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December 3, 1997, Vol 278, No. 21 >
ARTICLE | December 3, 1997

Trends in Antihypertensive Drug Use in the United States: Title and subTitle BreakDo the JNC V Recommendations Affect Prescribing? FREE

David Siegel, MD, MPH; Julio Lopez, PharmD
[+] Author Affiliations

The views expressed in the article do not necessarily represent the views of the Department of Veterans Affairs or the US government.

Reprints: David Siegel, MD, MPH, Chief, Medical Service (111), Department of Veterans Affairs NCHCS, 150 Muir Rd, Martinez, CA 94553 (e-mail: Siegel. David@Martinez.VA.gov).


JAMA. 1997;278(21):1745-1748. doi:10.1001/jama.1997.03550210043036
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References

Context.  —The choice of pharmacological treatment for the approximately 50 million people in the United States with hypertension has important therapeutic and financial implications.

Objectives.  —To describe national antihypertensive medication prescribing patterns for 1992 and 1995; to explore the influence of the Fifth Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure (JNC V), published in 1993, which recommended diuretics and β-blockers as firstline antihypertensive therapy unless contraindicated; and to estimate the impact of these prescribing patterns on the cost of antihypertensive treatment.

Design.  —All prescriptions for drugs approved for the treatment of hypertension dispensed by 35000 retail pharmacies were tabulated for 1992 and 1995 (62% of all US retail pharmacies were surveyed).

Main Outcome Measures.  —Number of prescriptions for each dosage form of medication and national cost estimates based on wholesale costs of medications dispensed.

Results.  —In 1992, of the 10 most frequently prescribed antihypertensive drugs, 3 were calcium antagonists, 3 were angiotensin-converting enzyme (ACE) inhibitors, 3 were β-blockers, and 1 was the combination of triamterene and hydrochlorothiazide. In 1995,4 were calcium antagonists, 3 were ACE inhibitors, 1 was a β-blocker, 1 was the combination of triamterene and hydrochlorothiazide, and 1 an a-blocker. In 1992, calcium antagonists accounted for 33% of antihypertensive prescriptions compared with 38% in 1995, ACE inhibitor use went from 25% to 33%, β-blocker use from 18% to 11% and diuretic use from 16% to 8%. The estimated wholesale costs for calcium antagonists in 1995 dollars increased from $2.67 billion in 1992 to $2.86 billion in 1995; ACE inhibitor costs increased from $1.37 billion to $1.67 billion; costs for diuretics declined from $353 million to $168 million; and costs for β-blockers declined from $763 million to $433 million.

Conclusions.  —From 1992 to 1995 use of calcium antagonists and ACE inhibitors for treatment of hypertension increased and diuretics and β-blockers declined, suggesting that the recommendations from JNC V had little effect on prescribing patterns. The cost implications of these practice patterns are enormous.

