Patient related choice of antihypertensive medication in the elderly

216
_________________________________
* Corresponding author:
Getachew Alemkere
Department of Pharmacy, Wollega University,
Wollega, Ethiopia
E-mail address: kume1036@gmail.com
Available Online at: www.ijrpp.com Print ISSN: 2278 - 2648
Online ISSN: 2278 - 2656
(Research article)
Patient related characteristics on the choice of antihypertensive medication
in the elderly in Jimma University Specialized Hospital, Jimma, Oromia
Region, South west Ethiopia
*1
Getachew Alemkere, 2
Chalachew Teshale , 3
Zeryawkal Ergetie, 3
Alemayehu Berhane
1
Department of Pharmacy, Wollega University, Wollega, Ethiopia
2
Department of Pharmacy, Jimma University, Jimma, Ethiopia
3
School of Pharmacy, University of Gondar, Gondar, Ethiopia
_________________________________________________________________________
ABSTRACT
The aim of this study was to determine the effect of some selected patient related characteristics on the choice of
antihypertensive medication in the elderly population in Jimma University Specialized Hospital. A cross
sectional retrospective study was used on cards of patients aged 65 and more, with documented arterial
hypertension and treated with at least one antihypertensive drug. Some common patient related risk factors to
hypertension and the specific drugs chosen for treatment were assessed well. Chi-square test and linear
regression analysis were used wherever appropriate and P-value <0.05 was considered as statistically
significant. During the study, 135 patient cards were included. Of which 99(73.33%) were males and
36(26.67%) were females. The commonly used antihypertensive medications were 100(74.07%) diuretics,
41(30.37%) calcium channel blockers and 41(30.37%) angiotensin converting enzyme inhibitors. Of all patients
98 (72.59%) were using combinations (≥ 2 drugs) of antihypertensive medication. Eleven (8.14%) hypertensive
patients were living with polymorbidity (> 4 diseases). Chronic heart failure 21(15.56%), cerebero vascular
accident 15(11.11%), ischemic heart diseases 11(8.15%) were the common cardiovascular co-morbidities.
Polymorbidity have higher odds of BB use (OR: 3.45, p<0.05). The odd of ACEI and BB use was high in males
than in females (OR: ACEIs = 1.75, BBs =1.24). But, there was no any significant statistical association
between sex and use of antihypertensive medication. A statistical association was found between use of ACEIs
and chronic hear failure and diabetes mellitus (p<0.05 vs. p<0.001). Use of beta-blockers was significantly
associated with arrhythmia, cerebro vascular accident, ischemic heart disease and diabetes mellitus. It was found
that socio-demographic, co- morbidity and other factors have an effect on the choice of antihypertensive
medication.
Keywords: Antihypertensive Medication, Patient Related Characteristics, Elderly, Jimma University
Specialized Hospital.
______________________________________________________________________________________________
INTRODUCTION
Hypertension is the most common cardiovascular
disease. It is defined conventionally as a sustained
increase in blood pressure > 140/90 mmHg. The
prevalence of hypertension increases with age.
About 50% of people between the age of 60 and 69
year old have hypertension, and the prevalence
further increased beyond age 70 [1]. The ages of 60
and 65years are arbitrarily used as a definition of
elderly persons in most developing countries [2].
International Journal of
Research in Pharmacology and
Pharmacotherapeutics

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Getachew Alemkere et al / Int. J. of Res. in Pharmacology and Pharmacotherapeutics Vol-1(2) 2012 [216-223]
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Hypertension is the most important health problem
in developed countries like western countries; also,
it is a major public health challenge to societies
who are on socioeconomic transition and affects
the development of the country as a whole. There is
no available definitive preventive or curative
measure to hypertension. In spite of this, some
associated risk factors have been epidemiologically
isolated [3]. Thus, the choice of antihypertensive
therapy is based on a combined assessment of
several characteristics of the patient coexisting
conditions, age, race or ethnic group, and the
response to previously used drugs, including the
presence or absence of adverse reactions [4].
