31 participants got the message that Micardis Plus is more effective at preventing cardiovascular events in the "early morning" than all other antihypertensive drugs.
10 got the message that Micardis Plus is more effective at suppressing the increase in blood pressure in the "early morning" than its components so it may be more effective at preventing cardiovascular events.
6 got a message that was somewhere in-between the above.
2 said they got different messages:
Micardis Plus is best (compared with other drugs) reduces early AM BP and by inference is likely to reduce CVS events (which correlate with early AM BP)
This means that if the Drs are prescribing it, they're getting some great big whopping "gratuities" from the health care/pharmaceutical companies
1 participant was unsure, and wrote:
I get the impression the drug has two actions (undefined) that will let you sleep and wake without having a blood pressure related cardiac event. I don't feel confident about the information and the image doesn't make any sense to me either.
1 had no opinion and one did not answer.
Additional comments included:
Adverts like this could scare some people into using this drug
Also get the message that CVA's are due to fluctuations in BP rather than BP at rest or average BP, not sure that is right. People who exercise get surges but are protected against cardiovascular events.
While I don't believe the ad style is justified, the image of peaceful/safe sleep is powerful, and will stay in my mind.
The ad does not contain statistical or clinical outcome data to support its assertions.
Conflicting views about costs
Too much emphasis on cost
Costs per year very informative
The more physicians and patients know what the price/effectiveness ratio of pharmaceuticals really is the better.
When there are no clear advantages of one drug over another on effectiveness, adverse effects or convenience then costs become important considerations. Wasting money on expensive drugs reduces resources that could be spent elsewhere in the health system for example on emergency departments and healthy lifestyle interventions. Advertisements rarely provide comparative information about costs so we feel it is useful for AdWatch to fill the gap.
Comments about lifestyle change
More effort should be given to lifestyle changes
Life style Changes are always beneficial with or without medication. Getting Patients to realise this is another matter.
The promotional skills of the pharmaceutical and advertising industry would be better used if focused on helping achieve lifestyle changes.
Confessions of lack of knowledge
I assume chlorthalidone must be a diuretic, my understanding was that this class was first line drug treatment
Correct.
I graduated in 2002 and have never heard of chlorthalidone! Is it similar in efficacy/price to indapamide?
Your medical school let you and your patients down. There is no comparative evidence to show if one if better than the other. We favored chlorthalidone because there is stronger evidence (eg ALLHAT ) that chlorthalidone is at least as good as more expensive non-thiazide blood pressure drugs than there is for the other thiazide type drugs. However I am not aware of any head-to-head comparisons to show if any thiazide type drugs have clinically significant benefits over the others. The best we have is indirect comparisons (by meta-analysis) between chlorthalidone and non-chlorthalidone diuretics that suggest no significant difference in major outcomes. (Psaty BM, Lumley T, Furberg CD. Meta-analysis of health outcomes of chlorthalidone-based vs nonchlorthalidone-based low-dose diuretic therapies. JAMA 2004; 292: 43-44 Medline)
However there is a big difference in price. According to http://www1.health.gov.au/pbs/index.htm currently in Australia the price of 30 days treatment is:
| chlorthalidone 25mg 1/2 daily |
$1.64 |
| indapamide 1.5mg 1 daily |
$6.58 |
| indapamide 2.5mg 1/2 daily |
$3.29 |
Pointing out that our recommendations for uncomplicated hypertension may not apply to complicated hypertension.
I'm not sure about the advice for diabetics - I would still go for an ACE inhibitor first
ACE inhibitors may be preferable to beta-blockers in diabetics and fall in price as more come off patent
Although good in theory I have difficulty with propranolol for diabetics, asthmatics and those who feel weary on it
Our recommendations were limited to uncomplicated high blood pressure because we wanted to to keep them simple so as to focus is on evaluation of advertising.
It is better to avoid beta-blockers for people who have asthma. However some asthmatics may be able to take small doses of atenolol without harm. (Ellis ME, Sahay JN, Chatterjee SS, Cruickshank JM, Ellis SH. Cardioselectivity of atenolol in asthmatic patients. Eur J Clin Pharmacol. 1981;21(3):173-6. Medline)
By contrast case against beta-blockers for diabetics is not as strong as is widely believed. The most relevant evidence that I am aware of is the UKPDS 39 trial which compared 358 hypertensive diabetics on atenolol vs 400 on captopril and found that neither "drug has any specific beneficial or deleterious effect". (Efficacy of atenolol and captopril in reducing risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 39. UK Prospective Diabetes Study Group. BMJ. 1998 Sep 12;317(7160):713-20. Full text )
Disagreements with our recommendations
Six lines seem too explicit to me. Why not: 2nd line = diuretic or ß-blocker. 3rd line = rest.
That would have been easier for us but less helpful when people have to choose between the lesser drugs. Also, we wanted to make the point that A2 blockers such as Micardis are 6th line therapy.
In line with the evidence, but who gives diuretics first, even the cardiologists don't, so what hope have we!
I do! I have been using thiazides first line in general practice for over 20 years. Anyone who values randomised controlled trial evidence above peer pressure or deference to cardiologists is likely to prefer thiazides. (Cardiologists may lack relevant expertise in general practice, evidence based medicine, clinical pharmacology, pharmacovigilance, epidemiology, public health and health economics.)
Interesting - in the UK we use bendrofluazide 2.5mg 1st line alongside advice on lifestyle.
