Trends in Antihypertensive Drug Therapy by US Office-Based Physicians
To the Editor:
We read with great interest the article by Nelson and Knapp1 on the trends of antihypertensive therapy by US office-based physicians. Their findings are clearly significant, but some of their conclusions are not supported by the data presented. The authors state that “physician antihypertensive drug prescribing was generally consistent with the basic antihypertensive drug guidelines of the JNC reports.” However, they also note that calcium channel blocker visits increased from 1.9% in 1985 to 39.8% in 1995 and that ACE inhibitor/receptor blocker visits increased from 6.4% to 37.0%, while all other drug classes decreased, including the JNC’s preferred step 1 agents of β-adrenergic blockers and diuretics. Moreover, while in 1995 monotherapy with either calcium channel blockers or ACE inhibitors together made up 39.5%, monotherapy with the JNC V’s preferred step 1 monotherapy of either diuretics or β-adrenergic blockers accounted for only 19.6% of antihypertensive drug visits.1 This is much more in accordance with the findings of previous studies in the United States2 and Europe,3 4 which found no effect of prescription guidelines on antihypertensive therapy by physicians. The profound increase in newer, expansive, patented products such as calcium channel blockers, ACE inhibitors, and angiotensin receptor blockers seen in this and other studies has been attributed to the effect of intense promotion by drug manufacturers.3 5 One can only wonder why doctors do not follow recommendations by their professional organizations but rather the promotion campaigns of pharmaceutical companies, and what could be done to change this unfavorable situation.
Nelson CR, Knapp DA. Trends in antihypertensive drug therapy of ambulatory patients by US office-based physicians. Hypertension. 2000;36:600–603.
Siegel D, Lopez J. Trends in antihypertensive drug use in the United States: do the JNC V recommendations affect prescribing? Fifth Joint National Commission on the Detection, Evaluation, and Treatment of High Blood Pressure. JAMA 997;278:1745–1748.
Szekacs B, Vajo Z, Szepezdi Z. Diuretics for hypertension JAMA.. 1999;282:524.
Clearly, what is needed to address your concerns is a better explanation of what we meant by “basic antihypertensive drug guidelines of the JNC reports.” What we meant as “basic” is any of the “initial” step 1 antihypertensive drug classes as given in JNC V (Table 7) and JNC VI (Figure 8) (see our article for references).