ABSTRACTObjectives: The main objectives of this study were to estimate the demographic details of patients with the first incidence of stroke and to study thevarious risk factors for ischemic stroke.Methods: It was a retrospective, observational study carried out for 1 year at the Department of Stroke Medicine of a tertiary care teaching hospitalin Kerala, India. A total of 636 patients were admitted under stroke medicine during the period from July 1, 2014, to July 1, 2015, and who satisfiedthe inclusion and exclusion criteria were included in the study. A standardized data collection form was prepared and necessary data were collectedfrom patient's medical records.Results: The maximum number of patients was in the age group of 60-69 years. 65.1% patients were residing in the rural area. 60.7% patients weremale. Most of them had hypertension as common comorbidity (21.35%) and the highest number of patients had diabetes mellitus and hypertension(21.7%). Majority of the patients were prescribed with antiplatelets (94.91%), followed by statins (93.8%).Conclusion: A strict control on the comorbid conditions and sticking on to the medications can prevent the occurrence of future stroke.Keywords: Stroke, Secondary prevention, Drugs, Prescribing pattern

G, Arya

Kc, Jithin

Nair, Lekshmi P

R, Lakshmi

English

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Online - 2455-3891 Print - 0974-2441Vol 9, Suppl. 3, 2016A STUDY ON PATTERN OF PRESCRIBING MEDICATIONS USED IN SECONDARY PREVENTION OF STROKEJITHIN KC, ARYA G, LEKSHMI P NAIR, LAKSHMI R*Department of Pharmacy Practice, Amrita School of Pharmacy, Amrita Vishwa Vidyapeetham, Amrita University, Kochi, Kerala, India. Email: lakshmir@aims.amrita.eduReceived: 15 March 2016, Revised and Accepted: 05 September 2016ABSTRACTObjectives: The main objectives of this study were to estimate the demographic details of patients with the first incidence of stroke and to study the various risk factors for ischemic stroke.Methods: It was a retrospective, observational study carried out for 1 year at the Department of Stroke Medicine of a tertiary care teaching hospital in Kerala, India. A total of 636 patients were admitted under stroke medicine during the period from July 1, 2014, to July 1, 2015, and who satisfied the inclusion and exclusion criteria were included in the study. A standardized data collection form was prepared and necessary data were collected from patient’s medical records.Results: The maximum number of patients was in the age group of 60-69 years. 65.1% patients were residing in the rural area. 60.7% patients were male. Most of them had hypertension as common comorbidity (21.35%) and the highest number of patients had diabetes mellitus and hypertension (21.7%). Majority of the patients were prescribed with antiplatelets (94.91%), followed by statins (93.8%).Conclusion: A strict control on the comorbid conditions and sticking on to the medications can prevent the occurrence of future stroke.Keywords: Stroke, Secondary prevention, Drugs, Prescribing pattern.INTRODUCTIONStroke is a preventable and treatable disease. Over the last two decades, an increasing picture of evidence has rewritten the traditional belief that reason behind stroke was merely aging which caused disability and death. Evidence shows effective primary and secondary prevention strategies, categorizing high-risk patients, and also other interventions done soon after the onset of symptoms have given a fruitful outcome in the management of the same [1]. The various types of stroke are as follows:•	 Ischemic	stroke•	 Hemorrhagic	stroke•	 Transient	ischemic	attack	(TIA).Stroke is classically characterized as a neurological deficit attributed to an acute focal injury of the central nervous system by a vascular cause, including cerebral infarction, intracerebral hemorrhage, intraventricular hemorrhage, and subarachnoid hemorrhage or infarction caused by infection or tumor with symptoms lasting more than 24 hrs or leading to death [2]. The ultimate result of ischemic cascade initiated by acute stroke is neuronal death along with an irreversible loss of neuronal function [3]. TIAs are often referred to as ministrokes, warning strokes, or transient strokes [4,5].Symptoms [6]•	 Sudden	numbness	or	weakness	of	the	face,	arm,	or	leg,	especially	on	one side of the body.