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INTRODUCTION
CKD comprises a set of heterogeneous disorders which affect the function and structure of the kidney1.It is becoming one of the global public health problem due to co-morbidities and Polypharmacy with an increasing incidence and prevalence with poor outcomes and high cost of treatment.3
Diabetes and hypertension report for two-third of the cases of CKD in western countries and 40-60% cases of CKD in India too.4 60% of all deaths worldwide is due to the chronic diseases. 80% of chronic disease deaths globally occur in low- and middle income countries. The projected number of deaths due to chronic kidney disease was around 5.21 million in 2008 in India and is expected to rise to 7.63 million in 2020 (66.7% of all deaths).5
If kidney function declines, wastes products can enhance to high levels in blood. We may develop complications like high blood pressure, anaemia, weak bones, poor nutritional health and nerve damage. The risk of having heart and blood vessel disease is also increased by kidney disease. These problems may happen slowly over a long period of time. Chronic kidney disease may be caused by diabetes, high blood pressure and other disorders. Early detection and treatment can often keep chronic kidney disease from getting worse. When kidney disease progresses, it may leads to kidney failure, which requires dialysis or a kidney transplant to maintain life. Dialysis is of two types i.e. haemodialysis and peritoneal dialysis.7
Haemodialysis removes toxins and excess fluid via extracorporeal circulation of blood through a dialyzer, or so-called “artificial kidney”. Most commonly treatments are scheduled three times weekly and last 3 to 4 hours. A vascular access is required, using an arterio-venous (AV) fistula, vascular graft, or indwelling vascular catheter. Predominantly the treatments are performed as “center haemodialysis” in a hospital-based or freestanding dialysis unit. In this setting patients’ dialyzers are commonly reprocessed. Thus, a given patient may reuse his/her dialyzer multiple times.8
Peritoneal dialysis involves in an exchange of solutes and fluids across the peritoneal membrane, which serves as the dialysis surface, via diffusion and convective transport regulate solute movement. Urea, creatinine, and potassium move into the peritoneal cavity dialysate across the peritoneal membrane, while bicarbonate and calcium move in the opposite direction. The concentration gradient between dialysate and blood facilitates small molecule movement. Convection is also responsible for solute movement across the peritoneal membrane. The peritoneal dialysis catheter is inserted by a surgeon or nephrologist as an out-patient procedure. Most catheters are double-cuffed, curled tip Tenckhoff catheters. Other types of catheters are available, but they are infrequently used.9
A kidney transplant often will give an ESRD patient the most nearly normal life. This is a surgical procedure where a single healthy kidney replaces a permanently damaged kidney within the patient's body. Best results are seen from a donor who is a living relative whose tissues closely match those of the recipient. Transplants from cadaver donors (individuals who have died) also are frequently successful. However, there are approximately 30,000 Americans waiting for kidney transplants. The wait can be anywhere from a few weeks to two years or more. Unfortunately, because of a shortage of suitable donors, less than half that number will receive transplants.10
Diabetes occurs when sugar in the blood is very high and damages many organs in the body, including the kidneys and heart, nerves, blood vessels and eyes. High blood pressure, or hypertension, occurs when the blood pressure against the walls of blood vessels increases. If uncontrolled, or poorly controlled, hypertension can be a leading cause of strokes, heart attacks and chronic kidney disease. Also, chronic kidney disease can cause hypertension.7
Since chronic kidney disease shares common risk factors with cardiovascular disease and diabetes, lifestyle modifications directed at smoking, obesity, alcohol consumption, exercise and diet are important. Dietary protein intake has been the focus of several trials. However, there is a lack of convincing evidence that the long-term restriction of protein intake (< 0.70 g/kg/day) delays the progression of chronic kidney disease. Thus, a protein-controlled diet (0.80–1.0 g/kg/day) is recommended. There have been no studies about dietary salt restriction and development or progression of chronic kidney disease. However, the benefits of salt reduction as they pertain to the development and control of hypertension are available.11
The main treatment goals are to prevent or slow further damage, reduce the risk of disease progression to ESRD and kidney failure, and treat complications arising from the loss of kidney function. Diabetes and hypertension are the most common causes of CKD. Thus, management of blood glucose levels and blood pressure are priorities. Diet and exercise are key factors, but medication is commonly prescribed as well. Although diabetes agents are not prescribed directly for the treatment of CKD or its complications, antihypertensives can be. For example, some antihypertensive medications are commonly prescribed for patients with proteinuria, a common indicator of kidney damage. Proteinuria is a risk factor for both the progression of renal disease and cardiovascular morbidity and mortality. Drugs that act upon RAAS have been shown to have a blood pressure-independent effect on urine protein levels. This type of reduction in urine protein levels has been shown to slow the progression of CKD. (In addition to proteinuria, complications arising from CKD are anemia, hyperphosphatemia, and SHPT. Each complication is managed through medications specifically developed for the complication.
