Hypertension

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Hypertension

• Drug Treatment

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NICE guideline 34. 2006
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Which drug? 1 NICE guideline 34. 2006

• When BP lowering effects are taken into account,
  there is little to choose between any of the
  major drug classes (thiazides, CCBs, or ACEIs)
• If drug therapy is necessary, this should begin
  with a low-dose thiazide diuretic or a CCB in
  patients who are Black (any age) and those aged
  55 years and above, or
• Unless there are good reasons to do otherwise,
  choose the less costly alternative (i.e. a
  non-proprietary thiazide diuretic)
• Choose an ACEI for patients younger than 55 years
  
• Consider AIIRAs if ACEIs not tolerated
• ß-blockers are an alternative if ACEIs
  contraindicated, e.g. pregnancy/possible
  pregnancy

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Which drug? 2 NICE guideline 34. 2006

• ß-blockers should not be used routinely, and
  should be used cautiously with diuretics (risk of
  diabetes)
• There is no robust evidence base to guide use of
  combinations or third/fourth step treatments (use
  NICE algorithm)
• Although not recommended by NICE, switching
  monotherapy before using a combination can be an
  effective option in some patients
• There may be compelling reasons to use a
  particular agent (e.g. ACEIs in heart failure,
  ß-blockers in angina)

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Which drug? 3 NICE guideline 34. 2006

• NICE guidance recommends BP treatment targets of
• 140/90mmHg for non-diabetic patients with
  hypertension
• 140/80mmHg for patients with type 2 diabetes or
  135/75mmHg if microalbuminuria or proteinuria is
  present
• A small reduction in BP is beneficial if targets
  are difficult to achieve
• a 10mmHg lower BP equates to a 40 reduction in
  the risk of death
• Aim to achieve the largest BP reduction possible
  given side effects, practicability, and
  concordance for each individual patient

140/90
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What about people with type 2 diabetes? NICE
Clinical Guideline. October 2002

• ACEIs, AIIRAs, BBs, or thiazide-diuretics as
  first-line treatments in people
• Long acting CCBs second-line (do not prescribe
  short-acting CCBs)
• Combination therapy with any of the above will be
  required in the majority of patients to meet
  target
• Assess response to treatment frequently (every
  3-6 months when stabilised, and more frequently
  when titrating treatment)
• If microalbuminuria or proteinuria present
• ACEI first-line (consider AIIRA if unsuitable or
  contraindicated)
• Drug classes that may be considered in
  combination include BBs, long-acting CCBs or
  thiazide diuretics.

However, the use of a ß-blocker as a first-line
treatment for hypertension would now seem
inappropriate in view of the NICE CG034
Hypertension guidelines, unless there are
compelling indications. MeReC Hypertension
Bulletin 2006
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What about people with diabetes in ALLHAT?
Whelton P, et al. Arch Intern Med 2005 165
1401-1409

• 31,512 patients in ALLHAT (not randomised to
  doxazosin arm) for whom a baseline FPG was
  recorded
• No differences in primary outcome (fatal or
  non-fatal CHD) between lisinopril and
  chlortalidone groups
• No difference in primary outcome for patients
  with DM or normal glycaemia randomised to
  chlortalidone or amlodipine
• Patients with IFG randomised to amlodipine had a
  higher risk of the primary outcome than those
  taking chlortalidone (RR 1.73, 1.10 to 2.72,
  P0.01)
• Patients with DM randomised to amlodipine had a
  higher risk of heart failure than those taking
  chlortalidone (RR 1.39, 1.22 to 1.59 Plt0.001)
• Patients randomised to chlortalidone were not
  disadvantaged for any other outcomes compared to
  those in other treatment arms

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The three steps to hypertension heaven

• Does the patient really need to use drug therapy?
• check the sphyg and your technique
• do several readings on different occasions
• review all potential drug causes and try non-drug
  therapies first (unless the BP is really high)
• attend to other risk factors e.g. smoking,
  lipids, etc.
• If you do need to treat, getting the pressure
  down is more important than worrying too much
  about which drugs to use
• thiazides are still first choice for most people,
  CCBs and Ace-Is are first choice for some people,
  ß-blockers should not routinely be used
  first-line, doxazosin is first choice for almost
  no-one
• choose agent(s) according to the individual (e.g.
  ACEI in heart failure)
• think about switching drug classes if you dont
  get a response
• Treat the patient, not the blood pressure
• compliance is important a drug that is not
  taken will not work
• remember the U-shaped curves in HOT the
  potential benefits to be gained from decreasing
  BP ever further must be weighed against the
  acceptability to the patient of aggressive
  therapy with multiple drugs