•	 Sudden	confusion,	trouble	speaking,	or	understanding.•	 Sudden	trouble	seeing	in	one	eye	or	both.•	 Sudden	trouble	walking,	dizziness,	loss	of	balance,	or	coordination.•	 Sudden	severe	headache	with	no	known	causes.Risk factors for stroke [7]Non-modifiable risk factors: Age, sex, low birth weight, race, family history of stroke, or TIA.Modifiable risk factors: Cigarette smoking, hypertension, high total cholesterol,	 low	 HDL	 cholesterol,	 atrial	 fibrillation,	 obesity,	 physical	inactivity, diet, asymptomatic carotid stenosis, postmenopausal hormone therapy, high sodium/low potassium diet, cardiovascular disorders, alcohol, etc.PharmacotherapyAntiplatelet therapy is the gold standard for the secondary prevention of non-cardioembolic strokes and anticoagulants for cardioembolic one. All antihypertensive drugs are used for the management of elevated blood pressure. ACE inhibitor + diuretic are used for both previously hypertensive or previously normotensive. Statins are initiated for both dyslipidemics and also for normal lipids [6].METHODSStudy designThis was a retrospective, observational study.Study durationThe study period was from July 1, 2015, to July 1, 2016.Study populationPatients with first incidence of ischemic stroke admitted to the Department of Stroke Medicine of a tertiary care teaching hospital in Kerala during the period (July 1, 2014, to July 1, 2015) and who satisfied the inclusion and exclusion criteria were included in the study.Inclusion criteria•	 Patients	who	had	the	first	incidence	of	ischemic	stroke.•	 Patients	who	were	discharged	with	drugs	for	secondary	prevention.•	 Patients	of	age	group	≥18	years.Exclusion criteria•	 Patients	diagnosed	with	hemorrhagic	stroke.•	 Patients	diagnosed	with	cancer	and	renal	failure.Research Article©	2016	The	Authors.	Published	by	Innovare	Academic	Sciences	Pvt	Ltd.	This	is	an	open	access	article	under	the	CC	BY	license	(http://creativecommons.	org/licenses/by/4. 0/) DOI: http://dx.doi.org/10.22159/ajpcr.2016.v9s3.14071Asian J Pharm Clin Res, Vol 9, Suppl. 3, 2016, 328-330 Jithin et al. 329Sample sizeSample size (n) was calculated statistically on the basis of the first incidence of stroke and patients prescribed with secondary prevention medications. The sample size was n>237.RESULTSIn this study, a total of 295 patients were studied during a period of 12 months. The age range was from 18 years to 100 years, with a mean age of 64.5 years. The maximum number of patients, i.e., 78 (26.44%) were in the age group of 60-69 years and 67 (22.71%) were in the age group of 70-79 years (Table 1). Furthermore, majority of them were residing in rural area (65.1%) (Table 2).Out of 295 patients, 60.7% were male and 39.3% were female (Fig. 1). After the assessment of comorbidities, the most common one was hypertension.	Highest	number	was	hypertension	combined	with	diabetes	mellitus (DM) in 64 patients (21.7%), followed by hypertension alone in 63 patients (21.35%), hypertension combined with dyslipidemia and DM in 51 patients (51%), and cardiac disease in 49 patients (16.6%) (Table 3).Table 1: Age distribution of patientsAge (years) Number of patients n=295 (%)18-29 7 (2.4)30-39 8 (2.71)40-49 40 (13.55)50-59 69 (23.38)60-69 78 (26.44)70-79 67 (22.71)≥80 26 (8.81)Table 2: Residential categorization of patientsArea of residence Number of patients n=295 (%)Rural 192 (65.1)Urban 103 (34.9)Table 3: Distribution of co‑morbidities in study sampleCo‑morbidities Number of patients n=295 (%)HTN 63 (21.35)DM 24 (8.13)DLP 11 (3.72)Cardiac disease 49 (16.6)HTN+DM 64 (21.7)HTN+DLP 23 (7.8)HTN+DM+cardiac	disease 27 (9.1)HTN+DLP+DM 51 (17.3)HTN+cardiac	disease 8 (2.7)DLP:	Dyslipidemia,	DM:	Diabetes	mellitusTable 4: Prescription pattern of antiplatelets in study sampleAntiplatelets Number of patients n=295 (%)Clopidogrel 40 (14.23)Aspirin 55 (18.6)Clopidogrel+aspirin 