Physician will discuss advantage and disadvantage of each modality to patient or patient party by considering multiple factors like laboratory investigations, fluid intake, future risks and benefits, patients condition etc. and the most appropriate treatment option is decided from their active communication.14
NEED FOR THE STUDY
Drug utilization studies are very important for evaluating and analysing the drug therapy from time to time, to observe the prescribing patterns of general physicians, with the aim to validate drug use15.This study was planned to analyse current prescribing trends in the management of CKD patients with and without haemodialysis and to suggest ways to justify the use of drug andminimize medicine related problem, and to improve therapeutic outcome16. Rational drug prescription is a difficult task in CKD patients as these patients need complex therapeutic regimens so that they are at higher risk of drug-related problems. These patients require frequent monitoring and dosage adjustments. In addition, they usually have other comorbidities including hypertension, diabetes mellitus, coronary artery disease and infection. Improper use of medications can increase adverse drug effects, the length of hospital stays, excessive health care utilization, and costs.17
ESRD patients receive nearly 10 to 12 medications daily who are on haemodialysis have complex drug regimens, many of which requires multiple doses per day. These patients are at high risk for developing drug related problems (DRPs) and nonadherence due to polypharmacy, frequent medication adjustments on dialysis versus non- dialysis days, medically unstable nature of the disease and restricted life styles.18
These studies are useful to monitor the pattern of drugs from particular therapeutic categories where the problems can be predicted. Improper drug use may reduce the quality of life of patients and increase the chance of adverse drug reactions. The study was planned to describe these issues and to assess drug utilization pattern of patients with Chronic Kidney Disease in a tertiary care hospital.3
AIM &OBJECTIVES:
AIM
To assess drug utilization pattern in Chronic Kidney Disease and hemodialysis patients.
Specific Objective:
• To analyze the prescribing trends in the management of hypertension and diabetes in Chronic Kidney Disease and haemodialysis patients.
• To quantify the rate and extent of utilization of IV iron and ESAs in anemic with CKD patients and haemodialysis patients.
MATERIAL AND METHODS
Study Site:
The study is conducting in the nephrology unit in Kasturba Hospital, Manipal.
Ethical Clearance:
The study protocol was approved by the institutional ethics committee of Kasturba Hospital,Manipal.
Study Period: one year.
Sample Size:
As per study criteria, CKD and Haemodialysis patients with hypertension, diabetes and anaemia during the year 2014 were taken in the study.
Methodology
• A data collection form was used to collect data from the patients' medical record.
• Demographic data, clinical data and all systemic medications for hypertension, diabetes and anaemia with stage 3 to 5 and 5D prescribed during hospitalization were included.
INCLUSION CRITERIA
• All CKD and Haemodialysis patients both male and female aged 18 years and above.
• All systemic anti- hypertensive and anti-diabetic medications prescribed in the treatment cohort were included.
• The patient who received ESA alone or ESA+IV iron treatment during the study’s time period.
EXCLUSION CRITERIA
Pregnant ladies, breast feeding mothers, acute renal failure patients were excluded from the study.
