ABSTRACT: When modern antihypertensive drugs cost far more than the old and tried, and have around 40% risk of adverse effects (Girerd 2002 Paris), and give inferior risk reduction, it is unethical for routine hypertension patients initially to be prescribed modern drugs before trying the gold standard old risk-free lowdose reserpine-amilozide combination.
Controlling hypertension asymptomatically before it causes damage and symptoms is the heart of successful prevention. Some claim that hypertension risk starts as low as >120/70, as opposed to the traditional 135-140/85-90, that we should be zealously targeting this level if tolerated. To avoid incapacitating dizzines if not falls, this can only be done gently and slowly, if possible by optimising diet, lifestyle and natural supplements, with minimum gentle slow-and long-acting drugs. .
So prevention especially in asymptomatic patients must especially:
be at most a once-a-day regime,
avoid causing symptoms,
and still give stable bloodpressure control even if taken erratically,
and especially for longterm primary prevention in what is often a benign or insidious condition for many years, avoid catastrophes like practolol, ticrynafen and doxazocin proved to be.
Only lowdose reserpine, with lowdose long-acting potassium-sparer, provides gentle cover lasting days to weeks.
Apart from the notorious adverse effects of the older antihypertensives like guanethidine, methyldopa and atenolol, search of Pubmed under ‘ARB OR ACEI Cough;’ and under metaanalysis ‘antihypertensive cough’, reveals at least 10 abstracts since the mid 1990s.
The nub of the matter is, the lowest-cost multiple-combination therapy (lowdose reserpine -amiloride – hydrochlorothiazide) gives the best bloodpressure and risk reduction with zero adverse effects – especially when combined with probably the best pluripotential drugs of all, fish oil and a basket of other natural antioxidant insulin sensitizer nitric-oxide-boosting antiatheroma nutrient supplements.
A new Cochrane metaanalysis from Univ Brit Columbia confirms that lowdose thiazide gives the best reduction of all antihypertensives in both all-morbidity and mortality outcomes -RR 0.89 (CI 0.82-0.97 ie p=0.0067 ie highly significant) . And that metaanalysis didn’t deign to mention reserpine in the abstract. There are at least a a dozen trials each of reserpine and thiazide showing that they are the best, ideally in lowdose combination .
A diuretic is still the first-line therapy for hypertension in all guidelines. And as Pillay Smith and Hill from WHO and Australia note in a new review in the Bulletin of the WHO, reserpine is still the second drug of choice after diuretic in guidelines. At recent MIMS prices with 1/3 retail markup, 1/4 tab of reserpine + 1/4 tab Betaretic 55mg adds up to about R7/month, so in bulk buy- the State or corporates- Managed Care- the cost is much lower.
As always, one fixed-dose combination pill (eg Brinerdin, Rautrax Imp) may work for many; but it is both cheaper, more efficient and scientific to prescribe the components separately ie so that reserpine and amilozide can each be titrated individually to tolerance, starting with eg reserpine (0.25mg tab ) 1/4/day and amilozide (55mg tab) 1/4 a day (costing locally retail perhaps US$0.5/month, $6/year) … In some patients eventually this dose 3 days a week is all that is needed.
With sensible advice about minimal-to-moderate alcohol, omitting sugar smoking salt and cooked fats, and adding a multinutrient including magnesium, vitamins and the many favourable biologicals (including appropriate physiological sexhormone replacement), few patients need more than 1/2 a tab each of reserpine and amilozide/day for optimal BP and metabolic-vascular risk control.
In the rare still- resistant cases, amlodipine or slowrelease verapamil is the next safest effective antihypertensive drug to add, although hydralazine in low dose eg 12/5mg/d is far cheaper . But of course in those with insulin resistance (ie most cases), metformin is the most appropriate, also at low cost.
Hydralazine may be popular in State clinics (like South Africa) as the next and cheap add-on drug, but it it indefensible, unethical to use for prevention a drug for a prevalent problem- resistant hypertension in a non-compliant population- especially in high-risk patients like women and blacks. The 5 to 20% risk of lupus has to be monitored but it is difficult to justify since even hydralizine-induced lupus may be fatal.