A prospective observational study on drug utilization evaluation of antihypertensives in a tertiary care hospital

 Corresponding author: DURGA PRASAD THAMMISETTY Copyright © 2025 Author(s) retain the copyright of this article. This article is published under the terms of the Creative Commons Attribution Liscense 4.0. A prospective observational study on drug utilization evaluation of antihypertensives in a tertiary care hospital DURGA PRASAD THAMMISETTY *, E THULASI M. HARI DEEPIKA and M HEMANTH YADHAV Department of Pharmacy Practice, Sri Padmavathi School of Pharmacy, Tirupati, Andhra Pradesh, India. World Journal of Biology Pharmacy and Health Sciences, 2025, 21(01), 451-459 Publication history: Received on 19 November 2024; revised on 06 January 2025; accepted on 08 January 2025 Article DOI: https://doi.org/10.30574/wjbphs.2025.21.1.1087 Abstract Background: Since hypertension plays a part in the development of major cardiovascular disorders and renal diseases, it is considered a serious health issue. To guarantee safe and effective treatment, a periodic evaluation of the drug utilization pattern in a tertiary care teaching hospital necessitates a study on antihypertensive consumption. Objective: To determine drug utilization evaluation of antihypertensives in the inpatient department at the tertiary care hospital. Method: It was a prospective observational study carried out at department of medicine, Sri Venkateswara Ramnaraian Ruia (SVRR) Government General Hospital, Tirupati, over a period of 6 months (September 2023 to February 2024). A total 150 patients were included for study and were assessed by patient treatment chart, patient past history, patient laboratory data and patient interview. Results: 150 patients of which 57% were males and 43% were females, out of them 62% were prescribed monotherapy antihypertensives, 29% with two-drug therapy, and 9% were prescribed with three-drug therapy. Among that 72% were receiving CCB, 20% with BB, 7% with ARB, and 1% with ACEI. In this investigation, significant variations in the use of various antihypertensive drug groups were found. Conclusion: These studies provide a general overview of the antihypertensive medicine prescription pattern and rational drug use Keywords: Hypertension; Antihypertensive; Systolic blood pressure; Diastolic blood pressure 1. Introduction Hypertension, often known as high blood pressure, is defined as a persistently elevated systolic blood pressure of 140 mm Hg or higher and/or a diastolic blood pressure of 90 mm Hg or higher. cardiovascular, cerebrovascular, or renal diseases can increase the risk of morbidity and mortality from untreated or insufficiently controlled hypertension. It was shown that the following factors were significant independent predictors of hypertension: drinking, smoking, being older, and male gender. Many drugs are required by most hypertensive patients in order to attain ideal blood pressure control. Expert panels recommend adopting combination treatments using two or more medications to treat patients who are at high risk, have higher blood pressure. However, the use of many medications lowers patient compliance. Patients on fixed-dose combination therapy are able to achieve the target blood pressure because of improved patient compliance.1 World Journal of Biology Pharmacy and Health Sciences, 2025, 21(01), 451-459 452 With the ultimate goal of improving medication-related outcomes for a group of patients or consumers, a Drug Use Evaluation (DUE) or Medication Use Evaluation (MUE) program is a planned, criteria-based, systematic procedure for tracking, assessing, and continuously improving medication use. Every venue where pharmacological care is given can benefit from the MUE improvement approach. Because of their background in pharmaceutical care, pharmacists are integral to a DUE program's general operation. This gives pharmacists the chance to spot patterns in patient prescriptions, such as those for people with diabetes, asthma, or high blood pressure. The pharmacist then takes the necessary steps to enhance the drug therapy in collaboration with the doctor and other medical teams.3 Given the rising prevalence of hypertension, the growing number of new antihypertensive medications, the growing number