Advertisement

Evaluation of antihypertensive prescriptions for rationality and adherence to treatment guidelines: An experience from United Arab Emirates

Published:February 02, 2020DOI:https://doi.org/10.1016/j.cegh.2020.01.016

      Abstract

      Objectives

      Prescription pattern focused drug utilization is an effective technique which provides an unbiased assessment of the prescribing habits and aids in identifying suboptimal prescribing. The aim of the present study was to evaluate rationality in antihypertensive prescribing and adherence to international treatment guidelines.

      Methods

      It was an observational, prospective, cross sectional study carried out in 588 adult patients with hypertension presenting to medicine department of a secondary care hospital in United Arab Emirates. Electronic medical records of the patients were reviewed and demographic, clinical and antihypertensive prescription data were obtained. The antihypertensive prescriptions were assessed for rationality and adherence to the latest Joint National Committee (JNC) and National Institute for Health and Care Excellence (NICE) guidelines for hypertension. Statistical analysis of the data was performed using statistical package for social sciences (SPSS) version 24.0.

      Results

      Out of the total 588 patients included in the study, majority (57.1%) of the patients were females. The mean age of the patients was 63.2 ± 14.3 years, with majority of them aged 68 years and above (37.9%). Majority of the patients (67.9%) were on combination therapy receiving multiple drugs for the management of their hypertension. Overall, 69% of our antihypertensive prescriptions were adherent to the JNC 7 recommendations and 80.9% were as per JNC 8 recommendations. Also, 55% of the antihypertensive prescriptions were adherent to the 2011 and 2019 NICE guidelines.

      Conclusion

      In conclusion, the antihypertensive prescriptions at the study site mostly adhere to the latest international guidelines for the management hypertension.

      Keywords

      1. Introduction

      More than one billion people in the world are suffering from hypertension and it is the major cause of premature deaths worldwide. The estimated prevalence of hypertension in the Arab countries is higher than the US and sub-Saharan Africa.
      • Tailakh A.
      • Evangelista L.S.
      • Mentes J.C.
      • Pike N.A.
      • Phillips L.R.
      • Morisky D.E.
      Hypertension prevalence, awareness, and control in Arab countries: a systematic review.
      Keeping in view the high burden of hypertension and its associated morbidity and mortality, Ministry of Health and Prevention, United Arab Emirates (UAE) has aligned the national strategy with World Health Organization's global target to reduce hypertension by 25% by 2025.
      • Ministry of Health and Prevention - United Arab Emirates
      Ministry of Health organizes workshop to launch 3rd edition of hypertension guide.
      Appropriate management of hypertension can lead to reduction in cardiovascular morbidity and mortality.
      • Lemogoum D.
      Challenge for hypertension prevention and control worldwide: the time for action.
      In spite of the advances in hypertension management, studies show that majority of the patients remain sub optimally controlled.
      • Wolf-Maier K.
      • Cooper R.S.
      • Kramer H.
      • et al.
      Hypertension treatment and control in five European countries, Canada, and the United States.
      ,
      • Kitt J.
      • Fox R.
      • Tucker K.L.
      • McManus R.J.
      New approaches in hypertension management: a review of current and developing technologies and their potential impact on hypertension care.
      Non-adherence to lifestyle modifications and non-compliance to antihypertensives are the major contributory factors to this suboptimal blood pressure control.
      • Agbor V.N.
      • Takah N.F.
      • Aminde L.N.
      Prevalence and factors associated with medication adherence among patients with hypertension in sub-Saharan Africa: protocol for a systematic review and meta-analysis.
      Prescription pattern focused drug utilization is an effective technique which provides an unbiased assessment of the prescribing habits and aids in identifying suboptimal prescribing.
      • Gupta S.
      • Nayak R.
      • Rahavi R.
      • et al.
      Provider adherence to national guidelines for managing hypertension in african Americans.
      Scientific organizations like National Heart, Lung, and Blood Institute (NHLBI),
      • Chobanian A.V.
      • Bakris G.L.
      • Black H.R.
      • et al.
      Seventh report of the Joint national committee on prevention, detection, evaluation, and treatment of high blood pressure.
      ,
      • James P.A.
      • Oparil S.
      • Carter B.L.
      • et al.
      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).
      National Institute for Health and Care Excellence (NICE),
      • National Institute for Clinical Excellence
      Hypertension in Adults: Diagnosis and Management.
      ,
      • National Institute for Clinical Excellence
      Hypertension in Adults: Diagnosis and Management.
      European Society of Hypertension (ESH)
      • Williams B.
      • Mancia G.
      • Spiering W.
      • et al.
      ESC/ESH Guidelines for the management of arterial hypertension.
      and others periodically publish reports or guidance for the prevention, diagnosis, evaluation, and management of high blood pressure. These guidelines assist healthcare providers in clinical decision making, minimize variations in practice and serve as measures of healthcare quality. However, implementation of these clinical guidelines in practice is affected by a number of factors and barriers.
      • Barreto J.O.M.
      Implementation of clinical guidelines: a knowledge translation challenge.
      Evaluating the antihypertensive drug utilization in UAE population is vital as the region is witnessing an increasing prevalence of hypertension, leading cause of mortality in the region is cardiovascular diseases
      • World Health Organization - Noncommunicable Diseases
      United Arab Emirates Profile.
      and lack of data on rationality and adherence of antihypertensive prescriptions to international treatment guidelines. Keeping these observations in view, the present study was conducted to evaluate rationality in antihypertensive prescribing and adherence to international treatment guidelines like the Eight
      • James P.A.
      • Oparil S.
      • Carter B.L.
      • et al.
      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).
      and Seventh
      • Chobanian A.V.
      • Bakris G.L.
      • Black H.R.
      • et al.
      Seventh report of the Joint national committee on prevention, detection, evaluation, and treatment of high blood pressure.
      Reports of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 8 and JNC 7) and NICE Hypertension in adults: diagnosis and management 2019
      • National Institute for Clinical Excellence
      Hypertension in Adults: Diagnosis and Management.
      and 2011
      • National Institute for Clinical Excellence
      Hypertension in Adults: Diagnosis and Management.
      guidelines.

