1. Antihypertensive drugs utilization in medical ward of North Okkalapa general and teaching hospital
Good Evening Madam Chair persons, Senior and Junior Colledges and audience
Now I would like to present Antihypertensive drugs utilization in medical ward of NOGTH
I’m Dr.PPT
AL from Department of Pharmacology, University of medicine 2, Ygn
Phyu Phyu Thet1, Ei Pye Phyo Aung1, Shin Hnaung Lwin1
1Department of Pharmacology, University of Medicine 2, Yangon

2. Introduction

3. Introduction antihypertensive drugs are widely used
not only for lowering the blood pressure in hypertensive patients
but also for other effects in conditions apart from hypertension such as heart failure, ischaemic heart disease, valvular heart disease, arrhythmia, corpulmonale, stroke, renal disease, liver disease, thyroid disease, etc

4. Introduction
periodic evaluation of antihypertensive drugs – for identifying drug differences in treatment
utilization research – to analyze the present state and developmental trends of drug use at various levels of the health care system whether international, national, regional, local or institutional1
1Suman, R.K., Mohanty, I.R. and Deshmukh, Y.A. (2014) The concepts of drug utilization study. World journal of pharmacy and pharmaceutical sciences: 3(10); p

5. Introduction
the measuring unit – WHO Anatomical Therapeutic Chemical (ATC) classification system and the Defined Daily Dose (DDD)
as a tool for presenting drug utilization statistics with the aim of improving drug use and comparison of drug consumption statistics at international and other levels1
1WHO. (2017a) Guidelines for ATC classification and DDD assignment, 20th ed. Oslo, Norway: WHO.

6. Introduction
Drug Utilization 90% (DU 90%) – how many drugs accounting for 90% of prescribing and can be applied for all drugs or for drugs within a selected therapeutic area1
Myanmar Essential Medicines Project, since December, 1988 and developed NLEM – as a supportive tool not only for procurement but also for good prescribing practices2
1WHO. (2003) Introduction to Drug Utilization Research. Oslo, Norway: WHO, p
2NLEM (2016) National list of essential medicines. The Republic of The Union of Myanmar, Ministry of Health, Department of Medical Services: p

7. Introduction
two types of drug utilization studies, qualitative study and quantitative study
this quantitative study – was conducted in medical ward of NOGTH to identify total usage of antihypertensive drugs and prescribing patterns of currently used antihypertensive drugs in all types of inpatients with any diseases and any indications

8. AIM AND Objectives

9. aim
To study antihypertensive drugs utilization in medical ward of North Okkalapa General and Teaching hospital

10. objectives
To determine the proportion of patients taking antihypertensive drugs in medical ward of North Okkalapa General and Teaching Hospital from 1st January, 2018 to 30th June, 2018
To describe the utilization pattern of antihypertensive drugs in medical ward of NOGTH by using ATC code and DDD/1000 inhabitants/day
To describe drug utilization 90% of antihypertensive drugs in medical ward of NOGTH

11. MATERIALS AND METHODS

12. MATERIALS AND METHODS
Study design ~~ Hospital - based, cross-sectional descriptive study Study population ~~ All hospitalized patients and their medical record files in medical ward of NOGTH during the study period Place of study ~~ Medical ward (Medical units 1, 2 and 3) of NOGTH Study Period ~~ 1st January, 2018 to 30th June, 2018

13. MATERIALS AND METHODS Inclusion Criteria
all hospitalized patients who were prescribing antihypertensive drugs class according to WHO, ATC classification with any indications in medical ward of NOGTH
such as hypertension, heart failure, ischaemic heart disease, valvular heart disease, arrhythmia, corpulmonale, stroke, renal disease, liver disease, thyroid disease, etc.