of drug combinations that are brought to market annually, and changes in guidelines, it is imperative that antihypertensive prescribing patterns be regularly evaluated. The goal of the current study is to examine the patterns of antihypertensive medication use in tertiary care hospitals.4 2. Material and methods Iwast a Prospective observational study carried at department of medicine of Sri Venkateswara Ramnaraian Ruia (SVRR) Government General Hospital, Tirupati, over a period of 6 months(September 2023 to February 2024). It is an a tertiary care teaching hospital.The study was approved by the institutional ethical committee with proposal no: SPSP/20232024/PD05. the study was conducted guidelines in acccordance with the ethical principles of the ethical committee . 2.1. Study population Inpatients of either gender aged ≥18 years with denovohypertention, know case of Hypertension with comorbidities and Patients receiving antihypertensive drugs were outlined as the main criteria for the inclusion of the patient prescription to the study sample. Patients attending outpatient department and patients with gestational hypertension, Psychiatric patients, Pulmonary and portal hypertension patients were excluded from the study.Upon applying the inclusion and exclusion criteria, a sample of n = 150 patient charts was considered for the analysis 2.2. Method of Data collection: Study participants were identified and selected based on inclusion and exclusion criteria in inpatient of general medicine wards were reviewed on daily basis. All of these individuals' medication information was gathered and entered into a data collection form. The information gathered from research participants includes • Sociodemographic information on the patient, including age, sex, weight, etc. • Disease specific information like past medical history, reason for admission, allergies, Risk factors and Comorbidities. • Medication history including drug administered, route of administration, dose, dosage, drugs involved in type of drug related problems, reason for intervention, suggestion made by student pharmacist. • The patient charts were assessed for obtaining the prescribing pattern, rationality, drug related Problems including adverse drug reaction, drug interaction, failure to receive drug and drug use without indication using Micromedex and JNC 8 guidelines. Statistical techniques were used to examine the effectiveness of hypertension medications. 2.3. Statistical analysis The statistical analyses were conducted using the software R programming. Difference between means of two groups were compared using a paired t test and a p-value below 0.05 was deemed statistically significant. 3. Results 3.1. Gender wise distribution of study population Out of 150 patients, males share a larger proportion 85(57%) than females 65(43%) 3.2. Age-wise distribution of the study populations Out of 150 patients, the majority of patients were under the age group of 60-69 years contributing 43(29%), followed by 70-79 years with 36(24%) patients and 20-29 years with 3(2%). World Journal of Biology Pharmacy and Health Sciences, 2025, 21(01), 451-459 453 3.3. Distribution of the study population based on stages of hypertension according to JNC VIII Out of 150 study population, 66(44%) patients had prehypertension followed by 46(31%) patients had stage I hypertension. 3.4. Distribution of the study population based on risk factors Among the study populations, the majority of patients 127(45%) were in the above 50 age group, 60(21%) patients had no physical activity, and 2(1%) patients chewed tobacco. 3.5. Distribution of the study population based on complications Among 86 (57.33%) patients with complications, 70 (81.39%) patients had single complications remaining 16(18.61%) had multiple complications. Among 70 (81.39%) patients who had single complications, the majority of patients 47(67.14%) were affected with CKD, 10 (14.29%) were affected with stroke, lowest patients 1(1.43%) were affected with HRS.Among 16(18.61%) patients who had multiple complications, the majority of patients 7 (43.75%) were affected with CKD and HF Figure 1 Distribution of the study population based on THPE of therapy Out of 150 patients 92(62%) patients were with mono therapy, 44(29%) patients were with dual therapy and 14(9%) patients were with multiple therapy 3.6. Distribution of the study population based on mono therapy among 92(62%) patients who had mono therapy, the most of patients 54(59%) Were prescribed amlodipine, 12(13%) were prescribed both cilnidipine and metoprolol, 6(7%) were prescribed telmisartan, 4(4%) were prescribed atenolol, 3(3%) were prescribed propranolol and one patient was using enalapril. 