Is it true , once a patient is labelled as a hypertensive he remains hypertensive life long ? Is it possible to withdraw antihypertensive drugs permanently ?
- Systemic hypertension is the most common clinical entity and it forms the bulk of the physician consultations world over.
- The anti hypertensive drugs are one of the most commonly prescribed medication by the medical professionals .
- It is estimated , the major chunk of revenue to pharma industry is contributed by antihypertensive drugs.
- SHT , is being maintained as a major , global cardiovascular risk factor , by periodically refixing the target blood pressure to lower levels by various committees.
- The terminology of pre hypertension for blood pressure between 120-140 was hugely controversial and some societies refused to accept this entity.
Is there a case for withdrawal of anti hypertensive agents among our patients ?
Yes , in fact there is a strong case for it.
While on the one hand there is a sustained effort ( By whom !) to increase the drug usage , very early in the course of hypertension , there is also a silent progress in our knowledge , regarding withdrawl of anti hypertensive agents in all those undeserving patients .
It is estimated 42% *of the so called hypertensives especially elderly can be successfully weaned of anti hypertensive drugs with out any adverse effect.( Mark R Nelson BMJ. 2002 October 12; 325(7368): 815.)
What are the situations where we can successfully with draw anti hypertensive drugs?
- The most common group of patients are the ones, where the anti hypertensive drugs are started prematurely , with out giving an option for non drug life style approach.These patients and their physicians continue to believe , anti HT drugs are sacred and essential !
- There is another major group of patients who have had a temporary elevation of BP due to a stressful environment.These patients get drugs permanently for a temporary problem . These patients need to be reassessed.
- Some of the elderly patients, with the onset of age related autonomic dysfunction ,these drugs are poorly tolerated and even have disastrous effects .In this population it is desirable , to wean off the anti HT drugs and switched over to life style medication whenever possible.
Final message
Essential or primary hypertension is not a permanent disease, in bulk of our population. It reflects the state of the blood pressure on a day to day basis and is a continuous variable. All patients who have been labelled as hypertensives( Either by us or others) should be constantly reviewed and considered for withdrawal of the drugs if possible.
* Note this rule does not apply in all secondary hypertensions, during emergencies, uncontrolled hyper tension with co existing CAD /diabetes /dyslipidemias etc .
Please refer to these forgotten Landmark articles
Does Withdrawl of Anti hypertensive Medication
Increase the Risk of Cardiovascular Events?
The TONE study
Source: The American Journal of Cardiology, Volume 82, Number 12, 15 December 1998 , pp. 1501-1508(8)
http://www.ncbi.nlm.nih.gov/pubmed/9874055
Conclusion of TONE study
The study shows that antihypertensive medication can be safely withdrawn in older persons without clinical evidence of cardiovascular disease who do not have diastolic pressure > or = 150/90 mm Hg at withdrawal, providing that good BP control can be maintained with nonpharmacologic therapy
Some of the references for successful withdrawl of antihypertenive drugs
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Am J Hypertens. 2001;
14:98–105.
[PubMed]
2.
Wing, LMH; Reid, CM; Ryan, P; Beilin, LJ; Brown, MA; Jennings, GLR, et al. Second Australian nationalbloodpressure study (ANBP2): Australian comparative outcome trial of ACE inhibitor- and diuretic-based treatment of hypertension in the elderly. Clin Exp Pharmacol Physiol. 1997;19:779–791.
3.
Lee, J. Odds ratio or relative risk for cross-sectional data.
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Lin, D; Wei, L. The robust inference for the Cox proportional hazards model. J Am Stat Assoc. 1989;84:1074–1079.
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Veterans Administration Cooperative Study Group on Antihypertensive Drugs. Return of elevated blood pressure after withdrawal of antihypertensive drugs.
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Medical Research Council Working Party on the Management of Hypertension. Course of blood pressure in mild hypertensives after withdrawal of long term antihypertensive treatment.
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Alderman, MH; Davis, TK; Gerber, LM; Robb, M. Antihypertensive drug therapy withdrawalin a general population.
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Blaufox, MD; Langford, HG; Oberman, A; Hawkins, CM; Wassertheil-Smoller, S; Cutter, GR. Effect of dietary change on the return of hypertension after withdrawal of prolonged antihypertensive therapy (DISH). J Hypertension. 1984;2(suppl 3):179–181.
9.
Mitchell, A; Haynes, RB; Adsett, CA; Bellissimo, A; Wilczynski, N. The likelihood of remaining normotensive following antihypertensive drug withdrawal.
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Myers, MG; Reeves, RA; Oh, PI; Joyner, CD. Overtreatment of hypertension in the community?
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Stamler, R; Stamler, J; Grimm, R; Gosch, F; Dyer, R; Berman, R, et al. Trial of control of hypertension by nutritional means: three year results. J Hypertens. 1984;2(suppl 3):167–170.
12.
Takata, Y; Yoshizumi, T; Ito, Y; Ueno, M; Tsukashima, A; Iwase, M, et al. Comparison of withdrawing antihypertensivetherapy between diuretics and angiotensinconverting enzyme inhibitors in essential hypertensives.
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Whelton, PK; Appel, LJ; Espeland, MA; Applegate, WB; Ettinger, WH; Kostis, JB, et al. Sodium reduction and weight loss in the treatment of hypertension in older persons: a randomised controlled trial of nonpharmacological interventions in the elderly (TONE).
JAMA. 1998;
279:839–846.
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Heart Outcomes Prevention Evaluation Study Investigators. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on death from cardiovascular causes, myocardial infarction, and stroke in high-risk patients.
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Howes, L; Krum, H. Withdrawing antihypertensive treatment. Curr Therapeutics. 1988;November:15–20.
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Fotherby, MD; Harper, GD; Potter, JF. General practitioners’ management of hypertension in elderly patients.
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Jennings, GL; Reid, CM; Sudhir, K; Laufer, E; Korner, PI. Factors influencing the success of withdrawal of antihypertensive drug therapy.
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Dr.S.Venkatesan MD 