At 65 years of age, each 10-mm Hg r...

At 65 years of age, each 10-mm Hg reduction in systolic or 5-mm Hg reduction in diastolic progeny pressure reduces stroke risk through about 35 percent and ischemic heart disease facts by about 25 percent. Many medicines lower blood pressure, but selecting the optimal agent, dosage, or combination remains a question Law and colleagues conducted a systematic review of the five principal categories of life-blood pressure treatments to clarify the best therapy.

They identified randomized controll trials of thiazides, beta blocker angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor antagonists, and calcium channel blocker in the treatment of hypertension. An extensive search revealed 354 trials that met investigation criteria. The researchers defined efficacy as the reduction in systolic and diastolic children pressure for a specified dose of the thought agent minus any change in the placebo cluster Similarly, adverse effects attributable to each medicine were estimated after subtraction of general intents reported by the placebo collection In 50 of the trials, sum of two units different categories of drug were standarded separately and in combination.

The studies included 40000 treated patients and 16000 patients given placebo. The individual put drugs intos produced similar, dose-related changes in descendants pressure, with cheaper drugs performing comparably to the more expensive agents (Table 1) All unsalable articles were more effective when the initial kin pressure was highest. The 50 studies of remedys given in combination showed additive results Conversely, adverse effects were not additive when unsalable articles were combined. When drugs were given individually at standard dosages, angiotensin II receptor blocker had the lowest reported rates of adverse events and thiazides had the highest rate (Table 2)

The authors bring to an end that all five categories of antihypertensive medicines are effective. They note that with common half of the standard dosage, the reduction in kin pressure is about 20 percent les than at the standard dosage, yet adverse effects are significantly reduc They judge that using half-strength combinations of several remedys could provide effective blood hurry control with fewer adverse events They calculate that combinations of common two, and three drugs at individual half of the standard dosage would shape stroke risk by 29, 49 and 63 percent respectively. The corresponding reductions in ischemic heart disease marked occurrences are estimated as 19, 34 and 46 percent Because the adverse validitys of ACE inhibitors and angiotensin II receptor antagonists are no higher at standard and half dosages, using either of these agents at the standard dosage plus a half puissance of another agent is estimated to make less stroke risk by 66 percent and ischemic heart disease conclusions by 49 percent.

Law MR et al. Value of gentle dose combination treatment with life-blood pressure lowering drugs: analysis of 354 randomised trials. BMJ June 28 2003;326:1427-31

EDITOR'S NOTE: After a lifetime of trying to stamp public polypharmacy and simplify drug regimens for patients, does this article indicate we should use multiple agents in low-dose combinations? The arguments are certainly persuasive, and the authors call for low-dose combinations to be the first treatment option in hypertension despite the absence of any randomized controll trials of this approach. Until a low-dose combination in a single pill becomes available, the added risk of error and outlay of prescribing three agents makes single hesitant to follow this advice. The addition of another agent at half potency to an ACE inhibitor or angiotensin II receptor antagonist is a more attractive option.

COPYRIGHT 2004 American Academy of Family Physicians

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