US agency launches initiative on better prescribing for hypertension

The US National Institutes of Health is launching a comprehensive programme to educate doctors on the management of hypertension, which is likely to result in the wider use of cheap diuretics.

The programme will disseminate the results of the antihypertensive and lipid lowering treatment to prevent heart attack trial (ALLHAT), which tested four classes of antihypertensive drugs and found that inexpensive diuretics are as effective as newer, dearer drugs.

The ALLHAT results, published more than three years ago (JAMA 2002;288;2981-97), were incorporated into clinical guidelines issued by the National Heart, Lung, and Blood Institute in May 2003.

The guidelines' chief recommendation is that for most patients an inexpensive diuretic should be the first drug for hypertensive patients on monotherapy and should be one of the drugs for patients who need more than one drug.

William Cushman, chairman of the ALLHAT dissemination committee, said that roughly 25% to 30% of US patients on monotherapy are taking a diuretic and that the “majority of patients on two or three drugs are not on diuretics.”

These numbers are far too low, said Dr Cushman, as approximately 80% to 90% of patients can take diuretics. In the ALLHAT trial the likelihood of stopping treatment because of side effects was lower among patients who took diuretics than among those who took any other class of antihypertensive agent, he said.

One reason doctors may not be prescribing diuretics, even as part of multidrug regimens, said Dr Cushman, is that doctors often begin treatment using free samples provided by drug company representatives. “Unless they're in a sample on a shelf, doctors often don't use [diuretics],” he said.

The $3.7m (£2.1m; €3.1m) initiative will last three years and is expected to reach 30 000 doctors by September 2006. Approximately 150 doctors in 34 states and in Washington, DC, have undergone special training so they can offer educational programmes to local doctors. They have been equipped with study results, clinical guidelines, slide programmes, and educational handouts. This is the first such educational initiative undertaken by the National Heart, Lung, and Blood Institute, said Dr Cushman.