Nearly half of Americans have high blood pressure and only 24% have it under control, but what's the best way to treat it — one high-dose pill or two at a lower dose?
A large new study suggests that two medications may be better than one for many older patients. Lowering elevated blood pressure to a sustainable level is important because it reduces a patient's risk of heart attack, stroke and kidney failure.
"In geriatrics, we typically try to limit the number of medications," said study author Dr. Lillian Min, associate professor of geriatric and palliative medicine at the University of Michigan. "The traditional method of practicing medicine is to start low, go slow, is the mantra."
That means that doctors typically prescribe one blood pressure medicine at a low dose and increase its strength as needed, to the maximum beneficial level. If blood pressure remains stubbornly high, they start a second medication.
But guidelines issued in the past decade recommend starting multiple doses of medicines. So patients might take two medications in one combo pill or separately in two pills, Min said. The aim is to lessen the risk of a side effect while offering the benefits of both medications.
"So now the question becomes: If we're going to go up on the medicine, should we exhaust one before starting another or should we now implement that new advice?" she said.
It depends on the patient, according to a new study of more than 178,000 seniors treated through the U.S. Veterans Health Administration.
Researchers noted that high blood pressure is one of the most common chronic conditions affecting older patients. And the older people get, the more chronic conditions they are likely to have and the more medications they are likely to take.
The new study included patients taking at least one blood pressure medicine but not at its maximum dose. About a quarter had been given an added blood pressure medication, while 75% had received higher doses of existing ones.
Both treatments reduced their blood pressure, the study found, but one reduced it more.
While taking just one medication was more likely to be something patients would continue, smaller doses of more meds led to slightly larger reductions in blood pressure, the study found.
Researchers found that when doctors intensified patients' treatment on one drug, 65% were still taking it months later compared to 50% of those whose doctors had added medications instead.
"Where this is the most clinically applicable would be to think about clinically complex patients who have a lot of medicines already, and to start considering more of the nuances of their preferences," Min said. "What makes sense in terms of discussing the blood pressure goals between the physician or provider and the patient based on what's going on in the big picture? Is it more important to have a more manageable regimen or is it more important to get to the goal just a little bit faster?"
The findings were published Oct. 4 in the Annals of Internal Medicine.
Dan Lackland, a professor of epidemiology at the Medical University of South Carolina in Charleston, reviewed the findings.
He said the advantage to receiving low doses of more than one medication is that the side effects tend to be lower with these smaller doses.
On the other hand, some patients don't want to take more than one pill or have a harder time accepting multiple pills because they feel it indicates their condition might be worse -- even if it's not, he said.
"What the paper was saying is: Take a good look at it. We need to do more studies … to really kind of compare those," Lackland said. "One pill with a higher dose, two pills with a lower dose. And also looking very strongly at the individual patient. Is the patient going to take two pills? Are they going to be reluctant?"
He said future research could consider what strategies would help patients be more comfortable taking more than one pill, helping them comply with that regimen and explaining the reasons for it.
"This is important and I think it, again, emphasizes the importance of taking your blood pressure medication and getting that blood pressure down," Lackland said. "And as you get the blood pressure down, you are indeed reducing your risk of cardiovascular disease and stroke, which is where we want to be."