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Antihypertensive Prescribing Pattern in Older Adults: Implications of Age and the Use of Dual Single-Pill Combinations

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Abstract

Introduction

Hypertension, if not appropriately treated, is associated with life-threatening complications.

Aims

This study evaluated antihypertensive prescribing patterns in older adults (≥ 65 years) versus young adults based on the current guidelines with an emphasis on the use of dual single-pill combinations (SPCs).

Methods

A nationwide audit of 8746 primary care prescriptions of hypertensive patients with comorbidities in Bahrain was performed.

Results

Antihypertensive combination therapy was prescribed more often to older (77.1%) than young adults (68.6%; P < 0.0001) whereas SPCs were under-used (57.6% vs. 69.4%; P < 0.0001). Recommended dual SPCs, without/with a combination of a free-dose complementary antihypertensive agent, were significantly less often prescribed for the older adult as compared to young adult adults (45.1% vs. 62.99% and 35.97% vs. 46.72%; P < 0.0001), respectively. Unacceptable two- and three-drug combinations (including those with limited clinical evidence and unacceptable ones) were prescribed more often to older adults rather than to young ones (20.06% vs. 12.6%; and 56.5% vs. 46.8%; P < 0.0001), respectively. In both age groups, the top-three antihypertensive classes prescribed as monotherapy were angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and β blockers.

Conclusion

The updated guidelines for hypertension treatment in older adults have had a limited impact on primary care practice in Bahrain. In both age groups, there was a high positive correlation between the number of antihypertensive drugs prescribed and prescribing unacceptable combinations. Unacceptable combinations comprising SPC-related antihypertensive therapy duplication were more common than those reported elsewhere. Introducing approved triple SPCs may discourage prescribing unacceptable antihypertensive drugs and their combinations that lack robust evidence.

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References

  1. Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet. 2005;365(9455):217–23.

    Article  PubMed  Google Scholar 

  2. Center for Disease Control and Prevention (2011) Morbidity and mortality weekly report (MMWR). Vital signs: prevalence, treatment, and control of hypertension—United States, 1999–2002 and 2005–2008. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6004a4.htm. Accessed 25 Aug 2019.

  3. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507–20. https://doi.org/10.1001/jama.2013.284427.

    Article  CAS  PubMed  Google Scholar 

  4. Sever PS, Messerli FH. Hypertension management 2011: optimal combination therapy. Eur Heart J. 2011;32(20):2499–506. https://doi.org/10.1093/eurheartj/ehr177.

    Article  PubMed  Google Scholar 

  5. Gradman AH, Basile JN, Carter BL, et al. Combination therapy in hypertension. J Am Soc Hypertens. 2010;4(2):90–8. https://doi.org/10.1016/j.jash.2010.03.001.

    Article  CAS  PubMed  Google Scholar 

  6. Wald DS, Law M, Morris JK, Bestwick JP, Wald NJ. Combination therapy versus monotherapy in reducing blood pressure: meta-analysis on 11,000 participants from 42 trials. Am J Med. 2009;122(3):290–300. https://doi.org/10.1016/j.amjmed.2008.09.038.

    Article  PubMed  Google Scholar 

  7. Gradman AH, Parisé H, Lefebvre P, Falvey H, Lafeuille MH, Duh MS. Initial combination therapy reduces the risk of cardiovascular events in hypertensive patients: a matched cohort study. Hypertension. 2013;61(2):309–18.

    Article  CAS  PubMed  Google Scholar 

  8. Fogari R, Zoppi A, Ferrari I, Mugellini A, Preti P, Derosa G. Time to achieve blood pressure goal with a combination versus a conventional monotherapy approach in hypertensive patients with metabolic syndrome. Clin Exp Hypertens. 2010;32(5):245–50. https://doi.org/10.3109/10641960903265212.

    Article  CAS  PubMed  Google Scholar 

  9. Leung AA, Daskalopoulou SS, Dasgupta K, et al. Hypertension Canada’s 2017 guidelines for diagnosis, risk assessment, prevention, and treatment of hypertension in adults. Can J Cardiol. 2017;33(12):1733–4. https://doi.org/10.1016/j.cjca.2017.03.005.

