|Year : 2017 | Volume
| Issue : 2 | Page : 94-98
Prescribing pattern and cost analysis of antihypertensives in India
Hemalatha Vummareddy1, Mohanraj Rathinavelu Mudhaliar2, Shaik Mohammad Ghouse Ishrar2, Balaiah Sandyapakula3, Lokesh Vobbineni4, Bijoy Thomas5
1 Drug Safety Associate, Bioclinica Safety and Regulatory Solutions, Mysore, Karnataka, India
2 Department of Pharmacy Practice, Raghavendra Institute of Pharmaceutical Education and Research, Anantapuramu, Andhra Pradesh, India
3 Department of Pharmacy Practice, Nirmala College of Pharmacy, Guntur, Andhra Pradesh, India
4 Department of Pharmacy Practice, A. M. Reddy Memorial College of Pharmacy, Guntur, Andhra Pradesh, India
5 Department of Pharmacy Practice, St. James College of Pharmaceutical Sciences, Thrissur, Kerala, India
|Date of Web Publication||14-Mar-2017|
Mohanraj Rathinavelu Mudhaliar
Division of Pharmacy Practice, Centre for Pharmaceutical Research, Raghavendra Institute of Pharmaceutical Education and Research, Anantapuramu, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Background: Hypertension has been reported to be the strongest modifiable global risk factor for cardiovascular morbidity, mortality as well as health burdens. Antihypertensive pharmacotherapy effectively reduces hypertension-related morbidity and mortality. Prescribing pattern surveys are one of the drug use evaluation techniques providing an unbiased picture and identification of suboptimal prescribing patterns. Objective: The 6-month cross-sectional study was designed to assess the prescription pattern and cost of antihypertensives therapy in a health-care resource-limited setting of India. Materials and Methods: The hypertensive patients were divided into two groups according to risk assessment using the World Health Organization and International Society of Hypertension guidelines for the management of hypertension. The average drug acquisition and the percentage expenditure costs were calculated for each drug class on a daily and annual basis, and InStat GraphPad Prism was the statistical tool used. Results: In our study of 100 patients, the most commonly prescribed antihypertensives were calcium channel blockers in 49.81% and beta-blockers in 12.73% patients, respectively. The cost analysis on antihypertensive medications utilized showed a total expenditure of Rs. 3823.58 invested in 1 year. Conclusion: The drug use pattern of antihypertensives was evidenced based but imposed economic burden in patients. Hence, rational use of generic medications was recommended.
Keywords: Antihypertensive therapy, cost analysis, cross-sectional study, drug utilization, hypertension, prescribing pattern
|How to cite this article:|
Vummareddy H, Mudhaliar MR, Ishrar SM, Sandyapakula B, Vobbineni L, Thomas B. Prescribing pattern and cost analysis of antihypertensives in India. CHRISMED J Health Res 2017;4:94-8
|How to cite this URL:|
Vummareddy H, Mudhaliar MR, Ishrar SM, Sandyapakula B, Vobbineni L, Thomas B. Prescribing pattern and cost analysis of antihypertensives in India. CHRISMED J Health Res [serial online] 2017 [cited 2017 May 25];4:94-8. Available from: http://www.cjhr.org/text.asp?2017/4/2/94/201995
| Introduction|| |
Hypertension means increased pressure of flowing blood on the lateral walls of arteries and veins. It is the best modifiable risk factor in case of Cardio Vascular System and renal disorders, also the strongest cause of morbidity and mortality. Due to increase in the prevalence of hypertension with the continuous increasing investment of treatment, factors that affect prescribing trends could have a significant impact on health economics. By 2000, it was estimated that over 1 billion individuals will be suffering with hypertension globally, and by 2025, approximately 60% of increase shall be observed globally is estimated from hypertension. The primary goal of antihypertensive therapy is to prevent morbidity and mortality associated with hypertension. Most patients with hypertension require two or more antihypertensive medications. Thiazide diuretics, beta-blockers (BBs), angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), and calcium channel blockers (CCBs) have all been shown to reduce complications of hypertension and may be used for initial drug therapy. Despite broad dissemination of the Joint National Committee (JNC) guidelines, prescribing practices have long remained discrepant with recommendations. Inappropriate prescribing is a recognized worldwide problem of the health-care delivery system. Drug utilization studies are powerful exploratory tools to ascertain the role of drugs in society. They create a sound sociomedical and health economic basis for health-care decision-making. It is one of the most effective methods to assess the prescribing pattern of physicians. The cost of medications has always been a barrier in effective treatment. The increasing prevalence of hypertension and the continually rising expense of its treatment influence the prescribing patterns among physicians and compliance to the treatment by the patients. Appropriate antihypertensive drug therapy is important as the prevalence of hypertension has risen dramatically in the last three decades. Any deviation from evidence-based guidelines in hypertension treatment contributes to the high cost of medications and creates difficulties in providing affordable prescription drugs. Hence, the present study was selected and designed to assess antihypertensives prescribing pattern and to perform cost analysis toward antihypertensive therapy.
