Can Drug Therapy be Discontinued in Well-Controlled Hypertension?

Each article was analyzed and key data related to the study design, definitions of hypertension and normotension, and baseline predictors were extracted. The criteria used for normotension varied between individual studies. Therefore, successful withdrawal was defined as maintaining blood pressure (BP) levels below those at which drug therapy was recommended to be resumed 12 months after discontinuation of treatment. Studies with follow-up periods of less than 12 months and those in which BP levels requiring re-treatment were not specified were excluded.

Studies with very long follow-up periods were also excluded if it was not possible to estimate a 12-month success rate from the data provided by the researchers. The monthly hazard (risk) of returning to hypertension occurred by calculating the risk within each reported time interval and averaging over the time interval. Summary relative risks describing the effects of sex, body weight reduction after withdrawal of antihypertensive drugs, and sodium reduction following withdrawal of antihypertensive drugs on the likelihood of requiring re-treatment were determined using the randomized effects model of by Simonian and Laird together with evidence of heterogeneity of effects in studies. Because there was little heterogeneity, the summarized relative risks are reduced to those obtained from a fixed-effects model.

Diastolic blood pressure standing longer duration of normotension with drugs but without lying BP; Reduced alcohol, weight and sodium; For potassium increase and sodium decrease; In most individual studies, information on possible predictors of return to hypertension was not provided in a form that made it possible to determine a summary measure of the effect. Most often, the characteristics of people with normotension were compared with those of people with recurrent hypertension at 12 months without providing individual data. The exceptions were for gender and those studies in which an intervention was introduced. A meta-analysis of baseline characteristics as predictors of subjects withdrawn from antihypertensive drugs and kept normotension off medication at 12 months Proportion to predictor who remained normotensive at 12 months after antihypertensive drug withdrawal.

However, all studies had at least 12 months of follow-up. In the absence of lifestyle interventions, success rates averaged approximately 42% in all studies with follow-up periods of this duration. With only one exception, studies with follow-up periods between 2 and 5 years show maintenance rates of normotension similar to those in which the follow-up period was limited to 12 months. Available information suggests that the recurrence rate decreases after 6 months.

Many studies have found that it is usually several weeks or months between cessation of drug treatment and the return of BP to higher levels. This is believed to be the result of a reduction in hypertrophy in the smaller arteries during treatment that reverses the elevated peripheral resistance. A considerable period of time may elapse before such hypertrophy develops again. This illustrates the need to establish long-term monitoring of BP in patients withdrawn from antihypertensive therapy in order to detect a return of hypertension.

The subsequent availability of 24-hour BP monitoring has also revealed the presence of white coat hypertension in which BP, which rises during the stress of a medical encounter, returns to normal levels at other times. The percentage of patients who successfully started treatment but subsequently became normotensive is likely to be much lower than the percentage in which treatment was started inadequately. However, it was notable in this review that the adoption of appropriate lifestyle changes was identified as a consistent predictor of successful drug abstinence. This is consistent with the results of several important trials that have shown that a reduction in body weight, a reduction in salt and alcohol consumption, and an increase in physical activity may be sufficient to reduce marginal elevations in BP to normotensive levels.

Interventions are low, continuous BP monitoring is adequate in these patients. This algorithm is derived from this systematic review and is intended as a guide only. It has not been tested in a clinical population and, therefore, no formal estimates of success rates are provided. Patients who do not meet all criteria may still be eligible for drug withdrawal, although success is likely to be lower.

Emphasis should be placed on the need to continue to attend regular BP checks for all patients, especially in the first 6 months. It is also recommended to encourage behavioral modification, as clinical trials have shown that such interventions almost double the rate of successful maintenance of normotension after withdrawal of antihypertensive drugs. Current recommendations of expert committees support reevaluation of the drug treatment for hypertension for the reduction of the dose and number of drug groups and withdrawal of antihypertensive drugs under certain circumstances with adequate follow-up. In conclusion, if antihypertensive medication is withdrawn from selected patients with mild to moderate hypertension, it is approximately 42% likely that these patients will remain normotensive for periods longer than 12 months.

Studies that have established this have had different designs, patient populations, and even definitions of hypertension. Several predictors have been identified as being associated with successful withdrawal from antihypertensive drugs - relatively low levels before starting treatment and during treatment with a single drug; adoption of appropriate lifestyle changes; willingness to change life habits; reduced alcohol consumption; weight loss; reduced salt intake; increased physical activity; and continuous BP monitoring - especially during the first 6 months after discontinuation. Discontinuation of ADHD increases the risk of cardiovascular mortality in elderly people due to misconceptions about drug-related symptoms or adverse effects or lack thereof information action programs that promote drug withdrawal in selected patients should emphasize these points as well as strategies for managing withdrawal symptoms.