      2. Methods

      2.1 Study design and sample size

      It was a prospective-observational study conducted in hypertensive patients presenting to the internal medicine department of Dibba Hospital, Fujairah, UAE. The study site is a multi-specialty hospital with Internal Medicine, Orthopedics, Obstetrics and Gynecology, Ophthalmology, Dermatology, Otorhinolaryngology, Pediatrics, Radiology, Accident and Emergency Medicine, Physical Medicine and Rehabilitation departments. The study sample was selected using convenience sampling technique and was calculated on the basis of number of patients visiting the internal medicine department (124 patients/month approximately) of the hospital during the six month study period considering 20% drop-out rate. A total of 588 patients were enrolled in the study. Out of these 588 patients, 88 patients were from the inpatient department whereas 500 patients were from the outpatient department.

      2.2 Study criteria

      2.2.1 Inclusion criteria

      Patients aged more than 18 years, of either gender with a confirmed diagnosis of hypertension and on antihypertensive medications attending the internal medicine department of the study site were included in the study.

      2.2.2 Exclusion criteria

      Patients with significant renal and hepatic diseases, malignant hypertension and pregnancy were excluded from the study.

      2.3 Data collection procedure

      Electronic patient case records were reviewed by the study investigators and demographic and clinical data were documented in the study specific data collection form. Patient data including age, gender, nationality, marital status, number of comorbidities, comorbidity types, concomitant medications, antihypertensive drugs with dose, frequency and duration were documented. Data completeness was ensured by the study investigators. Rationality of antihypertensive prescriptions was assessed as per NICE and JNC guidelines. Adherence to the guidelines was calculated as percentage of the total number of prescriptions in line with the recommendations of guidelines.

      2.4 Data analysis

      Statistical Package for the Social Sciences (SPSS) version 24.0 was used for analyzing the study data. The socio-demographic and clinical characteristics of the patients were examined by carrying out descriptive analyses. Pearson χ
      • Tailakh A.
      • Evangelista L.S.
      • Mentes J.C.
      • Pike N.A.
      • Phillips L.R.
      • Morisky D.E.
      Hypertension prevalence, awareness, and control in Arab countries: a systematic review.
      test was used for establishing relationship between different variables. P ≤ 0.05 were considered statistically significant.

      2.5 Ethical considerations

      The ethical approval of the study was obtained by Ras Al Khaimah (RAK) Medical and Health Sciences University Research and Ethics Committee (Number: RAKMHSU REC 3-2017-PG-P) and RAK Research and Ethics Committee (RAK REC 34-2017-PG-P), UAE.