Studies report that, it was not until controlled
clinical trials were in 1985 and onwards [5-8], that
the value of antihypertensive treatment in elderly
patients started to become more universally
accepted. In these trials various combinations of
diuretics, beta-blockers (BBs), calcium channel
blockers (CCBs), and angiotensin converting
enzyme inhibitors (ACEIs), were given.
Age and race have been shown to be determinants
of the response to specific antihypertensive
medications. The Department of Veterans Affairs
Cooperative Study reported that younger whites
had a good response to ACEIs and BBs, whereas
older blacks had a better response to diuretics or
CCBs [9]. Another study reported that African
Americans (blacks) are more responsive to
diuretics and CCBs than ACEIs and BBs [10].
Treatment decisions must be individualized and
take in to account co-morbidity and frailty [11, 12].
Diuretics, ACEIs or long acting dihydropyridine
CCBS are appropriate as initial monotherapy.
Studies [13- 18] report that which antihypertensive
drug(s) the physician choose can affect long term
BP control and should focus on treating
cardiovascular risk than blood pressure numbers
[19].
According to studies in Africa, it becomes
significantly evident that over the last few decades
hypertension related target organ damage is on the
expansion [20-22]. In Ethiopia, no nationwide
study on hypertension has been done so far and
hence the magnitude of the problem and its impact
on the country is not known, but the study on
cardiovascular disease reports, rheumatic heart
disease (42%) as the most prevalent followed by
hypertension (39.1%) [23]. Little small scale
hospital based and community based surveys show
it as a disease of public health importance [24, 25].
These studies try to associate the effect of socio-
demographic and clinical factors to the prevalence
of hypertension. However, no data was found to
associate the effect of these to their effect on the
choice of antihypertensive medication. Thus, this
study assessed the effect of patient related
characteristics on the choice of antihypertensive
medication in the elderly patients in Jimma
University Specialized Hospital.
METHODS
Study area and population
The study was conducted in the hypertension clinic
of Jimma University Specialized Hospital in Jimma
zone of Oromia region, South western Ethiopia in
February. It is one of the oldest public hospitals in
the country. Geographically, it is located in Jimma
city 350 Km southwest of Addis Ababa. Currently
it is the only teaching and referral hospital in the
southwestern part of the country. The catchment
population for the Jimma Zone reaches 2,788,390.
But it is difficult to enumerate figures the
catchment population in which Jimma University
Specialized Hospital is delivering health services as
it is the only referral hospital in the southern part of
the country where more than 15 million people
resides. It provides specialized health services
through its 9 medical and other clinical and
diagnostic departments for approximately 9000
inpatients and 80,000 outpatients each year with
bed capacity of 450 and a total of more than 550
staffs. The source populations were all patient
information cards of patients that have been getting
service in the Jimma University Specialized
Hospital and the study population were all patient
information cards of hypertensive patients that are
getting service in the hypertension clinic of Jimma
University Specialized Hospital.
Study design
A cross sectional retrospective study was
conducted using a patient information sheet. From
the sheet, patient related characters that affect the
choice of treatment and the possible drug given as
initial therapy was collected.
Sample and sampling techniques
The study was included all elderly (aged above or
equal to 65) hypertensive patients treated with an
initial therapy. The study excluded patients below
65 years, with no drug therapy and with acute
hypertension examination.

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Data Collection
Data was collected using data collection instrument
(check list) and by using patient information sheet
from physician record as a source of data. The
quality of the study was improved through training
data collectors on how and which data to be
collected from the patient information sheet,
supervision and daily check up of filled check list.
To assure quality of data, the pilot study was
conducted. Before starting the whole study, the
check list and the whole method as well was
pretested on fifteen patient cards using random
sampling from source population and therefore,
appropriate directions and corrections had been
taken accordingly. Data regarding the type of
drugs, co-morbidities to hypertension and socio-
demographics were collected.
Data processing and analysis
After collection, the data was clearly categorized
and analyzed. Data was statistically analyzed using
SPSS v 17. The type of drug chosen for treatment
was reported as percentage. The contribution of
patient related characteristics to hypertension drug
treatment were analyzed through Chi-square test
and linear regression analysis and P-value <0.05
was considered as statistically significant.
