medwireNews: Patients with hypertension and high cardiovascular risk can successfully monitor and titrate their own antihypertensive medication, shows research published in JAMA.
The UK trial involved 552 patients from 59 primary care practices, of whom 450 remained in the study for 12 months. During this time, systolic blood pressure (BP) among patients randomly assigned to self-management fell from 143.1 to 128.2 mmHg, compared with a fall of 143.6 to 137.8 mmHg among those who continued to receive usual care. This equated to a significant 9.2 mmHg difference in favour of self-management.
The study participants all had cardiovascular risk factors such as previous stroke or myocardial infarction, coronary surgery, diabetes or stage 3 chronic kidney disease.
This group has “the most to gain in terms of reducing future cardiovascular events from optimized blood pressure control”, say lead study author Richard McManus (University of Oxford) and co-workers, noting that the absolute risk reductions associated with BP control rise as cardiovascular risk increases.
After initial training, patients in the self-management group monitored their BP twice each morning for the first week of each month and alerted their general practitioner when a change of medication was required, with the actual choice of antihypertensive remaining at the discretion of the physician. Patients aimed to achieve a BP of 120/75 mmHg or lower, in accordance with guidelines for high-risk patients at the time.
The additional BP reduction among self-management patients was associated with use of 0.27 more medications than the control group at 12 months and a 0.91 difference in overall defined daily dose. Self-monitoring was not associated with an increase in adverse events.
Of the more than 10,000 patients initially considered for the trial, around a third were excluded because of being housebound, terminally ill or otherwise unsuitable. A high proportion of those invited to screening declined and about half of those screened were excluded because their BP was already controlled. From this, the team estimates that, in real-life practice, about 20% of high-risk hypertensive patients could be considered for self-management.
In an accompanying editorial, Peter Nilsson (Skåne University Hospital, Malmö, Sweden) and Fredrik Nystrom (Linkøping University, Sweden) say that more study is needed to address questions such as the best time of day for patients to measure their BP and what target to treat to. They also note that, contrary to other trials, home drug titration did not result in improved wellbeing for the participants.
They say: “Although the trial by McManus et al does not settle all questions regarding self-titration based on self-measurement, it is an important step toward adaptation of treatment for patients who want to actively take part in their own risk-factor control.”
medwireNews (www.medwirenews.com) is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2014
By Eleanor McDermid, Senior medwireNews Reporter