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Propranolol is preferred as initial antihypertensive therapy

Many physicians prescribe the newer more expensive antihypertensive agents, although there is insufficient evidence of comparative efficacy and cost-effectiveness to justify the extra expense. Therefore, a meta-analysis was done to compare the efficacy, cost effectiveness and effects on serum cholesterol of 5 kinds of antihypertensive agent in middle-aged patients. Using the Coronary Heart Disease Policy Model, the effects of propranolol 320/280 mg/day, hydrochlorothiazide 75/100 mg/day, captopril 75/225 mg/day, prazosin 12 mg/day and nifedipine 30/40 mg/day were assessed on the mortality, morbidity and cost of coronary heart disease in the USA for 20 years of simulated therapy (doses refer to initial diastolic BP of 94-105 mm Hg and ~ 105 mm Hg, respectively). The study assumed that changes in serum cholesterol would be -0.1 % for propranolol, +5.2% for hydrochlorothiazide, -2% for nifedipine, -6.1 % for prazosin and + 1.3% for captopril.

From analysis of 153 reports the estimated cost per year of life saved was US$ 10 900 for propranolol, US$ 16 400 for hydrochlorothiazide, US$ 31 600 for nifedipine, US$ 61 900 for prazosin and US$ 72 100 for captopril. A doubling of the effect of the agents on cholesterol would have only modest effects on their effectiveness, and likewise changes in doses had little impact on the analysis. When only hypertensive smokers were considered the medications were 60-80% more favourable, but propranolol remained the most effective.

The implications of this analysis are that ' ... propranolol may be the preferred initial treatment for essential hypertension. Newer, more expensive {3-adrenergic antagonists appear to be substantially more effective and only slightly less cost-effective than hydrochlorothiazide . .. ' Edelson JT, Weinstein MC, Tosteson ANA, Williams L, Lee TH, et al. Long·term cost·effectiveness of various initial monotherapies for mild to moderate hypertension. Journal of the American Medical Association 263: 407-413. 19 Jan 1990 ""

10 Feb 1990 INPHARMA® 0156-2703/ 90/02 10-0004/0$01.00/0 © ADIS Press