A stepped care algorithm developed by scientists has the potential to manage blood pressure in patients who develop intolerance to guideline-based regimens.
Side effects of antihypertensive medications is a commonly cited reason for patient nonadherence. Now, scientists at the Queen Mary University of London have devised an unconventional strategy to personalize treatment and improve patient intolerance to existing medications.
In their research published in the Journal of Clinical Hypertension, scientists from the Queen Mary University of London and Barts Health NHS Trust describe their strategy that included an algorithm-based sequence of monotherapies or combinations of maximally tolerated doses of fractional tablets, liquid formulations, transdermal patches, and even off-label medications. The study included 55 patients who were characterized as having multiple drug intolerances to antihypertensive medication (MDI-HTN), based on documented history of intolerance to at least 3 unrelated classes of antihypertensives, which made them ineligible to receive a conventional guideline-based regimen.
“This is an entirely new concept in tackling high blood pressure. Many of our patients have reported negative experiences with their doctors after complaining about drug side effects. Often the feeling is that reducing the health risks of patients with high blood pressure, such as stroke or heart attack, justifies the very serious drug intolerance that they can experience,” said the lead author on the study Melvin Lobo, director of the Barts Health Blood Pressure Clinic. “We, however, took a different view. We understand that some patients feel forced to cease their treatment due to how wretched it makes them feel. And so we set about trying to help them get around side effects, as opposed to forcing them to take drugs they felt were poisoning them.”
At baseline, the authors report, patients were intolerant to 7.6 ± 3.6 antihypertensives and were receiving 1.4 ± 1.1 medications. Six months after receiving a MDI-HTN treatment regimen, the average blood pressure measured in the clinic was reduced by an average of 13 ± 5/5±2 mm Hg from the high baseline recorded at 178 ± 24/94 ± 15 mm Hg and patients were now being treated with 2 ± 1.2 medications. At the 1-year time point, a further improvements in patient performance were observed. Blood pressure measured in the clinic a year into the program reduced an average of 17 ± 5/9 ± 3 mm Hg from baseline and patients were receiving 1.9 ± 1.1 medications.
The medication algorithm followed during this program was as follows:
Step 1: fractional tablet dosing (conventional medications)
Step 2: Liquid formulations (conventional medications)
Step 3: Transdermal formulations (available medications)
Step 4: Unlicenced tablet medications
Following the last step, device-based therapies would be considered (renal denervation or central arteriovenous coupler).
Based on their observations the authors conclude that their stratified medicine approach allowed patients to tolerate increased numbers of medications and achieved significant long-term lowering of blood pressure. However, they propose conducting additonal prospective studies to validate longer-term benefits on blood pressure and cardiovascular morbidity in this population of MDI-HTN patients.