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Hypertension Treatment Intensification in Older Adults
Quick Takes
- Intensifying antihypertensive therapy by maximizing dose was >3 times more common than adding a new medication.
- Adding a new medication was associated with greater systolic blood pressure reduction but less frequent sustained intensification, suggesting that adverse drug events might be more common in patients less willing to take additional medications.
- Follow-up visits within a month after dose changes or addition of a new drug are indicated to assess adherence, tolerance, and effectiveness and to perform further adjustments if needed.
Study Questions:
What is the frequency of intensification by adding a new medication versus maximizing dose, and what is the association of each method with intensification sustainability and follow-up systolic blood pressure (SBP)?
Methods:
The investigators conducted a large-scale, population-based, retrospective cohort study at the Veterans Health Administration from 2011–2013. Observational data were used to emulate a target trial with two groups, new medication and maximizing dose, who underwent intensification of their drug regimen. Veterans aged ≥65 years with hypertension, an SBP of ≥130 mm Hg, and ≥1 antihypertensive medication at less than the maximum dose were included. The following two intensification approaches were emulated: 1) adding a new medication, defined as a total dose increase with new medication; and 2) maximizing dose, defined as a total dose increase without new medication. Inverse probability weighting was used to assess the observational effectiveness of the intensification approach on sustainability of intensified treatment and follow-up SBP at 3 and 12 months.
Results:
Among 178,562 patients, 45,575 (25.5%) had intensification by adding a new medication and 132,987 (74.5%) by maximizing dose. Compared with maximizing dose, adding a new medication was associated with less intensification sustainability (average treatment effect, -15.2% [95% CI, -15.7% to -14.6%] at 3 months and -15.1% [CI, -15.6% to -14.5%] at 12 months), but a slightly larger reduction in mean SBP (-0.8 mm Hg [CI, -1.2 to -0.4 mm Hg] at 3 months and -1.1 mm Hg [CI, -1.6 to -0.6 mm Hg] at 12 months).
Conclusions:
The authors concluded that adding a new antihypertensive medication was less frequent and was associated with less intensification sustainability but slightly larger reductions in SBP.
Perspective:
This observational study reports that intensifying antihypertensive therapy by maximizing dose was >3 times more common than adding a new medication. Adding a new medication was associated with greater SBP reduction but less frequent sustained intensification, suggesting that adverse drug events might be more common in patients less willing to take additional medications. Trials of different strategies of dose intensification are indicated to provide definitive evidence for the optimal strategy for management of hypertension. Finally, this study underscores the need for follow-up visits within a month after dose changes or addition of a new drug to assess adherence, tolerance, and effectiveness and to perform further adjustments if needed.
Clinical Topics: Geriatric Cardiology, Prevention, Hypertension
Keywords: Antihypertensive Agents, Blood Pressure, Drug-Related Side Effects and Adverse Reactions, Geriatrics, Hypertension, Medication Adherence, Pharmaceutical Preparations, Primary Prevention, Treatment Outcome, Vascular Diseases, Veterans
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