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EVALUATING ANTI-HYPERTENSIVE DRUGS’ SUITABILITY BASED
ON THE HOSPITAL FORMULARY IN THE HOSPITAL’S
PHARMACEUTICAL INSTALLATION
Retno Fitriati
*
, Chusun
Pharmacy Academy of Bhumi Husada Jakarta, East Jakarta, DKI Jakarta, Indonesia
*
retnokartikadewi@gmail.com
PAPER INFO ABSTRACT
Received: March
2022
Revised: April
2022
Approved: April
2022
Background: Hypertension is a disease characterized by an increase in blood
pressure> 140/90 mmHg. Hypertension patients usually seek treatment using
a BPJS card. Medications used for BPJS patients must be in accordance with
the established Hospital Formulary.
Aim: This study aims to determine the suitability of the use of anti-
hypertension drugs based on the Hospital’s Formulary and the Hypertension
Therapy Algorithm.
Method: This research is a descriptive study with data collection
retrospectively with the research instrument being a prescription for
hypertension patients. The population in this study was the prescription of
Anti-Hypertension drugs in the RS. Jantung Diagram Siloam Cinere – Depok
in the period August to October 2015.
Findings: From the results of the study there were 50,816 samples of anti-
hypertensive drugs for 3 months consisting of August 16,807 drugs,
September 16,322 drugs, and October 17687. From these data obtained all
patients get a prescription in accordance with Formulary Hospital. Based on
the results of the study, it can be concluded that patients who get a
prescription according to the Hospital Formulary as much as 100%. From the
study results, the authors suggest that doctors of the Siloam Cinere Heart
Hospital Depok Depok prescribe Antihypertensive drugs in accordance with
the established Hospital Formulary.
KEYWORDS
conformity evaluation, anti-hypertension drugs, hospital formulary
INTRODUCTION
Health is one of the indicators of the level of human well-being so it becomes a priority in
the national development of a nation (Setyaningrum, Trisiana, & Kirana, 2021). One of the
most strategic components of health is the availability of drugs as part of health services to the
community. The availability of adequate amounts of drugs is an important factor in national
development, especially in the field of health (Satriawan, Pitoyo, & Giyarsih, 2021).
Hospitals are one of the public health service facilities that play an important role in
improving the degree of public health (Marnah, Husaini, & Ilmi, 2016). According to the
Regulation of the Minister of Health of the Republic of Indonesia Number 58 of 2014
concerning Standards of Pharmaceutical Services in Hospitals, the definition of a Hospital is a
health service institution that provides individual health services in a complete manner that
provides inpatient, outpatient, and emergency services (Indonesia’s Ministry of Health, 2014).
Hypertension needs to be watched out for because it is a silent killer where symptoms can
vary in each individual and are almost the same as other diseases (Kalehoff & Oparil, 2020).
The symptoms are headaches or heavy feelings at the nape of the neck, vertigo, heart
Evaluating Anti-Hypertensive Drugs’ Suitability Based on the Hospital Formulary in the Hospital’s
Pharmaceutical Installation
965 Interdisciplinary Social Studies, 1(7), Apr 2022
palpitations, fatigue, blurred vision, ringing of the ears, and nosebleeds (Indonesia’s Ministry
of Health, 2013a).
Hypertension or high blood pressure is an increase in systolic blood pressure of more than
140 mmHg and diastolic blood pressure of more than 90 mmHg. Increased blood pressure that
lasts for a long time can cause damage to the kidneys (Kidney failure), heart (Coronary heart
disease), and brain (Causing stroke) if not detected early and get adequate treatment
(Indonesia’s Ministry of Health, 2013b).
Hypertension is one of the leading causes of mortality and morbidity in Indonesia
(Zaenurrohmah & Rachmayanti, 2017). According to basic health research 2013, people with
hypertension in Indonesia at the age of ≥18 years is 25.8% while according to Riskesdas
Banten, the data of people with hypertension, especially in Tangerang City has a fairly high
number of 24.5%. However, diagnosed by health workers and/or a history of taking medication
is only 9.5%. This indicates that most cases of hypertension in the community have not been
diagnosed and affordable health services (Indonesia’s Ministry of Health, 2013b).
