Thiazide diuretics for hypertension: prescribing practices and predictors of use in 194,761 elderly patients with hypertension

Printed educational messages fail to increase use of thiazides as first-line medication for hypertension in primary care: a cluster randomized controlled trial [ISRCTN72772651]

Background

Evidence on the effectiveness of printed educational messages in contributing to increasing evidence-based clinical practice is contradictory. Nonetheless, these messages flood physician offices, in an attempt to promote treatments that can reduce costs while improving patient outcomes.

This study evaluated the ability of printed educational messages to promote the choice of thiazides as the first-line treatment for individuals newly diagnosed with hypertension, a practice supported by good evidence and included in guidelines, and one which could reduce costs to the health care system.

Methods

The study uses a pragmatic, cluster randomized controlled trial (randomized by physician practice group).

Setting

The setting involves all Ontario general/family practice physicians.

Messages advising the use of thiazides as the first-line treatment of hypertension were mailed to each physician in conjunction with a widely read professional newsletter. Physicians were randomized to receive differing versions of printed educational messages: an “insert” (two-page evidence-based article) and/or one of two different versions of an “outsert” (short, directive message stapled to the outside of the newsletter). One outsert was developed without an explicit theory and one with messages developed targeting factors from the theory of planned behaviour or neither (newsletter only, with no mention of thiazides).

The percentage of patients aged over 65 and newly diagnosed with hypertension who were prescribed a thiazide as the sole initial prescription medication. The effect of the intervention was estimated using a logistic regression model estimated using generalized estimating equation methods to account for the clustering of patients within physician practices.

Results

Four thousand five hundred four physicians (with 23,508 patients) were randomized, providing 97 % power to detect a 5 % absolute increase in prescription of thiazides. No intervention effect was detected. Thiazides were prescribed to 27.6 % of the patients who saw control physicians, 27.4 % for the insert, 26.8 % for the outsert and 28.3 % of the patients who saw insert + outsert physicians, p = 0.54.

Conclusions

The study conclusively failed to demonstrate any impact of the printed educational messages on increasing prescribing of thiazide diuretics for first-line management of hypertension.

Trial registration

ISRCTN72772651

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0486-3) contains supplementary material, which is available to authorized users.

Challenges in the Management of Hypertension in Older Populations

The prevalence of hypertension increases with age making it a significant health concern for older persons. Aging involves a range of physiological changes such as increases in arterial stiffness, widening pulse pressure, changes in renin and aldosterone levels, decreases in renal salt excretion, declining in renal function, changes in the autonomic nervous system sensitivity and function and changes to endothelial function all of which may not only affect blood pressure but may also affect individual response to pharmacotherapy used to manage hypertension and prevent end organ damage and other complications associated with poor blood pressure control.Unlike many chronic conditions where there is limited evidence for management in older populations, there is good evidence regarding the management of hypertension in the elderly. The findings from multiple large, robust trials have provided a solid evidence-base regarding the management of hypertension in older adults, showing that reduction of blood pressure in older hypertensive populations is associated with reduced mortality and morbidity. Diuretics, agents action on the renin angiotensin system, beta blockers and calcium channel blockers have all been well studied in older populations both in view of the benefits associated with blood pressure lowering and the risks associated with associated adverse events. While all antihypertensive agents will lower blood pressure, when managing hypertension in older persons the choice of agent is dependent not only on the ability to lower blood pressure but also on the potential for harm with older persons. Understanding such potential harms in older populations is essential with older persons experiencing increased sensitivity to many of the adverse effects such as dizziness associated with the use of antihypertensive agents.Despite the wealth of evidence regarding the benefits of managing hypertension in the old and very old, a significant proportion of older individuals with hypertension have suboptimal BP control. While there is good evidence supporting blood pressure lowering in older antihypertensive agents, these have not yet been optimally translated fully into clinical guidelines and clinical practice. There appear to be considerable differences between guidelines in terms of the guidance given to clinicians. Differences in interpretation of the evidence, as well as differences in study design and populations all contribute to differences in the guideline recommendations with respect to older populations, despite the strength of the underlying scientific evidence. Differences around who is considered "old" and what BP targets and management are considered appropriate may lead to confusion among clinicians and further contribute to the evidence-practice lag.