REFERENCES

1 +
Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure.  The Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V) . Arch Intern Med . 1993;;153:154-183.
2 +
Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure.  The 1988 Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure . Arch Intern Med . 1988;;148:1023-1038.
3 +
Weber MA, Laragh JH.  Hypertension: steps forward and steps backward . Arch Intern Med . 1993;;153:149-152.
4 +
Schmieder RE, Martus P, Klingbeil A.  Reversal of left ventricular hypertrophy in essential hypertension: a meta-analysis of randomized double-blind studies . JAMA . 1996;;275:1507-1513.
5 +
Neaton JD, Grimm RH Jr, Prineas RJ, et al.  Treatment of mild hypertension study: final results . JAMA . 1993;;270:713-724.
6 +
Kaplan NM, Gifford RW.  Choice of initial therapy for hypertension . JAMA . 1996;;275:1577-1580.
7 +
Collins R, Peto R, MacMahon S, et al.  Blood pressure, stroke, and coronary heart disease, part 2: short-term reductions in blood pressure: overview of randomised drug trials in their epidemiological context . Lancet . 1990;;335:827-838.
8 +
Lenfant C.  High blood pressure: some answers, new questions, continuing challenges . JAMA . 1996;;275:1604-1606.
9 +
Psaty BM, Heckbert SR, Koepsell TD, et al.  The risk of myocardial infarction associated with antihypertensive drug therapies . JAMA . 1995;;274:620-625.
10 +
Buring JE, Glynn RJ, Hennekens CH.  Calcium channel blockers and myocardial infarction: a hypothesis formulated but not yet tested . JAMA . 1995;;274:654-655.
11 +
Burt VL, Whelton P, Roccella EJ, et al.  Prevalence of hypertension in the US adult population: results from the Third National Health and Nutrition Examination Survey, 1988-1991 . Hypertension . 1995;;25:305-313.
12 +
Manolio TA, Cutler JA, Furberg CD, Psaty BM, Whelton PK, Applegate WB.  Trends in pharmacologic management of hypertension in the United States . Arch Intern Med . 1995;;155:829-837.
13 +
Psaty BM, Koepsell TD, Yanez D, et al.  Temporal patterns of antihypertensive medication use among adults, 1989 through 1992 . JAMA . 1995;;273:1436-1438.
14 +
 Top 200 survey . Am Drug . 1993;;207:49-53.
15 +
 The top 200 drugs . Am Drug . 1996;;212:18-26.
16 +
Ramspacher S. 1995 Hospital pharmacy review: leading dollar volume pharmaceuticals . Hosp Pharmacy . 1996;;31:624-42.
17 +
1995 Drug Topics Redbook. Montvale, NJ: Medical Economics Publishing; 1995.
18 +
Materson BJ, Reda DJ, Cushman WC, et al.  Single-drug therapy for hypertension in men . N Engl J Med . 1993;;328:914-921.
19 +
US Dept of Health and Human Services. Heart Failure:Management of Patients With Left Ventricular Dysfunction . Washington, DC: US Dept of Health and Human Services; June 1994;. Agency for Health Care Policy and Research Publication 94-0613.
20 +
Collins JG.  Prevalence of selected chronic conditions: United States, 1986-88 . Vital Health Stat 10 . 1993;;182:1-87.
21 +
Beta-blocker Heart Attack Trial Research Group.  A randomized trial of propranolol in patients with acute myocardial infarction, I: mortality results . JAMA . 1982;;247:1707-1714.
22 +
Conti CR.  Re-examining the clinical safety and roles of calcium antagonists in cardiovascular medicine . Am J Cardiol . 1996;;78( (suppl 9A) ):13-18.
23 +
Soumerai SB.  Factors influencing prescribing . Aust J Hosp Pharm . 1988;;18( (suppl) ):9-16.
24 +
Soumerai SB,McLaughlinTJ,Avorn J. Improving drug prescribing in primary care: a critical analysis of the experimental literature . Milbank Q . 1989;;67:268-317.
25 +
Wilkes MS, Doblin BH, Shapiro MF.  Pharmaceutical advertisements in leading medical journals: experts' assessments . Ann Intern Med . 1992;;116:912-919.
26 +
Simonsen LLP.  What are pharmacists dispensing most often? Pharm Times . 1993;;59:29-44.
27 +
 Top 200 drugs of 1995 . Pharm Times . 1996;;62:27-34.
28 +
Siegel D, Hulley SB, Black DM, et al.  Diuretics, serum and intracellular electrolyte levels, and ventricular arrhythmias in hypertensive men . JAMA . 1992;;267:1083-1089.
29 +
Davis BR, Cutler JA, Gordon DJ, et al, for ALLHAT Research Group.  Rationale and design for the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) . Am J Hypertens . 1996;;9:342-362.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure.  The Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V) . Arch Intern Med . 1993;;153:154-183.
