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What’s the best way to intensify treatment in older adults with hypertension?

Journal
Annals of Internal Medicine
Reuters Health - 04/10/2021 - For older adults who fail to reach a blood pressure target after initial anti-hypertensive therapy, upping the dose of a current medication might be simpler than adding a new medication, with the tradeoff of slightly less systolic-BP-lowering effect, a large observational study suggests.

The best strategy for older adults needing to intensify antihypertensive treatment - adding a new medication or maximizing the dose of existing medications - has not yet been established.

To investigate, Dr. Carole Aubert of the University of Michigan in Ann Arbor and colleagues analyzed data on more than 178,000 veterans with systolic BP above 130 mm Hg while taking at least one antihypertensive drug not at full dose; a quarter of the patients added new medications and three-quarters maximized doses of existing medications. The team compared outcomes at three and 12 months, adjusting for baseline characteristics.

At three months, those who added a new medication were significantly less apt to sustain this intensification compared with peers who upped the dose of existing medication (49.8% vs. 65.0%).

Both strategies reduced systolic BP, but adding a new medication had a slight advantage over maximizing the dose, with a 1.1 mm Hg larger mean decrease in systolic BP at 12 months (5.6 vs. 4.5 mm Hg).

Dr. Olivier Steichen of Sorbonne University, in Paris, notes in a linked editorial that the study included a large number of elderly patients, who are under-represented in clinical trials.

"The authors used sophisticated statistical methods to emulate a clinical trial in this observational cohort, but the results remain vulnerable to bias and confounding," as the authors acknowledge, he writes.

Nonetheless, Dr. Steichen says two results must be stressed.

"First, whatever the chosen strategy, treatment intensification leads to large BP decreases in patients who need it the most. Second, the two intensification strategies are associated with similar 12-month BP decreases in the emulated intention-to-treat analysis."

"In practice, this study provides support to several general principles of antihypertensive drug prescription," Dr. Steichen writes.

"When intensification is indicated, we should not waste time with elaborate reasoning: Either add a drug or maximize the dose of existing drugs, whichever seems to fit best with the patient's current treatment, clinical state, and preferences. We must try to keep the treatment as simple as possible but remember that increasing the dose of a single drug has a limited effect on the overall potency of a combination. We should use (single-pill combinations) whenever they simplify the treatment and explain any unavoidable complexity to the patient. A follow-up visit must be planned about one month later to assess adherence, tolerance, and effectiveness and to perform further adjustments if needed," he concludes.

Funding for the study was provided by the National Institute on Aging and the Veterans Health Administration.

SOURCE: https://bit.ly/2ZSAFRi and https://bit.ly/3BgQyyw Annals of Internal Medicine, online October 4, 2021.

By Reuters Staff



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