3.7. Distribution of the study population based on dual therapy Among 44(29%) who have had dual therapy, the majority of patients12 (27%) were prescribed CCB & ARB, followed by 11 (26%) patients were prescribed CCB & BB , 9(20%) patients were prescribed CCB & AB, 5(11%) patients were prescribed others, 3(7%) patients were prescribed CCB & ABB, 2(5%) patients were prescribed BB & ARB and 2(5%) patients were prescribed BB & ACEI 3.8. Distribution of the study population based on drug interactions Out of 150 patients, the majority of patients 86(57%) had no type of drug-drug interactions, 52(34%) patients had antihypertensive drugs with other drug interactions, 9(6%) patients had both interactions and 4(3%) patients had antihypertensive drug interactions. 3.9. Distribution of the study population based on severity of drug interaction Out of 150 patients, 64 patients were having drug interactions in their prescriptions. A total of 86 drug interactions were observed of which 50 were moderate 35 were major and 1 were minor. World Journal of Biology Pharmacy and Health Sciences, 2025, 21(01), 451-459 454 Table 1 Effect of mono therapy antihypertensive drugs on patient's hypertension Blood pressure (mean ± sem) On admission On discharge P-value T-value Amlodipine Sbp 132.8 ± 2.005 123.8 ± 1.593 0 7.5638 Dbp 87.6 ± 0.986 83.4 ± 0.988 0.0001 4.1303 Cilnidipine Sbp 131.7 ± 4.741 120 ± 4.082 0.0012 4.3112 Dbp 89.2 ± 2.289 83.3 ± 3.098 0.0463 2.2444 Metoprolol Sbp 131.7 ± 5.05 123.3 ± 3.333 0.0054 3.4578 Dbp 89.2 ± 1.93 86.7 ± 2.562 0.1911 1.3933 Propranolol Sbp 136.7 ± 8.819 123.3 ± 3.333 0.1835 2 Dbp 90 ± 5.774 86.7 ± 3.333 0.4226 1 Atenolol Sbp 130 ± 4.082 122.5 ± 2.5 0.2152 1.5667 Dbp 82.5 ± 2.5 80 ± 0 0.391 1 Telmisartan Sbp 138.3 ± 7.032 128.3 ± 4.773 0.0409 2.7386 Dbp 90 ± 2.582 85 ± 3.416 0.0756 2.2361 All the values are expressed as mean± SEM, *p<0.05, **p<0.01,and ***p<<0.00. [paired Student t-test] as compared to blood pressure on admission. Table 2 Effect of dual therapy antihypertensive drugs on patient's hypertension Blood pressure (mean ± sem) On admission On discharge P-value T-value Amlodipine+metoprolol Sbp 147.1 ± 5.654 124.3 ± 2.974 0.0068 4.0423 Dbp 92.9 ± 2.857 81.4 ± 2.608 0.0152 3.3607 Amlodipine+atenolol Sbp 155 ± 5 125 ± 5 0.0513 4.2426 Dbp 105 ± 5 85 ± 5 0.1056 2.8284 Cilnidipine+metoprolol Sbp 130 ± 10 120 ± 0 0.5 1 Dbp 85 ± 5 80 ± 0 0.5 1 Amlodipine+prazosin Sbp 142.9 ± 6.061 124.3 ± 2.02 0.0107 3.6527 Dbp 90 ± 4.88 81.4 ± 2.608 0.0167 3.2863 Amlodipine+telmisartan Sbp 142.9 ± 2.857 124.3 ± 2.02 0.0037 4.5962 World Journal of Biology Pharmacy and Health Sciences, 2025, 21(01), 451-459 455 Dbp 91.4 ± 2.608 82.9 ± 1.844 0.0167 3.2863 Metoprolol+telmisartan Sbp 115 ± 5 110 ± 0 0.5 1 Dbp 75 ± 5 75 ± 5 0 0 Metoprolol+enalapril Sbp 125 ± 25 115 ± 15 0.5 1 Dbp 85 ± 15 75 ± 5 0.5 1 Amlodipine+labetalol Sbp 166.7 ± 8.819 123.3 ± 3.333 0.0229 6.5 Dbp 103.3 ± 6.667 76.7 ± 3.333 0.0942 3.0237 All the values are expressed as mean± SEM, *p<0.05, **p<0.01 [paired Student t-test] as compared to blood pressure on admission. Table 3 Effect of multiple therapy antihypertensive drugs on patient's hypertension Blood pressure (mean ± sem) On admission On discharge P-value T-value Amlodipine +metoprolol+ labetalol SBP 180 ± 0 125 ± 5 0.0577 11 DBP 105 ± 5 80 ± 10 0.1257 5 Cilnidipine+metoprolol+prazosin SBP 165 ± 5 125 ± 5 0.0299 5.6569 DBP 90 ± 0 75 ± 5 0.2048 3 Amlodipine+metoprolol+telmisartan+labetalol SBP 175 ± 5 130 ± 0 0.0704 9 DBP 110 ± 0 85 ± 5 0.1257 5 All the values are expressed as mean± SEM, *p<0.05. [paired Student t-test] as compared to blood pressure on admission. Table 4 comparison of efficacy between mono, dual, and multiple therapy of amlodipine Drug Blood pressure Mean ± sem P-value T-value Amlodipine (n=54) Mean reduction in sbp 9 ± 1.19 0 7.5638 Mean reduction in dbp 4.1 ± 1.004 0.0001 4.1303 Amlodipine+ telmisartan (n=12) Mean reduction in sbp 18.6 ± 4.041 0.0037 4.5962 Mean reduction in dbp 8.6 ± 2.608 0.0167 3.2863 Amlodipine+telmisartn + Metoprolol+labetalol (n=2) Mean reduction in sbp 45 ± 5 0.0704 9 Mean reduction in dbp 25 ± 5 0.1257 5 Reduction in SBP = SBP on admission – SBP on discharge; Reduction in DBP = DBP on admission – DBP on discharge World Journal of Biology Pharmacy and Health Sciences, 2025, 21(01), 451-459 456 Table 5 Comparison of efficacy between mono, dual, and multiple therapy of metoprolol Drug Blood pressure Mean ±sem P-value T-value Metoprolol (n=12) Mean reduction in sbp 8.3 ± 2.41 0.0054 3.4578 Mean reduction in dbp 2.5 ± 1.794 0.1911 1.3933 Metoprolol+amlodipine (n=7) Mean reduction in sbp 22.9 ± 5.654 0.0068 4.0423 Mean reduction in dbp 11.4 ± 3.401 0.0152 3.3607 Metoprolol+amlodipine +labetalol (n=2) Mean reduction in sbp 55 ± 5 0.0577 11 Mean reduction in dbp 25 ± 5 0.1257 5 Reduction in SBP = SBP on admission – SBP on discharge; Reduction in DBP = DBP on admission – DBP on discharge Table 6 identified ADRs reported Class of antihypertensive Drug name Adverse even experienced No of patients (n=8) CCB Amlodipine Hyperpigmented nodules 1 4(50%) Swelling of lls, from ankle extended to knee 1 Sob 1 Headache 1 BB Metoprolol Decreased heart rate 1(12.5%) ARB Telmisartan Blurred vision 1(12.5%) ACEI Enalapril Hypotension 1(12.5%) AB Prazosin Rash 1(12.5%) 4. Discussion The study of drug use may shed light on various facets of drug use and prescription, including patterns, quality, determinants, and outcomes of drug use. Among the participants in the study, men were more affected (57%) than women in terms of gender. Elevated levels of androgen, such as testosterone, are thought to be the reason for the larger proportion of male patients since they contribute to blood pressure elevation.8, 11, 18, The prevalence of hypertension was 2% in the 18–29 age group and 29% in the 60–69 age group.Most of the patients belonged to the 50–70 age range. This population may have a higher prevalence of hypertension as a result of lifestyle modifications, comorbid illnesses, complications from hypertension, or poor treatment compliance. 1,2,11 Hypertension was staged following JNC VIII recommendations. Of the 150 patients, the majority of the patients 66 (44%) had prehypertension, 46 (31%) had stage I hypertension, and the lowest members13 (8%) had stage II hypertension.2;7,8,12, Risk factors for a higher prevalence of hypertension include aging, drinking, smoking, chewingtobacco, no physical activity, and heredity. Among the 150 participants, 127 patients had hypertension as a result of their advanced age. 88 had hypertension as a result of no physical activity. 53 people had hypertension as a result of drinking as a risk factor. 36 patients were smokers. Six individuals had genetically caused hypertension.2,7 Out of 150 patients, 86(87.33%) patients were with complications which included both single70(81.39) and multiple16(18.61%) complications. Among single complications, the majority of the patients 47(67.14%) were affected with CKD, 10(14.29%) patients were affected with stroke, and the lowest 1(1.43%) was affected with HRS.9 Among World Journal of Biology Pharmacy and Health Sciences, 2025, 21(01), 451-459 457 multiple complications, the majority of patients 7(43.75%) were affected with CKD and HF, and the lowest patients 2(12.5%) were affected with stroke and CKD Among the 150 patients, 92(62%) received monotherapy, 44(29%) received dual therapy and 14(9%) received multiple therapy.13,14,15 The current study found that single-drug therapy was used more frequently than multiple-drug therapy. This can be because of the patient's compliance, favorable response, and minimal frequency of side effects.11,12,17A study by Kale A. et al. [11] Rachana Pret al. [12], and Joseph et al. [17] found that CCBs were the most often utilized class of drugs, which is consistent with the results of our analysis. CCBs and ARBs 12 (27%) are the dual antihypertensive drugs that are prescribed the most, followed by CCBs and BBs 11 (26%).12 In our analysis, the use of amlodipine, the CCB, as an antihypertensive agent outpaces that of any other antihypertensive medication. The lengthy duration