REVIEW OF LITERATURE
CHRONIC KIDNEY DISEASE
• DEFINITION AND CLASSIFICATION OF STAGES OF SEVERITY.
“The Kidney Disease Outcomes Quality Initiative (KDOQI) of the National Kidney Foundation defines CKD as structural or functional abnormalities of the kidney for at least three months, manifested by kidney damage with or without a decreased glomerular filtration rate (GFR < 60 mL/min/1.73 m2) or a decreased glomerular filtration rate (GFR) with or without other evidence of kidney damage”.
According to the NKF, other possible tests that may be conducted after a diagnosis of CKD has been made include:
• Imaging tests, such as ultrasound or CT scans: These help doctors learn more about the size and condition of kidneys, as well as whether other conditions, such as tumorsor kidney stones, are present.
• Kidney biopsy: This test may be done to check for specific types of kidney disease or to see how much damage has occurred in order to plan further treatment.
• Kidney Markers: Such as proteinuria, abnormal urinary sediment11.
The findings of proteinuria not only definesthe CKD but also has important implications for the diagnosis of the type of kidney disease and is associated with a worse prognosis of kidney disease progression and development of CVD19.
“To facilitate assessment of CKD severity, the National idney Foundation developed criteria as part of its Kidney Disease Outcomes Quality Initiative (NKF K/DOQI) to stratify CKD patients. The NKF has classified chronic kidney disease into 5 stages”.14
Each patient is classified into one of the following 5 stages of CKD because management and prognosis varies according to the progression of damage.
KDOQI Classification of CKD by Disease Severity
ESRD is defined as GFR≤ 15ml/min-1/1.73m2 or treatment by dialysis. Approximately 98% of patients beginning dialysis for CKD in the United States have an estimated GFR of ≤ 15ml/min-1/1.73m2. Among individuals with CKD, the stage of severity is based on the level of GFR. Diagnosis of CKD is traditionally based on pathology and etiology.21
Pathophysiology of chronic renal failure
• In spite of, the primary loss of kidney function, some usually survive or are less severely damaged
• These kidneys then enlarge and reshaped, and clearance increases distinctly in both the kidneys
• If the initiating process is diffuse, sudden, and severe, such as in some patients with rapidly progressive glomerulonephritis (crescentic glomerulonephritis), acute or subacute renal failure may results with the rapid development of ESRD
• In most patients, however, disease progression is more gradual and nephron adaptation is possible
• Focal glomerulosclerosis develops in these glomeruli, and they eventually become non-functional
• At the same time that focal glomerulosclerosis develops, proteinuria markedly increases and systemic hypertension worsens
• This process of nephron adaptation has been termed the "final common path"
• Adapted nephrons enhance the ability of the kidney to postpone uraemia, but ultimately the adaptation process leads to the demise of these nephrons.
• Adapted nephrons have not only an increased GFR but also increased tubular functions.For example, potassium and proton secretion22
EPEDEMIOLOGY
According to the 2010 Global Burden of Disease study chronic kidney disease was ranked 27th in the list of causesof total number of global deaths in 1990 (age-standardisedannual death rate of 15•7 per 100 000), but rose to 18th in2010 (annual death rate 16•3 per 100 000).