Rational use of antihypertensive drugs will be able to lower blood pressure with minimal
toxicity risk in most patients. It should be remembered that hypertension is expressed based on
blood pressure measurements not on symptoms (Hasanudin, Ardiyani, & Perwiraningtyas,
2018).
Treatment or management of hypertension takes a long time, a lifetime, andis continuous
(Indonesia’s Ministry of Health, 2012). Hypertension can be prevented with a healthy lifestyle
and controlling risk factors, such as regulating diet, regular exercise, avoiding smoking and
alcoholic beverages, and checking blood pressure regularly (Indonesia’s Ministry of Health,
2012).
Healthy People 2010 for Hypertension advocates the need for a more comprehensive and
intensive approach to achieving optimal blood pressure control. Therefore, to achieve this goal,
it is necessary to actively participate with pharmacist colleagues in carrying out their
professional practices in every place of health services. Pharmacists can work with doctors in
educating patients about hypertension, monitoring patient responses through community
pharmacy, adherence to drug and non-drug therapies, detecting and reducing side effects, and
preventing and/or solving problems related to drug administration (Indonesia’s Ministry of
Health, 2006). In addition, pharmacists, especially those in hospitals, can perform clinical
pharmacy services in accordance with pharmaceutical service standards in hospitals. One of
the clinical pharmacy services that can be done is the evaluation of drug use (Indonesia’s
Ministry of Health, 2014).
This study aims to evaluate the suitability of the use of antihypertensive drugs with hospital
formulary for outpatients in Internal Poly and Poly Cardiac at Siloam Diagram Heart Hospital
Pharmaceutical Installation Period August-October 2015. It is hoped that this study can provide
more information and contribute to the field of health, especially heart health which is
undoubtedly very crucial.
METHOD
This study uses a descriptive type of research that is by evaluating the use of
antihypertensive drugs, with a cross-sectional design that is the collection of variable data to
find out the quantity of use of antihypertensive drugs by taking data on previous prescriptions
Evaluating Anti-Hypertensive Drugs’ Suitability Based on the Hospital Formulary in the Hospital’s
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966 Interdisciplinary Social Studies, 1(7), Apr 2022
in Internal Poly and Cardiac Poly at Siloam Diagram Heart Hospital Outpatient Pharmacy
Installation.
Data collection was carried out at Siloam Diagram Heart Hospital Outpatient Pharmacy
Installation from August to October 2015. Therefore, data sources based on prescriptions from
Outpatients Internal Poly and Cardiac Poly served at the Siloam Diagram Heart Hospital
Pharmaceutical Installation for the period August-October 2015.
The data collected in this study was carried out by retrospective methods, namely research
based on patient medical records in the form of:
1)
Antihypertensive name;
2)
Dosage form, dosage, the strength of the preparation, route of use, and rules of use;
3)
The number of antihypertensive drugs prescribed.
Data collection and collection is carried out by collecting prescriptions of Poly Internis
and Poly Cardiac to sort out the use of antihypertensive drugs for the period August-October
2015 at the Siloam Diagram Heart Hospital Outpatient Pharmacy Installation:
1) Collected data from Poly Internist and Heart prescriptions for the period August-
October 2015;
2) Grouping the class of antihypertensive drugs in August-October that are included in
formulary and non-formulary;
3) Calculate the highest number of antihypertensive drug use 3 based on Formularium
and Non-Formulary and present the results of observations in the form of tables and
graphs;
4) Grouping the prescribing of antihypertensive drugs according to Formulary and Non-
Formulary and presenting observational data in the form of tables and graphs;
5) Performs the calculation of the percentage of use of antihypertensive drugs according
to Formulary and Non-Formulary and presents observational data in the form of tables
and graphs;
6) Conduct discussions and conclusions from observations.
Data analysis is done using Microsoft Excel 2007, by editing data, coding data, data entry,
and cleaning data. The analysis was carried out to calculate the quantity of antihypertensive
use in hypertensive patients.