14. Expired cases within 24 hours of admission
MATERIALS AND METHODS
Exclusion Criteria
Expired cases within 24 hours of admission

15. Algorithm for Study Procedure
All hospitalized patients in medical ward of NOGTH during study period
Exclusion
Inclusion criteria
Informed consent
History taking and data collection for each patient about admission and discharge diagnosis, duration of hospitalization, antihypertensive prescription (drug name, dosage, route, frequency and duration) during hospital stay by going hospital daily .
All hospitalized patients in medical ward (medical units 1, 2 and 3) of North Okkalapa General and Teaching Hospital were recruited from 1st January, 2018 to 30th June, 2018 and those receiving antihypertensive drug class were included in the study. Informed consent was obtained from those who were willing to participate in the study, following a full explanation of research objectives and procedures.
The data collection for each patient was done from the admission to the discharge about ………………………….
For each antihypertensive drug prescribed, drug names (generic or trade), dosage (mg per day), route of administration (oral or parenteral), frequency of administration (od, bd, tds, qid) and duration of drug therapy were recorded.
Data analysis was done by using ATC/DDD methodology

16. Data analysis Number of items used x Amount of drug per item
Drug usage (DDD) =
WHO recommended DDD of a drug
Total Consumption in DDD x1000
DDD/1000 inhabitants per day =
Covered inhabitants x period of data collection in days
The ATC codes and DDD for each antihypertensive drug was obtained from ATC index with DDD 2017
Then the total numbers of DDD for each antihypertensive drug and DDD/1000 inhabitants/day was calculated from the collected data by the following formula.
Dukes, M.N.G. (ed) (1993) Drug utilization studies, methods and uses, WHO regional publications, European Series No. 45. Finland: WHO

17. Total items (tablets) of furosemide prescribed during the study period = Amount of furosemide per tablet = 40 mg DDD (denominator) of furosemide by ATC index = 40 mg Defined Daily Dose (DDD) of furosemide during the study period was calculated as Items issued x amount of drug per item DDD = WHO recommended DDD of drug 12459x40 = = DDD 40 Total consumption of furosemide during the study period was DDD.

18. Total Consumption in DDD x1000
DDD/1000 inhabitants per day =
Covered inhabitants x period of data collection in days
12459 x 1000
= =
7674 x 181
Covered inhabitants in this study = All admitted patients to medical ward of NOGTH (7674 patients in this study)
Days in the period of data collection = 181 days (for 6 months duration)
drug utilization of furosemide – DDD/ 1000 inhabitants/ day
9 people per 1000 patients admitted to medical wards of NOGTH were prescribed furosemide.

19. Data analysis DU 90% was calculated by
ranking antihypertensive drugs by volume of DDD,
after ranking the drugs used by volume of DDD, summing the DDD for these drugs
determining how many drugs accounted for 90% of drug use1
1Bergman, U., Popa, C., Tomson, Y., Wettermark, B., Einarson, T.R., Aberg, H. and Sjoqvist, F. (1998) Drug utilization 90% – A simple method for assessing the quality of drug prescribing. Eur J ClinPharmacol: 54; p

20. Table 3. Drug utilization 90% of antihypertensive drugs in medical ward of NOGTH
Generic Name
ATC Code
DDD (WHO)
Total DDD
DDD/1000
Percent (%)
Furosemide
C03CA01
40mg
12459
8.9698
32.91
Furosemide (Inj)
9268
6.6725
24.48
Amlodipine
C08CA01
5mg
6688
4.8149
17.66
Spironolactone
C03DA01
75mg
2.3372
8.57
Ramipril
C09AA05
2.5mg
1809
1.3024
4.78
Nifedipine
C08CA05
30mg
750
0.5399
1.98
Enalapril
C09AA02
10mg
662.5
0.4769
1.75
Perindopril
C09AA04
4mg
521
0.3751
1.38
Losartan
C09CA01
50mg
475
0.3419
1.25
Carvedilol
C07AG02
37.5mg
407.58
0.2934
1.08
Metolazone
C03BA08
362
0.2606
0.96
Metoprolol
C07AB02
0.15g
355.5
0.2559
0.94
Doxazosin
C02CA04
285.5
0.2055
0.75
Propranolol
C07AA05
0.16g
166.88
0.1201
0.44
Indapamide
C03BA11
104.4
0.0752
0.28
Bisoprolol
C07AB07
79.75
0.0574
0.21

