Increased Dose Versus Added Drug for BP Control: Randomized Trial

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In older adults requiring intensification of antihypertensive therapy, adding a new medication leads to a greater reduction in blood pressure (BP), but maximizing dosage provides a more sustainable effect, reports a study in Annals of Internal Medicine.

The observational study included 178,562 patients requiring intensified antihypertensive treatment in the Veterans Health Administration (VA) system between 2011 and 2013. All patients were aged 65 years or older, had systolic BP (SBP) of 130 mm Hg or higher, and were taking one or more antihypertensive medications at less than maximum dose. Mean age was 75.8 years, and 98.1% of patients were men. The intensification strategy chosen was maximizing dosage in 74.5% of patients and adding a new medication in 25.5%. At 3 months, sustained intensification was achieved in 65.0% of patients receiving a maximized dose compared to 49.8% of those receiving a new medication. The average treatment effect was 15.2% at 3 months and 15.1% at 12 months.

In contrast, patients receiving a new medication had a slightly greater reduction in BP. The 3-month change in SBP was −4.9 mm Hg with adding a new medication versus −3.8 mm Hg with maximizing dose. Average treatment effect was −0.8 mm Hg at 3 months and −1.1 mm Hg at 12 months. For both outcomes, there was no interaction between intensification strategy and cardiovascular conditions.

Designed to emulate a clinical trial, the analysis helps address the lack of evidence on best strategy for older adults when intensified antihypertensive therapy is needed. In this VA population, adding a new medication provides a slightly greater reduction in SBP but a less-sustained effect.

By comparison, dose maximization is a more commonly followed strategy that provides greater sustainability. The researchers conclude, “Trials of different strategies of dose intensification are certainly feasible and would ultimately provide the most definitive support for our findings” [Aubert CE, et al. Adding a new medication versus maximizing dose to intensify hypertension treatment in older adults: A prospective observational study. Ann Intern Med, published online ahead of print October 5, 2021. doi: 10.7326/M21-1456;].