US agency launches initiative on better prescribing for hypertension

New York

Jeanne Lenzer

The US National Institutes of Health is launching a comprehensive programme to educate doctors on the management of hypertension, which is likely to result in the wider use of cheap diuretics.

The programme will disseminate the results of the antihypertensive and lipid lowering treatment to prevent heart attack trial (ALLHAT), which tested four classes of antihypertensive drugs and found that inexpensive diuretics are as effective as newer, dearer drugs.

The ALLHAT results, published more than three years ago (JAMA 2002;288;2981-97), were incorporated into clinical guidelines issued by the National Heart, Lung, and Blood Institute in May 2003.

The guidelines’ chief recommendation is that for most patients an inexpensive diuretic should be the first drug for hypertensive patients on monotherapy and should be one of the drugs for patients who need more than one drug.

William Cushman, chairman of the ALLHAT dissemination committee, said that roughly 25% to 30% of US patients on monotherapy are taking a diuretic and that the "majority of patients on two or three drugs are not on diuretics."

These numbers are far too low, said Dr Cushman, as approximately 80% to 90% of patients can take diuretics. In the ALLHAT trial the likelihood of stopping treatment because of side effects was lower among patients who took diuretics than among those who took any other class of antihypertensive agent, he said.

One reason doctors may not be prescribing diuretics, even as part of multidrug regimens, said Dr Cushman, is that doctors often begin treatment using free samples provided by drug company representatives. "Unless they’re in a sample on a shelf, doctors often don’t use [diuretics]," he said.

The $3.7m (£2.1m; €3.1m) initiative will last three years and is expected to reach 30 000 doctors by September 2006. Approximately 150 doctors in 34 states and in Washington, DC, have undergone special training so they can offer educational programmes to local doctors. They have been equipped with study results, clinical guidelines, slide programmes, and educational handouts. This is the first such educational initiative undertaken by the National Heart, Lung, and Blood Institute, said Dr Cushman.

When the results of ALLHAT were first announced in December 2002, Kevin Brode, vice president of sales and marketing at marketRx, a marketing consulting firm that provides advice for drug companies, predicted that doctors would not change their prescribing habits despite the trial’s findings, because of heavy promotion of non-diuretic drugs for hypertension.

He said, "The day after [publication of ALLHAT] you’ve got 55 promotional events . . . for an ACE [angiotensin converting enzyme] inhibitor coming back in and saying, ‘Here’s why my ACE inhibitor is safe and here’s why you should be using this.’ I mean, it’s promotion. Can ALLHAT stand up to that?" (BMJ 2003;326:170).

Duncan Emerton, cardiovascular senior analyst at the independent market analysis company Datamonitor, said that although the number of prescriptions in the US for diuretics grew by 2.3% in 2004 after the publication of ALLHAT, the number of prescriptions for ACE inhibitors in combination pills grew by 14.4% that year. (The number for ACE inhibitors alone fell by 2.1%.) Numbers of prescriptions for angiotensin II receptor antagonists, alone and in combination, increased the fastest in 2004, with increases of 12.9% and 23.9% respectively.

The National Heart, Lung, and Blood Institute decided that educational initiatives are necessary "in light of the history of how long it takes to incorporate these expensive studies" into community practice, said Dr Cushman. Other educational projects may be undertaken, he said, for "any large trial that could impact the public health."

Elizabeth Nabel, the institute’s director, said, "It often takes years for the results of major studies to become part of standard health care. The results of ALLHAT and the clinical guidelines could have an enormous impact on the health of millions of Americans. We are confident that by playing a more active role in sharing the information, we will be able to put the results into action more quickly and more effectively."