2 +
Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure.  The 1988 Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure . Arch Intern Med . 1988;;148:1023-1038.
3 +
Weber MA, Laragh JH.  Hypertension: steps forward and steps backward . Arch Intern Med . 1993;;153:149-152.
4 +
Schmieder RE, Martus P, Klingbeil A.  Reversal of left ventricular hypertrophy in essential hypertension: a meta-analysis of randomized double-blind studies . JAMA . 1996;;275:1507-1513.
5 +
Neaton JD, Grimm RH Jr, Prineas RJ, et al.  Treatment of mild hypertension study: final results . JAMA . 1993;;270:713-724.
6 +
Kaplan NM, Gifford RW.  Choice of initial therapy for hypertension . JAMA . 1996;;275:1577-1580.
7 +
Collins R, Peto R, MacMahon S, et al.  Blood pressure, stroke, and coronary heart disease, part 2: short-term reductions in blood pressure: overview of randomised drug trials in their epidemiological context . Lancet . 1990;;335:827-838.
8 +
Lenfant C.  High blood pressure: some answers, new questions, continuing challenges . JAMA . 1996;;275:1604-1606.
9 +
Psaty BM, Heckbert SR, Koepsell TD, et al.  The risk of myocardial infarction associated with antihypertensive drug therapies . JAMA . 1995;;274:620-625.
10 +
Buring JE, Glynn RJ, Hennekens CH.  Calcium channel blockers and myocardial infarction: a hypothesis formulated but not yet tested . JAMA . 1995;;274:654-655.
11 +
Burt VL, Whelton P, Roccella EJ, et al.  Prevalence of hypertension in the US adult population: results from the Third National Health and Nutrition Examination Survey, 1988-1991 . Hypertension . 1995;;25:305-313.
12 +
Manolio TA, Cutler JA, Furberg CD, Psaty BM, Whelton PK, Applegate WB.  Trends in pharmacologic management of hypertension in the United States . Arch Intern Med . 1995;;155:829-837.
13 +
Psaty BM, Koepsell TD, Yanez D, et al.  Temporal patterns of antihypertensive medication use among adults, 1989 through 1992 . JAMA . 1995;;273:1436-1438.
14 +
 Top 200 survey . Am Drug . 1993;;207:49-53.
15 +
 The top 200 drugs . Am Drug . 1996;;212:18-26.
16 +
Ramspacher S. 1995 Hospital pharmacy review: leading dollar volume pharmaceuticals . Hosp Pharmacy . 1996;;31:624-42.
17 +
1995 Drug Topics Redbook. Montvale, NJ: Medical Economics Publishing; 1995.
18 +
Materson BJ, Reda DJ, Cushman WC, et al.  Single-drug therapy for hypertension in men . N Engl J Med . 1993;;328:914-921.
19 +
US Dept of Health and Human Services. Heart Failure:Management of Patients With Left Ventricular Dysfunction . Washington, DC: US Dept of Health and Human Services; June 1994;. Agency for Health Care Policy and Research Publication 94-0613.
20 +
Collins JG.  Prevalence of selected chronic conditions: United States, 1986-88 . Vital Health Stat 10 . 1993;;182:1-87.
21 +
Beta-blocker Heart Attack Trial Research Group.  A randomized trial of propranolol in patients with acute myocardial infarction, I: mortality results . JAMA . 1982;;247:1707-1714.
22 +
Conti CR.  Re-examining the clinical safety and roles of calcium antagonists in cardiovascular medicine . Am J Cardiol . 1996;;78( (suppl 9A) ):13-18.
23 +
Soumerai SB.  Factors influencing prescribing . Aust J Hosp Pharm . 1988;;18( (suppl) ):9-16.
24 +
Soumerai SB,McLaughlinTJ,Avorn J. Improving drug prescribing in primary care: a critical analysis of the experimental literature . Milbank Q . 1989;;67:268-317.
25 +
Wilkes MS, Doblin BH, Shapiro MF.  Pharmaceutical advertisements in leading medical journals: experts' assessments . Ann Intern Med . 1992;;116:912-919.
26 +
Simonsen LLP.  What are pharmacists dispensing most often? Pharm Times . 1993;;59:29-44.
27 +
 Top 200 drugs of 1995 . Pharm Times . 1996;;62:27-34.
28 +
Siegel D, Hulley SB, Black DM, et al.  Diuretics, serum and intracellular electrolyte levels, and ventricular arrhythmias in hypertensive men . JAMA . 1992;;267:1083-1089.
29 +
Davis BR, Cutler JA, Gordon DJ, et al, for ALLHAT Research Group.  Rationale and design for the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) . Am J Hypertens . 1996;;9:342-362.

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