Tuesday, July 18, 2006

Beta Blockers and the treatment of Hypertension

The NST carried and highlighted an article on the use of beta blockers, in this case, metoprolol, in the management of hypertension. Prof MacGregor, whom I know in passing, the President of the UK society of Hypertension, also holds rather strong views that salt is bad for us, and that metoprolol has too many side effects, mainly, lack of zest in life.

I remember when we were at dinner in Pulau Redang last year, he would survey all the food, to pick out those that were salt free or of very low salt, to eat. He would harp on the point that beta blockers, make one lose all of one's drive. "You have no drive for anything". His statement that beta blockers is bad for hypertensives, comes as no surprise. Perhaps there is some data to support his opinion.

The Ascot-BPLA study, enrolling 19,200 patients, compared norvasc with coversyl, against tenormin with thiazide diuretics, in the management of hypertension. Of course, norvasc and coversyl proved superior. What was very interesting was that there were much less new-onset diabetics in the norvasc/coversyl group. Whether this was due to the potentially diabetogenic effects of beta-blockers or the diabeto-protective effects of coversyl, is open for debate.

The previous ALLHAT trial also had an increase incidence of diabetics in the tenormin arm. We all remember that there was a reduction in incidence of new-onset diabetic in the VALUE trial, giving rise to the Novartis claim that Valsatan reduces new onset diabetics. The HOPE trial with Ramipril (Sanofi-Aventis) also showed a lower incidence of diabetes in the ramipril arm. It is true that ACE-I may reduce the incidence of new-onset diabetes. Beta blockers, are good medicine for the control of hypertension. They are effective, and also protects against stress induced myocardial ischemia. It therefore reduces angina and myocardial ischemia and is cardioprotective. However, it does make you a bit tired and can reduce your sexual drive. Of course the occasional patient may have an asthmatic attack triggered.

True, many of us are on the "use beta blockers less" train, except in those patients with concomitant coronary artery disease. There are many alternatives. CCBs and ACE-I are very effective anti-hypertensive agents without the extra baggage of lethargy and they are good for diabetics, and new-onset diabetics. It is also important to note that Prof. MacGregor's views is not exactly shared by his colleagues across the Atlantic ocean. The Americans, under their guidelines still advocates the use of beta-blockers in the management of hypertension. Interesting.

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