Rational pharmacotherapy of hypertension in the elderly: analysis of the choice and dosage of drugs

Objectives: To determine in older people with uncomplicated hypertension: (a) the pattern of prescribing of antihypertensives; (b) the extent of physicians’ adherence to recommendations on dosage for antihypertensive combinations; (c) whether prescribing practice conforms with recommended therapeutic guidelines; and (d) the frequency of prescribing of other drugs which have the potential to alter the efficacy of antihypertensive agents. Methods: A survey of prescribing in older patients with uncomplicated hypertension in primary care setting of Bahrain was conducted. Results: Of the 432 (56·5%) patients on monotherapy, 192 (44·4%) were treated with β-blockers, 87 (20·1%) with calcium channel blockers (CCBs), 53 (12·3%) with α-methyldopa, 47 (10·9%) with diuretics, 46 (10·6%) with angiotensin converting enzyme (ACE) inhibitors, and 7 (1·6%) with hydralazine. Of the 1146 patients on mono- or combination therapies, 434 (56·8%) were treated with β-blockers, 244 (31·9%) with diuretics, 211 (27·6%) with CCBs, 139 (18·2%) with ACE inhibitors, 103 (13·5%) with α-methyldopa 8 (1·0%) with brinerdine and 7 (0·9%) with hydralazine. In the 332 (43·5%) patients on combination therapy, 15 different two- and three-antihypertensive drug combinations were prescribed: a diuretic with a β-blocker (37·2%) and a β-blocker with either a CCB (20·9%) or an ACE inhibitor (12·4%) were the most popular two-drug regimens. The most commonly prescribed triple drug regimens were a diuretic and a β-blocker plus either a CCB (26·1%) or an ACE inhibitor (17·4%) and diuretic plus an ACE inhibitor and a CCB (15·2%). Daily dosage of β-blockers, ACE inhibitors and α-methyldopa were somewhat high in a considerable proportion of patients on both mono- and combined therapies. A substantial proportion (9·7%) of patients on monotherapy were treated with immediate release nifedipine. Conclusion: The pharmacotherapy of hypertension in elderly patients was found in some instances not to conform to recommended guidelines. For certain classes of antihypertensive agent such as β-blockers, ACE inhibitors and α-methyldopa, neither the principles of geriatric pharmacology nor of antihypertensive combination therapy, and in particular, the need to reduce daily dosage, were followed. The use of immediate release nifedipine in the elderly is irrational, and instead, the use of long-acting dihydropyridine CCBs should be considered. The results of long-term randomized clinical trials published during the last decade have had a minimal impact on clinical practice of primary care physicians in Bahrain.