Commentary

Author: Mark Rubino, RPh, MHA

Although hypertension continues to be a major cause of cardiovascular morbidity and mortality, renal disease, and stroke, it remains largely an untreated disease. In an editorial accompanying the publication of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7),Kottke and associates write, "Hypertension awareness has not changed in the past decade and treatment rates have increased by less than 10%".1 In keeping with this, a chart review showed that in our health plan, the blood pressure (BP) of 48.3% of 2333 patients was not under control (>140/90 mmHg).This is a major public health issue, which is exacerbated by the increasing incidence of obesity and sedentary lifestyles in our society.

Health maintenance organizations were created to combine the delivery and financing of health care. Their stated goal is the maintenance of health rather than treatment of disease. Chronic diseases, such as hypertension, represent a huge opportunity for managed care organizations to demonstrate their value to plan sponsors and employers by combining disease prevention, care management, and drug use guidelines with quality-of-care initiatives to manage major public health issues, such as high BP.

As in previous reports, JNC 7 emphasizes lifestyle modification as "an indispensable part of the management of those with hypertension." Pharmacologic treatment is often required in patients who are unable to make these changes or are still not at goal. JNC 7 recommends thiazide diuretics as first-line therapy because of their "unsurpassed" ability to reduce cardiovascular complications in outcome trials, their synergistic effects in combination with other agents, and their low cost.Although the study design and protocol have been criticized as being too restrictive and possibly inconsistent with actual medical practice, results of the large Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) supports the use of diuretics.2

The JNC 7 report also suggests that if BP is more than 20/10 mm Hg above goal, combination therapy can be considered as initial therapy. In this supplement, Thomas D. Giles states that a patient may require 2.5 to 4 drugs to control BP, and Michael A.Weber recommends an angiotensin-converting enzyme (ACE) inhibitor and a calcium-channel blocker (CCB) for initial therapy in those with significant hypertension. George L. Bakris notes the need to consider fixedcombination drugs in patients with existing renal disease and in African American patients. Kenneth A. Jamerson describes an ongoing randomized trial that will compare a combination of an ACE inhibitor and a CCB with a combination of a diuretic and an ACE inhibitor to prevent cardiovascular morbidity and mortality. Also in this supplement, a report on a study of a managed care population suggests that use of a single fixed-dose combination compared with a 2-pill regimen may improve compliance with antihypertensive treatment resulting in reduced total healthcare costs.

Most hospital and managed care organization formulary committees have traditionally recommended against fixed-dosed combination products in any therapeutic category. The rationale for this policy is that such formulations limit a physician to whatever doses were contained in the pill, thereby decreasing the physician?s ability to modify dosage to maximize efficacy and minimize side effects.The JNC 7 recommendations and the evidence discussed by the participants in this supplement suggest that this policy needs to be re-examined. In addition, many managed care organizations are now taking a more holistic approach to formulary decisions by using pharmacoeconomic research and modeling to demonstrate that, in some therapeutic situations, a more costly drug may actually lower medical costs by eliminating repeated physician visits, reducing hospital lengths-of-stay or eliminating emergency department care.

References

1. Kottke TE, Stroebel RJ, Hoffman RS. JNC 7?It?s More Than High Blood Pressure. JAMA. 2003;289:2573-2575.

2. ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in highrisk hypertensive patients randomized to angiotensinconverting enzyme inhibitor or calcium channel blocker vs diuretic.The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA. 2002;288:2981-2997.