Selecting an initial antihypertensive drug

This is a general question.

Fact 1: JNC V recommends initial treatment with diuretics or beta blockers, unless contraindicated. This issue is extremely controversial.

Fact 2: Most HMOs agree with this approach, mainly because of cost. These HMOs are monitoring treatment provided and may force physicians to comply with these guidelines, at a risk of diminishing freedom of thought and of medical practice.

Fact 3. Most likely, better outcome will be observed when long-term studies support other treatments, especially ACE inhibitors. However, outcome and end-point studies are in progress, not available for awhile.

QUESTIONS:

Given the enormous advances in our understanding of the pathophysiology of hypertension, and the role of the angiotensin system in LVH, arteriolar hypertrophy, the roles of calcium , and other important areas:

What is a responsible physician to use as a primary agent for the initial treatment of hypertension ?

Should one use diuretics and / or beta blockers for everyone except when contraindicated, or practice INDIVIDUALIZED treatment based on hemodynamic patterns, demographic factors and co-morbidities ?

How to respond effectively to policing attempts by the HMO directors ?

I would appreciate a frank answer to this dilemma.

Armando Lindner MD
(Nephrology VAMC and University of Washington, Seattle)


Response by Alan Weder, M.D., University of Michigan, Ann Arbor
To be fair, while much of the enthusiasm for diuretics and beta-blockers on the part of HMOs is a cost issue, much of the reaction to the recommendation comes from the pharmaceutical industry, which obviously has an interest in proprietary products. It is a question of whose ox is being gored.

My own opinion is that there are good reasons to have a wide variety of medications available, but there is at present no really conclusive counterargument to those who tout "evidence-based medicine" as the holy grail. As Dr. Lindner points out, the trials are under way, but we won't have the results for at least a few more years. I personally am not so very certain that the newer drugs will be demonstrably superior to the older agents, but I'm certainly interested in seeing trial results.

For the present, my prejudice is to make my life and that of my patients as simple as possible. This means in essence, once daily dosing, a minimum of side effects and as little office contact and testing as is prudent. For me, this translates into the use of ACEI and AII blockers and CEB. I have no reason not to use diuretics and beta-blockers, and I certainly employ them, but I just don't think they are as well tolerated. I know there are trials out there that suggest equivalent side effect rates between all the classes, but I tend to believe my own experience (and prejudice) as well as studies like TOMHS. The only other factor that enters into my drug selection thinking is concomitant disease, which obviously needs to be considered in all patients. I will say that I am a believer that diuretics and beta-blockers do affect lipids, so that makes them slightly inappropriate for the majority of hypertensives. I have stopped arguing with those who believe otherwise, as I think it's basically a matter of prejudice. I also do believe, as Mickey Alderman has stressed, that we should pay more attention to absolute risk and consider lowering BP in all patients at high absolute risk.

One further comment: I really don't believe in any of the "individualized" treatment schemes. They tend to be constructed by people with a vested interest in demonstrating that their own research is the answer to the world's ills (and they are pleased to act as consultant sfor the preparation of beautiful slide sets supporting their schemes and then to deliver paid lectures on the topic). The only factor that seems to hold up is racial differences in responsiveness to diuretics, beta-blockers and ACEI/AII-blockers, and the differences, while significant, are too small to be usefully predictive in one-on-one practice situations. I'm not a public policy guy, so that argument that the small race- related differences, when spread over the whole country, are important doesn't move me. If people want to do something important, they should go out and identify the 75% of hypertensives who are uncontrolled and treat them effectively. Then we can argue public policy. Ray Gifford was quoted once when asked about the importance of renin, that "More people are living off it than dying from it". I feel somewhat the same way about "individualized treatment schemes.

Regarding the last point on how to respond to HMO directors, I have no real answer. These people have an MBA mind set, which means they look primarily at costs, and their horizon is one year or less. This means that basically the only figure they look at is acquisition cost, which is clearly going to be lower for diuretics and beta-blockers. Enlightened ones add in the costs of office visits and lab tests. What will help is trial data showing increased effectiveness of new drugs, which would permit calculation of cost-effectiveness. Unfortunately, such calculations always show that the cost of life-long therapy for hypertension is an enormous expense for the prevention of CVA and CHD. I think the only semi- practical way to affect formulary composition is either through political or regulatory means, i.e., force the managers via consumer or governmental pressure to do the right thing. Having come of age in the 60s, I am doubtful that this approach is feasible when the issue is of as small concern to most consumers as the choice of antihypertensive drug.