Prevalence, prescribing and barriers to effective management of hypertension in older populations: a narrative review

Objectives

Hypertension is the leading modifiable cause of mortality worldwide. Unlike many conditions where limited evidence exists for management of older individuals, multiple large, robust trials have provided a solid evidence-base regarding the management of hypertension in older adults. Understanding the impact of age on how the prevalence of hypertension and the role of pharmacotherapy in managing hypertension among older persons is a critical element is the provision of optimal health care for older populations. The aim of this study was to explore how the prevalence of hypertension changes with age, the evidence regarding pharmacological management in older adults and to identify known barriers to the optimal management of hypertension in older patients.

Methods

A review of English language studies published prior to 2013 in Medline, Embase and Google scholar was conducted. Key search terms included hypertension, pharmacotherapy, and aged.

Results

The prevalence of hypertension was shown to increase with age, however there is good evidence for the use of a number of pharmacological agents to control blood pressure in older populations. System, physician and patient related barriers to optimal blood pressure control were identified.

Conclusions

Despite good evidence for pharmacological management of hypertension among olderpopulations, under treatment of hypertension is an issue. Concerns regarding adverse effects appearcentral to under treatment of hypertension among older populations.

Olmesartan in the treatment of hypertension in elderly patients: a review of the primary evidence

Hypertension, particularly systolic hypertension, is prevalent in the elderly and increases with advancing age, in part because of age-related endothelial dysfunction and increased arterial stiffness. There is strong evidence from randomized clinical trials that supports the use of antihypertensive treatment for effective and sustained blood pressure (BP) control in older patients to reduce the risk of vascular-related morbidity and mortality, particularly cerebrovascular accidents, including stroke. Furthermore, current evidence and guidelines suggest that all major classes of antihypertensive agents are equally effective in controlling BP and preventing cardiovascular events in older patients. Diuretics are commonly used in elderly patients, but recent outcomes data have raised doubt about their long-term benefits. Renin-angiotensin system inhibitors have a better tolerability profile than diuretics. Extensive clinical evidence has demonstrated the excellent efficacy and tolerability profile of olmesartan medoxomil (OM)--an angiotensin II receptor blocker AT1 receptor antagonist--including in elderly patients. Randomized and observational studies have shown that OM provides effective BP control across the 24 h dosing interval in the elderly. It also has a good tolerability profile, a pharmacokinetic profile unaffected by age and a low propensity for drug interactions. An additional factor is that OM once-daily regimens are simple and straightforward, which can be an important factor in maintaining adherence to therapy in elderly patients. This article provides an overview of the main recent clinical evidence supporting the use of OM-based therapy in elderly patients with hypertension.

Diuretics for hypertension-reasons for a contradiction in primary care prescribing behavior: a qualitative study

There has been a long international discussion on diuretics as first-line therapy for hypertension. In Germany, thiazide diuretics are very rarely prescribed in monotherapy and concurrently highly prescribed in fixed-combinations. The aim of this study was to approach the reasons for this inconsistency in primary care prescribing behavior. A qualitative study design consisting of single interviews with general practitioners (GPs) was chosen. Most GPs perceived diuretics as too weak to treat arterial hypertension effectively in monotherapy. In combination therapy, GPs expected to spare the dose and to offset certain side effects of other drugs. The convenient availability of diuretics in most fixed-dose combinations on the German drug market was seen as an important reason for their frequent prescription in combination therapy. Thus, the reasons given by the GPs differed from the main arguments of the academic debate. Dissemination strategies for guidelines should take the perceptions and opinions of practicing GPs into account.

