First-line drugs for hypertension (Review)

Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, 2176 Health Sciences Mall, Vancouver, BC, Canada, V6T 1Z3.
Cochrane database of systematic reviews (Online) (Impact Factor: 6.03). 07/2009; 164(3):CD001841. DOI: 10.1002/14651858.CD001841.pub2
Source: PubMed


One of the most important decisions in treating people with elevated blood pressure is what drug class is used first. This decision has enormous consequences in terms of health outcomes and cost. In this review health outcomes resulting from 4 drug classes are summarized. Most of the evidence demonstrated that first-line low-dose thiazides reduce mortality and morbidity (stroke, heart attack and heart failure). No other drug class improved health outcomes better than low-dose thiazides, and beta-blockers and high-dose thiazides were inferior. Low-dose thiazides should be the first choice drug in most patients with elevated blood pressure. Fortunately, thiazides are also very inexpensive.

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Available from: Vijaya M Musini
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    • "Given the power of lifestyle in preventing and reversing as well as managing hypertension [1] [2], pressing questions that need to be addressed relate to maximizing these benefits and eliminating the need for drugs, augmenting them with medication if indicated, that is, which medication for which patient in the presence of lifestyle behavior change (e.g., smoking cessation, nutrition, and physical activity), and understanding how healthy lifestyles impact the pharmacokinetics of the medications of interest. A possible limitation of our analysis of the review by Wright and Musini [8] is that this Cochrane review is restricted to a subset of RCCTs, albeit it from a high quality established database; thus is not a comprehensive assessment of the methodology of all RCCTs investigating antihypertension drugs. Furthermore, although this review was published in 2009, some of the initial studies began as early as 1970. "
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    ABSTRACT: Established standards for first-line hypertension management include lifestyle modification and behavior change. The degree to which and how lifestyle modification is systematically integrated into studies of first-line drug management for hypertension is of methodological and clinical relevance. This study systematically reviewed the methodology of articles from a recent Cochrane review that had been designed to inform first-line medical treatment of hypertension and was representative of high quality established clinical trials in the field. Source articles (n = 34) were systematically reviewed for lifestyle interventions including smoking cessation, diet, weight loss, physical activity and exercise, stress reduction, and moderate alcohol consumption. 54% of articles did not mention lifestyle modification; 46% contained nonspecific descriptions of interventions. We contend that hypertension management research trials (including drug studies) need to elucidate the benefits and risks of drug-lifestyle interaction, to support the priority of lifestyle modification, and that lifestyle modification, rather than drugs, is seen by patients and the public as a priority for health professionals. The inclusion of lifestyle modification strategies in research designs for hypertension drug trials could enhance current research, from trial efficacy to clinical outcome effectiveness, and align hypertension best practices of a range of health professionals with evidence-based knowledge translation.
    Full-text · Article · Jan 2014 · International Journal of Hypertension
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    • "Pharmacotherapies are associated with different mechanisms of action, harm profiles and costs. The optimal choice of a first line agent remains unclear, as some works suggest that thiazide diuretics are best [11,12], while others suggest calcium channel blockers should be considered as first line therapy in patients over 55 years of age or of Caribbean or African descent [13]. In Canada, all but alpha blockers are considered reasonable first line therapies, with patients’ demographics and comorbidities playing a role in selection [2]. "
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    ABSTRACT: Hypertension has been cited as the most common attributable risk factor for death worldwide, and in Canada more than one of every five adults had this diagnosis in 2007. In addition to different lifestyle modifications, such as diet and exercise, there exist many pharmaco-therapies from different drug classes which can be used to lower blood pressure, thereby reducing the risk of serious clinical outcomes. In moderate and severe cases, more than one agent may be used. The optimal mono- and combination therapies for mild hypertension and moderate/severe hypertension are unclear, and clinical guidelines provide different recommendations for first line therapy. The objective of this review is to explore the relative benefits and safety of different pharmacotherapies for management of non-diabetic patients with hypertension, whether of a mild or moderate to severe nature. Searches involving MEDLINE and the Cochrane Database of Systematic Reviews will be used to identify related systematic reviews and relevant randomized trials. The outcomes of interest include myocardial infarction, stroke, incident diabetes, heart failure, overall and cardiovascular related death, and important side effects (cancers, depression, syncopal episodes/falls and sexual dysfunction). Randomized controlled trials will be sought. Two reviewers will independently screen relevant reviews, titles and abstracts resulting from the literature search, and also potentially relevant full-text articles in duplicate. Data will be abstracted and quality will be appraised by two team members independently. Conflicts at all levels of screening and abstraction will be resolved through team discussion. Random effect pairwise meta-analyses and network meta-analyses will be conducted where deemed appropriate. Analyses will be geared toward studying treatment of mild hypertension and moderate/severe hypertension separately. Our systematic review results will assess the extent of currently available evidence for single agent and multi-agent pharmacotherapies in patients with mild, moderate and severe hypertension, and will provide a rigorous and updated synthesis of a range of important clinical outcomes for clinicians, decision makers and patients.Trial registration: PROSPERO Registration Number: CRD42013004459.
    Full-text · Article · Jun 2013 · Systematic Reviews
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    • "The hypertensive medication selected for evaluation was based on a published systematic review whose aim was to evaluate the medication which should be first-line drug of choice for hypertension [5]. The study included randomized trials of at least one year duration, comparing one of 4 major classes of antihypertensive drugs (Table  1). "
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    ABSTRACT: Background Many drugs are available for control of hypertension and its sequels in Nigeria but some are not affordable for majority of the populace. This serious pharmacoeconomic question has to be answered by the nation’s health economists. The objective of this study was to evaluate the cost-effectiveness of drugs from 4 classes of antihypertensive medications commonly used in Nigeria in management of hypertension without compelling indication to use a particular antihypertensive drug. Methods The study employed decision analytic modeling. Interventions were obtained from a meta-analysis. The Markov process model calculated clinical outcomes and costs during a life cycle of 30 years of 1000 hypertensive patients stratified by 3 cardiovascular risk groups, under the alternative intervention scenarios. Quality adjusted life year (QALY) was used to quantify clinical outcome. The average cost of treatment for the 1000 patient was tracked over the Markov cycle model of the alternative interventions and results were presented in 2010 US Dollars. Probabilistic cost-effectiveness analysis was performed using Monte Carlo simulation, and results presented as cost-effectiveness acceptability frontiers. Expected value of perfect information (EVPI) and expected value of parameter perfect information (EVPPI) analyses were also conducted for the hypothetical population. Results Thiazide diuretic was the most cost-effective option across the 3 cardiovascular risk groups. Calcium channel blocker was the second best for Moderate risk and high risk with a willingness to pay of at least 2000$/QALY. The result was robust since it was insensitive to the parameters alteration. Conclusions The result of this study showed that thiazide diuretic followed by calcium channel blocker could be a feasible strategy in order to ensure that patients in Nigeria with hypertension are better controlled.
    Full-text · Article · Jan 2013 · Cost Effectiveness and Resource Allocation
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