of action and once-daily dosage, which enhance patient compliance and allow for sustained and regulated blood pressure management, are the qualities that make it an excellent antihypertensive medication. Similar patterns have also been observed in research conducted by Rachana et al. and Xavier et al. [12,13]While studying the efficacy of mono and dual therapy in our study it was observed that monotherapy showed more significance than dual therapy. This was opposed by Shalavad HM et al. [1] Out of 150 patients, 64 (53%) patients had drug-drug interaction and the remaining 86(57%) patients had no drugdrug interaction. Among 64 (53%) patients, the majority of the patients 52(34%) had antihypertensive drugs with other drug interactions, 9(6%) patients had both interactions and 4(3%) patients had antihypertensive drug-drug interactions, These outcomes were comparable to those of Shalavad HM et al. [1], Out of 150 patients, 64 patients were having drug interactions in their prescriptions. A total of 86 drug interactions were observed of which 24 were major 13 were minor and 6 were moderate. Out of 150 patients, 8 ADRs were recorded. Four (50%) of the eight adverse drug reactions were caused by amlodipine.The other four ADRs were 12.5% Metoprolol, 12.5% Telmisartan, 12.5% enalapril, and 12.5% prazosin these results were supported by Baig MA et al. [8], Shalavad HM et al. [1] According to recommendations made by the JNC VIII guidelines, first-line drugs for the management of hypertension can be any one of the four drug classes CCBs, ARBs, ACEIs, and diuretics. The fact that CCBs are prescribed more frequently than other antihypertensive medications indicates that the prescribing pattern complies with the guidelines. Compared to other medications, amlodipine use was high in our study. 4.1. Complication Hypertension is a progressive and complex disorder that is difficult to treat effectively in the long term. Evaluate the antihypertensive medication use pattern in the general medicine department utilizing the current study. This study has shed light on the prescribing practices for antihypertensive drugs concerning the degree of blood pressure management. In this study, post-analysis of 150 case sheets, denoted that the physicians preferred single drug therapy more than multiple drug therapy and the most frequently prescribed class was the CCBs class of antihypertensive agents. Among CCBs, amlodipine was the most frequently utilized antihypertensive drug. The knowledge and prescription of the drug were concluded to be the baseline idea of ADRs and drug interaction of antihypertensive drugs in hypertensive patients. The ADRs were identified and reported to the pharmacovigilance center. Patients too need to show their desire in knowing more about the drugs they have been prescribed, and proper counseling regarding antihypertensive drug interactions can promote safe knowledge of their condition and particular treatment, which would improve their quality of life. According to our study examination of antihypertensive drug use, the JNC VIII Guidelines were compared for the treatment of hypertension. Most of the patients' drug prescriptions do not follow JNCVIII guidelines, other than empirical therapy was followed for the treatment of hypertension due to various comorbidities and complications of the patients. 5. Conclusion The Eighth Report of the JNC on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8) guidelines for the treatment of hypertension were fully complied with by the prescribing pattern, according to our study's analysis of antihypertensive medication usage. CCBs were the preferred medication for hypertensive patients, and monotherapy was consistently more advised in the early stages of hypertension to reach the target blood pressure goal.The baseline understanding of adverse drug reactions (ADRs) of antihypertensive medications in hypertension patients who visited the outpatient department of a tertiary teaching care hospital in India was determined by the knowledge and prescription of the medication. We can conclude from this study that all of the prescriptions were reasonable; nonetheless, further adjustments must be made to the way antihypertensive medications are prescribed World Journal of Biology