INTRODUCTION:

Prescription pattern monitoring studies (PPMS) are essential tools for evaluating the prescribing, dispensing, and distribution of medications in a specific area. They provide insights into drug use trends and profiles, revealing the extent and nature of medication practices. The significance of PPMS has grown with the increase in new drug marketing, changes in prescribing trends, concerns about delayed adverse effects, drug costs, and prescription volumes.¹

Cardiovascular disease (CVD) encompasses a range of conditions affecting the heart and blood vessels, including hypertension, arrhythmias, and ischemic heart disease. The global burden of CVD is rising, with heart attacks and strokes accounting for 85% of cardiovascular deaths. In 2019, CVDs were responsible for approximately 17.9 million deaths, representing 32% of all global deaths, with the majority due to heart attacks and strokes. Beyond mortality, morbidity associated with CVD presents significant challenges, such as timely diagnosis, access to life-saving medications, early intervention, and treatment affordability.^2,3

Periodic review of drug use within hospital settings provides valuable feedback for clinicians, allowing them to refine and enhance their practices to deliver cost-effective care. Monitoring medication prescription patterns and recommending strategies to manage drug costs are crucial for optimizing treatment.⁴ Essential medicines are those deemed critical for addressing key health needs, based on disease prevalence, clinical efficacy, safety, and cost-effectiveness.⁵ Essentiality of drugs identified using lists from WHO and national health authorities.

This study evaluates the prescribing patterns of common cardiovascular drugs in the cardiology department of a rural tertiary care hospital in Anand. It aims to analyze prescribing practices using WHO core prescribing indicators and to assess the essentiality of the prescribed drugs according to the WHO Essential Medicines List (EML) and the National List of Essential Medicines (NLEM).

METHODOLOGY:

The study was an observational, hospital-based investigation conducted at the cardiac department of Shree Krishna Hospital, Karamsad. The study protocol (IEC/BU/151/Faculty/39/52/2024) was authenticated by the Institutional Ethics Committee-2 (IEC-2) of Bhaikaka University, Karamsad. The study was conducted from February 2024 to March 2024, involving patients visiting the outpatient department (OPD) of the cardiac department.

Participants of the patients, who were aged between 18 and 60 years old, had attended the OPD and had a diagnosis of a cardiac disease. Those patients admitted to the hospital were excluded from the study. Data on disease diagnosis (CVD, CVD alone and CVD with other conditions) and prescribed drug regimen were collected using a Data Collection Form (DCF) and analyzed for indications and prescribing trends according to WHO core prescribing indicators.

Evaluation parameters included the types of drugs prescribed for cardiovascular diseases, the presence of comorbid conditions, prescribing of drugs by generic versus brand-name drugs, monotherapy versus combination therapy, and the essentiality of drugs based on the Essential Drugs List (EDL 2023) and the National List of Essential Medicines (NLEM 2022).

Prescribing trends according to WHO core prescribing indicators were evaluated for the following:⁶

1. Average number of medicines per encounter = Total number of medicines prescribed ÷ number of encounters.

2. Percentage of medicines prescribed by generic name = (Total number of medicines prescribed in the INN (International Non-proprietary Name) format ÷ Total number of medicines prescribed) × 100.

3. Percentage of encounters with an antibiotic prescribed = (Number of clinical encounters in antibiotic was prescribed ÷ Total number of encounters) × 100.

4. Percentage of encounters with an injection prescribed = (Number of clinical or drug use encounters in which an injectable form of medicine prescribed ÷ Total number of encounters) × 100.

5. Percentage of medicines prescribed from the essential medicines list = (Number of medicines prescribed from the EML ÷ Total number of medicines prescribed) × 100.

Data analysis was performed using Microsoft Excel to determine the frequency distribution of various parameters.

Figure 1. Distribution of Prescriptions based on CVD, Co-morbidities, and other Condition

RESULTS

Over three months, a total of 176 patients’ prescriptions, encompassing 97 different drugs were evaluated. The prescriptions were analyzed for cardiovascular diseases (CVD) and associated comorbid conditions and other conditions. Among the 176 patients, 24.48% (n=59) had CVD, 27.79% (n=67) had CVD with comorbid conditions such as diabetes mellitus, COPD/asthma, or hypothyroidism, and the majority, 47.63% (n=115), had CVD along with other conditions, including constipation, hyperacidity, and similar issues. (Figure 1)

Prescribing pattern of Cardio-vascular drugs

Out of the 176 prescriptions analyzed, approximately 62.43% of the drugs were prescribed using their generic names, while 37.57% were prescribed by brand names (Figure 2).

