Antihypertensive Prescriptions for Newly Treated Patients Before and After the Main Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial Results and Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure Guidelines
Paul MuntnerMarie Krousel‐WoodAmanda D. HyreErin StanleyWilliam C. CushmanJeffrey A. CutlerLinda B. PillerGary GoforthPaul K. Whelton
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Main results of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial were published in December 2002. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, published in May 2003, recommended thiazide-type diuretics as initial pharmacological treatment alone or in combination with another drug in most patients with hypertension. To assess changes from before to after these publications, we compared antihypertensive medication prescriptions filled by patients who initiated pharmacological antihypertensive treatment in a large managed care organization during 3 time periods: (1) July 1, 2001, to June 30, 2002 (before these publications; n=1354); (2) July 1, 2003, to June 30, 2004 (to assess short-term changes; n=1542); and (3) July 1, 2004, to June 30, 2005 (to assess extended changes; n=1865). The percentage of patients initiating antihypertensive treatment with a thiazide-type diuretic increased from 30.6% to 39.4% (P<0.001) between 2001-2002 and 2003-2004, and the increase was maintained at 36.5% in 2004-2005 (P<0.001 compared with 2001-2002 and P=0.33 compared with 2003-2004). Among patients without diabetes mellitus, renal disease, a history of myocardial infarction, or heart failure, the percentage initiating pharmacological antihypertensive treatment with a thiazide-type diuretic increased from 33.1% in 2001-2002 to 43.4% in 2003-2004 (P<0.001) and remained increased (41.0%) in 2004-2005 (P<0.001 and P=0.23 compared with 2001-2002 and 2003-2004, respectively). Despite a sustained increase in the use of thiazide-type diuretics, this study indicates that an opportunity exists to increase adherence to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines.Keywords:
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Benzothiadiazines
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Abstract Evidence on the prescription patterns of antihypertensive drug use in children and adolescents in China is scarce. A descriptive analysis of the Beijing Medical Claim Data, which covered over 95% of the urban residents, was conducted to investigate antihypertensive prescribing patterns and trends in children and adolescents aged under 18 from 2009 to 2014 in Beijing, China. An additional meta-analysis of trends in hypertension prevalence was conducted to compare trends with antihypertensive medications. A total of 11,882 patients received at least 1 prescription for antihypertensive drugs from 2009 to 2014. The number of annual antihypertensive users increased from 2009 to 2012, then declined steadily until 2014, which was consistent with the trend of the hypertension prevalence estimated from the meta-analysis. β-receptor blockers, thiazide diuretics, and angiotensin-converting enzyme inhibitors were the 3 most commonly prescribed antihypertensive drugs. More boys took the antihypertensive drugs than girls. For users aged under 3 years, thiazide diuretics, α-receptor blockers, and angiotensin-converting enzyme inhibitors were the most prescribed drugs, while β-receptor blockers, thiazide diuretics were the most used drugs for users above 3 years. In conclusion, antihypertensive drug prescribing for children and adolescents increased from 2009 to 2014, with different characteristics in different subgroups.
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The effect of the new diuretic antihypertensive drug, indapamide (2.5 mg a day), was compared with the effect of thiazide diuretics in 24 patients with hypertension (seven of whom were receiving a diuretic alone, six were taking a beta-blocker plus a diuretic, and 11 received other combinations of drugs, including a diuretic in all cases). The randomized crossover study with two six-week phases indicated that indapamide is an effective hypotensive agent with potency similar to that of the thiazide diuretics in lowering the blood pressure and in increasing the excretion of potassium.
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Abstract Diuretic effects of seven orally-acting diuretic agents have been examined in the mouse. The following compounds, examples of various types of orally active compound available, produced their characteristic diuretic effects: bendrofluazide, frusemide, ethacrynic acid, acetazolamide, triamterene, aminophylline and Su 15049A. The diuretic effects of the various agents were demonstrated under both water and saline-loading conditions. After allowing for differences in baseline sodium excretion, all diuretics except acetazolamide caused a further enhancement of sodium excretion after saline-loading compared with water-loading tests. The mouse possesses several advantages over the more commonly used rat since the range of diuretic responsiveness is greater. These results suggest that the mouse is a suitable species for diuretic testing.
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Thiazide diuretics are widely used for the treatment of hypertension, but the mechanism by which these drugs lower blood pressure in the long term remains unknown. This article reviews current knowledge about the hypotensive actions of thiazides and thiazide-like diuretics and discusses possible mechanisms of action.
