Monday, January 03, 2011


Resistant hypertension, by definition is hypertension, not responding to treatment with at least three anti-hypertensive agents at their proper doses. Often, this maybe due to secondary causes like coarctation of the aorta, primary arteritis, renal artery stenosis, Conn's syndrome, Pheochromacytoma, and others. The standard teaching is that when patients' BP do not respond, the doctor must always rule out a secondary cause.
Having done that, the other common reason for " resistant " hypertension is poor compliance with medication. Some patients just do not take their medications, because of side effects, like impotence with beta blockers, and are too embarrassed to discuss with their doctors. In our part of the world, it may be that they have stopped our " Western" medications with their side effects, for traditional herbal medication ( without side effects ).
In an attempt to increase compliance to reduce the incidence of resistant hypertension, pharmas have started to bring out double and triple drug combinations, so that instead of taking two pills, they take one pill, and instead of taking three pills, they take two. In 2009, FDA approved the Exforge HCT ( amlodipine+valsartan+HCT ) drug combination for treatment of hypertension. In July 2010, FDA approved Tribenzor ( Olmesartan+Amlodipine+HCT ) combination, and before the close of the year, FDA approved Amturnide ( Aliskerin+amlodipine+HCT ) combination. This combination ( the latest to be approved ), is the only one with a direct renin inhibitor. An interesting combination.
The Autumn meeting of the AHA, also saw the release of the Simplicity HTN clinical trial result. This is an interesting, novel approach to disrupt the sympathetic pathway at the region of the renal artery, in an attempt to do essentially a sympathectomy. The new approach is use to treat patients with severe resistant hypertension ( hypertension not controlled with 5 antihypertensive medications ). They do what we now call an Ardian procedure.
I believe that most cases of hypertension can be control with a combination of one to two medications, a good dose of counselling on lifestyle modification and also counselling on work and sleeping habits. Weight lost, greens veges and fruits are better alternatives to more drugs.
One of the biggest criticism to combination pills is that the cost of the combo pill may be more then the cost of individual pills. In some countries, this maybe be true, as they have good generics.

1 comment:

vagus said...

Good points; one should always consider secondary causes of hypertension.
Happy New Year, doc!