RESULTS
Of all patients registered from September 2005 up
to November 2010, 255 patients were within the
age range of 65 years and above. Because of loss of
whole cards, laboratory results and poor
documentation, the actual number of cards
analyzed were 135 (52.94%). Of these 99 (73.33%)
were males and 36(26.67%) were females. One
hundred twenty six (93.30%) were in the age of <
85 years and 9(6.70%) of patients were in age
range of above 84 years. Since hypertension is a
chronic disease on several days or months of
follow up, the data was mainly taken from the first
date of registration and the last date of follow-up.
As a result, the data was taken in reference that the
patient was already put on antihypertensive
therapy. This study reveals diuretics as the most
widely 100(74.07%) prescribed class of
antihypertensives followed by calcium channel
blockers (CCBs) and angiotensin converting
enzyme inhibitors (ACEIs) each accounting for
41(30.37%) of the population (Table 1). Of all
patients 37 (27.41%) were with monotherapy and
98 (72.59%) were using combinations (≥ 2 drugs)
of antihypertensive medications.
In this study, co-morbidities to hypertensive
patients were common. Among them, chronic heart
failure (CHF) was the most prevalent 21 (15.56%)
cardiovascular co-morbidity followed by
cerebrovascular accident 15 (11.11%) and ischemic
heart disease 11 (8.15%). Gastrointestinal disorder
and chronic obstructive pulmonary disorder
(COPD)/asthma were the most prevalent non-
cardiovascular co-morbidities each accounting 22
(16.30%), 14(10.37%) of the population
respectively (Table 2). From the total patients 11
(8.14%) were living with polymorbidity (> 4
diseases).
The univariate analysis of the effect of different
factors on the choice of antihypertensive drugs
showed that diuretics 96 (76.2%) in the age of < 85
years, diuretics and ACEIs (each 4(44.4%)) in the
age of ≥85 years were widely used drug classes.
Diuretics were the commonly prescribed
antihypertensive medications in both males and
females. Besides socio-demographic
characteristics, co-morbidities influence on the
choice of antihypertensive medication was studied.
Patients with polymorbidities (≥4 diseases) were
prescribed more of diuretics and beta-blockers
(each 6(54.5%)) than any other groups of drugs.
Among cardiovascular co-morbidities, diuretics
14(66.7%) and ACEIs 11(52.4%) were common to
hypertensive patients with CHF where as BBs
8(72.7 %) were common for those with ischemic
heart diseases. BBs 9(60.0%), diuretics 7(46.7%)
and CCBs 6(40.0%) with cerebrovascular accident
were prescribed commonly. Diuretics and BBs
(each 6(60%)) were commonly prescribed drugs
with arrhythmia. ACEIs 7(87.5%), diuretics and
BBs (each 5(62.5%)) with diabetes mellitus were
prescribed commonly (Table 3).

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Table 1. Antihypertensive use pattern of patients in JUSH, Ethiopia, February, 2010
Class Commonly used drugs Number Percent
Diuretics
Calcium channel blocker (CCBs)
Angiotension converting enzyme
inhibitors(ACEI)
Beta blockers (BB)
sympathomimetics
Vasodilators
Others
Hydrochlorothiazide &
furesamide
Nefidipine
Captopril & enalapril
Propranolol & atenolol
methyldopa
Hydralazine
(Spironolactone, KCl, digoxin)
100
41
41
38
36
4
7
74.07 %
30.37%
30.37%
28.15 %
26.67 %
2.92%
5.19%
Table 2. Co-morbidities to hypertensive patients on antihypertensive medication in JUSH,
Jimma, South western Ethiopia, Feb. 2010
Co- morbidities Number Percent
Cardiovascular
Chronic heart failure
Cerebrovascular accident (CVA)
Ischemic heart diseases
Arrhythmia
Diabetes mellitus (DM)
21
15
11
10
8
15.56%
11.11%
8.15%
7.41%
5.92%
Non Cardiovascular
GI disorders
COPD/Asthma
Osteoporosis and arthritis
Renal failure
Pneumonia
Generalized Toni colonic seizure
(GRCs)
Others
22
14
11
9
8
2
11
16.30%
10.37%
8.15%
6.67%
5.92%
1.48%
8.15%
Others: Upper respiratory tract infection, prostate cancer, malaria, typhoid,
Urinary tract infection, cardiomegaly, dyspepsia and pulmonary Tuberculosis

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Table 3. The univariate analysis of the influence of socio-demographic and clinical variables on the choice
of antihypertensive drug class
Values represent absolute numbers (% of n in the bracket). In case of statistical significance, the values are expressed in bold
and marked by asterisk. ACEI, angiotensin-converting enzyme inhibitors; CCB, calcium channel blockers;CHF,chronic heart
failure; CVA, cereberovascular accident; IHD, ischemic heart disease; DM, diabetes mellitus.
