New hypertension treatment recommendations
Beta-blockers are no longer recommended as routine initial therapy for hypertension in England and Wales, say the National Institute for Health and Clinical Excellence and the British Hypertension Society in an updated guideline published this week. It recommends calcium-channel blockers, thiazide-type diuretics or angiotensin-converting enzyme inhibitors as first-line treatment depending on age and ethnic origin (see Panel).
The guideline updates recommendations for the management of hypertension published by NICE in 2004 (PJ, 28 August 2004, p279). The BHS also published guidelines in 2004, which differed from the recommendations made by NICE. The two organisations have now collaborated to produce the updated guideline.
NICE reviewed the 2004 guideline earlier than planned owing to the emergence of new evidence. A total of 20 studies were included in the meta-analysis, four of which (ASCOT, JMIC-B, PHYLLIS and VALUE) were new studies not included in the original guideline.
In head-to-head trials, beta-blockers were usually less effective than a comparator drug at reducing major cardiovascular events, particularly stroke, says the guideline. It adds that beta-blockers were also less effective than ACE inhibitors or calcium-channel blockers at reducing the risk of diabetes, particularly when taken with a thiazide diuretic.
“We are not saying in any way that beta-blockers are ineffective but we are saying that we now have better treatments,” said Bryan Williams, member of the guideline development group and professor of medicine, University Hospitals NHS Trust, Leicester, at the launch of the guideline. He added that if people are already taking beta-blockers and their blood pressure is well controlled then they can stay on them for the time being. If, however, their blood pressure is not well controlled then their drug treatment should be reviewed at their next routine appointment. “Our aspiration is to see the majority of people in this country treated via [the guideline’s] algorithm,” he said. If beta-blockers are withdrawn they should be done so gradually, the guideline says.
Beta-blockers will still be appropriate for some people and should be considered for women of child-bearing age, patients with increased sympathetic drive and patients who are intolerant of, or have contraindications to, ACE inhibitors and angiotensin-II receptor antagonists. Beta-blockers should not normally be withdrawn in those people taking them for other reasons, such as heart failure or angina, it adds.
NICE estimates that the net financial benefit of implementing this guideline in full is a saving of £192m (£58m more in drug costs offset by an expected £250m in benefits).
Recommendations
· Hypertensive patients over 55-years old or black patients (those of African or Caribbean descent, not mixed race, Asian or Chinese) of any age: a calcium-channel blocker or a thiazide-type diuretic should be prescribed as first-line therapy. If a second drug is required, an angiotensin-converting enzyme inhibitor (or an angiotensin-II receptor antagonist if an ACE inhibitor is not tolerated) can be added.
· Hypertensive patients under 55-years old: an angiotensin-converting enzyme inhibitor (or an angiotensin-II receptor antagonist if an ACE inhibitor is not tolerated) should be prescribed first-line. If this does not control blood pressure, a calcium-channel blocker or a thiazide-type diuretic can be added.
· If treatment with three drugs is required in either group, a combination of ACE inhibitor, calcium-channel blocker and thiazide-type diuretic should be used. |
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