الفهرس 
Introduction and aim of the studyOnly 14 pages are availabe for public view
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Abstract
Noncommunicable diseases (NCDs) are one of the major health and development challenges of the21st century, in terms of both the human suffering they cause and the harm they inflict on the socioeconomic fabric of countries .NCDs were responsible for 71% of the deaths which occurred globally. The major NCDs responsible for these deaths were the cardiovascular diseases (CVD) which accounted for 40 % of all NCDs deaths. An even higher proportion (75%) of the premature adult deaths occurring in those aged 30 - 69 years old were caused by NCDs, demonstrating that NCDs are not only a problem for older population .Burden of NCDs is greatest within low and middle income countries.
Hypertension (HTN) or raised blood pressure (BP) is one of the major CVDs. Globally ,one in four men and one in five women had raised BP. Prevalence of raised BP has declined in high and middle income countries in contrast has being increasing in low income countries. HTN is a major risk factor for coronary artery diseases (CAD), choronic kidney diseases (CKD) and stroke. If left uncontrolled, complications from raised BP include heart failure, peripheral vascular diseases, renal failure, retinal hemorrhage, visual impairment, stroke and dementia.
According to the country profile of Egypt (2016), NCDs were estimated to account for 84% of all deaths. The proportional mortality for CVDs by 2016 was 40% in which HTN is one of the major CVDs. The prevalence of HTN and attendant CVD burden is increasing globally including our country. Our goal is auditing antihypertensive prescriptions and assessing patients with HTN for BP control which is an important step on the path of reducing HTN related morbidity, mortality, and health expenditure. The aim of the present study was to study the prescribing pattern of antihypertensive drugs in Alexandria University Students Hospital and the adherence to standard treatment guidelines (JNC8) and with the following Specific objectives:
1. To describe the prescription pattern of antihypertensive drugs including its classes, combinations and comorbidities. To identify the extent of adherence of physicians to the standard treatment guidelines of Joint National Committee (JNC 8) in prescribing antihypertensive drugs.
3. To estimate the proportion of prescribing errors of antihypertensive drugs.
A cross sectional study was conducted at Alexandria University Students Hospital on antihypertensive prescriptions for hypertensive patients aged 18 years and above.
A data collection sheet was prepared to collect information extracted from prescriptions of antihypertensive patients. The data included personal characteristics, their medical data including blood pressure whether controlled or uncontrolled, stage of HTN, drug therapy and associated comorbidities. A checklist was developed to assess the prescription of antihypertensive drugs based on JNC-8 guidelines depending on the selective antihypertensive classes in each comorbidity associated with hypertension. Moreover, data was collected about the prescriber regarding his age, gender, qualification, occupation and years of experience.
The prescription pattern of antihypertensive drugs based on JNC-8 guidelines recommendations are as follows:
• Initial drug treatment options arethiazide-type diuretic, ACEI, ARB, or CCB for general population (no associated comorbidities).
• Initial drug treatment options areACEI or ARB for CKD and diabetic populations
• Treatment choices for comorbid conditions are: ACEI/ARB+BB+diuretic+spironolactone for heart failure- ACEI/ARB, CCB, diuretic in diabetes
- ACEI/ARB in CKD-ACEI/ARB and BB for post- MI /clinical CAD -ACEI, diuretic for recurrent stroke prevention
- Labetolol (first line), nifedipine, methyldopa for pregnancy
The sample size was calculated using Epi- info software 7. Based on a percent of adherence to guidelines of 65 % with confidence limit of 5%, the minimum required sample size at 95% confidence level was 349. It was rounded to 350 prescriptions.
The collected data were revised, coded, and analyzed using the Statistical Package for Social Sciences (SPSS) program, version 23 for tabulation and analysis. Statistical analysis was performed in both descriptive and inferential forms.
The study revealed the following main results:
Section I: Description of the study sample
a- Antihypertensive prescriptions
- The age of patients ranged between 19-88 years with a mean of 56±13.5 years.
- Hypertension was more prevalent in adults under the age of 60 (58.6%). Older age wasn’t directly related to a higher incidence of HTN.
- The female gender predominance in HTN in which the proportion of hypertensive females (54.6%) were more than males (45.5%)
- The majority of the cases were married (88%) and about half (48.6%) ofhypertensive patients were employees
- The proportion of patients with controlled BP was 43.1% while 56.9% of the patients were with uncontrolled BP.
- Stage II of HTN (55.3%) was more predominant than Stage I of HTN (44.7%).
- Heart failure (37.1%) followed by diabetes (34%) were the most predominant comorbidities associated with HTN.
- Hypertensive patients which were free from any associated comorbidities accounted for 27.7%.
- The study showed that most of the hypertensive patients received monotherapy (48.9%) while 45.1% received polytherapy.
B- Description of the prescribers ‘data
- The maximum percent of antihypertensive prescriptions were written by male physicians of age group from 50-59 years old, consultants with a doctorate degree. The years of experience of physicians ranged from 3 to 15 years old.
Section II: Prescription patterns of the antihypertensive drugs
- The most frequently prescribed class of antihypertensive drugs were BB (54.3%) followed by Thiazide diuretics (39.4%).
- Bisoprolol (28.4%) and Amlodipine (13.2%) were the most prescribed antihypertensive drugs.
- The under-utilization of the prescription of ACEI/ARB as monotherapy in diabetics and CKDs hypertensive patients.
- The most common prescribed antihypertensive drug combinations were BB +ACEI/ARB, Thiazide diuretics + ACEI/ARB and Thiazide diuretics +ACEI/ARB +CCB.
- No significant difference in terms of prescribing antihypertensive classes in younger and older age.
- No significant difference in the utilization of the prescribed antihypertensive classes in both sexes.
- A significant association between the utilization of the prescribed antihypertensive classes and drug therapy.
Section III: Adherence of the prescribers to the JNC 8 guidelines
- Methyle dopa was the drug of choice for hypertensive pregnants with 100% of adherence to JNC8 guidelines.
- The prescriptions of heart failure as a comorbidity associated with HTN were 94.6% adhered to JNC8 guidelines.
- The adherence of antihypertensive prescriptions of diabetics or CKD patients were 50.4% adhered to standard treatment guidelines which reflects the under-utilization of ACEIs (56.3%) and ARBs (45.3%) in diabetes or CKD patients.
- ACEI were prescribed with the highest percent of adherence 76.3% to standard treatment guidelines while BB were prescribed with a low percent of adherence about 42.6% to standard treatment guidelines (JNC8).
- Prescribers overall adherence to standard treatment guidelines was 55.1% of the antihypertensive prescriptions (44.9% of prescribing error).
- The maximum percent of overall adhered prescriptions were written by male resident physicians of internal medicine and cardiology with a bachelors’ degree.