Chronic kidney disease (CKD) is the ninth leading cause of death in the United States, and 41% of US adults are estimated to have CKD. A patient experiencing CKD has weak kidneys that lead to hemodynamic overload, as well as metabolic and endocrine abnormalities that adversely affect the cardiovascular system.6
Globally, CKD is the 12th cause of death and the 17th cause of disability, respectively. This is an underestimate as patients with CKD are more likely to die of cardiovascular disease (CVD) than to reach end-stage renal disease (ESRD). Approximately 30% of patients with diabetes mellitus (DM) have diabetic nephropathy and with the growing number of DM patients and aging population there is likely a parallel increase in CKD incidence.24
In India, given its population >1 billion, the rising incidence of CKD is likely to pose major problems for both healthcare and the economy in future years. Indeed, it has been recently estimated that the age-adjusted incidence rate of ESRD in India to be 229 per million population (pmp)25and >100,000 new patients enter renal replacement programs annually in India26. On the other hand, because of scarce resources, only 10% of the Indian ESRD patients receive any renal replacement therapy (RRT).27
CKD and Hypertension
Hypertension can be either a cause or a consequence of CKD. Hypertension may develop early in the course of CKD and can be associated with adverse outcomes such as worsening renal function and development of cardiovascular disease. Ultimately hypertension is a major promoter of the decline in GFR in CKD.29
A strong relationship was observed between systolic(SBP) and diastolic blood pressure(DBP) and end stage renal disease (ESRD), regardless of other known risk factors, in men who were recruited in the Multiple Risk Factor Intervention Trial. The relative risk(RR) for ESRD was >20-fold higher for patients with stage IV hypertension(SBP>210 mmHg or DBP>120 mmHg.30The recent study of the Okinawa General Health Maintenance Association confirmed these results in women as well.31
In an ongoing effort to decrease the complicationsassociated with CKD, the National Kidney foundation(NKF), Kidney Disease Outcomes Quality Initiative(K/DOQI) appointed a Work Group and an Evidence Review Team in 2001 to develop clinical practice guidelines on hypertension and the use of Anti-hypertensives in CKD. At the same time, clinical practice guidelines on this topic relevant to CKD were also developed by the seventh report of the Joint National Committee on Prevention Detection Evaluation and treatment of hypertension.
CKD and Diabetes
Diabetes is the most common cause of kidney failure, accounting for nearly 44 percent of new cases. Even when diabetes is controlled, the disease can lead to CKD and kidney failure. Most people with diabetes do not develop CKD that is severe enough to progress to kidney failure.32Diabetes is caused by problems with the production and/or action of insulin, which is a hormone that controls the amount of sugar in your blood.Diabetes can damage the kidney filters, leading to diabetic kidney disease (diabetic nephropathy). Around one-third of people who start dialysis or receive a transplant have end stage kidney disease caused by diabetes.33
CKD and Anaemia
A common complication of CKD, first occurring early in the development of the diseaseand becoming more severe as the CKD progresses. Anaemia occurs primarily because of the inability of damaged kidneys to produce sufficient EPO to maintain normal physiological levels. The kidneys are responsible for producing approximately 90% of EPO, a hormone that stimulates erythropoiesis. Hypoxia caused by this anaemia stimulates the RAAS and contributes to vasoconstriction, increasing proteinuria.34
In view of the increasing number of cases of CKD and the fact that treating hypertension and diabetes and anaemia in these patients effectively can decrease the complications and risk of CKD to the maximum, we have undertaken a drug utilisation study of anti-hypertensives and antidiabetic and anti-anaemic in chronic kidney diseases.
In this study we have looked in to the prescription profile of anti-hypertensives, antidiabetic and anti-anaemic used in the setting of different chronic kidney diseases in the tertiary care hospital.
DISCUSSIONS:
The findings of the prescription pattern study conducted in a tertiary care hospital, KMC gives an idea about the demographic data and drugs prescribed in CKD patients.
Demographics
The Mean age of the study population was found to be 54.40±13.64 years which is comparable with the NEOERICA (New Opportunities for Early Renal Intervention by Computerized Assessment) project results (58.1 ± 18.1 years), SEEK (Screening and Early Evaluation of Kidney Disease) study in India (52.27 ± 14.78 years) and KEEP (Kidney Early Evaluation Program) study.35,36,37
The maximum number of patients was in the age group of 40-59 years which is similar to the study conducted by Pyarelal.