RESULTS AND DISCUSSION
Distribution of The Amount of Use of Antihypertensive Drugs
Table 1. Distribution of Patterns of Use of Antihypertensive drugs based on Types of
Hypertension drugs in Siloam Diagram Heart Hospital
Drug Name
Amount of Use of
Antihypertensive
Drugs
Number
(Tab)
Average/Month
Aug
Sept
Oct
Bisoprolol 5mg
2780
3265
3784
9829
3276,3
Candesartan
8mg
3442
1788
2407
7637
2545,6
Evaluating Anti-Hypertensive Drugs’ Suitability Based on the Hospital Formulary in the Hospital’s
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967 Interdisciplinary Social Studies, 1(7), Apr 2022
Amlodipine
5mg
2677
1867
2073
6617
2205,6
Furosemide
40mg
1886
2554
1938
6378
2236
Candesartan
16mg
1405
1855
2193
5453
1817,6
Amlodipine
10mg
905
1169
1336
3410
1136,6
Valsartan
160mg
1027
990
689
2706
902
Furosemide
40mg
790
870
854
2514
838
Letonal 25mg
590
893
733
2216
738,6
Ramipril 5mg
468
297
678
1443
481
Captopril
12.5mg
376
225
467
1068
356
Concor 5mg
216
165
238
619
206,3
Lasix 40mg
99
167
108
374
124,6
Canderin 8mg
88
133
82
303
101
Captopril 25mg
58
84
107
249
83
Sum
16807
16322
17687
51146
From the results of the study, there were 50,816 samples of antihypertensive drugs for 3
months consisting of August 16,807 drugs, September 16,322 drugs, and October 17687 drugs
that were evaluated for suitability of antihypertensive drugs. Based on the Hospital Formulary
and Hypertension Therapy Algorithm, which can be seen in figure 1.
Figure 1. Distribution of Patterns of Use of Antihypertensive drugs based on Types of
Hypertension drugs in Siloam Diagram Heart Hospital
Evaluating Anti-Hypertensive Drugs’ Suitability Based on the Hospital Formulary in the Hospital’s
Pharmaceutical Installation
968 Interdisciplinary Social Studies, 1(7), Apr 2022
Suitability of Antihypertensive Drug Use with Hospital Formulary
The overall use of antihypertensive drugs in outpatient hypertension patients at Siloam
Diagram Heart Hospital compared to the Hospital Formulary. Table 4 shows that the use of
antihypertensive drugs is in accordance with the Hospital Formlarium with conformity of up
to 100%.
Table 4. Suitability of The Use of Antihypertensive Drugs with Hospital Formulary at
Siloam Diagram Heart Hospital
Use of Antihypertensive Drugs at Siloam Diagram Heart Hospital in August-October of
2015
The results of research conducted by researchers at the Siloam Heart Diagram Hospital
obtained data on the use of the most antihypertensive drugs, namely as found in table 5.
Groups
Generic Name
Dosage
Compliance with
the RS Formulary
ACE Inhibitor
Captopril
Tablet
√
Lisinopril
Tablet
√
Ramipril
Tablet
√
b-blocker
Bisoprolol
Fumarate
Membrane
coating
tablets
√
Calcium Channel Blocker
Amlodipine
besylate
Tablet
√
Nicardipine
Injection
√
Nifedipine
Tablet,
oros
√
Nimodipine
Injection
√
Angiotensin Receptor Blocker
Valsartan
Tablet
√
Candesartan
Tablet
√
Irbesartan
Tablet
√
Diuretic
Furosemide
Tablets,
injections
√
Spironolactone
Tablet
√
Central a2 Agonist
Clonidine HCL
Tablet
√
% Conformity
100%
Evaluating Anti-Hypertensive Drugs’ Suitability Based on the Hospital Formulary in the Hospital’s
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969 Interdisciplinary Social Studies, 1(7), Apr 2022
Table 5. Use of Antihypertensive Drugs at Siloam Diagram Heart Hospital in August-
October of 2015
No
Antihypertensive
Usage (%)
DU segment
1
Amlodipine
40,27
90%
2
Ramipril
28,57
3
Irbesartan
9,01
4
Captopril
7,89
5
Furosemide
5,65
10%
6
Candesartan
2.65
7
Bisoprolol
1.72
8
Lisinopril
1.70
9
Nifedipine
1.12
10
Clonidine
0.67
11
Spironolactone
0.43
12
Valsartan
0.22
13
Nimodipine
0.09
14
Nicardipine
0.03
Sum
100,00
From the data in table 5. It shows that antihypertensive drugs that are widely used are 90%
of the Calcium Channel Blocker group (amlodipin 40.27%), ace inhibitors (ramipril 28.57%,
captopril 7.89%), ARB group (9.01%). While the less used 10% are furosemid 5.65%,
candesartan (2.65%), bisoprolol (1.72%), lisinopril (1.70%), nifedipin (1.12%), clonidin
(0.67%), spironolactone (0.43%), valsartan (0.22%), nimodipin (0.09%), and nicardipin
(0.03%).
