My doctor didn't give me one of the new drugs that are good for my blood pressure. Is this because she is not up to date?
Recently the New York Times ran an editorial and several pieces on the "Op Ed" page about lecturers having conflicts of interest when giving such lectures. I am currently on a plane preparing to give grand rounds to doctors at a community hospital on the subject of hypertension control. At this particular hospital, and others at which I have lectured, they were quite careful to make sure that I disclose any such conflicts. As do many other physicians, I receive indirect support for some of my research from drug companies. It is indirect because the research that I do has to do with adjudication (or judging) of adverse events, reporting of side effects, and what is called "investigator initiated research" (not related to the use of the drug or device, directed at finding out why the disease does what it does). As such, the type of research that I do, and the lectures that I give are not likely to be useful for pharmaceutical sales or marketing. This is my disclosure.
What am I going to say in my lecture? That is relatively easy. Here is a quick summary:
1. The goal of hypertension control is to keep the patient in optimal blood pressure at all times for the purpose of lowering long-term risk of stroke, heart attack, kidney failure, aortic or peripheral vascular catastrophe and heart failure. Optimal control means under 140/90 for patients without any kidney problem, diabetes, or increased risk of heart disease, 130/80 for people with any of these problems. This should be done with safety for the long-term and absence of side effects or disability to the patient.
2. There is no evidence that switching a patient with good blood pressure control to any other regimen is of any benefit.
3. We know the long-term side effects of drugs only if they have been used for a long time. A thirty year old with high blood pressure can expect to be on a drug for several decades. Why use a drug in such a situation that has only been around for one year? How many drugs have been pulled off the market due to adverse events after they were said to be safe?
4. There are currently over 200 drugs approved for blood pressure control in the US. If one drug worked best, we would only need one drug. If one size fit all. We would only need one size.
5. Most hypertensive patients will need more than one drug to obtain optimal control.
6. Recent studies have shown that there is little difference between most of the classes of drugs in the long run.
7. There is no evidence that the "hard end-points" listed above for which we treat blood pressure are prevented better by the expensive newer drugs.
8. More money is being spent to promote new drugs and their "physiologic benefits" then is spent on research aimed at finding out if there is a true benefit. Likewise, more insurance company money is spent on trying to keep doctors from ordering expensive drugs then is spent on educating the public about the dangers of high blood pressure.