      3. Results

      3.1 Socio-demographic and clinical characteristics

      Out of the total 588 patients included in the study, majority (57.1%) of the patients were females. The hypertensive patients had a mean age of 63.2 ± 14.33 years, with majority of them aged 68 years and above (37.9%). Since the study site was a government hospital, majority of the patients were Emirati (79.6%) followed by Omani (16.8%) and other nationalities (3.6%). Table 1 represents the socio-demographic and clinical characteristics of the study population stratified by type of antihypertensive therapy. Five major classes of antihypertensive drugs namely angiotensin converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), calcium channel blockers (CCB), beta blocker (BB) and diuretic were prescribed to the hypertensive patients at the study site. Majority of the patients (67.9%) were on combination therapy receiving multiple drugs for the management of their hypertension. Calcium channel blocker was the most frequently prescribed antihypertensive drug class (300 prescriptions) followed by ARB (274 prescriptions), diuretics (220 prescriptions), ACEI (210 prescriptions), BB (198 prescriptions) and other antihypertensive class (8 prescriptions).
      Table 1Socio-demographic and clinical characteristics of hypertensive patients: Overall and by antihypertensive therapy.
      VariableOverall (n = 588)Antihypertensive TherapyP-value
      Monotherapy (n = 189)Combination Therapy (n = 399)
      Age, year (%)0.003
      18–271.41.61.3
      28–373.44.23.0
      38–478.313.85.8
      48–5718.022.216.0
      58–6731.026.533.1
      68 and above37.931.740.9
      Gender (%)
      Female57.160.855.40.246
      Male42.939.244.6
      Nationality (%)0.247
      Emirati79.681.578.7
      Omani16.813.818.3
      Others3.64.83.0
      Number of comorbidities (%)0.001
      No comorbidity23.633.319.0
      One comorbidity37.531.740.1
      Two comorbidity38.934.940.9
      Type of Comorbidities (%)<0.001
      Diabetes Mellitus8.210.17.3
      Hyperlipidemia23.217.525.8
      Ischemic Heart Disease6.04.27.0
      Diabetes Mellitus + Hyperlipidemia32.731.733.1
      Diabetes Mellitus + Ischemic Heart Disease6.33.27.8
      Statistically significant values are in bold.