*p < 0.05; **p < 0.01; ***p < 0.001.
Factors
Diuretics Beta-blockers ACEI CCBs methyldopa
With
(n=100)
Without
(n=35)
With
(n=38)
Without
(n=97)
With
(n=41)
Without
(n=94)
With
(n=41)
Without
(n=94)
With
(n=36)
Without
(n=99)
Age < 85
(n= 126)
Age > 85 (n= 9)
Female (n= 36)
Male (n=99)
> 4 diseases
(n= 11)
< 4 diseases
(n=124)
96(76.2)
4 (44.4)
27(75.0)
73(73.7)
6(54.5)
94(75.8)
30(23.8)*
5 (55.6)
9(25.0)
26(26.3)
5(45.5)
30(24.2)
37(29.4)
1 (11.1)
8(22.2)
30(30.3)
6(54.5)
32(25.8)
89 (70.6)
8 (88.9)
28(77.8)
69(69.7)
5(45.5)*
92(74.2)
37(29.4)
4 (44.4)
8(22.2)
33(33.3)
1(9.1)
40(32.3)
89 (70.6)
5 (55.6)
28(77.8)
66(66.7)
10(90.9)
84(67.7)
38(30.2)
3 (33.3)
12(33.3)
29(29.3)
2(18.2)
39(31.5)
88(69.8)
6 (67.7)
24(66.7)
70(70.7)
9(81.8)
85(68.5)
36(28.6)
0 (0.0)
12(33.3)
24(24.2)
5(45.5)
31(25.0)
90(71.4)
9(100.0)
24(66.7)
75(75.8)
6(54.5)
93(75.0)
Cardiovascular
with CHF (n=21)
without CHF
(n=114)
14(66.7)
86(75.4)
7(33.3)
28(24.6)
9(43.0)
29(25.4)
12(57.0)
85(74.6)
11(52.4)
30(26.3)
10(47.6)*
84(73.7)
4(19.0)
37(32.5)
17(81.0)
77(67.5)
3(14.3)
33(28.9)
18(85.7)
81(71.1)
With CVA
(n=15)
without CVA
(n=120)
7(46.7)
93(77.5)
8(53.3)*
27(22.5)
9(60.0)
29(24.2)
6(40.0)**
91(75.8)
1(6.7)
40(33.3)
14(93.3)
80(66.7)
6(40.0)
35(29.2)
9(60.0)
85(70.8)
5(33.3)
31(25.8)
10(66.7)
89(74.2)
with IHD
(n= 11)
without IHD
(n= 124)
6(54.5)
94(75.8)
5(45.5)
30(24.2)
8(72.7)
30(24.2)
3(27.3)**
94(75.8)
6(54.5)
35(28.2)
5(45.5)
89(71.8)
6(54.5)
35(28.2)
5(45.5)
89(71.8)
2(18.2)
34(27.4)
9(81.8)
90(72.6)
with arrhythmia
(n=10)
without
arrhythmia
(n=125)
6(60.0)
94(75.2)
4(40.0)
31(24.8)
6(60.0)
32(25.6)
4(40.0)***
93(74.4)
2(20.0)
39(31.2)
8(80.0)
86(69.8)
5(50.0)
36(28.8)
5(50.0)
89(71.2)
4(40.0)
32(25.6)
6(60.0)
93(74.4)
with DM (n= 8)
without DM
(n=127)
5(62.5)
95(74.8)
3(37.5)
32(25.2)
5(62.5)
33(26.0)
3(37.5)*
94(74.0)
7(87.5)
34(26.8)
1(12.5)***
93(73.2)
2(25.0)
39(30.7)
6(75.0)
88(69.3)
1(12.5)
35(25.9)
7(87.5)
92(72.4)

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Table 4 The Multivariate analysis of the influence of socio-demographic characteristics as well as co-
morbidity on the choice of antihypertensive in JUSH, South western Ethiopia Feb, 2010
DISCUSSION
Hypertension has been long treated with both non
pharmacologic and pharmacologic methods. Since
it is a multi-factorial disorder, treatment requires
strict adherence to existing guidelines and updating
the clinical knowledge to existing new discoveries.
