Effectiveness of common blood pressure drugs varies widely
Click Here to Manage Email Alerts
Key takeaways:
- Widely used antihypertensive drugs vary in effectiveness between individuals.
- Models suggest personalized therapy is associated with substantial blood pressure reductions.
Blood pressure lowering with common antihypertension drugs varies widely among adults with hypertension, yet greater reductions are possible with personalized therapy, researchers reported.
It is unknown whether the optimal choice of BP-lowering therapy varies from one person to another and whether individually targeted BP treatments can maximize clinical benefit, Johan Sundström, MD, PhD, of the department of medical sciences at Uppsala University Hospital, Sweden, and colleagues wrote in JAMA. Clinicians and patients often misinterpret variation in serial clinic and home measures of BP as indicating treatment effects, they wrote.
Image: Adobe Stock
“The Precision Hypertension Care (PHYSIC) study showed that the BP-lowering effect varied greatly between individuals for some medications,” Sundström told Healio. “By finding the optimal treatment for an individual, BP levels could be reduced to twice the levels typically achieved by doubling the dose of a suboptimal treatment. Optimizing treatment by personalization also has more than half the effect of adding a second BP medication.”
In a randomized, double-blind, repeated crossover trial, Sundström and colleagues analyzed data from 270 adults with stage I hypertension at low risk for CV events at an outpatient research clinic in Sweden. Each participant was scheduled for treatment in random order with four different classes of BP-lowering drugs: lisinopril, candesartan, hydrochlorothiazide and amlodipine, with repeated treatments for two classes for a total of 1,468 treatment periods (median length, 56 days). The mean age of participants was 64 years and 54.3% were men.
Patients had hypertension for a mean of 3 years; mean office BP after a placebo run-in period was 154/89 mm Hg. Researchers assessed the extent to which individuals responded better to one treatment than another and estimated additional BP lowering achievable by personalized treatment. The primary outcome was ambulatory daytime systolic BP, measured at the end of each treatment period.
The BP response to different treatments varied considerably between individuals (P < .001), specifically for lisinopril vs. hydrochlorothiazide, lisinopril vs. amlodipine, candesartan vs. hydrochlorothiazide, and candesartan vs. amlodipine. The researchers excluded large differences for the choices of lisinopril vs. candesartan and hydrochlorothiazide vs. amlodipine.
“These data showed that variation in systolic BP was large between treatments on average, between participants on average, within participants taking the same treatment, and between treatments in the same participant,” the researchers wrote.
On average, personalized treatment had the potential to provide an additional 4.4 mm Hg lower systolic BP.
“Assuming the fitted model to be true, personalized treatment using single-drug therapy would on average lead to a 4.4 mm Hg-lower systolic BP in the trial population than a fixed choice,” the researchers wrote. “Taking into consideration that lisinopril was found to be on average most efficacious of the drugs at the selected doses, personalized treatment compared with lisinopril would still lead to a 3.1 mm Hg systolic BP improvement.”
The researchers noted that the study evaluated effects of monotherapy for practical reasons, but it is likely that there would also be benefits from personalization of the dual combination therapies recommended for initial treatment by most guidelines.
“Personalized treatment may reduce the need for higher doses and multiple medications, with the potential to improve treatment adherence, patient outcomes and cost efficacy,” Sundström told Healio. “Notably, the study established the potential for personalized treatment and gauged the size of the BP effect of personalization but did not investigate methods for finding the optimal treatment for each individual.”
For more information:
Johan Sundström, MD, PhD, can be reached at johan.sundstrom@uu.se; Twitter: @drsundstrom.
Perspective
Back to Top
Keith C. Ferdinand, MD, FACC, FAHA, FASPC, FNLA
The effective treatment of hypertension is an essential component of reducing the global burden of CV morbidity and mortality. However, for most U.S. adults, especially older patients, Black Americans, people with obesity status, diabetes and chronic kidney disease, combination agents — from different classes — will be required to effectively control high BP.
The concept that clinicians should expect to see significant differences in one class of modern agents vs. another will mislead and perhaps deflect from the need for combination therapy for most patients. In terms of adherences, using combination therapy at lower doses will give a better benefit compared with simple titration of monotherapy. The potential for BP-lowering gains with intensive BP reduction, as shown in SPRINT and other studies, will be lost.
As with any research, clinicians should be aware of the patient population studied and which medications are used. This population was a relatively low-risk, grade I hypertension group, conducted in Sweden. The use of one agent vs. another is not the concern. The concern is lowering BP intensively, especially in high-risk populations, which were not studied here. The authors recognize that the calculation of risk was not done for this study due to a lack of lipid assessments. Clinicians should recognize that an assessment of ASCVD risk is needed to effectively determine which patients need combination antihypertensive therapy.
The use of one medication vs. another as monotherapy is not considered the appropriate modern approach to pharmacotherapy, especially in higher-risk populations. In a heterogenous population in the United States, this particular approach can mislead as opposed to guiding clinicians to optimal outcomes.
Collapse
Click Here to Manage Email Alerts