      3.2 Rationality of prescriptions as per international guidelines

      3.2.1 Rationality of prescriptions as per JNC guidelines

      According to JNC 7 guidelines for the management of stage 1 hypertension thiazide type diuretics should be considered for most patients and ACEI, ARB, BB or CCB may also be considered either alone or in combination. In the present study 98% of antihypertensive prescriptions were adherent to this JNC 7 recommendation for the management of stage 1 hypertension. Out of the 188 stage 1 hypertensive patients, 10 patients were prescribed thiazide diuretics, 67 patients were prescribed ARBs, 39 patients were on CCBs, 38 patients with ACEIs and 30 patients were prescribed BBs. Two patients were on non-thiazide diuretics and one each on moxonidine and terazosin respectively. These four prescriptions were not as per the JNC 7 recommendations for stage 1 hypertension (Table 2). However, as per JNC 8 for the initial antihypertensive therapy only four classes; thiazide diuretic, ACEI, ARB or CCB alone or in combination are recommended. Hundred and fifty-six (82.9%) of our antihypertensive prescriptions were adherent to this JNC 8 recommendation. Thirty-two prescriptions (17.1%) for initial antihypertensive therapy did not have the recommended four classes of antihypertensive drugs.
      Table 2Rationality of prescriptions as per JNC guidelines.
      JNC 7 Hypertension ClassificationRecommendationsNo. of PrescriptionsNon-adherence (%)Adherence (%)
      Stage 1 Hypertension (n = 188)Thiazide Diuretic10-5.4
      ARB67-35.7
      CCB39-20.8
      ACEI38-20.2
      BB30-15.9
      Diuretic but not thiazide21-
      Centrally acting21-
      Total1882%98%
      Stage 2 Hypertension (n = 210)Two drug combination
      ACEI/ARB + Thiazide39-18.6
      CCB + Thiazide8-3.8
      BB + Thiazide1-0.5
      Other two drug combination16277.1
      Total21077.1%22.9%
      Three drug combinationThree drug combination
      Thiazide diuretic + CCB+ ACE/ARB51-37.5
      Thiazide diuretic + BB + ACE/ARB21-15.5
      Other three drug combination6447-
      Total13647%53%
      Four, five and six combinationsNot Recommended54100%-
      Overall Adherence to JNC407-69%
      Overall Non-Adherence to JNC18131%-
      ACEI: Angiotensin-converting-enzyme inhibitors, ARBAngiotensin receptor blockers, BB: Beta blockers, CCB: Calcium channel blockers, JNC: Joint National Committee.
      For the management of stage 2 hypertension, JNC 7 recommends use of two drug combination for most patients usually a combination of thiazide diuretic and ACEI/ARB or thiazide diuretic and CCB or thiazide diuretic and BB. In our study only 22.9% of antihypertensive prescriptions were adherent to this two drug combination recommendation of JNC 7. Out of the 210 prescriptions of two drug combination, only 48 prescriptions were having two drug combination as per JNC 7 while the remaining 162 prescriptions were not as per the guidelines. Of these 48 prescriptions, 39 prescriptions were of thiazide diuretic and ACEI/ARB, 8 patients were on thiazide diuretic and CCB, while only 1 prescription had a combination of thiazide diuretic and BB. Whereas, majority (75.2%) of two drug combination prescriptions were in line with the JNC 8 recommendation for two drug combination.
      According to JNC 7 recommendation for three drug combination therapy, thiazide diuretic should be one of the three classes and it can be combined with ACEI, ARB, BB, or CCB. Fifty-three percent of the prescriptions were adherent to this recommendation with 51 patients on combinations of thiazide diuretic, ACEI/ARB and CCBs, 21 patients were on combinations of thiazide diuretic, ACEI/ARB and BB. Sixty-four prescriptions contained other three drug combinations which were not as per JNC 7 recommendations. Regarding JNC 8 recommendation for adding a third antihypertensive drug, 126 three drug prescriptions (92.6%) of the study adhered to this recommendation. For four drug antihypertensive therapy, 72.9% of our prescriptions were as per the JNC 8 recommendation. Overall, 69% of the antihypertensive prescriptions were adherent to the JNC 7 recommendations and 80.9% were as per JNC 8 recommendations (Fig. 1).