| Materials and Methods|| |
The cross-sectional study of 6-month duration was performed in the department of general medicine of a 300 bedded secondary care referral hospital in resource-limited settings of Andhra Pradesh, India. A structured process was followed for obtaining permission from hospital authority by submitting a detailed pro forma of the study which includes protocol of study, evidence of critically evaluated biomedical literatures, data collection form, and patient informed consent form. After the initial acceptance from the hospital, the study was registered in the Institutional Review Board of the institution for ethical approval. Study included 100 participants who are on antihypertensive medications for a period more than 2 months; all primary hypertensive and hypertensive patients with comorbidities showing willingness toward the study were included in this study, and patients showed no willingness were excluded from this study. A documentation form (data collection form) was designed to collect the patient's information which was kept confidential; the information from patients was collected only after explaining the merits and demerits of the study and obtaining their consent, for which an informed consent form was designed separately. In our study, all the participants who were diagnosed with hypertension and along with comorbidities were assessed, and the findings were documented using data collection form. The prescription pattern of antihypertensives and the drug utilization data was collected from the prescription of patients regularly. Demographic profile of patients was also recorded from the same prescription itself. Frequency of drug prescription among different age groups, frequency of administration of individual drugs, frequency of prescribing combination drugs, frequency of prescribing fixed drug combinations, number of prescriptions per drug, number of drugs prescribed per total number of prescription, percentage of patients in the treatment of hypertension with comorbidities, percentage of economic difference, percentage of expenditure cost, and average drug acquisition cost (ADAC) were calculated. In our study, patients diagnosed with hypertension and along with comorbidities were given a 15 or 30 days' supply of antihypertensive drugs (based on their severity of illness) at each visit, and refilled prescriptions were collected between follow-up.
The antihypertensive medications dispensed were recorded either during the consultation or retrospectively from the pharmacy records of patients. Costs of individual medicines were calculated and documented. During the study, the first and last recorded blood pressure for each patient at each visit during the study period was documented along with name and frequency regimen of each antihypertensive medication from the prescription and the total cost of antihypertensive medications for each prescription. The data collected are processed and presented using InStat GraphPad Prism statistical program software, and the data were subjected to analysis of variance to determine t-tests; Mann–Whitney U-tests are also performed to compare the differences between drug group utilization, age groups, gender, and ADAC.
| Results|| |
The study was based on a sample of 100 participants diagnosed with hypertension along with comorbidities. The present study gives information on drug utilization and cost analysis of antihypertensive medications. A total of 192 prescriptions of 100 participants were studied.
Demographic details of study participants
The study observed equal number of men and women developed risk of hypertension. The present study showed a higher incidence of hypertension in male patients with age group of 50–60 years (16%) and female patients with age group of 30–50 years (15%) suggesting an earlier onset of hypertension in female population. In our study, mean age accounts for 54.32 ± 1.872 in males and 48.36 ± 1.581 in female which showed statistically significant association on age distribution (P = 0.0084). The results are summarized in [Table 1].
