ABSTRACT
Title
ACE inhibitors and 
Angiotensin II Receptor Blockers (ARBs) prescribing patterns: 6 years follow-up in general practice
Authors
R. Ferrara1, C. Sirianni1, M.S. Gagliostro1, A. Cannata1, C. Pagliaro2, I. Lombardi2, S. Moretti2, M. Tari2, A. Capuano3, F. Rossi3, A.P. Caputi1, V. Arcoraci1.
1Department of Clinical and Experimental Medicine and Pharmacology, Pharmacology Unit, University of Messina, Italy; 2”Caserta-1” Local Health Unit, 3Pharmacovigilance and Pharmacoepidemiology Centre of Campania Region, Dept. of Experimental Medicine, Pharmacology Section, Second University of Napoli, Italy.
1Department of Clinical and Experimental Medicine and Pharmacology, Pharmacology Unit, University of Messina, Italy; 2”Caserta-1” Local Health Unit, 3Pharmacovigilance and Pharmacoepidemiology Centre of Campania Region, Dept. of Experimental Medicine, Pharmacology Section, Second University of Napoli, Italy.
Abstract
The use of Renin Angiotensin system drugs (RADs) have been progressively increasing worldwide since their marketing, supported by scientific evidence showing both their effectiveness and good safety profile in the treatment of several cardiovascular diseases (CV). However, RADs effectiveness is closely related to continuous drug assumption and CV risk quickly increases when RADs are discontinued or underused. ACE inhibitors (ACE), are suggested as the first choice in most of guide lines and angiotensin receptor blockers(ARBs) should be prescribed only as an alternative for patients who show intolerance to ACE. Indeed, ACE showsimilar efficacy in blood pressure control, reduction of mortality, incidence of cardiovascular events, major adverse events and in improving the quality of life. Moreover, more information and lower costs are available for ACE than ARBs. Nevertheless, in Italy, ARBs are the most expensive therapeutic class in the cardiovascular drugs group and their use is increasing in the last years.
Aims:
to assessthe prescription pattern of RADs in general practice; to characterize the RADs users; to assess the adherence to the treatment and the interclass switch.
Methods:
Data were extracted from the Arianna database that currently contains information about a population of almost 150,000 individuals living in the area of Caserta and registered in 118 general practitioners’ (GPs) lists. Patients aged over 14 who received at least one RADs prescription during 2004-2009 were identified. The use of ACE and ARBs was calculated as one-year prevalence and incidence; RADs consumption was evaluated as DDD 1000/inh day. Adherence was calculated as Medication Possession Ratio (MPR) defined as ratio between real and estimated exposition days. Sub-analyses by gender, age and indication of use were performed
Results:
Prevalence of RADs use increases linearly during the follow-up (from 16.1/100 ab in 2004 to 21.9/100 ab in 2009), while the incidence of use remains almost the same during the studyperiod. No differences by gender or indication of use, but an increasing trend by age were shown in RADs treatments. Most of new RADs users start treatment with ACE. However, the incidence of use of ACE decreases linearly during the follow-up, whereas ARBs increased. Concerning new ACE users, 22.7% of them made a switch to ARBs while 7.1% changed from ARBs to ACE. Most of patients switched within the first year of treatment. Switching from ACE inhibitors to ARBs increased significantly until 2008 while it increased fromARBs to ACE during 2009. A good adherence to treatment, with MPR> 80%, was shown only in 37.9% of patients and it is inversely related to monitoring time. No difference in adherence was shown between ACE and ARBs users.
Conclusions:
ARBs use increases during the study period despite ACE inhibitors reduction. ACE inhibitors should be, generally, preferred to ARBs. The increasing use of ARBs is probably inappropriate in most of cases. The use of ARBs as starting treatment is appropriate only in few cases. Switching from ACE inhibitors to ARBs may be justified in case of cough or other side effects within the first year of treatment. Conversely, the opposite, detected during 2009, could be due to health policy interventions aimed to increase appropriateness of treatments. Adherence to treatment is acceptable in less than 40% of cases. This finding confirms the trend of newly marketed drugs to be widely prescribed in general practice, despite the lack of effectiveness and safety data derived from clinical practice. Low adherence to RADs treatment was recorded and no significant differences were observed among different molecules. Only a small number of patients reached the minimum adherence level needed to obtain clinical efficacy.
Aims:
to assessthe prescription pattern of RADs in general practice; to characterize the RADs users; to assess the adherence to the treatment and the interclass switch.
Methods:
Data were extracted from the Arianna database that currently contains information about a population of almost 150,000 individuals living in the area of Caserta and registered in 118 general practitioners’ (GPs) lists. Patients aged over 14 who received at least one RADs prescription during 2004-2009 were identified. The use of ACE and ARBs was calculated as one-year prevalence and incidence; RADs consumption was evaluated as DDD 1000/inh day. Adherence was calculated as Medication Possession Ratio (MPR) defined as ratio between real and estimated exposition days. Sub-analyses by gender, age and indication of use were performed
Results:
Prevalence of RADs use increases linearly during the follow-up (from 16.1/100 ab in 2004 to 21.9/100 ab in 2009), while the incidence of use remains almost the same during the studyperiod. No differences by gender or indication of use, but an increasing trend by age were shown in RADs treatments. Most of new RADs users start treatment with ACE. However, the incidence of use of ACE decreases linearly during the follow-up, whereas ARBs increased. Concerning new ACE users, 22.7% of them made a switch to ARBs while 7.1% changed from ARBs to ACE. Most of patients switched within the first year of treatment. Switching from ACE inhibitors to ARBs increased significantly until 2008 while it increased fromARBs to ACE during 2009. A good adherence to treatment, with MPR> 80%, was shown only in 37.9% of patients and it is inversely related to monitoring time. No difference in adherence was shown between ACE and ARBs users.
Conclusions:
ARBs use increases during the study period despite ACE inhibitors reduction. ACE inhibitors should be, generally, preferred to ARBs. The increasing use of ARBs is probably inappropriate in most of cases. The use of ARBs as starting treatment is appropriate only in few cases. Switching from ACE inhibitors to ARBs may be justified in case of cough or other side effects within the first year of treatment. Conversely, the opposite, detected during 2009, could be due to health policy interventions aimed to increase appropriateness of treatments. Adherence to treatment is acceptable in less than 40% of cases. This finding confirms the trend of newly marketed drugs to be widely prescribed in general practice, despite the lack of effectiveness and safety data derived from clinical practice. Low adherence to RADs treatment was recorded and no significant differences were observed among different molecules. Only a small number of patients reached the minimum adherence level needed to obtain clinical efficacy.