Figure 2. Frequency distribution of Drugs prescribed by Generic Names and Brand Names

In the frequency distribution of cardiovascular (CVD) drugs, Sympatholytics were the most commonly prescribed at 20.74% (n=173), followed by Diuretics at 18.22% (n=152). Other frequently prescribed classes included HMG-CoA reductase inhibitors at 16.78% (n=140), RAAS blockers at 14.14% (n=118), Vasodilators at 10.43% (n=87), Antiplatelets at 7.79% (n=65), and Anticoagulants at 4.31% (n=36). Calcium channel blockers and Digitalis glycosides were also prescribed, representing 3.47% (n=29) and 2.99% (n=25) of the total, respectively. Additionally, other drugs such as Sympathomimetics, Potassium channel openers, and Antianginals were prescribed infrequently, accounting for just 0.35% (n=3) of the prescriptions (Figure 3).

Prazosin (α-blocker) and Metoprolol (β-blocker) were the most commonly prescribed sympatholytic agents, with prescription rates of 57.15% (n=4) and 74.1% (n=123), respectively. Clonidine (α-agonist), a sympathomimetic agent, was prescribed in 100% of the cases (n=3). Among RAAS inhibitors, Ramipril (ACE inhibitor), Telmisartan (AT-II receptor blocker), and Sacubitril (AT-receptor neprilysin inhibitor) were prescribed at rates of 40.68% (n=48), 47.46% (n=56), and 5.93% (n=7), respectively. In the diuretics category, Furosemide, Spironolactone, and Chlorthalidone were the most frequently prescribed, with rates of 28.95% (n=44), 41.45% (n=63), and 22.36% (n=34), respectively. Among vasodilators, Isosorbide dinitrate was the most prescribed nitrate at 58.62% (n=51), followed by nitroglycerine at 33.33% (n=29), isosorbide mononitrate at 3.43% (n=3), and hydralazine at 4.6% (n=4). As a hypolipidemic agents, Atorvastatin was prescribed at a rate of 52.86% (n=74), followed by Rosuvastatin at 47.14% (n=66). The predominant calcium channel blockers were Amlodipine (41.38%, n=12) and Diltiazem (37.93%, n=11). Digoxin (n=25), Amiodarone (n=3), and Ranolazine (n=3) were each prescribed in 100% of the cases within their respective drug classes of digitalis glycoside, potassium channel blocker, and antianginal agents. Among anticoagulants, Warfarin and Acenocoumarol, both Coumarin derivatives, were prescribed at rates of 61.11% (n=22) and 19.44% (n=7), respectively. Dabigatran (5.56%, n=2), a direct thrombin inhibitor, and Apixaban (5.56%, n=2), a Factor Xa inhibitor, were also prescribed. For antiplatelet therapy, Clopidogrel, Ticagrelor, and Prasugrel were prescribed at rates of 87.69% (n=57), 7.69% (n=5), and 4.62% (n=3), respectively, with low-dose Aspirin being prescribed in 64.67% (n=119) of cases. (Table 1)

