The Ins and Outs of Treating Resistant Hypertension

When blood pressure remains high despite the use of three antihypertensive agents, a resistant hypertension diagnosis can be made. Well-known treatments are available, but novel approaches are showing promise.

Combination treatment is often needed for patients with hypertension. However, when even three drugs used simultaneously don’t do the trick, the condition just became more challenging by being deemed resistant hypertension. George L. Bakris, MD, from the University of Chicago Pritzker School of Medicine, presented an update on the condition at the 10^th Annual Cardiometabolic Health Congress (CMHC 2015) in Boston, Massachusetts.

“Believe it or not, there have been changes, and there are more coming,” Bakris said during the presentation.

First off, it’s important to realize that not all patients who do not respond to antihypertensive therapy have resistant hypertension. True-resistant hypertension is categorized as blood pressure ˃ 140/90 mmHg despite inadequate doses of at least three drugs, including a diuretic. “Resistant hypertension is a diagnosis of exclusion,” Bakris explained. Therefore, spurious hypertension would have to be ruled out before a true diagnosis.

Old age and excessive dietary salt ingestion are among the top characteristics associated with the condition. One of the challenges with resistant hypertension is that patients have poor medication adherence.

Bakris referenced two studies in which, for the first time, patients were told that they were being tracked for medication usage. One would think that in these cases the results would end up biased because the patients would be extra diligent about taking their drugs. However, outcomes from urine samples and questionnaires revealed that only 45% of patients were taking all of their medications. What was the patients’ response when asked about this shortcoming? They said that the urine test was wrong and they were taking all of their prescription.

So, how do you go about improving medication adherence?

“Patient attitude, no matter what you do or say, is really important,” Bakris said. In order to build up that attitude, communication and trust with the physician is a must.

Clinical trial data has backed up the use of pill boxes, especially for older people. Another practice to encourage adherence is close follow-up. All too often clinicians write a prescription and say, “see you in three months.” Bakris suggested asking patients to report their blood pressure and how they’re feeling and follow up with them two weeks later.

Patient satisfaction is another part that contributes to better treatment adherence, but that should be taken with a grain of salt. “I’m not Walmart,” Bakris said, which was quickly followed by applause from the audience filled with health care providers.

Novel therapies have been in the works Do not push monotherapy for resistant hypertension, Bakris advised; “combination therapy is the way to go.” Going off of that, he said that it’s also better to add a second medication rather than doubling the dose of the first one.

The crossover trial PATHWAY-2 looked at spironolactone versus placebo. After three months, patients who took spironolactone had the greatest blood pressure reduction against the placebo as well as doxazosin and bisoprolol.

“Denervation isn’t dead,” Bakris proclaimed. Device treatment for resistant hypertension is actually growing and a recent study analyzed renal denervation. They looked at radio frequency (RF) treatment of just the main artery, of each branch, and of both the main artery and branches. There was seemingly no difference in blood pressure when just the main artery was treated, however, focusing on the main artery and branches showed statistical significance. There are also a number of studies currently researching the approach, including SPYRAL HTN-ON MED and ACHIEVE.

There isn’t anyone that you can’t get under reasonable control as long as they take all of their medications, according to Bakris. “Simplicity may not be so simple, in terms of doing this correct,” he said. It’s not about getting every single patient down to 115 with the use of five different drugs. Each patient has their own biological profile. “There’s no substitute for good judgment,” Bakris concluded.