Hypertension or high blood pressure is a leading risk factor behind coronary heart disease and stroke, two of the top three leading causes of death in the US. The morbidity, mortality and cost to the society have made it the subject matter of extensive research in the last three decades. Research, patient education and the efforts of physicians has led to a significant decrease in the rate of deaths due to multiple organ failure that untreated hypertension often leads to.
Stepped care in the treatment of hypertension is one of the treatment modalities that emerged from the extensive research associated with high blood pressure. A precise set of rules specifying how, which and when high blood pressure medication should be prescribed for treatment was published in 1977. The algorithm suggested that:
- A thiazide diuretic should be used at first, starting with a smaller dose.
- A second drug should be added if a diuretic does not bring the desired results and fails to meet the therapeutic goal.
- The second step drug should be chosen from antihypertensive drugs like reserpine and methyldopa or propanolol, the first beta blocker.
- Hydralazine or clonidine should be added in case a third drug was needed.
This concept of a step by step approach of evaluating the effects of the first drug and adding another is known as ‘stepped care’. As newer and more effective drugs came on the scene, which were better tolerated, the list of drugs has been modified to keep up with the development of newer drugs. The basic concept of a stepped approach to treatment, however, remained the same and diuretics still remained the preferred first choice for initial treatment.
There have been a lot of criticisms of this approach and the fact that diuretics were the preferred drug to be administered in the first step. The recommendation of beta blockers as the preferred initial treatment has also been criticized.
Recent studies provide reasonable evidence that diuretics are as effective in treating hypertension as the newer ACE inhibitor drugs and calcium channel blockers. There is also sufficient evidence that most of the patients do not respond to a single drug, irrespective of which therapy is being used. This includes the recently launched angiotensin receptor blockers (ARB’s).
The rationale behind a stepped care treatment has been that it is easier to identify the side effects if and when they occur. That again has been refuted on the basis that it is easy to pin point which drug gives a particular side effect.