A senior man opens a pill organizer

Although adding an agent was a less common anti-hypertensive intensification strategy than increasing the dose, it was more effective, as a large observational study showed.

Of the 178,000 veterans who were increasing treatment for uncontrolled hypertension, only 25% received the new antihypertensive, while the rest maximized the dose of existing medications. du Annals of Internal Medicine.

As expected, at 3 months fewer patients adhered to the added agent – with a higher potential for pill burden and potential adverse new events and potential for drug interaction – compared to a higher dose of medication (49.8% vs. 65.0%).

However, the antihypertensive extract cuts the systolic pressure significantly more, 0.8 mm Hg more in 3 months and 1.1 mm Hg more in 12 months than the dose maximization (-5.6 vs -4.5 mm Hg).

This difference will reduce the relative risk of major cardiovascular events by 2 percentage points, or 5 percentage points, if analyzed without adjusting basal systolic blood pressure – “an analysis that may be closer to that performed in hypertension trials.” the researchers noted.

“Our findings are consistent with a strategy to target multiple mechanisms to address hypertension simultaneously,” the group concluded.

However, the researchers warned: “When adapting regimens for antihypertensive medications, it is important not only to consider [blood pressure] control but also the risk-benefit ratio of each antihypertensive medication taking into account all comorbidities and comedicities and the added complexity of adding a complementary drug, especially in older patients with multiple combined conditions, who are weaker and often more vulnerable to adverse drug effects. receive various medications “.

Not surprisingly, the addition of antihypertensive drugs has a greater effect than increasing the dose, as half a dose is usually more than 25% stronger than the full dose, says Dr. Olivier Steichen, Assistance Publique-Hôpitaux of Paris and the Sorbonne University in Paris.

The key is to increase treatment when necessary, he explained: “When intensification is indicated, we should not waste time with elaborate reasoning: Either add a medication or maximize the dose of existing medications. we should try to make it as easy as possible, but remember that increasing the dose of a single drug has a limited effect on the overall potency of a combination. [single-pill combinations] Each time they simplify treatment and explain the inevitable complexity to the patient. A follow-up visit should be made about a month later to assess adherence, tolerance, and effectiveness and to make further adjustments if necessary. “

The study conducted a clinical trial treating 178,562 of its patients, randomly treated at a Veterinary Health Services (VA) facility, to achieve a systolic blood pressure of 130 mm Hg or more, at least in the antihypertensive regimen. the drug was not in the maximum dose.

The researchers used administrative and clinical data from VA pharmaceutical records, Medicare Part D medication files, and VA meetings with specialists in primary care, geriatric care, cardiology, endocrinology, nephrology, and neurology from July 2009 to June 2013.

Among the researchers ’limitations were older men (mean age 75.8, 98% male), most of whom had at least one chronic comorbid condition of hypertension, as well as a lack of standard office measurements.

Oliver added that the main shortcoming of the study is the diverse set of conditions that patients had to exacerbate due to doses of antihypertensive drugs, number of pills per day, blood pressure level (130 mm Hg systolic or higher), comorbidity. conditions and physical condition.

More trials comparing dose-intensification strategies would “ultimately provide the most definitive support for our discovery, as the possibility of confusion and bias cannot be completely ruled out, even with our ordinary efforts to approximate the conditions of a trial,” Aubert’s team added.


It was supported by the National Institute on Research Aging and the Veterans Health Administration.

Aubert provided support from the Swiss National Science Foundation.

Steichen did not express any significant relationship with the industry.