Effect of antihypertensive treatment at different blood pressure levels in patients with diabetes mellitus: systematic review and meta-analyses

According to the new guidelines for treatment of hypertension, it is recommended to initiate pharmacological treatment in diabetic patients when their blood pressure goes above 140/90. This recommendation is one of many that come from JNC 8, a trusted guideline by pharmacists and doctors all over the world. One issue with the JNC treatment guidelines, however, is that while they give extensive and thorough recommendations about the initiation of antihypertensive therapy, they offer little to no recommendations about when antihypertensives should be continued or stopped after a goal blood pressure has been reached.

 

In this review article that looked at 49 randomized controlled trials, it was determined that further treatment of diabetes patients with anti-hypertensives after they were below goal blood pressure actually increased risk of cardiovascular death as well as correlated to an increase towards all types of mortality. This surprised me because it seems counterintuitive that antihypertensive medications could ever increase the possibility of a cardiovascular death, even in a patient with healthy blood pressure.

 

I think this article may shed some light on the “if it ain’t broke don’t fix it” attitude of many doctors towards maintenance medications. Many doctors will keep their patients on anti-hypertensives or statins even if the patient’s blood pressure or lipid levels are at goal. This attitude, as shown by this review article, could have some negative effects on patient outcomes. What do you think? Should patients be discontinued on medications when they reach their goals? Or is this review finding specific to patients with both hypertension and diabetes?

 

Brunström M. & Carlberg, B. Effect of antihypertensive treatment at different blood pressure levels in patients with diabetes mellitus: Systematic review and meta-analyses. Bmj 2016;352:I717.

3 thoughts on “Effect of antihypertensive treatment at different blood pressure levels in patients with diabetes mellitus: systematic review and meta-analyses”

  1. I find this article to be interesting because I think a lot of healthcare providers don’t think to discontinue medications if the health status appears stable. However, it may be in the best interest for the patient to discontinue. In the case of patients with diabetes, it can lead to cardiovascular complications as you have shown. But in other populations it may just be more convenient for a patient to not be on as many medications. I don’t think medications should always be discontinued when patients reach their goals right away. However, if a patient has been stable for quite some time it may be beneficial to take them off medications and monitor closely to see if the disease state of interest remains stable. I obviously don’t know enough information now, but in the future I would like to use the knowledge we attain in school to not only know when a medication is appropriate but also when it is appropriate to discontinue a medication.

  2. I agree that patients should not be discontinued on medications immediately once they reach their goal levels but there is definitely a point at which patients should discontinue their medications to prevent the development of other medical conditions. Overtreatment is a real issue and can lead to even more health problems. Blood pressures should be continuously monitored even once a patient reaches the goal level because antihypertensive treatment may decrease the patient’s blood pressure to dangerous levels if left unattended, leading to hypotension. Different medical conditions and medications should be discussed on a case-to-case basis because overtreatment obviously varies and may be more severe in certain conditions. As a general rule of thumb, I believe that medications should not be taken lightly and that their effectiveness should be continuously observed and/or measured at all times.

  3. I think this article is interesting because sometimes I think that people forget that we can be over-treating patients. While we think that we are helping to treat their hypertension, we are actually being too aggressive and causing potential harm to the patient. I also think this is interesting because it is studies like this one that drive changes in future guidelines. Therefore, I think it will be interesting to see what changes are made to such guidelines.

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