Clinical question: Which is the better strategy for treatment intensification in older patients with hypertension—maximizing the antihypertensive or adding a new antihypertensive?
Background: Randomized controlled trials suggest that half-dose dual combination antihypertensive therapy provides better blood pressure control compared with a full-dose single antihypertensive with minimal adverse effects. However, the appropriate strategy for older patients who require additional antihypertensive intensification is still unclear.
Study design: A retrospective cohort study
Setting: Veterans Health Administration, between July 1, 2009, and June 30, 2013
Synopsis: This retrospective analysis included 178,562 patients (average age 75.8 ±7.5 years, 98.1% male) with a mean systolic blood pressure >130 mm Hg and at least one antihypertensive drug not at full dose. 74.5% of patients received an increase in their antihypertensive dose as the intensification method, while adding a new antihypertensive medication was selected for 25.5% of patients. At three months, maximizing dosage was associated with a significantly higher antihypertensive medication adherence compared with adding a new medication (65% [95% CI 64.7% to 65.2%] versus 49.8% [95% CI 49.3% to 50.4%]). However, at 12 months, the addition of a new drug was associated with a 1.1 mm Hg (95% CI 0.6 to 1.6 mm Hg) larger reduction in blood pressure compared with dosage maximization. Limitations of the study include a predominantly male population and the vulnerability of the results to confounding and bias. A clinician should choose an intensification strategy depending on the patient’s clinical condition, existing therapy, and preferences.
Bottom Line: The study suggests that adding a new antihypertensive medication may lead to a slight improvement in blood pressure, but at the price of lower medication adherence.
Citation: Aubert CE, et al. Adding a new medication versus maximizing dose to intensify hypertension treatment in older adults: a retrospective observational study. Ann Intern Med. 2021;174(12):1666-1673. doi: 10.7326/M21-1456.
Dr. Chevli is an assistant professor of internal medicine at Wake Forest School of Medicine, Winston-Salem, N.C.