Stepped-Down Therapy
Therapy Versus Intermittent in Systemic Hypertension Frank A. Finnerty,
uring the past 30 years many investigators have suggested the possibility of “step-down” therapy and discontinuing therapy in hypertensive patients.lL20 Reducing the dosage of 1 drug or eliminating another in patients after blood pressure has been controlled for a specific length of time is different than discontinuing therapy. Step-down therapy should be reserved for patients with moderately severe or severe hypertension requiring >l drug to control the arterial pressure, whereas discontinuation of therapy should be considered only in patients with mild hypertension who only need 1 drug. It is obvious, therefore, why the many studies1-20 evaluating discontinuation of therapy have demonstrated such a wide variation of success: 3 to 74%.
In 1978, in an attempt to determine the minimum amount of therapy needed to control arterial pressure in patients receiving multiple antihypertensive agents, I began in a stepwise fashion to reduce the dose of 1 of the drugs and then discontinue use of >l of the agents after the blood pressure had been at goal limits for 6 months.20 Of the 51 patients available for the study, 20 were originally receiving 3 antihypertensive agents, and 3 1 were receiving 2. Each had objective evidence of vascular disease, i.e., fundal changes and electrocardiographic evidence of left ventricular hypertrophy. After 6 months it was possible to eliminate 1 drug or reduce the dose of another in 49 of 51 patients. In addition, there was a significant reduction in the frequency of adverse effects. At the beginning of step-down therapy there were 161 complaints of side effects from the 5 1 patients. After step-down therapy 29 (18%) reported side effects were unchanged, 42 (26%) were significantly decreased and 90 (56%) were completely absent. Since these original observations, I have continued with the practice of stepping-down therapy in patients with moderately severe hypertension receiving >l drug after the diastolic pressure has remained -2 years. A 46% reduction in side effects resulted. Prompted by these observations, the dosage of chlorthalidone (monotherapy) was decreased in a stepwise fashion and then discontinued after the diastolic blood pressure had been maintained
Therapy Versus Intermittent in Systemic Hypertension Frank A. Finnerty,
uring the past 30 years many investigators have suggested the possibility of “step-down” therapy and discontinuing therapy in hypertensive patients.lL20 Reducing the dosage of 1 drug or eliminating another in patients after blood pressure has been controlled for a specific length of time is different than discontinuing therapy. Step-down therapy should be reserved for patients with moderately severe or severe hypertension requiring >l drug to control the arterial pressure, whereas discontinuation of therapy should be considered only in patients with mild hypertension who only need 1 drug. It is obvious, therefore, why the many studies1-20 evaluating discontinuation of therapy have demonstrated such a wide variation of success: 3 to 74%.
In 1978, in an attempt to determine the minimum amount of therapy needed to control arterial pressure in patients receiving multiple antihypertensive agents, I began in a stepwise fashion to reduce the dose of 1 of the drugs and then discontinue use of >l of the agents after the blood pressure had been at goal limits for 6 months.20 Of the 51 patients available for the study, 20 were originally receiving 3 antihypertensive agents, and 3 1 were receiving 2. Each had objective evidence of vascular disease, i.e., fundal changes and electrocardiographic evidence of left ventricular hypertrophy. After 6 months it was possible to eliminate 1 drug or reduce the dose of another in 49 of 51 patients. In addition, there was a significant reduction in the frequency of adverse effects. At the beginning of step-down therapy there were 161 complaints of side effects from the 5 1 patients. After step-down therapy 29 (18%) reported side effects were unchanged, 42 (26%) were significantly decreased and 90 (56%) were completely absent. Since these original observations, I have continued with the practice of stepping-down therapy in patients with moderately severe hypertension receiving >l drug after the diastolic pressure has remained -2 years. A 46% reduction in side effects resulted. Prompted by these observations, the dosage of chlorthalidone (monotherapy) was decreased in a stepwise fashion and then discontinued after the diastolic blood pressure had been maintained