Categories of antihypertensive medications prescribed
The most commonly prescribed antihypertensive category of medications was CCB in 49.81% patients followed by BBs in 12.73% patients; the results are summarized in [Table 2].
|Table 2: Frequency of antihypertensive category prescribed in different age groups|
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Frequency of administration of individual antihypertensive medication
The ranking of category of antihypertensive medications based on its frequency of administration was CCBs > BBs > diuretics and ACEIs > ARBs > nonselective BBs/alpha blockers. In diuretics, most commonly prescribed agents were thiazide followed by loop and potassium diuretics, results of which are summarized in [Table 3].
|Table 3: Frequency of administration of individual antihypertensive medication|
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Frequency of prescribing combination drugs and number of antihypertensives in prescription
In the present study, only two prescriptions with two drugs fixed-dose combination have been identified; monotherapy accounts more than combination of drug therapy including prescription of two, three, and four medication combination, results of which are summarized in [Table 4].
|Table 4: Frequency of prescribing combination drugs and number of antihypertensives in prescription|
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Cost analysis of antihypertensive therapy
The cost analysis was determined by relationship between the profits obtained for the investment. Main determinants for cost analysis are investment of drug therapy and the initial risk of hypertension to the patients. A total of Rs. 3823.58 was invested in 1 year on drug acquisition for 100 patients of hypertension along with comorbidities. In our study, the least cost drug was furosemide (Rs. 0.67/tab), and high-cost drug was losartan (Rs. 4.5/tab), results of which are thoroughly analyses and reported in [Table 5].
| Discussion|| |
Hypertension is a serious public health problem worldwide. It is the leading cause of death in the world and is the most common cause for outpatient visits to physicians. Our study shows a higher incidence of hypertension in elderly male patients aged between 50 and 60 years (16%). The present study observed that single-drug therapy (55.86%) with CCBs was more commonly employed than multiple-drug therapy. These results support the work of (Sindhu and Srinivasa Reddy, 2013) which showed blood pressure could be adequately controlled with the help of single-drug therapy. This might be attributed to patient's compliance, good response, and less incidence of adverse effects. In a study by Anand and Maniyar in 2013, CCBs were found to be the most frequently used group of drugs which is parallel to findings of our study. In our study, BBs were prescribed most frequently next to CCBs the findings of which are similar to the study performed in a tertiary care hospital of India (Rachana et al., 2014). In our study, patients with comorbidities mainly were prescribed with one or two antihypertensive medications along with other drugs to treat their associated comorbidities such as diabetes mellitus, ischemic heart disease, Congestive Cardiac Failure, thyroid disorder, pedal edema, and left ventricular hypertrophy.
In our study, most commonly prescribed drugs were CCBs, BBs, ACEIs and ARBs where as in the study conducted by (Beg et al., 2014) ARBs and ACEIs were prescribed.
Major drawback of drug utilization studies is a lack of detailed, accurate patient records for justifying the prescribed drugs depending on the presence of comorbidities, stage of hypertension, and medication history.
In our study, a total of Rs. 3823.58 was invested in 1 year on drug acquisition for 100 patients of hypertension and along with comorbidities. Furosemide (Rs. 0.67/tab) and hydrochlorothiazide (Rs. 1.01/tab) were the least costly drugs followed by atenolol (Rs. 1.59/tab) and aldactone (Rs. 1.85/tab). Valsartan (Rs. 6.9/tab), amlodipine (Rs. 6.5/tab), losartan (Rs. 4.5/tab), and carvedilol (Rs. 4.3/tab) were the expensive drugs used.
In the study, cost of brand drugs such as valsartan and amlodipine is higher compare to their generic one. Amlodipine (CCBs) accounted for 69.4% of annual drug expenditure which mostly prescribed even though it is highly expensive. This may be due to good compliance, better relief from illness, and less incidence of ADRs. The ADAC was least for atenolol (Rs. 17.06) and very higher for valsartan (Rs. 2518.5).
