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RAY SUAREZ: Hypertension, or high blood pressure, affects about 50 million Americans — one in four of the population– and can cause stroke, heart failure, and other serious health problems. For many years, water pills, or diuretics, were the most common treatment. But recently, several highly marketed new drugs have increased in popularity. A study in today’s Journal of the American Medical Association compared the benefits of different drugs with some surprising results. Dr. Paul Whelton was one of the leaders of the study. He’s a professor of epidemiology and medicine at Tulane University.
Dr. Whelton, what is hypertension?
DR. PAUL WHELTON, Tulane University: Hypertension is high blood pressure. And as you said, as it goes up, it increases the risk of complications — stroke, heart failure, kidney failure, and a number of others.
RAY SUAREZ: So there is just excess fluid, pressure on your circulatory system?
DR. PAUL WHELTON: There is excess pressure on the blood vessels and eventually that leads to damage of the vessels with clotting or sometimes with destruction of the vessels and bleeding as you will see with hemorrhagic stroke.
RAY SUAREZ: Well, if last week or last month a person in consultation with their doctor decided to start using drugs as part of their management course for hypertension, what would they have commonly done?
DR. PAUL WHELTON: Very likely in the very recent past, they would have received advice on lifestyle change, probably — getting a good weight, being physically active; being careful with diet, and so on, but if they were to be start on a medication, many would be, they probably would have been advised to start on one of the newer agents. Calcium channel blocker agent or an ace inhibitor, two of the drugs we tested in the study.
RAY SUAREZ: So what do you find out when looking across the range of commonly offered medications?
DR. PAUL WHELTON: Well, we found a very interesting result. All of the drugs that we tested — and as you said, we tested the diuretic or the fluid pill against the calcium channel blocker and we also tested it against the ace inhibitor. And what we found out is that the diuretic seemed to be the best.
All three of these drugs are known to lower blood pressure, all three are known to reduce the risk of complications. But none… no study had really compared all three head to head before. And we found that the diuretic certainly was as good with respect to important outcomes like heart attacks, and better with respect to preventing stroke and heart failure, very impressive results.
RAY SUAREZ: The other drugs did work, though? I mean, they weren’t found to be ineffective?
DR. PAUL WHELTON: Right. The other drugs are very effective. And, in fact, although we are recommending diuretics as the first step for drug treatment, and that is a very appropriate recommendation based on our results, many people will require a second drug. And these two other drugs that we tested are very appropriate as second drugs.
RAY SUAREZ: Well, as you look at this as a specialist in this field, and you look back over your shoulder, how do you think it happened that a drug that is now found to be very effective and very cheap compared to the others ended up being a treatment in a minority of cases over the years?
DR. PAUL WHELTON: Well, the diuretics have always been known to be very effective. And we’ve done lots of trials, but naturally you are looking for new agents, and thank goodness we have many other agents. As those new ones came out, for many doctors, and for many researchers, there was the opinion and the feeling that they would be better than diuretics. In fact, of course, that is why we did the study. We wanted to know were these newer, drugs which cost a lot more, seriously better than the diuretic?
I would say, you know, in the 30 years that I’ve been a doctor and a researcher, this question comes up every time a doctor treats a patient, and probably every time a patient asks a doctor for advice. So it’s has been a question that has been around for a long time. Now we’ve resolved the question.
RAY SUAREZ: But we’re not talking about a close call in this case, are we? I mean, these drugs cost ten to twenty times as much as a diuretic.
DR. PAUL WHELTON: Yes, the newer drugs clearly are a lot more expensive. And it seems that for the average person, they can do as well and better with the cheaper, old friend than with the newer agent. Now, not to say there isn’t a place for these newer drugs, and sometimes you are treating not only high blood pressure and worrying about its complications, but you are treating something else as well.
For instance, a patient might have angina pectoris or heart pain. And in that instance, another drug, such as a calcium channel blocker, would be very appropriate because it not only lowers blood pressure and the complications of blood pressure, but also is an effective treatment of angina. So these new drugs do have a place, but I think what we are saying is for most patients the starting drug ought to be a diuretic, and if they need a second drug, that is when you add one of those other agents on top.
RAY SUAREZ: Might this be particularly good news to certain high-risk populations for hypertension, like African Americans, who also have an access and cost problem when gaining medical care at the same time?
DR. PAUL WHELTON: Yeah, I think this is good news for everyone. It’s great news for African Americans. It’s great news for anyone really to get the answer to the question, “Which is the best drug to start with?” It’s particularly good news for the person who has to pay for their own medications. And it could be the difference between getting treatment for what is a serious risk factor for cardiovascular complications or having untreated hypertension with all of the adverse consequences.
RAY SUAREZ: Now if you are one of the millions of Americans currently on a drug regimen to help manage your hypertension, should you be on the phone in the morning running down to your doctor or your clinic and saying get me on diuretics or stop taking what you been taking? How do you proceed?
DR. PAUL WHELTON: Well, I think you proceed to see your doctor. And hypertension is a lifelong problem. It isn’t that the consequences occur overnight, and there may be reasons that the doctor put the patient on that particular medicine other than to lower their blood pressure. So I think it’s very important that people have the conversation with their health care provider. And I think in many instances, the health care provider will likely switch that person to a diuretic, or if they are starting treatment, start them on a diuretic. But it’s not a good idea to change one’s own medications.
RAY SUAREZ: And can this help control health care cost inflation, news like this?
DR. PAUL WHELTON: Well, I think this is important news and this is an important model for how we can test these questions. It is unlikely, in my opinion, that the pharmaceutical industry is going to do these kinds of studies of head-to-head comparisons on their own.
Here is an instance where the National Heart, Lung and Blood Institute, with a lot of help from the Veterans Administration, from over 600 practitioners around the country and indeed help from the pharmaceutical industry as well, stepped up to the plate, did an important study that needed to be done, got an answer and got it at a relatively low price given the importance of the marketplace, both in terms of health and indeed the fact that we spend probably about $20 billion a year on anti-hypertensive drugs. So I think there is a message for other common treatments where we need to do these kinds of studies.
RAY SUAREZ: Dr. Whelton, thanks a lot.
DR. PAUL WHELTON: My pleasure.