Anti-hypertensive medicines prescribing for medical outpatients in a premier teaching hospital in Nigeria: a probable shift of paradigm

  • Unyime I. Eshiet
  • Kazeem B. Yusuff
Keywords: Antihypertensive Agents, Angiotensin-Converting Enzyme Inhibitors, Calcium Channel Blockers, Drug Utilization, Nigeria



Background: Previous studies of anti-hypertensive medicines utilization pattern in Nigeria showed that Angiotensin converting enzyme inhibitors (ACEIs) were often the least prescribed. However, the appropriate use of ACEIs in the black population achieves good blood pressure control and provides additional long term cardio- and renovascular protection benefits.


Objective: To assess the current utilization pattern of anti-hypertensive medicines with specific emphasis on identifying possible shift in the frequency of use of ACEIs.


Methods: A prospective cross-sectional assessment of the current utilization pattern of anti-hypertensive medicines was conducted among 300 randomly selected cohort at a 900-bed premier Teaching Hospital located in Ibadan, Southwestern Nigeria. The current utilization pattern was compared with the results of a study conducted at the same site and published 10 years ago.


Results: Of the 300 random cohorts, a majority (79%) were females (237) with mean age 58.7 years (SD=2.81 years. Stage 2 hypertension was the most frequent diagnosis (54.3%). The utilization of ACEIs and long acting CCB (amlodipine) significantly increased from 8.6% and 21% (Ten years ago) to 29.93% and 36.68% respectively (p ˂ 0.0001). The use of thiazide diuretic and methyldopa declined significantly from 39.4% and 23.3% (Ten years ago) to 16.12% and 9.7% respectively (p ˂ 0.0001). Adverse drug reactions due to ACEIs were documented in 1.5% (3), while laboratory monitoring of serum potassium, urea and creatinine was conducted in only 37% (111) of cohort. Potentially harmful drug-drug interactions were identified in 25% (75) of cohorts, and the most frequent were ACEIs + NSAIDs (53.3%), ACEIs + amiloride / hydrochlorothiazide (22.6%).


Conclusions: Anti-hypertensive medicines utilization has significantly shifted towards the increased use of ACEIs and long acting dihydropyridine CCBs. The use of thiazides and methyldopa has declined significantly. Physicians appeared more cognizant of the long term cardio- and renovascular benefits inherent in using ACEIs in a high cardiovascular risk group such as black hypertensive.


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Author Biographies

Unyime I. Eshiet

MPharm Candidate,

Department of Clinical Pharmacy & Pharmacy Admnstration,

Faculty of Pharmacy

Kazeem B. Yusuff

Assistant Professor,

Department of Pharmacy Practice, College of Clinical Pharmacy



1. World Health Report: Reducing risks, promoting healthy life. Geneva, Switzerland: World Health Organization.2002. (Accessed Feb 14, 2014).

2. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R; Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: A meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360(9349):1903-1913.

3. Vasan RS, Larson MG, Leip EP, Evans JC, O’Donnell CJ, Kannel WB, Levy D. Impact of high normal blood pressure on the risk of cardiovascular disease. N Engl J Med. 2001;345(18):1291-1297.

4. James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, Lackland DT, LeFevre ML, MacKenzie TD, Ogedegbe O, Smith SC Jr, Svetkey LP, Taler SJ, Townsend RR, Wright JT Jr, Narva AS, Ortiz E. 2014 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). JAMA. 2014;311(5):507-520. doi: 10.1001/jama.2013.284427

5. Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Böhm M, Christiaens T, Cifkova R, De Backer G, Dominiczak A, Galderisi M, Grobbee DE, Jaarsma T, Kirchhof P, Kjeldsen SE, Laurent S, Manolis AJ, Nilsson PM, Ruilope LM, Schmieder RE, Sirnes PA, Sleight P, Viigimaa M, Waeber B, Zannad F, Redon J, Dominiczak A, Narkiewicz K, Nilsson PM, Burnier M, Viigimaa M, Ambrosioni E, Caufield M, Coca A, Olsen MH, Schmieder RE, Tsioufis C, van de Borne P, Zamorano JL, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C, Erol C, Fagard R, Ferrari R, Hasdai D, Hoes AW, Kirchhof P, Knuuti J, Kolh P, Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Sirnes PA, Tamargo JL, Tendera M, Torbicki A, Wijns W, Windecker S, Clement DL, Coca A, Gillebert TC, Tendera M, Rosei EA, Ambrosioni E, Anker SD, Bauersachs J, Hitij JB, Caulfield M, De Buyzere M, De Geest S, Derumeaux GA, Erdine S, Farsang C, Funck-Brentano C, Gerc V, Germano G, Gielen S, Haller H, Hoes AW, Jordan J, Kahan T, Komajda M, Lovic D, Mahrholdt H, Olsen MH, Ostergren J, Parati G, Perk J, Polonia J, Popescu BA, Reiner Z, Rydén L, Sirenko Y, Stanton A, Struijker-Boudier H, Tsioufis C, van de Borne P, Vlachopoulos C, Volpe M, Wood DA. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34(28):2159-219. doi: 10.1093/eurheartj/eht151

6. Flack JM, Sica DA, Bakris G, Brown AL, Ferdinand KC, Grimm RH Jr, Hall WD, Jones WE, Kountz DS, Lea JP, Nasser S, Nesbitt SD, Saunders E, Scisney-Matlock M, Jamerson KA; International Society on Hypertension in Blacks. Management of high blood pressure in Blacks: an update of the International Society on Hypertension in Blacks consensus statement. Hypertension. 2010;56(5):780-800. doi: 10.1161/HYPERTENSIONAHA.110.152892

7. Kadiri S, Olutade BO. The clinical presentation of malignant hypertension in Nigerians. J Hum Hypertens. 1991;5(4):339-343.

8. Kadiri S, Olutade BO, Osobamiro O. Factors influencing the development of malignant hypertension in Nigeria. J Hum Hypertens. 2000;14(3):171-174.

9. Yusuff KB, Balogun OB. Pattern of drug utilization among hypertensives in a Nigerian teaching hospital. Pharmacoepidemiol Drug Saf. 2005;14(1):69-74.

10. Etuk E, Isuezo SA, Chika A, Akuche J, Ali M. Prescription pattern of antihypertensive drugs in a tertiary health institution in Nigeria. Ann Afr Med. 2008;7(3):128-132.

11. Adigun AQ, Ishola DA, Akintomide AO, Ajayi AA. Shifting trends in the pharmacologic treatment of hypertension in a Nigerian tertiary hospital: a real-world evaluation of the efficacy, safety, rationality and pharmaco-economics of old and newer antihypertensive drugs. J Hum Hypertens. 2003;17(4):277-285.

12. Tamuno I. Fadare J. Drug treatment for hypertension in a tertiary health care facility in Northern Nigeria. Int J Pharm Biomed Res. 2011;2(2):104-109.

13. Katibi IA. Olarinoye JK. Antihypertensive therapy among hypertensive patients as seen in the middle belt of Nigeria. Ann Afr Med 2004;3:177-180.

14. Yusuff KB, Balogun O. Physicians’ prescribing of antihypertensive combinations in a tertiary care setting in Southwestern Nigeria. J Pharm Pharm Sci. 2005;8(2):235-242.

15. ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA. 2002;288(23):2981-2997.

16. Lopes AA. Hypertension in black people: pathophysiology and therapeutic aspects. J Hum Hypertens. 2002;16(Suppl 1):S11-S2.

17. Mokwe E, Ohmit SE, Nasser SA, Shafi T, Saunders E, Crook E, Dudley A, Flack JM. Determinants of blood pressure to quinapril in black and white hypertensive patients: the Quinapril Titration Interval Management Evaluation Trial. Hypertension. 2004;43(6):1202-1207.

18. Flack JM1, Yunis C, Preisser J, Holmes CB, Mensah G, McLean B, Saunders E: ATIME Research Group. The rapidity of drug dose escalation influences blood pressure response and adverse effects burden in patients with hypertension: the Quinapril Titration Interval Management Evaluation (ATIME) Study. Arch Intern Med. 2000;160(12):1842-1827.