21. Ethical considerations
This study was approved by Ethics Review Committee of University of Medicine 2, Yangon
This study was ethical because it was approved by Ethics Review Committee of University of Medicine 2, Yangon

22. Results

23. results
antihypertensive drugs therapy – 2911 (37.93%) out of total 7674 patients with
male – 1346 (46.24%) and
female – 1565 (53.76%)
among antihypertensive drugs prescribed patients,
hypertension history – 1134 (38.96%)
history of regular taking of antihypertensive drugs – 186 (16.40%) of 1134 patients

24. results
the indications – heart failure (24.22%), hypertension (22.91%), ischaemic heart disease (13.39%), liver disease (12.64%), renal disease (9.55%), stroke (5.49%), arrhythmia (4.98%), valvular heart disease (2.61%), corpulmonale (2.51%), thyroid disease (0.99%) and the other causes (0.69%) such as oedema, anxiety, anaemia for blood transfusion, etc

25. Indications for antihypertensive therapy
Table 1. Distribution of indications for antihypertensive therapy and groups of antihypertensive drugs used
Indications for antihypertensive therapy
Diuretics
Beta blockers
Calcium channel blockers
ACEI
ARB
Alpha adrenoreceptor antagonists
Methyldopa
Heart failure
1384
402
123
345 25 7
Hypertension 17 67
560
109 54
Ischaemic heart disease 51
369 58
234 31 1
Valvular heart disease 61 4 11
Arrhythmia 8
137 22 13 3
Corpulmonale
126 5
Stroke 10 23 72
135
Renal disease
463 45
175 29 6 2
Liver disease
506
167
Thyroid disease 30
Others
Among these indications, hypertension was associated with stroke (83.13%), renal disease (60.43%), ischaemic heart disease (56.92%), heart failure (46.10%), arrhythmia (22.76%), corpulmonale (10.96%), thyroid disease (6.9%), valvular heart disease (2.63%) and liver disease (1.36%). Indications for antihypertensive therapy versus groups of antihypertensive used shown in table 1.
Antihypertensive drugs prescribed with generic name 3670 (60.17%) and trade name 2430 (39.84%).

26. Figure 1. Monotherapy and combined therapy of antihypertensive drugs
combination therapy – 1639 (56.30%)
monotherapy – 1272 (43.70%)
in monotherapy,
calcium channel blockers (38.29%),
beta blockers (25.08%),
diuretics (22.96%),
ACEI (11.01%), ARB (2.59%) and
alpha blockers (0.08%)
among the patients with monotherapy, amlodipine (35.61%) – most commonly used antihypertensive monotherapy
Figure 1. Monotherapy and combined therapy of antihypertensive drugs

27. Table 2. Utilization of antihypertensive drugs by ATC code and DDD/1000 inhibitants/day in medical ward of NOGTH
Generic Name
ATC Code
DDD (WHO)
Total DDD
DDD/1000
Percent (%)
Methyldopa
C02AB01
1 g
7.5
0.0054
0.02
Doxazosin
C02CA04
4 mg
285.5
0.2055
0.75
Hydrochlorothiazide
C03AA03
25 mg
1.5
0.0011
0.004
Metolazone
C03BA08
5 mg
362
0.2606
0.96
Indapamide
C03BA11
2.5 mg
104.4
0.0752
0.28
Furosemide
C03CA01
40 mg
12459
8.9698
32.91
Furosemide (Inj)
9268
6.6725
24.48
Torasemide
C03CA04
15 mg
73.3
0.0528
0.19
Spironolactone
C03DA01
75 mg
2.3372
8.57
Propranolol
C07AA05
0.16 g
166.88
0.1201
0.44
Metoprolol
C07AB02
0.15 g
355.5
0.2559
0.94
Bisoprolol
C07AB07
10 mg
79.75
0.0574
0.21
Labetalol
C07AG01
0.6 g 7
0.0050
Labetalol (Inj)
1.17
0.0008
0.003
Carvedilol
C07AG02
37.5 mg
407.58
0.2934
1.08
The overall use of antihypertensive drugs in this study was DDD/1000 inhabitants/day. Utilization of antihypertensive drugs by ATC code and DDD/1000 inhibitants/day in medical ward of NOGTH was shown in table 2.