    Article  Google Scholar 

  10. Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J. 2018;39(33):3021–104. https://doi.org/10.1093/eurheartj/ehy339.

    Article  PubMed  Google Scholar 

  11. Mancia G, Rea F, Corrao G, Grassi G. Two-drug combinations as first-step antihypertensive treatment. Circ Res. 2019; 29;124(7):1113–1123. https://doi.org/10.1161/circresaha.118.313294.

    Article  CAS  PubMed  Google Scholar 

  12. Farrell B, French Merkley V, Ingar N. Reducing pill burden and helping with medication awareness to improve adherence. Can Pharm J (Ott). 2013;146(5):262–9. https://doi.org/10.1177/1715163513500208.

    Article  PubMed Central  Google Scholar 

  13. Moriarty F, Bennett K, Fahey T. Fixed-dose combination antihypertensives and risk of medication errors. Heart. 2019;105(3):204–9. https://doi.org/10.1136/heartjnl-2018-313492.

    Article  CAS  PubMed  Google Scholar 

  14. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. J Am Coll Cardiol. 2018;71:e127–248. https://doi.org/10.1016/j.jacc.2017.11.006.

    Article  PubMed  Google Scholar 

  15. Weber MA, Schiffrin EL, White WB, et al. Clinical practice guidelines for the management of hypertension in the community: a statement by the American Society of Hypertension and the International Society of Hypertension. J Clin Hypertens. 2014;16(1):14–26. https://doi.org/10.1111/jch.12237.

    Article  Google Scholar 

  16. Qaseem A, Wilt TJ, Rich R, et al. Pharmacologic treatment of hypertension in adults aged 60 years or older to higher versus lower blood pressure targets: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2017;166(6):430–7. https://doi.org/10.7326/M16-1785.

    Article  PubMed  Google Scholar 

  17. Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34(28):2159–219. https://doi.org/10.1093/eurheartj/eht151.

    Article  PubMed  Google Scholar 

  18. NICE. Hypertension in adults: diagnosis and management. Clinical guideline [CG127]. Updated 2016. https://www.nice.org.uk/guidance/cg127. Accessed 25 Aug 2019.

  19. Al Khaja KAJ, Sequeira RP, Mathur VS. Rational pharmacotherapy of hypertension in the elderly: analysis of the choice and dosage of drugs. J Clin Pharm Ther. 2001;26(1):33–42.

    Article  CAS  Google Scholar 

  20. Gulf Cooperation Council (GCC). Annual Statistical Yearbook 2015, Issue No. 2, August 2017.

  21. Al Khaja KA, Sequeira RP, Al-Ansari TM, Damanhori AH. Prescription writing skills of residents in a family practice residency programme in Bahrain. Postgrad Med J. 2008;84(990):198–204. https://doi.org/10.1136/pgmj.2007.062547.

    Article  CAS  PubMed  Google Scholar 

  22. Düsing R, Waeber B, Destro M, Santos Maia C, Brunel P. Triple-combination therapy in the treatment of hypertension: a review of the evidence. J Hum Hypertens. 2017;31(8):501–10. https://doi.org/10.1038/jhh.2017.5.

    Article  CAS  PubMed  Google Scholar 

  23. Bramlage P, Schmidt S, Sims H. Fixed-dose vs free-dose combinations for the management of hypertension-An analysis of 81958 patients. J Clin Hypertens. 2018;20(4):705–15. https://doi.org/10.1111/jch.13240.

    Article  CAS  Google Scholar 

  24. Verma AA, Khuu W, Tadrous M, Gomes T, Mamdani MM. Fixed-dose combination antihypertensive medications, adherence, and clinical outcomes: a population-based retrospective cohort study. PLoS Med. 2018;15(6):e1002584. https://doi.org/10.1371/journal.pmed.1002584.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Gorard DA. Escalating polypharmacy. QJM. 2006;99(11):797–800. https://doi.org/10.1093/qjmed/hcl109.

    Article  CAS  PubMed  Google Scholar 

  26. Sica DA. Fixed-dose combination antihypertensive drugs. Do they have a role in rational therapy? Drugs. 1994;48(1):16–24. https://doi.org/10.2165/00003495-199448010-00003.