19. Fenves A, Ram CV. Are angiotensin converting enzyme inhibitors and angiotensin receptor blockers becoming the treatment of choice in African-American? Curr Hypertens Rep. 2002 Aug;4(4):286-289.

20. Douglas JG, Agodoa L. ACE inhibiton is effective and renoprotective in hypertensive nephrosclerosis: the African American Study of Kidney Disease and Hypertension (AASK) trial. Kidney Int Suppl. 2003;(83):S74-S76.

21. Kizer JR, Arnett DK, Bella JN, Paranicas M, Rao DC, Province MA, Oberman A, Kitzman DW, Hopkins PN, Liu JE, Devereux RB. Differences in left ventricular structure between black and white hypertensive adults: the Hypertension Genetic Epidemiology Network study. Hypertension. 2004;43(6):1182-1188.

22. Bild DE, Bluemke DA, Burke GL, Detrano R, Diez Roux AV, Folsom AR, Greenland P, Jacob DR Jr, Kronmal R, Liu K, Nelson JC, O'Leary D, Saad MF, Shea S, Szklo M, Tracy RP. Multi-ethnic study of atherosclerosis: objectives and design. Am J Epidemiol. 2002;156(9):871-881.

23. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ; Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42(6):1206-1252.

24. British National Formulary (BNF). London: BMJ Publishing Group and Royal Pharmaceutical Society of Great Britain; 2010.

25. Elliott WJ, Meyer PM. Incident diabetes in clinical trials of antihypertensive drugs: a network meta-analysis. Lancet. 2007;369(9557):201-207.

26. Carlsen JE, Køber L, Torp-Pedersen C, Johansen P. Relation between dose of bendrofluazide, antihypertensive effect, and adverse biochemical effects. BMJ. 1990;300(6730):975-978.

27. Barzilay JI, Davis BR, Cutler JA, Pressel SL, Whelton PK, Basile J, Margolis KL, Ong ST, Sadler LS, Summerson J; ALLHAT Collaborative Research Group. Fasting glucose levels and incident diabetes mellitus in older nondiabetic adults randomized to receive 3 different classes of antihypertensive treatment: a report from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Arch Intern Med. 2006;166(20):2191-2201.

28. Zillich AJ, Garg J, Basu S, Bakris GL, Carter BL. Thiazide diuretics, potassium, and the development of diabetes: a quantitative review. Hypertension. 2006;48(2):219-224.

29. Carter BL, Einhorn PT, Brands M, He J, Cutler JA, Whelton PK, Bakris GL, Brancati FL, Cushman WC, Oparil S, Wright JT Jr; Working Group from the National Heart, Lung, and Blood Institute. Thiazide-induced dysglycemia: call for research from a working group from the national heart, lung, and blood institute. Hypertension. 2008;52(1):30-6. doi: 10.1161/HYPERTENSIONAHA.108.114389

30. Franse LV, Pahor M, Di Bari M, Somes GW, Cushman WC, Applegate WB. Hypokalemia associated with diuretic use and cardiovascular events in the Systolic Hypertension in the Elderly Program. Hypertension. 2000;35(5):1025-1030.

31. Parati G, Pomidossi G, Albini E, Malaspina D, Mancia G. Relationship of 24 hour blood pressure mean and variability to severity of target organ damage in hypertension. J Hypertens. 1987;5(1):93-98.

32. Thomas MC. Diuretics, ACE inhibitors and NSAIDS - the triple whammy. Med J Aust. 2000;172(4):184-185.

33. Abuelo JG. Normotensive ischemic acute renal failure. N Engl J Med. 2007;357(8):797-805.

34. Morgan T, Anderson A. The effect of non-steroidal anti-inflammatory drugs on blood pressure in patients treated with different anti-hypertensive drugs. J Clin Hypertens (Greenwich). 2003;5(1):53-57.

35. White WB. Cardiovascular effects of the cyclooxygenase inhibitors. Hypertension. 2007;49(3):408-418.

36. Radosević N, Gantumur M, Vlahović-Palcevski V. Potentially inappropriate prescribing to hospitalized patients. Pharmacoepidemiol Drug Saf. 2008;17(7):733-737.
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