The commonly used antihypertensives in this study
were diuretics, calcium channel blockers,
angiotensin converting enzyme inhibitors, beta-
blockers and sympathomimetics (methyldopa)
(74.04%, 30.37%, 30.37%, 28.15% and 26.67% of
patients respectively). This is in one hand, similar
to the existing guidelines from the British
Hypertension Society (BHS) [26] that puts CCBs
and diuretics at first rank for those greater than 55
years and in the other hand, it is not coincide with
the use of ACEIs and BBs that BHS puts them for
patients less than 55 years old. Centrally acting
sympatomimetics have little role because of side
effects [11, 26]. Unlike to the British Hypertension
Society (BHS) guideline, this study found out
significant contribution of sympathomimetics
(methyldopa) (26.67% of patients). Recently beta-
blockers have been put in to controversy [11] as
less effective to hypertension treatment. Similarly
this finding placed at the fourth stage next to
diuretics, CCBs and ACEIs. But this was in
contrary to European Society of Hypertension/
European Society of Cardiology (ESH/ESC)
guideline [27]. Hypertension is more common in
African Americans (blacks) and high incidence in
non Hispanics than Hispanics. These populations
are more responsive to diuretics and CCBs than
ACEIs and BBs because of lower rennin level in
plasma of these populations [10]. All the study
populations were blacks. Diuretics (74.07% of
population) and CCBs (30.37% of population) were
the two most widely prescribed classes in this study
which is in line with the above research finding.
Principles in the treatment of hypertension in
elderly have in common with those applying to
younger age groups. Treatment considers a lot of
factors in individualizing therapy than blood
pressure numbers alone. Taking all these into
account, a number of studies dealt factors in drug
choices of hypertension treatment [9-19]. In this
study, statistical association has been found
between age and diuretic use. The Ethiopian drug
formulary considers diuretics (especially thiazids)
as first line particularly in elderly [28]. The
multivariate analysis of different factors affecting
drug choices showed that patients with
polymorbidity have higher odds of BB use (OR:
3.45) and methyldopa use (OR: 2.5) than others
(Table 4). Polymorbidity has statistical association
to BB use (p<0.05). Methyldopa and CCBs (each
8.89% of population) in females and ACEIs
Factor Diuretics Beta-blockers ACEIs CCBs Methyldopa
Age < 85 4.00(1.01 -15.85) 3.33(0.40,27.54) 0.52(0.13,2.04) 0.86(0.20,3.63)
-
Male sex 0.94(0.39-2.25) 1.24(0.52-2.97) 1.75(0.72,4.26) 0.83(0.37,1.88) 0.64(0.28,1.47)
Polymorbidity
(> 4 disease)
0.38(0.11-1.35) 3.45 ( 0.98,12.08) 0.21(0.03,1.69) 0.48(0.10,2.35) 2.5(0.71,8.77)
Chronic heart failure 0.65(0.24-1.77) 2.2( 0.84,5.75) 3.08(1.18,7.98) 0.49(0.15,1.56) 0.41(0.11,1.48)
Cerebrovascular disease 0. 25(0.08-0.76) 4.71(1.54,14.35) 0.32(0.07,1.49) 1.62(0.54,4.90) 1.44(0.45,4.53)
Ischemic heart disease 0.38(0.11-1.35) 8.36(2.09,33.52) 3.05(0.87,10.65) 3.05(0.87,10.65) 0.59(0.12,2.86)
Arrhythmias 0.49(0.13-1.87) 29.79(3.62,245.08) 0.55(0.11,2.72) 2.47(0.67,9.06) 1.94(0.51,7.31)
Diabetes mellitus 0.56(0.12-2.48) 4.75 (1.07,20.96) 19.15(2.27,161.41) 0.75(0.14,3.89) 0.37(0.05,3.16)

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(24.44% of population) in males were commonly
prescribed drug classes. The odd of ACEI and BB
use was high in males than in females (OR: ACEIs
= 1.75, BBs =1.24, diuretics = 0.94 and
methyldopa = 0.64). But there was no any
significant statistical association between sex and
use of antihypertensive medication. Diuretics
14(66.7%) and ACEIs 11(52.4%) were commonly
prescribed classes to hypertensive patients with
