparing diuretic or an angiotensin inhibitor. Diuretics are not preferred in patients with gout, hyperuricemia, diabetes, or renal impairment. [17] On the other hand, ACEIs decrease the risk of major vascular events in elderly patients with hypertension. Other than BP control, the renin-angiotensin system blockade may play an unequivocal role in reducing the possibility of Alzheimer's dementia and cognitive deterioration in elderly patients and have many functionally helpful consequences on muscle function and exercise capability. Beta-blockers are not recommended as primary therapy for hypertension in the elderly. [1]

Healthcare professionals must be attentive of the complexities related with using antihypertensive drugs therapies in elderly patients so that hypertension in elderly patients does not remain a management dilemma to them. [3] Hence it is being emphasized that there is the need for creating more awareness among general practitioners and clinicians on this vital public health concern by planning and organizing more Continued Medical Education activity on drug therapy of hypertension in the elderly.

Major limitations of the study include inclusion of only inpatient cases and exclusion of outpatient cases. Another limitation is the small sample size. Because of the small sample size the result of the study cannot be generalized. The study population refers to patients admitted to tertiary care teaching hospital and although hypertension was not the primary diagnosis in most cases, it is hypothesized that antihypertensive drugs were used for optimal control of BP. Also, the high prevalence of cardiovascular co-morbidity might have made it difficult to identify the specific indication for which the given drug was prescribed. [18]


  Acknowledgment Top


We gratefully acknowledge the help of Management and Head of the Institute of the Dhanalakshmi Srinivasan Medical College and Hospital, Siruvachur, Perambalur - 621 212 (Tamil Nadu).

 
  References Top

1.Tomasik T, Gryglewska B, Windak A, Grodzicki T. Hypertension in the elderly: How to treat patients in 2013? The essential recommendations of the Polish guidelines. Pol Arch Med Wewn 2013;123:409-16.  Back to cited text no. 1
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2.Elliott WJ. Management of hypertension in the very elderly patient. Hypertension 2004;44:800-4.  Back to cited text no. 2
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3.Lionakis N, Mendrinos D, Sanidas E, Favatas G, Georgopoulou M. Hypertension in the elderly. World J Cardiol 2012;4:135-47.  Back to cited text no. 3
    
4.Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42:1206-52.  Back to cited text no. 4
    
5.Pant S, Neupane P, Ramesh KC, Barakoti M. Hypertension in the elderly: Are we all on the same wavelength? World J Cardiol 2011;3:263-6.  Back to cited text no. 5
    
6.Schäfer HH, De Villiers JN, Sudano I, Dischinger S, Theus GR, Zilla P, et al. Recommendations for the treatment of hypertension in the elderly and very elderly: A scotoma within international guidelines. Swiss Med Wkly 2012;142:w13574.  Back to cited text no. 6
    
7.Prisant LM, Moser M. Hypertension in the elderly. Can we improve results of therapy? Arch Intern Med 2000;160:283-9.  Back to cited text no. 7
    
8.Ogihara T, Hiwada K, Morimoto S, Matsuoka H, Matsumoto M, Takishita S, et al. Guidelines for treatment of hypertension in the elderly-2002 revised version. Hypertens Res 2003;26:1-36.  Back to cited text no. 8
    
9.Chaudhry KN, Chavez P, Gasowski J, Grodzicki T, Messerli FH. Hypertension in the elderly: Some practical considerations. Cleve Clin J Med 2012;79:694-704.  Back to cited text no. 9
    
10.Pimenta E, Calhoun DA. Resistant hypertension: Incidence, prevalence, and prognosis. Circulation 2012;125:1594-6.  Back to cited text no. 10
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11.Aronow WS, Fleg JL, Pepine CJ, Artinian NT, Bakris G, Brown AS, et al. ACCF/AHA 2011 expert consensus document on hypertension in the elderly: A report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents developed in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension. J Am Soc Hypertens 2011;5:259-352.  Back to cited text no. 11
    
12.Mohd AH, Mateti UV, Konuru V, Parmar MY, Kunduru BR. A study on prescribing patterns of antihypertensives in geriatric patients. Perspect Clin Res 2012;3:139-42.  Back to cited text no. 12
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13.Zeglin MA, Pacos J, Bisognano JD. Hypertension in the very elderly: Brief review of management. Cardiol J 2009;16:379-85.  Back to cited text no. 13
    
14.Chobanian A. Clinical practice. Isolated systolic hypertension in the elderly. N Engl J Med 2007;357:789-96.  Back to cited text no. 14
    
15.Lindholm LH, Carlberg B, Samuelsson O. Should beta blockers remain first choice in the treatment of primary hypertension? A meta-analysis. Lancet 2005;366:1545-53.  Back to cited text no. 15
    
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18.Onder G, Gambassi G, Landi F, Pedone C, Cesari M, Carbonin PU, et al. Investigators of the GIFA Study (SIGG-ONLUS). Trends in antihypertensive drugs in the elderly: The decline of thiazides. J Hum Hypertens 2001;15:291-7.  Back to cited text no. 18
    


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