When blood pressure needs more control, what's better: An additional
drug or more of the same?
Study in veterans shows importance of personalizing the approach to intensifying treatment in sustainable ways

Date:
October 4, 2021
Source:
Michigan Medicine - University of Michigan
Summary:
Nearly 34 million Americans have blood pressure that's still too
high even though they take medicine to control it. A new study
may help them and their doctors decide whether to increase the
dose of one of their existing drugs, or add a new one, to bring
down their pressure and lower their risk of future health problems.



FULL STORY ========================================================================== Nearly 34 million Americans have blood pressure that's still too high
even though they take medicine to control it. A new study may help them
and their doctors decide whether to increase the dose of one of their
existing drugs, or add a new one, to bring down their pressure and lower
their risk of future health problems.


==========================================================================
In a look back at data from nearly 179,000 veterans over age 65 who
received treatment over two years at VA hospitals nationwide, researchers
find that patients have a better chance of sticking to their medication
regimen if their doctor maximizes the dosage of one of the drugs they're already taking. They also found that both strategies decrease blood
pressure, but adding a new medication has a very slim advantage over
increasing the dose of an existing medication, despite some of the
patients being unable to stay on the new medication.

In the end, the researchers say, the new findings could add to discussions between physicians and patients whose blood pressure remains elevated
despite starting medication treatment.

The findings, published in the Annals of Internal Medicine by a team from
the University of Michigan and the VA Ann Arbor Healthcare System, focus
on patients whose initial systolic blood pressure was above 130 mm Hg.

By looking back at VA and Medicare data, the researchers were able
to see patterns in treatment and blood pressure readings over time,
in a kind of natural experiment. All the patients were taking at least
one blood pressure medication at less than the maximum dose and had a
treatment intensification at the start of the study period, indicating
that their physicians thought they needed more intense treatment.

Because intensification of blood pressure treatment can come with risks -
- whether a drug interaction if a new drug is added, or an electrolyte imbalance with high doses, or fainting and falling if a person's pressure
gets too low -- such decisions must be carefully made.

This is the first time a study has directly compared the effects of
the two approaches, said first author Carole E. Aubert, M.D., M.Sc.,
a general internist from Bern University in Switzerland who performed
much of the research while a scholar at the U-M Institute for Healthcare
Policy and Innovation.

"There's increasing guidance on approaches to starting treatment in
older adults, but less on to the next steps to intensify treatment,
especially in an older and medically complex population that isn't usually included in clinical trials of blood pressure medication," she said. "How
can we increase medications safely in a population already taking many medications for hypertension and other conditions." "Treatment guidelines
do suggest starting treatment with multiple medications, and clinicians
are comfortable with an approach of 'starting low and going slow' in
older patients," said senior author Lillian Min, M.D., M.S.H.S. "But these results show that in older patients, we have further opportunity to tailor choices in intensifying drug therapy for hypertension, depending on the individual patient's characteristics." She continued, "Is the patient
more likely to stick to a simpler regimen? Then increase an existing medication. Or is the blood pressure very high and the clinician is more concerned about reducing it? Then consider starting a new medication
now." Min is a geriatrician at the Division of Geriatrics and Palliative
Care at Michigan Medicine, U-M's academic medical center, and the VA Ann
Arbor Healthcare System Geriatric Research Education and Clinical Center.

For older adults who already take a range of medications, the added
complexity of having to take one more kind of pill may be too much. The
risks of polypharmacy, the term for taking multiple medications, are
already well-known from other research, Min said. In fact, Medicare
covers an annual medication review with a pharmacist for many older
adults who take many drugs.

The research was funded by the National Institute on Aging and the
Veterans Health Administration. In addition to Aubert and Min, the
research team included Jeremy B. Sussman, M.D., M.S.; Timothy P. Hofer,
M.D., M.Sc.; William C. Cushman, M.D.; and Jin-Kyung Ha, PhD.

========================================================================== Story Source: Materials provided by
Michigan_Medicine_-_University_of_Michigan. Original written by Kara
Gavin. Note: Content may be edited for style and length.


========================================================================== Journal Reference:
1. Carole E. Aubert, Jeremy B. Sussman, Timothy P. Hofer, William C.

Cushman, Jin-Kyung Ha, Lillian Min. Adding a New Medication Versus
Maximizing Dose to Intensify Hypertension Treatment in Older Adults.

Annals of Internal Medicine, 2021; DOI: 10.7326/M21-1456 ==========================================================================

Link to news story: https://www.sciencedaily.com/releases/2021/10/211004203430.htm

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