Additional drug or more of the same for better BP control?

A new study by the University of Michigan and the VA Ann Arbor Healthcare System, U.S.A., could help decide whether to increase the dose of an existing drug, or add a new one, to bring down blood pressure that is still not satisfactorily controlled with an existing drug regimen. The study, published in the Annals of Internal Medicine, focused on patients with initial systolic blood pressure above 130 mm Hg. The researchers studied data of nearly 179,000 veterans over 65 who received treatment over two years at VA hospitals. All were taking at least one blood pressure drug at less than the maximum dose and had a treatment intensification at the start of the study period. Treatment intensification can have risks, such as interaction due to addition of a new drug, electrolyte imbalance due to high dose, or fainting if pressure gets too low. This is why such a decision must be carefully made.
The researchers found that adding a new medication had a very slim advantage over increasing the dose of an existing medication, but maximizing the dose of an existing drug elicited better patient compliance. Older adults already take a range of medications, and the risks of polypharmacy (taking multiple medications) are already well-known. First author Carole E. Aubert, a general internist, said, “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.”

According to senior author Lilian Min, a geriatrician, while treatment guidelines suggest starting treatment with multiple medications, doctors are comfortable with starting low and going slow in older patients. She suggests that if the patient is more likely to stick to a simpler regimen, increasing an existing medication is a better alternative, but if the blood pressure is very high and reducing it is more important, starting a new medication would be called for.