Treatment of hypertension in otherwise healthy patients - Uncomplicating uncomplicated hypertension Treatment of hypertension in otherwise healthy patients - Uncomplicating uncomplicated hypertension This document originally appeared in the informed newsletter, Vol. 1 No. 4, September 1995. During the past 15 years, a dazzling array of new drugs that are useful in the treatment of hypertension have been developed. There is an eqally massive volume of new research about these drugs, demonstrating that some agents are clearly preferable for treating hypertensive patients with co-existing medical conditions. For example, we know that angiotensin-converting enzyme (ACE) inhibitors have been shown to be superior in the treatment of hypertension associated with congestive heart failure and that beta-blockers should be avoided in hyptertensive patients with asthma. However, according to Dr. Jan Hux, an internist and researcher at ICES, practising physicians probably hear a lot less about the management of uncomplicated hypertension. "And yet," says Hux, "up to 70% of the adult population who report that they have been told they have high blood pressure do not report any co-existing illness." What is the best treatment for this group? According to the current Canadian Hypertension Society (CHS) guidelines, a low-dose diuretic (e.g., 12.5 mg po daily of hydrochlorothiazide to start) is still a first-line choice for the treatment of uncomplicated hypertension among patients in all age groups. Beta-blockers are also a good choice, beginning with doses that are significantly lower than those used previously (e.g. 25 mg po OD of atenolol, or 25 mg po BID of metoprolol to start). The CHS also points out that non-pharmacologic therapy is recommended for all patients with elevated blood pressure. In a recent study, up to 60% of patients with mild hypertension receiving placebo and nutritional information did not require the addition of medication to control their blood pressure. Facts about hypertension in Ontario Eighteen percent (or an estimated 1.3 million) of Ontario residents aged 18 to 74 were found to be hypertensive Of these, 35% were not aware that they were hypertensive Among those who had ever been told they had hypertension, 62% reported that they had been prescribed some treatment, of these, 62% reported taking medications The most commonly reported non-pharmacologic measures reported by patients who knoew they have hypertension were: weight control (36%), salt restriction (17%), avoidance of stress (17%), and exercise (16%) Source: The 1992 Ontario Heart Health Survey What drugs to use for hypertension in otherwise healthy patients The first choice and what to try next Look to the second, then third and then fourth choices if there are contraindications, side effects or inadequate response. Age <65 Top of the list: Low dose diuretic OR a beta-blocker Next choices: 2. The other agent; i.e. if the low-dose diuretic won't do the job, try a beta-blocker or vice versa. 3. Choose either low-dose diuretic and beta-blocker OR monotherapy with an ACE inhibitor, calcium antagonist or other agent. Age 65-80* Top of the list: Low-dose diuretic Next choices: 2. Low-dose beta-blocker alone. 3. Low-dose diuretic and low-dose beta-blocker. 4. Monotherapy with an ACE inhibitor, calcium antagonist or other agent. Lifestyle modification is recommended for all hypertensive patients. *In elderly patients, the initial dose of diuretics or beta-blockers should be half the usual dose and increased gradually. For patients over 80, there is inadequate evidence about the efficacy of treatment and clinical judgement should be used. Adapted from the 1993 Canadian Hypertension Guidelines Q & A About Treating Hypertension in the Otherwise Healthy Patient Are diuretics as effective as other agents in the initial treatment of mild to moderate hypertension? In comparisons with other classes of antihypertensives, low doses of thiazide diuretics are equally or more effective in reducing both systolic and diastolic blood pressure. <1> More importantly, long-term treatment of hypertension with a diuretic has been shown to decrease the likelihood of stroke and coronary events. Don't patients have more difficulty tolerating the side effects of diuretics and beta-blockers when compared to calcium antagonists and angiotensin converting enzyme (ACE) inhibitors? In a large trial comparing agents from these four groups, none of the drugs led to decreased quality of life. <1> While the side effects experienced differ among drugs and among patients, antihypertensive medications are in general well tolerated. A minority of patients, however, will have side effects that necessitate switching drugs, no matter which agent is used as first-line therapy. Do beta-blockers cause impotence and sexual dysfunction more often than other classes of antihypertensive medication? The relationship of hypertension and antihypertensive drugs to sexual dysfunction remains unclear. <3> Impotence has been reported with most agents. However, a recent study found that a greater number of placebo-treated patients reported difficulties than those assigned to a drug treatment. <1> I've heard that diuretics and beta-blockers have adverse effects on lipid levels and glucose metabolism. Can I prescribe diuretics and beta-blockers to my patients who do not have diabetes or lipid problems? Diuretics and non-ISA beta-blockers do have minor negative effects on levels of insulin, glucose and lipids. While such effects are theoretically interesting, evidence from clinical trials has show that these agents reduce long-term rates of illness and death despite their metabolic effects. <2,4> Studies currently available have not shown that agents from other drug classes are any better at reducing the morbidity and mortality caused by hypertension. Haven't diuretics been found to cause arrythmias secondary to hypokalemia? Thiazide diuretics in currently recommended doses may lower serum potassium levels, but the decrease is usually not clinically significant. An increase in arrythmias related to diuretic use was seen in early studies in which the dose used was markedly greater than that recommended today (50-100 mg vs 12.5-15 mg hydrochlorothiazide). <1> The serum potassium level should be checked once within two weeks of starting treatment with a diuretic. I would like to offer my hypertensive patients an effective medication they could take once a day. Does that mean I have to use one of the new long-acting agents? No, all of the diuretics and some beta-blockers are recommended for once daily use. References Neaton JD, Grimm RH, Prineas RJ et al: Treatment of mild hypertension study. Final results. JAMA 1993;270:713-723 Hypertension Detection and Follow-up Program Cooperative Group: Persistence of reduction in blood pressure and mortality of participants in the hypertension detection and follow-up program. JAMA 1988;259:2113-2122 Prisant LM, Carr AA, Bottini PB et al: Sexual dysfunction with antihypertensive drugs. Arch Intern Med 1994;154:730-736 Dahlof B, Lindholm LH, Hanson L et al: Morbidity and mortality in the Swedish Trail in Old Patients with Hypertension (STOP-Hypertension). Lancet 1991;338:1281-1285 .