CHF but the odds of ACEI use was higher than
diuretics use in this patients (3.08 and 0.65
respectively) and this was further confirmed by the
presence of statistical association between ACEI
use and chronic heart failure (p< 0.05). This is in
line with the study in Australia [11] and the
Ethiopian drug formulary [28] both of which states
the use of diuretics for all cases without
contraindication and ACEIs for patients with
chronic heart failure than other drugs as initial
therapy. Similar to ESH/ESC guidelines [27], in
this study, BBs were found to be worthy in
hypertensive patients with arrhythmias (OR: 29.79,
p < 0.001) and ischemic heart diseases (OR: 8.36,
p<0.01) than other drug classes. In this study, BBs
9(60.0%) and diuretics 7(46.7%) were most
prevalently used for cereberovascular accident
management. Cereberovascular accident has
statistical association with diuretics and BBs.
Findings from two studies, however, indicated that
BBs have fewer efficacies than other
antihypertensive agents in preventing stroke [29,
30]. Angiotensin converting enzyme inhibitors
7(87.5%), and diuretics and BBs (each 5(62.5%))
for diabetic patients were the most commonly
prescribed classes. Diabetes mellitus has high
strength of casual statistical association with ACEI
and BB choice. The odd of ACEI use is much
higher than BB use for diabetics as compared to
non diabetics (19.15 vs. 4.75). Some of these data,
however, are somewhat different from that done in
Australia [11] which puts diuretics as
contraindication to diabetics. In case of diabetic
hypertensive patients the result was somewhat in
line with that done in Ireland [17] which states
ACEIs as the most frequently and BBs as the least
frequently prescribed class of drugs in diabetic
patients. Similarly, Ethiopian drug formulary also
recommends ACEIs for diabetic neuropathy [28].
Most of the prescribed treatments 98 (72.59%)
were combination therapies. More likely this may
be due to the fact that the patients had been already
on hypertension treatment previously. So, for better
control or any failure to control blood pressure (as
seen from BP records) and for any further
complication occurrence combination therapy is
required. The study in Australia supports this fact
[11]. Though, treating co-morbid conditions needs
use of more than one drug, drug therapy decisions
should consider a least number of drugs in the
treatment of hypertension.
The limitations were, however, lack of
appropriately filled patient information sheet; loss
of whole patient cards and old cards. The
retrospective study by itself may not allow for a
direct investigation of casual relation between the
factors studied and the outcome of interest.
CONCLUSION
Treatment of hypertension in developing countries
like Ethiopia needs especial attention particularly
in elderly people. It was found that, diuretics,
calcium channel blockers and angiotensin
converting enzyme inhibitors are important as the
first choice of treatment in elders. The integral
doctor patient relation is important in the treatment
decision so as to individualize the treatment and to
take in to account the effect of socio-demographic,
co-morbidity and other factors. Concomitant illness
has a strong influence on what to treat and what
therapy to use. For effective treatment, concerned
health professionals should be abided by the
existing guidelines and updated to the new
findings.
ACKNOWLEDGEMENT
This study was carried out with the financial
support obtained from Jimma University, College
of Public Health and Medicine. Our appreciation
also extends to Hypertension Clinic of JUSH staffs,
supervisors, and the data collectors for their full
participation.
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