      Fig. 1
      Fig. 1Overall adherence of antihypertensive prescriptions to international Guidelines.
      JNC: Joint national committee, NICE: National institute for health and care excellence.

      3.3 Rationality of prescriptions as per NICE guidelines

      NICE guidelines recommend four steps for the management of hypertension. In the present study, 42.8% of the prescriptions were adherent to the step 1 treatment recommendation of NICE 2011 and 2019 guidelines. Out of 189 patients falling under the step 1 antihypertensive treatment, only 81 patients were treated as per the step 1 recommendation. For patients aged less than 55 years, ACEI or ARB were prescribed to 39 patients, 32 patients aged more than 55 years were prescribed CCB, 9 patients were treated as per the third point of step 1 recommendation while one patient was on a combination of thiazide diuretic and BB.
      A high proportion of prescriptions (71.3%) were adherent to the step 2 treatment recommendation of NICE 2011 and 2019 guidelines as elaborated in Table 3. Out of the 208 patients needing drugs as per Step 2 antihypertensive treatment, 110 patients were prescribed CCB with either ACEI or ARB, 39 patients were on thiazide diuretic with ARB or ACEI. Sixty patients were receiving drug combinations which were not as per recommendations of NICE guidelines.
      Table 3Rationality of prescriptions as per NICE 2011 and 2019 guidelines.
      NICE GuidelineRecommendationsNo of PrescriptionsNon-adherence (%)Adherence (%)
      Step 1ACEI or ARB for less than 55 years39-20.7
      CCB for above 55 years32-16.8
      Thiazide diuretic if CCB intolerant for above 55 years9-4.7
      BB + Thiazide1-0.6
      Prescriptions with other monotherapy1857.2
      Total18957.2%42.8%
      Step 2CCB with ARB/ACEI110-52.6
      Thiazide diuretic with ARB/ACE (CCB intolerant)39-18.7
      Prescriptions other two drug combination6028.7-
      Total20928.7%71.3%
      Step 3Thiazide diuretic + ARB/ACEI+ CCB51-38.3
      Prescriptions with other three drug combination8261.7
      Total13361.7%38.3%
      Step 4Thiazide diuretic + ARB/ACEI+ CCB + another diuretic (spironolactone)1-2
      Higher dose thiazide diuretic + ARB/ACEI+ CCB3-5.9
      Thiazide diuretic + ARB/ACEI+ CCB + α blocker/BB34-66.6
      Prescriptions with other four drug combination1325.5-
      Total5125.5%74.5%
      Five & Six Drug CombinationNot Recommended6100%
      Overall Adherence to NICE323-55%
      Overall Non- Adherence to NICE26545%-
      ACEI: Angiotensin-converting-enzyme inhibitors, ARBAngiotensin receptor blockers, BB: Beta blockers, CCB: Calcium channel blockers, NICE: National Institute for Health and Care Excellence.
      Step 3 treatment recommendation of NICE guidelines states that if treatment with three drugs is required, the combination of ACEI/ARB, CCBs and thiazide like diuretic should be used. In the present study 38.3% prescriptions were adherent to this step 3 treatment recommendation with 51 prescriptions with a three drug combination of thiazide diuretic, ARB and CCB.
      Step 4 treatment is recommended in cases of resistant hypertension. NICE guidelines recommend three options for the management of resistant hypertension. First option is adding a low dose diuretic with spironolactone dose to the three drug combination in step 3 recommendation. In the present study only one patient is treated as per this recommendation. Second option is to consider high dose thiazide diuretic treatment in the three combination therapy; 3 of our prescriptions were as per this recommendation. Final option is to consider addition of an alpha blocker or BB to the three drug combination. In the study 34 patients were on this type of prescription. For step 4 treatment recommendation, 55% of prescriptions were in the line with the NICE guidelines. Overall, 55% of the antihypertensive prescriptions were adherent to the NICE 2011 and 2019 guidelines (Fig. 1).