Table 1. Categories of different prescribed CVD drugs

Class of Drug	Sub-class	Name of Drug(s)	n (No. of times prescribed)	Frequency Distribution (%)
Sympatholytic	α blocker	Prazosin	4	57.15%
	α blocker	Tamsulosin	3	42.85%
	β blocker	Metoprolol	123	74.1%
		Carvedilol	22	13.25%
		Bisoprolol	20	12.05%
		Propranolol	1	0.6%
Sympathomimetic	α agonist	Clonidine	3	100%
RAAS blocker	ACE inhibitors	Ramipril	48	40.68%
	Angiotensin II receptor blocker	Telmisartan	56	47.46%
	Angiotensin II receptor blocker	Valsartan	7	5.93%
	Angiotensin receptor neprilysin inhibitors	Sacubitril	7	5.93%
Diuretics	Loop diuretics	Torsemide	11	7.24%
	Loop diuretics	Furosemide	44	28.95%
	Potassium-sparing diuretics	Spironolactone	63	41.45%
	Thiazide diuretics	Chlorthalidone	34	22.36%
Vasodilators	Nitrates	Isosorbide dinitrate	51	58.62%
		Isosorbide mononitrate	3	3.45%
		Nitro-glycerine	29	33.33%
		Hydralazine	4	4.6%
Statins	Statins	Atorvastatin	74	52.86%
Statins	Statins	Rosuvastatin	66	47.14%
Calcium channel blocker	Calcium channel blocker	Amlodipine	12	41.38%
		Azelmidipine	1	3.45%
		Clinidipine	4	13.8%
		Diltiazem	11	37.93%
		Verapamil	1	3.44%
Digitalis glycosides	Digitalis glycosides (Ionotropic)	Digoxin	25	100%
Potassium channel opener	Potassium channel opener	Amiodarone	3	100%
Anticoagulant	Direct thrombin inhibitors	Dabigatran	2	5.56%
	Coumarin derivative	Warfarin	22	61.11%
	Coumarin derivative	Acenocoumarol	7	19.44%
	Factor Xa inhibitors	Apixaban	2	5.56%
	Factor Xa inhibitors	Rivaroxaban	3	8.33%
Antianginal drugs	Antianginal	Ranolazine	3	100%
Anti-platelet agents	Purinergic receptor antagonist	Clopidogrel	57	30.98%
		Ticagrelor	5	2.72%
		Prasugrel	3	1.63%
	Cyclooxygenase/TxA2 synthase inhibitors	Aspirin	119	64.67%

In the frequency distribution of different prescribed drugs for conditions co-occurring with cardiovascular disease (CVD), vitamins were the most commonly prescribed, accounting for 69.33% (n=104) of the prescriptions. Iron supplements were the second most frequently prescribed at 7.33% (n=11), followed by calcium supplements at 6% (n=9). Domperidone, a dopamine antagonist, was prescribed in 4% (n=6) of cases. Laxatives, including Isabgol, Milk of Magnesia, and Sodium Picosulphate, were prescribed in 3.32% (n=5) of cases. Antibiotics such as Benzylpenicillin and Clarithromycin were prescribed in 2% (n=3) of cases. Levetiracetam, an anticonvulsant, and Fexofenadine, an antihistamine, were each prescribed in 1.33% (n=2) of cases. Several drugs were each prescribed in 0.67% (n=1) of cases, including Dutasteride (5α-reductase inhibitor), Sodium Bicarbonate (alkalinizing agent), Succinic Acid (anti-ulcer agent), Loperamide (antidiarrheal agent), Econazole (antifungal agent), Tinidazole (antiprotozoal), Alprazolam (benzodiazepine), and Sildenafil (phosphodiesterase-5 inhibitor).

Among the 176 analyzed prescriptions, which included a total of 97 drugs, 60 were prescribed as monotherapy, 43 as two-drug regimens, 8 as three-drug regimens, and 1 as a regimen with more than three drugs, including multivitamins. Fixed-dose combinations were prescribed in 45 cases as two-drug regimens, in 8 cases as three-drug regimens, and 1 case as a regimen with more than three drugs.

Essentiality of Prescribed Drugs:

According to the WHO Model List of Essential Medicines - 2023: In this study, 71.73% of the prescribed drugs were for cardiovascular diseases (CVD), including Digoxin, Metoprolol, Carvedilol, Bisoprolol, Propranolol, Amlodipine, Verapamil, Atorvastatin, Clopidogrel, Warfarin, Dabigatran, Rivaroxaban, Furosemide, Spironolactone, Torsemide, Hydralazine, Isosorbide dinitrate, and Ramipril. Vitamins accounted for 12.58% of the prescriptions, comprising Cholecalciferol, Thiamine, Cyanocobalamin, Folic acid, Pyridoxine, and Ferrous salt. Anti-diabetic drugs represented 7.95%, including Dapagliflozin and Metformin. Bronchodilators made up 2.97%, such as Acebrophylline, Salbutamol, Formoterol, and Ipratropium bromide. Hypothyroidism drugs, specifically Levothyroxine, constituted 1.87% of prescriptions. Antibiotics (Benzylpenicillin, Clarithromycin) were prescribed at 0.22%, while corticosteroids (Budesonide) accounted for 0.88%. Additionally, 0.99% of the prescriptions were for Calcium, 0.22% for antihistamines (Fexofenadine) and anticonvulsants (Levetiracetam), and 0.11% for antidiarrheals (Loperamide) and antiprotozoals (Tinidazole).