Antihypertensive medication prescribing patterns in a university teaching hospital

Treatment of hypertension among hospitalized patients represents an opportunity to improve blood pressure recognition and treatment. To address this issue, the authors examined patterns of antihypertensive medication prescribing among 5668 hypertensive inpatients. Outcomes were treatment with any antihypertensive medication and treatment with first-line therapy, defined as angiotensin-converting enzyme inhibitors, beta-blockers, thiazide diuretics, or calcium channel blockers. Logistic regression models adjusting for age, sex, race, length of stay, service line, and comorbidity were used for all comparisons. The multivariate-adjusted odds ratios for treatment were higher for men (1.4, P<.001), older patients (2.5 for age older than 80 vs 1.0 for age younger than 40; P<.001), non-white race (1.2 vs 1.0 for white race; P<.004), and generalist service line (1.4 vs 1.0 for all other services; P<.001). Multivariate-adjusted odds ratios for receiving first-line agents were higher for older patients and generalist service line. Among surgical patients, receipt of medical consultation was only marginally associated with higher odds of antihypertensive or first-line treatment after adjustment for relevant clinical variables. Demographic factors and service line appear to play a major role in determining the likelihood of inpatient hypertension treatment. Understanding and addressing these disparities has the potential to incrementally improve hypertension control rates in the population.

Severe hyponatraemia in elderly hospitalized patients: prevalence, aetiology and outcome

BACKGROUND

Hyponatraemia is the commonest electrolyte disorder in the elderly. Data on severe hyponatraemia and the prevalence of cerebral salt wasting syndrome (CSWS) in elderly hospitalized patients are lacking. We studied the incidence, frequency of various aetiologies, outcome and the possible role of CSWS in severe hyponatraemia in elderly medical patients.

METHODS

A prospective, observational, non-interventional study conducted over a 5-month period in medical wards. Eighty-six patients aged over 65 years with serum sodium levels < or =125 mEq/L were included. All patients were examined by one of the authors, who also evaluated potential contributing factors. Demographic, clinical and outcome data were extracted from the medical records.

RESULTS

The mean age of the patients was 82.1 + 8.7 years. The prevalence of hyponatraemia was 6.2% (8.1% women and 4.0% men (P < 0.001)). There was no increase in incidence of hyponatraemia with age. The leading cause of hyponatraemia was the syndrome of inappropriate antidiuretic hormone secretion (SIADH), whose aetiology could be determined in only 46% of cases. Aetiology was multifactorial in 51% of patients (1.7 aetiological factors per patient). All patients with thiazide-induced hyponatraemia had other contributing factors. Hyperglycaemia and hypoalbuminaemia were predictors of neurological manifestations of hyponatraemia. Overall in-hospital mortality was 19%. Only hypoalbuminaemia was found as an independent risk factor for death. In none of the patients was the hyponatraemia due to CSWS.

CONCLUSION

Severe hyponatraemia in elderly hospitalized medical patients is more frequent in women and of multifactorial aetiology in 50% of cases. It is most commonly caused by SIADH; CSWS is an unlikely cause.

Diuretics and diabetes incidence--an appeal against the reluctance to prescribe a medication that is safe and proven

The publication of the scientific report of the Institute for Quality and Efficiency in Health Care (IQWiG) in Germany on the 'Comparative evaluation of the benefits and harms of different antihypertensive drug classes [diuretics, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, calcium-channel blockers and angiotensin II (AT-II) blockers] as first-choice therapy for patients with essential hypertension' raised an enormous public debate, particularly as diabetes incidence was not judged to be a patient-relevant outcome. In this assessment, the overall view of the patient-relevant results was that diuretics can be used as first-line antihypertensive treatment. Diabetes incidence is highest with diuretics, but minimal differences in fasting plasma glucose of approximately 0.28 mmol/l are magnified by the transformation of continuous blood glucose values into categorical data: with the establishment of thresholds, the diagnosis of diabetes depends on being above a certain blood glucose value. The protective cardiovascular effects of diuretics do not seem to be reduced in hypertensive patients who develop new-onset diabetes during treatment. Since blood pressure control is often worse, detection, treatment and control should be urgently improved. The debate on antihypertensive agents is mainly of scientific interest and has only minor clinical relevance for everyday patient care.