      4. Discussion

      This is the first study in Dibba hospital, Fujairah, UAE which assessed the antihypertensive prescriptions for rationality and adherence to international treatment guidelines. We have previously reported that majority of the antihypertensive prescriptions at the study site were of combination type.
      • Alkaabi M.
      • Rabbani S.
      • Rao P.M.
      • Ali S.
      Prescription pattern of antihypertensive drugs: an experience from a secondary care hospital in the United Arab Emirates.
      Combination antihypertensive therapy has shown to be more effective in controlling hypertension in patients with comorbidities than the monotherapy.
      • Materson B.J.
      • Preston R.A.
      Combination therapy in the treatment of hypertension.
      Combining two drugs with different mechanisms can give an antihypertensive effect which is two to five times greater than obtained by monotherapy.
      • Burnier M.
      Antihypertensive combination treatment: state of the art.
      Selection of antihypertensive treatment is governed by a number of factors like patient's comorbidities and concomitant medications, physician's choice depending on patient characteristics, availability of drugs at the hospital site and guidelines followed by the hospital. Overall, 69% of the antihypertensive prescriptions were adherent to the JNC guidelines, 80.9% were as per JNC 8 and 55% of the study prescriptions were adherent to 2011 and 2019 NICE guidelines.
      For the management of stage 1 hypertension, JNC 7 recommend thiazide diuretics as initial therapy for most patients and ACEI, ARB, BB or CCB may also be considered. For initial antihypertensive therapy JNC 8 also recommend thiazide, ACEI, ARB or CCB alone or in combination but does not recommend BB. The JNC 8 panel did not recommend BB for the initial antihypertensive therapy based on a clinical trial which showed a higher rate of cardiovascular events with use of BB compared with use of an ARB.
      • Dahlöf B.
      • Devereux R.B.
      • Kjeldsen S.E.
      • et al.
      Cardiovascular morbidity and mortality in the Losartan Intervention for Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol.
      Majority of our study prescriptions (98% to JNC 7 and 82.9% to JNC 8) were adherent o the JNC recommendations for initial antihypertensive therapy. These findings are in line with the results of a study conducted in a tertiary hospital in India.
      • Tandon V.
      • Sharma S.
      • Mahajan S.
      • et al.
      Antihypertensive drug prescription patterns, rationality, and adherence to Joint National Committee-7 hypertension treatment guidelines among Indian postmenopausal women.
      However contrasting findings were reported by many studies where thiazide diuretics were not the preference of the physicians for initial management of hypertension.
      • Beg M.
      • Dutta S.
      • Varma A.
      • et al.
      Study on drug prescribing pattern in hypertensive patients in a tertiary care teaching hospital at Dehradun, Uttarakhand.
      • Liu P.H.
      • Wang J Der
      Antihypertensive medication prescription patterns and time trends for newly-diagnosed uncomplicated hypertension patients in Taiwan.
      • Kuchake V.G.
      • Maheshwari Od
      • Surana S.J.
      • Patil P.H.
      • Dighore P.N.
      Prescription pattern of antihypertensive drugs in uncomplicated hypertensive patients at teaching hospital.
      Studies have shown that in stage 2 hypertension combination therapies afford better blood pressure control and effect of combining drugs is greater than doubling the dose of a single antihypertensive.
      • Esfehani R.J.
      • Gharai A.M.
      • Esfehani A.J.
      • Kalat A.R.
      • Abbasi F.
      • Jalalyazdi M.
      A comparative study of the management of stage 2 hypertension by combined therapy with Losartan, Amlodipine and hydrochlorothiazide.
      For the management of stage 2 hypertension JNC 7 also recommends use of two drug combination for most patients usually a combination of thiazide diuretic with ACEI/ARB or thiazide diuretic with CCB or thiazide diuretic with BB. Our results revealed that only 22.9% of antihypertensive prescriptions were adherent to this two drug combination recommendation of JNC 7. A study conducted by Tandon et al. reported a higher proportion (43.2%) of antihypertensive prescriptions in line with the JNC 7 recommendation for stage 2 hypertension.
      • Tandon V.
      • Sharma S.
      • Mahajan S.
      • et al.
      Antihypertensive drug prescription patterns, rationality, and adherence to Joint National Committee-7 hypertension treatment guidelines among Indian postmenopausal women.
      JNC 8 states that if after initial antihypertensive therapy blood pressure goal is not achieved titrate drugs to the maximum doses or add second drug from ACEI, ARB, CCB or thiazide class. Majority (75.2%) of our two drug study prescriptions were in line with this JNC 8 recommendation. Majority of the two drug combination prescriptions (52.8%) were of ARB/ACEI with CCB. Studies have shown that ARB/ACEI and CCB combinations are more effective in decreasing blood pressure with greater clinical benefits in cardiovascular outcomes.