Discussion
The distribution of drug usage patterns aims to find out what drugs are used by
hypertensive patients at Siloam Diagram Heart Hospital. Based on the results of the study,
shows that patients get more antihypertensive therapy than one drug, namely antihypertensive
combination therapy as much as 78%. This is in accordance with the theory that states that in
patients with stage 2 hypertension it is recommended to use a combination therapy of 2 or more
drugs (Ministry of Health, 2006).
The selection of antihypertensive drugs needs to be considered in addition to lowering
blood pressure can also maintain blood pressure optimally (Dasgupta et al., 2014). This can be
done by selecting treatment with monotherapy or combination therapy. The most
antihypertensive used as monotherapy by the subjects of this study were calcium channel
blockers. The most widely used combination therapy is combination therapy with 2
antihypertensive drugs, namely the Calcium Channel Blocker + ACE Inhibitor group.
According to JNC VIII, monotherapy can be given as initial therapy for stage 1
hypertension with low or moderate/moderate cardiovascular total risk factors, starting with the
initial dose can then be raised to the maximum dose if the blood pressure target has not been
Evaluating Anti-Hypertensive Drugs’ Suitability Based on the Hospital Formulary in the Hospital’s
Pharmaceutical Installation
970 Interdisciplinary Social Studies, 1(7), Apr 2022
reached. Furthermore, if the blood pressure target has not been reached, it can be replaced with
a drug that has a different mechanism of action, starting with a low dose, and then the dose is
increased to the maximum dose. If it is still not achieved the desired target can be added 2 to 3
kinds of drugs. Combination therapy 2 low-dose drugs are given for initials therapy in stage 2
hypertension with high or very high-risk factors, if 2 kinds of blood pressure target drugs are
not achieved can be given 3 kinds of antihypertensive drugs.
The quantity of antihypertensive use in Siloam Diagram Heart Hospital is shown in table
5. The quantity of antihypertensive use that had the highest amount in 2015 was amlodipine.
Calculations for amlodipine in 2015 mean that there were 89 patients from all study subjects
who took amlodipine at 5 mg daily.
Amlodipin is a group of Calcium Channel Blocker dihydrodropiridin. Calcium Channel
Blocker is used in elderly systolic hypertension patients (DiPiro et al., 2008). Systolic
Hypertension–Europe conducted a trial on a controlled placebo that showed that the long-
acting Calcium Channel Blocker dihydropyridine reduced the risk of cardiovascular events
significantly in systolic hypertension. Calcium Channel Blockers cause relaxation of the heart
and smooth muscles by inhibiting voltage-sensitive calcium channels, thereby reducing the
entry of extracellular calcium into cells. Relaxation of the vascular muscles causes vasodilation
and is associated with blood pressure reduction (DiPiro et al., 2008).
There are 2 classes of Calcium Channel Blockers namely dihydrodropiridin (amlodipine
and nifedipine) and non-dihydrodropiridin (verapamil, diltiazem). Non-dihydrodropiridin
works by blocking calcium channels in both the heart and vascular. Diltiazem (non-
dihydrodropiridin) is used in patients with complications of heart disease and angina (Isik,
Delibasi, Berker, Aydin, & Guler, 2009).