According to the National List of Essential Medicines (NLEM) 2022: In this study, 75.82% of the prescribed medications were for CVD, including Digoxin, Metoprolol, Amiodarone HCL, Amlodipine, Atorvastatin, Clopidogrel, Dabigatran, Diltiazem, Furosemide, Isosorbide dinitrate, Propranolol, Telmisartan, Spironolactone, Verapamil, Warfarin, and Ramipril. Vitamins comprised 7.84% of the prescriptions, including Cholecalciferol, Folic acid, Thiamine, and Pyridoxine. Anti-diabetic drugs (Metformin) accounted for 6.10%. Bronchodilators made up 3.68%, such as Budesonide, Salbutamol, Tiotropium, and Ipratropium. Hypothyroidism treatment (Levothyroxine) constituted 2.15% of prescriptions. Iron supplements, including Iron and Ferrous salt, represented 1.40%. Calcium was prescribed at 1.13%. Dopamine antagonists (Domperidone) made up 0.76% of the prescriptions, laxatives (Ispaghula) 0.38%, antibiotics (Benzylpenicillin, Clarithromycin) and anticonvulsants (Levetiracetam) each accounted for 0.25%, and antidiarrheals (Loperamide) and antacids (Sodium bicarbonate) were each at 0.12%.

WHO Core Prescribing Indicators:

Analysis of 176 prescriptions revealed an average of 5.35 drugs prescribed per prescription. The majority (62.43%) of these drugs were prescribed by their generic names. Additionally, 42.27% of the drugs were listed as essential according to the Essential Drug List (EDL), and 58.19% of the prescriptions included vitamins. (Table 3)

Table 3. WHO Core Prescribing Indicators

Average no. of drugs per prescription	5.35
Percentage of drugs prescribed by generic name	62.43%
No. of Antibiotics prescribed	3
No. of Injections prescribed	0
Percentage of drugs prescribed from EDL	42.27%
Percentage of Vitamins per prescription	58.19%

DISCUSSION:

In the present study, a total of 176 prescriptions from patients visiting the cardiac outpatient department (OPD) over two months were assessed. These patients had cardiovascular diseases (CVD), with or without comorbid conditions. Of these patients, 24.48% had only CVD, 27.79% had CVD with comorbidities such as diabetes mellitus, chronic obstructive pulmonary disease (COPD)/asthma, and hypothyroidism, and 47.63% had CVD along with other conditions like constipation and hyperacidity. The analysis revealed that 62.43% of the drugs were prescribed by their generic names, while 37.57% were prescribed by brand names. The use of generic names can enhance the availability and affordability of medications.⁷ Rational drug use, promoted by prescribing medications using their generic names from an Essential Medicines List (EML), can reduce prescription costs and reduce the financial burden on patients.^8,9

The World Health Organization’s Essential Medicines List (EML) identifies medications deemed most effective and safe to meet the critical needs of a health system. Its goal is to ensure access to necessary medicines in appropriate dosage forms at affordable prices. In this study, 71.73% of prescribed cardiovascular drugs were found essential according to the WHO-EML 2023, and 39.18% were prescribed according to NLEM-2022.