28. Table 2. Utilization of antihypertensive drugs by ATC code and DDD/1000 inhibitants/day in medical ward of NOGTH
Generic Name
ATC Code
DDD (WHO)
Total DDD
DDD/1000
Percent (%)
Amlodipine
C08CA01
5 mg
6688
4.8149
17.66
Nifedipine
C08CA05
30 mg
750
0.5399
1.98
Nimodipine
C08CA06
0.3 g 73
0.0526
0.19
Cilnidipine
C08CA14
10 mg 5
0.0036
0.01
Verapamil
C08DA01
0.24 g
14.33
0.0103
0.04
Diltiazem
C08DB01
0.5
0.0004
0.001
Enalapril
C09AA02
662.5
0.4769
1.75
Perindopril
C09AA04
4 mg
521
0.3751
1.38
Ramipril
C09AA05
2.5 mg
1809
1.3024
4.78
Losartan
C09CA01
50 mg
475
0.3419
1.25
Valsartan
C09CA03
80 mg
0.1
0.0002
Candesartan
C09CA06
8 mg 15
0.0108
Telmisartan
C09CA07
40 mg 26
0.0187
0.06
Total
27.26
100
The overall use of antihypertensive drugs in this study was DDD/1000 inhabitants/day. Utilization of antihypertensive drugs by ATC code and DDD/1000 inhibitants/day in medical ward of NOGTH was shown in table 2.

29. Table 3. Drug utilization 90% of antihypertensive drugs in medical ward of NOGTH
Generic Name
ATC Code
DDD (WHO)
Total DDD
DDD/1000
Percent (%)
Furosemide
C03CA01
40mg
12459
8.9698
32.91
Furosemide (Inj)
9268
6.6725
24.48
Amlodipine
C08CA01
5mg
6688
4.8149
17.66
Spironolactone
C03DA01
75mg
2.3372
8.57
Ramipril
C09AA05
2.5mg
1809
1.3024
4.78
Nifedipine
C08CA05
30mg
750
0.5399
1.98
Enalapril
C09AA02
10mg
662.5
0.4769
1.75
Perindopril
C09AA04
4mg
521
0.3751
1.38
Losartan
C09CA01
50mg
475
0.3419
1.25
Carvedilol
C07AG02
37.5mg
407.58
0.2934
1.08
Metolazone
C03BA08
362
0.2606
0.96
Metoprolol
C07AB02
0.15g
355.5
0.2559
0.94
Doxazosin
C02CA04
285.5
0.2055
0.75
Propranolol
C07AA05
0.16g
166.88
0.1201
0.44
Indapamide
C03BA11
104.4
0.0752
0.28
Bisoprolol
C07AB07
79.75
0.0574
0.21
The DU 90% of antihypertensive therapy in medical ward of NOGTH was shown in table 3. In this study, five drugs (furosemide, amlodipine, spironolactone, ramipril and nifedipine) were involved in DU 90% showing by green colour.

30. DISCUSSION

31. DISCUSSION
drug utilization research – increase the understanding of how drugs are being used and estimate the numbers of patients exposed to specified drugs within a given time period
studies comparing trends in the use of certain groups of drug (antidiabetics, antihypertensives) in a range of countries have shown differences – difficult to explain a differing prevalence of the diseases concerned1
1Dukes, M.N.G. (ed) (1993) Drug utilization studies, methods and uses, WHO regional publications, European Series No. 45. Finland: WHO.

