Hypertension: So many treatments, yet so undermanaged - Rising in prevalence and no longer age-discriminating, hypertension is still the silent killer in our midst. - Drug Topics
In the wake of a century marked by health awareness and preventive medicine, hypertension (HTN) appears to remain the very
same silent killer it was dubbed decades ago, when blood pressure (BP) inevitably wreaked havoc on unsuspecting, sporadically
compliant patients. With the Food & Drug Administration having recently approved two new products—Bystolic (nebivolol, Forest
Labs), and Tekturna (aliskiren, Novartis)—and expanded product indications for Diovan (valsartan, Novartis) and Avalide (irbesartan-hydrochlorothiazide,
Bristol-Myers Squibb), HTN is certainly not devoid of therapeutic options. Yet today, "HTN remains a problematic disorder,
despite functioning healthcare systems, a large number of effective treatments, and overwhelming evidence in various patient
populations," acknowledged authors of an editorial published in the August issue of the Lancet.
The Lancet authors pointed out that the risk of becoming hypertensive during a lifetime exceeds 90% for a person in a developed country.
At this rate, the estimated number of hypertensive adults worldwide is expected to reach 1.56 billion in 2025—up from 972
million in 2000. Recent studies published in both Circulation and JAMA indicate that the prevalence of pediatric pre-HTN and HTN is increasing, yet the diagnosis is frequently missed. Of 507 hypertensive
children and adolescents included in the JAMA study, only 26% had the diagnosis documented in their medical chart and 41% had undiagnosed stage II HTN. ACE inhibitors
and calcium channel blockers (CCBs) are generally preferred for management of HTN in children and, just recently, valsartan
was approved for treatment of high BP in children and adolescents ages six to 16.
For patients of all ages, the Lancet authors emphasize that screening for HTN is not done systematically, and diagnosis is often made at a late stage when target-organ
damage has already started. Therapeutic inertia is another major issue, according to several practicing clinicians. "A physician
may start treating a patient with a relatively high BP and become easily appeased when BP drops substantially but does not
reach recommended goals," acknowledged Michael A. Weber, M.D., professor of medicine and associate dean for research at the
SUNY Downstate College of Medicine in New York. In the experience of Linda Fang, Pharm.D., BCPS, "Clinicians are not comfortable
with dropping BP too much—especially in patients who have gone from systolic BP levels of, say, 180 mm Hg to 150 mm Hg. They
often believe that for patients who have become accustomed to living with very high BP levels, a systolic BP of 130 mm Hg
may be considered hypotensive." Fang is a clinical assistant professor at Ernest Mario School of Pharmacy and clinical pharmacist
at Saint Barnabas Medical Center in New Jersey. For severely hypertensive patients, "you don't want to drop BP too quickly,
but eventually you do want to drop it to a normotensive level," she stressed.
Position statement: Antihypertensive treatment: Preferred drugs
According to a survey conducted by the healthcare market research firm, Decision Resources, nearly 65% of newly diagnosed
hypertensive patients do not receive drug treatment in the first year of their diagnosis. "We believe that physicians are
prescribing lifestyle modifications to the majority of these patients; however, this non-pharmacologic approach is contrary
to the advice of thought leaders, who only recommend a two- to three-month trial of lifestyle interventions," said Jeremy
Goldman, M.D., analyst at Decision Resources.
Drug Topics is a monthly news magazine, guided by a board of pharmacy leaders, reporting on all phases of community, retail, and health-system issues and trends. We cover managed care and professional, national, and state activities as well as new therapies involving prescription and OTC drugs.
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