Identification of factors driving differences in cost effectiveness of first-line pharmacological therapy for uncomplicated hypertension

Klarenbach, Scott; McAlister, Finlay A.; Johansen, Helen; Tu, Karen; Hazel, Maureen; Walker, Robin; Zarnke, Kelly B.; Campbell, Norman R.C.

doi:10.1016/s0828-282x(10)70383-4

Cited by 12 publications

(6 citation statements)

References 18 publications

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“…In the present study pretreatment with propranolol reduced the heart rate significantly in comparison to control portal hypertension group. Propranolol blocks β1 receptors in cardiac muscles with subsequent reduction in heart rate (Klarenbach et al, 2010). These results are in agreement with the work of Dib et al (2006) who reported that propranolol decreased MABP and heart rate in rats with pre-hepatic portal hypertension.…”

Section: Esctj;supporting

confidence: 92%

Effect of Ginger and Propranolol on Experimentally Induced Portal Hypertension in Adult Male Albino Rats

El-Menshawy¹,

El-Barody²,

Fayed³

et al. 2014

Egyptian Society of Clinical Toxicology Journal

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Background: The incidence and prevalence of portal hypertension in Egypt is very high. Propranolol is one of the most commonly used drugs for lowering portal pressure and preventing variceal bleeding. Ginger was reported to have anti-inflammatory and hepatoprotective effect. Objectives: The aim of this study is to evaluate the effects of ginger and its co-administration with propranolol in prehepatic portal hypertension in male albino rats. Design: One hundred fifty six adult male albino rats weighting 140-220 gm were divided into 7 groups. Group1 (Sham group), the remaining groups were subjected to partial portal vein ligation (PPVL). Group2 (control group): received orally distilled water. Group 3 (propranolol 75mg/Kg/ day). Group 4 (ginger 90mg/Kg/ day). Group 5 (ginger 180mg/Kg/ day). Group 6 ginger (90mg/kg/day) plus propranolol (75mg/kg/day). Group 7 ginger (180mg/kg/day) plus propranolol (75mg/kg/day). Propranolol was given orally one day before portal vein ligation (PVL) while ginger powder was given orally 30 days before PVL. These medications were given maximally for 90days after PVL. The following parameters were measured in all previous groups after PVL either at 14, 45 or 90 days: mean arterial blood pressure (MABP), heart rate, portal pressure, then rats were sacrificed and blood samples were collected to assess liver function tests and hepatic and gastro-intestinal tissues were obtained for histopathological examination. Results: Group (2) showed significant increase in portal pressure, heart rate, liver functions as well as pathological changes in liver, esophagus, stomach and intestine while MABP was reduced. The other groups from the 3 rd group to the 7 th group showed significant reduction in portal pressure and in the mean values of the pathological changes.Conclusion: Ginger especially in a dose of 90mg/kg/day has a protective effect against portal hypertension induced in adult male albino rats. In addition, co-administration with propranolol enhances its protective effect especially hepatic and gastro-intestinal lesions however ginger at a dose of 180mg/kg/day carries risk of drug-herb interaction.Recommendations: Further clinical studies on ginger extracts are needed to evaluate the effect of ginger on portal hypertension.

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Section: Esctj;supporting

confidence: 92%

Effect of Ginger and Propranolol on Experimentally Induced Portal Hypertension in Adult Male Albino Rats

El-Menshawy¹,

El-Barody²,

Fayed³

et al. 2014

Egyptian Society of Clinical Toxicology Journal

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“…Pharmacotherapies are associated with different mechanisms of action, harm profiles and costs. The optimal choice of a first line agent remains unclear, as some works suggest that thiazide diuretics are best [11,12], while others suggest calcium channel blockers should be considered as first line therapy in patients over 55 years of age or of Caribbean or African descent [13]. In Canada, all but alpha blockers are considered reasonable first line therapies, with patients’ demographics and comorbidities playing a role in selection [2].…”

Section: Introductionmentioning

confidence: 99%

Comparative effectiveness of monotherapies and combination therapies for patients with hypertension: protocol for a systematic review with network meta-analyses

et al. 2013

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BackgroundHypertension has been cited as the most common attributable risk factor for death worldwide, and in Canada more than one of every five adults had this diagnosis in 2007. In addition to different lifestyle modifications, such as diet and exercise, there exist many pharmaco-therapies from different drug classes which can be used to lower blood pressure, thereby reducing the risk of serious clinical outcomes. In moderate and severe cases, more than one agent may be used. The optimal mono- and combination therapies for mild hypertension and moderate/severe hypertension are unclear, and clinical guidelines provide different recommendations for first line therapy. The objective of this review is to explore the relative benefits and safety of different pharmacotherapies for management of non-diabetic patients with hypertension, whether of a mild or moderate to severe nature.Methods/DesignSearches involving MEDLINE and the Cochrane Database of Systematic Reviews will be used to identify related systematic reviews and relevant randomized trials. The outcomes of interest include myocardial infarction, stroke, incident diabetes, heart failure, overall and cardiovascular related death, and important side effects (cancers, depression, syncopal episodes/falls and sexual dysfunction). Randomized controlled trials will be sought. Two reviewers will independently screen relevant reviews, titles and abstracts resulting from the literature search, and also potentially relevant full-text articles in duplicate. Data will be abstracted and quality will be appraised by two team members independently. Conflicts at all levels of screening and abstraction will be resolved through team discussion. Random effect pairwise meta-analyses and network meta-analyses will be conducted where deemed appropriate. Analyses will be geared toward studying treatment of mild hypertension and moderate/severe hypertension separately.DiscussionOur systematic review results will assess the extent of currently available evidence for single agent and multi-agent pharmacotherapies in patients with mild, moderate and severe hypertension, and will provide a rigorous and updated synthesis of a range of important clinical outcomes for clinicians, decision makers and patients.Trial registrationPROSPERO Registration Number: CRD42013004459

