Drug Treatment of Hypertension: Stepped Care
Stepped care versus individualized care
In the 1960s, the stepped-care approach to the drug treatment of hypertension was introduced in large-scale clinical trials. This involved 1) the initial use of a diuretic in all patients; 2) stepwise addition of reserpine as a second drug, if needed; 3) the further addition of a vasodilator, such as hydralazine, if a third drug was needed; and 4) addition of guanethidine if four drugs were needed for control.
When methyldopa and P-blockers became popular, they were subsequently used as standard Step 2 drugs.
Epidemiologic studies suggested that, with compliance, most mild and moderately hypertensive patients could be controlled with one or two drugs and suggested that morbidity and mortality from stroke decreased. Several problems arose from the stepped-care approach, however. Patients often complained that their quality of life was compromised by subjective side effects from p-blockers and diuretics. Furthermore, the decrease in mortality from coronary heart disease was not as great as had been anticipated. (It was suggested that the potential adverse effects of diuretics and p-blockers on lipids might be offsetting the potential advantage of blood pressure reduction.)
In 1984, the Joint National Committee on the Detection, Evolution and Therapy of Hypertension updated the stepped-care approach to include the use of β-blockers as first-line agents and angiotensin-converting enzyme (ACE) inhibitors and calcium channel blockers as potentially useful agents at any step. But the basic philosophy did not change: initial monotherapy, followed by stepwise addition of drugs if adequate control was not achieved.
In the late 1980s, support has grown for a non-stepped-care approach that attempts to tailor antihypertensive drug therapy to the individual patient’s clinical characteristics. Such an approach is now well established for patients with hypertension and concomitant medical disorders.
For hypertensive patients with no other important diseases, the approach to treatment remains somewhat controversial. A recent Hypertension Society Consensus Conference continued to recommend the use of diuretics and β-blockers as first-line therapy in this group of patients, because of lack of evidence from controlled, prospective trials that the newer, more expensive drugs (ACE inhibitors, calcium entry blockers) further reduce mortality or morbidity. Substitution of second- or third-choice drugs as mono-therapy before the stepwise addition of drugs was recommended for patients unresponsive to or intolerant of the initial drug.
The current United States’ approach, as recommended by the Joint National Committee, is more flexible, allowing any drug to be used as a first-choice agent
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