      Kostis JB. Antihypertensive therapy with CCB/ARB combination in older individuals: focus on amlodipine/valsartan combination. Am J Therapeut. 17(2):188–196.

      ,
      • Chi C.
      • Tai C.
      • Wang J.
      • et al.
      2A.04.
      According to JNC 8, if blood pressure goal cannot be reached with two drugs, a third drug can be added and titrated from the recommended classes of drugs. Nearly one-fourth of our total antihypertensive prescriptions were of three drug combination. This finding can be attributed to the fact that majority of our study participants had more than two comorbidities. Majority (92.6%) of these three drug combination prescriptions were in line with the JNC 8 recommendations. JNC 8 recommend that if blood pressure goal is not achieved by using three drugs from ACEI, ARB, BB, or CCB then a fourth antihypertensive drug can be added from other classes. Only a fraction (8.2%) of our antihypertensive prescriptions contained four drugs, out of these majority of them were as per the recommendation of JNC 8.
      NICE 2011 and 2019 guidelines for diagnosis and management of hypertension in adults state that “offer step 1 antihypertensive treatment with a CCB to people aged over 55 years. If a CCB is not suitable, offer a thiazide-like diuretic”. Our results revealed that 42.8% of our prescriptions were adherent to this recommendation. Several studies have shown that in elderly population CCB are effective and safe providing good blood pressure control.
      • Staessen J.A.
      • Fagard R.
      • Thijs L.
      • et al.
      Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension.
      ,
      • Nguyen Q.T.
      • Anderson S.R.
      • Sanders L.
      • Nguyen L.D.
      Managing hypertension in the elderly: a common chronic disease with increasing age.
      According to Step 2 of NICE guidance 2011 and 2019, if hypertension is not controlled in adults taking CCB in step 1 then combine CCB with ARB/ACEI or thiazide diuretic. Majority of our antihypertensive prescriptions (71.3%) were in accordance with this recommendation of NICE guidelines.
      NICE guidance recommend that before considering the step 3 treatment for hypertension a review of patients’ medications should be done ensuring that they are being taken at the optimal tolerated doses and adherence should also be discussed with the patients.
      • National Institute for Clinical Excellence
      Hypertension in Adults: Diagnosis and Management.
      For step 3 hypertension treatment, both the 2011 and 2019 NICE guidelines recommend that “if treatment with three drugs is required, the combination of ACEI/ARB, CCBs and thiazide like diuretic should be used”. In our study, 38.3% of the prescriptions were adherent to this step 3 treatment recommendation.
      If hypertension is not controlled by the three drug combination as per step 3 recommendation then it should be regarded as resistant hypertension. For the management of resistant hypertension addition of a fourth antihypertensive should be considered as step 4 treatment. More than half (55%) of our study prescriptions were in line with this recommendation of NICE 2011 and 2019 guidance for diagnosis and management of hypertension.
      The present study reports that the antihypertensive prescriptions at the study site largely adhere to the latest JNC and NICE guidelines for the management of hypertension. There are a number of barriers which affect the implementation of clinical practice guidelines.
      • Barreto J.O.M.
      Implementation of clinical guidelines: a knowledge translation challenge.
      This adherence pattern in the study can be attributed to number of factors like specific patients' characteristics, presence of different comorbidities, adverse reactions and contraindication to drugs, availability of drugs at the study site, lack of awareness towards guideline recommendations, time constraints and physicians’ disagreement with the guidelines.
      Antihypertensive prescriptions at the study site are mostly as per the international guidelines for the management of hypertension. For appropriate management of hypertension there is a significant use of different antihypertensive drug combinations at the study site. Overall, evaluation of antihypertensive prescriptions for rationality remains largely understudied in UAE and the present study gave a picture of antihypertensive drug utilization at a secondary care hospital in the region. This study can be the foundation for further research in the region and can assist the clinicians in achieving rational drug utilization leading to better therapeutic outcomes.
      There are some limitations to our study. Firstly, since it a single center study the sample may not be a complete depiction of region's patient population. Secondly, physicians' prescriptions were considered as sole measure of adherence to the guidelines. Achievement of blood pressure goals, follow up and monitoring should also have been evaluated for determining the adherence to treatment guidelines. Thirdly due observational nature of our study, factors like physicians' educational background, influence of pharmaceutical companies and hospital administration, and availability of drugs at the study site were not evaluated.

      5. Conclusion

      In conclusion, antihypertensive prescribing at the study site is largely rational and adheres to the latest international guidelines but still there is a scope for improvement in terms of achieving rational drug utilization. This study can serve as the stepping stone for large scale multicenter prescription focused drug utilization studies.

      Funding

      This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

      Declaration of competing interest

      None declared.

      Acknowledgements

      The authors would like to thank the administration of Dibba Hospital, Fujairah, UAE. The authors also thank Dr. S Gurumadhva Rao, President; Dr. Sathvik BS, Chairperson; RAK Medical and Health Sciences University for their support and encouragement.