As mentioned above: We favored chlorthalidone because there is stronger evidence that it is at least as good as more expensive non-thiazide blood pressure drugs (eg ALLHAT ) than there is for the other thiazide type drugs. However I am not aware of any head-to-head comparisons to show if any thiazide type drugs have clinically significant benefits over the others.
I thought:
* most hypertensives are uncontrolled on one pill
The definition of what is "uncontrolled" blood pressure is arbitrary. However it is true that no drug alone is strong enough to "control" hypertension in all people.
The current consensus is to add drugs in the expectation that lower blood pressure is better. There is much observation evidence supporting that idea. However, except for diabetics, there is no RCT evidence on whether using more than one pill is better than one.
The only study of intensity of blood pressure control for non-diabetics that I am aware of is the HOT study. That study showed a trend for harm with lower blood pressure in the non-diabetic subgroup. There were more deaths and cardiovascular events in the most intense treatment group (where the aim was diastolic <80 and the achieved mean diastolic was 81.1) vs the least intense treatment group (where the aim was diastolic <90 and the achieved mean diastolic was 85.2). This key finding was not mentioned by the authors but the information can be extracted from the tables by subtracting the results for the diabetic subgroup from the total. This was discussed briefly in Therapeutics Letter, issue 27, November - December 1998 and in more a little more detail in the July/August 2000 Healthy Skepticism International News.
I conclude that no one knows how intensively to treat hypertension but the limited evidence suggests not aiming to go below diastolic 90. Because we don’t know it is reasonable to go along with the consensus as far as getting diastolics down to 90. However pushing reluctant patients to accept polypharmacy that causes immediate adverse effects in the hope of long term benefits is not justified by currently available evidence.
* perindopril was a cheaper ACEI than ramipril
No. According to http://www1.health.gov.au/pbs/index.htm the current prices in Australia for a pack of 30 are:
| ramipril 1.25 mg |
$13.56 |
| ramipril 2.5 mg |
$17.55 |
| perindopril 2 mg |
$19.47 |
| ramipril 5 mg |
$20.73 |
| perindopril 4 mg |
$24.76 |
| ramipril 10 mg |
$36.97 |
| perindopril 8 mg |
$42.84 |
* combination medication (reducing pill numbers) was one of the few proven ways to improve medication adherence
Correct.
* "uncomplicated" HTN is often uninvestigated HTN; many GP's do not do urine urine albumin:creatinine ratios annually or at all
Correct. To be convinced that we should test albumin:creatinine ratios I would need to see evidence that treating people differently on the basis of this test produced enough benefit to be cost effective. This depends on several factors including how common are adverse albumin:creatinine ratios? and how accurate is the test?
* HTN with proteinuria is a powerful indication for ACEI (or ARBs) as first line therapy - their effectiveness is most cost-effectively augmented by using a thiazide combination pill
* as a nephrologist, I spend all my time retarding CRF progression - combination ACEI/ARB/thiazide is my most powerful & effective tool (see COOPERATE trial, Lancet 2003)
To attempt to confirm or deny these claims is beyond our focus on an advertisement targeting GPs. (See an emergency physician's comments about ACE inhibitors as a cause of acute renal failure below.)
I thought Beta blockers would come after ACEI in HTN.
We are not aware of any evidence of superiority of either for uncomplicated hypertension but beta-blockers are cheaper.
I think that efficacy of thiazides as first line therapy is no longer regarded as being as good as ACEI/A2RB.
That is widely believed. It is further evidence for the effectiveness of promotion by drug companies. However there is no convincing evidence of superiority of ACE inhibitors or A2 blockers over thiazide type drugs. The ANBP2 and ALLHAT trials have been used to support opposing opinions but there is probably little difference between ACE inhibitors and thiazides except that the latter are much cheaper so should be used first line.
Further reading:
Turnbull F, Neal B. Resolving the differences between ACE inhibitors and diuretics - ALLHAT and ANBP2. Australian Prescriber 2004;27:98-101
Davis BR, Furberg CD, Wright JT Jr, Cutler JA, Whelton P; ALLHAT Collaborative Research Group. ALLHAT: setting the record straight. Ann Intern Med. 2004 Jul 6;141(1):39-46.
I am not happy about blanket recommendations especially when people react differently to drugs.
That is why we included many choices in our list. If drugs at the top of the list are unsuitable for an individual then try one further down.
I am well aware re guidelines to have diuretics 1 st line, but in reality find this not a good way to go clinically due to Na, Mg and K effects, gout, glucose effects and variable effect in reaching target BPs
All antihypertensive drugs have adverse effects. Clinical experience is not an accurate way to reach conclusions about which drugs have more and/or worse adverse effects overall. The clinical trial evidence suggests that adverse effects of low dose thiazide type drugs are no worse than with other antihypertensive drugs.
Agreement with our recommendations
Straightforward and easy to follow
seems very realistic and sensible
reasonable and accord with other opinion I have read eg NPS info.
makes sense
I agree.
The Standard Treatment Guidelines for Hypertension serve as excellent guidelines for rational treatments.
Allhat was convincing, looks right to me. I don't know the relative proportions of prescribing so its difficult to know, but as an emergency physician I see acute renal failure (usually reversible) every week & in a busy dept, most days in elderly people who are on ACE inhibitors & get an intercurrent illness. Combination with diuretics increases that risk. Indapamide seems to be the diuretic most likely to be at fault when there are significant electrolyte imbalances.