The current study showed male predominance 79.4% which is similar to study conducted by S.K. Agarwal and R.K. Srivastava where 70% of study population were males.39
The average BMI of the study population was found to be 23.12 ± 4.57 kg/m2 which is comparable to study conducted by Wei-Hung Kuo et al where average BMI was 24.5 ± 4.2 kg/m2.40 But study conducted by G. R. Bailie et al. showed little higher range of BMI that is 29.0±6.9.41
The mean SBP of the participants in our study was 148±29.25 and the mean DBP was found to be 90.16±13.55 mm of Hg which is comparable with the study conducted by R M Pathapatil et al where the mean SBP of the participants was 151.98±17.75 and DBP was 93.44±10.55 mm of Hg.42
In our study the mean fasting and postprandial blood glucose levels were 144.46± 96.50 and 215.28±127.62 which is comparable with the study conducted by B Patel et al. where Mean fasting and postprandial blood glucose levels were 147.5 ± 73.1 and 215.6 ± 97.3 mg/dl respectively.43
The mean haemoglobin was found to be 9.56 ± 4.37 which is comparable with the study conducted by G. R. Bailie et al. where mean haemoglobin found to be 11.8±1.6 g/dl.
The Co-morbid conditions, hypertension was 92.7% and diabetes 44.8% in our study which is comparable with the study conducted by G. R. Bailie et al. where hypertension was found to be 90% and diabetes was 30%.41
Antihypertensive drugs utilization pattern:
In our study, the Calcium Channel blockers were used in (75.23%) patients, Diuretics were used in (46.45%)of patients, Centrally acting alpha agonists were used in (45.1%)of patients, Beta blockers were used in (35.3%) of patients, Alpha blockers were used in( 27.4%), Vasodilators were used in (7.5% )of patients, ARBs were used in (4.8%) of patients and ACE inhibitors were given to (3.5% )of patients with Hypertension and CKD. Among CCB, amlodipine (48%), clinidipine (40.6%,) nifidipine( 9.7%), diltiazem(1.8%) among diueretics, furosemide (91%), torasemide (10%), metolazone(0.4%), spironolactone (0.4%), among CAA, clonidine (93.28%), moxonidine (7%),among beta blocker metoprolol (64.13%), carvedilol (20.1%),atenolol (6%), propranolol(4.38%), nevibolol(4.38%), bisoprolol(1.08%), among alpha blocker, prazosin (100%), among vasodilators dihydralazine so4 (97.4%), minoxidil (2.6), among ARB telmisartan(64%) losartan(28%), olmesartn (4%), valsartan (4%), among ACE, enalapril(56%), Ramipril (44.4%) which is similar to the study conducted byBhanuPriya B* and Basavanna P Lwhere among the anti-hypertensives, most commonly prescribed was calcium channel blockers (39.5%) in which amlodipine(61), nifedipine(20%) and clinidipine(11%) was given. Followed by diuretics(25.12%) which included furosemide (50%), metazolamide(2%) and torsemide(7); then β blockers (9.7%) were atenolol (8) and metaprolol(12); α blocker (7.9%) was prazosin(17); centrally acting drugs (10.2%) were moxonidine (12) and clonidine(10), carvidilol (3%) and nebivolol (3%), vasodilators (3.2%) were nicorandil (7%) and isosorbidedinitrate(3%) and Angiotensin converting enzyme inhibitors (1.4%) was enalapril(3%).44
In our study monotherapy was prescribed to (23%), 2 drugs were given to (24%) and 3 drugs were given to (24)%, 4 drugs were given to (17.2)%, 5 drugs were given to (16%) and 6 drugs were given to (1.15)% of the patients which is comparable to the study conducted by Johnson et al where monotherapy was prescribed to (23.7%), 2 drugs were given to (24%), 3 and 4 drugs (18%) and (15.2)% of patients respectively.45
In our study, the CCBs were prescribed to (58%) of the patients, followed by diuretics which were prescribed to (21 %) of the patients and beta-blockers which were prescribed to (10%)of the patients which is contrary to a study conducted by Shah J et al where in mono-therapy, ACEI/ARB were (65%), followed by BB which was (13.15%) and Diuretics (5%) and CCBs were prescribed to (4%) of the patients.46
In our study, in the 2 drug therapy, CCBs + Diuretics were prescribed to (30%)of the patients followed by CCBs+ BB were prescribed to (14%) of the patients but in the study conducted by Shah J et al showed that CCB+BB were the most prescribed drug combination which is followed by ARB+ DU and CCB+DU.45
In our study 3 drugs therapy, CCB+ DU+ CAA was prescribed to (27%) followed by CCB+ DU+BB was prescribed ton (21 %) of the patients. But in the study conducted by Shah J et al CCB+DU+ACE were the most commonly prescribed combination i.e(62.5%)followed by DU+BB+AB which were prescribed to (25%) of the patients.45
In our study four drug combinations, CCB+DU+AB+CAA were prescribed to (23.3%) of the patients, followed by CCB+DU+BB+CAA were prescribed to 20% of the patients, 5 drug therapy CCB+DU+AB+BB+CAA were given to (38%) of the patients which is followed by CCB+AB+BB+CAA+VA were prescribed to (27%) of patients and in 6drug combination, the most commonly prescribed combination was CCB+DU+AB+BD+CAA+VA.