185 (62.7)Table 5: Prescription pattern of anticoagulants in study sampleAnticoagulants Number of patients n=295 (%)Warfarin 26 (8.8)Heparin 9 (3)Dabigatran 5 (1.6)Table 6: Prescription pattern of anti‑hypertensivesAntihypertensives Number of patients n=295 (%)CCB 161 (54.5)ACE inhibitor 13 (4.4)ARB 86 (29.1)Diuretics 33 (11.1)Beta	blocker 72 (24.4)Alpha blocker 18 (6.1)CCB+Beta	blocker 1 (0.33)Fig. 1: Gender distribution of patientsAmong 295 patients, antiplatelet drug such as aspirin was administered to 55 (18.6%) patients, clopidogrel was administered to 40 (14.23%) patients, and aspirin-clopidogrel combination was given to 185 (62.7%) patients (Table 4). Cardioembolic stroke patients were treated with anticoagulants such as warfarin to 26 (8.8%) patients and heparin to 9 (3%) patients (Table 5).Patients with hypertension were treated with different classes of antihypertensives such as calcium channel blockers to 161 (54.5%) patients, followed by angiotensin receptor blockers for 86 (29.1%) patients and beta-blockers to 72 (24.4%) patients (Table 6). Atorvastatin was given to 268 (90.8%) patients for aggressive lipid reduction (Table 7). For diabetic control, insulin was prescribed to 38 (12.8%) patients and metformin to 30 (10.1%) patients (Table 8); however, in combination therapy, metformin had the highest percentage (27.1%) than insulin (19.3%).Antiepileptics such as levetiracetam were given to 23 (7.7%) patients, followed by clonazepam to 20 (6.7%) patients to control post-stroke seizures (Table 9). Post-stroke depression was managed using antidepressants such as fluoxetine (9.1%) and venlafaxine (3.7%). Vitamin supplements were given to 118 patients to decrease the hyperhomocysteinemia and possible neural damage; Remylin D (folic acid,	B12,	and	B6)	was	the	most	prescribed	one.	Lactulose	was	given	for constipation in 100 patients and gastrointestinal (GI) protectives were given to minimize the antiplatelet-induced gastric irritation and ulceration and the most commonly prescribed one was pantoprazole to 164 patients.DISCUSSIONThe male to female ratio of the study patients was 1.54:1 and male were more in number; further, the most common age group experienced stroke was between 60-69 years. This result closely relates with studies done by Bhattacharya	et al. [8] and Sethi [9]. Utmost of the patients who were included in this study were staying in the rural area, i.e., 179 (60.7%), and Table 7: Prescription pattern of statins in the study sampleLipid lowering agents Number of patients n=295 (%)Atorvastatin 268 (90.8)Rosuvastatin 9 (3)Asian J Pharm Clin Res, Vol 9, Suppl. 3, 2016, 328-330 Jithin et al. 330116 (39.3%) in urban area. The present study emphasized the risk factors and drugs used in secondary prevention of stroke. In our study patients, the most common risk factors associated with stroke were hypertension and the highest was hypertension combined with DM, followed by cardiac diseases. In the present study, most of the patients were prescribed with antiplatelets, anticoagulants, and statins, which are in close quarter with	 the	 American	 Heart	 Association	 Guidelines.	 The	most	 frequently	prescribed drug in our study was atorvastatin (90.8%), followed by aspirin-clopidogrel combination (62.7%) and calcium channel blockers (54.5%). Multivitamins were also prescribed extensively to 118 patients to	control	hyperhomocysteinemia	and	neural	damage.	Levetiracetam	was	prescribed to control post-stroke seizures which showed an even result as	that	of	a	study	done	by	Belcastro	et al.	[10].	