MILD-TO-MODERATE HYPERTENSION: WHY DO DOCTORS CONTINUE TO IGNORE THE EVIDENCE AGAINST INITIAL BETABLOCKERS AND ACEIs/ARBs?

  The Medline review BetaBlockers in Hypertension today again raises this hoary question:

 

            Why does one still continue to see patients on unnecessary atenolol and angiotensin converting enzyme inhibitors ACEIs  for mild-to-moderate hypertension?

 

eg  from public Day Hospitals, postmenopausal fat domestic maidservants  with severe acute bronchitic cough; on atenolol 50mg/d, HCT hydochlorothiazide 25mg/d, enalapril 20mg ;  & if needed hydralazine 50mg/d.  They have usually never had any problem but obesity and thus related insulin resistance –  hypertension- mild  lipidemia,  and painful knees. Thus what they need above all else is encouragement about weight loss- swopping sugar to eg stevia; cooked fats to a supplement of cod liver oil; and early supplement with permanent metformin to tolerance if they do not soon start to lose 1/2 kg weight a month.  

 

 

               It is surely criminal negligence that patients (especially the poor fat, prone to infections, acute asthma bronchitis  and diabetes) are still being dispensed atenolol  with 25mg/day HCT  as first line therapy for hypertension, and enalapril and hydrazine as 2nd/third line;  when

* atenolol  (ie betablockade) has been confirmed not to have global benefit,  and  is therefore  restricted strictly to specific types of heart disease; avoiding problems with eg diabetes; asthma; fatigue; impotence and depression;

* ACEIs  & ARBs are notorious for causing chronic cough let alone angiodema;

* hydralazine is a potent if rare trigger of  systemic lupus SLE, which is common in our poor population.

 

* diuretic doses eg 25mg HCT have notorious adverse metabolic effects.

 

Conversely, it has been known for many years- and repeatedly reviewed in this column- , seen every day in the poor and rich,  that

* reserpine is the safest and best protectant of all hypertensive problems at a dose of 1/8 to 1/2 tablet  ie 0.03 to 0.125mg  day – mean about 0.625mg/d, with trivial  if any adverse effects combined with

* co-amiloretic 1/8 to  1/2 ie 7   ie 7 to  25mg  a day - mean  about 13.5mg/d - potassium-sparing combination diuretic  being the only antihypertensive which in the CACHE County study halved the incidence of  dementia.    (the standard available tablet is still 50mg HCT plus 5mg amiloride).

*amlodipine is the best  if needed add-on “next-line drug “, with negligible adverse effects, if lowdose reserpine + amiloretic do not suffice. (It remains to be seen if carvedilol does any better than amlodipine long term – no comparative long term studies yet appear on Pubmed).

the doses of these are  easily titrated downwards from if necessary  the top dose as the bloodpressure settles gradually and safely. In the longterm low doses , they have no adverse effects.

 

At least two old  (Finnish) studies (1, 2) show the risks of even 25mg HCT a day  and  with or without amiloride.

Do  complaints of malpractice have to be  lodged  to have such adverse prescribing  – dictated by senior academic doctors (whose research and travel is often  funded by drug companies) - stopped, and all clinics supplied with what has been gold standard for hypertension for ages-  reserpine  and amiloretic  tablets with an average retail monthly cost of  R5 for good blood pressure  control?