In case of patients having Hypertension and Diabetes associated with CKD,
In our study monotherapy was prescribed to 19.32%, 2 drugs were given to 28% and 3 drugs were given to 24%, 4 drugs were given to 17%, 5 drugs were given to 8% and 6 drugs were given to 1.26% of the patients which is comparable to the study conducted by Johnson et al where monotherapy was prescribed to 23.7%, 2 drugs were given to 24%, 3 and 4 drugs 18% and 15.2% of patients respectively.44
In our study, the CCBs were prescribed to 50% of the patients, followed by diuretics which were prescribed to 33 % of the patients and beta-blockers which were prescribed to 11% of the patients which is contrary to a study conducted by Shah J et al where in mono-therapy, ACEI/ARB were 65%, followed by BB which was 13.15% and Diuretics 5% and CCBs were prescribed to 4% of the patients.45
In our study, in 2 drug combination, CCBs + Diuretics were prescribed to 34.3% of the patients followed by CCBs+ CAA were prescribed to 19.4% of the patients but in the study conducted by Shah J et al showed that CCB+BB were the most prescribed drug combination which is followed by ARB+ DU and CCB+DU.45
In our study 3 drugs therapy, CCB+ DU+BB was prescribed to 23% followed by CCB+ DU+ CAA which was prescribed to 21% of the patients. But in the study conducted by Shah J et al CCB+DU+ACE were the most commonly prescribed combination i.e. 62.5% followed by DU+BB+AB which were prescribed to 25% of the patients.45
In our study 4 drug combinations, CCB+DU+AB+CAA were prescribed to 20% of the patients, followed by CCB+DU+BB+CAA were prescribed to 18% of the patients, 5 drug therapy CCB+DU+AB+BB+CAA were given to 56% of the patients which is followed by CCB+AB+BB+CAA+VA were prescribed to 11% of patients and 6 drug combination, the most commonly prescribed combination was CCB+DU+AB+BD+CAA+VA.
Antidiabetic drugs utilization pattern:
In our study, the usage of antidiabetic medications were as follows Sulphonylureas were given to 25% in that Glimepride, Gliclazide and Glipizide were given to 66%, 24.1% and 9.67% of patients respectively. Biguanides were prescribed to 2.38% of the patients (Metformin -100%), AGI i.e., Voglibose was prescribed to 7.1% of patients, DDP4 inhibitors i.e. Vildagliptin were prescribed to 0.8%, Meglitinides i.e. Repaglinide were prescribed to 0.8% and Insulin were prescribed to 71% of the patients. But in the study conducted by Rani et al, the usage of Antidiabetic medications in the study population were as follows sulphonylureas such as Glimepride and Glipizides were given to 5.2% and 1.7% of patients respectively, biguanides for 1.7%, AGI for 3.5% and insulin for 87.7% of the patients.
In our study, monotherapy was prescribed in 75.4%, 2 drug therapy was prescribed in 14.7%, 3 drug therapy was prescribed in 3.57% of the patients but in the study conducted by Kannan et al monotherapy was prescribed in 2.47% , 2 drug therapy was prescribed in 57%, 3 drug therapy was prescribed in 9.4% of the patients.48
In our study, insulins were found to be prescribed more in monotherapy which accounts for 79% followed by SU were prescribed in 18%.