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I believe my major contribution was the Veterans Administration (VA) Cooperative Study on the prevention of morbid events using antihypertensive drug treatment. The principal conclusions of this trial were as follows: The study proved for the first time in patients with moderately severe to severe hypertension that morbidity and mortality were significantly reduced by lowering blood pressure with antihypertensive drug treatment. This demonstration reversed much of the medical opinion at that time, which stated that no attempt should be made to reduce blood pressure with medications in patients with essential hypertension. The VA study was also the first example of a multiclinic, prospective, randomized, double-blind trial for determining the effectiveness of treatment in cardiovascular diseases. It established a model for future trials. Hypertension is the most common cause of death in the United States and other developed countries. Our VA study, therefore, has had a considerable impact on medical treatment both here and in the rest of the world. Other contributions to the treatment of hypertension of which I am a part include the first official announcement (at the annual meeting of the American Heart Association in fall 1957) of the antihypertensive effectiveness of the thiazide diuretics when used alone and in enhancing the antihypertensive effectiveness of other blood pressure-lowering drugs. The observation led me to use combination treatment with a thiazide plus other drugs as initial treatment, a method we started using in the VA trial 35 years ago and have used since. Dr. Moser and I have consistently defended the thiazide diuretics against ill-founded claims of their toxicity. We have come a long way since we first compared notes in 1952 on the use of adrenergic blockade for lowering blood pressure. I believe small, fixed-dose combination drugs containing a diuretic as one of the constituents will one day replace monotherapy as the most effective way to initiate antihypertensive drug treatment. At present, compliance is probably the most important challenge in the treatment of hypertension. What can a physician do about it? Here are some suggestions from an old-timer that you may find useful: Reduce the blood pressure as rapidly as can be done safely. This impresses the patient with the seriousness of the disorder and with the skill of the doctor. Adjust drugs and doses rapidly by making weekly, rather than monthly, appointments during the drug titration period. Set your treatment goal to have the patient reach the blood pressure goal in fewer than 30 days. The patient should be impressed that you consider the disorder serious and urgent. Two or more drugs are usually needed to lower blood pressure to <140/90 mm Hg (in diabetics and patients with renal disease to <130/80 mm Hg). Initiate treatment with the smallest available dose of a two-drug combination tablet. Titrate up to the next higher-strength combination tablet as needed. Combination drugs are less likely to produce side effects than monotherapy because the dose of each component is less than the dose required to reduce the blood pressure to the same degree using one drug. Side effects are dose related. It is well established that compliance is improved if the patient is required to take one tablet once daily rather than several tablets more than once per day. Use fixed-dose combination drugs that contain a diuretic, such as 12.5–25 mg chlorthalidone. In a controlled trial, Materson et al.1 demonstrated that combination drugs containing a diuretic as one of the constituents reduced systolic blood pressure to 140 mm Hg in 77% of patients, significantly more than the average of 49% of patients who had their blood pressure reduced by treatment with combinations not containing a diuretic. A compassionate and motivated nurse may do a better job at follow-up care and obtain better long-term compliance than most doctors. Nurses can spend more time with a patient, emphasizing the importance of continuous control of blood pressure and answering questions. Home blood pressure measurements taken by a family member or the patient him- or herself makes the patient a partner in achieving goal pressure. Many patients, including some who are well educated, have a fear of taking "chemicals" for the rest of their lives. This fear is fostered by exaggerated and often erroneous media claims of death or disability caused by some well known drug. I ask my patients if they have this fear. If they do, I tell them the drugs I am prescribing for them have been used in millions of people for at least 10 years. It is extremely doubtful that a serious toxic effect would not have been recognized within that time. However, because almost all drugs have some side effects, patients should be told what they are so they can be recognized and changes can be made as indicated. Some of you may be curious if I take antihypertensive drugs. I do, and at age 91 years, my blood pressure is maintained between 110/60 mm Hg and 125/70 mm Hg. I have never felt weak or faint at these levels.
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The review presents results of clinical studies of efficacy and safety of thiazide and thiazide-like diuretics in the treatment of patients with arterial hypertension. In this work we have compared the role of diuretics in modern clinical recommendation on control of arterial pressure, and assessed in comparative aspect metabolic effects of thiazide-like diuretics.
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Utilization of antihypertensive drugs in the hypertension outpatient clinic is surveyed periodically in the Queen Mary Utilization of Antihypertensive Drugs Study (QUADS).Two hundred and fifty-one patients (123 men, 128 women) were interviewed in April to December 1996, 439 patients (232 men, 207 women) in January to December 99 and 228 patients (109 men, 119 women) in April to May 2004. Their case notes were reviewed.The percentages of patients receiving no drug (lifestyle modification), one, two, three and over three drugs were 7%, 48%, 36%, 7%, 3%, respectively, in 1996; 14%, 34%, 36%, 13% and 1%, respectively, in 1999; and 3%, 30%, 40%, 22% and 6%, respectively, in 2004. The number of drugs correlated with age and overweight. In 1996, 51% patients received calcium channel blockers (CCB); 46% beta-blockers (BB); 32% angiotensin-converting enzyme inhibitors (ACEI); 15% thiazide diuretics; 5% alpha-blockers; and 0% angiotensin receptor blockers (ARB). In 1999, the respective figures were 52% CCB, 49% BB, 24% ACEI, 22% thiazide diuretics, 4%alpha-blockers and 2% ARB. In 2004, the respective figures were 65% CCB, 64% BB, 33% ACEI, 24% thiazide diuretics, 4% alpha-blockers and 7% ARB. Fewer patients on BBs reported side-effects. Only 11% were on alpha statin and 9% on aspirin. Blood pressure on treatment was 147 +/- 21/84 +/- 11 mmHg in 1999 and 144 +/- 21/82 +/- 11 mmHg in 2004.Increasingly, multiple drugs were used for blood pressure control. Blood pressure control needs improvement, especially in diabetics. CCBs and BBs were consistently popular. Thiazide diuretics, ARBs, statins and aspirin were underused, despite favourable clinical trial evidence.
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