The most frequently prescribed medications for cardiovascular disease include antiplatelet agents, sympatholytics, sympathomimetics, RAAS blockers, diuretics, vasodilators, HMG-CoA reductase inhibitors, calcium channel blockers, digitalis glycosides, potassium channel blockers, anticoagulants and antianginal drugs. This study reveals that 75.82% of cardiovascular disease (CVD) medications, including Digoxin, Metoprolol, Amiodarone HCl, Amlodipine, Atorvastatin, Clopidogrel, Dabigatran, Diltiazem, Furosemide, Isosorbide dinitrate, Propranolol, Telmisartan, Spironolactone, Verapamil, Warfarin, and Ramipril, were found essential according to the NLEM-2022. In this study, 71.73% of the prescribed drugs included cardiovascular (CVD) medications such as Digoxin, Metoprolol, Carvedilol, Bisoprolol, Propranolol, Amlodipine, Verapamil, Atorvastatin, Clopidogrel, Warfarin, Dabigatran, Rivaroxaban, Furosemide, Spironolactone, Torsemide, Hydralazine, Isosorbide dinitrate, and Ramipril were essential according to the WHO Essential Medicines List 2023.

Antiplatelet drugs were the most frequently prescribed medications. Aspirin, at low doses (50–325 mg/day), irreversibly inhibits platelet TxA2 synthesis, prevents its aggregation and delays blood clotting, making it effective for managing coronary artery disease, valve thrombosis, and thromboembolism. Clopidogrel, a purinergic (P2Y12) receptor antagonist, irreversibly blocks ADP-mediated platelet aggregation and works synergistically with aspirin or GP IIb/IIIa antagonists.^10,11

Sympatholytic agents were the second most frequently prescribed medications, with metoprolol, a β-adrenergic antagonist, being the most common choice for hypertension management. Metoprolol, approved by the FDA for conditions such as angina, heart failure, myocardial infarction, atrial fibrillation/flutter, and hypertension, was shown in the Metoprolol Atherosclerosis Prevention in Hypertensives (MAPHY) study to be superior to diuretics in reducing sudden cardiac death and myocardial infarction risk.¹² Second-generation β-blockers like metoprolol preferentially bind to β₁-adrenergic receptors but can also affect β₂ receptors at higher doses, making them advantageous due to their primary action on cardiac tissue.¹³ This study’s findings contrast with those of Abhijith Rao et al. on β-blocker efficacy.^7,14 Metoprolol’s essential status is highlighted by its inclusion in the EML-2023 and NLEM-2022. Additionally, prazosin, an α1-adrenergic receptor antagonist, was used to induce vasodilation, primarily affecting resistance vessels. Clonidine, a sympathomimetic α₂-adrenergic receptor agonist, was prescribed to lower blood pressure and induce bradycardia.⁹

Diuretics are the primary treatment for edema or volume overload, particularly in patients with congestive heart failure (CHF), as they effectively reduce pulmonary edema and venous congestion. In some cases, diuretics alone may be sufficient for managing mild heart failure.⁷ In this study, diuretics were the most frequently prescribed drug class after antiplatelet and sympatholytic agents. Specifically, spironolactone (K⁺sparing diuretic) was prescribed in 41.45% of cases, furosemide (Loop diuretic) in 28.95%, and chlorthalidone (Thiazide diuretic) in 22.36% of cases for patients with cardiovascular disease. The high prescription rate of spironolactone is consistent with findings from a study by Abhijith Rao.⁷ Both spironolactone and furosemide are included in the Essential Medicines List (EML-2023) and the National List of Essential Medicines (NLEM-2022).

HMG-CoA reductase inhibitors, or statins, are widely prescribed for CVD, accounting for 14.69% of such prescriptions due to their potent hypolipidemic effects. These drugs inhibit the enzyme HMG-CoA reductase, which catalyzes the rate-limiting step in cholesterol biosynthesis.⁹ Atorvastatin, comprising 52.86% of statin prescriptions, significantly lowers LDL and VLDL levels while raising HDL levels, reducing the risk of atherosclerosis, coronary heart disease, myocardial infarction, and stroke.¹⁵ Atorvastatin is also listed as essential according to the EML 2023.