Pharmacy and Health Sciences, 2025, 21(01), 451-459 458 for people with hypertension. In order to improve quality of life, patients must give knowledge and appropriate counselling about medication adverse drug reactions. Compliance with ethical standards Disclosure of conflict of interest No conflict of interest to be disclosed. Statement of informed consent Informed consent was obtained from all individual participants included in the study. References [1] Shalavadi MH, Chandrashekhar VM, George J, Skaria AM, and Siby S. Drug Use Evaluation of Antihypertensive Drugs Prescribed for In-patients at Tertiary Care Teaching Hospital. RGUHS Journal of Pharmaceutical Sciences, 2015;5 (2):16-29. [2] Akhila James et al. Drug Utilization Pattern of Antihypertensive Drugs in A Tertiary Care Teaching Hospital in Davangere. Indo-American Journal of Pharmaceutical Research.2017:7(07):198-204. [3] Islam H, D. B., Abedini, D. A., Suvijin C, D., Shinad AV, D., MH, S., Kumar G, D. M., & Venkataraman, D. R. (2021, November 2). Drug Utilization Evaluation of Antihypertensive In A Tertiary Care Teaching Hospital. Journal of the University of Shanghai for Science and Technology, 23(11), 930-950. [4] Eslampanah Z. Drug Utilization evaluation of antihypertensive agents in a medical care hospital. International Journal Pharmaceutical Sciences and Research, 2016;7(2): 862-867. [5] Asif Baig, M. A., & Altaf, N. (2021, March 27). Drug Utilization Pattern of Antihypertensive Drugs at Tertiary Care Teaching Hospital. EAS Journal of Pharmacy and Pharmacology, 2021;3(2): 45-50. [6] Suthar J, Shah P, Patel K, Pathak P. A Study On Drug Utilization In Hypertension In Medical Care Hospital. Indian Journal of Public Health Research & Development, 2020;11(3). [7] Mankadavath, A., Chandrasekhar, D., Thomas, T., Zuhra, F.,Kaipanthodi, S., & Parambil, J. C.(2014, Augst 19). A prospective drug use evaluation of antihypertensive drugs in in-patients of tertiary referral care hospital. Journal of basic and clinical physiology and pharmacology, 2014;26(3):295-300. [8] Ramadas, S., Sujath, M. B., Andrews, M. A., & K. B., S. (2019, January 24). Drug Utilization Study of Antihypertensive drugs and Prevalence of blood pressure control in adult Hypertensive patients based on JNC VIII Guidelines In A Tertiary Care Hospital: a Cross-sectional Study. International Journal of Basic & Clinical Pharmacology, 2019;8(2): 245-252. [9] Akhila James et al. Drug Utilization Pattern of Antihypertensive Drugs in A Tertiary Care Teaching Hospital in Davangere. Indo-American Journal of Pharmaceutical Research.2017:7(07):198-204. [10] Adake P, Bhat, NP, Nayak, RP, Hafis, T, Bhagyashree, A, Raj, PV. Study on the prescribing pattern of antihypertensive drugs in a tertiary care hospital. Adv Pharmacol Pharm.2017;5(2):2124. [11] Kale A, Maniyar YA, Kale A. Prescribing Patterns of Antihypertensive Drugs in A Tertiary Care Hospital. SchAcad J Pharm,2013;2(5):416–418. [12] Rachana PR, Anuradha HV, Shivamurthy M. Antihypertensive prescribing patterns and cost analysis for primary hypertension: A retrospective study. J Clin Diagn Res 2014;8(9): HC19-22. [13] Torvi JR, Narendra SH. Prescription Pattern of Antihypertensive Drugs in a Tertiary Hospital. J Pharm Biomed Sci. 2011;9(9). [14] Tandon V, Sharma S, Mahajan S, Mahajan A, Khajuria V, Mahajan V, 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(2):78-83. [15] Konwar M, Paul PK, Das S. Prescribing pattern of antihypertensive drugs in essential hypertension in medicine outpatients department in a tertiary care hospital. Asian J Pharm Clin Res. 2014;7(2):142-144. World Journal of Biology Pharmacy and Health Sciences, 2025, 21(01), 451-459 459 [16] Datta S. Utilization study of antihypertensives in South Indian tertiary care teaching hospital and adherence to standard treatment guidelines. J Basic Clin Pharm 2016;8(1):33-37. [17] Paradkar SG, Sinha, SR. (2018). Drug utilization among hypertensive patients in the outpatient department of medicine in a tertiary care hospital: a cross-sectional study. Clin Exp Hypertens. 2018;40(2):150154. [18] Brianna A, Ammunition A, spirits A, Debussy A, and Kumar A. Drug utilization study of antihypertensive medications in a tertiary care hospital in Tamilnadu. World J pharma Sci. 2016:5(10):1534-1540.