The antihypertensive with the second largest percentage of use is ramipril. Ramipril is an
ACE inhibitor class drug that works by inhibiting angiotensin-converting enzyme (ACE) which
under normal circumstances is in charge of activating angiotensin I into angiotensin II (Qian et
al., 2019). ACE inhibitors also inhibit bradykinin degradation and stimulate the synthesis of
other vasodilator substances such as prostaglandin E2 and prostacyclin (Baxter & Ebrahim,
2002). Increased bradykinin may increase the blood-pressure-lowering effects of ACE
inhibitors but also cause side effects of dry cough (DiPiro et al., 2008).
There are 3 ACE inhibitors commonly used, namely ramipril, captopril, and lisinopril. The
use of ramipril is the highest compared to captopril and lisinopril. The next most common use
of antihypertension is irbesartan. Irbesartan is an ARB class drug that works by blocking
angiotensin II type 1 (AT1) receptors that can cause vasoconstriction, aldosterone release,
sympathetic activation, the release of antidiuretic hormones, and efferent renal constriction and
constriction of the glomerulus (DiPiro et al., 2008).
Table 5. Use of Antihypertensive Drugs at Siloam Diagram Heart Hospital in August-
October of 2015
No
Antihypertensive
Usage (%)
DU segment
1
Amlodipine
40,27
90%
2
Ramipril
28,57
3
Irbesartan
9,01
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971 Interdisciplinary Social Studies, 1(7), Apr 2022
4
Captopril
7,89
5
Furosemide
5,65
10%
6
Candesartan
2.65
7
Bisoprolol
1.72
8
Lisinopril
1.70
9
Nifedipine
1.12
10
Clonidine
0.67
11
Spironolactone
0.43
12
Valsartan
0.22
13
Nimodipine
0.09
14
Nicardipine
0.03
Sum
100,00
From the data in table 5. Showed that antihypertensive drugs that are widely used are 90%
of the CCB group (amlodipine 40.27%), ace inhibitor group (ramipril 28.57%, captopril
7.89%), ARB group (9.01% increase). The less used 10% are furosemid 5.65%, candesartan
(2.65%), bisoprolol (1.72%), lisinopril (1.70%), nifedipin (1.12%), clonidin (0.67%),
spironolactone (0.43%), valsartan (0.22%), nimodipin (0.09%), and nicardipin (0.03%).
The results of this study are different from the results of research conducted by Ivonia, et
al., 2015 which showed that antihypertensive drugs used in geriatric patients (60 years and
above) at Karanganyar Hospital in 2011 were captopril (60.69%), furosemide (11.26%),
amlodipine (8.17%), nifedipine (9.45%), hydrochlorothiazide (5.94%), lisinopril (3.44%),
bisoprolol (1.05%), and widely used drugs 90% are captopril, furosemide, and amlodipine.
This is because the formulary used by each hospital is different.
A formulary is a list of drugs used by hospitals, compiled by the Pharmaceutical and
Therapeutics Committee consisting of several doctors and pharmacists (Matlala, Gous,
Godman, & Meyer, 2017). The formulary of the hospital will make the management of the
hospital more effective, because the procurement of drugs becomes clear, considering that in
addition to having the medical aspect side also has an economical side so that the formulary is
used as a guide by doctors in providing drug therapy in accordance with those available in the
hospital (Allerberger et al., 2016; Economou, Kaitelidou, Kentikelenis, Maresso, & Sissouras,
2015).
According to hypertension governance guidelines compiled by the Indonesian Association
of Cardiovascular Specialists (PERKI) states that first-line therapy in adult hypertension
patients ≥18 years old with blood pressure ≥140/90 mmHg is a lifestyle modification to control
their blood pressure. If the blood pressure target has not been achieved, pharmacological
therapy is starting to be given, especially in patients with stage 2 hypertension and patients who
have complications. In stage 1 patients the selection of therapy is distinguished again based on
age, if the patient is <60 years old the first-line therapy given is ACEI or ARB and if the patient
is ≥60 years old then the first-line therapy is CCB or Tiazid. While in stage 2 patients, you
should start with a combination of two drugs. The combination therapy that can be given is
CCB or Tiazid in combination with ACEI or ARB.
