Therapeutic choice in the treatment of hypertension. Initial treatment of newly diagnosed hypertension and secular trends in the prescribing of antihypertensive medications for Medicaid patients.

A "stepped-care" approach has been widely recommended for more than 10 years as an empiric method for the treatment of hypertension. This approach encourages the use of diuretics or beta blockers as initial monotherapy for hypertension. Although these and other antihypertensive regimens tested in clinical trials have substantially reduced morbidity and mortality from cerebrovascular disease, their relative effectiveness in reducing the sequelae of coronary artery disease is not as well established. These findings, coupled with the development of new drug regimens, have led to a re-examination of the stepped-care guidelines. This re-examination will stimulate increased interest in the therapeutic choices made by practicing physicians, particularly because the newer drugs are more costly than the traditional treatments. To address this question, we performed two specific studies, using data bases from Michigan and Tennessee Medicaid programs. The first study analyzed prescriptions for newly diagnosed cases of essential hypertension. The second study analyzed secular trends in the prescribing of antihypertensive regimens since that time. The data suggest that in 1982 and 1983 (the time period under consideration in the first part of the study), physicians treating hypertension for Medicaid enrollees followed the stepped-care recommendations, the majority using diuretics as step-one monotherapy. The secular trend data in the second study showed a moderate decrease in the use of diuretics since 1983. There were marked increases in the use of newer antihypertensive medications such as calcium channel blockers and the angiotensin converting enzyme inhibitor captopril. Because the costs of the newer drugs are substantially higher, a shift to these drugs would significantly increase the cost of treating hypertension in this country. Prospective, controlled trials are necessary to ascertain if the increased costs of the newly developed drugs are justified by potential benefits.