Wednesday, August 09, 2006

Managing Hypertension, withdrawing Beta Blockers

The lastest European Society of hypertension and the British Society of Hypertension guidelines on hypertension, recommend that we should not use beta blockers (BB) as the first line treatment of hypertension. This was partly due to their analysis of the results of ASCOT-BPLA, which showed that patients on beta blockers (BB) had a higher incidence of diabetes, when compared to those on Calcium Channel blockers (CCB). ASCOT-BPLA also showed that those on BB also had a slightly higher incidence of strokes. Because of their well publicised recommendations, some patients and also many practitioners have asked for their beta blockers to be withdrawn and be replaced by alternatives.

We can argue whether or not it was the CCB protective effect against strokes and not necessarily a stroke inducing BB effect. It does appear that BB, when used for a long time, may be associated with a higher incidence of T2DM. Also, chronic use of BB is associated with a feeling of generalised lethergy and loss of libido. Well whatever it is, many hypertensives would rather not be on BB. We would like to warn against BB being suddenly withdrawn. Whenever necessary, BB should be withdrawn gradually.

I would normally not withdraw BB if the patient also has associated significant CAD. Sudden withdrawal may aggravate CAD and angina. Whenever necessary, the dose of BB should be halved for weeks before cessation. The patients should also be warned that reducing BB may bring about symptoms of palpitations and sudden feeling of more aggression and activity. A good replacement agent for BP control would be a CCB like norvasc, or ACE-I like coversyl or ramipril. Of course for those who are sensitive to ACE-I, ARBs like valsartan, are reasonable alternatives.

No comments: