SOURCE: Williams B, et al. Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2): A randomised, double-blind, crossover trial. Lancet 2015;386:2059-2068.
Resistant hypertension (r-HTN) is currently defined as persistence of uncontrolled blood pressure (BP) despite full therapeutic doses of three antihypertensive medications, one of which is diuretic. As evidenced by clinical trial data, the prevalence of r-HTN is generally in the 15-18% range. While it is appropriate to seek a secondary cause for r-HTN (e.g., sleep apnea, aldosteronism, etc.), an underlying correctable cause is not identified in most cases, so additional medications must be added to attain BP goals.
While essentially any medication not already present in the three-medication regimen could be considered as an add-on, several clinical trials point to the utility of aldosterone antagonists such as spironolactone and eplerenone, demonstrating considerable success in controlling otherwise resistant hypertension. But is aldosterone antagonism the best way to go?
Williams et al reported results of their double-blind, placebo-controlled, crossover trial in adults with r-HTN. Study subjects (n = 285) were randomized to one of four treatment arms: spironolactone, doxazosin, bisoprolol, or placebo added to their current three-drug regimen. Treatment periods lasted 12 weeks.
Spironolactone provided statistically significant greater reductions in BP than the other two active agents; adverse effects and withdrawal were similar among the three active treatment arms. Spironolactone is an inexpensive and effective way to address r-HTN.
Spironolactone provided statistically significant greater reductions in blood pressure than two other active agents.
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