An overview of totality of evidences recommends that the major groups of drugs used in hypertension are approximately equivalent in safety and efficacy except the drug amlodipine (CCBs) which is majorly prescribed is highly expensive even though there is safety and efficacy. At the same time, the generic drugs are least expensive compare to branded one.
Medication cost is the highest proportion of the overall cost of managing hypertension. In a developing country like India, one of the smart ways to reduce the prescription costs is to use the generics. Hence, our study suggests that the use of generic drugs leads to most cost-effective and better pharmacologic therapy with accurate safety and efficacy.
| Conclusion|| |
In conclusion, our study analyzed the drug utilization of antihypertensive medication and found that the prescribing pattern was totally consistent with the JNC VII (the Seventh Report of the JNC on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure) guidelines for the treatment of hypertension. Monotherapy was consistently more recommended in the early stages of hypertension to achieve target goal of blood pressure, and CCBs were the drugs of choice for hypertensive patients. Cost analysis of the study recommends the use of generic medications in place of branded drugs may decrease the economic burden of the patient. Further revision of Drug Price Control Order 2013 is suggested for attaining optimum benefit of patients both in terms of health care and economy.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: Analysis of worldwide data. Lancet 2005;365:217-23.
Rimoy GH, Justin Temu M, Nilay C. Prescribing patterns and cost of antihypertensive drugs in private hospitals in Dar es Salaam. East Cent Afr J Pharm Sci 2008;11:69-73.
Guo JD, Liu GG, Christensen DB, Fu AZ. How well have practices followed guidelines in prescribing antihypertensive drugs: The role of health insurance. Value Health 2003;6:18-28.
Akhtar AK, Divya V, Pillai KK, Kiran D. Drug prescribing practices in pediatric department of a North Indian University Teaching Hospital. Asian J Pharm Clin Res 2012;5:146-9.
Sutharson L, Hariharan RS, Vamsadhara C. Drug utilization study in diabetology outpatient setting of a tertiary hospital. Indian J Pharmacol 2003;35:237-40. [Full text]
Bakssas I, Lunde PK. National drug policies: The need for drug utilization studies. Trends Pharmacol Sci 1986;7:331-4.
Yuen YH, Chang S, Chong CK, Lee SC, Critchley JA, Chan JC. Drug utilization in a hospital general medical outpatient clinic with particular reference to antihypertensive and antidiabetic drugs. J Clin Pharm Ther 1998;23:287-94.
Rachana PR, Anuradha HV, Shivamurthy M. Antihypertensive prescribing patterns and cost analysis for primary hypertension: A retrospective study. J Clin Diagn Res 2014;8:19-22.
Gupta R. Trends in hypertension epidemiology in India. J Hum Hypertens 2004;18:73-8.
Fischer MA, Avorn J. Economic implications of evidence-based prescribing for hypertension: Can better care cost less? JAMA 2004;291:1850-6.
Harvey Motulsky. Statistical significance and hypothesis testing. Intuitive Biostatistics: A Nonmathematical Guide to Statistical Thinking. 2nd
ed. Newyork: Oxford University Press; 2010. p. 123-4.
Perkovic V, Huxley R, Wu Y, Prabhakaran D, MacMahon S. The burden of blood pressure-related disease: A neglected priority for global health. Hypertension 2007;50:991-7.
Dalal PM. Hypertension: A Report on Community Survey on Casual Hypertension in Old Bombay. Sir H.N. Hospital Research Society; 1980.
Sindhu PR, Srinivas Reddy M. Study of prescriptive patterns of antihypertensive drugs in South India. Int J Adv Res Technol 2013;2:295-311.
Anand K, Maniyar YA. Prescribing patterns of antihypertensive drugs in a tertiary care hospital. Sch Acad J Pharm 2013;2:416-8.
Beg MA, Dutta S, Varma A, Kant R, Bawa S, Anjoom M, et al
. A study on drug prescribing pattern in hypertensive patientsin a tertiary care teaching hospital at Dehradun, Uttarakhand. Int J Med Sci Public Health 2014;3:922-6.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]