The Renin-Angiotensin-Aldosterone System (RAAS) regulates hemodynamics, electrolyte balance and vascular resistance. RAAS activation starts with renin release, leading to angiotensin-II formation. Angiotensin-II induces vasoconstriction, aldosterone secretion, and antidiuretic hormone (ADH) release, raising blood pressure and maintaining sodium balance. Clinically, RAAS blockers were prescribed to 12.38% of patients, with Telmisartan used in 47.46% of these cases. Telmisartan, an angiotensin-II receptor blocker (ARB), inhibits angiotensin-II binding to the AT1 receptor, reducing its effects. ARBs like Telmisartan are used for hypertension, heart failure, myocardial infarction (MI), and diabetic nephropathy and are preferred when ACE inhibitors cause adverse effects like a persistent cough. Ramipril, an ACE inhibitor, accounted for 40.68% of RAAS blocker prescriptions, reducing angiotensin-II formation, leading to vasodilation, decreased peripheral vascular resistance, reduced aldosterone production, and lowered blood pressure, protecting cardiovascular and renal function. Both Telmisartan and Ramipril are included in the EML-2023 and NLEM-2022, highlighting their therapeutic importance in RAAS-related conditions.¹⁰ Sacubitril, an angiotensin receptor neprilysin inhibitor (ARNI), combined with Valsartan, is FDA-approved for chronic heart failure with reduced ejection fraction (HFrEF) and is used alongside β-blockers and aldosterone antagonists.¹⁶

Vasodilators were prescribed for cardiovascular disease (CVD), with Isosorbide dinitrate being the most common. Nitrates like Isosorbide dinitrate increase coronary flow by dilating coronary arteries through nitric oxide release, although their effectiveness may diminish with prolonged use.^9,15 Comparable findings have been reported by authors Abhijith Rao et al and Nkeiruka Grace Osuafor et al.^7,14 Isosorbide dinitrate is clinically significant, as highlighted by its inclusion in both the EML-2023 and NLEM-2022. This drug is administered to patients on an SOS basis due to its rapid onset and short duration of action, whereas Isosorbide mononitrate is preferred for its long duration of action and delayed release effect.¹⁷

Platelet inhibitors and anticoagulants are extensively used for managing and preventing thrombus formation in the vasculature. Among anticoagulants (3.79%) prescribed, the utilization rates were as follows: Warfarin (a coumarin derivative) at 61.11%, Rivaroxaban (a Factor Xa inhibitor) at 5.56%, and Dabigatran (a direct thrombin inhibitor) at 5.56% in patients with cardiovascular disease (CVD). These agents are indicated for conditions such as venous thromboembolism, atrial fibrillation, and myocardial infarction, functioning to prevent or reduce blood coagulability.¹⁰Rivaroxaban was found essential with the EML 2023.

Calcium channel blockers (CCBs), particularly Amlodipine, were commonly prescribed to patients with CVD. CCBs are first-line agents for antihypertensive therapy and are also used in the management of angina pectoris and cardiac arrhythmias.⁹ The utilization pattern of Amlodipine aligns with previous studies, including those by Nkeiruka Grace Osuafor, and it is considered essential according to both the EML 2023 and NLEM 2022.

Digitalis glycosides were administered to patients diagnosed with CVD, with Digoxin being the most frequently prescribed among them. Digitalis compounds exert a positive inotropic effect on the myocardium by directly inhibiting the Na⁺/K⁺-ATPase pump and indirectly stimulating the vagus nerve (vagomimetic effect), leading to enhanced cardiac output. These pharmacological actions make digitalis glycosides a cornerstone in the management of congestive heart failure and cardiac arrhythmias.¹⁰ Digoxin is an essential drug according to EML-2023 and NLEM-2022. Amiodarone, a class III antiarrhythmic agent, functions as a potassium channel blocker, exhibiting a concentration of 0.31%. By inhibiting potassium channels, amiodarone prolongs the duration of the cardiac action potential, thereby extending the refractory period. This action effectively suppresses abnormal automaticity in cardiac tissue.¹⁰ Amiodarone is essential according to NLEM-2022.

Ranolazine, a novel anti-anginal medication, was used as a pharmacotherapeutic intervention for angina pectoris. It exerts its effects by mitigating calcium overload within myocardial cells, functioning as both an anti-anginal and anti-ischemic agent.¹⁸

Cardiovascular disease (CVD) is influenced by risk factors such as hypertension, hypercholesterolemia, obesity, and diabetes mellitus, which can be managed through a balanced diet, regular exercise, and tobacco avoidance. This study identified diabetes mellitus as the most common comorbidity associated with CVD (67.17%), followed by COPD/Asthma (22.72%) and Hypothyroidism (10.1%), aligning with a study done by Fehmi M. Mukada.¹⁹ Diabetes mellitus significantly increases the risk of CVD.

