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 physi cians' adherence to recommendations on dosage for antihypertensive combinat ions; (c) whether prescribing practice conforms with recommended therapeuti c guidelines; and (d) the frequency of prescribing of other drugs which hav e the potential to alter the efficacy of antihypertensive agents. Methods: A survey of prescribing in older patients with uncomplicated hyper tension in primary care setting of Bahrain was conducted. Results: Of the 432 (56.5%) patients on monotherapy, 192 (44.4%) were treat ed with beta -blockers, 87 (20.1%) with calcium channel blockers (CCBs), 53 (12.3%) with alpha -methyldopa, 47 (10.9%) with diuretics, 46 (10.6%) with angiotensin converting enzyme (ACE) inhibitors, and 7 (1.6%) with hydralaz ine. Of the 1146 patients on mono- or combination therapies, 434 (56.8%) we re treated with beta -blockers, 244 (31.9%) with diuretics, 211 (27.6%) wit h CCBs, 139 (18.2%) with ACE inhibitors, 103 (13.5%) with alpha -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-antihypertens ive drug combinations were prescribed: a diuretic with a beta -blocker (37. 2%) and a beta -blocker with either a CCB (20.9%) or an ACE inhibitor (12.4 %) were the most popular two-drug regimens. The most commonly prescribed tr iple drug regimens were a diuretic and a beta -blocker plus either a CCB (2 6.1%) or an ACE inhibitor (17.4%) and diuretic plus an ACE inhibitor and a CCB (15.2%). Daily dosage of beta -blockers, ACE inhibitors and alpha -meth yldopa were somewhat high in a considerable proportion of patients on both mono- and combined therapies. A substantial proportion (9.7%) of patients o n monotherapy were treated with immediate release nifedipine. Conclusion: The pharmacotherapy of hypertension in elderly patients was fou nd in some instances not to conform to recommended guidelines. For certain classes of antihypertensive agent such as beta -blockers, ACE inhibitors an d alpha -methyldopa, neither the principles of geriatric pharmacology nor o f antihypertensive combination therapy, and in particular, the need to redu ce daily dosage, were followed. The use of immediate release nifedipine in the elderly is irrational, and instead, the use of long-acting dihydropyrid ine CCBs should be considered. The results of long-term randomized clinical trials published during the last decade have had a minimal impact on clini cal practice of primary care physicians in Bahrain.