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“…For this reason, and because they are the least costly agents [7], many evidence-based guidelines have recommended that low doses of diuretics should be considered as the first-line treatment of mild to moderate uncomplicated hypertension [9,17,18]. …”

Section: Introductionmentioning

confidence: 99%

“…Hypertension has been identified as the most important modifiable risk factor for cardiovascular morbidity and mortality [ 4 , 5 ], and pharmacotherapy is an important aspect of hypertension management [ 6 ]. Numerous pharmacological agents exist for the treatment of hypertension, including thiazide diuretics, angiotensin converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), calcium channel blockers (CCBs), and beta-blockers (BBs) [ 7 - 9 ], and these agents vary considerably in cost [ 7 ].…”

Section: Introductionmentioning

confidence: 99%

“…While there is evidence that specific pharmacological agents have benefits for patients with particular co-morbidities (e.g., diabetes or nephropathy) [ 8 ], for the majority of patients with mild to moderate hypertension, the major randomized control trials [ 10 , 11 ], meta-analyses and systematic reviews [ 12 - 16 ] have provided evidence that initial monotherapy with a thiazide diuretic is as equally effective as the other therapeutic agents in preventing cardiovascular mortality and morbidity. For this reason, and because they are the least costly agents [ 7 ], many evidence-based guidelines have recommended that low doses of diuretics should be considered as the first-line treatment of mild to moderate uncomplicated hypertension [ 9 , 17 , 18 ].…”

Section: Introductionmentioning

confidence: 99%

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What differentiates primary care physicians who predominantly prescribe diuretics for treating mild to moderate hypertension from those who do not? A comparative qualitative study

2012

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BackgroundThiazide diuretics are cost-effective for the treatment of mild to moderate hypertension, but physicians often opt for more expensive treatment options such as angiotensin II receptor blockers or angiotensin converting enzyme inhibitors. With escalating health care costs, there is a need to elucidate the factors influencing physicians' treatment choices for this highly prevalent chronic condition. The purpose of this study was to describe the characteristics of physicians' decision-making process regarding hypertension treatment choices.MethodsA comparative qualitative study was conducted in 2009 in the Canadian province of Quebec. Overall, 29 primary care physicians--who are also participating in an electronic health record research program--participated in a semi-structured interview about their prescribing decisions. Physicians were categorized into two groups based on their patterns of prescribing antihypertensive drugs: physicians who predominantly prescribe diuretics, and physicians who predominantly prescribe drug classes other than diuretics. Cases of hypertension that were newly started on antihypertensive therapy were purposely selected from each physician's electronic health record database. Chart stimulated recall interview, a technique utilizing patient charts to probe recall and provide context to physician decision-making during clinical encounters, was used to elucidate reasons for treatment choices. Interview transcripts were synthesized using content analysis techniques, and factors influencing physicians' decision making were inductively generated from the data.ResultsWe identified three themes that differentiated physicians who predominantly prescribe diuretics from those who predominantly prescribe other drug classes for the initial treatment of mild to moderate hypertension: a) perceptions about the efficacy of diuretics, b) preferred approach to hypertension management and, c) perceptions about hypertension guidelines. Specifically, physicians had differences in beliefs about the efficacy, safety and tolerability of diuretics, the most effective approach for managing mild to moderate hypertension, and in aggressiveness to achieve treatment targets. Marketing strategies employed by the pharmaceutical industry and practice experience appear to contribute to these differences in management approach.ConclusionsPhysicians preferring more expensive treatment options appear to have several misperceptions about the efficacy, safety and tolerability of diuretics. Efforts to increase physicians' prescribing of diuretics may need to be directed at overcoming these misperceptions.

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Identification of factors driving differences in cost effectiveness of first-line pharmacological therapy for uncomplicated hypertension

Cited by 12 publications

References 18 publications

Effect of Ginger and Propranolol on Experimentally Induced Portal Hypertension in Adult Male Albino Rats

Effect of Ginger and Propranolol on Experimentally Induced Portal Hypertension in Adult Male Albino Rats

Comparative effectiveness of monotherapies and combination therapies for patients with hypertension: protocol for a systematic review with network meta-analyses

What differentiates primary care physicians who predominantly prescribe diuretics for treating mild to moderate hypertension from those who do not? A comparative qualitative study

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