For the management of Type-2 Diabetes Mellitus (T2DM), oral hypoglycemic agents were primarily prescribed, with Metformin being the most common due to its effectiveness, safety, low risk of hypoglycemia and affordability. Its inclusion in the EML-2023 and NLEM-2022 underscores its importance. SGLT-2 inhibitors, particularly Dapagliflozin, were the second most prescribed class, aiding in renal protection and reducing heart failure-related hospitalizations. It is an essential drug in EML-2023. Glimepiride, a sulfonylurea, is widely used for its role in stimulating insulin release from pancreatic β-cells and has been associated with reduced cardiovascular mortality in T2DM patients with chronic heart failure.²⁰ Dipeptidyl peptidase-4 (DPP-4) inhibitors, such as sitagliptin, inhibit the DPP-4 enzyme, degrade incretins like GLP-1 and GIP, and enhance Insulin secretion.²⁰ Voglibose, an α-glucosidase inhibitor, was frequently used to manage postprandial glucose levels by inhibiting carbohydrate digestion and absorption.¹⁹ Meglitinides like Repaglinide, which act similarly to sulfonylureas but with a shorter duration, were also employed to stimulate insulin secretion.⁹

In the study, Chronic Obstructive Pulmonary Disease (COPD) and asthma were the second most common comorbidities among patients with CVD. The primary pharmacotherapeutic approach included corticosteroids, Long-Acting Beta Agonists (LABAs), and bronchodilators. Formoterol, a long-acting selective β2 agonist, was notable for its 12-hour relief and rapid onset within 10 minutes, making it effective for both acute and chronic management.⁹ Formoterol is listed as essential in EML-2023 and NLEM-2022. Selective β1 blockers like Bisoprolol (5mg) were used as an alternative due to the contraindication of β-blockers in asthma. Acebrophylline was effective in treating various bronchitis types, reducing the need for β2-agonists and improving ventilatory function.²¹ It is also listed as essential in EML-2023.

Anticholinergics, including both short-acting (Ipratropium Bromide) and long-acting agents (Tiotropium Bromide), were used for symptom relief and prophylaxis, with Tiotropium having a significantly higher affinity for muscarinic receptors.^9,22 Both are included in EML-2023 and NLEM-2022. Levosalbutamol used to manage bronchospasm, demonstrated greater efficacy than racemic salbutamol.^23,24 It is also essential according to EML-2023 and NLEM-2022.

Corticosteroids like Budesonide provide superior symptomatic relief by reducing mucus hypersecretion and inflammatory responses, potentially slowing disease progression.^9,25 Budesonide is included in EML-2023 and NLEM-2022. Theophylline, a non-selective phosphodiesterase inhibitor, promotes bronchodilation by relaxing bronchial smooth muscle and reducing airway sensitivity.²⁶ Montelukast, a leukotriene receptor antagonist, was effective in mitigating bronchoconstriction and improving pulmonary function.^27-30 and is essential according to NLEM-2022.

Thyroid hormones significantly influence cardiac and peripheral vascular function by increasing myocardial contractility, and heart rate, and inducing peripheral vasodilation, which together enhance cardiac output. Severe deficiency in thyroid hormones can lead to cardiovascular complications and exacerbate existing conditions.³¹ In this study, hypothyroidism was a notable comorbidity among cardiovascular disease (CVD) patients. Levothyroxine, used in 85% of these cases, is the primary treatment for hypothyroidism, a condition marked by insufficient production of thyroid hormones. It raises levels of Triiodothyronine (T3) and Thyroxine (T4), alleviating symptoms like fatigue, dry skin, and weight gain.³¹ Levothyroxine is essential as per EML-2023 and NLEM-2022.

Treatment approaches include monotherapy and combination therapy. Monotherapy involves using a single medication to manage a condition, valued for its simplicity, cost-effectiveness, lower risk of adverse effects, and easier monitoring. However, when monotherapy fails to provide adequate control due to limited efficacy, resistance, or poor disease management, combination therapy is recommended. Combination therapy targets multiple aspects of cardiovascular disease-such as blood pressure, cholesterol, and clotting factors—offering synergistic benefits and potentially improving patient adherence by reducing the number of medications. Despite its advantages, combination therapy has drawbacks, including higher costs, increased risk of adverse effects or drug interactions, and limited applicability.³² The present study highlights the value of combination therapy in cases where monotherapy is insufficient, as it can enhance risk factor control and disease management in cardiovascular conditions.

