Lifestyle takes a front seat in JNC-VI
And there's a new take on managed care and HT
Among the issues covered in the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VI) are:
· The importance of improving lifestyle - A major emphasis of the new guideline is on lifestyle changes regardless of risk group. Lifestyle modifications include tobacco avoidance, weight loss, moderation of alcohol, fat, caffeine, and sodium intake, increasing physical activity, and increasing potassium and calcium intake. For example, a patient in risk group A with stage 1 hypertension (HT) and no cardiovascular disease, organ damage, or other risk factors would try lifestyle changes for one year before taking drugs. By contrast, the earlier guideline suggested that such patients try lifestyle changes for only three to six months before starting medication.
· The use of BP self-measurement - Four advantages are seen:
- Self-measurement distinguishes sustained from white-coat HT.
- Self-measurement assesses response to medication.
- Self-measurement improves patient adherence.
- Self-measurement reduces costs.
· The role of managed care in HT treatment - Managed care companies know that the cost of controlling HT is lower than the direct and indirect costs of resulting heart disease, stroke, and renal failure and associated hospitalizations and surgical procedures.1 And the cost is lower if you get it right the first time:
Investigators looked earlier this year at the clinical and cost impact of unsuccessful outcomes in compliant patients whose initial treatment was either an ACE inhibitor or a CCB.2 They found that total medical costs increased as therapy was modified. Cost impact was measured pre- and post-therapy modification. Outcomes measured were number, type, and first-year acquisition cost of modifications of therapy. Over the first year, nearly half had at least one modification to their therapy - either an increase in dosage or addition of a new class of drug. The first-year cost for patients whose therapy was not modified was $322 for those on ACE inhibitors and $427 for those on CCBs. As the number of modifications increased, so did that cost - $391 to $880 for the ACE group and $496 $861 for the CCB group for 1-6 modifications. The pharmacy cost per member per month increased post-modification in both groups.
· The introduction of ARBs and new combination medications - The ideal antihypertensive would be cost-effective, have minimal side effects, avoid drug interactions, and provide end-organ protection. A relatively new class of medications, the angiotensin II receptor blockers (ARB) attempts to answer that ideal. Many physicians view ARBs as useful primarily in patients who cannot tolerate angiotensin converting enzyme (ACE) inhibitors. The JNC-VI supports this view for patients with concurrent heart failure and diabetes. ARBs produce hemodynamic effects similar to those of ACE inhibitors while avoiding the most common adverse effect, dry cough. (See chart on combination drugs, above left.)
The use of ACE inhibitors and CCBs has increased dramatically over the past 10 years, and combined CCB/ACE therapy was introduced in 1995 in the form of low-dose amlodipine-benazepril (Novartis's Lotrel). A recent study assessed the financial impact of substituting that combination drug for separate therapies.3 The investigator looked at 219 patients, of whom a quarter were on a combination regimen costing $135 per month per patient. If the single agent were substituted, it would cost $45 a month. He points out that compliance is enhanced as well using the combination pill.
Researches have found also that the combination therapy produces significantly less edema than increasing doses of nifedipine or amlodipine (Pfizer's Norvasc). The amlodipine-benazepril combination is not indicated for initial therapy.
References
1. The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and the National High Blood Pressure Education Program Coordinating Committee. The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VI). Arch Intern Med 1997; 157:2,413-2,446.
2. Wilson M, Patwell J, Shoheiber O, et al. The clinical and economic implications of drug utilization patterns in the treatment of hypertension with ACE inhibitors and calcium channel blockers in a managed care setting. J Managed Care Pharm 1998; 4:194-202.
3. Kountz DS. Cost containment for treating hypertension in African Americans: Impact of a combined ACE inhibitor-calcium channel blocker. J Natl Med Assoc 1997; 89:457-460.
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