    Article  CAS  PubMed  Google Scholar 

  27. Moser M, Black HR. The role of combination therapy in the treatment of hypertension. Am J Hypertens. 1998;11(6 Pt 2):73S–78S (discussion 95S–100S). https://doi.org/10.1016/s0895-7061(98)00060-0.

    Article  CAS  PubMed  Google Scholar 

  28. Al Khaja KA, Al-Ansari TM, Sequeira RP. An evaluation of prescribing errors in primary care in Bahrain. Int J Clin Pharmacol Ther. 2005;43(6):294–301. https://doi.org/10.5414/cpp43294.

    Article  CAS  PubMed  Google Scholar 

  29. Guideline for management of hypertension in primary care settings and outpatient clinics in the Kingdom of Bahrain. Kingdom of Bahrain, Ministry of Health, November 2014.

  30. Calhoun DA, Lacourcière Y, Chiang YT, Glazer RD. Triple antihypertensive therapy with amlodipine, valsartan, and hydrochlorothiazide: a randomized clinical trial. Hypertension. 2009;54(1):32–9. https://doi.org/10.1161/HYPERTENSIONAHA.109.131300.

    Article  CAS  PubMed  Google Scholar 

  31. Chrysant SG. Single-pill triple-combination therapy: an alternative to multiple-drug treatment of hypertension. Postgrad Med. 2011;123(6):21–31. https://doi.org/10.3810/pgm.2011.11.2492.

    Article  PubMed  Google Scholar 

  32. Dahlöf B, Devereux RB, Kjeldsen SE, et al. Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet. 2002;359(9311):995–1003. https://doi.org/10.1016/S0140-6736(02)08089-3.

    Article  PubMed  Google Scholar 

  33. Dahlöf B, Sever PS, Poulter NR, et al. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial. Lancet. 2005;366(9489):895–906. https://doi.org/10.1016/S0140-6736(05)67185-1.

    Article  CAS  PubMed  Google Scholar 

  34. Mann SJ. Redefining beta-blocker use in hypertension: selecting the right beta-blocker and the right patient. J Am Soc Hypertens. 2017;11(1):54–65. https://doi.org/10.1016/j.jash.2016.11.007.

    Article  CAS  PubMed  Google Scholar 

  35. Al Khaja KA, Sequeira RP, Damanhori AH. Treatment of hypertension in Bahrain. Ann Pharmacother. 2003;37(10):1511–7. https://doi.org/10.1345/aph.1C430.

    Article  CAS  PubMed  Google Scholar 

  36. Westerholm B. Therapeutic auditing at the national and international level. Br J Clin Pharmac. 1986;22(Suppl 1):55S–9S.

    Article  Google Scholar 

  37. Jentzer JC, DeWald TA, Hernandez AF. Combination of loop diuretics with thiazide-type diuretics in heart failure. J Am Coll Cardiol. 2010;56(19):1527–34. https://doi.org/10.1016/j.jacc.2010.06.034.

    Article  CAS  PubMed  Google Scholar 

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Acknowledgements

We acknowledge the help and assistance given to us by the Ministry of Health, Kingdom of Bahrain, and Ms. Mini James, who has been of immense help in preparing the manuscript.

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Authors and Affiliations

  1. Department of Pharmacology and Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, P.O. Box 22979, Manama, Kingdom of Bahrain

    Khalid A. J. Al Khaja, Henry James, Sindhan Veeramuthu, Yasin I. Tayem, Kannan Sridharan & Reginald P. Sequeira

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  1. Khalid A. J. Al Khaja
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  2. Henry James
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Corresponding author

Correspondence to Khalid A. J. Al Khaja.

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The authors have no conflict of interest.

Ethical approval

This study was approved by the Research & Ethics Committee of the College of Medicine & Medical Sciences, Arabian Gulf University, and the Ministry of Health, Kingdom of Bahrain.

Informed consent

Since this study is observationally based on prescription analyses, informed consent is not applicable.

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Al Khaja, K.A.J., James, H., Veeramuthu, S. et al. Antihypertensive Prescribing Pattern in Older Adults: Implications of Age and the Use of Dual Single-Pill Combinations. High Blood Press Cardiovasc Prev 26, 535–544 (2019). https://doi.org/10.1007/s40292-019-00353-1

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