Can I Stop Taking This Blood Pressure Medicine?

Although great emphasis is placed in clinical practice on methods to encourage patients to continue (or even increase) their antihypertensive medication, patients often ask if they “really need this drug.” Hypertension is usually not curable, and if untreated leads to premature target organ damage, so our usual response is to assure patients that they really do need this (or these) drug(s). Possibly, though, an occasional patient who was started on antihypertensive medication no longer needs drug therapy. How might you suspect that?

The question is not without interest in the literature. Several studies have addressed antihypertensive drug withdrawal in treated patients. A recent systematic review of these studies ¹ confirms what we have used as rule‐of‐thumb indicators to predict which patients could be considered for step‐down therapy (less medication) or drug discontinuation.

In many patients hypertension is weight‐related. If someone has lost 15 pounds (or more), and had modest elevations in blood pressure before therapy, that patient may be a candidate for drug reduction. The same is true regarding salt intake, though my experience has been that weight loss is a more potent blood pressure reduction measure. The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) ² also supports antihypertensive drug reduction particularly in conjunction with successful lifestyle modification.

Patients with consistently low blood pressures in the office (I use a rough guide of <120 mm Hg systolic in nondiabetics) may be candidates for drug reduction. Well‐controlled hypertensive patients on a single drug, particularly in a low dose, may also be candidates for drug reduction or a trial of discontinuation.

The study I remember most clearly which addresses the role of dietary factors and medication reduction ³ showed that hypertensive patients who remained normotensive after discontinuing drug therapy did so when they were well coached and successful at lifestyle modification (about one half of the patients were still off medication at 3 years; this was group I in the study). When no targeted attempt was made to intervene with lifestyle changes about five out of six patients became hypertensive again within 3 years after discontinuing drug treatment (this was group II in the study; they functioned as the control group).

The important thing in pursuing drug reduction is vigilant monitoring, either through one's office or in the patient's home if they take home blood pressures. Nothing is without risk; although, the cardiovascular risks are small in otherwise healthy hypertensive patients without target organ damage. Keep in mind that it may take months or even years for hypertension to recur. Motivation is a wonderful thing. Some patients maintain lifestyle changes indefinitely and are still controlled on less medicine, or even off drug therapy, for a long time.