Costs of eprosartan versus diuretics for treatment of hypertension in a geriatric population: an observational, open-label, multicentre study

BACKGROUND

Diuretics are considered to be agents of first choice when treating hypertension in the elderly because of their clinical efficacy and, in particular, their low cost. Indeed, the latter consideration has been used by health resource managers to promote the use of diuretics. However, when considering the costs of treating hypertension in a population it is also necessary to assess the adverse effects that diuretics produce, particularly in elderly people.

OBJECTIVE

To compare the overall expenditure associated with the treatment of hypertension (specifically the angiotensin II type 1 receptor antagonist eprosartan vs diuretics) in an elderly population, taking into consideration not only the drug acquisition costs but also the adverse effects of treatment and the costs associated with such adverse effects.

METHODS

This was a prospective, observational, nonrandomized, open-label, multicentre study based in eight community health centres and the Hypertension Unit of the University Hospital of Salamanca, Spain. The study included 220 hypertensive geriatric outpatients (males and females aged >or=65 years) referred from general practitioners and the Hypertension Unit, with a mean age of 71.8 years and distributed into two groups: one (n = 90) treated with diuretics and the other (n = 130) treated with eprosartan. Following an initial clinical assessment of patients at the beginning of the study, monitoring of treatment continued for 1 year with follow-up consultations scheduled for 3, 6 and 12 months. Both the costs relating to acquisition of the drugs and the costs derived from secondary adverse effects of drug treatment were included in the analysis.

RESULTS

The response to the antihypertensive therapy was similar in both groups. In patients taking diuretics, adverse events resulted in increased use of healthcare resources because of urinary incontinence, purchase of adsorbents, hyponatraemia and the need to admit two patients to hospital. The patient/day cost was euro 1.05 for the group treated with diuretics and euro 0.98 for the group treated with eprosartan (year of costing 2006).

CONCLUSION

In the geriatric population, the acquisition cost of the prescribed diuretics is not representative of the actual antihypertensive treatment expenditure. According to the results obtained in our study, the overall costs of eprosartan therapy were no different to those of diuretics, despite the fact that eprosartan had a higher acquisition cost. This is consistent with a more favourable safety profile for eprosartan, which may possibly contribute to improved prescription compliance. This conclusion should be taken into consideration when evaluating economic restrictions on the use of drugs.

Management of hypertension in elderly long-term care residents

OBJECTIVE

To determine the adequacy of hypertension management in institutionalized elderly patients.

METHODS

Retrospective chart review of all patients with a physician-documented diagnosis of hypertension at 15 long-term care facilities in Edmonton, Alberta.

RESULTS

Of 2063 long-term care residents, 733 (36%) were diagnosed with hypertension (mean age 84 years), and 566 (77%) of this cohort were receiving antihypertensive medication. The most frequently prescribed antihypertensive drugs were angiotensin-converting enzyme inhibitors (341 patients [60%]). Of the long-term residents prescribed antihypertensive therapy, 274 (48%) were on one medication, 203 (36%) were on two and 89 (16%) received three or more agents. Blood pressure readings were taken every 14 days on average (interquartile range two to 31 days). Overall, 467 (64%) of these residents with a diagnosis of hypertension achieved target blood pressure.

CONCLUSION

Hypertension treatment and control rates are better in elderly patients who are institutionalized than those reported in studies of patients who reside in the community. Determining the reasons for this discrepancy will be important for the design of strategies to improve hypertension control rates in the community.