32. DISCUSSION
patients received antihypertensive drugs in medical ward of NOGTH within the 6 months study period – 2911 (37.93%) out of total of 7674
diuretics – mostly prescribed
use of diuretics – DDD per 1000 inhabitants per day
When the result was compared with other countries, there was a variation in percentage of antihypertensive prescription. This might be due to variation in location, race, ethnicity and life style, etc 1
Among antihypertensive prescribed patients during this study period, 1134 (38.96%) had previous hypertension history with male (37.30%) and female (62.70%). A study conducted in tertiary care teaching hospital in India for one year study period showed that known case of hypertension 42 (20.89%) out of 100 male patients and 35 (17.41%) out of 101 female patients collected from past medical history of patients.
This might be due to hypertension was diagnosed for the first time only when they were admitted with the comorbidities.1
A total of 186 (16.40%) in patients with previous hypertension history with male (38.17%) and female (61.83%) took antihypertensive drugs regularly. Bjertness et al (2016) found that 6% of males and 11% of females of the total population used antihypertensive medications by a nationwide cross sectional study in Myanmar.
This indicates that 2.73 percent of patients were prescribed the standard dose of individual antihypertensive drug everyday in medical ward of NOGTH.
It showed that most of the patients were admitted due to the consequences of inappropriate control of hypertension which might be due to the requirement of medical knowledge.1
Variation in the frequency of patients having indications observed would be influenced in choice of antihypertensive drugs. Various antihypertensive drug classes are used to control and prevent the progress of diseases.

33. DISCUSSION
combination therapy (56.30%) was more used than monotherapy (43.70%)
since large number of patients suffering from multiple concomitant diseases, they were likely to have required multiple antihypertensive drugs to achieve target control and to reduce the side effect of maximum dose of drugs.
hypertension is usually associated with diabetic mellitus, ischaemic heart disease, nephropathy and it is also modifiable risk factors for cardiovascular diseases such as heart failure, stroke, etc.

34. DISCUSSION
amlodipine – the most commonly used antihypertensive monotherapy and exceeds the utilization of any other single drug
supplied by government to the hospitals in Myanmar
generic names in the prescription – to decrease the financial burden on the patient
It may be due to long duration of action, sustained and consistent blood pressure control with minimum side effect, once daily dosing and improved compliance1
1Datta, S. (2017) Utilization study of antihypertensives in South Indian tertiary care teaching hospital and adherence to standard treatment guidelines. Journal of Basic and Clinical Pharmacy; p

35. DISCUSSION
DU 90% – furosemide, amlodipine, spironolactone, ramipril and nefidipine
although ramipril was involved in DU 90% but not included in NLEM
out of 26 antihypertensive drugs, 17 (65.38%) drugs – from NLEM
amlodipine, nifedipine, verapamil, diltiazem, furosemide, spironolactone, metolazone, indapamide, hydrochlorothiazide, carvedilol, metoprolol, propanolol, labetalol, enalapril, perindopril, losartan and methyldopa
Amlodipine Spironolactone Furosemide (tab) Furosemide (inj) Labetalol (inj) Losartan Carvedilol Propanolol Metoprolol Enalapril Perindopril Nefidipine
100% 81% 18% 100% 100% 100% 56.23% 47.04% 76.89% 100% 28.31% 60.44%

36. Conclusion

37. Conclusion
This study provides information in some extent of antihypertensive utilization related to their indications in medical ward of NOGTH.
It can provide information to prescribers for reimbursement of drugs in hospital.
By knowing DU 90% of antihypertensive drugs, it can contribute a data helping the administrator for drug procurement in preparing drug budgets and can also provide information to the essential drugs list for Myanmar.

38. THANK YOU FOR YOUR ATTENTION