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972 Interdisciplinary Social Studies, 1(7), Apr 2022
The Role of Pharmacists in Hospitals
Based on the Regulation of the Minister of Health No. 58 concerning Pharmaceutical
Service Standards in Hospitals, it is stated that the role of Pharmacists in Hospitals is one of
them is to perform Clinical Pharmacy Services. Clinical pharmacy services are direct services
provided by pharmacists to patients in order to improve therapeutic outcomes and minimize
the risk of side effects due to drugs, for patient safety purposes so that patient quality of life
(quality of life) is guaranteed (Indonesia’s Ministry of Health, 2014).
Clinical pharmacy services carried out include assessment and prescription services,
tracing drug use history, drug reconciliation, Drug Information Services (PIO), counseling,
visite, Drug Therapy Monitoring (PTO), Drug Side Effects Monitoring (MESO), Drug Use
Evaluation (EPO), sterile preparation dispensing, and Monitoring of Drug Levels in the Blood
(PKOD).
One of the clinical pharmacy services that can be done is drug use evaluation (EPO). EPO
is a program that is structured and continuous qualitatively and quantitatively. The purpose of
EPO is to get an overview of the current state of drug use patterns, compare drug use patterns
in a certain period of time, provide input for improvements in drug use, and assess the influence
of interventions on drug use patterns (Indonesia’s Ministry of Health, 2014).
Evaluation of drug use is very important to be done by pharmacists because it can
guarantee the accuracy of prescribing and use of drugs, is cost-effective, and can improve the
quality of health services so as to determine the basis of rational treatment. The results of
subsequent assessments become the basis for identifying shortcomings and strategizing for
improvement. When a problem is identified, an intervention is designed and applied to correct
the pattern of drug use. Interventions that can be carried out include educational programs,
provision of drug information, changes in hospital policies and procedures, and changes in
hospital formulary (WHO Int WG for Drug Statistics Methodology, 2003).
CONCLUSION
1) Based on the amount of use of antihypertensive drugs in outpatient hypertension
patients at Siloam Diagram Heart Hospital compared to Hospital Formulary. Show
that the use of antihypertensive drugs is in accordance with the Hospital Formlarium
with conformity reaching 100%in Poli Internis and poly cardiac hospitals. Siloam
Diagram Heart;
2) Based on the number of uses, the most antihypertensive use was obtained in the 3rd
most hypertensive patients included in the Hospital Formulary at Poli Internis and Poly
Heart Hospital. Siloam diagrams are Amlodipin, Ramipril and Captopril;
3) Based on the number of uses of this type of antihypertensive drug there is no writing
of antihypertensive drugs that are outside the Formulary of hospitals in Poli Internis
and poly cardiac hospitals. Siloam Diagram Heart; and
4) Based on the number of uses of antihypertensive drugs, it shows that antihypertensive
drugs that are widely used are 90% consisting of the Calcium Channel Blocker group
(amlodipine 40.27%), ace inhibitors (ramipril 28.57%, captopril 7.89%), ARB group
(9.01%). While the less used 10% are furosemid 5.65%, candesartan (2.65%),
bisoprolol (1.72%), lisinopril (1.70%), nifedipin (1.12%), clonidin (0.67%),
Evaluating Anti-Hypertensive Drugs’ Suitability Based on the Hospital Formulary in the Hospital’s
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973 Interdisciplinary Social Studies, 1(7), Apr 2022
spironolactone (0.43%), valsartan (0.22%), nimodipin (0.09%), and nicardipin
(0.03%).
Therefore, it is necessary to conduct research using prospective methods and optimization
of evaluations with interviews with patients, doctors, and pharmacists to dig deeper into
information about the treatment provided to patients. In addition, it is also necessary to use the
ATC / DDD method in order to research the use of other drugs, especially for drugs that are
suspected to be widely used irrationally, used by high-risk patients, and have significant side
effects and a narrow therapeutic index.
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