      References

        • World Health Organization
        Hypertension.
        (Available from:) (Last accessed on 2019 Sep. 12)
        • Tailakh A.
        • Evangelista L.S.
        • Mentes J.C.
        • Pike N.A.
        • Phillips L.R.
        • Morisky D.E.
        Hypertension prevalence, awareness, and control in Arab countries: a systematic review.
        Nurs Health Sci. 2014; 16: 126-130
        • Ministry of Health and Prevention - United Arab Emirates
        Ministry of Health organizes workshop to launch 3rd edition of hypertension guide.
        (Available from:) (Last accessed on 2019 Nov 18)
        • Lemogoum D.
        Challenge for hypertension prevention and control worldwide: the time for action.
        J Clin Hypertens. 2014; 16: 554-556
        • Wolf-Maier K.
        • Cooper R.S.
        • Kramer H.
        • et al.
        Hypertension treatment and control in five European countries, Canada, and the United States.
        Hypertension. 2004; 43: 10-17
        • Kitt J.
        • Fox R.
        • Tucker K.L.
        • McManus R.J.
        New approaches in hypertension management: a review of current and developing technologies and their potential impact on hypertension care.
        Curr Hypertens Rep. 2019; 21: 44
        • Agbor V.N.
        • Takah N.F.
        • Aminde L.N.
        Prevalence and factors associated with medication adherence among patients with hypertension in sub-Saharan Africa: protocol for a systematic review and meta-analysis.
        BMJ Open. 2018; 8: 1-6
        • Gupta S.
        • Nayak R.
        • Rahavi R.
        • et al.
        Provider adherence to national guidelines for managing hypertension in african Americans.
        Int J Hypertens. 2015; 6: 101-108
        • Chobanian A.V.
        • Bakris G.L.
        • Black H.R.
        • et al.
        Seventh report of the Joint national committee on prevention, detection, evaluation, and treatment of high blood pressure.
        Hypertension. 2003; 42: 1206-1252
        • James P.A.
        • Oparil S.
        • Carter B.L.
        • et al.
        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).
        J Am Med Assoc. 2014; 311: 507-520
        • National Institute for Clinical Excellence
        Hypertension in Adults: Diagnosis and Management.
        2011 (Available from:) (Last accessed on 2019 June 12)
        • National Institute for Clinical Excellence
        Hypertension in Adults: Diagnosis and Management.
        2019 (Available from:) (Last accessed on 2019 Sept 14)
        • Williams B.
        • Mancia G.
        • Spiering W.
        • et al.
        ESC/ESH Guidelines for the management of arterial hypertension.
        Eur Heart J. 2018; 39: 3021-3104
        • Barreto J.O.M.
        Implementation of clinical guidelines: a knowledge translation challenge.
        Rev Bras Epidemiol. 2018; 21e180022
        • Masudi F.
        Around 30% of UAE Residents Have Hypertension, Studies Show.
        2019 (Available from:) (Last accessed on 2019 Jan 11)
        • World Health Organization - Noncommunicable Diseases
        United Arab Emirates Profile.
        2018 (Available from:) (Last accessed on 2019 Jan 11)
        • Alkaabi M.
        • Rabbani S.
        • Rao P.M.
        • Ali S.
        Prescription pattern of antihypertensive drugs: an experience from a secondary care hospital in the United Arab Emirates.
        J Res Pharm Pract. 2019; 8: 92-100
        • Materson B.J.
        • Preston R.A.
        Combination therapy in the treatment of hypertension.
        Hypertens Princ Pract. 2005; : 547-560
        • Burnier M.
        Antihypertensive combination treatment: state of the art.
        Curr Hypertens Rep. 2015; 17: 51
        • Dahlöf B.
        • Devereux R.B.
        • Kjeldsen S.E.
        • 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: 995-1003
        • Tandon V.
        • Sharma S.
        • Mahajan S.
        • et al.
        Antihypertensive drug prescription patterns, rationality, and adherence to Joint National Committee-7 hypertension treatment guidelines among Indian postmenopausal women.
        J Midlife Health. 2014; 5: 78-83
        • Beg M.
        • Dutta S.
        • Varma A.
        • et al.
        Study on drug prescribing pattern in hypertensive patients in a tertiary care teaching hospital at Dehradun, Uttarakhand.
        Int J Med Sci Publ Health. 2014; 3: 922-926
        • Liu P.H.
        • Wang J Der
        Antihypertensive medication prescription patterns and time trends for newly-diagnosed uncomplicated hypertension patients in Taiwan.
        BMC Health Serv Res. 2008; 8: 1-11
        • Kuchake V.G.
        • Maheshwari Od
        • Surana S.J.
        • Patil P.H.
        • Dighore P.N.
        Prescription pattern of antihypertensive drugs in uncomplicated hypertensive patients at teaching hospital.
        Indian J Pharm Pract. 2009; 2: 74-80
        • Esfehani R.J.
        • Gharai A.M.
        • Esfehani A.J.
        • Kalat A.R.
        • Abbasi F.
        • Jalalyazdi M.
        A comparative study of the management of stage 2 hypertension by combined therapy with Losartan, Amlodipine and hydrochlorothiazide.
        Iran Cardiovasc Res J. 2012; 6: 79-83
      1. Kostis JB. Antihypertensive therapy with CCB/ARB combination in older individuals: focus on amlodipine/valsartan combination. Am J Therapeut. 17(2):188–196.

        • Chi C.
        • Tai C.
        • Wang J.
        • et al.
        2A.04.
        J Hypertens. 2015; 33: e19-20
        • Staessen J.A.
        • Fagard R.
        • Thijs L.
        • et al.
        Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension.
        Lancet. 1997; 350: 757-764
        • Nguyen Q.T.
        • Anderson S.R.
        • Sanders L.
        • Nguyen L.D.
        Managing hypertension in the elderly: a common chronic disease with increasing age.
        Am Heal Drug Benefits. 2012; 5: 146-153