First-Line First? Trends in Thiazide Prescribing for Hypertensive Seniors

Abstract

BackgroundEvidence of reduced cardiovascular morbidity and mortality as well as cost support thiazide diuretics as the first-line choice for treatment of hypertension. The purpose of this study was to determine the proportion of senior hypertensives that received thiazide diuretics as first-line treatment, and to determine if cardiovascular and other potentially relevant comorbidities predict the choice of first-line therapy.Methods and FindingsBritish Columbia PharmaCare data were used to determine the cohort of seniors (residents aged 65 or older) who received their first reimbursed hypertension drug during the period 1993 to 2000. These individual records were linked to medical and hospital claims data using the British Columbia Linked Health Database to find the subset that had diagnoses indicating the presence of hypertension as well as cardiovascular and other relevant comorbidities. Rates of first-line thiazide prescribing as proportion of all first-line treatment were analysed, accounting for patient age, sex, overall clinical complexity, and potentially relevant comorbidities. For the period 1993 to 2000, 82,824 seniors who had diagnoses of hypertension were identified as new users of hypertension drugs. The overall rate at which thiazides were used as first-line treatment varied from 38% among senior hypertensives without any potentially relevant comorbidity to 9% among hypertensives with previous acute myocardial infarction. The rate of first-line thiazide diuretic prescribing for patients with and without potentially relevant comorbidities increased over the study period. Women were more likely than men, and older patients were more likely than younger, to receive first-line thiazide therapy.ConclusionsFindings indicate that first-line prescribing practices for hypertension are not consistent with the evidence from randomized control trials measuring morbidity and mortality. The health and financial cost of not selecting the most effective and least costly therapeutic options are significant.

Long-Term and Short-Term Changes in Antihypertensive Prescribing by Office-Based Physicians in the United States

“…Our data and other studies find that thiazide diuretics have increased but may remain underprescribed despite clinical evidence that they are the most cost-effective antihypertensive agents. 34 Multiple reasons may explain why thiazide diuretics are not more commonly prescribed as a preferred antihypertensive therapy. First, the recommendation to prescribe thiazide diuretics in most hypertensive patients is not universally accepted, and an alternative perspective instead considers all antihypertensive drug classes to be equivalent.…”

Effects of Initial Antihypertensive Drug Class on Patient Persistence and Compliance in a Usual‐Care Setting in the United States

“…JNC 7 recommended that thiazide diuretics be used as first‐step therapy for hypertension management in the absence of high‐risk conditions. Despite these recommendations, the use of diuretics as first‐step therapy in hypertension has remained less common than might be expected, 6 especially since they are available at a low cost.…”

Managing Cardiovascular Risk Factors: The Gap between Evidence and Practice

“…A similar evidence–practice gap, this time for blood pressure, is highlighted in the other article, by Morgan et al [3]. In this paper, data from public, medical, hospital, and pharmaceutical programs in British Columbia are used to determine trends in the use of thiazide diuretics compared with other, more costly agents as a first-line treatment to lower blood pressure among older, newly treated patients with hypertension.…”