Are many hypertensive patients being treated with more medication than they need? The recent JNC8 report said yes, but for the wrong reason! It said that in treating people over the age of 60, we should ease up and accept a systolic pressure (the upper number) up to 150 and not bother to keep it below the longstanding target of 140. In a recent blog I discussed why I and many other hypertension specialists disagree with this recommended change. We've achieved a substantial reduction in cardiovascular events, particularly stroke, aiming at the traditional target of 140. There is insufficient evidence to abandon that goal. It does not constitute over-treatment.
That said, it is nevertheless true that, for other reasons, millions are on more medication than they need and are suffering unnecessary adverse effects, such as fatigue, dizziness and even fainting, and unneeded extra costs. You need to be on as much medication as is necessary to bring your blood pressure under control. However, you are best off if you are on as little medication as you truly need.
Are you on more medication than you need? Here are a few clues that suggest that you might be. If any of them ring true, you shouldn't make changes on your own, but consider discussing these questions with your physician.
1. Is your blood pressure usually normal, but occasionally elevated? Blood pressure can and does vary, quite a bit, in all of us. If your blood pressure is usually in the normal range, your physician should not increase your medication because you had an elevated reading at your most recent check-up. He and you should first follow your blood pressure and see if the increase is sustained or frequent, or not. If it is usually normal, you probably don't need a bump in your medication.
2. Have you checked your blood pressure at home? Many people with an elevated reading at the doctor's office have a lower or normal reading at home. This is widely known as "white coat hypertension" and is more likely if you tend to be anxious, particularly about your blood pressure. At some point you should check your blood pressure at home to make sure that you truly have hypertension and need medication. Another option is a 24-hour blood pressure monitor that your doctor can arrange.
3. Are you taking a medication that never worked? If your doctor prescribed a medication that did not lower your blood pressure at all, and then added a second drug that did work, you might not need the first drug.
4. Are you older than 70 or 80 and is your systolic pressure below 120? There is no evidence that at that age aiming for a systolic pressure in the 120s or lower is safer or more beneficial than aiming for a systolic pressure below 140. And there is always present a risk of drug side effects; the more medication the greater the risk. Studies also suggest that at the lower blood pressure levels, often with even lower standing blood pressure levels, the risk of falls is increased. The ongoing SPRINT trial will determine whether or not elderly patients would benefit, or not, from a target systolic pressure lower than 140. If it took a combination of three or more medications to get your systolic pressure down to the 120s or lower, you might do and feel just as well, or better, on less medication, and with a blood pressure in the 130s.
5. Are you on a greater number of blood pressure medications than you think you need? Millions end up on any number of medications that they don't need because they are not on a diuretic, or are not on a high enough dose of a diuretic, that they do need. Although the lowest necessary dose of a medication is always desirable, in millions the blood pressure can be hard or impossible to control, no matter how many other medications are given, without a higher than usual dose of a diuretic, or combination of diuretics. With the right diuretic regimen, your doctor will often be able to eliminate one or more of your other medications.
6. Are you on a beta-blocker and do you lack energy? Most people being treated for hypertension don't need a beta-blocker. If you are on one a beta-blocker and don't feel your usually energy, there is a good chance other blood pressure drugs can do the job without the beta-blocker.
7. Are you taking clonidine? Clonidine is the most effective drug I try not to prescribe. Some patients truly need it. But most don't. And if you are taking clonidine, there is a good chance you are suffering from side effects such as dry mouth, fatigue and sexual dysfunction. In most patients who are taking clonidine, hypertension can be controlled without it if better use is made of other better-tolerated drugs. You need a physician who feels about clonidine as I do.
These are not the only reasons why you might be on more medication than is necessary or good for you, but they are among the most common reasons, and are affecting millions of people who are taking blood pressure medication. As I explain in Hypertension and You, we have great medications, but they are still not being used as wisely as possible. It is clear we can do much better with the medications available to us, by figuring out which drugs are right for you, and which are not. With the right drugs, at the right doses, you'll need fewer drugs to get your blood pressure to target, and you'll feel better.