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“You, or at least many of your colleagues, have failed to provide optimal care to your patients with high blood pressure.” This stinging critique of physician prescribing practices starts off an editorial in the Journal of General Internal Medicine for October 2000 that commented on a Harvard Medical School study of high blood pressure in older adults that appeared in the same issue.
Recommendations from the National Institutes of Health released in 1993 as the fifth report of the Joint...
“You, or at least many of your colleagues, have failed to provide optimal care to your patients with high blood pressure.” This stinging critique of physician prescribing practices starts off an editorial in the Journal of General Internal Medicine for October 2000 that commented on a Harvard Medical School study of high blood pressure in older adults that appeared in the same issue.
Recommendations from the National Institutes of Health released in 1993 as the fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (“JNC V” for short) cited thiazide diuretics (water pills) and beta-blockers as the initial treatment for high blood pressure unless specific medical reasons exist for beginning treatment with a different family of drugs. These recommendations came after three major clinical trials in older adults were published in 1991 and 1992, and were confirmed in 1997 with the publication of JNC VI. The 1993 study has been the basis for our recommendations for the initial treatment of high blood pressure in the book Worst Pills, Best Pills.
A table of representative brand and generic names of the various families of blood pressure lowering drugs mentioned in the study appears below.
Additionally, other controlled clinical trials indicated that patients with certain illnesses were likely to benefit from specific blood pressure drugs. For example, among those with high blood pressure and congestive heart failure or diabetes, an angiotensin converting enzyme (ACE) inhibitor is a good choice based on evidence that ACE inhibitors reduce mortality in patients with congestive heart failure and can reduce kidney damage in diabetic patients. Also, a beta-blocker would be a good choice for most high blood pressure patients with a history of heart attack, because there are also trials showing a reduction in the risk of death when a beta-blocker is used.
The Harvard researchers examined the prescribing practices of physicians for older high blood pressure patients enrolled in the New Jersey Medicaid program from January 1, 1991 through December 31, 1995. This involved 23,748 new users of a high blood pressure drug. Their average age was 76 years and 11,103 had at least one of the following conditions: diabetes, congestive heart failure, history of heart attack, or history of angina (chest pain.)
They found that the most commonly prescribed initial blood pressure lowering drugs were calcium channel blockers (42 percent), next were ACE inhibitors (24 percent), followed by thiazides (17 percent), beta-blockers (10 percent), central antiadrenergic agents (4 percent) , peripheral antiadrenergic agents (3 percent), alpha blockers (less than 1 percent), direct vasodilators (less than 1 percent), and angiotensin II receptor blockers (less than 1 percent).
For 12,645 patients with uncomplicated high blood pressure who did not have any of the conditions listed above, calcium channel blockers were the most commonly prescribed initial drugs (38 percent), followed by thiazides (22 percent), ACE inhibitors (21 percent), and beta-blockers (11 percent).
The researchers concluded that despite the results of well done clinical trials and the recommendations contained in JNC V, the prescribing of thiazides and beta-blockers actually declined during the early 1990s. One explanation offered by the researchers has been the effect of aggressive marketing of calcium channel blockers by drug companies for the initial treatment of high blood pressure.
The researchers noted that in addition to issues of quality of care raised by their results, the prescribing practices documented in this study have huge economic implications. The wholesale cost of a one year supply of a calcium channel blocker can be as much as $1,000, compared to less than $15 for hydrochlorothiazide.
There is no reason to believe that the prescribing pattern seen in this study would not also be seen in the prescribing for elderly patients who must pay for their own drugs. It is conceivable that some seniors are having to choose between paying their rent and buying an inappropriate drug for their high blood pressure when the first line drug, hydrochlorothiazide, costs less than two percent of what a calcium channel blocker would cost. If the basis for prescribing high blood pressure drugs were science, more elderly people with high blood pressure would not have to choose between paying their rent and getting the most effective drug treatment.
We strongly support the aggressive-marketing explanation that the researchers suggest. Physicians have allowed big drug companies to advertise their way into the public’s medicine cabinet through high-powered advertising campaigns. The trend toward prescription drug advertising to the lay public in non-medical journals and on TV, thereby putting patient/consumer pressure on doctors, can only make the situation worse.
What You Can Do
Do Not stop any high blood pressure medication without first consulting your doctor.
If you are being treated for high blood pressure and have never been tried on a low-dose water pill you should ask your doctor: Why not?