I hope some of this makes sense. It's likely that others have dramatically different views: to quote Dennis Miller, "It's just my opinion; I could be wrong."

(August, 1996)

Very good summary of HTN meds. I dont know if I would always start someone on a beta blocker and water pill. We must individualize treatment.
Pat Donohoo
Rockford, Il USA-Sunday, October 27, 1996 at 23:08:40 (CST)

One of the reasons that this question remains controversial (but not THE ONLY reason), is that many of us in the nephrology community see only complicated or severely hypertensive patients. I suspect that the average internist (what I call the REAL doctor) who sees the majority of mild to moderate hypertensive will have a different point of view. The internist will be more likely to accept low dose diuretic (25 mg HCTZ/day) or a beta-blocker as the initial therapeutic agent, after the usual non-pharmacological measures have been implemented. When we see the worst or complicated hypertensives (renal insufficiency, chronic CHF, diabetic, etc, etc,) we tend to fit the medication to the concomitant diseases. Overall, in my opinion, the best pharmaceutical agent for the initial treatment of hypertension of an uncomplicated patient is low-dose diuretic, because it is effective in the majority of such patients. If there is no response, I make it a habit of obtaining 24-hour urinary sodium and sometimes urinary HCTZ to determine if the patient is compliant before I start a second medication.
Vincent R. Pateras MD FACP (v-pateras)
Evanston, IL USA-Sunday, December 22, 1996 at 10:37:41 (PST)

Dear all, It seems to me that both latest available research results and our clinical experience at least for last five years shows the very clear tendency in anti - hypertensive first - choice drugs. I mean diuretics (furosemide & thiaside), CCB (Verapamil, but not Nifedipine!) and ACE inhibitors, with beta - blockers following mostly for some specific conditions (thyroid crisis, etc.). In pediatric practice we use Verapamil for years as a first - line, any - case drug with excellent results and we do not intend to switch our policy. Some latest reseach results shows even more advantages of Verapamil in renal hypertension such as reducing apostosis, improving ultrafiltration, etc. We have seen only two cases in a last five years where the use of Verapamil was ineffective. And, besides, it is not expensive, even when using IV bolus in acute hypertension management. Unfortunately, I can not say the same for Captopril, especially in renal hypertension in ESRD patients where it either fails to help at all or results in a severe hypotension in approximately 50% of cases. It might be slightly different in adults, where ACE inhibitors are reported yo work better and with lesser side - effects. Anyway, the final decision is up either to a individual doctor or to a approved treatment protocol, but not to any outsider whatever official position he helds. My strong opinion is that step - by - step treatment protocols are highly effective both in medical and financial means as well as they saves crucial time in emergency situations, especially where and when less qualified personel is involved. Thank you, Vladimirs Strazdins, MD Head, Nephrology Department Latvian Medical Academy Hospital for Children
Vladimirs Strazdins, MD (voldis@mail.bkc.lv)
Riga, Latvia-Thursday, August 14, 1997 at 13:41:47 (PDT)

I am presently working as Nephrology locums in the Caribbean. I have been confronted by the local (non-nephrology) MD's who state that there is extensive literature on the use, effectiveness and absolute need for ALDOMET in the Black population. They are having serious difficulty with my Nephrology approach. Does this literature exist? I cannot find it and only use Aldomet in the pregnant or stubborn pt that won't change. Am I missing something?
Dorothy Nemec, MD (dnemec@anguillanet.com)
Sanford, Florida USA-Sunday, January 18, 1998 at 05:25:15 (PST)

I am surprissing with your colleagues my dear doctor. I work in a country with many black people, and we do not have evidence about the use of the Aldomet in that population,because Aldomet does not have better results than any other medication.By opposite the side efects like mental disturbances, impotence, and disturbs of sexual function,are strongs and have directly relationship with dosage. There are not reason for use in black people at present, more because Aldomet does not make a good control of blood pressure without side effects, and there are others antihypertensive drugs with strong evidence of efficacy and efficiency like diuretics, and calcim chanel blockers.I am glad to write you, and perdon my for my English. I am Fellowship in Nephrology in my country and like you Iam in love of nephrology.
jairo hernan gonzalez b (jagbauti@telesat.com.co)
cali, valle - Wednesday, June 30, 1999 at 10:33:04 (PDT)