Lactulose	was	prescribed	to manage constipation and GI protectants such as pantoprazole were used to minimize gastric bleeding.CONCLUSIONThe present study helped identify copious risk factors and prerequisite for early and satisfactory management of stroke to prevent future complications. Majority of patients in this study were male (60.7%) between the age group 60-69 years living in rural area (65.1%). Residential categorization revealed that patients were more from rural area rather from urban. Common comorbidities were identified and in which hypertension. Diabetes and dyslipidemia were high in number. These were the modifiable risk factors which could be controlled with adequate treatment and medications. The information from the study could be helpful in avoidance of risk factors and early apposite medical therapy in these patients. The study also revealed various medicines prescribed in stroke such as antiplatelets, anticoagulant, antihypertensive, statins, and antidiabetics. Post-stroke disabilities such as post-stroke depression, post-stroke seizures, neural damage, and constipation were minimized by prescribing drugs such as antidepressants, antiepileptics, multivitamins, and laxatives, respectively. GI protectants were additionally added to reduce gastric bleeding.A first-ever stroke significantly increases the likelihood of further events; thus, secondary prevention is of major importance. The absolute and relative risks of recurrent stroke are highest early after the first stroke but remain elevated for several years thereafter. Effort on the secondary prevention should be initiated as soon as possible and continued for several years to gain the greatest benefit [11]. Thus, it is imperative that public should be made aware of the significance for the secondary prevention of stroke as it helps to reduce the recurrence.REFERENCES1. National Collaborating Centre for Chronic Conditions. Stroke: National Clinical Guideline for Diagnosis and Initial Management of Acute Stroke and Transient Ischaemic Attack (TIA). 3rd ed. London: Royal College of Physicians; 2008.2. Sacco RL, Kasner SE, Broderick JP, Caplan LR, Connors JJ, Culebras A, et al. An updated definition of stroke for the 21st century: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44(7):2064-89.3. Deb P, Sharma S, Hassan KM. Pathophysiologic mechanisms of acute ischemic stroke: An overview with emphasis on therapeutic significance beyond thrombolysis. Pathophysiology 2010;17(3):197-218.4. Johnston SC. Clinical practice. Transient ischemic attack. N Engl J Med 2002;347(21):1687-92.5. Albers GW, Caplan LR, Easton JD, Fayad PB, Mohr JP, Saver JL, et al. Transient ischemic attack – Proposal for a new definition. N Engl J Med 2002;347(21):1713-6.6. Dipiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM. Pharmacotherapy a Pathophysiologic Approach. 8th ed. New York: McGraw-Hill Medical; 2008.7. Lakshmi R, James E, Kirthivasan R. Study on impact of clinical pharmacist’s interventions in the optimal use of oral anticoagulants in stroke patients. Indian J Pharm Sci 2013;75(1):53-9.8. Bhattacharya S, Saha SP, Basu A, Das SK. A 5 years prospective study of incidence, morbidity and mortality profile of stroke in a rural community of eastern India. J Indian Med Assoc 2005;103(12):655-9.9. Sethi PK. Stroke-incidence in India and management of ischaemic stroke. Neuroscience 2002;4(3):139-41.10. Belcastro V, Costa C, Galletti F, Autuori A, Pierguidi L, Pisani F, et al. Levetiracetam in newly diagnosed late-onset post-stroke seizures: A prospective observational study. Epilepsy Res 2008;82(2-3):223-6.11. Burn J, Dennis M, Bamford J, Sandercock P, Wade D, Warlow C. Long-term risk of recurrent stroke after a first-ever stroke. The Oxfordshire Community Stroke Project. Stroke 1994;25(2):333-7.Table 8: Prescription pattern of antidiabetics in the study sampleAntidiabetics Number of patients n=295 (%)Insulin 38 (12.8)Metformin 30 (10.0)Glimipride 14 (4.74)Glibenclamide 2 (0.67)Glipizide 2 (0.67)Metformin+insulin 17 (5.7)Metformin+glimipride 28 (9.49)Metformin+sitagliptin 4 (1.35)Metformin+glibenclamide 1 (0.33)Glimipride+insulin 2 (0.67)Table 9: Prescription pattern of antiepilepticsAnticonvulsants Number of patients n=295 (%)Clonazepam 20 (6.7)Levitiracetam 23 (7.7)Phenytoin 13 (4.4)Gabapentein 3 (1)Sodium valproate 4 (1.35)

A STUDY ON PATTERN OF PRESCRIBING MEDICATIONS USED IN SECONDARY PREVENTION OF STROKE

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A STUDY ON PATTERN OF PRESCRIBING MEDICATIONS USED IN SECONDARY PREVENTION OF STROKE

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