In 2 drug therapy, SU+Insulin were found to be prescribed in 46% of the patients followed by AGI+insulin which accounts for 24.32%.
In 3 drug therapy, B+SU+AGI, B+SU+I, SU+AGI+I accounts for 22.2% of patients.
In case of patients having Hypertension and Diabetes associated with CKD,
In our study, the usage of antidiabetic medications were as follows Sulphonylureas were given to 23% in that Glimepride, Gliclazide and Glipizide were given to 65%, 25.4% and 9% of patients respectively. Biguanides were prescribed to 1.7% of the patients(Metformin -100%), AGI i.e., Voglibose was prescribed to 25.45% of patients, DDP4 inhibitors i.e. Vildagliptin were prescribed to 0.42%, Meglitinides i.e. Repaglinide were prescribed to 0.84% and Insulin were prescribed to 76% of the patients. But in the study conducted by Rani et al, the usage of Antidiabetic medications in the study population were as follows sulphonylureas such as Glimepride and Glipizides were given to 5.2% and 1.7% of patients respectively, biguanides for 1.7%, AGI for 3.5% and insulin for 87.7% of the patients.
In our study, monotherapy was prescribed in 67.22%, 2 drug therapy was prescribed in 15%, 3 drug therapy was prescribed in 4% of the patients but in the study conducted by Kannan et al monotherapy was prescribed in 2.47%, 2 drug therapy was prescribed in 57%, 3 drug therapy was prescribed in 9.4% of the patients.47
In our study, insulins were found to be prescribed more in monotherapy which accounts for 78% followed by SU were prescribed in 21%.
In 2 drugs therapy, SU+Insulin were found to be prescribed in 29% of the patients followed by AGI+insulin which accounts for 20%.
In 3 drugs therapy, SU+AGI+I accounts for 33.33%, SU+I+M and B+SU+AGI accounts for 22.22% of the patients.
Anti-anaemic drugs utilization pattern:
In our study, Oral iron is prescribed to 25.4%, IV iron accounts for 4.5%, IV erythropoietin accounts for 60%, Darbepoietin alpha accounts for 4.1% of patients.
Iron + ESA accounts for 12.35% of the patients.
Conclusions
In this study the drug utilisation pattern in CKD patients were analysed. From this study the following conclusions can be made
• CCBs, Diuretics and Centrally acting alpha agonists are the major drugs used to treat hypertension in CKD patients across all the stages and they are followed by Beta and Alpha blockers.
Amlodipine and Clinidipine are the major CCBs used across all the stages,they are followed by Nifedipine and Diltiazem.
Furosemide is the diuretic that is being used prominently over other diuretics like Torasemide, metolazone across all the stages of CKD.
Enalapril and Ramipril are the ACE inhibitors that are being used extensively to treat Hypertension in CKD patients.
Telmisartan and Losartan are the major ARBs used across the stages; However the usage of ARBs is not seen much in Stage-V CKD.
The major Beta blocker used is Metaprolol, followed by Carvedilol across all the stages of CKD.
Clonidine is the highly prescribed Alpha agonists which is used to treat HTN in CKD patients.
Prazosin was the only Alpha blocker present which accounts for 27% of the total patients.
Vasodilators plays a small role if we see the landscape of Antihypertensive agents; Dihydralazine sulphate is the only Vasodilator used across.
• Insulin, Sulfonyl Ureas and Alpha Glucosidase inhibitors are the major anti-diabetic drugs used across the stages of CKD.
Anti-diabetic Monotherapy holds the major share across the stages of CKD.
• There was no significant difference found in the pescribing pattern of antihypertensive and antidiabetic drug between CKD patients with hypertentension, diabetes and CKD patients with both hypertension and diabetes.
• In the initial stages of CKD Iron+Folic acid is used to treat Anaemia, but in the advanced stages IV Erythropoeitin is used.