The present study has several limitations. The study findings may not be as the study was conducted at a single hospital for a short duration limiting the ability to capture seasonal variations in cardiovascular disease and prescribing practices. By excluding hospitalized patients, the study does not address prescribing for severe cases, which could differ from outpatient settings. Additionally, including only outpatient department patients may introduce selection bias, potentially underrepresenting certain groups. The observational design identifies associations but does not establish causality. The use of a Data Collection Form (DCF) and WHO core prescribing indicators may not fully capture all influencing factors or the complexities of prescribing practices. Furthermore, the study does not assess patient outcomes, such as therapy effectiveness, adherence, or adverse drug reactions.

Future research should include multi-center studies across diverse regions and hospital types to improve generalizability and assess a wider range of prescribing patterns. Longer duration of studies could reveal trends and seasonal variations in cardiovascular disease and prescribing practices. The inclusion of hospitalized patients could provide more insights into severe cases and allow comparisons between outpatient and inpatient prescribing. Addition and analysis of patient outcomes such as therapy effectiveness, adherence and adverse reactions can provide significant impact on prescribing practices. The findings can serve as benchmarks for national and international standards, informing quality improvement efforts and policy development in cardiovascular care.

CONCLUSION:

The present study provides valuable insights into prescription patterns and pharmacotherapeutic approaches in the management of CVD and its comorbidities. It highlights the holistic approach to patient care, recognizing the complex relationship between cardiovascular health and other ailments. Prescription patterns revealed a preference for generic over brand-name medications, aligning with principles of rational drug use aimed at improving medication accessibility and affordability. Antiplatelet agents emerged as the most frequently prescribed class of medications, followed by Sympatholytic agents and Diuretics. Among these, Aspirin and Metoprolol were prominently prescribed, reflecting their established efficacy in cardiovascular risk reduction and blood pressure management, respectively. The study findings highlight the necessity of adopting a comprehensive and individualized approach to patient care, with a focus on rational drug use, responsible and judicious selection of medications to optimize therapeutic outcomes while minimizing potential risks.

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Received on 13.03.2025 Revised on 03.09.2025

Accepted on 16.12.2025 Published on 22.04.2026

Available online from April 24, 2026

Res.J. Pharmacology and Pharmacodynamics.2026;18(2):117-126.

DOI: 10.52711/2321-5836.2026.00016

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.

Comorbid Conditions	Sub Class	Drugs	Frequency	Frequency Distribution (%)
Diabetes mellitus	Biguanide	Metformin	48	36.09%
	Sulfonylurea	Glimepiride	17	12.78%
	Sulfonylurea	Glipizide	4	3.01%
	DPP-4 Inhibitors	Sitagliptin	16	12.03%
		Linagliptin	1	0.75%
		Teneligliptin	5	3.76%
		Vidagliptin	2	1.50%
	SGLT 2 Inhibitors	Dapagliflozin	24	18.04%
	Meglitinide	Repaglinide	1	0.75%
	Competitive α Glucosidase Inhibitors	Voglibose	15	11.29%
Hypothyroidism	Hypothyroidism	Levothyroxine	17	85%
Hypothyroidism	Hypothyroidism	Thyroxine Sodium	3	15%
COPD/Asthma	Corticosteroids	Budesonide	8	17.78%
	LABA	Formoterol	8	17.78%
	Non-Selective Pde Inhibitors	Theophylline	1	2.22%
	Short-acting Anticholinergics	Ipratropium Bromide	3	6.68%
	Long-acting Anticholinergics	Tiotropium	6	13.33%
	β2 Sympathomimetics	Salbutamol	2	4.44%
	β2 Sympathomimetics	Levosalbutamol	6	13.33%
	Bronchodilators	Acebrophyline	8	17.78%
	Bronchodilators	Etofyline	1	2.22%
	Leukotriene Receptor Antagonist	Montelukast	2	4.44%